Rheumatology Flashcards
What conditions fall in the category of seronegative spondyloarthropathy?
Reactive arthritis
Psoriatic arthritis
Ankylosing spondylitis
What gene is associated with the development of ankylosing spondylitis?
HLA B27
What joints are largely affected in ankylosing spondylitis?
Sacroiliac joints
Joints of the vertebral column
What is the classical appearance of ankylosing spondylitis seen on spinal XR?
Bamboo spine
What is the classical presentation of ankylosing spondylitis?
Young adult male
Lower back pain and stiffness - improves on exercise, worse at night and in the morning
Pain takes at least 30 minutes to improve on the morning
What are they systemic associations of ankylosing spondylitis?
Apical fibrosis
Anterior uveitis
Aortic regurgitation
Enthesitis - achilles tendonitis, plantar fasciitis
What clinical examination is important in identifying patients with ankylosing spondylitis?
Modified Shober’s test
What treatments can be used in the management of ankylosing spondylitis?
Morning exercises
NSAIDs
Local steroid injections
TNF alpha blocker - if failed on >2 NSAIDs
What features might be evident on spinal XR which are indicative of ankylosing spondylitis?
Bilateral sacroiliac erosion - more suggestive than HLA B27
Squaring of vertebral bodies
Syndesmophytes
Define osteoarthritis
A disease of synovial joints characterised by cartilage loss and accompanying periarticular change
What are the risk factors of developing osteoarthritis?
Increasing age
Female sex
Abnormal joint
External joint stress (obesity, occupational stress on joints, trauma)
Internal joint stress (crystal deposits, previous joint infection)
What is the classical presentation of osteoarthritis?
Joint pain exacerbated by exercise and relieved by rest
Joint stiffness ROM Joint swelling Signs of synovitis (warmth, effusion) Tenderness around joint Crepitus
In OA, what should ESR and CRP be?
Normal
What are the classical features seen on XR in a joint with osteoarthritis?
Loss of joint space
Osteophytes
Subchondral cysts
Sub-articular sclerosis
What is the management of osteoarthritis?
Conservative:
Exercise/physio
Weight loss
Pharmaceutical: Regular paracetamol Topical NSAIDs Topical capsaicin Oral NSAIDs (gastro-protection) Consider intra-articular steroids
Surgical:
Arthroscopy & debridement
Joint replacement
In what group of patients, can a diagnosis of osteoarthritis be made without requiring further investigation?
Over 45
Typical activity related pain
No morning stiffness or stiffness that lasts less than 30 minutes
Describe the typical presentation of septic arthritis
Single hot, red, swollen painful joint
What pathogens are associated with septic arthritis?
S.aureus
Streptococci
Neisseria gonorrhoeae
Haemophilus
What disease can cause an inflammatory arthritis?
Lyme disease (erythema migrans)
What investigations should be instigated in a patient with suspected septic arthritis?
Bloods - FBC (WBC raised), CRP, ESR
Blood cultures
Joint aspirate
Swabs - skin, throat, sputum, urine
XR
If a patient presents with septic arthritis with no risk factor of atypical organisms, what antibiotic should be initiated?
Flucloxacillin
If a patient has suspected septic arthritis and has a risk of MRSA, what antibiotic should be used?
Vancomycin
Define amyloidosis
Deposition of a normally soluble protein in a tissue that disrupts normal function
What are the three main subtypes of amyloid?
AL
AA
Beta-2 microglobulin
Define AL amyloid
Light chain deposition in tissues
Associated with multiple myeloma and Waldenstrom’s macroglobulinaemia
Define AA amyloid
Complication of chronic inflammatory conditions (RA) and chronic infections (TB, osteomyelitis)
Deposition of serum amyloid A protein predominantly in liver, spleen and kidneys
Define Beta-2 microglobulin amyloid
Typically occurs in dialysis patients
How can amyloidosis present?
