MSK and rheumatology Flashcards

Question

what is the non-medical treatment of OA?

Answer 1

* exercise to improve local muscle strength, improve mobility of weight bearing joints and general aerobic fitness * lose weight if obese * local heat or ice packs applied to affected joint * bracing devices, joint supports, insoles for joint stability and footwear with shock-absorbing properties for lower limb OA * acupuncture, physiotherapy and occupational therapy

Answer 2

• paracetamol prescribed before NSAIDs • can take weak opioids alongside paracetamol • intra-articular corticosteroid injections produce short-term improvement when there is a painful joint effusion: - systemic corticosteroids not used - do not administer if joint is going to be replaced

Answer 3

- arthroscopy - arthroplasty - osteotomy - fusion

Answer 4

endoscope inserted into joint through small incision to assess damage and remove loose bodies; this is the only indication for arthroscopy in osteoarthritis

Answer 5

- articular surface of a MSK joint is replaced, remodelled or realigned by osteotomy - indications: uncontrolled pain and significant limitation of function - prosthetic joint has lifespan of 10-15 years and will need replacement, in a young person it could be done up to 3 times

Answer 6

surgical operation whereby a bone is cut to shorten or lengthen it or to change its alignment

Answer 7

- usually of ankle and foot to prevent painful grinding of bones - loss of mobility

Answer 8

- long-term, chronic systemic autoimmune disorder that primarily affects joints - causes symmetrical deforming polyarthropathy - disease of the synovial joints - inflammatory autoimmune arthritis

Answer 9

- it is common affecting 1% of the population worldwide with a peak prevalence between 30-50 yrs - prevalence is increased in smokers - not seen as much in the elderly in contrast to OA - more common in females than males

Answer 10

HLA-DR4 and HLA-DRB1 confer susceptibility to RA and are associated with development of more severe erosive disease

Answer 11

• triggering antigen in RA is unknown but factors are produced by activated: - T cells: interferon, IL-2 and IL-4 - macrophages: IL-1, IL-8 and TNF-alpha - mast cells: histamine and TNF-alpha - fibroblasts: IL-6 • these cause/contribute the ongoing synovial inflammation • local production of rheumatoid factor (autoantibodies directed against the Fc portion of immunoglobulin) by B cells and formation of immune complexes with complement activation maintains the chronic inflammation

Answer 12

- gender - family history - genetic factors - smoking - immune system

Answer 13

- over-production of TNF-alpha leads to synovitis and joint destruction - the interaction of macrophages, T and B lymphocytes drives this overproduction - in RA the synovium becomes greatly thickened and becomes infiltrated by inflammatory cells - generation of new synovial blood vessels is induced by angiogenic cytokines and activated endothelial cells produce adhesion molecules which force leucocytes into the synovium where they can trigger inflammation - the synovium proliferates and grows out over the surface of the cartilage past the joint margins, producing a tumour-like mass called ‘pannus’ - this pannus of inflamed synovium damages the underlying cartilage by blocking its normal route for nutrition and by direct effects of cytokines on the chondrocytes - the cartilage becomes thin and the underlying bone exposed - the pannus destroys the articular cartilage and subchondral bone, resulting in bony erosions

Answer 14

- the inflamed synovium proliferates and grows out over the surface of the cartilage past the joint margins, producing a tumour-like mass called ‘pannus’ - this pannus of inflamed synovium damages the underlying cartilage by blocking its normal route for nutrition and by direct effects of cytokines on the chondrocytes - the cartilage becomes thin and the underlying bone exposed - the pannus destroys the articular cartilage and subchondral bone, resulting in bony erosions

Answer 15

* small joints of the hand; MCP and PIP joints * usually the DIPs are spared * MTP joints of the feet * wrists, elbows, shoulders, knees and ankles * in most cases, many joints are involved

Answer 16

- slowly progressive, symmetrical swollen, painful, tender, warm and stiff joints - symptoms worse in the morning and in the cold - morning stiffness lasting more than 30 minutes - symmetrical peripheral polyarthritis - movement limitation and muscle wasting - fatigue and disturbed sleep - shoulder and elbows may become swollen and stiff - feet pain in MTP joints, foot becomes broader and hammer toe deformity leading to ulcers and callouses - synovitis and effusions in the knees - tenosynovitis

Answer 17

* ulnar deviation * swan neck/Z thumb * Boutonniere deformity

Answer 18

pleural effusions, fibrosing alveolitis, pneumoconiosis (Caplan’s syndrome, especially in miners), interstitial lung disease, bronchiectasis

Answer 19

dry eyes, episcleritis (non severe mild redness of eyes), scleritis (severe pain, can’t look at bright lights)

Answer 20

- peripheral sensory neuropathies - compression/entrapment neuropathies - cord compression due to instability of the cervical spine; occurs in severe RA, presents with sensory loss, weakness and disturbed bladder function

Answer 21

amyloidosis, nephrotic syndrome and CKD

Answer 22

subcutaneous nodules

Answer 23

- normocytic normochromic anaemia - ESR and/or CRP raised in proportion to the activity of the inflammatory process; useful for monitoring treatment - positive rheumatoid factor in 80% - positive anti cyclic citrullinated peptide in 30% (indicates likelihood of progression to RA, those positive have worse prognosis)

Answer 24

- soft tissue swelling in early disease - joint space narrowing in late disease - periarticular erosions

Answer 25

erosions at joint margins and bones

Answer 26

if effusion present then do an aspiration of joint; will be cloudy due to high white cells

Answer 27

- no cure - smoking cessation to reduce risk of CV disease - reduce weight - exercise - surgery e.g. synovectomy to reduce bulk of inflamed tissue and prevent damage

Answer 28

- NSAIDs and COX inhibitors | - paracetamol with/without opioids

Answer 29

* suppress disease activity but risk of long term toxicity * can cause osteoporosis (most common cause of secondary osteoporosis) and increase risk of fracture * oral corticosteroids have many side effects * IM injection of depot for those waiting for DMARDs to work * intra-articular injection; semicrystalline steroid (rapid but short-lived effect)

Answer 30

Disease-Modifying Anti-Rheumatic drugs • inhibit inflammatory cytokines • used early to reduce inflammation and slow development of joint erosions and irreversible damage • take 6 weeks to start working • all have serious side effects so monitoring with blood tests is required

Answer 31

- methotrexate (oral) - sulfasalazine (oral) - leflunomide (oral)

Answer 32

- csDMARD - gold standard drug used for more active disease - purine metabolism inhibitor - contraindicated in pregnancy - side effects: nausea, mouth ulcers, diarrhoea, abnormal LFTs, neutropenia, thrombocytopenia, renal impairment

Answer 33

- csDMARD - for mild/moderate disease - used in young people and women - suppression of IL-1 and TNF-alpha; induces apoptosis of inflammatory cells and increases chemotactic factors - side effects: nausea, skin rashes, mouth ulcers, neutropenia, thrombocytopenia, abnormal LFTs

Answer 34

- csDMARD - pyrimidine synthesis inhibitor - block T cell proliferation - side effects: diarrhoea, neutropenia, thrombocytopenia, alopecia, hypertension

Answer 35

- very expensive - TNF-alpha blockers - B cell inhibitors - interleukin blockers - T cell activation blockers

Answer 36

- first line biological treatment - slows/halts erosion formation - given alongside methotrexate - TNF is produced early on to initiate the immune response - TNF levels are raised in the synovial fluid and synovium; this leads to local inflammation through signalling of synovial cells to produce metalloproteinases and collagenase - TNF regulates other cytokines, it also stimulates osteoclast development

Answer 37

- infliximab (IV) - etanercept (SC) - adalimumab (SC)

Answer 38

- chimeric monoclonal antibody biologic used in RA - binds to TNF-alpha and prevents it from binding to its receptor - side effects: demyelination and autoimmune syndromes - IV

Answer 39

- fusion protein produced by recombinant DNA - used in RA - fuses the TNF receptor to the constant end of the IgG1 antibody; reduces the effects of naturally present TNF - side effects: hypersensitivity reactions, infection - SC

Answer 40

- monoclonal antibody used in RA - inactivates TNF-alpha - side effects: hypersensitivity reactions, heart failure - SC

Answer 41

- B cells produce rheumatoid factor (binds to Fc portion of IgG forming immune complex) - rituximab

Answer 42

- monoclonal antibody used in RA - B cell inhibitor - destroys normal and malignant B cells that have CD20 on their surfaces - IV - used in patients that have failed to respond to anti-TNF agents - side effects: hypo/hypertension, skin rash, nausea, pruritus, back pain

Answer 43

- tocilizumab | - anakinra

Answer 44

* monoclonal antibody that binds to IL-6 cytokine before it reaches target receptor; used in RA * IL-6 and IL-1 are the most important in joint inflammation * used alongside methotrexate

Answer 45

- used in RA - a recombinant and slightly modified version of the human IL-1 receptor antagonist protein - SC

Answer 46

abatacept • blocks T cell activation which means macrophages and B cells cannot be activated, which reduces inflammation • fusion protein composed of the Fc region of the immunoglobulin IgG1 fused to the extracellular domain of CTLA-4 • abatacept binds to the CD80 and CD86 molecule, and prevents the signal required to activated the T cell

Answer 47

RA: pain eases with use OA: pain increases with use, and there are clicks/clunks

Answer 48

RA - significant (>30 mins) - early morning/at rest OA - not prolonged (<30 mins) - morning/evening or after periods of activity

Answer 49

RA - synovial and/or bony swelling - hot and red - painful, swollen and stiff joints OA - joints ache and may be tender but have little or no swelling - not clinically inflamed

Answer 50

RA - young, psoriasis, family history - can begin any time in life - relatively rapid onset, over weeks to months OA - older, prior occupation/sport - usually begins later in life - slow onset, over years

Answer 51

RA - hands and feet - often affects small and large joints on both sides of the body (symmetrical) OA - 1st CMCJ, DIPJ, knees - often begin on one side of the body and may spread to other side - symptoms begin gradually and are often limited to one set of joints

Answer 52

RA - frequent fatigue and a general feeling of being ill - systemic symptoms OA - whole-body symptoms are not present

Answer 53

- asystemic skeletal disease characterised by low bone mass and a microarchitectural deterioration of bone tissue, with an increase in bone fragility and susceptibility to fracture - defined as bone mineral density (BMD) more than 2.5 standard deviations below the young adult mean value (T score < 2.5)

Answer 54

- precursor to osteoporosis characterised by low bone density - defined as BMD between 1-2.5 standard deviations below the young adult mean value (-1 < T score < 2.5)

Answer 55

poor bone mineralisation leading to soft bone due to lack of Ca2+ (adults form of Ricket's)

Answer 56

- standard deviation score ascertained using a Dual Energy X-ray absorptiometry (DEXA) scan - compared with the gender-matched young adult average (peak bone mass)

Answer 57

- in those over 50 it is more common in females than males due to women losing trabeculae with age, whereas men, have stable numbers of trabeculae and reduced lifetime fracture risk - Caucasian and Asian races at risk - risk increases with age

Answer 58

- old age - women - family history of osteoporosis or fracture - previous bone fracture - smoking/alcohol

Answer 59

risk factors - Steroid (prednisolone) use and other drugs e.g. heparin, ciclosporin, PPIs, anticonvulsants, GnRH analogues, SSRIs, androgen deprivation - Hyperthyroidism and Hyperparathyroidism - Alcohol and tobacco: bad for bones - Thin: BMI <22 - Testosterone decreased; leads to increased bone turnover - Early menopause: oestrogen drop leading to increased bone turnover - Renal or liver failure - Erosive/inflammatory bone disease e.g. RA/myeloma; cytokines (TNF alpha and IL6) increase bone turnover - Dietary calcium decrease/malabsorption, DMT1

