Rheumatology Flashcards
How do you distinguish between inflammatory and non inflammatory joint pain
Inflammatory
- morning stiffness over an hour
- swelling and redness
- more stiffness than pain
- improves with activity
- ESR and CRP elevated
Non inflammatory
- morning stiffness less than an hour
- Less swelling
- More pain than stiffness
- worse with activity
- normal ESR and CRP
Difference in treatment for inflammatory vs non inflammatory joint pain
Inflammatory - steroids, immune modulating medications
Non inflammatory - NSAIDs, weight loss, physio, joint replacement
Examples of inflammatory joint conditions vs non inflammatory joint conditions
Inflammatory - RA, psoriatic arthritis, reactive arthritis, lupus
Non inflammatory - osteoarthritis
Describe rheumatoid arthritis (what it is, how it presents and common progressive symptoms)
Systemic inflammatory joint condition
Onset 20-30s
Poly arthritis - esp peripheral joints (hands and feet)
Symmetrical joint pain, stiffness, effusions and swelling
Functional loss in hands
Progresses to joint destruction/deformity
Tendons rupture and bone alignment changes
Systemic signs of inflammation - fever, malaise and anorexia due to loss of appetite, dry eyes and dry mouth
What are some specific features of RA seen in hands
Ulnar deviation
Swan neck deformity
Boutonnière
Z thumb deformity
What are the investigations for RA
FBC - anaemia, increased platelets and decreased white blood cells
ESR and CRP increased
Antibodies - anti CCP and rheumatoid factor
Anti CCP - SPECIFIC TEST FOR RA
Rheumatoid factor - not specific and can be positive in healthy pts too
X ray for erosions of bones
How would RA look different from osteoarthritis on X ray
RA - erosion of bone
Osteoarthritis - loss of cartilage
When do you refer for RA
Small joints of hands / feet affected
More than one joint affected
3 months of symptoms present
Even if blood tests and antibodies normal!!
What primary care is offered for RA
NSAIDs until reheumatology appointment
PPI for gastro protection
DO NOT GIVE STEROIDS AS MAY MASK SYMPTOMS BEFORE RHEUMATOLOGY APPOINTMENT
What is the treatment for RA
DMARDs - methotrexate
- symptoms only improve after 2-3 months
Check liver before and after starting treatment as DMARDs are hepatotoxic
What are the cautions before starting someone on methotrexate
Hepatotoxic - liver function needs to be assessed
Contraindicated in pregnancy so careful giving to women of childbearing age
May increase risk of infection by lowering WBC
MAY CAUSE PULMONARY FIBROSIS!!! - REMEMBER THIS
Take with folic acid
What are the differences between OA and RA
OA
- non inflammatory so ESR and CRP are normal
- gets worse throughout day
- DIPs and PIPs mostly affected
- stiffness in morning lasts less than 15 mins
- symptoms not symmetrical
- older age more common
- larger weight bearing joints affected (knees and hips)
- x ray - loss of joint space, osteophytes and sub hi deal sclerosis
- no swelling or redness
- no systemic symptoms
RA
- inflammatory so ESR and CRP raised
- gets better with use throughout day
- MCPs and PIPs most affected
- morning stiffness lasts hours
- symptoms are symmetrical
- onset at any age
- smaller joints affected (hands and feet)
- x ray - erosion
- swelling and redness of joints
CCP POSITIVE
SYSTEMIC SYMPTOMS
What is psoriatic arthritis
Chronic inflammatory joint disease associated with psoriasis
What is juvenile rheumatoid arthritis
Chronic (over 6 weeks) inflammatory arthritis in patients younger than 16 years
How does juvenile rheumatoid arthritis present + clinical findings
Family history of autoimmunity
Joint pain and swelling - esp in knees
INTERMITTENT SPIKING FEVERS (1 or 2 a day that come and go quickly)
Uveitis (red eyes)
CRP and ESR elevated
Possibly RF +ve
Juvenile arthritis treatment
NSAIDs first line
DMARDs second line
What is psoriatic arthritis
Chronic inflammatory joint disease with psoriasis
How does psoriatic arthritis present differently from RA
PsA is…
Not symmetrical
arthiritis in DIPs
Psoriasis history
Clinical findings and investigations findings of psoriatic arthritis
Pitting of nails
Dactylitis (sausage fingers)
Enthesitis (swelling when tendon attaches to bone)
ESR and CRP elevated BUT CCP NEGATIVE !!!
