Rheumatology AS Flashcards
What are the monoarthritis?
Septic Arthritis
Crystal Arthritis: gout, CPPD
Osteoarthritis
Trauma: haemarthrosis
What are the oligoarthritis (<5 joints)
Crystal arthritis Psoriatic arthritis Reactive Arthritis Ankylosing spondylitis Osteoarthritis
What are the symmetrical polyarthritis?
RA
Osteoarthritis
Viruses: Hep A, B, C, mumps
What are the asymmetrical polyarthritis?
Reactive arthritis
Psoriatic arthritis
What systemic disease cause polyarthritis?
Systemic disease: SLE, sarcoid, endocarditis, TB. HSP.
What are the investigations in rheumatology?
Joint aspiration - Key investigation in a monoarthritis - Appearance - Send for WCC, Grain stain and culture. Polarised light microscopy.
Bloods
- Basic: FBC, U+E, ESR, CRP, Urate
- Culture: septic arthritis
- Abs: RF, ANA, others
- HLA-B27
- Viral serology, urine chlamydia PCR: reactive arthritis
Radiology
- CXR: RA, SLE, Vasculitis, TB, Sarcoid
- US/MRI: more sensitive for synovitis, enthesis, infection.
What are the radiological signs of osteoarthritis?
- Loss of joint space
- Osteophytes (smooth bony deposit)
- Subchondral cysts (below the cartilage surface)
- Subchondral sclerosis (hardening of bone)
On aspiration = Calcium phosphate crystals associated with degeneration of cartilage, coffin-lid shaped with no birefringence.
What are the radiological signs of rheumatoid arthritis?
- Loss of joint space
- Soft tissue swelling
- Periarticular osteopenia (around joint) (Juxta-articular osteoporosis)
- Deformity
- Subluxation
- Symmetrical
LESS
- Loss of joint space
- Erosions
- Soft tissue swelling
- Soft bones (osteopaenia)
Joint aspiration - Cholesterol crystals, rhombic/brick shaped with negative birefringence.
What are the red flags for back pain?
- Age <20 or >55
- Neurological disturbance
- Sphincter disturbance
- Bilateral or alternating leg pain
- Constant or progressive pain
- Nocturnal pain
Systemic symptoms
- Current or recent infection
- Fever, weight loss night sweats
History
- History of malignancy
- Thoracic back pain
- Morning stiffness
- Acute onset in elderly people
What are the main causes of back pain?
Mechanical Degenerative Inflammatory Neoplasm Infection
What are the mechanical causes of back pain?
- Strain/idiopathic
- Trauma
- Pregnancy
- Disc prolapse
- Spondylolisthesis (forward shift of one vertebra)
What are the degenerative causes of back pain?
- Spondylosis (degeneration of vertebrae by any cause)
- Vertebral collapse
- Cervical Stenosis
What are the inflammatory causes of back pain?
- Ank spond
- Paget’s
What are the neoplastic causes of back pain?
Mets
Myeloma
What are the infective causes of back pain?
TB
Abscess
What weakness is present in a L2 lesion?
Hip FLEXION and adduction
What weakness is present in a L3 lesion?
Knee EXTENSION
Hip Adduction
Knee jerk test
What weakness is present in a L4 lesion?
Foot inversion + dorsiflexion
Knee extension
Knee jerk test
What weakness is present in a L5 lesion?
Great toe dorsiflexion
Foot inversion + dorsiflexion
Knee Flexion
Hip extension + abduction
What weakness is present in a S1 lesion?
Foot eversion
Foot and toe plantarflexion
Knee flexion
Ankle Jerk
Investigations for back pain?
- Only if red flags
- FBC, ESR, CRP, ALP, se electrophoresis, PSA
- MRI
Conservative management for back pain?
- Neurosurgical referral if neurology
- Conservative
Max 2 day bed rest
Education: keep active, how to lift/stoop
Physiotherapy
Psychological issues re chronic pain and disability
Warmth
Medical management for back pain?
Analgesia = paracetamol ± NSAIDS (ibuprofen/naproxen) ± codeine
Muscle relaxant: low-dose diazepam (Short-term) - metaxalone/tizanidine
Facet Joint injections
Surgical management of back pain?
