Rheumatology Conditions A Flashcards
Osteoarthritis - Description
mechanical degeneration of synovial joint articular cartilage
Osteoarthritis - Risk Factors (9)
1) >50 years old
2) female
3) genetic (50%)
4) obesity
5) diabetes mellitus
6) inflammatory arthritis
7) trauma
8) occupation
9) joint hypermobilility
Osteoarthritis - Pathophysiology (6)
1) progressive articular cartilage degradation (many causes)
2) exposed underlying bones damage
3) increased osteoblast bone synthesis (repair mechanism)
4) subarticular sclerosis (bone overgrowth around articular surface)
5) osteophytes (calcified bone overgrowth at joint margins)
Osteoarthritis - Symptoms (5)
1) progressive joint pain (esp. after activity)
2) joint stiffness (esp. after rest, <30 mins in morning)
3) limited joint movement
4) crepitus (crunching sensation when moving joint)
5) tenderness around joint
Osteoarthritis - Signs (4)
1) Bouchard’s nodes (PIPJ bone swelling)
2) Herberden’s nodes (DIPJ bone swelling)
3) joint effusion (increased intra-articular fluid)
4) surrounding muscle wasting
Osteoarthritis - Investigations (2/3)
initial
1) joint x-ray (LOSS, loss of joint space, osteophytes, subchondral cysts, subchondral sclerosis)
2) normal CRP + ESR (exclude RA)
consider
1) joint MRI
2) rheumatoid factor (negative, exclude RA)
3) anti-CCP (negative, exclude RA)
Osteoarthritis - Management (6/1/3)
conservative 1) regular exercise 2) weight loss 3) hot/cold packs 4) joint braces 5) joint supports 6) insoles medical 1) analgesia surgery 1) joint replacement (hip, knee) 2) osteotomy (change bone shape) 3) arthrodesis (joint immobilisation) (unmanageable pain)
Osteoarthritis - Management (Analgesia) (4)
1) paracetamol ± TOP NSAID
2) NSAID + PPI
3) codeine
4) IA corticosteroid (short term severe symptoms)
Rheumatoid Arthritis - Description
chronic systemic autoimmune inflammation that affects joints (synovium)
Rheumatoid Arthritis - Risk Factors (6)
1) 40-55 years old
2) female (2:1)
3) family history
4) genetic (HLA-DR1, HLA-DR4)
5) infection (e.g. gingivitis)
6) smoking
Rheumatoid Arthritis - Pathophysiology (9)
1) environmental trigger (e.g. smoking)
2) citrullination (arginine —> citrulline) of proteins (e.g. type 2 collagen)
3) genetic susceptibility (e.g. HLA-DR1)
4) citrullinated proteins no longer recognised as self-antigens
5) autoimmune reaction to citrullinated proteins (anti-CCP)
6) overproduction of inflammatory cytokines in joints
7) synovium proliferates forming pannus (thick swollen synovial membrane with granulation tissue)
8) articular cartilage degeneration due to pannus
9) underlying bones are exposed and damage (bony erosions)
Rheumatoid Arthritis - Symptoms (9)
1) joint pain (esp. MCP, PIP, MTP
2) joint stiffness (esp. in cold, >1 hour in morning)
3) joint tenderness (esp. MCP, PIP, MTP)
4) joint swelling (esp. MCP, PIP, MTP)
5) joint erythema (esp. MCP, PIP, MTP)
6) joint warmth (esp. MCP, PIP, MTP)
systemic
1) fatigue
2) fever
3) weight loss
Rheumatoid Arthritis - Signs (6)
1) ulnar deviation (swelling of MCPJ causes fingers to drift towards little finger)
2) Z thumb deformity (MCPJ hyperextension, PIPJ flexion)
3) swan neck deformity (PIPJ hyperextension, DIPJ flexion)
4) Boutonniere’s deformity (PIPJ flexion, DIPJ hyperextension)
5) rheumatoid nodules (esp. elbows)
6) surrounding muscle wasting
Rheumatoid Arthritis - Complications (9)
1) frozen shoulder
2) neuropathies (e.g. carpal tunnel syndrome)
3) tenosynovitis
4) pleural disease (inc. pleural effusion)
