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Rheum/MSK > Rheum 2 > Flashcards

Rheum 2 Flashcards

1
Q

What is the pathophysiology behind systemic vasculitis?

A
  • inflammation of the vessel wall
  • inflammation and necrosis of blood vessel walls with subsequent impaired blood flow
    i) Vessel wall destruction - aneurysm, rupture and stenosis
    ii) endothelial injury - thrombosis +ischaemia/infarction of dependent tissues
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2
Q

What are some examples of large vessel vasculitis?

A

GIant-cell arteritis/polymyalgia rheumatica

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3
Q

What are some examples of medium-vessel vasculitis?

A

classical polyarteritis nodose (PAN)

kawasaki’s

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4
Q

What are some examples of small-vessel vasculitis?

A

ANCA-associated - microscopic polyangitism granulomatosis

ANCA-negative - essential cryoglobulinaemiam cutaneous leucocytoclastic vasculitis

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5
Q

What are all systemic vasculitis associated with?

A

Anaemia
Raised ESR

Subacute infective endocarditis, RA, SLE, scleroderma, polymyositis

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6
Q

What are some risk factors for polymyalgia rheumatica?

A

Affect those over 50
Females
SLE
Polymyositis

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7
Q

How does polymyalgia rheumatic present?

A

sudden onset of severe pain and stiffness of the shoulder, neck, hips and lumbar spine

worse in the morning - 30 mins to several hours

mild polyarthritis of peripheral joints

fatigue, fever, weight loss and depression

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8
Q

What investigations should you run in polymyalgia rheumatica?

A

CRP - raised
ESR - >40
ALP - raised
CK - normal (differentiate from myositis)

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9
Q

How would you treat polymyalgia rheumatica?

A

Oral Pred

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10
Q

What crystals do you find in crystal arthropathies?

A

monosodium urate crystals - needle-shaped urate crystals, negatively bifringent under polarised light

calcium pyrophosphate crystals - small rhomboid brick-shaped pyrophosphate crystals, positively bifringent under polarised light

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11
Q

What is the pathophysiology behind crystal arthropathies?

A

Neutrophils ingest the crystals and initiate a pro-inflammatory reaction

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12
Q

What are risk factors for Gout?

A

Male
High alcohol (beer > spirits > wine)
Purine rich food (red meat, liver, seafood)
High fructose intake
High saturated fat
Low dose aspirin
*Ischaemic heart disease
*Diabetes
*Renal - defective URAT1 transporter, high insulin - lower urate excretion
*increased production of uric acid - increased purine turnover, leukaemia, carcinoma, psoriasis

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13
Q

How would gout present?

A

sudden onset, agonising pain, swelling and redness of the first MTP

  • normally one joint but can be polyarthritic
  • attack precipitated by excess food, alcohol, dehydration, diuretic therapy, cold, traum or sepsis

Tophaceous gout - persistently high levels of uric acid - tophi in skin, joints, ear, fingers or achilles

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14
Q

In gout, what do tophi do to bone?

A

Release enzymes and cause erosions to bone forming circular punch-like holes

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15
Q

How would investigate Gout?

A

Arthrocentesis with synovial fluid analysis - strongly negative bifringent crystals under polarised light

Uric acid level

X-ray of affected joint

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16
Q

How would you manage gout?

A

Acute - NSAIDs, colchicine, corticosteroid

Recurrnt - Allopurinol, NSAIDs

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17
Q

What is pseudogout?

A

deposition of calcium pyrophosphate crystals on joint surface

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18
Q

What are some causes/risk factors for pseudogout?

A 
old age
diabetes
osteoarthritis
joint trauma
metabolic disease - hyperparathyroidism, haemochromatosis
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19
Q

How would pseudogout present?

A

acute synovitis that resembles gout but more common in elderly women

usually KNEE or WRIST

very painful, acute hot swollen wrist or knee

hot joint and fever - can be mistaken for septic arthritis (steroid effect can be devastating)

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20
Q

How would you investigate pseudogout?

A

arthrocentesis with synovial fluid analysis - positive intracellular birefringent rhomboid-shaped crystals, fluids often bloody

X-ray

Serum calcium and parathyroid hormone - exclude hyperparathyroidism

Iron studies - exclude haemochromatosis

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21
Q

How would you treat pseudogout?

