Rheumatology Flashcards
Clinical Features of Osteoarthritis
Typically affects women aged >55yrs (3:1 F:M ratio)
- Typically bilateral affecting one joint at a time. DIP and CMC affected more than PIP
- Episodic joint pain & stiffness - provoked by movement + relieved by rest
- Herbedens nodes - at DIP
- Bouchard’s nodes - PIP
- Squaring of the base of the thumb
X ray changes; (LOSS)
* Loss of joint space
* Osteophytes (boney spurs)
* Subarticular sclerosis
* Subchondral cysts
Clinical Features of Rheumatoid Arthritis
Inflammatory arthritis - autoimmune condition.
Genetic associations = HLA DR4 & HLA DR1
Antibodies = **RF and Anti-CCP **(more sensitive)
Presentation;
* Symmetrical distal polyarthropathy (mainly hands & feet)
* Morning stiffness + pain improves on activity
* Gradually worsens with large joints getting involved
* May have systemic Sx = fatigue, weight loss, flu-like Sx
* Rheumatoid nodules - typically on the elbow
* Hand signs = Z shaped thumb deformity, Swan-neck deformity, Boutonnieres + ulnar deviation of the fingers.
O/E - Positive Squeeze test + palpation of synovium gives a **boggy **feeling due to inflammation.
Diagnosis + Management of Rheumatoid arthritis
Diagnostic criteria; Score >6 is diagnostic
* Joints that are involved (1 per joint)
* Serology +ve
* Inflammatory markers raised
* Duration of symptoms (> 6 weeks)
Do RF first line and then check Anti-CCP if its +ve.
Xray changes;
* Joint destruction/deformity
* Soft tissue swelling
* Pertiarticular osteopenia
* Boney erosions (= worse prognosis)
Joint aspiration = high WBC & Yellow turbid fluid.
Management;
1. DMARDs 1st line (e.g methotrexate, leflunomide or Sulfalazine)
2. Add in Anti-TNF or Rituximab.
How to manage an acute flare of RA
IM steroids (e.g methylpred) - as DMARDs take up to 2-3months to be effective
Poor prognostic factors in Rheumatoid arthritis
Younger onset
Male
More joints affected
Presence of RF or Anti-CCP
Boney erosions on xray
Extra articular manifestations in Rheumatoid arthritis
- Caplan’s syndrome - Pulmonary fibrosis due to pulmonary nodules
- Felty’s syndrome = RA + Neutropenia + Splenomegaly
- Sicca’s syndrome = Sjogren’s symptoms due to RA
- Episcleritis + Scleritis
- Lymphadenopathy
- Carpel tunnel
- Amyloidosis
NOTE - another complication is Atlantoaxial subluxation - this occurs in the C spine and can resultin spinal cord compression. (especially important if a patient is going for surgery due to head positioning - they should have anterior and lateral cervical spine radiographs prior to surgery).
What is palindromic rheumatism
Short episodes of inflammatory arthritis with joint pain, stiffness + swelling affecting a few joints. Typically only lasts 1-2 days then completely resolves.
Psoriatic arthritis
An inflammatory arthritis associated with psoriasis.
It is a **seronegative spondylarthropathy (HLA-B27) **
Typically occurs 10 years after skin changes and is present in 20% of psoriasis patients.
Features;
* Mostly a symmetrical polyarthritis (V similar to RA) but 20% are asymmetrical oligoarthritis affecting hands & feet (this is the main differentiator from RA)
* Sacroilitis
* Telescoping fingers
Other signs = Psoriatic skin lesions, Tenosynovitis & Enthesitis (e.g achilles tendinopathy) + dactylitis. May have psoriatic nail change.s
Xray changes;
* Shows periarticular erosions + new bone formation
* Periositis = periosteum inflammation (thickened bone outline)
* Osteolysis + Ankylosis
* **Pencil in cup appearance. **
Management;
* Basically the same as RA however for mild disease NSAIDs are enough (DMARDs not needed unless severe)
* Monocloncal antibodies e.g Ustekinumab can be trialled after Anti-TNF therapy
Reactive arthritis
Can’t see, can’t pee can’t climb a tree
A spondylarthropathy - HLAB27
Commonly triggered by Chlamydia or Gastroenteritis.
