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2.5 BRS Musculoskeletal & Rheumatology > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

What is arthritis?

A

Disease of the joints

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2
Q

What are the 2 types of arthritis?

A
  1. Degenerative
    • Osteoarthritis
  2. Inflammatory
    • Infection —> septic
    • Crystal —> gout, pseudo-gout
    • Autoimmune —> rheumatoid, seronegative, SLE
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3
Q

What is osteoarthritis?

A

Arthritis caused by articular cartilage loss
- Risks —> elderly
—> previous joint trauma
—> lots of manual labour
- Onset —> gradual

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4
Q

How is osteoarthritis diagnosed? (3)

A
  1. Clinical:
    • Pain —> worse with activity
    • Crepitus —> cracking sound with movement
    • Enlargement
    • Limited range of motion
    • Specific joints —> DIP, PIP, CMC, MTP etc.
  2. Blood:
  3. X-ray:
    • Joint space narrowed —> articular cartilage loss
    • Subchondral bony sclerosis —> inc whiteness
    • Osteophytes —> bony lumps
    • Subchondral cysts —> fluid filled space
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5
Q

Which joints are typically affected by osteoarthritis? (3)

A

Hand:
1. DIP = Distal InterPhalangeal
—> Heberden’s nodes
2. PIP = Proximal InterPhalangeal
—> Bouchard’s nodes
3. First CMC = CarpoMetaCarpal of thumb

Spine

Limbs (weight-bearing):
4. Knees
5. Hips
6. First MTP = MetaTarsoPhalangeal
- base of big toe

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6
Q

What are the 5 clinical signs of inflammatory arthritis?

A
  1. Rubor - red
  2. Dolor - pain
  3. Calor - heat
  4. Tumor - swelling
  5. Loss of function
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7
Q

What are the 3 causes of inflammatory arthritis?

A
  1. Infection - secondary, non-sterile
    —> septic
    —> TB
  2. Crystal - secondary, sterile
    —> gout
    —> pseudo-gout
  3. Autoimmune - primary, sterile
    —> rheumatoid
    —> seronegative
    —> SLE
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8
Q

What are the 2 types of inflammatory arthritis via infection?

A
  1. Septic arthritis
  2. Tuberculosis
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9
Q

What are the 2 types of inflammatory crystal arthritis?

A
  1. Gout
  2. Pseudo-gout
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10
Q

What are the 3 types of inflammatory autoimmune arthritis?

A
  1. Rheumatoid arthritis
  2. Seronegative arthritis
  3. SLE = Systemic Lupus Erythematous (Lupus)
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11
Q

What is septic arthritis?

A

Arthritis cause by a bacterial infection
- Usually spread via blood
- Medical Emergency —> can destroy joint
- Bacteria —> staphylococcus aureus
—> streptococci
—> gonococcus

  • Risks —> immunosuppressed
    —> pre-existing joint damage
    —> IVDU (IntraVenous Drug Use)
  • Onset —> acute
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12
Q

How is septic arthritis diagnosed? (3)

A
  1. Clinical:
    • Inflammation —> red, hot, painful, swollen
    • Monoarthritis - except gonococcal (poly)
    • Fever —> systemically unwell
  2. Blood:
    • WCC high
    • PLT high/normal
    • ESR high/normal
    • CRP high
  3. Joint Aspiration:
    • MC&S —> gram stain
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13
Q

How is septic arthritis treated? (2)

A
  1. Surgical washout - use lavage
  2. IV antibiotics
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14
Q

What is gout?

A

Arthritis caused by deposition of MSU crystals
- MonoSodium Urate —> needle shape

  • Risks —> hyperuricaemia (high uric acid)
    - genetics
    - high purine diet
    - kidney failure —> dec excretion
  • Onset —> abrupt
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15
Q

What is pseudogout?

A

Arthritis caused by deposition of CPPD crystals
- Calcium PyroPhosphate Dihydrate —> brick shape

  • Risks —> elderly
    —> background osteoarthritis
    —> intercurrent infection
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16
Q

How is gout diagnosed? (5)

A
  1. Clinical:
    • Gouty arthritis —> sudden, severe joint pain
    • Tophi —> visible MSU crystal deposits
      - hands, feet, elbows, ears
    • Monoarthritis
    • Specific joints —> podagra (first MTP), feet, ankle,
      knee, wrist, finger, elbow
  2. Blood:
    • CRP inc
    • Serum urate inc
  3. X-rays:
    • Juxta-articular erosions —> looks like rat bite
      - over time
  4. Joint Aspiration:
    • MC&S —> gram stain (rule out septic)
    • Polarising Light Microscopy —> -ve birefringence
      (+ve = pseudo-gout)
  5. Synovial Fluid Aspiration
    • MC&S —> gram stain (rule out septic)
    • Polarising Light Microscopy —> -ve birefringence
      (+ve = pseudo-gout)
17
Q

How is gout treated? (4)

A

Acute —> dec inflammation
1. NSAIDs = Non-Steroidal Anti-Inflammatory Drugs
2. Glucocorticoids

Chronic —> dec uric acid levels
3. Lifestyle eg. dec purine intake, dec beer
4. Drugs - allopurinol
- febuxostat

18
Q

What is rheumatoid arthritis?

