Rheumatology / orthopaedics Flashcards
Name a large vessle / medium / small primary vasculitis
Large - giant cell / Takayasu
[Giant samurai]
medium
PAN, kawasaki
[Cows are cooked in medium PANS]
small
Henoch-schonlein purpura, Wegner’s granulomatosis, churg strauss, microscopic polyangitis
[German sounding + microscopic obvs]
Secondary causes of vasculitis
Aortitis in RA
Autoimmune, malignancy, durgs, infection
Eg of infective / drug / autoimmune causes of secondary vasculitis
BBV, strep
penicillin, steroids
RA, SLE, sjorgrens
What are the ANCA associated vasculities?
Wegners, microscopic polyangitis, Churg strauss, drug induced
What is ANCA? How are they detected? 2 types and associated antibody?
Anti-neutrophil cystoplasmic antibodies
Detected with indirect immunofluorescence microscopy
Cytoplasmic ANCA
Peri-nuclear ANCA
C-ANCA = Proteinase 3 (PR3) P-ANCA = Myeloperoxidase (MPO)
69 M
Sinus problems, blocked nose with bloody discharge
No improvement with antibiotics and steroid spray
Constitutional symptoms
Hearing problems
Arthralgia
Rash on legs
Nasal tone of voice
Vasculitic rash on legs
Small joint and ankle swelling
Ix
Low Hb
Raised Ur & Cr
CRP 109
Wegners
For exams
c-ANCA / PR3 ?
P-ANCA / MPO?
c anca - wegners
p anca - churg strauss
Triad of affected areas in wegners
lung, kidney, ENT
Usual vasculitis with raised eosinophils
Churg Strauss
Often get new / worsening asthma
New name for wegners?
what and Who usually affected?
Granulomatosis with polyangitis
Necrotising vasculitis of arterioles, capillaries and post-capillary venules
Typically affects men aged 25-60
Causes of cavitation on lung XR?
wegners, malignancy, septic emboli, TB, Klebsiella, Staph aureus, pulmonary infarcts
main 3 affected organs features of Granulomatosis with polyangitis?
Upper resp - Sinusitis
Otitis
Nasal crusting & bleeding
Saddle nose deformity
Lungs
Cavitation
haemorrhage
Renal
Glomerularnephritis (haematuria/proteinura)
Also Eyes nervous system heart Gi
52 F Increasing SOB on minimal exertion Poor appetite 5 stone weight loss in previous 6 months Rash on legs
PMH Asthma Nasal polyps Psoriasis Syndrome X Β thalassaemia trait
DH Diltiazem Amitriptyline Serotide Salbutamol Betnovate cream
O/E
Scattered wheeze
Vasculitic rash on legs
No joint swelling
Ix Low Hb Raised EO 5.8 CRP 291, ESR 35 CK 654 RF + cANCA + MPO +
What is it?
Usual organs and features?
Eosinophilic granulomatosis with polyangitis
(Churg Strauss)
Systemic necrotising vasculitis of arterioles, capillaries and post-capillary venules
Lungs
New/worsening asthma
Pulmonary infiltrates
Alveolar haemorrhage
CNS
Mono/polyneuropathy
ENT
Polyps
conductive hearing loss
allergic rhinitis
Skin
Pupura
nodules
Renal disease RARE
Common Ix in wegners/churg strauss
Hb, RF, CRP, ESR, CK
Eosinophils (raised in churg)
ANCA
Biopsy if needed
Mx of Churg / Wegners ?
Maintanence of remission?
Induction of remission
High dose steroids + Cyclophosphomide or Rituximab
Plasma exchange if life threatening/Cr >500
(if no organ threatening involvement)
High dose steroids + Methotrexate or Mycophenolate
Maintenance of remission
Methotrexate + pred + folic acid
or Azathioprine
Which vasculitis is microscopic polyangitis similar to?
Difference?
Churg straus
pANCA +ve
No granuloma formation
Predominantly affects kidneys
Main features of HSP
Children IgA Purpuric rash Arthritis Abdominal pain Glomerulonephritis
How to remember main feature of polyarteritis nodosa ?
Other features ?
Nodosa means knots (aneurysms)
Medium vessel
Common co-infection with Hep B
Hypertension
Epididymitis
constitutional Sx
Mx of Giant cell arteritis if visual disturbance? W/O disturbance?
What else do you give?
Prednisolone 40mg if no visual disturbance
Prednisolone 60mg if visual disturbance
Dramatic response normally seen within 48 hours
May require steroid sparing agents
- PPI
- Osteoporosis prophylaxis
- Aspirin
What condition is linked to temporal arteritis ?
Polymyalgia rheumatica
Sx / signs of GCA
Headache, severe, sharp dull throbbing, wouldn’t improve without steroids
TA swollen, tender, pulseless
Diplopia, ptosis, ischaemic optic neuropathy (sudden painless monocular visual loss)
Papilloedema, haemorrhages, optic atrophy later
Features of PMR
Shoulder / pelvic pain
morning stiffness
Weakness on exertion due to pain (rather than intrinsic muscle disease)
Can start asymmetrically then becomes bilateral
Decreased appetite can lead to weight loss
3 Ix in PMR ? What is this in part for?
mX?
