Rheumatology Flashcards
Symptoms of gout
pain, swelling, erythema
Joints affected by gout
1st MTP
ankle, wrist, knee
Investigations of gout
fluid: needle shaped negatively birefingement monosodium urate crystals
XR: joint effusion, punched out erosions
Uric acid: check 2 weeks after acute episode
Gout Management
1) NSAIDS/cochicine +PPI
2) PO steroids
3) intra-articular steroids
URT
What is URT
Urate lowering therapy
allopurinol OD titrated until uric acid <360
+ colchicine
When is URT used?
if >=2 attacks in 1 year
tophi
renal disease
uric acid renal stones
What is gout
deposition of monosodium urate monohydrate in synovium caused by chronic hyperuricaemia
causes of gout
decrease uric acid secretion
-diuretics
-CKD
-lead toxicity
Increased production
- myelo/lymphoproliferative disorders
-cytotoxic drugs
-psoriasis
Pseudogout affected joints
knee, wrist, shoulder
pseudogout patho
deposition of calcium pyrophosphate dihydrate crystals in synovium
pseudogout investigations
fluid: +ve birefringement rhomboid shaped crystals
XR: chondrocalcinosis
Pseudogout management
Aspiration
NSAIDS or steroids
SLE epidemiology
women of childbearing age
SLE gene associations
HLA B8 DR2 DR3
Explained SLE pathophysiology
environmental trigger (sun, infection) causes apoptosis, cells aren’t cleared effectively (genetic) so there are XS nuclear antigens which are seen as foreign (genetic) causing immune response-> ANA, deposits in tissues causing inflam
What kind of reaction is SLE
type 3 hypersensitivity reaction
Features for diagnosis of SLE
1) malar rash
2) discoid rash
3) photosensitivity
4) mouth/nose ulcers
5) serositis (pericarditis, pleuritis)
6) arthritis 2+
7) renal disease - abnormal urine protein, glomerulonephritis
8) neuro - seizures, psychosis
9) blood - anaemia, thrombocytopenia
10) ANA
11) other antibody - anti smith, anti dsDNA anti phospholipid
Monitoring SLE
ESR
C3 C4
Management SLE
hydroxychloroquinine
NSAIDS
pred if internal organ involvement
Complications of SLE with pregnancy
neonatal lupus, congential heart block
associated with anti-RO (SSA) antibodies
RA presentation
swollen painful joints hands/feet
morning stiffness
gradual worsening
RA examination
+ve squeeze test
swan neck
boutonniere
Bloods RA
+ve RF (70-80%)
+ anti CCP antibody (70%)
XR RA
loss of joint space
soft tissue swelling
juxta-articular osteoporosis
later
periarticular erosions
subluxation
Management of RA
DMARD monotherapy +/- bridging pred
flares: PO/IM corticosteroids
TNF-inhibs: etanercept, infliximab
Examples of DMARDs
methotrexate: monitor FBC/LFT as risk of liver cirrhosis and myelosuppression
TNF-inhibs e.g infliximab, etanercept
Poor prognostic features of RA
RF +Ve anti CCP antibodies +ve
poor function status
early XR erosions (<2yrs)
extra articular features
HLA DR4
Complications of RA
resp: fibrosis, effusion, nodules
occular: keratoconjunctivitis sicca
OP
IHD
Example of safe and unsafe DMARD in pregnancy
MTX - stop 6/12 prior to conception
safe: sulfasaline, hydroxycholorquine
symptoms of PMR
over 60 and rapid onset
aching and morning stiffness in prox limb muscles
lethargy, low grade fever
Pathophysiology of Reactive Arthritis
following GI or STI infection
Symptoms develop 4 weeks later
What is Reactive Arthritis grouped with
HLA B27 gene, seronegative spondyloarthropathy
How does reactive arthritis present
Cant see cant pee cant climb a tree
1) arthritis - lower joints asymmetrical
2) conjuctivitis, anterior uveitis
3) circinate balanitis, urethritis
last around 4-6 months
Reactive arthritis management
NSAIDs, intra-articular steroids
MTX, sulfsalazine if persistent
Most common organism causing septic arthritis
Staph aureus
Most likely organism causing septic arthritis in sexually active adult
neisseria gonorrhoea
Most common cause of septic arthritis
haematogenous spread
Most common location of septic arthritis
knee
Presentation of septic arthritis
acute swollen joint
warm and fluctuant
fever
Investigations of septic arthritis
synovial fluid aspiration before Abx
blood cultures
imaging
Management of septic arthritis
IV fluxclox (clindamycin)
PO switch after 2 weeks (4-6 weeks Abx total)
needle aspiration to decompress
arthroscopic lavage
What is psoriatic arthritis
seronegative spondyloarthropathy
Psoriatic arthritis epidemiology
10-20% of psorasis patients within 10 years of skin lesions
Presentation of psoriatic arthritis
1) symmetrical: hands, wrists, ankles, DIJ
2) asym: digits
3) spondylitis: back stiffness, sacroilitis
Examination findings of psoriatic arthritis
Skin lesions
nail pitting, onycholysis, dactylitis
enthesis
Ix psoriatic arthritis
XR
- erosive changes + new bone formation
- periostitis
- pencil in a cup appearance
Management of psoriatic arthritis
mild: NSAIDS
mod: MTX
What is ankylosing spondylitis
HLA B27 gene - seronegative spondyloarthropathy
How does ank spon present
young male
gradual onset
back pain and stiffness, worse in the morning improves throughout the day
how do you examine ?ank spon
Schobers test
mark 10cm above and 5cm below L5
if <20cm when bending forward indicates restriction
Investigations ank spon
XR sacroiliac joints
-sacroiliitis
-squaring of lumbar vertebrae
- bamboo spine
MRI if XR -ve but high suspicion
Management ank spon
Regular exercise, PT
NSAIDS
DMARDs if peripheral joint involvement
anti-TNF (etanercept/adalimumam) if persistent
Risk factors for osteoporosis
glucocorticoids
RA
alcohol
Smoking
Low BMI
Hx parental hip #