Toronto Notes: Basics

Question 1

Describe a degenerative joint

Answer 1

Loss of joint space
Cartilage destruction
Osteophytes
Cartilage particle

Question 2

Describe a inflammatory joint

Answer 2

Erosions
Cartilage destruction 
Joint space narrowing 
Effusion 
Synovitis

Question 3

What is a Type 1 immune response

Answer 3

Anaphylactic. IgE caused release of mediators from mast cells. E.g Asthma, allergic rhinitis

Question 4

What is a Type 2 immune response

Answer 4

Cytotoxic. Antibody formed, attached to antibody → phagocytosis and lysis E.g. Autoimmune hemolytic anemia, goodpasture, graves disease, pernicious anaemia

Question 5

What is a Type 3 immune response

Answer 5

Immune complex. Ag-Ab couplex activates complement → attracts inflammatory cells. SLE, PAN, post-strep glomerulonephritis

Question 6

What is a Type 4 immune response

Answer 6

Cell mediated/delayed hypersensitiivty. Release of cytokines by sensitised T cells and T cell mediated cytotoxicity. Contact dermatitis

Question 7

What gene on what chromo some codes for HLA?

Answer 7

Chromosome 6, MHCs genes

Question 8

MHC Class 1 are found on which cells

Answer 8

All cells
HLA-A,B,C
Reconginsed by CD8+ (cytotoxic cells) T lymphocytes

Question 9

MHC Class 2 are found on which cells

Answer 9

Ag presenting cells

HLA-DP, DQ, DR. Recognised by CD4+ (helper) T lymphocytes

Question 10

Which conditions are related the HLA B27

Answer 10

Ankylosing spondylitis

Rheumatoid arthritis

Question 11

Which condition is related the HLA DR4, DR1

Answer 11

RA

Question 12

Which conditions are related the HLA DR3

Answer 12

SLE, Sjogrens

Question 13

When thinking about joint involvement what are the key patterns you are looking for

Answer 13

Symmetrical vs asymmetrical
Small vs large
Mono vs oligo (2-4) vs poly articular (>5joints)
Axial vs peripheral

Question 14

Differentials for monoarthritis

Answer 14

Infection: septic
Crystal: gout, pseudogout
Degen: OA
Trauma: Hemarthrosis, osteonecrosis 
Neoplastic: Tumour 
Other: systemic inflame disease, polyarthtiris first presenting in 1 joint

Question 15

Differential for acute (<6weeks) oligo/poly arthritis

Answer 15

First presentation of inflammatory arthritis
Post viral (parvovirus B19)
Acute rheumatic fever
Infectious (GC, non-GC)

Question 16

Differential for chronic (>6weeks) oligo/poly arthritis

Answer 16

Seropositive inflammatory arthritis (RA, SLE, scleroderma)
Seronegative: AS, EA, PsA, ReA, crystal
OA

Question 17

Symptoms of inflammatory arthritis vs degenerative arthritis

Answer 17

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

Question 18

What does seropositive mean and what conditions does it include?

Answer 18

seropositive means RF positive and includes: RA, SLE, scleroderma, SS and DMM. Seronegative includes

Question 19

What seronegative conditions are there

Answer 19

Symmetrical: AS, EA

Non-symmetical: ReA, PsA

Question 20

Compare the difference of seropositive and seronegative rheumatic disease.
Demographics 
Peripheral Arthritis 
Pelvix/axial disease
Enthesitis 
Extra-articular

Answer 20

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

Question 21

The following slides are about investigations in Rheumatology.
What are the acute inflammatory markers?

Answer 21

ESR, CPR, ferritin, albumin, fibrinogen, platelets

Question 22

Name as many autoimmune Abs

Answer 22

ANA, anti-dsDNA, anti-Jo-1, anti-Sm, anti-La, anti-Ro, RF, and anti-CCP

Question 23

What bedside test is essential for SLE

Answer 23

U/A: detects renal involvement (proteinuria)

Question 24

Slide just to summarise all investigations

Answer 24

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)

Question 25

What is synovial fluid?

Answer 25

synovial fluid is an ultrafiltrate of plasma plus hyaluronic acid; it lubricates joint surfaces and
nourishes articular cartilage

Question 26

Indications for synovial fluid analysis

Answer 26

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

Question 27

What are the 3 Cs you are testing for in the synovial fluid?

Answer 27

Cell count
Culture + gram stain (bacteria, mycobacteria, fungi)
Crystal examination (gout (monosodium urate) or pseudogout (calcium pyrophosphate dihydrate)