Rheumatology Flashcards
What are the X-Ray changes in Osteoporosis?
LOSS Loss of joint space Osteophytes Subchondral/subarticular sclerosis Subchondral cysts
Risk factors for osteoarthritis
Obesity Old age Female Family history Occupation
Presentation for osteoarthritis
Pain on movement Crepitus Worse at end of day/no morning stiffness Worsened by exercise/relieved by rest No systemic features Stiffness after rest - gelling Bony swelling & deformity - Heberden's and Bouchard's nodes
Where does Heberden’s node affect?
DIP
Where does Bouchard’s node affect?
PIP
Management for osteoarthritis
Weight loss
Exercises for muscle strength - physiotherapy
Aids and devices/walking stick - occupational therapy
Oral paracetamol and topical NSAIDs
Oral NSAID + PPI e.g. Omeprazole
Intra-articular steroid injections (methylprednisolone)
Joint replacement (hip and knee)
What joint is most commonly affected in septic arthritis?
Knee
What is the commonest bacteria causing septic arthritis
Staph aureus
What other bacteria cause septic arthritis
Step pyogenes
H. influenzae
E. coli
Nesisseria gonorrhoea (in sexually active)
Risk factors for septic arthritis
Prosthetic joint Rheumatoid arthritis Diabetes IV drug abuse Alcohol Immunosuppression
Presentation for septic arthritis
Usually only affects ONE joint - the KNEE Hot Red Swollen Painful Immobile/restricted Fever lethargy Sepsis
Investigations for septic arthritis
Joint aspiration for synovial fluid microscopy and culture
WCC
Polarised microscopy (exclude gout = urate crystals & pseudogout = calcium pyrophosphate)
ESR/CRP raised
X-ray
Management for septic arthritis
Empirical antibiotics
Flucloxacillin for staph + rifampicin
Vancomycin for MSRA/penicillin allergy
Define rheumatoid arthritis
Chronic inflammatory autoimmune disease characterised by synovial joint inflammation leading to joint destruction
What is the pattern of rheumatoid arthritis
Symmetrical and affects multiple joints
Genetic associations for rheumatoid arthritis
HLA DR4
HLA DR1
Who is more commonly affected in rheumatoid arthritis
50 year old woman
Presentation for rheumatoid arthritis
Symmetrical polyarthritis Joint pain + swelling Worse after rest/improves with exercise Morning stiffness Sudden onset Fatigue Weight loss Fever Muscle aches and weakness
What joints are affected in rheumatoid arthritis
MCP MTP PIP Wrist and ankle Cervical spine Knee, hips, shoulders
Signs on examination for rheumatoid arthritis
Z-shaped deformed thumb
Swan neck deformity
Boutonnieres deformity - flexed at PIP and extended at DIP
Ulnar deviation of the fingers
What is palindromic rheumatism?
Self-limiting short episodes of inflammatory arthritis. Only lasts 1-2 days then resolves
Extra-articular manifestations of rheumatoid arthritis
Rheumatoid nodules Lymphadenopathy Secondary Sjogren's syndrome Felty's syndrome = RA + splenomegaly + neutropenia Obliterative bronchiolitis Caplan's syndrome (pulmonary fibrosis with pulmonary nodules) Anaemia Cardiovascular disease Epscleritis and scleritis Carpal tunnel syndrome Amyloidosis
Investigations for rheumatoid arthritis
Anti-CCP
Rheumatoid factor
FBC
X-ray
X-ray features seen in rheumatoid arthritis
LESS Loss of joint space Bony Erosions Soft tissue swelling Softening of bones (osteopenia)
Treatment for rheumatoid arthritis
1st line = DMARDs - Methotrexate
2nd line = two DMARDS - methotrexate + sulfasalazine/hydroxychloroquine/leflunomide
3rd line = Methotrexate + TNF inhibitor - adalimumab
4th line = Methotrexate + rituximab
Side effects of methotrexate
Pneumonitis
Oral ulcers
Hepatotoxicity
Teratogenic - harmful to pregnancy - PRESCRIBE WITH FOLIC ACID 5MG
Side effects of hydroxychloroquine
Irreversible retinopathy
Side effects of sulfasalazine
Reduced sperm count
Skin rash
Bone marrow suppression
Side effects of leflunomide
Teratogenic
Oral ulcers
Hepatotoxicity
Peripheral neuropathy
Examples of Anti-TNF drugs
Infliximab
Adalimumab
Golimumab
Etanercept
Side effects of Anti-TNF drugs
Reactivation of TB
Infection/sepsis
Hepatitis B
What is rituximab
A monoclonal antibody
Side effects of rituximab
Infections/sepsis
Night sweats
Thrombocytopenia (low platelets)
What treatment do you give in an acute exacerbation of rheumatoid arthritis?
