Rheumatology Flashcards
What is the presentation of rheumatoid arthritis?
*Joint pain
*Tender, swollen joints
*Early morning stiffness ≥1 hour and joint gelling
*Symmetrical
*Typical sparing of the DIP joint
Investigations for rheumatoid arthritis
*Rheumatoid factor
*Anti CCP
*Radiograph
*Ultrasound
*CRP
*ESR
Criteria for rheumatoid arthritis
*EULAR - score of 6 or more
*2-10 large joints = 1
*1-3 small joints =2
*4-10 small joints=3
*>10 joints, at least 1 small = 5
*Low positive RF or anti CCP (≤3 time upper limit) = 2
*High positive RF or anti CCP = 3
*ongoing for ≥6 weeks = 1
*Abnormal CRP or ESR = 1
What should be checked before commencing treatment for rheumatoid arthritis?
*Hep B and C
*Purified protein derivative (PPD)
*FBC, LFTs
What is the management of rheumatoid arthritis?
*DMARD: sulfasalazine if low disease activity, consider oral prednisolone and NSAID
*DMARD: methotrexate if moderate/severe disease, oral prednisolone, NSAID, COX-2 inhibitor
*Second line: add another DMARD
*Third line: biological therapy (anti-TNF)
*Fourth line: methotrexate + rituximab
What are the complications of rheumatoid arthritis?
*Deformity: swan neck, ulnar deviation, z-thumb, boutonniére
*Work disability
What are the extra articular manifestations of rheumatoid arthritis?
*Pulmonary fibrosis with pulmonary nodules
*Felty’s syndrome
*Anaemia of chronic disease
*Cardiovascular disease
*Episcleritis and scleritis
*Carpal tunnel syndrome
What is Felty’s syndrome?
*Rheumatoid arthritis
*Neutropenia
*Splenomegaly
NAme two anti-TNF drugs
*Rituximab (monoclonal antibody against CD-20)
*Adalimumab
What is the presentation of osteoarthritis?
*Joint pain and stiffness worsened by activity
*Common joints: knee, hip, hand, spine
*Signs in the hands: Heberden’s nodes, Bouchard’s nodes, squaring at the base of the thumb
Investigation for osteoarthritis
*X ray of affected joints
*CRP and ESR (should be normal)
X ray of osteoarthritis
*Osteophytes
*Joint space narrowing
*Subchondral sclerosis
*Subchondral cysts
When can you diagnose osteoarthritis based on clinical history?
*If >45
*Typical activity related pain
*No early morning stiffness, or less than 30 mins of EMS
What is the management of oseteoarthritis?
*Patient education
*Weight loss
*Physio and occupational therapy and orthotics
*Oral paracetamol, topical NSAID
*Oral NSAID (+PPI)
*Consider opiates
*Intra-articualr steroid injection
*Join replacement (end stage, tried most non-operative)
What are the patterns of psioratic arthritis?
- Symmetrical polyarthritis: hands, wrists, ankles, DIP joints
-Spondylitic pattern: back stiffness, sacroilliitis, atlanto-axial joint involvement
-Assymetrical pauciarthritis: fingers, toes, feet
What are the signs of psioratic arthritis?
*Plaques of psoriasis
*Pitting of the nails
*Onycholysis
*Dactylitis (inflammation of the full finger)
*Enthesitis (inflammation of the insertion point of the tendon into the bone)
What is the screening tool for psoriatic arthritis?
PEST
What are the associations of psoriatic arthritis?
*Eye disease
*Aortitis
*Amyloidosis
What is the presentation of septic arthritis?
*Hot, swollen, painful, restricted joint (knee most common)
*Acute presentation
*May have fever
What is the most common cause of septic arthritis?
Staph aureus
Investigation for septic arthritis
*Synovial fluid microscopy /culture/WCC
*Gram stain and polarising microscopy of synovial fluid
*Blood culture
*White cell count
*ESR and CRP
What is the management of septic arthritis?
*Joint aspiration
*IV antibiotics for 4-6 weeks
*Surgery if no response within 48 hours
What is gout?
Hyperuricaemia and deposition of urate crystals causing attacks of acute inflammatory arthritis, tophi around the joints, renal glomerular, tubular and interstitial disease and uric acid urolithiasis
What is the presentation of gout?
*Rapid onset of severe pain
*Joint stiffness
*Swelling and joint effusion
*Tenderness
*Tophi
What is the presentation of gout?
