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Rheumatology Flashcards

1
Q

Describe rheumatoid arthritis

A

Symmetrical synovial inflammation (synovitis) causing a polyarthritis

Chronic inflammation of the synovial lining of the joints, tendon sheaths and bursa

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2
Q

Name two gene associations of RA

A

HLADR4 - often present

HLADR1 - occasionally present

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3
Q

Describe rheumatoid factor

A

Autoantibody present in 70% of RA patients

Targets the Fc portion of the IgG antibody

Causes activation of the immune system against the patients own IgG causing systemic inflammation

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4
Q

Describe cyclic citrullinated peptide antibodies

A

Autoantibodies that are more sensitive and specific to rheumatoid arthritis than rheumatoid factor
Often predate the development of RA

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5
Q

Describe the presentation of Rheumatoid arthritis

A

Symmetrical distal polyarthropathy
Joint pain, swelling and stiffness of the small joints of hands and feet, wrist, ankle, MCP and PIP, knees, shoulders and elbows

Systemic symptoms - fatigue, weight loss, flu like illness, muscle aches and weakness

Pain is worse after rest

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6
Q

Describe palindromic Rheumatism

A

Self limtiing short episodes of inflammatory arthritis with joint pain, stiffness and swelling typically only affecting a few joints
Lasts 1-2 days and then completely resolves
Having positive antibodies indicates it may progress into RA

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7
Q

Which condition involves painful and swollen DIP joints

A

Osteoarthritis

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8
Q

Name some signs you may see in the hands of someone with RA

A

Z shape deformity of the thumb - IP and CMC flexion with MP hyperextension

Swan neck - Hyperextension of the PIP joint and flexion of the DIP

Boutonnieres deformity - hyperextension of the DIP joints and flexion of the PIP

Ulnar deviation of the fingers at the MCP joints

Palpation of the synovium in around joints when disease is active will give a body feeling related to the inflammation and swelling

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9
Q

List some extra-articular manifestations of RA

A 
Pulmonary fibrosis
Bronchiolitis obliterans
Feltys syndrome 
Secondary Sjogren's - sicca syndrome 
Anaemia of chronic disease
Cardiovascular diseaase
Episcleritis and scleritis
Rheumatoid nodules 
Lymphadenopathy 
Carpal tunnel syndrome 
Amyloidosis
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10
Q

List the investigations for rheumatoid arthritis

A

Rheumatoid factor
If RF negative, check anti-CCP antibodies
Inflammatory markers such as CRP and ESR
X-ray of hands and feet
Ultrasound scan of the joints can be used to evaluate and confirm synovitis

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11
Q

Describe the Xray changes in RA

A

Joint destruction and swelling
Soft tissue swelling
Bony erosions

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12
Q

What is the American college of rheumatology diagnosis of RA based on

A

The joints that are involved - more and smaller score higher
Serology - RF and anti-CCP
Inflammatory markers - CRP and ESR
Duration of symptoms - more/less than 6 weeks

Scores are added and a score greater than 6 indicates a diagnosis of Rheumatoid arthritis

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13
Q

Describe a DAS28 score

A

Assessment of 28 joints
Points are given for swollen joints, tender joints and ESR/CRP result
Useful in monitoring disease activity and response to treatment

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14
Q

Describe features which indicate a worse prognosis for RA

A 
Younger onset
Make
More joints and organs affected
Antibodies
Erosions
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15
Q

Describe the management of Rheumatoid arthritis

A

MDT
Short course of steroids at initial presentation and during flares
NSAIDs/COX2i (coxibs) but risk GI bleeding so either avoided or prescribed with PPI

Monotherapy with methotrexate, leflunomide or sulfalazine, hydroxychloroquine may be considered in mild disease

2nd line - any 2 of the above combination of DMARDs

3rd line - methotrexate and a biological therapy (TNFi)

4th line - methotrexate plus rituximab

Surgery in very severe joint deformity

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16
Q

Which rheumatoid drugs are safe in pregnancy

A

Sulfalazine and hydroxychloroquine

Pregnancy improves RA symptoms - natural production of steroid hormones

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17
Q

Describe how rituximab works

A

Antibody which binds to the CD20 portion of B cells

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18
Q

How does methotrexate work

A

Interferes with folate metabolism and suppresses certain components of the immune system

