Rheumatology Flashcards
(305 cards)
1
Q
What kind of arthritis is osteoarthritis?
A
Non-inflammatory degenerative mechanical shearing
2
Q
Name some risk factors for developing osteoarthritis
A
Age:>50
Female
Obesity
Occupation: sports/manual labour
Genetic: COL2A1
3
Q
Which gene is associated with osteoarthritis?
A
COL2A1
4
Q
Describe the pathophysiology of osteoarthritis.
A
Imbalance between cartilage breakdown and repair
Increased chondrocyte metalloproteinase secretion degrades T2 collagen and causes cysts
Bone tries to overcome this with T1 collagen leading to abnormal bony growths(osteophytes) and remodelling
5
Q
How is osteoarthritis diagnosed?
A
Ruel out other causes: normal CRP and ESR, anti-CCP, RF etc
X-ray:
LOSS
L-loss of joint space
O-osteophytes
S: subchondral sclerosis
S: subchondral cysts
6
Q
What are osteophytes?
A
Spurs of bone on ends of joints
7
Q
What is subchondral sclerosis?
A
Increased bone density along joint line
8
Q
What are subchondral cysts?
A
Fluid filled holes in bone along joint line
9
Q
How do patients with osteoarthritis typically present?
A
<30min mornign pain
Pain increases with use
Asymmetrical, hard, non inflamed joints
No extra-articular symptoms
Bouchard(PIPJ) and Heberden(DIPJ) nodes on fingers
10
Q
Which joints are typically affected by osteoarthritis?
A
Knees
Hips
Hands: DIPS, PIPS
Spine ,especially cervical
11
Q
What can be seen/felt on the hands of patients with osteoarthritis
A
Bouchard nodes: PIPJ
Heberden nodes: DIPJ
12
Q
Describe the treatment for osteoarthritis
A
Lifestyle changes: weight bearing and physio
NSAID pain relief
Last resort: surgery-arthroplasty-knee and hip replacement
13
Q
What kind of arthritis is rheumatoid arthritis?
A
Inflammatory autoimmune polyarthritis
Symmetrical
14
Q
Name some risk factors for developing rheumatoid arthritis
A
Smoking
Women 30-50 pre-menopausal
Genetic link: HLADR4/HLADR1
15
Q
Describe the male:female distribution of rheumatoid arthritis
A
Pre menopausal: 3 times more likely in women than men
Post menopause: M=F
16
Q
What genes is rheumatoid arthritis linked to?
A
HLA-DR4
HLADR1
17
Q
How do rheumatoid arthritis symptoms change throughout the day?
A
Worse in morning-30 minutes
Pain improves with use
18
Q
Describe the presentation of patients with rheumatoid arthritis
A
Symmetrical, hot, inflamed joints, most commonly hands and feet
Hands: boutonniere, swan neck, ulnar deviation, Z thumb
Extra articular: lungs, heart, eyes, kidneys, skin
19
Q
How can rheumatoid arthritis affect the lungs?
A
PE
Pulmonary fibrosis
20
Q
How can rheumatoid arthritis affect the heart?
A
Increased IHD risk
21
Q
How can rheumatoid arthritis affect the eyes?
A
Episcleritis
Keratoconjunctivitis sicca(dry eyes)
22
Q
How can rheumatoid arthritis affect the skin?
A
Rheumatoid skin nodules-often on elbows
23
Q
How can rheumatoid arthritis affect the kidneys?
A
CKD
24
Q
Which hand joint is commonly spared in rheumatoid arthritis and in which kind of arthritis is commonly affected?
A
DIPJ
Psoriatic arthritis
25
Name some hand signs seen in rheumatoid arthritis
Boutonniere
Swan neck
Ulnar deviation
Z thumb
26
What is Boutenniere's sign
Extensor tendon splits
PIP flexion, DIP hyperextension
27
What is swan neck sign?
PIP hyperextension, DIP flexion
28
What is ulnar finger deviation?
Fingers deviate towards ulnar(pinkie)
29
What is Z thumb?
Carpometacarpal flexion, MP hyperextension, IP flexion
30
Describe the pathophysiology of rheumatoid arthritis
Arginine->Citruline mutation in T2 collagen->anti-CCP mutation
IFN-alpha also causes more pro-inflammatory recruitment to synovium
Results in expansion of synovial lining and pannus to grow past joint margins
->Destruction of subchondral bone and articular cartilage
31
What is a pannus?
Tumour like mass
32
What is Felty syndrome?
Triad of:
Rheumatoid arthritis
Granulocytopenia
Splenomegaly
33
What is the main cause of death in patients with Felty syndrome?
Life-threatening risk of infection
34
What tests can be used to help diagnose rheumatoid arthritis?
Bloods: CRP and ESR elevated, anaemia
Serology: anti CCP and RF
X-rays:
LESS
Loss of joint space
Eroded bone
Soft tissue swelling
Soft bones(osteopenia)
35
How useful are anti-CCP and RF in diagnosing RA?
anti-CCP: 80% specific
RF: 70% non specific
36
What can be used to monitor RA disease progression?