X ray may show DIP arthritis and pencil in cup deformity
Treatment for psoriatic arthritis
NSAIDs for mild cases
If both skin and joint affected
DMARDs - methotrexate
TNF alpha inhibitors (immunosuppressants) if DMARDs fail
What is Sjogrens syndrome
Chronic inflammatory autoimmune disorder causing sicca complex (dry eyes and dry mouth) by affecting the lacrimal glands and salivary glands
How does sjogrens syndrome present
SEVERE dry eyes and dry mouth, fatigue and poor dentition
Can be secondary to RA or SLE
What are the investigations and treatment for sjogrens syndrome
Schirmer test
Test for antibodies = +SSA/Ro antibodies and/or +SSB/LA antibodies
Can be +ANA
GOLD STANDARD - SALIVARY GLAND BIOPSY - but not done in practice
Treat symptoms - eye drops, sialogogues (help salivate) and punctal plugs (keep any tears produced in eyes)
What is Reiter syndrome / Reactive arthiritis
Inflammatory arthiritis that occurs AFTER EXPOSURE TO CERTAIN GASTROINTESTINAL OR GENITOURINARY INFECTIONS
How does Reiter syndrome/reactive arthiritis present - common exam question
After exposure to vertain GI and genitourinary infections (usually chlamydia 1-4 weeks before)
CLASSIC TRIAD OF ARTHRITIS, UVEITIS AND URETHRITIS
Male and +HLAB27
Systemic symptoms (fever), oligoarthiris (of large joints), asymmetric, enthesitis, dactylitis, conjunctivitis, skin lesions
Reiter syndrome / reactive arthritis diagnosis and treatment
Clinical diagnosis
Tx - NSAIDs first line, steroids 2nd line
WHAT IS POLYMYALGIA RHEUMATICA
Inflammatory condition causing PAIN in the hip and shoulder girdles (NOT WEAKNESS)
Presentation of polymyalgia rheumatica (PMR)
Common in women, over 50s, acute onset or episodic
Diagnosis and treatment for PMR (polymyalgia rheumatica)
ESR and CRP elevated
Steroids
What is a PMR red flag to remember
May be associated to giant cell arteritis/temporal cell which is a RHEUMATOLOGICAL EMERGENCY - MAY CAUSE VISION LOSS
MUST BE TREATED WITH STEROIDS
How does giant cell arteritis / temporal arteritis present
scalp pain/tenderness over temples
head pain
jaw pain
systemic symptoms
VISION LOSS/CHANGE
Diagnosis and treatment of Giant cell arteritis / temporal arteritis
gold standard diagnosis - temporal artery biopsy
Tx - HIGH DOSE steroids
What are some side effects of long terms steroids
Obesity/weight gain
Diabetes
Osteoporosis
What is polymyositis
idiopathic inflammatory myopathies characterised by WEAKNESS in proximal muscles (no pain unlike PMR)
How does polymyositis present
Weakness in proximal muscles - may struggle to get in and out of chairs or brushing hair (check in pt can get out of seat without using arm rests)
Chronic or subacute onset
Typical over 40
Investigations and treatment for polymyositis
CK MASSIVELY ELEVATED
EMG
Muscle biopsy - for definitive diagnosis
Tx - steroids
What is polyarteritis nodosa
Rare form of vasculitis - affects medium/small aterities - causes aneurysms and micro-aneurysms
How does Polyarteritis nodosa (PAN) present
40-60 yrs
HBV infection
fevers
weight loss
myalgias
mononeuritis multiplex (painful, symeetric peripheral neuropathy) , skin manifestations (ulcers, LIVEDO RETICULARIS, purpuric rash)
HEP B and Lacy rash = most likely PAN - remember this bit
PAN Ix and Tx
Ix - biopsy of affected tissue shows thic necrotizing inflammation
Tx - steroids +/- DMARDs
What is GOUT? - key exam condition
Uric acid crystal deposition in joint causing episodic acute swelling/pain in joints
Gout associations and risk factors
Either mono or oligoarthiritis
HTN and CHD
