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Rheumatology Flashcards

1
Q

What is rheumatology

A 
The medical speciality dealing with diseases of the musculoskeletal system including 
Joints
Tendons
Ligaments
Muscles
Bones
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2
Q

What is a joint

A

Where two bones meets

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3
Q

Tendons

A

Cords of strong fibrous collagen tissue attaching muscle to bone

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4
Q

Ligaments

A

Flexible fibrous connective tissue which connects two bones

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5
Q

Which joint allows free movement ( diarthroses)

A

Synovial joints ( have a space between adjoining bones called the synovial cavity) and this space is filled with synovial fluid

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6
Q

Fibrous joint structural classification

A

No space between the bones

E.g. sutures in the skull, syndesmosis ( sheet of connective tissue) in the tibia and fibula joint ( ankle)

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7
Q

What kind of movement does the fibrous joint allow for

A

Synarthroses ( generally allow no movement)

Amohiarthroses ( allows very limited movement)

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8
Q

What kind of movement does the cartilaginous joint allow

A

Synarthroses

Amphiarthroses

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9
Q

Cartilaginous joint

A

Joints in which the bones are connected by cartilage

E.g. joints between the spinal vertebrae

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10
Q

What is the synovium made up of

A

1-3 cell deep lining containing macrophage like phagocytic cells ( type A synoviocyte) and fibroblast like cells that produce hyaluronic acid ( type B synoviocyte)

Type 1 collagen

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11
Q

What does synovial fluid contain

A

Hyaluronic acid rich viscous fluid

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12
Q

What is articulate cartilage made up of

A

Type II collagen

Proteoglycan ( aggrecan )

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13
Q

What is cartilage composed of

A

Specialised cells called chondrocytes
Extra cellular matrix - water, collagen and proteoglycans ( mainly aggrecan) . Cartilage is a vascular - has no blood supply so cartilage heals poorly after injuries

Aggrecan is a proteoglycan that possesses many chondrites sulfate and keratin sulfate chains
Characterised by its ability to interact with hyaluronan to form large proteoglycan aggregates

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14
Q

What is arthritis

A

Disease of the joints

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15
Q

Two types of arthritis

A

Osteoarthritis ( degenerative arthroscopic where the cartilage is worn out)

Inflammatory arthritis ( main type is rheumatoid arthritis - main problem is inflammation )

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16
Q

Pathological changes in osteoarthritis

A

Cartilage is worn out and there is bony remodelling leading to bone Spurs

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17
Q

Epidemiology of osteoarthritis

A

More prevalent as age increases
Previous joint trauma ( e.g. footballers knees)
Jobs involving heavy manual labour
Gradual onset and slowly progressive disorder

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18
Q

Joints of the hand affected by osteoarthritis

A

Distal inter phalanges joints ( DIP)
Proximal inter phalangeal joints ( DIP)
First carpometacarpal joint ( CMC)

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19
Q

Other joints affected by osteoarthritis

A

Spine
Weight bearing joints of lower limbs
esp knees and hips
First metarsophalangeal joint (MTP)

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20
Q

What can osteoarthritis be associated with

A 
Joint pain ( worse with activity but better with rest)
Joint crepitus - creaking, cracking , grinding sound on moving affected joint
Joint instability ( giving way) 
Joint enlargement - herberdens nodes 
Joint stiffness after immobility - gelling
Limited partition of range of motion
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21
Q

How can you tell from an x ray that there are subchondral bony sclerosis

A

Increased white appearance

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22
Q

What is inflammation

A

A physiological response to deal with injury or infection . But excessive / inappropriate inflammatory reactions can damage the host tissues

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23
Q

What are the manifestations of inflammation

A 
Red ( rub or)
Pain ( donor)
Hot ( calor)
Swelling ( tumor) 
Loss of function

There is an increased blood flow
Migration of white blood cells ( leukocytes) into tissues
Activation / differentiation of leucocytes
Cytokine production - TNF alpha, IL1 , IL6 , IL17

24
Q

Causes of joint inflammation

A

Infection
Crystal arthritis
Immune mediated ( autoimmune)

25
Q

Infection related joint inflammation

A

Septic arthritis - acute presentation such as acute bacterial infection
Tuberculosis - chronic presentation

26
Q

Crystal arthritis joint inflammation

A

Gout

Pseudogout

27
Q

Immune mediated joint inflammation( autoimmune)

A

Rheumatoid arthritis
Psoriasis arthritis
Reactive arthritis
Systemic lupus erythematosus ( SLE)

28
Q

Septic arthritis

A

Bacterial infection of a joint

Risk factors ; immunosuppressed, pre existing joint damage , IVDU

Untreated, it can eventually destroy a joint

29
Q

How many joints are affected in sceptic arthritis

A

1 ( mono arthritis)