Bloods: ESR and CRP
37
What x-ray features show rheumatoid arthritis?
LESS
Loss of function
Eroded bone
Soft tissue swelling
Soft bones (osteopenia)
38
What anaemia is most commonly associated with rheumatoid arthritis?
Normocytic normochromic->anaemia of chronic disease
39
Which anaemias can occur in patients with rheumatoid arthritis?
Normocytic normochromic->anaemia of chronic disease
Microcytic->NSAID use->PUD->Fe deficiency anemia
Macrocytic->Methotrexate use->folate deficiency
40
How can rheumatoid arthritis cause microcytic anaemia?
NSAID use->PUD->Fe deficiency anaemia
41
How can rheumatoid arthritis cause macrocytic anaemia?
Methotrexate use inhibits folate
42
Describe the treatment of rheumatoid arthritis
NSAID analgesia
Intra-articular steroid injections for pain
DMARD-methotrexate
Biologics: 1st line: infliximab: TNF alpha inhibitor
2nd line: rituximab: B cell inhibitor
43
Which biologics can be used to treat rheumatoid arthritis?
Infliximab: TNF alpha inhibitor
Rituximab: B cell inhibitor (CD20 target)
44
When is methotrexate contraindicated?
Pregnancy->folate inhibitor so can affect DNA synthesis
45
Name 2 crystal arthropathies
Gout
Pseudogout
46
What kind of arthritis is gout?
Crystal arthritis
47
How does hyperuricaemia affect gout?
Increases risk, doesn't cause it!
48
Describe the pathophysiology of gout
Hyperuricaemia->sodium urate crystal deposition along joints and intra-articularly
49
What is the most common inflammatory arthritis in the UK?
Gout
50
Name some risk factors for developing gout
Middle-aged, overweight men
Purine rich foods (meat, beer, seafood)
CKD+diuretics
51
Name some purine-rich foods
Meat
Beer
Seafood
52
Which food group can be anti-gout?
Dairy products
53
What is the equation linking purine and monosodium urate?
Purines->uric acid->monosodium urate
Purines->uric acid catalysed by xanthine oxidase
Uric acid secreted by kidneys
54
How is CKD a risk factor for gout?
Kidneys are responsible for excreting uric acid so CKD leads to impaired uric acid secretion and therefore increased monosodium urate deposits
55
Name a differential diagnosis for gout
Septic arthritis
56
Describe the symptoms of gout
Sudden onset, severe swollen, red toe, can't put weight on it
Monoarticular, typically metatarsophalangeal joint (big toe)
57
How is gout diagnosed?
Joint aspirate and polarised microscopy
Negative birefringent needle-shaped crystals
58
Describe the treatment for gout
Diet: low in purines, high in dairy
NSAIDS, then colchicine, then steroid injections for acute flare
Prevention: allopurinol
59
How does allopurinol help prevent gout?
Xanthine oxidase inhibitor
Will decrease uric acid production and therefore decrease monosodium urate
60
What is the difference in pathophysiology between gout and pseudogout?
Gout: monosodium urate crystals
Pseudogout: calcium pyrophosphate crystals
61
What is the difference in diagnosis between gout and pseudogout?
Gout: Negatively birefringent needle shaped crystals
Pseudogout: Positively birefringent rhomboid shaped crystals
62
What is pseudogout?
Calcium pyrophosphate crystals deposited along joint capsule
63
What is the difference in treatment between gout and pseudogout?
Gout: Allopurinol as prevention
Pseudogout: No preventative treatment
64
Name some risk factors for developing pseudogout
Most commonly seen in females, >70yrs
Diabetes
Metabolic diseases
Osteoarthritis
65
Name a differential diagnosis for pseudogout
Septic arthritis
66
Describe the symptoms of pseudogout
Often polyarticular with knee involvement
Swollen, red, hot joint
67
How is pseudogout diagnosed?
Joint aspirate and polarised light microscopy
Positively birefringent rhomboid-shaped crystals
68
Describe the treatment of pseudogout
NSAIDS, then colchicine, then steroid injections
No preventative treatment
69
Define osteoporosis
Decreased bone density by >2.5 standard deviations below young adult mean value (T<2.5)
70
What is the difference between osteomalacia and osteoporosis?
Osteoporosis: low bone density
Osteomalacia: low bone mineralisation
71
What characteristic group tends to be affected most by osteoporosis?
>50 post-menopausal caucasian women
72
Name the risk factors for osteoporosis
SHATTERED
Steroids
Hyperthyroidism/hyperparathyroidism
Alcohol and smoking
Thin (low BMI)
Testosterone-low
Early menopause(low oestrogen)
Renal/liver failure
Erosive and inflammatory disease
DMT1/malabsorption
73
Describe the symptoms of osteoporosis
Fractures!
