Rheumatology Flashcards
(29 cards)
What are the three cardinal features of FELTY SYNDROME?
- rheumatoid arthritis
- splenomegaly
- neutropenia
Identify two auto-antibodies seen commonly in RHEUMATOID ARTHRITIS.
- anti-RF antibody (IgM antibody produced against the Fc component of IgG)
- anti-CCP antibody (anti cyclic citrullinated protein)
What are the characteristic features within the hand of RHEUMATOID ARTHRITIS?
✔️ symmetrical swelling and inflammation of the small joints of the hand, specifically the metacarpophalyngeal (MCP) joints and the proximal interphalyngeal (PIP) joints
✔️ ulnar deviation
✔️ Z-line deformity of the thumb
✔️ Boutinerre’s deformity of the thumb
✔️ swan neck deformity of the fingers
✔️ subluxation of the MCP joint
✔️ small muscle wasting within the hand (thenar and hypothenar eminence wasting)
✔️ synovial thickening of the wrist joint
✔️ Phalen’s sign +ve
✔️ rheumatoid nodules of the elbow
Describe how to diagnose RHEUMATOID ARTHRITIS.
RA is currently diagnosed using the American College of Rheumatology and the European League Against Rheumatology classification system, which includes categories around: ✔️ joint involvement ✔️ serology (anti-RF, anti-CCP) ✔️ inflammatory markers ✔️ duration of the disease
A score > 6 is diagnostic for RA and requires urgent referral to a specialist.
Identify the principles of management for RHEUMATOID ARTHRITIS.
✔️ induce clinical remission
✔️ maintain clinical remission
✔️ monitor and manage side effects of medication
✔️ manage pain, depression and fatigue
✔️ optimise immune system function
✔️ monitor and manage complications of the disease
What are THREE classes of drugs that can be used in the management of RA?
- Disease modifying anti-rheumatic drugs (DMARDs)
- Corticosteroids
- Biological agents
Identify some complications of RA?
✔️ anaemia of chronic disease ✔️ Felty syndrome ✔️ osteoporosis ✔️ pleural and pericardial effusions ✔️ carpal tunnel syndrome ✔️ depression / mood disorders ✔️ side effects of medication (e.g. recurrent, opportunistic infections)
Describe the key clinical features of RA.
PAIN
✔️ symmetrical joint pain; affects small joints preferentially
✔️ morning-time joint stiffness
✔️ duration > 30 mins
✔️ alleviated by movement / activity; worsened with rest
ASSOCIATED FEATURES ✔️ Sjogen's Syndrome --> dry eyes, mouth, secretions etc. ✔️ vasculitis ✔️ pulmonary and pericardial effusions ✔️ carpal tunnel syndrome
SYSTEMIC FEATURES
✔️ fatigue
✔️ weight loss
✔️ low-grade fever
Define OSTEOARTHRITIS.
Osteoarthritis is an inflammatory condition of joints. Unlike RA, it is NOT auto-immune mediated. It tends to occur asymmetrically and affect large joints preferentially.
Describe some risk factors for OSTEOARTHRITIS.
✔️ increasing age
✔️ history of trauma / damage to the joint
✔️ obesity
✔️ congenital joint abnormalities
✔️ metabolic and endocrine conditions affecting the joint capsule (e.g. gout, RA)
Identify clinical features of OSTEOARTHRITIS.
PAIN ✔️ asymmetrical, large-joint pain ✔️ pain is worse in the afternoon / evening ✔️ night-pain is characteristic ✔️ morning time stiffness < 30 mins ✔️ associated with crepitus
SYSTEMIC FEATURES –> typically observed LESS than in RA
✔️ fever
✔️ weight loss
✔️ fatigue
Mood disorders (e.g. depression) is common due to the presence of chronic pain.
Identify two key findings in OSTEOARTHRITIS (that are not seen in RHEUMATOID ARTHRITIS).
- Heberden’s Nodes (seen at DIP)
2. Bouchard’s Nodes (seen at PIP)
Compare the typical X-Ray findings of RHEUMATOID ARTHRITIS versus OSTEOARTHRITIS.
RHEUMATOID ARTHRITIS ✔️ reduced bone density ✔️ synovial cyst formation ✔️ symmetrical erosions ✔️ uniform loss of joint space
OSTEOARTHRITIS ✔️ normal bone density ✔️ subchondral cyst formation ✔️ asymmetrical erosions and loss of joint space ✔️ osteophyte formation
Outline the management options for OSTEOARTHRITIS/
LIFESTYLE OPTIONS ✔️ weight loss ✔️ smoking cessation ✔️ reduced alcohol consumption ✔️ appropriate physical activity (non-weight bearing)
NON-PHARMACOLOGICAL THERAPY
✔️ physiotherapy / rehabilitation
✔️ heat packs / cool packs
PHARMACOLOGICAL THERAPY
✔️ NSAIDs
✔️ duloxetine
✔️ intra-articular injections
SURGICAL OPTIONS
✔️ joint replacement
Define SYSTEMIC SCLEROSIS / SCLERODERMA.
