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W19 71 rheumatology and connective tissue disorders Flashcards

1
Q

What is osteoarthritis?

A

Mechanical joint disease
Non-inflammatory arthritis
Wear of the cartilage occurs and new bone is formed at the margins of the joints

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2
Q

What does osteoarthritis affect?

A

Many joints:
TMJ and cervical spine - pain on movement, restricted movement
Other joints

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3
Q

What is rheumatoid arthritis?

A

Chronic multi systemic disease. Inflammatory arthritis - persistent. Affects synovial lining of joints, bursae and tendons. Characterised by joint pain, swelling and stiffness. Characterisation: polyarticular, symmetrical, hand joints

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4
Q

How do you diagnose rheumatoid arthritis?

A

Blood tests:
- rheumatoid factor RF - antibodies, when positive seropositive
- anti-CCP antibodies (ACPA)
- acute phase reactants (APR)
Radiographic changes - looking for erosions or joint space narrowing

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5
Q

Image of the joints in RA - PG675

A

Look at image :)

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6
Q

What common joints can be involved in RA?

A

TMJ
Cervical spine
Atlanto-axial joint

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7
Q

What are some systemic manifestations of RA?

A

Constitutional - weight loss, fatigue
Organ specific - eye, mouth, skin, lungs, nerves, heart, bone

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8
Q

What are nodules?

A

Areas of pressure, internal. Result from small vessel vasculitis with fibrin oil necrosis forming the centre of the nodule. Can occur in RA.

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9
Q

What disease can affect the lacrimal and salivary glands secondary to RA and what does this cause?

A

(Secondary) Sjrogren’s syndrome to RA
Dry eyes, dry mouth, dental caries

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10
Q

Describe inflammatory eye disease from RA

A

Epicleritis
Scleritis - may progress to scleromalacia
Corneal melt
Drugs can cause toxicity in the eyes: steroids can lead to cataract; chloroquine can lead to retinopathy

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11
Q

How might RA affect the lungs?

A

Fibrosing alveolitis
Pulmonary nodules

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12
Q

Describe what osteoporosis is (bone loss) caused by RA by the imbalance of bone remodelling

A

Bone resorption process mediated by osteoclasts
Cytokines involved in inflammation in the synovial accelerate osteoclasts differentiation by upregulating RANKL, leading to bone loss in RA. More prone to bone loss and bone fracture.

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13
Q

What dental disease is prevalent in RA?

A

Periodontitis and tooth loss
(strength of relation not confirmed yet)

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14
Q

What is the aim for management of RA?

A

Early intervention to control inflammation and prevent structural damage and prevent loss of function

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15
Q

How do you manage RA?

A

NSAIDs
Disease modifying anti-rheumatic drugs (eg methotrexate) - control progression, inflammation and damage
Steroids - not used long term due to side effects
Biological therapies (eg anti-TNF therapy)

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16
Q

What if TNF?

A

A very powerful inflammatory cytokines, with effects at many levels eg on osteoclast activation

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17
Q

What are the destructive effects of TNF? PG680 IMAGE

A

Effects on osteoclasts, synoviocytes and chondrocytes to cause:
Bone resorption leading to bone erosion; join inflammation leading to pain and swelling; cartilage degradation leading to join space narrowing

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18
Q

What are some seronegative spondyloarthropathies?

A

Ankylosing spondylitis (AS)
Psoriatic arthritis (PsA)
Reactive arthritis
Crohn’s disease/UC associated arthritis

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19
Q

What is common between the seronegative spondyloarthropathies?

A

These disease groups affect the skin, eyes, gut, and joints
Common genetic risk factor - HLA B27

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20
Q

What is anthesis?

A

Anthesis = where the tunnel attaches to the bone

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21
Q

What is ankylosing spondylitis?

A

Spondylitis and arthritis
Arthritis of the spine, can be affected at many levels but also the saccryl joints and the coccyx.
Causes enthesitis and new bone formation - causes hard time moving the spine/joints

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22
Q

What is psoriatic arthritis?

A

Causes nail pitting, arthritis, swollen digits.
Complex polygenic autoimmune disease with diverse clinical features
Can affect skin, joints, eyes and many systemic parts
Sacrolytis is a prominent feature

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23
Q

What other oral condition can come from diseases of rheumatology eg lupus and arthritis and medication use?

A

Mucosal ulcers

24
Q

What is anterior uveitis?

A

Eye involvement in ankylosing spondylitis
Inflammation of the uveal tract
Symptoms: painful, red eyes, photophobia, floaters, blurred vision

