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Rheum Flashcards

1
Q

What are the symptoms af arthritis?

A 
Pain
Stiffness
Swelling
Functional impairment
Systemic symptoms
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2
Q

What are the signs of arthrtiis?

A 
Tenderness
Swelling
Restriction of movement
Heat
Redness
Systemic features
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3
Q

What are the types of rheumatoid disease?

A 
RA
Sero-negative arthritis
Crystal arthritis
Connective tissue diseases
Systemic vasculitis
Bone disease
Osteoarthritis
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4
Q

What are the functions of the synovium?

A

Maintenance of intact tissue surface
Lubrication of cartilage
Control of synovial fluid volume + composition
Nutrition of chondrocytes within joints

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5
Q

How does rheumatoid affect a joint?

A

Cartilage thinned
Inflammed synovium across joint surface
Inflammed tendon
Erosion of corner of bone

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6
Q

What is rheumatoid arthritis?

A

Chronic symmetric polyarticular inflammatory joint disease
Characterised by inflammatory cell infiltration, synoviocyte proliferation and neoangiogenesis
Synovial fluid contains neutrophils
Synovial panus causes bone and cartilage destruction

Primarily affects small joints of hand and feet

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7
Q

What auto-antibodies are associated with rheumatoid arthritis?

A

Rheumatoid factors

Anti-citrullinated protein

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8
Q

In what type of rheumatoid arthritis are autoantibodies found?

A

Seropositive RA

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9
Q

What genes are associated with RA?

A

HLA-DRB1 - role in promoting autoimmunity
PTPN22
CTLA4

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10
Q

What environmental factors are associated with RA?

A

Smoking and bronchial stress
Infective agents
Repeated insults to joints

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11
Q

What infective agents are associated with RA?

A

Viruses
E. coli
Mycoplasma
Perodontal disease

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12
Q

What is the pathophysiology of synovitis in RA?

A

Villous hyperplasia
Infiltration of T cells, B cells, macrophages and plasma cells
Intimal cell proliferation causing thickening of membrane
Production of cytokenes
Cytokines along with local hypoxic conditiosn causes increase vascularity
Makes self worse

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13
Q

Whar are the main cytokines produced?

A

TNF-a

IL-6

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14
Q

What is the action of the inflammatory cytokines?

A

Induce expression of endothelial cell adhesion molecules
Promote angiogensis
Supress T-regs
Activate leukocytes
Promote autoAB production
Activates synovial fibroblasts, chondrocytes, osteoclasts

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15
Q

What is the action of IL-6?

A

Mediates systemic effects

Acute phase response
Anaemia
Cognitive dysfunction
Lipid metabolism dysregulation

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16
Q

What mediates cartilage and bone destruction in RA?

A

Bone mediated y osteoclasts that are activated under the influence of RANKL
Cartilage - metalloproteinases + aggrecanases

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17
Q

What are teh systemic consequences of uncrontrolled chronic RA?

A

Vasculitis
Nodules
Scleritis
Amylodosis

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18
Q

What are the systemic consequences of RA?

A

Cardiovascular disease - altered lipid metabolism
Secondary fibromyalgia (congnitive fuction decline as well)
Muscles - sarcopenia
Bone - osteoporosis
Secondary sjogrens syndrome
Liver - anaemia (IL-6)

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19
Q

Who is likely to get rheumatoid arthritis?

A

1% of population
3x more common in women
Often 4-5th decade - any age from 16

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20
Q

What is the aeitiology of rheumatoid?

A

Genetic ~ 50-60% contribution

Environmental - smoking, chornic infection

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21
Q

How do you investigate rhuematoid arthritis?

A

Immunology - rheumatoid factor (IgG, IgM)
Anti-cyclic citrullinated antibodies (anti-CCP, ACPA) - Better test, more specificity
Ultrasound

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22
Q

How do you diagnose RA?

A

Joint involvement (multiple more likely)
Serology
Acute phase reactants
Duration more than 6 weeks

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23
Q

What are the therapeutic categories for reheumatoid arthritis?

A

NSAIDS
Disease modifying anti rheumatic drugs
Biologics
Corticosteroids

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24
Q

What are the common disease modifying anti rheumatic drugs?

