Rheumatology Flashcards
1
Q
What secretes the rank ligand?
A
Osteoblasts
2
Q
What does the RANK ligand do?
A
Binds to osteoclasts and is essential for their formation, function and survival
3
Q
What protein inhibits the rank ligand?
A
OPG
4
Q
What is the function of OPG?
A
Inhibits osteoclast formation, function and survival by binding to RANK ligands, preventing them from binding to osteoclasts.
5
Q
What happens if you have an unopposed RANK ligand?
A
increased bone loss, more osteoclasts are stimulated due to lack of OPG
6
Q
What is responsible for bone resorption?
A
Cathepsin K
7
Q
What is the best treatment for symptomatic relief of ankylosing spondylitis?
A
Exercise.
8
Q
What are the 5 cardinal signs of inflammation?
A
- Rubor (Redness)
- Calor (Heat)
- Dolor (Pain)
- Tumor (swelling)
- Loss of function
9
Q
What are 3 causes of inflammatory joint pain?
A
- AI disease e.g. RA, vasculitis and connective tissue disease
- Crystal arthritis
- Infection
10
Q
What are 2 causes of non-inflammatory joint pain?
A
- Degenerative e.g. osteoarthritis
2. Non-degenerative e.g. fibromyalgia
11
Q
How does inflammatory joint pain differ from degenerative pain?
A
inflammatory pain eases with use whereas degenerative pain increases with use
Synovial swelling is much more likely to be witnessed in inflammatory pain, whereas in degenerative pain there is often no swelling.
12
Q
What blood tests can be used to detect inflammatory markers?
A
- ESR (Erythrocyte sedimentation rate)
2. CRP
13
Q
Why would you have a high ESR?
A
ESR levels are high in inflammatory joint pain as Inflammation causes increased fibrinogen which means RBC clump together
- RBC fall faster and so you have increased ESR
14
Q
Why would you have a high CRP?
A
CRP levels are high in inflammatory joint pain as Inflammation causes increased levels of IL-6
- CRP is produced in the liver as a response to IL-6 and therefore is raised
In lupus ESR is raised but CRP is low.
15
Q
What are 3 things that increase the volume of pain?
A
- Substance P
- Glutamate
- Serotonin
16
Q
What are 3 things that decrease the volume of pain?
A
- Opioids
- GABA
- Cannabinoids
17
Q
What 4 diseases are fibromyalgia associated with?
A
- Depression
- Chronig fatigue
- Chronic headache
- IBS
18
Q
What are two examples of NSAIDs?
A
Ibuprofen
Naproxen
19
Q
What are the side effects of NSAIDs?
A
Peptic ulcer disease, renal failure and increased risk of MI and CV disease
20
Q
How can you prevent gastric ulcers and bleeding?
A
- Co prescribe PPi’s
- Prescribe low doses and short courses
21
Q
What are the side effects of steroids?
A
- Diabetes
- Muscle wasting
- Osteoporosis
- Fat redistribution
- Skin atrophy
- Hypertension
- Acne
- Infection risk
22
Q
What is an example of a DMARD?
A
Methotrexate or hydroxychloroquine or sulfasalazine
23
Q
How do DMARDs work?
A
Nonspecific inhibition of inflammatory cytokine cascade
This reduces joint pain, stiffness and swelling
24
Q
How often should methotrexate be taken?
A
Once weekly.
25
What are the side effects of methotrexate?
Bone marrow suppression, abnormal liver enzymes, nausea, diarrhea, teratogenic
26
What should be given alongside methotrexate?
Folic acid should be prescribed alongside methotrexate to reduce the risk of side effects
27
What is dermatomyositis?
A rare disorder of unknown cause --> inflame and necrosis of skeletal muscle fibers and skin
28
What are the symptoms of dermatomyositis?
1. Rash
2. Muscle weakness
3. Lungs are often affected
29
What investigations would you do in dermatomyositis?
1. Muscle enzymes --> Raised
2. EMG
3. Muscle/skin biopsy
4. Screen for malignancy
5. CXR
30
What is the treatment for dermatomyositis?
Steroids and immunosuppressants
31
What is dactylitis?
Inflammation of of an entire digit.
32
What is a physis?
growth plate in the pediatric bone --> thick perisoteum means it can heal rapidly.
33
What are the initial steps for fracture management?
