Rheumatology Flashcards
Presentation of OA
pain ± stiffness
Thumb base, hip, knee
random exacerbations for weeks/months
what would you find on examination for OA
Heberdens nodes - DIP
Bouchards nodes - PIPs
synovial thickening
deformity effusion
crepitus
decreased function
muscle weakness and wasting
X-ray findings for OA
- decreased joint space
- osteophytes
- subchondral sclerosis
- subchondral cysts
management of OA
regular review
pain relief: para/NSAIDS -> opioid/cox2 inhib
IA steriod injections
joint replacement
lifestyle: weight, physio
What is the pathology of Rheumatoid arthritis?
synovial inflammation -> synovial proliferation -> pannus -> art cart destruction -> bony erosions
RF by B cells locally
Inflam caused by factors produced by T cells, macrophages, mast cells and fibroblasts
Presentation of RA
joint pain and stiffness (>30m in morning)
PIPJs small joints in hands/wrists/feet
General fatigue and malaise
+systemic features
Examination findings for RA
symmetrical joint inflam
muscle wasting
ulnar deviation
swam neck
boutonnieres
Z deformity
Systemic features of RA
eyes: Sjorens syndrome
Skin: ulcers rashes
Rheumatoid nodules: eyes, subcut, lungs, heart
Neuro: peripheral nerve entrapment
resp: pulmonary fibrosis
Cardio: MI
Liver: hepatomegaly
RA investigations
Rheumatoid factor
Anti CCP (cyclic citrullinated peptide)
X-ray
- soft tissue swelling
- periarticular osteopenia
- loss of joint space
- erosions
RA management
NSAIDS and Cox 2 inhib
Corticosteriods - PO/ injection, symptomatic
2 X DMARD - methotrexate, sulfasalazine, leflunomide, hydroxychloroquinine
TNF inhib - infliximab
Septic arthritis causative organsisms
STAPH AUREUS
Strep
neisseria (young person, sexual history)
Septic arthritis risk factors
IVDU
immunosuppressed
prosthetic (prior joint damage)
Diabetes
Septic arthritis presentation
acute painful red swollen monoarthritis with fever
Septic arthritis management
Start broad spec ABx
X-ray
Aspirate (gram stain m C&S, crystal analysis)
fluclox 6 weeks clindamycin if allergic
Gout crystal
sodium urate
gout presentation
acute painful red swollen joint
MPJ, ankle, knee, elbow, wrist, fingers
tophi (chalk appearance under skin, asymmetrical)
gout diagnosis
clinical
serum urate >360
aspiration: needle shaped crystals
Gout management
NSAIDS (diclofenac, naproxen, indometacin)
Colchicine (4-6 daily until symptoms resolve)
Pred
Canankinumab
Gout triggers
red meat
alcohol
dehydration
diuretics
Gout prophylaxis
allopurinol (after symtoms settle)
lifestyle
Pseudogout crystals
calcium pyrophosphate
pseudogout presentation
acute painful red swollen joint (milder than gout)
Knee, ankle, wrist, feet, shoulder
Pseudogout diagnosis
X-ray Chondrocalcinosis
aspiration: rhomboid shaped crystals
Sign and condition
Chondrocalcinosis
pseudogout
Management of pseudogout
NSAIDS
colchicine
steriod injection
treat any primary conditions
triggers for pseudogout
illness: flu, chest infection, fever
hyperparathyroid, hypothyroid, hypomagnesaemia
Causes of Reactive arthritis
post enteric: campylobacter, salmonella
post veneral: gonorrhea, chlamydia
Reactive arthritis presentation
1-6 weeks post infectious
- asymmetrical lower extremity oligoarthritis
- commonly pain lower back
- conjunctivitis, urethritis, arthritis,
reactive arthritis investigations
Aspirate: increased WCC
RBC: increased ESR/CRP
Stool sample cultures: causative organism
serology: gono or chlamydia
HLA-B27 antigen +Ve
What is this and in which condition is it seen
Keratoderma blenorrhagicum - reactive arthritis
how is reactive arthritis managed
self limiting, symptoms resolve 3-12 months
- rest and aspirate
- physio
- NSAIDS
- corticosteriods (PO/inject)
- Abx
what is perthes and who gets it
self limiting hip disorder caused by ischaemia -> necrosis of femoral head
males 4-8 with delayed skeletal maturity
How does perthes present?