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19
Q

What is prescribed with methotrexate

A

Folic acid 5mg taken once a week on a different day to the methotrexate

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20
Q

List some side effects of methotrexate

A

Mouth ulcers and mucositis
Bone marrow suppression
Liver toxicity
Teratogenic - also avoid before conception

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21
Q

Describe the mechanism of action of leflunomide

A

Immunosuppressant by interfering with pyrimidine which is needed for RNA/DNA

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22
Q

List some side effects of leflunomide

A 
Mouth ulcers/mucositis
Hypertension
Rash
Peripheral neuropathy
Teratogenic
Bone marrow suppression
Liver toxicity
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23
Q

Give the side effects of sulfalazine

A

Temporary male infertility

Bone marrow suppression

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24
Q

How does hydroxychloroquine work

A

Immunosuppressant which interferes Toll like receptors, disrupting antigen presentation and increasing the pH of the lysosomes of the immune cells

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25
List some notable side effects of hydroxychloroquine
Nightmares Reduced visual acuity Liver toxicity Skin pigmentation
26
How do anti-TNF drugs work
Block TNF which normally stimulates inflammation
27
List some side effects of anti-TNF drugs
Vulnerability to severe infection and sepsis | Reactivation of TB and hep B
28
List some side effects of rituximab
``` Vulnerability to severe infection and sepsis Night sweats Thrombocytopenia Peripheral neuropathy Liver and lung toxicity ```
29
What does joint aspiration in rheumatoid arthritis show
High WBC count - polymorphonuclear neutrophils Yellow, cloudy Absence of crystals
30
Describe psoriatic arthritis
Inflammatory arthritis associated with psoriasis Seronegative spondyloarthropathy
31
Describe a symmetrical polyarthritis pattern of psoriatic arthritis
Presents similarly to RA and more common in women Hand, wrists, ankles and DIP joints are affected
32
Describe an asymmetrical pauciarthrits pattern of psoriatic arthritis
Mainly the digits and feet | Few joints
33
Describe the spondylitic pattern of psoriatic arthritis
``` Back stiffness Sacroiliitis Atlanto-axial joint involvement Spine Achilles tendon Plantar fascia ```
34
Describe some signs of psoriatic arthritis
Plaques of psoriasis on skin Pitting of the nails Onycholysis - separation of the nail from the nail bed Dactylitis - inflammation of the full finger Enthesitis - inflammation where points of tendons insert onto bone Eye disease - conjunctivitis and anterior uveitis Aortitis Amyloidosis
35
Describe a PEST (psorisasis epidemiogical screening tool)
``` Several questions about joint pain Swelling History of arthritis Nail pitting High score triggers referral to rheumatologist ```
36
List the X-ray changes of psoriasis
Periostitis - inflammation of the periosteum - irregular outline of bone Anklyosis - bones join together causing stiffening Osteolysis - destruction of bone Dactylitis - inflammation of the whole digit which shows as soft tissue swelling Pencil in cup - central erosion of the bone besides the joints
37
Describe arthritis mutilans
Most severe form of psoriatic arthritis Occurs in the phalanxes Osteolysis of the bones around the joints in the digits Leads to progressive shortening of the digit Skin then folds as the digit shortens giving appearance of telescopic finger
38
Describe the management of psoriatic arthritis
NSAIDs for pain DMARDs - methotrexate, leflunomide or sulfasalazine Anti-TNF medications Ustekinumab - IL 12 and 23 monoclonal antibody
39
Describe reactive arthritis
Synovitis occurring in joints as a reaction to a recent infective trigger Acute monoarthritis Seronegative spondyloarthropathy - HLAB27 link Bilateral conjunctivitis, anterior uveitis, urethritis, keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles) and balanitis may occur
40
What are the two most common infections that trigger reactive arthritis
