rheumatology Flashcards
in OA, where would you find Heberdens nodes?
DIP joint
in OA, where would you find Bouchards nodes?
PIP joint
what are the x-ray findings in OA?
loss of joint space
osteophytes
subchondral sclerosis
subchondral cysts
what would be the treatment for OA in the knee and hip?
arthroplasty
what would be the treatment for OA in the MTP, wrist and ankles?
arthrodesis (fusion of bones together)
what mediates RA?
HLA-DR4
what are some triggers of RA?
smoking
infection
stress
what joints does RA mainly affect?
small joints of hands and feet - MCP and PIP
typically spares DIP joints
wrist and ankle
what are some later deformities seen with RA?
joint subluxation of the cervical spine
swan neck - PIP joint hyperextension, DIP joint flexion
boutonieres - PIP joint flexion, DIP joint hyperextension
z thumb
when are extra articular features present in RA?
when serology is positive and include: lung fibrosis (lower lungs) keratoconjunctivitis sicca vasculitis osteoporosis scleritis neutropenia Raynauds Carpal tunnel pericarditis
what is felty’s syndrome?
RA + splenomegaly + neutropenia
what x ray findings are seen in RA?
loss of joint space
peri-articular erosions
subluxations
junta-articular osteoporosis
what is seen on serology in RA?
raised RF
raised anti-CCP
raised ESR and CRP
how is a diagnosis made in RA?
clinical diagnosis
serology not completely sensitive
what is the 1st line treatment for RA?
DMARD (methotrexate) +/- short course of prednisolone
how is disease monitored in RA?
using CRP and DAS28
how is a flare up of RA treated?
using corticosteroids (oral or IM)
what needs to be done and why before starting methotrexate?
FBC - agranulocytosis
LFTs - hepatotoxicity (cirrhosis)
what are names of DMARDs apart from methotrexate?
leflunomide
sulfasalazine
hydroxychloroquine
when are steroids used in RA?
for remission induction in flares
as filler while other drugs start to work
when can anti-TNF therapy be used in RA?
after inadequate response to 2 DMARDs (one being methotrexate)
name anti-TNF therapy
etanercept
infliximab
what are biologics co-prescribed with?
methotrexate
what is the DAS28 score?
<2.6 remission
2.6-3.2 low disease activity
3.2-5.1 moderate disease activity
>5.1 active disease
what features do spondyloarthritides share?
seronegative - negative for RF
positive for HLA-B27 mutation
arthritis of spine and SI joints
involves less then 5 lower limb joints
dactylitis (sausage fingers)
enthesitis (inflammation of tendon and ligament insertion)
extra articular features - anterior uveitis, rash, IBD and aortic valve incompetence
what pathophysiology is seen with AS?
widening and subchondral sclerosis of SIJ (eventual fusion of SIJ joint)
formation of syndesmophytes that fuse together causing stiffness and immobility
calcification of vertebral ligaments
what are calcified vertebral ligaments described as on x-ray in AS?
bamboo spine
what additional symptoms are associated with AS?
fatigue anterior uveitis painful heel and feet (Achilles tendonitis, plantar fasciitis) SOB - atypical upper zone fibrosis aortic regurgitation amyloidosis IgA nephropathy
what spinal posture is seen in advanced AS?
questions mark posture
- thoracic kyphosis
- cervical spine hyperextension
what is seen on examination for AS?
tender SIJ
Schobers test positive (reduced lunar flexion)
reduced chest expansion
what is schobers test?
when patient flexes lumbar spine, should increase from 15cm to greater than 20cm but in AS reduced lumbar flexion
how is a diagnosis made in AS?
clinically due to late radiographic changes
what imaging can be used in AS?
MRI of spine and SIJ
what is the first line management of AS?
NSAIDs, physio, encourage exercise
what treatment can be used to help enthesitis?
intra-articular steroids
what treatment can be used to help peripheral joint disease?
sulfasalazine
mainly of the hip joint
if there is non responsive pain and stiffness in AS what treatment can be used?
anti-TNF
what develops first in PA, the arthritis or the psoriasis?
psoriasis
what joints does PA affect most commonly?
DIP of hands and feet
what other joint patterns can PA affect?
symmetrical polyarthritis
unilateral sacroilitis
what other presentations are seen with PA?
psoriatic rash
nail changes - pitting, onycholysis, subungual hyperkeratosis
what is seen on x-ray with PA?
pencil in dup deformity (due to osteolysis)
how is PA treated?
1st line - NSAIDs and physio
progressive disease - methotrexate or anti-TNF
what is reactive arthritis?
sterile synovitis occuring 1-4 weeks after infection
what infections are commonly associated with reactive arthritis?
GI - salmonella
STI - chlamydia
what is another name for reactive arthritis?
Reiter’s syndrome
what is Reiter’s syndrome? and what phrase can help remember it?
uveitis, urethritis, arthritis
–> can’t see, can’t pee, can’t bend the knee
what symptoms are associated with reactive arthritis?
asymmetrical lower limb pain (knee common) red eye, blurred vision pain on urination mouth ulcers rash on soles of feet and palms of hands
what is the rash on hands and feet seen with reactive arthritis?
keratoderma blennorhagica (painful, brown, raised lesion)
what investigations are done for reactive arthritis?
joint aspiration to rule out septic arthritis
urine sample for chlamydia
what is the treatment for reactive arthritis?
rest and NSAIDs
if recurring, potentially DMARD treatment started
what is enteropathic arthritis?
arthritis associated with IBD or post gastric bypass surgery
what are associated symptoms of enteropathic arthritis?
GI symptoms
erythema nodosum
what investigations are done for enteropathic arthritis?
stool sample
FBC, LFTs
colonoscopy or upper GI endoscopy
what is the treatment for enteropathic arthritis?
treat underlying IBD
NSAIDs
intra articular steroids
what can cause gout?
increased urate production:
- alcohol
- red meat and fish
- haemolytic diseases
decreased excretion:
- CKD
- hypothyroidism
- drugs (diuretics, chemotherapies)
what is acute gout?
mono arthritis that typically presents in 1st MCP, ankle or knee joint
lasts 3-10 days
what is chronic gout?
multiple acute attacks that cause tophi to develop in joints
(large, painless white deposits of sodium urate)
what are the investigations for gout?
blood - urate levels
joint aspiration - needle shaped, negatively birefringent crystals
what is the treatment for acute gout?
1st line: NSAIDs and PPI
2nd line: cochicine
3rd line: steroids
(around 2 weeks for acute attack)
why would a patient be put on colchicine instead of NSAIDs in gout? what should you warn patients off with colchicine?
peptic ulcer disease
D & V
when is chronic treatment started for gout?
after 1st attack of gout
what is the treatment for chronic gout?
1st: allopurinol
2nd: febuxosat
when should chronic gout treatment be started?
2 to 4 weeks after attack
not to be started during attack
what extra treatment should patients be given when starting chronic gout treatment and why?
cover with acute drug (colchicine)
can potentially precipitate an attack
what is deposited in the joints in pseudogout?
calcium pyrophosphate crystals
what is deposited in the joints in gout?
sodium urate crystals
what is the difference between the crystals in gout and pseudogout?
gout - needle shaped negatively birefringent pseudogout - rhomboid shaped weakly positive birefringent
what conditions are associated with psuedogout?
metabolic ones - diabetes, haemochromatosis, hyperparathyroidism
ageing
injury
what joints are affected in pseudo gout?
knee, wrist and shoulder
what is the treatment for pseudogout?
1st line: NSAIDs +/- intra articular steroids
2nd line: colchicine
(no prophylactic treatment)
