Clinical (Weeks 1+2) Flashcards
What genes are associated with a susceptibility to RA?
HLA DR4
HLA DR1
What cells invade the synovium in RA?
Macrophages
Fibroblasts
Multinucleated giant cells
What is the basic process behind RA?
- Synovial expansion
- Invasion of bone
- Erodes bone and cartilage
Articular symptoms of RA?
Joint pain
Morning stiffness
Joint swelling
Extra-articular manifestations of RA
Respiratory: - Effusions - Fibrosis - Nodules Rheumatoid nodules on extensor surfaces Ocular involvement: - Keratoconjunctivitis - Episcleritis - Uveitis - Nodular scleritis Increased CVS morbidity and mortality
What hand joint is not affected by RA?
DIP
What pattern of joint involvement is seen in RA?
Symmetrical
How is RA defined by the EULAR/ACR Classification?
Synovitis in >/=1 joint Absence of better diagnosis Achievement of >/=6/10 of: - Number and site of affected joints (0-5) - Serological abnormality (0-3) - Increased CRP/ESR (0-1) - Symptom duration (0-1)
What is the best autoantibody to test for to aid in the diagnosis of RA?
Anti-CCP (Cycli citrullinated peptide) Antibody
Does a patient need to be Rheumatoid Factor positive (RhF) to have RA?
No
What chronic haematological change may be seen in RA?
Anaemia
What x-ray changes are seen in RA?
Osteopaenia:
- Loss of joint space
- Periarticular erosions
Soft tissue swelling
What late complications can be seen in RA?
Infection Cervical myelopahy secondary to: - Atlanto-axial/Subaxial subluxation ILD Peripheral neuropathy
What comorbidities is RA associated with?
Severe infections
CVS mortality
Lymphoma
What genetic factor is a poor prognostic factor in RA?
HLA DR4 positive
How soon must treatment be begun in RA to prevent irreversible damage?
Within 3 months
What are the principles of RA treatment?
DMARDs
Steroids to cover lag phase
Frequent reviews
Give examples of DMARDs and when they might be used?
1st line - Methotrexate
2nd line and in pregnancy - Sulphasalazine
Hydroxychloroquine
Leflunamide
What four approaches to biologic therapy can be used in RA and give examples of drugs in each class?
TNF-alpha inhibition: - Infliximab - Adalimumab - Etanercept B cell depletion: - Rituximab Disruption of T cell co-stimulation: - Abatecept Interleukin inhibition: - Anankira (IL-1) - Tocilizumab (IL-6) (Jak-2 inhibitors)
What is the pathogenesis of OA?
Loss of matrix (Collagen ii with chondrocytes embedded)
Cytokine release:
- IL-1
- TNF-alpha
- Metalloproteinases
- Prostaglandins from chondrocytes
Surface fibrosis and attempted repair -> Oestophytes
How are localised and generalised idiopathic OA defined
Localised: - Hands - Feet - Knee - Hip - Spine Generalised is >/= 3 sites involved
What are some secondary causes of OA?
Previous injury RA Genetic Acromegaly Crystal arthropathy Perthes SUFE
Risk factors of OA
Age Female Obesity Job Injury/Sports
When is pain typically present in OA?
During exercise
How long does morning stiffness last in OA?
Less than 30 minutes
What might be found on examination of a patient with OA?
Crepitus
Bony enlargements
Joint tenderness and effusion
What can lumbar spine OA result in?
Spinal stenosis
Where does hip OA pain radiate to?
Groin/back
OA at what site can result in genu valgum and a Baker’s cyst?
Knee
What are some features of OA in the hand?
Heberden’s nodes (DIP OA)
Bouchard’s nodes (PIP OA)
Thumb base squaring (CMC OA)
Sterotypical x-ray features of OA?
Loss of joint space Osteophyte formation Subchondral sclerosis Subchondral cysts (LOSS)
Define the grades of OA according to the Kellgren-Lawrence scale?
Grade 0: - No findings Grade 1: - Minute osteophytes Grade 2: - Definite osteophytes - Unimpaired joint space Grade 3: - Definite osteophytes - Moderate loss of joint space Grade 4: - Definite osteophytes - Severe space loss and sclerosis
What are the main non-pharmacological treatments of OA?
Physiotherapy
Weight loss
Exercise
What pharmacological treatments are prescribed in OA?
