Rheumatology Flashcards
what is inflammation
reaction of microcirculation
movement of fluid and WBC into extra-vascular tissues
pro-inflammatory cytokines
what are the 4 pillars of inflammation
rubor = red dolor = painful calor = heat tumour = swollen
how may inflammation present
4 pillars +
stiffness
poor mobility/function
deformity
how may inflammatory joint pain progress
eases with use of joint
how may degenerative pain progress
pain increases with use = clicks/clunks
describe the difference in presentation of inflammatory and degenerative joint pain
- inflammatory = >60 mins vs <30 mins for degenerative
- degenerative = not clinically inflamed (hot and red)
- inflammatory responds to NSAIDs, degenerative not so much
- inflamm = hands and feet, degenerative = CMC, DIP joints (NOT AS A RULE)
what is the demographic for inflammatory pain
young
psoriasis
family history
what is the demographic for degenerative joint pain
older
prior occupation/sport
what does PRISMS stand for
Pain Rash/skin lesions Immune Stiffness Malignancy Swelling/sweats
what acronym can be used for history taking of rheumatological complaint
PRISMS
what is dactylitis
inflammation of a digit
what is enthesitis
inflammation of the entheses = site where tendon or ligament insert into bone
describe how ESR is measured
- blood sample is centrifuged
- time taken for RBC to fall is measured
- increased fibrinogen in inflammation = stick to RBC = makes them heavier = fall faster
what is an ESR
erythrocyte sedimentation rate = increases in inflammation/infection
takes weeks to change relative to inflammation
what is CRP
C-reactive protein
increases in inflammation
rises and falls rapidly = good indicator of current inflammation
what are auto-antibodies
immunoglobulins that bind to self most commonly looked for: IgM IgG CCP ANA anti-dsDNA
what auto-antibodies are found in rheumatoid arthritis
RF = rheumatoid factor CCP = cyclic citrullinated peptide
what auto-antibodies are found in systemic lupus erythematosus
ANA = antinuclear antibody = binds to antigens in cell nucleus dsDNA = double stranded DNA
what is spondyloarthritis (SpA)
umbrella term for group of conditions with inflammatory joint changes 1. ankylosing spondylitis AS 2. psoriatic arthritis PsA 3. enteropathic arthritis 4. reactive arthritis = associated with HLA-B27 gene = seronegative so no RF
what is HLA B27
human leucocyte antigen B27
= a tissue type that plays a role in antigen presenting in immune system
a person is either HLAB27 positive or negative = +ve does not mean you will get AS
where is CRP produced
produced by liver in response to IL-6
name the 3 hypothesis of how HLAB27 is linked with disease
- molecular mimicry
- mis-folding theory
- HLA B27 heavy chain homodimer hypothesis
SPINEACHE to describe features of SpA
Sausage digit tabiasis Inflammatory back pain NSAID good response Enthesitis (heel) Arthritis Crohns/Colitis/CRP elevated HLA B27 Eye uveitis
what is particular in diagnosis of alkylosing spondylitis
can have normal CRP
what is syndesmophytes
new bone formation and vertical growth from anterior vertebral corners
what is sacroiliitis
sclerosis erosions loss of space fusion = of sacroiliac joint
what is delayed damage theory
once inflammation has occurred = new bone formation is inevitable
what factors would differentiate inflammatory back pain IBP from general back pain
age of onset below 40 insidious onset improvement with exercise pain at night no improvement with rest
how is axial spondyloarthritis diagnosed using the ASAS classification criteria
- sacroiliitis on imaging plus 1+ SpA feature (SPINAECHE)
2. HLA B27 plus 2+ SpA features
what is osteoporosis
systemic skeletal disease
low bone mass
microarchitectural deterioration of bone tissue
increase in bone fragility and susceptibility to fracture
= bone not weaker, just less of it there
describe the changes in trabecular architecture with ageing
decrease trabecular thickness
decrease in connections between horizontal trabeculae
decrease in trabecular strength
why does osteoporosis increase in women
menopause = loss of restraining effects of oestrogen on bone turnover
high bone turnover = more resorption than formation
cancellous bone loss
michroarchitectural disruption
what is DEXA
dual energy Xray absorptiometry
= low radiation
= measures important fracture sites
what is a T score
standard deviation score = compared with gender matched young adult average of peak bone mass (??)
