Rheumatology Flashcards
Osteoarthritis treatment
NSAIDs (use topical gel if any renal impairment)
paracetamol
Movement
Education
CBT / mindfulness
mechanical vs inflammatory arthritis - how to specifiy
Better or worse w movement
Morning stiffness - if so how long does it last (inflammatory is hours)
Symmetrical or asymmetrical
DIP joint involvement - what type of arthritis
osteoarthritis
psoriatic (nail involvement)
SLE and RA SPARE the DIPJ
Lots of different joints (large/small) suddenly involved
Reactive arthritis
- Gastro bugs
- STI (reiters syndrome: cant see/pee/climb a tree)
What hand signs do you get in OA
Bocuhards (PIPJ)
Heberdens (DIPJ)
What hand signs do you see in RA
MCP swelling, ulnar subluxation and deviation
Sparing of DIPJ
What can a positive RF be from
RF (50-60% specificity)
Hep B and C
some malignancies
anti-CCP has 95% specificity for
What types of psoriasis are highest risk for developing psoriatic arthritis
Scalp and nail psoriasis
What are the features of psoriatic arthritis
can look like rheumatoid (symmetrical, multiple joints)
or asymmetrical with one joint
Often has dactylitis
What is normal ankylosing spondylitis
Seronegative inflammatory arthritis (related to HLAB27)
* symmetrical
* Sacroilitis joints most commonly involved
* Tx: NSAIDs, TNF alpha therapy
- asymmetric oligoarthritis (≤4 joints)
- Enthesitis (Achilles tendinitis, plantar fasciitis and intercostal enthesitis)
- M>F, <45yrs
- Extra axial manifestations (due to overlap with HLA B27): iritis, IBD
5% of population has HLAB27, 5% of these have related pathology
Why does ank spondylitis primarily affect the sacroiliac joints
Ethesitis (where tendons/ligaments connect) of the spine, SI joints have the most of this
This inflammation can stimulate secondary bone formation
Extra articular features of SLE
- butterfly malar rash (sparing of nasolabial folds)
- Raynauds
- ulcers / nose ulcers
- Patchy alopecia
- Serositis (linings, pleurisy, peritonitis, pericarditis)
- lupus nephritis
Always do MSU + ACR looking for blood/protein
Bloods for SLE
- ANA
- ENA
- Double stranded DNA
- Low complement
- ESR (high), CRP normal
high ESR and low CRP indicates high disease activity
Monitoring for DMARDs
3 monthly bloods
FBC, UEs, LFTs
MTX, leflunomide, hydroxychloroquine, salazopyrin
* tetratogenic
key thing to remember with biologic tocilizumab
inhibitis production of CRP, even when unwell
What should you consider if someone is unwell and on a biologic
adalimumab, entanercept, inliximab, rituximab, tocilizumab
they wont mount an immune response, can quickly deteriorate
Treat immediately, if unwell can WH biologic until well
Why is probenecid second line to allopurinol
because it pushes /drains lots of urate out of the kidneys and can increase risk of kidney stones
Whereas allopurinol is a xanthine oxidase inhibitor blocks purines formi
How does starting allopurinol cause a flare
Lower serum urate concentration means urate moves out of the joint down the concentration gradient.
The moving of the urate out (and in) to the joint triggers a flare
What are your urate targets
<0.30 with tophi
<0.36 without tophi
What are purines
From DNA, therefore anything living has purines in it. things like animal products have a higher purine load
Purine gets broken. down into urate
Age cutoff for GCA
> 50’s
What are the additional features of ankylosing spondylitis
the ‘A’s;
Apical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
AV node block
Amyloidosis
Signs on exam of ‘tennis elbow’
Lateral epicondylitis
Pain on resisteed wrist extension
pain and tenderness localised to the lateral epicondyle
self resolves within 12 months, PT is first line
RF: repetitive movement >2hrs
What are the features of PMR
AI mediated inflammation of the bursa/tendons
Causes pain and stiffness without muscle weakness
Shoulder, neck, hips
>50yrs, peaks 70-75
W>M
- Pain starts on one side but then becomes bilateral
- worse w rest (night and mornings for 45mins), better w movement
- Muscles are actually spared, but tendons/bursa get inflammed causing referred pain
- Strongly linked w GCA
Tests for PMR
Treatment
high ESR/CRP
Normal CK as muscles are spared (unlike polymyositis)
15-20mg PO OD until symptoms controlled, with a very slow wean
50% of patients relapse
Age >50yrs
What is GCA
Vasculitis of large and small IC vessels causing thickening
Strongly associated with PMR
Although it is often termed temporal arteritis, it does not just affect the temporal artery
Symptoms of GCA
Fever, anorexia
New onset or new type of headache
Temporal artery or scalp tenderness
Jaw or tongue claudication
Sudden visual impairment, e.g. diplopia, reduced acuity, vision loss
Thickened temporal artery
Unexplained elevated levels of CRP +/- ESR
High ESR/CRP, low Hb
features of dermatomyositis
Gottrons papules (erythematous papules over the knuckles) - itchy/painful/photosensitive
symmetrical proximal muscle weakness /pain/tenderness
mainly larger muscle groups (shoulder and hip)
dysphagia
Heliotrope rash
Malar rash
This condition is strongly linked to malignancy, with 25% of patients having an undiagnosed malignancy at the time of diagnosis of dermatomyositis.
What is dermatomyositis
Inflammatory disorder of skin and muscle (from destruction of blood vessels)
Strongly linked to HLA gene, can be triggered by coxsackie virus or tumours