ESR/CRP - THESE WILL BE HIGH RhF/ACCP ANA CK - THIS WILL BE NORMAL AS MUSCLES ARE ACTUALLY SPARED. THIS DISTINGUISHES IT FROM OTHER MUSCLE PATHOLOGIES SUCH AS polymyositis. TFT Myeloma screen CXR
(ruling out other conditions that can present similary
RA, SLE, polymyositis, hypo/hyperthyroid, myeloma
Pred 15mg
Bone protection
PPI
The main complication is steroid induced osteoporosis
Is GCA only in temporal?
name 2 Constitutional sx
Leading question - Obvs not
15% - carotid, subclavian, axillary
Arm claudication Paraesthesia Digital ischaemia Raynaud’s Absent pulses Aortic aneurysm & dissection Aortic insufficiency
What are the aspects of the vasculitic screen? - Name 4
[FUEL Breaks Cars]
FBC Normochromic normocytic anaemia Leucocytosis Thrombocytosis Eosinophilia
Urine PCR Urine dip Blood Protein
LFT
Clotting
ESR/CRP
ANCA
CXR
Biopsy
Post vasculitic screen what further Ix might you do?
[EM…III]
Imaging
MRA
PET
Infection screen
General septic screen
Serology Eg HepB in PAN
Immunology RF/ACCP ANA ENA dsDNA
Myeloma screen
EMG - if neuropathy
What 5 things would you use when describing a fracture
Complexity
- Simple = closed, compound = open
Type
-FIG-TACOS
Fissure, impaction, greenstick, transverse, avulsion, comminuted, oblique, spir
Comminution
-Number of pieces broken into
location
-distal, radial shaft
displacement
-Translation (sideways), angle, shortening
What is the FRAX score for?
Name 3 things on it
Estimate 10 year risk of fracture with BMD
Age, sex, BMI
Previous fracture, parent hip fracture, low femoral neck BMD
Alcohol, smoking, glucocorticoids
RA, secondary osteoporosis
Which 2 fractures can lead to avascular necrosis
femoral head
scaphoid
What is a colles fracture
distal radius with dorsal displacement fragments
Mx of wrist frac
Reduction via manipulation with *anaesthesia
*Immobilisation -initially avoid full cast as swelling may impede circulati
Sign of scaphoid frac?
tenderness in anatomical snuff box
What runs through anatomical snuff box?
radial sensory branch
Comp of colles
median nerve damage (/ulnar)
Fall backwards - opposite of collies is what? Apperance?
smiths fracture
[distal fracture of radius with volar]
garden spade deformity
Seen on lateral Xray of colles
dinner fork sign
How does a NOF frac present
Affected leg shortened, adducted and externally rotated
2 main sub types of NOF
intracapsular
extra-capsular
Which is worse and why - intra vs extra capsular
intra
(medial and lateral circumflex artery)
-> May disrupt blood supply to femoral head - avascular necrosis
General Ix in NOF
AP and lateral XR (Shenton’s line)
[MRI if # suspected but not obvious on XR]
FBC, cross-match, renal, glucose, ECG
Mx of intracapsular
analgesia - no NSAIDS
Surgery within 1 day
Mx of displaced vs undisplaced NOF
Undisplaced - internal fixation with screws
*Displaced - hemiarthroplasty (replace head)
When do you xray an ankle - name 3 points
Ottawa ankle rules
> 55
Inability to wt bear (4 steps) now and at time of injury
Bone tenderness at posterior edge or tip of lateral malleolus (6cm)
Bone tenderness at posterior edge or inf tip medial malleolus
Mx of ankle frac if dislocation
If neurovascular compromise or dislocation (obvious deformity) then reduce immediately (before XR, under sedation or analgesia)
When do you xray ankle frac for monitor
reduction, 48 hours, 7 days, then 2 weekly
Main worry comp with #
Compartment syndrome
Signs of compartment syndrome
Pain out of proportion: 6Ps, pain, parasthesia, pallor, paralysis, perishingly col
Mx of compartment
Prompt fasciotomy
Comp post fasciotomy for compartment syndrome ? Mx?
Myoglobinuria -> renal failure
Aggressive IV fluids
Stages of # healing
Haematoma formation *hours
MP and inflamm leukocytes
callus formation (soft callus) *days Inflammation leads to angiogenesis and increased number of chondrocytes.
Bony callus formation *weeks
ossification and direct bone formation. Soft callus replaced by woven bone
Bone remodelling *months
Woven bone replaced by organised cortical bone. Continually remodelled therefore no scarring
What is frozen shoulder - main sx? when does it occur?
Thickening and contraction of glenohumeral joint capsule ± formation of adhesions
pain and loss of function
spont or post rotator cuff injury
Key movement lost in frozen shoulder
external rotation
Define osteoperosis
by low bone mass and micro-architectural deterioration leading to increasing fragility and fracture risk
DEXA results for osteoperosis /penia
T-score < -2.5 (s.d. below young healthy adult mean)
-2.5 < T
What is the pathogenesis of osteoperosis
Increased breakdown by osteoclasts
Decreased bone formation by osteoblasts
Common locations for osteoperotic #
Spine (vertebral crush), wrist (distal radius), hip (proximal femur), pelvis
Name 3 secondary risk factors for osteoperosis
SHATTERED
S - steroids + Cushing’s (>7.5mg for 3 months)
H - hyperTh, hyperPTh, hypercalciuria
A - alcohol and tobacco
T - thin (BMI<19) or AN
T - testosterone decreased - primary hypogonadism, or anti-androgens @ PrCa
E - early menopause (<45)
R - renal/liver function - renal osteodystrophy in CKD, chronic liver disease
E - erosive/inflammatory disease: RA, multiple myeloma, metastasis
D - dietary Ca/T1DM - malabsorption, malnutrition
name 2 ways steroids increase risk of osteoperosis
Decrease Ca absorption from gut
Increase osteoclast activity
Decrease muscle mass
Why are XRAYS often normal in OP ? Name 1 thing you might you see
nothing seen till lose 30% BMD
Radiolucency, cortical thinning, biconcave vertebrae
Key DDx in OP?
