Rheumatology/ MSK Flashcards
RHEUMATOID ARTHRITIS
What is it?
- chronic systemic inflammatory disease with a symmetrical, deforming and peripheral polyarthritis
RHEUMATOID ARTHRITIS
Epidemiology between males and females pre and post menopausal?
PRE- F:M 3:1
POST- 1:1
RHEUMATOID ARTHRITIS
Aetiology?
Genetics- HLA-DR4 and HLA-DR1
Presence of rheumatoid factor- autoantibodies against Fc portion of IgG
RHEUMATOID ARTHRITIS
Pathology?
1) Lymphocytes and macrophages produce IL-1 and TNFalpha, releasing metalloproteinases that destroy cartilage
2) Proliferation and growing of synovium over the articular cartilage (known as pannus), destroys articular cartilage and subchondral bone producing bony erosions
RHEUMATOID ARTHRITIS
Features of Inflammatory?
1) Pain eases with use
2) Significant stiffness >60 min
3) Synovial +- bony soft swelling
4) Hot and red
5) Younger patients with possible family history
6) Hands and feet
7) Responds to NSAID’s
OSTEOARTHRITIS
Features of Degenerative?
1) Pain increases with use
2) <30 mins of stiffness; not prolonged
3) no swelling (maybe hard swelling)
4) Not inflamed
5) Older people, prior occupation/sport
6) Common in CMCJ, DIPJ and knees
7) Less response to NSAID’s
RHEUMATOID ARTHRITIS
Signs?
What are the late deformities?
- symmetrical painful and stiff small joints (MCP, PIP, MTP, wrist)
Nodules and neuropathy
Early= inflammation but no joint damage
Later= Deformities:
1) Ulnar deviation of fingers
2) Boutonnieres
3) z thumb (swan neck)
4) Swan neck
RHEUMATOID ARTHRITIS
Diagnosis?
bloods- Anaemia, rheumatoid factor +ve (70%), anti- CCP positive (90%), increased CRP, ESR, platelets
X-Rays 1) loss of joint space 2) Soft tissue swelling
3) Osteopenia next to cartilage 4) Joint deformity
RHEUMATOID ARTHRITIS
Treatment? (1st line, 2nd line and symptom and flare up relief)
1st - DMARDs (methotrexate, hydroxychloroquine)
2nd- biological agents alongside 1st line (infliximab, rituximab)
NSAIDs = symptom relief
Steroids (IM,IV) treat bad flare ups
OSTEOARTHRITIS
Risk factors and M:F RATIO?
1) Obesity
2) Age
3) Joint trauma
4) Active occupation
F:M 3:1
OSTEOARTHRITIS
What is the difference between primary and secondary
primary OA is generalised. Secondary is in joints that have already been damaged
OSTEOARTHRITIS
Signs?
1) Pain on movement and relieved by rest
2) Stiffness <30 mins
3) Crepitus present
4) bony swelling
5) 1st MCPJ and knees
6) Decreased RoM
OSTEOARTHRITIS
Diagnosis?
1) negative rheumatoid factor
2) X-Ray = LOSS
Loss of joint space
Osteophytes
Subchondral cysts
Subarticular sclerosis
OSTEOARTHRITIS
Treatment?
1) Physical management (padded shoes, stick, weight loss, brace)
1st- Paracetamol + topical NSAID
2nd- weak opioid and PO NSAID/PPI
OSTEOARTHRITIS
Treatment to relieve severe pain?
intra-articular steroids
OSTEOARTHRITIS
What if a patient works at night and has significant limitations of function?
consider surgery
OSTEOPOROSIS
What is the definition?
A bone density of >2.5 standard deviations below young adult mean
What is Osteopenia?
A bone density of between -1 and -2.5 standard deviations below young adult mean
OSTEOPOROSIS
Causes?
1) Increased bone loss
2) Inadequate peak adult bone mass
3) Women lose trabeculae with age
OSTEOPOROSIS
rISK FACTORS?
