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Musculoskeletal > Introduction to Rheumatology > Flashcards

Introduction to Rheumatology Flashcards

1
Q

what is a tendon?

A

cords of strong fibrous collagen tissue attaching muscle to bone

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2
Q

what is a ligament?

A

flexible fibrous connective tissue which connect two bones

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3
Q

components of a synovial joint

A

synovium
synovial fluid
articular cartilage

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4
Q

two major divisions of arthritis are?

A 
osteoarthritis (degenerative)
inflammatory arthritis (main type is rheumatoid arthritis)
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5
Q

what is inflammation?

A

physiological response to deal with injury or infection

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6
Q

inflammation manifests clinically as?

A 
rubor (redness)
dolor (pain)
calor (heat)
tumor (swelling)
loss of function
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7
Q

list physiological, cellular and molecular changes of inflammation

A

increased blood flow
migration of WBC
activation/differentiation of leucocytes
cytokine production e.g. TNFalpha, IL1, IL6, IL17

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8
Q

two main types of crystal arthritis

A

gout

pseudogout

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9
Q

immune mediated joint inflammation

A

rheumatoid arthritis
Seronegative spondyloarthropathies
Connective tissue diseases

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10
Q

infective causes of joint arthritis

A

septic arthritis

tuberculosis

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11
Q

what is gout?

A

syndrome caused by deposition of urate (uric acid) crystals -> inflammation

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12
Q

risk factor for gout

A

High uric acid levels (hyperuricaemia)

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13
Q

causes of hyperuricaemia

A 
genetic tendency
increased intake of purine rich food
reduced excretion (kidney failure)
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14
Q

what is pseudogout?

A

syndrome caused by deposition of calcium pyrophosphate dihydrate (CPPD) crystal deposition crystals -> inflammation

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15
Q

risk factors for pseudogout

A

background osteoarthritis
elderly patients
intercurrent infection

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16
Q

acute gout can lead to?

A

gouty arthritis

tophi (aggregated deposits of MSU in tissue)

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17
Q

gouty arthritis commonly affects which joint?

A

metatarsophalangeal joint of the big toe (‘1st MTP joint’)

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18
Q

overview of gouty arthritis

A

Abrupt onset
Extremely painful
Joint red, warm, swollen and tender
Resolves spontaneously over 3-10 days

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19
Q

gout finding on x-ray

A

juxta-articular ‘rat bite’ erosions at the MTPJ of the great toe

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20
Q

investigations for suspected crystal arthritis (gout)

A

joint aspiration - synovial fluid analysis

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21
Q

management for an acute attack of gout

A

colcihine
NSAIDs
steroids

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22
Q

management for chronic gout

A

allopurinol

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23
Q

synovial fluid samples are analysed for

A

pathogens + crystals
rapid Gram stain > culture > antibiotic sensitivity assay
polarising light microscopy

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24
Q

gout vs pseudogout examination findings

A

gout: urate crystals, needle shape, negative birefrigence
pseudogout: calcium pyrophosphate dihydrate crystals, brick shaped, positive birefrigence

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25
Q

what is rheumatoid arthritis?

A

chronic autoimmune disease characterised by pain, stiffness and symmetrical synovitis
(inflammation of the synovial membrane) of synovial (diarthrodial) joints

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26
Q

synovium becomes a pannus in rheumatoid arthritis due to?

A 
Neovascularisation
Lymphangiogenesis
inflammatory cells:
activated B and T cells
plasma cells
mast cells
activated macrophages
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27
Q

pathogenesis of rheumatoid arthritis

A

Dominant detrimental role of TNFα (GO BACK TO SLIDES)

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28
Q

how is TNFα inhibition achieved?

A

parenteral administration (most commonly sub-cutaneous injection) of antibodies or fusion proteins

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29
Q

key features of rheumatoid arthritis

A 
chronic arthritis (polyarthritis, early morning stiffness, joint erosions on radiographs)
extra articular disease can occur e.g. rheumatoid nodules
autoantibody against IgG may be in blood
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30
Q

pattern of joint involvement of rheumatoid arthritis

A

symmetrical
affects multiple joints (polyarthritis)
particularly hands and feet

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31
Q

commonest affected joints in rheumatoid arthritis

A

Metacarpophalangeal joints (MCP), proximal interphalangeal joints (PIP), wrists , knees, ankles, metatarsophalangeal joints (MTP)

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32
Q

primary site of synovial inflammation in rheumatoid arthritis is?

A

synovium

33
Q

synovial inflammation in rheumatoid arthritis includes?

A

proximal inter-phalangeal joint synovitis
extensor tenosynovitis
olecranon bursitis

34
Q

common extra-articular features of rheumatoid arthritis

A

fever
weight loss
subcutaneous nodules

35
Q

uncommon extra-articular features of rheumatoid arthritis

A

vasculitis
Ocular inflammation e.g. episcleritis
Neuropathies
Amyloidosis
Lung disease – nodules, fibrosis, pleuritis
Felty’s syndrome – triad of splenomegaly, leukopenia and rheumatoid arthritis

36
Q

what are subcutaneous nodules in rheumatoid arthritis?

A

central area of fibrinoid necrosis surrounded by histiocytes and peripheral layer of connective tissue

37
Q

subcutaneous nodules in rheumatoid arthritis occurs in what percentage of patients?

A

approximately 30%

38
Q

subcutaneous nodules in rheumatoid arthritis are associated with?

A

severe disease
extra-articular manifestations
rheumatoid factor

39
Q

list the two antibodies found in the blood of patients with rheumatoid arthritis

A 
rheumatoid factor (recognize the Fc portion of IgG as target antigen, typically IgM antibodies)
antibodies to citrullinated protein antigens
40
Q

Patients with RA test with rheumatoid factor present at __% at disease onset and further __% over first 2 years of diagnosis.