myeloma
Name 3 Ix in OP
FBC, ESR, CRP
Bony profile: Ca, PO4, ALP, PTH
-All normal at OP
U+E, LFT, TFT, serum Ca
Testosterone/gonadotrophins (in men)
Serum Ig, paraproteins,
3 lifestyle Mx for OP
smoking, alcohol, wt bearing exercise, balance (fall risk), calcium + vit D rich diet, fall prevention
3 Meds for OP
Bisphosphonates + Ca + vit D supplements
Method of fall prevention in OP
Try and avoid polypharmacy
Intollerant to bisphosphonates can give?
denosumab (monoclonal aB to RANKL)
[denos u mad, why dont you like bisphos]
How do bisphosphonates work?
Inhibit osteoclastic bone resorption
Name 2 SEs of bisphosphonates
Difficulty swallowing, oesophagitis, gastric ulcers
Osteonecrosis of the jaw
What is osteomalacia ? rickets?
Cause ?
Disorder of mineralisation of bone matrix (osteoid) after fusion of epiphyses
Rickets is before fusion
Vit D deficiency
What does Vit D do ?
To bone: increases Ca mobilisation, increases osteoclast function
To intestine: increases Ca absorption, increases PO4 absorption
decreases PTH
PTH mech Ca/PO4?
To bone -> increase osteoclast function -> increase Ca
To kidney -> increases 1,25vD3, + decreases Ca excretion + increases PO4 excretion
Low levels of what stimulate PTH
Ca
RFs / causes of vit D deficiency
Name 3
Lack of sunlight, lack of adequate diet, dark skin, alcohol, fam Hx
Malabsorbsion
Renal disease
Liver disease
-(+anticonvulsants, rifampicin )
Name 2 points on pres of rickets
leg bowing, knock knees
softening of skull, frontal bossing
delayed walk / waddling
Osteomalacia name 2 key Sx
Widespread bone pain + tenderness (low back pain and hips)
Proximal muscle weakness - waddling gait (if severe)
Fatigue
Often get low phosphate in osteomalacia - what sx?
Muscle weakness, parasthesia
Name 3 ix in osteomalacia
Vit D - Low
Renal, LFT, FBC
Ca - low
PO4- low
PTH - high
ALP - v high
Urinary Ca (low), PO4(high)
XR
DEXA
Iliac crest biopsy - failed mineralisation
Mx of vit D deficiency
vit D + Ca
What happens in paget
increased turnover of bone
2 parts of the increased turn over in pagets
Lytic phase - increased bone resorption by osteoclasts
Sclerotic phase - *Rapid bone formation by osteoblasts - > deformed
Where is affected by Pagets
Axial skeleton: lumbosacral spine, pelvis, skull, femur, tibia
2 key Sx in pagets
bone pain
deformity
Name 2 comps of pagets
pathological # - + lots of bleeding as V vascular
Deafness / tinnitus - Compression of CN8
Deformity
Name 3 Ix in Pagets
ALP - HIGH
[Ca, PO4, PTH normal]
Isotope bone scans
XR
Seen on XR of pagets
Osteolysis and osteosclerosis (lytic and scleortic lesions)
*Blade of grass lesion between healthy and sclerotic long bone
Cotton wool pattern of multifocal sclerosis in skull
Mx pagets
pain and prevent progression
NSAIDS/ para
Bisphosphonates
Basic inflam vs degenerative arthritis
Inflam:
Ease on use, worse in morning (>60 mins), hot and red (r/d/c/t/LoF), responds to NSAIDs, swelling *synovial and bony, young/psoriasis/fam Hx
Denerative:
Worse with use, morning (<30 mins), mainly evening, prior occ, sport, *no swelling, not inflamed
Name the key tings stimulating inflamation
IL1, IL6, TNF
Key joints in OA
Knees, hips, small joints hands, spine
Name 3 signs of OA
Joint swelling/synovitis - warmth + effusion
Reduced ROM
Crepitus
Pain on movement
Bony swelling and deformity - osteophytes: DIP (Heberden’s) + PIP (Bouchard’s)
No systemic features
XR of OA
LOSS Loss of joint space Osteophytes Subchondral/subarticular sclerosis Subchondral cysts
3 Non med Mx of OA
Patient education, weight loss, screen depression, *exercise for muscle strength, aids and devices (walking sticks, tap turners)
2 Med Mx of OA? If acute exacerbation?
Local analgesia: capsaicin or topical NSAID (first line)
+ Paracetamol
+ NSAIDs ± PPI
Intra-articular steroid injections - mPred
Surgical Mx of OA
Replacement (arthroplasty), fusion (arthrodesis)
RA XR?
