Rheumatology Flashcards
Alendronic acid
Bisphosphonate
Scleroderma symptoms
Shiny skin patches (SCLERO DERMA) from fibrosis
Raynaud’s
Dysphagia
Limited ROM
Investigation for scleroderma
Serum nuclear antigens (anti nuclear antibodies ANA)
- Anti-SCL 70
- Anti-centromere antibodies (ACA)
Ankylosing spondylitis presentation
YOUNG, MALE BACK STIFFNESS (inflammatory - improves with exercise) + worse morning/night Weight loss, fever, fatigue Uveitis (red inflamed eyes) FHx arthritis Other autoimmune conditions
Non-inflammatory presentation in MSK
Does NOT improve with exercise
Ankylosing spondylitis investigation
X-Ray: BAMBOO SPINE (calcification of ligaments), narrowing of joint spaces, fusion of sacro-iliac joints, squaring of the vertebral bodies,
Bloods: HLA B27 (90%)
Reactive arthritis presentation
Post-infection e.g. STI (chlamydia)
Can’t see (conjunctivitis)
Can’t pee (urethritis)
Can’t climb a tree (arthritis)
SeroNEGATIVE spondyloarthropathy
= ABSENCE of RF and anti-CCP
+ strong HLA-B27 association
Psoriatic arthritis
Ankylosing spondylitis
Reactive arthritis
IBD associated
SPINEACHE Sausage digit (dactylitis) Psoriasis Inflammatory back pain NSAIDs: good response Enthesitis (particularly in the heel) Arthritis Crohn’s/Colitis/elevated CRP (can be normal in AS) HLA-B27 Eye (Uveitis)
Multiple myeloma investigations
Diagnostic: Serum electrophoresis (IgG, IgA, light chain proteins) + CRAB symptoms
Prognostic: Serum LDH (lactate dehydrogenase), CRP, B2-microglobulin, albumin
Management of septic arthritis
SEPSIS 6 (TAKE 3 + GIVE 3) Joint aspiration (Dx - cultures, Tx - arthrocentesis)
Risk factors for septic arthritis
immunosuppressants diabetes HIV old age IV drug use
Most likely causative organism for septic arthritis
Staph aureus
Presentation of septic arthritis
RED, HOT, SWOLLEN joint (isolated, different to reactive = multiple areas affected)
Fever + systemically unwell
Paget’s disease of the bone
Abnormal bone turnover: body absorbs OLD bone (osteoclasts) and forms ABNORMAL NEW bone
= structurally disorganised + weaker mosaic bone (woven bones)
1st line treatment of Paget’s
Bisphosphonates: IV Zoledronate (suppresses osteoclast OR osteoblast overactivity)
- used for ANY bone turn over abnormality
Adjunct: NSAIDs
Goodpasture’s syndrome Ix
anti glomerular basement membrane (anti-GBM) antibodies
Gold standard investigation for RA
Anti-CCP (specific)
RF is 70% sensitive
key clinical features found in the arms/hands of RA patients
ulnar deviation
swan neck deformity
boutonniere deformity
RA signs on X-ray
LESS:
loss of joint space
EROSION of bones
soft tissue swelling
Soft bones
one joint never affected in RA
DIPJ
marker to monitor progression of RA
CRP
ESR takes too long to change so not immediate
RA treatment
DMARDs
Autoimmune cause of miscarriage
Antiphospholipid syndrome
- antibodies stop the egg from implanting and inhibit growth of foetal cells
Autoimmune cause of increased clotting
APL
APL treatment
Lifestyle
Anticoagulation:
- Chronic: warfarin
- Pregnancy: heparin + aspirin (warfarin is TERATOGENIC)
SLE risk factors
female HLA gene other autoimmune conditions FHx UV radiation
SLE clinical manifestations
systemic: glomerulonephritis, CNS (psychiatric), glomerulonephritis, joint pain, pericarditis
erythematosus: RED MALAR PHOTOSENSITIVE RASH
two gold standard diagnostic markers for SLE
ANA (anti nuclear antibodies) - VERY SENSITIVE but not very specific
