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Year 3 Medicine Block > RHEUM: Arthritis > Flashcards

RHEUM: Arthritis Flashcards

1
Q
A
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2
Q

Define rheumatoid arthritis

A

An autoimmune disease associated to Fc portion of IgG (RF) and anti-CCP

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3
Q

Describe the pathogenesis of RA in as much detail as you can

A

1) Citrullination of self antigens. These are recognised by T and B cells. T and B cells produce antibodies aka RF and anti-CCP.
2) Macrophages and fibroblasts get stimulated and release TNFalpha
3) Inflammatory cascade starts - causes proliferation of synoviocytes = these will grow over cartilage and cut off nutrition to it = damages cartilage !
4) Macrophages also stimulate osteoclast = get bone damage

Note: citrullination is just where amino acid arginine is converted to citrulline. This is v important bc citrulline is not one of the 20 amino acids in our DNA code - so leads to modification (here it causes RA!)

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4
Q

What is clinical presentation of RA?

A 
Female gender (3:1). 
30-50yrs
Symptoms are progressive, peripheral and symmetrical polyarthritis 
Affects MCPs,PIPs, MTPs - does NOT affect DIPs
Affects hips, knees, shoulders, c-spine
History over 6 weeks
Morning stiffness for over 30 mins. 
Commonly have fatigue, malaise
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5
Q

What can be found on examination in a pt with RA?

A

Soft tissue swelling and tenderness.
Ulnar deviation, or palmar subluxation of MCPs
Swan neck or/and Boutonniere deformity to digits
Rheumatoid nodules (usually on elbow)
Median N - carpal tunnel association

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6
Q

Name three investigations (or more!) you would consider for a pt with suspected RA

A

RF, anti-CCP, FBC, WCC, inflammatory markers, X ray or can do MRI or USS in early disease.

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7
Q

Why is a WCC done in blood test for suspected RA?

A

Can be elevated due to complication of septic arthritis

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8
Q

Why is FBC carried out as an investigation for RA?

A

May show normocytic anaemia which is a feature of chronic disease

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9
Q

How is RA initially treated?

A

DMARD monotherapy - methotrexate

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10
Q

Describe treatment you would discuss with patient recently diagnosed with RA

A
  • DMARD such as methotrexate. Can discuss use of combination
  • Steriods to be used acutely both orally or intra-articular
  • NSAIDs + PPI to aid with symptom control
  • Non drug options - OT/PT, podiatry, psychological
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11
Q

What are the extra-articular features of severe RA?

A

Remember with mnemonic CAPS: (come in 3s)
C - carpal tunnel, CVD, cord compression
A - anaemia, amyloidosis, arteritis
P - pericarditis, pleural dosease, pulmonary disease
S - Sjögren’s, scleritis, Splenic enlargement

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12
Q

What features are characteristically seen in an XRAY of RA?

A 
LESS 
Loss of joint space 
Erosions (periarticular)
Soft tissue swelling 
Subluxation
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13
Q

Patterns of Joint / Muscle involvement:

If joint involvement was symmetrical it would suggest ____(1)____

Whereas, asymmetrical joint involvement would suggest ___(2)_____ or ____(3)_____

A

(1) RA
(2) Gout
(3) Psoriatic Arthritis

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14
Q

Patterns of Joint / Muscle involvement:

Small joint only would suggest___(1)_____

Large joints only would suggest ___(2)____

Large and small joints would suggest ____(3)______

A

(1) Early stages of RA
(2) OA
(3) Late stages of RA

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15
Q

Give the medical term for describing the number of joints involved for the below:

(1) 1 joint
(2) 2-4 joints
(3) >4 joints

A

(1) monoarticular
(2) Oligoarticular / pauciarticular
(3) Polyarticular

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16
Q

List some causes of acute polyarthritis. Use categories below to give specific conditions

  1. Inflammatory arthritis
  2. Autoimmune arthritis
  3. Viral infection
  4. Crystal arthritis
A
  1. Inflammatory arthritis
    - RA
    - PsA
    - Reactive arthritis
  2. Autoimmune arthritis
    - SLE
    - Vasculitis
  3. Viral infection
    - HIV
    - Parovirus
    Chikungunya
  4. Crystal arthritis
    - UNcontrolled Gout
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17
Q