LESS Loss of jt space Erosions Softening of bones (osteopenia) Soft tissue swelling
Whats formed in prolifferation in RA?
Pannus
Name 3 extra articular pres of RA
Rheumatoid nodules @ extensor surface of tendons and *lungs
Vasculitic lesions - commonly skin rashes, leg ulcers
Pleuritic chest pain - pleuritis or pericarditis
Eye problems: secondary Sjogren’s
Neurological: peripheral nerve entrapment, mononeuritis multiplex, atlanto-axial subluxation (C1,C2) - soft tissue swelling within rigid tunnel
Respiratory system: rheumatoid nodules, Caplan’s syndrome, pulmonary fibrosis
Anaemia of chronic disease
Triad in fetty syndrome
[RANS fatty]
RA
Neutropenia -
Splenomegaly
[Also - Leg ulcers and brown pigmentation of legs
Lymphadenopathy ]
3 key Ix in RA
1) RF (70%)
2) Anti-CCP (cyclic citrullinated peptide)
3) XR hands and feet
What is RF?
Antibody against Fc portion of IgG
Mx in RA - Non med / 1/2 line?
Physiotherapy, OR, psych services (depression), podiatry
1st line
DMARD (sulphasalazine) + methotrexate
Adjunct - corticosterid +NSAID - lowest effective dose
2ND LINE - Biologicals
how often is methotrexate given?
weekly
SE of methotrexate
Bone marrow suppression, mucosal damage - mouth ulcers
Long term -
PULM FIBROSIS
[cirrhosis / Renal failure]
monitoring in methotrexate
CXR, FBC, LFT, U+E
[ before starting, then 2 weekly till established (6 weeks post dose increase), then 3 monthly ]
Eg of a biologic in RA
Anti-TNF-alpha
infliximab, adalimumab, enteracept
When can you give a biologic for RA?
Failure to respond to 2 DMARDS after 2 trials of 6 months
Name 3 RFs for gout
Alcohol (beer highest), purine rich foods (red meat/sea food), fructose (sugary drinks/cakes), diuretics, DM, CKD, CHD, HTN, hyperlipidaemia
3 Ix in gout
Serum urate
Joint aspiration
XR
Seen on joint aspiration in gout
Negatively birefringent needles of mono sodium urate
Seen on early vs late gout
early - tissue swelling
late - punched out lesions
Mx of acute gout
NSAID - naproxen
If poorly tolerated - > colchicine
Prophylaxis of more gout
Lifestyle modification + manage RFs Eg diuretics
allopurinol or febuxostat
Crystal in pseudo gout ? most common where?
Calcium pyrophosphate
Knee / wrist
Mx pseudogout
Sx Mx
Ice packs, elevation, aspiration of joint, NSAIDs, IA steroid injection
ABs in SLE ?
Antinuclear antibodies
Genetics in SLE
HLA DR2/DR3
Most common pres of SLE
Raynauds
Main drug mx of SLE
Hydroxychloroquine
Name 3 signs of SLE
Oral ulcers - usually painless
Photosensitive rash - skin rash from sunlight
Arthritis - non erosive 2 or more peripheral joints
Malar rash
seizures or psychosis
ESR raised (*not CRP) Renal disorder - proteinuria > 0.5g/day or +++,
Pleuritis / pericarditis
ESR / CRP in SLE
CRP normal
ESR raised
Name 3 Ix in SLE
Autoantibodies: ANA (95%), antidsDNA (60%), antiSmith (30%)
Complement levels: low C4 and C3
[ESR/CRP - ESR raised, CRP normal
FBC - anaemia, leukopenia, thrombocytopenia
Urinalysis: haematuria, casts, proteinuria
U+E (renal disease)
CXR: pleural effusions, cardiomegaly
ECG: pericarditis]
Mx of joints SLE?
Kidney / neuro?
NSAID ± hydroxychloroquine ± steroids
Cyclophosphamide
Key AB in antiphospholipid syndrome
Anticardiolipin
Pres of antiphospholipid
Thrombosis, DVT, pregnancy loss, pre-eclampsia, thrombocytopenia, livedo reticularis: violaceous lace like on trunk, stroke
Mx antiphospholipid
Warfarin: target 2-3
Avoid clotting lifestyle: smoking, contraceptive pill, healthy diet, low alcohol
Seen on clotting studies of Antiphosphplipid
Paradoxically low platelets and prolonged APTT
Gene in sjogrens
HLA DR 3
Complex in sjogrens? ->?
Sicca complex diminished lacrimal and salivary glands:
dry eyes, dry mouth, enlarged parotid gland
Ix in sjogrens
Schirmer tear test - filter paper
Autoantibodies
sialography
Biopsy salivary gland - mononuclear cell infiltrate (B and T cells)
Mx in sjogrens dryness?
Joint pain?
