Rheumatology Flashcards
If suspect RA on a hand exam, what else to examine?
- Other joints including C spine
- Blood pressure (overall CV risk)
- Extra-articular manifestations of disease
- Face: conjunctival pallor for anemia, eyes (Sjogren’s)
- Lungs: fibrosis (RA-ILD, MTX-ILD), pleural effusions, Caplan’s syndrome / rheumatoid pneumoconiosis (nodular condition in RA when exposed to dust)
- Heart: pericardial rubs (pericarditis)
- Abdomen - splenomegaly (Felty’s), HSM (RA is a/w increased risk of lymphoma), injection sites (biologics)
- Lower limbs - pyoderma gangrenosum, neuropathy, feet
Who gets rheumatoid nodules in RA?
And where are rheumatoid nodules, typically?
Rh factor +ve patients only
(Nothing to do with CCP)
Elbows (but can be anywhere)
What are the lung manifestations of RA?
- ILD
- Usually UIP
- Pleural effusion
- Exudative (high protein, LDH)
- Low glucose (<2.2, rule out empyema & malignancy)
- pH < 7.2 (rule out empyema, oesophageal rupture)
- Lung nodules
Which single autoantibody is most specific for RA?
Which is more sensitive?
Anti-CCP / ACPA (specificity 95%)
RhF is more sensitive (but only 70%)
What are markers of poor prognosis in RA?
Early erosions on XR (the strongest)
RhF / Anti CCP
HIgh levels of inflammation (ESR and CRP)
HLA DRB1*04
Smoking
Extra articular features
Alfred lecture also said: high number of swollen and tender joints, functional limitation
What is this?
Remitting, seronegative, symmetric synovitis with pitting edema (RS3PE)
An atypical presentation of RA
A tenosynovitis
Might be a paraneoplastic pheneomenon
Very good response to low dose glucocorticoids
What are the features of OA on XR?
L: loss of joint space
O: osteophytes
S: subchondral cysts
- can be mistaken as erosions
S: subchondral sclerosis
- NB in RA there is periarticular osteopenia
What is the cause of this?
Psoriatic artthritis
- Pencil in cup deformity
- Ankylosis
- Subluxation
- Periostitis
- Absence of periarticular osteopenia (differentiates from RA)
- Arthritis mutilans
- Hand joint involvement:
- DIP, PIP
- Other joints:
- Feet, sacroiliac, spine
- Knee, elbow, ankles, shoulders much less common
Remember: tends to effect ‘ray’ not ‘row’ in PsA
What is the cause of this?
Rheumatoid arthritis
- Soft tissue swelling
- Juxta-articular osteopenia
- Joint space narrowing
- Marginal erosions
- Subchondral cysts
- Subluxation and deformity - ulnar deviation MCP, boutonniere and swan neck, hitchhiker thumb
- Hand joint involvement:
- PIP and MCP (esp. MCP 2-3)
- Ulnar styloid
- Triquetrum
- DIP spared
- Other joints:
- Feet (PIP, MTP esp 4-5)
- Shoulder, hip, knee, C-spine
What are the causes of a positive rheumatoid factor?
- SLE (~30%)
- Sjogren’s (<100%)
- Scleroderms (30%)
- MCTD (50%)
- Mixed cryoglobulinemia (100%)
- Certain infections (malaria, rubella, Hep C, TB)
- Malignancy
- Healthy subjects (5-10%)
Can you use RhF or anti-CCP to monitor disease activity in RA?
No
What is palindromic rheumatism?
Atypical presentation of RA
- Articular or sometimes periarticular pain, then swelling and erythema
- Symptoms worsen for hours to a few days
- Symptoms resolve in reverse sequence (think palindrome) with no residua
- 50% will go on to develop RA - ACPA +vity helpful in predicting
Treatment: hydroxychloroquine (may reduce risk of progression to RA)
Who tends to get nodal generalised osteoarthritis?
post-menopausal females
usually have female family history of same
- Compare the XR findings, specifically:*
- -erosions*
- joint space*
- bone density*
- in:*
Gout
RA
PsA
Gout
Punched out erosions, joint space preservation, tophi
RA
Juxta articular cortical erosions, joint space narrowing, osteopenia
Psoriatic arthritis
Pencil in cup, bony proloferation / periostitis, DIPJ involvement
What tests would you like to order if you suspect RA?
