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Y2 MSK > Inflammatory arthritis > Flashcards

Inflammatory arthritis Flashcards

1
Q

What are spondyloarthropathies

A

A group of conditions associated with the HLA B27 gene

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2
Q

List of spondyloarthropathies

A

Ankylosing spondylitis
Reactive arthritis
Psoriatic arthritis
Enteropathic arthritis

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3
Q

Shared features of the spondyloarthropathies

A

Sacroiliac and spinal involvement
Enthesitis
Asymmetrical arthritis
Dactylitis
Ocular inflammation
Mucocutaneous lesions

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4
Q

What is enthesitis

A

Inflammation at insertion of tendons into bones

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5
Q

Examples of enthesitis

A

Plantar fasciitis
Achilles tendinitis

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6
Q

What are the features of inflammatory back pain

A

Morning stiffness
Worse at rest or inactivity

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7
Q

Difference between inflammatory and mechanical back pain

A

Mechanical back pain is worse at activity whereas inflammatory back pain is better with activity
Mechanical back pain does not cause morning stiffness

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8
Q

What is dactylitis

A

Inflammation of the entire digit causing “sausage” digits

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9
Q

What is ankylosing spondylitis

A

Chronic systemic inflammatory disorder that mainly affects the spine

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10
Q

Mechanism of ankylosing spondylitis

A

1) Annulus fibrosus undergoes ossification and forms syndesmophytes, reducing spinal mobility
2) Syndesmophytes can joint together along the spine which further reduces spinal mobility and causes spinal deformity

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11
Q

What is annulus fibrosis

A

Outer fibrous layer of intervertebral discs

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12
Q

Who are at risk of ankylosing spondylitis

A

Men
Late adolescents / young adults
Family history of spondyloarthropathies

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13
Q

Who to suspect to have ankylosing spondylitis

A

< 45 years old
3 months back pain
Pain relieved by exercise, not rest
Patients with family history of spondyloarthropathies

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14
Q

Clinical features of ankylosing spondylitis

A

Back pain
Spinal deformity (if left untreated for a long time)
Enthesitis
Anterior uveitis
Aortic regurgitation
Apical lung fibrosis
Asymptomatic enteric mucosal inflammation
Amyloidosis

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15
Q

“A” disease is describing

A

Ankylosing spondylitis due to its clinical features:

Axial arthritis
Anterior uveitis
Aortic regurgitation
Apical fibrosis
Amyloidosis
Achilles tendinitis
plAntar fasciitis

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16
Q

Investigations for ankylosing spondylitis

A

Xray / MRI
Blood tests
Schober test
Chest expansion

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17
Q

What can be found on X-rays that suggest ankylosing spondylitis

A

Dagger sign
Bamboo spine

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18
Q

What is Dagger sign

A

Central single radio dense line on X-rays due to fusion of syndesmophytes

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19
Q

How does ankylosing spondylitis affect chest expansion

A

Reduces chest expansion

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20
Q

Describe the schober test

A
  1. Palpate the PSIS on both sides
  2. Draw a horizontal line and a center point
  3. Measure 5cm below and 10 cm above the point
  4. Place measuring tape between the 2 points
  5. Ask the patient to bend over and measure the change in distance
  6. If the increase in distance <5cm = positive schober
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21
Q

What does a positive schober test suggest

A

Limited lumbar motion

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22
Q

Management of ankylosing spondylitis

A

Smoking cessation
Physiotherapy
Steroid eye drops
NSAID
Anti-TNF
Secukinumab

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23
Q

When should you use secukinumab in AS

A

If the patient is unresponsive to NSAID + Anti TNF

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24
Q

What should patients be screened for before using biologics

A

Whether they have
TB
Hepatitis B
HIV
Hepatitis C

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25
Q

Why should patients be screened before using biologics

A

Because biologics may reactivate those conditions

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26
Q

What is psoriatic arthritis

A

Inflammatory arthritis associated with psoriasis

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27
Q

Around how much % of patients with psoriasis has psoriatic arthritis and around how much % of patients with psoriatic arthritis will have psoriasis

