Rheumatology Flashcards
Define rheumatoid arthritis
Chronic symmetrical inflammatory polyarthritis of unknown origin
It’s involve the small joint
Mostly affects young females
And has extra articular manifestations
What are the risk factors for rheumatoid arthritis?
Genetic’s – HL8 types
Females
Smoking if rheumatoid factor (+) or ACPA (+)
Stress
Infections - EBV, CMV an E. coli
What is the pathogenesis of rheumatoid arthritis?
It targets the synovium
Inflammatory cascade is activated to release inflammatory cytokines TNF-alpha, IL-1 and IL-6
Stimulates the synovium to produce pannus
Release of degrading proteolytic enzymes
Activates osteoclasts
Describe clinical picture of rheumatoid arthritis
Acute insidious onset of pain
Early morning stiffness - wrist, mcp and pip
Monoarticular
Gradual loss of joint function
Constitutional symptoms
What are the articular manifestations of early rheumatoid arthritis?
Boggy tender soft tissue swelling at MCP and PIP
Inability to fully closed fist secondary to synovitis
Saville sign
Swelling of the dorsum of the wrist secondary to ulnar synovitis
Wasting of intrinsic hand muscles
What are the articular manifestations of advanced rheumatoid arthritis?
Swan neck deformity
> flexion of MCP + DIP
> extension of PIP
Bouttonierre deformity
> flexion of PIP
> hyperextension of DIP
Z-deformity of thumb
> flexion of MCP
> hyperextension of IP
Ulnar deviation + subluxation + dislocation of MCP
What are the extra articular manifestations of rheumatoid arthritis?
Rheumatoid nodules
Tenosynovitis
Scleritis or episcleritis
Pericardial effusion
Idiopathic lung disease
Leg ulcer
Anaemia
Carpal tunnel syndrome
What is the classification criteria for rheumatoid arthritis?
A. Joint involvement
B. Serological abnormality - RF (+), ACPA (+)
C. Acute phase reactant
D. Duration of symptoms >6 weeks
Describe the synovial fluid of a patient with rheumatoid arthritis
Straw coloured
5000 to 50,000 WBC
> 50% polymorphs
RF (+)
Decreased glucose
What are the x-ray findings of rheumatoid arthritis?
Soft tissue swelling
Periarticular osteopenia
Erosions
What is the medical management of rheumatoid arthritis?
First educate the patient
Methotrexate weekly
Chloroquine daily
Sulfasalazine daily
Analgesias
> paracetamol
Anti-inflammatories
> Ibuprofen
> diclofenac
> indomethacin
Steroids
> prednisone
Biologics > Infliximab > Tocoluzimab > Rituximab > Abethacept
What does the indications for joint replacement in rheumatoid arthritis?
Improvement of function / restoration of movement
Not responding to medical treatment
Severe pain
What is the classification of primary generalized osteoarthritis?
>4 joints affected: • DIP/PIP • Base of thumb • C5-C7 • AC joint • Lumbar spine • Hips + knees • Big toe
Females
What is the classification of primary localized osteoarthritis?
Nodal arthritis
Worse on dominant side
Joints: • DIP (Heberden nodes) • PIP (Bouchard nodes) • 1 CMC • 1st MTP
Flexion deformity and lateral deviation of the distal phalanx
What are the symptoms of osteoarthritis?
Mechanical pain that is worse with movement and better with rest
Morning stiffness <30mins
Muscle spasm
No constitutional symptoms
What are the signs of osteoarthritis?
Swelling and tenderness of the joints
Boney (hard) joints
Crepitus
Palpable osteophytes
Deformity
Periarticular muscle atrophy
What are the x-ray findings of osteoarthritis?
Joint space narrowing/loss of joint space
Osteophytes in the joint space
Subchondral sclerosis
Subchondral bone cysts
Malalignment
Gullwing sign in DIP + PIP
What is the medical management of osteoarthritis?
Weight loss and exercise
Analgesia:
• Paracetamol
• NSAIDs
• Opioids
Corticosteroids
When is anthroplasty the indicated in osteoarthritis?
Unresponsive to medical treatment
Pain wakes patient from sleep
Unable to stand for >20 minutes
Loss of joint function
What are the causes of secondary gout?
Alcohol
Polycythaemia
Psoriasis
Leukaemia
Obesity
Polycystic kidney disease
Hypothyroidism
Hyperparathyroidism
Drugs • Cyclosporine • Thiazides • Lasix • Ethambutol • Aspirin
What are the symptoms of acute gout?
Pain, swelling and redness that awakens the patient
Monoarticular
First MTP joint involvement
How is gout diagnosed?
Clinically
Aspirate joint synovial fluid to visualise crystals is the gold standard
Increased serum uric acid
X-ray shows soft tissue swelling and lifting cortex
What are the complications of Chronic gout?
Stones
Interstitial fibrosis
Acute urate nephropathy
How would you manage an acute gout attack?
Bedrest
NSAIDS
• 75mg Voltaren IM STAT
Colchicine
• 0.5mg 8hrly until UA <0.3mmol/l
Advice on diet/alcohol
