Rheumatology Flashcards
Definition of Osteoarthritis
Age related degenerative synovial joint disease & degenerative of articular cartilage leading to structural changes, pain & reduced function
Aetiology & Risk Factors - OA
primary - unknown, secondary - predisposing factor which accelerated degeneration (trauma, congenital abnormalities, inflammatory e.g. RA)
Risk factors: obesity, female sex, occupation, genetic factors, age
Clinical Features - OA
Joint pain
Stiffness - <30mins in morning
Better at rest/worse with exercise
Reduced function
Joint Deformities
- Heberden's nodes - DIP - Bouchard's nodes - PIP
Investigations & Findings - OA
X-ray - LOSS
loss of joint space, osteophytes, subchondral cysts & subchondral sclerosis
Management - OA
Conservative
• Patient education
• Lifestyle advice - weight loss, stretching, exercise
Medical
• Paracetamol - safest & often helps w/ symptoms
• NSAIDs - topical & remember PPI/risks in elderly
Steroid Injections
Surgical
• Arthroscopy - not routine, if loose body or mechanical locking
• Joint replacement - consider ‘shelf life’, when impacting QOL significantly,
Definition of Rheumatoid Arthritis
an inflammatory arthritis - autoimmune condition that causes chronic inflammation of the synovial lining of the joints, tendon sheaths & bursa
Aetiology& Risk Factors - RA
Autoimmune of unknown cause/trigger
a/w other AI conditions e.g. Raynaud’s, Sjogren’s
HLA-DR1 & HLA-DR4 haplotypes
Female sex, lower socioeconomic status, family history, other AI conditions, smoking
Clinical Features - RA
Gradual onset (occasionally rapid) Joint pain & swelling - symmetrical & many (MCP > Wrists > PIP > knee > MTP)
Morning stiffness >30mins, better with movement/worse with rest
Constitutional symptoms: myalgia, fatigue, low-grade fever, weight loss, and low mood
Investigations - RA
Bloods • FBC, U&Es, bone profile, vit D, LFTs, ESR & CRP (normal in 40%), autoimmune screen • Rheumatoid factor & anti-CCP Imaging • X-rays - hands & feet • CXR - extra-articular manifestations • USS - for effusions
Management options - RA
Symptom control - NSAIDs, occupational & physio
DMARDs - methotrexate (1st line + bridging therapy of steroids for first 2-3mths)
Biologics - Anti-TNF e.g. infliximab, Rituximab: anti-CD20, Tocilizumab: anti-IL-6
Acute flares - steroids
Definition of Osteomalacia
Vitamin D or calcium deficiency leads to defective bone mineralisation in adult remodelling bones; bones become soft
When this occurs in children (before growth plate closure) it leads to condition called Ricket’s
Aetiology of osteomalacia
Aetiology & Risk factors:
• Vit D deficiency - poor diet, malabsorption or lack of exposure to sunlight
• Renal osteodystrophy - due to AKI/CKD
• Inherited Vit D resistance
• Anticonvulsants
• Malignancy - tumour induced osteomalacia
* Lots of time indoors * Ethnicity - darker skin * Live in colder climates * Malabsorption conditions * Renal issues
Clinical presentation - Osteomalacia
Patients often present w/ bone pain, muscle weakness/aches, pathological or abnormal fractures
• Looser zones are fragility fractures that go partially through the bone.
Investigations - Osteomalacia
Bloods • Serum Vit D (75mmol/L or more is optimal) • Calcium • Phosphate • PTH - secondary HPTH may be present Imaging • X-ray; shows radiolucent bones • DEXA; will show low mineral density
Treatment - Osteomalacia
Vit D supplements
• Correct deficiency (loading regime) followed by maintenance dose
Definition of Osteoporosis
Reduction in bone mineral density
less than 2.5 standard deviations below mean peak mass of healthy adult (T score)
Risk factors - Osteoporosis
Older age - as we age osteoclasts activity is not matched by osteoblasts
Female sex - especially post menopausal women
Alcohol & Smoking
Long term corticosteroid use
Other medications inc SSRIs, PPIs, anti-epileptics, anti-oestrogens
Rheumatoid arthritis
Low BMI <18.5
Reduced mobility & activity
Assessment tools & Investigations - Osteoporosis
Assessment tools e.g. FRAX calculate the overall 10yr risk of having a major fracture
• If high risk - offer DEXA
• Intermediate risk - DEXA
Low - optimise RFs & repeat after 5yrs
DEXA interpretation
• T score - standard deviations below that of a healthy adult
○ >-1 = normal
○ -1 to -2.5 = osteopenia
○
Management of Osteoporosis
Lifestyle & risk factors modification - good diet & weight, smoking, alcohol, exercise
Vit D & Ca supplements
Bisphosphonates - alendronate 70mg weekly
Denosumab - ab
HRT - in premature menopause
Follow up - repeat FRAX & DEXA 3-5yrs
Considerations for Bisphosphonates
Taken weekly, on empty stomach & sitting upright for 30mins
SE inc: reflux/oesophageal erosions, atypical fractures, osteonecrosis of jaw & external auditory canal
Definition of Paget’s Disease of Bone
Increased bone turnover is due to the excessive activity of both osteoclasts & osteoblasts. However turnover isn’t co-ordinated or regulated leading to patchy areas of high density (sclerosis) and low density (lysis). This makes the bones structurally weak, deformed & overall enlarged. Particularly affects axial skeleton (head & spine).