Answer 60

- other endocrine diseases e.g. Cushing’s (high cortisol) - thyroid hormone and parathyroid hormone increase bone turnover - cortisol increases bone resorption via osteoclasts and induces osteoblast apoptosis - oestrogen/testosterone control bone turnover

Answer 61

- peak bone mass is at around 25 yrs, then you start losing bone mass - osteoporosis results from increased bone breakdown by osteoclasts and decreased bone formation by osteoblasts, leading to loss of bone mass - bone mass decreases with age, but will depend on the ‘peak’ mass attained in adult life and on the rate of loss in later life - multiple genes are involved, including collagen type 1A1, vitamin D receptor and oestrogen receptor genes - nutritional factors, sex hormone status and physical activity also affect peak bone mass - oestrogen deficiency - changes in trabecular architecture with ageing

Answer 62

- says how much mineral is in bone | - determined by the amount gained during growth and amount lost during ageing

Answer 63

- short and fat is stronger than long and thin | - distribution of cortical bone

Answer 64

- bone turnover, architecture and mineralisation affect bone strength - if there is not enough mineralisation then bone breaks, but if too much then bones are stiff and will shatter

Answer 65

* results in increased numbers of osteoclasts, premature arrest of osteoblastic synthetic activity and perforation of trabeculae with a loss of resistance to fracture * high bone turnover * predominantly cancellous bone loss

Answer 66

* decrease in trabecular thickness; as we age the strain is felt on bones from head to tail and in response we tend to preferentially preserve vertical trabeculae and lose horizontal trabeculae * decreased trabecular strength and increased susceptibility to fracture

Answer 67

- fracture is the only cause of symptoms in osteoporosis - vertebral crush fracture: • sudden onset of severe pain in the spine, often radiating to the front • thoracic vertebral fractures may lead to kyphosis - Colles’ fracture of the wrist follows a fall on an outstretched arm - fractures of the proximal femur usually occur in older individuals that fall on their side or back

Answer 68

- abnormally excessive convex curvature of the spine as it occurs in the thoracic and sacral regions - occurs in osteoporosis

Answer 69

demonstrates fractures but is insensitive for osteopenia

Answer 70

dual energy X-ray absorptiometry • low radiation dose and measures important fracture sites (lumbar spine and proximal femur) • gold standard for measuring bone density and diagnosing osteoporosis • generates T scores

Answer 71

* quit smoking and reduce alcohol consumption * increase weight-bearing exercise * calcium and vitamin D rich diet * balance exercises to reduce falls

Answer 72

- bisphosphonates (1st line treatment) - strontium renelate - denosunab - HRT - raloxifene - testosterone (for men)

Answer 73

* inhibit bone resorption through the inhibition of enzyme farnesyl pyrophosphate synthase, which is in the cholesterol pathway; this reduces osteoclast activity by removing their ruffled border * encourage osteoclasts to undergo apoptosis * prevent the loss of bone density * increases bone mass at hip and spine * reduce incidence of fracture and are cheap and effective * e.g. oral aldendronate (most common), oral risedronate, IV zoledronate (once yearly) * oral bisphosphonates should be taken fasting, with a large drink of water while standing or sitting upright * associated with oesophagitis

Answer 74

* helps reduce fracture rates | * alternative for those who are intolerant to bisphosphonates

Answer 75

* osteoblasts produce RANKL to activate osteoclasts and thus bone resorption * denosumab is a monoclonal antibody that inhibits RANKL signals * reduces fracture risk

Answer 76

• 2nd line for osteoporosis; used in menopausal women • reduces fracture risk and stops bone loss • prevents hot flushes and other menopausal symptoms, also reduces colon cancer • side effects; breast cancer, stroke and cardiovascular disease

Answer 77

* selective oestrogen receptor modulator (SERM); activates oestrogen receptor on bone whilst having no stimulatory effect on endometrium (similar to HRT) * side effects; increased risk of thrombus formation, cramps and stroke

Answer 78

• increases osteoblast activity and bone formation • reduce fracture risk • improves bone density, improves trabecular structure • useful in those who suffer further fractures despite treatment with other agents • side effects; increased risk of renal malignancy and hypercalcaemia • e.g. teriparatide

Answer 79

erythrocyte sedimentation rate - rises with inflammation/infection - the rate at which RBCs in anticoagulated whole blood descend in standardised tube over a period of one hour - increased fibrinogen makes RBCs ‘stick together’ and thus fall faster (fall is measured in mm) - thus if ESR rises the rate of fall is faster - ESR rises and falls slowly (days to weeks) - false positives i.e. falsely high: females, age, obesity, SE asians, hypercholesterolaemia, high immunoglobulins

Answer 80

C-reactive protein - acute phase protein - released in inflammation/infection - produced by the liver in response to IL-6 - rises and falls rapidly: • high at 6 hours and peaks at 48 hours • so if patients has infection in 24 hours, the ESR won’t have risen yet since it rises slowly but CRP would have!

Answer 81

- SLE - antiphospholipid syndrome - Sjogrens syndrome - systemic sclerosis (scleroderma) - CREST syndrome - polymyositis and dermatomyositis

Answer 82

an inflammatory, multisystem autoimmune disorder where healthy tissues in the body are attacked, with arthralgia and rashes as the most common clinical features, and cerebral and renal disease as the most serious problems

Answer 83

- more common in females than males - peak age of onset between 20-40 yrs; typically women of childbearing age - commoner in African-Caribbeans and Asians

Answer 84

- cause unknown - family history - HLA genes have been linked to SLE - pre-menopausal women are most affected - drugs: hydralazine, isoniazid, procainamide and penicillamine - UV light can trigger flares of SLE - Epstein-Barr virus is a potential trigger for SLE

Answer 85

- immune complex mediated tissue damage - when cells die by apoptosis, the cellular remnants appear on the cell surface as small blebs that carry self antigens - these antigens include nuclear constituents such as DNA and histones, which are normally hidden from the immune system - in SLE, removal of these blebs by phagocytes is inefficient, so that they are transferred to the lymphoid tissues, where they can be taken up by APCs - these self-antigens from the blebs can then be presented to T cells, which stimulate B cells to produce autoantibodies directed against the antigens - can be years before clinical features develop

Answer 86

the combination of availability of self antigens and failure of the immune system to inactivate the B cells and T cells that recognise these self antigens as foreign, and thus target them, leads to the following: • development of autoantibodies that either from circulating complexes or deposit by binding directly to tissues • activation of complement and influx of neutrophils, causing inflammation in those tissues • abnormal cytokine production; increased IL-10 and interferon-alpha resulting in inflammation

Answer 87

- SLE of the skin and kidneys is characterised by deposition of complement and IgG antibodies, and by influx of neutrophils and lymphocytes - biopsies of other tissues show vasculitis affecting capillaries, arterioles and venules - the synovium of joints can be oedematous and may contain immune complexes - haematoxylin bodies (rounded, blue) are seen in inflammatory infiltrates and result form the interaction of antinuclear antibodies and cell nuclei

Answer 88

- most patients suffer fatigue, fever, arthralgia and/or skin poblems - joint involvement in more than 90% - skin involvement in 85% - lung involvement in 50% - heart involvement in 25% - kidney involvement in 30% - CNS involvement in 60% - eyes - GI

Answer 89

- more than 90% of cases - symptoms similar to RA*: symmetrical small joint arthralgia - joints are painful sometimes with soft tissue swelling - avascular necrosis of hip and knee rarely

Answer 90

* 85% of cases * erythema in a butterfly distribution* on the cheeks and across the bridge of the nose * vasculitis lesions on the fingertips and nails * photosensitive rash* * alopecia * Raynaud’s phenomenon

Answer 91

- 50% of cases - recurrent pleural effusions and pleurisy, pneumonitis and atelctasis - pulmonary fibrosis rarely

Answer 92

- 25% of cases - pericarditis and pericardial effusions - myocarditis - arrhythmias - arterial and venous thromboses - increased frequency of ischaemic heart disease and stroke

Answer 93

- 30% of cases | - glomerulonephritis with persistent proteinuria*

Answer 94

- 60% of cases - depression - epilepsy - migraines - cerebellar ataxia - seizures* (with no causative agent) - psychosis*

Answer 95

- retinal vasculitis - episcleritis - conjunctivitis - Sjorgren's (15% of cases)

Answer 96

mouth ulcers* - very common

Answer 97

- acute pericarditis - antiphospholipid syndrome - B-cell lymphoma - fibromyalgia - scleroderma - Sjogren's

Answer 98

* raised ESR * normal CRP * may show leucopenia, lymphopenia and/or thrombocytopenia * anaemia of chronic disease or autoimmune haemolytic anaemia * urea and creatinine only raised if renal disease is advanced * autoantibodies * serum complements C3 and C4 are reduced due to consumption

Answer 99

- anti-nuclear antibodies (ANA) - 95% positive - a raised anti-double-stranded DNA (anti-dsDNA) antibody is highly specific for SLE but only positive in 60% - anti-Ro, anti-Sm and anti-La - 40% are rheumatoid factor (RhF) positive

Answer 100

- think SLE if ESR is raised but CRP is normal - think infection, serositis or arthritis if CRP is raised - blood - histology to see deposition of IgG and complement - MRI and CT for lesions in brain

Answer 101

IV cyclophosphamide and high dose prednisolone

Answer 102

- reduce sunlight exposure - reduce CVD risk factors - prevent rashes with high-factor sunblock - treat BP and give statins to control CVD risk

Answer 103

* NSAIDs for arthralgia, fever and arthritis | * oral/IM corticosteroids for severe flares of arthritis, pleuritis and pericarditis

Answer 104

- topical corticosteroids for rashes - antimalarial drugs e.g. chloroquine or hydroxychloroquine help mild skin disease, fatigue and arthralgia that cannot be controlled by NSAIDs, but watch for retinal toxicity - corticosteroids in moderate to severe disease - immunosuppressives e.g. oral azathioprine, oral methotrexate

Answer 105

• e.g. renal or cerebral disease and severe haemolytic anaemia or thrombocytopenia • immunosuppressives e.g. oral aziroprine, oral methotrexate • high dose oral corticosteroid e.g. prednisolone and oral cyclophosphamide or mycophenolate mofetil (fewer side effects) • biologicals - target B cells via CD20 on B cells: - e.g. rituximab (anti-CD20)

Answer 106

syndrome characterised by thrombosis (arterial or venous) and/or recurrent miscarriages with positive blood tests for antiphospholipid antibodies (aPL)

Answer 107

- associated with SLE in 20-30% of cases - more often occurs as a primary disease - more common in females than males

Answer 108

- antiphospholipid antibodies (aPL) play a role in thrombosis by binding to phospholipid on the surface of cells such as endothelial cells, platelets and monocytes - once bound, this change alters the functioning of those cells leading to thrombosis and/or miscarriage - antiphospholipid antibodies cause CLOTs