1. Reduce fracture --> restore the length, alignment and rotation
2. Immobilise
3. Rehabilitate
34
What is the first line management for paediatric fractures?
1. Non operative management e.g. traction, casts, splints
| 2. This is because pediatric bone heals quickly anyways
35
What happens if the physis is damaged?
growth arrest = deformity.
36
What is the salter harris fracture classification?
Name of classification used for fractures involving the physis
Type 1 fracture -->Transverse fracture through the growth plate.
Type 2 fracture --> fracture through growth plate and metaphysis.
Type 3 Fracture --> Fracture through the growth plate and epiphysis
Type 4 Fracture --> Fracture through metaphysis, physis and epiphysis --> need fixation.
Type 5 Fracture --> Crush injury of growth plate --> poor prognosis and growth arrest
37
What are red flags of non accidental injury in children?
Long bone fracture in child unable to walk, multiple bruises and fractures.
38
What is the management of non accidental injury in children?
- Admit the child
- Skeletal muscle
- Referal to paediatric medics and safeguarding services
39
How does a child get a supracondylar fracture?
Falling on an outstretched hand.
There is often median nerve involvement.
40
What is the treatment for a supracondylar fracture?
K wires.
41
What are the complications of fractures?
1. Open fractures
2. Neurovascular compromise
3. Mal union – bone heals with deformity
4. Non union – bone fails to heal
5. Compartment syndrome
6. Cast problems e.g. tightness, compartment syndrome, plaster burns and blisters.
42
What is osteoarthritis?
A non-inflammatory degenerative disorder of movable joints characteristed by deterioration of articular cartilage and the formation of new bone.
43
Why does osteoarthritis increase with age?
OA increases with age due to cumulative effect of trauma and a decrease in neuromuscular function
44
What cells are responsible for Osteoarthritis?
Chondrocytes
45
What are the risk factors for osteoarthritis?
1. Genetic predisposition
2. Trauma
3. Abnormal biomechanics
4. Occupation e.g. manual labour
5. Obesity – pro inflammatory state
46
What are the symptoms of osteoarthritis?
1. Morning stiffness of over 30 minutes
2. Pain – aggravated by activity
3. Tenderness
4. Walking and ADLs affected
5. Joint swelling and bony enlargement
6. Deformities
7. Crepitus
47
What are the radiological features of OA?
1. Joint space narrowing
2. Osteophyte formation
3. Sub-chondral sclerosis
4. Sub chondral cysts
5. Abnormalities of bone contour
48
What are 3 joints in the hands which are commonly affected in OA?
1. Distal interphalangeal joint
2. Proximal Interphalangeal joint
3. Carpal metacarpal joint
49
What area of the knee is commonly affected in OA?
Medial surface of knee
50
What investigation should be ordered in OA?
X-ray --> Asymmetric loss of joint space, sclerosis, cysts and osteophytes
51
What are the features of non-medical management of OA?
1. Education
2. Exercise
3. Weight loss
4. Physio
5. OT
6. Walking aids
52
What is the pharmacological management of OA?
1. NSAIDs --> topical better
2. Paracetamol
3. Intra-articular steroid injections
4. DMARDs
53
What is the surgical management of OA?
1. Arthroscopy for loose bodies
2. Osteotomy (changing bone length)
3. Arthroplasty (Joint replacement)
4. Fusion – usually ankle and foot.
54
What are some indications for surgery for OA?
1. Significant limitation of function
2. Uncontrolled pain
3. Waking at night from pain
55
What is the treatment for loose bodies?
Arthroscopy
56
A patient complains of knee locking, what could be the cause?
A loose body
57
What is the pathway leading to monosodium urate formation?
Purines --> hypoxanthine --> xanthine --> uric acid --> monosodium urate.
58
What is the function of xanthine oxidase?
It converts hypoxanthine to xanthine.
59
What are 5 factors leading to an increased level of monosodium urate?
1. Increased intake e.g. alcohol, red meat and seafood
2. Cell turnover
3. Cell damage due to surgery
4. Cell death e.g. due to chemo
5. Reduced excretion (Renal problems)
6. Drugs e.g. Bendroflumethiazide diuretics impair urate excretion
7. High insulin
60
What is the epidemiology of gout?
most common in men over 75 y/o.
61
What are the symptoms of gout?
Hot and swollen joints, toes are commonly effected
62
What are tophi?
onion like aggregates of urate crystals with inflame cells
| - Proteolytic enzymes are released --> erosion
63
What 4 diseases is someone with gout likley to develop?