Gastroenteritis | STI - chlamydia or gonorrhoea
41
Describe the management of reactive arthritis
Exclude septic arthritis Aspirate and send for gram staining, culture and sensitivity plus crystal examination NSAIDs Intraarticular steroid injections Oral steroids if multiple joints affected Most resolve within 6 months and don't recur Recurrent cases may need DMARDs and anti-TNF medications
42
What is found in synovial fluid aspirate in reactive arthritis
Sterile synovial fluid with high WCC
43
Describe ankylosing spondylitis
Inflammatory condition affecting the spine that causes progressive stiffness and pain Seronegative spondyloarthropathy - HLA B27 gene Slow onset >3 months Lower back pain and stiffness with sacroiliac pain in the buttock, pain and stiffness is worse with rest and improves with movement Pain is worse at night and in the morning. Takes at least 30 minutes for the stiffness to improve in the morning and gets progressively better with activity throughout the day Fluctuate with flares of worsening symptoms and other periods where symptoms improve Vertebral fractures are a key complication
44
Which joints are affected in ankylosing spondylitis
Sacroiliac joints | Vertebral column joints
45
List some associated symptoms of ankylosing spondylitis
``` Systemic - fatigue and weight loss Chest pain - costovertebral and costosternal joints Enthesitis - plantar fascitis and Achilles tendonitis Dactylitis Anaemia Anterior uveitis Aortitis Hear block Restrictive lung disease Pulmonary fibrosis IBD ```
46
Describe a test on clinical examination to diagnose ankylosing spondylitis
Schober's test Have patient stand straight and find the L5 vertebrae - mark 10cm above and 5cm below it. Get patient to bend over and measure the distance between these points. If <20cm then this is restricted lumbar movement
47
What investigations can be done for ankylosing spondylitis
Inflammatory markers - CRP/ESR HLA B27 X-ray spine and sacrum MRI of the spine - bone marrow oedema
48
Describe the X-ray changes of ankylosing spondylitis
Bamboo spine Squaring of the vertebral bodies Subchondral sclerosis and erosion Syndesmophyte - areas of bone growth where the ligaments insert into the bone. They occur related to the ligaments supporting the intervertebral joints Ossification of the ligaments, discs and joints Fusion of the facet, sacroiliac and costovertebral joints
49
Describe the management of ankylosing spondylitis
NSAIDs - 2-4 weeks for maximum dose then consider switching to another NSAID Steroids - flares to control symptoms Anti-TNF medications - etanercept or monoclonal antibody against TNF such as infliximab, adalimumab or certolizumab pegol Secukinumab - monoclonal antibody against IL 17 Additional management - physiotherapy, exercise and mobilisation, avoid smoking, bisphosphonates to treat osteoporosis, treatment of complications, surgery is occasionally required for deformities of the spine
50
Describe systemic lupus erythematosus
Inflammatory autoimmune connective tissue disease Relapsing remitting course Chronic inflammation Anti-nuclear antibodies - antibodies to proteins within own cells nucleus cause activation of the immune system to the body and generates an inflammatory response
51
How does SLE present
Non-specific symptoms ``` Fatigue Weight loss Arthralgia Myalgia Fever Photosensitive malar rash - butterfly shaped rash across the nose and cheek bones which spares the nasolabial folds and gets worse with sunlight Lymphadenopathy and splenomegaly Pleuritic chest pain SOB Mouth ulcers Hair loss Raynaud's phenomenon ```
52
Describe the investigations for SLE
Autoantibodies - ANA and anti-double stranded DNA, antiphospholipid antibodies may be seen in antiphospholipid syndrome secondary to SLE FBC - normocytic anaemia of chronic disease C3 and C4 levels - reduced as inflammation uses up complement CRP/ESR - raised Immunoglobulins - raised due to activation of B cells with inflammation Urinalysis and urine protein: creatinine ratio for proteinuria in lupus nephritis Renal biopsy - lupus nephritis
53
What is needed for an SLE diagnosis