- Decompression
- Prolapse surgery
What are the neurosurgical emergencies?
- Acute Cord Compression
- Acute Cauda Equina Compression
What is acute cord compression going to present with?
- Bilateral pain: Back and radicular
- LMN Signs at compression level
- UMN sign and sensory level below compression
- Sphincter disturbance
What is acute cauda equina compression going to present with?
- Alternating or bilateral radicular pain in the legs
- Saddle anaesthesia
- Loss of anal tone
- Bladder ± bowel incontinence.
How do you manage neurosurgical emergencies?
Large prolapse: laminectomy/discectomy
Tumour: radiotherapy and steroids
Abscesses: Decompression
What is the definition of osteoarthritis?
- Degenerative joint disorder in which there is progressive loss of hyaline cartilage
Aetiology/Risk factors of osteoarthritis?
- Age (80% >75yrs)
- Obesity
- Joint abnormality
What is the pathophysiology of osteoarthritis?
- MMP catalyse break down of collagen + cartilage.
- Resulting bone remodelling + subchrondral bone lesion, synovial inflammation.
What is the classification of osteoarthritis?
- Primary: no underlying cause
- Secondary: obesity, joint abnormality.
What are the symptoms of osteoarthritis?
- Affects: knees, hips, DIPS, PIPs, thumb CMC.
- Pain: worse with movement, background rest/night pain, worse @ end of day.
- Stiffness: especially after rest, lasts ~30 mins (eg AM).
- Deformity
- Decreased ROM
What are the signs of osteoarthritis in the hands?
- Bouchard’s (prox) and Heberden’s nodes (distal).
- Thumb CMC squaring.
- Fixed Flexion Deformity
History and investigations for OA?
- Focus on ADLs and social circumstances
- X-ray
Differentials for OA?
- Septic
- Crystal
- Trauma
What is the conservative management of Osteoarthritis?
- Decreased weight
- Alter activities: increase rest, decreased sport
- Physio
- Walking aids, supportive footwear, home mods
What is the medical management of osteoarthritis?
Analgesia
- 1st line: Paracetamol
- 1st line: Topical NSAIDs e.g arthrotec (diclofenac + omeprazole/misoprostol ( which can cause diarrhoea). Topical is for hands and feet.
2nd line: Normally for hip give oral NSAIDs. Also opiods such as Tramadol, capsaicin cream and then intra-articular steroids.
Joint injections: Intra-articular Local anaesthetic and steroids.
What is the surgical management of osteoarthritis?
- Arthroscopic washout: esp knee. Trim cartilage, remove foreign body.
Options for Thumb OA
- Arthroplasty: replacement (or excision)
- Osteotomy: small area of bone cut out
- Arthrodesis: last resort for pain management (fusion of joints for pain management)
What is the pathophysiology of septic arthritis?
Source: local or haematogenous Organisms: - Staph Aureus: commonest overall (60%) - Gonococcus: commonest in young sexually active - Strep pneumo/ - Gm -ve bacilli. (neisseria) - Haemophilus
What are the risk factors for Septic Arthritis?
- Joint Disease (e,.g RA)
- Chronic renal failure
- Immunosuppression (DM)
- Prosthetic joints
Symptoms of Septic Arthritis?
- Acutely inflamed tender, swollen joint
- Decreased ROM
- Systemically unwell
Investigations for Septic Arthritis?
Joint Aspiration for MCS
- Increased WCC (e.g >50,000/mm): mostly PMN
Bloods:
- Increased ESR/CRP, Increased WCC, Blood cultures
- X-ray (degenerative changes)
Management of Septic Arthritis?
Urgent review by orthopaedics. This is for urgent aspiration and consideration of a washout.
- Gram +ve = IV Abx: Vanc and cefotaxime (or Clinda)
- Gram -ve = Cephalosporin/Gentamicin
If confirmed SA or strep = IV flucloxacillin
Antibiotic normally given for 6-12 weeks.
Consider joint washout under GA or aspiration.
