Rheumatology Flashcards
Which of the following is now a rare cause for joint infection in infants, due to the standard childhood immunisation schedule in the UK?
a. Staph aureus
b. Gp A (ß haemolytic) Strep
c. Varicella Zoster
d. Rubella
e. Haemophilus Influenzae
Haemophilus influenzae
HiB used to be commonest cause of septic arthritis in infants <2 (and 3rd cause in children >2) – but now rare
Staph a/ Strep are now leading 2 causes.
Varicella and rubella are immunised against, but don’t cause septic (pyogenic) arrhtirits (might get transient non-specific viral reactive arthritis)
Which of the following is the most frequent infecting organism after hip replacement?
a. Methicillin resistant Staph Aureus
b. Coagulase negative staph
c. Salmonella
d. Enterococcus faecalis
e. Propionibacterium acne
b. Coagulase negative staphylococcus
Describe the pathophysiology of osteoporosis
Changes in trabecular architecture with ageing
↓ in trabecular thickness, more pronounced for non load-bearing horizontal trabeculae
↓ in connections between horizontal trabeculae
↓ in trabecular strength and increased susceptibility to fracture
3 major characteristics seen in RA
Symmetrical arthopathy
Hands & feet > 80% cases
Early morning stiffness
What does SPINEACHE stand for
Sausage digit (dactylitis)
Psoriasis
Inflammatory back pain
NSAID good response
Enthesitis (heel)
Arthritis
Crohn’s/colitis
HLA B27
Eye (uveitis)
Pathogenesis of systemic sclerosis
Vasculopathy
Excessive collagen deposition
Inflammation
Auto-antibody production
How do you diagnose septic arthritis
Aspiration
- Turgid fluid
- Thick, discoloured fluid is suggestive of infection
Blood cultures
Radiological features of osteoarthritis
JOSSA:
Joint space narrowing
Osteophyte formation
Subchondral sclerosis
Subchondral cysts
Abnormalities of bone contour
Aetiology of osteoarthritis
The exact aetiology is unknown.
Age, hereditary predisposition, female sex, and obesity are associated with increased risk of OA.
Articular congenital deformities or trauma to the joint also increase the risk of developing OA.
Pathophysiology of osteoarthritis
In the affected joint, there is a failure in maintaining the homeostatic balance of the cartilage matrix synthesis and degradation, resulting from reduced formation or increased catabolism.
Give 3 differential diagnoses to osteoarthritis & how you can differentiate them from OA.
Bursitits
- Greater trochanteric bursitis in the hip and pes anserine bursitis in the knee present with pain over the lateral aspect of the hip and over the medial aspect of the knee, respectively. There is local tenderness in these areas that is usually absent in simple OA.
Gout
- The onset of arthritis in gout is usually more acute (over a period of a few hours),
RA
- RA usually causes a symmetrical small joint polyarthritis
- Typically, RA is associated with more prolonged morning stiffness than OA.
How are patients with osteoarthritis managed?
Patients are examined for declining range of motion in the affected joint, and for other signs reflecting advanced disease.
If the patient is taking an NSAID or a COX-2 inhibitor, tests for renal function and full blood count are obtained every 3 to 6 months.
Complications of osteoarthritis
Functional decline and inability to perform activities of daily living
NSAID-related GI bleeding
Risk factors for rheumatoid arthritis
Age
F>M
Family history
Smoking
Obesity
3 differential diagnoses to rheumatoid arthritis & how you can differentiate between them
Psoriatic arthritis (PsA)
Psoriasis is present in >90% of PsA patients, but is unusual in RA patients.
Gout
A small percentage of gout patients present with polyarticular gout, which can mimic RA. Tophi and high levels of uric acid are specific for gout, but are very rare in RA.
SLE
Systemic lupus erythematosus (SLE) can present with polyarthritis in the small joints of the hands and feet.
SLE arthritis is usually non-deforming.
