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3B General Care > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

Signs of acute cauda equina compression

A
  • alternating or bilateral root pain in legs
  • saddle anaethesia
  • loss of anal tone on PR
  • bladder +/- bowel incontinence
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2
Q

Signs of acute cord compression

A
  • bilateral pain
  • LMN signs at level of compression
  • UMN and sensory loss below
  • Sphincter compression
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3
Q

Management of Mechanical Back Pain

A
  • education
  • self management
  • normal activities - analgesia as necessary - regular paracetamol, NSAIDs, codeine
  • consider low dose amitriptyline
  • Physio
  • accupuncture
  • exercise programme
  • psychosocial referral
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4
Q

Investigations for back pain

A
  • FBC, ESR, CRP (myeloma, infection, tumper)
  • U&Es, ALP (Pagets)
  • serum/ urine electrophoresis (myeloma)
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5
Q

Nerve Root Lesions

L2

A

Pain- Across the upper thigh

Weakness - Hip flexion and adduction

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6
Q

Nerve Root Lesions

L3

A

Pain - Across lower thigh
Weakness- hip aDducation, knee extension
Reflex- Knee jerk affected

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7
Q

Nerve Root Lesions

L4

A

Pain- Across knee to medial malleolus
Weakness- Knee Extension, Foot inversion and dorsiflexion
Reflex - Knee Jerk Affected

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8
Q

Nerve Root Lesions

L5

A

Pain- Lateral shin to dorsum of foot and great toe
Weakness- Hip extension and aBduction,
foot inversion and dorsiflexion
Reflex- Great toe jerk affected

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9
Q

Nerve Root Lesions

S1

A

Pain - Posterior calf to lateral foot and little toe
Weakness- Knee flexion, foot and toe plantar flexion, foot eversion
Reflex - Ankle jerk

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10
Q

Signs of OA

A

Pain on movement
Worse at the end of the day
Background pain at rest

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11
Q

Red Flags of Back Pain

A
  • Age <20, >55
  • acute onset in the elderly
  • constant or progressive
  • nocturnal pain
  • worse pain on being supine
  • fever, night sweats, weight loss
  • abdominal mass
  • history of malignancy
  • thoracic back pain
  • morning stiffness
  • bilateral or alternating leg pain
  • neurological disturbance
  • sphincter disturbance
  • current or recurrent infection
  • immunosuppression
  • leg claudication/ exercise related leg weakness/ numbness
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12
Q

Osteoarthritis

A

commonest joint condition
women: men 3:1
typical onset >50
usually primary, may be secondary to joint disease or other conditions - e.g. haemochromatosis, obesity, occupational

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13
Q

Signs and symptoms of osteoarthritis

Localised disease

A 
Pain on movement and crepitus 
Worse at the end of the day 
Background pain at rest 
joint gelling - stiffness after rest up to ~30 mins 
Joint instability
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14
Q

Signs & symptoms of osteoarthritis

generalised disease

A 
Commonly affected joints- DIP, thumb metocarpal joints, Knees
Joint tenderness 
Joint derrangement 
Bony swelling (Herbenden's nodes (post menopausal women) DIP, Bouchard's at PIP)
Decreased range of movement
Mild synovitis
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15
Q

Tests for osteoarthritis

A

L- loss of joint space
O- osteophytes
S - subarticular sclerosis
S- sub chondral cysts

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16
Q

Management of Osteoarthritis

A

Core - Exercise, weight loss
Analgesia - regular paracetamol ± NSAIDs
Topical capsaicin
Intra-articular steroid injections
Intra-articular hyaluronic acid injections

Physio/OT- hot /cold packs, walking aids, stretching orTENS
Surgery

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17
Q

Septic Arthritis

Risk Factors

A 
Pre-existing joint disease esp. Rheumatoid
DM 
Immunosuppression
Chronic renal failure 
Recent joint surgery 
Prosthetic joint 
IV drug use
age >80 yrs
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18
Q

Investigations

Septic Arthrtis

A

Joint aspiration - synovial MC&S
X-R and CRP may be normal
main DD = crystal arthopathies
Blood cultures for guiding abx

