Rheumatology Flashcards
Define osteoarthritis
Wear and tear of the joints - non inflammatory degeneration of joints.
Risk factors for osteoarthritis
Obesity
Age
Occupation
Trauma
Female
FH
Signs of osteoarthritis on xray
LOSS
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts
History of osteoarthritis
Joint pain and stiffness
Worsened by activity
Better in the morning
Deformity
Instability
Reduced function
Commonly affected joints in osteoarthritis
Hips
Knees
Sacro-iliac joints
DIP
CMC joint at base of thumb
Wrist
Cervical spune
Signs of osteoarthritis in the hands
Heberden’s nodes
Bouchard’s nodes
Squaring at the base of thumb
Reduced motion
Management of osteoarthritis
Weight loss
Physio
OT
NSAIDs
(Opiates)
Intra-articular steroids
Joint replacement
Define rheumatoid arthritis
An autoimmune condition that causes chronic inflammation of the synovial lining of the joints, tendon sheaths and bursa. A symmetrical polyarthritis.
What genetics are associated with rheumatoid arthritis
HLA DR4
HLA DR1
What auto antibodies should be tested in rheumatoid
Rheumatoid factor - not sensitive or specific
Anti-CCP - much better
History of rheumatoid arthritis
Symmetrical distal polyarthropathy
Pain
Swelling
Stiffness - morning
Fatigue
Weight loss
Flu like illness
Muscle aches and weakness
Pain worse after rest and improves with activity
Common joints affected in rheumatoid arthritis
PIP
MCP
Wrist and ankle
Metatarsophalangeal joints
Cervical spine
Large joints
Not distal inter phalangeal joints!
Signs of rheumatoid arthritis in the hands
Palpation of the synovium feels boggy
Z shaped deformity of the thumb
Swan neck deformity
Boutonniers deformity
Ulnar deviation
Extra-articular manifestations of rheumatoid arthritis
Pulmonary fibrosis - caplan’s syndrome
Bronchiolitis
Felty’s syndrome - RA, neutropenia and splenomegaly
Sjorgren’s syndrome
Anamia
Cardiovascular disease
Episcleritis and scleritis
Rheumatoid nodules
Lymphadenopathy
Carpel tunnel syndrome
Amyloidosis
Investigations in rheumatoid arthritis
Clinical diagnosis
RF
Anti-CCP
CRP and ESR
Xray
Ultrasound - synovitis
Xray changes seen in rheumatoid arthitis
Joint destruction and deformity
Soft tissue swelling
Periarticular osteopenia
Boney erosions
Management of rheumatoid arthritis
Physio
OT
NSAIDs
DMARDs - methotrexate (+folic acd), leflunomide, sulfasalazine (hydroxychloroquine)
2 in combination
Biologicals - TNF inhibitors (infliximab, asalimumab)
Surgery - deformities
Rituximab
Define psoriatic arthritis
Inflammatory arthritis associated with psoriasis. Part of the seronegative spondyloarthropathy group
What are the possible patterns of psoriati arthritis
Symmetrical polyarthritis - simmilar to RA but DIP affected
Asymmetrical pauciarthritis - affect only a few joints in fingers and toes
Spondylitic pattern - back stiffness, sacroiliitis, atlanto-axial joint involvement
Clinical signs of psoriatic arthritis
Plaques of psoriasis
Pitting of the nails
Onycholysis - separation of nail from ben
Dactylitis - inflammation of full finger
Enthesitis - inflammation of entheses, points of tendon insertion on bone.
Eye disease
Aortitis
Amyloidosis
Xray changes seen in psoriatic arthritis
Periostitis
Ankylosi - bones joining together
Osteolysis
Dactylitis - soft tissue swelling
Pencil-in-cup appearance!
Management of psoriatic arthritis
Similar the rheumatoid
NSAIDs
DMARDs
Anti-TNF
Ustekinumab
Define reactive arthritis
Where synovitis occurs in the joints as a reaction to a recent infective trigger. typically acute monoarthritis in the lower limb.