Steroids Hyperthyroidism Alcohol and smoking Thin BMI <22 Testosterone low Early menopause Renal/liver failure Erosive bone disease (RA) Dietary calcium low
OSTEOPOROSIS
Gold standard diagnosis?
DEXA scan- only needed for <75 years
OSTEOPOROSIS
Treatment? (lifestyle)
- cessation of smoking
- alcohol
- calcium/ vit D increase
- weight bearing exercise
OSTEOPOROSIS
Medical treatment?
1st- Bisphosphonates
2nd - strontium ranelate
3) Teriparatide
4th- denosumab
SYSTEMIC LUPUS ERYTHEMATOSUS
Epidemiology?
- Women aged 20-40
- F:M 9:1
- Afro-american
SYSTEMIC LUPUS ERYTHEMATOSUS
Pathogenesis?
1) Apoptotic cell fragments aren’t closed fully by phagocytes
2) Taken up by APC’s in lymphoid tissue
3) Self antigens presented to T cells, stimulates B cells
4) Increase in complement activation, immune complex deposition and neutrophils = CLINICAL MANIFESTATIONS
SYSTEMIC LUPUS ERYTHEMATOSUS
Symptoms and Signs? (by organ)
Skin - butterfly/ Malar rash, photosensitivity
MSK- myalgia, arthralgia
general- tired, malaise, fever
CVS- Raynaud’s & pericarditis
Blood- anaemia, thrombocytopenia, leukopenia
Renal- proteinuria
Neuro- Epilepsy, migraines, neuropathies
SYSTEMIC LUPUS ERYTHEMATOSUS
Diagnosis?
4 of the Signs
FBC= anaemia, thrombocytopenia, leukopenia
increased ESR and normal CRP = Lupus
low complement factors (C3&4)
presence of anti-nuclear antibody (ANA)
What does ESR stand for?
erythrocyte sedimentation rate
SYSTEMIC LUPUS ERYTHEMATOSUS
Treatment?
Major organ involvement= IV Cyclophosphamide
Just MSK manifestation= PO prednisolone
For rashes= topical steroids and avoid sun
Maintenance- NSAIDs, hydroxychloroquine, steroids, azathioprine/ methotrexate
ANTIPHOSPHOLIPID SYNDROME
What is it?
- Recurrent thromboses/ miscarriages
- Persistently negative blood tests for antiphospholipid antibodies
ANTIPHOSPHOLIPID SYNDROME
Cause?
C- Coagulation defect
L- Livedo reticulosis (lace-like purplish discoloration of the skin)
O- Obstetrics (miscarriage)
T- Thrombocytopenia
ANTIPHOSPHOLIPID SYNDROME
Features?
Arteries- stroke, TIA, MI
Veins- DVT
Miscarriages
ANTIPHOSPHOLIPID SYNDROME
Treatment?
No previous thromboses = Aspirin/Clopidogrel
Previous thromboses = Warfarin/ NOAC
Pregnant = Aspirin and Heparin
POLYMYOSITIS/ DERMATOMYOSITIS
What are they and what is the difference?
DERMATOMYOSITIS involves the skin
POLYMYOSITIS/ DERMATOMYOSITIS
What are they?
- Inflammation of muscle
- progressive symmetrical proximal muscle weakness
- autoimmune mediated striated muscle inflammation (myositis)
POLYMYOSITIS/ DERMATOMYOSITIS
Signs?
1) Proximal muscle wasting
2) Proximal muscle weakness
3) Macular rash
4) General (fever, malaise)
5) Arthralgia
6) Hard to move (e.g. off of a chair/ up the stairs)
POLYMYOSITIS/ DERMATOMYOSITIS
Specific dermatomyositis features?
purple eyelids and scaly red plaques on knuckles
POLYMYOSITIS/ DERMATOMYOSITIS
Tests?
- Muscle biopsy
- Electromyography
- Creatine Kinase increased
-Anti-JO antibodies (SPECIFIC)
POLYMYOSITIS/ DERMATOMYOSITIS
Treatment?