- FBE (anaemia related to disease e.g. chronic disease / Felty’s or related to treatment eg bleeding due to NSAIDs / steroids, folate deficiency / cytopenia related to MTX)
- ESR / CRP
- RhF (not specific, do NOT monitor for disease activity)
- Anti-CCP (specific, do NOT monitor for disease activity)
- Hand XR
Other / wholistic tests
- Imaging of the other joints including lateral C spine XR to rule out atlanto-axial subluxation
- CXR /CT chest if suspect ILD / effusions / Caplan’s syndrome / nodules
- TTE if suspect pericarditis
- Lipids / HbA1c for CV risk
- Vitamin D / calcium / DEXA if suspect OP (due to treatment / steroid exposure or RA on its own)
What are the causes of a symmetrical, deforming polyarthopathy?
- Rheumatoid arthritis
- Psoriatic arthritis or enteropathic arthritis (other spondyloarthopathies eg. reactive arthritis tend to cause a mono arthritis)
- Osteoarthritis [although usually asymmetrical or a mono/oligo arthritis]
- Polyarticular gout / chronic tophaceous gout [although gout / CPDD usually asymmetrical or a mono/oligo arthritis]
- Jaccoud’s arthropathy of SLE
- ??Systemic sclerosis
What are the XR features of RA
L - loss of joint space
O - osteopenia
S - soft tissue swelling
E - erosions (juxta/periarticular, but intra-articular in severe)
D - deformity
Spiel for assessing disease activity
Number of tender / swollen joints
in conjunction with inflammatory markers
+ in a SpA may also examine for activity of eye / bowel / skin involvement which can mimic disease activity
Types of PsA?
Types of psoriatic arthritis
- Symmetrical-deforming polyarthritis sparing the DIPJs (rheumatoid-like)
- Most common
- Very similar to RA but usually sero-negative
- Asymmetrical oligoarthritis involving the DIPJs
- Second most common
- associated with dactylitis (soft tissue swelling)
- DIP arthritis
- Second-least common
- Associated with nail changes
- Spondylitis / sacroiliitis
* Third most common - Arthritis mutilans
- Least common
- Severe osteolysis / pencil in cup
OTHER EXAMINATION IF SUSPECT PSA?
Other joints
Including back exam for axial disease (and perform Schober’s test)
Including enthesopathy (achilles tendons and plantar fascia)
Skin - scalp, navel, natal cleft and behind the ears for evidence of psoriasis
Face - uveitis, episcleritis
Lung - apical lung fibrosis in AS
Heart - murmur of aortic regurgitation
Abdomen - tenderness due to association with IBD
What are the XR changes of PsA?
Osteolysis & pencil in cup deformity
Periostitis (to make ‘mouse ears’ and ‘fluffy’ appearance)
Involvement of DIPJs
(DDx erosive OA)
Tests to order in a symmetrical deforming polyarthopathy
FBE (anaemia related to disease e.g. chronic disease)
ESR / CRP
RhF, Anti-CCP (although the former not specific to RA)
ANA, anti-dsDNA, anti-Smith (if suspect SLE / Jaccoud’s Arthopathy)
U1RNP if suspect MCTD
Anti-centromere Ab, RNA-polymerase III, scl-70
HLAB27
Uric acid level
Hand XR
Other / wholistic tests
Imaging of the other joints including lateral C spine XR to rule out atlanto-axial subluxation, spine/SIJ if suspect lumbar spine involvement in SpA
CXR /CT chest if suspect ILD / effusions / Caplan’s syndrome
TTE if suspect pericarditis
Lipids / HbA1c for CV risk
Vitamin D / calcium / DEXA if suspect OP (due to treatment / steroid exposure or RA on its own)
Urinylasis if suspect Jaccoud’s arthopathy / SLE
What is the features of gout on synovial fluid analysis?
What is the features of pseudogout on synovial fluid anlaysis?