Analgesia: - Paracetamol - Topicals NSAIDs Pain modulators: - TCAs - Gabapentin
What intra-articular medications can be used in OA?
Steroids
Hyaluronic acid
Surgical treatments of OA
Arthroscopic washout
Soft tissue trimming
Joint replacement
What causes gout?
Uric acid crystals
Is gout more common in men or women?
Men
What results in increased urate production?
Enzyme defects Psoriasis Haemolytic disorders Alcohol High purine diet (red meat, seafood)
What results in decreased urate excretion?
Renal impairment Volume depletion Hypothyroidism Diuretics Cytotoxics
True or false; Blood uric acid can be normal in acute gout?
True
What joint is the most common site of acute gout?
1st MTP (Podagra)
What is chronic tophaceous gout associated with?
Diuretics
What is the best diagnostic investigation for gout?
Polarised microscopy:
- Negatively birefringent - Needle shaped crystals
What appearance will gout show on x-ray?
Erosive arthritis features
How do we treat an acute flare of gout?
NSAIDs
Steroids
Colchicine
How can we prevent gout?
Xanthine oxidase inhibitors:
- Allopurinol - Febuxostat
How do we use allopurinol?
Start 2-4 weeks after acute
Continue use during future acute flares
Titrate dose up until serum urate
What causes psuedogout?
Deposition of calcium pyrophosphate crystals
What does pseudogout cause?
Calcinosis:
- Deposition of calcium in cartilage and soft tissue - No inflammation
How does pseudogout appear on polarised micropscopy?
Mildly positive birefringement
Envelope-shaped crystals
What is pseudogout associated with?
Hyperparathyroidism Hypothyroidism Amyloidosis Haemochromatosis Gout Trauma Ageing Haemosiderosis
A 54 year old female prevents with reduced shoulder movement, that is painful and tender to touch. There is hydroxyapatite in the synovial fluid. How would we treat this?
Milwaukee shoulder:
- NSAIDs - Intra-articular steroids - Physiotherapy - Arthroplasty
How could we differentiate between soft tissue rheumatism and fibromyalgia?
Fibromyalgia is a more generalised pain
Soft tissue rheumatism is confined to one site
What genetic syndromes are associated with joint hypermobility?
Marfan’s
Ehlers Danlos
How do we measure joint hypermobility?
Modified Beighton Score
When do we treat joint hypermobility?
If there is arthralgia or permature OA
What is the female to male ratio in SLE?
F:M is 9:1
What does SLE stand for?
Systemic Lupus Erythematosus
What populations is SLE most common in?
Asians
African-Americans
Afro-Caribbeans
Hispanic Americans
What population is SLE least common in?
African blacks
What is the environmental aetiology of SLE?
Smoking
UV light
Silica dust
What infection can trigger SLE?
EBV
Order these steps in the pathogenesis of SLE:
- B+T cells stimulated
- Loss of immune regulation
- Autoantibodies made
- Increase in defective apoptosis
- Immune complexes
- Nuclear material persists -> Acts as autoantigens
- Autoimmunity due to extended exposure to nuclear and intraceullar proteins
- Loss of immune regulation
- Increase in defective apoptosis
- Nuclear material persists -> Acts as autoantigens
- Autoimmunity due to extended exposure
- B+T cells stimulated
- Autoantibodies made
- Immune complexes
Where do the immune complexes in SLE gather and what does this cause?
In blood vessel walls: - Skin - Kidneys Complement release -> Neutrophils release enzymes Damage to basement membrane results
Are complement levels high or low in SLE?
Low
What are some of the distinguishing cutaneous features of SLE?
Photosensitivity Malar 'butterfly' rash: - Spares labial-nasal fold Discoid LE Subacute cutaneous lupus
What deforming arthropathy can be seen in SLE?
Jaccoud’s arthritis
What pulmonary features can be present in lupus?
Pleurisy -> Pleuritis Effusion PE Pulmonary hypertension Fibrosis (diffuse) -> ILD
What cardiac features can be present in SLE?
Pericarditis
Cardiomyopathy -> MI
Libman-Sachs endocarditis
What haematological conditions can be seen in lupus?
Lymphadenopathy
Leukopaenia
Anaemia
Thrombocytopaenia
Why are patients with lupus more susceptible to infections?
Decreased complement
Impaired cell mediated immunity
Defective phagocytosis
Poor Ab response
What is the most specific autoantibody in lupus?
Anti-double stranded DNA antibody (Anti-DNA)`