Rheumatology Flashcards
What is Rheumatoid Arthritis?
Autoimmune disease which causes inflammation in the joints causing joint swelling, pain and stiffness
Which joints are affected first in RA?
Smaller joints in the hands, wrists and feet
Describe the pathophysiology of RA
The body attacks the synovium in the joints and causes inflammation so fluid and inflammatory cells build up around the joint. The fluid stretches the joint capsule so the joint becomes unstable and over time the joint space is worn away due to repeat inflammation
Give 5 symptoms of RA
joint pain, joint swelling, morning stiffness, tiredness, amnesia, depression, irritability, weight loss
Worse in the cold
Give 6 hand signs found in RA
Swelling of PIP and MCP joints
Boutonniere deformity (loss of thumb mobility and pincher grasp)
Swan-neck deformity
Ulnar deviation of the fingers at the MCP joint
Synovial cysts
Z-shaped thumb
MCP subluxation
Trenching of the dorsal extensor ligaments
Give 3 risk factors for developing RA
Smoking Excessive red meat Caffeine Low vitamin C Alcohol excess Family history
Which tests aid RA diagnosis?
FBC ESR or CRP Rheumatoid factor Anti-CCP X-ray of joints
What may be seen on joint x-ray in a patient with RA?
Soft tissue swelling Osteopenia Joint space narrowing Hand deformities Ulnar deviation Joint fusion
When monitoring and diagnosing RA, what criteria are used to assess the progression of the condition?
Joint involvement (1 point for 2-10 large joints, 2 points for 1-3 small joints, 3 points for 4-10 small joints, 5 points for >10 joints)
Serology (2 points for slight abnormality in RF and anti-CCP, 3 points for large abnormality)
Acute phase reactants (1 point for abnormal CRP/ESR)
Duration (1 point for >6 weeks)
If >6 points in total, diagnosis of RA can be made
Which classes of medications can be given to treat RA?
NSAIDs
DMARDs
Steroid injections
Analgesics
Give 5 respiratory complications of RA
Pulmonary fibrosis Pleural effusion Pulmonary nodules Bronchiolitis obliterans Methotrexate pneumonitis Pleurisy
Give 5 ocular complications of RA
Keratoconjunctivitis Sicca Episcleritis Scleritis Corneal ulceration Keratitis Steroid-induced cataracts Chloroquine retinopathy
What is osteoarthritis?
Surfaces of the joints become damaged so the joint does not move smoothly.
Describe the pathophysiology of osteoarthritis
The cartilage on the bone surface wears away with use and becomes rough. The underlying bone becomes thicker and grows outwards creating osteophytes. The synovium thickens and produces extra fluid which causes the joints to swell. The capsule and ligaments around the joint thicken and shorten to try and stabilise the joint but this causes joint stiffness.
Which joints does osteoarthritis normally affect?
Larger weight bearing joints
Hip, knee and spine
Give 4 symptoms of osteoarthritis
Pain at the end of the day Stiff joints Crepitus Joint swelling Loss of function in the joints
Symptoms worse in the damp weather
Give 4 risk factors for developing osteoarthritis
Old age Female Obesity Previous joint injury Congenital joint abnormalities Genetics Previous history of RA
What changes may be seen on a joint x-ray in a patient with osteoarthritis?
Loss of joint space
Sclerosis of the bone
Osteophytes
Bone cysts
How can OA be treated conservatively?
Exercise
Weight loss
Physiotherapy
How can OA be treated medically?
Steroid injections
NSAIDs
Capsaicin cream
How can OA be treated surgically?
Joint replacement
What are people with OA more at risk of developing?
Gout
Chondrocalcinosis (calcium pyrophosphate crystals form in the cartilage)
What is psoriatic arthritis?
Inflammation in and around the joints with associated psoriasis skin rashes
What are the symptoms of psoriatic arthritis?
Pain and stiffness in the joints Buttock pain (from spondylitis) Pitting discolouration Thickening of the nails Fatigue Psoriatic rash
How is psoriatic arthritis treated?
Physiotherapy Exercise Stop smoking NSAIDs DMARDs Steroid injections Vitamin A and D Joint replacement
What is reactive arthritis?
Condition which causes painful joint swelling after an event such as an infection of the bowel, genital tract or throat. It usually lasts for about 6 months
Give 5 symptoms of reactive arthritis
Pain and swelling in the joints which occurs suddenly Swollen toe or finger Conjunctivitis Scaly rash over hands and feet (keratoderma blennorrhagica) Diarrhoea Genital tract discharge Weight loss Fever
What is Reiter’s Syndrome?
Classic triad of urethritis, conjunctivitis and arthritis
What is the most common cause of reactive arthritis?