A

20% of patients with psoriasis has psoriatic arthritis

90% of patients with psoriatic arthritis will have psoriasis

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28
Q

5 patterns of joint involvement in psoriatic arthritis

A
  1. Symmetrical poly arthritis
  2. Asymmetrical oligoarthritis
  3. Arthritis mutilans
  4. Spondylitis
  5. Distal interphalangeal joints dominant
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29
Q

What is arthritis mutilans

A

Destructive form of arthritis causing loose skin and “telescoping” of the digits

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30
Q

Extra-articular manifestations of psoriatic arthritis

A

Dactylitis
Enthesitis - Achilles tendonitis
Nail pitting
Nail onycholysis
Nail ridging

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31
Q

What is nail onycholysis

A

Nail separating from nail bed

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32
Q

Since psoriatic arthritis can present with symmetrical poly arthritis which is same as RA, how should you differentiate between psoriatic arthritis and RA

A

Psoriatic arthritis is seronegative hence anti CCP and rheumatoid factor will not be present whereas RA is seropositive

Psoriatic arthritis can affect DIP whereas RA often spares DIP

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33
Q

Management of psoriatic arthritis

A
  1. convetional synthetic DMARD (e.g. methotrexate )
  2. Biologic DMARD (anti TNF)
  3. targeted DMARD (tofacitinib)
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34
Q

What DMARDS are offered first line for psoriatic arthritis

A

methotrexate
leflunomide

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35
Q

What DMARDS are offered second line for psoriatic arthritis

A

anti-TNF

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36
Q

What DMARD is offered third line for psoriatic arthritis

A

tofacitinib

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37
Q

Why isn’t steroid injection recommended for psoriatic arthritis

A

Because skin symptoms may flare up after stopping administration of steroids

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38
Q

What is reactive arthritis

A

Inflammatory arthritis that occurs after an infection

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39
Q

What are the common infection triggers of reactive arthritis

A

Gastroenteritis
Sexually transmitted diseases esp Chlamydia

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40
Q

What type of arthritis does gonorrhoea usually cause

A

Gonococcal septic arthritis

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41
Q

Clinical joint feature of reactive arthritis

A

Asymmetrical Acute monoarthritis / oligoarthritis

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42
Q

Which other arthropathy presents with acute asymmetrical mono arthritis / oligoarthritis

A

Septic arthritis

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43
Q

Extra-articular manifestations of reactive arthritis

A

Bilateral conjunctivitis
Circinate balantis
Anterior uveitis
Oral ulcers
Keratodema Blenorrhagica
Enthesitis
Dactylitis

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44
Q

What is circinate balantis

A

Ring shaped dermatitis of the head of the penis, present in reactive arthritis

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45
Q

What is keratodema blenorraghica

A

dark maculopapular rash on palms and soles seen in reactive arthritis

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46
Q

Keratoderma blenorrhagica is another term for

A

palmoplantar pustulosis - a form of psoriasis

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47
Q

What is an important differential diagnosis or reactive arthritis that must be ruled out ASAP

A

Septic arthritis

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48
Q

How do you rule out septic arthritis in the diagnosis of reactive arthritis

A

Joint aspiration of affected joint.
The joint fluid of reactive arthritis should not show infection (bacteria not present) because there is no infection in the joint in reactive arthritis

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49
Q

Investigations for reactive arthritis

A

Bloods
Cultures
Joint aspiration
Xray

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50
Q

Management of reactive arthritis

A

NSAID
Steroid injections into the joints (after ruling out septic arthritis)
Smoking cessation

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51
Q

What is enteropathic arthritis

A

Inflammatory arthritis associated with IBD

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52
Q

Which condition in IBD is more commonly associated with enteropathic arthritis

A

Crohn’s

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53
Q

Clinical joint features of enteropathic arthritis

A

Asymmetrical oligoarthritis
Sacrolilits
Spondylitis

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54
Q

Extra-articular manifestations of enteropathic arthritis

A

Pyoderma gangrenosum
Erythema nodosum
Anterior uveitis
GI symptoms (abdominal pain, loose watery stool with mucous and blood)
Mouth ulcers
Enthesitis
Dactylitis

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55
Q

Signs of pyoderma gangrenosum

A

Large painful ulcers on skin

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56
Q

What is erythema nodosum

A

Inflammatory condition affecting subcutaneous fat layer causing red, tender, swollen bumps ; present in enteropathic arthritis