Gonococcal sceptic arthritis is an exception : it often affects multiple joints ( poly arthritis ) it is also less likely to cause joint destruction

30
Q

Sceptic arthritis presentation

A

Acute painful, red, hot, swelling of a joint, especially if there is fever

Diagnosis is by joint aspiration , send sample for urgent gram stain and culture

Treatment is with surgical wash out ( lavage) and IV antibiotics ( but antibiotics by itself won’t work well)

31
Q

Common organisms which cause sceptic arthritis

A

Staphylococcus aureus, streptococci , gonococcus

32
Q

Gout

A

Gout is the syndrome caused by deposition of Urate crystals leading to inflammation

33
Q

Hyperuricaemia

A

High Uris acid levels

34
Q

Causes of hyperuricaemia

A 
Genetic tendency
Increased intake of purine rich foods
Reduced excretion ( kidney failure)
35
Q

Pseudogout

A

A syndrome caused by deposition of calcium pyrophosphate dihedral ( CPDD) Crystal deposition crystals - inflammation

36
Q

Risk factors for pseudogout

A

Background osteoarthritis
Elderly patients
Inter current infection

37
Q

Clinical features of gout

A

Acute mono arthritis of rapid onset ( first metatarsophalangeal joint is the most commonly affected joint - podagra)

Gout also affects other joints ; joints in foot, ankle, knee, wrist, finger, and elbow are the most frequently affected

Crystal deposits ( to phi) may develop around hands, feet, elbows and ears

38
Q

What are shown on the X days of gout

A

Juxta articulate ‘rat bite’ erosions at the MTPJ of the great toe

39
Q

Crystal arthritis synovial fluid analysis

A

Use polarised light to see it

Gout ; needle shapes crystals with negative birefringence
Pseudogout ; rhomboid shaped crystals with positive birefringence

40
Q

RA

A

Chronic autoimmune disease characterised by pain , stiffness and symmetric synovitis ( inflammation of the synovial membrane ) of synovial ( diarthrodial) joints

41
Q

Overview of RA

A

Chronic arthritis - poly arthritis : swelling of small joints of the hand and wrists is common
Symmetrical
Early morning stiffness in and around joints
May lead to joint damage and destruction - joint erosions

Extra artcular diseases can occur
Rheumatoid nodules - others such as vasculitiw and epsicoeritis

Rheumatoid factor may be detected in blood - autoantibody agains IgG

42
Q

Rheumatoid arthritis ; pattern of joint involvement

A

Symmetrical
Poly arthritis
Affects small and large joints, but particularly hands and feet

Common affected joints;
MCP
PIP
Wrists
Knees
A led 
MTP
43
Q

Primary site of pathology in RA

A

Synovial arthritis

44
Q

Common extra articulate features of RA

A

Fever
Weight loss
Subcutaneous nodules
Generally not feeling well

45
Q

What are subcutaneous nodules

A

Nodules are classically found just below elbows but also on the fingers

Associated with severe disease of RA so may act as a prognostic factor

46
Q

What cytokine is the most predominant in RA

A

TNF alpha

47
Q

Primary clinical treatment of RA

A

TNFalpha inhibition

48
Q

Rheumatoid arthritis autoantibodies

A

Rheumatoid factor ( typically IgM antibodies - IgM anti IgG antibody)

Antibodies to citrullinated protein antigens - mediated by enzymes termed as peptidyl arginine deiminases

49
Q

Drug treatment of anti rheumatic drugs

A

1 st line treatment
Methotrexate in combination with hydroxyxhloroquine or sukfasalazine

2nd line ;
Biological therapies offer potent and targeted treatment strategies

50
Q

Biological therapies of RA

A

Inhibition of TNF alpha
B cell depletion
Modulation of T cell co stimulation
Inhibition of IL6 signalling

51
Q

RA Randi graphical changes

A 
Joint space narrowing - Y
Subchondral sclerosis - N
Osteophytes - N
Osteopenia- Y
Bony erosions - Y
52
Q

Osteoarthritis radio graphical changes

A 
Joint space narrowing - Y
Subchondral sclerosis - Y
Osteophytes - Y
Osteopenia - N
Bony erosions -  N
53
Q

Psoriatic arthritis

A

Psoriasis is an autoimmune disease affecting the skin

Rheumatoid factors are not present

54
Q

Reactive arthritis

A

Sterile inflammation in joint FOLLOWING infection especially urogenital and gastrointestinal
Reactive arthritis is the first manifestation of HIV or HepC infection

55
Q

Systemic Lupus Erythematous ( SLE)

A

Can affect any organ

56
Q

Clinical tests for SLE

A

Antinuclear antibodies ( ANA) - high sensitivity for SLE but not specific so a negative test rules out SLE but positive tests does not mean SLE

Antidouble stranded DNA antibodies ( anti -ddDNA Abs)
High specificity for SLE in the context of the appropriate clinical signs

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