1st - PO prednisolone
2nd- Azathioprine/ methotrexate
SYSTEMIC LUPUS ERYTHEMATOSUS
Symptoms and Signs by the Pneumonic-
Serositis Oral ulcers Arthritis Photosensitivity Blood disorders (low RBC,WBC,Platelets) Renal disorders (lupus nephritis) Antinuclear Ab Immunological disorder (anti-dsDNA/ antiphospholipid Ab) Neurological disorder (cerebral lupus)
Malar rash- fixed erythema over malar eminence
Discoid rash - erythromatous raised patches with adherent keratotic scaling and scarring
GOUT
What is it and what is the male to female ratio?
Hyperuricaemia and intra articular sodium urate crystals
GOUT
How may hyperuricaemia occur?
(aetiology)
Increased production- psoriasis, genetics, diet (shellfish, red meat, alcohol)
or
Decreased excretion from the kidneys - (CKD, NTN, thiazides, alcohol)
90% IS IDIOPATHIC
GOUT
Signs?
- Acute severe pain
- swelling and redness (inflammation)
50% occurs at 1st MTPJ
GOUT
What is it precipitated by?
- cold
- alcohol
- diuretics
GOUT
Investigations?
- Joint aspiration- shows urate crystals in synovial fluid
- X-ray shows:
1) Soft tissue swelling
2) Peri-articular erosions
3) Norma joint space
GOUT
Treatment?
- NSAIDs, Colchicine, Steroids (prednisolone injection)
- Allopurinol
GOUT
Lifestyle advice?
Lose weight
stop drinking
avoid meats with high purines (red meat, shellfish)
PSEUDO-GOUT
What is it?
deposition of calcium pyrophosphate crystals in articular cartilage - normally in the larger joints
PSEUDO-GOUT
What would an X-ray show?
1) Chondrocalcinosis and soft tissue calcium deposits
2) Positive birefringent (optical property of a material having a refractive index)
3) Calcium pyrophosphate crystals
PSEUDO-GOUT
who is it most commonly found in
elderly women
PSEUDO-GOUT
Investigations and Treatment?
- Joint aspiration
NSAIDs, colchicine, intra-articular steroid injections
Features of SERONEGATIVE SPONDYLARTHROPATHIES
blood
MSK
Extra
1) negative rheumatoid factor
2) HLA-B27 positive
3) Dactylitis- inflammation of an entire digit (a finger or toe)
4) Enthesitis- irritability of soft tissues (muscles, tendons or ligaments) where it enter into the bones
5) Asymmetrical large joint oligoarthritis
6) extra- articular problems
such as aortic valve incompetence or IBD
ANKYLOSING SPONDYLITIS
What is it and what is the epidemiology?
inflammatory disorder of the spine
F:M 1:6 (most common in young men)
ANKYLOSING SPONDYLITIS
What is it relieved by?
Exercise
ANKYLOSING SPONDYLITIS
Features in terms of spine shape?
1) Increased T spine kyphosis= top of back is excessively curved
2) Loss of lumbar lordosis, hip and knee flexion
= bottom of the back is curved
they will have a very straight back at the bottom then curve over like a C shape
ANKYLOSING SPONDYLITIS
Other features? (not spine)
- Achilles tendonitis (swelling and pain of Achilles)
- Plantar fasciitis (heel pain)
ANKYLOSING SPONDYLITIS
Investigations?
- X-ray
- MRI
these will show:
1) bony spurs
2) calcified interspinous ligaments - bamboo spine
3) Erosion and sclerosis of SI joints
ANKYLOSING SPONDYLITIS
Treatment?
- NSAIDs and exercise
- TNF alpha blockers if NSAIDs aren’t working
- Local steroid injections
SEPTIC ARTHRITIS
Septic arthritis can destroy a whole joint in only 24 hours. What organisms are common causes?
Staph aureus
Streptococci
N.gonnorhoeae
gram negatives
SEPTIC ARTHRITIS
Risk factors?