Chlamydia infection
What is ankylosing spondylitis?
A systemic, chronic autoimmune spondyloarthropathy which mainly affects the axial spine.
What is the epidemiology of ankylosing spondylitis?
Males at higher risk
Aged 30-40
Strong genetic link
Which blood tests can be done to diagnose ankylosing spondylitis?
HLA-B27 = positive
Rheumatoid factor = negative
ESR/CRP = high
What is the pathophysiology of ankylosing spondylitis?
HLA-B27 aggregates with peptides in the joints and starts a degenerative process due to the cytotoxic T-cell reaction against the HLA-B27. The soft tissue between the joints becomes inflamed and causes bony erosion, soft tissue ossification and joint stiffness.
Give 3 symptoms of ankylosing spondylitis?
Lumbosacral pain and stiffness Worse in the mornings Loss of horizontal gaze Shortness of breath Sciatica
What are some other features of ankylosing spondylitis? (The As)
Apical fibrosis Anterior uveitis Aortic regurgitation Achilles tendonitis AV node block Amyloidosis Peripheral arthritis
What is found on physical examination of a patient with ankylosing spondylitis?
Reduced chest wall expansion
Decreased forward flexion (can do Schober’s test)
Reduced lateral flexion
Kyphotic spine deformity
Name 2 signs which may been seen on an x-ray of ankylosing spondylitis
Bamboo spine
Dagger sign
How can ankylosing spondylitis be treated nonoperatively?
NSAIDs
Physiotherapy
Exercise (walking will help to ease pain)
TNF-alpha blocking agents (Infliximab)
How can ankylosing spondylitis be treated operatively?
Spinal decompression
Lumbar osteotomy
Hip replacement
What is gout?
A form of arthritis characterised by a buildup of sodium urate crystals in the joints. If more than 1 joint is affected at a time it is called polyarticular gout.
How does gout present?
Sudden onset of symptoms which usually start at night and last for about a week. The patient will have flare ups occasionally but will mainly be asymptomatic
What are the symptoms of gout?
Joint become red, painful, hot and swollen. The overlying skin becomes shiny and peels. Pain on contact with the skin is very severe.
The crystals can collect outside the skin and cause small firm white lumps called tophi. The tophi can break down and start secreting pus-like fluid
Give 4 risk factors for developing gout
Genetics Obesity High cholesterol Hypertension Type II diabetes Kidney disease Diuretics use Family history Alcohol Drugs (cytotoxic agents, pyrazinamide)
Give 4 things which may trigger an attack of gout
Injury to the joint Febrile illness Surgery Overeating Excess alcohol
How is gout diagnosed?
Serum urate levels
X-ray
Ultrasound
Synovial fluid biopsy to check for crystals
How is an acute attack of gout managed?
NSAIDs
Colchicine
Steroid tablet/injection
Heat/ice pack
How is gout managed in the long-term?
Lose weight Avoid foods high in purines (seafood, meat) Reduce alcohol intake Allopurinol Febuxostat
What is another name for pseudogout?
Acute CPP crystal arthritis
What is pseudogout?
Similar to gout but when there is an accumulation of calcium pyrophosphate crystals in the joints.
Give 4 causes of pseudogout
Metabolic disease Hyperparathyroidism Haemochromatosis Hypomagnesaemia Genetic link
How is pseudogout diagnosed?
X-ray
Synovium biopsy
U&Es
CRP/ESR
What shape are the crystals in gout and are they birefringent?
Needle-like
Negative birefringent
What shape are the crystals in pseudogout and are they birefringent?
Rhomboid shaped
Weakly positive birefringent
Which joint is most commonly affected in gout?
1st MTP (big toe)
Which joint is commonly most affected in pseudogout?
Knee
What is osteoporosis?
Osteoporosis is when the spongy trabecular network in bone becomes less dense and so the bones become very fragile and more likely to fracture
How does osteoporosis normally present?
Normally presents with a low-energy fracture or vertebral crush fracture where the vertebrae spontaneously lose height and become weak
Where are fractures most likely to occur in osteoporosis?
Hip, spine or wrist
Give 4 risk factors for developing osteoporosis
Elderly Post-menopause Chronic steroid use Early menopause Lack of exercise Vitamin D deficiency Excessive alcohol Family history Low body weight Previous fractures Coeliac disease
How can osteoporosis be diagnosed?
DEXA scan (measures density of bones)
What is the FRAX tool?
Tool used to decide who needs a DEXA scan and to predict future risk of having a fracture
What factors does the FRAX tool use?