Proximal femur-falls
Colles'-forked wrist
Compression of vertebrae-may cause kyphosis/widow stoop
74
How is osteoporosis diagnosed?
DEXA scan
Dual x-ray absorptiometry
Yields T score
FRAX score
75
What is T score-osteoporosis?
Compares patient's bone mineral density to reference
0-1: normal
1-2.5: Low BMD-osteopenia
>2.5: Osteoporosis
76
What is the FRAX score?
Fracture risk assessment score
Assessess 10 year fracture risk in osteoporotic patients
77
Describe the treatment for osteoporosis
Bisphosphonates:(alendronate, risedronate)
mAB denosumab
HRT
Oestrogen receptor modulator: raloxifene
Recombinant PTH-teriparatide
78
How can HRT help treat osteoporosis?
Increases testosterone and oestrogen levels
79
How do bisphosphonates help treat osteoporosis?
Inhibit RANK-L signalling and osteoclastic inhibitors
80
How does mAB denosumab work to treat osteoporosis?
Inhibits RANK-L
81
What is the precursor to osteoporosis?
Osteopenia
82
What T score indicates osteopenia?
1
83
What is fibromyalgia?
Chronic widespread MSK pain >3 months and all other causes ruled out
Non-nociceptive pathway affected
84
What characteristic group is usually affected by fibromyalgia?
Typically: females with depression/stress/poor
>60
85
Describe the symptoms of fibromyalgia
Stressed, depressed females, >60
Fatigue
Sleep disturbance
Morning stiffness (especially neck and back)
Pain
86
What is the difference between nociceptive and non-nociceptive pain?
Nociceptive: painful stimuli like trauma
Non-nociceptive: neuropathic pain and CNS processing of pain, neuropathies, sciatica etc
87
Which pain pathway is affected by fibromyalgia?
Non-nociceptive
88
Name a differential diagnosis for fibromyalgia
Polymyalgia rheumatica
89
How is fibromyalgia diagnosed?
Bloods: normal ESR and CRP
Serology: negative ANA, aPL, anti-CCP, RF
Clinical: Pain in >11/18 specific regions
90
What are the 18 specific regions to test for pain in a patient with fibromyalgia?
Front:
Base of skull
Shoulders
Top of butt
Top of femur
Back:
Base of neck
2nd rib
Lateral elbows
Knee
91
Describe the treatment for fibromyalgia
Educate patient
Physiotherapy
Antidepressants if severe neuropathic pain
(TCA's, amytriptyline)
CBT
92
What is polymyalgia rheumatica?
Large cell vasculitis that presents as a chronic pain syndrome
Muscles and joints
93
What characteristic groups are affected by polymyalgia rheumatica?
Females, >50
94
Which condition is closely linked to polymyalgia rheumatica?
Giant cell arteritis
95
Describe the symptoms of polymyalgia rheumatica
Chronic pain syndrome
Often bilateral shoulder pain and/or pelvic girdle aching discomfort for >2 weeks
Morning stiffness
Systemic: fever, weight loss, fatigue, depression etc
96
How is polymyalgia rheumatica diagnosed?
High ESR and CRP
Temporal artery biopsy may show GCA
Might have anaemia of chronic disease: normocytic normochromic
97
How is polymyalgia rheumatica treated?
Oral prednisolone
98
What is Sjogren's syndrome?
Autoimmune exocrine dysfunction
Can be primary or secondary
99
Name some conditions that can cause secondary Sjogren's syndrome
Other AI diseases:
SLE, RA
100
Name some risk factors for developing Sjogren's
Females
40-50yrs
fHx
Other AI diseases
HLAB8/DR3
101
Which genes are associated with Sjogren's
HLAB8/DR3
102
Describe the symptoms of Sjogren's
Dry eyes: keratoconjunctivitis sicca
Dry mouth: xerostomia
Dry vagina
103
How is Sjogren's diagnosed?
Serology: anti-Ro and anti-La antibodies positive
ANA also often positive
Schirmer test: induce tears and place filter paper under eyes-tears travel <10mm
104
What is the Shirmer test?
Induce tears and place filter paper under eyes
Tears travel<10mm-dry eyes
(Should be >20mm)
105
Describe the treatment for Sjogren's
Artificial tears
Artificial saliva
Lube for sexual activity
Sometimes hydroxychloroquine
106
Name a complication that can arise from Sjogren's
Increased risk of lymphomas
107
What is antiphospholipid syndrome characterised by?
Thrombosis, recurrent miscarriage and aPL antibodies
108
Is APS commonly seen in males or females?
Females
109
Name a condition associated with APS
SLE
110
Describe the symptoms of APS
CLOTS
Coagulopathy
Livedo reticularis
Obstetric issues-miscarriages
Thrombocytopenia
Also increased risk of arterial (stroke, MI) and venous thrombosis (DVT)
111
How is APS diagnosed?