A

intra-articular corticosteroids - dexamethasone
NSAIDs
Colchicine
Systemic corticosteroids - prednisolone

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22
Q

What is Paget’s disease of bone? What are causes /RFs?

A

focal disorder of bone remodelling

incidence increases with age - rare under 40
females
latent viral infection may be cause
fam hx

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23
Q

How does Paget’s disease of bone present?

A 
Pelvis, lumbar spine, femur, thoracic spine, skull and tibia
Maj. Asymp
Bone pain
Joint pain
Bowed tibia
Nerve compression - deafness, paraparesis
high-output cardiac failure
osteosarcoma
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24
Q

How would you investigate Paget’s disease of bone?

A

X-ray
Bone scan
Serum alk phos
Bone specific alk phos
Calcium
Procollagen 1 N-terminal peptide (P1NP) - marker of bone formation - initially elevated
C-terminal propeptide of type 1 collagen (CTX) - marker of bone resorption - initially elevated

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25
Q

How would you treat Paget’s disease of bone?

A

Bisphos - zolendronic acid

Physio

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26
Q

What is osteomalacia? rickets?

A

Normal amount of bone but its mineral content is LOW - defective mineralisation

Rickets - defective mineralisation during bone growth at the epiphyseal growth plate

Both clinical manifestations of profound vitamin D deficiency

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27
Q

What are some causes of osteomalacia?

A 
Hyperparathyroidism
Vit D deficiency
Renal disease
Drug induced - anticonvulsant, rifampicin
Liver disease
28
Q

How does osteomalacia present?

A

muscle weakness - waddling gait, difficulty climbing stairs

Widespread bone pain - dull ache worse on weight-bearing and walking

Fractures especially on femoral neck

*rickets - growth retardation, hypotonia, knock knees, bowed legs

29
Q

How would you investigate osteomalacia?

A

Serum calcium, 25-hydroxyvitamin D, phosphate

Urea & creatinine

Alk phos

30
Q

How would you treat osteomalacia?

A

Calcium plus Vit D

Dihydrotachysterol

31
Q

Which age group are most affected by vertebral disc degeneration? Which discs are most commonly affected?

A

Disease of younger people (compression more likely in elderly)

S1, L5, L4

32
Q

Disc degeneration of S1 would result in pain where? loss of which reflex? Other signs?

A

Buttock down back of thigh to ankle/foot

Ankle jerk lost

Diminished straight leg raising

33
Q

Disc degeneration of L5 would result in pain where? loss of which reflex? Other signs?

A

Buttock to lateral aspect of leg and top of foot

no reflex lost

diminished straight leg raising

34
Q

Disc degeneration of L4 would result in pain where? loss of which reflex? Other signs?

A

Lateral aspect of thigh to medial side of calf

knee jerk reflex lost

positive femoral strtch test - on tummy extend hip

35
Q

How would you investigate vertebral disc degeneration?

A

X-rays are often normal

MRI in whom surgery is being considered

36
Q

How would you treat vertebral disc degeneration?

A

Paracetamol/NSAID
Topical analgesia - capsaicin
Opiod analgesia - codeine phosphate
Muscle relaxant - diazepam

37
Q

What are some causes of bone tumours?

A

Multiple myeloma, Lymphoma

Primary tumours - osteosarcoma, fibrosarcoma, Ewing’s tumour, chondrosarcome

Secondary tumour - LUNG, BREAST, PROSTATE, thyroid, kidney

38
Q

What are some characteristics of osteosarcomas?

A

arise from osteoblasts in the metaphysis of adolescents

39
Q

What mutations are associated with osteosarcomas?

A

pRB protein - also in familial retinoblastoma

p53 - Li-fraumeni syndrome

40
Q

What are some characteristics of Ewing’s sarcoma?

A

common in adolescents

arise from neuroectodermal cells

41
Q

What mutations are associated with Ewing’s sarcoma?

A

Translocation of EWSR1 gene from chromosome 22 and FL1 gene on chromosome 11

This fusion causes formation of ewing sarcoma protein

42
Q

What are some characteristics of chondrosarcoma?

A

affects the elderly
arise from chondrocytes
mass normally in the medullary cavity

43
Q

What are some characteristic presentations of bone tumours?

A

Osteoid Osteoma - worse at night

Osteochondromas and osteoblastomas - numbness, limb weakness and avascular necrosis

  • MALIGNANT TUMOURS - chronic inflammatory response (fever, night sweats and weight loss)
  • commonly spread to lung (coughing, shortness of breath)
44
Q

What are some characteristic findings of bone tumours on imaging?