Cardiac - heart failure esp restrictive cardiomyopathy, arrhythmias
Renal failure
Gastro - vomiting, GI bleed, diarrhoea, splenomegaly
Polyneuropathy
Macroglossia
What stain should be used in the diagnosis of amyloidosis?
Apple green birefringence under Congo red staining
How should AL amyloid be managed?
Treat myeloma (chemo/BMT)
How should AA amyloid be managed?
Treat underlying condition to reduce inflammation
What artery is classically affected in giant cell arthritis?
Temporal artery
What other condition is giant cell arthritis strongly linked to?
Polymyalgia rheumatica
What group of patients have the highest risk of developing giant cell arthritis?
Caucasian females >50 years
How might giant cell arthritis present?
Severe unilateral headache typically around the temporal/forehead
Scalp tenderness
Jaw claudication
Blurred/double vision
Irreversible painless complete sight loss
What are some of the potential systemic symptoms of giant cell arthritis?
Fever Muscle aches Fatigue Anorexia and weight loss Peripheral oedema
How can a definitive diagnosis of giant cell arthritis be made?
Clinical presentation
Raised ESR
Temporal artery biopsy - multinucleated giant cells
What additional investigations should be performed in giant cell arthritis and what may they show?
FBC - normocytic anaemia and thrombocytosis
LFT - raised Alk Phos
CRP - raised
Duplex ultrasound of the temporal artery - hyperechoic halo sign
In a patient with suspected giant cell arthritis, when should steroids be started and why?
Immediately
Reduces the risk of permanent vision loss
Along with steroids, what other medications should be prescribed in patients with giant cell arthritis and why?
Aspirin - reduce risk of vision loss and strokes
PPI - gastroprotection against steroids
Bisphosphonates and Calcium and Vit D supplements - osteoporosis prevention
If a patient presents with potential giant cell arthritis, where should they be referred to?
Vascular surgeons - temporal artery biopsy
Rheumatology - specialist diagnosis and management
Ophthalmology - emergency same day appointment if they have visual changes
What are the complications of giant cell arthritis?
Early (neuro-ophthalmic complications)
Vision loss
CVA
Late: Relapse Complications from steroids CVA Aoritis - aortic aneurysm and aortic dissection
What are some of the features that suggest a possible vasculitis?
Purpura - purple-coloured non-blanching rash Joint and muscle pain Peripheral neuropathy Renal impairment GI disturbances Anterior uveitis and scleritis Hypertension
What type of blood test is key in the diagnosis of vasculitis?
ANCA (anti-neutrophil cytoplasmic antibodies)
What are the two types of ANCA blood tests?
p-ANCA (anti-PR3)
c-ANCA (anti-MPO)
In what vasculitis conditions is p-ANCA elevated?
Microscopic polyangiitis
Churg-Strauss Syndrome (eosinophilic granulomatosis with polyangiitis)
In what vasculitis condition is c-ANCA elevated?
Granulomatosis with polyangiitis (Wagener’s)
What treatment classes can be used in the management of vasculitis?
Steroids
Immunosuppressants
What immunosuppressants can be used in the management of vasculitis?
Cyclophosphamide
Methotrexate
Azathioprine
Rituximab
What type of vasculitis is Henoch-Schonein purpura (HSP)?
IgA vasculitis
How does Henoch-Schonein purpura (HSP) commonly present?
Purpuric rash affecting the lower limbs and buttocks of children (under 10)
What commonly triggers Henoch-Schonein purpura (HSP) ?
Upper airway infections (tonisiitis)
Gastroenteritis
What are the four classical features of Henoch-Schonein purpura?
Purpura Joint pain Abdominal pain Renal involvement (IgA nephritis)
How is Henoch-Schonein purpura usually managed?
Supportive - analgesia, fluids and rest
What type of vasculitis is Kawasaki Disease?
Medium vessel vasculitis
How is generally affected by Kawasaki Disease?
Young children, under 5
What are the clinical features of Kawasaki Disease?
Persistent fever for > 5 days Erythematous rash Bilateral conjunctivitis Erythema and desquamation of palms and soles Strawberry tongue
What is a complication of Kawasaki Disease?