1. Hypertension
2. CV disease
3. Renal disease
4. T2DM Treatment aim --> to get urate to <300umol/L
64
What is the treatment options for gout?
1. Lifestyle modification e.g. diet, weight loss and reduced alcohol
2. Allopurinol (blocks xanthine oxidase)
3. Colchicine or NSAIDs
4. Switch from Bendroflumethiazide to cosartan
5. Rasburicase – rapid urate reduction
65
If a patient is taking Bendroflumethiazide, what would you replace their drug with to treat gout?
Cosartan as BFT is a diuretic so impairs urate excretion.
66
What 6 things can cause a sudden acute attack of gout?
1. Sudden overload
2. Cold
3. Trauma
4. Sepsis
5. Dehydration
6. Drugs
67
What is giant cell arteritis?
Temporal arteritis
68
What is the epidemiology of GCA?
- Affects those >50y/o
- Incidence increases with age
- Twice as common in women
69
What are the symptoms of GCA?
- Headache
- Scalp tenderness
- Jaw claudication
- Acute blindness
- Malaise
70
What investigations would you order in suspected GCA?
1. Bloods for inflammatory markers e.g. CRP, ESR
| 2. Temporal artery biopsy
71
What clinical investigation findings could you see in GCA?
- Palpable and tender temporal arteries w reduced pulsation
| - Sudden monocular visual loss, optic disc is swollen
72
What is the diagnostic criteria for GCA?
- Age >50
- New headache
- Temporal artery tenderness
- Abnormal artery biopsy
73
What is the treatment for GCA?
- Prompt corticosteroids e.g. prednisolone
- Methotrexate sometimes
- Osteoporosis prophylaxis is important lifestyle advice and vit D
74
What is a complication of arthroplasty surgery?
Prosthetic joint infection
75
How can prosthetic joint infections be prevented?
- Asceptic environment and laminar air flow
| - Systemic prophylactic AB
76
What investigations would you do in suspected prosthetic joint infection?
1. Aspirate --> Microbiology
2. Bloods for inflammatory markers and FBC
3. X-rays
You must never give AB before aspirating a joint
77
What are the aims of treatment in prosthetic joint infections?
1. Eradicate sepsis
2. Relieve pain
3. Restore function
78
What treatment would you choose for a patient that is unfit for surgery with a prosthetic joint infection?
AB suppression.
79
What is the gold standard treatment for prosthetic joint infections?
Exchange arthroplasty
1. Radical debridement of all infected and dead tissue
2. Systemic and local ab cover
3. Sufficient joint and soft tissue reconstruction
80
What is scleroderma?
A multi-system disease characterized by skin hardening and raynauds phenomenon
81
What are the signs of limited scleroderma?
1. Calcinosis
2. Raynauds phenomenon
3. Oesophageal reflux
4. Sclerodactyly – Thickening and tightening of the skin
5. Telangiectasia – visible small red blood vessels
6. Pulmonary arterial hypertension
82
What are the signs of diffuse scleroderma?
- Proximal scleroderma
- Pulmonary fibrosis
- Bowel involvement
- Myostitis
- Renal crisis
83
What is the pathophysiology of scleroderma?
1. Various factors cause endothelial lesion and vasculopathy
| 2. Excessive collagen deposition (Skin hardening) --> inflammation and auto-AB production
84
What is the management of Scleroderma?
1. Raynauds --> physical protection and vasodilators
2. GORD – PPIS
3. Annual echo and pulmonary function tests
4. ACEi to prevent renal crisis
85
What is wegener's granulomatosis and what is it associated with?
It is characterized by inflammation in various tissues, including blood vessels (vasculitis), but primarily parts of the respiratory tract and the kidneys.
Wegners Granulomatosis is associated with c-ANCA
86
What is the effect on URT in WG?
Sinusitis, otitis and nasal crusting
87
What is the effect on the lungs in WG?
Pulmonary haemorrhage/nodules + Inflam infiltrates are seen on xray
88
What is the effect on the kidney in WG?
Glomerulonephritis
89
What is the effect on the skin in WG?
Ulcers
90
What is the effect on the eyes in WG?
Uveitis, Scleritis and episcleritis
91
What is the treatment for wegeners granulomatosis?
1. If severe – high dose steroids
| 2. If non-end organ threatening – moderate steroids
92
What is vasculitis?