Symptoms and positive antibodies
Lupus anticoagulant
Anticardiolipin antibodies (IgG/M)
Anti B2 glycoprotein-1-antibodies
112
Describe the treatment for APS
Warfarin long term if have had a thrombosis
Prophylactic(not had thrombosis)-aspirin
Aspirin and heparin if pregnant instead of warfarin
113
Describe the treatment of APS in a pregnant patient
Aspirin and heparin
114
What is SLE?
Hypersensitivity T3 reaction->antigen-antibody complex deposition->autoimmune systemic inflammation
115
Which groups of people are more commonly affected by SLE?
Females
Afro/Caribbeans
20-40(pre-menopausal)
116
Name some risk factors for developing SLE
Females (12 times more than men)
HLAB8/DR2/DR3
Drugs (isoniazid, procainamide)
117
Name 2 drugs that can cause SLE
Isoniazid
Procainamide
118
Describe the pathophysiology of SLE
Impaired apoptotic debris presented to TH2->B cell activation->antigen-antobody complexes
119
Describe the symptoms of SLE
Butterfly rash and hypersensitivity
Glomerulonephritis(nephritic syndrome)
Seizures and psychosis
Mouth ulcers
Serositis(pleural/peritoneal/pericardial inflammation of lungs)
Anaemia
Joint pain
Raynaud's
Pyrexia
120
How is SLE diagnosed?
Bloods: anaemia
High ESR and normal CRP
Urine dipstick: haematuria, proteinuria
Serology: ANA, anti dsDNA
Anti Ro, anti Sm, anti La
Low C3 and C4
121
Describe the treatment for SLE
Lifestyle changes(decrease sunlight exposure)
Corticosteroids
Hydroxychloroquine
NSAID's
Azathioprine if severe
122
What is scleroderma?
Autoimmune systemic condition
123
What is the most common type of scleroderma?
Limited cutaneous scleroderma
CREST
124
Describe the signs and symptoms of limited cutaneous scleroderma (CREST)Q
Calcinosis-Ca deposits in SC tissue-renal failure
Raynaud's-digit ischaemia due to sudden vasospasm
Eosophageal dysmotility/strictures-GI sx
Sclerodactyly-local skin thickening or tightening on fingers/toes-movement restriction
Telangiectasia-spider veins->risk of pulmonary hypertension
125
What is calcinosis?
Ca deposits in SC tissue->renal failure
126
What is raynaud's?
Digit ischaemia due to sudden vasospasm
Often precipitated by cold, relieved with heat
127
What is sclerodactyly?
Local skin thickening/tightening on fingers/toes->movement restriciton
128
What is telangiectasia?
Spider veins->risk of pulmonary hypertension
129
How is scleroderma diagnosed?
Anti centromere antibodies (ACA's)-70% cases
ANA often positive
130
How is scleroderma treated?
No cure
Treat symptoms
Raynauds-hand warmers
GI symptoms: PPI
131
What is polymyositis/dermatomyositis?
Inflammation and necrosis of skeletal muscle
132
What is the difference between polymyositis and dermatomyositis?
If it also involves skin->dermatomyositis
133
Name some risk factors for developing polymyositis/dermatomyositis
Females
HLAB8/DR3 genetic link
134
Describe the symptoms of polymyositis/dermatomyositis
Symmetrical wasting of muscles of shoulders and pelvic girdle->hard to stand from sitting, hard to squat, hard to put hands on head
Dermatomyositis-skin changes too
135
Name some skin changes associated with dermatomyositis
Gottron's papules->scales on knuckles
Heliotrope rash->purple/red eyelids
Shawl sign
136
How is polymyositis/dermatomyositis diagnosed?
Muscle fibre biopsy->necrosis
LDH and CK raised
Anti-Jo1 antibodies: both
Anti-Mi2 antibodies: dermatomyositis
137
Which antibody is specific to dermatomyositis and what dermatological sign is it associated with?
Anti-Mi2 antibodies
Shawl sign
138
How is polymyositis/dermatomyositis treated?
Bed rest
Prednisolone for 1 month then tapering regime
139
Describe the mutation and inheritance of Marfan's
Autosomal dominant FB1 mutation->decreases connective tissue tensile strength
140
Describe the signs and symptoms of Marfan's
'Marfan's body habits'-tall and thin, arachnodactyly, pectus excavatum(sunken breastbone) pectus carinatum(protruding breastbone)
And aortic complications
aortic regurgitation, AAA, aortic disseciton
141
Name some aortic complications associated wtih Marfan's
Aortic regurgitation, AAA, aortic dissection
142
How is Marfan's diagnosed?
Clinical presentation and FBN-1 mutation
143
What is EDS caused by?
Autosomal dominant mutations affecting collagen proteins
13 subtypes
144
Describe the symptoms of EDS
Joint hypermobility, stretchy skin, easy bruising, CV complications (mitral regurgitation, AAA, aortic dissection)
145
Name some CV complications associated with EDS
Mitral regurgitation
AAA
Aortic dissection
146
How is EDS diagnosed?