A

Methotrexate!

Sulfasalazine
Hydrochloroquine
Leflunomide

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25
How do you approach rheumatoid treatment?
Early and aggressive intervention | Effective suppression of inflammation improves symptoms + prevents disaability
26
What are the downsides to biologics?
Toxciity - increased rate of infection Expensive Injection Efficacy - increased when used with methotrexate
27
What are the advantages of biologics?
Work rapidly and well tollerated
28
What are the benefits of methotrexate?
Effective Well tollerated Cheap
29
What gene is seronegative arthritis associated with?
HLA-B27
30
What is seronegative arthritis?
Arthritis with negative rheumatoid factor Usually asymmetric Involves axial skeleton (spine) Enthesitis (soft tissue irritability) Extra-articular features - uveitis, inflammatory bowel disease
31
What are the different presentations of seronegative arthritis?
Ankylosing spondylitis Psoriatic arthritis Bowel related arthritis (chron's, UC) Reactive arthrits
32
What is ankylosing spondylitis?
Chronic inflammatory rheumatic disorder | Predilection for axial skeleton + Antheses
33
Who is most likelt to get ankylosing spondylitis?
Males more than females | Onsets 2nd-3rd decade
34
How is spinal mobility tested?
Modified shober test Lateral spinal flexion Occiput/tragus to wall Cervical rotation
35
What is the modified shober test?
Patient stading erect Line connected posterior superior iliac spine. Then line 10cm above Patient bends and see difference between two lines
36
What is the lateral spinal flexion test?
Hand down against thigh without bending | Measure difference between normal hand + how far it can go
37
What is the cervical rotation test?
Sit in chair Goniometer in line with nose Record how far they can turn head
38
What are the clinical features of anylosing spondylitis?
Inflammatory back pain Limitation of movements in antero-posterior + lateral planes at lumbar spine Limitation of chest expansion Bilateral sacroiliitis on x-rays
39
What is the grading for sacroiitis?
0 - normal 1 - suspicious changes 2 - minimal abnormality (no alteration to joint width) 3) unequivicol abnormality (moderate-advanced, erosions, sclerosis, widening, narrowing or partial ankylosis) 4 - severe, total ankyloitis
40
What are the other features of anyylosing spondylitis?
``` Peripheral joint arthritis Achilles tendonitis, dactylitis Uveitis Cardiac (aortic incompetence, heart block) IBD Osteoporosis /spinal fractures Cauda equina syndrom Secondary amyloidosis ```
41
How do you manage aknylosing spondylitis?
``` Physio NSAIDs Disease modifying rheumatoid drugs - sulfasalazine Anti-TNF Anti-IL-17 Joint replacements ```
42
What joints are commonly affected by psoriatic arthritis?
``` Neck/shoulder Elbows/knees Toes + ankles Hand + wrist Base of spine ```
43
What is the treatment for psoaritic arthritis?
DMARD - sulfasalazine Methotrexate Leflunomide ``` Cyclosporine Anti-TNF Anti-IL 17/23 Steroids Physio/occupational therpay ```
44
What isreactive arthritis?
Sterile synovitis after distant infection
45
What infections often cause reactive arthritis?
``` Salmonella Shingella Campyloobacter Chlamydia (often recurrent attacks) Trachomatis Pneumonia Borrelia Neisseria Streptococci ``` (throat, urogenital, GI)
46
How does reactive arthritis present?
Mono or oligoarthritis Dactylitis or enthesitis also seen Skin/mucous membrane involvement
47
What conditions are seen in skin/mucous membrane involvement?
``` Keratoderma Blenorrhagica Circinate Balanitis Urethritis Conjunctivitis Iritis ```
48
What is reiters syndrome?
Arhtritis Urethritis Conjunctivitis
49
What indicates chronic reactive arthritis?
Hip/heel pain High ESR Family history + HLA-B27 positive
50
How do you treat reactive arthritis?
NSAIDs If acute - joint injection if no infection Antibiotics in chlamudia If chronic - DMARD
51
What is enteropathic arthritis?
