Rheumatology Flashcards
Describe rheumatoid arthritis
Symmetrical synovial inflammation (synovitis) causing a polyarthritis
Chronic inflammation of the synovial lining of the joints, tendon sheaths and bursa
Name two gene associations of RA
HLADR4 - often present
HLADR1 - occasionally present
Describe rheumatoid factor
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
Describe cyclic citrullinated peptide antibodies
Autoantibodies that are more sensitive and specific to rheumatoid arthritis than rheumatoid factor
Often predate the development of RA
Describe the presentation of Rheumatoid arthritis
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
Describe palindromic Rheumatism
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
Which condition involves painful and swollen DIP joints
Osteoarthritis
Name some signs you may see in the hands of someone with RA
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
List some extra-articular manifestations of RA
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
List the investigations for rheumatoid arthritis
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
Describe the Xray changes in RA
Joint destruction and swelling
Soft tissue swelling
Bony erosions
What is the American college of rheumatology diagnosis of RA based on
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
Describe a DAS28 score
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
Describe features which indicate a worse prognosis for RA
Younger onset Make More joints and organs affected Antibodies Erosions
Describe the management of Rheumatoid arthritis
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
Which rheumatoid drugs are safe in pregnancy
Sulfalazine and hydroxychloroquine
Pregnancy improves RA symptoms - natural production of steroid hormones
Describe how rituximab works
Antibody which binds to the CD20 portion of B cells
How does methotrexate work
Interferes with folate metabolism and suppresses certain components of the immune system
What is prescribed with methotrexate
Folic acid 5mg taken once a week on a different day to the methotrexate
List some side effects of methotrexate
Mouth ulcers and mucositis
Bone marrow suppression
Liver toxicity
Teratogenic - also avoid before conception
Describe the mechanism of action of leflunomide
Immunosuppressant by interfering with pyrimidine which is needed for RNA/DNA
List some side effects of leflunomide
Mouth ulcers/mucositis Hypertension Rash Peripheral neuropathy Teratogenic Bone marrow suppression Liver toxicity
Give the side effects of sulfalazine
Temporary male infertility
Bone marrow suppression
How does hydroxychloroquine work
Immunosuppressant which interferes Toll like receptors, disrupting antigen presentation and increasing the pH of the lysosomes of the immune cells
List some notable side effects of hydroxychloroquine
Nightmares
Reduced visual acuity
Liver toxicity
Skin pigmentation
How do anti-TNF drugs work
Block TNF which normally stimulates inflammation
List some side effects of anti-TNF drugs
Vulnerability to severe infection and sepsis
Reactivation of TB and hep B
List some side effects of rituximab
Vulnerability to severe infection and sepsis Night sweats Thrombocytopenia Peripheral neuropathy Liver and lung toxicity
What does joint aspiration in rheumatoid arthritis show
High WBC count - polymorphonuclear neutrophils
Yellow, cloudy
Absence of crystals
Describe psoriatic arthritis
Inflammatory arthritis associated with psoriasis
Seronegative spondyloarthropathy
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
Describe an asymmetrical pauciarthrits pattern of psoriatic arthritis
Mainly the digits and feet
Few joints
Describe the spondylitic pattern of psoriatic arthritis
Back stiffness Sacroiliitis Atlanto-axial joint involvement Spine Achilles tendon Plantar fascia
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
Describe a PEST (psorisasis epidemiogical screening tool)
Several questions about joint pain Swelling History of arthritis Nail pitting High score triggers referral to rheumatologist
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
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
Describe the management of psoriatic arthritis
NSAIDs for pain
DMARDs - methotrexate, leflunomide or sulfasalazine
Anti-TNF medications
Ustekinumab - IL 12 and 23 monoclonal antibody
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
What are the two most common infections that trigger reactive arthritis
Gastroenteritis
STI - chlamydia or gonorrhoea
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
What is found in synovial fluid aspirate in reactive arthritis
Sterile synovial fluid with high WCC
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
Which joints are affected in ankylosing spondylitis
