Rheumatology and Bone Disease I and II Flashcards by Soph 1

What is rheumatology?

Deals with joints, bone and muscle disease
Diseases normally inflammatory - usually autoimmune
Arthritis

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Systemic features of rheumatology?

Fever, skin rash, pain and stiffness, heart and lung involvement, neurological problems

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Joint pain:

Inflam… TABLE

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TABLE

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Rheumatoid arthritis features?

Disease of synovial joints
Affects 1% population
Autoimmune, systemic inflam illness
Symmetrical joint inflam and deformity
Extra articular features - makes it systemic

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Rheumatoid arthritis pain features?

Early morning stiffness
Stiffness after rest
Ease with use/exercise
Swelling
Flu like symptoms
Anti-inflam drugs: NSAIDs e.g. ibuprofen may be helpful

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What is inflammation?

Red
Hot
Painful
Swollen

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What can rheumatoid arthritis lead to?

Progressive joint deformity

Z thumb deformity
Boggy swelling
Spares DIPJs
Swelling and subluxation of MCPJs
Ulnar deviation
Swan-neck deformity

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Extra-articular features of rheumatoid arthritis?

Lungs:

Nodules
Lung fibrosis
Pleural effusions
Increased lung cancer

CV:

Pericardial inflam/effusions
Myocarditis
Valve inflam

Kidneys:
- Amyloidosis

Skin:

Rheumatoid nodules
Vasculitis

2ndry Sjogren’s syndrome

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What is commonly found via blood tests with you have rheumatoid arthritis?

Anaemia
High/low platelets
High inflam markers - C reactive protein, erythrocyte sedimentation rate
Auto-antibodies: up to 75% positive for RF and/or anti-CCP

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What is found on x-rays from early and late rheumatoid arthritis?

Early:
Osteopenia around joints (thinning)
Soft tissue swelling

Late:
Erosions
Joint space narrowing
Subluxation/dislocation
Fusion (ankylosis)

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Tx of rheumatoid arthritis?

Immediate relief:

NSAIDs
Steroids - injected into joint/intra-muscular/iv/oral

Control of disease (immunosuppressive):

DMARDS (Disease modifying anti-rheumatic drugs)
e. g. methotrexate (= 1st choice drug)

Biological drugs (SC or IV injecs)

Anti TNF (Tumour necrosis factor) e.g. infiximab
B cell depletion e.g rituximab

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How to first treat rheumatoid arthritis?

Methotrexate first and hydroxychloroquine later

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Side effects of rheumatoid arthritis drugs?

Infec - all increase risk, for biological drugs: reactivation of TB
Bone marrow toxicity: low white cell count/low platelets/pancytopenia
Hepatotoxic: abnormal liver tests (rise in enzymes)
Gastric upset: nausea, diarrhoea
Skin rashes

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When to stop taking DMARDs/biological drugs?

For course of antibiotics and for up to 2 weeks after as they are immunosuppressed

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Features of methotrexate (DMARD)?

Weekly dose: 15-25mg/week
Never co-prescribe trimethoprim/septrin = risk of severe bone marrow suppression: all anti-folate drugs

Lung complications: pneumonitis, fibrosis
Renally excreted: reduce dose/stop or contact doctors if pt develops new renal impairment

Contra-indicated in men and women pre-conception
Nausea, mouth ulcers

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When is methotrexate never co-prescribed?

When is it contraindicated?

Never co-prescribed trimethoprim/septrin = risk of severe bone marrow suppression: all anti-folate drugs
Contra-indicated in men and women pre-conception

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Features of biological drugs?

Greater infection risk

Stop 2 weeks before surgery
Restart 2 weeks later or when wound’s healing
Ask pt if on biological drug
Contact doctor

Reactivation of TB/Hep B and C
Contraindicated if pt develops cancer
May cause/exacerbate MS

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Rheumatoid neck features?

Erosive change at C1/C2
Leads to subluxation at the atlanto-axial level or subaxial levels or both
Instability can lead to neurological deficit from spinal cord compression
= problem with intubation or positioning a pt in the dental chair

What occurs to the neck in rheumatic neck?

Atlas (C1)
Axis (C2) with dens
Erosive change disrupts ligament = does not hold bone in place = bone moves backwards into spinal cord = compression of spinal cord = numbness in fingers (difficulty doing buttons)

What to do if a pt has rheumatoid arthritis?

Ask about neck pain
Ask if know about rheumatoid neck
When positioning pt, check no new neck pain develops or neurological symptoms such as pins and needles…..