anti-dsDNA (double stranded) - periods of active disease
ESR and CRP changes in SLE
high ESR
normal CRP
SLE Tx
1st line: oral corticosteroids (prednisolone)
hydroxychloroquine
methotrexate
Gout causes
Thiazides (urea reabsorption)
High purine diet
Tumour lysis syndrome
Gout treatment
a) <1 flare up
b) acute + >1 flare up
b) long-term
a) educate on lifestyle changes
b)
1st line - NSAIDs or Colchicine (C for aCute😚)
2nd line - intra-articular steroid injection
c)
1st line - Allopurinol [inhibits xanthine oxidase synthesis] with colchicine
2nd line - febuxostat
Gout investigation
1st line: bloods
- confirm hyperuricaemia
Gold standard: BIOPSY
- polarised light microscopy of the synovial fluid: NEEDLE SHAPED NEGATIVELY birefringent crystals
Psuedogout investigation
polarised light microscopy of the synovial fluid: RHOMBOID POSITIVELY birefringent
Osteoarthritis Px + X-Ray signs
LOSS: Loss of (Narrowed) joint space Osteophytes Subchondral sclerosis Subchondral cysts
Joint pain worse with movement
Stiffness on rest
Limited joint movement
Bone swelling in fingers (Heberden, Bouchard)
Osteoarthritis:
HD
BP
Heberden - distal
Bouchard - proximal
Red flags for BACK PAIN - TUNA FISH
1st line management: refer to hospital for urgent assessment
Osteoporosis DEXA scan results
DEXA: Dual Energy X-Ray Absortiometry
T score below -2.5 = diagnostic
Osteoporosis risk factors
Age (post-menopausal women) Steroid use Hyperthyroidism Alcohol and smoking Low BMI Alcohol abuse Female
Osteoporosis treatment
1st line: Bisphosphonates (alendronate) and AdCal (Vit D + calcium)
2nd line: Denosumab (monoclonal RANK ligand)
Side effects of bisphosphonates
TMJ osteonecrosis GI upset (sit upright after taking medication to prevent oesophageal cancer + take first thing in the morning with water)
Rickets presentation
young
malnourished (Vit D deficiency)
bowed femur + tibia (may present as waddling gait)
Rickets in adults = Osteomalacia
Rickets pathophysiology
Inadequate calcium for mineralisation = excessive non-mineralised osteoid build up
RANK-L
activates osteoclasts, promoting bone reabsorption
Osteomyelitis causative organisms
Staph aureus: most common
Salmonella species: SICKLE CELL
Neisseria gonorrhoea: sexually active
Pseudomonas aeruginosa: diabetes, IVDU, puncture wounds
Multiple myeloma
Bone marrow cancer
Cancerous PLASMA cells (>10%)
Multiple myeloma symptoms
CRAB: Calcium (HIGH) Renal Anaemia Bone problems
Osteoarthritis
LOSS of CARTILAGE + DISORDERED BONE repair
Most common arthritis
F > M
Major risk factor for OA
Obesity
Joints affected in OA
Large weight bearing joints (knees, hips)
Osteoarthritis treatment
Paracetamol (analgesics ladder > NSAIDs etc)
Cortisol intraarticular injections (methylprednisolone)
Joint replacement
Weight loss
Lifestyle
RA diagnostic criteria
RF RISES Rheumatoid factor POSITIVE Fingers/hand/wrist involvement Rheumatoid nodules present Involvement of >3 joints Stiffness in the morning for >1 hour Erosions seen on X-Ray Symmetrical involvement
More than 6 weeks, More than 4 of the above
Rheumatoid arthritis
Autoimmune disease
Symmetrical, deforming, peripheral polyarthris
F X3 > M
RA Px
Pain in affected joints
Hand deformities
Morning stiffness >30 minutes
Systemic: scleritis, pleural effusions, pericarditis
RA Tx
DMARDs (disease modifying antirheumatic drugs)
- METHOTREXATE (with folate)
Steroids
Biologics (TNF-a blockers, Infliximab, B-cell inhibitors (Rituximab))