Famil history, obesity, EXCESS ALCOHOL INTAKE, high purine diet (red meat, yeast), diuretics, acute infection, renal failure
Gout symptoms and signs
Painful swollen joint mimicing septic arthritis
Sudden onset of pain lasting 1-2 weeks
Spontaneous
Usually in big toe, ankle, finger joints or elbow - typically in 1st metacarpal
Skin is red and shiny, swollen and hot
VERY PAINFUL - can’t even let bed sheet touch it
Gout Ix
Serum uric acid levels may be raised chronically (may be normal during acute episode as uric acid is in the joint not in blood at this time)
Leucocytosis
Raised ESR and CRP during acute episode
GOLD STANDARD - JOINT ASPIRATION AND CRYSTAL ANALYSIS
Acute gout management
Should self resolve in 2 weeks - ensure there isn’t infection then conservative management - PRICE M and NSAIDs for pain management
2nd line - Colchicine (don’t give if history of GI bleeds)
3rd line - prednisolone (don’t give if pt has diabetes)
Steroid injection - must ensure there is no infection first
Prophylactic gout treatment
Allopurinol (don’t give during active episode or it’ll become worse!!!) - daily medication to prevent
If episodes recur frequently give regular dose of steroids/NSAIDs and pain medication
What is pseudogout
Deposition of calcium pyrophosphate crystals into joint during acute attack
How is pseudogout different from gout
Pseudogout most common in knee and crystals are positively birefringent
presents same as gout otherwise
Ix and Tx for pseudogout
Joint aspiration and crystal analysis
IA steroids and NSAIDs (same treatment as gout)
Risk factors for osteoporosis
Post menopause
Increasing age
Smoking
Steroid use
Low BMI
How is osteoporosis diagnosed
DEXA scan - looks at bone mineral density
T score of 0 is normal
T score from 0 to -2.5 is osteopenia
T score less than -2.5 is osteoporosis
ASYMPTOMATIC UNTIL FRACTURE APPEARS - NO PAIN
Causes of secondary osteoporosis
Endocrine - hypogonadism, hyperthyroidism, cushings, hyperparathyroidism
Inflammation
IBD
Ankylosing spondylitis
RA
Medications
Steroids
Thyroxine
Alcohol
Osteoporosis treatment + considerations of the medications
To: bisphosphonates, calcium and vitamin D
Bisphosphonated rare side effect osteonecrosis of jaw
Needs drug holiday after 3-5 years
What is scleroderma
Autoimmune disease
Functional and structural abnormalities of small blood vessels, fibrosis of skin and internal organs
How does scleroderma present
Family history
Autoimmune diseases
Skin thickening
Hand and feet swelling
CREST
calicinosis (calcium salts deposited in skin and subcut tissue
Raynaud’s phenomenon (lack of blood flow to fingers and toes leads to digital pits and ulcers)
oesophageal dysmotility
SCLERODACTYLY (hardening of skin causing fingers to curl into claw shape)
telangiectasia (spider veins)
What is systemic lupus erythematous (SLE)
Chronic disorders affecting immune system - that affects women in reproductive years and can affect any body system (multi system disorders) esp joint and muscles and kidneys
Signs and symptoms of SLE
Malar flush that spares nasolabial folds
Photosensitivity
Fatigue
Fevers
Oral ulcers
Alopecia
Weight loss
Ix for SLE and treatment
ANA + - if negative rules out but if positive doesn’t definitively mean pt has SLE
dsDNA+ - diagnositive for SLE
Anti smith antibody
Treatment - 1st line anti malarias - hydroxychloroquine
Antibody review - what does each of these antibodies tests for
SCL 70
Anti dsDNA
Anti CCP
Ro(SSA) / La(SSB)
HLAB27 genotype
SCL 70 - scleroderma
Anti dsDNA - SLE
Anti CCP - RA
Ro(SSA) / La(SSB) - sjogrens
HLAB27 genotype - Ankylosing spondylitis, reactive arthritis/reiter syndrome and IBD