SLICC or ACR criteria - confirm ANA presence and establish a number of clinical features suggestive of SLE
54
List some complications of SLE
``` CVD - HTN and CAD Anaemia of chronic disease Infection Pericarditis Pleuritic chest pain Lupus nephritis Neuropsychiatric SLE - optic neuritis, transverse myelitis and psychosis Recurrent miscarriage VTE ```
55
What is the first line treatment for SLE
NSAIDs Steroids Hydroxychloroquine (treatment of choice) Sun cream and sun avoidance - photosensitive malar rash
56
What can be used in resistant SLE
``` Methotrexate Mycophenolate mofetil Azathioprine Tacrolimus Leflunomide Ciclosporin ```
57
What is given to patients with severe SLE and those non responsive to other treatment
Biological therapies - monoclonal antibodies such as rituximab and belimumab (targets B cell activating factor)
58
What type of hypersensitivity reaction is SLE
Type 3 - autoimmune reaction - antigen-antibody complexes
59
Which autoantibody is most specific for SLE
anti-dsDNA
60
Which autoantibody is most sensitive for SLE
ANA
61
How does hydroxychloroquine work
DMARD | Anti-lysosomal - stops lysosomes from working
62
Describe discoid lupus erythematosus
Non-cancerous skin condition More common in young women and darker skinned people and smokers May develop into SLE or SCC
63
Describe the presentation of discoid lupus erythematosus
``` Lesions on face, scalp and ears Photosensitive Associated with a scarring alopecia Hyperpigmented or hypopigmented scars Appears inflamed, dry, erythematous, patchy, crusty and scaling ```
64
Describe the management of discoid lupus erythematosus
Skin biopsy Sun protection, topical steroids, intralesional steroid injections and hydroxychloroquine
65
What is systemic sclerosis
Autoimmune inflammatory and fibrotic connective tissue disease
66
What are the two types of systemic sclerosis
Limited cutaneous systemic sclerosis Diffuse cutaneous systemic sclerosis
67
Describe the features of limited cutaneous systemic sclerosis
CREST syndrome ``` Calcinosis Raynaud's phenomenon oEsophageal dysmotility Sclerodactyly Telangiectasia ```
68
Describe the features of diffuse cutaneous systemic sclerosis
CREST syndrome plus cardiovascular (HTN and CAD), respiratory (pulmonary HTN and fibrosis), kidney (glomerulonephritis and scleroderma renal crisis)
69
What is scleroderma
Hardening of the skin Shiny, tight skin without the folds on normal skin Most notable on hands and face
70
What is sclerodactyly
As the skin hardens and tightens around joints it leads to a restricted range of movement and reduces function Fat pads are lost Skin can break and ulcerate
71
Describe telangiectasia in systemic sclerosis
Dilated blood vessels in the skin | Fine thread appearance
72
Describe calcinosis
Calcium deposits under the skin in the fingertips
73
Describe Raynaud's phenomenon
When fingertips go completely white and then blue in response to even mild cold - vasoconstriction in the vessels supplying the fingers
74
What does oesophageal dysmotility in systemic sclerosis cause
Reflux Oesophagitis Swallowing difficulty
75
Describe scleroderma renal crisis
Severe hypertension and renal failure
76
Which antibodies are present in systemic sclerosis
ANA Anti-centromere antibodies Anti-scl-70 antibodies
77
Which type of systemic sclerosis is anti-scl-70 antibody most associated with
Diffuse cutaneous systemic sclerosis
78
Which type of systemic sclerosis is anti-centromere antibody associated with
Limited cutaneous systemic sclerosis
79
What investigation is useful in Raynaud's
Nailfold capillaroscopy - help to rule out systemic sclerosis
80
What is seen on nailfold capillaroscopy in systemic sclerosis
Microhaemorrhages Avascular areas Abnormal capillaries
81
How is systemic sclerosis diagnosed
Clinical features Nailfold capillaroscopy Antibodies ACR and EULAR classification criteria
82
How is systemic sclerosis managed