Sacroiliac joints
Vertebral column joints
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
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
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
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
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
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
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
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
What is needed for an SLE diagnosis
SLICC or ACR criteria - confirm ANA presence and establish a number of clinical features suggestive of SLE
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
What is the first line treatment for SLE
NSAIDs
Steroids
Hydroxychloroquine (treatment of choice)
Sun cream and sun avoidance - photosensitive malar rash
What can be used in resistant SLE
Methotrexate Mycophenolate mofetil Azathioprine Tacrolimus Leflunomide Ciclosporin
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)
What type of hypersensitivity reaction is SLE
Type 3 - autoimmune reaction - antigen-antibody complexes
Which autoantibody is most specific for SLE
anti-dsDNA
Which autoantibody is most sensitive for SLE
ANA
How does hydroxychloroquine work
DMARD
Anti-lysosomal - stops lysosomes from working
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
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
Describe the management of discoid lupus erythematosus
Skin biopsy
Sun protection, topical steroids, intralesional steroid injections and hydroxychloroquine
What is systemic sclerosis
Autoimmune inflammatory and fibrotic connective tissue disease
What are the two types of systemic sclerosis
Limited cutaneous systemic sclerosis
Diffuse cutaneous systemic sclerosis
Describe the features of limited cutaneous systemic sclerosis
CREST syndrome
Calcinosis Raynaud's phenomenon oEsophageal dysmotility Sclerodactyly Telangiectasia
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)
What is scleroderma
Hardening of the skin
Shiny, tight skin without the folds on normal skin
Most notable on hands and face
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
Describe telangiectasia in systemic sclerosis
Dilated blood vessels in the skin
Fine thread appearance
Describe calcinosis
Calcium deposits under the skin in the fingertips
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
What does oesophageal dysmotility in systemic sclerosis cause
Reflux
Oesophagitis
Swallowing difficulty
Describe scleroderma renal crisis
Severe hypertension and renal failure
Which antibodies are present in systemic sclerosis
ANA
Anti-centromere antibodies
Anti-scl-70 antibodies
Which type of systemic sclerosis is anti-scl-70 antibody most associated with
Diffuse cutaneous systemic sclerosis
Which type of systemic sclerosis is anti-centromere antibody associated with
Limited cutaneous systemic sclerosis
What investigation is useful in Raynaud’s
Nailfold capillaroscopy - help to rule out systemic sclerosis
What is seen on nailfold capillaroscopy in systemic sclerosis
Microhaemorrhages
Avascular areas
Abnormal capillaries
How is systemic sclerosis diagnosed
Clinical features
Nailfold capillaroscopy
Antibodies
ACR and EULAR classification criteria
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
What do you use to treat scleroderma renal crisis
ACEi (lisinopril)
Describe polymyalgia rheumatica
Inflammatory condition that causes pain and stiffness in the shoulders, pelvic girdle and neck
What condition is PMR related to
Giant cell arteritis
Who does PMR usually affect
White women >50
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
List some additional features of PMR
Carpal tunnel
Upper arm tenderness
Pitting oedema
Systemic symptoms - weight loss, fatigue, low grade fever and low mood
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)
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
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
Describe giant cell arteritis
Vasculitis of the medium and large arteries
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
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
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
What are some early complications of GCA
Vision loss
Stroke
What are some late complications of GCA
Relapse
Steroid related effects
Stroke
Aortic aneurysm and dissection
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
What is a key blood test in polymyositis/dermatomyositis
Creatine kinase - will be elevated
List some causes of raised creatine kinase
Strenous exercise AKI Rhabdomyolysis MI Statins
What may cause dermatomyositis or polymyositis
Underlying malignancy - paraneoplastic condition
Which cancers cause dermatomyositis and polymyositis
Lung