Answer 109

``` antiphospholipid antibodies cause: • Coagulation defect • Livedo reticularis; lace-like purplish discolouration of skin • Obstetric issues i.e. miscarriage • Thrombocytopenia ```

Answer 110

- thrombosis - miscarriage - ischaemic stroke, TIA, MI - deep vein thrombosis, Budd-chiari syndrome - thrombocytopenia - valvular heart disease, migraines, epilepsy

Answer 111

- anticardiolipid test: detects IgG or IgM antibodies that bind the negatively charged phospholipid cardiolipin - lupus anticoagulation test: detects changes in the ability of the blood to clot - anti-B2-glycoprotein I test: detects antibodies that bind B2-glycoprotein I, a molecule that interacts closely with phospholipids

Answer 112

- long term warfarin to minimise thrombosis - oral aspirin and SC heparin early on in pregnancy; reduces chance of miscarriage but pre-eclampsia and poor fetal growth remain common - prophylaxis: aspirin or clopidogrel

Answer 113

- chronic autoimmune disease that affects the body's moisture producing glands - characterised by immunologically mediated destruction of epithelial exocrine glands, especially the lacrimal and salivary glands

Answer 114

* syndrome of dry eyes (keratoconjunctivitis sicca) in the absence of RA or any other autoimmune diseases * more common in female than males * associated with HLA-B8/DR3 * onset in 40s-50s; thus mainly affects middle-aged women

Answer 115

associated with connective tissue disease e.g. RA, SLE and systemic sclerosis

Answer 116

lymphocytic infiltration and fibrosis of exocrine glands, especially the lacrimal and salivary glands

Answer 117

- dry eyes (keratoconjunctivitis sicca) due to decrease in tear production - dry mouth due to decreased saliva production (xerostomia) - salivary and parotid gland enlargement - dryness of the skin and vagina - dryness and fatigue may be the only symptoms - systemic symptoms in a minority

Answer 118

* arthralgia and occasional non-progressive polyarthritis * Raynaud's phenomenon * dysphagia and abnormal oesophageal motility * other organ specific autoimmune diseases including thyroid disease, myasthenia gravis, primary biliary cirrhosis, autoimmune hepatitis and pancreatitis * renal tubular defects (uncommon) causing nephrogenic diabetes insipidus and renal tubular acidosis * pulmonary diffusion defects and fibrosis * polyneuropathy; fits and depression * vasculitis * increased incidence of non-Hodgkin’s B-cell lymphoma

Answer 119

- Schirmer tear test - Rose-Bengal staining - lab tests - salivary gland biopsy shows lymphocytic infiltration

Answer 120

strip of filter paper is placed on the inside of the lower eyelid; wetting of <10 mm in 5 mins indicates defective tear production and thus Sjogrens

Answer 121

staining of the eyes shows punctate or filamentary keratitis

Answer 122

* raised immunoglobulin levels * rheumatoid factor is usually positive * antinuclear antibodies (ANA) usually found in 80% * anti-Ro (SSA) antibodies are found in 60-90%

Answer 123

lymphocytic infiltration

Answer 124

- artificial tears and saliva replacement - NSAIDs and hydroxychloroquine for fatigue and arthralgia - corticosteroids are rarely needed, used to treat persistent salivary gland swelling or neuropathy

Answer 125

- autoimmune rheumatic disease characterised by excessive production and accumulation of collagen in the skin and internal organs - multisystem disease with involvement of skin and Raynauds phenomenon - distinct from localised scleroderma such as morphea, that do not involve internal organ disease and are rarely associated with vasospasm

Answer 126

- has the highest case-specific mortality of any autoimmune rheumatic disease - occurs worldwide - more common in females than males - peak incidence is between 30 and 50 years of age - rare in children

Answer 127

- exposure to vinyl chloride, silica dust, adulterated rapeseed oil and trichloroethylene - drugs such as bleomycin - genetic

Answer 128

- widespread vascular damage involving small arteries, arterioles and capillaries is an early feature - there is initial endothelial cell damage with release of cytokines, including endothelin-1, causing vasoconstriction - continued vascular damage and increased vascular permeability and activation of endothelial cells - production of cytokines and growth factors mediate the proliferation and activation of vascular and connective tissue cells - fibroblasts activated by mediators (IL-1, -4, -6 and -8, TGF-B and PDGF synthesise) increase collagen type 1 and 2, producing fibrosis in the lower dermis of the skin and internal organs - the end result is uncontrolled and irreversible proliferation of connective tissue and thickening of vascular walls with narrowing of the lumen - damage to small blood vessels produces widespread obliterative arterial lesions and subsequent chronic ischaemia

Answer 129

* upregulation of adhesion molecules - E-selectin, VCAM and intracellular adhesion molecule 1 (ICAM-1) * cell adhesion - T and B cells, monocytes and neutrophils * migration of cells through leaky endothelium and into the extracellular space

Answer 130

- Raynaud’s phenomenon is seen in almost 100% of cases and can precede the onset of the full-blown disease by many years - limited cutaneous scleroderma (LcSSc)/crest syndrome; 70% of cases - diffuse cutaneous scleroderma (DcSSc); 30% of cases

Answer 131

* starts with Raynaud’s phenomenon many years (up to 15) before any skin changes * skin involvement is limited to the hands, face, feet and forearms * skin is tight over the fingers and often produces flexion deformities of the fingers * face and skin involvement produces characteristic ‘beak’-like nose and a small mouth (microstomia) * painful digital ulcers and telangiectasia * GI tract involvement is common; oesophageal dysmotility or strictures

Answer 132

previously known as CREST syndrome: - Calcinosis; calcium deposition in subcutaneous tissue - Raynauds - Eosophageal dysmotility or strictures - Sclerodactyly - local thickening/tightness of skin on fingers/toes - Telenagiectasia

Answer 133

• skin changes develop more rapidly and are more widespread than in limited cutaneous scleroderma/CREST • there is early involvement of other organs: - GI involvement with dilation and atony in: • oesophagus, resulting in heartburn and dysphagia • small intestine, resulting in bacterial overgrowth and malabsorption • colon, resulting in pseudo-obstruction - renal involvement: • acute and chronic kidney disease • acute hypertensive crisis is a complication of the renal involvement - lung disease: • fibrosis and pulmonary vascular disease resulting in pulmonary hypertension - myocardial fibrosis leads to arrhythmias and conduction disturbances

Answer 134

* normochromic, normocytic anaemia * microangiopathic haemolytic anaemia is seen in some people with renal disease * urea and creatine rise in acute kidney injury

Answer 135

- limited cutaneous scleroderma/CREST: speckled, nucleolar or anti-centromere antibodies (ACAs) - 70% cases - diffuse cutaneous scleroderma: • anti-topoisomerase-1 antibodies (anti-Scl-70) - 30% of cases • anti-RNA polymerase - 20-25% of cases - rheumatoid factor is positive in 30% - anti-nuclear antibodies (ANA) is positive in 95%

Answer 136

- CXR: to exclude other pathology, for changes in cardiac size and established lung disease - hand X-ray: to see deposits of calcium around the fingers - barium swallow: confirms impaired oesophageal motility - high resolution CT: to confirm fibrotic lung involvement

Answer 137

- no cure - Raynaud's: hand warmers, oral vasodilators (calcium channel blocker and endothelin receptor antagonists) - oesophageal involvement (PPI) - nutritional supplementation to treat malabsorption - prevention of renal crisis (ACE inhibitor) - early detection of pulmonary hypertension with annual echos and pulmonary function tests - pulmonary fibrosis: immunosuppresant and oral prednisolone

Answer 138

- type of chronic inflammation of the muscles related to dermatomyositis and inclusion body myositis - unknown aetiology where there is inflammation and necrosis of skeletal muscle fibres - when skin is involved it is called dermatomyositis - lungs can be affected, resulting in interstitial lung disease

Answer 139

- very rare - both affect adults and children - more common in females than males

Answer 140

- viruses implicated are coxsackie, rubella and influenza | - genetic predisposition; those with HLA-B8/DR3 (Sjogrens) appear to be at higher risk

Answer 141

* there is symmetrical progressive muscle weakness and wasting affecting the proximal muscles of the shoulder and pelvic girdle * patients have difficulty squatting, going upstairs, rising from a chair and raising their hands above their head * pain and tenderness are uncommon * involvement of pharyngeal, laryngeal and respiratory muscles can lead to dysphagia, dysphonia and respiratory failure

Answer 142

* characteristic skin changes; heliotrope (purple) discolouration of the eyelids and scaly erythematous plaques over the knuckles (Gottron’s papules) * arthralgia, dysphagia resulting from oesophageal muscle involvement and Raynauds phenomenon * increased incidence of underlying malignancy

Answer 143

- muscle biopsy - muscle enzymes - ESR usually not raised - serum antibodies - electromyography (EMG) used to detect typical muscle changes - MRI can detect abnormally inflamed muscles

Answer 144

shows fibre necrosis and inflammatory cell infiltrates; confirms diagnosis

Answer 145

serum creatine kinase, aminotransferases, lactate dehydrogenase (LDH) and aldolase are all raised

Answer 146

* antinuclear antibody (ANA) positive in dermatomyositis * rheumatoid factor positive in 50% * myositis-specific antibodies (MSAs)

Answer 147

- bed rest may be helpful but must be combined with exercise - oral prednisolone is main treatment and is continued until at least 1 month after the myositis has become clinically and enzymatically inactive, then tapered down slowly - hydroxychloroquine or topical tacrolimus may help with skin disease

Answer 148

early intervention with steroid sparing immunosuppressive therapy is useful in relapse: • oral azathioprine • oral methotrexate • oral ciclosporin

Answer 149

* intermittent spasm in the arteries supplying the fingers and toes leading to episodes of reduced blood flow, usually precipitated by cold and relieved by heat * if there is no underlying cause it is known as Raynaud’s disease * if there is an underlying cause it is known as Raynaud’s phenomenon

Answer 150

- affects 5% of the population | - more common in females than males

Answer 151

- peripheral digit ischaemia due to sudden vasospasm, precipitated by cold or emotion and relieved by heat - usually bilateral and fingers are affected more commonly than toes

Answer 152

- vasoconstriction (causing ischaemia) causes skin pallor followed by cyanosis due to sluggish blood flow, then redness due to hyperaemia - white, blue then red - duration of the attacks is variable but they can sometimes last for hours - numbness, a burning sensation and severe pain occur as the fingers warm up - in chronic disease, infarction and digital loss can occur - smoking can aggravate symptoms

Answer 153

* connective tissue disorders: SLE, systemic sclerosis, rheumatoid arthritis, dermatomyositis/polymyositis * occupational: using vibrational tools * drugs: beta-blockers and smoking

Answer 154

- avoid cold by wearing gloves and warm clothes - stop smoking and beta-blockers - vasodilators: • oral nifedipine • might be unacceptable as cerebral vasodilation causes severe headaches

Answer 155

- group of diseases involving the axial skeleton and having a negative serostatus - seronegative: diseases are negative for rheumatoid factor, indicating different pathophysiology from RA

Answer 156

- axial inflammation; spine and sacroiliac joints - asymmetrical peripheral arthritis - absence of rheumatoid factor hence ‘seronegative’ - strong association with HLA-B27, but aetiological relevance is unclear

Answer 157

- axial spondyloarthritis - reactive arthritis - enteropathic arthropathy or spondylitis association with IBD - psoriatic arthritis - isolated acute anterior uveitis - juvenile idiopathic arthritis - undifferentiated spondyloarthropathy

Answer 158

- Human Leucocyte Antigen (HLA) B27 - class I surface antigen; present on all cells, except RBCs, and presents antigenic peptides (from self and non-self antigens) to T cells - encoded by B locus of Major Histocompatibility Complex (MHC) on chromosome 6

Answer 159

diseases associatied with the HLA-B27 subtype: - Psoriasis - Ankylosing spondylitis - IBD - Reactive arthritis

Answer 160

main theory is ‘molecular mimicry’ whereby an infection triggers an immune response and the infectious agent has peptides very similar to the HLA-B27 molecules so there is an auto-immune response triggered against HLA-B27

Answer 161

think seronegative spondyloarthropathies (SpA) if SPINEACHE: - Sausage digit (dactylitis) - Psoriasis - Inflammatory back pain - NSAIDs good response - Enthesitis (particularly in heel - planter fasciitis) - Arthritis - Crohn's/Colitis/elevated CRP (can be normal in AS) - HLA-B27 - Eye (uveitis)

Answer 162

type of arthritis in which there is a long-term inflammation of joints of the spine, ribs and sacroiliac joints

Answer 163

abnormal stiffening and immobility of joint due to new bone formation

Answer 164

- more common and more severe in males than females - usually presents at 16 yrs; young adults <30yrs - 88% are HLA-B27 positive - women present later and are under-diagnosed - low incidence in African and Japanese people - native North Americans have high incidence