Aetiology unknown
Clinical Presentation - Paget’s Disease
Typically affects older adults & p/w • Bone pain • Bone deformity • Hearing loss - if affects bones of ear Pathological fractures
Investigations - Paget’s Disease
Bloods • Raised ALP - other LFTs normal • Calcium - normal • Phosphate - normal Imaging - X-ray • Enlarged & deformed bones • Osteoporosis circumscripta describes well defined osteolytic lesions that appear less dense compared with normal bone • Cotton wool appearance of skull • V shaped defects in long bones - osteolytic bone lesions within the healthy bone
Management - Paget’s Disease
• Bisphosphonates - interfere with osteoclast activity & return normal bone metabolism, improve sx
• Vit D & Calcium supplementation
• NSAIDs for bone pain
Monitor ALP & symptoms
Complications - Paget’s Disease
Two key complications are osteosarcoma (at increased risk) & spinal stenosis/spinal cord compression
Examples of Crystal Arthropathies
Gout - deposition of urate crystals in joints
Pseudogout - calcium pyrophosphate crystals
Risk factors - Gout
High purine diet - meat, seafood Alcohol Diuretics Existing CVD or renal dysfunction Family hx Male
Clinical presentation - Gout
Red hot swollen painful joint
Gouty tophi on hands, elbows & ears
typical joints: base of the big toe (metatarsophalangeal joint) Wrists Base of thumb (carpometacarpal joints) Also knee and ankle
Differentials for hot swollen joint
SEPTIC ARTHRITIS
Gout
Pseudogout
Bleeding into joint
Investigations - Red, hot joint
Bedside
• Observations - considering if systemically unwell
• Joint examination - red, hot, swollen, ROM
Bloods • FBC - Hb, WBC • U&Es • LFTs • ESR/CRP - ESR may be high • Cultures - exclude sepsis
Imaging
• X-ray - assessing for joint damage, signs of OA etc
Specialist
• Joint aspiration & microscopy/culture - gold standard for diagnosis of crystal arthropathies
○ Gout - negatively birefringent needles
Pseudogout - positive birefringence, rhomboid/brick shaped crystals
• Cell count > 50,000 cell/cm3 - think septic arthritis!
Management of Gout
• Acute attacks - NSAIDs (1st line) –> colchicine (2nd or if CA) –> intraarticular corticosteroids (3rd line)
• Prophylaxis - allopurinol (xanthine oxidase inhibitor), lifestyle changes
Start allopurinol after acute attack has settled
Risk factors - septic arthritis
Diabetes Advancing age Prothesis Immunodeficiency/suppression IVDU
Clinical Features - septic arthritis
Symptoms • Pain • Swelling • Fevers Inability to weight bear
Signs • Pain on active and passive movement • Reduced ROM (range of motion) • Erythema • Warmth • Joint effusion
Management - Septic Arthritis
Antibiotics - typically at least 6 week course (flucloxacillin 200-500mg 4x times a day, 2week IV then 6 week oral), liase w/ microbiology
Joint aspirate/washout
Reactive Arthritis - Definition
Definition: Synovitis occurs in joints as a reaction to recent infective trigger (one of the spondyloarthropathies)
Typically causes acute monoarthritis, affecting a single joint in the lower limb (most often the knee) presenting with a warm, swollen and painful joint.
Triggers - Reactive Triggers
The most common infections that trigger reactive arthritis are gastroenteritis or sexually transmitted infection. Chlamydia is the most common sexually transmitted cause of reactive arthritis. Gonorrhoea commonly causes a gonococcal septic arthritis.