Methylprednisolone
Risk factors for gout
Male Obesity High purine diet (meat and seafood) Alcohol Diuretics Cardiovascular or kidney disease Family history
Which joints are affected in gout
BIG TOE >50% Wrists Thumb Knee Ankle
Investigations for gout
Joint aspiration and polarised light microscopy of synovial fluid = negative birefringent needles, URATE crystals
Serum urate raised
X-ray: Soft tissue swelling, ‘punched out’ erosions, tophi
Treatment for gout
1st line = NSAIDs e.g. Ibuprofen/naproxen
2nd line = Colchicine
3rd line = Steroids - in patients with renal failure
Rest, elevation, ice
Contraindications for NSAIDS
Peptic ulcer
Heart/renal failure
Side effects of colchicine
GI upset
Diarrhoea
Prophylaxis for gout
Lose weight
Reduce alcohol consumption
Avoid purine rich meats
Allopurinol - xanthine oxidate inhibitor
Side effects of allopurinol
Rash
Fever
Reduced WCC
Avoid allopurinol until acute attack has settled
How does gout present?
Hot, swollen, painful joint
How does pseudogout present?
Hot, swollen, painful
More common in elderly
Large joints - knee, shoulders, wrist and hips
Causes of pseudogout
Hyperparathyroidism
Surgery
Trauma
Illness
Investigations for pseudogout
Polarised light microscopy of synovial fluid - positive rhomboid crystals, CALCIUM PYROPHOSPHATE
X-ray: Chondrocalcinosis - calcium deposition
Exclude septic arthritis
Management for pseudogout
NSAIDs + colchicine
Joint aspiration
Intra-articular steroids
Icepacks + rest
Define SLE
Inflammatory autoimmune connective tissue disease with antinuclear antibodies
“Systemic” because it affects multiple organs
What age group and people are typically affected by SLE?
Women of CHILD-BEARING age
Symptoms for SLE
Fatigue Weight loss Fever Myalgia Lymphadenopathy Alopecia Raynauds
Criteria for SLE
4 out of 11: Discoid rash Malar butterfly rash Photosensitivity Oral ulcers Non-erosive arthritis Serositis - pleuritis/pericarditis Renal disorder CNS disorder - seizures or psychosis Haematological disorder - leukopenia, thrombocytopenia, lymphopenia Immunological disorder - Anti-dsDNA, Anti-Sm, Antiphospholipid antibodies ANA +ve in >95%
Investigations for SLE
ESR raised + CRP normal
FBC - anaemia, leukopenia, thrombocytopenia
Autoantibodies - ANA, Anti-dsDNA, Anti-smith
C3 & C4 decreased
Proteinuria in lupus nephritis
Treatment for SLE
NSAIDs Steroids (prednisolone) Hydroxychloroquine Suncream and sun avoidance Methotrexate Azathioprine Mycophenolate Rituximab + belimumab
Define ankylosing spondylitis
Inflammatory condition affecting the spine that causes progressive stiffness and pain
What is the genetic association with ankylosing spondylitis
HLA B27
How does ankylosing spondylitis present?
