Arthritis

Question 1

Define OLIGO and POLY arthritis:

Answer 1

Oligo = 2-4 joints
Poly = >4 joints

Question 2

Main differentials for arthritis’:
- Mono
- Oligo
- Poly

Answer 2

1- Distribution
2- Inflamm or non-inflamm?
3- Infectious or non-infectious?

___________
MONO
- Septic arthritis
- Crystal: Gout, CPP
- Haemarthrosis
- Trauma (meniscal, FB)
- Mono presentation of oligo/poly disease

OLIGO
- Reactive arthritis (Reiter’s- STI, enteric)
- Gonococcal (migratory)
- Sickle cell crisis (hip necrosis)

POLY (>4)
- Rheumatoid
- SYSTEMIC: - SLE, IBD, Psoriatic
- VASCULITIS: HSP, Kawasaki
- INFECTIVE: Gonococcal, Viral (Parvo, Ross River)
- POST INFECTIVE: Rheumatic Fever
- Serum sickness
- Leukaemia

Question 3

REACTIVE Arthritis:

Answer 3

AKA Reiter’s Syndrome

Adult men

CAUSES:
2-4 (up to 12) weeks following an infection. Commonly:
STI: Chlamydia
Food poisoning: Campylobacter, salmonella, shigella

PRESENTATION
TRIAD:
1- Arthritis (asymmetric oligo/poly)
2- Urethritis
3- Conjunctivitis
Can’t see, can’t pee, can’t climb a tree

NSAIDs, steroids, DMARDs

50% recurrent, 30% become chronic

Question 4

JOINT features of Rheumatoid Arthritis:

Answer 4

Symmetrical, polyarticular
Cervical: AtlantoAxial instability (tranv lig)
Hands: Swan-neck, Boutonniere, Z-thumb, Wrist: ulnar deviation, carpal tunnel
Hip
Knees

Question 5

EXTRA-ARTICULAR features of Rheumatoid Arthritis:

Answer 5

• Purpura, petechiae, rheumatoid nodules
• Cervical myelopathy, peripheral neuropathy
• Scleritis, conjunctivitis, keratitis (incl ulcerative)
• Pulmonary fibrosis, restrictive lung disease, pleural effusion, pulmonary nodules
• Restrictive pericarditis, valve pathology, IHD
• Renal failure
• Tenosynovitis
• Vasculitis
• Immunosuppression

Question 6

Diagnostic criteria for Rheumatoid Arthritis:

Answer 6

General categories:
- Arthritis distribution
- Serology (rheum factor) positivity
- Inflamm markers: ESR/CRP
- Duration ? >6weeks

Question 7

Which serology should be done to diagnose Rheumatoid Arthritis:

Answer 7

Rheumatoid factor (75%)
Anti-CCP (more specific + prognostic)

Question 8

What are the main DMARDS in Rheumatoid Arthritis? What are main adverse effects?

Answer 8

Methotrexate
Cyclophosphamide
Cyclosporin
Leflunomide
Sulfasalazine
Hydroxychloroquine
Azathioprine
‘Mabs (biologics)

_____

• Immunosuppression
• Bone marrow suppression incl. neutropaenia
• Lung injury (pneumonitis)
• Transaminitis
• Steven’s Johnson

Question 9

GOUT: about

Answer 9

MEN, 30-60

Monosodium urate crystals –> inflamm

From hyperuricaemia:
- Production: Purine (beer, shellfish), tumour lysis
- Excretion: CKD, thiazide, aspirin

CLINICAL
- Triggers:
–> ETOH or purine binge
–> Dehydration
–> Illness or stress
- 1st MTP (75%) (‘Podagra’)
- +/- fever

Question 10

GOUT: management of acute exacerbation

Answer 10

NSAID for 5 days
Eg. Celecoxib 100mg BD
Naproxen 250mg TDS

OR

COLCHICINE 500microg TDS for 4 days

OR

PREDNISOLONE 50mg daily for 3 days, then wean.
Or, intra-articular inj.

…Avoid aspirin, diuretics, purines, stopping allopurinol.

Question 11

When is aspiration indicated in suspected gout?

Answer 11

NOT required if first presentation of typical Podagra (or typical, recurrent gout Hx)

Question 12

Calcium Pyrophosphate Deposition Disease:

Answer 12

eg. Pseudogout

WOMEN >65

UPPER limb more common, but usually knee

Spontaneous, not triggered.

Often also causes tenosynovitis or bursitis and chrondrocalcinosis on Xray

MANAGEMENT
- Analgesia, NSAIDs, steroids
- Aspiration often relieves

Question 13

Answer 13

Haemarthrosis

Dense effusion
May ‘settle’ on lateral
If THREE densities seen: lipohaemarthrosis

Spont vs traumatic

R.I.C.E
Immobilise 72 hours
Therapeutically aspirate only if difficult to manage pain (may need to do diagnostically anyway)