Rheumatology Flashcards
(29 cards)
What are the four key changes on x-ray for osteoarthritis?
L – Loss of joint space
O – Osteophytes
S – Subchondral sclerosis (increased density of the bone along the joint line)
S – Subchondral cysts (fluid-filled holes in the bone, aka geodes)
What are signs of osteoarthritis in the hands?
Heberden’s nodes (in the DIP joints)
Bouchard’s nodes (in the PIP joints)
Squaring at the base of the thumb at the carpo-metacarpal joint
Weak grip
Reduced range of motion
Management of osteoarthritis:
Start with patient education about the condition and advise on lifestyle changes such as weight loss if overweight to reduce the load on the joint, physiotherapy to improve strength to support the joint and occupational therapy and orthotics to support activities and function.
Pain medication (work down the analgesic ladder).
Intra-articular steroid injections provide a temporary reduction in inflammation and improve symptoms.
Joint replacement can be used in severe cases. The hip and knee are the most commonly replaced joints.
Summarise rheumatoid arthritis:
- Pathogenesis
- presentation
- Epidemiology
Rheumatoid arthritis is an autoimmune condition that causes chronic inflammation of the synovial lining of the joints, tendon sheaths and bursa. It is an inflammatory arthritis. Synovial inflammation is called synovitis. Rheumatoid arthritis tends to be symmetrical and affects multiple joints. Therefore it is a symmetrical polyarthritis. Inflammation of the tendons increases the risk of tendon rupture.
It is three times more common in women than men. It most often develops in middle age but can present at any age. Family history is relevant and increases the risk of rheumatoid arthritis.
What antibodies are linked to rheumatoid arthritis?
Cyclic citrullinated peptide antibodies (anti-CCP antibodies) are autoantibodies that are more sensitive and specific to rheumatoid arthritis than rheumatoid factor. Anti-CCP antibodies often pre-date the development of rheumatoid arthritis and give an indication that a patient will go on to develop rheumatoid arthritis at some point.
Rheumatoid factor
Symptoms of rheumatoid:
- Pain
- Swelling
- Stiffness
- Fatigue
- Weight loss
- Flu like illness
- Muscles aches and weakness
Pain from an inflammatory arthritis is worse after rest but improves with activity.
Features of rheumatoid arthritis in the hands:
Very important!!
- Z shaped deformity to the thumb
- Swan neck deformity (hyperextended PIP with flexed DIP)
- Boutonnieres deformity (hyperextended DIP with flexed PIP)
- Ulnar deviation of the fingers at the knuckle (MCP joints)
Investigations for rheumatoid arthritis:
- Check rheumatoid factor
- If RF negative, check anti-CCP antibodies
- Inflammatory markers such as CRP and ESR
- X-ray of hands and feet
- Ultrasound scan of the joints can be used to evaluate and confirm synovitis. It is particularly useful where the findings of the clinical examination are unclear.
What are the features of RA on xray?
- Joint destruction and deformity
- Soft tissue swelling
- Periarticular osteopenia
- Boney erosions
How is RA managed?
A short course of steroids can be used at first presentation and during flare ups to quickly settle the disease. NSAIDs/COX-2 inhibitors are often effective but risk GI bleeding so are often avoided or co-prescribed with proton pump inhibitors (PPIs).
First line is monotherapy with methotrexate, leflunomide or sulfasalazine. Hydroxychloroquine can be considered in mild disease and is considered the “mildest” anti rheumatic drug.
Second line is 2 of these used in combination.
Third line is methotrexate plus a biological therapy, usually a TNF inhibitor.
Fourth line is methotrexate plus rituximab
What biologic therapies are used to managed RA and what complications can occur with these?
The most important biologics to remember are the TNF inhibitors adalimumab, infliximab and etanercept and it is also worth remembering rituximab. The others are very unlikely to come up in your exams but are worth being aware of. Just remember they all lead to immunosuppression so patients are prone to serious infections. They can also lead to reactivation of dormant infections such as TB and hepatitis B.
Side effects
Methotrexate: pulmonary fibrosis
Leflunomide: Hypertension and peripheral neuropathy
Sulfasalazine: Male infertility (reduces sperm count)
Hydroxychloroquine: Nightmares and reduced visual acuity
Anti-TNF medications: Reactivation of TB or hepatitis B
Rituximab: Night sweats and thrombocytopenia
Side effects
Methotrexate: pulmonary fibrosis
Leflunomide: Hypertension and peripheral neuropathy
Sulfasalazine: Male infertility (reduces sperm count)
Hydroxychloroquine: Nightmares and reduced visual acuity
Anti-TNF medications: Reactivation of TB or hepatitis B
Rituximab: Night sweats and thrombocytopenia
Methotrexate can cause what side effect?
