Week 6: Rheumatology (2) (conditions and investigations)

Question 1

hypermobility spectrum disorder

Answer 1

• Pain syndrome in people with joints that move beyond normal limits (often referred to as being “double-jointed”).
• There is no precise definition as joint mobility is a graduated phenomenon. It may affect any number of joints.
• Pathophysiology- It is due to laxity of ligaments, capsules and tendons.
  
  • It is thought that the origin of pain is from microtrauma

Question 2

RF for hypermobility spectrum disorder

Answer 2

• 10% of pop- very few symptomatic
• Familial
• More common in women and Asian people
• Presents in childhood or young adulthood
• Recurrent subluxations or dislocations

Question 3

presentation of hypermobility spectrum disorder

Answer 3

Pain around the joints, worse after activity, but pain may generalize and fatigue is prominent too.
Other features:

• soft tissue rheumatism e.g. epicondylitis
• abnormal skin: papyraceous scars, hyperextensible, thin, striae
• marfanoid habitus
• arachnodactyly
• drooping eyelids, myopia
• hernias and uterine/rectal prolapses

Question 4

HSD Treatment

Answer 4

aims to improve pain and reduce disability

• Non-drug therapy (mainstay)
  
  • strengthening exercises to reduce joint subluxation
  • work on posture and balance
  • splinting and evening surgical intervention
  • advice on pacing and goal setting
  • specialist pain management
• Pharmacological therapy
  
  • No good evidence base on which to advise
  • Paracetamol mainstay

Question 5

osteoarthritis

Answer 5

This is the commonest type of arthritis: a degenerative joint disorder in which there is progressive loss of articular cartilage accompanied by new bone formation and capsular fibrosis.

Question 6

OA pathophysiology

Answer 6

3 possible scenarios

• Failure of normal cartilage subject to abnormal or incongruous loading for long periods
• Damaged or defective cartilage failing under normal conditions of loading
• Break up of cartilage due to defective stiffened subchondral bone passing more load to it

Question 7

key features of OA

Answer 7

• loss of elasticity with a reduced tensile strength
• cellularity and proteoglycan content are reduced

Question 8

risk factors for OA

Answer 8

• age
• women
• obesity
• trauma
• hereditary

Question 9

presentation of OA

Answer 9

• hip knee and spine most commonly affected
• pain is provoked by movement and weight-bearing
• at first intermittent, but later constant
• at the knee inactivity gelling a feeling that the joint will give way are common

Question 10

investigation for OA

Answer 10

x-ray

Question 11

OA x-ray findings

Answer 11

· Joint space narrowing

· Subarticular sclerosis

· Bone cysts

· Osteophytes

Question 12

treatment of OA- non pharmacological

Answer 12

• Strengthening and range of movement exercises
• Weight loss to reduce joint loading
• Laterally wedged insoles/ walking stick

Question 13

treatment of OA- pharmacological

Answer 13

• Paracetamol regularly
• NSAIDs short-term
• Topical NSAIDs
• Intraarticular corticosteroids (evidence of benefit from glucosamine or chondroitin sulphate supplements not convincing

Question 14

treatment of OA - surgery

Answer 14

• Surgery
  
  • If pharmacological and physical modalities of treatment don’t work
  • Younger patients have higher chance of revision surgery int eh future

Question 15

osteoporosis

Answer 15

A skeletal condition characterized by low bone mass, deterioration of bone tissue, and disruption of bone architecture that leads to compromised bone strength and an increased risk of fracture

Question 16

risk factors for osteoporosis: non-mdoifiable

Answer 16

Non-modifiable

• Advanced age (>65 years)
• Female gender
• Caucasian or south Asians
• Family history of osteoporosis-genetic
• History of low trauma fracture (fall from standing height or less, at walking speed or less.

Question 17

risk factors for osteoporosis - modifiable

Answer 17

• Low body weight (58 kg or body mass index [BMI] <21)
• Premature menopause (age<45)
• Calcium/vitamin D deficiency
• Inadequate physical activity
• Cigarette smoking
• Excessive alcohol intake (>3 drinks/day)
• Iatrogenic: e.g. corticosteroids, aromatase inhibitors

Question 18

secondary causes of osteoporosis

Answer 18

coeliac, eating disorders, hyperparathyroidism and hyperthyroidism, MM

Question 19

investigations for osteoporosis

Answer 19

• Dual energy x-ray absorptiometry (DEXA) of the lumbar spine and hip is considered the gold standard for the diagnosis of osteoporosis.
• T-score is the number of SDs from the mean bone density of persons of same gender at age of peak density (25 years)
• T-score minus 2.5 or less = osteoporosis
• Normal BMD = T-score ≥ −1
• Osteopenia = T-score between −1 and −2.5

Question 20

important considerations for osteoporosis

Answer 20

• The Z-score is a comparison of the patient’s BMD with an age- & gender-matched population.
• A Z-score
• Plain radiographs lack sensitivity to diagnose osteoporosis, but rib fractures or vertebral compression fractures without trauma history should prompt evaluation for osteoporosis.