Management - Reactive Triggers
Management of reactive arthritis when septic arthritis is excluded:
• NSAIDs
• Steroid injections into the affected joints
Systemic steroids may be required, particularly where multiple joints are affected
Anklylosing Spondylitis - definition & clinical features
Chronic multi-system inflammatory disorder characterised by inflammation of the sacroiliac joints & axial skeleton. Part of the SpA group & a/w HLA-B27 - tends to present in young men as chronic back pain, morning stiffness & eventually spinal deformity
• Back pain - worse w/ rest, better w/ exercis • Neck pain • Alternating buttock pain • Morning stiffness • Fatigue • Arthritis • Enthesitis (inflammation at the insertion of tendons and ligaments) • Positive Schöber test (assesses decrease in lumbar spine flexion) Spinal deformity (seen in advanced disease)
Ankylosing Spondylitis - Extra-atricular Manifestations
○ Aortitis - can lead to aortic regurgitation
○ Anterior uveitis - unilateral red eye, pain & photophobia
○ AV block
○ Apical lung fibrosis
○ Amyloidosis
IgA nephropathy
Ankylosing Spondylitis - investigations & management
Modified New York criteria - clinical & radiological criteria
Bloods - FBC, U&Es, LFTs,CRP & ESR, HLA-B27
Imaging - Plain SIJ XR OR MRI SIJ & whole spine if XR normal
Management - Non-pharmacological Treatments • Patient Education • Smoking Cessation • Input from PT & Ots • Psychological support Pharmacological • NSAIDs - naproxen, ibuprofen, celecoxib ○ Along w/ PPI ○ Relieve symptoms & help w/ physio DMARDs - tend to be ineffective
Clinical Features & Complications - Systemic Sclerosis
• Thickening of skin in 2 distinct subtypes:
○ Limited (distal elbows, knees & neck) or diffuse
• Raynaud’s phenomenom
• Digital ulceration
• ILD
• Renal disease - accelerated HTN & proteinuria
• Pulmonary hypertension
Investigations & Diagnosis:
Auto-antibodies
• ANA, Scl-70, anticentromere, anti-RNA polymerase
Others - investigations for complications
• Lung (pulmonary fibrosis) - CXR, pulmonary function tests, high resolution CT scan
Heart (pericariditis) - ECG, echo
ClinicalFeatures of SLE
Fatigue Weight loss Arthralgia (joint pain) and non-erosive arthritis Myalgia (muscle pain) Fever Photosensitive malar rash. This is a “butterfly” shaped rash across the nose and cheek bones that gets worse with sunlight. Lymphadenopathy and splenomegaly Shortness of breath Pleuritic chest pain Mouth ulcers Hair loss Raynaud’s phenomenon
Giant Cell Arteritis - definition, S&S, investigations & management
Definition: Large vessel vasculitis which is sight-threatening
Inflammation of medium & large sized arteries - preferential involvement of branches of carotid (Temporal, ophthalmic & occipital)
Presentation/Clinical Features:
• Unilateral headache - usually temporal
• Scalp pain
• Jaw/tongue claudication
• Visual symptoms - blurring, amaurosis fugax (temporary monocular blindness), diplopia
• Constitutional symptoms: fever, weight loss, fatigue
Investigations & Diagnosis:
Suspected GCA should be assessed immediately w/ urgent referrals to rheumatology & ophthalmology team
Bloods
• FBC
• U&E
• LFT
• ESR/CRP: typically elevated but may be normal at presentation (<5%). Keep a high index of suspicion
Temporal artery biopsy
Sampling of a small piece of tissue from the temporal artery. Due to the presence skip lesions, a negative biopsy does not exclude GCA
Management:
Immediate management
• Start steroids immediately - do not wait for investigations
○ 40mg OD if no visual sx or jaw/tongue claudication
○ 60mg OD if those sx are present
○ Consider IV steroids if signs of cerebral ischaemia or visual loss
Ongoing management
• Regular monitoring - ESR & CRP
• Steroid reducing plans
○ + protection i.e. bone, PPI cover
Examples & Clinical Features of Small Vessel Vascultitides
o Granulomatosis w/ polyangiitis – small vessel vasculitis which affects respiratory tract & kidneys, a/w cANCA
Epistaxis, crusty nasal secretions, hearing loss & sinusitis
Cough, wheeze, haemoptysis, ILD
Glomerulonephritis
Rashes
o Eosinophilic granulomatosis with polyangiitis – small & medium vessel vasculitis, a/w pANCA
Lung & skin manifestations but can affect other organs inc kidneys
Often presents w/ severe asthma in late teenage years or adulthood
Elevated eosinophil levels on FBC
o
Sjogren’s Syndrome - definition, clinical features & management
o Autoimmune disease which attacks exocrine glands, resulting in
Dry eyes, dry mouth, dry vagina & dry skin
o Extra-glandular features: dysphagia, ILD, sensory neuropathy, arthralgia, CNS complications
o Can also cause gland swelling – but if persists think about lymphoma
Substitute lubricants for dry eyes & mouth, steroids & immunosuppressants can be used for systemic disease
Types of Inflammatory Myositis - S&S & management
Polymyositis & dermatomyositis are autoimmune disorders where there is inflammation in the muscles (myositis)
® Polymyositis – chronic inflammation of muscles
® Dermatomyositis – is a CTD where there is chronic inflammation of the skin and muscles
• Clinical Features: muscle pain, fatigue, weakness ○ Occurs bilaterally & typically affects proximal muscles ○ Mostly affects shoulder & pelvic girdle Develops over weeks
Can be a paraneoplastic syndrome for ovarian, lung, breast & gastric cancers
• Corticosteroids are the first line treatment of both conditions. • Other medical options where the response to steroids is inadequate: • Immunosuppressants (such as azathioprine) • IV immunoglobulins Biological therapy (such as infliximab or etanercept)