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19
Q

Treatment

A
  • Empirical Abx- common causes s. aureus, strep, neisseria gonococcus and gram -ve bacilli
    Abx 2/52 IV, 2-4/52 PO
    Removal of prosthetic joints
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20
Q

Rheumatoid arthritis

A

chronic systemic inflammatory disease
characterised by symmetrical deforming, peripheral polyarthritis
HLA DR4/DR1 linked

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21
Q

Presentation of RA

Typical

A

symmetrical swollen, painful and stiff small joints of the hands & feet
worse in the morning

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22
Q

Less common presentation of RA

A

Sudden onset widespread arthritis
Recurring mono/polyarthritis
Persistent monoarthritis
Systemic illness with extra-articular symptoms - fatigue, fever, weight loss, pericarditis and pleurisy
Polymyalgic onset - vague limb girdle aches
Recurrent soft tissue problems - frozen shoulder/carpal tunnel

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23
Q

Early Signs of RA

A

inflammation, no joint damage
swollen MCP, PIP, wrist or MTP joints
Look for tenosynovitis or busitits

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24
Q

Later signs of RA

A

joint damage, deformity

  • ulnar deviation
  • dorsal wrist subluxation
  • Boutonniere and swan neck deformities of the fingers
  • Z - shaped thumbs
  • hand extensor tendons my rupture
  • atlanto-axial joint subluxation may threaten spinal cord
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25
Extra-articular signs of RA
``` Nodules - elbows and lungs Lymphadenopathy Vasculitis Fibrosing alveolitis Obliterative bronchiolitis Pleural and pericardial effusions Raynaurds carpal tunnel peripheral neuropathy splenomegaly ```
26
Investigation in RA
Rheumatoid Factor positive in ~70% ACPA/ anti- CCP antibodies Anaemia of chronic disease Inflammation = raised platelets, ESR & CRO X-rays show soft tissue swelling, juxta-articular osteopenia and reduced joint space Later may have bony erosions, subluxation or complete carpal destruction
27
Management of RA
- Early use of DMARDs and biologics - Steroids reduce symptoms and inflammation - NSAIDs good for symptom relief - specialist physio and OT - Surgery - relieve pain, improve function and prevent deformity
28
Disease modifying anti-rheumatic drugs
start within 3 months of persistent symptoms - may take 6-12 weeks for symptomatic benefit - combination of methotrexate, sulfasalazine and hydroxychloroquine
29
SE of DMARDs
Immunosupression - potentially fatal Methotrexate - pneuomonitis, ulcers, hepatotoxicity Sulfasalazine - rash, reduced sperm count, oral ulcers
30
Biological agents and RA
1. TNFa inhibitors (infliximab, enanercept) 2. B Cell depletion e.g. rituximab with methotrexate 3. IL-1 & Il-6 inhibition 4. Disruption of T-cell function - abatacept
31
SE of biological agents
``` Serious infection, reactivation of TB and hep B, worsening heart failure hypersensitivity reaction injection site reaction blood disorders ```
32
Gout presentation
Acute monoarthropathy with severe joint inflammation >50% of MTP of big toe - podagra - may be polyarticular - caused by the deposition of monosodium urate crstals Precipitated by trauma, surgery, starvation, infection or diuretics --> long term = deposits (tophi) in pina, tendons and joints- renal disease may also occur
33
Differential diagnosis of gout
septic arthritis haemarthrosis CCPD palidromic RA
34
Causes of gout
``` hereditary increased dietary purines alcohol excess diuretics leukaemia cytotoxics ``` Associated with: CVD, HTN, DM, CKD
35
Gout investigations
polarised light microscopy of synovial fluids - negatively birefringent urate crystals X-R shows only soft tissue swelling in early stages later--> punched out erosions in juxta-articular bone - no sclerotic reaction and joint spaces preserved until late
36
Treatment of Gout Acute
High dose NSAIDs or coxib (etoricoxib) | if CI - colchicine is effective but slower to work