Features;
* Bilateral conjunctivitis
* Anterior uveitis
* Circinate balantitis (dermatitis of the penis)
* Arthritis - typically a hot swollen knee
Management;
1. Rule out septic arthritis - aspirate & culture the joint
2. Rule out gout - send for crystal examination
NSAIDs + steroid injections can be of use. Will resolve in 6 months and unlikely to recur. If recurrent start DMARDs.
Enteric arthritis
Part of the seronegative spondylarthropathies - HLAB27
10-15% of patients will have IBD (mainly UC) & Remission of disease usually remits joint disease (may persist in chrons)
Can also be secondary to intestinal bypass, bacterial overgrowth syndrome, coeliac etc
Features;
* Typically asymmetrical and worse in lower limb
* Sacroiliits or spondylitis common
* Joint pain may precede the bowel disease
Gout Fluid aspirate + Xray findings
Fluid aspirate shows;
* No bacteria.
* Monosodium urate crystals
* **Needle-shaped crystals with negative bifringement of polarised light. **
Xray shows;
* Joint space is maintained!!!
* Lytic lesions in bone + Punched out erosions with sclerotic borders.
Causes of gout
DART
Diuretics - particularly thiazides
Alcohol
Renal disease
Trauma
Management of gout
NSAIDs or Colchicine are 1st line
Steroids 2nd line
Prophylaxis = Allopurinol (do not start this until the acute attack has settled) + lifestyle changes
Measure serum urate 2 weeks after inflammation settles
Pseudogout Features
Caused by calcium pyrophoshate crystals.
Aspiration shows **rhomboid shaped crystals with +ve birefringement. **
Xray shows chondrocalcinosis - thin white line in middle of joint. May have OA features also.
Types of seronegative spondylarthropathies + features
Psoriatic arthritis
Reactive arthritis
Enteric arthritis / IBD
Ankylosing spondylitis
Features;
* Enthesopathy - e.g achilles tendinopathy / plantar fasciitis
* Pulmonary fibrosis
* Sacroiliitis
* Uveitis
* Amyloidosis
* Aortic regurg
Ankylosing spondylitis
Inflammation / fusion of Vertebral column + Sacroiliac joints.
Presentation;
* Typically young male aged 20ish yrs with Low back pain, stiffness + sacroiliac pain in buttocks.
* Develops gradually.
* Pain worse at rest + improves with activity.
* Morning stiffness
O/E
- Reduced lateral flexion
- Schober’s test: *reduced forward flexion, distance between points does not increase >5cm *
- Reduced chest expansion
Xray;
- Bamboo spine (squaring of the vertebral bodies)
- subchondral sclerosis + erosions
- syndesmophytes: areas of bone growth where the ligaments insert into bone
CRP/ESR will be high. HLABS27 gene testing. Pelvic radiograph useful to see sacro-ileitis.
Management = 1st line is phsyiotherapy for 4 weeks. NSAIDs. Steroids may be useful in flairs. Commence Anti-TNF if failure to respond to 2 NSAIDs
Still’s disease
Bimodal age distribution - 15-25yrs and 35-46yrs.
Presentation;
* Salmon-pink maculopapular rash
* Fever - typically highest in the evening
* Athralgia
This condition may mimic sepsis as patient can be severely unwell.
**Raised Ferritin **- is a clue for this condition + progression marker
Management = NSAIDs, steroids or Anti-TNF.
SLE
Autoimmune connective tissue disease (T3 hypersensitivity = immune deposition in organs)
MarkerS = ANA & Anti-dsDNA, Also Anti-smith + Antiphospholipid antibodies (syndrome is a complication of SLE)
Presentation;
* More commin in young-middle aged females & Asians
* Systemic = Fatigue + weight loss + fever
* MSK = Arthralgia + Myalgia
* Derm = Photosensitive bufferly rash on cheeks
* Lymphadenopathy / Splenomegaly
* Raynaud’s
* SOB + Chest pain
* Mouth ulcers + Hair loss
Management;
1. NSAIDs & Steroids/Hydroxychloroquine & Suncream 1st line
2. other immune modulators e.g methotrexate, tacrolimus, ciclosporin etc can be used
3. For severe disease can try rituximab or belimumab
Complications of SLE
- Lupus nephritis - severe complication which can lead to ESRF. Has a ‘wire-loop’ appearance to the glomeruli. Treat with glucocorticoids + Mycophenolate
- CVD
- Infection
- Pericarditis - the most common cardiac manifestation
- Interstitial lung disease
- Antiphospholipid syndrome
- Neuropsychiatric SLE