Artificial tears
Artificial saliva, drink plenty
Oral pilocarpine
Joint - NSAID + hydroxychloroquine + steroid
Key sx of limited sclerosis
CREST
Calcium deposists in skin
Raynauds 100%
OEsophageal dysfunction
Sclerodactlyly
Telangiectasia
[fatigue, wt loss]
GI / pulm / renal features of systemic sclerosis
Heartburn + reflux oesophagitis + watermelon stomach (gastric antral vascular ectasia - bleeding
Pulm
Pulm fibrosis / HTN
Renal
ANCA glomerulonephritis
*Scleroderma renal crisis: accelerated HTN
Most important features of systemic sclerosis
Pulm HTN - leading cause of death
GI bleed
Renal crisis
Name 3 Ix in Systemic Sclerosis
LuFT
CXR
Autoantibodies - ANA (most common one)
ECG
FBC
U+E
Barium swallow if oesophageal disorder
drug for raynauds
nifedipine
Mx of pulm HTN / Fibrosis in Systemic sclerosis
sildenafil (PA HTN )
Cyclophosphamide (fibrosis)
monitoring in systemic sclerosis
Monitor and record BP weekly
Yearly LuFT (spirometry, lung volumes and DLCO) + echo for interstitial lung disease and PAH
What is this
Not painful
Progressive symmetrical proximal muscle weakness - pelvic girdle
Difficulty rising from chair, climbing stairs, combing hair
Pharyngeal weakness - dysphagia
Interstitial lung disease and AV nodal disease
Polymyositis
polymyosistis Ix?
CK elevated x 50
AAb - anti Jo-1 (poor prognosis - lung disease) in ⅓
Elevated muscle enzymes: LDH, aldolase
*EMG and muscle biopsy - for Dx and confirmation
Whats the worry with polymyositis and what Ix do you do ?
Can be paraneoplastic cause (lung, ovarian, bowel)
ca125, Ca19-9, CEA
CXR
[Consider CT-TAP]
What does this describe and 3 IX?
Rash: (may be UV related) Heliotrope violaceous eyelid Gottron’s papules - purple scaly patches on extensors Nailfold erythema Shawl sign - macular rash
Systemic upset: fever, arthralgia, malaise, weight loss
AV conduction defects
Interstitial lung disease 50%
GI ulcers
Dermatomyositis
CK elevation, LDH, aldolase
AAb: anti-Jo1 (more common in poly), anti-Mi2 (specific), ANA
EMG + muscle biopsy
CXR, LuFT
Mx of Polymyositis + dermatomyositis? If lungs involved?
Steroids
If fail - immunosuppressives
For lung disease
cyclophosphamide
Name 3 features of Ehler danlos
mitral valve prolapse, aortic root dilatation
pes planus (flat feet)
Increased elasticity + fragility of skin
Hyper mobile / lax joints
mx of elher danlos
Physiotherapy, regular gentle exercise, genetic counselling
Periodic echo for floppy mitral valve or aortic root dilatation
Gene in marfans
AD fibrillin gene FBN1
Usual cause of death in marfans
Aortic root dilatation and aortic dissection
Name 3 features of marfans
CV: aortic dilatation, dissection, mitral regurgitation
Lungs: pleural rupture - pneumothorax
Eyes: lens dislocation, closed angle glaucoma
Skeleton: arachnodactyly (Long arms / legs ), hypermobility, pectus excavatum
Facial: high arched palate
Monitoring in marfans
Annual ECHO - aortic root width
CV MRI - every 5 years
Prophylactic med in marfans
propanolol
What is meant by sero neg arthropathies? What do they affect?
RF -ve
1) axial skeleton,
2) peripheral joints,
3) enthesitis (tendons and ligaments) and dactylitis
Anterior uveitis, IBD (similar to Crohn’s)
Common gene in seronegative arthropathies
HLA B27
Eg 3 sero neg arthropathy
Ankylosing spondylitis, Reiter’s syndrome, enteropathic arthritis, psoriatic arthritis, Behcet’s disease, JIA
OA
OA AS PA
Ankylosing spondylitis age? Features?
<40 onset
Inflammatory back pain + enthesitis
Tenderness at sacroiliac region (felt in buttocks) or limited spinal motion
Peripheral enthesitis (50%): Achilles and plantar fascia
Peripheral arthritis (50%): asymmetrical
Name 2 extra articular sx of ank spond
Eyes: acute anterior uveitis
CV: aortitits and *dissection of the aorta and aortic regurgitation
Lung - apical fibrosis
Seen OE for ank spond
Reduced chest expansion <5cm
Schober’s test: reduced forward flexion <5cm + loss of lumbar lordosis
Reduced lateral flexion
3 Ix in ank spond and what you expect
HLA B27: +ve
XR of whole spine: *Bamboo spine
LuFT
Pelvic XR - sacroiliitis
Name 3 associations with ank spond
The A’s
Apical fibrosis Anterior uveitis Aortic regurg Achilles tendonitis AV node block Amyloidosis
General Mx for ank spond
Physiotherapy + rehabilitation + exercise
First line: NSAIDs (± analgesics - paracetamol)
[will also give corticosteroids / sulfasalazine for tendon/joint involvement ]
Mx of enthesitis in ank spond? Peripheral arthritis ?
Enthesitis-
intra-articular corticosteroid injection
Arthritis -
DMARD: sulfasalazine
Most common joint in PA
dip
[Think of nail changes]
2 things seen in PA xray
2 other Ix
Plain film XR feet and hands: -Erosion in DIP -Pencil in cup deformity -[Periarticular new bone formation Osteolysis]
Anti CCP (-ve)
ESR/CRP (normal or elevated)
RF (+ve or -ve) *+ve in 2-10%
Mx of limited PA ? More progressive?
NSAID + physio ± joint injection
If high ESR/CRP -> DMARD (methotrexate)
When does reactive arthritis occur? common bugs?
