Rheumatology Flashcards
what is rheumatoid arthritis?
it is a autoimmune disease (associated with antibodies against rheumatoid factor and anti-CCP) resulting in synoviocytes and damaged joint spaces
describe the pathophysiology behind rheumatoid arthritis?
citrullination of self antigens which are recognised by T and B cells which produce antibodies -> RF and anti-CCP
Stimulated macrophages and fibroblasts then release TNFalpha and inflammatory cascade leads to proliferation of synoviocytes (RA joint swelling) which grow over the cartilage and leads to restriction of nutrients
activated macrophages also stimulate osteoclast differentiation contributing to bone damage
what is the typical history of a patient with RA?
usually female 30-50y/o progressive, peripheral and symmetrical polyarthritis affects MCPs, PIPs, MTPs (sparing DIPS) history >6wks morning stiffness > 30 mins \+ fatigue, malaise
how would you examine clinically for diagnpsis pf RA?
soft tissue swelling and tenderness
ulnar deviation + palmar sublaxation of MCPs
swan neck and boutonniere deformities
rheumatoid nodules (espec at elbows)
check median nerve - carpal tunnel association
what investigations are done to diagnose RA?
- RF and anti-CCP
- FBC - normocytic anaemia (chronic disease), WCC is concerns re septic arthritis
- inflammatory markers - elevated
- xray changes in established disease, US/MRI in early disease
- may need PFTs and HRCT chest is lung involvment (pulmonary ifbrosis)
what is the treatment for RA?
- initially DMARD monotherapy - usually methotrexate or combo (leflunomide, hydroxychloroquine, sulfasalazine)
- steroids
- symptom control with NSAIDS if no contraindication
- biologics (anti-TNFs life etanercept) - as last resort
(non drug - OT/PT, podiatry, psychological)
name some extra articular manifestations of RA - using the 3Cs, 3As, 3Ps, 3Ss
3Cs - carpal tunnel syndrome, elevated cardiac risk, cord compression
3As - anemia, amyloidosis, arteritis
3Ps - pericarditis, pleural disease, pulmonary disease
3Ss - sjogrens, scleritis/episcleritis, splenic enlagrment
what are the xray features of RA?
- Loss of joint space
- Erosions
- Soft tissue swelling
- Sublaxation
LESS
what is osteoartheritis?
the most common type of arthritis - degenerative disorder with progressive loss of articular cartilage + new bone formation +capsular fibrosis
what are the causes of OA (physiology)?
- failure of normal cartilage subject to abnormal or incongruous loading for long periods
- damaged or defective cartilage failing under normal conditions of loading
- break up of cartilage due to defective stiffened subchondral bone passing more load to it
what are teh key features of cartilage in OA?
- loss of elasticity with a reduced tensile strenght
- cellularity and proteoglycan content are reduced
what are teh risk factors fo developing OA?
- increases with AGE
- gender - WOMEN
- OBESITY
- TRAUMA
- FHx - for knee and hand OA
A Woman Of Traumatic History
what are the signs and symptoms of OA?
- hip, knee and spine most commonly affects
- pain provoked by movement and weight bearing
- intermittent at first , then constant
- feeling of joint giving way
- Heberdens and Bouchards nodes
what rae the key features of OA of xray?
- loss of joint space
- subchondral sclerosis
- subchondral cysts
- osteophytes
what is teh treatment for OA?
non drug:
- strengthening and range of movement exercises
- weight loss
- laterally wedged insoles or walking stick
pharm:
- paracetamol
- NSAIDs
- topical rubefacients, capsaicin
- intraarticular corticosteroids
surgery:
- replacement of joint
what is fibromyalgia?
a common disorder of central pain processing characterised by chronic widespread pain in all 4 quadrants of body + allodynia present (heightened and painful response to innocuous stimuli)
what is the pathogenesis of fibromyalgia
can be induced by deliberate sleep deprivation (reduced REM sleep and delta wave sleep) = hyperactivation in response to noxious stimualtion and neural activation in brain regions associated with pain perception in response to non painful stimuli
what are teh signs and symptoms of fibromyalgia?
- joint/muscle stiffness
- profond fatigue
- unrefreshed sleep
- numbness
- headaches
- IBD (bowel and bladder)
- depression and anxiety
- poor concentration and memory fibrofog
only physical abnormalities = tender points of muscles
what are the risk factors for developing fibromyalgia?
- affecrs 5% of population
- female:male = 9:1
- peak onset 40-50
- onset may have obvious trigger e.g. emotional or physical
what is the treatment for fibromyalgia?
- specifically based on symptoms e.g. depression, fatigue, sleep disturbance
- drug treatment: low dose amitrypytline (or pregabalin)
- CBT also effective
what is osteoporosis?
skeletal condition characterised by low bone mass, deterioration of bone tissue and architecture = compromised bone strength bone strenght and increased fracture risk
what are the risk factors for osteroporosis?
non modifiable:
- advanced age
- female
- caucasian
- FHx
- Hx of low trauma fracture
modifiable:
- Low BMI
- premature menopaus e
- calcium/vit D deficiency
- inadequate physical activity
- smoking
- XS alcohol
- iatrogenic e.g. corticosteroids, aromatase inhibitors
how is the diagnosis of osteroporosis made?
- dual energy xray absorptiometry (DEXA) of lumbar spine and hip
- T score (bone density for age and gender compared to same gender at age of peak density - 25y/o) < 2.5 = osteoporosis
what is the treatment of osteopenia and osteroporosis?
risk modification in osteopenia : weight bearing exercises, Vit D supplementation, reduced alcohol, smoking cessation, dietary advice about calcium intake + supplements
osteoporosis: vit D and calcium supplementation + oral bisphosphonates (+ denosumab or teriparatide)