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Flashcards in Rheumatology Deck (132)
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1

What is rheumatoid arthritis?

Chronic systemic inflammatory disorder of unknown cause with characteristic joint involvement

2

Diagnostic criteria for rheumatoid arthritis?

4/7 of:

morning stiffness >1 hour
Arthritis of 3 or more joints
Arthritis of hand joints
Symmetrical arthritis
Rheumatoid nodules
Rheumatoid factor positive
X-ray changes

3

Clinical features of rheumatoid arthritis - hands?

Symmetrical poly arthritis sparing the DIPS

Ulnar deviation and prominent ulnar styloid
Swan neck deformity
Boutonniere deformity
Z-thumb
Subluxation at MCP's and wrist

4

Clinical features of rheumatoid - not hands?

Atlanto-axial instability due to weakening of transverse ligament holding odontoid of C2 against arch of C1
- diagnosed when odontoid > 3mm from anterior arch

Anaemia of chronic disease

Scleritis

Interstitial fibrosis, pulmonary nodules

5

X-ray changes in rheumatoid?

BENJ

Bone cysts
Erosions
Narrowing of joint space
Juxta-articular osteoporosis

6

What markers should you look for in rheumatoid arthritis?

Rheumatoid factor = 70%
- IgM to Fc of IgG

Anti-CCP, much more specific but less sensitive

7

Management of Rheumatoid arthritis?

Conservative = info/counselling, OT.

Medical:
Analgesics and NSAIDs

1st line = Methotrexate 7.5mg PO once weekly + 1 other DMARD e.g. Sulfasalazine

2nd line = biologicals, only if you have tried two DMARDs one being methotrexate, and DAS score >5.1 twice

Steroids used for bridging when starting DMARDs + for systemic flair ups

8

Examples of DMARDs and their SE's in rheumatoid arhtirits?

Methotrexate = Pulmonary fibrosis, BM suppression

Sulfasalzine = reduced sperm, Heinz body anaemia, BM supression

Leflunomide = HTN and interstitial lung disease

Hydroxychloroquinine = Rash, retinopathy

9

Examples of biologicals and their SE's in rheumatoid arthritis?

Anti-TNF e.g. Etanercept and infliximab = BM suppression and hair loss

Anti-B cell e.g. Rituximab = Cytokine release syndrome, infusion reaction

Anti-IL6 e.g. tocilizumab = BM suppression and mouth ulcers

CTLA4-Ig fusion e.g. Abatacept = GI and BM suppression

10

Monitoring in rheumatoid?

LFT's and FBCs every 1-2 months early doors then every 3-4 months once stable

DAS score = disease activity score

11

What is osteoarthritis?

The degenerative loss of articular cartilage

12

Clinical features of osteoarthritis?

Pain on activity and worse at end of day / night

morning stiffness <45 minutes

Functional limitation

Affects weight bearing joints = knees, hips

Hands DIP

Spine lumbar affected most

13

X-ray changes in OA?

Loss of joint spaces
Osteophytes
Subchondral cysts
Sclerosis

14

Management of osteoarthritis?

Conservative = weight control, exercise and appropriate orthotics

Medical = analgesia:
1st line = paracetamol
Then NSAIDs
Then Opioids

Intra-articular steroid injections

Surgery = Replace joints

15

What is septic arthritis?

Inflammation of the joint due to the presence an MO

16

Common MO's in septic arthritis?

Staph aureus = 60%
S. Pyogenes = 15%
N. Gonnorhoea in sexually active patients

17

Diagnosis of septic arthritis?

Joint aspiration prior to antibiotics:
Gram stain
WCC > 50,000/mm3
+ve culture

18

Management of septic arthritis?

Local guidelines = IV for two weeks or until improvement then four weeks orally

No RF's for atypical = Vancomycin 1g IV BD for two weeks, then clindamycin

If high risk G-ve in elderly / UTI / recent abdo surgery = Ceftriaxone 2g IV OD for 2 weeks, then cefalexin

19

What is gout?

Disorder of purine metabolism, characterised by hyperuricaemia and the deposition of monosodium rate crystals in joints

20

Precipitating factors for acute gout?

Starvation or alcohol excess

Surgery

drugs = Thiazides, furosemide, high dose salicylates

Reduced excretion in renal failure

21

What does synovial fluid show in gout?

-vely birefringent needle shaped crystals

22

Management of acute gout?

NSAIDS e.g.naproxen 500mg PO BD 2 weeks

2nd line = prednisolone

3rd line = colchicine
- useful if contraindication to NSAIDS e.g. GI bleed

23

Prophylaxis for gout?

Conservative = weight loss, dietary modifications and avoid alcohol

Medical prophylaxis if recurrent attacks, tophi and erosive disease

Xanthine oxidase inhibitor = allopurinol 100mg PO OD
- don't start within 2 weeks of attack

2nd line = Probenecid = increased renal excretion

Refractory = pegolticase

24

What is pseudogout?

Deposition of calcium pyrophosphate crystals in joint

25

Pseudogout associations?

4 H's

Hypoparathyroid
Haemochromatosis
Hypomagnesaemia
Hypophosphatia

26

Synovial fluid findings in pseudogout?

+vely birefringent rhomboid crystals

27

X-ray change in gout vs pseudogout?

Gout = punched out erosions

Pseudogout = linear calcium deposition in cartilage

28

Management of pseudogout?

Accessible joints = IA corticosteroids

Inaccessible = Colchicine + NSAIDs

If refractory = systemic corticosteroids

29

What is a seronegative spondyloarthritis

Any joint disease of the vertebral column that is seronegative i.e. RF -ve

30

Types of seronegative spondyloarthritis?

Anyklosing spondylitis = HLA-B27

Psoriatic arthritis

Reactive arthritis

Enteropathic arthritis