1-4 weeks post exposure to GI and GU infections
chlamydia
Campylobacter/salmonella/shigella
Famous sx with reactive ?
Can’t see, can’t wee, can’t bend your knee (typically lower limb)
Conjunctivitis, non-gonococcal urethritis + post-infectious arthritis
Name 3 Ix in Reactive A
ESR/CRP very high, FBC - WCC
Joint aspiration - rule out septic or crystal arthropathies
Culture: stool, throat UG tract - for causative organism
Serology chlamydia: PCR or NAAT and contract tracing
Mx reactive A
NSAID + rest ± intra-articular steroids ± ABX chlamydia (azithromycin)
What is Enteropathic arthritis? mx?
Arthritis associated with IBD (CD or UC), coeliac
sulfasalazine (bowel and rheumatic)
What happens in behcet’s disease?
association ?
mx?
Recurrent oral ulcers
joints - non-erosive arthritis (lower limb)
HLA B51
Topical corticosteroids, systemic steroids
Key arteries in GCA
granulomatous disease of aorta and large cerebral
Eye feature in GCA
anterior ischaemic optic neuritis
QUE ES?
Recent onset temporal headache + scalp tenderness + transient visual symptoms (diplopia) + jaw claudication (on chewing)
GCA
What can happen to aorta in GCA
thoracic aneurysm
Ix in GCA
ESR > 50mm/hr + temporal artery tenderness + *temporal artery biopsy
Consider - aortic arch angiography
2 things Seen on biopsy GCA
Granulomatous inflammation, multinucleated giant cells, intimal hypertrophy and inflammation
Mx GCA ? What might you try and prevent?
What if it is refractory?
High dose oral prednisolone 1mg/kg/day for 4 weeks then taper
+ Aspirin (lower visual problems)
Osteoporosis prevention - Ca + Vit D + bisphosphonate
If refractory - methotrexate
que es?
Severe bilateral pain and morning stiffness: shoulders, neck, pelvic girdle (>2 weeks)
with systemic features at onset (malaise, fever, fatigue)
key association?
Polymyalalgia rheumatica
GCA
What is takyasu’s also called? who does it affect and how?
Pulseless disease
young women 20-40 / Japanese
Chronic, progressive, inflammatory, occlusive disease of aorta and branches
2 stages of takyasus
Systemic: fever, fatigue, wt loss, arthralgia, tenderness on arteries
Occlusive: Limb claudication TIA HTN Angina [+ other features of occlusion]
Name 2 things seen OE of takyasus
Difference in SBP of >10mmHg between arms
Impalpable peripheral pulse
High BP - renal artery stenosis
Arterial bruits on all arteries and
aortic regurgitation
2 Ix in takyasus
ESR > 50 CRP elevated with active disease
Aortic angiography: (CT/MRI) of aorta and main branches and pulmonary arteries
Mx takyasus? 2nd line?
Glucocorticoids + aspirin + bone protection
TNF alpha antagonist
If you treat with a TNF alpha antagonist what should you consider
Vaccine
influenza + pneumococcal as immunosuppressed
Reactivation of TB
polyarteritis nodosa key association
HBV
How to differentiate polyarteritis nodosa from other small /medium vessle?
No ANCA
Seen on angiography for PAN
Microaneurysms and focal narrowing - rosary sign
Define PAN
Necrotising inflammation of medium sized or small arteries
Spares lung
Pres of PAN
Nerves and skin most common
Nerves: *mononeuritis multiplex
Skin:
Livedo reticularis, purpura, nodules, necrotic ulcers
GI
Pain post eating from ischemia
Renal - HTN
What does livedo reticularis look like
mottled
-cyanotic discolouration surrounds pale central skin
Name 3 Ix in PAN
[P(L)AN B - Hep B and Beads]
HBsAg - 30%
p-ANCA - negative
Acute phase response: leukocytosis/neutrophilia, ESR
Complement - reduced C3/C4
*Arteriography: microaneurysms in small and medium sized arteries (looks like ROSARY beads)
Small artery biopsy: necrotising inflammation
Urinalysis: proteinuria
Mx of PAN ? If key association also?
Prednisolone ± DMARD (cyclophosphamide)
If active Hep B: antivirals and plasma exchange
Key Comp of PAN
Renal failure
Due to micro aneurysms -> accelerated HTN
Who gets kawasaki? classic features?
Children 6M - 5Y (mainly asian)
CRASH and BURN
Conjunctivitis (bilateral + non-purulent)
Rash - non vesicular
Adenopathy (cervical + unilateral)
Strawberry tongue + inflammation of lips and mouth (cracked lips)
Hands/feet - palmar erythema/swelling/desquamation (2-5 days after onset)
Fever > 5 days (burn)
Don’t forget what Ix in Kawasaki
Coronary artery aneurysm and dilatation - echo
Mx Kawasaki
First line IVIg + high dose aspirin
Why are kids not normally given aspirin ?