Breast
Ovarian
Gastric
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
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
Which antibodies are present in dermatomyositis
Anti-Mi-2 antibodies
Anti-nuclear antibodies
Anti-Jo-1 antibodies
Which antibodies are present in polymyositis
Anti-Jo-1 antibodies
How is dermatomyositis/polymyositis diagnosed
Clinical presentation Elevated CK Autoantibodies EMG Muscle biopsy - definitive diagnosis
How is dermatomyositis/polymyositis managed
Corticosteroids are 1st line
Immunosuppressants (azathioprine), IV immunoglobulins and biological therapy (infliximab or etanercept) if steroids are inadequate
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)
What may antiphospholipid syndrome be secondary to
SLE
Which antibodies are present in antiphospholipid syndrome
Lupus anticoagulant
Anticardiolipin antibodies
Anti-beta2-glycoprotein 1 antibody
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
How is antiphospholipid syndrome managed
Warfarin with INR 2-3 (3-4 if recurrent thrombosis)
LMWH (enoxaparin) and aspirin if pregnant
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)
What antibodies are involved in Sjogren’s syndrome
Anti-Ro and Anti-La
How is Sjogren’s diagnosed on examination
Schirmer test <10mm
What is the management of Sjogren’s
Artificial tears
Artificial salvia
Vaginal lubricants
Hydroxychloroquine may slow progression
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
What is vasculitis and how can it be categorised
Inflammation of the blood vessels
Size of the vessels
List the small vessel Vasculitides
Henoch Scholein purpura
Eosinophilic granulomatosis with polyangitis (churg Straus)
Microscopic polyangitis
Granulomatosis with polyangitis (Wagner’s granulomatosis)
List the medium vasculititides
Granulomatosis with polyangitis
Polyarteritis nodosa
Kawasaki disease
List the large vessel Vasculitides
Giant cell arteritis
Takayasu’s arteritis
What blood test is importnant in vasculitis
Anti neurtrophil cytoplasmic antibody ANCA
What are the two types of ANCA
pANCA and cANCA
What is pANCA associated with
Microscopic polyangitis and esoinophilic granulomatosis with polyangitis
What is c-ANCA associated with
Granulomatosis with polyangitis
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
Describe microscopic polyangitis
Small vessel vasculitis
Renal failure
Lungs - sob and haemoptysis
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
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
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
Which gene is Behcet’s disease associated with
HLAB51
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
Where do Gouty tophi occur
DIP mainly but can occur in the elbows and ears
List the risk factors for gout
Male Obese High purine diet - meat Alcohol Diuretics CVD/Kidney disease FH
Which joints are typically affected in gout
Base of the big toe
Wrists
Base of the thumb
Ankle and knee
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
What may be seen on an X-ray in gout
Joint space maintained
Lytic lesions
Punched out erosions with sclerotic borders and overhanging edges
Describe the management of an acute flare of gout
NSAIDs are 1st line
Colchicine is 2nd line
Steroids can be 3rd line
When is colchicine used in gout
For patients where NSAIDs are inappropriate 0- renal impairment or heart disease
What is a common side effect of colchicine
Diarrhoea
When is colchicine contraindicated
Blood/bone marrow disorders
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
When should you start gout prophylaxisis
When the acute attack has settled
What so you do with the allopurinol if a patient has another attack
Continue them on this during the attack
Describe pseudogout
Crystal arthropathy
Calcium pyrophosphate crystals
Chondrocalcinosis
Acutely hot, swollen, stiff and painful knee, shoulder, wrist or hip
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
How is pseudogout managed
NSAIDs Colchicine Joint aspiration Steroid injection Oral steroids joint washout in severe cases
What is osteomalacia
Defective bone mineralisation - soft bones
Insuffieicnt vit D
Weak bones, muscle weakness, bone pain and fractures
Seocndary hyperparathyroidism
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
How is Osteomalacia treated
Supplementary vitamin D - colecalciferol 50,000IU once weekly for 6 weeks
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
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
What biochemical test will be abnormal in pagets disease of bone
ALP - raised
How is pagets disease of bone treated
Bisphosphonates - interfere with osteoclast activity
NSAIDs - pain
Calcium and vit D supplementation
Surgery
List 2 complications of pagets disease
Osteosarcoma
Spinal stenosis