What are the causes of chronic monoarthritis? Use categories below to think of specific conditions

  1. Infections
  2. Inflammatory
  3. Non- inflammatory
  4. Tumours
A
  1. Infections
    - TB
  2. Inflammatory
    - Psoriatic arthritis
    - Reactive arthritis
    - Foreign body
  3. Non- inflammatory
    - OA
    - Trauma (meniscal tear)
    - Osteonecrosis (prednisolone use)
    - Neuropathic ( Charcots arthropathy )
  4. Tumours
    - he says v rare!
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18
Q

What 2 conditions __(1)____ and ____(2)______can cause arthritis of the DIPJs?

In ___(1)___ changes will also be seen on the nail of the digit.

___(2)___ is the most common disease affecting this joint. ____(3)____ nodes can be seen on the DIPJ in this disorder.

A

(1) PsA
(2) OA
(3) Heberden’s Nodes affecting the DIPJ in OA

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19
Q

History taking - PMHS HISTORY of a rheum patient

Seronegative Spondyloarthropathy is associated with which 3 conditions?

A history of STI / diarrhoea could indicate what 2 types of arthiris

A

Seronegative Spondyloarthropathy is associated with:

  • Anterior uveitis
  • Psoriasis
  • IBD

Hx of STI / Diarrhoea could indicate:

  • reactive arthritis
  • gonococcal arthritis
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20
Q

History taking - Social HISTORY of a rheum patient
SMOKING:

Smoking is implicated in causing and making ___(1)____more severe

Patients with ____(2)____ symptoms in the hands should be advised to stop smoking

A

Smoking is implicated in causing and making ___RA____more severe

Patients with ____Raynaud’s ____ symptoms in the hands should be advised to stop smoking

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21
Q

Compare and Contrast the features of Inflammatory vs Mechanical disease.

E.g. Morning stiffness / effect of activity / effect of resting / Fatigue/ systemic involvement

A 
Inflammatory disease:
> 1 hour morning stiffness
Activity - improves 
Resting - worsens
Fatigue - profound 
Systemic symptoms - yes
Mechanical Disease
< 30 mins morning stiffness
Activity - worsens 
Resting - improves 
Fatigue - minimal 
Systemic symptoms - no
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22
Q

History taking - Constitutional symptoms

What are some examples of constitutional symptoms?

What do they indicate? (3)

What are some conditions which may present with constitutional symptoms?

A

Constitutional symptoms

  • Fever
  • Weight loss
  • Night sweats
  • Loss of appetite

What do they indicate?

  1. Inflammation
  2. Infection
  3. Neoplasia

What are some conditions which may present with constitutional symptoms?
Ankylosing spondylitis (all)
GCA
SLE - fever

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23
Q

What are some extra - articular features of RA?

A

Mouth / Eyes

  • scleritis
  • Dry mouth / eyes

Skin
- subcutaneous nodules

Genito-urinary

  • renal failure / hypertension
  • Micro -haematuria / proteinuria

Neuro
- Compressive - e.g. carpal tunnel syndrome

Cardio- Resp
SOB - alveolitis

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24
Q

What are some extra - articular features of RA?

A

Mouth / Eyes

  • scleritis
  • Dry mouth / eyes

Skin
- subcutaneous nodules

Genito-urinary

  • renal failure / hypertension
  • Micro -haematuria / proteinuria

Neuro
- Compresive - e.g. carpal tunnel syndrome

Cardio- Resp
SOB - alveolitis

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25
Q

What gene are the Spondyloarthropathies associated with?

A

HLA - B27

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26
Q

How would a pt with Psoriatic Arthritis present?

  1. Typical patient ?
  2. Pattern ?
A
  1. 10 % pts with hx of psoriasis
    - often middle aged.
    - Male and females equally affected.
    - Nail
    - Psoriasis extensor
  2. Different patterns! can be symmetrical like RA. Hands/ wrists / ankles /DIP (not MCP like in RA)
    - OFTEN Asymmetrical olgio / arthritis- swollen feet / fingers. “Dactylitis” = swollen fingers
27
Q

What signs might you see on a pt with Psoriatic Arthritis?