Risk of reyes
2 catergoris of small vessle vasculitis
ANCA associated: microscopic polyangiitis, GPA (granulomatosis with polyangiitis) - Wegener’s,
EGPA (eosinophilic) - Churg Strauss
Immune complex mediated:IgA vasculitis
HSP, Anti GBM
2 types of ANCA and thier antigens
C-ANCA - cytoplasmic major antigen proteinase-3
P-ANCA - perinuclear major antigen myeloperoxidase
Glassic triad in GPA - Wegners
ELK disease (ENT, lungs, kidneys)
Upper respiratory tract involvement
Lower respiratory tract involvement
Glomerulonephritis
Name 3 parts of pres of wegners /GPA
Upper resp
Saddle nose deformity, nasal septal perforation (due to chronic rhinosinusitis)
Lower resp
SOB, cough, pain, haemoptysis…
Renal
oedema, HTN, haematuria (later)
[Eyes
visual blurring marked bilateral periorbital oedema from kidney…
Skin
: palpable purpura or petechia
MSK
Myalgia / arthralgia
Neuro
Numb / weak ]
Name 3 Ix in GPA /wegners
Kidney: urinalysis and microscopy + renal biopsy
Haematuria, proteinuria, RBC casts
Lung
CT chest - lung nodules (cavitating)
ANCA by immunofluorescense
c-ANCA (anti-PR3)
FBC - anaemia, ESR - raised
Mx of GPA/wegeners if serious organ involvement?
Non - life threatening?
IV methylpred (3d) + pred oral + cyclophosphamide
IV methylpred (3d) + oral prednisolone + methotrexate
How to reamin remission in GPA/wegeners
oral pred + methotrexate + folic acid
2 Main worries in GPA/wegeners
aki
resp failure
When would you be very suspicous something might be EGPA -Churg strauss
Adult onset asthma
Name 3 organs and features of churg strauss
[ENT, Resp, Nerves]
***ENT - allergic rhinitis, paranasal sinusitis, nasal polyposis
Lower RT - pneumonitis, haemoptysis
Renal - glomerulonephritis - HTN
*Peripheral neuropathy - mononeuritis multiplex
Skin - purpura, skin nodules
Name 3 Ix in churg strauss
p-ANCA (antimyeloperoxidase Ab) - 40%
FBC - eosinophilia + anaemia, elevated ESR/CRP
CXR - pulmonary infiltrates
Pulmonary CT - peripheral consolidation - ground-glass attenuation
Biopsy small necrotising granulomas and necrotising vasculitis
Mx churg strauss ? severe?
IV Mpred -> oral pred
If severe -> cyclophosphamide
+Asthma management
When do you suspect mcroscopic polyangitis ? Which key seen on Ix?
Mx?
Rapidly progressive glomerulonephritis and pulmonary haemorrhage
p-ANCA
Pred and cyclophosphamide
HSP also called? Who gets it?
IgA vasculiitis
Young man with previous URTI - Gp A strep (pyogenes)
Pres of IgA vasculitis /HSP
abdominal pain and vomiting, purpuric rash on buttocks and extensor, joint pain
low grade fever
Triad of HSP /IgA
Arthralgia, abdo pain, rash
Other than triad what organ commonly affected in IgA vasculitis?
kidney - 40% nephrotic syndrome
key single Ix in IgA vasculitis
Urinalysis: proteinuria, RBC, casts, 24 hour urine protein
Mx HSP
Pain relief
Kidney - steroids
Anti GBM disease called? affects what?
Goodpastures
Lung / kidney
glomerulonephritis and pulmonary haemorrhage -> haemoptysis and renal failure
2 Ix in AntiGBM
Renal function: abnormal
Renal biopsy: crescentic glomerulonephritis - perform *urgently
Anti-GBM - positive
Mx anti GBM
oral prednisolone + cyclophosphamide + plasmapheresis
Name 3 things that woudl CI a renal biopsy
Sole native kidney ESRD Neoplasm Bleeding disease Uncontrolled severe HTN Acute pyelonephritis
Vasuculitis screen
Haem
FBC, ESR, clotting screen
Biochem
U+E + Cr - renal function
LFT: PAN and cryo assoc HBV and HCV
CRP
Immunology
Immunoglobulins and protein electrophoresis
ANCA, RF, complement (C3/C4), anti-cardiolipin, cryoglobulins
Microbiology
HBV and HCV serology
Urine microscopy and culture
Radiology
CXR
usual suspects in septic A
S.aureus / GBS
gonococcal in sexually active
Rfs for septic A
Prothetic joint
IVDU, diabetes, skin infection, immunosuppression….
3 key Ix in Septic A
Urgent joint aspiration - synovial fluid Gram stain and culture, WCC, polarised microscopy (exclude gout)
Blood culture x2 ± gonococcal cultures (rectal, urethral, pharyngeal)
Acute phase markers: ESR, CRP, WCC raised
XR in septic A is of limited value - what can be seen early / late ?
Early: Oedema, swelling and effusion - join space widening
Late: Joint space narrowing / bone loss and cartilage destruction
Best way of assessing perarticular abscess / osteomyelitis in septic A
MRI /CT
Mx Septic A
Surgical drainage and lavage (wash) + high dose IV abx
Septic A which Abx…
Gon
Staph
MRSA
vancomycin / Ceftriaxone
fluclox
vancomycin
2 key comps in septic A
osteomyelitis
joint destruction
Mx of septic A if prothesis
*Remove joint and fill with antibiotic impregnated spacer
2 main mechs of osteomyelitis cause
haematogenous - Commonly associated with *children
Direct - ie post surgery / trauma
Most common org in osteomyeleitis
staph A / MRSA
Most common locations haematogenous osteomyelitis in children / adults?