25
How do you manage spondyloarthropathies?
NSAIDs Disease modifying anti-rheumatic drugs eg methotrexate for psoriatic arthritic Steroids - to control active disease but much less than in RA Biologic therapies (anti-TNF therapy)
26
What connective tissue diseases and vasculitis are there?
SLE, systemic sclerosis, Sjögren’s syndrome Behçet’s disease, Temporal arteritis
27
SLE, systemic lupus erythematous is a multisystemic disease. What can it affect?
Rashes, hair loss, mouth ulcers Inflammatory arthritis and myositis Renal disease Pulmonary disease Neurological disease Haematological disease
28
Connective tissue disease and vasculitis eg SLE, might come with antiphospholipid syndrome where platelets are low. What is the issue with this?
Thrombosis occurs so clots are a problem in these patients, so need to take anticoagulants for life.
29
What other diseases are common in lupus too?
Raynaud’s phenomenon, Livedo reticularis, alopecia
30
What is Raynaud’s phenomenon?
Blood vessels narrow reducing blood flow to hands. Fingers become cold and white. Feeling of ions and needles and numbness. Fingers then turn blue and red. Sometimes painful.
31
What is livedo reticularis?
Mottled reticulated vascular pattern that appears like a lace-like purplish discolouration of the lower extremities.
32
What is scleroderma?
Skin thickening Difficulty opening mouth Raynaud’s syndrome Internal organ disease - lungs, kidneys, gut Skin changes
33
What skin changes occur in scleroderma?
Inflammatory, indurative then atopic phase Oedema, tightening, thickening, waxy feel Loss of function in hands, arms, legs Chest involvement Telangeclasia
34
What is Sjögren’s syndrome?
A slowly progressive inflammatory disease affecting primarily the exocrine glands (eg salivary glands). Lymphocyte infiltrates these glands. Characteristic autoantibodies - Ro, La. Causes mucosal dryness - eyes, mouth, genital tract
35
What extra-glandular disease might come from Sjogren’s?
Poly arthritis, lungs, kidneys, liver, blood vessels
36
What other autoimmune diseases might Sjogren’s be associated with?
RA, SLE, systemic sclerosis, polymyositis (fibromyalgia) Can present as a secondary disease to these conditions
37
What are the types of vasculitis?
Temporal arteritis or giant cell arteritis (GCA)
38
Symptoms of vasculitis
Headache, scalp tenderness, jaw claudication, fatigue Visual loss (permanent) if not treated quickly
39
How can ENT disease present in patients with vasculitis?
Granulomatosis with polyangitis (GPA) (rare) Bloody nasal discharge Nasal crusting Nasal collapse Stridor Shortness of breath Cough and haemoptysis Renal involvement
40
What is the treatment for most connective tissue diseases and vasculitis?
Steroids Immunosuppressants eg methotrexate, cyclophosphamide Anticoagulants in SLE and anti-phospholipid syndrome
41
What is Paget’s disease?
A metabolic bone disease causing excess bone turnover
42
What is Paget’s disease characterised by?
Bone pain, bone deformity and fracture, vascular bone, bleeding, hypercementosis of teeth and fracture Affects maxilla more than mandible Can have enlarged skull with cotton wool appearance on radiograph
43
How is Paget’s disease treated?
Bisphosphonates
44
What are the risk factors for developing ONJ from bisphosphonates?
Potency of bisphosphonate (highest for zoledronate), route of administration, cumulative dose, duration and type of malignant disease, concomitant treatment, smoking, comorbid conditions and history of dental disease
45
Which patients have a higher risk of developing ONJ from bisphosphonates?
Risk of osteonecrosis of the jaw is substantially greater for patients receiving intravenous bisphosphonates in the treatment of cancer than for patients receiving oral bisphosphonates for osteoporosis or Paget’s disease
46
What should you advise patients starting bisphosphonates?
All patients should have a dental check-up before bisphosphonate treatment or asap after starting treatment.
47
Is ONJ from bisphosphonates common?
Rare. Usually occurs in associated with dental surgery or dental infection but can also occur spontaneously. Relatively uncommon but potentially serious side effect of treatment with either bisphosphonates or denosumab
48
What do the international task force say on ONJ recommendations?
Completion of dental work prior to initiation of antiresorptive therapy Use antibiotics before and after procedure Antimicrobial mouth rinsing Appropriate closure of wound following surgery Maintenance of good oral hygiene Discontinuation of BPs should be made via clinical judgement.
49
When might you want to discontinue bisphosphonates?
Not needed in low risk osteoporosis patients Maybe needed in patients who require extensive invasive oral surgery and in those with multiple risk factors for ONJ (eg glucocorticoids treatment, diabetes, immune deficiencies, smoking etc), and to restart when bone has healed?
50
FLOW DIAGRAMS FOR TISK OF ONJ AND MANAGEMENT PG690
VIEW AND PRINT!
51
When should you review healing post extraction in patients on bisphosphonates?
8 weeks
52
What is fibromyalgia?
Widespread pain, above and below the diaphragm. Classic tender points. Characterised by >=11/18 tender points.
53
What overlap does fibromyalgia overlap with other diagnoses?
Temporomandibular syndrome Irritable bowel syndrome Headache syndromes All can cause sleep disturbance
54
What is treatment for fibromyalgia?
Analgesics to control pain - often including codeine Antidepressants to help sleep/muscle relaxation - eg amytriptiline, fluoxetine Anti-seizure drugs to help pain and sleep - eg gabapentin or pregabalin Graded exercise programme, relaxation techniques, self care programmes
55
What things could cause pain on chewing?
TMJ - osteoarthritis, RA, ankylosing spondylitis etc Bone involvement eg Paget’s Vasculitis eg temporal arteritis Pain syndrome Salivary glands Sinuses Ear Neurological eg trigeminal neuralgia
56
What rheumatological diseases might cause mouth ulcers?
Arthrides - reactive arthritis Connective tissue disease and vasculitides - Behçet’s disease, SLE Drugs Infective eg HIV Bowel disease eg Crohn’s disease, coeliac disease

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