NSAIDs, Opioids for pain management
Feltys syndrome/triad
Presence of 3 conditions:
SPLENOMEGALY
RA
GRANULOCYTOPENIA (neutropenia)
Osteoporosis
DECREASE in bone density and micro-architectural deterioration
» INCREASE in bone fragility and susceptibility in fracture
Causes of osteoporosis
Endocrine (Cushing’s, PTH)
Haematology (Myeloma)
GI (malabsorption)
Iatrogenic (steroids)
Osteoporosis Px
Not clinically apparent until a fracture occurs
Risk assessment for osteoporosis
FRAX
Qfracture
Systemic lupus erythematosus
Inflammatory, multisystem autoimmune disorder with arthralgia and rashes
Female 9X > Males
Peak 20-40 yo
TYPE 3 Hypersensitivity
Antiphospholipid syndrome
Antibody-mediated thrombophilia characterised by thrombosis (arterial or venous) and/or recurrent miscarriages
Associated with SLE in 20-30%
APL syndrome Px
Coagulation defects
Pregnancy issues
Thrombocytopenia
Livedo reticularis (below)
APL diagnostic criteria
At least 1 clinical and 1 lab
Clinical:
- vascular thrombosis
- pregnancy morbidity
Lab:
- anticardiolipin antibody
- lupus anticoagulant
- anti B2 glycoprotein 1 antibody
APL arterial thrombosis
More common in males
MI, stroke
Libman-Sacks endocarditis
APL venous thrombosis
More common in females
PE, DVT
Sjogrens definition
Chronic inflammatory autoimmune disorder
destruction of EPITHELIAL EXOCRINE glands (especially the LACRIMAL and SALIVARY glands)
typically occurs in women
Sjogrens Px
Dry eyes, mouth, parotid gland enlargement
Joint pain
Raynauds
Systemic features
Associated with RA, SLE, PBC, scleroderma
Sjogrens Ix
Rose Bengal staining and slit lamp eye exam
Rheumatoid factor, ANA, Anti-Ro (SSA), Anti-La (SSB)
Sjogrens Tx
Lifestyle: humidifier, eye drops, mouth wash
Medications: NSAIDs, hydroxychloroquine, pilocarpine (M3 agonist - increase exocrine secretions)
Raynaud’s phenomenon
Intermittent spasm in the arteries supplying the fingers and toes usually precipitated by cold and relieved by heat
Associated with: SLE, scleroderma, RA, dermatomyositis
Tx: CCB
Exocrine vs endocrine gland
Exocrine: ductal system
Endocrine: directly into bloodstream
Systemic sclerosis patho
Multisystem autoimmune disease
Increased fibroblast activity (causing increased COLLAGEN deposition) = abnormal growth of connective tissue
Highest mortality of autoimmune rheumatic diseases
CREST
Calcinosis - calcium deposits in subcutaneous tissue
Raynaud’s
Eosophageal dysmotility or strictures
Sclerodactylyl (local thickening on fingers/toes)
Telenagiectasia (spider veins)
Scleroderma Px
Limited (CREST): hands, face, feet, forearms; ‘beak’ like nose and small mouth (microstomia)
Diffuse: widespread skin changes, organ damage occurs earlier (GI e.g. GORD, renal, lung)
Scleroderma Tx
Immunosuppressants
Symptom relief: PPIs (GI) ACEi (renal) Cyclophosphamide (pulmonary fibrosis) CCB (Raynaud’s)
Polymyositis/dermatomyositis
RARE MUSCLE DISORDER
Unknown aetiology
Inflammation and necrosis of skeletal muscle fibres
Dermatomyositis = poly + skin involvement
Polymyositis Px
Symmetrical progressive muscle weakness and wasting of the proximal muscles of the shoulder and pelvic girdle
Dermatomyositis Px
Heliotrope (purple) discolouration of eyelids
Scaly erythematous plaques over the knuckles
Polymyositis Ix
Muscle biopsy
Bloods: INCREASED creatine kinase, aminotransfersases, LDH, aldolase
Immunology: ANA
Polymyositis Tx
- ORAL PREDNISOLONE