A

70

10-15

41
Q

treatment goal for RA

A

prevent joint damage

42
Q

RA treatment requires?

A

Early recognition of symptoms, referral and diagnosis
Prompt initiation of treatment: joint destruction = inflammation x time
Aggressive treatment to suppress inflammation

43
Q

1st line drug treatment for RA

A

methotrexate in combination with hydroxychloroquine or sulfasalazine

44
Q

2nd line drug treatment for RA

A

Biological therapies offer potent and targeted treatment strategies
New therapies include Janus Kinase inhibitors : Tofacitinib & Baricitinib

45
Q

what are DMARDs?

A

Disease-modifying anti-rheumatic drugs

46
Q

avoid long term use of what in the treatment of RA and for what reason?

A

glucocorticoid therapy (prednisolone)

side effects

47
Q

what are biological therapies?

A

proteins (usually antibodies) that specifically target a protein such as an inflammatory cytokine

48
Q

examples of biological therapies mechanisms for rheumatoid arthritis

A

inhibition of TNFalpha
B cell depletion
modulation of T cell co-stimulation
inhibition of IL6 signalling

49
Q

name the biological therapies that treat RA via inhibition of TNFalpha

A 
antibodies (infliximab, and others)
fusion proteins (etanercept)
50
Q

name the biological therapies that treat RA via B cell depletion

A

Rituximab – antibody against the B cell antigen, CD20

51
Q

name the biological therapies that treat RA via modulation of T cell co-stimulation

A

Abatacept - fusion protein - extracellular domain of human cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) linked to modified Fc (hinge, CH2, and CH3 domains) of human immunoglobulin G1

52
Q

name the biological therapies that treat RA via inhibition of IL6 signalling

A

Tocilizumab (RoActemra) – antibody against interleukin-6 receptor.
Sarilumab (Kevzara) – antibody against interleukin-6 receptor.

53
Q

difference between joints in RA and osteoarthritis on x-ray

A

osteo no spaces but still some space for RA

54
Q

what is ankylosing spondylitis?

A

type of arthritis in the spine, causing inflammation and gradual fusing of the vertebrae

55
Q

common demographic of ankylosing spondylitis

A

20-30 years

male

56
Q

ankylosing spondylitis is associated with what genetic marker on the MHC?

A

HLA B27

57
Q

clinical presentation of ankylosing spondylitis

A 
lower back pain + stiffness (early morning, improves w/ exercise)
reduced spinal movement
peripheral arthritis
plantar fascitis, achilles tendonitis
fatigue
58
Q

investigations for ankylosing spondylitis

A

bloods

imaging: x-ray, MRI

59
Q

positive results in bloods for ankylosing spondylitis?

A

Normocytic anaemia
Raised CRP, ESR
HLA-B27

60
Q

positive results in imaging for ankylosing spondylitis?

A

Squaring Vertebral bodies, Romanus lesion
Erosion, sclerosis, narrowing SIJ
Bamboo Spine
Bone marrow oedema

61
Q

management of ankylosing spondylitis

A

physiotherapy
exercise regime
NSAIDs
peripheral joint disease - DMARDs

62
Q

are rheumatoid factors present in ankylosing arthritis?

A

no

‘seronegative’

63
Q

what is psoriasis?

A

autoimmune disease affecting the skin (scaly red plaques on extensor surfaces eg elbows and knees)

64
Q

psoriatic arthritis classically clinically presents as?

A

asymmetrical arthritis affecting IPJs

65
Q

psoriatic arthritis can also manifest as?

A

Symmetrical involvement of small joints (rheumatoid pattern)
Spinal and sacroiliac joint inflammation
Oligoarthritis of large joints
Arthritis mutilans

66
Q

investigations for psoriatic arthritis?

A

X-rays of affected joints – pencil in cup abnormality
MRI – sacroiliitis and enthesitis
Bloods – no antibodies as seronegative

67
Q

management for psoriatic arthritis?

A

DMARDs – methotrexate

68
Q

avoid what drug in the treatment of psoriatic arthritis? why?

A

oral steroids

risk of pustular psoriasis due to skin lesions

69
Q

list other connective tissue diseases

A

Systemic Sclerosis
Myositis
Sjogrens syndrome
Mixed connective tissue disease

70
Q

what is Reiter syndrome?

A

describes the triad of arthritis, urethritis and conjunctivitis in a patient following a bacterial infection

71
Q

reactive arthritis

A

Sterile inflammation in joints following infection especially urogenital (e.g. Chlamydia trachomatis) and gastrointestinal (e.g. Salmonella, Shigella, Campylobacter infections) infections

72
Q

Important extra-articular manifestations of reactive arthritis include?

A

Enthesitis (tendon inflammation)
Skin inflammation
Eye inflammation

73
Q

Reactive arthritis may be first manifestation of what infections?

A

HIV

hepatitis C

74
Q

reactive arthritis commonly presents in what demographic?

A

young adults with genetic predisposition (e.g. HLA-B27) and environmental trigger (e.g. Salmonella infection)

75
Q

management of reactive arthritis

A

usually self-limiting – can be managed with NSAIDS or DMARDs if required

76
Q

epidemiology of SLE

A

F:M ratio 9:1
Presentation 15 - 40 yrs
Increased prevalence in African and Asian ancestry populations
Prevalence varies 4-280/100,000

77
Q

clinical tests for SLE

A

Antinuclear antibodies:
^ sensitivity for SLE but not specific, -ve test rules out SLE, but a + ve test does not mean SLE.

Anti-double stranded DNA antibodies

78
Q

what is lupus?

A

multi-system autoimmune disease

Musculoskeletal (7 decks)

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