How is a patient being treated for RA monitored
After starting DMARDs:
Laboratory monitoring for FBC and LFT abnormalities is done every 4 to 8 weeks at the start of treatment. When the patient is on a stable dose, they should be checked every 3 to 4 months.
Complications of RA
Work disability
Increased joint replacement surgery
Define gout
Gout is a syndrome characterised by: hyperuricaemia and deposition of urate crystals causing
- attacks of acute inflammatory arthritis
- tophi around the joints and possible joint destruction
- renal glomerular, tubular, and interstitial disease
- uric acid urolithiasis.
Aetiology of gout
There is a causal relationship between hyperuricaemia (high urate level) and gout.
(Urate is a metabolite of purines and the ionised form of uric acid (a weak acid at a physiological pH); hence, uric acid exists mostly as urate.)
Pathophysiology of gout
Humans and some other higher primates develop gout spontaneously.
Humans no longer express the gene for the enzyme uricase, which, in animals, degrades uric acid to a more soluble compound.
This, coupled with a high rate of renal re-absorption of urate, results in hyperuricaemia and gout
1st investigation to order if you suspect gout
Arthrocentesis with synovial fluid analysis
Provides definitive diagnosis
Differentials of gout & how you can rule them out
_Pseudogout (_calcium pyrophosphate deposition disease)
- Presentation may be identical to that of gout.
- Pseudogout is more likely to affect wrist and knee joints.
Trauma
- A positive history will be present
Septic arthritis
- Identical presentation
- RF for infection, eg IVDU, immunocompromised.
- Get blood cultures
Monitoring of gout patients
Patients should be monitored for adverse effects of NSAIDs and colchicine, especially if they are used for prolonged periods.
For NSAIDs, colchicine, and allopurinol, FBC, RFTs & LFTs should be obtained every 3 to 6 months.
Define calcium pyrophosphate arthritis
Acute CPP crystal arthritis is an acute inflammatory arthritis of one or more joints.
The chronic form of CPP arthritis mimics osteoarthritis or rheumatoid arthritis and is associated with variable degrees of inflammation
Risk factors for AS
HLA-B27
ERAP1 & IL23R gene
Positive family history
Male sex
Key diagnostic factors of calcium pyrophosphate arthritis
- Presence of risk factors
- Painful & tender joints
- OA-like involvement of joints (wrists, shoulders)
- Sudden worsening of osteoarthritis
Risk factors for pyrophosphate arthritis
- Advanced age
- Injury
- Hyperparathryoidism
- Haemochromatosis
Key diagnostic factor of osteoporosis
Presence of risk factors
- Female
- Prior fragility fracture
- White ancestry
- Older age >50 W, >65 M
Give 3 differentials for osteoporosis & how you can differentiate between them.
Multiple myeloma
- Bone pain & symptoms of anaemia & renal failure
- Serum electrophoresis reveals monoclonal gammopathy - in multiple myeloma
Osteomalacia
- PTH levels elevated; bone biopsy standard for confirmation of poor mineralisation.
CKD- bone and mineral disorder
- Serum creatinine & PTH will be elevated
Difference between osteomalacia & osteoporosis?
Osteomalacia - bones not hardening
Osteoporosis - bone thinning
Define ankylosing spondylitis
Axial spondyloarthritis (axSpA) is a chronic progressive inflammatory arthropathy.
1st investigation to order if you suspect ankylosing spondylitis
Pelvic X-ray
Aetiology of AS
Genetic
3 differentials to AS & how you can distinguish between them
Osteoarthritis
- The history differentiates mechanical back pain from inflammatory back pain (OA is non-inflammatory, AS is inflammatory)
Psoriatic arthritis
- Tends to present in the 35- to 45-year age group. No sex bias
- Sacroiliitis may be unilateral.
- History of psoriasis.
Reactive arthritis
- Patients usually recall a specific infection
- Pelvic x-rays may demonstrate unilateral sacroiliitis.