The true purist would say you need to see intracellular (intra-neutrophil) crystals; you can see uric acid crystals in a joint with OA!
- Monosodium urate (gout)
- Brightly, negatively birefringent in polarized light, needle-shaped
- Negatively birefringent = turn yellow when aligned parallel to the light source, turn blue when perpendicular
can remember: yeLLow when paraLLel
- Calcium pyrophosphate dehydrate (pseudogout)
- Weakly, positively birefringent, rhomboid or rectangular
- Positively birefringent = turn blue when aligned parallel to the light source, turn yellow when perpendicular
How should gout be diagnosed?
- Definitive diagnosis requires the identification of monosodium urate crystals under polarised microscopy in synovial (or bursal) fluid or tophi
- Once have a definitive diagnosis, diagnostic aspiration is not required for recurrent attacks unless infection is suspected
What is the target serum uric acid concentration of patients on uric-acid lowering therapy?
What is a normal uric acid level?
- Target serum uric acid < 0.36 mmol/L (6 mg/dL) for patients with non-tophaceous gout
- Target serum uric acid < 0.30 mmol/L (5 mg/dL) for patients with tophaceous gout
- The presence of tophi indicates a higher urate load
Normal uric acid is <0.41
On synovial fluid analysis, what WCC is typical of a non-inflammatory cause of an arthopathy?
200 - 2,000
On synovial fluid analysis, what WCC is typical of an inflammatory cause of an arthopathy?
2,000
to
50,000 - 100,000
On synovial fluid analysis, what WCC is typical of an infective cause of an arthopathy?
> 50,000
Differntial diagnosis of monoarthritis
- Septic arthritis
- Bacterial, non-gonoccal arthritis
- Gonococcal arthritis
- Crystal
- Gout (monosodium urate crystals)
- Pseudogout (calcium pyrophsophate deposition disease)
- Sondyloarthopathies
- OA
Xray changes in pseudogout
Chondrocalcinosis
radiographic calcification in hyaline and/or fibrocartilage
What are the sites of CPDD?
Wrist
Knee
Hand and face findings in systemic sclerosis?
Hands
Dilated nail fold capillaries
Nail dystrophy
Sclerodactyly
Ask them to put the pulps of their fingers on their MCPs, not make a fist
Loss of finger pulps and pseuoclubbing
Raynauds
Digital ulceration
Calcinosis
Face
Telangiectasia (in the mouth also)
Perioral puckering
Reduced mouth apeture
Systemic sclerosis other things to examine?
Chest and abdomen to see if sclerodactyly involvement there
Blood pressure & urine disptick renal exam for SRC
Resp exam - evidence of ILD
Cardiac exam - pericardial rub (pericarditis), pulmonary hypertension
Gastrointestinal exam and examination of oral cavity for dental hygeine (reflux and reduced mout aperture)
Invetsigations for scleroderma
ANA
Anti-centromere antibody
Scl-70 (topoisomerase)
RNA polymerase
HRCT / TTE
Urine dipstick
UEC
Colour changes in Raynauds
White then blue then red
What are some differntials for nodules?
Gouty tophi
Rheumtoid nodules
Calcinosis cutis
CPDD can also cause nodules
Tenodon xanthelmatas
IF YOU DON’T SEE OBVIOUS DEFORMITY THINK OF
Systemic sclerosis
Dermatomyositis / Polymyositis
DIfferentials for a rash in a rheum exam
Psoriasis
Rash of Still’s disease
Telangiactasia
Mechanic’s hands
Gottren’s papules
Heliotrope rash
Shawl sign
Ix in dermatimyositis / polymyositis
CK
ANA
ENA
‘Myositis specific antibodies’
EMG
MRI
Skin / Muscle biopsy
What other examination in dermatomyositis / polymyositis?
Proximal muscle strength
Respiratory exam for anti-synthetase syndrome (anti-Jo1)
Examine for LAD and abdomen given increased risk of cancer (adenocardinomas)
Xray PsA vs erosive OA
Both involve DIPJ
PsA - pencil in cup, periosititis, M=F
erosive OA - gull wing, post menopausal females
