Rheumatology Flashcards
What are the red flags for back pain?
age <20 or >55 sphincter disturbance current or recent infection history of malignancy morning stiffness constant or progressive pain neurological disturbance bilateral or alternating leg pain FLAWS thoracic back pain acute onset in elderly people nocturnal pain
what does a nerve root lesion at L2 cause?
weakness in hip flexion and adduction
what does a nerve root lesion at L3 cause?
weakness in knee extension and hip adduction
what does a nerve root lesion at L4 cause?
weakness in foot dorsiflexion + inversion + knee extension
what does a nerve root lesion at L5 cause?
weakness in: great toe dorsiflexion foot dorsiflexion + inversion knee flexion hip extension + abduction
what does a nerve root lesion at S1 cause?
weakness in foot plantar flexion + eversion
nerve roots of knee jerk reflex?
L3,L4
nerve roots of ankle jerk reflex?
S1,S2
Ix lower back pain?
MRI only if suspected malignancy, infection, fracture, CES or ank spond
DRE
Mx lower back pain?
c: physical activity and exercise
M: NSAIDS + PPI if >45
Other: group exercise programme
manual therapy (techniques such as massage)
radio frequency denervation
epidural injections of Land steroid for acute/severe sciatica
what is rheumatoid arthritis?
chronic systemic inflammatory condition characterised by a symmetrical defaming poly arthritis
epidemiology RA?
F>M (2:1), 50-60yo, 1% prevalence (higher in smokers)
HLA DR1, DR4
what are some poor prognostic indicators of rheumatoid arthritis?
\+ve RhF insidious onset early erosions HLA DR4 \+ve anti-CCP extra-articular features
S/S rheumatoid arthritis?
swollen, painful small joints in hands and feet
ulna deviation of MCP and radial deviation at wrist
stiffness better with exercise/worse in morn
swan neck, boutonniere, z-thumb
associated features rheumatoid arthritis?
eyes - episcleritis, keratoconjunctivitis sicca
neck - Atlanta-axial subluxation (may cause cord compression)
heart -pericarditis
lungs - fibrosis, rheumatoid nodules
hands - de quervains tenosynovitis, CTS, trigger finger
speen -splenomegaly, felty’s syndrome
kidneys - amyloid
all - rheumatoid nodules
what is Felty’s syndrome?
SANTA Splenomegaly anaemia neutropenia thrombocytopenia arthritis
Diagnostic criteria for rheumatoid arthritis?
American College of Rheumatology Criteria
NICE recommend clinical diagnosis
ix rheumatoid arthritis?
- DAS28 [disease activity score]
- squeeze test positive (pain across MCPJ or MTPJ)
Bloods: FBC (anaemia, raised ESR, CRP), RhF (+ve 70%), anti-CCP (90-95% specific, 80% sensitive), ANA(+ve in 30%)
TJC/SJC
Imaging: XR (baseline), USS (synovitis), MRI, CXR
what are TJC and SJC
tender joint count and swollen joint count (part of DAS28)
What should be monitored in rheumatoid arthritis?
DAS28, CRP
if DAS28 >5.1 consider stepping up Mx
Mx rheumatoid arthritis?
1st line: conventional DMARD
2nd line: combination cDMARD therapy (2x)
3rd line: biological DMARD + cDAMRD
Surgery: ulna stylectomy, joint prosthesis
Flare ups: corticosteroids (PO, IM methylprednisolone)+/-NSAIDs
Give some examples of cDMARDs?
methotrexate sulfasalazine hydroxychloroquine MMF cyclophosphamide azathioprine
Give some examples of bDMARDs?
(TNF-a inhibitors, B cell/T depletion) EtanercepT (SE demyelination) Infliximab Adalimumab Rituximab
How are methotrexate, sulfasalazine and hydroxychloroquine monitored?
M- regular FBC and LFT (risk of myelosuppression and cirrhosis)
S - salicylate so not given if aspirin sensitive
H - annual visual acuity testing. OK IN PREGNANCY.
what joints does OA affect?
weight bearing: hip and knee
hands: CMCJ, DIPJ, PIPJ
What joints does RA affect?
MCPJ, PIPJ
What is swan neck deformity?
stretching of the volar plate
PIPJ hyperextension
DIPJ flexion
what is seen on XR in OA?
LOSS loss of joint space osteophytes subchondral cysts subchondral sclerosis
what is seen on XR in rheumatoid?