Inflammation of the blood vessels.
93
What would you see histologically in vasculitis?
- Neutrophils and giant cells
94
What is the chapel hill classification?
- Used to classify vasculitis
95
What is an example of a large primary artery disorder?
Giant cell arteritis
96
What is an example of a large secondary artery disorder?
Aortitis in RA
97
What is an example of medium/small artery primary disorder?
Wegeners granulomatosis
98
What is an example of a medium/small artery secondary disorder?
Vasculitis secondary to AI disease, malignancy and drugs.
99
What is the common cause of septic arthritis?
Staph aureus
100
What are the causes of septic arthritis?
1. Staph aureus
2. Streptococci
3. Neisseria
Consider clinical context of patient.
101
What are the risk factors of septic arthritis?
1. Any cause of bacteremia e.g. cannula and UTI
2. Local skin breaks/ulcers
3. Damaged prosthetic joints
4. RA
5. Elderly
102
What are the symptoms of septic arthritis?
1. Painful
2. Red
3. Swollen
4. Hot
5. Fever
103
What is the treatment for septic arthritis?
1. AB guided by aspirate cultures
2. Joint wash out/repeated aspiration
3. Rest/splint/physio
4. Analgesia
104
What is a sarcoma?
A rare tumour of mesenchymal origin --> a malignant connective tissue neoplasm
105
Describe the nature of sarcomas?
80% soft tissue and the remaining 20% are boney.
106
What are 3 soft tissue sarcomas?
1. Liposarcoma
2. Leiomyosarcoma
3. Rhabdomyosarcoma
107
What is a liposarcoma?
A malignant neoplasm of adipose tissue
108
What is a leiomyosarcoma?
A malignant neoplasm of smooth muscle
109
What is a rhabdomyosarcoma?
A malignant neoplasm of skeletal muscle
110
What are 3 bony sarcomas?
1. Osteosarcoma
2. Ewing’s sarcoma – responds well to chemo
3. Chondrosarcoma – malignant neoplasm of cartilage
111
What are 3 features of sarcomas?
1. Fast growing
2. Aggressive
3. Typically affects 15-17 yo
112
What are red flag symptoms for sarcoma?
1. Non-mechanical pain
| 2. Pain at night
113
What are 4 signs that could suggest malignancy to diagnose soft tissue sarcoma?
1. Lump >5cm
2. Lump increases in size
3. Lump is deep in fascia
4. Pain
114
What are the investigations in suspected sarcoma?
1. MRI
2. Core needle biopsy
3. CT scan
115
What is the treatment of sarcomas?
1. MDT meeting
2. Surgery for localized soft tissue sarcomas
3. Amputation
4. If non resectable --> Adjuvant Chemo and radiotherapy
116
What is sjorgen's syndrome?
- Immunologically mediated destruction of epithelial exocrine glands especially lacriminal and salivary glands.
117
When does sjorgens syndrome often occur?
Often occurs secondary to other auto-immune disorders e.g. SLE, RA and scleroderma
118
What are the symptoms of sjorgen's syndrome?
1. Dry eyes + mouth
2. Inflam arthritis
3. Rash
4. Neutrophils
5. Vasculitis
119
What are the investigations in Sjorgen's syndrome?
1. Serum auto-antibodies e.g. Anti – RO, RF, ANA
| 2. Also raised ESR and raised immunoglobulins
120
What is the treatment of sjorgen's syndrome?
Tear and saliva replacement + immunosuppression for systemic complications
121
What is the pathophysiology of pseudogout?
- Calcium pyrophosphate crystals are deposited on joint surfaces
- The crystals elicit an inflame response
122
What is the cause of pseudogout?
1. Hypo/hyperthyroidism
2. Diabetes
3. Haemochromatosis
4. Magnesium levels
123
What are the symptoms of pseudogout?
Acute, hot and swollen joints typically wrists and knees
124
What is the investigations of pseudogout?
1. Aspiration --> fluid for crystals or blood cultures
| 2. X-rays --> Can show chondrocalcinosis
125
What is the differential diagnosis of pseudogout?
Infection
126
What is the treatment for pseudogout?
Treat underlying cause and use methotrexate for inflammation
127
You do some investigations on a 30 yo woman who has painful red and swollen MCP and PIP joints. XR shows swelling of soft tissues, deformity and loss of joint space. What Auto-antibodies would you expect to see in the serum?