Young adult male <30 years old
Gradual onset of lower back pain >3 months
Worse at night and in the morning
Pain and stiffness is worse with rest and improves with movement/exercise
Pain radiates from the sacroiliac joints to hips/buttocks
Loss of spinal movement hence decreased thoracic expansion
Kyphosis
Neck hyperextension (question mark posture)
Spino-cranial ankylosis
Associations with ankylosing spondylitis
Enthesitis Dactylitis Anterior uveitis Aortitis Anaemia Heart block Restrictive lung disease Pulmonary fibrosis Inflammatory bowel disease
Investigations for ankylosing spondylitis
Clinical - Schober’s test
MRI spine - bone marrow oedema
CRP & ESR raised
X-ray of spine: ‘Bamboo spine’, subchondral erosions and sclerosis, fusion of the facet, sacroiliac and costovertebral joints, syndesmophytes, ossification
Treatment for ankylosing spondylitis
Exercise + physiotherapy NSAIDs - ibuprofen + naproxen Local steroids injections Anti-TNF medications - etanercept, inflixiumab Surgery - hip replacement
Associations with enteric arthropathy
Inflammatory bowel disease
GI bypass
Coeliac disease
Whipple’s disease
Define psoriatic arthritis
Inflammatory arthritis associated with psoriasis
Occurs in 10-20% of people with psoriasis
How does psoriatic arthritis present?
Symmetrical polyarthritis - hands, wrists, ankles, DIP
Asymmetrical pauciarthritis - digits (toes and feet), fingers
Spondylitic pattern - back stiffness, sacroiliitis, atlanto-axial joint involvement
Other areas: spine, achilles tendon, plantar fascia
Signs of psoriatic arthritis
Plaques of psoriasis on the skin
Pitting of the nails
Onycholysis - separation of the nail from the nail bed
Dactylitis - inflammation of the digits
Enthesitis - inflammation of the points of insertion of tendon into bone
Other associations with psoriatic arthritis
Eye disease (conjunctivitis and anterior uveitis) Aortitis Amyloidosis
Investigations for psoriatic arthritis
X-ray: "Pencil in cup" appearance Central erosions Osteolysis Dactylitis Ankylosis Periostitis
Define arthritis mutilans
Occurs in the phalanxes, there is osteolytic destruction of the bones around the joints in the digits. Leads to shortening of the digits “telescopic finger”
Treatment for psoriatic arthritis
NSAIDs
DMARDs - methotrexate, sulfasalazine
Anti-TNF medications - etanercept, infliximab
Ustekinumab - last line monoclonal antibody
Define reactive arthritis
Where synovitis occurs in the joints as a reaction to a recent infective trigger - affecting the lower limb
Typically causes an acute monoarthritis affecting a single joint most often the knee - warm, swollen and painful joint
Differential diagnoses for reactive arthritis
Septic arthritis - in reactive arthritis there is no infection in the joint
Most common causative organisms which trigger reactive arthritis
Gastroenteritis (campylobacter, salmonella, shigella, Yersinia)
Chlamydia
What is Reiter’s syndrome?
