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MBChB YR2 MSK > Disease Profiles: Inflammatory Arthritis > Flashcards

Disease Profiles: Inflammatory Arthritis Flashcards

(102 cards)

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1
Q

What is the ASAS classification criteria for ankylosing spondylitis?

A

In patients with ≳ 3 months back pain and age of onset <45 years: Sacroiliitis on imaging and ≳1 SpA feature OR HLA-B27 positive and ≳ 2 other SpA features

Examples of SpA features include inflammatory back pain, arthritis, psoriasis, IBD, family history, uveitis and raised inflammatory markers

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2
Q

What is a Swan neck deformity?

A

PIP hyperextension and DIP flexion

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3
Q

Describe some x-ray signs of ankylosing spondylitis

A

Usually normal in early disease

Late disease - sclerosis and fusion of the sacroiliac joints, bony spurs from the vertebral bodies (syndesmophytes), skinny corners

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4
Q

What are gouty tophi?

A

Painless white accumulations of uric acid which can occur in the soft tissues and occasionally erupt through the skin, can result in a destructive erosive arthritis

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5
Q

What is Boutonniere deformity?

A

PIP flexion and DIP hyperextension

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6
Q

Describe the usual management of acute calcific tendonitis of the shoulder

A

NSAIDs, subacromial steriod and local anaethetic injections for pain relief

Physio

Usually self-limiting as calcification re-absorbs

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7
Q

Name two shared extra-articular features of the spondyloarthropathies

A

Ocular inflammation (anterior uveitis, conjunctivitis)

Mucocutaneous lesions e.g. oral ulcers

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8
Q

How are immune complexes formed in rheumatoid arthritis?

A

Anti-citrullinated peptide antibodies (can be generated in the lungs from smoking) can form immune complexes with the citrullinated proteins produced in an inflamed synovium

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9
Q

What is the specificity of rheumatoid factor for rheumatoid arthritis?

A

60-70% specific

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10
Q

Describe the appearance of monosodium urate crystals under polarised microscopy

A

Needle shaped, negative birefringent crystals

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11
Q

When would biological agents be considered in the treatment of rheumatoid arthritis?

A

If 2 DMARDs have been tried and patient still has very active disease (DAS28 score > 5.1)

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12
Q

Which patient group is reactive arthritis most common in?

A

Young adults (20-40 years), equal sex distribution, HLA B27 positive

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13
Q

Describe the management of refractory acute calcific tendonitis of the shoulder

A

Surgical removal of calcifications, partial/total arthroplasty is last line

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14
Q

What crystal is responsible for pseudogout?

A

Calcium pyrophosphate

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15
Q

What is anti-CCP?

A

Autoantibody found in rheumatoid arthritis associated with current/previous smoking history, more likely to be associated with smoking history

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16
Q

Why does gout prophylaxis require cover with NSAIDs for first 6 months (or colchicine/steroids)?

A

Rapid reduction in uric acid level may result in further exacerbation of gout

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17
Q

Which types of hypersensitivity reaction are associated with rheumatoid arthritis?

A

Driven by type IV (T cell mediated), secondary type III reactions also occur

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18
Q

What patient group is most affected by pseudogout and why?

A

The elderly, and because chondrocalcinosis increases with age

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19
Q

What is ankylosing spondylitis?

A

Chronic inflammatory disease of the axial skeleton that leads to partial or even complete fusion and rigidity of the spine, 90% HLA B27 positive

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20
Q

What may an x-ray of late rheumatoid arthritis show?

A

Erosions, sublaxation

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21
Q

What may an MRI be used for in rheumatoid arthritis?

A

Extremely sensive but only use if diagnostic doubt

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22
Q

What is gout?

A

Inflammatory crystal arthropathy caused by the precipitation and deposition of monosodium urate crystals into joints and soft tissues

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23
Q

Which patient group is most commonly affected by Hydroxyapatite Deposition Disease?

A

Females, 50-60 years

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24
Q

What are Bouchard’s nodes?