why is Cushing’s syndrome a risk factor for osteoporosis
cortisol increases bone resorption and induces osteoblast apoptosis
what is osteomalacia
metabolic bone disorder = low mineral bone content and vitamin D deficiency = soft bones but normal amount
what causes osteomalacia
vit D deficiency resistance to vit D liver disease tumour induced osteodystrophy
what are the signs/symptoms of osteomalacia
bone pain
myalgia
pathological fracture
how does osteomalacia present in children
= rickets
= bowed legs and knocked knees
how is osteopenia diagnosed
DEXA scanning = score of -1 to -2.5 = osteopenia
how is osteoporosis diagnosed
DEXA scanning = score -2.5 or worse = osteoporosis
how is osteomalacia treated
increase Vit D and calcium dietary intake
Vit D and calcium supplements = cholecalciferol or calcitriol
what is vasculitis
inflammation of blood vessel walls with subsequent impaired blood flow =
vessel wall destruction = perforation = haemorrhage into tissues
also causes endothelial injury = thrombosis and ischaemia/infarction of tissues
how is vasculitis classified
primary/secondary = if due to pre-existing condition or random
vessel size = small/large
ANCA = positive or negative
target organ affected
what are ANCA
anti- nuclear cytoplasmic antibody = specific antibodies for antigens in cytoplasmic granules of neutrophils and monocyte lysosomes
name the main large vessel vasculitis
giant cell arteritis (temporal arteritis) = primary
Takayasu’s arteritis = primary
aortitis in RA = secondary
name the main small vessel vasculitis
granulomatosis with polyangiitis (GPA) = primary
Churg Strauss = primary
microscopic polyangiitis = primary
vasculitis secondary to autoimmune disease = secondary
what is the name of vasculitis classification
Chapel Hill
what is the most common condition affecting the synovial joints
osteoarthritis
what is osteoarthritis
a degenerative arthritis which affects synovial joints and characterised by articular cartilage degeneration
what tissues of the joint are involved in osteoarthritis
all tissues are involved but articular cartilage is most affected
describe the process of osteoarthritis
metabolically active and dynamic process = mediated by cytokines including: IL1 TNFalpha NO as well as driven by mechanical forces
what are the main pathological features of osteoarthritis
loss of cartilage
disordered bone repair
what joints does OA affect
knees = medially spreading laterally through patellofemoral compartment hips big toe spine hands = DIP, PIP, CMC joints
what is an arthroscopy
removal of loose bodies = prevents joint locking
what is an osteotomy
realignment of the knee by removing section of bone
what is fusion surgery
done in complex joints where replacement cant be done = fuse joints
what joints are affected in OA of the hands
distal interphalangeal joint
carpometacarpal joint
where is the CMC joint
connecting trapezium of thumb to first metacarpal of the thumb
what compartment of the knee is most affected by osteoarthritis
medial
what is erosive/inflammatory OA
subset of OA
strong inflammatory component
can be treated with DMARDs
what is a loose body
bone or cartilage fragment leads to locking of joint
what is a discoid rash
red patches of skin associated with scaling and plugging of hair folicles
what is a butterfly rash
fixed red patches over cheeks
what is marfans syndrome
inherited autosomal dominant condition causes lack of fibrillin
caused by mutation in FBN1 gene
not curable = genetic counselling, surgical management
what are the signs/symptoms of marfans
aortic aneurism (root)
aortic dissection
coarctation of aorta
tall, long arms
dislocation of lens
high arched pallet
what is EDS
Ehlers-Danlos syndrome
autosomal dominant condition causes defective type 1 and 2 collagen production
no treatment = manage complications
what are the signs/symptoms of EDS
hyper elastic skin
hypermobile joints
joint deformities
early onset osteoarthritis
easy bruising
anal prolapse
valvular heart disease
what population groups are more commonly affected by SLE
afro-Caribbean/asian
what test are done to diagnose SLE and which is specific for SLE
anti-nuclear antibody
double stranded DNA antibody = specific
what diseases can Raynauds be seen as a secondary condition to
systemic sclerosis
mixed connective tissue disease
SLE
what are the vascular damage causes of raynauds
atherosclerosis
frost bite
vibrating tools
what is Raynauds phenomenon
lack of blood flow in the microvasculature circulation causing cold and cyanosed fingers in the cold and increased blood flow in the warm = red/purple hands
what is the difference between scleroderma and systemic sclerosis
scleroderma only affects skin/underlying soft issue
systemic sclerosis affects internal organs
how is localised scleroderma divided
morphea = discoloured oval patches, itchy and hairless linear = thick skin along face, scalp, legs, arms
how is systemic scleroderma divided
limited = milder form, mostly affecting skin diffuse = affects whole body/ internal organs
what is dermatomyositis
inflammation of muscles with a skin rash
more common in women
what is polymyositis