*Rapid onset of severe pain
*Joint stiffness
*Swelling and joint effusion
*Tenderness
*Tophi
What are the risk factors for gout?
- Male
*Age
*Aspirin/ciclosporin/tacrolimus/pyrazinmide
*Alcohol
*Consumption of meat or seafood
What are the investigations for gout?
*Arthrocentesis with synovial fluid analysis: WBC>2x10^9, negatively birefringent needle shaped crystals under polarised light, monosodium urate crystals
*Serum uric acid level
What is the acute management of gout?
*NSAIDs, corticosteroid (intra-articular or parenterally) or colchicine
*Cold packs
What is the long term management of gout?
*Decreased purine and fructose intake
*Weight loss of max 1kg/month
*Exercise
*Decrease alcohol intake
*Allopurinol if ≥2 attacks in 12 months, presence of tophi, renal impairment, on diuretics, older than 40, urate>500micro mol/l
When would you prescribe allopurinol for gout?
≥2 attacks in 12 months, presence of tophi, renal impairment, on diuretics, older than 40, urate>500micro mol/l
What is the presentation of pseudogout?
*Hot, swollen, stiff joint (most often knee)
*Joint effusion
Investigation for pseudogout
*Arthrocentesis +synovial fluid analysis
*Rhomboid shaped positively birefringent crystal under polarised light
*X ray: chondrocalcinosis (thin white line in the middle of the joint space)
*Serum calcium: normal or elevated
*Serum parathyroid hormone: excludes hyperparathyroidism
What is the management of pseudogout?
*NSAIDs
*Colchicine
*Joint aspiration
*Steroid injection
*Oral steroids
What is giant cell arteritis?
*Temporal arteritis
*Systemic vasculitis of medium and large arteries
What are the risk factors for giant cell arteritis?
Female, >50
What is the presentation of giant cell arteritis?
*Headache, typically unilateral and around the forehead/temple
*Scalp pain or tenderness
*Aching, stiffness, claudication in extremities, tongue or jaw
*Blurred or double vision, painless sight loss
*May be associated with systemic symptoms
*Tenderness/thickening, or nodularity of superficial temporal arteries
Investigations for giant cell arteritis
*CRP
*ESR
*FBC
*Vascular ultrasonography or temporal artery biopsy (multi nucleated giant cells)
What is the management of giant cell arteritis
*Oral prednisolone 40-60mg per day straight away if suspected, taper this down with aim to stop steroids by 12-18 months
*Methotrexate or tocilizumab if relapse
What are the complications of giant cell arteritis?
*Vision loss
*cerebrovascular accident (stroke)
What is the presentation of polymyalgia rheumatica
*Bilateral shoulder pain that radiates to the elbow
*Bilateral pelvic girdle pain
*Worse with movement
*Interferes with sleep
*Stiffness for at least 45 minutes in the morning
*Constitutional symptoms: fever, anorexia, malaise, weight loss, low mood
Investigation for polymyalgia rheumatica
*Elevated CRP
*Elevated ESR
*FBC
What is the management for polymyalgia rheumatica?
*15mg prednisolone per day, if no response after 1 week, unlikely to be polymyalgia rheumatica
*Once symptoms are fully controlled, decrease to 12.5mg for 3 weeks then 10mg for 4-6 weeks, then reduce by 1mg every 4-8 weeks
What are the risk factors for osteoporosis?
*Older age
*Female
*Post menopausal (oestrogen protective)
*Decreased mobility
*Alcohol
*Smoking
*Long term corticosteroids
*SSRIs
*PPIs
*Anti-epileptics
*Aromatase inhibitors
Normal T score at hip
> -1
Osteopenia T score
-1 to -2.5
Osteoporosis T score
Less than -2.5
FRAX tool
Predicts the risk of fragility fracture over the next 10 years
Low risk FRAX score:
Reassure
Medium risk FRAX
Offer DEXA
High risk FRAX
treat
What is the management of osteoporosis?
*Lifestyle: activity and exercise, healthy weight, stop smoking, reduce alcohol, avoid falls
*Vitamin D and calcium supplements
*Bisphosphonates (aledronate)
*HRT in women entering menopause early
*Raloxifene (selective oestrogen receptor modulator) as secondary prevention
*Denosumab (blocks osteoclast activity)
What is ankylosing spondylitis?