Splint joint + physiotherapy after infection resolved/
Complications of septic arthritis?
- Osteomyelitis
- Arthritis
- Ankylosis: fusion
Differentials for septic arthritis?
- Crystal Arthropathy
- Reactive arthritis (TB).
What is rheumatoid arthritis?
- Chronic systemic inflammatory disease characterised by a symmetrical, deforming, peripheral polyarthritis.
What is the epidemiology of RA?
Prev: 1% (increased in smokers)
- Sex: F>M = 2:1
- Age: 5th - 6th decade
- Genetics: HLA-DR4/DR1 linked.
What the features of Rheumatoid Arthritis?
ANTI CCP Or RF
Arthritis
Nodules
Tenosynovitis
Immune
Cardiac
Carpal Tunnel Syndrome
Pulmonary
Ophthalmic
Raynaud’s
Felty’s Syndrome
What are the features of the arthritis in rheumatoid arthritis
- Symmetrical, polyarthritis of MCPs, PIPs of hands and feet
- -> pain, swelling, deformity.
- Swan Neck (DIP flex with PIP hyperextension)
- Boutonniere (PIP extended) and DIP hyperextension.
- Z-thumb (hyperextension of interphalangeal joint, fixed flexion + subluxation of MCP joint)
- Ulnar deviation of fingers + Radial deviation at wrist
- Dorsal Subluxation of ulnar styloid
- Morning stiffness for >1hr
- Improves with exercise
- Larger joints may become involved
What are the nodules in RA?
Commonly elbows also fingers, feet, heal.
- Firm, non-tender, mibile or fixed.
Also in lungs
What is tenosynovitis in RA?
Inflammation of fluid-filled sheath around nerves.
- De Quervain’s Tenosynoviitis (inflammation at wrist)
- Atlanto-axial subluxation
Carpal Tunnel Syndrome
What are the immune conditions associated with RA?
- AIHA
- Vasculitis
- Amyloid
- Lymphadenopathy
What are the cardiac features of RA?
Pericarditis + pericardial effusion
What are the pulmonary features of RA?
- Fibrosing Alveolitis (lower zones)
- Pleural effusions (exudates)
What are the ophthlamic features of RA?
Episcleritis
2nd Sjorgen’s Syndrome
What is Felty’s Syndrome
- RA + Splenomegaly + neutropenia
- Splenomegaly alone in 5%, Felty’s in 1%.
- Inflammatory response
Diagnosis of Rheumatoid Arthritis?
6/10 definite rheumatoid. 1 joint with definite clinical synovitis not explained by another disease.
Joint Distribution
- 1 large joint - 0 point
- 2-10 joint - 1 point
- 1-3 small joints (large joints excluded) - 2 points
- 4-10 small joints - 3 points
- > 10 joints (at least 1 small joint) - 5 points.
Serology
- Negative rheumatoid factor (RF) and negative anti-cyclic citrullinated peptide (anti-CCP) antibodies - 0 points
- Low positive RF or anti-CCP antibodies (≤3 x upper normal limit) - 2 points
- High positive RF or anti-CCP antibodies (>3 x upper normal limit) - 3 points.
Symptom duration
- <6 weeks - 0 points
- ≥6 weeks - 1 point.
Acute-phase reactants
- Normal CRP and erythrocyte sedimentation rate (ESR) - 0 points
- Abnormal CRP or ESR - 1 point.
What are the investigations for Rheumatoid arthritis?
- Bloods: FBC (anaemia, decreased PMN, increased platelets), increased ESR, Increased CRP.
- RF+ve (also in Hep C, chronic infections, Sjorgen’s, Felty’s, IE, SLE, SS)
High titre associated with severe disease, erosions and extra-articular disease - Anti-CCP: 98% specific
- ANA: +ve in 30%
- X-ray, US/MRI
Management of Rheumatoid Arthritis? Conservative
- Refer to rheumatologist
- Regular exercise
- PT
- OT: aids, splints
- Painkillers. Start patients on paracetamol, codeine) to reduce need for long-term treatment with NSAIDs or cyclo-oxygenase-2 inhibitors.
