Rheumatology Flashcards
What is the presentation of rheumatoid arthritis
- symmetrical swollen, stiff painful joints, typically starting with small joints eg of the hand
- worse on the morning
What deformities of the fingers might be seen in rheumatoid arthritis
- boutonniere deformity
* swan neck deformity
What blood tests could you order for RA
- anti-CCP
* rheumatoid factor
Which blood test is most specific for rheumatoid arthritis
anti CCP
What might you see on x-ray of a joint affected by rheumatoid arthritis
- loss of joint space
- bony erosion
- juxta-articular osteopenia
- soft tissue swelling
What is the treatment for rheumatoid arthritis
- NSAIDs
- steroids (oral or steroid injections)
- DMARDs (methotrexate, hydroxycloroquine, sulfasalazine)
- anti-TNFalpha biologics (infliximab, etanercept)
- anti-b cell biologics (rituximab)
- physio
- surgery
What is the typical presentation of osteoarthritis
- pain and stiffness of one (usually large) joint, typically the knee or hip
- pain on movement
- crepitus
- worse at end of day
Osteoarthritis and rheumatoid arthritis differ on which time of the day the pain is worse - which is which?
- osteoarthritis pain worse at end of day
* rheumatoid pain worse in morning
What will you see on x ray of an osteoarthritic joint
Loss of joint space
Osteophytes
Subarticular sclerosis
Subchondral cysts
What is treatment for osteoarthritis
- physio
- NSAIDs
- steroid injections
- surgery
What is psoriatic arthritis highly associated with
psoriatic nail disease
What is the presentation of psoriatic arthritis
- symmetrical polyarthritis similar to RA
* spondylarthropathy
What is treatment of psoriatic arthritis
NSAIDs and DMARD if necessary
most commonly used medication is methotrexate
What treatment should be avoided in psoriatic arthritis
oral and IM steroids
intra-articular steroids may be used
What are the two ways a joint may become septic
- contiguous spread
* haematogenous spread
What are the common causative pathogens in septic arthritis
contiguous spread
- straph A
- strep
haematogenous spread
* neisseria gonococcus
What are risk factors for septic arthritis
- immobility
- recent surgery
- recent injury
- immunosuppression
- IVDU
- prosthetic joint
When should you suspect septic arthritis
- red, hot swollen joint acute onset
What investigation must be done for septic arthritis
- joint aspiration - MCS (microscopy, culture and sensitivity)
What treatment should be done for septic arthritis
- start empirical antibiotics after joint aspirate and fine tune treatment when sensitivity results get back
Where is the most common site for gout
first MTP joint (podagra)
what causes inflammation in gout
monosodium urate crystals accumulating at the joint capsule causing inflammation
What might increase risk of gout
- alcohol intake
- diet high in purines
- stress eg surgery
- low water intake
- starvation
How is gout diagnosed
joint aspiration with light microscopy
- will show urate crystals
How is gout treated
- high dose NSAID
- colchicine
- 3 weeks after flare up prescribe allopurinol to prevent future flare ups
Why wouldn’t you prescribe allopurinol during a gouty attack?
allopurinol should be given three weeks after attack because it can cause a flare up
What causes temporal arteritis?
giant cell arteritis - vasculitis of the temporal artery
- fibrosis and wall weakening of this artery
What are the symptoms of temporal arteritis
- headache
- scalp tenderness
- unilaterall blindness
- jaw claudication
What should you do if you suspect temporal arteritis?
- do ESR
* start prednisolone immediately
What blood result would you expect in GCA
- VERY elevated ESR
- platelets elevated
- alk phos elevated
What investigation should you do in GCA? When should you order it?
temporal artery biopsy - within 7 days
What is the main cause of death and morbidity in GCA?
long-term steroid use - so titrate when appropriate
What is polymyalgia rheumatica
a condition that causes neck, shoulder and hip stiffness and pain
Which condition does polymyalgia rheumatica commonly occur with
giant cell arteritis
What is the treatment of polymyalgia rheumatica
prednisolone
What is the creatinine kinase level like in polymyalgia rheumatica?