A

Bony swellings of proximal IPJ seen in RA and OA

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25
How long does acute gout take to settle with and without treatment?
10 days without treatment, 3 days with treatment
26
Describe the common x-ray findings in psoriatic arthritis
Marginal erosions and 'whiskering', osteolysis, enthesitis
27
What is the WHO target for serum uric acid to prevent further attacks of gout?
300-360µmol/L
28
Which forms of T cell are involved in rheumatoid arthritis?
CD4+ T cells, CD4+ Th1 and Th17 effector cells
29
What is pseudogout?
Deposition of calcium pyrophosphate in the joints and soft tissues, leading to inflammation
30
Name the diseases associated with HLA B27
Psoriatic arthritis, ankylosing spondylitis, IBS (+ enteropathic arthritis), reactive arthritis
31
Name two other treatment options for gout prophylaxis other than xanthine oxidase inhibitors
Uricosuric drugs, IL-1 inhibitors
32
Are autoimmune conditions more common in males or females?
Females
33
What is the first line treatment for rheumatoid arthritis?
DMARDs
34
Describe the main articular manifestations of rheumatoid arthritis
Symmetrical pain and swelling of affected joints, most commonly in the small joints of the hands and feet (larger joints affected as disease progresses) Early morning stiffness \> 30 mins that usually improves with activity
35
Describe the appearance of calcium pyrophosphate crystals under polarised microscopy
Envelope shaped, mild positively birefringent
36
Which joints are usually affected in reactive arthritis?
Asymmetrical monoarthritis or oligoarthritis of large joints e.g. the knee
37
What causes recurrent gout flares?
The acute inflammatory response to deposited MSU crystals
38
How many attacks of gout per year in spite of lifestyle modification would indicate the need for gout prophylaxis?
2+ attacks
39
Name the crystal responsible for gout
Monosodium urate crystals
40
How are autoantibodies generated in rheumatoid arthritis?
Susceptibility genes lead to the conversion of arginine (A) into citrulline (C), resulting in an unfolded protein The unfolded protein acts as an antigen
41
Describe the x-ray findings in acute calcific tendonitis of the shoulder
Calcification can be seen just proximal to the greater tuberosity
42
Which joint is most commonly affected by pseudogout?
Swollen, painful, warm knee
43
What is arthritis mutilans?
A particularly aggressive and destructive form of psoriatic arthritis that usually occurs in the hands and involves the reabsorption of bone and collapse of soft tissue
44
What is enteropathic arthritis?
Refers to an inflammatory arthritis involving the peripheral joints and sometimes the spine, occuring in patients with inflammatory bowel disease
45
What is pannus?
Inflammatory granulation tissue that occurs in rheumatoid arthritis; it produces proteinases that destroy the cartilage extracellular matrix
46
Describe the histology of gouty tophi
Amorphous eosinophilic debris and inflammation (giant cells)
47
What is the first line treatment for ankylosing spondylitis?
NSAIDs (+ symptomatic relief e.g. corticosteroid injections, eyedrops)
48
Patients with high titres of rheumatoid factor are more at risk of \_\_\_\_\_\_\_\_\_\_\_\_
Extra-articular disease
49
Which to antibodies are associated with rheumatoid arthritis?
Rheumatoid factor, anti-CCP
50
Name a seropositive inflammatory arthritis
Rheumatoid arthritis
51
What is the 'question mark' posture?
Loss of lumbar kyphosis with pronounced cervical lordosis seen in late ankylosing spondylitis
52
Name two blood values which may be raised in gout
Serum uric acid, inflammatory markers
53
What usually causes gout?
High serum uric acid levels (hyperuricaemia)
54
Name a shared feature of the spondyloarthopathies that affects tendons
Enthesitis - inflammation at insertion of tendons into bones e.g. Achilles tendinitis, plantar fasciitis
55
Describe the articular symptoms of ankylosing spondylitis
Gradual onset of dull spinal and neck pain, morning stiffness \> 30 mins that improves with activity
56
How would you treat unresponsive psoriatic arthritis?
Consider DMARDs, then anti-TNF or other biologics
57
What is Reiter's syndrome?
Triad of urethritis, conjuctivitis/uveitis/iritis and arthritis sometimes seen in reactive arthritis
58
What is rheumatoid factor?
IgM or IgA antibody that binds to Fc region of IgG
59
What may an ultrasound be used for in rheumatoid arthritis?
May be useful in detecting synovial inflammation if their is clinical uncertainty (especially in early RA), useful in making treatment changes
60
Name a shared feature of the spondyloarthopathies that affects the fingers
Dactylitis ('sausage' digits) - inflammation of the entire digit
61
If indicated, when should prophylactic therapy for gout be started?
4-6 weeks after acute attack
62
What is psoriatic arthritis?
Inflammatory arthritis associated with psoriasis, HLA B27 positive
63
Describe the histology of rheumatoid nodules
Necrotising granulomas with a palisade of macrophages surrounding a central area of collagen necrosis
64
What is chondrocalcinosis?
Calcium pyrophosphate deposition occurs in cartilage and other soft tissues in the absence of acute inflammation
65
How are infection and smoking implicated in rheumatoid arthritis?