- Before surgery and has rheumatoid arthritis - Atlantoaxial sublucation - rare complication of RA but important as it can lead to cervical cord compression.
Management of Rheumatoid Arthritis? Medical
- DAS28: Monitor disease activity
- IN newly diagnosed active rheumatoid arthritis, NICE recommends that DMARDS started as soon as possible, with methotrexate, and an oral steroid.
- DMARDS and biologics: use early (Methotrexate, sulfasalzine) - Disease modifying antirheumatic drug.
- Steroids: IM, PO or intra-articular for exacerbations
(Avoid giving until seen by rheumatologist). Normally in combo with DMARDS.
Flares: Corticosteroids.
- Management in pregnancy, stop methotrexate, hydroxychloroquine is ok. Etanercept used for significant flare.
- NSAIDs: good for symptom relief (ibuprofen, naproxen, diclofenac)
- Mx CV risk: RA accelerates atherosclerosis.
Surgical management of rheumatoid arthritis?
- Ulna Stylectomy
- Joint prosthesis
Which drugs are first line for RA?
DMARDS
- Early DMARD use associated with better long-term outcome
- All DMARDs can –> myelosuppression –> pancytopenia.
What are the main DMARD drugs?
Methotrexate
Sulfasalazine
Hydroxychloroquine
(Leflunomide, gold, penicillamine).
Risks with biological agents
- Opportunistic infections: fungals, bacterial, viral
- Activation of latent TB ± progression to miliary TB
- Anaphylaxis
What are the side-effects of methotrexate?
Methotrexate is an antimetabolite.
Used in: Inflamamtory arthritis, rheumatoid arthritis, psoriasis, some chemotherapy.
SE: Hepatotoxic, pulmonary fibrosis. Mucositis, myelosuppression, liver fibrosis, pulmonary fibrosis.
Women should avoid pregnancy for at least 6 months. (RA gets better in pregnancy).
BNF also advises that men using methotrexate need to use effective contraception for at least 6 months after treatment
Prescribing methotrexate
- Drug with high potential for patient harm.
- Taken weekly
- FBC, U+E, LFTs need to be regularly monitored.
- Co-prescribe 5mg folic acid.
- Starting dose = 7.5mg.
Avoid - trimethroprim or co-trimoxazole can increase risk of marrow aplasia.
Don’t double up on your meth.
Folinic acid for toxicity.
What are the side-effects of sulfasalazine?
Hepatotoxic, SJS, azoospermia
What are the side-effects of hydroxychloroquine?
Retinopathy
Seizures
What are the side-effects of leflunomide?
Increased risk of infection and malignancy
What are the side-effects of gold?
Nephrotic syndrome
What are the side-effects of pencillamine?
Drug-induced lupus
Taste change
When do you use biologicals in RA?
Anti-TNF
- Severe RA not responding to DMARDs
- Screen and Rx TB first.
Which anti-TNF biologics are used?
- Infliximab
- Etanercept
- Adalimumab
- SE: increased infection
- (Sepsis, TB), increased AI disease, increased cancer.
What does infliximab target?
Chimeric anti-TNF Ab
What does Etanercept target?
TNF-receptor. It is a TNF-alpha inhibitor which may reactive TB.
What does Adalimumab target?
Human anti-TNF Ab
What other biologicals do you know?
- Rituximab - Anti-CD20 mAB. B cell modulator. = Severe RA not responding to anti-TNF therapy
- IL-6 inhibitor - Tocilizumab and sarilumab.
- Baricitinab/Tofacitinib (Janus Kinase inhibitor).
What is the anatomy of a Boutonierre’s rupture?
- Rupture of central slip of extensor expansion –> PIP prolapses through ‘button-hole’ created by two lateral slips.
What is the anatomy of Swan neck deformity?
- Rupture of lateral slips - PIPJ hyperextension.
What are the differentials for rheumatoid hands?
- Psoriatic arthritis: nail changes and plaques. Beta-blockers makes psoriasis worse.
- Jaccoud’s arthropathy: Reducible in extension
- Chronic Crystal arthritis.