Clinical presentation-Beighton score
Collagen mutations
147
Name a common cause of back pain in people aged 20-55
May be normal and self limiting
Trauma/work related
148
Name some signs for serious pathology when a patient presents with mechanical lower back pain
Elderly-e.g. myeloma
Neuropathic pain-spinal cord compression
149
What is lumbar spondylosis?
Degeneration of IV disc->loses its compliance and thins over time
150
What age group is most commonly affect by lumbar spondylosis?
Older patients
151
Describe the symptoms of lumbar spondylosis
Initially asymptomatic, progressively worsens
L4/5 or L5/S1
152
Name an investigation for mechanical lower back pain if serious pathology is suspected
X-ray or MRI
153
Describe the treatment for simple mechanical lower back pain
Analgesia and physio
154
What connects bone to bone?
Ligaments
155
What connects muscle to bone?
Tendons
156
Name the primary bone tumours
Osteosarcoma
Ewing sarcoma
Fibrosarcoma
Chondrosarcoma
157
Are primary or secondary bone tumours more common?
Secondary
158
Which age group is predominantly affected by primary bone tumours
Children
159
Where do secondary bone tumours arise from?
BLT KP
Breast
Lung
Thyroid
Kidneys
Prostate
160
Name a cancer that can cause bone pain
Myeloma (OLD CRAB)
161
Which secondary bone tumours are osteolytic?
Breast
Lung
162
Which secondary bone tumours are osteosclerotic?
Prostate
163
What is the most common primary bone malignancy?
Osteosarcoma
164
What disease is osteosarcoma associated with?
Paget's
165
What age group is most affected by osteosarcoma?
15-19 years
166
Where does osteosarcoma often metastasise to?
Lungs
167
How is osteosarcoma diagnosed?
X-ray: 'sunburst' appearing bone
168
What is chondrosarcoma?
Cartilage cancer
169
What cells does Ewing sarcoma arise from?
Mesenchymal stem cells
170
What is the most common age Ewing sarcoma presents?
15yrs
171
Describe the symptoms of bone cancer
Local severe pain, worst at night
Decreased range of motion of longbone/verterbrae
Pathological fractures
Systemic: weight loss, fever, malaise, fatigue
172
How is bone cancer diagnosed?
Skeletal isotope scan (shows changes before x ray)
X-ray->osteolysis (osteosclerosis->prostatic mets)
High ALP, high ESR/CRP, hypercalcemia of malignancy
173
Describe the treatment for bone cancer
Chemo/radiotherapy
Bisphosphonates
174
What should be considered when prescribing long term steroids?
Bone protection-bisphosphonates
Stomach protection-PPI
175
What is the general treatment for vasculitis?
Corticosteroids
176
Name some conditions that cause large vessel vasculitis
Giant cell arteritis
Takayatsu arteritis
177
What groups are mainly affected by Takayatsu arteritis?
Asian women
178
What does Takayatsue arteritis mainly affect?
Aortic arch
179
Name some conditions that cause vasculitis of medium-sized vessels
Polyarteritis nodosa
Buerger's disease
Kawasaki disease
180
What groups are most affected by Buerger's disease?
Male smokers aged 20-40
181
What is Buerger's disease also called?
Thromboangiitis obliterans
182
What does Buerger's disease cause?
Peripheral skin necrosis
183
What group does Kawasaki disease affect?
Children
184
What does Kawasaki disease cause?
Coronary artery aneurysms
185
Name some conditions that cause vasculitis of the small vessels
Granulomatosis with polyangiitis(Wegener's)
Eosinophilic granulomatosis with polyangitis (EGPA/Churg Strauss disease)
Henoch Schonlein purpura
186
What is eosinophilic granulomatosis with polyangitis also called?
Churg Strauss disease
187
What test can be used to diagnose Churg Straus disease?
pANCA
188
What is granulomatosis with polyangitis also called?
Wegener's disease
189
What test can be used to diagnose Wegener's granulomatosis?
cANCA
190
Name some signs and symptoms of Wegener's granulomatosis
Saddle shaped nose
Pulmonary renal syndrome: glomerulonephritis and diffuse alveolar haemorrhage
(Glomerulonephritis and pulmonary symptoms)
191
What is Henloch Schontein purpura?
IgA vasculitis
DDx for IgA nephropathy
192
How is Henloch Schontein purpura different to IgA nephropathy
HSP has a purpuric rash on shins and affects other organs-joints, abdomen, renal
IgA nephropathy-renal only
193
What groups tend to be affected by GCA
50+ caucasian female
194
How do patients with GCA typically present?
50+ caucasian females
Unilateral temple headache
Jaw claudication with/without vision changes
Temporal scalp tenderness
195
Which vessel is affected by GCA?
External carotid branches
196
What causes scalp tenderness in GCA patients?