Increase anti-CCP
66
What medication is often associated with gouty tophi?
Diuretics
67
What patient group is ankylosing spondylitis most common in?
Young males (20-40 years), HLA B27 positive
68
What may an x-ray of early rheumatoid arthritis show?
Can be normal, may show soft tissue swelling and periarticular oseopenia
69
Which antibody is most sensitive for rheumatoid arthritis?
Rheumatoid factor
70
Which joints are usually affected in psoriatic arthritis?
Usually an asymetrical oligoarthritis, predominantly affects joints of hands and feet, 20% of cases involve sacro-iliac joints
71
Which infections most commonly proceed reactive arthritis?
Urogenital (e.g. chlamydia) or GI (e.g. salmonella, shigella, yersinia, campylobacter)
72
How would you treat unresponsive ankylosing spondylitis?
Consider DMARDs, then anti-TNF or other biologics
73
What are the spondyloarthopathies?
Family of inflammatory arthritides characterised by the involvement of both the spine and the joints, principally in genetically predisposed individuals Anklosing spondylitis is the most common form, but the family also includes reactive arthritis, psoriatic arthritis and enteropathic arthritis
74
What is the first line treatment for psoriatic arthritis?
NSAIDs (+ symptomatic relief e.g. corticosteroid injections, eyedrops)
75
What is Schobers test?
Used to measure lumbar spine flexion, reduced in ankylosing spondylitis
76
What is acute calcific tendonitis of the shoulder?
Hydroxyapatite crystal deposition in the supraspinatus tendon which causes the release of collagenases, serine proteinases and IL-1
77
Describe the management of pseudogout
Treat acute episodes appropriately - NSAIDs, colchicine, steroids, rehydration No prophylactic management
78
What causes chronic gouty arthritis and tophaceous gout?
Chronic granulomatous inflammatory response to deposited crystals
79
What is the first line medication for gout prophylaxis?
Allopurinol (xanthine oxidase inhibitor)
80
Describe the management of acute gout
1. NSAIDs 2. Colchicine if NSAIDs contraindicated 3. Steroids - orally, IM or intra-articular + lifestyle modification to prevent further flares
81
How is rheumatoid arthritis usually diagnosed?
Usually clinical diagnosis using classification criteria
82
Describe the classic presentation of acute gout
Severe pain, hot swollen joint, most commonly the first MTP joint Ankle and knee are the other most commonly affected joints
83
What causes symmetrical synovitis (doughy swelling) in rheumatoid arthritis?
Synovial proliferation and reactive joint effusion cause soft tissue swelling
84
What results of a compression test indicates rheumatoid arthritis?
Positive - tenderness upon lateral compression (squeezing) of the MCP and/or MTP joints
85
Name the seronegative inflammatory arthritis's
Ankylosing spondylitis, psoriatic arthritis, enteropathic arthritis, reactive arthritis
86
What is the second line medication for gout prophylaxis if allopurinol not tolerated?
Febuxostat (xanthine oxidase inhibitor)
87
Name two clinical tests used in examination of ankylosing spondylitis, and what result would indicate AS
Schobers test \>20 cm Chest expansion - reduced
88
Describe the articular manifestation of enteropathic arthritis
Patients present with arthritis in several joints, especially knees, ankles, elbows, and wrists, sometimes spine, hips, or shoulders
89
How would you manage reactive arthritis?
Treatment is aimed at the underlying infectious cause and symptomatic relief, including IA or IM steroid injections 90% self limiting 10% will develop chronic disease - require DMARDs
90
What is Caplan syndrome?
Combination of rheumatoid arthritis and pneumoconiosis
91
Name a spinal complication of rheumatoid arthritis
In longstanding disease involvement of the cervical spine may cause atlanto-axial subluxation → cervical cord compression
92
What is rheumatoid arthritis?
Inflammatory autoimmune disorder characterized by joint pain, swelling, and synovial destruction
93
What is reactive arthritis?
Infection induced systemic illness characterised primarily by an inflammatory synovitis from which viable microorganisms cannot be cultured
94
Which gene complexes have been associated with rheumatoid arthritis?
Specific HLA gene types e.g. HLA DRB1 gene
95
What patient group is rheumatoid arthritis most common in?
Middle aged females (35-50 years)
96
What is the specificity of anti-CCP for rheumatoid arthritis?
90-99% specific
97
How would you manage enteropathic arthritis?
Manage underlying IBD, manage arthritis with physio, DMARDs, anti-TNF
98
Which imaging modality can detect early changes in ankylosing spondylitis such as sacrilitis and bone marrow oedema?
MRI
99
Describe the clinical presentation of acute calcific tendonitis of the shoulder
Acute onset of severe shoulder pain
100
How many weeks after the initial infection will a patient present with reactive arthritis?
1-4 weeks
101
What are rheumatoid nodules?
Firm lumps that develop under the skin in 25% of RA patients, most commonly on extensor surfaces or sites of frequent mechanical irritation
102
What percentage of patients with rheumatoid arthritis have rheumatoid factor?
~80% of patients

MBChB YR2 MSK (36 decks)

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