- Stronger immunosuppressants
Symptomatic treatment of skin disease
Paget’s disease of the bone Px
Rare under 40 y/o 60-80% are ASYMPTOMATIC - bone + joint pain - SKULL CHANGES - neurological changes - bowed tibia
Paget’s disease of the bone Ix
Bloods: marked increase in ALP but NORMAL calcium + phosphate
Urinary hydroxyproline increased
X-ray: osteoarthritis
Osteomalacia
DEFECTIVE MINERALISATION of newly formed bone matrix or osteoid in ADULTS
Due to inadequate phosphate or calcium, or due to increased bone resorption (hyperPTH)
Rickets
DEFECTIVE MINERALISATION at EPIPHYSEAL GROWTH PLATE (not present in adults)
AKA osteomalacia in CHILDREN
Osteomalacia aetiology
Malnutrition (most common) - Vit D, PO4, Ca
Drug induced
Defective 1-alpha hydroxylation
Liver disease
Px of osteomalacia in adults
Widespread bone pain and tenderness
Gradual onset and persistent fatigue
Muscle weakness
FRACTURES
Px of rickets
LEG BOWING and knock knees - WADDLING GAIT - tender swollen joints - IMPAIRED GROWTH - bone and joint pain Dental deformities
Osteomalacia Ix
Bloods: U&Es (low calcium), high serum ALP, low Vit D
X-Rays: defective mineralisation, rachitic rosary
Osteomalacia Tx
Lifestyle: nutrition, sunlight
Medications: Vit D replacement
Malabsorption/renal disease: IM calcitrol
Alkaline phosphatase (ALP) role
- Osteoblast activity = increased ALP e.g. Paget’s
2. Bone mineralisation (calcium + phosphate deposition into osteoid)
why can liver disease cause osteomalacia
LIVER: Inactive vitamin D > 25-OH-Vitamin D
Kidneys: 1-alpha-hydroxylase converts 25-OH-Vit D to CALCITRIOL i.e. active Vitamin D which increases renal reabsorption of calcium + intestinal absorption of calcium + phosphate)
Parathyroid hormone
Secreted in response to LOW blood CALCIUM
- Stimulates resorption of calcium (and a small amount of phosphate) from the bone
- Boost 1-alpha hydroxylase activity = active Vit D
- Increases calcium reabsorption and phosphate excretion from the kidneys
Most common cause of rickets and osteomalacia
VITAMIN D DEFICIENCY
- intestinal malabsorption (coeliac, crohns)
- lack of UV light exposure (home bound)
- medications e.g. phenytoin (uses hydroxylase enzymes)
- liver + kidney disease
PAMPs
Pathogen associated molecular patterns
Bacterial surface antigens recognised by the innate immune system as FOREIGN
Antibiotic management septic arthritis
Staph aureus:
Flucoxacillin
- penicillin-allergy: gentamicin
- MRSA: vancomycin
Gonococcal or Gram -ve (E. Coli)
- cefotaxime
Causative organisms of septic arthritis
Most common: staph aureus
Sexually active: neisseria gonorrhoea
Kids: Haemophilus influenza
Gram -ve: E. Coli
Gonococcal arthritis
Sexually active adolescents
SPREADS HAEMATOGENOUSLY from initial infection
Affects MULTIPLE JOINTS
Skin lesions + tenosynovitis
Food high in purines
Red meat Organ meat e.g. liver Seafood Beans Beer
Breakdown product of purines
Uric acid
Tumour lysis syndrome
Large number of cancer cells die within a short period, releasing their contents into the blood
Gout
Uric acid deposits in joint spaces = inflammation (usually of the big toe - podagra)
Tophi gout
Uric acid crystals form masses of white growths around the joints and tissues that gout has affected
Stages of gout
Pseudogout
Px of gout but caused by CALCIUM PYROPHOSPHATE crystals
Osteomyelitis
INFECTION of the BONE MARROW causing INFLAMMATION
Myelo = bone marrow
Three main ways of organism entry in osteomyelitis