Vasculitis of temporal branch of external carotid
197
What causes vision changes in GCA patients?
Vasculitis of ophthalmic branch of external carotid
198
What causes jaw claudication in GCA patients?
Vasculitis of facial branch of external carotid
199
How is GCA diagnosed?
High ESR: normal/high CRP
Temporal artery biopsy is diagnostic: granulomatous inflammation of intima and media->patchy skip lesions so you need a big chunk
200
What would you expect to find on a temporal artery biopsy in a GCA patient?
Granulomatous inflammation of intima and media
Patchy skin lesions
201
What is the treatment for GCA?
Corticosteroids-prednisolone
202
Name a complication of GCA
Sudden painless vision loss in one eye-optic neuropathy-can become permanent if not treated quickly
203
What is temporary vision loss in one eye called and when does it typically occur?
Amaurosis fugax-typically seen in TIA
204
How is amaurosis fugax from GCA treated?
High does IV methylprednisolone
205
Does polyarteritis nodosa typically affect males or females?
Males
206
What disease is polyarteritis nodosa associated with?
Hepatitis B
207
Describe the symptoms of polyarteritis nodosa
Severe systemic symptoms:
Multineuritis multiplex(ischaemia of vasa nervosum)
GI bleeds-mesenteric artery
CKD/pre-renal AKI (renal artery)
Skin SC nodules and haemorrhage
208
How is polyarteritis nodosa diagnosed?
CT angiogram-'Beads on string' microaneurysm
Biopsy, e.g. kidney->necrotising vasculitis, e.g. due to hypertension
209
Describe the treatment for polyarteritis nodosa
Corticosteroids
Control hypertension->ACEi
Hep B treatment after corticosteroids
210
What is enteric arthritis?
Arthritis associated with IBD
211
What are spondyloarthropathies?
Asymmetrical, seronegative inflammatory arthritis, associated with HLAB27-an MHC1 serotype
212
Which gene is associated with spondyloarthropathies?
HLAB27
213
Name some spondyloarthropathies
Ankylosing spondylitis
Psoriatic arthritis
Reactive arthritis
Enteric arthritis
214
What are the general features of spondyloarthropathies?
SPINEACHE
Sausage fingers-dactylitis
Psoriasis
Inflammatory back pain
NSAID's-good response
Enthesitis
Arthritis
Crohn's/colitis
HLA B27
Eyes-uveitis
215
What is reactive arthritis?
Sterile inflammation of synovial membranes and tendons , reacting to distant infections, usually GI or STI
216
Which organisms can cause reactive arthritis?
GI: gastroenteritis
C.jejuni
Salmonella
Shigella
STI:
C.trachomatis
N.gonorrhoea
217
Name a differential diagnosis for reactive arthritis
Septic arthritis
Painful, hot, red, swollen joint
Signs/history of infection
218
What triad is associated with reactive arthritis?
Reiter's triad
Uveitis, Urethritis, arthritis/enthesitis
Can't see, can't pee, can't climb a tree
219
Describe the symptoms of reactive arthritis
Reiter's triad: urethritis/balanitis, uveitis, arthritis/enthesitis
May also have keratoderma blenorrhagicum(skin lesions)
220
How is reactive arthritis diagnosed?
Joint aspirate:
mc+s:no organisms
Polarised light microscopy: no crystal arthropathy
High ESR and CRP
HLAB27 positive
Sexual health review and stool culture for cause
221
How is reactive arthritis treated?
Symptoms: NSAIDs, steroid injecitons
Methotrexate, anti-TNFa if this doesn't work
222
Is reactive arthritis acute or chronic?
Mostly an single acute attack
>6months recurrence-chronic
223
Is reactive arthritis acute or chronic?
Mostly a single acute attack
>6months recurrence-chronic
224
What is ankylosing spondylitis?
Abnormal stiffening of joints (sacroiliac and verterbral) due to new bony formation
225
Are males or females more affected by ankylosing spondylitis?
young Males
226
What gene is associated with ankylosing spondylitis
HLAB27
227
Describe the pathophysiology of ankylosing spondylitis
Syndesmophytes replace spinal bone damaged by inflammation which decreases spine mobility
228
What are syndesmophytes?
Vertical abnormal bony growths-cause fusion of verterbral bodies
229
What body parts are commonly inflamed with ankylosing spondylitis?
Vertebrae and sacroiliac joints
Tendons
Eyes
Fingers
230
Describe the typical presentation of a patient with ankylosing spondylitis
Young male, progressively worsening back stiffness
Worst in morning and night, better with movement
231
Name the signs of ankylosing spondylitis
Anterior uveitis
Enthesitis
Dactylitis
Lumbar pathology: decreased natural lumbar lordosis->more kyphosis
Schober test: decreased lumbar flexion (<20cm)
232
What is the Schober test used for?
ankylosing spondylitis
Detects reduced flexion
233
Describe the Schober test
While standing, mark 5th lumbar spinal process(usually dimple of Venus) and 10cm above
On forward flexure, space between 2 marks should increase to >20cm
234
How is ankylosing spondylitis diagnosed?