Pulmonary fibrosis
Read summary of psoriatic arthritis:
Psoriatic arthritis is an inflammatory arthritis associated with psoriasis. This can vary in severity. Patients may have a mild stiffening and soreness in the joint or the joint can be completely destroyed in a condition called arthritis mutilans.
It occurs in 10-20% of patients with psoriasis and usually occurs within 10 years of developing the skin changes. It typically affects people in middle age but can occur at any age.
It is part of the “seronegative spondyloarthropathy” group of conditions.
How does psoriatic arthritis present?
Asymmetrical pauciarthritis affecting mainly the digits (fingers and toes) and feet. Pauciarthritis describes when the arthritis only affects a few joints.
Spondylitic pattern is more common in men. It presents with:
What are the examination signs of psoriatic arthritis?
Plaques of psoriasis on the skin
Pitting of the nails
Onycholysis (separation of the nail from the nail bed)
Dactylitis (inflammation of the full finger)
Enthesitis (inflammation of the entheses, which are the points of insertion of tendons into bone)
What xray changes are seen in psoriatic arthritis?
Periostitis is inflammation of the periosteum causing a thickened and irregular outline of the bone
Ankylosis is where bones joining together causing joint stiffening
Osteolysis is destruction of bone
Dactylitis is inflammation of the whole digit and appears on the xray as soft tissue swelling
Pencil-in-cup appearance
The classic xray change to the digits is the “pencil-in-cup appearance”. This is where there are central erosions of the bone beside the joints and this causes the appearance of one bone in the joint being hollow and looking like a cup whilst the other is narrow and sits in the cup.
Treatment of psoriatic arthritis?
Similar to RA
NSAIDs for pain
DMARDS (methotrexate, leflunomide or sulfasalazine)
Anti-TNF medications (etanercept, infliximab or adalimumab)
What is reactive arthritis?
aka SARA
Reactive arthritis is where synovitis occurs in the joints as a reaction to a recent infective trigger. It used to be known as Reiter Syndrome. Typically it causes an acute monoarthritis, affecting a single joint in the lower limb (most often the knee) presenting with a warm, swollen and painful joint.
What are the most common causes of reactive arthritis?
The most common infections that trigger reactive arthritis are gastroenteritis or sexually transmitted infection. Chlamydia is the most common sexually transmitted cause of reactive arthritis. Gonorrhoea commonly causes a gonococcal septic arthritis.
What other associations occur with reactive arthritis?
Typically it causes an acute monoarthritis, affecting a single joint in the lower limb (most often the knee) presenting with a warm, swollen and painful joint.
- Bilateral conjunctivitis (non-infective)
- Anterior uveitis
- Circinate balanitis is dermatitis of the head of the penis
TOM TIP: These features of reactive arthritis (eye problems, balanitis and arthritis) lead to the saying “can’t see, pee or climb a tree”.
What is the management of reactive arthritis?
Patients presenting with an acute warm, swollen, painful joint need to be treated according to the local “hot joint” policy. This will involve giving antibiotics until the possibility of septic arthritis is excluded. Aspirate the joint and send a sample for gram staining, culture and sensitivity testing to exclude septic arthritis.
The aspirated fluid can also be sent for crystal examination to look for gout and pseudogout.
Management of reactive arthritis when septic arthritis is excluded:
- NSAIDs
- Steroid injections into the affected joints
- Systemic steroids may be required, particularly where multiple joints are affected.
Describe Ankylosing spondylitis (AS)
Ankylosing spondylitis (AS) is an inflammatory condition mainly affecting the spine that causes progressive stiffness and pain. It is part of the seronegative spondyloarthropathy group of conditions relating to the HLA B27 gene. Other conditions in this group are reactive arthritis and psoriatic arthritis.
The key joints that are affected in AS are the sacroiliac joints and the joints of the vertebral column. The inflammation causes pain and stiffness in these joints. It can progress to fusion of the spine and sacroiliac joints. Fusion of the spine leads to the classical “bamboo spine” finding on spinal xray that often appears in medical exams.
What gene is linked to AS?
There is a strong link with the HLA B27 gene. Around 90% of patients with AS have the HLA B27 gene however around 2% of people with the gene will get AS. This number is higher (around 20%) if they have a first degree relative that is affected
