Rheumatology Flashcards
define OA
A progressive disorder of the joints caused by gradual loss of cartilage and resulting in the development of bony spurs and cysts at the margins of the joints.
Commonest form of arthritis
‘Wear & Tear’ or ‘Degenerative Joint Disease’
pathophysiology of OA
Pathophysiology
Loss of cartilage & narrowing of the joint space
Low grade synovial inflammation
Thickening of subchondral bone
Development of bony outgrowths - osteophytes
secondary causes of OA
Primary causes of Osteoarthritis
- Metabolic
- Ochronosis, hemochromatosis, acromegaly, COPD - TRAUMA
- major trauma , fracture, meniscectomy, chronic occupation, repetitive injury / stress - ANATOMICAL
- congenital, slipped epiphysis, AV necrosis, congenital hip - POST ARTHRITIS
- inflam arthritis, RA
Primary causes of OA
Age (4) Obesity Heredity (TWIN STUDY - mutation in type 2 college fibre) Sex (WOMEN) Occupation Predisposing secondary causes Trauma/injury Joint shape Repetitive Use Muscle weakness Joint Laxity
how does increase age put you at risk of OA
- Old cartilage heals less well
- Decrease muscle strength and muscle bulk
- decrease joint propiception
- increase incidence to old age
ddx for OA
- Crystalloid arthritis (gout, pseudo gout)
- inflam arthritis
- SN arthropathies
- Septic arthritis
- Pos-infectious arthropathy
- Fibromyalgia
- tendonitis
important mediators involved in cartilage damage
Cytokines: TNF-a, IL-1, Il-6
collagenases, metalloprotineases, aggrecanases
important mediators in protecting cartilage
IL-4 and TIMP , TGF-b, & IGF-1 protective
Complications of OA
Chondrolysis – Rapid, complete breakdown ofcartilageresulting in loose tissue material in thejoint(Bone death (osteonecrosis). Stressfractures(hairline crack in the bone that develops gradually in response to repeated injury or stress). Heamarthroses – Bleedinginside the joint. Septic arthritis – Infection in the joint. Gout/Pseudogout Joint instability – Deterioration or rupture of the tendons and ligaments around the joint, leading to loss of stability. Pinched nerve (in osteoarthritis of the spine)
strong risk factors for gout
Increasing age Male gender Menopausal state Use of diuretics Iatrogenic Tacrolimus, aspirin High cell turnover Lymphoma’s, chemo Genetic susceptibility Triggers: Alcohol, dehydration
Ddx gout
Pseudogout (calcium pyrophosphate deposition)
Septic arthritis Trauma Rheumatoid arthritis Psoriatic arthritis Reactive arthritis
when do you do uric acid level
Wait > 2 weeks
DO NOT PERFORM in acute attack
x- ray findings in gout
X-Ray of affected joint:
Peri-articular erosions
Punched out appearance
Over hanging edge
3 complication of gout
Nephrolithiasis
Acute uric acid nephropathy
Increased CAD/CVD risk
A 46 year old female patient of Maori heritage presents to her General Practitioner with an acute mono-articular pain, very sudden on onset and 10 out of 10 in severity. She has a history of diabetes mellitus and peptic ulcer disease. The presumptive diagnosis is acute gout. What is the most likely risk factor contributing to her illness?
