Rheum/MSK > Rheum 2 > Flashcards

Rheum 2 Flashcards

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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
How would you treat Paget's disease of bone?
Bisphos - zolendronic acid | Physio
26
What is osteomalacia? rickets?
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
27
What are some causes of osteomalacia?
``` Hyperparathyroidism Vit D deficiency Renal disease Drug induced - anticonvulsant, rifampicin Liver disease ```
28
How does osteomalacia present?
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
How would you investigate osteomalacia?
Serum calcium, 25-hydroxyvitamin D, phosphate Urea & creatinine Alk phos
30
How would you treat osteomalacia?
Calcium plus Vit D | Dihydrotachysterol
31
Which age group are most affected by vertebral disc degeneration? Which discs are most commonly affected?
Disease of younger people (compression more likely in elderly) S1, L5, L4
32
Disc degeneration of S1 would result in pain where? loss of which reflex? Other signs?
Buttock down back of thigh to ankle/foot Ankle jerk lost Diminished straight leg raising
33
Disc degeneration of L5 would result in pain where? loss of which reflex? Other signs?
Buttock to lateral aspect of leg and top of foot no reflex lost diminished straight leg raising
34
Disc degeneration of L4 would result in pain where? loss of which reflex? Other signs?
Lateral aspect of thigh to medial side of calf knee jerk reflex lost positive femoral strtch test - on tummy extend hip
35
How would you investigate vertebral disc degeneration?
X-rays are often normal MRI in whom surgery is being considered
36
How would you treat vertebral disc degeneration?
Paracetamol/NSAID Topical analgesia - capsaicin Opiod analgesia - codeine phosphate Muscle relaxant - diazepam
37
What are some causes of bone tumours?
Multiple myeloma, Lymphoma Primary tumours - osteosarcoma, fibrosarcoma, Ewing's tumour, chondrosarcome Secondary tumour - LUNG, BREAST, PROSTATE, thyroid, kidney
38
What are some characteristics of osteosarcomas?
arise from osteoblasts in the metaphysis of adolescents
39
What mutations are associated with osteosarcomas?
pRB protein - also in familial retinoblastoma p53 - Li-fraumeni syndrome
40
What are some characteristics of Ewing's sarcoma?
common in adolescents arise from neuroectodermal cells
41
What mutations are associated with Ewing's sarcoma?
Translocation of EWSR1 gene from chromosome 22 and FL1 gene on chromosome 11 This fusion causes formation of ewing sarcoma protein
42
What are some characteristics of chondrosarcoma?
affects the elderly arise from chondrocytes mass normally in the medullary cavity
43
What are some characteristic presentations of bone tumours?
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
What are some characteristic findings of bone tumours on imaging?
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
What is fibromyalgia?
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
What is the pain in fibromyalgia described as ?
Central non-nociceptive pain
47
What are some causes/RFs for fibromyalgia?
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
What is the presentation of fibromyalgia?
Predominantly neck and back Generalised morning stiffness Paraesthesia of hands and feet Fatigue is often extreme
49
How would you investigate fibromyalgia?
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
How would you treat fibromyalgia?
``` Education CBT Amitryptyline Pregabalin Venlafaxine ```
51
What are some red flags to look out for with mechanical lower back pain?
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
What are some causes of mechanical lower back pain?
``` lumbar disc prolapse osteoarthritis fractures spondylolisthesis heavy manual handling ```
53
How does mechanical lower back pain present?
``` Muscular spasm Pain often unilateral - helped by rest short-lived and self-limiting sudden onset exercise aggravates pain ```
54
What conditions are differential diagnosis for mechanical lower back pain?
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
What is septic arthritis? What joint is most commonly affected?
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
What organisms are most commonly responsible in septic arthritis?
Staph Aureus - MOST COMMON Streptococci Neisseria gonorrhoea Haemophilus Influenzae
57
What are some risk factors for septic arthritis?
``` Pre-existing joint disease (RA) Diabetes Immunosupression Chronic renal failure IV drug abuse recent intra-articular steroid injection ```
58
How does septic arthritis present?
Agonisingly painful red, swollen hot joint Fever 90% monoarthritis Knee, hip and shoulder most common
59
How would you investigate septic arthritis?
Urgent joint aspiration - synovial M&C | Blood culture
60
How would you treat septic arthritis?
Stop MTX and anti-TNF alpha Abx - IV fluclox (gram-negative), IV vancomycin (MRSA) Joint drainage repeatedly NSAIDs
61
What is osteomyelitis?
bone marrow inflammation | metastatic haematogenous spread or local infection
62
What organisms responsible for osteomyelitis?
Staph Aureus Haemophilus Influenzae Salmonella Pseudomonas Aeruginosa
63
How does osteomyelitis present?
Dull pain at site of osteomyelitis Fever, sweats, rigors and malaise Tenderness, warmth, erythema and swelling
64
How would you investigate osteomyelitis?
X-rays MRI - marrow oedema Bloods - culture, ESR & CRP, WCC
65
How would you treat osteomyelitis?
Immobilisation Abx - teicoplanin, flucloxacillin Surgical debridement
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