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
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