A

Osteochondroma - exostosis

Giant cell tumour - multicystic bone lesions look like soap bubbles

Osteosarcoma - lytic bone lesions (sunburst appearance), periosteum to lift = Codman;s triangle

Ewing Sarcoma - lytic bone lesion ‘onion skin appearance’

Chondrosarcoma - moth eaten cloth lesions

45
Q

What is fibromyalgia?

A

widespread musculoskeletal pain AFTER other diseases have been excluded

Symptoms present atleast 3 months and other causes have been excluded

Pain at 11/18 tender point sites on digital palpation

46
Q

What is the pain in fibromyalgia described as ?

A

Central non-nociceptive pain

47
Q

What are some causes/RFs for fibromyalgia?

A

Central disturbance in pain processing
Often >60 y/o
Females
Associ. with RA, depression, IBS

Assoc. with low household income, divorced, low educational status

48
Q

What is the presentation of fibromyalgia?

A

Predominantly neck and back

Generalised morning stiffness

Paraesthesia of hands and feet

Fatigue is often extreme

49
Q

How would you investigate fibromyalgia?

A

Clinical - >3 months, widespread body pain in muscle and joints, atleast 11/18 tender points

ESR/CRP - exclusion
TFT - exclude hypothy
Rh factor & anti-ccp - exclude RA

50
Q

How would you treat fibromyalgia?

A 
Education
CBT
Amitryptyline
Pregabalin
Venlafaxine
51
Q

What are some red flags to look out for with mechanical lower back pain?

A

Less than 20 or greater than 55 y/o

violent trauma

constant, progressive, non-mechanical pain

thoracic pain

systemic steroids, drug abuse or HIV

systemically unwell, weight loss

persisting severe restriction or lumbar flexion

widespread neurology

structural deformity

52
Q

What are some causes of mechanical lower back pain?

A 
lumbar disc prolapse
osteoarthritis
fractures
spondylolisthesis
heavy manual handling
53
Q

How does mechanical lower back pain present?

A 
Muscular spasm
Pain often unilateral - helped by rest
short-lived and self-limiting
sudden onset
exercise aggravates pain
54
Q

What conditions are differential diagnosis for mechanical lower back pain?

A

Lumbar spondylosis - lesion in an intervertebral disc

facet joint syndrome - pain worse on bending backwards, radiates to buttock, well seen on MRI

fibrositic nodulosis - low back and buttock pain

postural back pain

sway back of pregnancy

55
Q

What is septic arthritis? What joint is most commonly affected?

A

Joint become infected by direct injury or by blood-borne infection from infected skin lesion or other site

Knee affected in more than 50%

56
Q

What organisms are most commonly responsible in septic arthritis?

A

Staph Aureus - MOST COMMON
Streptococci
Neisseria gonorrhoea
Haemophilus Influenzae

57
Q

What are some risk factors for septic arthritis?

A 
Pre-existing joint disease (RA)
Diabetes
Immunosupression
Chronic renal failure
IV drug abuse
recent intra-articular steroid injection
58
Q

How does septic arthritis present?

A

Agonisingly painful red, swollen hot joint

Fever

90% monoarthritis

Knee, hip and shoulder most common

59
Q

How would you investigate septic arthritis?

A

Urgent joint aspiration - synovial M&C

Blood culture

60
Q

How would you treat septic arthritis?

A

Stop MTX and anti-TNF alpha

Abx - IV fluclox (gram-negative), IV vancomycin (MRSA)

Joint drainage repeatedly

NSAIDs

61
Q

What is osteomyelitis?

A

bone marrow inflammation

metastatic haematogenous spread or local infection

62
Q

What organisms responsible for osteomyelitis?

A

Staph Aureus
Haemophilus Influenzae
Salmonella
Pseudomonas Aeruginosa

63
Q

How does osteomyelitis present?

A

Dull pain at site of osteomyelitis

Fever, sweats, rigors and malaise

Tenderness, warmth, erythema and swelling

64
Q

How would you investigate osteomyelitis?

A

X-rays
MRI - marrow oedema
Bloods - culture, ESR & CRP, WCC

65
Q

How would you treat osteomyelitis?

A

Immobilisation
Abx - teicoplanin, flucloxacillin
Surgical debridement

Rheum/MSK (5 decks)

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