A chronic inflammatory arthritis developing in people with inflammatory bowel diseases Rarely seenin infectious enteritis, whipples disease or coeliac disease however Enthesopathy common
52
How do you treat enteropathic arthritis?
``` Sulfasalazine Methotrexate Steroids Anti-TNF Bowel resection may alleviate peripheral disease ```
53
What is a crystal depositation disease?
Where mineralised material is deposited in joints and periarticular tissue
54
What are the common crystal deposition diseases?
gout - Monosodium urate pseudogout - Calcium pyrophosphate dihydrate (CPPD) calcific perarthritis/tendonitis - Basic calcium phosphate hydroxy-apatite (BCP)
55
What is a tophi?
A massive accumulation of uric acid
56
What are the methods by which hyperuricaemia can occur?
Overproduction | Underexcretion
57
What can cause overproduction of uric acid?
``` Malignancy Severe exfoliative psoriasis Drugs (ethanol, cytotoxic drugs) Hereditary erros of metabolism HGPRT deficiency ```
58
What can cause under excretion of uric acid?
``` Renal impairment Hypertension Hypothyroidism Drugs (alohol, low dose, aspirin, diuretics, cyclosporin) Exercise, starvation, dehydration Lead poisoning ```
59
What is Lesch Nyan syndrome?
``` Deficiency of HGPRT X-linked recessive disease Intellectual disability People have aggressive + impulsive behaviour Self mutilate Have gout + renal disease ```
60
Who is likely to get gout?
Men more common in all ages | After menopause gout rate increases in women
61
How is an acute flare up of gout treated?
NSAIDs Colchine Steroids
62
When is hyperuricaemia treated?
1st attack not treated unless - single attack of polyarticular gout Tophaceous gout Urate calculi Renal insufficiency Do not treat asymptomatic hyperuricaemia
63
What drugs are used to lower uric acid?
Xanthine oxidase inhibitor (allopurinol) Febuxostat Uricosuric agents (sulphinpyrazone) Canakinumab
64
What are the rules regarding lowering uric acid levels?
Wait until any acute attack has settled before treatment Prohylatic NSAIDs/low dose cholchinie/steroids until urate acid normal Adjust allopurinol dose occording to renal function
65
What is the main treatment for gout?
Adjust lifestyle factors
66
What is pseudogout?
Common in knee | Erratic flares, often triggered by trauma or intercurrent illness
67
Who gets pseudogout?
Elderly females
68
How do you manage pseudogout?
NSAIDs | Steroids
69
What is polymyalgia theumatica?
Inflammatory arthritic condition of the elderly | Associated with giant cell arteritis & high ESR
70
Who is likely to get polymyalgia pheumatica?
Women 2x than men | Rare in under 50s, usually over 70
71
What are the clinical features of polymyalgia rheumatica?
``` Sudden onset of shoulder +/- pelvic girdle stiffness ESR > 45, often over 100 Anaemia Malaise Weight loss Fever depression Arthralgia /synovitis occasionally ```
72
How do you diagnose polymyalgia rheumatica?
``` 50+ ESR 50+ Dramatic steroid response Compatible hisotry No specific diagnostic test ```
73
How do you treat polymyalgia rheumatica?
Prednisolone 15mg/day for 18-24 months | Bone prophylaxis
74
What are the differentials of polymyalgia rheumatic?
``` Myalgic onset inflammatory joint disease Underlying malignancy Inflammatory muscle disease Hypo/hyper thyroidism Bilateral shoulder capsulitis Fibromyalgia ```
75
What is juvenile idiopathic arthtis?
A group of systemic inflammatory disorders affecting children younger than 16 Important cause of disability and blindness
76
What is the most common juvenile idiopathic arthritis?
Rheumatic disease
77
What type of disease is JIA?
autoimmune disease
78
What are the diagnostic criteria for juvenile idiopathic arthritis?
``` Younger than 16 Symptoms for more than 6 weeks Joint swelling or 2 of following Painful/limited joint motion Tenderness Warmth ```
79
What are the three main subtypes of juvenile idiopathic arthritis?
Pauciarticular (most common - 55%) Polyarticular Systemic onset
80
What is pauciarticular juvenile idiopathic arthritis?
