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Finals > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

Definition of Osteoarthritis

A

Age related degenerative synovial joint disease & degenerative of articular cartilage leading to structural changes, pain & reduced function

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2
Q

Aetiology & Risk Factors - OA

A

primary - unknown, secondary - predisposing factor which accelerated degeneration (trauma, congenital abnormalities, inflammatory e.g. RA)

Risk factors: obesity, female sex, occupation, genetic factors, age

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3
Q

Clinical Features - OA

A

Joint pain
Stiffness - <30mins in morning
Better at rest/worse with exercise
Reduced function

Joint Deformities

- Heberden's nodes - DIP
- Bouchard's nodes - PIP
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4
Q

Investigations & Findings - OA

A

X-ray - LOSS

loss of joint space, osteophytes, subchondral cysts & subchondral sclerosis

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5
Q

Management - OA

A

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,

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6
Q

Definition of Rheumatoid Arthritis

A

an inflammatory arthritis - autoimmune condition that causes chronic inflammation of the synovial lining of the joints, tendon sheaths & bursa

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7
Q

Aetiology& Risk Factors - RA

A

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

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8
Q

Clinical Features - RA

A 
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

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9
Q

Investigations - RA

A 
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
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10
Q

Management options - RA

A

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

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11
Q

Definition of Osteomalacia

A

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

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12
Q

Aetiology of osteomalacia

A

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
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13
Q

Clinical presentation - Osteomalacia

A

Patients often present w/ bone pain, muscle weakness/aches, pathological or abnormal fractures
• Looser zones are fragility fractures that go partially through the bone.

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14
Q

Investigations - Osteomalacia

A 
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
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15
Q

Treatment - Osteomalacia

A

Vit D supplements

• Correct deficiency (loading regime) followed by maintenance dose

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16
Q

Definition of Osteoporosis

A

Reduction in bone mineral density

less than 2.5 standard deviations below mean peak mass of healthy adult (T score)

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17
Q

Risk factors - Osteoporosis

A

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

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18
Q

Assessment tools & Investigations - Osteoporosis

A

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

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19
Q

DEXA interpretation

A

• T score - standard deviations below that of a healthy adult
○ >-1 = normal
○ -1 to -2.5 = osteopenia
○

20
Q

Management of Osteoporosis

A

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

21
Q

Considerations for Bisphosphonates

A

Taken weekly, on empty stomach & sitting upright for 30mins

SE inc: reflux/oesophageal erosions, atypical fractures, osteonecrosis of jaw & external auditory canal

22
Q

Definition of Paget’s Disease of Bone

A

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

23
Q

Clinical Presentation - Paget’s Disease

A 
Typically affects older adults & p/w 
	• Bone pain
	• Bone deformity
	• Hearing loss - if affects bones of ear
Pathological fractures
24
Q

Investigations - Paget’s Disease

A 
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
25
Q

Management - Paget’s Disease

A

• Bisphosphonates - interfere with osteoclast activity & return normal bone metabolism, improve sx
• Vit D & Calcium supplementation
• NSAIDs for bone pain
Monitor ALP & symptoms

26
Q

Complications - Paget’s Disease

A

Two key complications are osteosarcoma (at increased risk) & spinal stenosis/spinal cord compression

27
Q

Examples of Crystal Arthropathies

A

Gout - deposition of urate crystals in joints

Pseudogout - calcium pyrophosphate crystals

28
Q

Risk factors - Gout

A 
High purine diet - meat, seafood
Alcohol 
Diuretics 
Existing CVD or renal dysfunction 
Family hx 
Male
29
Q

Clinical presentation - Gout

A

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
30
Q

Differentials for hot swollen joint

A

SEPTIC ARTHRITIS
Gout
Pseudogout
Bleeding into joint

31
Q

Investigations - Red, hot joint

A

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!

32
Q

Management of Gout

A

• 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

33
Q

Risk factors - septic arthritis

A 
Diabetes
Advancing age 
Prothesis 
Immunodeficiency/suppression
IVDU
34
Q

Clinical Features - septic arthritis

A 
Symptoms
	• Pain
	• Swelling
	• Fevers
Inability to weight bear
Signs
	• Pain on active and passive movement
	• Reduced ROM (range of motion)
	• Erythema
	• Warmth
	• Joint effusion
35
Q

Management - Septic Arthritis

A

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

36
Q

Reactive Arthritis - Definition

A

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.

37
Q

Triggers - Reactive Triggers

A

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.

38
Q

Management - Reactive Triggers

A

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

39
Q

Anklylosing Spondylitis - definition & clinical features

A

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)
40
Q

Ankylosing Spondylitis - Extra-atricular Manifestations

A

○ Aortitis - can lead to aortic regurgitation
○ Anterior uveitis - unilateral red eye, pain & photophobia
○ AV block
○ Apical lung fibrosis
○ Amyloidosis
IgA nephropathy

41
Q

Ankylosing Spondylitis - investigations & management

A

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
42
Q

Clinical Features & Complications - Systemic Sclerosis

A

• 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

43
Q

ClinicalFeatures of SLE

A 
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
44
Q

Giant Cell Arteritis - definition, S&S, investigations & management

A

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

45
Q

Examples & Clinical Features of Small Vessel Vascultitides

A

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

46
Q

Sjogren’s Syndrome - definition, clinical features & management

A

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

47
Q

Types of Inflammatory Myositis - S&S & management

A

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)

Finals (16 decks)

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