A

Arthritis of synovial joints caused by auto-antibodies:
- Rheumatoid factor —> IgM antibodies
—> bind to Fc of IgG
- not definitive
ACPA = Antibodies to Citrullinated Protein Antigens
- test for anti-CCP antibody (Cyclic Citrullinated
Peptide) —> more definitive + suggests more
aggressive
- inhibit: aginine —> citrulline (enzyme = PADs)
- Onset —> chronic

19
Q

How is rheumatoid arthritis diagnosed? (5)

A
  1. Clinical:
    • Morning stiffness
    • Symmetrical joints affected —> hands, feet, wrists
    • Polyarthritis
    • Synovitis —> PIP, tenosynovium (around tendons),
      bursa (knee)
    • Extra-articular disease - ocular (episcleritis)
      - interstitial lung disease
      - nodules (ulner border)
      - vasculitis
  2. Blood:
    • Hb low/normal (anaemia)
    • PLT high/normal
    • ESR high (Erythrocyte Sedimentation Rate)
    • CRP high
    • Rheumatoid factor —> +ve in 80% diagnosed
  3. X-ray:
    • Soft-tissue swelling
    • Peri-articular osteopenia
    • Joint erosions —> established
  4. Ultrasound:
    • Synovial hypertrophy —> thicker
    • Doppler signalling —> inc blood flow
    • Erosions
  5. MRI
    • Synovitis
    • Doppler signalling —> inc blood flow
20
Q

Which joints are typically affected by rheumatoid arthritis? (6)

A
  1. PIP = Proximal InterPhalangeal
  2. MCP = MetaCarpoPhalangeal
  3. MTP = MetaTarsoPhalangeal
  4. Wrists
  5. Knees
  6. Ankles
21
Q

What is the pathology of rheumatoid arthritis?

A
  1. Inc pro-inflammatory cytokines (TNF-α) to synovium
  2. Synovium proliferation —> neovascularisation
    —> lymphangiogenesis
    —> inflammatory cell
    recruitment
22
Q

How can blood tests differentiate between different types of arthritis? (5)

A
  1. Hb - low —> rheumatoid
  2. WCC - high —> septic
  3. PLT - high —> rheumatoid
    —> septic
  4. ESR - high —> rheumatoid
    —> septic
  5. CRP - high —> rheumatoid
    —> septic
23
Q

How is rheumatoid arthritis treated? (4)

A

Short-term —> dec inflammation
1. NSAIDs (sometimes)
2. Glucocorticoids

Long-term —> DMARDs (Disease-Modifying Anti-
Rheumatic Drugs)
3. Combination - first line
—> methotroxate + hydrochloroquine
(+ sulfasalazine)
—> Intramuscular injection or oral
steroids (short course)
4. Biological - second line
—> inhibit TNF-α via antibodies/ fusion
proteins (IV infusion or sub-cutaneus
injection)
—> eg. anti-TNF-alpha blockade

24
Q

What are the clinical differences between rheumatoid arthritis vs osteoarthritis?

A

RA:
- age —> 30-50
- onset —> rapid
- joint pattern —> symmetric (bilateral)
- movement —> pain better
- morning stiffness > 1 hour
- joints —> hand: PIP, MCP
—> wrist, ankle, elbow
- swelling —> inflammation
- blood ESR/CRP —> high
- serology (RF) —> +ve

OA:
- age —> >50
- onset —> slow
- joint pattern —> asymmetric
- movement —> pain worse
- no morning stiffness
- joints —> hand: DIP, first CMC
- swelling —> bony
- blood ESR/CRP —> normal
- serology (RF) —> -ve

25
Q

What is seronegative inflammatory arthritis?

A

Arthritis caused by auto-immunity (not antibodies)

26
Q

What are the 4 types of seronegative inflammatory arthritis?

A
  1. Psoriatic arthritis
  2. Reactive arthritis
  3. Ankylosing spondylitis
  4. IBD-associated arthritis
27
Q

What is psoriatic arthritis?

A

Arthritis associated with psoriasis
- 10% psoriasis patients
- usually —> asymmetrical
—> DIPs and PIPs
- also —> symmetrical of small
—> oligo (2-4) of large
—> spinal and sacroiliac inflammation

28
Q

What is reactive arthritis?

A

Arthritis following an infection elsewhere
- Sterile arthritis
- Infections —> urogenital
—> GI
- 1-4 weeks before
- Extra-articular manifestations —> tendons
(enthesitis), skin, eye
- May indicate HIV or Hep C infection

  • Risks —> genetic (HLA-B27) + environmental trigger
29
Q

What is SLE?

A

Arthritis caused by autoantibodies against nucleus (nucleic acids and proteins):
- ANA = AntiNuclear Antibodies
- not specific - -ve —> no SLE
- +ve —> maybe SLE
anti-dsDNA antibodies = Anti-Double Stranded DNA
- high specificity
- Multi-site inflammation —> joints, skin, kidneys,
blood
- Risks —> female 9:1
—> age 15-40
—> ethnicity African + Asian

30
Q

How can you differentiate between degenerative and inflammatory arthritis?

A

Degenerative —> no inflammation
Inflammatory —> inflammation

31
Q

How can you differentiate between the 3 types of inflammatory arthritis?

A

Septic —> infection
—> acute + mono
Crystal —> acute + usually mono
Autoimmune —> chronic

32
Q

How can you differentiate between the 3 types of inflammatory autoimmune arthritis?

A

Rheumatoid —> poly + symmetrical
Seronegative —> mono/oligo + asymmetrical
SLE —> polyarthralgia

33
Q

What clinical questions should be asked to diagnose arthritis? (8)

A
  1. Inflammation?
  2. Onset?
  3. Movement —> worse/better?
  4. Morning stiffness?
  5. Joint number?
  6. Joint size?
  7. Joint pattern?
  8. Spine?

2.5 BRS Musculoskeletal & Rheumatology (7 decks)

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