Rheumatology : Key Conditions Flashcards
Reactive Arthritis
- Presentation
Triad of arthritis, urethritis and conjunctivitis.
- peripheral arthritis 1-4 weeks after infection, commonly an asymmetrical oligoarthritis but may be polyarticular/ monoarticular, usually affecting larger joints in lower limb
- Axial arthritis
- recently had a viral or bacterial infection (STI common)
- no direct infection in the joint, but it can cause symmetric hand and feet arthritis.
Extra-articular features of Reactive Arthritis (3)
Constitutional symptoms
Enthesitis:Achilles tendonitis or plantar fasciitis
Painless mucosal ulcers
Dark maculopapular rash on palms and soles called keratoderma blenorrhagica
Ocular inflammation: conjunctivitis and anterior uveitis
Urethritis and sterile dysuria, inflammation of bladder and prostate may cause cystitis and prostatitis
Circinate balanitis (painless ulceration of glans)
Aphthous ulcers in the mouth
Anterior uveitis
Erythema nodosum
Reactive Arthritis
- Investigations and Mx
Bedside
- stool MC&S and urethral / cervical swabs for chlamydia.
Blood tests
CRP , ESR
Seronegative
HLA-B27- supportive only
Imaging
Joint X-rays usually appear normal and changes are only seen in severe, chronic disease.
Pelvic X-rays may show sacroiliitis, and spinal X-rays may show squaring of vertebrae and syndesmophytes creating a “bamboo spine”, as in ankylosing spondylitis.
Treatment
- NSAIDs
- possibly corticosteroid injections.
- severe subset may require DMARDs to prevent joint damage.
How is a diagnosis of limited cutaneous systemic sclerosis made?
Anti-centromere antibodies (90%)
- specific to limited cutaneous SSc.
- Note: Most patients are ANA positive
How is a diagnosis of diffuse systemic sclerosis made?
Anti-Scl-70 antibodies
- specific to diffuse cutaneous SSc.
- Note: Most patients are ANA positive
Diffuse systemic sclerosis
- Multi-system autoimmune disease
- Skin involvement is over widespread areas at onset and is characterised by early visceral involvement.
Limited (cutaneous) systemic sclerosis
- Features
Skin fibrosis is limited to the hands and forearms, feet and legs, and the head and neck.
CREST Calcinosis Raynaud's oEsophageal dysmotility Sclerodactyly Telangiectasia.
Rare complication of systemic sclerosis
Scleroderma renal crisis
Initial Mx- Captopril
- worsening kidney failure and high BP
- ACEi to reduce BP
Risk factors for pseudogout
Advanced age
Injury or previous joint surgery
Hyperparathyroidism
Haemochromatosis
Hypomagnesaemia
Hypophosphataemia
Microscopy findings in Pseudogout
Positively berefringent romboid shaped crystals made of calcium pyrophosphate
Treatment for acute episodes of pseudogout
(1) Treatment is usually with a course of NSAIDs.
(2) If NSAIDs are contraindicated, a course of colchicine may be used instead. Colchicine is problematic because it is very prone to causing significant GI disturbances, especially diarrhoea.
(3) If both NSAIDs and colchicine are contraindicated, a short course of oral steroids, or an intra-articular steroid injection may be used.
Specific antibodies for Sjogrens
Anti-Ro and Anti-La Autoantibodies are both specific for Sjogren’s syndrome.
What test can aid in the diagnosis of Sjogrens?
Schirmer’s test - this demonstrates reduced tear production using a strip of filter paper on the lower eyelid: wetting of <5mm is positive.
Acute management lupus nephritis
- High dose prednisolone
- Cyclophosphamide (fertility issues)
Common organisms in septic arthritis
The most common organism that causes septic arthritis is Staphylococcus Aureus.
Gonococcus: commonest in young sexually active individuals
Streptococcus
Gram negative bacilli
Septic arthritis
- Ix and Management
Ix
- Joint aspiration for Microscopy Culture and Sensitivity. The fluid itself will appear turbid and yellow, resembling pus.
Blood tests show: high white cells, high ESR/CRP
Blood cultures
X-ray of the joint
Management
IV antibiotics according to local guidelines
Considering joint washout under general anaesthetic
Physiotherapy after acute infection resolves
Management of acute gout
- NSAIDs first line (indomethacin)
- if renal impairment- then steroids (as NSAIDs and colchicine contrainidicated)
Allopurinol should be commenced at a low dose at least 2 weeks following an attack.
Rheumatoid arthritis
- Presentation
- Specific antibody
anti-CCP
It tends to present as a symmetrical polyarthritis affecting the proximal interphalangeal joints
What is swan neck finger deformity?
MCP flexion, PIP hyperextension, DIP hyperflexion
What is Boutonniere finger deformity?
PIP flexion, DIP hyperextension
Name 4 risk factors for osteoporosis
Corticosteroid therapy
Alcohol excess
Early menopause
RA
Initial treatment for PMR
Oral prednisolone
Management of osteoarthritis
- Dietary and lifestyle/supportive interventions
- Paracetamol and topical NSAIDs (knee/hand OA only)
- second-line treatment is oral NSAIDs/COX-2 inhibitors, opioids, capsaicin cream and intra-articular corticosteroids. (+PPI)
What is the MOA of capsaicin?
Works by depleting substance P if used regularly
Name 2 examples of COX-2 inhibitors?
etoricoxib
celecoxib
What is Takayasu’s arteritis?
Chronic granulomatous vasculitis affecting large arteries: primarily the aorta and its main branches.
Takayasu’s arteritis
- Presentation
- Diagnosis
- Management
- Absent upper extremity pulse
- discrepancy in blood pressure between the arms (>10 mm Hg)
- constitutional symptoms, arthritis, myalgia, skin nodules, visual defects, and stroke.
- Vascular examination reveals abnormalities in the peripheral pulses, bruits over the central pulses, and there may be aortic regurgitation suggestive of aortic root dilation.
Diagnosis is made by vascular imaging.
Mx- Steroids
Henoch-Schonlein purpura
- Small vessel vasculitis that usually affects children.
- IgA mediated often triggered by viral URTI
- triad of purpura over the extensor surfaces of the lower limb, abdominal pain and arthritis.
Microscopic polyangiitis
- ANCA associated vasculitis
- Typically affects middle aged people
- tiredness, loss of appetite, joint and muscle aches
- raised pANCA
Churg-Strauss syndrome
- ANCA associated vasculitis
- raised pANCA
- respiratory symptoms
Granulomatosis with polyangiitis
- ANCA associated vasculitis
- positive cANCA and pANCA
- It is also more common in middle aged/older patients and usually affects the ears, nose, sinuses, kidneys and lungs.
Antiphospholipid syndrome
prolonged APTT + low platelets
Features Features venous/arterial thrombosis recurrent fetal loss livedo reticularis thrombocytopenia prolonged APTT other features: pre-eclampsia, pulmonary hypertension
Mx primary thromboprophylaxis low-dose aspirin secondary thromboprophylaxis initial venous thromboembolic events: lifelong warfarin with a target INR of 2-3
