Rheumatology Flashcards
Name 4 systemic features of Marfan’s syndrome. (4)
Clue: MARFANS
Mitral prolapse Aortic dissection Regurg of aortic valve Fingers long Arm span>height Nasal voice (high arched palate) Sternal excavation
What is arthralgia? (1)
joint pains when the joint appears normal on examination
Describe the synovial membrane. (3)
Sterile, vascularised connective tissue without a basement membrane.
Contains type A cells (derived from monocytes) and type B cells (produce synovial fluid).
Synovial fluid contains hyaluronic acid.
What is the enthesis? 1)
Point on the bone at which ligaments and tendons insert.
What does hyaline cartilage consist of? (3)
Water, type 2 collagen and proteoglycans.
Name 3 differentials for polyarticular arthritis in a young adult? (3)
Males: reactive arthritis, ankylosing spondylitis
Both: Psoriatic arthropathy, Enteropathic arthropathy, Lyme disease, HIV
Females: SLE, RA, Sjogren’s
Name 3 differentials for polyarticular arthritis in a middle aged adult? (3)
Male: gout
Both: OA, Lyme disease, HIV
Female: RA
Name 3 differentials for polyarticular arthritis in an older adult? (3)
Both: OA, PM, Pseudogout
Name 3 differentials for a large joint monoarthritis. (3)
OA, gout, pseudogout, trauma, septic arthritis, disseminated gonnococcal infectino.
Less common: RA, spondyloarthopathies, TB, haemarthrosis.
What is arthroscopy? (1)
Direct means of visualising the inside of a joint, particularly knee and shoulder.
name 3 things that synovial fluid is analysed for? (3)
Colour, cell count, culture, glucose, viscosity, protein
How can golfer’s elbow and tennis elbow be distinguished? (2)
Tennis is lateral epicondyle tenderness caused by insertion of wrist extensor tendon.
Golfers is medial epicondyle tenderness caused by wrist flexor tendon.
Milo has back pain.
Name 3 red flags for back pain. (3)
Age 50 years Thoracic pain Constant pain without relief History of TB, HIV, carcinoma or steroid use Systemically unwell: ever, weight loss Localised bone tenderness Bilateral signs in the legs Neurological deficit involving more than on e root level Bladder, bowel or sexual dysfunction
Karl has lumbar back pain.
What are the differences in the history and examination that may distinguish between a mechanical and an inflammatory cause? (2)
Name 2 mechanical causes of lumbar pain? (2)
Name 2 inflammatory causes of lumbar pain. (2)
Mechanical: sudden onset, pain worse in evening, no morning stiffness, pain aggravated by exercise.
Causes: lumbar disc prolapse, spondylolisthesis, OA, fractures, spinal stenosis.
Inflammatory: gradual onset, morning stiffness, pain relieved by exercise, pain worst in the morning.
Ankylosing spondylitis, Infection.
Name 2 serious causes of lumbar back pain. (2)
Metastases Multiple myeloma TB osteomyelitis Bacterial osteomyelitis Spinal and root canal stenosis
Why is lumbar disc prolapse more a disease of younger people (20-40 years)? (1)
The inter vertebral discs degenerate with age and so in the elderly is no longer capable of prolapse
What are the most likely causes of sciatica in younger patients (1) and in older patients? (1)
Younger: Lumbar disc prolapse
Older: Osteophytes int he lateral recess of spinal canal causing compression.
Ralph has an S1 root lesion caused by a lumbar disc prolapse. Describe the symptoms he may be experiencing and signs on examination. (3)
Pain: from buttock, down back of thigh and leg to ankle and foot
Sensory: loss on sole of foot and posterior calf
Motor: loss of plantar flexion of ankle and toes
Reflex: loss of ankle jerk
Pain on straight leg raising test.
Troy has an L5 nerve root lesion caused by a lumbar disc prolapse. Describe the symptoms he may be experiencing and signs on examination. (3)
Pain: from buttock, to lateral aspect of leg and dorsum of foot
Sensory: loss of dorsum of foot and anterolateral aspect of lower leg
Motor: loss of dorsiflexion of foot and toes
Reflex: none affected
Yves has an L4 nerve root lesion caused by a lumbar disc prolapse. Describe the symptoms he may be experiencing and signs on examination. (3)
Pain: on lateral aspect of thigh to medial calf
Sensory: loss of medial aspect of calf and shin
Motor: weakness of dorsiflexion and inversion of ankle, and extension of knee
Reflex: loss of knee jerk
Positive femoral stretch test
What is spondylolisthesis? (1)
Which level is most commonly affected? (1)
Characterised by slipping forward of one vertebra onto another, most commonly at L4/5.
What is spinal stenosis? (2)
Name 2 causes. (2)
Narrowing of the lower spinal canal compresses cauda equina resulting in back and buttock pain, particularly after exercise.