5) pericarditis
6) ischaemic heart disease
7) vasculitis
8) scleritis
9) osteopenia—>osteoporosis
Rheumatoid Arthritis - Investigations (5/2)
initial 1) joint x-ray (periarticular erosions: early—>soft tissue, late—>joint space loss, later—>bone) 2) high CRP + ESR* 3) rheumatoid factor* (70% positive) 4) anti-CCP* (70% positive) 5) FBC (anaemia, leucocytosis) consider 1) joint MRI 2) joint ultrasound
Rheumatoid Arthritis - Diagnosis (5/3/2/2)
≥6 = diagnosis joints 1) 1 large joint = 0 2) 2-10 large joints = 1 3) 1-3 small joints = 2 4) 4-10 small joints = 3 5) >10 small joints = 4 serology 1) negative RF + anti-CCP = 0 2) low positive RF or anti-CCP = 2 3) high positive RF or anti-CCP = 3 inflammation 1) normal CRP + ESR = 0 2) high CRP or ESR = 1 duration 1) <6 weeks = 0 2) >6 weeks = 1
Rheumatoid Arthritis - Management (4/4/2)
conservative
1) regular exercise
2) weight loss
3) smoking cessation
4) physiotherapy
medical
1) DMARDs (e.g. methotrexate*, sulfasalazine)
2) IM, PO, IA corticosteroids (short term symptomatic flares)
3) NSAID
4) biological agent (e.g. TNF-αi infliximab)
surgery
1) synovectomy (reduce inflamed tissue bulk)
2) arthroplasty (severely affect joints)
Gout - Description
inflammatory arthritis due to intra-articular monosodium urate crystals
Gout - Causes (1)
1) hyperuricaemia
Gout - Risk Factors (Decreased Urate Excretion) (8)
90%
1) elderly
2) male (4:1)
3) post-menopausal
4) diabetes mellitus
5) hypertension
6) kidney disease
7) thiazide diuretic
8) aspirin
Gout - Risk Factors (Increased Urate Production) (5)
10%
1) alcohol (esp. beer)
2) purine rich foods (e.g. red meat)
3) sweeteners
4) lymphoproliferative disorders (e.g. ALL)
5) myeloproliferative disorders (e.g. CML)
Gout - Precipitants (5)
1) heavy meal
2) heavy drinking
3) cold
4) trauma
5) infection
Gout - Symptoms (5)
1) rapid onset severe joint pain (esp. 1st MTP, big toe >50%)
2) joint tenderness
3) joint swelling
4) joint erythema
5) joint warmth
Gout - Signs (2)
1) tophi (aggregates of monosodium urate crystals that form nodules in joints, esp. elbows, knees)
2) few joints affected (usually <4)
Gout - Complications (3)
1) osteoarthritis
2) nephrolithiasis
3) kidney disease
Gout - Investigations (1/3)
initial
1) joint fluid aspiration + microscopy (negatively bifringent crystals)
consider
1) serum uric acid (high, 2 weeks after attack)
2) joint x-ray (punched-out periarticular erosions)
3) joint ultrasound
Gout - Management (4/5/0)
conservative 1) dietary advice (avoid purine rich foods, eat dairy) 2) weight loss 3) alcohol control 4) monitor RFT medical 1) NSAID (high dose) + PPI 2) colchicine (NSAID intolerant) 3) IM, PO, IA corticosteroids 4) allopurinol (3 weeks after attack) 5) replace thiazide diuretics with ARBs
Pseudogout - Description
inflammatory arthritis due to intra-articular calcium pyrophosphate crystals
Pseudogout - Risk Factors (7)
1) old age
2) female
3) hyperparathyroidism
4) haemochromatosis
5) diabetes mellitus
6) oestoarthritis
7) joint trauma
Pseudogout - Symptoms (6)
1) rapid onset severe joint pain (esp. wrist, knee)
2) joint tenderness
3) joint swelling
4) joint erythema
5) joint warmth
6) fever
Pseudogout - Investigations (2/4)
initial
1) joint fluid aspiration + microscopy* (positively birefringent crystals)
2) joint fluid aspiration + culture (exclude septic arthritis)
consider
1) joint x-ray (chondrocalcinosis - linear calcification parallel to articular surfaces)
2) FBC (leucocytosis)