A 
Nail pitting 
Onycholysis - nail coming away from bed
Psoritatic plaques 
Dactylitis (inflammation of full finger)
Enthesitis (inflammation where tendon inserts into bone)

Associated :
EYe - uveitis / conjunctivitis
Aortitis - inflammation of aorta
Amyloidosis

28
Q

What signs might you see on a pt with Psoriatic Arthritis?

A 
Nail pitting 
Onycholysis - nail coming away from bed
Psoritatic plaques 
Dactylitis (inflammation of full finger)
Enthesitis (inflammation where tendon inserts into bone)

Associated :
EYe - uveitis / conjunctivitis
Aortitis - inflammation of aorta
Amyloidosis

29
Q

What screening test do patients with Psoriasis complete to see if need to be referred to a rheum?

A

PEST
Psoriasis Epidemiological Screening tool - asks questions about:

Joint pain
Swelling
Hx of Arthitis
Nail pitting

High score - get you to the rheumatologist.

30
Q

What is arthritis Mutlians? How related to Psoriatic Arthritis?

A

most severe form of psoriatic arthritis.

Osteolysis of bones around the joints in the phalanxes.

Causes digit to get shorter and skin to fold over the shortened finger - “telescopic finger”

31
Q

What is arthritis Mutlians? How related to Psoriatic Arthritis?

A

most severe form of psoriatic arthritis.

Osteolysis of bones around the joints in the phalanxes.

Causes digit to get shorter and skin to fold over the shortened finger - “telescopic finger”

32
Q

How do you manage Psoriatic Arthritis?

A

Rheum and Derm together.

Drugs:
NSAID (pain)
DMARDS e.g. methotrexate / sulfasalazine
Anti-TNF eg.g. infliximab
Last line is a IL12/23 Inhibitor Ustekinumab
33
Q

What is reactive arthritis?

A

Synovitis in joints post an infective trigger

34
Q

How does reactive arthritis typically present?

A

acute monoarthriits (often lower limb asymmetrical)

35
Q

What are some triggers for reactive arthritis?

A

Z2F: Most common triggers: gastroenteritis and STI (chlamydia)

Distant infection

Gastroenteritis:
Camplyobacter
Shigella
Salmonella

STI 
Chlamydia Trachomatis (post urethritis / cervicitis)
(Gonorrhoea = gonococcal septic arthritis )
36
Q

Associated symptoms with reactive Arthritis ?

A

Eye: Bilateral conjunctivitis / uveitis
Skin: Circinate Balanitis (dermatitis on head of penis) and urethritis

“can’t SEE, can’t PEE, cant CLIMB A TREE” as arthritis, eye prob, balanitis

37
Q

Investigations for Reactive Arthritis?

A

Bloods:
Inflammatory markerts - CRP

Rule out:
Septic arthritis- aspirate, gram stain, culture + sensitivities. GIVE AB until excluded
Crystal arthritis - aspirate to check for gout / pseudo gout

38
Q

Investigations for Reactive Arthritis?

A

Bloods:
Inflammatory markerts - CRP

Rule out:
Septic / crystal arthritis - aspirate to check for bacteria / crystals

39
Q

Management for Reactive Arthritis?

A

Treat infection (may not help arthritis)

NSAIDs
Steroid injection to joint
most resolve within 6 months

If reoccurs DMARDS / Anti-TNFA drugs especially likely if HLA-B27 +ve

40
Q

What is Enteropathic arthritis?

A

10-20% of pts with IBD develop

2/3 get peripheral arthritis
1/3 get axial arthritis

41
Q

With Enteropathic arthritis what are the 2 types of peripheral arthritis and how do they related to IBD flares?

A

Type 1: correlation with IBD flares - oligoarticular and asymmetric arthritis

Type 2 : NO correlation with IBD flares- poly articular symmetrical arthritis

42
Q

How to treat Enteropathic arthritis? What be mindful of?