- Anti CCP and RF positive
| - Patient has rheumatoid arthritis
128
An elderly man presents with worsening bone pain and is found to bhave an enlarged and bowed tibia, what is the most likely diagnosis?
Pagets disease of the bone
129
An elderly lady with bone is found to have hypocalcaemia, hypophosphataemia and a raised ALP, what is the most likely diagnosis?
Osteomalacia
130
With which disease would you associate positively birefringent crystals ?
Pseudogout – pyrophosphate crystals are rhomboid shaped.
131
With what disease would associate negatively birefringenet crystals?
Gout – Monosodium urate crystals are thin and needle shaped
132
A patient presents with acute mono-arthropathy of their big toe. What are the two main differential diagnosis?
Gout and septic arthritis
133
A patient presents with acute mono-arthropathy of their big toe. What investigations might you do?
Joint aspirate
- If septic arthritis --> high WCC and neutrophilia and baceteria on gram stain
- If Gout --> urate crystals
134
What is fibromyalgia?
A symptom characterized by widespread MSK pain accompanied by fatigue, sleep, memory and mood issues.
135
What are 3 diseases included in the differential diagnosis of fibromyalgia?
1. Hypothyroidism
2. SLE
3. Low Vit D
136
What are the symptoms of fibromyalgia?
1. Neck and back pain
2. Pain is aggravated by stress cold and activity
3. Generalised morning stiffness
4. Subjective swelling of extremities
5. Frequent waking during the night
6. Walking unrefreshed
7. Low mood, irritable and weepy
8. Headache and IBS common
137
What are the triggers of fibromyalgia?
1. Physical trauma
2. Distress
3. Hormonal alterations e.g. hypothyroid
4. Infections
5. Certain catastrophic events
138
What is the diagnostic criteria for fibromyalgia?
- Chronic widespread pain lasting for over 3 months with other causes excluding
- Pain is at 11 of 18 tender point sites
139
What is the management of fibromyalgia?
1. Educate the patient and family
2. Low dose amitriptyline can help with sleep
3. Graded aerobic exercise
4. Acupuncture
140
What is essential to the management of fibromyalgia?
- Explaining sleep disturbance is central to what they’re feeling
- Emphasise the importance of exercise and fitness
141
What is reactive arthritis?
Sterile inflammation of synovial membrane, tendons and fascia triggered by an infection at a distant site (usually Gut or genital)
142
What are some associated gut infections with reactive arthritis?
Salmonella, shigella
143
What are associated STIs with reactive arthritis?
Chlamydia
144
What are the triad symptoms for reactive arthritis?
- Arthritis
- Conjunctivitis
- Urethritis
145
What is the aetiology of juvenile idiopathic arthritis?
- Unknown as its idiopathic
| - It is an AI disease so genetic factors must be associated.
146
Why is it important to check the eyes in JIA?
Risk of uveitis
147
What is the criteria for diagnosing JIA?
- Joint swelling and stiffness for over 6 weeks in children <16 with no other cause identified
148
What is the presentation of oligoarthritis?
Oligoarthritis affects over 4 joints and usually is ANA positive
- It has a high risk of developing uveitis
149
What is enthesitis related JIA?
Enthesitis related JIA – inflammation of where tendon joins a bone – HLAB27 positive
- Like ankylosing spondylitis
150
What is the non-medication treatment for JIA?
1. Information
2. Education
3. Support
4. Liaison with school
5. Physiotherapy
151
What is the medical treatment for JIA?
1. Steroid joint injections
2. NSAIDs
3. Methotrexate
4. Systemic steroids
152
What are consequences if you fail to treat JIA?
1. Damage
2. Deformity
3. Disability
4. Pain
5. Bony overgrowth
6. Uveitis
153
What is spondylarthritis?
An umbrella term for the following conditions
1. Ankylosing spondylitis
2. Reactive arthritis
3. Psoriatic arthritis
4. Enteropathic arthritis
5. Juvenile idiopathic arthritis
154
What is spondylarthritis associated with?
Tissue type HLAB27 --> Antigen presenting cell.
155
What is the molecular mimicry theory for why HLAB27 is associated with spondylarthritis?
- Infectious agents have peptides similar to HLAB27
| - An AI response is triggered against HLAB27
156
What are other theories of Spondylarthritis and HLAB27 association?