37
Prevention of gout
- loose weight | - avoid prolonged fasts , alcohol excess, purine rich meats and low dose aspirin
38
Prophylaxis of gout
allopurinol (wait 3 weeks after an acute episode to begin)
39
Calcium pyrophosphate deposition
- acute CPP crystal arthritis (pseudogout) - chronic CPPD - osteoarthritis with CPPD
40
Acute CPPD crystal arthritis (pseudogout)
acute monoarthropathy typically larger joints in older patients usually spontaneous and self limiting may be provoked by illness, surgery or trauma
41
Chronic CPPD
inflammatory RA-like symmetrical polyarthritis and synovitis
42
Osteoarthritis with CPPD
chronic polyarticular osteoarthritis with super imposed acute CPP attacks
43
Risk factors for CPPD
Old age hyperparathyroidism haemochromatosis hypophosphataemia
44
Tests for CPPD
polarised light microscopy of synovial fluid shows weakly positive birefringent crystals Associated with soft tissue calcium deposition on X-ray
45
Management of CPPD
acute attacks- cool packs, rest, aspiration and intra-articular steroids NSAIDs + PPI± cochicine may prevent attacks Methotrexate and hydroxychlorquine have a role in chronic CPPD
46
What is ankylosing spondylitis
chronic inflammatory disease of the spine and sacroiliac joints
47
Prevalence of ankylosing spondylitis
0.25-1% men present earlier 6:1 at 16, 2:1 at 30 ~90% HLA B27 positive
48
Signs and symptoms of ankylosing spondylitis
gradual onset low back pain, worse at night morning stiffness relieved by exercise pain radiates from sacroiliac joints to hips/ buttocks , usually improves towards the end of the day Progressive loss of spinal movement --> decreased thoracic expansion
49
Extra-spinal presentations of ankylosing spondylitis
enthesitis- achilles tendonitis, plantar fascitis, tibial and ischial tuberosities costchondritis and fatigue acute iritis associated with osteoporosis, aortic valve incompetence and pulmonary apical fibrosis
50
Testing for ankylosing spondylitis
Dx is clinical and supported by imaging- bamboo spine, sacroilitis vertebral syndesmophytes bony proliferations
51
Management of ankylosing spondylitis
Exercise NSAIDs TNF alpha blockers - etanercept, adalimumab adn golimumab local steroid injections = temporary relief Surgery to improve pain and mobility Bisphosphonates - risk of osteoporotic spinal fractures
52
Enteric arthropathy
associated with inflammatory bowel disease, GI bypass, coeliac and whipple's disease arthropathy improves with treatment of bowel syndromes
53
Psoriatic arthritis
occurs in 10-40% of psoriasis- can present before skin changes - symmetrical polyarthritis - DIP joints - asymmetrical oligoarthritis - spinal due to AS radiology -associated with nail changes, acneform rahses and palmo-plantar pustulosis
54
Psoriatic arthritis radiology
-> erosive changes 'pencil in cup' deformity,
55
Associated features of psoriatic arthritis
nail changes acneiform rashes palmo-plantar pustulosis
56
Management of psoriatic arthritis
``` NSAIDs Sulfasalazine Methotrexate ciclosporin anti-TNF agents are also effective ```
57
Reactive arthritis
A sterile arthritis, typically the lower limb 1-4 weeks after urethritis or dysentry chronic or relapsing may have iritis, keratoderma blenorrhagica, circinate balanitis, mouth ulcers and enthesitis
58
Reiter's syndrome
urethritis arthritis conjunctivitis
59
Investigations for reactive arthritis
``` ESR & CRP raised culture stool if diarrhoea infectious serology sexual healthreview x-ray may show enthesitis with periosteal reaction ```
60
Management of reactive arthritis
splint affected joints acutely NSAIDs or local steroid injections treating original infection may make little difference to the arthritis
61
Shared features of spondyloarthropathies
- seronegativity (Rheumatoid factor -ve) - HLA B27 - axial arthritis- pathology in spine and sacroiliac joints - asymmetric large joint oligoarthritis or monoarthritis - enthesitis - dactylitis - extra-articular manifestation
62