Disc prolapse, degenerative osteophyte formation, tumour, congenital narrowing.
What is cervical spondylosis? (2)
Chronic cervical disc disease (in association with OA) causes stiffness and pain of the neck, with or without radiation to the arm.
Name 3 risk factors for developing OA. (3)
Females FH Obesity Fracture through a joint Congenital joint dysplasias Pre-existing joint damage of any cause Occupation (famers and labourers) Repetitive use (associated with some sports)
What is the difference between primary and secondary OA? (2)
Primary OA occurs with no obvious predisposing factor
Secondary OA occurs in a damaged joint or congenitally abnormal joint.
What are osteophytes? (1)
Calcified cartilaginous growths at the margins of joints caused by repair attempts.
Name the 4 changes on x-ray that suggest OA. (4)
Narrowing of joint space
Osteophyte formation
Subchondral sclerosis
Subchondral cysts
Name 3 joints most commonly affected by OA. (3)
Distal interphalangeal joints First Carpometocarpal joint First Metatarsophalangeal joint Vertebrae Hips Knees
(Elbows, wrists and ankles are rarely affected)
What are Heberden’s and Bouchard’s nodes? (2)
Heberden’s nodes: bony swellings at the DIP’s
Bouchard’s nodes: bony swellings at the PIP’s.
Florence has severe OA of the knee.
Name 4 management options for her. (4)
Conservative: - weight loss - physiotherapy: local strengthening and aerobic exercise - Heat or ice packs - Contralateral sided walking stick - Joint brace or support - Acupuncture Medical: - Paracetamol with weak opioid if necessary - Topical NSAIDs - Oral NSAIDs or Coxibs for short term - Intra-articular steroid injections Surgical: - Total knee replacement
How would an FBC and an ESR result differ in John who has OA and Jackie who has RA? (2)
OA: normal
RA: normocytic normochromic anaemia, raised ESR/CRP
Name 3 risk factors for developing RA. (3)
Women before menopause.
FH
HLA-DR4
define RA. (2)
Chronic systemic autoimmune disorder causing a symmetrical polyarthritis
Describe the pathology of RA. (3)
RA is characterised by synovitis, with thickening of the synovial lining and infiltration by inflammatory cells.
There is generation of new synovial blood vessels and activated endothelial cells produce adhesion molecules (e.g. VCAM-1) which expedite extravasation of leucocytes into synovium.
Synovium proliferates and grows out over surface of cartilage producing tumour-like mass called pannus.
pannus destroys articular cartilage and subchondral bone causing bony erosions.
Describe some of the clinical articular features seen by patients with RA. (4)
Gradual onset of pain
Early morning stiffness lasting over 30 mins
Swelling in small joints of hands and feet
Spindling of fingers (swollen PIPs, unaffected DIPs)
Joint instability
Subluxation
Deformity of joints
Joint effusions
Wasting of muscles around affected joints
Ulnar deviation
Boutonniere deformity
Swan-neck deformity
Z shaped thumb
Name 4 non-articular manifestations of RA. (4)
- Systemic: fever, fatigue, weight loss, greater risk of infection
- Eyes: Sjogren’s, scleritis
- Neuro: carpal tunnel, atlanto-axial subluxation, cord compression, polyneuropathy, mononuritis multiplex
- Haem: Lymphadenopathy, Felty’s syndrome, anaemia, thrombocytosis
- Pulm: pleural effusion, lung fibrosis, rheumatoid nodules in pleura or lung, rheumatoid pneumoconiosis, obliterative bronchiolitis
- CV: pericarditis, pericardial effusion, pericardial rheumatoid nodules, Raynaud’s syndrome
- Kidneys: amyloidosis, analgesic nephropathy
- Vasculitis: leg ulcers, nail fold infarcts, gangrene of fingers and toes.
- Periarticular: osteoporosis, bursitis, tenosynovitis, muscle wasting, subcut nodules over pressure points.
What is Felty’s syndrome? (1)
Triad of RA, Splenomegaly and neutropenia.
How is a diagnosis of RA made? (3)
Clinically: symmetrical peripheral polyarthritis with morning stiffness.
Bloods:
-FBC and ESR: normocytic, normochromic anaemia and thrombocytosis; ESR and CRP raised.
-Autoantibodies: anti-cyclic citrullinated peptide, Rf
Radiology:
-X-ray: soft tissue swelling in early disease and later joint narrowing, erosions at joint margins and porosis of periarticular bone and cysts.
What result would you expect in a analysis of synovial fluid? (1)
Uncomplicated disease: Synovial fluid is sterile with high neutrophil count.
Louise is a 27 year old female who has a symmetrical polyarthritis.
You suspect RA due to morning stiffness over 30 minutes.