Question 21

dexa score: osteopenia vs osteoporosis

Answer 21

• For osteopenia (BMD between -1 and 2.5)
  
  • Risk modification: weight-bearing exercise, VitD3 supplementation (800-20000 IU/day), limiting alcohol and smoking cessation. Dietary advice regarding calcium intake
• For osteoporosis (BMD -2.5)
  
  • VitD +- calcium supplementation
  • Oral bisphosphonates or IV if oral not tolerated
  • 2^nd line: `Denosumab or teriparatide

Question 22

advice for taking bisphosphonates for osteoporosis

Answer 22

Always take on an empty stomach with a full glass of water. Stand or sit upright for 30 mins after taking them. Wait between 30 mins and 2 hours before eating or drinking

Question 23

prevention of osteoporosis

Answer 23

Regular weight-bearing exercise prevents osteoporosis

Question 24

Fibromyalgia

Answer 24

A common disorder of central pain processing characterised by chronic widespread pain in all 4 quadrants of the body (both sides and above and below the waist).

• Allodynia, a heightened and painful response to innocuous stimuli, is often present.

Question 25

fibromyalgia pathogenesis

Answer 25

• It can be induced by deliberate sleep deprivation.
• Sleep disturbance is probably the trigger in most patients -EEG studies show reduced REM sleep and delta wave sleep.
• This causes hyper-activation in response to noxious stimulation, and neural activation in brain regions associated with pain perception in response to non-painful stimuli.

Question 26

risk factor of fibromyalgia

Answer 26

• affects 5% of population
• female : male = 9 : 1
• peak age of onset 40-50
• onset may have an obvious trigger – emotional or physical e.g. painful arthritis

Question 27

presentation of fibromyaglia

Answer 27

Fibromyalgia symptoms are not restricted to pain

• joint/muscle stiffness
• profound fatigue
• unrefreshed sleep
• numbness
• headaches
• irritable bowel/bladder syndrome
• depression and anxiety
• poor concentration and memory “fibrofog”

On examination, there should be no physical abnormalities to the MSK or neurological systems. Patients may have “tender points” on palpation of their muscles. These are present if the patient experiences excess discomfort when palpating with just sufficient pressure to blanch your finger nails. There is no specific diagnostic test.

Question 28

management of fibromyalgia

Answer 28

• treatment modalities should be specifically tailored to pain intensity, function and associated features such as depression, fatigue and sleep disturbance
• improve sleep and physical activity levels
• low dose amitriptyline and pregabalin
• opiates not recommended
• CBT

Question 29

describe and diagnose this condition

Answer 29

aysmmetrical oligoarthritis

→ psoriatic arthritis

→ usually have had psoriasis before onset of arthritis

→ nail involvement → pitting in the nails

→ drug treatment for both arthritis and psoriasis: methotrexate

Question 30

describe and diagnose

Answer 30

reactive arthritis

• sterile inflammaotry arthriits preceiptated by a distant infection
• usually oligoarhtirits of lowe limb
• young patients
• chamydia trachomatis, chlamydia pneumonia, shigella, slamonells
• can occur up to a month post infection
• prompt antimicrobial treatment of infection may improve outcomes
• most resolve <6 months

Question 31

differential diagnosis of widespread pain

Answer 31

fibromyalgia

• diagnosis of exclusion
• middle aged women
• fatigue and unrefreshing sleep
• treatment withe exercise, CBT, SSRIs and tricyclics

Question 32

describe and diagnose

Answer 32

acute monoarticular joint disease

→ septic arthritis

→ RFL extremes of age, prosthetic joint, diabetic, immunosuppression, IVDU

→ staph aureus

→ investigate (mc&s of joint aspirate and blood cultures- best before antibiotics), CRP FBC

Question 33

to diagnose gout you need at least 2 of

Answer 33

typical history

tophi

raised serum urate

crystals in joint during attach

Question 34

differential diagnosis of chronic monoarticular joint diseaser

Answer 34

inflammatory arthritis e.g. psoriatic

osteoarthritis

foreign body

Question 35

key finding of MRI spine in patient with ankylosing spondylitis

Answer 35

bamboo spine and sclerosis of SIJ joint (erosion)- fusion

Question 36

risk factors for osteoporosis

Answer 36

FRACTURES
family Hx

RA

alcohol

cigarettes

thin

UC

reduced mobility

endocrinopathies

steroid use

Question 37

what is the most likely diagnosis

Answer 37

systemic lupus erythematosus

afrocaribbean > south asian > caucasians