hip/knee pain -> limp
decreased ROM
Perthes investigations
FBC, ESR, X-ray
X ray shows widening joint space and remodelling deformities
Perthes management
if <50% of fem head affected then bed rest and NSAIDS
If >50% fem head affected then plaster cast and surgery
Perthes X ray findings
Widening joint space
decreased size of nuclear femoral head with patchy density
collapse and deformity of femoral head
what is pagets
bone remodelling disorder with increased osteoclast -> increased osteoblasts -> weak and disorganised bone
pagets presentation
- axial skeleton
- normally asymptomatic picked up incidentally
- bone pain
Pagets investigations
- Bone specifc alkaline phosphatase levels increased
- X-ray
- isotope scan
Pagets management
NSAIDS
IV/PO bisphosphonates (zoledronate) + calcium and vit D
what is charcots?
neuropathic joints caused by decreased sensation leading to damage
causes of charcots
Developed countries: diabetes, diabetic neuropathy
developing: leprosy
charcots presentation
redness, warmth, swelling, deformity., loss of function
pain non proportional to state of joint
charcots investigations
x-ray, early OA changes, disruption later
HbA1c to assess db control
charcots management
education and treatment of underlying disease
immbolisation, cast changed weekly for 3-6 months
podiatry referral
bisphosphonates can help heal bone in acute phase
surgery in chronic - amputation
Pagets complications
Triad: Pain, deformity, fractures
Deafness, osteosarcoma
Symptoms of antiphospholipid syndrome
Venous/arterial thrombosis
recurrent mis
Pre-E
Mottled skin - livedo reticularis
thrombocyopenia
How do u confirm antiphospholipid syndrome?
anti-cardiolipin antibodies
how do u manage antiphospholipid syndrome?
What is it associated with?
Warafin 6m or lifelong if recurrent
SLE
What is systemic scleorsis?
hardened sclerotic skin and other connective tissues
What factor results would u get in systemic sclerosis?
ANA +ve
RF +ve
Anti-scl-70: diffuse cutatneous systemic
Anti-centromere: limited cutaneous systemic
Symptoms of limited cutaneous systmic sclerosis?
CREST
Calcinosis (white deposits)
Raynauds
oEsophageal (dysphagia)
Sclerodactyly
Telangiectasis (spider naevia)
Management of systemic sclerosis
Raynaurds: nifedipine
consider Methotrexate
what is polymyalgia rheumatica?
giant cell vasculitis
How does PMR present?
pt >60 onset <1m
morning aches and stiffness in prox limbs, lethary, depression, low grade fever, anorexia, night sweats
PMR Ix and Mx
Increased ESR (diagnosis of exclusion)
Pred
What causes Marfans?
Autosomal dominant condition causes decreased fibrin
Features of Marfans
Tall
pectus excavatum
scoliosis
archnodactyly
Heart things in Marfans
dilated aortic sinus
increased risk of aneurysms, dissection and regurg
Mx of Marfans
Echo
BB and ACE-I
What is SLE
autoimmune type 3 hypersensitiviy reaction
Symptoms of SLE
General: fatigue, mouth ulcers
Skin: photosensitive rash, malar rash which comes and goes, alopecia
CV: pericarditis
Renal: Lupus nephritis (test urine, deadly)
Haem: pancytopenia
Causes of pancytopenia in SLE and how to differentiate between
Treatment: hypoplastic
conditon: hyperplastic
Investigations in SLE
Anti dsDNA and anti Smith +Ve
Low C3 and C4
ANA +Ve
RF: either
Management of SLE
Education and support
NSAIDS: joint pain
hydroxycholoroquinine: skin lesions, malasia, myalgia
steriods reserved for life threatening
What is dermatomyosis
Inflam disorder causing symmetrical proximal weakness and skin lesions
Causes of dermatomyosis
Idiopathic
symptoms of dermatomyosis
photosensitive, back/shoulders red papules over extensor surfaces of fingers
Raynaurds, muscle weakness and tenderness
Ix and management for dermatomyositis
ANA +ve
Sun block
steriods
azathioprine
Presentation of ank spon
young male with lower back pain and stiffness worse in morning better with exercise
OE ank spond
decreased lat and forward flex
decreased chest expansion
Ix for ank spon
X-ray: sacroiliitis, lumbar sparing, bamboo spine
management of ank spon
NSAIDs
sulphasalazine
what is Sjorgrens syndrome
autoimmune disorder affecting exocrine glands
How does Sjogrens present?
dry: eyes, mouth vagina
arthralgia, Raynaurds, myalgia
Investigations of Sjorgrens
RF +ve
ANA +ve
Anti Ro and La
Management of Sjorgrens
artificial tears
pilocarpine