Systemic sclerosis
features scleroderma (skin fibrosis) and vascular disease
63
Limited cutaneous systemic sclerosis
``` Calcinosis (subcutaneous tissues) Raynaud's oEphageal and gut dysmotility Sclerodactyly (swollen tight digits Telangiectasia ``` - skin involvement limited to hands, feet and face - anticentromere antibodies - pulmonary hypertension subclinically Rx- sildenafil, bosentan
64
Diffuse cutaneous systemic sclerosis
diffuse skin involvement early organ fibrosis - lung, cardiac, GI and renal Anti-poisomerase 1 and anti-RNA polymerase prognosis poor control BP, annual ECG and spirometry
65
Management of systemic sclerosis
no cure immunosuppressive regimens used for organ involvement or progressive skin disease (cyclophosphamide) try anti-fibrotic tyrosine kinase inhibitors Monitor BP and renal function - ACE-i ±ARB
66
Mixed connective tissue disease
combines features of systemic sclerosis, SLE and polymyositis
67
Relapsing polychondritis
attacks cartilage - pinna, nasal septum, larynx (= stridor) and joints - aortic valve disease, polyarthritis and vasculitis - underlying rheumatic or autoimmune disease Rx- steroids and immunosuppressives
68
Polymyositis and dermatomyositis
rare conditions with insidious onset of progressive symmetrical proximal muscle weakness and autoimmune mediate striated muscle inflammation wtih myalgia ± arthralgia
69
Muscle weakness in Polymyositis and dermatomyositis
causes - dysphagia - dysphonia (poor phonation, not dysphasia) - respiratory weakness may be a paraneoplastic phenomenon- commonly from lung, pancreatic, ovarian or bowel malignancy
70
Dermatomyositis
myositis + skin signs - macular rash - lilac-purple rash on eyelids with oedema - nailfold erythema - Gottron's papules - subcutaneous calcifications
71
Extramuscular signs | Polymyositis and dermatomyositis
``` fever arthralgia Raynauds interstitial lung fibrosis myocardial involvement (myocarditis, arrhythmias) ```
72
Polymyositis and dermatomyositis Tests
Muscle enzymes (AST, ALT, LDH, CK & aldolase) raised electromyography - fibrillation potentials muscle biopsy MRI- muscle oedema in acute myositis Anti-M2, anti-Jo1 associations
73
Polymyositis and dermatomyositis Differeentials
``` carcinomatous myopathy inclusion body myositis muscular dystrophy PMR endocrine/metabolic myopathy (steroids) rhabdomyolysis infection drugs (penicillamine, colchicine, statins or chloroquine ```
74
Polymyositis and dermatomyositis Management
screen systemically for malignancy start prednisolone 1mg/kg/day immunosuppressives & cytotoxics
75
Behcet's Diseaes
Systemic inflammatory disorder of unknown origin associated with HLA B5 Common along the old silk road
76
Behcet's disease | features
``` recurrent oral and genital ulceration uveitis skin lesions- erythema nodosum, papulpustular lesions arthritis (non-erosive large joint oligoarthropathy) thrombophlebitis vasculitis myo/pericarditis CNS involvement (pyramidal signs colitis ```
77
Treatment of Behcet's disease
Cochicine for orogenital ulceration azathioprine or cyclophosphadmie for systemic disease infliximab
78
what is SLE
multisystemic autoimmune disease where autoantibodies are made against a variety of autoantigens Polyclonal B-cell secretion of pathogenic autoantibodies cause tissue damage- immune complex formation and deposition, complement activation and other direct effects
79
Epidemiology of SLE
9:1 women to men | commoner in Afro-Carribean populations, Asian people, HLAB8, DR2 or DR3 +ve
80
Clinical features of SLE
Relapsing and remitting variable presentation - non-specific constitutional symptms of malaise, fatigue, myalgia and fever - lymphadenopathy - weight loss - alopecia - nail fold infarcts - non-infective endocarditis (Libman-Sacks syndrome) - Raynaurds - migraine - Strokes - retinal exudate
81
Revised criteria for diagnosising SLE 4/11 needed for diagnosis