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57
Q

Investigations for enteropathic arthritis

A

Upper and Lower GI endoscopy to look for IBD
Joint aspiration
Bloods
Xray

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58
Q

Which DMARD is most recommended to be used in enteropathic arthritis and why

A

Sulfasalazine because it treats symptoms of arthritis and IBD

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59
Q

What is gout

A

erosive inflammatory arthritis caused by the deposition of monosodium urate crystals into joints and soft tissues

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60
Q

Risk factors of gout

A

Male
Over 50 years old
Family history

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61
Q

What causes deposition of urate crystals into soft tissues and joint

A

High uric acid (hyperuricaemia)

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62
Q

2 types of causes of hyperuricaemia

A

Increased urate production
Reduced urate excretion

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63
Q

What causes increased urate production

A

Diet
Alcohol
Inherited enzyme defects
Psoriasis
Haemolytic disorders

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64
Q

What kind of diet can cause increased urate production

A

High intake of
- red meat
- seafood
- corn syrup

65
Q

What inherited enzyme disorders can cause increase in urate production

A

Mostly idiopathic
HGPRT enzyme deficiency

66
Q

What causes decrease in urate excretion

A

Chronic renal impairment
Drugs (loop and thiazide diuretics, ACEi, aspirin)
Lead toxicity

67
Q

What is the syndrome of HGPRT enzyme deficiency called

A

Lesch-Nyhan syndrome

68
Q

Lesch-Nyhan syndrome is only present in

A

Males

69
Q

Inheritance pattern of Lesch-Nyhan syndrome

A

X linked recessive

70
Q

Why is gout rare in women before menopause

A

Due to oestrogen. Oestrogen is protective against gout

71
Q

What are the 2 main general reasons of flares of gout

A

Increased uric acid production due to
- increased cell turnover
- increased digestion of protein

72
Q

What factors can cause an acute flare of gout

A

Seafood/ protein binges
Chemotherapy - increases cell break down
Trauma and surgery - increases cell break down

73
Q

Symptoms of acute flares of gout

A

Asymmetrical
Sudden, excruciating pain
Swelling and redness
Warmth
Stiffness
Mild fever
Tachycardia (due to pain)

74
Q

Which joint is the most commonly affected by acute gout

A

1st MTP joint (big toe)

75
Q

What joints can be affected by acute gout

A

1st MTP joint
Ankle
Knee

76
Q

What are the main differentials of monoarthropathy

A

Septic arthritis
Gout / pseudogout
Acute flares of rheumatoid arthritis / osteoarthritis

77
Q

How do you differentiate between septic arthritis and gout

A

Aspirate the joint fluid
Send for culture

78
Q

How long does acute gout usually take to settle with and without treatment

A

without - 10 days
with - 3 days

79
Q

What is chronic tophaceous gout

A

Chronic inflammatory response to deposited urate crystals

80
Q

Presentation of chronic tophaceous gout

A

Painless
White accumulation of uric acid forming a bulge
May get acute flares

81
Q

Most common cause of chronic tophaceous gout

A

Diuretics

82
Q

Investigations for gout

A
  1. joint aspiration with synovial fluid analysis
  2. xray
  3. bloods 2 weeks after the flare
83
Q

Why is uric acid level only measured 2 weeks after the flare

A

Because it can be falsely normal during the attack
OR
Low during the attack

84
Q

Use of synovial fluid analysis

A

To differentiate between gout and pseudogout
To rule out septic arthritis

85
Q

What synovial fluid result confirms gout and differentiates it from pseudogout

A

Needle shaped, negative birefringent crystals

86
Q

management of acute gout

A
  1. NSAID- indomethacin
  2. Colchicine if NSAID is not suitable
  3. Intra-articular Steroids
87
Q

Contraindications of NSAID

A

Those with
- HF
- chronic kidney disease
- peptic ulcers

88
Q

Side effect of colchicine

A

Diarrhoea

89
Q

What should not be used if you suspect septic arthritis

A

Intra-articular steroids

90
Q

When is intra-articular steroids used for gout

A

If the side effect of colchicine (diarrhoea) is intolerable

91
Q

What should be managed after treating acute gout

A

Lifestyle modification to prevent more flares
Prophylactic therapy
Bloods - uric acid level

