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MSK > Arthiritis and other stuff like GOUT > Flashcards

Arthiritis and other stuff like GOUT Flashcards

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1
Q

Signs of Inflammatory arthitis

A

New onset joint SWELLING:
Synovial (compressible, tender)
Often red
Warm to touch

Worst in morning / inactivity
Stiffness > 30 mins (usually longer)
Constant or intermittent
Patterns of joint +/- spine involvement vary by arthritis type

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2
Q

Causes of joint inflammation

A

Inflammatory Arthritis:
RA
Seronegative Spondyloarthritis
Crystal arthrits – gout and pseudogout

Septic arthirits

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3
Q

Egs of Seronegative Spondyloarthritis

A

Psoriatic
Ank Spond
Reactive Arthritis
Enteropathic – Crohns and Ulcerative Colitis related

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4
Q

RA epidemiology

A

1% population
2-3x more common in females
Main risks – family history and smoking
Middle age (but any age

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5
Q

What is involved in RA

A

Symmetrical small joints, hands wrists feet
Big joints involved later, bad prognostic sign if involved at presentation
No spinal involvement

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6
Q

Epidemiology of Seronegative arthiritis

A

Asymmetrical big joints, with spinal involvement
More common in men
Associated symptoms
Inflammatory bowel, or GI infection, eye inflammation and psoriasis
Nail involvement predicts arthritis in patients with psoriasis

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7
Q

Features of psoriatic arthiritis

A

RA like
Distal interphalangeal involvement (OA more common)
Mutilans - rare
Dactylitis – sausage digit / toe
Asymetrical large joints + spine
CRP may not be significantly raised

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8
Q

Crystal Arthritis (Gout/) features

A

Typically acute intermittent episodes joint inflammation
Gout (6x more common in men)
feet, ankles, knees, elbows, hands
Hyperuricaemia
Risks – beer, renal impairment, diuretics, aspirin, FH

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9
Q

Crystal Arthritis Pseudogout features

A

3 x more common in women
wrists, knees, hands
Typically on background of OA
Chondrocalcinosis on xray

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10
Q

Features of osteoarthiritis

A

Usually slow onset – months to years
Typically weight bearing joints DIPs, PIPs, thumb bases, big toes
Minimal early morning stiffness (gelling)
No variability to joint swelling
Normal CRP
Clear changes on xray

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11
Q

Example degenerative arthiritis

A

Osteoarthritis

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12
Q

IA/RA features

A

Age of onset: Any age
Speed of onset: Rapid- weeks to months
Distribution: Symmetrical polyarthiritis
Joints affected: Small joints of hands and feet
Duration of morning stiffness: Worse in morning for 1 hour
Systemic symptoms: fatigue, fever, night sweats, malaise, myalgia
Swan - neck deformity
Ulnar deviation of fingers

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13
Q

Osteoarthirits features

A

Age of onset: Later in life
Speed of onset: Slow over the years
Distribution: Initially asymmetrical monoarthirits> polyarthiritis
Joints affected: Weight bearing joints- knees, hips , thumb base, big toe
Duration of morning stiffness: <1hour and worse at the end of the day (after activity)

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14
Q

How do we make a diagnosis

A

Is it inflammatory?
Visible joint swelling
Elevated CRP
Variable symptoms with flares

Which joint pattern?

Associated symptoms / risks
Psoriasis (particularly with nail involvement)
Inflammatory eye / bowel symptoms
Family / Smoking history (RA)

Tests
RF / CCP+ (RA only). Uric acid between attacks if ?gout
Xrays

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15
Q

Case 1
Mrs Green – 58
Pain in hands
Worsening over 12-18 months
Decreased grip strength
Stiff am – 15 mins
Worst end of fingers, thumbs
Paracetamol and occasional brufen helps a bit
CRP 1.3 (normal range 1-5)
RF 24 (normal range 0-20)
Xray – degenerative changes in DIP joints of both hands and first CMC joints. No erosions.
What is the diagnosis?
What next?

A

Answer

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16
Q

Brian -45
Presents with acute onset swelling of his right 1st MTP
Woke him from sleep
No trauma
No other joints involved
Pain so bad he can’t put his sock on
Background of high blood pressure
Takes aspirin, bendrofluazide and ramipril
Drinks 15 pints of beer each week at weekends

Blood tests – CRP 56, normal renal function, normal uric acid.
What is the diagnosis?
Why is the uric acid normal?
What are you going to do next?

