Rheumatology Revision 5 Flashcards
A 66-year-old man presents to his GP with a 2-day history of pain in his right big toe. He reports having had similar pain on 2 previous occasions but did not seek medical help. His past medical history includes hypertension and hypercholesterolaemia.
On closer inspection, there is a swollen, erythematous 1st metatarsophalangeal joint on the right foot. The rest of the foot examination, and examination of other joints, are unremarkable
The patient is prescribed the first-line medication to prevent future presentations after the flare has settled. What is the most common side effect of this medication?
Vertigo
Jaundice
Constipation
Rash
Fatigue
The first-line medication for prevention of gout attacks is allopurinol. Allopurinol should started 2-4 weeks after the acute flare of gout has settled. According to the BNF, a common side effect of allopurinol is rash, in which case the medication should be stopped.
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Define juvenile idiopathic arthritis (JIA) [1]
Juvenile idiopathic arthritis (JIA) refers to a condition affecting children and adolescents where autoimmune inflammation occurs in the joints. It is diagnosed where there is arthritis without any other cause, lasting more than 6 weeks in a patient under the age of 16.
What are the 5 types of JIA? [5]
Systemic JIA - aka Still’s disease.
Polyarticular JIA
Oligoarticular JIA
Enthesitis related arthritis
Juvenile psoriatic arthritis
Describe the clinical presentation of Still’s disease / systemic JIA [+]
Systemic illness that can occur throughout childhood in boys and girls. It is an idiopathic inflammatory condition. Usually has:
* Subtle salmon-pink rash
* High swinging fevers
* Enlarged lymph nodes
* Weight loss
* Joint inflammation and pain
* Splenomegaly
* Muscle pain
* Pleuritis and pericarditis
TOM TIP: Think of Still’s disease (systemic JIA) when a patient presents with a salmon-pink rash, fevers and joint pain.
In children that have fevers for more than 5 days, the key non-infective differentials to remember are [4]
Kawasaki disease, Still’s disease, rheumatic fever and leukaemia.
How do you investigate for Still’s disease? [4]
Clinical picture
Serology:
- ANA and RF negative
- Raised CRP; ESR; platelets and ferritin
Describe a key complication of Still’s disease / systemic JIA? [1]
How does it present? [6]
Macrophage activation syndrome (MAS):
- massive inflammatory response
Presentation:
- DIC
- Anaemia
- Thrombocytopenia
- Bleeding
- Non-blanching rash
- Low ESR
Describe the pattern of pyrexia experienced in Still’s disease in adults [1]
typically rises in the late afternoon/early evening in a daily pattern and accompanies a worsening of joint symptoms and rash
Tx for Still’s disease (in adults) [2]
NSAIDs
* should be used first-line to manage fever, joint pain and serositis
* they should be trialled for at least a week before steroids are added.
steroids
* may control symptoms but won’t improve prognosis
Describe the presentation of polyarticular JIA [2]
- idiopathic inflammatory arthritis in 5 joints or more
- symmetrical arthritis
- mild systemic symtpoms
NB - think of it like a seronegative juvinilie RA
Describe the presentation oligoarticular JIA [4]
- It involves 4 joints or less.
- Usually it only affects a single joint, which is described as a monoarthritis - often knee or ankle
- Classically associated with anterior uveitis - refer to an opthamologist
- ANA positive
How can you think of Enthesitis-Related Arthritis? [1]
A paediatric version of the seronegative spondyloarthropathy group of conditions that affect adults. These conditions are ankylosing spondylitis, psoriatic arthritis, reactive arthritis and inflammatory bowel disease-related arthritis.
The majority of patients with enthesitis-related arthritis have the HLA B27 gene.
Describe the managment of juvenile idiopathic arthrits
NSAIDs, such as ibuprofen
Steroids, either oral, intramuscular or intra-artricular in oligoarthritis
DMARDs, such as methotrexate, sulfasalazine and leflunomide
Biologic therapy, such as the tumour necrosis factor inhibitors etanercept, infliximab and adalimumab