LESS loss of joint space erosions (periarticular) soft tissue swelling subluxation and deformity
aetiology of gout?
monosodium urate crystals deposition in and around joints -> erosive arthritis
epidemiology of gout?
M>F 5:1
gout associations?
HTN
IHD
Metabolic syndrome
Causes of gout?
hereditary
drugs (loop diuretics, thiazide diuretics,aspirin,)
decreased excretion (primary gout, renal impairment)
increased cell turnover (lymphoma, leukaemia, haemolysis
ETOH XS
Purine rich foods
S/s gout?
mono arthritis with severe joint inflammation (ankle, foot, hand, wrist elbow) 60% get podagra trophy radiolucent kidney stones interstitial nephritis
Ix gout?
polarised light microscopy (-ve birefringent needle shaped crystals) XR (late; para-articular punched out erosions, reduced joint space) serum urate (increased OR normal)
Acute Mx gout?
Acute:
1st line = colchicine, NSAIDs (not aspirin) +/- PPI
renal impairment = PO steroids (prednisolone 15mg /d)
intraarticular steroid injection
follow up in 4-6w and check BP, HbA1c, serum urate, U&E and lipids -> consider urate lowering therapy
- do not stop allopurinol if already established
- do not stop aspirin 75 if for cardioprotective
Chronic mx for gout?
conservative: WL, avoid ETOH XS, avoid prolonged fasting
urate lowering therapy: started after inflammation stopped
- XO inhibitors: 1. allopurinol, 2. febuxostat
- uricosuric drugs: probenecid, losartan
- recombinant urate oxidase: rasbicurase
what are the S/S of pseudo gout?
mono arthritis (knee, wrist, hip - BIGGER JOINTS)
RFs for pseudo gout?
increased age OA DM hypothyroidism hyperparathyroidism hereditary haemochromatosis Wilsons
Ix pseudo gout?
polarised light microscopy (+ve birefringent, rhomboid shaped crystals)
XR chondrocalcinosis
Mx pseudo gout?
analgesia
NSAIDs
PO/IM/intra-articular steroids
what are seronegative spondyloarthropathies?
a group of inflammatory arthritidies affecting the spine and peripheral joints with no production of rheumatoid factors and associated with HLA-B27 allele
Give some examples of seronegative spondyloarthropathies?
PEAR HEADS Psoriatic arthritis Enteropathic arthritis Ankylosing spondylitis Reactive arthritis HLA B27 allele Enthesitis Axial, asymmetrical, oligoarthritis Dactylitis Seronegative
what is the key difference between ankylosing spondylitis and psoriatic arthritis?
lack of hand S/S in AS
What are the S/S of ankylosing spondylitis?
back pain relieved by exercise anterior chest pain (costochondritis) SOB (pulmonary fibrosis) morning stiffness eye pain osteoporosis (60%)
epidemiology of ankylosing spondylitis?
M>F (6:1); 18-25
Ank Spond associated features?
AAAAAA anterior uveitis apical lung fibrosis aortic regurgitation AV node block achilles tenoditis amyloidosis
Ankylosing spondylitis investigations?
Graded by New York Criteria Schobers test (<5cm increase = positive) 1st: XR (late changes) 2nd: MRI (if XR normal as more sensitive) HLA-B27 testing ESR +/- CRP
what is seen on XR/MRI of ankylosing spondylitis?
sacroilitis > vertebrae (corner erosions, syndesmophytes)
scerlosis
ankylosis (fusion)
bamboo sign (squaring of lumbar vertebrae)
dagger sign (supraspinatus ossification)
what is the management of ankylosing spondylitis?
conservative: exercise/physiotherapy
medical: NSAID, anti-TNFa (etanercept), secukinumab
surgical: hip replacement to decrease pain and increase mobility
what % of those with psoriatic arthritis are affectedly psoriasis?
10-40%
40-60yo
S/S of psoriatic arthritis?
psoriasis nail (posh = pitting, onycholysis, sublingual hyperkeratosis) enthesitis dactylitis arthritis affects DIP
what is oligoarthritis ?
<= 4 joints
what arthritic features are seen in psoriatic arthritis?
asymmetrical hligoarthritis (20-30%) distal arthritis of the DIPJ symmetrical poly arthritis (30-40%, RA but w DIPJ) arthritis mutilans spinal (50%)
what is the investigations for psoriatic arthritis?
XR: pencil in cup deformity
Mx psoriatic arthritis?