Answer 165

- HLA-B27 | - environment: Klebsiella, Salmonella, Shigella

Answer 166

lymphocyte and plasma infiltration occurs with local erosion of bone at the attachments of the intervertebral and other ligaments (enthesitis; inflammation where tendons/ligaments insert into bone), which heals with syndesmophyte formation 1. normal spine 2. inflammation (erosion, sclerosis and squaring) 3. formation of syndesmophytes 4. fusion (total bony bridge)

Answer 167

- 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 - new bone formation and vertical growth from anterior vertebral corners

Answer 168

- typical patient is a man <30 yrs with gradual onset of low back pain, worse at night, with spinal morning stiffness that is relieved by exercise - episodic inflammation of the sacroiliac joints in the late teenage years or early twenties is the first manifestation; if severe then bamboo spine may be present - pain radiates from the sacroiliac joints to hips/buttocks, and usually improves towards the end of the day - progressive loss of spinal movement resulting in reduced thoracic expansion - asymmetrical joint pain, normally oligoarthritis (1 or 2 joints), unlike RA which is symmetrical and affects smaller joints and more joints - two characteristic spinal abnormalities - enthesitis - non-articular features

Answer 169

- fusion of spinous processes | - seen in ankylosing spondylitis

Answer 170

* loss of lumbar lordosis and increased kyphosis * limitation of lumbar spine mobility in both sagittal and frontal planes; reduced spinal flexion is demonstrated by the Schober test

Answer 171

- mark is made at the 5th lumbar spinous process and 10cm above, with patient in the erect position - on bending forward, the distance should increase to more than 15cm in normal individuals - shows limitation of lumbar spine mobility in both sagittal and frontal planes and reduced spinal flexion

Answer 172

- inflammation of the entheses, the sites where tendons or ligaments insert into the bone - e.g. achilles tendinitis, plantar fasciitis and tenderness around the pelvis and chest wall

Answer 173

* anterior uveitis: inflammation of middle layer of eye * associated with osteoporosis * rarely, aortic incompetence, cardiac conduction defects and apical lung fibrosis, amyloidosis and IgA nephropathy

Answer 174

* ESR and CRP raised - note: CRP can be normal * normocytic normochromic anaemia * HLA-B27 positive - not diagnostic

Answer 175

* can be normal * erosion and sclerosis of the margins of the sacroiliac joints which can proceed to ankylosis * blurring of the upper or lower vertebral rims at the thoracolumbar junction caused by enthesitis at the insertion of intervertebral ligaments * this heals with new bone formation resulting in syndesmophytes; progressive calcification of these can lead to bamboo spine * fusion of the sacroiliac joints

Answer 176

- treat quickly to prevent irreversible syndesmophyte formation and progressive calcification - morning exercise to maintain posture and spinal mobility - NSAIDs useful at night - methotrexate to help with peripheral arthritis but not with spinal disease - TNF-alpha blocker: • can improve spinal and peripheral joint inflammation, the earlier you start the less syndesmophytes form - local steroid injections for temporary relief - surgery to improve pain and mobility

Answer 177

- long-term inflammatory arthritis that occurs in people affected by the autoimmune disease psoriasis (which is characterised by abnormal patches of skin) - can occur without psoriasis

Answer 178

occurs in 10-40% with psoriasis and can present before skin changes

Answer 179

family history of psoriasis

Answer 180

* asymmetrical oligoarthritis * symmetrical seronegative polyarthritis; closely resembling RA * spondylitis * distal interphalangeal arthritis * arthritis mutilans

Answer 181

- unilateral or bilateral sacrolitis and early cervical spine involvement - similar to ankylosing spondylitis but only 50% are HLA-B27 positive

Answer 182

- DIPJs involvement only - most typical pattern of joint involvement in psoriasis - often with adjacent nail dystrophy, reflecting enthesitis extending into the nail root - dactylitis, in which an entire finger or toes is swollen, with joint and tendon sheath involvement is characteristic of this condition

Answer 183

- affects about 5% of people with psoriatic arthritis and causes periarticular osteolysis and bone shortening (‘telescopic fingers’) - destruction of the small bones in the hands and feet - pencil-in-cup X-ray changes - rare

Answer 184

* behind ear/inside ear * scalp * pitting in nails or onokylisis; where the nail lifts off the nail bed and looks brittle and flaky * umbilicus, natal cleft and penile psoriasis

Answer 185

bloods and ESR are often normal

Answer 186

* psoriatic arthritis is erosive but the erosions are central in the joint, not juxta-articular * may be a ‘pencil in cup’ deformity in the interphalangeal joints; bone erosions create a pointed appearance and the articulating bone is concave * skin and nail disease can be mild and may develop after arthritis

Answer 187

- similar to that of RA - NSAIDs and/or analgesics to help the pain but can occasionally worsen the skin lesions - local synovitis responds to intra-articular corticosteroid injections - early intervention with DMARDs can help skin lesions - methotrexate and ciclosporin for severe disease - anti-TNF alpha agents are highly effective and safe for severe skin and joint disease; used when methotrexate has failed

Answer 188

- form of inflammatory arthritis that develops in response to an infection in another part of the body (cross-reactivity) - sterile inflammation of the synovial membrane, tendons and fascia triggered by an infection at a distant site, usually GI or genital - typically affects the lower limb

Answer 189

- in males who are HLA-B27 positive they have an 30-50 fold increased risk - women are less commonly affected

Answer 190

* GI infections: salmonella, shigella, and yersinia enterocolitica * sexually acquired: urethritis from chlamydia trachomatis and ureaplasma urealyticum

Answer 191

bacterial antigens or bacterial DNA have been found in the inflamed synovium of affected joints, suggesting that this persistent antigenic material is driving the inflammatory response

Answer 192

- arthritis is typically an acute, asymmetrical, lower-limb arthritis - occurring a few days to a couple of weeks after the infection - the arthritis may be the presenting complaint if the infection is mild or asymptomatic - 'can't see, can't wee, can't climb a tree' - in those who are HLA-B27 positive (60-85%), sacroiliitis and spondylitis may also develop - sterile conjunctivitis occurs in 30% - skin lesions resemble psoriasis

Answer 193

* acute anterior uveitis * circinate balanitis: painless ulceration of the penis * enthesitis: common and causes plantar fasciitis (heel) and Achilles tendon enthesitis

Answer 194

serpiginous ring-shaped dermatitis of the glans penis - in the uncircumcised male this causes painless superficial ulceration of the glans penis - in the circumcised males, the lesion is raised, red and scaly - seen in reactive arthritis - both heal without scarring

Answer 195

involves the skin of the feet and hands, which develops painless, red and often confluent raised plaques and pustules that are histologically similar to pustular psoriasis

Answer 196

- ESR and CRP raised in acute phase - culture stool if diarrhoea - sexual health review - aspirated synovial fluid is sterile with a high neutrophil count: • if the joint is hot and swollen can exclude crystal arthritis and septic arthritis using aspiration - X-ray may show enthesitis

Answer 197

- joint inflammation - NSAIDs and corticosteroid injections - treat persisting infection with antibiotics - screen sexual partners - majority of individuals with reactive arthritis have a single attack that settles, but a few develop disabling relapsing and remitting arthritis - relapsing cases use methotrexate or sulfasalazine - if that doesn't work and is severe and persistent disease then use TNF-alpha blockers

Answer 198

inflammation and necrosis of blood vessel walls with subsequent impaired blood flow resulting in: - vessel wall destruction; aneurysm, rupture and stenosis: resulting in perforation and haemorrhage into tissues - endothelial injury: resulting in thrombosis and ischaemia/infarction of dependent tissues

Answer 199

- size of blood vessel involved: large, medium, small - presence or absence of anti-neutrophil cytoplasmic antibodies (ANCA): small-vessel vasculitis tend to be ANCA positive e.g. microscopic polyangitis and granulomatosis with polyangitis

Answer 200

- refers to the aorta and its major tributaries - examples: • giant cell arteritis/polymyalgia rheumatica • Takayasu’s arteritis

Answer 201

- refers to medium and small-sized arteries and arterioles - examples: • classical polyarteritis nodosa (PAN) • Kawasaki’s disease

Answer 202

- microscopic polyangitis - granulomatosis with polyangitis (Wegener's) - eosinophilic granulomatosis with polyangitis (Churg-Strauss)

Answer 203

- cryoglobulinaemic vasculitis - IgA vasculitis (Henoch-Schoenlein) - hypocomplementaemic urticarial vasculitis (anti C1a vasculitis)

Answer 204

* vasculitis with RA * SLE * scleroderma * polymyositis/dermatomyositis * good pasture syndrome and IBD

Answer 205

* polymyalgia rheumatica (PMR) and giant cell (temporal) arteritis (GCA) are systemic illnesses affecting patients older than 50yrs * both are associated with the finding of GCA on temporal artery biopsy * these are two separate conditions but normally co-exist

Answer 206

- systemic disease of the elderly - affects those over 50 yrs - more common in females than males - pathogenesis is unknown

Answer 207

syndrome with pain or stiffness, usually in the neck, shoulders, upper arms and hips but can occur all over the body

Answer 208

- sudden onset of severe pain and stiffness of the shoulders and neck, and of the hips and lumbar spine; a limb girdle pattern - symptoms are worse in the morning, lasting from 30 mins to several hours - mild polyarthritis of peripheral joints - 1/3rd experience fatigue, fever, weight loss, depression

Answer 209

- RA, spondyloarthropathies, SLE, polymyositis/dermatomyositis - osteoarthritis, malignancy - chronic pain syndrome e.g. fibromyalgia and depression

Answer 210

- clinical history is usually diagnostic and the patient is always over 50 - both ESR and CRP are raised; diagnostic - ANCA negative - serum alkaline phosphatase raised - mild normochromic, normocytic anaemia - temporal artery biopsy: shows giant cell arteritis in 10-30% cases - note: creatinine kinase is normal - helps to distinguish from myositis/myopathies

Answer 211

corticosteroids produce a dramatic reduction of symptoms within 24-48 hours of starting treatment • if improvement does not occur then diagnosis should be questioned • decrease dose slowly • used long-term so give GI and bone protection (to prevent osteoporosis due to steroid use)

Answer 212

- an inflammatory disease of large blood vessels - inflammatory granulomatous arteritis of large cerebral arteries as well as other large vessels, which occurs in association with PMR

Answer 213

- primarily in those over 50 - incidence increases with age - more common in females than males

Answer 214

- over 50 - female - RA, SLE, scleroderma

Answer 215

- arteries become inflamed, thickened and can obstruct blood flow - cerebral arteries affected in particular e.g. temporal artery - opthalmic artery can also be affected potentially resulting in permanent or temporary vision loss

Answer 216

- severe headaches (temporal pulsating) - tenderness of scalp (combing hair can be painful) or temple - claudication of the jaw when eating - tenderness and swelling of one or more temporal or occipital arteries - sudden painless vision loss; arteritic anterior ischaemic optic neuropathy; optic disc is very pale/swollen - malaise, lethargy, fever - associated symptoms of PMR - dyspnoea, morning stiffness and unequal or weak pulses

Answer 217

- migraine - tension headache - trigeminal neuralgia - polyarteritis nodosa

Answer 218

* over 50 * new headache * temporal artery tenderness or decreased pulsation * ESR raised * abnormal artery biopsy - inflammatory infiltrates present

Answer 219

- normochromic, normocytic anaemia - ESR raised - ANCA negative - CRP very high - serum alkaline phosphatase may be raised

Answer 220

* definitive diagnostic test * should be taken before or within 7 days of starting high dose corticosteroids * lesions are patchy so take a big chunk

Answer 221

- cellular infiltrates of CD4+ T lymphocytes, macrophages and giant cells in the vessel wall - granulomatous inflammation of the intima and media - breaking up of the internal elastic lamina

Answer 222

- high dose corticosteroids to stop vision loss; gradual reduction of steroids over 12-18 months - corticosteroids are used long-term so give GI and bone protection - monitor treatment progress by looking at ESR/CRP (should fall)

Answer 223

systemic necrotising inflammation of blood vessels affecting medium-sized muscular arteries, typically involving arteries of the kidneys and other internal organs but generally sparing the lungs

Answer 224

- rare in the UK - usual occurs in middle-aged men - more common in males than females - associated with Hep B

Answer 225

- male - Hep B - RA, SLE, scleroderma

Answer 226

- fever, malaise, weight loss and myalgia; these initial symptoms are followed by dramatic acute features that are due to organ infarction - lung involvement is rare