- DM
- Immunosuppression
- Prosthetic joint
SEPTIC ARTHRITIS
Features?
hot, red, swollen and painful joint
SEPTIC ARTHRITIS
Which joint is it found most commonly in? (>50%)
knee joint
SEPTIC ARTHRITIS
Investigation?
- joint aspiration for synovial fluid
- bloods (WCC) and cultures
SEPTIC ARTHRITIS
Treatment?
S.aureus/ strep= Flucloxacillin
Gram negatives/ gonorrhoeae = Cefuroxime
BACK PAIN
types?
Mechanical
Inflammatory
Serious
BACK PAIN
Name some examples of inflammatory and mechanical back pain
Mechanical=disc prolapse, fracture, osteoarthritis
Inflammatory= ankylosing spondylitis, infection
BACK PAIN
Give some examples of reasons for serious back pain
- Myeloma
- TB
- Metastases
- Osteomyelitis
BACK PAIN
Red flags?
1) Age between 20&50
2) Constant pain- no relieved by rest
3) History of cancer, TB, HIV or immunosuppression
4) Systemically unwell
5) Neuro deficit
BACK PAIN
Investigation and treatment?
MRI and treat with analgesia, rest and physio
MALIGNANT LUMPS
Features?
over 5cm, increasing growth, deep in fascia, painful
MALIGNANT LUMPS
Investigations?
Ultrasound-based sarcoma score
For malignancy, this will show irregular/nodular edges and vascularity on the doppler
- CT and MRI plus biopsy for diagnosis
MALIGNANT LUMPS
Treatment?
surgery + Radiotherapy adjunct
OSTEOMYELITIS
Who normally gets it?
children
OSTEOMYELITIS
What is it?
infection through the blood or compound fracture
Develops in the metaphysis due to blood network
OSTEOMYELITIS
Organisms involved?
s.aureus
influenzae
salmonella
OSTEOMYELITIS
Pathology?
1) Transient bacterium
2) Acute inflammation of bone
3) Necrosis
4) Formation of new bone
5) If untreated, sinuses to skin form
OSTEOMYELITIS
Symptoms?
- fever
- erythema
- Pain
- swelling
OSTEOMYELITIS
Tests?
- MRI and CT
- blood cultures
- aspirate
OSTEOMYELITIS
Treatment?
Flucloxacillin + fusidic acid for 4-6 weeks
General Sequence of Raynauds?
white (vasoconstriction) to blue (cyanosis) then red (hyperaemia)
FIBROMYALGIA
What is it?
- chronic fatigue/ pain & Absence of pathology
- much more common in women
FIBROMYALGIA
Yellow flags?
1) Social withdrawal
2) Emotional problems
3) Work problems
4) Lack of support
FIBROMYALGIA
What is it associated with?
- chronic fatigue syndrome
- IBS
- pain at 11-18 pressure points
FIBROMYALGIA
Treatment?
- educate and reassure
- painkillers
- Amitriptyline (TCAs)
What is Raynaud’s and how is it treated?
- spasms of the arteries supplying hands & feet
treated with heat! and stop beta blockers if able to
SJOGRENS SYNDROME
What is it
immunological mediated destruction of epithelial exocrine cells
SJOGRENS SYNDROME
Epidemiology?
F:M 9:1, middle aged women
SJOGRENS SYNDROME
Signs?
- dry eyes
- dry mouth (xerostomia)
- dry vagina
- Raynaud’s
- RA
- SLE
SJOGRENS SYNDROME
Difference between primary and secondary?
P- occurring by itself
S- secondary to SLE or RA
SJOGRENS SYNDROME
Diagnosis?
ANA +ve in 74%
Anti- RO SPECIFIC
Rheumatoid factor positive
Labial gland biopsy- shows destruction of gland plus lymphocyte infiltration
SJOGRENS SYNDROME
Treatment?
1) Tear and saliva replacement
2) NSAID’s and hydroxychloroquine for arthralgia
SCLERODERMA
What is it?
multisystem disease involving skin and Raynaud’s occurring early
SCLERODERMA
Pathology?