NSAIDs methotrexate ciclosporin sulfasalazine anti-TNF
what is reactive arthritis/reiters?
sterile arthritis 1-4w after urethritis or dystentery
what causes urethritis?
chlamydia, ureaplasma (not gonorrhoea)
what causes dysentery?
campylobacter, salmonella, shigella, yersinia
what are the S/S of reactive arthritis?
cant see, pee or climb a tree
- lower limb oligarthritis
- conjunctivitis/uveitis
- urethritis
keratoderma blenorrhagicum (plaques on soles/palms) circinate balanitis (penile ulceration) enthesitis, mouth ulcers
Ix reactive arthritis?
raised ESR
raised crp
stool culture if diarrhoea, urine chlamydia PCR
Mx reactive arthritis?
NSAIDs, PO steroids
relapsing -> sulfasalazine
what is enteropathic arthritis?
arthritis occurs in 15% of those with UC or Crohn’s
S/S of enteropathic arthritis?
asymmetrical lower limb oligoarthritis, sacroilitis
Mx enteropathic arthritis?
treat IBD
nsaids
local steroids
what are some autoimmune CTDs?
SLE Sjogrens Mixed CTD systemic sclerosis myositis relapsing polychondritis Behcets
Which conditions are anti rheumatoid factor +ve?
sjogrens (50%)
feltys (100%)
RhA (70%)
SLE (20%)
Which conditions are ANA +ve?
SLE (99%)
autoimmune hepatitis (75%)
sjogrens (70%)
RhA (30%)
Which conditions are anti dsDNA +ve?
SLE (70%)
Which conditions are anti CCP +ve?
RhA (80%)
Which conditions are anti histone +ve?
drug induced SLE (100%)
which conditions are anti centromere +ve?
CREST (limited sclerosis)
which conditions are ENA +ve?
SLE sjogrens MCTD polymyositis CREST diffuse systemic sclerosis
which conditions are anti-Ro?
SLE, sjogrens (70%), heart block
which conditions are anti-La?
SLE
sjogrens (30%)
which conditions are anti-smith?
SLE (30%)
which conditions are anti-RNP ?
SLE
MCTD
which conditions are anti-jO-1?
polymyositis>dematomyositis
which conditions are anti Mi-2?
dermatomyositis > polymyositis
which conditions are anti SCL70/topoisomerase?
diffuse systemic sclerosis
which conditions are anti RNA pol 1,2,3?
diffuse systemic sclerosis
what are the indications for urate lowering therapy?
the British Society of Rheumatology Guidelines now advocate offering urate-lowering therapy to all patients after their first attack of gout
ULT is particularly recommended if:
>= 2 attacks in 12 months
tophi
renal disease
uric acid renal stones
prophylaxis if on cytotoxics or diuretics
(allopurinol 1st line)
what is atlantoaxial subluxation and how is it screened for?
rare complication of rheumatoid arthritis
Anteroposterior and lateral cervical spine radiographs preoperatively screen for this complication
ensuring the patient goes to surgery in a C-spine collar and the neck is not hyperextended on intubation.
What is hyperparathyroidism a risk factor for?
development of calcium pyrophosphate dihydrate deposition (CPPD) or pseudogout
chonedrocalcinosis
What is Antisynthetase syndrome?
Antisynthetase syndrome is caused by autoantibodies against aminoacyl-tRNA synthetase e.g. anti-Jo1.
It is characterised by
- myositis
- interstitial lung disease
- thickened and cracked skin of the hands (mechanic’s hands)
- Raynaud’s phenomenon
what is temporal arteritis?
Temporal arteritis is large vessel vasculitis which overlaps with polymyalgia rheumatica (PMR) (50%)
what is seen on histology of temporal arteritis?
Histology shows changes that characteristically ‘skips’ certain sections of the affected artery whilst damaging others.
what are the features of temporal arteritis?
typically patient > 60 years old
usually rapid onset (e.g. < 1 month)
headache (found in 85%)
jaw claudication (65%)
visual disturbances:
- amaurosis fugax
- blurring
- double vision
- vision testing is a key investigation in patients with suspected temporal arteritis
- secondary to anterior ischemic optic neuropathy
tender, palpable temporal artery
around 50% have features of PMR: aching, morning stiffness in proximal limb muscles (not weakness)
also lethargy, depression, low-grade fever, anorexia, night sweats
ix temporal arteritis?
raised inflammatory markers
ESR > 50 mm/hr (note ESR < 30 in 10% of patients)
CRP may also be elevated, alp raised, plts raised
USS temporal artery (halo sign, if -ve do biopsy)
temporal artery biopsy
skip lesions may be present
note creatine kinase and EMG normal