Rheumatology

Question 1

Define ankylosing spondylitis.

Answer 1

Chronic progressive inflammatory disease of spine and sacroiliac joints.

Question 2

Is ankylosing spondylitis more common in males or females?

Answer 2

M>F

6: 1 at 16 years old
2: 1 at 30 years old

Question 3

Which HLA type is normally present in ankylosing spondylitis?

Answer 3

90% HLA B27 positive

Question 4

What is the pathophysiology of ankylosing spondylitis?

Answer 4

Inflammation in the axial skeleton is initially dominated by mononuclear cell infiltrates and by increased number of osteoclasts at bone cartilage interface.
AS involves: inflammation, cartilage erosion, ossification.

Question 5

What are the symptoms of ankylosing spondylitis?

Answer 5

Gradual onset severe low back pain. 
Worse at night. 
Spinal morning stiffness.
Relieved by exercise. 
Better towards end of day. 
Ultimately may lead to spinal fusion.

Question 6

What are the investigations for ankylosing spondylitis?

Answer 6

FBC
ESR
CRP
RF
HLAB27
X-ray
MRI

Question 7

What are the complications of ankylosing spondylitis?

Answer 7

Asymmetrical oligoarthropathy
Restrictive lung disease
Enthesitis
Acute iritis
Osteeoporosis
Aortic valve incompetence

Question 8

What is the management of ankylosing spondylitis?

Answer 8

Exercise
NSAIDs
Sulphasalazine
TNF alpha blockers (infliximab, adalimumab, etanercept)
Local steroid injections
Joint replacements

Question 9

What are the symptoms of polymyalgia rheumatica?

Answer 9

Acute onset
Muscle aches, tenderness, morning stiffness
Fatigue
Fever - low grade
Weight loss and anorexia
Malaise
Night sweats
Depression may be present
The patient may report asymmetrical joint pain, carpal tunnel sydrome symptoms and swelling of the hands and feet.

Question 10

Who is polymyalgia rheumatica more common in?

Answer 10

Women

>50s

Question 11

What investigations would you do in suspected polymyalgia rheumatica?

Answer 11

ESR
CRP
TFTs
Immunoglobulins
CK (to rule out myositis)
Ultrasound
MRI (to check for synovitis/bursitis, will be absent in PMR)

Question 12

What is the management of polymyalgia rheumatica?

Answer 12

Prednisolone 15mg per day with marked response.
Failure of response should be a cause to question diagnosis.
Gradually reduce as symptoms improve and CRP normalised.
Methotrexate may be needed.
NSAIDs not indicated long term.

Question 13

Define temporal arteritis.

Answer 13

Immune mediated vasculitis characterised by granulomatous inflammation in the wall of medium sized and large arteries.

Question 14

What is the pathophysiology of temporal arteritis?

Answer 14

T cell and macrophages.
IL-6 plays a role
Inflammation starts from outer layer and moves in.
Thickening and narrowing of lumen with subsequent ischaemia occurs due to healing.

Question 15

Which other illness is temporal arteritis associated with?

Answer 15

Polymyalgia rheumatica.

Question 16

Which age group is temporal arteritis associated with?

Answer 16

Over 50s

Question 17

What are the symptoms of temporal arteritis?

Answer 17

Headache
Temporal artery tenderness
Jaw claudication
Amaurosis fugax
PMR
Low grade fever
Weight loss and fatigue
Neurological manifestations occur in about one third of patients and may include stroke, TIA, or neuropathy.

Question 18

What are the examination findings in temporal arteritis?

Answer 18

Temporal artery thickening, tenderness and nodularity
Pallor and oedema of the optic disc (Possibly with cotton-wool patches and haemorrhages. Optic neuropathy is irreversible).
Carotid or subclavian arteries bruits in patients with large vessel involvement: pulses in the neck or the arms may be decreased or absent in this subset of giant cell arteritis.
Patients with large-vessel stenoses may have asymmetric blood pressures or decreased pulses.

Question 19

What would be the investigation findings in a patient with temporal arteritis?

Answer 19

ESR >50
Most patients have normochromic, normocytic anaemia - related to chronic inflammation and elevated platelet count.
1/3 of patients have mildly abnormal results on LFTs, particularly ALP.
Temporal artery biopsy is definitive test.
If systemic large vessel involvement suspected then CT/MRI angio.

Question 20

What is the management of temporal arteritis?

Answer 20

Prednisolone 60mg
Usually 2 year course.
Reduce steroids if symptoms reduce.

Question 21

What is the pathophysiology of rheumatoid arthritis?

Answer 21

Inflamed synovium is central to the pathogenesis.
Increased angiogenesis, cellular hyperplasia, influx of inflammatory cells, changes in the expression of cell surface adhesion molecules, many cytokines.
T cells, B cells, macrophages and plasma cells.
High levels of metalloproteinase activity are thought to contribute to joint destruction.

Question 22

What is the intra-articular presentation of rheumatoid arthritis?

Answer 22

Symmetrical, swollen, painful and stiff small joints.
>6 weeks.
Lasts >1 hour after waking
Larger joints may become involved.

Question 23

What is the extra-articular presentation of rheumatoid arthritis?

Answer 23

Weight loss
Fatigue
Fever
Pericarditis
Nodules
Vasculitic skin disorders
Lymphadenopathy
Fibrosing alveolitis
Obliterative bronchiolitis
Pleural and pericardial effusion
Raynaud's
Carpal tunnel syndrome
Peripheral neuropathy
Splenomegaly

Question 24

Which signs may be visible in a patient with rheumatoid arthritis?

