Deck 1 Flashcards
(28 cards)
Q. Name four characteristic differences between inflammatory and degenerative
MSK disease
A. Inflammatory: pain eases with use, Degenerative: pain increases with use
(clicks/clunks)
B. Inflammatory: significant stiffness > 60 mins in early morning/and at rest,
Degenerative: stiffness, not prolonged < 30 mins, morning/evening
C. Inflammatory: swelling, synovial +- bony, Degenerative: no swelling, bony
D. Inflammatory: hot and red? Degenerative: not clinically inflamed
E. Inflammatory: affects young, family history
Degenerative: affects older pts, prior occupation/sport
F. In: hands and feet, Degen:1 st CMCJ, DIPJ, knees
G. In: responds to NSAIDS, Degen: less convincing response to NSAIDS
Q. What does elevated ESR suggest? What disease has a very high ESR?
A. Inflammatory marker
B. Erythrocyte sedimentation rate: RBCs stick together and so they fall faster
(shorter ESR) – fibrinogen (acute phase protein)
C. (subject to false positives)
D. Systemic Lupus Erythematosus (SLE)
Q. Name another inflammatory marker that is produced by the liver in response to
IL-6
A. C-reactive protein (CRP)
B. Acute phase protein released in inflammation and infection
C. Rises and falls rapidly, peak in 48hrs
Q. Name two proteins associated with Rheumatoid arthritis
A. Rheumatoid factor (RF) and cyclic citrullinated peptide (CCP)
Q. Name two proteins associated with systemic lupus erythematosus
A. Anti-nuclear antibody (ANA): binds to antigens within the cell nucleus
B. dsDNA – double stranded DNA
Q. What is spondyloarthopathy?
A group of over-lapping conditions which are all variously associated with the tissue type HLA B27
B. Patients often display features of more than one individual disease from this group – helpful to think in terms of SpA rather than individual disease sometimes
Q. What is HLA b27?
Human Leucocyte Antigen (HLA) B27: Essentially it is a tissue type. You are either HLA B27 (+) or HLA B27 (-)
Class I surface antigen (all cells, except red blood cells)
D. Encoded by Major Histocompatibility Complex (MHC) on chromosome 6
E. Antigen presenting cell
F. UK has a B27 prevalence of 8% and AS prevalence of around 0.6%
A. Link between spondyloarthopathy unknown – many theories
Q. Name 4 clinical features of SpA?
A. Inflammatory arthritis of axial skeleton (spine, rib cage, hips): results in bone formation and fusion of vertebra/costovertebral/SIJ, known as ‘ankylosing or axial spondylitits’ (bamboo spine seen): this typically starts in teenage years
B. Enthesitis: inflammation at the junction between ligament/tendons and bone
C. Acute anterior uveitis/iritis: inflammation of anterior chamber of the eye and peripheral arteries
D. Skin psoriasis
E. May also have IBD – inflammatory bowel disease
Q. Name 5 features of “SPINE ACHE” – SpA
A. Sausage digit (dactylitis)
B. Psoriasis
C. Inflammatory back pain
D. NSAID good reponse
E. Enthesitis (heel)
F. Arthritis
G. Crohn’s/ Colitis/ elevated CRP* (may also be normal)
H. HLA B27 – 80%? (May be useful for diagnosis when clinical symptoms are present)
I. Eye (uveitis)
What are syndesmophytes?
A. Asyndesmophyteis a bony growth originating inside a ligament, commonly seen
in the ligaments of the spine, specifically the ligaments in the intervertebral
joints leading to fusion of vertebrae.Syndesmophytesare pathologically similar
to osteophytes.
B. Occurs due to inflammatory arthritis of the spine and rib cage leading to new
bone formation and fusion of the joints
Q. What is sacroilitis?
A. Inflammation of sacroiliac joints (where lower spine and pelvis connect)
B. Can cause pain in buttocks or lower back and can extend down both legs
C. –can cause erosions, loss of joint space and fusion
Q. Name some features of a classical spA pain presentation
A. Age at onset < 40yrs (Classically develops in early 20s)
B. Duration of back pain > 3 months
C. Insidious onset
D. Morning stiffness > 30 mins
E. Improvement with exercise, not with rest
F. Awakening at night – 2 nd half of night – with improvement upon getting up
G. (Alternating) buttock pain
- Q. What is the most important treatment for pts with SpA?