Children - metaphysis of long bones
Adults - vertebral bodies
What is potts disease
vertebral osteomyelitis from haematogenous spread of TB
-> abscess
Ix osteomyelitis
Plain radiograph FBC (WCC) Blood cultures (+ve) Acute phase markers: ESR + CRP + WCC Culture from debrided bone
2 things Seen on XR of osteomyelitis
dark, soft tissue swelling, periosteal thickening , patchy osteopenia
Mx of osteomyelitis
Bone / soft tissue debridement
Stabailise + immobilise
IV aBX
[Reconstruction)]
Dx of fibromyalgia
4 quadrant pain at 11/18 tender points for >3 months
[4 quads - Front and back, left and right, above and below diaphram]
Mx of firbromyalgia ?
First line: amitriptyline + CBT
[2nd gabapentin / pregabalin]
Name 4 red flags of back pain
TUNA FISH
Trauma
Unexplained weight loss, loss of appetite - cancer/myeloma
Neurological symptoms including bowel bladder dysfunction - cauda equina
Age > 50 or < 20
Fever and night sweats - osteomyelitis/cancer
IVDU/immunosuppression - osteomyelitis
Steroid use - immunocompromise + osteoporotic fracture
History of cancer (prostate, breast, lung, renal)
What are your main worries in back pain
Cauda equina
Multiple myeloma
Metastatic cancer
Psoas abscess
Usual cause of cervical back pain
Cervical spondylosis
chronic disk degenertion
How does cervical spondylosis present?
Simple neck pain
+ radiculopathy (pain, numbness, tingling, weakness in upper limbs)
+ myelopathy (spinal cord)
Ix cervical spondylosis
Plain XR - osteophytes, narrowing of disc space, encroachment of intervertebral foramen
Neuropathy -> MRI
Pres of disk prolapse
Pain localised to spine + relevant radiculopathy, sensory disturbance in dermatomal distribution
Issue with disk prolapse
significant restrictions and exclusion of domestic, leisure, educational activities
Differentiate spinal fracture and Ca / infection
Spinal fracture: sudden onset pain relieved by lying down, structural deformity e.g. step
Cancer or infection (e.g. discitis) - PAIN REMAINS ON LYING DOWN, night pain>50 or <20, recent infx, IVDU etc….
Mx of herniation disk
Keep active + give analgesia
Analgesics: NSAIDs + acupuncture
Lumbar discectomy *only if severe nerve compression
What psychosocial factors prevent people getting better with chornic back pain ? What do you need to do as a healthcare professional
Beliefs that activity is harmful sickness behaviour withdrawal dissatisfaction at work depression
manage expectations
Osteoid osteoma Size? who? XR findings? Mx?
<1cm, surrounded by dense osteoid
[small dense name / oid sounds sore]
Young adults
Radiolucency surrounded by
dense bone
Pain with NSAIDs, local excision = curative
Osteochondroma
Who
Where
Pres
[long benign = painless name]
Most common benign
Young adults
Next to epiphyseal plate
Painless lump or joint pain, nerve compression = spur on XR
Chondroma\
Where
Rx
Single or multiple lesions
Hands or feet, tubular bones
Excise lesion + graft bone
Osteosarcoma Who? assocciation where? pres? what happens next?
Most common malignant in children (15-19)
Paget’s
In epiphyses of long bones - knee (75%) or proximal humerus
Painless
Destroys bone and spreads locally, rapidly *mets to lung
Seen on XR of osteosarcoma
soft tissue calcification = sunburst/hair on end + Codman’s triangle
Ewing’s sarcoma
Who?
Pres?
Primitive neuroectodermal tumour
15 yo boy
Mass or swelling, long bones, pain
Ewings on XR
Bone destruction with onion skin layers of periosteal bone formation + Codman’s triangle
Mets to bone, usual cause of lytic lesions? scleroitic?
both?
Lytic - Myeloma - pepperpot skull, lung, renal (bisphosphonates)
Sclerotic - Prostate
Both - Breast
Thromboangitis obliterans also called?
What does it cause?
In who?
Mx
Buerger disease
Distal thrombosis of fingers (go necrotic)
Men 30-50 who smoke
STOP SMOKING
Which vasculitis can present similarly to HSP
Eg haematuria, palapble purpura, arthralgia,
Key sx differences
Cause?
Mx?
Cryglobulinemic vasculitis
No GI pain / doesn’t classically follow URTI
Hep C
Mx of hep c
3 complications of compartment syndrome
rhabdomyolysis / renal failure
weakness/paralysis
amputation
Name 3 causes of cauda equina
degenerative - disk herniation / spinal stenosis
inflam - Ank spond
Infective - TB / abscess
Traumatic - fractures / haematomas [eg post spinal anaesthetic]
Tumours
NOF parts of Mx
ABCDE
Analgesia + nerve block
VTE prophylaxis
Early surgery [36 hours]
Benefits of surgery over bed rest for NOF
Less bed time = less VTE
less likely Hospital infection
pressure sores
Improved outcomes
3 post op mx NOF
mobilise day 1
PT/OT
bone protection
optimise meds / address polypharmacy
3 comps of NOF
Avascular necrosis dislocation non-union infections reduced mobility increased social care needs
What do you always give with steroids (unless v short term)
PPI
Bone protection - bisphos
