Rheumatology

Question 1

Extra cardiac features of RA?

Answer 1

Resp
* Lower lobe fibrosis
* Obliterative bronchiolitis
* Pleural effusions
* Caplans nodues
* Methotrexate related pneumonitis
Eyes
* Scleritis (painful and red)/Episcleritis (painless)
* Scleromalacia – progressive thinning of sclera with no signs of inflammation – get a blue/black discolouration (melanocytes in the choroidal layer becomes visible), topical and systemic immune suppression)
* Keratoconjunctivits sicca
Neurological:
* Carpal tunnel syndrome as a result of subluxation
* Atlanto-axial subluxation – quadriplegia
* Peripheral neuropathy
Haematological:
* Feltys syndrome – RA + Splenomegaly + Neutropenia
* Anaemia (multifactorial)
o Anaemia of chronic disease
o Peptic ulceration from long term steroids
o Bone marrow suppression from DMARDs
o Splenomegaly (as part of Felty’s syndrome)
o Can get autoimmune haemolytic anaemia
Cardiac:
* Constrictive pericarditis or pericardial effusions
Renal:
* Nephrotic syndrome
o Secondary amyloidosis or membranous glomerulonephritis e.g. due to penicillamine

Question 2

The 4 main seronegative spondyloarthropathies?

Answer 2

o Ankylosing spondylitis
o Psoriatic arthritis
o Reactive arthritis
o Enteropathic arthritis

Question 3

Investigations in RA (and radiological findings)?

Answer 3

• Inflammatory markers
• XR - Radiological findings
  o Loss of joint space with potential subluxation
  o Articular erosions
  o Soft tissue swelling
  o Periarticular osteopenia
• Rheumatoid factor
• Anti CCP

Question 4

Objective measurement of disease activity in RA?

Answer 4

• Can measure symptoms objectively using DAS 28 (disease activity score 28) – number tender joints, swollen joints, global pain score and blood marker of inflammation
  o >5.1 implies active disease
  o <2.6 implies remission

Question 5

American college of Rheumatology diagnostic criteria for RA?

Answer 5

4/7 American college of rheumatology criteria:
* Morning stiffness >1hr
* Swelling in 3 or more joints
* Swelling in the small joints of the hands or wrist joints
* Symmetrical arthritis
* Rheumatoid nodules
* Positive Rheumatoid factor
* Erosions on XR or periarticular osteopenia

Question 6

Management of RA?

Answer 6

MDT
PT
OT
DMARDS - Methotrexate first line, sulfasalazine, leflunomide also options
If not controlled on 2 different DMARDS then biologic therapy

Question 7

What is the management of reactive arthritis?

Answer 7

• Management is supportive (analgesia, NSAIDs and para) and treatment of the underlying cause, usually self limiting, most pts don’t need steroids or anti rheumatic drugs

Question 8

How would you investigate a suspected reactive arthritis?

Answer 8

o XR of knee and joints above and below
o Bloods – FBC, U&E, CRP, LFT, RF and anti CCP, Urate (consider HLA B27)
o Stool cultures if diarrhoeal illness
o Could do a sexual health screening – swab for chlamydia and gonorrhoea
o Try and get a joint aspirate – septic arthritis is a clinical emergency and needs acute treatment

Question 9

How would chlamydia and gonorrhoea present differently in relation to arthritis?

Answer 9

Chlamydia = causes a reactive arthritis
Gonorrhoea = causes a septic arthritis