A. Biological drugs: block cytokines, e.g. anti TNF, IL-17 blockers
B. Improves symptoms almost instantly in vast majority – evidence of benefit in
terms of new bone formation comes after 9 years, improves mobility, prevents
radiologically advances
C. (Physio and NSAIDS)
Q. Name 3 patterns of psoriatic arthritis
5 patterns of disease: DIPJ only, RA like (symmetrical small joint), large joint oligoarthritis, axial, arthritis mutilans)
Q. What occurs in reactive arthritis? What can trigger it?
A. Sterile inflammation of the synovial membrane, tendons and fascia triggered by an infection at a distant site, usually gastro-intestinal or genital.
B. Gut associated: salmonella, shigella, yersina
C. STI: chlamydia, ureaplasma urealyticum
Q. Describe 4 features of classical presentation of reactive arthritis (ReA), and investigations
A. 2 days to 2 weeks post infection
B. Large joint
C. Classic triad: arthritis/conjunctivitis/sterile urethritis
D. Psoriatic like skin lesions – keratoderma/circinate balanitis (dermatitis of glans penis)
E. DD: septic arthritis, gout
F. Raised SER/CRP
G. Aspirate joint to exclude infection/crystals
H. Urethral swab, stool culture
What is Enteropathic Arthritis? What condition is it highly associated with?
A. Episodic peripheral synovitis occurs in up to 20% of patients with IBD
a. Asymmetric lower limb arthritis
b. Remission generally related to suppression of bowel disease.
Q. What is central (non-nociceptive) pain? Name 2 associated conditions
A. Central disturbance pain, with bio-psych factors
B. Examples: fibromyalgia, irritable bowel syndrome, tension and migraine
headache, interstitial cystitis/vulvodynia, non-cardia chest pain etc
C. Often related to fatigue, anxiety, stressful life events, work stress, depression,
previous suicide attempts
D. Causes by: genes? Stress? Cognitive and behavioural adaptation to acute
symptoms
Q. What help is available to patients with chronic central pain?
A. Pain clinic: CBT, group work, individual – stress, anxiety and sleep management
Q. What is fibromyalgia? (CWP) Name 3 closely related disorders
A. Widespread pain – after other diseases excluded, 3 months of symptoms
B. Pain at 11 of 18 tender point sites on digital palpation
C. Pain: predominantly neck and back, aggravated by stress, cold and activity,
associated with generalised morning stiffness, subjective swelling of extremities,
paraesthesia of hands and feet
D. Also: fatigue and non-restorative sleep, headache and diffuse abdo pain
E. More women than men
F. Closely related: depression, chronic headache, IBS, chronic fatigue syndrome,
myofascial pain syndrome
Q. What is hypermobility? What does it commonly affect?
A. Joints that move easily beyond their expected range, may be asymptomatic, may
cause widespread joint pain
B. Normal variant – common in children, incidence decreases with age
C. Benign joint hypermobility syndrome
a. affects joints and soft tissue
b. tendency to recurrent sprain or dislocation
c. hyperextensible skin
D. Associated with Ehlers Danlos and Marfans syndromes
Q. What is juvenile idiopathic arthritis? What causes it? Describe 2 features of typical presentation
A. Arthritis in children – unknown cause
B. Under-recognised, genetic? Autoimmune? Diagnosis is critical
C. Presentation: under 6 years, affects 1-4 joints, most commonly the knees (notice
limps!), majority are ANA+ve, high risk of uveitis (screen!!)
Q. Name 2 differences between rheumatoid factor positive and negative polyarticular disease (JIA)
A. Rheumatoid factor –ve: acute onset in 5 joints, usually symmetrical, malaise,
fever, anaemia, decreased risk of uveitis (still screen!)
B. Rheumatoid factor +ve: onset in late adolescene, affects more girls than boys,
RhF positive twice in 3 months, usually CCP Ab –ve, related to smoking habit?,
decreased risk of uveitis (still screen!)
Q. Describe 2 features of a typical presentation of enthesitis related JIA
A. Often HLAB27 +ve, typically male > 6 yrs
B. Related to spondyloarthropathy
C. High risk of uveitis
D. Clusters with IBD, inflammatory back or sacroiliac pain