3) UnE (exclude hyperparathyroidism)
4) iron studies (exclude haemochromatosis)
Pseudogout - Management (0/4/2)
medical 1) NSAID (high dose) + PPI 2) colchicine (NSAID intolerant) 3) IM, PO, IA corticosteroid 4) paracetamol surgery 1) joint fluid aspiration 2) joint replacement
Osteoporosis - Description
decreased bone density
Osteoporosis - Risk Factors (10)
1) >50 years old (female)
2) >65 years old (male)
3) female
4) family history
5) Caucasian
6) Asian
7) smoking
8) alcohol
9) steroids
10) low BMI (<19)
Osteoporosis - Symptoms (2)
1) vertebral pain
2) vertebral tenderness
Osteoporosis - Signs (1)
1) increased kyphosis (abnormally outwardly curved thoracic spine)
Osteoporosis - Complications (1)
1) fracture (wrist, spine, hip)
Osteoporosis - Investigations (5/0)
initial
1) x-ray (fracture, not osteopenia)
2) dual absorption x-ray absorptiometry (DEXA) scan* (T score<2.5)
3) serum Ca2+ (normal)
4) serum PO43- (normal)
5) serum ALP (normal)
Osteoporosis - Management (6/3/0)
conservative
1) dietary advice (high dietary calcium, vitamin D intake)
2) weight bearing exercise
3) balance exercise
4) home fall prevention (inc. home visits)
5) smoking cessation
6) alcohol control
medical
1) bisphosphonates (1st line)
2) calcium supplement (e.g. calcium carbonate)
3) vitamin D supplement (e.g. ergocalciferol)
Ankylosing Spondylitis - Description
spine and sacroiliac joint sclerosis and immobility due to new bone formation caused by chronic inflammation
Ankylosing Spondylitis - Risk Factors (5)
1) 15-30 years old
2) male (more severe)
3) HLA-B27
4) Native American
5) Klebsiella pneumoniae
Ankylosing Spondylitis - Pathophysiology (3)
1) inflammation of enthesis (site of ligament attachment to bone)
2) enthesitis heals with sclerosis and new bone formation (syndesmophytes)
3) fusion of vertebral bodies
Ankylosing Spondylitis - Symptoms (7)
1) sacroiliac joint pain (radiates to hips/buttocks, better at night)
2) progressive lower spinal pain (worse at night, relieved by exercise)
3) progressive spinal stiffness (relieved by exercise)
4) progressive limited spinal movement (frontal, sagittal)
5) sleep disturbances
6) fatigue
7) dyspnoea (kyphotic or costochondral joint)
Ankylosing Spondylitis - Signs (4)
1) decreased thoracic expansion
2) decreased lordosis (abnormally straight cervical and lumbar spine)
3) increased kyphosis (abnormally outwardly curved thoracic spine)
4) Schober’s test
Ankylosing Spondylitis - Complications (5)
1) enthesitis (e.g. Achilles tendonitis, plantar fasciitis)
2) iritis/uveitis
3) aortitis —> aortic regurgitation
4) osteoporosis
5) anaemia
Ankylosing Spondylitis - Investigations (3/3)
initial
1) MRI (sacroiliitis, bone marrow oedema)
2) pelvic x-ray (sacroiliitis, sacroiliac joint margin erosion/sclerosis)
3) cervical, thoracic, lumbar x-ray (bamboo spine, sacroiliac joint margin erosion/sclerosis, syndesmophytes)
consider
1) FBC (normocytic anaemia)
2) high CRP + ESR
3) rheumatoid factor (negative)
Ankylosing Spondylitis - Management (3/4/2)
conservative 1) regular exercise 2) good posture 3) physiotherapy medical 1) NSAID 2) analgesia (e.g. paracetamol, codeine) 3) IA corticosteroid (short term severe symptoms) 4) TNF-αi (refractory, severe) surgery 1) hip replacement 2) spinal osteotomy
Psoriatic Arthritis - Description
chronic autoimmune inflammatory joint disease associated with psoriasis
Psoriatic Arthritis - Risk Factors (3)
1) psoriasis
2) HLA-B27
3) family history
Psoriatic Arthritis - Patterns (5)