ESR ad CRP raised
HLA B27 positive-but not needed for diagnosis
Xray
MRI
235
Is MRI or xray better for diagnosis ankylosing spondylitis?
MRI can detect sacroilitis before x ray so is a better screening tool
236
What x ray findings would you expect in a patient with ankylosing spondylitis?
Bamboo spine
Sacroiliitis
Squared verterbral bodies
Syndesmophytes
237
Describe the treatment for ankylosing spondylitis
Exercise, NSAIDs
DMARD
TNFa blockers-infliximab, etanercerpt
238
Name 2 TNFa blockers used to treat ankylosing spondylitis
Infliximab
Etanercept
239
Describe the symptoms of moderate psoriatic arthritis
Inflamed DIPJ's
Nail dystrophy
Dactylitis
Enthesitis
Psoriatic rash on skin
240
What are the hidden sites for a psoriatic rash?
Behind ears, scalp, under nails, penile
241
Descirbe the symptoms of severe psoriatic arthritis
Arthritis mutilans
Penicl in cup deformity (fingers telescope in on themselves-osteolysis of bone->progressive shortening)
242
Describe the treatment for psoriatic arthritis
NSAIDS/steroid injection sot improve symptoms
Methotrexate
If fails: antiTNFa: inflixumab, etanercept
If fails: IL12+23 inhibitor: ustekenumab
243
Name an IL12+23 inhibitor and what i might be used to treat
Ustekenumab: treat psoriatic arhtritis when methotrexate and snti TNF alpha fails
244
Name 2 infective arthritis
Septic arthritis
Osteomyelitis
245
What is septic arthritis?
Direct bacterial infection of joints (either direct access or haematogenous spread)
246
What is meant by haematogenous spread?
Spreads from elsewhere in the body
247
Why is septic arthritis a medical emergency and what can this look like?
Acutely inflamed joint with fever, very painful
Can destory knee in <24 hours
(Typically knee)
248
What organism most commonly causes septic arthritis?
S.aureus
249
Which organism is often the cause of septic arthritis in prosthetic joints?
Coagulase negative staphs
S epidermis
250
Which organisms commony cause septic zrthritis?
H influenza(children, less common due to vaccination now)
N. gonorrhoea
E.Coli/pseudomonas (IVDU)
251
Name some risk factors for developing septic arthritis
IVDU
Immunosuppression
Recent surgery
Trauma
Prosthetic joints and inflammatory joint disease, especially RA
252
How is septic arthritis diagnosed?
Urgent joint aspirate
mc+s and polarised light microscou
Spetic arthritis will show causative organism
253
Name some differential diagnoses for septic arthritis and how you can distinguish between them
Reactive arthritis: Sterile, crystal free joint
Gout: sterile, negative befringent needle crystals
Pseudogout: sterile, positive befringent rhomboid crystals
254
Describe the treatment of septic arthritis
Joint aspirate(drainage) them epirical antibiotics
Stop methotrexate/anti TNF
If on steroids, double dose
NSAIDS for analgesia
255
Which antibiotics would you use to treat septic arthritis caused by gram negative bacteria like E.coli and p. aeruginosa
Flucoxacillin
256
Which antibiotics would you use to treat septic arthritis caused by MRSA or s aureus
Vancomycin
257
Which antibiotics would you use to treat septic arthritis caused by N. gonorrhoea?
ceftriaxone and azithromycin
258
What would you do if a patient on prednisolone develops septic arthritis?
Double the dose-stress response
259
What is osteomyelitis?
Acutely inflamed infected bone marrow, haematogenous or local spread
260
Which organism most commonly causes osteomyelitis?
S.aureus
261
Which organism most commonly causes osteomyelitis in sickle cell patients?
Salmonella
262
Name some risk factors for developing osteomyelitis
IVDU
Immunosuppression
PVD, DM
Sickle cell anaemia
Inflammatory arthritis
Trauma
263
Describe the pathophysiology of osteomyelitis
Direct inoculation/local spread/haematogenous spread
All result in acute bone changes->inflammation and bone oedema
Chronic bone changes->sequestra and involucrum
264
What is sequestra and involucrum
Sequestra: necrotic bone embedded in pus
Involucrum: thick sclerotic boneplaces around sequestra to compensate for support
265
Describe the acute symptoms of osteomyelitis
Dull bony pain
How and swollen
Worse with movement
266
Describe the chronic symptoms of osteomyelitis
Dull bony pain, hot and swollen, worse with movement
Also deep ulcers (sequestrate)
267
Name a differential diagnosis to osteomyelitis
Charcot joint: damage to sensory nerves due to diabetic neuropathy->causes progressive degeneration of weight bearing joint and bony destruction
Often affects foot-diabetic feet'
268
How is osteomyelitis diagnosed?