Urethritis
Arthritis
Conjunctivitis
CANT SEE, CANT WEE, CANT CLIMB A TREE
Investigations for reactive arthritis
ESR & CRP raised
Aspirate joint and send sample for gram staining, culture and sensitivity - EXCLUDE septic arthritis
Crystal examination of fluid - rule out gout & pseudogout
Treatment for reactive arthritis
NSAIDs
Steroid injections
DMARDs - methotrexate, sulfasalazine
Define Behcet’s disease
A systemic inflammatory disorder of unknown cause
Characteristically presents with recurrent oral and genital ulcers
Link with HLA-B5 gene
Features of Behcet’s disease
Mouth ulcers - at least 3 a year Genital ulcers Skin - erythema nodosum, papules & pustules Eyes - Anterior or posterior uveitis, retinal haemorrhage MSK - morning stiffness, arthralgia GI - inflammation and ulcers CNS - Meningitis, migraines Veins - Budd-Chari syndrome, DVT
Investigations for Behcet’s disease
Clinical diagnosis
Pathergy test - needle prick leads to papule formation
Treatment for Behcet’s disease
Topical steroids for mouth ulcers Systemic steroids - oral prednisolone Colchicine Immunosuppressants - azathioprine Infliximab
Define Polymyalgia Rheumatica
Inflammatory condition that causes pain and stiffness in the shoulders, pelvic girdle and neck
Strong association to giant cell arteritis
Features of Polymyalgia Rheumatica
Age >50 years, more common in female caucasians Subacute onset <2 weeks Bilateral shoulder pain radiating to elbows Bilateral pelvic girdle pain Worse with movement Morning stiffness >45 minutes Carpal tunnel syndrome Weight loss, fever, fatigue
Investigations for Polymyalgia Rheumatica
Clinical diagnosis + response to steroids
ESR & CRP elevated
Creatine kinase levels are normal
Treatment for Polymyalgia Rheumatica
Prednisolone 15mg
Consider other diagnosis if no response after 1 week
Risk of adrenal crisis if steroids stopped abruptly
Define Giant Cell Arteritis
Systemic vasculitis of the medium and large arteries
Strong link with polymyalgia rheumatica
Symptoms of Giant Cell Arteritis
Headache - severe unilateral
Scalp tenderness
Jaw claudication
Amaurosis fugax - sudden blindness in one eye
Investigations for Giant Cell Arteritis
Clinical presentation Raised ESR >50 Raised CRP Temporal artery biopsy Raised alkaline phosphatase
Treatment for Giant Cell Arteritis
Prednisolone 60mg/day
Aspirin
PPI - Omeprazole for gastric prevention whilst on steroids
Bisphosphonates for osteoporosis prevent
Define polymyositis
Condition of chronic inflammation of muscles
Define dermatomyositis
Connective tissue disorder where there is chronic inflammation of the skin and muscles
What is the key investigation for diagnosing polymyositis and dermatomyositis
Creatine kinase blood test = >1,000
What are the causes of a raised creatine kinase level
Polymyositis and dermatomyositis Rhabdomyolysis Acute kidney injury MI Stains/colchicine Strenuous exercise HIV
Presentation for polymyositis and dermatomyositis
Muscle pain, fatigue and weakness
Occurs bilaterally and affects proximal muscles - affecting shoulders and pelvic girdle
What skin involvement is there in dermatomyositis
Gottren's lesions - patches on knuckles Macular rash Purple rash on face and eyelids Preorbital oedema Subcutaneous calcinosis
Investigations for polymyositis and dermatomyositis
Clinical presentation Elevated creatine kinase >1,000 Electromyography Muscle biopsy Autoantibodies - Anti-Jo-1 = Polymyositis, Anti-Mi-2 = Dermatomyositis, ANA = Dermatomyositis
What autoantibody is present in polymyositis?
Anti-Jo-1
What autoantibody is present in dermatomyositis?
Anti-Mi-2
ANA
Treatment for polymyositis and dermatomyositis
Prednisolone
Immunosuppressants - azathioprine
Define osteoporosis
Reduction in the density of the bones
Define osteopenia
Less severe reduction in bone density than osteoporosis
Risk factors for osteoporosis
SHATTERED Steroid use Hyperthyroidism, hyperparathyroidism, hypercalciuria Alcohol and smoking Thin (BMI<22) Testosterone low Early menopause - low oestrogen Renal or liver failure Erosive/inflammatory bone disease (myeloma/RA) Dietary low calcium/malabsorption
What is the tool to measure the risk of a fracture in the next 10 years?
FRAX
Uses age, BMI, co-morbidities, smoking, alcohol, family history to calculate
How is bone mineral density measured?