Answer 227

- mononeuritis multiplex due to arteritis of the vasa nervorum: numbness, tingling, abnormal/lack of sensation and inability to move part of the body - pain due to arterial involvement of the abdominal viscera, mimicking acute cholecystitis, pancreatitis or appendicitis - GI haemorrhage due to mucosal ulceration - haematuria and proteinuria - hypertension and acute/chronic kidney disease - coronary arteritis causes myocardial infarction and heart failure - subcutaneous haemorrhage and gangrene

Answer 228

- fever caused by infection - Crohn’s - connective tissue disease e.g. SLE or RA - other vasculitis

Answer 229

- anaemia - WCC raised - ECR raised - ANCA negative (very rarely positive) - biopsy, of kidney in particular to look for hypertension and other damage; can be diagnostic - angiography: demonstrates micro-aneurysms in hepatic, intestinal or renal vessels

Answer 230

- control BP with ACE-inhibitors - corticosteroids combined with immunosuppressive drugs - Hep B should be treated with an antiviral after initial treatment with steroids

Answer 231

gout: monosodium urate crystals • needle-shaped (long and thin) • negatively bifringent under polarised light • does not require special stain pseudogout: calcium pyrophosphate dihydrate crystals • small rhomboid brick-shaped • positively bifringent under polarised light • does not require special stain pseudopseudogout: hydroxyapatite • small • non-bifringent under polarised light • requires Alizarin red stain

Answer 232

a form of inflammatory arthritis characterised by recurrent attacks of a red, tender, hot and swollen joint - due to persistently elevated levels of uric acid in the blood - at high levels, uric acid crystallises and the crystals deposit in joints, tendons and surrounding tissues, leading to an attack - associated with hyperuricaemia and intra-articular monosodium urate crystals

Answer 233

- common - prevalence is increasing especially in developing countries - more common in males than females - rarely occurs before young adulthood - most common inflammatory arthritis in the UK

Answer 234

- high alcohol intake (highest risk for beer, then spirits, then wine) - purine rich foods; red meat e.g. liver and seafood - high fructose intake (sugary drinks, cakes, sweets and fruit sugars); reduces uric acid excretion - high saturated fat diet - drugs such as low-dose aspirin - ischaemic heart disease - renal causes - increased production of uric acid - family history of gout

Answer 235

* defective gene for URAT1 transporter in kidney (URAT1 reabsorbs urate and then actively secretes it), seen in kidney disease * high insulin levels lower urate excretion e.g. in diabetes mellitus * diuretics impair uric acid excretion

Answer 236

* increased purine turnover * myeloproliferative * lymphoproliferative disorders * carcinoma and psoriasis, due to increased cell turnover * cell damage/surgery * cell death; chemotherapy

Answer 237

purines -> hypoxanthine -> xanthine -> uric acid | - catalysed by xanthine oxidase

Answer 238

monosodium urate or allantoin (uricase)

Answer 239

- purines come from high purine foods e.g. red meat but mainly from energy production (increases with increased sugar intake); purines need to be excreted - in the body they are broken down and in the last two steps of purine metabolism, hypoxanthine is converted to xanthine and then xanthine is converted to uric acid under the action of the enzyme xanthine oxidase

Answer 240

- humans do not possess the enzyme uricase which is needed to convert uric acid to allantoin - instead we excrete the uric acid via the kidneys, however this is not efficient and if there is hyperuricaemia then it may be converted to monosodium urate crystals, causing symptomatic gout and pain

Answer 241

serum uric acid level greater than 420 μmol/L (males) or 360 μmol/L (females)

Answer 242

- if there is hyperuricaemia then it may be converted to monosodium urate crystals, causing symptomatic gout and pain - serum uric acid (SUA) levels are higher in men than in women - only 1 in 5 with hyperuricaemia will develop gout thus for the most part, hyperuricaemia is asymptomatic - you need to have hyperuricaemia to develop gout but having hyperuricaemia does not guarantee gout, just increases the risk - in hyperuricaemia, osteoarthritic joints are more prone to attacks of gout

Answer 243

* age * obesity * diabetes mellitus * ischaemic heart disease and hypertension

Answer 244

- monosodium urate crystals tend to form in joints that have had previous trauma, and crystals form at lower temperatures, so the big toe is more susceptible as it's the coolest peripheral joint - monosodium urate crystals can also trigger intracellular inflammation resulting in more pain

Answer 245

- occurs when monosodium urate crystals form - typically in middle-aged men - sudden onset of agonising pain, swelling and redness of the first MTP joint - usually just one joint is affected but can sometimes be polyarthritic - attack may be precipitated by excess food (especially red meat), alcohol, dehydration or diuretic therapy, cold, trauma or sepsis

Answer 246

rare, except in the elderly who are on long term diuretics in renal failure or if they have been started on allopurinol too soon

Answer 247

- differential for acute gout - in people with persistently high levels of uric acid they can get chronic tophaceous gout, due to monosodium urate forming smooth white deposits (tophi) in the skin and around joints, on the ear, fingers or the Achilles tendon - tophi are onion-like aggregates of monosodium urate crystals with inflammatory cells - tophi release local proteolytic enzymes hence erosions to bone, forming circular punch-like holes - associated with renal impairment and/or the long-term use of diuretics

Answer 248

- acute gout - chronic polyarticular gout - tophaceous gout - urate renal stone formation - recurrent gout attacks can lead to renal impairment

Answer 249

exclude septic arthritis in any acute monoarthropathy

Answer 250

* diagnostic | * shows long needles shaped crystals that are negatively bifringent under polarised light

Answer 251

- serum uric acid is raised: if it is not, it should be rechecked several weeks after the attack, as levels fall immediately after an acute episode - serum urea and creatinine and eGFR used to monitor for renal impairment

Answer 252

- aim to get the uric acid level down below normal in blood so crystal reverse and start to increase uric acid levels to below 300 μmol/L - lose weight - less alcohol - avoid purine rich food - dairy can help reduce gout

Answer 253

• high dose NSAIDs or COX inhibitors • if NSAID not tolerated well or due to contraindication due to renal impairment then use colchicine (targets uric acid crystallisation): - very toxic in overdose - side effects; diarrhoea and abdomen pain • IM, oral or intra-articular (most effective, but can be painful) corticosteroids

Answer 254

* stop diuretics and switch to angiotensin receptor blocker e.g. losartan (uricosuric; promotes uric acid excretion) * allopurinol * febuxostat

Answer 255

- inhibits xanthine oxidase meaning there is less uric acid production and thus less monosodium urate production - reduces serum urate levels rapidly - side effects: rash, fever and low white cell count - introduction of allopurinol may trigger an attack so wait for 3 weeks after an acute episode

Answer 256

- non-purine xanthine oxidase inhibitor | - use if allopurinol is contraindicated or due to side effects

Answer 257

calcium pyrophosphate dihydrate crystal deposition disease (pseudogout) - rheumatological disease which is secondary to abnormal acccumulation of calcium pyrophosphate dihydrate crystals within joint soft tissue - knee joint is most commonly affected

Answer 258

affects elderly women in particular

Answer 259

- old age - diabetes - osteoarthritis - joint trauma/injury - metabolic disease: hyperparathyroidism or haemochromatosis

Answer 260

deposition of calcium pyrophosphate in articular cartilage and periarticular tissue producing the radiological appearance of chonedrocalcinosis (linear calcification parallel to the articular surfaces)

Answer 261

- shedding of crystals into a joint produces acute synovitis that resembles acute gout but is more common in elderly women and usually affects the knee or wrist - the attacks are very painful - acute hot swollen wrist or knee - since it presents with hot joint and fever it can be mistaken for septic arthritis (if steroid given effects can be devastating)

Answer 262

* small rhomboidal crystals under microscopy * positively bifringent crystals under polarised light; remember since Pseudogout = Positively bifringent * joint fluid looks purulent so should be sent for culture to exclude septic arthritis

Answer 263

shows chonedrocalcinosis (linear calcification parallel to the articular surfaces)

Answer 264

- high dose NSAIDs or COX inhibitor s - if NSAID is not tolerated well or due to contraindication due to renal impairment then colchicine: • very toxic in overdose • side effects: diarrhoea and abdomen pain - IM, oral or intra-articular (most effective, but can be painful) corticosteroid - aspiration of the joint reduces pain dramatically

Answer 265

- a condition involving cellular remodelling and deformity of one or more bones - affected bones show signs of dysregulated bone remodelling at the microscopic level, specifically excessive bone breakdown and subsequent disorganised new bone formation - also known as osteitis deformans

Answer 266

- incidence increases with age; rare under 40 yrs - affects up to 10% of individuals by the age of 90 - more common in Europe and Northern England - UK has highest prevalence in the world - more common in females then males

Answer 267

- aetiology is unknown - may result from latent viral infection (canine distemper virus, measles or respiratory syncytial virus) in osteoclasts in genetically susceptible individuals - family history

Answer 268

- there is increased osteoclastic bone resorption followed by formation of weaker new bone, increased local bone blood flow and fibrous tissue - ultimately, formation exceeds resorption but the new woven bone is weaker than normal bone - this leads to deformity and increased fracture risk - disease doesn't spread but can become symptomatic at previously silent sites

Answer 269

pelvis, lumbar spine, femure, thoracic spine, skull and tibia, although any bone can be involved but small bones rare

Answer 270

- 60%-80% are asymptomatic - bone pain - joint pain leading to cartilage damage and osteoarthritis - deformities, in particular bowed tibia and skull changes - high-output cardiac failure and myocardial hypertrophy due to increased bone blood flow - osteosarcoma

Answer 271

• nerve compression: - deafness from 8th cranial nerve involvement - paraparesis; partial paralysis of lower limbs • hydrocephalus due to blockage of the aqueduct of Sylvius

Answer 272

- increased serum alkaline phosphatase with normal calcium and phosphate - reflects increased bone turnover - urinary hydroxyproline excretion is raised (marker of disease activity)

Answer 273

* localised bony enlargement and distortion * sclerotic changes (increased density) * osteolytic areas (loss of bone and reduced density)

Answer 274

useful to determine the extent of skeletal involvement but is unable to distinguish between Paget’s disease and sclerotic metastatic carcinoma (especially in breast and prostate)

Answer 275

- bisphosphonates which inhibit bone resorption by decreasing osteoclast activity; 1st line treatment - NSAIDs for pain - disease activity monitored by symptoms and measurement of serum alkaline phosphatase or urinary hydroxyproline

Answer 276

disease characterised by softening of the bones caused by impaired bone metabolism primarily due to inadequate levels of available phosphate, calcium and vitamin D, or because of resorption of calcium. the impairment of bone metabolism causes inadequate bone mineralisation.

Answer 277

defective bone mineralisation during bone growth at the epiphyseal growth plate, during childhood

Answer 278

produced in the skin through the action of ultraviolet B sunlight on 7-dehydrocholesterol, forming cholecalciferol (vitamin D3)

Answer 279

small amount from diet, e.g. oily fish, egg yolks and margarine; D2 and D3

Answer 280

converted to 25-hydroxycholecalciferol by 25-hydroxylase/CYP2R1

Answer 281

converted to 1,25-dihydroxy-cholecalciferol/calcitriol by 1alpha-hydroxylase (CYP27B1)

Answer 282

increased PTH and decreased phosphate

Answer 283

- increased 24-hydroxylase (CYP24R1) -> 24,250dihydroxyD3 - decreased 1alpha hydroxylase (CYP27B1) - increased Ca2+ absorption in the gut - increased calcification and resorption in the bone

Answer 284

most common cause of osteomalacia is hypophosphataemia due to hyperparathyroidism secondary to vitamin D deficiency

Answer 285

• due to malabsorption, since vitamin D is fat soluble so GI disease can result in malabsorption e.g. in Coeliac or Crohn’s • poor diet - not enough oily fish or egg yolks • lack of sunlight: - those with pigmented skin, using sunscreen, concealing clothing - the elderly and institutionalised

Answer 286

renal failure means there is inadequate conversion of 25-hydroxycholecalciferol to 1,25-dihydroxycholecalciferol

Answer 287

reduced hydroxylation of vitamin D to 25-hydroxy vitamin D e.g. cirrhosis

Answer 288