BM biopsy and culture(and blood mc+s) to ID causative organism
High ESR and CRP
XR: osteopenia
MRI after Xray can show bone marrow oedema
269
Describe the treatment for osteomyelitis
Immobilise
Antibiotics
270
Which antibiotics could be used to treat osteomyelitis caused by MRSA/S.aureus?
Vancomycin or teicoplanin
271
What are the advantages and disadvantages of using teicoplanin over vancomycin
Longer lasting but more side effects (GI upsets and pruritus)
272
Which antibiotics could be used to treat osteomyelitis caused by S aureus
Fusidic acid
273
Which antibiotics could be used to treat osteomyelitis caused by salmonella
Flucoxacillin
274
What must be ruled out when diagnosisng and treating osteomyelitis?
TB osteomyelitis
275
How can TB osteomyelitis be ruled out?
Bone marrow biopsy-positive for caseating granuloma)
276
What is osteomalacia?
Defective bone mineralisation after epiphyseal fusion
277
What is rickets?
Defective bone mineralisation before epiphyseal fusion
278
What is the main cause of osteomalacia/rickets?
Vitamin D deficiency, so causes decreased Ca2+ and PO43-
279
Describe the vitamin D pathway
7-dehyrocholesterol->cholecalciferol(inactive D3) by UV light
Cholecalciferol->25-hydroxyvitamin D(liver)
25-hydroxyvitamin D->1,25-dihydroxyvitamin D(active D3/calcitrol) by kidneys
280
Name the action of 1,25-dihydroxy-vitamin D
Overall increases serum calcium and phosphate
Increases Ca2+ bone and kidney resorption
Increases Ca2+ GI absorption
281
Name the causes of osteomalacia/rickets
Hyperparathyroidism
Vitamin D deficiency
CKD/renal failure
Liver failure
Anticonvulsant drugs
282
How does hyperparathyroidism cause osteomalacia/rickets?
Increased PTH->increased Ca2+ resorption from the bone so less available for mineral formation
283
Name some primary causes of a vitamin D deficiency
Malabsorption
Low dietary intake
Poor sunlight exposure
284
How does vitamin D deficiency result in osteomalacia/rickets?
Vitamin D responsible for increasing intestinal absorption of Ca2+
Low vitamin D->lose Ca2+ you would be getting from GI tract
285
How does renal failure/CKD cause osteomalacia/rickets?
Kidneys responsble for converting 25-hydroxyvitamin D->1,25-dihydroxyvitamin D, so causes a decrease in active D3
286
How does liver failure cause osteomalacia/rickets?
Liver responsible for cholecalciferol->25-hydroxyvitaminD, so decrease in hydroxyvitamin Dand therefore active D3
287
How can anticonvulsant drugs result in osteomalacia/rickets?
Increase CY-450 metabolism of vitamin D
288
Describe the symptoms of osteomalacia
Fractures
Proximal weakness and difficulties with weight bearing
289
Describe the symptoms of rickets
Skeletal deformities
Knocked knees and bowed legs
Wide epiphyses
290
How is osteomalacia diagnosed?
BM biopsy->incomplete mineralisation
Bloods: hypocalcaemia, high PTH, low 25(OH)D
Xray-Looser's zones (defective mineralisation)
291
Describe the treatment for osteomalacia
Vitamin D replacement(calcitrol) and increase dietary intake (D3 tablets, eggs
292
What would you expect on a BM biopsy in a patient with osteomalacia?
Incomplete mineralisation
293
What would you expect in the bloods of a patient with osteomalacia?
Hypocalcaemia
High PTH
Low 25(OH)D
294
Why would you expect high PTH in a patient with osteomalacia?
Secondary to low Ca2+
295
What would you expect on an xray of a patient with osteomalacia?
Looser's zones: defective mineralisation
296
What is Paget's disease also called?
Osteitis deformans
297
What is Paget's disease?
Focal disorder of bone remodelling
Areas of patchy bone due to improper osteoblast/osteoclast action->areas of sclerosis and lysis
298
What group is most commonly affected by paget's disease/
Females, >40
299
What is the most common cause of Paget's disease?
Idiopathic
300
Describe the signs and symtpoms of Paget's
Bone pain
Bone changes-> bowed tibia and skull
Neurological symptoms-> nerve compression of CN8-deafness
Hydrocephalus due to sylvian aquaduct blockage
301
How is Paget's disease diagnosed?
Xray: osteoporosis circumscripta
Cotton wool skull(areas of lysis and sclerosis)
High ALP
Urinary hydroxyproline high
302
Describe the treatment for Paget's disease
Bisphpsphonates
NSAIDs for pain relief
303
What is urinary hydroxyproline?
Protein consituent of bone collagen
304
What can be useful for monitoring Paget's disease progression?
Urine hydroxyproline
305
Name 2 neurological complications of Paget's disease
Deafness->compression of CN8
Hydrocephalus->compression of sylvian aqueduct
