Week 6: Rheumatology (2) (conditions and investigations) Flashcards
hypermobility spectrum disorder
- 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
RF for hypermobility spectrum disorder
- 10% of pop- very few symptomatic
- Familial
- More common in women and Asian people
- Presents in childhood or young adulthood
- Recurrent subluxations or dislocations
presentation of hypermobility spectrum disorder
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
HSD Treatment
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
osteoarthritis
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.
OA pathophysiology
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
key features of OA
- loss of elasticity with a reduced tensile strength
- cellularity and proteoglycan content are reduced
risk factors for OA
- age
- women
- obesity
- trauma
- hereditary
presentation of OA
- 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
investigation for OA
x-ray
OA x-ray findings
· Joint space narrowing
· Subarticular sclerosis
· Bone cysts
· Osteophytes
treatment of OA- non pharmacological
- Strengthening and range of movement exercises
- Weight loss to reduce joint loading
- Laterally wedged insoles/ walking stick
treatment of OA- pharmacological
- Paracetamol regularly
- NSAIDs short-term
- Topical NSAIDs
- Intraarticular corticosteroids (evidence of benefit from glucosamine or chondroitin sulphate supplements not convincing
treatment of OA - surgery
- Surgery
- If pharmacological and physical modalities of treatment don’t work
- Younger patients have higher chance of revision surgery int eh future
osteoporosis
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
risk factors for osteoporosis: non-mdoifiable
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.
risk factors for osteoporosis - modifiable
- 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
secondary causes of osteoporosis
coeliac, eating disorders, hyperparathyroidism and hyperthyroidism, MM
investigations for osteoporosis
- 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
important considerations for osteoporosis
- 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.
dexa score: osteopenia vs osteoporosis
- 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
- 2nd line: `Denosumab or teriparatide
advice for taking bisphosphonates for osteoporosis
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
prevention of osteoporosis
Regular weight-bearing exercise prevents osteoporosis
Fibromyalgia
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.
fibromyalgia pathogenesis
- 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.
risk factor of fibromyalgia
- 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
presentation of fibromyaglia
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.
management of fibromyalgia
- 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
describe and diagnose this condition
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
describe and diagnose
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
differential diagnosis of widespread pain
fibromyalgia
- diagnosis of exclusion
- middle aged women
- fatigue and unrefreshing sleep
- treatment withe exercise, CBT, SSRIs and tricyclics
describe and diagnose
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
to diagnose gout you need at least 2 of
typical history
tophi
raised serum urate
crystals in joint during attach
differential diagnosis of chronic monoarticular joint diseaser
inflammatory arthritis e.g. psoriatic
osteoarthritis
foreign body
key finding of MRI spine in patient with ankylosing spondylitis
bamboo spine and sclerosis of SIJ joint (erosion)- fusion
risk factors for osteoporosis
FRACTURES
family Hx
RA
alcohol
cigarettes
thin
UC
reduced mobility
endocrinopathies
steroid use
what is the most likely diagnosis
systemic lupus erythematosus
afrocaribbean > south asian > caucasians
