Rheumatology Flashcards

Question

Ankylosing spondylitis

Answer 1

Ankylosing spondylitis is a HLA-B27 associated spondyloarthropathy. It typically presents in males (sex ratio 3:1) aged 20-30 years old. Features typically a young man who presents with lower back pain and stiffness of insidious onset stiffness is usually worse in the morning and improves with exercise the patient may experience pain at night which improves on getting up Clinical examination reduced lateral flexion reduced forward flexion - Schober's test - a line is drawn 10 cm above and 5 cm below the back dimples (dimples of Venus). The distance between the two lines should increase by more than 5 cm when the patient bends as far forward as possible reduced chest expansion Other features - the 'A's Apical fibrosis Anterior uveitis Aortic regurgitation Achilles tendonitis AV node block Amyloidosis and cauda equina syndrome peripheral arthritis (25%, more common if female)

Answer 2

External rotation (on both active and passive movement) is classically impaired in adhesive capsulitis

Answer 3

The most prominent restriction in movement would be impaired abduction.

Answer 4

The most prominent restriction in movement would be impaired abduction.

Answer 5

Gout is a form of microcrystal synovitis caused by the deposition of monosodium urate monohydrate in the synovium. It is caused by chronic hyperuricaemia (uric acid > 450 µmol/l) Acute management NSAIDs or colchicine are first-line the maximum dose of NSAID should be prescribed until 1-2 days after the symptoms have settled gastroprotection (e.g. a proton pump inhibitor) may also be indicated colchicine inhibits microtubule polymerization by binding to tubulin, interfering with mitosis. Also inhibits neutrophil motility and activity has a slower onset of action may be used with caution in renal impairment: the BNF advises to reduce the dose if eGFR is 10-50 ml/min and to avoid if eGFR < 10 ml/min BNF the main side-effect is diarrhoea oral steroids may be considered if NSAIDs and colchicine are contraindicated. a dose of prednisolone 15mg/day is usually used another option is intra-articular steroid injection if the patient is already taking allopurinol it should be continued Indications for urate-lowering therapy (ULT) the British Society of Rheumatology Guidelines now advocate offering urate-lowering therapy to all patients after their first attack of gout ULT is particularly recommended if: >= 2 attacks in 12 months tophi renal disease uric acid renal stones prophylaxis if on cytotoxics or diuretics Urate-lowering therapy it has traditionally been taught that urate-lowering therapy should not be started until 2 weeks after an acute attack, as starting too early may precipitate a further attack. The evidence base to support this however looks weak in 2017 the BSR updated their guidelines. They still support a delay in starting urate-lowering therapy because it is better for a patient to make long-term drug decisions whilst not in pain the key passage is: 'Commencement of ULT is best delayed until inflammation has settled as ULT is better discussed when the patient is not in pain' allopurinol is first-line initial dose of 100 mg od, with the dose titrated every few weeks to aim for a serum uric acid of < 360 µmol/l a lower target uric acid level below 300 µmol/L may be considered for patients who have tophi, chronic gouty arthritis or continue to have ongoing frequent flares despite having a uric acid below 360 µmol/L a lower initial dose of allopurinol should be given if the patient has a reduced eGFR colchicine cover should be considered when starting allopurinol. NSAIDs can be used if colchicine cannot be tolerated. The BSR guidelines suggest this may need to be continued for 6 months the second-line agent when allopurinol is not tolerated or ineffective is febuxostat (also a xanthine oxidase inhibitor) in refractory cases other agents may be tried: uricase (urate oxidase) is an enzyme that catalyzes the conversion of urate to the degradation product allantoin. It is present in certain mammals but not humans in patients who have persistent symptomatic and severe gout despite the adequate use of urate-lowering therapy, pegloticase (polyethylene glycol modified mammalian uricase) can achieve rapid control of hyperuricemia. It is given as an infusion once every two weeks Lifestyle modifications reduce alcohol intake and avoid during an acute attack lose weight if obese avoid food high in purines e.g. Liver, kidneys, seafood, oily fish (mackerel, sardines) and yeast products Other points consideration should be given to stopping precipitating drugs (such as thiazides) losartan has a specific uricosuric action and may be particularly suitable for the many patients who have coexistent hypertension - increased vitamin C intake (either supplements or through normal diet) may also decrease serum uric acid levels.