Coronary artery aneurysms
How is Kawasaki disease managed?
Aspirin
IV immunoglobulins
How can eosinophilic granulomatosis with polyangiitis be known as?
Churg-Strauss Syndrome
What type of vasculitis is eosinophilic granulomatosis with polyangiitis?
Small and medium vessel vasculitis
How can eosinophilic granulomatosis with polyangiitis present?
Severe asthma in late teens or adults
What organs can be affected in eosinophilic granulomatosis with polyangiitis?
Lung
Skin
Kidneys
What is the characteristic finding on the FBC in eosinophilic granulomatosis with polyangiitis?
Elevated eosinophil levels
What type of vasculitis is microscopic polyangiitis?
Small vessel vasculitis
What is the main feature of microscopic polyangiitis?
Renal failure
Lungs - SOB and haemoptysis
How can granulomatosis with polyangiitis be known?
Wegener’s granulomatosis
What type of vasculitis is granulomatosis with polyangiitis?
Small vessel
What systems are affected in granulomatosis with polyangiitis?
Respiratory tract
Kidneys
What facial feature is associated with granulomatosis with polyangiitis?
Saddle shaped nose (perforated nasal septum)
What symptoms are associated with granulomatosis with polyangiitis?
Epistaxis
Crusty nasal secretions
Hearing loss
Sinusitis
Saddle shaped nose
Cough
Wheeze
Haemoptysis
Rapidly progressing GN
How might granulomatosis with polyangiitis appear on a CXR?
Consolidation
What type of renal condition is associated with granulomatosis with polyangiitis?
Rapidly progressing GN
What type of vasculitis is polyarthritis nodosa (PAN)?
Medium vessel vasculitis
What is polyarthritis nodosa (PAN) associated with?
Hep B
Hep C and HIV
Where can polyarthritis nodosa (PAN) affect?
Medium vessels of the: Skin GIT Kidneys Heart
What are the potential effects of polyarthritis nodosa (PAN)?
Renal impairment
CVA
MI
What type of rash is polyarthritis nodosa (PAN) associated with?
Livedo reticularis (mottle purplish lace like rash)
What type of vasculitis is Takayasu’s arteritis?
Large vessel vasculitis
What blood vessels are mainly affected in Takayasu’s arteritis?
Aorta and branches
Pulmonary arteries
What is the effect of Takayasu’s arteritis?
Large arteries and branches can:
Swell - aneurysms
Narrowed and blocked - pulseless disease
How does Takayasu’s arteritis commonly present?
Before 40
Non-specific symptoms:
Fever
Malaise
Muscle aches
Specific symptoms:
Arm claudication
Syncope
How can Takayasu’s arteritis be diagnosed?
CT/MRI angiography
Doppler US of carotids - carotid disease
Define reactive arthritis
Synovitis occur in the joints as a reaction to a recent infective trigger
What is the typical presentation of reactive arthritis
Acute mono arthritis - in the lower limb, most often the knee
Warm, swollen, painful joint
What Ddx needs to be excluded in reactive arthritis?
Septic arthritis
What are the common triggers for reactive arthritis
Gastroenteritis
STIs (chlamydia, gonorrhoea –> gonococcal septic arthritis usually)
What gene potentially predisposes a patient to developing reactive arthritis
HLA-B27
What are the associations of reactive arthritis
Bilateral conjunctivitis
Anterior uveitis
Circinate balanitis (dermatitis of the head of the penis)
“Can’t see, can’t pee, can’t climb a tree’
In reactive arthritis, what should the joint aspirate be sent off for?
Gram staining, culture and sensitivity - exclude septic arthritis
Crystal examination - exclude gout and pseudogout
How can reactive arthritis be managed?
NSAIDs
Steroid infections into affected joint
Systemic steroids - esp if multiple joints affected
How long does it take for most cases of reactive arthritis to resolve?
6 months
If a patient has recurrent cases of reactive arthritis, how can they managed?
DMARDs
Anti-TNF alpha