1) asymmetrical oligoarticular - <5 joints (esp. weight bearing)
2) symmetrical polyarticular - >5 joints (esp. small joints) (RA like)
3) spondylarthritis - sacroiliac joints and cervical spine (AS like)
4) distal interphalangeal predominate - DIP joints
5) arthritis mutilans - DIP joints (severe)
Psoriatic Arthritis - Symptoms (5)
1) joint pain
2) joint swelling
3) joint stiffness
4) joint erythema
5) joint warmth
Psoriatic Arthritis - Signs (3)
1) dactylitis (DIP, AM)
2) nail abnormalities (e.g. ringing, pitting) (DIP, AM)
3) telescoping fingers (bone resorption collapses finger soft tissue) (AM)
Psoriatic Arthritis - Complications (1)
1) cardiovascular conditions
Psoriatic Arthritis - Investigations (6/0)
initial
1) joint x-ray* (erosion) (AO, SP)
2) pelvic, spinal x-ray (sacroiliitis, syndesmophytes) (SA)
3) hand, feet x-ray (DIP ‘pencil in cup’ erosion) (DIP, AM)
4) normal CRP + ESR
5) rheumatoid factor (negative)
6) anti-CCP (negative)
Psoriatic Arthritis - Management (1/4/2)
conservative
1) physiotherapy
medical
1) DMARD (e.g. methotrexate, sulfasalazine)
2) NSAID
3) IA corticosteroid (short term severe symptoms)
4) TNF-αi (e.g. infliximab) (refractory, severe)
surgery
1) hip replacement
2) joint replacement
Reactive Arthritis - Description
acute inflammatory arthritis post GI or GU infection
Reactive Arthritis - Causes (5)
GI 1) Salmonella 2) Shigella 3) Campylobacter GU 4) Gonorrhoea 5) Chlamydia
Reactive Arthritis - Risk Factors (3)
1) 20-40 years old
2) male
3) HLA-B27
Reactive Arthritis - Symptoms (8)
large joints asymmetrical (esp. sacroiliac, knees, ankles) 1) joint pain 2) joint swelling 3) joint stiffness 4) joint erythema 5) joint warmth systemic 1) fever 2) fatigue 3) weight loss
Reactive Arthritis - Signs (1)
1) dactylitis
Reactive Arthritis - Complications (6)
1) conjunctivitis
2) uveitis
3) urethritis
4) cervicitis
5) enthesitis
6) secondary osteoarthritis
Reactive Arthritis - Investigations (6/0)
initial
1) stool culture (gen. negative unless tested very early)
2) urine culture (gen. negative unless tested very early)
3) high CRP + ESR
4) rheumatoid factor (negative)
5) anti-CCP (negative)
6) x-ray (chronic - sacroiliitis, enthesitis)
Reactive Arthritis - Management (3/4/0)
conservative 1) screen sexual partners 2) rest 3) splint medical 1) antibiotics 2) NSAID 3) IA corticosteroid (short term severe symptoms) 4) DMARD (chronic, >6 months)
Septic Arthritis - Description
acute inflammatory arthritis due to joint infection (medical emergency)
Septic Arthritis - Causes (5)
1) Staphylococcus aureus
2) Streptococci
3) Neisseria gonorrhoea
4) Haemophilus influenzae
5) Escherichia coli
Septic Arthritis - Risk Factors (7)
1) osteoarthritis
2) rheumatoid arthritis
3) prosthetic joint
4) IA corticosteroid
5) IV drug abuse
6) diabetes mellitus
7) alcohol
Septic Arthritis - Symptoms (7)
1) joint pain (agonising in young, muted in old)
2) joint swelling
3) joint tenderness
4) joint erythema
5) joint warmth
6) loss of joint function
7) fever
Septic Arthritis - Complications (2)
1) joint destruction
2) osteomyelitis
Septic Arthritis - Investigations (4)
initial
1) blood culture (identify bacteria)
2) joint fluid aspiration + stain, culture (identify bacteria)
3) joint fluid aspiration + microscopy (exclude gout/pseudogout)
4) high CRP + ESR (CRP may be normal)
Septic Arthritis - Management (3/4/1)
conservative 1) monitor CRP + ESR 2) joint immobilisation 3) physiotherapy medical 1) stop DMARDs + TNFαi 2) double corticosteroid dose 3) IV antibiotics (2 weeks) (after fluid aspiration) 4) NSAID surgery 1) joint drainage