Maori heritage (family history)
Red flags for back pain
Major trauma
Relative minor trauma if known or suspected osteoporosis
Fever, weight loss, systemic symptoms
Intractable pain
No improvement in 4-6/52, or increasing pain severity
Nocturnal pain
Neurologic symptoms or signs especially if bilateral
Morning pain and stiffness in younger patients
Inflammatory back pain
History of cancer or symptoms suggestive of cancer or referred pain
Check PSA in men
Renal disease in Multiple Myeloma
Hypercalcaemia
Light chain nephropathy
Amyloidosis
Analgesic nephropathy
what gene is ass. w/ RA
HLADR4
Associated with part of HLA-DR4 and the DR– associated alleles
(DRB10401 and DRB10404
Sometimes called the “Shared Epitope
eye finds in RA (10)
Anterior uveitis (iritis) Conjunctivitis Keratoconjunctivitis Keratoconjunctivitis sicca Scleritis Episcleritis Retinal detachment Sicca complex (xerophthalmia and xerostomia) Scleromalacia Scleromalacia perforans
lung findings in RA (6)
Pulmonary nodules Pleural effusions Pulmonary fibrosis Caplan syndrome Bronchiolitis obliterans Organising pneumonia
heart (8) and vascular RA(3) symptoms
Pericarditis Myocarditis Cardiac nodules Coronary artery disease Pericardial effusions Heart failure Atrial fibrillation Aseptic endocarditis
Valvular: PVD, stroke , Vasculitis
neuro symptoms RA (5)
Peripheral neuropathy Mononeuritis multiplex Compression neuropathy/radiculopathy Atlanto-axial subluxation- cervical subluxation Muscle weakness/myositis
team RA smp (4)
Anaemia
NN– chronic disease
Meg and mac – B12/Folate deficiency, methotrexate/azathioprine therapy
HC, microcytic – Fe decrease - chronic GI bleeding (NSAIDs)
Haemolytic anaemia – rare
Pancytopaenia - aplastic anaemia (gold, penicillamine, azathioprine, cyclophosphamide)
Felty’s syndrome (anaemia, neutropaenia, splenomegaly)
Kidney RA ( 4)
Drug-induced injury – penicillamine, gold, ciclosporin
Glomerulonephritis
Amyloidosis
Increased UTIs due to immunosuppression
Skin RA 7
Rheumatoid nodules Ulcers Pyoderma gangrenosum Vasculitic rash Drug-induced urticaria Neutrophilic dermatoses Steroid induced skin tinning and ecchymoses
2010 ACR/EULAR criteria
Number and site of involved joints 2 - 10 large joints = 1 point 1 - 3 small joints = 2 points 4 to 10 small joints = 3 points >10 joints (including at least 1 small joint) = 5 points
Serological abnormality (rheumatoid factor or anti-citrullinated peptide/protein antibody) Low positive (> ULN) = 2 points High positive (3X >ULN) = 3 points
Elevated acute phase response (erythrocyte sedimentation rate or C-reactive protein) above the ULN = 1 point
Symptom duration at least six weeks = 1 point
NEW PRESENTATION OF RA
ongoing follow up if patient is on MTX
3 monthly bloods for FBC, UE, LFT
if starting immunosuppressant medications what should be done first
CXR and Tb skin test
complications of septic arthritis
Septic shock
Osteomyelitis
Persistent, recurrent infections
Marked decrease in joint mobility, ankylosis, persistent pain
Irreversible joint destruction and an increase in mortality
DDX septic arthritis
- Primary Rheum Disorders (Rheumatoid and osteoarthritis , Psoriatic arthritis, SLE, Crystal arthropathies e.g. gout and pseudo gout)
2.Lyme Disease - Reactive arthritis
Post-infectious diarrhoea (salmonella, campylobacter, cryptosporidium), Reiter’s Syndrome (chlamydia), Post-meningococcal , Post-gonococcal ) - Trauma/joint injury (Haemarthrosis (warfarin), Meniscal tear
Effusion) - Systemic conditions (Sarcoidosis, haemochromotosis, malignancy, IBD,Sickle cell anaemia
risk factor for scleroderma
- Genetic
- Enciromental (silica and vinyl exposure)
- Viral triggers
- Drugs - Bleomycin
MSK findings in Systemic scleroderma
Non-erosive arthritis
Fibrosis of fascia and muscle
Tendon friction rubs
treatment of pulm hTN seen in diffuse scleroderma
Endothelin 1 antagonists (Bostentan)
Prostaglandins
Phosphodiesterase inhibitors