Most common infections - gastroenteritis, STI (chlamydia, gonococcal septic arthritis)
What conditions are associated with reactive arthritis
Bilateral conjunctivitis
Anterior uveitis
Circinate balanitis
Can’t see, pee or climb a tree
Management of reactive arthritis
Exclude septic arthritis - aspirate (culture and crystal)
NSAIDs
Intraarticular Steroids
Systemic steroids
Define ankylosing spondylitis
An inflammatory condition mainly affecting the spine that causes progressive stiffness and pain. It mainly affects the sacroiliac joints and can progress to fusion,
What genetics are associated with ankylosing spiondylitis
HLA B27
History of ankylosing spndylitis
Young adult male in late teens or 20s
Gradual onset of lower back pain and stiffness
Worse at night and in the morning
Symptoms fluctuate with flares
What conditions are associated with ankylosing spondylitis
Systemic symptoms - fatigue, weight loss
Chest pain - costovertebral cost sternal joints
Enthesitis
Dactylitis
Anaemia
Anterior uveitis
Aortitis
Heart block
Restrictive lung disease
Pulmonary fibrosis
Inflammatory bowel disease
Investigations in ankylosing spondylitis
Inflammatory markers - CRP and ESR
HLAB27
Xray
MRI - bone marrow oedema
What xray changes are seen in ankylosing spondylitis
Bamboo spine - later stagees
Squaring of vertebral bodies
Subchondral sclerosis and erosions
Syndesmophytes
Ossification of ligaments
Fusion
Management of ankylosing spondylitis
NSAIDs
Steroids - during flares
Anti-TNF
Secukinumab
Physio
Exercise
Avoid smoking
Bisphosphonates
Manage complications
Surgery for deformities
Define systemic lupus erythematosus
Inflammatory autoimmune connective tissue disease. Immune response to proteins within nuclei.
History of SLE
Fatigue
Weight loss
Arthralgia
Myalgia
Fever
Photosensitive malar rash - butterfly shaped
Lymphadenopathy and splenomegaly
Shortness of breath
Pleuritic chest pain
Mouth ulcers
Hair loss
Raynaud’s
Investigations in SLE
Auto antibodies
FBC
C3 and C4
CRP + ESR
Immunoglobulins
Urinalysis - protein creatinine ratio
Renal biopsy
What auto antibodies are tested in SLE
ANA
anti-diDNA - very specific to SLE
anti-ENA
Complications of SLE
Cardiovascular - chronic inflammation in blood vessels, HTN and coronary artery disease
Infection - 2dry to immunosuppression
Anaemia
Pancytopenia
Pericarditis
Interstitial lung disease - pulmonary fibrosis
Lupus nephritis
Neuropsychiatric SLE - inflammation of the central nervous system
Recurrent miscarriage
VTE
Management of SLE
First line
NSADs
Steroids
Hydroxychloroquine
Suncream
Immunosuppression
Methotrexate, mycophenolate mofetil, azathioprine, tacrolimus, leflenomide, ciclosporin
Biological
Rituximab
Belimumab
Define discoid lupus erythematosis
A non-cancerous chronic skin condition often found in women and associated with SLE. Rarely leisions can progress to squamous cell carcinoma
History of discoid lupus erythematosus
Lesions on face, ears and scalp
Photosensitive
Scaring alopecia
Hyper or hypo-pigmented scars
What do discoid lupus erythematosus lesions look like
Inflamed
Dry
Erythematous
Patchy
Crusty and scaling
Management of discoid lupus erythematosus
Sun protection
Topical steroids
Intralesional steroid injection
Hydroxychloroquine
Define systemic sclerosis
Often call scleroderma - autoimmune inflammatory and fibrotic connective tissue disease
What are the main patterns of systemic sclerosis
Limited cutaneous systemic sclerosis
Diffuse cutaneous systemic sclerosis
Define limited cutaneous systemic sclerosis
Previously called CREST syndrome
Calcinosis
Raynaud’s
oEsophageal dysmotility
Sclerodactyly
Telangiectasia
Define diffuse cutaneous ststemic sclerosis
Includs features of CREST syndrome plus:
Cardiovascular problems
Lung problems
Kidney problems
Define scleroderma
Hardening of the skin
Shiny tight skin without normal folds.
Most notable on the hands and face
Define sclerodactyly
Skin tightens around the joints restricting motion. Skin hardens and tightens further there is loss of fat pads
Skin can also break and ulcerate
Define telangiectasia
Dilated small blood vessels in the skin - fine thready appearance
Define calcinosis
Calcium deposits built up under the skin - commonly in fingertips
Define Raynaud’s phenomenon
Where fingertips go completely white and then blue in response to mild cold
Caused by vasoconstriction
Define oesophageal dysmotility
Connective tissue dysfunction in the oesophagus commonly associated with swallowing difficulties, acid reflux and oesophagitis
Define scleroderma renal crisis
Acute condition where there is a combination of severe hypertension and renal failure
What auto antibodies are found in systemic sclerosis
ANA
Anti-centromere antibodies - limited
Anti-Scle-70 - diffuse
Management of systemic sclerosis
Steroids and immunosuppressants
Avoid smoking
Gentle skin stretching
Regular emollients
Avoid cold triggers
Physio
OT
Nifedipine - raynauds
PPI - gi symptoms
Analgesia
Abx for skin infection
Antihypertensive
Treat pulmonary hypertension
Supportive management
Define polymyalgia rheumatica
Inflammatory condition that causes pain and stiffness in the shoulders, pelvic girdle and neck. Strongly associated with giant cell arteritis
Features of polymyalgia rheumatica
Present for at least 2 weaks
Bilateral should pain that may radiate to the elbow
Bilateral pelvic girdle pain
Worse on movement
Interferes with sleep
Stiffness for atleast 45 minutes
Others - systemic symptoms, upper arm tenderness, carpel tunnel, pitting oedema
Differentials for polymyalgia rheumatica
Osteoarthritis
Rheumatoid arthritis
SLE
Myositis
Cervical spondylitis
Adhesive capsulitis
Hyper or hypothyroidism
Osteomalacia
Fibromyalgia
Investigations in polymyalgia rheumatica
Clinical diagnosis and response to steroids
Inflammatory makers - ESR CRP
FBC
UE
LFT
Calcium
Serum protein electrophoresis - myeloma
Thyroid
Creatinine kinase - myositis
Rheumatoid factor
Urine dip
Autoantibodies
Management of polymyalgia rheumatica
Steroids!
