RHEUMATOLOGY Flashcards
Define: Gout
Microcrystal synovitis due to the deposition of Monosodium Urate Monohdrate in the synovium
Form of inflammatory Arthritis
Define: Psuedogout
A.K.A Acute CPP Crystal Arthritis
Form of microcrystal synovitis caused by deposition of Calcium Pyrophosphate Dihydrate in the synovium
Chronic CPPD: inflammatory RA-like poly arthritis and synovitis
Osteoarthritis with CPPD: chronic polyarticular osteoarthritis with superimposed CPP attacks
What is the aetiology of Gout?
Hyperuricaemia (uric acid >0.45mmol/L) 1. Decrease excretion - Drugs: diurteitcs - CKD - Lead toxicity 2. Increased production - Myeloprolferative/lymphoproliferative disorder - Cytotoxic drugs - Severe psoriasis 3. Lesch-Nyhan syndrome - Hypoxanthine-guanine phosphoribosyl transferase deficiency x-linked recessive so only seen in boys features: Gout, Renal failure, neurological defects and learning disorders and self-mutilation
What is the aetiology of Psuedogout?
Hyperparathyroidism Hypothyroidism Haemochromatosis Acromegaly Low Mg+ Low phosphate Wilson's
What is the pathogenesis of Gout?
Monosodium Urate crystals are deposited precipitated by trauma, surgery and starvation
What is the pathogenesis of Psuedogout?
Usually spontaneous (but can be provoked by illness and trauma)
What are the demographics of gout and psuedogot?
Gout: M:F 4:1 ~1% prevalence
Psuedogout: More likely in elderly
How does gout present?
Typically a flare of symptoms lasting several days with maximal intensity over 12 hours:
- pain
- swelling
- erythema
~50% of first presentations affects the first MTP (also anke, wrist and knee)
How does pseugout present?
Knee, wrist and shoulders
Acute monoarthropathy
What are the crystals present in Gout?
Needle-shaped negatively birefringent urate crystals
Sometimes increased serum ur
What are the crystals present in psuedogout?
Weakly-positively birefringent rhomboid shaped crystals on joint aspiration
What are the features of Gout on xray?
- Joint effusion
- Well-defined, ‘punched out’ erosions with sclerotic margins in a junta-articular distribution, often with overhanging edges
- Relative preservation of joint space until late disease
- Eccentric erosions
- No periarticular osteopenia
- Soft tissue swelling
- Joint space is maintained
What are the features of Psuedogout on xray?
Chondrocalcinosis soft tissue calcium deposition in the hyaline and/or fibrocartialage
How is Gout managed?
Acute:
NSAIDs e.g. Dichlofenac (Oral steroids if NSAIDs contraindcated e.g. if taking warfarin)
Intra-articular steroids
Colhicine: (SE is dairrhoea)
Prophylaxis: Allopurinal, don’t start until 2 weeks after an acute attack as it may precipitate
If no risk factors for the development of gout and no evidence of gouty tophi on examination then only start allopurinol if another attack <12 months
Reduce intake of: alcohol and high purine food (liver)
Lose weight
How is Psuedogout managed?
Usually self-limiting so NSAIDs or intra-articular, IM or oral steroids
What are is the prognosis for Gout?
If left untreated can damage the joints, more chronic problems
Can be a marker for CVS, HTN, DMT2 and CKD
What is Ankylosing Spondylitis?
Spinal ARTHRITIS causing ankylosing (stiffening and immobility) of the VERTEBRAL and SACROILIAC joints due to FUSION OF THE BONES
What are the features of Ankylosing Spondylitis?
SPINAL-E:
Sacroiliac and low back (lumbar and gluteal) pain
Pleuritic chest pain
Inhereted HLA-B27
Neck hyperextension- ‘?’ posture
Asymmetrical Oligoarthritis in peripheries
Loss of lumbar spinal flexion and Thoracic Kyphosis (progressive) and increased risk of fracture
Enthesitis: achilles tendon
What are the extra-articular features of Ankylosing Spondylitis?
CHISAL:
Corda Equina Heart: - AV node block - Aortic regurgitation - Aortitis Inflammation and ulceration of ileum and colon Secondary Amyloidosis Anterior Uveitis Lung fibrosis (UZ)
What are the findings on X-Ray of Ankylosing Spondylitis?
Sacrolitis: sunchondral erosions and sclerosis: c-ray blurring and widening of SI joints
Squaring of lumbar vertebra
Syndesmophytes: ossification of annulous fibrosus, fuse the vertebrea causing ‘Bamboo spine’
What is Schober’s test?
<5cm = Ank Spon
What are the causes of Vasculitis Rash?
- RA
- Polyarteritis nodosa
- Strep infection
- Drug allergy
What causes low Phosphate concentrations (plasma)?
Hypercalcaemia of malignancy
Inherited rickets
Prolonged TPN
1’ (3’) Hyperparathyroidism
What are the shared features of Spondyloarthropathies?
- Seronegativity
- HLA-B27
- ‘Axial arthritis’
- Asymmetrical large-joint oligoarthritis (<5 joints) or monoarthritis
- Enthesitis: inflammation of tendon/ligament insertion sites e.g. plantar fasciitis, Achilles tendonitis
- Dactylitis: inflammation of entire digit ‘sausage digit’ due to soft tissue oedema and joint inflam
- Extra-articular manifestations
What are the Extra-articular Manifestations of the Spondyloarthropathies?
- Anterior uveiits
- Psoriaform rashes
- Oral ulcers
- Aortic valve incompetence
- IBD
What are the HLA-B27 associated joint diseases?
Ankylosing Spondylitis (88%) Acute Anterior Uveitis (50-60%) Reactive arthritis (60-85%) Enteric Arthropathy (50-60%) Psoriatic Arthritis (60-70%)
What is De Quervain’s Tenosynovitis?
Sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflamed.
30-50y/o females
Features
- pain on the radial side of the wrist
- tenderness over the radial styloid process
- abduction of the thumb against resistance is painful
FINKLESTEIN’s test: thumb is flexed across the palm of the hand, pain is reproduced by movement of the wrist into flexion and ulnar deviation
analgesia
steroid injection
splint (spica)
surgical treatment