A

Answer

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17
Q

Features of crystal arthritis

A

Crystal Arthritis is the commonest cause of acute joint swelling
Gout most common in men
Pseudogout in women

Easy to diagnose and treat
Miserable for patients

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18
Q

Gout features

A

Caused by the deposition of monosodium urate crystals within joint
The immunological reaction initiated to try and remove them, leads to acute pain and swelling
Only ‘Curable’ form of inflammatory arthritis

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19
Q

Epidemiology of gout

A

UK General Practice Research Database – prevalence 1.4% (1999)
7.3% of men aged >75yrs
Overall male : female ratio 5:1

Hyperuricaemia much more common – affects 15% population
Gout prevalence increases with age

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20
Q

Pathogenesis of Gout

A

Under exretion urate + overproduction urate >
Hyperuricaemia >
Crystal formation & shedding >
Synovial cells > Inflammatory response

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21
Q

What causes under excretion urate in gout

A

Genetics
Drugs
CKD
Diuretics
Lead toxicity

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22
Q

What causes overproduction of urate in gout

A

Diet
Alcohol
Metabolic proliferation
Obesity
Psoriasis
Purine rich diet

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23
Q

Causes of Gout

A

Alcohol - mostly beer
Red meat, shellfish, offal
Soft drifts
Psoriasis
Haematological malignancy

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24
Q

What affects renal clearance of uric acid

A

Renal impairment (any cause)
Drugs
Low dose aspirin reduces renal clearance by 10%
Diuretics – worse with higher dose
Cyclosporin, TB drugs, theophyllines

Genetics – affects renal clearance of uric acid
Fructose – shares renal uric acid transporter