inflammation of muscles which affects many different muscles particularly shoulders hips and thighs
more common in women
what organ can be affected in dermatomyositis/polymyositis
lungs = interstitial lung disease
what is the treatment of dermatomyositis/polymyositis
steroids
immunosuppressant drugs
how is osteomalacia diagnosed
low calcium
low phosphate
high alkaline phosphatase
biopsy shows incomplete mineralisation
what does SHATTERED stand for (Presentation of osteoporosis)
Steroid use >5mg/day Hyperthyroidism/parathyroidism/calciuria Alcohol and tobacco Thin Testosterone low Early menopause Renal/liver failure Erosive/inflammatory bone disease Dietary calcium low/DMT1 \+ Family history
explain SOAP BRAIN MD in the presentation of SLE
Serositis = pleurisy/pericarditis Oral ulcers Arthritis Photosensitivity Blood cytopenias Renal involvement Antinuclear antibodies Immunological phenomena (dsDNA) Neurological = psychosis/seizures Malar rash Discoid rash
what does CREST stand for and what disease does it describe
systemic sclerosis: Calcinosis = Ca skin deposits Raynauds Esophageal stricture/reflux Sclerodactyly = thick skin fingers/toes Telangiectasia = dilated facial spider veins
what is the treatment progression for osteoporosis
alendronice acid –> denosumab –> teriparatide
denusomab can be used if alendronic acid is CI or not tolerated
what drugs can cause osteoporosis
steroids alcohol anti-epileptics lithium cyclosporin PPI
what DMARDs can precipitate gout
methotrexate
sulfasalazine
what is polymalgia rheumatica
common
old people
muscle stiffness
raised inflamm markers ESR >40mm/hr
how does polymyalgia rheumatica present
> 60
rapid onset
morning stiffness in proximal limbs
mild polyarthralgia, lethergy, low-grade fever
how is polymyalgia rheumatica managed
prednisolon 15mg/OD
usually dramatic response
what is polyarteritis nodosa (PAN)
vasculitis
affects medium arteries
necrotising inflammation leading to aneursym formation
what are the features of polyarteritis nodosa
middle age men + hep B
fever, malaise, WL
hypertension
testicular pain
haematuria
ANCA in 20%
hep B +ve in 30%
what is systemic sclerosis
unknown aetiology
4x more in females
hardened sclerotic skin and other connective tissues
3 patterns:
1. limited cutaneous systemic sclerosis (incl CREST)
2. diffuse cutaneous systemic sclerosis
3. scleroderma
describe limited cutaneous systemic sclerosis
raynauds
scleroderma affecting face + distal limbs
anti-centromere antibodies
CREST is a subtype
describe diffuse cutaneous systemic sclerosis
scleroderma affecting trunk + proximal limbs
anti-scl-70 antibodies
interstitial lung disease + pulmonary hypertension = mortality +++
renal disease
poor prognosis
describe the antibodies found in systemic scleroderma
ANA Ab in 90%
RF +ve in 30%
antiscl-70 in diffuse
anticentromere in limited
describe the findings of joint aspiration in gout
monosodium needle shaped crystals
negatively befringent
what is raised in gout and what is first line and second line treatment
uric acid
1. nsaids
2. colchicine (in renal impairment)
what is the treatment for polymyalgia rheumatica and what should you co-prescribe
15mg prednisolone OD
+ PPI
+ bisphosphonates
+ Ca + VitD
triad of reactive arthritis
- conjunctivitis
- urethritis
- arthritis
describe the management for SLE + what can discoid LE rarely progress to
sun protection
hydroxychloroquine
topical steroids
injected steroids
squamous cell carcinoma
what is the management of GCA
40-60mg OD prednisolone
500-1000mg OD methylprednisolone if vision loss or jaw claudication
what is henoch schonlein purpura caused by and what are the 4 main features
IgA immunoglobulin
1. joint pain
2. abdo pain
3. renal involvement
4. purpura
55 year old with pain and weakness in thighs, shoulders, upper arms
purplish rash on eyelids
rash over interphalangeal joints on hands
dermatomyositis
raised creatinine kinase
anti MI 2 + ANA antibodies
muscle biopsy is definitive
treat with corticosteroids
what is behcets disease?
how does it present?
what gene is it associated with?
how is it treated?
oral and genital ulcers
joint pain and swelling
HLA B51
treat with topical steroids
medicine to treat raynauds
prophylactic nifedipine
what is the problem in sjogrens?
what conditions can it be secondary to?
what antibodies?
treatment?
exocrine glands
RA and SLE
anti RO + anti LA
hydroxychloroquine can halt progression
what investigations for synovitis and what is the scoring system for RA
USS
DAS28
first line treatments for RA
methotrexate
sulfasalazine
leflunamide
(with a bridging dose prednisolone)
- TNF inhibitors
what investigations must you do when starting a TNF inhibitor and why
chest XR
can reactivate TB
what cancers cause erythema nodosum EN?
what infections cause EN?
what medications cause EN?
leukemia
lymphoma
strep throat
TB
mycoplasma pneumonia
GE
COCP
NSAIDs
what is the screening tool for psoriasis and what is an extreme form
psoriasis epidemiological screening tool
arthritis mutilans
what is buergers disease
thromboangiitis obliterans
smoker with blue fingers
= ulcers, gangrene, amputation
corkscrew collaterals on angiography
STOP SMOKING COMPLETELY