Define psoriatic arthritis
Psoriatic arthritis is a chronic inflammatory joint disease associated with psoriasis.
Risk factors for psoratic arthritis
Psoriasis
Family history of psoriasis or psoriatic arthritis
History of joint or tendon trauma
1st line investigations if you suspect psoriatic arthritis
Plain film x-rays of hands & feet
ESR & CRP
RF
Anticyclic citrullinated peptide antibody
2 differentials of psoriatic arthritis & how to distinguish between them
RA
- Dactylitis is not a feature of RA
- RA does not affect lumbar spine or sacroiliac joints
Gout
- History of acute & relapsing course with resolutiong withint 7-14 days should indicate gout
Key diagnostic factors of reactive arthritis
Presence of risk factors
- Male sex
- HLA-B27
- Preceding chlamydial or GI infection
Peripheral arthritis
Axial arthritis
1st line investigations to order when you suspect reactive arthritis
ESR (elevated)
CRP (elevated)
ANA (negative)
RF (negative)
3 differentials to reactive arthritis
AS
- Evidence of ‘bamboo’ spine is indicative of AS.
- AS has less prominent peripheral joint involvement than ReA.
Psoriatic arthritis
- In psoriatic, distal interphalangeal joins are more commonly affected
RA
- Rheumatoid factor and anti-CCP (cyclic citrullinated peptide) antibodies may be positive in RA. Hand x-rays reveal typical erosive changes.
- RA does not affected lumbar spine or sacroiliac joints
Define septic arthritis
Septic arthritis is defined as the infection of 1 or more joints caused by pathogenic inoculation of microbes. It occurs either by direct inoculation or via haematogenous spread.
Key diagnostic factors of septic arthritis
Hot, swollen, painful, restricted joint
Acute presentation <2 weeks
RF for septic arthritis
Underlying joint disease
Prosthetic joint
Age
Immunosuppression
1st line investigations to order if you suspect septic joint
Synovial fluid microscopy & cultures *PT MUST BE OFF ANTIBIOTICS FOR 2 WEEKS TO DO THIS*
Bloods
WCC
ESR
CRP
3 differentials to septic arthritis & how to rule them out
Osteoarthritis
Psoriatic arthritis
Rheumatoid arthritis
For all to rule out septic:
- Known history of the condition
- Many joints symptomatic to a similar degree
- Synovial fluid aspirate will not reveal any micro-organisms
Risk factors for osteomyelitis
- Previous osteomyelitis
- Penetrating injury
- IVDU
- DM
A 40-year-old man who suffered an open tibial fracture in a motor vehicle accident 6 months ago presents with swelling and pain in his lower leg.
1st investigations to order & what condition do you suspect?
Osteomyelitis
FBC
ESR
CRP
Blood culture
Key diagnostic factors for osteomyelitis
Risk factors
Limp or reluctance to weight-bear
Non-specific pain at site of infection
Malaise & fatigue
Risk factors for SLE
Female
Age >30
African descent in Europe & US
Drugs
Key diagnostic factors for SLE
Malar (butterfly) rash
Photosensitive rash
Discoid rash
Differential for SLE
Rheumatoid arthritis
- Pt with SLE less symmetrial pattern of inflammatory arthritis
Which of the following clinical features is typical os osteoarthritis?
a. 60 mins of early morning stiffness
b. Painful, swelling across the MCP joints & proximal ICP joints
c. Pain in 1st carpometacarpal joints
d. Mobile, subcutaenoues nodules at points of pressure
e. Alternating buttock pain
c. Pain in the 1st carpometacarpal joints
Morning stiffness should be <30mins
OA does not classically affect the metacarpophalangeal (MCP) joints, and if these joints are affected, rheumatoid arthritis should be considered.
Which of the following is an extra-articular manifestation of RA?
a. Subcutaenous nodules
b. Episcleritis
c. Peripheral sensory neuropathy
d. Pericardial effusion
e. All of the above
e. All of the above
Describe rheumatoid nodules
Rheumatoid nodules - necrosis in middle, pallisading macrophages & then cuff of lymphocytes around the outside.
