Flashcards in Rheumatology Deck (132)
What is rheumatoid arthritis?
Chronic systemic inflammatory disorder of unknown cause with characteristic joint involvement
Diagnostic criteria for rheumatoid arthritis?
morning stiffness >1 hour
Arthritis of 3 or more joints
Arthritis of hand joints
Rheumatoid factor positive
Clinical features of rheumatoid arthritis - hands?
Symmetrical poly arthritis sparing the DIPS
Ulnar deviation and prominent ulnar styloid
Swan neck deformity
Subluxation at MCP's and wrist
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
Interstitial fibrosis, pulmonary nodules
X-ray changes in rheumatoid?
Narrowing of joint space
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
Management of Rheumatoid arthritis?
Conservative = info/counselling, OT.
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
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
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
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
What is osteoarthritis?
The degenerative loss of articular cartilage
Clinical features of osteoarthritis?
Pain on activity and worse at end of day / night
morning stiffness <45 minutes
Affects weight bearing joints = knees, hips
Spine lumbar affected most
X-ray changes in OA?
Loss of joint spaces
Management of osteoarthritis?
Conservative = weight control, exercise and appropriate orthotics
Medical = analgesia:
1st line = paracetamol
Intra-articular steroid injections
Surgery = Replace joints
What is septic arthritis?
Inflammation of the joint due to the presence an MO
Common MO's in septic arthritis?
Staph aureus = 60%
S. Pyogenes = 15%
N. Gonnorhoea in sexually active patients
Diagnosis of septic arthritis?
Joint aspiration prior to antibiotics:
WCC > 50,000/mm3
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
What is gout?
Disorder of purine metabolism, characterised by hyperuricaemia and the deposition of monosodium rate crystals in joints
Precipitating factors for acute gout?
Starvation or alcohol excess
drugs = Thiazides, furosemide, high dose salicylates
Reduced excretion in renal failure
What does synovial fluid show in gout?
-vely birefringent needle shaped crystals
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
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
What is pseudogout?
Deposition of calcium pyrophosphate crystals in joint
Synovial fluid findings in pseudogout?
+vely birefringent rhomboid crystals
X-ray change in gout vs pseudogout?
Gout = punched out erosions
Pseudogout = linear calcium deposition in cartilage
Management of pseudogout?
Accessible joints = IA corticosteroids
Inaccessible = Colchicine + NSAIDs
If refractory = systemic corticosteroids
What is a seronegative spondyloarthritis
Any joint disease of the vertebral column that is seronegative i.e. RF -ve