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25
Essential risk factors for Gout
Renal impairment Beer Diuretics Aspirin Family History Fructose Elderly Men Impaired renal function
26
Clinical features of Gout
Acute episodes Onset often at night Resolve spontaneously (quicker with treatment) Usually recur in a predictable pattern of joint involvement
27
Typical joints that gout affects
1st MTPJ 90% Midfoot, ankle, knee, wrist, elbow hand Periarticular involvement Olecranon bursitis Systemic features can occur
28
Differntial diagnosis for Gout
Septic Arthritis Trauma Calcium Pyrophosphate Arthritis Rheumatoid Arthritis (Osteoarthritis!)
29
Investigations for Gout
FBC (expect raised WCC) U+E LFT if concern re alcohol Serum Uric Acid (often normal during acute attack) CRP Xray if recurrent episodes or concern re sepsis Joint aspiration Joint X ray
30
4 clinical phases of gout
 asymptomatic hyperuricemia,  acute/recurrent gout,  intercritical gout,  chronic tophaceous gout
31
Acute treatment of Gout
Explain the disease Advice about lifestyle - alcohol diet weight loss fluid intake NSAID (short course) unless: Renal failure Peptic Ulcer Disease Some pts with asthma Colchicine 500ug 2-3 times daily Corticosteroids Intra-articular Oral - low dose (5-10mg short course) Ice packs
32
Indication of chronic gout
1. Recurrent attacks 2. Evidence of tophi or chronic gouty arthritis 3. Associated renal disease 4. Normal serum Uric acid cannot be achieved by life-style modifications
33
Medications for chronic gout
1. Allopurinol – Xanthine Oxidase Inhibitor 2. Febuxostat – more potent Xanthine Oxidase Inhibitor 3. Benzbromarone / Probencid – if allergic / intollerant
34
Complications of Gout
Disability and misery Tophi Renal disease: Calculi 10 -15% Chronic urate nephropathy Acute urate nephropathy (cytotoxics
35
Mrs Jones – 43 4 week history of pain and definite swelling across MCPs and PIPs both hands Started suddenly, struggling to use hands Stiff 1-2 hours am Tingling in hands at night Started with pain under toes in last week Swelling MCPs, decreased fist and tender MCP and MTP squeeze CRP – 12.7 RF – 38 CCP – 150 (normal range 0-10) ANA – weak pos Xrays – normal What is the diagnosis? What next?
Answer
36
For RA
Inflammation x time = damage Inflammation reversible, but damage not So our job is to identify and treat inflammation as rapidly as possible, in order to prevent damage and reduce (stop) patients symptoms.
37
RA pathogenesis
Look at Nazias notes
38
Clinical presentation of RA
Pain and Swelling of joints Typically small joints hands, wrists, forefeet Early morning stiffness (often prolonged) Sudden change in function Intermittent, Migratory or Additive involvement
39
Physical examination for RA
Decreased grip strength / fist formation Often subtle synovitis – MCPs, PIPs, MTPs, ankles DIPs are spared Usually symmetrical Deformity unusual at presentation
40
Tests for RA
CRP (+/- ESR) Rheumatoid Factor Falsely positive in 10-15% population 70% of patients with RA are positive Anti-CCP (cyclic citrullinated peptide) Almost never falsely positive 70% of patients with RA are positive Selects the subset of patients with most aggressive disease Joint X rays
41
X rays in RA
Hands and Feet – many joints on a single Xray Used as diagnostic, and prognostic tools, and to monitor therapy Xray changes of RA Soft tissue swelling Periarticular osteopenia Joint space narrowing Bone erosion
42
Treatment of RA
to suppress inflammation as completely and quickly as possible once diagnosis confirmed without making our patients ill Improve symptoms, prevent/reduce damage, prevent premature mortality Primary care: NSAID, physio, specialist care - primary Introduce DMARD early - secondary care Refer to physio, OT, podiatry
43
Drugs to use for RA
Methotrexate 10-25mg per week Sulphasalazine 2-3g daily Leflunomide 10-30mg daily Hydroxychloroquine 200mg od Cheap Limited by toxicity Efficacy (effective control of disease) in 65-75% patients – significantly higher if earlier
44
Pro inflammatory cytokines
TNF a IL-1
45
Anti inflammatory cytokines
IL-1R a IL-10 sTNFR
46
Anti TNF medications that can be used
Infliximab Etanercept Adalimumab Certolizumab
47
Other medications for RA
Rituximab (anti CD20 – anti-B cell) Abatacept (anti-T cell) Tocilizumab (anti-IL-6)
48
Other treatments for RA
NSAIDs – usually helpful for most inflammatory causes of pain Colchicine – helpful for crystal arthritis Steroids – as tablets or injected into inflamed joints
49
Differential diagnosis for RA
- Psoriatic arthritis - Infectious arthritis - Gout - SLE - Osteoarthritis
50
How do you manage flareups of RA
NSAIDS Glucocorticoids
51
Complications of RA
Rheumatoid nodules scleritis Corneal ulceration Pericarditis Increased risk of Heart disease Carpal tunnel Pulmonary nodules
52
What is urate?
metabolite of purine synthesis and the incidence of gout increases with hyperuricaemia (uric acid > 0.45 mmol/L). However, the disease can also occur at completely normal urate levels. Untreated gout can lead to chronic joint damage. Uric acid is formed as a breakdown product of purines.
53
Gout pathophysiology
Uric acid has limited solubility in the blood. When there is too much uric acid in the blood, it can become a urate ion and bind sodium, leading to the formation of monosodium urate crystals which deposit in areas with slow blood flow, including joints and kidney tubules.
54
Signs of Gout
Joint inflammation Gouty tophi
55
Symptoms of Gout
- Red, tender, hot, and swollen joint. - Joint stiffness - Rapid onset severe joint pain
56
Complications of Gout
Urate nephrolithiasis: there is an association between gout and urate renal stones due to hyperuricaemia
57
What is pseudogout?
Pseudogout is a form of inflammatory arthritis caused by deposition of calcium pyrophosphate crystals in the synovium.
58
Pseudogout epidemiology
Mostly women Most patients affected by acute pseudogout are over the age of 65
59
RF for pseudogout
- Increasing age: the greatest known risk factor for pseudogout - Previous joint trauma - Hyperparathyroidism - Haemochromatosis - Acromegaly - Wilson's disease - Hypomagnesaemia - Hypophosphataemia
60
Pathophysiology of pseudogout
The deposition of calcium pyrophosphate crystals is thought to trigger synovitis, with the knee, shoulder, and wrist being most commonly affected.
61
Acute pseudogout
Acute - mainly affects larger joints in the elderly and is usually spontaneous but can be provoked by illness, surgery or trauma
62
Chronic Pseudogout
Chronic - inflammatory RA-like symmetrical polyarthritis and synovitis
63
Signs of Gout
Very similar to gout and usually indistinguishable until joint aspiration is performed. - Joint inflammation: pain, erythema and swelling - Signs can be monoarticular (1 joint) or polyarticular (several joints)
64
Symptoms of Pseudogout
- Rapid onset severe joint pain: knee, shoulder and wrist are most commonly affected - Joint stiffness
65
Primary investigations for pseudogout
- **Joint aspiration:** weakly-positively birefringent rhomboid-shaped crystals under polarised microscopy confirm the diagnosis. If any bacterial growth, then patient is likely to have septic arthritis - **Joint X-ray:** chondrocalcinosis (calcification of articular cartilage) is seen in 40% of cases and is highly suggestive of pseudogout but is not diagnostic; the **absence** of chondrocalcinosis does **not** exclude pseudogout In the knee, this is seen as linear calcifications of the articular cartilage and meniscus
66
Investigating the underlying cause for pseudogout
Usually only done in young patients: - **Serum bone profile and PTH**: investigate for hyperparathyroidism and hypophosphataemia - **Iron studies**: investigate for haemochromatosis - **Serum magnesium**: investigate for hypomagnesaemia
67
DD for pseudogout
- Gout - Septic arthritis - Rheumatoid arthritis - Osteoarthritis
68
Acute management for Pseudogout
- **Anti-inflammatory:** NSAIDs or colchicine, particularly in polyarticular disease - **Corticosteroid:** **intra-articular** steroids can be used in monoarticular disease or **systemic** steroids in polyarticular disease - **Cool packs and rest** - **Aspiration of the joints -** relieves pain
69
Chronic management for Pseudogout
- **DMARDs:** e.g. methotrexate and hydroxychloroquine may be considered in chronic pseudogout - **Joint replacement**: only indicated in chronic, recurrent cases with severe joint degeneration
70
Prognosis Pseudogout
Resolution usually happens within a few days of treatment but some can become chronic

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