1) Endothelial cell lesion
2) Increased vascular permeability = increased cytokine + growth factors
3) This activates fibroblasts in ECM
4) Uncontrolled and irreversible thickening of connective tissue and blood vessel walls
SCLERODERMA
Limited Cutaneous Scleroderma signs? CREST
Calcinosis Raynauds oesophageal dysnfunction Sclerodactyly (tight and thick hands) Telangiectasia (spider veins, e.g. appearance of elderly overweight persons cheeks)
SCLERODERMA
Diffuse cutaneous Scleroderma signs?
- skin involvement
- heart involvement
- kidney = CKD
- Lung = pulmonary HTN and fibrosis
SCLERODERMA
Investigation?
X-rays - calcinosis a fibrosis
Barium swallow - oesophagus dysfunction
SCLERODERMA
Treatment?
Immunosuppression = IV cyclophosphamide
- PPI’s, ACE-I, ARB’s
PSORIATIC ARTHRITIS
Features?
- Asymmetrical oligoarthritis
- symmetrical polyarthritis resembling RA
- Arthritis Mutilans- severe form that destroys bones in hands and feet
PSORIATIC ARTHRITIS
Investigations?
on X-ray you will see pencil in cup deformity and narrowed joint space
PSORIATIC ARTHRITIS
Treatment?
NSAIDs
Local steroid injections
Severe= methotrexate and infliximab
REACTIVE ARTHRITIS
What is it?
sterile arthritis following an infection e.g. salmpnella, shigella, campylobacter, chlamydia
PSORIATIC ARTHRITIS
Features?
- young an <4 week after infection
- joints of lower limb affected asymmetrically
- superficial ulcers on penis and mouth
- red plaques on palms and soles
PSORIATIC ARTHRITIS
What will X-ray show and how is it treated?
X-ray will show enthesitis- joint irritability where it enters bones
Treat- NSAIDs and local steroids
Methotrexate if relapse
What is enteropathic arthritis?
large joint oligoarthritis due to IBD
VASCULITIS
What is it?
inflammation of blood vessel walls
VASCULITIS
Signs?
- Anaemia
+
increased ESR/CRP
VASCULITIS
Give examples of Problems related to large, medium and small Blood Vessels
Large = Giant cell arteritis, Takayasu's arteritis Medium = Polyarteritis Nodosa, Kawasaki's Small = ANCA +ve and -ve vasculitis
Features of Giant Cell arteritis?
1) headache
2) tenderness over temple
3) Jaw claudication on chewing
4) Dilated temporal artery (tender)
5) Sudden transient loss of vision due to retinal artery involvement= EMERGENCY
6) >50 year old women
7) increased ESR
Features of Polymyalgia rheumatica
increased ALP, ESR, CRP
Neck and shoulder stiffness/ pain- cant lift arms
Creatine Kinase is NORMAL so shows its not a myositis/ myopathy
treatment of Polymyalgia Rheumatica?
Oral prednisolone then Azathioprine if it doesn’t work
Epidemiology of Polyarteritis Nodosa?
MIDDLE AGED MEN + Hep B associates
Features of Polyarteritis Nodosa?
1) Fever, malaise, weight loss
2) HTN
3) Renal impairment
4) Rash
5) Malabsorption
how is it diagnosed and treated?
Angiogram/ Biopsy and steroids (small vessel arteritis is ANCA +VE and treated with steroids)
What is Dactylitis?
Dactylitis- inflammation of an entire digit (a finger or toe)
What is Enthesitis?
Enthesitis- irritability of soft tissues (muscles, tendons or ligaments) where it enter into the bones
Example of a Bisphosphonate and its pathophysiology
Alendronic acid - inhibit osteoclast activity
same as calcitonin
denosumab inhibits osteoclast formation
teriparatide stimulates osteoblast formation
Common fracture sites for osteoporosis?
Pathological- distal radius, proximal femur
other - ribs, hip, upper arm, wrist, spine, forearm
