Toronto Notes: Basics Flashcards
Describe a degenerative joint
Loss of joint space
Cartilage destruction
Osteophytes
Cartilage particle
Describe a inflammatory joint
Erosions Cartilage destruction Joint space narrowing Effusion Synovitis
What is a Type 1 immune response
Anaphylactic. IgE caused release of mediators from mast cells. E.g Asthma, allergic rhinitis
What is a Type 2 immune response
Cytotoxic. Antibody formed, attached to antibody → phagocytosis and lysis E.g. Autoimmune hemolytic anemia, goodpasture, graves disease, pernicious anaemia
What is a Type 3 immune response
Immune complex. Ag-Ab couplex activates complement → attracts inflammatory cells. SLE, PAN, post-strep glomerulonephritis
What is a Type 4 immune response
Cell mediated/delayed hypersensitiivty. Release of cytokines by sensitised T cells and T cell mediated cytotoxicity. Contact dermatitis
What gene on what chromo some codes for HLA?
Chromosome 6, MHCs genes
MHC Class 1 are found on which cells
All cells
HLA-A,B,C
Reconginsed by CD8+ (cytotoxic cells) T lymphocytes
MHC Class 2 are found on which cells
Ag presenting cells
HLA-DP, DQ, DR. Recognised by CD4+ (helper) T lymphocytes
Which conditions are related the HLA B27
Ankylosing spondylitis
Rheumatoid arthritis
Which condition is related the HLA DR4, DR1
RA
Which conditions are related the HLA DR3
SLE, Sjogrens
When thinking about joint involvement what are the key patterns you are looking for
Symmetrical vs asymmetrical
Small vs large
Mono vs oligo (2-4) vs poly articular (>5joints)
Axial vs peripheral
Differentials for monoarthritis
Infection: septic Crystal: gout, pseudogout Degen: OA Trauma: Hemarthrosis, osteonecrosis Neoplastic: Tumour Other: systemic inflame disease, polyarthtiris first presenting in 1 joint
Differential for acute (<6weeks) oligo/poly arthritis
First presentation of inflammatory arthritis
Post viral (parvovirus B19)
Acute rheumatic fever
Infectious (GC, non-GC)
Differential for chronic (>6weeks) oligo/poly arthritis
Seropositive inflammatory arthritis (RA, SLE, scleroderma)
Seronegative: AS, EA, PsA, ReA, crystal
OA
Symptoms of inflammatory arthritis vs degenerative arthritis
Inflammatory: Pain at rest, relieved by motion Morning stiffness >1 h Warmth, swelling, erythema Malalignment/deformity Extra-articular manifestations
Degenerative:
Pain with motion, relieved by rest
Morning stiffness
What does seropositive mean and what conditions does it include?
seropositive means RF positive and includes: RA, SLE, scleroderma, SS and DMM. Seronegative includes
What seronegative conditions are there
Symmetrical: AS, EA
Non-symmetical: ReA, PsA
Compare the difference of seropositive and seronegative rheumatic disease. Demographics Peripheral Arthritis Pelvix/axial disease Enthesitis Extra-articular
Demographics
S+ve: F>M
S-ve: M>F
Peripheral Arthritis
S+ve: Symmetrical. Small (PIP, MCP) and medium joints (wrist, knee, ankle, elbow) - DIP less common involved
S-ve: Usually asymmetrical. Usually larger joints, lower extremity (PsA exception). DIP in PsA. Dactylitis
Pelvix/axial disease
S+ve: No (except C Spine)
S-ve: Yes
Enthesitis
S+ve: No
S-ve: Yes
Extra-articular:
S+ve: Nodules, vasculitis, Sicca (dryness), Raynaud’s phenomenon
S-ve: Iritis (anterior uveitis), oral ulcers, GO, dermatological features
The following slides are about investigations in Rheumatology.
What are the acute inflammatory markers?
ESR, CPR, ferritin, albumin, fibrinogen, platelets
Name as many autoimmune Abs
ANA, anti-dsDNA, anti-Jo-1, anti-Sm, anti-La, anti-Ro, RF, and anti-CCP
What bedside test is essential for SLE
U/A: detects renal involvement (proteinuria)
Slide just to summarise all investigations
Common Investigations in Rheumatology
• general: CBC, electrolytes, Cr
• acute phase reactants: ESR, CRP, ferritin, albumin, fibrinogen, platelets
• complement (C3, C4)
• U/A to detect disease complications (proteinuria, active sediment)
• serology: autoimmune Abs (ANA, anti-dsDNA, anti-Jo-1, anti-Sm, anti-La, anti-Ro, RF, and
anti-CCP)
• synovial fluid analysis
• radiology (plain film, CT, MRI, U/S, bone densitometry, angiography, bone scan)
What is synovial fluid?
synovial fluid is an ultrafiltrate of plasma plus hyaluronic acid; it lubricates joint surfaces and
nourishes articular cartilage
Indications for synovial fluid analysis
Indications
• diagnostic: mandatory if septic arthritis suspected; advised if crystal arthritis or hemarthrosis
suspected; advised if unexplained effusion in accessible joint
• therapeutic: drainage of blood, purulent or tense effusions; corticosteroid injection
What are the 3 Cs you are testing for in the synovial fluid?
Cell count
Culture + gram stain (bacteria, mycobacteria, fungi)
Crystal examination (gout (monosodium urate) or pseudogout (calcium pyrophosphate dihydrate)