1. Molecular mimicry
2. Misfolding theory
3. HLAB27 heavy chain hypothesis
157
What are the signs of spondylarthritis?
1. Psoriasis
2. Inflammatory spine and buttock pain
3. Good response to NSAIDs
4. Enthesitis
5. Arthritis
6. Crohn’s/UC association
7. Uveitis
158
What is the general treatment for spondylarthritis?
- Initially DMARDs (disease modifying anti-rheumatic drugs)
- Biological agents if DMARDs fail
- Responds well to NSAIDs
159
What is the pathophysiology of anklylosing spondylitis?
Inflammation of spine --> erosive damage --> repair/bone formation --> irreversible fusion of spine
160
What are the symptoms of anklyosing spondylitis?
1. Back Pain
2. Morning stiffness
3. Waking in second half of night
4. Usually above 40 at onset
5. Buttock pain
6. Insidious onset
161
What are the investigations neccesary in diagnosing anklyosing spondylitis?
- X-ray
- MRI
- HLAB27 test
162
What is the diagnostic criteria for ankylosing spondylitis?
- >3 months back pain
- Aged <45 at onset
- Plus one of the SPINEACHE symptoms
Enteropathic Arthritis is a type of spondylitis occurring in 20% of patients with IBD.
163
Where does psoriasis usually occur at?
1. Elbows
2. Knees
3. Fingers
164
What is ANCA?
Anti-neutrophil cytoplasmic antibodies
165
What is the protocol for treating trauma patients?
ATLS Greatest threat to life first (ABCDE)
166
What is a cytokine?
Short acting hormone
167
What is a TNF blocker example?
Adalimumab
168
How does rituximab work?
Binds to cd20 on the B cell leading to b cell depletion
169
Why is osteomyelitis difficult to treat with ABx?
Abx dont penetrate bone well.
170
What type of erosion is seen in psoriatic arthritis?
pencil in cup.
171
How can you stop bone turnover?
Give bisphosphonates e.g. aldendronate
172
How does aldendronate work?
bone turnover by inhibiting osteoclast mediated bone resorption
173
What are two drugs that work on the HMGCoA pathway?
1. Bisphosphonates e.g. alendronate
| 2. Statins e.g. simvastatin
174
What AB present in people with RA?
RF and anti-CCP
175
Nodal osteoarthritis affects the DIP and PIP Joints. What is the name for these nodes?
- PIP --> Bouchard’s nodes
| - DIP --> Herbeden nodes
176
What joint is most commonly affected in gout?
MTP of big toe.
177
What joints are affected in seronegative spondyloarthropathies ?
asymetrical large joints
178
Which joints are affected in RA?
1. MCP
2. PIP
3. Wrist
179
How does antiphospholipid syndrome present?
thrombosis
| recurrent miscarriage
180
What is polymyalgia rheumatica?
A condition that causes pain, stiffness and inflammation in the muscles around the shoulders, neck and hips.
181
How can you differentiate between fibromyalgia and PR?
PMR shows raised inflam markers.
182
What can cause raynaud's syndrome?
Beta blockers
183
What is the treatment of raynauds syndrome
Nifedipine – CCB --> relaxes blood vessels and stops vasospasm
184
What joint is commonly affected in psoriatic arthritis?
DIP joint.
185
What are the symptoms of osteomalacia?
1. Bone pain and tenderness
2. Fractures
3. Wadding gait
186
What would the x-ray in someone with ankylosing spondylitis be like?
1. Sacroilitis
| 2. Syndesmophytes (Bamboo spine)
187
What are the two features of psoriatic plaque?
- Pink, scaling lesions
| - Occur on extensor surfaces on the limbs
188
What are the differences between RA and psoriatic arthritis?
Psoriatic --> psoriatic lesions, sausage like swelling on DIP joint, pencil cup erosion and HLAB27 associated
RA --> Hands and wrists typically affected --> periarticular erosion on x-ray and rheumatoid nodules
189
What is the swelling like in psoriatic arthritis?
Dactylitis and sausage like swelling would be seen in psoriatic arthritis
190
What is the systemic lupus erythematosus?
inflame multi-system disease characterized by presence of ANA
191
What is the epidemiology of SLE?
90% young women, genetic component and more common in afro-Caribbean’s
192
What is the pathogenesis of SLE?