DEXA scan
What is a T-score and what scores indicate what diagnosis?
The T-score gives you the number of standard deviations below the mean for a healthy young adult.
> -1 = normal
-1 - -2.5 = osteopenia
Lifestyle treatment for osteoporosis
Weight-bearing exercise Stop smoking Reduce alcohol consumption Calcium & Vitamin D rich diet Avoid falls
Pharmacological treatment for osteoporosis
Bisphosphonates - 1st line
Alendronate, risedronate, zolendronic acid
Calcium with Vitamin D supplements
Denosumab - monoclonal antibody
Strontium ranelate
Raloxifene
How do bisphosphonates work?
Reduce osteoclastic activity, preventing reabsorption
Side effects of bisphosphonates
Reflux
Oesophageal ulcers - sit upright
Jaw osteonecrosis
Photosensitivity
Define osteomalacia
Normal amount of bone but it is soft (low mineral content).
Results from insufficient vitamin D
The result if it occurs after the fusion of the epiphyses
What is Rickets?
Rickets is the result of osteomalacia is this occurs during the period of bone growth in children
Causes of osteomalacia
Vitamin D deficiency - due to malabsorption, poor diet or lack of sunlight Renal osteodystrophy Vitamin D resistance Drug induced - anticonvulsants Liver disease
Symptoms of Rickets
Growth retardation
Hypotonia
Knock-kneed
Bow-legged
Symptoms of osteomalacia
Bone pain
Fractures
Muscle weakness
Fatigue
Investigations for osteomalacia
Serum-25-hydroxyvitamin D <25nmol/L Serum calcium low Serum phosphate low Alkaline phosphate may be high PTH high (secondary hyperparathyroidism) X-ray=osteopenia
Treatment for osteomalacia
Vitamin D
Define Paget’s disease
Disorder of bone turnover. Increased bone turnover due to increased numbers of osteoblasts and osteoclasts. Results in remodelling, bone enlargement, deformity and weakness
Symptoms of Paget’s disease
Bone pain
Bone deformity
Fractures
Hearing loss if bones of the ear are affected
Complications of Paget’s disease
Osteoarthritis
Increased calcium
Nerve compression due to bone overgrowth in spine
Osteosarcoma
Investigations in Paget’s disease
X-ray - Bone enlargement and deformity
‘Cotton wool’ appearance of skull
‘V-shaped’ defects in the long bones
Osteoporosis circumscripta - osteolytic lesions
Raised alkaline phosphatase
Normal calcium
Normal phosphate
Treatment for Paget’s disease
Bisphosphonates - Alendronate
NSAIDs for bone pain
Define systemic sclerosis
An autoimmune inflammatory and fibrotic connective tissue disorder
Scleroderma is hardening of the skin
Two types - limited and diffuse cutaneous systemic sclerosis
What antibodies are present in diffuse cutaneous systemic sclerosis?