Haematogenous spread
Open wound/surgery
Contiguously (skin infection e.g. cellulitis > bone)
Stages of osteomyelitis
Acute inflammation
Resolution Or progression to Chronic:
Subperiosteal abcess
Sequestrum (necrotic bone within pus)
Involvcrum (new bone surrounding sequestrum)
Cloacae (opening to allow dead bone and bus to come out)
Most common causative organism of osteomyelitis
Staphylococcus aureus
- skin > bone
- haematogenous spread
High risk individuals for salmonella infections
Sickle cell disease patients
Osteomyelitis diagnosis
FBC: CRP, ESR, WCC
X-Ray, MRI
Gold standard: Biopsy + culture
Psoriatic arthritis (summary)
Occurs in 10-40% of people with psoriasis (psoriasis = autoimmune destruction of skin cells) - T cells activate osteoblasts + osteoblasts
Painful, swollen, stiff joints
Psoriatic plaques
Dactylitis (sausage fingers)
Telescopic fingers
X-ray: PENCIL IN CUP (thin bone in soft tissue swelling)
Osteosarcoma
Primary bone malignancy
Associated with Paget’s disease
Sunburst appearance on X-Ray
Osteochondroma
Benign overproduction of bone which deposits on metaphysis
Very common in males <25
Exostosis on X-Ray
Secondary bone tumours
PB KTL (Lead kettle) Prostate Breast Kidneys Thyroid Lungs
Most common cause of back pain
Mechanical (sprains and strains)
Red flags diseases for lower back pain
Cauda equina
Cancer of the spine
Spinal fracture (trauma or osteoporotic collapse)
Spinal infection
Ix: inflammatory markers, FBC, ALP, DEXA scan, MRI (bone pathology)
Neuropathic pain relief
TCA
Gabapentin
Pregabalin
DMARDs
Non-biologic: methotrexate, leflunomide, sulfasalazine
Biological: TNF-a inhibitors
Ankylosing spondylitis patho
Spondylitis = inflammation of the vertebrae
Autoimmunity against type 1+2 collagen (intervertebral discs + sacroiliac joints) = fibrous deposits + ossification
ANCA positive vasculitis
Granulomatosis with polyangiitis
Citrullination
Deimination: arginine > citrulline
Immune system attacks citrullinated proteins
Occurs in RA
Anti-citrullinated peptide antibodies (ACPA)
- detected by anti-cyclic citrullinated peptides (anti-CCP) (98% specific for RA diagnosis and can preclude diagnosis)
Complications of SLE
Kidney failure
CV: Heart attack, Pericarditis
CNS: Seizures, Stroke
Super infection
Lofgrens triad (sarcoidosis)
- Erythema nodosum
- Bilateral hilar lymphadenopathy
- Polyarthralgia (pain in more than one joint)
Sarcoidosis Ix
CXR: hilar lymphadenopathy
Serum ACE
FBC: anaemia, leukopenia
Serum Urea:Creatinine (kidney involvement)
Serum CALCIUM (hypercalcaemia): elevated Vitamin D due to macrophages
Spirometry
Histology (non caseating granulomas)
Sarcoidosis Tx
Corticosteroids Ventilators support Oxygen Lung transplant Hydroxychloroquine
Dermatomyositis Ix
Creatine kinase Electromyography Muscle biopsy Autoantibodies: Anti-Jo-1 antibodies, Anti-Mi-2 antibodies, Anti-nuclear antibodies Spirometry
Dermatomyositis Tx
IV corticosteroids
1st line Mx for ankylosing spondylitis
NSAIDs and physiotherapy
pain and pins-and-needles in his left hand
worse in the morning than at night, and it usually feels quite numb when he first wakes up until he starts to move it around more
You lightly tap the area just below the palm in the middle of the wrist with your finger and he gets the same sensation of the pins and needles he has been experiencing.
Which nerve is responsible for these symptoms?
Median nerve - CARPAL TUNNEL SYNDROME