Just below the skin
Typically painless, but are mobile
Which of the following is a classical features of RA on xray?
a. Peri-articular sclerosis
b. Sub-chondral cysts
c. Osteophytes
d. Peri-articular erosions
e. New bone formation
d. Peri-articular erosions
Due to inflammatory cytokines causing lysis of the bone
For a lytic tumour to be visible on x-ray it must have lost:
a. Greater than 6% bone density
b. Greater than 16% bone density
c. Greater than 60% bone density
d. Greater than 90% bone density
e. 100% bone density
c. Greater than 60% bone density
Which of the following is not an autoimmune connective tissue disease?
a. SLE
b. Ehler Danlos syndrome
c. Primary Sjorgen’s syndrome
d. Systemic sclerosis
e. Dermatomyositis
Ehler Danlos syndrome - a connective tissue disease. However, genetic inherited not autoimmune.
Which of the following treatments is used in the treatment of SLE?
a. Anti-TNF
b. Anti-malarials
c. Ustekinuab (IL12/23 blocker)
d. Sulfazalzine
e. Allopurinol
b. Anti-malarials
Work well for arthritis, skin & mucosal membrane manifestations
(c used in spondylarthritis.)
A 60-year-old woman presents complaining of bilateral knee pain almost daily for the past few months. The pain was gradual in onset. The pain is over the anterior aspect of the knee and gets worse with walking and going up and down stairs.
She complains of stiffness in the morning that lasts for a few minutes, and a buckling sensation at times in the right knee. On examination, there is a small effusion, diffuse crepitus, and limited flexion of both knees. Joint tenderness is more prominent over the medial joint line bilaterally. She has a steady but slow gait, slightly favouring the right side.
What are the first investigations you would order?
X-Ray of affected joints - knee
Serum CRP
Serum ESR
A 60-year-old woman presents complaining of bilateral knee pain almost daily for the past few months. The pain was gradual in onset. The pain is over the anterior aspect of the knee and gets worse with walking and going up and down stairs.
She complains of stiffness in the morning that lasts for a few minutes, and a buckling sensation at times in the right knee. On examination, there is a small effusion, diffuse crepitus, and limited flexion of both knees. Joint tenderness is more prominent over the medial joint line bilaterally. She has a steady but slow gait, slightly favouring the right side.
What is her most likely diagnosis?
Osteoarthritis
A 57 year old man presents with 3 day history of painful 1st MTP joint. On exam the area is red and warm. He has a BMI of 32 & hypertension and has had identical episodes before. Which of the following dietary changes would reduce his risk of future similar episodes?
a. A diet with a high red meat content
b. A diet rich in dairy products
c. Drinking >5 cans of non-diet fizzy drinks per day
d. A diet rich in sugary foodstuffs
e. Switching from drinking beer to lager
A diet rich in dairy products
Diagnosis = gout
A 20-year-old man presents to his primary care physician with low back pain and stiffness that has persisted for more than 3 months. There is no history of obvious injury but he is an avid sportsman. His back symptoms are worse when he awakes in the morning, and the stiffness lasts more than 1 hour. His back symptoms improve with exercise. He has a desk job and finds that sitting for long periods of time exacerbates his symptoms. He has to get up regularly and move around. His back symptoms also wake him in the second half of the night, after which he can find it difficult to get comfortable. He normally takes an anti-inflammatory drug during the day, and finds his stiffness is worse when he misses a dose. He has had 2 bouts of iritis in the past.
What is his most likely diagnosis?
Ankylosing spondylitis
A 53 year old man presents to you with a 3 day history of pain in his lower back.
The pain started sponateously and he firstnoticed it at work. He works as a builder and has been unable to go to work for the last three days. Physical exam reveals him slightly overweight BMI 29, but no neurological deficits or spinal deformity and the pain is not easily localised on exam.