Name 2 other differentials of a symmetrical polyarthritis. (2)
Symmetrical seronegative spondyloarthropathies
Form of Psoriatic arthritis (arthritis mutilans)
SLE (joints normal on examination)
Acute viral polyarthritis (usually recovered by 6 weeks)
Julie is a 54 year old smoker who has RA.
Name 3 healthcare professionals who should be involved in her care. (3)
Describe management options for her. (3)
Rheumatologists, Occupational health, Physiotherapists, Smoking cessation team, Orthopaedic surgeons.
- Analgesia: NSAIDs, Coxibs, Paracetamol/dihydrocodeine
- Steroids: suppress disease activity but large doses required, and long term is not advised.
- DMARDs: inhibit inflammatory cytokines and used early to reduce disease inflammation. Also slows joint erosion, irreversible damage and reduces CV risk.
Sulfasalazine (in mild-moderate disease & desire for family), Methotrexate (more active disease, teratogenic, do not use 3 months before conception), Leflunomide (blocks T cell proliferation) - Biologicals: TNF-a inhibitors (infliximab, etanercept); lysis of B cells (rituximab); IL-6 receptor antibody (tocilizumab)
When can biological agents be tried in a patient with RA? (2)
Active disease despite adequate treatment with at least 2 DAMRDs, including methotrexate.
TNF-a inhibitors are the first line and slow or halt erosion formation in up to 70% of patients.
Why is regular monitoring of FBC undertaken in DMARD therapy? (1)
Myelosuppression (anaemia, thrombocytopenia and neutropenia)
Roger has been told he has a seronegative spondyloarthropy and would like to know what clinical features are common within this group of diseases.
Name 3. (3)
- Predilection for axial (sacra and sacroiliac) inflammation.
- Asymmetrical peripheral arthritis
- Absence of Rf
- Inflammation of the enthesis
- Strong associated with HLA-B27
Tom is a 24 year old man who attends GP surgery with increasing pain and morning stiffness in his back and buttocks, which improves with exercise but not with rest.
He has also noticed progressive restriction in the movement of his spine.
What do you suspect? (1)
What do you expect to find on inspection of the spine? (2)
Ankylosing spondylitis
- Loss of lumbar lordosis and increased kyphosis
- Limitation of lumbar spine mobility in both sagittal and frontal planes. (Spinal flexion measured by Schober test)
What is Schober test? (2)
Assessment of spinal flexion. Mark is made at L5 spinous process and 10cm above with patient erect. Normal result is >15cm on bending forward.
Name 3 seronegative spondyloarthropathies. (3)
Ankylosing spondylitis Psoriatic arthritis Reactive arthritis Post-dysenteric reactive arthritis Enteropathic arthritis (UC or Crohn's)
Name 2 non auricular features sometimes seen in patients with ankylosing spondylitis. (2)
Anterior uveitis
Aortic incompetence
Cardiac conduction defects
Apical lung fibrosis
What changes may you seen in an x-ray of ankylosing spondylitis? (2)
- Normal
- Erosion and sclerosis of margins of the sacroiliac joints
- Blurring of upper or lower vertebral rims at the thoracolumbar junction caused by enthesitis at insertion of the intervertebral ligaments.
- Syndesmophytes: enthesitis heals with new bone formation resulting in bony spurs (syndesmophytes)
- Bamboo spine: progressive calcification of interspinous ligaments and syndesmophytes.
What is the management of ankylosing spondylitis? (1)
Morning exercises to maintain posture and mobility.
Slow release NSAIDs at night for morning pain.
Methotrexate helps peripheral arthritis but not spinal disease
TNF-a blocking drugs are effective in active disease and help both spinal and peripheral arthritis.
What proportion of patients with psoriasis will develop psoriatic arthritis? (1)
20% (especially if nail disease)
Name 2 types of psoriatic arthritis. (2)
- Asymmetrical involvement of the small joints of hand
- Symmetrical seronegative polyarthritis resembling RA
- Arthritis mutilans: severe with destruction of small bones in hands and feet
- Sacroilitis: uni or bilateral
How is psoriatic arthritis treated? (2)
Analgesia and NSAIDs.
Local synovitis: intra-articular corticosteroid injections
Sever: methotrexate or TNF-a blockers
Name 2 causes of reactive arthritis. (2)
Reactive arthritis is a sterile synovitis caused by;
- GI: shigella, campylobacter, yersinia or salmonella
- STI: non-specific urethritis or cervicitis due to chlamydia
What is Reiter’s syndrome? (2)
Urethritis, reactive arthritis and conjunctivitis
What is enteropathic arthritis? (2)
Large joint mono or asymmetrical oligoarthritis occurring in 10-15% of UC/Crohn’s patients. It usually mirrors disease activity.