4 joints or less affected | Split into three types
81
who is affected by type 1 pauciarticular juvenile idiopathic arthritis?
``` Mainly girls (8:1) Before 5 yrs, most commoon 1-3 ```
82
How does type 1 pauciarticular juvenile idiopathic arthritis present?
``` Limp rather than pain No constitutional manifestations Mainly lower limb affected With knee being most common (ankle, then hand or elbow) +ve ANA in 40-75% Chronic uveitis in 20% Asymptomatic in 50% Irregular iris due to posterior synechiae ```
83
Who is affected by type 2 pauciarticular juvenile idiopathic arthritis?
Boys more often than girls (7:1) | After 8-9 yrs old
84
What is the presentation of type 2 pauciarticular juvenile idiopathic arthritis?
Constiutional features rare Limp due to LL affection (knee, ankle mostly) Hip can be affected with rapid damange (needs total hip replacement early in life) Enthesitis Sacroilliac joints affected Acute iridocyclitis in 10-20%
85
Who is characterised to have juvenile ankylosing spondylitis?
HLA-B27 positive people with back involvement
86
Who presents with type 3 pauciarticular juvenile idiopathic arthritis?
Girls (4:1) more than boys | Any age during childhood
87
How does pauciarticular juvenile idiopathic arthritis present?
``` Asymmetric UL/LL arthritis (destructive) Dactylitis Family history of psoriasis Nail pitting Chronic iridocyclitis (10-20%) ```
88
What is polyarticular juvenile idiopathic arthritis?
5+ joints involved
89
What are the subtypes of polyarticular juvenile idiopathic arthritis?
Rhuematoid factor positive | Rhuematoid factor negative
90
Who gets RF negative polyarticular juvenile idiopathic arthritis?
Girls (9:1) more than boys | Any age, but often early
91
What is the presentation of RF negative polyarticular juvenile idiopathic arthritis?
Constitutional manifestations (low grade fever, malaise) Hepato-splenomegaly Mild anaemia Growth abnormalities Symmetric large and small joints affection: knees, wrists, ankles, MCPs, PIPs, neck Iridocyclitis rare.
92
What is the presentation of RF positive polyarticular juvenile idiopathic arthritis?
Constitutional manifestations (low grade fever, malaise, weight loss) Anaemia Nodules. Can be complicated by sjogren’s, Felty or vasculitis, AR, pulmonary fibrosis, AAS, CTS. Similar to adult RA but in a child Erosions in x ray occur early Iridocyclitis rare.
93
What is likely to get RF positive polyarticular juvenile idiopathic arthritis?
Girls (7:1) more than boys | Late childhood - teens (12-16)
94
What defines systemic onset JIA (still's disease)?
Extra-articular features | Start eraly and dissappear after 2-5 years
95
Who gets systemic onset juvenile idiopathic arthritis?
Throughout childhood, bu ages 4-6 most common | Roughly equal across gender girls (3:2) to boys
96
How does systemic onset juvenile idiopathic arthritis present?
Fever rising to 39.5 for at least weeks Rash Lymph nodes non-tendor generalise lymphadenopathy Abdominal pain (hepatosplenmegaly in 50-75%) Serositis Arthritis (within 3-12 months of fever)
97
Describe the fever in systemic onset juvenile idiopathic arthritis present.
Evening/late afternoon, then returns to normal in morning | Whilst feverish looks toxic with chills, normal otherwise
98
Describe the rashin systemic onset juvenile idiopathic arthritis present.
Evanescent salmon red erruption on trunk/thighs Accompanies fever Brought on by scratching
99
How do you treat Juevenile idiopathic arthritis?
``` Simple pain killers NSAIDs If no response steroid injections Then disease modifying drugs/biologics Local steroids RARELY systemic steroids ```
100
When are systemic steroids used in JIA?
In systemic JIA to control pain/fever In the case of serious disease complications Bridge between DMARDs If child undergoing surgery
101
What are the surgical treatments for JIA?
Synovectomy | Reconstructive/joint replacement

Conditions + definitions (68 decks)

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