- malar rash - discoid rash - photosensitivity - oral ulcers - non-erosive arthritis - serositis- pleuritis, pericarditis - renal disorder- persistent proteinuria, cellular casts - CNS disorder- seizures or psycosis - haematological disorder - haemolytic anaemia, leukopenia, lymphopenia, thrombocytopenia - Immunological disorder - anti-dsDNA, anti-Sm antibody, antiphospholipid +ve - ANA +ve
82
Immunology of SLE
>95% ANA +ve (antinuclear antibody)
83
Monitoring SLE
1. Anti dsDNA antibody titres 2. Complement (low C3, C4) 3. ESR Also- BP, urine for casts or proteins, FBC, U&E, LFT, CRP
84
Drug induced lupus
incl. isoniazid, hydralazine antihistone antibodies - skin and lung signs prevail
85
Management of SLE | severe flare
IV cyclophosphamide + high dose prednisolone
86
Management of SLE Cutaneous symptoms
treat rashes with topical steroids prevent rashes with high factor sun block creams sun exposure may also trigger acute systemic flare
87
Management of SLE Maintenance
- NSAIDs and hydroxychloroquine- joints and skin - low dose steroids may be useful - azathioprine, methotrexate and mycophenolate are used as steroid-sparing agents
88
lupus nephritis management
may require more intensive immunosuppression - steroids, cyclophosphamide or mycophenolate --> BP must be controlled, renal replacement therapy may be needed
89
managment of SLE | B-cell depletion
Belimuma
90
Future treatments of SLE
interferon alpha, interleukin 6 inhibition and t-cell targets
91
Antiphospholipid syndrome
associated with SLE - antiphospholipid anti-bodies cause CLOTS C- coagulation defect L- Livedo reticularis O- Obstetric (recurrent miscarriage) T- THrombocytopenia treat with low dose aspirin
92
What is vasculitis?
inflammatory disorder of blood vessel walls, causing destruction (aneurysm/ rupture) or stenosis - Primary - Secondary to SLE, RA, Hep B/C, HIV
93
Classification of Vasculitis
Large- GCA, Takayasu's arteritis Medium- Polyarteritis nodosa, Kawasaki Small- ANCA +ve - resp & renal. incl- p-ANCA microscopic polyangitis, glomerulonephritis & Churg Strauss syndrome & Wegner's - ANCE -ve - Henoch-Schonlein purpura, goodpasture's and cyroglobulinaemia
94
Symptoms of Vasculitis
- Systemic - fever, malaise, weight loss, arthralgia, myalgia - Skin - purpura, ulcers, livedo reticularis, nail bed infarcts, digital gangrene - Eyes - episcleritis, scleritis, visual loss - ENT - epistaxis, nasal crusting, stridor, deafness - Pulmonary - haemoptysis & dyspnoea - Cardiac - angina or MI, heart failure, pericarditis - GI - pain or perforation - Renal - hypertension, haematuria, proteinura, casts and renal fialure - Neurological - strokes, fits, chorea, psychosis, confusion, impaired cognition, altered mood - GU - orchiditis- testicular pain or tenderness
95
Vasculitis investigations
``` Raised ESR/CRP ANCA may be +ve raised creatinine in renal failure proteinuria, haematuria, casts on microscopy Angiography ± biopsy ```
96
Management of vasculitis
Large vessel - steroids Medium vessel - steroids + IV cyclophsophamide Azathioprine may be used as a steroid sparing agent
97
GCA- Giant Cell Arteritis Cranial or Temporal Arteritis
Common in elderly Headache, temporal artery and scalp tenderness jaw claudication amaurosis fugax Dyspnoea, morning stiffness, uneuqal or weak pulses start 60mg prednisolone ASAP Tests- ESR & CRP very raised, high plts & ALP, low HB Temporal artery biopsy within 7 days of starting steroids PPI & bisphosphonate 2 year disease course then remission
98
Polyarteritis nodosa
Necrotising vasculitis that causes aneurysms and thrombosis in medium sized vessels --> infarction associated with Hep B Typically systemic with skin (punched out ulcers), renal (main cause of death), cardiac, GI and GU involvement CNS anuerysms in Kawasaki disease WCC raised, mild eosinophilia, anaemia, raised ESR and CRP, ANCA -ve Treatment - control BP, treat hep B. Corticosteroids and cyclophosphamide
99
Microscopic polyangitis
necrotising vasculitis that affects small and medium sized vessels Rapidly progressive glomerulonephritis and pulmonary haemorrhage pANCA +ve Treatment - control BP, treat hep B. Corticosteroids and cyclophosphamide