MDT - physio and OT Steroids and immunosuppressants if diffuse disease and complications No proven treatment Non-medical management - avoid smoking, gentle skin stretching to maintain the range of motion, regular emollients, avoid cold triggers Medical management to treat symptoms and complications - Nifedipine for Raynaud's, antacids (PPIs) and pro-motility drugs (metoclopramide) for GI symptoms, analgesia for joint pain ,antibiotics for skin infection, antihypertensive, supportive management of pulmonary fibrosis
83
What do you use to treat scleroderma renal crisis
ACEi (lisinopril)
84
Describe polymyalgia rheumatica
Inflammatory condition that causes pain and stiffness in the shoulders, pelvic girdle and neck
85
What condition is PMR related to
Giant cell arteritis
86
Who does PMR usually affect
White women >50
87
List the core features of PMR
>2 weeks Bilateral shoulder pain that might radiate to the elbow Bilateral pelvic girdle pain Worse with movement Interferes with sleep Stiffness in the morning ;lasting >45mins
88
List some additional features of PMR
Carpal tunnel Upper arm tenderness Pitting oedema Systemic symptoms - weight loss, fatigue, low grade fever and low mood
89
How is a diagnose of PMR made
Clinical presentation Response to steroids Rule out other conditions Inflammatory markers - usually raised but can be normal FBC U&Es LFTs Ca - may be raised in hyperparathyroidism and cancer or low in Osteomalacia Serum protein electrophoresis for myeloma and other protein disorders Thyroid stimulating hormone for thyroid function Creatine kinase for myositis RF for RA Urine dipstick Urine Bence jones protein - myeloma CXR - lung and mediastinal abnormalities ANA - SLE Anti-cyclic citrullinated peptide (anti-CCP)
90
Describe the treatment of PMR
15mg prednisolone Review after 1 week, if no response then stop steroid and consider alternative diagnosis Review after 3-4 weeks and if stable then think about a reducing regime of steroids 15mg till stable, 12.5mg for 3 weeks then 10mg for 4-6 weeks and then 1mg reduction every 4-8 weeks. May take 1-2 years to reduce
91
Describe the Don't STOP points for patients on long term steroids
Don't - make them aware they are steroid dependent as without the steroids may risk adrenal crisis Sick day rules - double steroids on days when ill Treatment card - alert others they are steroid dependent in case found unresponsive Osteoporosis prevention - bisphosphonates, vit D and calcium Proton pump inhibitors - gastric protection
92
Describe giant cell arteritis
Vasculitis of the medium and large arteries
93
List the symptoms of GCA
Headache - severe, unilateral around the temple and forehead Scalp pain Jaw claudication Blurred or double vision Irreversible painless complete sight loss Fever, muscle aches, fatigue, weight loss, loss of appetite, peripheral oedema
94
How is GCA diagnosed
Clinical presentation Raised ESR Temporal artery biopsy - multinucleated giant cells FBC - normocytic anaemia and thrombocytosis LFTs - raised ALP CRP usually high Duplex ultrasound - Hypoechoic halo sign Start steroids immediately before confirming diagnosis
95
Describe the management of GCA
High dose steroids - 40-60mg prednisolone od (60 if visual symptoms or jaw claudication) Review the steroids within 48hrs Continue high dose steroids until symptoms resolved and then wean off Aspirin 75mg OD - decreases visual loss and strokes PPI - stomach protection with steroids Refer to vascular for the biopsy, rheum for management and ophthalmology if visual symptoms
96
What are some early complications of GCA
Vision loss | Stroke
97
What are some late complications of GCA
Relapse Steroid related effects Stroke Aortic aneurysm and dissection
98
What are polymyositis and dermatomyositis
Polymyositis - autoimmune disorder where there is chronic inflammation of muscles Dermatomyositis - autoimmune connective tissue disorder where there is inflammation of the skin and muscles
99
What is a key blood test in polymyositis/dermatomyositis
Creatine kinase - will be elevated
100
List some causes of raised creatine kinase
``` Strenous exercise AKI Rhabdomyolysis MI Statins ```
101
What may cause dermatomyositis or polymyositis
Underlying malignancy - paraneoplastic condition
102
Which cancers cause dermatomyositis and polymyositis
Lung Breast Ovarian Gastric
103
