rheumatology Flashcards
What is rheumatology?
Medicine- joint, bone and muscle disease
Inflammatory- auto immune, crystal arthritis, infection
Non inflammatory- degenerative (osteoarthritis), non degenerative (fibromyalgia)
What are examples of auto immune joint disorders?
Rheumatoid arthritis
Spondylo-arthropathy (HLAB27)
Connective tissue disease
What is rheumatoid arthritis?
Synonvial joint disease, 1% pop
Symmetrical joint inflam and deformity
Early morning stiffness (>30 mins)
Stiffness after rest
Ease with use/exercise
Swelling
Flu like symptoms
NSAIDs may help
How can inflam be characterised?
Red (rubor)
Hot (calor)
Painful (dolor)
Swollen (tumour)
What are physical features of rheumatoid arthritis?
Z thumb deformity
Swelling and subluxation of metacarpal joints
Ulnar deviation of fingers
Boggy swelling
Spares distal interphalangeal joint
Swan neck deformity
What are extra articular features of rheumatoid arthritis?
Lungs- nodules, lung fibrosis, pleural effusions
Cardiovascular- pericarditis, myocarditis, endocarditis
Kidneys- amyloidosis
Skin- rheumatoid nodules, vasculitis
Secondary Sjögren’s syndrome
How might blood tests and X-rays indicate rheumatoid arthritis?
Anaemia
High/low platelet
CRP and ESR
Auto antibodies
Early- osteopenia, soft tissue swelling
Late- erosions, joint space narrowing, subluxation, fusion
What is the tx for rheumatoid arthritis?
IMMEDIATE
NSAIDs, steroids
CONTROL
DMARDs (eg. methotrexate), biologic drugs (eg. Anti TNF such as infliximab)
Biologic drugs don’t appear on prescription list as it’s SC or IV
What side effects can the tx for rheumatoid arthritis cause?
Infection (all increase)
Bone marrow toxicity (pancytopenia)
Hepatotoxic (rise in enzymes)
Gastric upset (nausea, diarrhoea, flatulence)
Skin rashes
What is methotrexate?
DMARD- once weekly dose (15-25mg/wk)
Never coprescribe w Trimethoprim/Septrin (risk of severe bone marrow suppression)
Lung complications
Renally excreted
Contraindicated women pre conception
Side effects- nausea, mouth ulcers
What are biologic drugs?
Much greater infection risk- stop before surgery/significant procedure
Reactivation of TB/Hep B &C
Anti TNF may cause/exacerbate MS
What is rheumatoid neck?
Erosive change at C1 C2
Subluxation at atlantoaxial +/- subaxial levels
Instability can lead to neurological deficit from spinal cord compression
How do you manage rheumatoid neck?
Ask about neck pain and known rheumatoid neck
When positioning, check no new pain/neurological symptoms appear
Preintubation- flexion and extension X-rays of cervical spine and discuss w anaesthetist
What is the caries/gingivitis risk in rheumatoid arthritis?
Poor motility can affect hygiene
Immune suppressive drugs can compound
May have osteoporosis and bisphosphonates (BRONJ risk)
Gingivitis/caries may be a trigger for RA
What is Juvenile Idiopathic Arthritis?
Before 16 yrs
>50^ grow out of it by adulthood
Jaw underdevelopment- TMJ inflam, malocclusion, micrognathia, pain, biomech problems
What is spondylo arthropathy?
Collective term for-
Ankylosing spondylitis
Reactive arthritis
Psoriatic arthritis
Enteropathic arthritis (crohns/UC)
What is ankylosing spondylitis?
Progressive new bone formation/calcification in spine- severe limitation of movement
Can have rigid/fused neck +/- atlanto-axial subluxation
-risk of fracture
What are common features of spondylo arthropathy?
Enthesitis- inflam between tendon/ligament and bone
Dactylitis- sausage digits, joint and tendon sheath inflam
Skin/nail psoriasis
Inflam eye disease- anterior uveitis
IBS- crohns/UC
What is osteoarthritis?
Degenerative process- exaggerated repair response
Pain, stiffness, deformity, reduced joint movement, joint instability
Increases w age
Occupation/hobbies risk
X-rays- loss of joint space, osteophytes, sub chin desk sclerosis
Signs- Bouchards node, Heberdens node
Tx= physiotherapy, weight loss, analgesics, NSAIDs, surgery (uncontrolled pain/joint failure)
What is gout?
Urate crystals precipitate from bloodstream into joints/soft tissues
Intense neutrophil inflam response
Due to high serum urate
Tx= NSAIDs, colchicine, steroids
Prevention= urate lowering drugs eg. Allopurinol
Why might someone have high serum urate?
Genetic
Renal impairment diuretics
Dehydration
Inter current illness
High alcohol/red meat/shellfish diet
Part of metabolic syndrome
What are connective tissue diseases?
Rare autoimmune systemic diseases
Can be life threatening, eg. Renal failure, lung fibrosis, myocarditis
More common in women
Systemic lupus erythematous
Scleroderma
Primary Sjogrens
Polymyositis/dermatomyositis
What are common features of connective tissue disorders?
Mouth ulcers
Cardio resp disease
Raynauds (vasoconstriction in digits to cold)
What are features of SLE?
Non erosive arthritis
Butterfly rash
Photosensitivity
What are features of scleroderma?
Progressive skin thickening/tightening
Severe Raynauds
Limited- pulmonary hypertension, severe acid reflux, telangiectasia, microsomia, oral tethering
Widespread- pulmonary fibrosis, renal failure
What is Sjögren’s syndrome?
Primary- on its own w/o rheumatic illness
Secondary- w rheumatic illness and other autoimmune disorders
What are features of primary Sjögren’s?
Dry eyes and mouth
Ro and La antibodies
High Ig, high ESR and +ve RF
Fatigue
Joint pain
Rare complications- vasculitis, renal tubular acidosis, peripheral neuropathy, primary biliary cirrhosis, lymphoma
What is polymyositis/dermatomyositis?
Inflam and painless wasting of muscles
Weakness of arms/thighs
Associated w lung fibrosis
POLYMYOSITIS
-muscle only
DERMATOMYOSITIS
-muscle and skin
-photo sensitivity (purple heliotrope rash around eyes)
-strong association w internal malignancy
What is the tx for connective tissue disorders?
NSAIDs
Steroids
DMARDs
Cytotoxic drugs
Biologic drugs (anti TNF contraindicated in SLE)
