rheumatology

Question 1

What is rheumatology?

Answer 1

Medicine- joint, bone and muscle disease

Inflammatory- auto immune, crystal arthritis, infection

Non inflammatory- degenerative (osteoarthritis), non degenerative (fibromyalgia)

Question 2

What are examples of auto immune joint disorders?

Answer 2

Rheumatoid arthritis
Spondylo-arthropathy (HLAB27)
Connective tissue disease

Question 3

What is rheumatoid arthritis?

Answer 3

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

Question 4

How can inflam be characterised?

Answer 4

Red (rubor)
Hot (calor)
Painful (dolor)
Swollen (tumour)

Question 5

What are physical features of rheumatoid arthritis?

Answer 5

Z thumb deformity
Swelling and subluxation of metacarpal joints
Ulnar deviation of fingers
Boggy swelling
Spares distal interphalangeal joint
Swan neck deformity

Question 6

What are extra articular features of rheumatoid arthritis?

Answer 6

Lungs- nodules, lung fibrosis, pleural effusions

Cardiovascular- pericarditis, myocarditis, endocarditis

Kidneys- amyloidosis

Skin- rheumatoid nodules, vasculitis

Secondary Sjögren’s syndrome

Question 7

How might blood tests and X-rays indicate rheumatoid arthritis?

Answer 7

Anaemia
High/low platelet
CRP and ESR
Auto antibodies

Early- osteopenia, soft tissue swelling
Late- erosions, joint space narrowing, subluxation, fusion

Question 8

What is the tx for rheumatoid arthritis?

Answer 8

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

Question 9

What side effects can the tx for rheumatoid arthritis cause?

Answer 9

Infection (all increase)
Bone marrow toxicity (pancytopenia)
Hepatotoxic (rise in enzymes)
Gastric upset (nausea, diarrhoea, flatulence)
Skin rashes

Question 10

What is methotrexate?

Answer 10

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

Question 11

What are biologic drugs?

Answer 11

Much greater infection risk- stop before surgery/significant procedure

Reactivation of TB/Hep B &C
Anti TNF may cause/exacerbate MS

Question 12

What is rheumatoid neck?

Answer 12

Erosive change at C1 C2
Subluxation at atlantoaxial +/- subaxial levels
Instability can lead to neurological deficit from spinal cord compression

Question 13

How do you manage rheumatoid neck?

Answer 13

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

Question 14

What is the caries/gingivitis risk in rheumatoid arthritis?

Answer 14

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

Question 15

What is Juvenile Idiopathic Arthritis?

Answer 15

Before 16 yrs
>50^ grow out of it by adulthood
Jaw underdevelopment- TMJ inflam, malocclusion, micrognathia, pain, biomech problems

Question 16

What is spondylo arthropathy?

Answer 16

Collective term for-
Ankylosing spondylitis
Reactive arthritis
Psoriatic arthritis
Enteropathic arthritis (crohns/UC)

Question 17

What is ankylosing spondylitis?

Answer 17

Progressive new bone formation/calcification in spine- severe limitation of movement
Can have rigid/fused neck +/- atlanto-axial subluxation
-risk of fracture

Question 18

What are common features of spondylo arthropathy?

Answer 18

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

Question 19

What is osteoarthritis?

Answer 19

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)

Question 20

What is gout?

Answer 20

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

Question 21

Why might someone have high serum urate?

Answer 21

Genetic
Renal impairment diuretics
Dehydration
Inter current illness
High alcohol/red meat/shellfish diet
Part of metabolic syndrome

Question 22

What are connective tissue diseases?

Answer 22

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

Question 23

What are common features of connective tissue disorders?

Answer 23

Mouth ulcers
Cardio resp disease
Raynauds (vasoconstriction in digits to cold)

Question 24

What are features of SLE?

Answer 24

Non erosive arthritis
Butterfly rash
Photosensitivity

Question 25

What are features of scleroderma?

Answer 25

Progressive skin thickening/tightening
Severe Raynauds

Limited- pulmonary hypertension, severe acid reflux, telangiectasia, microsomia, oral tethering

Widespread- pulmonary fibrosis, renal failure

Question 26

What is Sjögren’s syndrome?

Answer 26

Primary- on its own w/o rheumatic illness

Secondary- w rheumatic illness and other autoimmune disorders

Question 27

What are features of primary Sjögren’s?

Answer 27

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

Question 28

What is polymyositis/dermatomyositis?

Answer 28

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

Question 29

What is the tx for connective tissue disorders?

Answer 29

NSAIDs
Steroids
DMARDs
Cytotoxic drugs
Biologic drugs (anti TNF contraindicated in SLE)