Ineffecient phagocytosis causes cell fragments to be transferred to lymphoid tissue
Take up by APC. T Cells stimulate B cells to produce antibodies against self antigens
Immune complex deposition --> Neutrophil and cytokine influx = inflame and tissue damage
193
Why may thrombosis occur in SLE?
Thrombosis can be caused by the presence of antiphospholipid antibodies
194
What is anti-dsDNA specific to?
SLE
195
What are the symptoms of SLE?
1. Butterfly rash
2. Mouth ulcers
3. Raynaud’s phenomenon
4. Fatigue
5. Depression
6. Weight loss
196
What are the investigations for SLE?
- Blood count --> may show normocytic anaemia --> neutropenia
- Raised ESR and normal CRP
- Serum autoantibodies --> ANA and Anti-dsDNA
197
What is the non-medical treatment of SLE?
1. Education and support
2. UV protection
3. Screening for organ involvement
4. Reduce CV risk factors e.g. smoking cessation
198
What is the medical treatment of SLE?
- Corticosteroids
- NSAIDs
- Anti-malarials (DMARDs)
- Anticoagulants – for those with antiphospholipid antibodies
- Bio therapy --> targeting B cells e.g. rituximab
199
What are the signs of SLE?
1. Glomerulonephritis
2. Thrombocytopenia
3. Photosensitivity
4. Vasculitis
5. Anaemia
6. Deforming arthritis
7. Pericarditis
200
What is a cause of inflammatory joint pain?
AI disease
201
What is two examples of inherited connective tissue disease?
1. Marfan’s syndrome
| 2. Ehler Danlos syndrome
202
What is 3 examples of AI connective tissue disease?
1. SLE
2. Systemic Sclerosis
3. Sjorgen’s syndrome
4. Dermatomyositis
203
What is osteomyelitis?
Bone inflammation secondary to infection
204
What causes osteomyelitis?
1. S.aureus
2. Coag neg staphylococci e.g. s. epidermidis
3. Aerobic gram negative bacilli
4. Mycobacterium TB
205
What histological changes would you see in someone with acute osteomyelitis?
- Inflammmatory cells
- Oedema
- Vascular congestion
206
What histological changes would you see in someone with chronic osteomyelitis?
1. Necrotic bone – sequestera
2. New bone formation
3. Neutrophil exudates
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What are the signs of osteomyelitis?
1. Fever, Rigors, Sweats, Malaise, Tenderness, Swelling and Erythema
Sign specific to chronic osteomyelitis Sinus formation
208
What investigations would you order in suspected osteomyelitis?
1. Bloods --> Raised inflame markers and WCC
2. Plain radiographs and MRI
3. Bone biopsy
4. Blood cultures
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What are the differential diagnoses for osteomyelitis?
Cellulitis, Avascular necrosis and Gout
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What is the treatment of osteomyelitis?
1. Large does IV AB tailored to culture findings often flucloxacillin
2. Surgical treatment --> debridement
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What is the difference in osteomyelitis and TB caused ostemyelitis?
1. Slower onset
2. Epidemiology is different
3. Biopsy is essential – case eating granuloma
4. Longer treatment
212
How can pathogens get into the bone?
- Easy – Inoculation of infection into bone e.g. trauma or open wound
- Quite easy – contagious spread of infection to bone from adjacent tissues
- Difficult – hematogenous seeding e.g. due to cannula infection ( vertebrae in adults, long bones in kids)
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Why do the vertebrae get infected more often?
become more vascularised
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Why do long bones get infected more often?
as they have a high blood flow and BM are absent meaning bacteria can move from the blood to bone.
215
Which Group of people at risk of hematogenous osteomyelitis?
IVDU and other groups at risk from bacteraemia
216
Give 3 host factors that affect the pathogenesis of osteomyelitis?
1. Behavioural e.g. risk of trauma
2. Vascular supply e.g. arterial disease
3. Pre-existing bone/joint problems e.g. RA
4. Immune deficiency
217
How does chronic ostemyelitis lead to sequestra and bone formation?
- Inflammatory exudate ruptures periosteum --> blood supply impaired --> necrosis --> sequestera --> new bone forms
218
What is rheumatoid arthritis?
An AI inflammatory synovial joint disease.
219
What is the epidemiology of RA?
- 2-3 times more common in women
| - 1% of pop effected
220
What is the aetiology of RA?
- Auto-antibodies e.g. RF and anti CCP lead to defected cell mediated immune responses
221
What is the pathophysiology of RA?