* muscle weakness leading to characteristic waddling gait and difficulty climbing stairs and getting out of a chair * widespread bone pain; dull ache that is worse on weight-bearing and walking * bone pain and tenderness * fractures, especially of the femoral neck

Answer 289

* growth retardation, hypotonia * knock knees, bowed legs * widened epiphyses at the wrists * hypocalcaemic tetany may occur in severe cases

Answer 290

* low Ca2+ and phosphate * raised serum alkaline phosphatase * elevated parathyroid hormone * low 25-hydroxy vitamin D

Answer 291

* shows incomplete mineralisation | * gold standard test but not practical

Answer 292

* shows defective mineralisation * Looser’s pseudofractures/zones - low-density bands extending from the cortex inwards in the shafts of the long bones e.g femur and pelvis

Answer 293

* in dietary insufficiency: calcium D3 fortefication * in malabsorption/hepatic disease: oral ergocalciferol or IM calcitriol * in renal disease: alfacidol or calcitriol

Answer 294

a medical condition in which there are anatomic changes and a loss of function of varying degrees of one or more intervertebral discs of the spine which causes symptoms. - root cause is thought to be loss of soluble proteins within fluid with resultant loss of oncotic pressure, causing loss of fluid volume

Answer 295

- disease of younger people (20-40 yrs) since the disc degenerates with age and in the elderly it is no longer able to prolapse - in older patients sciatica is more likely to be the result of compression (as opposed to prolapse) of the nerve root by osteophytes in the lateral recess of the spinal canal

Answer 296

- sudden onset of severe back pain, often following a strenuous activity - pain is often clearly related to position and is aggravated by movement - muscle spasm leads to sideways tilt when standing - the radiation of the pain and clinical findings depend on the disc affected - lower three discs are most commonly affected

Answer 297

- pain: from buttock down back of thigh to ankle/foot - reflex lost: ankle jerk - other signs: diminished straight leg raising

Answer 298

- pain: from buttock to lateral aspect of leg and top of foot - reflex lost: none - other signs: diminished straight leg raising

Answer 299

- pain: lateral aspect of the thigh to medial side of the calf - reflex lost: knee jerk - other signs: positive femoral stretch

Answer 300

- X-rays | - MRI in whom surgery is being considered

Answer 301

- acute stage; bed rest on a firm mattress, analgesia and epidural corticosteroid injection - surgery only for severe or increasing neurological impairment e.g. foot drop or bladder symptoms - physio in recovery phase; helping correct posture and to restore movement

Answer 302

* associated with degenerative changes in the lower lumbar discs and facet joints * pain is usually of the mechanical type * sciatic radiation may occur with pain in the buttocks radiating into the posterior thigh * usually the pain is long-standing and there is no cure * NSAIDs, physiotherapy and weight reduction can be useful * surgery can be done when pain arises from a single identifiable level; fusion at this level with decompression of the affected nerve roots

Answer 303

- multiple myeloma - lymphoma - primary tumour of bone; rare and only seen in young - metastases - pain is typically unremitting and worse at night and there are other clinical clues e.g. weight loss or ill-health

Answer 304

* osteosarcomas * fibrosarcomas * chondromas * Ewing’s tumour

Answer 305

* lungs - bronchus * breast * prostate - often osteosclerotic too * thyroid - less common * kidney - less common most common are from the bronchus, breast and prostate

Answer 306

* may show metastases as osteolytic areas (for lytic tumour to be visible it must have lost greater than 60% bone density) with bony destruction * osteosclerotic (increased bone density) metastases are characteristic of prostatic carcinoma

Answer 307

- serum alkaline phosphatase (from bone) is usually raised - hypercalcaemia occurs in 10-20% who have metastatic malignancies - PSA is raised in the presence of prostatic metastases

Answer 308

- analgesics and anti-inflammatory drugs - local radiotherapy to bone metastases relieves pain and reduces the risk of pathological fracture - some tumours respond to chemotherapy - some tumours are hormone-dependent and respond to hormonal therapy - bisphosphonates can help symptoms

Answer 309

* aggressive malignant neoplasm that arises from primitive transformative cells of mesenchymal origin that produces malignant osteoid * most common primary bone malignancy in children * usual peak onset 15-19 yrs * associated with Paget’s disease in adult life

Answer 310

* occurs in metaphyses of long bones * common sites are knee (75%) or proximal humerus * often presents as a relatively painless tumour * destroys bone and spreads into the surrounding tissue * rapidly metastasises to the lung

Answer 311

- bone destruction and formation | - soft tissue calcification produces a sunburst appearance

Answer 312

* type of cancer that forms in bone or soft tissue * thought to arise from mesenchymal stem cells * very rare * average age of onset is 15 yrs

Answer 313

• presents with a mass/swelling, most commonly in the long bones of the: - arms, legs, pelvis and chest - occasionally in the skull and flat bones of the trunk • painful swelling, redness in the area surrounding the tumour, malaise, anorexia, weight loss, fever, paralysis and/or incontinence if affecting the spine, numbness in affected limb

Answer 314

- cancer composed of cells derived from transformed cells that produce cartilage - most common adult bone sarcoma

Answer 315

associated with dull, deep pain and affected area is swollen and tender

Answer 316

pelvis, femur, humerus, scapula and ribs

Answer 317

- also known as chronic persistent pain - widespread musculoskeletal pain after other diseases have been excluded - symptoms present for at least 3 months and other causes have been excluded - pain at 11/18 tender point sites on digital palpation (with enough pressure so that the thumb blanches)

Answer 318

central (non-nociceptive) pain: - due to central disturbance in pain processing - bipsychosocial factors are important

Answer 319

- can develop at any age but often over 60 yrs - more common in females than males - 12% of those with RA have fibromyalgia

Answer 320

- female - middle age - low household income - divorced - low educational status

Answer 321

- depression - chronic headache - IBS - chronic fatigue syndrome - myofascial pain syndrome

Answer 322

- chronic pain (more than 3 months) that is widespread - fatigue is often extreme and occurring after minimal exertion - non-restorative sleep - anxiety and anger

Answer 323

* predominantly neck and back but may be all over * aggravated by stress, cold and activity * associated with generalised morning stiffness * paraesthesiae of hands and feet

Answer 324

- lower neck in front - base of the skull - upper edge of breast - neck and shoulder - upper inner shoulder - below side bone at allow - upper outer buttock - hip bone - just above knee on inside

Answer 325

* frequent waking during the night * waking unrefreshed * poor concentration and forgetfulness * low mood, irritable and weepy * lack of non-REM sleep causes functional pain

Answer 326

- hypothyroidism - SLE - polymyalgia rheumatica - high calcium - low vitamin D - inflammatory arthritis

Answer 327

- pain at 11 of 18 tender point sites on digital palpation - thyroid function test (to exclude hypothyroidism) - ANA’s and DsDNA (to exclude SLE) - ESR and CRP (to exclude PMR) - Ca2+ and electrolytes (to exclude high calcium) - Vit D (to exclude low vitamin D) - examine patient and CRP (to exclude inflammatory arthritis)

Answer 328

- educate patient and family - avoid unnecessary investigations - reset pain thermostat (correct non-restorative sleep and improve aerobic fitness) - low-dose antidepressants and anticonvulsants (tricyclics and pregabalin) - NSAIDs and steroids rarely work in fibromyalgia

Answer 329

- age of onset less than 20 or greater than 55 yrs - violent trauma - constant, progressive, non-mechanical pain - thoracic pain - systemic steroids, drug abuse or HIV - systemically unwell, weight loss - persisting severe restriction of lumbar flexion - widespread neurology - structural deformity

Answer 330

- common back pain in young people - 20-55 yrs - associated with heavy manual handling, stooping and twisting whilst lifting, exposure to whole body vibration, psychosocial distress, smoking and dissatisfaction with work

Answer 331

* lumbar disc prolapse * osteoarthritis * fractures * spondylolisthesis * heavy manual handling * stooping and twisting whilst lifting * exposure to whole body vibration

Answer 332

* female * increasing age * pre-existing chronic widespread pain - fibromyalgia * psychosocial factors

Answer 333

- back is stiff and a scoliosis may be present when patient is standing - muscular spasm is visible and palpable and causes local pain and tenderness - lessens when sitting or lying - pain is often unilateral and helped by rest - episodes are generally short-lived and self-limiting, but once you've had one there is a significantly increased risk of further back pain episodes - sudden onset - pain worse in the evening - morning stiffness is absent - exercise aggravates pain

Answer 334

- spinal movement occurs at the disc and the posterior facet joints; stability is normally achieved by a complex mechanism of spinal ligaments and muscles - any of these structures may be a source of pain - some typical syndromes are recognised: lumbar spondylosis, facet joint syndrome, fibrositic nodulosis, postural back pain and swayback of pregnancy

Answer 335

spondylosis is the degeneration of the vertebral spinal column from any cause

Answer 336

* main lesion occurs in an intervertebral disc * the disc allows rotation and bending * changes in the discs occasionally start in teenage years or early twenties and often increase with age * the gel changes chemically, breaks up, shrinks and loses its compliance * the surrounding fibrous zone develops circumferential or radial issues * in the majority this is initially asymptomatic but visible on MRI as dehydration * later the discs become thinner and less compliant * these changes cause circumferential bulging of the intervertebral ligaments * reactive changes develop in adjacent vertebrae; the bone becomes sclerotic and osteophytes form around the rim of the vertebra

Answer 337

L5/S1 and L4/L5

Answer 338

protrusions of the nucleus pulposus of the intervertebral disc through the vertebral body endplate and into the adjacent vertebra - this process is painless but may accelerate disc degeneration

Answer 339

- may be asymptomatic - episodic spinal pain - progressive spinal stiffening - facet joint pain - acute disc prolapse, with or without nerve irritation - spinal stenosis

Answer 340

syndrome in which the facet joints (synovial diarthroses, from C2 to S1) cause painful symptoms

Answer 341

- a set of synovial, plane joints between the articular processes of two adjacent vertebrae - two facet joints in each spinal motion segment - each facet joint is innervated by the recurrent meningeal nerves - function of each pair is to guide and limit movement of the spinal motion segment

Answer 342

* pain is typically worse on bending backwards and when straightening from flexion - it is lumbar in site, unilateral or bilateral and radiates to the buttock * facet joints are well seen on MRI and may show osteoarthritis, an effusion or a ganglion cyst * treatment consists of direct corticosteroid injections under imaging * physiotherapy and weight loss

Answer 343

* low back pain is common in pregnancy and reflects altered spinal posture and increased ligamentous laxity * weight control and pre- and postnatal exercises are helpful, and the pain usually settles after delivery * analgesics and NSAIDs are best avoided during pregnancy and breastfeeding * poor posture causes a similar syndrome in the non-pregnant, owing to obesity or muscular weakness * poor sitting posture at work is a frequent cause of chronic low back pain

Answer 344

in the elderly, ESR and CRP will distinguish mechanical back pain form polymyalgia rheumatica

Answer 345

only for red flags: - starts before age of 20 or over 50 - persistent and a serious cause is suspected - worse at night or in the morning; inflammatory arthritis e.g ankylosing sponylitis, infection or a spinal tumour - associated with systemic illness, fever or weight loss - is associated with neurological symptoms or signs

Answer 346

- spinal X-rays - MRI more preferable to CT (better for bone pathology) - bone scans

Answer 347

- urgent neurosurgical referral if any neurological deficit - analgesia - combined with physiotherapy, back muscle training regimens and manipulation - acupuncture helps some - excessive rest avoided - re-education in lifting and exercises to prevent further attacks of pain - comfortable sleeping position using a medium-firm mattress

Answer 348

- heavy manual handling - lifting above shoulder height - lifting from below knee height - incorrect manual handling technique - forceful repetitive work - poor postures

Answer 349

- mechanical tension neck - thoracic outlet syndrome - rotator cuff tendonitis - carpal tunnel syndrome - tenosynovitis - hand-arm vibration syndrome - medial and lateral epicondylitis

Answer 350

