Rheumatology Flashcards
what is ankylosis?
abnormal stiffening and immobility of a joint due to fusion of bones
What HLA is Ankylosing spondylitis associated with? main population affected?
HLA B27 (+ve in 90-95%)
affects young males 20-30 / 15-40
Modified Schober’s test - how?
The modified Schober’s test should be used for serial measurement
To perform this test, mark two points on the back (one 5 cm below and one 10 cm above a line drawn between the dimples of Venus)
On forward flexion, the distance between the two points should be >5 cm
If the distance is <5 cm, this indicates restricted forward flexion
-> tests lumbar spine in ankylosing spondylitis
what is ankylosing spondylitis?
A seronegative spondyloarthropathy and a chronic inflammatory disease of the axial skeleton that leads to partial or complete fusion and rigidity of the spine.
- a seronegative spondyloarthropathy
- features include pain, morning stiffness and reduced range of motion
- mainly affects young men
Aetiology of ankylosing spondylitis
Genetic predisposition (90-95% patients are +ve for HLA B27)
Most commonly affects young males 20-30yo / 15-40yo
symptoms of ankylosing spondylitis
- inflammatory back pain
- morning stiffness (improves with movement)
- peripheral enthesitis
- peripheral arthritis may occur in up to 1/3 pts with hips and shoulders being most commonly affected.
- tenderness of SI joints
Extra-articular
- anterior uveitis (20-30%)
- aortitis -> AR
- upper lobe pulmonary fibrosis
- IgA nephropathy (5%)
- may also have IBD
examination findings in ankylosing spondylitis
- limited spinal motion
- tenderness of the SI-joints (e.g. on FABER test)
Specific tests of the spine:
- lumbar: modified Schober’s test
- thoracic: reduced chest expansion in some (<5cm), dorsal kyphosis can develop as the disease progresses
- cervical: globally reduced movements, measure occiput to wall distance
ankylosing spondylitis management
Non-pharmacological:
- exercise and PT -> critical to maintain posture, flexibility and motility
Pharmacological:
-NSAIDs with PPI are first line
- DMARDs (sulfalazine, methotrexate -> for peripheral disease, don’t improve spinal inflammation)
- local steroid injections
- biologics (anti-TNF are first line biologics, anti-IL17 are second line, can also use anti-IL12/23)
Surgery may be indicated in some patients to improve QoL.
ix in ankylosing spondylitis
- Lab: no diagnostic ix! FBC and inflammatory markers in primary care before referral; In secondary care HLA testing is carried out.
- Imaging: plain X-rays useful in established disease but can be normal early on (pelvic, lumbar);
MRI is the most sensitive, can also be useful in evaluating response to treatment.
oligoarthritis and polyarthritis definition
Oligo: 2-4
Poly: 5+
Nociplastic pain
a type of chronic pain that is not due to tissue damage or nerve damage
a third group of pain
Scoring system for hyper mobility
Beighton
(keep in mind that the score gets worse with age, so ask about childhood)
screening questions for fibromyalgia
- sleep
- fatigue
- irritable bowel
Symptoms of fibromyalgia
- Fatigue
- exhaustion
- chronic pain (back, chest, pelvic…)
- headache
- poor sleep (unrefreshing sleep)
- palpitations
- difficulty concentrating
- brain fog
- urine frequency
- urge incontinence
- IBS / change in bowel habit
- reflux
- depression anxiety
- dry mouth
Definition and Aetiology of fibromyalgia
Definition: acquired disorder of pain/sensory processing (‘nociplastic pain’). It is a syndrome, not a disease.
Aetiology: Acquired, genetic predisposition; CNS is overreacting to sensations in the body.
More common in females (5:1), peak incidence at 30-40yo
Signs on clinical examination in fibromyalgia
- tenderness
- no joint swelling/redness/warmth, heat
- GALS: many show generalised pain
- hyperalgesia (things that should not be painful are painful)
- alodynia (things that should be slightly painful are very painful)
Ix in fibromyalgia
Fibromyalgia is NOT a diagnosis of exclusion!!