Osteomyelitis - Description
infection of bone and/or bone marrow
Osteomyelitis - Causes (5)
1) Staphylococcus aureus (90%)
2) Streptococci
3) Pseudomonas
4) Escherichia coli
Osteomyelitis - Risk Factors (5)
1) trauma (penetrating)
2) surgery (contamination)
3) IV drug abuser
4) diabetes mellitus
5) peripheral vascular disease
Osteomyelitis - Routes (3)
1) direct (e.g. trauma, surgery) - common
2) contiguous (e.g. DM, PVD)
3) haematogenous (skin—>blood—>bone) - rare
Osteomyelitis - Symptoms (9)
1) dull pain at infection site
2) infection site swelling
3) infection site tenderness
4) infection site erythema
5) infection site warmth
6) fever
7) fatigue
8) malaise
9) draining sinus tracts (chronic)
Osteomyelitis - Complications (3)
1) septic arthritis
2) fracture
3) growth retardation
Osteomyelitis - Investigations (3/3)
initial 1) FBC (leucocytosis - acute) 2) high CRP + ESR 3) x-ray (osteopenia) consider 1) bone MRI (marrow oedema) 2) bone marrow biopsy* 3) bone marrow culture*
Osteomyelitis - Management (2/1/1)
conservative 1) monitor CRP + ESR 2) limb immobilisation medical 1) antibiotics (high dose) surgery 1) surgical debridement
Systemic Lupus Erythematosus - Description
multisystemic inflammatory autoimmune disorder
Systemic Lupus Erythematosus - Risk Factors (7)
1) 20-40 years old
2) female
3) family history
4) African/Asian descent in West
5) genetics
6) drugs (e.g. hydralazine, penicillamine)
7) smoking
Systemic Lupus Erythematosus - Pathophysiology (7)
1) inefficient phagocytise removal of apoptotic cellular remnant bless
2) blebs transferred to lymphoid tissue
3) normally hidden nuclear antigens are recognised as foreign
4) antigens stimulate production of autoantibodies
5) autoantibodies either circulate or deposit in tissues
6) autoantibodies actuate complement system and neutrophil influx
7) multisystem inflammatory autoimmune disorder
Systemic Lupus Erythematosus - Symptoms (8)
1) arthralgia (RA like)
2) seizures
3) psychosis
systemic
4) fever
5) fatigue
6) weight loss
7) malaise
8) myalgia
Systemic Lupus Erythematosus - Signs (7)
1) butterfly erythema
2) photosensitive rash
3) discoid rash
4) oral ulcers
5) alopecia
6) vasculitic lesions
7) Raynaud’s pheno (digit colour change to red—>white—>blue due to artery spasm)
Systemic Lupus Erythematosus - Complications (7)
1) anaemia (chronic haemolytic)
2) pericarditis/myocarditis/endocarditis
3) cardiovascular disease
4) pleuritis/pleural effusion
5) nephritis
6) vasculitis
7) depression
Systemic Lupus Erythematosus - Investigations (7/1)
initial
1) anti-nuclear antibodies (95% positive)
2) anti-dsDNA antibodies (60% positive, highly specific) (confirmation)
3) anti-Smith antibodies (confirmation)
4) FBC (anaemia, leucopenia, thrombocytopenia)
5) normal CRP
6) high ESR
7) UnE (high urea, creatine)
consider
1) any test that confirms complications
Systemic Lupus Erythematosus - Monitoring (3)
1) anti-dsDNA antibodies
2) C3 + C4 levels
3) ESR
Systemic Lupus Erythematosus - Management (4/6/0)
conservative
1) monitor
2) high factor sunscreen
3) weight loss (CVD risk)
4) smoking cessation (CVD risk)
medical
1) hydroxychloroquine (arthralgia, fatigue, skin disease)
2) NSAID (arthralgia, fever)
3) PO/IM corticosteroid (arthralgia, serositis)
4) TOP corticosteroid (rash)
5) immunosuppressant (e.g. methotrexate, azarthioprine)
6) cyclophosphamide (neuropsychotic symptoms, nephritis)