- Chronic inflammation --> BT Cells and neutrophils infiltrate
- Proliferation --> Pannus formation
- Pro inflammatory cytokines --> proteinases --> cartilage destruction
222
What are the symptoms of RA?
1. Early morning stiffness for over an hr
2. Pain that eases with use
3. Swelling
4. General fatigue and malaise
5. Extra-articular involvement
223
What are the signs of RA?
1. Symmetrical
2. Deforming
3. Polyarthropathy
4. Erosion on X-ray
5. 80% are RF positive
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What investigations would you associate with RA?
1. Bloods for inflammatory markers – ESR and CRP will be raised
2. Test for anaemia
3. Test for RF and Anti-CCP
225
What is the treatment for RA?
1. NSAIDs
2. Corticosteroids
3. DMARDs
4. Biological agents
226
Describe the RA extra-articular involvement effects on Soft tissues
- Nodules, Bursitis and Muscle wasting
227
Describe the RA extra-articular involvement effects on the eyes
- Dry eyes, Scleritis and Episcleritis
228
Describe the RA extra-articular involvement effects on neurology
- Sensory peripheral neuropathy
- Entrapment neuropathies e.g. carpal tunnel syndrome
- Instability of C spine
229
Describe the RA extra-articular involvement effects --> haematology
- Palpable lymph nodes, Splenomegaly and Anaemia
230
Describe the RA extra-articular involvement effects on the pulmonary system.
pleural effusion
231
Describe the RA extra-articular involvement effects on the heart
Pericardial rub and effusion
232
Describe the affect of RA on the kidneys
Amyloidosis
233
What is rheumatoid factor?
An antibody against the Fc portion of IgG
234
What are 2 factors for predicting the likelihood of osteoporotic fracture?
Propensity to fall and bone strength
235
Give 4 factors that contribute to bone strength
1. Bone mineral density
2. Bone size
3. Bone turnover
4. Bone micro-architecture
5. Mineralisation
6. Geometry
236
What can control osteoclast action and bone turnover?
Oestrogen can control osteoclast action so control bone turnover.
Women over 50 are likely to be post-menopausal --> less estrogen so osteoclast isn’t inhibited
- There is a high rate of bone turnover --> bone loss and deterioration --> fracture risk
237
What happens when to our bones when we get older?
- Trabecular thickness decreases especially in horizontal plane.
- There are fewer connections between trabecular so there’s a decrease in strength
- This causes an increased fracture risk
238
How can RA cause osteoporosis?
RA is an inflammatory disease --> high levels of IL-6 and TNF so are responsible for bone resorption.
239
How can high cortisol cause osteoporosis?
cortisol increases turnover, leads to increased bone resorption so induces osteoblast apoptosis
240
How can cushings sydrome cause osteoporosis?
cortisol leads to increased bone resorption and osteoblast apoptosis
241
How can hyperparathyroidism and hyperthyroidism cause osteoporosis?
TH + PTH --> increased bone bone turnover.
242
What skeletal areas does a dexa scan focus on?
Lumbar spine
| Hip
243
What is a T score?
T score --> Standard deviation that is compared to a gender-matched young adult mean.
T score
244
What is FRAX?
A tool that can be used to assess someone’s risk of osteoporotic fracture.
245
What are 2 examples of anti-resorptive treatments used in osteoporosis management?
1. Bisphosphonates
2. HRT
they reduce osteoclast activity.
246
What is an example of anabolic treatment in OP?
Teriparatide --> Anabolic treatments increase osteoblast activity
247
Give 3 advantages of HRT treatment in OP?
- Reduces fracture risk
- Stops bone loss
- Prevents menopausal symptoms
248
Give 3 disadvantages of HRT treatment in OP?
- Increased risk of breast cancer
- Increased risk of stroke and CV disease
- Increased risk of thrombo-embolism
249
What is osteoporosis?
A systemic skeletal disease characterized by low bone mass and micro-architectural deterioriation --> patient is at increased risk of fracture.
250
What is the epidemiology of osteoporosis?
50% of women over 50 and 20% of men --> incidence increases w/ age.
251
What investigation would be done in osteoporosis?
1. DEXA scan --> A T score will be generated.
252
What are the risk factors for osteoporosis?
1. Previous fracture
2. FHx
3. Excessive alcohol
4. Smoking
5. Medications e.g. steroids, depo provera
6. Immobility