Describe the presentation of polymyositis and dermatomyositis
Muscle pain, fatigue and weakness Occurs bilaterally (proximal muscles) Shoulder and pelvic girdle Develops over weeks Polymyositis does not have any skin features
104
List the skin features found in dermatomyositis
Gottrons lesions - scaly red skin patches on knuckles, elbows and knees Photosensitive rash on back, shoulders and neck Purple rash on face and eyelids - heliotrope rash Periorbital oedema SC calcinosis
105
Which antibodies are present in dermatomyositis
Anti-Mi-2 antibodies Anti-nuclear antibodies Anti-Jo-1 antibodies
106
Which antibodies are present in polymyositis
Anti-Jo-1 antibodies
107
How is dermatomyositis/polymyositis diagnosed
``` Clinical presentation Elevated CK Autoantibodies EMG Muscle biopsy - definitive diagnosis ```
108
How is dermatomyositis/polymyositis managed
Corticosteroids are 1st line Immunosuppressants (azathioprine), IV immunoglobulins and biological therapy (infliximab or etanercept) if steroids are inadequate
109
What is antiphospholipid syndrome
Disorder with antiphospholipid antibodies where the blood becomes hypercoagulabe and the patient is prone to clotting (thrombosis an pregnancy related complications)
110
What may antiphospholipid syndrome be secondary to
SLE
111
Which antibodies are present in antiphospholipid syndrome
Lupus anticoagulant Anticardiolipin antibodies Anti-beta2-glycoprotein 1 antibody
112
List some conditions associated with antiphospholipid syndrome
VTE Arterial thrombosis - stroke, MI, renal thrombosis Pregnancy related complications - recurrent miscarriage, still birth, pre-eclampsia Livedo reticularis - purple lace like rash that gives a mottled appearance to the skin Libmann-sacks endocarditis - type of non-bacterial endocarditis where there are growths on the mitral valves of the heart Thrombocytopenia
113
How is antiphospholipid syndrome managed
Warfarin with INR 2-3 (3-4 if recurrent thrombosis) LMWH (enoxaparin) and aspirin if pregnant
114
Describe Sjogren's syndrome
Autoimmune condition of the exocrine glands - symptoms of dry mucous membranes (dry mouth, eyes and vagina) Primary Sjogren's or secondary Sjogren's (SLE or RA)
115
What antibodies are involved in Sjogren's syndrome
Anti-Ro and Anti-La
116
How is Sjogren's diagnosed on examination
Schirmer test <10mm
117
What is the management of Sjogren's
Artificial tears Artificial salvia Vaginal lubricants Hydroxychloroquine may slow progression
118
List some complications of Sjogren's syndrome
Eye infection - conjunctivitis and corneal ulcers Oral problems - cavities and candida Vagina; problems - candidiasis and sexual dysfunction ``` Pneumonia and bronchiectasis Non-hodgkins lymphoma Peripheral neuropathy Vasculitis Renal impaiment ```
119
What is vasculitis and how can it be categorised
Inflammation of the blood vessels Size of the vessels
120
List the small vessel Vasculitides
Henoch Scholein purpura Eosinophilic granulomatosis with polyangitis (churg Straus) Microscopic polyangitis Granulomatosis with polyangitis (Wagner's granulomatosis)
121
List the medium vasculititides
Granulomatosis with polyangitis Polyarteritis nodosa Kawasaki disease
122
List the large vessel Vasculitides
Giant cell arteritis | Takayasu's arteritis
123
What blood test is importnant in vasculitis
Anti neurtrophil cytoplasmic antibody ANCA
124
What are the two types of ANCA
pANCA and cANCA
125
What is pANCA associated with
Microscopic polyangitis and esoinophilic granulomatosis with polyangitis
126
What is c-ANCA associated with
Granulomatosis with polyangitis
127
Describe eosinophilic granulomatosis with polyangitis (churg strauss syndrome)
Small and medium sized vasculitis Lung and skin problems Severe asthma in teenage/adulthood with raised eosinophils
128
Describe microscopic polyangitis
Small vessel vasculitis Renal failure Lungs - sob and haemoptysis
129
Describe granulomatosis with polyangitis (wegeners)
Small vessel vasculitis of the upper respiratory tract and kidneys Epistaxis, crusty nasal secretions, hearing loss, sinusitis, saddle shaped nose due to perforated nasal septum Lungs - cough, wheeze and haemoptysis, CXR may show consolidation Kidney - glomerulonephritis