Inflammatory condition mainly affecting the spine. Part of the seronegative spondyloarthropathy group relating to the HLA B27 gene
Radiological stage of axial spondyloarthritis
Presentation of ankylosing spondylitis
*Inflammatory back pain (early morning stiffness, insidious onset, age<40, lasting >3 months)
*Iritis/uveitis
*Entethesitis -> plantar fasciitis, achilles tendonitis
*Presentation in late teens or early 20s
*Fatigue and sleep disturbance
*Schober’s test positive
Schober’s test
*Find L5 and mark 10cm above and 5cm below
*Get patient to lean forwards
*If <20cm =lumbar restriction
Investigations for ankylosing spondylitis
*Pelvic X ray: sacroiliitis
*HLA B27 genetic test
*CRP and ESR
*MRI: bone marrow oedema (allows early diagnosis)
X ray changes of ankylosing spondylitis
*Bamboo spine
*Syndesmophytes - bone growth where ligaments insert into the bones
*Fusion and ossification
What is the management of ankylosing spondylitis?
*NSAIDs
*Steroids for flare
*Anti-TNF
*Physio
*Exercise
*Avoid smoking
*Bisphosphonates
What are the small vessel vasculitides?
- Henloch scholein
- Eosinophilic granulomatosis with polyangiitis
- microscopic polyangiitis
- granulomatosis with polyangiitis
What are the medium vessel vasculitides?
- Polyarteritis nodosa
- eosinophilic granulomatosis with polyangiitis
- kawasaki disease
What are the large vessel vasculitides?
- giant cell arteritis
- Takayasu’s arteritis
What is the presentation of giant cell arteritis?
- headache: temporal, tender, subacute, constant, little relief from analgesia
- Vision changes
- Jaw claudication
- constitutional symptoms
- polymyalgia rheumatica symptoms (pelvic and shoulder girdle pain_
Investigation for giant cell arteritis
- Temporal artery biopsy
- Temporal artery USS
- ESR
Presentation of henoch-schonlein purpura
- palpable purpuric rash (and localised oedema) pn buttocks and extensor surfaces
- abdominal pain
- Polyarteritis
- IgA nephritis
Presentation of eosinophilic granulomatosis with polyangiitis
- asthma
- blood eosinophilia
- paranasal sinusitis
- mononeuritis multiplex
- pANCA positive in 60%
Presentation of microscopic polyangiitis
- renal impairment: raised creatinine, haematuria, proteinuria
- fever
- lethargy, malaise, weight loss
- rash: palpable purpura
- cough, dyspnoea, haemoptysis
- mononeuritis monoplex
- pANCA/cANCA
Presentation of granulomatosis with polyangiitis
- URT: epistaxis, sinusitis, nasal crusting
- LRT: dyspnoea, haemoptysis
- Pauci-immune, rapidly progressive glomerulonephritis
- Saddle shaped nose deformity
- Vasculitic rash
- eye involvement, cranial nerve lesion
- cANCA (>90%), pANCA(25%)
- X ray (can show cavitating lesions
Presentation of polyarteritis nodosa
- fever, malaise, arthralgia
- weight loss
- hypertension
- mononeuritis multiplex
- livedo reticularis (rash)
- Hep B serology is positive in 30%
Presentation of kawasaki disease
- high grade fever lasting >5 days
- Conjunctival injection
- Bright red, cracked lips
- Strawberry tongue
- Cervical lymphadenopathy
- Red palms and soles which then peel
Presentation of takayasu’s arteritis
- systemic features
- unequal blood pressure
- carotid bruit and tenderness
- absent/weak peripheral pulse
- Upper and lower limb claudication on exertion
- aortic regurgitation
Investigation takayasu arteritis
MRA or CTA for vascualr imaging
What is Paget’s disease of the bone?
Chronic localised bone remodelling, resulting in overgrowth of poorly organised bone -> osseous deformity, nerve compression, and pathological fractures.
Disorder of osteoclasts with excessive osteoclastic activity followed by increased osteoblastic activity
Presentaiton of Paget’s disease of the bone
- asymptomatic
- long bone or back pain
- pathological fracture
- Bony deformities
- hearing loss
- isolated rise in alkaline phosphate
Investigation for paget’s disease of the bone
- x ray
- bone scan
- total serum alkaline phosphatase or bone specific
- serum calcium (usually normal)
What are the benign bone tumours?
- osteoma
- osteochondroma
- giant cell tumour
What are the malignant bone tumours?
- osteosarcoma
- Ewing’s sarcoma
- Chondrosarcoma
What is the most common benign bone tumour?
Osteochondroma
What is the msot common malignant bone tumour?