Normal
What is osteoporosis
decreased bone density
What is the DEXA score that diagnoses osteopenia?
T score between -1 and -2.5
What is the DEXA score for osteoporosis
-2.5
What are risk factors for osteoporosis
- early menopause
- steroid use
- smoking
- increased age
- low BMI
- low calcium intake
- low vitamin D
Where are the three most common sites of frailty fracture
- radius
- vertebrae
- neck of femur
What pharmacological treatment can be given for osteoporosis
- bisphosphonates (eg alendronate)
- calcium and vitamin D
- HRT
What non-pharmacological treatment can be given for osteoporosis
- physiotherapy
* exercise
What advice must be given to patients about bisphosphonates
they must be taken sitting upright and after meals - causes oesophagitis
What is ankylosing spondylitis
chronic inflammation of the IV discs of the spine and the sacroiliac joints
How does ankylosing spondylitis present
- gradual onset of stiff, painful back and buttock pain
* progressive loss of spinal movement
How is ankylosing spondylitis diagnosed
it is a clinical diagnosis supported by MRI
How is ankylosing spondylitis treated
- exercise
- TNF-alpha blockers
- local steroid injections
What virus might trigger SLE
epstein barr virus
What is SLE
an autoimmune condition that causes production of anti-nuclear antibodies that can deposit in tissue and cause inflammation
What is the presentation of SLE
remitting and relapsin illness presenting with noon-specific constitutional symptoms (malaise, fatigue, fever)
- possibly also lymphadenopathy, erythematous skin, weight loss
What is the diagnostic test for SLE
ANA (anti-nuclear antibody) (95% +ve)
What inflammatory marker will be raised in SLE
ESR
What is Sjogren’s syndrome
inflammatory autoimmune disorder that causes lymphocytic infiltration and fibrosis of exocrine glands, particularly the salivery and lacrimal glands
What does Sjogren’s syndrome cause
- reduced tear production
- reduced saliva
- parotid gland swelling
What is polymyositis
autoimmune inflammation of (typically large) muscle groups
How does polymyositis present
With weakness and wasting typically of large muscle groups
What is vasculitis
Inflammation of blood vessels (usually arteries) causing weakness (and aneurysms) and fibrosis, which can cause organ ischaemia
What is the most common type of vasculitis
Kawasaki disease
What are the large vessel vasculitides
- GCA
* Takayasu’s arteritis
When should you consider vasculitis?
In any unidentified multisystem disorder
What tests should you consider in vasculitis
- ESR/CRP may be raised
* may be ANCA-positive
What are the main causes of reactive arthritis
- STIs
* gastroenteritis
What is reactive arthritis
- sterile arthritis
What is the investigation of reactive arthritis
must joint aspirate to rule out septic arthritis
What is treatment of reactive arthritis
- NSAIDs
- consider local steroid injection
- consider DMARDs if chronic
When does reactive arthritis usually occur after an infection
1-2 weeks
What causes Paget’s disease of bone
excessive bone remodelling
What are the symptoms of Paget’s
- may be asymptomatic
- deep, boring bone pain
- bony deformity and enlargement
may cause
- deafness/blindness
- leonitis of facial features
- fractures
Which bones are typically affected in Paget’s
- skull
- lumbar spine
- pelvis
- femur
- tibia
What is the investigations of Paget’s
- X-ray for deformities and sclerotic lesions
- bone scan may reveal ‘hot spots’
- alk phos will be raised
What is treatment for Paget’s
- analgesia
* bisphosphonates
What malignancies commonly metastasise to bone
- breast
- thyroid
- prostate
- lung
- renal
- lymphoma
What are the primary cancers of the bone
- osteosarcoma
- chrondrosarcoma
- Ewing’s sarcoma