130
Describe polyarteritis nodosa
Medium vessel vasculitis Associated with hep B and c and HIV Skin, GI tract and heart - renal impairment, strokes and MI Associated with livedo reticularis rash
131
Describe takayasus arteritis
Large vessel vascultiis Affects the aorta and branches (pulmonary arteries) From aneurysms or become narrow and blocked - pulseless disease <40 yo and non specific symptoms with more specific symptoms of arm claudication and syncope Diagnosed using doppler US in carotid disease or CT/MRI angiography
132
Which gene is Behcet's disease associated with
HLAB51
133
What is Behcet's disease
Inflammation Recurrent oral and genital ulcers Inflammation in other areas such as skin, eye, GI tract, lungs, blood vessels, MSK, CNS
134
Where do Gouty tophi occur
DIP mainly but can occur in the elbows and ears
135
List the risk factors for gout
``` Male Obese High purine diet - meat Alcohol Diuretics CVD/Kidney disease FH ```
136
Which joints are typically affected in gout
Base of the big toe Wrists Base of the thumb Ankle and knee
137
How is gout diagnosed
Exclude septic arthritis Aspirated fluid will show no bacterial growth, needle shaped crystals, negatively birefringent of polarised light, monosodium urate crystals Joint X ray
138
What may be seen on an X-ray in gout
Joint space maintained Lytic lesions Punched out erosions with sclerotic borders and overhanging edges
139
Describe the management of an acute flare of gout
NSAIDs are 1st line Colchicine is 2nd line Steroids can be 3rd line
140
When is colchicine used in gout
For patients where NSAIDs are inappropriate 0- renal impairment or heart disease
141
What is a common side effect of colchicine
Diarrhoea
142
When is colchicine contraindicated
Blood/bone marrow disorders
143
Describe the prophylaxis of gout
Allopurinol (xanthine oxidase inhibitor) reduces uric acid levels Lifestyle change - lose weight, keep hydrated, minimise consumption of alcohol and purine foods
144
When should you start gout prophylaxisis
When the acute attack has settled
145
What so you do with the allopurinol if a patient has another attack
Continue them on this during the attack
146
Describe pseudogout
Crystal arthropathy Calcium pyrophosphate crystals Chondrocalcinosis Acutely hot, swollen, stiff and painful knee, shoulder, wrist or hip
147
How is pseudogout diagnosed
Aspirated fluid shows no bacterial growth, calcium pyrophosphate crystals, rhomboid shaped, positively birefringent of polarised light Chondrocalcinosis (white line in middle of joint space) on XRAY
148
How is pseudogout managed
``` NSAIDs Colchicine Joint aspiration Steroid injection Oral steroids joint washout in severe cases ```
149
What is osteomalacia
Defective bone mineralisation - soft bones Insuffieicnt vit D Weak bones, muscle weakness, bone pain and fractures Seocndary hyperparathyroidism
150
What are the investigations of Osteomalacia
``` Serum 25-hydroxyvitamin D <25 Serum calcium low Serum phosphate low Serum ALP may be high PTH may be high Xray - osteopenia DEXA - reduced BMD ```
151
How is Osteomalacia treated
Supplementary vitamin D - colecalciferol 50,000IU once weekly for 6 weeks
152
What is Pagets disease of bone
Disorder of bone turnover - excessive activity of osteoblasts and osteoclasts Sclerosis and lysis of bone also bone enlargement and deformity Axial skeleton Increased risk of pathological fractures
153
List some Xray changes in pagets disease of bone
Bone enlargement and deformity Osteoposiris circumscripta - osteolytic lesions less dense than normal bone Cotton wool appearance of the skull - decreased density and increased densoity V sahped defects in long bones
154
What biochemical test will be abnormal in pagets disease of bone
ALP - raised
155
How is pagets disease of bone treated
Bisphosphonates - interfere with osteoclast activity NSAIDs - pain Calcium and vit D supplementation Surgery
156
List 2 complications of pagets disease
Osteosarcoma | Spinal stenosis

Finals (18 decks)

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