Osteosarcoma
X ray osteosarcoma
- codman triangle and sunburst pattern
X ray Ewing’s sarcoma
Onion skin appearance
X ray Giant cell tumour
Double bubble or soap bubble appearance
Where does osteosarcoma occur most frequently?
in the metaphyseal region of long bones prior to the epiphyseal closure (femur, tibia, humerus)
Where does Ewing’s sarcoma most frequently occur?
Pelvis and long bones
Where does Chondrosarcoma most commonly occur?
Axial skeleton
Where does osteoma more commonly occur?
Skull
Which tumours most commonly cause bone metastases?
- prostate
- lung
- breast
Starting with the most common, where are the common sites of bone mets?
- spine
- pelvis
- ribs
- skull
- long bones
What are the features of bone mets?
- pathological fractures
- hypercalcaemia
- raised ALP
Calcium, phosphate, ALP and PTH in osteoporosis
- Calcium: normal
- Phosphate: normal
- ALP: normal
- PTH: normal
Calcium, phosphate, ALP and PTH in Osteomalacia
- Calcium: decreased
- Phosphate: decreased
- ALP: Increased
- PTH: Increased
Calcium, phosphate, ALP and PTH in Primary hyperparathyroidism
- Calcium: increased
- Phosphate: decreased
- ALP: increased
- PTH: Increaesd
Calcium, phosphate, ALP and PTH in chronic kidney disease (secondary hyperparathyroidism)
- Calcium: decreased
- Phosphate: increased
- ALP: increased
- PTH: increaesd
Calcium, phosphate, ALP and PTH in Paget’s disease
- Calcium: normal
- Phosphate: normal
- ALP: Increased
- PTH: normal
What is the mechansim of bone destruction in cancer?
OSteoclasts stimulated by cytokines from tumour cells
What is the presentation of osteosarcoma?
- bone pain
- swelling
- pathological fracture
Where does osteosarcoma metastasise to?
Lungs- early
What is the presentation of osteoma?
- Pain, worse at night
- pain releived by aspirin
- scoliosis
- juxta-articualr tumours can cause sympathetic synovitis
What is SLE?
Autoimmune disease (type 3 hypersensitivity reaction) associated with HLA B8, DR2, DR3. Immune complex deposition can affect any organ including the skin, joints, kidney and brain
Epidemiology of SLE
- more common in women
- afro-carribbeans and asian communities
- onset aged 20-40
Presentation of SLE
- General: fatigue, fever, mouth ulcers, lympahadenopathy
- Sking: malar or discoid rash, photosensitivity, raynaud’s, livedo reticularis, non scarring alopecia
- MSK: arthralgia, non-erosive arthritis
- CV: pericarditis, myocarditis
- Resp: Pleurisy, fibrosing alveolitis
- Renal: proteinuria, glomerulonephritis
- Neuro/psych: anxiety and depression, psychosis, seizure
Investigation of SLE
- ANA (99% positive)
- 20% rheumatoid factor positive
- anti-dsDNA
- anti-smith
- ESR (CRP during active disease may be normal so if raised, may suggest infection)
- C3 and C4 may be low during active disease
What is Sjogren’s syndrome?
Autoimmune disorder affecting the exocrine glands resulting in dry mucosal surfaces
What are the features of Sjogren’s?
- Dry eyes
- dry mouth
- vaginal dryness
- arthralgia
- raynauds, myalgia
- sensory polyneuropathy
- recurrent episodes of parotitis
- renal tubular acidosis
Investigations for Sjogrens
- Rheumatoid factor
- ANA positive
- Anti Ro (70%), Anti la (30%)
- Schirmer’s test
What is Polymyositis?
Inflammatory disorder causing symmetrical, proximal muscle weakness, thought to be t cell mediated against muscle fibres
What are the features of polymyositis?
- proximal muscle weakness ± tenderness
- Raynaud’s
- respiratory muscle weakness
- interstitial lung disease
- dysphagia, dysphonia
Investigations for polymyositis
- elevated creatinine kinase
- elevated muscle enzymes e.g. LDH, AST and ALT
- EMG
- muscle biopsy
- Amti-synthetase antibodies (Anti-Jo-1)
What is dermatomyositis?
Variant of polymyositis in which skin manifestations are prominent e.g. purple (helitrope) rash on the cheeks and eyelids
what class of HLA rheumatoid
DR4
What are the signs of osteoarthritis in the hands?
- Heberdens nodes
- squaring of the base of the thumb
- Bouchard’s nodes