How does RA impact OH?

Poor hand/neck/shoulder func = impair OH
Immuno-suppressive drugs may compound this
RA pts have co-existent osteoporosis = bisphosphonates

Increasing evidence that gingivitis/caries may trigger RA

Juvenile idiopathic arthritis (JIA) features?

Inflam arthritis before 16yrs old
40% grow out of it by adulthood
Jaw underdevelopment:
- TMJ inflam = altered mandibular growth
- Malocclusion (class II)
- Pain, biomechanical problems

Spondyloarthropathy types?

Ankylosing spondyloarthropathy
Psoriatic arthritis
Enteropathic artihritc (crohns/UC)
Reactive arthritis

What is Spondyloarthropathy associated with?

HLA B27

What is ankylosing spondyloarthropathy?

Calcification in spine = severe limitation of movement Inflam spinal pain Progressive new bone formation Rigid fused neck (fracture risk) or atlanto-axial subluxation

Common features of spondyloarthropathy?

Enthesitis: - Inflam of junction between tendon/ligament and bone Dactylitis: - Sausage finger/toe - Combination of joint and tendon sheath inflam Skin/nail psoriasis Inflam eye disease = iritis Inflam bowel disease = UC/crohns

Psoriatic arthritis signs?

Nail pitting Dactylitis Distal joints can be effected

Osteoarthritis features?

Degenerative process, with exaggerated repair response = Pain, stiffness, deformity, reduced joint movement and joint instability Increases with age Occupation/hobbies increase risk Cartilage erosion E.g footballers - knees

X-ray features in osteoarthritis?

Loss of joint space Osteophytes Sub0chondral sclerosis

OA tx?

Physiotherapy/exercise Weight loss Paracetamol, co-codamol, NSAIDs Surgery: for uncontrolled pain, joint failure

What is gout?

Hot, red, swollen, painful arthritis Urate crystals precipitate out from bloodstream into joints/soft tissues Induces intense neutrophil-led inflam response

Why do you get gout?

``` Pt has high serum urate Causes of high urate: - Genetic - Renal impairment - Diuretics - Dehydration - High alcohol/fructose/red meat - Part of metabolic syndrome - central obesity, diabetes, high BP and chol ```

Tx of gout?

Acute: NSAIDs, Colchicine, steroids Prevent future attacks: Urate lowering drugs (allopurinol and febuxostat)

Features of CT diseases?

Group of rare auto-immune systemic diseases Can be life threatening, usually due to organ involvement e.g. renal failure, lung fibrosis, myocarditis Associated with auto-antibodies More common in women

CT diseases examples?

``` Systemic lupus erythematosus Scleroderma 1 sjogren's Polymyositis ALL ASSOCIATED WITH Anti-nuclear antibody (ANA) ```

Common features of CT disease?

Raynauds - vasoconstriction finger and toes in response to cold Mouth ulcers Cardio resp disease

SLE features? (lupus)

Non-erosive arthritis Butterfly rash on face around nose Photosensitivity

Sclerodema features?

Progressive skin thickening and tightening Severe raynaud's = leads to digital ulcers, oral tethering, telaniesctasia (red dots on lip/face), nose beaking Can be limited to hands, feet and face (LcSSc) Or widespread (diffuse systemic scelorsis - DcSSc)

Define Primay Sjogren's

Primary = occurs on its own without an associated rhumatic illness but with its own systemic manifestations

Define Secondary Sjogren's

Occurs with a rheumatic illness eg RA, SLE | Associated with other auto-immune disorders including interstitial lung disease, auto-immune liver disease etc

Primay Sjogren's features?

Dry eyes and mouth Associated with Ro and La antibodies High immunoglobulins, high ESR, positive RF Fatigue, joint pain Atrophic, shrunked parotid gland, glossitis Rare complications: - Vasculitis - Renal involvement (renal tubular acidosis) - Neurological - peripheral neuropathy - Primary biliary cirrhosis - Lymphoma

Polymyositis and dermatomyositis features?

Inflam of muscles Weakness of arms and thighs Painless wasting of muscles Associated with lung fibrosis

What differs polymyositis from dermatomyositis?

``` Polymyositis = muscles only Dermatomyositis = Muscles and skin, photosensitivity/purple rash around eyes (heliotrope rash), internal malignancy ```

Tx for CT disease?

NSAIDS/steroids DMARDS Cytotoxic drugs for life-threatening complications Biological drugs