Answer 24

Boutonniere deformity
Swan neck deformity
Ulnar deviation

Question 25

Which investigations would be carried out for rheumatoid arthritis?

Answer 25

``` Rheumatoid factor Anti-cyclic citrullinated peptide antibodies (anti-CCP) FBC (anaemia) CRP X-rays US/MRI ```

Question 26

What are the x-ray findings of rheumatoid arthritis?

Answer 26

Juxta-articular osteopenia. Soft tissue swelling Joint deformity. Loss of joint space.

Question 27

What is the diagnostic criteria for rheumatoid arthritis?

Answer 27

``` 4 out of 7: Morning stiffness (>1 hour, lasting >6 weeks) Arthritis >3 joints Arthritis of hand joints Symmetrical arthritis Rheumatoid nodules +ve rheumatoid factor Radiographic evidence ```

Question 28

What is the management of rheumatoid arthritis?

Answer 28

``` DMARDS - methotrexate +/- hydroxychlorouine/sulfasalzine - monitor bloods Biological agents - infliximab etc Steroids NSAIDs Physio OT Surgery ```

Question 29

What is the pathophysiology of gout?

Answer 29

Urate is a metabolite of purines and the ionised form of uric acid. Hyperuricaemia is due to renal under-excretion of urate in 90% of cases and to over production in 10%,. High urate levels result in super-saturation and crystal formation. Crystals in the joint interact with undifferentiated phaocytes, this triggers an acute inflammatory response cuasing neutrophilic synovitis. Urate crystals can induce chronic inflammation, leading to synovitis, cartilage loss and bone erosions.

Question 30

What are the risk factors for hyperuricaemia?

Answer 30

Dietary factors such as consumption of seafood, meat and alcohol, esp. beer. High cell turnover, such as haematological cancer and chemotherapy. Diuretics can increase urate levels. Obesity. Insulin resistance. Hypertension.

Question 31

Who is gout most common in?

Answer 31

Men and pre-menopausal women.

Question 32

How is diagnosis confirmed?

Answer 32

Arthrocentesis showing monosodium urate crystals. Strongly negative birefringent crystals.

Question 33

Which are the most commonly affected joints in gout?

Answer 33

First metatarsophalangeal Tarsometatarsal Ankle Knee joints

Question 34

What are the other clinical features of gout?

Answer 34

In older people, the disease may be polyarticular and associated with marked oedema and swelling of the hands and feet.

Question 35

What are the criteria for gout identified by the American College of Rheumatology?

Answer 35

6 or more of: More than one attack of acute arthritis. Maximum inflammation developed within 1 day. Monoarthritis attack, redness observed over joints. First metatarsophlaangeal joint painful or swollen. Unilateral first metatarsophalangeal joint attack. Unilateral tarsal joint attack. Tophus (confirmed or suspected) Hyperuricaemia Asymmetric swelling with a joint on x-ray film. Subcortical cyst without erosion on x-ray film. Joint culture negative for organism during attack.

Question 36

What is the management of gout?

Answer 36

NSAIDs Colchicine (interupts neutrophil-endothelial interaction) Steroids Allopurinol

Question 37

What are the indications for allopurinol?

Answer 37

Recurrent attacks (2-3 per year) Tophaceous gout Radiographic changes and chronic destructive joint disease. Urate nephrolithiasis Patient preference because of severe and debilitating polyarticular attacks.

Question 38

What is pseudogout?

Answer 38

The deposition of calcium pyrophosphate. It is associated with both acute and chronic arthritis.

Question 39

Describe the crystals found in pseudogout?

Answer 39

Positive birefringent rhomboid-shaped crystals under polarised light. Fluids are often bloody.

Question 40

What might be found on x-ray of a joint with pseudogout?

Answer 40

Cartilage calcification.

Question 41

Define psoriatic arthritis.

Answer 41

A chronic inflammatory joint disease associated with psoriasis.

Question 42

Describe the pathophysiological changes in psoriatic arthritis.

Answer 42

It is a seronegative inflammatory arthritis. HLA-B27 is involved. Psoriatic synovium is characterised by hypervascularity and morphologically tortuous vessels and inflammation leads to deformities.

Question 43

What are the x-ray changes seen in psoriatic arthritis?

Answer 43

``` Loss of joint space Deformity Bony erosion Periarticular osteopaenia Soft tissue swelling ```

Question 44

How is psoriatic arthritis distinguished from rheumatoid arthritis?

Answer 44

By the presence of dactylitis and the absence of anticyclic citrullinated peptide antibodies. Dactylitis DIP involvement, monoarticular pattern.

Question 45

What are the clinical features of psoriatic arthritis?

Answer 45

In a patient with psoriasis: prolonged morning stiffness in joint (lasting >30 minutes), morning first-step foot pain, join or digit swelling.

Question 46

What is the management of psoriatic arthritis?

Answer 46

NSAIDs usually sufficient to treat limited disease. Articular steroids Physio Patients with progressive peripheral arthritis or oligoarthritis refractory to NSAIDs and intraartiular corticosteroids: require disease-modifying antirheumatic disease therapy (e.g. methotrexate) early in disease course. Infliximab if 2 failed DMARDs.