15mg Pred OD
Reducing regieme
What additional measures should be in place for patients of long term steroids
Don’t STOP
Don’t immediately stop steoird
Sick day rules -
Treatment card
Osteoporosis - bisphosphonates
Proton pump inhibitor
Define giant cell arteritis
A systemic vasculitis of the medium to large arteries, typically presenting with temporal arteritis.
History of giant cell arteritis
Severe unilateral headache around the temple or forehead
Scalp tenderness may be noticed on brushing hair
Jaw claudication
Blurred or double vision
Irreversible painless complete sight loss can occur rapidly
Fever
Muscle aches
Fatigue
Weight loss
Loss of appetite
Peripheral oedema
Investigations in giant cell arteritis
Clinical diagnosis
Raised ESR
Temporal artery biopsy
FBC
LFT - alp
CRP
Duplex US - hypoechoic halo sign
What is seen on temporal artery biopsy in giant cell arteritis
Multinucleated giant cells
Management of giant cell arteritis
Steroids!
40-60mg prednisolone
Aspirin - decreases visual loss and stroke
PPI for Gi protection on steroids
Define myositis
Infalmmation within the muscles
Define polymyositis
Condition of chronic inflammation in the muscles
Define dermatomyositis
A connective tissue disorder where there is chronic inflmmation of the skin and muscles
Features of dermatomyositis
Gottron lesions - scaly erythematous patches on knuckles, elbows and knees
Photosensitive erythmatous
Purple rash on the face and eyelids
Periorbital oedema
Subcutaneous calcinosis
Define antiphospholipid syndrome
A disorder associated with antiphospholipid antibodies where the blood becomes prone to clotting. Can occur on its own or with other autoimmue conditions, maily SLE
What conditions are associated with antiphospholipid syndrome
DVT
PE
Stroke
MI
Renal thrombosis
Recurrent miscarriage
Stillbirth
Preeclampsia
Livedo reticularis - purle lace like rash
Libmann0Sacks endocarditis - non bacterial growths on valves
Thrombocytopenia
Management of antiphospholipid syndrome
Warfarin
Pregnancy - LMWH
Define Sjogren’s sndrome
Autoimmune condition that affects the exocrine glands - leads to symptoms of dry mucous membranes like mouth and eyes. Can be secondary to SLE
What test can be done for Sjogren’s syndrome
Schirmer test
Folded piece of filter paper under eyelid - tears don’t travel as far in Sjogren’s
Management of Sjogren’s syndrome
Replacement of fluids
Artificial tears, saliva, lubricants
Hydroxychloroquine
Complications of Sjogren’s syndrome
Infections
Rarely can affect other organs
Define vasculitis
Inflammation of the blood vessels
Examples of small vessel vasculitis
Henoch-Schonlein purpura
Eosinophilic granulomatosis with polyangitis - Churg-strauss syndrome
Microscopic polyangitis
Granulomatosis with polyangitis
Examples of medium vessel vasculitis
Polyarteritis nodosa
Churg-Strauss syndrome
Kawasaki disease
Examples of large vessel vasculitis
Giant cell arteritis
Takaysu’s arteritis
Presentation of vasculitis
Purpura
Joint and muscle pain
Peripheral neuropathy
Renal impairment
Gastrointestinal disturbance
Anterior uveitis
Hypertension
Systemic manifestations
Investigations in vasculitis
Inflammatory markers
ANCA!
p-ANCA - microscopic polyangitis and Churg-Straus syndrome
c-ANCA - granulomatosis with polyangitis
Management of vasculitis
Steroids
Immunosuppressants
Define Henoch-Schonlein purpura
IgA vasculitis commonly presenting with purpuric rash in lower limbs and buttocks.