A

NSAIDs can cause IBD flare up.

use DMARDS

TNF inhibitors treat both the bowel disease and arthritis

43
Q

Mnemonic for extra - articular Ankylosing Spondylitis features - 5 As

A 
Anterior uveitis 
Aortic incompetence  
AV block 
Apical lung fibrosis 
Amyloidosis
44
Q

What are features on inflammatory back pain? Mnemonic IPAIN

A 
Insidious onset
Pain at night (getting up helps)
Age <40
Improves when exercise
No improvement with rest
45
Q

What is a DEXA scan?

A

Measures the amount of radiation absorbed by the bones - indicating bone mineral density - BMD

46
Q

Where should a DEXA scan reading be done to classify and manage OA?

A

At the hip - neck of femur to confirm OA and monitor treatment .

47
Q

What scores can bone density be represented as?

Which score is key for the WHO classification of OA?

A

Z score ( how much bone mineral density falls below mean of pts age)

T score (how much bone mineral density falls below mean of healthy young person)

T SCORE - CLINICALLY IMPORTANT

48
Q

How is OA defined?

A

Degenerative joint disorder where there is progressive loss of articular cartilage accompanied by new bone formation and capsular fibrosis

49
Q

What are the aetiology possibilities for OA?

A

Failure of normal cartilage subject to abnormal or incongruous loading for long periods

Damaged or defective cartilage failing under normal conditions of loading

Break up of cartilage due to defective stiffened subchondral hone passing more load to it

50
Q

What are the key features of cartilage in OA

A

Loss of elasticity with reduced tensile strength

Cellularity and proteoglycan content are reduced

51
Q

What are the RF for OA?

A 
Age- over 65 
Women are more symptomatic than men 
Obesity- hand and knee 
Trauma and joint malalignment  
Fhx
52
Q

What are the most common joints to be affected by OA?

A

Hip, knee and spine

53
Q

What are the symptoms of OA?

A

Pain provoked by movement and weight bearing
Pain starts off intermittent but as it progresses becomes constant
Knee-inactivity gelling and feeling that joint will give way is common

54
Q

What are the xray features of OA?

A

LOSS

loss of joint space
osteophytes
subchondral scerlosis
subchondral cysts

55
Q

What is the aim of treatment?
(regarding osteoarthritis)

A

Pain improvement and reduce disability

56
Q

What non-drug therapy is recommended in patients with OA?

A

Hip and Knee- strengthening and range of movement exercises
Weight loss to reduce joint loading
Laterally wedged insoles or walking stick

57
Q

What pharmacological therapy is given for OA?

A

Paracetamol is first line
NSAIDs- short term
Topical NSAIDS, topical rubefacients and capsaicin can be used.
Intra- articular corticosteroids can be offered.

58
Q

What surgical therapy is offered in OA?

A

If physio and pharmatherapy is not helpful- joint replacement surgery can be offered

59
Q

What is the triad of reactive arthritis?

A

Arthritis, urethritis, conjunctivitis

60
Q

Reactive vs Septic arthritis?

A

Reactive- response to a systemic infection, or post systemic infection e.g. gastroenteritis or chlamydia. No infection in joint

Septic- infection is in the joint e.g staphylococcus aureus

61
Q

Never give methotrexate and which AB?

A

Never give methotrexate and trimethoprim

Causes: Bone marrow suppression and severe or fatal pancytopaenia

Pt might present with : infection, bleeding anaemia
Adverse effect made worse by renal impairment

62
Q

Felty’s syndrome?

A

triad of RA, low WCC and splenomegaly

63
Q

Xray changes in psoriatic arthiritis?

A

Dactylitis - soft tissue swelling as whole digit is inflammed

‘Pencil in cup’ appearance

Osteolysis - destruction of bone

Periostitis - inflammation of periosteum thick border

Ankylosis - bones join together - stiff

64
Q

What is scoring system for RA?

A 
DAS28 is disease activity score:
1.  Swollen joints
2. Tender joints
3. Raised ESR / CRP 
Used to monitor progression and response to treatment

Diagnostic score is ACR score:

  1. Joint involvement (lots of small joints score higher)
  2. Presence of AB - RF / Anti-CCP
  3. Inflammatory markers - raised ESR / CRP
  4. Duration of symptoms >6 weeks

Score > or = to 6 = diagnose RA

Year 3 Medicine Block (56 decks)

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