100
Polymyalgia Rhuematica Features
Age >50 Sub-acute onset (<2 weeks) of bilateral aching, tenderness and morning stiffness in the shoulders and proximal limb muscles ± polyarthritis, tenosynovitis and carpal tunnel Weakness is not a feature Maybe associated with fatigue, fever, weight loss, anorexia and depression
101
Polymyalgia Rheumatica Investigations
Raised CRP ESR> 40 raised ALP creatinine kinase is normal
102
Polymyalgia Rheumatica Differential diagnoses
``` Recent onset RA polymyositis hypothyroidism primary muscle disease ocult malignancy or infection osteoarthritis - cervical spondylosis/ shoulder OA neck lesion bilateral subacromial impingement spinal stenosis ```
103
Polymyalgia Rheumatica Management
Prednisolone 15mg OD PO Dramatic response within one week decrease dose slowly
104
Fibromyalgia Prevalence
10% of new rheumatology referrals | 0.5-4%, women 10:1 men
105
Fibromyalgia Risk Factors
female sex middle age low household income divorced low educational status belief that pain and activity are harmful sickness behaviours - extended rest social withdrawal emotional problems such as low mood, anxiety or stress problems or dissatisfaction at work problems with compensation or time off work overprotective family or lack of support inappropriate expectations of treatment
106
Features of Fibromyalgia
- chronic pain >3 months - widespread L&R, above and below waist, axial skeleton - absence of inflammation - presence of pain on palpation at at least 11/18 tender points - morning stiffness - fatigue - poor concentration - low mood - sleep disturbance
107
Palpation points fibromyalgia
- suboccipital insertions - anterior aspects of inter-transverse spaces C5-7 - midpoint of upper border of trapezius - origin of supraspinatus near medial border of the scapular spine - costochondral junction of 2nd rib - 2cm lateral from lateral humeral epicondyle - upper outer gluteal quadrant - posterior to greater trochanter - knee at medial fat pad proximal to joint line
108
Management of Fibromyalgia
Education of pt and family - Explain relapsing & remitting, no easy cure, good & bad days - reassure no serious underlying pathology - CBT - discuss psychosocial issues - low dose tricyclic antidepressants - e.g. 10mg amitriptyline and pregabalin/ venlaflaxine
109
Chronic Fatigue Syndrome
persistant disabling fatigue lasting more than 6 months affecting mental and physical function, present > 50% of the time + >4 of - polyarthralgia - decreased memory - unrefreshing sleep - fatigue after exertion >24h - persistent sore throat - tender cervical/ axillary lymph nodes - management similar to fibromyalgia with graded exercise and CBT
110
Sjorgren's Syndrome
Chronic inflammatory autoimmune disorder primary or secondary lymphatic infiltration & fibrosis of exocrine glands- esp lacrimal and salivary - decreased tear production - decreased salivation - parotid swelling - may also have vaginal dryness, dyspareunia, dry cough and dysphagia
111
Systemic signs of Sjorgren's Syndrome
``` polyarthritis/arthralgia Raynaurds Lymphadenopathy vasculitis lung/ liver/ kidney involvement peripheral neuropathy myositis fatigue ```
112
Treatment of Sjorgren's Syndrome
Treat sicca symptoms - hypromellose (artificial tears) - frequent drinks/ sugar free pastilles/ gum - NSAIDs and hydroxychloroquine for arthralgia
113
Churg-Strauss syndrome
``` triad of - adult onset asthma - eosinophilia - vasculitis ± vasospasm ±MI ±DVT affecting lungs, nerves, heart and skin septic shock picture or systemic inflammatory response syndrome with glomerulonephritis may occur ```
114
Treatment of Churg-Strauss
steroids | if refractory - biologics- e.g.rituximab
115
Henoch-Schonlein Purpura
small vessel vasculitis presents with purpura over buttocks and extensor surfaces typically affects young men may be glomerulonephritis, arthritis and abdominal pain ± intussusception

3B General Care (8 decks)

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