Anti-Scl-70 antibodies Antinuclear antibodies (ANA)
Features of diffuse cutaneous systemic sclerosis
Includes features of CREST
Cardiovascular problems - hypertension, coronary artery disease
Lung problems - pulmonary hypertension, pulmonary fibrosis
Kidney problems - glomerulonephritis
Features of limited cutaneous systemic sclerosis
Calcinosis - calcium deposits under the skin - fingertips
Raynaud’s phenomenon - Fingertips go white -> blue due to cold
Oesophageal dysmotility - swallowing difficulties
Sclerodactyly - swollen, tight digits
Telangiectasia - dilated small blood vessels in the skin
What is Raynaud’s phenomenon
Fingertips go white -> blue due to cold
What causes Raynaud’s phenomenon
SLE RA Dermato/polymyositis Vibrating tools Beta-blockers Hypothyroidism Thrombocytosis
Treatment for Raynaud’s phenomenon
Keep warm
Stop smoking
Nifedipine, sildenafil
Antibodies present in limited cutaneous systemic sclerosis
Anti-centromere antibodies Antinuclear antibodies (ANA)
Investigations for systemic sclerosis
Clinical features
Antibodies
Nailfold capillaroscopy
Treatment for systemic sclerosis
Immunosuppressants: IV cyclophosphamide in diffuse disease
Avoid smoking
Regular emollients
Define osteomyelitis
Infection of the bone
Common organisms causing osteomyelitis
Staphylococcus aureus
Pseudomonas
E.coli
Streptococci
Risk factors for osteomyelitis
Diabetes Vascular disease Impaired immunity Sickle cell disease Open fractures
Clinical features of osteomyelitis
Cancellous bone affected in adults - vertebrae = IV drug users, feet = diabetic
Vascular bone affected in children - distal femur, upper tibia
Infection leads to cortex erosion, with holes
Gradual onset pain
Tenderness, warmth, erythema
Investigations in osteomyelitis
ESR increased CRP increased Blood culture positive in 60% Bone biopsy and culture - gold standard X-ray after 14 days = haziness, loss of density
Treatment for osteomyelitis
6 weeks of antibiotics: Vancomycin & Cefotaxime
Ciprofloxacin for pseudomonas
Complications of osteomyelitis
Septic arthritis
Fractures
Deformity
Chronic osteomyelitis
Define compartment syndrome
Occurs when swelling of tissues in an anatomic compartment occludes the vascular supply leading to necrosis and hypoxia
Features of compartment syndrome
Pain, especially on movement
Paraesthesia
Pallor
Paralysis of the muscle group
Investigations for compartment syndrome
Intracompartmental pressure: >20mmHg = abnormal
>30mmHg = critical
Treatment for compartment syndrome
Prompt fasciotomy
IV fluids in renal failure due to myoglobinuria following fasciotomy
Define cauda equina syndrome
Compression of the cauda equina
Caused by large herniation or prolapses of lumbar discs, but may be from cord tumours or spondylosis
Features of cauda equina syndrome
Poor anal tone Severe back pain - sudden onset Saddle area (perianal) sensation loss Incontinence/retention of faeces or urine Paralysis +/- sensory loss
Investigations for cauda equina syndrome
MRI within 4 hours
Define carpal tunnel syndrome
Due to compression of the median nerve
Symptoms of carpal tunnel syndrome
Tingling or pain in the thumb, index and middle fingers
Pain is relieved by dangling the hand over the edge of the bed and shaking it ‘wake and shake’
Sensory loss and weakness of abductor pollicis brevis
Wasting of the thenar eminence
Investigations for carpal tunnel syndrome
Phalen’s test
Tilen’s test
What is Phalen’s test?
Wrist hyperflexed for 1 minute -> reverse prayer sign
What is Tinel’s test?
Tapping over the nerve induces tingling
Treatment for carpal tunnel syndrome
Splinting
Corticosteroid injections
Carpal tunnel decompression
Associations with carpal tunnel syndrome
Hypothyroidism Diabetes Obesity RA Acromegaly Amyloidosis Pregnancy Gout Psuedogout
What inheritance pattern is Marfan’s syndrome?
Autosomal dominant
What causes Marfan’s syndrome
Defect in the FBN1 gene on chromosome 15 that codes for the protein fibrillin-1
Features of Marfan’s syndrome
Tall stature Long neck Long limbs Long fingers (arachnodactyly) High arch palate Hypermobility Pectus excavatum
Associated conditions with Marfan’s syndrome
Lens dislocation in the eye
Joint dislocations and pain due to hypermobility
Scoliosis of the spine
Pneumothorax
GORD
Mitral valve prolapse (with regurgitation)
Aortic valve prolapse (with regurgitation)
Aortic anuerysms
Treatment for Marfan’s syndrome
Biggest risk = aortic dissection - treatment with beta blockers
Echocardiogram