What is the pathophysiology of gout?
- Syndrome of hyperuricaemia + urate crystals.
- Deposition of monosodium urate crystals in and around joints –> Erosive arthritis.
What is the presentation of Gout?
M>F = 5:1
1) Acute monoarthritis with severe joint inflammation
- 60% occur @ great toe MTP = Podagra. (can also form at the ankle, foot, hand joints, wrist, elbow and knee).
Most likely to affect the MTP!!
2) Asymmetric oligoarthritis
Urate deposits in pinna and tendons (tophi).
Renal disease: leads to radiolucent stones and interstitial nephritis.
What are the differentials for gout?
- Septic arthritis
- Pseudogout
- Haemarthrosis
What are the causes of gout?
- Hereditary
- Drugs: diuretics, NSAIDs, cytotoxics, pyrazinamide
- decreased excretion: primary gout, renal impairment
- Increased cell turnover: lymphoma, leukaemia, psoriasis, haemolysis, tumour lysis syndrome
- ETOH excess
- Purine rich foods: beef, pork, lamb, seafood.
What are the associations of gout?
HTN
IHD
Metabolic Syndrome
What are the investigations for Gout?
- Arthrocentesis with synovial fluid: Polarised light microscopy = Negatively birefringent needle-shaped crystals.
- Increased serum urate (may be normal). Normally uric acid >450)
- X-ray changes occur late
Punched-out erosions in juxta-articular bone.
Decreased joint space.
What is the ACUTE management of gout?
NSAIDs: diclofenac or indomethacin
Colchicine: used when NSAIDS and COX-2 inhibitors are contraindicated. (chronic renal failure, HF, warfarin due to risk of bleeding).
In renal impairment: NSAIDs and colchicine are CI –> Use steroids.
Colchicine = diarrhoea side-effect. Makes you run before you can walk.
What treatments are used for the prevention of gout?
Conservative
- Weight loss
- Avoid prolonged fasts and ETOH excess. (high purine foods such as liver, kidney, seafood oily fish, yeast products).
Xanthine Oxidase Inhibitors: Allopurinol
- Use if recurrent attacks tophi or renal stones (>= 2 attacks in 12 months, tophi, renal disease, uric acid renal stones).
- If patient is already on allopurinol they should continue to take it at the same dose during acute episodes.
- Introduce with NSAIDs or Colchicine cover for 3/12.
SE: rash, fever, decreased WCC (with azathiprine).
Allo and Aza
S and S
Meth and Meth
- 2nd line Can also use Febuxostat if hypersensitivity
Uricosuric drugs: probenecid, losartan (rarely used)
Recombinant urate oxidase: rasburicase
- May be used pre-cytotoxic therapy.
What is pseudogout?
acutely presents with acute monoarthropathy
- usually knee, wrist or hip.
- Usually spontaneous and self-limiting.
Chronically -
- Can be destructive like OA
- Can present as poly-arthritis (pseudo-rheumatoid)
Can mimic OA or RA
What are the risk factors of pseudogout?
Calcium Pyrophoshate crystals.
Hereditary haemochromatosis - Important Acromegaly Increased Age OA DM Hypothyroidism Hyperparathyroidism Wilson's disease
What are the investigations of pseudogout?
- Arthrocentesis with synovial fluid analysis- polarised light microscope = positively birefringent rhomboid-shaped crystals.
- X-ray of affected joints may show chondrocalcinosis (Soft-tissue Ca deposition in the knee cartilage) which differentiates it from gout.
- Bloods: Calcium, PTH.
Management of pseudogout?
Analgesia
NSAIDs
May try steroids: PO, IM or intra-articular.
What are the seronegative spondyloarthropathies?
- Group of inflammatory arthritidies affecting the spine and peripheral joints without production of RF and associated with HLA-B27 allele.
What are the common features of the seronegative spondyloarthropathies?
- Axial arthritis and sacroiliitis
- Asymmetrical large-joint oligoarthritis or monoarthritis
- Enthesitis
- Dactylitis
- Extra-articular: iritis, psoriasiform rashes, oral ulcers, aortic regurg, IBD.