Age, gender, weight, height
Clinical risk factors (previous fracture, parental history of hip fracture, smoker, glucocorticoid treatment, RA, alcohol intake >3 units a day)
BMI
Give examples of people who should have a DEXA scan
Low impact fracture Menopause <45 years old Steroid treatment >3 months Parental hip fracture BMI <19
What scoring system does the DEXA scan use?
+1 to -1 = normal bone
- 1 to -2.5 = osteopenia
- 2.5 to -4 = osteoporosis
How is osteoporosis treated?
Treat fractures Painkillers NSAIDs HRT Calcium supplements Vitamin D supplements Bisphosphonate Calcitonin
What is osteomalacia?
Softening of the bones as mineralisation does not take place properly
Give 3 causes of osteomalacia
Vitamin D deficiency Coeliac disease Liver disease Kidney disease Epilepsy medication
What are the symptoms of osteomalacia?
Bone pain
Muscle weakness
Partial fractures
Limitation to daily activities
How is osteomalacia diagnosed?
ALP will be raised Serum PTH Vitamin D levels Phosphorus Calcium X-ray to check for fractures
How is osteomalacia treated?
Vitamin D supplements
Calcium supplements
Analgesia
Manage cause
What is Fibromyalgia?
A chronic condition which causes widespread pain and tenderness over the whole body. There is no obvious cause for the pain and no lasting damage on the body
What are the symptoms of fibromyalgia?
Widespread pain Extreme tiredness Sleep disturbance Memory problems Worse pain in the very hot, cold or damp weather Headache Irritability Poor circulation Urgent need to urinate Bowel changes
Give 4 conditions which are commonly linked to fibromyalgia
Chronic fatigue Depression Anxiety Headaches Restless leg syndrome Dry eyes IBS Hypothyroidism
How is fibromyalgia treated?
Physiotherapy Pain management classes CBT Mindfulness Antidepressants Analgesics Exercise
What is SLE (lupus)?
An autoimmune disorder where the body’s immune system attacks the body’s own tissues.
Give some symptoms of lupus
Joint pains and swelling Skin rashes Fatigue Fever Weight gain Lymphadenopathy Cold, numb fingers (Raynaud's) Mouth ulcers Hair loss Joint hypermobility Hypertension Anaemia Migraines Depression High cholesterol Dry eyes and mouth
How is SLE diagnosed?
Positive ANA Positive anti-dsDNA Positive anti-Ro antibody Positive antiphospholipid antibody Reduced complement level ESR U&Es LFTs FBC x-ray USS Urine dip
How is SLE treated?
NSAIDs Steroid creams Steroid tablets DMARDs Biological therapies Steroid injections
What are the symptoms of Sjogren’s Syndrome?
Dry eyes Dry mouth Hoarse voice Fatigue Swollen joints Painful joints
What conditions can Sjogren’s Syndrome be associated with?
RA
SLE
Scleroderma
What is the pathophysiology of Sjogren’s Syndrome?
Autoimmune condition where the body attacks the lacrimal glands in the eyes and the salivary glands in the mouth. The glands are damaged so produce less saliva and tears.
Which special blood tests will be positive in Sjogren’s Syndrome?
Anti-Ro
Anti-La
ESR high
What is Schirmer’s test used in Sjogren’s Syndrome?
Place litmus paper under the eyelids to measure how many tears are produced in a certain amount of time.
How is Sjogren’s Syndrome treated?
Eye drops Mucolytic agents (acetylcysteine eye drops) Artificial saliva Mouth sprays Antifungal treatment (if oral thrush infection) Painkillers NSAIDs Steroid injections into joints
What is dermatomyositis?
Autoimmune condition where muscles are inflamed and there is an associated skin rash.
What are the symptoms of dermatomyositis?
Weak and tired muscles Myalgia Malaise Weight loss Night sweats Red rash around eyes, face, neck and backs of fingers
How is dermatomyositis diagnosed?
Creatinine phosphokinase (high) ESR high ANA positive Anti-Jo-1 positive ENA
How is dermatomyositis treated?
Steroid tablets or injection Bisphosphonates Vitamin D tablets DMARDs Exercise Biological agents (infliximab)
What is Scleroderma (Systemic Sclerosis)?
Autoimmune condition where there is excessive fibrous tissue production resulting in excess collagen which is stiff and thick
What are the symptoms of scleroderma?
Raynaud's Skin thickening Hands and feet swelling Shiny skin Pain and stiffness in the joints Muscle weakness Digestive problems
How is scleroderma diagnosed?
Positive ANA in 90%
Positive Rheumatoid factor in 30%
Anti-centromere antibody positive
How is scleroderma treated?
No cure
Treat symptoms as they come with steroids or immunosuppression