- you can do a ‘fibromyalgia syndrome diagnostic’ worksheet - ‘symptoms severity index’
- explain to the patient that there is no test you can do to confirm the diagnosis
- normal bloods
Tests to do just in case / ‘to make sure I am not missing anything’
- ESR
- FBC
- U&E (?renal failure)
- Ca, phosphate
- TFT
- HbA1c
- urine dip
DO NOT DO: RF, ANA, ANCA, CK, Igs, Vit D (unless you have a goof reason; e.g. a % of people have RF+ but no RA, everyone is Vit D deficienct so that won’t help you
Management of fibromyalgia
Conservative
- MDT: relationship, careful communication
- Education/Information
- Exercises - slow and steady
- CBT/ACT
Medical
- antidepressant (amitriptyline) - NO gabapentin/opioids/benzos/NSAIDs
Other
- acupuncture
Prognosis of fibromyalgia
- can expect to have the condition for a longer time, perhaps even life long.
- some treatments and measures can help with symptoms
- may experience flares
RFs for fibromyalgia
- female
- traumatic childhood
- stressful or traumatic events/PTSD
- family history
- repetitive injuries
- illness (such as viral infections)
- obesity
prevalence of RA in the UK
1%
what is secondary prevention?
stop at 1 -> after an incident prevent further ones
Counsel someone on a bisphosphonate
oesophagitis is a common side effect and a big reason why people stop
Fracture risk assessment tool name
FRAX
https://frax.shef.ac.uk/FRAX/tool.aspx?country=9
Where are Bouchard’s and Heberden’s nodes? What conditions do you see them in?
HD BP
Heberdens - distal
bouchards - proximal
seen in OA
X-ray features of OA
LOSS
loss of joint space
osteophytes
subchondral cysts
subchondral sclerosis
X-ray features of RA
uniform joint space loss
periarticular osteopenia
marginal erosions
soft tissue swelling
pathognomonic findings of ank spond on x-ray
syndesmophyte formation
bamboo spine
dagger sign
-> seen in advanced forms of ank spond in the spine
imaging for ank spond
MRI is better in early diseases
X-ray can have some typical findings as well
extradural bleed
MMA bleeding
subdural bleed shape
banana/crescenteric
subdural
What type of blood? Which vessles? Which patients?
venous bleeding
shearing of the bridging vessels
commoner in elderly patients
alcoholic patients, pts on blood thinners, pts with liver disease
NAI in children
SAH
causes
- most commonly due to ruptured Berry aneurysm
- ## can be due to trauma
intraparenchymal haemorrhage - causes and location
HTN is the most commonest cause
commonly located in brainstem/other deep grey matter structures
can be due to tumours or haemorrhagic transformation of an infarct
Impacted vs distracted #
impacted: 2 ends of a bone are pressed into one another.
distracted: bones pulled apart and there is a gap in the middle
1st line gold standard medication in RA
methotrexate
what medication can be used in women of childbearing age to manage RA?
sulfalazine
What is Birt Hogg Dube syndrome?
it is an AD condition featuring:
- skin lesions (fibrofolliculomas)
- lung cysts
- increased risk of renal cancer
-> regular monitoring (every 2 years lung and kidneys MRI/CT) and derm review
(first described and named after 3 Canadian physicians )
enthesitis
inflammation of where the tendon inserts
e.g. Achilles tendonitis
plantar fasciitis
What does non-radiographic change mean in the context of SpA?
No x-ray changes
may have MRI changes and changes in inflammatory markers
which biologic DMARDs are licensed in SpA?
TNF alpha blockers
IL-17a
IL-23i
JAKi (not in PMH of VTE)
what ocular adverse effect is hydroxychloroquine associated with?
retinopathy
Diagnostic criteria for PMR
age over 50
sx > 2/52
bilateral shoulder and/or pelvic girdle aching
morning stiffness lasting 45 minutes
evidence of an acute phase response
normal muscle strength
Radiograph features of Ank Spond
Radiographs may be normal early in disease, later changes include:
- sacroiliitis: subchondral erosions, sclerosis
squaring of lumbar vertebrae
- ‘bamboo spine’ (late & uncommon)
- syndesmophytes: due to ossification of outer fibers of annulus fibrosus
- CXR: apical fibrosis
What are the extra-articular features of and spond?
- Anterior Uveitis
- Atlanto-Axial subluxation
- Apical Fibrosis
- Aortic Regurgitation
- AV conduction defect
- IgA Nephropathy
- Amyloidosis
Posture in Ank spons
stooped
-> loss of lumbar lordosis
-> hyperextended neck
-> flexed hips and knees
Radiographic features of ank spond
- Squaring Vertebral bodies, Romanus lesion
- Erosion, sclerosis, narrowing SIJ
- Bamboo Spine
- Bone Marrow Oedema
Which condition is pencil in a cup deformity associated with?
Psoriatic arthritis