Which of the following describes the best management for this gentleman?
a. Given his age, he should be referred to a specialist
b. He should be sent for an x-ray to look for any pathological changes in his spine
c. He should not be given a sick note & advised to return to work straight away.
d. He should be reassured and advised to take simple analgesics & return to normal activity as soon as he can manage
e. He should be advised to seek other employment
He should be reassured and advised to take simple analgesics & return to normal activity as soon as he can manage
Short history - not worried about anything pathological, no trauma history.
No red flags, no fever, nothing strange on exam.
Likely mechanical back pain.
Back X-ray is only helpful in few situations, eg bone cancer
A 55-year-old woman presents with a 1-week history of pain and swelling in her left wrist. She was diagnosed with rheumatoid arthritis at the age of 36 years but the rest of her joints are currently asymptomatic. Her rheumatoid arthritis is well controlled on her current medication. On examination her left wrist is found to be hot, swollen, tender, and highly restricted in its range of movement. There is no sign of inflammation in any of her other joints. She has a temperature of 37.5˚C (99.5˚F).
What is the first investigation you would do?
Aspiration with pt off antibiotics - identify organism
A 23 year old woman presents with mouth ulcers, fever, painful white fingers and pleuritic chest pain. She is ANA+, her ESR is 52 (0-15) and her WCC is low (leucopenic).
Which of the following features would you not expect to be associated with her illness?
a. Deforming arthritis
b. Photosensitive rash
c. Seizures
d. PE
e. Thrombocytosis
Thrombocytosis - high platelets
In SLE you would usually see thrombocytopenia
Diagnosis - SLE
SLE can affect CNS → seizures.
PE: SLE associated with antiphospholipid system → clots
A 25-year-old man presents with painful forefeet, a swollen right knee, and a swollen index finger. These symptoms developed over 2 months. He has had a history of psoriasis since the age of 18 years. Examination reveals psoriatic plaques at the knees and elbows, as well as at the posterior hair line and psoriatic nail changes of both fingers and toes. There is a dactylitis of the right index finger and several toes, as well as synovitis of the right knee.
What is the most likely diagnosis
Psoratic arthritis
A 64 year old woman with type 2 diabetes mellitus has been struggling with cellulitis of her right forefoot for 4 weeks. After making no progress with oral antibiotics, she has now had 14 days of intravenous flucloxacillin and co-amoxiclavulanic acid but the pain and erythema persist and her CRP has only fallen to 47 from its peak of 91. What is the next most appropriate investigation?
a. Blood cultures
b. MRI right forefoot
c. Plain X-ray right forefoot
d. Skin biopsy of right forefoot
e. Ultrasound scan of right forefoot
c. Plain X-ray right forefoot
The risk is that contiguous spread from the soft tissues has developed osteomyelitis in one of the bones of her feet. As this has now been going on a number of weeks, a plain film is likely to show something and this can be organised much more quickly than an MRI.
a. The blood cultures will be unhelpful as likely to be negative if on antimicrobials
b. MRI foot would be a good test but is less easily available and may not be necessary if plain film shows OM
d. Skin biopsy will not show bacteria and not exclude OM
e. Ultrasound right foot could be useful to exclude a soft tissue abscess but these are rare in the feet if not clinically apparent.
A 70-year-old woman presents to the emergency department after falling while getting out of bed. She sustained an intertrochanteric fracture of the right hip. Preoperative chest x-ray before repair of the hip reveals that she had existing asymptomatic vertebral fractures before her fall.
What is the 1st investigation you would order?
What is her most likely diagnosis?
Dual-energy x-ray absoptiometry (DXA)
- DXA is considered the gold standard for measurement of bone density
Osteoporosis
A 52-year-old woman presents with a 2-month history of bilateral hand and wrist pain, and swelling in her fingers. She has also recently noted similar pain in the balls of her feet. She finds it hard to get going in the morning and feels stiff for hours after waking up. She also complains of increasing fatigue and is unable to turn taps on and off or use a keyboard at work without a significant amount of pain in her hands. She denies any infections before or since her symptoms started.