92
Q

What are the lifestyle modification advised for gout

A

Reduction of alcohol consumption
Reduction of purine-based foods- meat and seafood
Review medications if using diuretics / aspirin / ACEi / chemotherapy

93
Q

When should prophylactic therapy for gout be started

A

4-6 weeks after acute attack

94
Q

Describe the prophylactic therapy for gout

A

Allopurinol to lower uric acid level
+ NSAID indometacin or colchicine for first 6 months

95
Q

Why is NSAID indometacin / colchicine required in prophylactic therapy of gout in the first 6 months

A

Because rapid reduction in uric acid level can cause acute flare of gout

96
Q

Which drug is used if allopurinol is not suitable for prophylactic therapy of gout

A

febuxostat

97
Q

What is pseudogout

A

Deposition of calcium pyrophosphate in the joints and soft tissues leads to inflammation

98
Q

Risk factors of pseudogout

A

Increasing age
Hyperparathyroidism
Haemochromatosis
Hypothyroidism
Trauma / previous joint surgery
Hypomagnesaemia
Hypophosphataemia

99
Q

Which joint disease is pseudogout related to

A

Osteoarthritis - calcium deposit can occur in some OA

100
Q

Symptoms of pseudogout

A

Monoarthritis - painful, swollen, warm

101
Q

Which joint is most commonly affected by pseudogout

A

Knee

102
Q

Investigations for pseudogout

A

Aspiration of synovial fluid and analysis
Bloods

103
Q

What will the synovial fluid analysis result be for pseudogout

A

Positively birefringent
rhomboid shaped calcium pyrophosphate crystals

104
Q

Management of pseudogout

A

NSAID (naproxen)
Colchicine if NSAID contraindicated
Oral / intra-articular steroids

105
Q

Is there a prophylactic treatment for pseudogout

A

No

106
Q

What is rheumatoid arthritis

A

Chronic inflammatory autoimmune disorder causing joint pain, swelling and synovial destruction

107
Q

Risk factors of RA

A

Female
40-60 years old
Smoking
Genetic predisposition

108
Q

Pathophysiology of RA

A
  1. Susceptibility genes lead unfold of proteins due to conversion of arginine into citrulline
  2. the unfolded protein acts as an antigen
  3. triggers autoimmune inflammation by T cells
  4. Causes progressive destruction and deterioration of cartilage and bone
109
Q

Which type of hypersensitivity is RA part of

A

Type 4
can be type 3

110
Q

How can RA be type 3 hypersensitivity as well

A
  1. Anti-CCP antibodies generated in lungs by smoking
  2. Form immune complexes with the citrullinated proteins
  3. Deposit and triggers inflammation in the snyovium
111
Q

Describe the erosive arthritis in RA

A

Initially
- Hyperplasia of synovium causing eroded cartilage
- Increase in osteoclast activity due to cytokines release = bone loss

later on progresses into
- Fibrosis
- deformity
- Damage tendons, ligaments and blood vessels

112
Q

Articular presentation of RA

A

symmetrical, polyarthralgia
Inflammatory type of arthritis
- better with movement
- morning stiffness >30mintues
Atlanto-axial subluxation
Joint deformities

113
Q

What is atlanto-axial subluxation

A

Instability and subluxation of the atlanto-axial joint due to damage of stability ligaments

114
Q

What does atlanto-axial subluxation cause

A

neck pain radiating to the occiput
weakness in upper limbs
altered sensation in the upper limbs

115
Q

Back pain in spondyloarthropathies vs RA

A

RA tends to spare lumbar region and affect the upper region
whereas spondyloarthropathies cause lower back pain

116
Q

Where is the atlanto-axial joint

A

C1-C2

117
Q

Progression of affected joints in RA

A

small joints of the hands and feet
-PIP
-MCP
-MTP

then
Larger joints
- knees
- shoulders
- elbows
- atlantoaxial joints

118
Q

Which joints are often spared by RA

A

Distal interphalangeal joint (DIP)

119
Q

What joint deformities are seen in RA

A

Swan neck deformity (hand
Boutonniere deformity (hand
Hallux valgus
Hammer toes
MTP subluxation