- compression of nerves, arteries or veins in the passageway from the lower neck to the armpit - three main types: neurogenic, venous and arterial - pain or tingling down arms or blanching of fingers related to posture of arm - may also present as wasting of hands - due to compression of the brachial plexus or subclavian artery/vein in the neck - may be due to a cervical rib, cervical band or other abnormalities of anatomy in neck - associated with poor posture, loading of shoulders and working at a keyboard - Roos sign - X-ray neck, MRI scan - treatment: surgery

Answer 351

- inflammation of the rotator cuff tendon - rotator cuff tendon tears leading to swelling and further impingement beneath arch - jobs with high risk involve heavy manual handling, lifting above shoulder height and throwing

Answer 352

- more common in females than males - compression of median nerve by flexor tendons; gives pain, numbness, tingling, weakness and wasting of muscles supplied by median nerve - associated with; obesity, short stature, pregnancy, diabetes, hypothyroidism and RA - seen in occupations with forceful, repetitive work done with abnormal wrist postures - extremes of flexion-extension of wrist e.g. abattoir workers

Answer 353

- inflammation of the fluid-filled sheath that surrounds the tendon - joint pain, swelling, stiffness, tenderness, crepitus - job with forceful and repetitive hand movements e.g. hammering - more common in females than males - treatment: NSAIDs, steroid injection, rest

Answer 354

- Raynaud's phenomenon of industrial origin - caused by excessive exposure to hand-transmitted vibration - high risk if using chain saws, grinders, jack hammers and drills - vascular (blanching) and sensorineural (tingling, numbness and loss of dexterity) components - eligible for state benefit

Answer 355

- medial (common flexor tendon): pain against resisted flexion of wrist, Golfer's elbow - lateral (common extensor tendon): pain against resisted extension of wrist, Tennis elbow - seen where there is repetitive bending and straightening of elbow e.g. tennis players and golfers - treatment: NSAIDs, steroid injection, rest and surgery

Answer 356

* infection of the joints is usually caused by bacteria and rarely by fungi * some viruses e.g. rubella, mumps and hep B infections are associated with a mild self-limiting arthritis but this is not due to direct joint involvement

Answer 357

- invasion of a joint by an infectious agent resulting in joint inflammation - can destroy a joint in under 24hrs - knee is affected in more than 50% of cases - joints become infected by direct injury or by blood-borne infection from an infected skin lesion or other site

Answer 358

increases with age - 45% for those over 65 yrs

Answer 359

* S. aureus is most common cause * streptococci * Neisseria gonorrhoea * Haemophilus influenzae in children * Gram negative bacteria e.g. E.coli or Pseudomonas aeruginosa in the elderly or very young or those who are systemically unwell/IV drug user

Answer 360

- pre-existing joint disease, especially RA (chronically inflamed joints are at more risk of infection than normal joints) - diabetes melllitus - immunosuppression e.g. HIV - chronic renal failure - recent joint surgery - prosthetic joints - IV drug abuse - those over 80yrs and infants - recent intra-articular steroid injection - direct/penetrating trauma

Answer 361

- in the young and previously fit: agonisingly painful, red, swollen, hot joint - in the elderly and immunosuppressed and in RA the signs may be muted and less dramatic - children might not use joint; limping or protecting joint - fever - 90% monoarthritis but possibly polyarthritis - most common in knee, hip and shoulder but can occur in any joint - early infection: wound inflammation/discharge, joint effusion, loss of function and pain - late disease: presents with pain or mechanical dysfunction

Answer 362

gout and pseudogout

Answer 363

- urgent joint aspiration - polarised light microscopy for crystals to exclude gout/pseudogout - ESR, CRP and WCC raised; CRP may not always be raised - X-ray: no value in septic arthritis, loosening or bone loss around a previously well fixed implant will suggest infection - skin wound swabs, sputum and throat swab or urine if gonoccal infection is possible

Answer 364

* send fluid for urgent Gram-staining and culture * fluid will be purulent/opaque/thick/pussy due to high WCC in it * note normal fluid is clear yellow and quite thin i.e. not very viscous * always aspirate before giving antibiotics

Answer 365

- stop methotrexate and anti-TNF alpha - double prednisolone dose, only if already on long term prednisolone; giving it on its own carries infection risk - joint should be immobilised early, followed by early physiotherapy to prevent stiffness and muscle wasting - start antibiotics after joint aspiration - joint drainage repeatedly until no recurrent effusion can help relieve pain - NSAIDs for pain

Answer 366

- IV flucloxacillin for most Gram negatives - IV erythromycin/clindamycin if allergic to penicillin - IV cefotaxime for Gram negatives or gonococcal - IV vancomycin for MRSA - for immunocompromised, give IV flucoxacillin and gentamycin - IV antibiotics given for 2 weeks - monitor progress by looking at ESR and CRP

Answer 367

- gonococcal arthritis - meninococcal arthritis - tuberculous arthritis

Answer 368

- involves one or several joints and occurs secondary to genital, rectal or oral infection (often asymptomatic) - caused by Gram negative Neisseria gonorrhoea - most common cause of septic arthritis in previously fit young adults; more common in women and men who have sex with men - patients present with a fever and characteristic pustules on distal limbs as well as polyarthralgia and tenosynovitis

Answer 369

- culture blood and fluid to diagnose - treatment consists of oral penicillin, ciprofloxacin or doxycycline for 2 weeks and joint rest

Answer 370

- may complicate meningococcal septicaemia and presents as a migrating polyarthritis - results from the deposition of circulating immune complexes containing meningococcal antigens - treatment with penicillin

Answer 371

- 1% of patients with tuberculosis have joint and bone involvement - usually caused by Mycobacterium tuberculosis - can occur as primary disease in children - hip, knee and intervertebral discs are most commonly affected - there are caseating granulomas and rapid destruction of cartilage and adjacent bone - insidious onset of pain, swelling and dysfunction - fever, night sweats and weight loss

Answer 372

- culture synovial fluid - biopsy synovial fluid or intervertebral disc for diagnosis; CT guided - joint or spinal X-ray may be normal but joint-space reduction and bone destruction develop rapidly if treatment is delayed - treatment is the same as for pulmonary tuberculosis with therapy for 9 months, joint should be rested and the spine immobilised in the acute phase

Answer 373

* infection localised to bone | * either due to metastatic haematogenous spread or due to local infection

Answer 374

- osteomyelitis predominantly occurs in children - increasing incidence of chronic osteomyelitis - majority of haematogenous acute osteomyelitis occurs in children - adolescents and adults tend to get osteomyelitis due to infection secondary to direct trauma - elderly get it due to risk factors

Answer 375

* Staphylococcus aureus is the most common organism - 90% of acute osteomyelitis * coagulase negative staphylococci e.g. Staphylococcus epidermidis * Haemophilus influenzae * Salmonella - can occur as a complication of sickle cell anaemia * Pseudomonas aeruginosa and Serratia marcesans in IVDU

Answer 376

- diabetes mellitus - peripheral vascular disease - malnutrition - inflammatory arthritis - debilitating disease - decreased immunity - sickle cell disease - prosthetic material - immunosuppressive drugs - trauma

Answer 377

* direct inoculation of infection into the bone by trauma or surgery (easy) * contiguous spread of infection into bone (medium) * haematogenous seeding (hard)

Answer 378

- without breaking skin - infection of adjacent soft tissue spreading into bone - seen in elderly who tend to have diabetes mellitus, chronic ulcers, vascular disease, joint replacements and prostheses

Answer 379

in children the infection is more likely to go to the long bones: • most common site of infection is in the metaphysis of the long bone • here the blood flow is slower, endothelial basement membrane is absent and the capillaries lack or have inactive phagocytic lining cells - all these factors predispose to bacteria migrating from blood into bone and the growth of bacteria in the bone

Answer 380

more likely to get into the vertebra: | • with age the vertebra become more vascular thereby making bacterial seeding of the vertebral endplate more likely

Answer 381

- happens in mainly children and adults over 50 yrs - risk in IVDU (tend to be younger and infection tends to go to clavicle and pelvis) - people with risk factors for bacteraemia: • central line, dialysis, sickle cell disease (more likely to get vascular necrosis of the hip), urethral catheterisation and UTI • similar factors as those for endocarditis

Answer 382

- inflammatory cells - oedema - vascular congestion - small vessel thrombosis

Answer 383

- necrotic bone ‘sequestra’ - new bone formation - involucrum - neutrophil exudates - lymphocytes and histiocytes

Answer 384

* inflammatory exudate (in response to bacteria) in the marrow leads to increased intramedullary pressure, with extension of exudate into the bone cortex * this causes rupture through the periosteum and interruption of periosteal blood supply resulting in necrosis * this leaves pieces of separated dead bone known as sequestra * new bone forms here, called involucrum

Answer 385

- onset over several days - dull pain at site of osteomyelitis that may be aggravated by movement - fever, sweats, rigors and malaise - acute: tenderness, warmth, erythema and swelling - note: osteomyelitis in sites such as the hip, vertebrae or pelvis will present as pain but with very few other symptoms - can also present as septic arthritis: • when infection breaks through cortex resulting in discharge of pus into the joint - knee, hip or shoulder • more common in infants due to patent transphyseal blood vessels and immature growth plates

Answer 386

* tenderness, warmth, erythema and swelling | * draining sinus tract which is associated with deep/large ulcers that fail to heal despite treatment

Answer 387

- charcot joint; damage due to sensory nerves affected by diabetes - soft tissue infection e.g. cellulitis and erysipelas - avascular necrosis of the bone, causes; steroids, radiation or bisphosphonate use - gout - fracture - malignancy

Answer 388

* plain X-ray may show osteopenia * MRI may show marrow oedema from 3-5 days (sign of osteomyelitis) - done after X-ray * bone scans are also helpful

Answer 389

* blood culture to determine aetiology * ESR and CRP raised * acute - raised WCC * chronic osteomyelitis - can have normal WCC

Answer 390

- immobilisation - antimicrobial therapy: • tailored to culture and sensitivity findings • IV teicoplanin; side effects: rash, pruritus, GI upset • IV flucoxacillin • oral fusidic acid • stop treatment guided by ESR/CRP monitoring - surgical debridement and removal of dead bone (sequestrum)

Answer 391

* usually due to haematogenous spread from a reactivated primary focus in the lungs or GI tract * may be slower onset with systemic symptoms e.g. malaise, fever and night sweats * local pain and swelling if pus collected

Answer 392

* biopsy is essential - look for caseating granuloma! | * longer treatment - 12 months with same treatment as for pulmonary tuberculosis

Answer 393

- most serious complication of arthroplastic surgery - based on hips and knees - incidence is increasing due to increasing age, diabetes and obesity

Answer 394

- S. aureus - coagulase negative Staphylococci - mainly Gram positives

Answer 395

- majority are not acutely infected - systemically well - tender, hot, swollen joint

Answer 396

- tissue sample from surgery - X-ray - both ESR and CRP raised; sign of infection: • check ESR and CRP repeatedly - alpha defensin; 95% sensitive - joint aspiration

Answer 397

- gold standard diagnostic - identifies organism and antibiotic sensitivities - must be done with patient off antibiotics for 2 weeks minimum

Answer 398

* if patient is unfit for surgery e.g. too frail or multiple co-morbidities * multiple prosthetic joint infections * will not eliminate sepsis

Answer 399

* for early post-op infections or acute haematogenous infection * not for chronic infection

Answer 400

* for high risk frail and multiple co-morbidities who have infection that is uncontrolled with antibiotic suppression * people with low functional demand * effective in removing infection but not good at restoring function

Answer 401

* radical debridement * implantation of new prosthesis with antibiotic cement * systemic and local antibiotics * avoids bone graft * 85% success rate

Answer 402

* radical debridement * local antibiotic spacer +/- systemic antibiotics * interval stage i.e. suture up and wait for infection to clear * implantation of new prosthesis with antibiotic cement * routine antibiotic prophylaxis * 90-95% success

Answer 403

- antibiotic suppression - debridement and retention of prosthesis - excision arthroplasty - one-stage arthroplasty exchange - two-stage arthroplasty exchange - amputation if severe infection and if all else fails

Answer 404

* serious and often multiple injuries where there is a strong possibility of death or disability with an injury severity score (ISS) greater than 15 * leading cause of death for adults under the age of 45 * majority is caused by major road traffic accidents - typically males are involved

Answer 405