Systemic sclerosis (also known as scleroderma) is a disease in which excessive collagen deposition causes fibrosis of various organ structures. The exact aetiology and pathophysiology is unknown.
Systemic sclerosis can be divided into:
- localised systemic sclerosis (CREST syndrome)
- diffuse systemic sclerosis (characterised by involvement of numerous organ systems)
Identify features of CREST syndrome.
C = calcinosis R = Raynaud's phenomenon E = oesophageal dysmotility S = sclerodactyly T = telangiectasia
Describe the clinical presentation of SYSTEMIC SCLEROSIS.
DERMATOLOGY / SKIN SIGNS
✔️ calcinosis (deposition of calcium within the dermis of the skin)
✔️ sclerodactyly (tightening of the skin on the hands and the face)
✔️ telangectasia
✔️ atrophy of finger pulp
✔️ Raynaud’s phenomenon
MUSCULOSKELETAL
✔️ polyarthralgia / polyarthritis
✔️ flexion contractures in the fingers, skin, elbows etc.
CARDIOPULMONARY ✔️ interstitial lung disease ✔️ pulmonary hypertension ✔️ aspiration pneumonia ✔️ RSHF ✔️ pleural or pericardial effusions
GASTROINTESTINAL ✔️ reflux ✔️ GORD ✔️ oesophageal dysmotility ✔️ biliary cirrhosis ✔️ malabsorption (due to poor motility of the small bowel)
RENAL
✔️ segmental glomerulsclerosis
Describe the ACR / ELAR Diagnostic Criteria for SYSTEMIC SCLEROSIS.
✔️ skin thickening on both sides of the hand ✔️ fingertip lesions ✔️ telangiectasia ✔️ abnormal nail-fold capillaries ✔️ pulmonary arterial hypertension ✔️ interstitial lung disease ✔️ systemic sclerosis auto-antibodies ✔️ Raynaud's phenomenon
What is the name of the allele closely associated with ANKYLOSING SPONDYLITIS?
HLA-B27 allele; present in 90% of patients with ankylosing spondylitis.
N.B. this allele has a high sensitivity but a low specificity for the disease, as 10% of the population have this allele. Not all those with the allele go on to develop the disease.
Outline clinical features of ANKYLOSING SPONDYLITIS.
✔️ sacroilitis (inflammation of the sacra-iliac joint), progresses to involve the lumbar, thoracic and cervical spine
✔️ morning time stiffness > 30 minutes
✔️ night time pain
✔️ pain and stiffness improves with physical activity / movement
✔️ responds well to NSAIDs
✔️ acute anterior uveitis seen in 30% of patients
✔️ ulcerative colitis is not uncommon
✔️ systemic features (e.g. fever, night sweats, weight loss) may be present in some cases
Identify some differentials for SERONEGATIVE ARTHROPATHIES.
✔️ ankylosing spondylitis
✔️ psoriatic arthritis
✔️ reactive arthritis
✔️ enteropathic arthritis
Other conditions to consider include:
✔️ rheumatoid arthritis
✔️ osteoarthritis
N.B. All seronegative arthropathies are considered a single disease, with clinical manifestations in the joints, skin, eyes, gastrointestinal tract and other organs.
Outline the management options for ANKYLOSING SPONDYLITIS.
LIFESTYLE MANAGEMENT ✔️ patient education ✔️ smoking cessation ✔️ encourage weight loss ✔️ reduce alcohol consumption ✔️ address co-morbidities
MEDICAL MANAGEMENT
✔️ NSAIDs
✔️ DMARDs (e.g. 10mg methotrexate once per week PLUS 5 to 10mg folic acid PO, daily)
✔️ biologic agents (e.g. infliximab)
✔️ intra-articular corticosteroid injections
What are two key features of PSORIATIC ARTHRITIS?
- dactylitis –> inflammation of the entire joint, leading to “sausage shaped” joints
- enthesitis –> inflammation of the tendon
Define PSORIAIC ARTHRITIS. What are some risk factors for this condition?
Psoriatic arthritis is inflammation of the joints that complicates around 30% of arthritis cases. It is characterised by dactylitis and enthesitis.
Risk factors include:
✔️ HLA-B27 allele positive
✔️ family history of psoriasis or psoriatic arthritis
✔️ personal history of psoriasis