Often triggered by upper airway infection or gastroeenteritis. Children under 10.
Classic features of Henoch-Scholein purpura
Purpura
Joint pain
Abdominal pain
Renal involvement
Define granulomatosis with polyangitis
Previously Wegener’s granulomatosis
Small vessel vasculitis affecting respiratory tract and kidneys
Clinical features of Kawasaki disease
Persistant high fever >5 days
Erythematous rash
Bilateral conjuntivitis
Erythema and desquamation
Strawberry tongue
Complication of Kawasaki disease
Coronary artery aneurysm
Management of Kawasaki disease
Aspirin
IV Ig
Define Takayasu’s arteritis
Large vessel vasculitis mainly affecting the aorta and its branches. These swell and form aneurysms or become narrowed and blocked
Define Behcet’s disease
Complex inflammatory condition that characteristically presents with recurrent oral and genital ulcers.
Define gout
A type of crystal arthropathy associated with chronically high blood uric acid levels. Urate crystals are deposited in the joint causing it to become hot, swollen and painful
Risk factors for gout
Male
Obesity
High purine diet - meat, seafood
Alcohol
Diuretics
Existing cardiovascular or kidney disease
FH
Joints most commonly affected by gout
Base of the big toe - metatarsophalangeal joint
Wrists
Base of thumb - carpometacarpal joints
Large joints - knee and ankle
Investigations in gout
Exclude septic arthritis - aspiration
Xray
What crystals are seen in gout
Needle shaped negatively birefringent monosodium urate crystals
Xray changes seen in gout
Maintained joint space
Lytic lesions
Punched out lesions
Erosions can have sclerotic borders with overlying edges
Managenent of gout
Acute flare
NSAIDs
Colchicine
Steroids
Cholchicine
Prophylaxis
Allopurinol - once acute attack over
Weight loss, hydration, diet improvement
Define pseudo gout
Crystal arthropathy caused by calcium pyrophosphate, also known as chondrocalcinosis
Crystals seen in pseudo gout
Rhomboid shaped positively birefringent calcium pyrophosphate crystal
Management of pseudo gout
NSAIDS
Cholchicine
Joint aspiration
Steroid injections
Oral steroids
Define osteoporosis
Condition where there is a reduction in the density of bones
Define osteopenia
Refers to a less severe reduction in bone density than osteoporosis
Risk fractures for osteoporosis
Age
Female
Reduced mobility
Low BMI
Rheumatoid arthritis
Alcohol and smoking
Long term corticosteroids
SSRIs, PPIs, anti-epileptics and anti-oestrogens
Post menopausal women! no oestrogen
What tool is used to assess risk of fragility fracture
FRAX tool
10 year proability or major osteoporotic fracture and hip fracture
What is measured with a DEXA scan
Bone mineral density
What is measured with a DEXA scan
Bone mineral density - give this as a T score
What T score is considered normal
> -1
What T score suggests osteopenia
-1 to -2.5
What T score suggests osteoporosis
<-2.5
Management of osteoporosis
Lifestyle
Activity and exercise
Maintain weight
Calcium intake
Adequate vit D
Avoid falls
Stop smoking and alcohol
Vit D and calcium supplementation
Bisphosphonates
Denosumab
Strontium ranelate
Raloxifene
Hormone replacement
Define osteomalacia
A condition where there is defective bone mineralisation causing soft bones. Results from vitamin D insufficiency. If present can lead to rickets.
Presentation of osteomalacia
Fatigue
Bone pain
Muscle weakness
Muscle aches
PAthological fractures
Risk factors for vit D deficiency
Darker skin
Low exposure to sunlight
Live in colder climates
Spend more time indoors
Investigations in osteomalacia
Vit d levels
Serum calsium + phosphat low
Raised ALP
PArathyroid hormone raised
Xray
DEXA
Management of osteomalacia
Vit D supplement
Define pagets disease
Refers to disorder of bopne turnover - excessive bone turnover due to excessive activity if blasts and clasts leads to patchy areas of high and low density resulting in misshapen bones with structural problems increasing the risk of fracture.
Xray changes seen in pagets disease of bone
Bone enlargement and deformity
Osteoporosis circumscripta - well defined osteolytic lesions that appear less dense compared with normal bone
Cotton wool appearance - skull
Vshaped defects - in long bones
Management of pagets diseas of bone
Bisphosphonates
NSAIDs
Calcium and vit D supplementation
Surgery - fracture, severe deformity or arthritis
Complications of Paget’s disease of bone
Osteogenic sarcoma - osteosarcoma
Spinal stenosis
Define osteosarcoma
A type of bone cancer with very poor prognosis
Presents with increased focal bone pain swelling and fracture.
