Rheumatology (Quesmed) Flashcards
What is the main investigation that should be done for Acute Monoarthritis?
Aside from diagnosis, what is the other benefit of this?
Joint Aspiration
Removing pus is protective for the joint (or any other fluid)
What should be ruled out in joint aspiration?
Septic arthritis
It is important to make the diagnosis of septic arthritis as the damage to a joint can happen very quickly and the patient be left with long-standing joint issues and osteoarthritis in the future. Prompt action with aspirating the joint and starting antibiotics is important to save the joint.
Prosthetic joint infection
Remember to ask if the patient has previously had a joint replacement as an infected prosthetic joint is an essential diagnosis to make as soon as possible. The orthopaedic surgeons will likely take the patient to theatre for a full wash out and the prosthetic joint may need to be replaced.
What is a leading cause of Septic Arthritis in sexually active young people- especially if they present with TENDER NECROTIC PUSTULES?
Neisseria Gonorrhoea
(otherwise is it usually Staph Aureus)
What investigation should be done before commencing Methotrexate?
Chest Xray as Methotrexate can cause PNEUMONITIS- so get a baseline
What are the signs of Adult onset Still’s Disease?
Adult-onset Still’s disease is an idiopathic autoinflammatory condition characterised by:
1) Pyrexia (often very high and of uncertain origin at first)
2) Arthralgia
3) A fine nonpruritic salmon pink rash
Patients are often hypotensive, and sepsis is a common misdiagnosis
What else is seen in investigations ordered for Adult onset Still’s Disease? (2 things)
(Ferritin>10,000 is very suggestive of this)
Classically patient’s have a very high ferritin (>10,000), driven by a profound inflammatory response secondary to interleukin-1. Causes of a ferritin >10,000 include: adult-onset still’s disease, and haemophagocytic lymphohistiocytosis (HLH).
Often, patient’s have elevated liver enzymes, particularly ALT, AST as well as LDH.
What is Ankylosing Spondylitis?
Ankylosing spondylitis is a sero-negative inflammatory arthritis primarily involving the axial skeleton.
What is the Epidemiology of Ankylosing Spondylitis?
Patients often develop Ankylosing spondylitis between the ages of 20-30 years old. It is three times more common in males than females. It often has strong family history.
What are the signs of Ankylosing Spondylitis?
1) Inflammatory back pain: often early morning stiffness (gets better with activity) with tenderness of the sacroiliac joints and limited range of spinal motion on examination
2) Peripheral enthesitis (Achilles tendonitis, plantar fasciitis) and peripheral arthritis may occur in up to 1/3 of patients
3) On examination, measure chest expansion, lateral lumbar flexion and forward lumbar flexion as these form part of the diagnostic criteria
4) Extra-articular involvement can be severe and includes:
- anterior uveitis
- aortitis (which can lead to aortic regurgitation)
- upper lobe pulmonary fibrosis
- reduced chest expansion
What investigations can be ordered for Ankylosing Spondylitis?
No laboratory tests are diagnostic of ankylosing spondylitis.
In primary care, FBC and inflammatory markers should be taken prior to referral.
Once in secondary care, antibodies and HLA testing are carried out.
HLA-B27 is not diagnostic, its sensitivity and specificity are around 90%. HLA-B27 should not be tested in all patients with back pain.
In a patient with inflammatory back pain and normal X rays, a positive HLA-B27 in the presence of other features of ankylosing spondylitis should prompt an MRI.
What are the HLA B27 associated conditions?
Ankylosing spondylitis: 88% of patients are HLA-B27 positive
Psoriatic arthritis: 60-70% are HLA- B27 positive
Enteric arthropathy: 50-60% are HLA- B27 positive
Acute anterior uveitis: 50-60% are HLA-B27 positive
Reactive arthritis: 50-85% are HLA-B27 positive
What imaging should be ordered in Ankylosing Spondylitis?
X rays are the most helpful in established disease but may be normal in early stages of the disease. Squaring of vertebral bodies, development of syndesmophytes (bony bridges between adjacent vertebrae) sacroiliitis and eventually fusion of the joint may be visible
MRI is the most sensitive investigation for sacroiliitis, and may demonstrate abnormality in the presence of normal radiographs. MRI may also be useful in evaluating response to treatment. In young patients, early use of MRI may be advocated to avoid excessive radiation from plain radiographs
When looking at lumbar X-rays, the vertebral bodies may become ‘squared’. In later stages, bony bridges called syndesmophytes form between adjacent vertebrae, and there is ossification of spinal ligaments. In late disease, there may be complete fusion of the vertebral column. This is known as bamboo spine.
What is the treatment for Ankylosing Spondylitis?
NON PHARMACOLOGICAL-
Treatment options for ankylosing spondylitis are limited and there are no treatments known to reduce remission or significantly delay the progress of the disease.
Non-pharmacological treatments including exercise and physiotherapy which is critical to improve and maintain posture, flexibility and mobility.
PHARMACOLOGICAL-
1) NSAIDs first line often prescribed with a proton pump inhibitor
2) Disease- modifying-anti-rheumatic- drugs (DMARDs) such as sulfasalazine and methotrexate are more useful in patients with enthesitis than axial symptoms, so are given in addition to analgesia in patients with concomitant peripheral disease. These drugs do not improve spinal inflammation.
Local steroid injections can be used as an adjunct
Patients who have failed to control symptoms with NSAIDs/ have severe disease may be offered TNF-alpha inhibitors such as Infliximab.
There is good evidence that Inflixmab can improve both clinical and X-ray outcomes in ankylosing spondylitis.