``` assigned to one of six body regions: • head and neck including cervical spine • face • chest including thoracic spine • abdomen/pelvic contents and lumbar spine • extremity - includes pelvic skeleton • external ```

Answer 406

* 1: minor - superficial laceration * 2: moderate - fractured sternum * 3: serious - open fracture humerus * 4: severe - perforated trachea * 5: critical - ruptured liver * 6: unsurvivable - total aortic transection

Answer 407

- anatomical score - each injury scored according to the AIS - assigned to one of six body regions - abbreviated injury scale - scoring system is done retrospectively - only the highest score in each region is counted - the 3 highest scores are counted and then squared and then x3 to generate the ISS - score of 6 in any region gives an automatic ISS of 75

Answer 408

- defined as joint swelling/stiffness/limitation in those older than 6 weeks but under 16 with no other causes - 7 subtypes according to presentation - 1 in 1000 children - under diagnosed

Answer 409

- unknown cause - could be autoimmune disease - different gene combinations give different forms of JIA

Answer 410

* infection * reactive * trauma * malignancy * connective tissue disease

Answer 411

- synovitis - common in all - persistent oligoarthritis (4 or less joints) - extended oligoarthritis - rheumatoid factor negative polyarthritis - rheumatoid factor positive polyarthritis - enthesitis related JIA - Stills disease - systemic onset JIA

Answer 412

* inflammation of the synovial membrane resulting in synovial fluid being pumped out of the joint resulting in swelling and causing the joint to become stiff * in a child with juvenile idiopathic arthritis (JIA) they are at high risk of uveitis * the membrane lining the eyes is very similar to that of the joints and is thus a potential target of they inflammation * many children will suffer from chronic anterior uveitis due to their JIA, however the child may not complain of their vision becoming cloudy until they go blind * thus need to ensure opthalamic screening every 3 months to prevent blindness

Answer 413

* aged less than 6 yrs * 1-4 joints involved * 50% affect only 1 joint and this is most commonly the knee * majority are ANA negative * high risk for uveitis - screen for uveitis * will most likely grow out of it

Answer 414

* 1-4 joints in first 6 months * more joints affected thereafter * girls more frequently affected * peak age is 2-4 yrs * has a worse prognosis than persistent oligoarthritis * 50% have active disease into adult life * screen for uveitis

Answer 415

* acute or insidious onset of arthritis in more than 5 joints (polyarthritis) * usually symmetrical * may be some low grade systemic features e.g. malaise, fever and anaemia/thrombocytosis * less risk of uveitis but still screen for it

Answer 416

* often starts in late adolescence * more common in girls * confirmed by being tested rheumatoid factor positive in 3 months * the only form of JIA that is similar to RA * CCP antibody is usually negative unlike in RA * possibly related to smoking habit * less risk of uveitis but still screen

Answer 417

* essentially its spondyloarthritis in young people * often HLA-B27 positive * typically affects males over 6 yrs * high risk uveitis so screen * associated with IBD * inflammatory back pain or sacroiliac pain

Answer 418

* can occur at any age but peaks at 4-6 yrs * equal male to female ratio * systemic illness with daily (quotidian) fever - fever spikes daily, usually at same time each day * evanescent rash and arthritis * anaemic, raised platelets (thrombocytosis) and high ferritin * lymphadenopathy, hepatosplenomegaly and serositis are common

Answer 419

• steroid joint injections: - general anaesthetic or Entonox (laughing gas, inhale, anaesthesia, shorter half life) • NSAIDs • methotrexate • systemic steroids • biological drugs such as TNF-alpha inhibitors

Answer 420

- transverse - linear - oblique, nondisplaced (common in ankle due to axial load injury) - oblique, displaced - spiral (twisting injury) - greenstick - comminuted

Answer 421

* specific to children * unicortical fracture in which the bone bends and breaks due to thick periosteum * very easy to treat * bone not completely broken

Answer 422

- classification for fractures involving the physis (growth plate) - higher the number the more damage and thus worse prognosis - the most involved areas in a fracture are the epiphysis and metaphysis - major complication is growth arrest

Answer 423

- reduce fracture → restore length, alignment and rotation → immobilise (to allow healing) → rehabilitate - most kids fractures can be healed non-operatively due to extremely quick healing as a result of their thick periosteum with excellent blood supply - consequently, need to X-ray regularly to ensure no rotational/angular movement

Answer 424

* surgical implentation of implants for reparation of bone; positioned entirely within the patient's body * plate, screws, intramedullary nails or K-wire * note: if the nails or K-wire invade the physis (growth plate) then there will be growth arrest

Answer 425

- where rods are screwed into bone and exit the body to be attached to a stabilising structure on the outside of the body - useful for when there are lots of soft tissue swellings and damage so don't want to open skin to reduce risk of infection and bad healing - ex-fix or lizarov frame

Answer 426

- open fracture - infection risk - neurovascular compromise - malunion - bone heals but with deformity - non-union - failure of the bone to heal - compartment syndrome

Answer 427

- condition in which increased pressure within one of the body's anatomical compartments results in insufficient blood supply to tissue within that space - acute and chronic - common in tibia - caused by cast or post-op bleeding of the fascia - treated with fasciotomy where the fascia is removed

Answer 428

Alendronate, Zolendronate, Disodium pamidronate

Answer 429

- alendronate is first line treatment for patients at risk of osteoporosis - severe hypercalcaemia of malignancy - myeloma and breast cancer bone metastases to reduce pathological fractures and need for radiotherapy or surgery - Paget’s disease to reduce bone turnover and pain

Answer 430

- reduce bone turnover by inhibiting osteoclasts (responsible for bone resorption) and promoting apoptosis - have a similar structure to naturally occurring pyrophosphate so are readily incorporated into bone - net effect is reduction in bone loss and improvements in bone mass

Answer 431

- oesophagitis can occur when taken orally - hypophosphataemia - rarely jaw osteonecrosis or atypical femur fractures can occur - avoid in severe renal impairment and hypocalcaemia and in upper GI disorders, used with care in patients with dental disease or who smoke - absorption is reduced if taken with calcium containing products such as antacids and iron salts

Answer 432

Calcium carbonate, Calcium gluconate, Colecalciferol, Alfacalcidol

Answer 433

- used in osteoporosis to ensure positive calcium balance when dietary intake/sunlight exposure are insufficient - used in CKD to treat and prevent secondary hyperparathyroidism and renal osteodystrophy - calcium used in severe hyperkalaemia to prevent life threatening arrhythmias - used in symptomatic hypocalcaemia - vitamin D is used in prevention and treatment of vitamin D deficiency for rickets and osteomalacia

Answer 434

- calcium homeostasis is controlled by: • parathyroid hormone and vitamin D which increase serum calcium levels and bone mineralisation • calcitonin which reduces serum calcium levels - restoring positive calcium balance reduces the rate of bone loss and prevents fractures

Answer 435

- may cause dyspepsia and constipation - can cause cardiovascular collapse if administered too fast IV - do not use in hypercalcaemia - calcium can reduce absorption of iron, bisphosphonates and tetracycline antidepressants

Answer 436

allopurinol

Answer 437

- to prevent acute attacks of gout - to prevent uric acid and calcium oxalate renal stones - to prevent hyperuricaemia and tumour lysis syndrome associated with chemotherapy

Answer 438

- allopurinol is a xanthine oxidase inhibitor that blocks metabolism of xanthine (produced from purines) to uric acid - results in lower plasma uric acid concentration and reduces precipitation of uric acid in the joints or kidneys

Answer 439

- most common side effect is a skin rash (if severe may indicate hypersensitivity reaction) - should not be started during acute gout attacks as may worsen these, and is contraindicated in patients with recurrent skin rash on the drug - use with care in renal impairment and hepatic impairment - azathioprine requires xanthine oxidase for metabolism so allopurinol may increase their activity - use with care with amoxicillin, ACE inhibitors or thiazides as increase risk of hypersensitivity

Answer 440

colchicine

Answer 441

- used to prevent acute gout attack and relieve pain of attack when they do occur - also used to treat familiar mediterranean fever

Answer 442

- colchicine inhibits microtubule polymerisation by binding to tubulin, which is essential for mitosis - also inhibits neutrophil motility and activity which leads to a net anti-inflammatory effect which is useful in acute attacks

Answer 443

- may cause GI disturbances - more rarely causes myalgia, fever - fatigue can occur due to anaemia in high doses - peripheral neuropathy due to peripheral nerve damage - contraindicated in renal impairment - colchicine toxicity can be enhanced when using statins

Answer 444

- sore mouth, GI upset, bone marrow suppression and rarely hypersensitivity reactions - long term use can cause hepatic cirrhosis or pulmonary fibrosis - contraindicated in severe renal impairment and abnormal liver function

Answer 445

- IgM antibodies against the Fc portion of IgG; type 3 hypersensitivity - more sensitive than specific - positive in 80% of those with RA

Answer 446

- positive in 60-70% of RA patients - very specific - predictive of erosions and joint deformity

Answer 447

- specific subtype of ANA - IgG - very specific for SLE - not senstivie for SLE - correlates with SLE activity

Answer 448

- Smith antigen - 25% of SLE patients have anti-SM; not sensitive - specific for SLE - no clinical correlation

Answer 449

- antibodies against SnRNP70 (RNA binding protein) - very sensitive for MCTD - found in SLE - associated with idiopathic inflammatory myositis

Answer 450

- autoantibodies against proteins in the ribosomes - specific for SLE - not sensitive for SLE

Answer 451

limited scleroderma/CREST syndrome

Answer 452

diffuse/systemic scleroderma

Answer 453

diffuse/systemic scleroderma

Answer 454

- not sensitive (30-40%) - not specific - Sjogrens syndrome and SLE - HLADR3 - increased risk of non-hodgkins lymphoma

Answer 455

- not sensitive (15-20%) - not specific - Sjogrens syndrome and SLE - HLADR3 - increased risk of non-hodgkins lymphoma

Answer 456

polymyositis and dermatomyositis

Answer 457

- anti-gp210 - anti-p62 - anti-sp100 - anti-mitochondrial antibody

MSK and rheumatology Flashcards

(482 cards)