120
Q

What causes swan neck deformity

A

PIP hyperextension
DIP hyperflexion

121
Q

What causes boutounniere deformity

A

PIP flexion
DIP hyperextension

122
Q

What causes hallux valgus

A

proximal phalanx deviating laterally
1st metatarsal bone deviating medially

123
Q

What are the organs involved in extra-articular manifestations of RA

A

lungs
Heart
Skin
Eye

124
Q

What are the lung manifestations in RA

A

Interstitial fibrosis
Caplan syndrome
Rheumatoid lung nodules
Pleuritis
Pleural effusion
Infections secondary to immunosuppression

125
Q

What is Caplan syndrome

A

Inflammation and scarring of the lungs occurs in people with rheumatoid arthritis who have breathed in dust, such as from coal

126
Q

What are the heart manifestations of RA

A

Pericarditis
Myocarditis
Increased risk of CVD

127
Q

What are the skin manifestations of RA

A

Pyoderma gangrenosum
Raynaud’s phenomenon
Rheumatoid skin nodules

128
Q

What are the eye manifestations of the RA

A

keratoconjunctivitis
scleritis

129
Q

What are the peri-articular manifestations of RA

A

Carpal tunnel syndrome
Tenosynovitis
Bursitis

130
Q

Which tendons are most commonly affected by RA causing tenosynovitis

A

Flexors of hands

131
Q

Which bursae are most commonly affected by RA causing bursitis

A

olecranon (elbow) bursae
sub-acromial (shoulder) bursae

132
Q

Complications of RA

A

Amyloidosis
Felty’s syndrome

133
Q

What is Felty’s syndrome

A

Triad of
- RA
- Splenomegaly
- Neutropenia

134
Q

Investigations for RA

A

Bloods
Xray - first line
US
MRI (only if in doubt)

135
Q

What are tested in blood tests for RA

A

CRP - raised
ESR - raised
Plasma viscosity - raised
Autoantibodies

136
Q

What autoantibodies are present in RA

A

Anti CCP
Rheumatoid factor

137
Q

Which autoantibody is more specific to RA

A

Anti CCP

138
Q

Does presence of autoantibodies confirm the diagnosis of RA

A

No

139
Q

What is shown in xray in patient with RA

A

Can be normal in early stages
Erosions
Soft tissue swelling
Narrowing of joint space

140
Q

What can be used to detect RA at early stages

A

US
Xray not used because it is often normal

141
Q

What scoring is used to monitor RA disease activity

A

DAS score

142
Q

DAS score of 2.6 indicates

A

RA in remission

143
Q

2 types of treatment for RA

A

Symptomatic relief
Disease modifying treatment

144
Q

Symptomatic relief management for RA

A

NSAID
paracetamol
Oral steroids short course

145
Q

When is disease modifying treatment for RA indicated

A

DAS > 5.1

146
Q

Describe the disease modifying treatment for RA

A
  1. csDMARD (conventional)
  2. csDMARD + bDMARD (biologic)
147
Q

csDMARD used in RA

A

Methotrexate
Sulfasalazine
hydroxychloroquine
leflunomide

148
Q

Describe the first line DM treatment of RA

A
  1. 1 csDMARD
  2. If no remission + another csDMARD
149
Q

When should you start DMARD in RA

A

within 3 months of symptom onset

150
Q

What are the bDMARD (biological DMARD) used

A

anti TNF - infliximab

151
Q

When is bDMARD indicated in RA

A

If after csDMARD therapy the DAS score is still >5.1

152
Q

What should patients be aware of before starting DMARD

A

Risk of infections
Must use contraception during therapy

153
Q

What should patients also get once they start their DMARD therapy

A

Influenza vaccine and the Pneumococcal vaccine every 5 years
Regular blood tests checking WCC
Cardiovascular monitoring

154
Q

Side effect of DMARD

A

immunosuppression
low WCC
risk of infection

155
Q

Why should patients with RA have regular cardiovascular monitoring

A

Because they are at increased risk of CVD

156
Q

Side effects of methotrexate

A

Teratogenicity
Interstitial pneumonitis
Pulmonary fibrosis
Liver toxicity
Folate deficiency
GI disturbance
Immunosuppression

157
Q

What is the most common causative pathogen of septic arthritis

A

S aureus

158
Q

What is the most common causative pathogen of septic arthritis in prosthetic joint

A

Staph. epidermidis

Y2 MSK (19 decks)

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