What is her most likely diagnosis?
Rheumatoid arthritis
A 37 year old man with a 10 year history of back pain presents with a “flare” of symptoms – pain in his lower back radiating out over his buttocks and down the back of his thighs, and pain between the shoulder blades. Ibuprofen has been helping significantly. He finds it very difficult to get moving in the mornings.
Which of the following features would support a diagnosis of inflammatory back pain?
a. Worsening pain on bending forwards
b. Worsening pain on bending backwards
c. Pain shooting down his leg to the ankle
d. Pain across the costochondral joints
e. Improved pain whilst sitting at work
d. Pain across the costochondral joints
A 72-year-old woman presents with polyarticular joint pain. She has long-standing mild joint pain, but over the last 10 years notes increasing discomfort in her wrists, shoulders, knees, and ankles. She has had several recent episodes of severe pain in one or two joints, with swelling and warmth of the affected areas. These episodes often last 3-4 weeks. Her examination shows severe bony changes consistent with osteoarthritis in many joints, and slight swelling, warmth, and tenderness without erythema in the second and third metacarpophalangeal joints, left shoulder, and the right wrist.
She is diagnosed with pseuodogout.
How can this diagnosis be differentiated from gout?
Her large joints are affected
- Gout is more likley to affect smaller joints, eg MTP joint
- Duration of attack in gout is generally shorter.
A 72-year-old woman presents with polyarticular joint pain. She has long-standing mild joint pain, but over the last 10 years notes increasing discomfort in her wrists, shoulders, knees, and ankles.
She has had several recent episodes of severe pain in one or two joints, with swelling and warmth of the affected areas. These episodes often last 3-4 weeks.
Her examination shows severe bony changes consistent with osteoarthritis in many joints, and slight swelling, warmth, and tenderness without erythema in the second and third metacarpophalangeal joints, left shoulder, and the right wrist.
What is her most likely diagnosis?
Calcium pyrophosphate deposition (pseudogout)
An adult male presents with a 6 week history of right sided headache, general malaise, early morning stiffness, and pain in his jaw when eating. His CRP is 63 (0-5), ESR 78 (0-15). Which of the following is true about his underlying disease?
a. It is associated with ANCA positivity
b. It typically affects those between 50 & 60 years old
c. It can present with acute sight loss
d. It rarely responds to corticosteroids
e. It is a vasculitis affecting small blood vessels
It can present with acute sight loss
What is diagnosis? GCA or temporal arteritis – temporal headache (usually unilateral), polymyalgic symptoms, jaw claudiction, high inflammatory markers.
ANCA vasculitis = small vessel vasculitis eg wegener’s or CSS. GCA is sero-negative
Typically >60 yrs
Typicallly responds overnight to steroids.
Large vessel vasculitis – proximal aorta and its branches (including temporal artery)
An adult male presents with a 6 week history of right sided headache, general malaise, early morning stiffnes and pain in his jaw when he is eating. His CRP is 63 (0-5), ESR 78 (0-15).
Which of the following is true about his underlying disease?
a. It has associated ANCA positivity
b. It typically affects those between 50&60 years old
c. It can present with acute site loss
d. It rarely responds to corticosteroids
e. It is a vasculitis affecting small blood vessels
c. It can present with acute site loss
(giant cell arteritis)
A 64 year old woman with T2 DM has been struggling with cellulitis of her right forefoot for 4 weeks. After making no progress with oral antibiotics, she has now had 14 days of IV flucloxacillin and co-amoxiclavulanic acid, but the pain & erythema persist and her CRP has only fallen to 47 from its peak of 91.
What is the next most appropriate investigation?
a. Blood cultures
b. MRI R forefoot
c. Plain X-ray R forefoot
d. Skin biopsy R forefoot
e.
