Week 11 Flashcards

Question

When might interventional radiology be indicated in MSK disease?

Answer 1

Chronic multisystem autoimmune disease Hallmark is synovitis affecting any synovial joint More common in females, clusters in families and at high risk if 1st degree relative affected Genetic factors and smoking influence aetiology, as well as infection (?) Synovitis- immune cells invading an acellular synovium in the form of a pannus (hyperplastic invasive tissue leading to cartilage breakdown, erosions and reduced function)

Answer 2

Synovitis – any synovial joint Symmetrical Small jts hands and feet early on; shoulder/hip at onset rare MCPs/PIPs/wrists Inflammatory – pain, erythema, swelling, EMS Tenosynovitis, bursitis, CTS Consitutional sx: fatigue, weakness, low grade fever, weight loss, anorexia ``` Extra-articular features: Respiratory Cardiac Dermatological Ophthalmic Neurological Haematological ```

Answer 3

``` OA SLE/other connective tissue disease PMR Psoriatic arthropathy Sponyloarthropathies Reactive arthritis Sarcoid CPPD (calcium pyrophosphate) Lyme’s ```

Answer 4

FBC U+Es LFTs ESR/CRP RF- not diagnostic, but part of assessment ACPA- prognostic indicator and picks ups some RF-ve (ANA)

Answer 5

Symptomatic - NSAIDs, Analgesia etc Disease Modifying (DMARDs) - Glucocorticoids (oral, IA, IM) - MTX/SASP/LEF/Gold/HCQ - MTX: dihydrofolate reductase inhibitor, anti-inflammatory, SEs GI, hair, skin and rashes more serious lungs, liver, BM. Pregnancy is total contraindication - SASP: serious BM Sesames, safe in pregnancy - Biologics (anti-TNF, anti-CD20, anti-IL6, etc)

Answer 6

Anti-TNF Etanercept, infliximab, adalimumab, golimumab, certolizumab TB, Infection risk, MS, CHF Anti-CD20 Rituximab Infection, PML, Hypogammaglobulinaemia Anti-IL6 Tocilizumab Minimal CRP, infections, high lipids, CTLA4-Ig Abatcept Infections, (JAK inhibitors) Tofacitinib and others e.g. Baricitinib High lipids, infections esp VZV, reduced CRP SEs: High rate of infections (esp first 6 months)- TB, VZV, opportunistic infections (listeria, salmonella) Should be vaccinated against influenza and pneumococcus annually- avoid live vaccines

Answer 7

Definition: Multi-system autoimmune disease in which autoantibodies are made against auto antigens. Immune pathology results from polyclonal B cell secretion of autoantibodies causing tissue damage by immune complex formation and deposition, complement activation and other direct effects. Presentation: Remitting and relapsing illness of variable presentation. Typically presents with malaise, fatigue, myalgia and fever. Specific features are found in SLICC criteria

Answer 8

Immunology: >95% are ANA positive, high double stranded DNA (highly specific but 60% sensitive) With 4 or more diagnostic criteria and at least 1 immune feature 1. Malar rash 2. Discoid rash 3. Photosensitivity 4. Oral ulcers 5. Non-erosive arthritis 6. Serositis/pleuritis 7. Renal disorder 8. CNS disorder 9. Haematological disorder 10. Immunological disorder; anti-DsDNA antibody, anti-Sm antibody, antiphospholipid antibody 11. ANA

Answer 9

Mild Disease: Cutaneous symptoms with topical steroids, prevent rashes with high factor sunblock MSK- NSAIDs, IA/IM steroid, low dose oral prednisolone, HCQ ± MTX Serositis- NSAIDs, MTX Moderate disease: treat as mild disease plus: - oral prednisolone - MTX, Aza, MMF, cyclosporine - belimumab - rituximab in refractory disease Severe disease: - High dose steroid - DMARDs - B cell therapy - Cyclophosphamide - IVIg - Plasmapheresis

Answer 10

Chronic inflammatory autoimmune disease associated with CTD. There is lymphocytic infiltration of exocrine glands, especially lacrimal and salivary Decreased tear production and salivation, parotid swelling Vaginal dryness, dyspareunia, dry cough, dysphagia Measure conjunctival dryness Treat sicca symptoms

Answer 11

Can be limited cutaneous or diffuse. Limited- calcinosis, Raynaud's, oesophageal and gut dysmobility, sclerodactyly and telangiactasia. Pulmonary hypertension is common Diffuse: whole body, early organ fibrosis: lung, cardiac, GI and renal Management: no cure, immunosuppressive regimens; IV cyclophosphamide in organ involvement or progressive skin conditions

Answer 12

Insidious onset of progressive symmetrical proximal muscle weakness and auto-immune mediated striated muscle inflammation associated with myalgia and arthralgia Myositis may be paraneoplastic, commonly from lung, pancreatic, ovarian or bowel malignancy Management: - screen for malignancy - start prednisolone - immunosuppressives

Answer 13

See summary sheets for diagram Large vessel vasculitis - giant cell arteritis Medium vessel vasculitis - polyarteritis nodosa Immune complex small vessel vasculitis ANCA-associated small vessel vasculitis - microscopic polyangiits - granulomatosis with polyangitis - eosinophilic granulomatosis with polyangiitis

Answer 14

- Thickened non-pulsatile temporal artery - Pain in upper legs and arms - Sudden blindness - Jaw claudication - Rarely, coronary or large-vessel involvement

Answer 15

GwP - ENT symptoms such as nose bleeds and deafness - pulmonary fibrosis or haemorrhage - glomerulonephritis - neuropathy EGwP - late-onset asthma - eosinophilia in blood - rash - glomerulonephritis - peripheral neuropahty Microscopic Polyangiits - pulmonary fibrosis - ENT symptoms - rash - glomerulonephritis - peripheral neuropathy

Answer 16

Diagnosis of GCA: ``` Clinical presentation: - typical headache, age, other CFs Clinical exam findings: - temporal artery asymmetry, non-pulsatile Acute phase response: - ESR/CRP Further investigations: - temporal artery biopsy - temporal artery USS - MRI, PET CT ``` ANCA key points: MUST be done in correct clinical setting cANCA with PR3 very suggestive of GPA pANCA with strong MPO suggestive of MPA (or EGPA) Positive ANCA by indirect immunofluorescence but negative PR3/ MPO is of doubtful significance and does not support a diagnosis of AAV Not all AAV has a +ve ANCA

Answer 17

ANCA: 1. Achieve remission a. Prednisolone AND b. In severe disease i. Cyclophosphamide (PO/IV) 1. SEs: infection, cytopenia, malignancy, infertility ii. Rituximab 1. Anti-B cell biologic agent 2. As effective and safer than CPO c. In moderate disease; methotrexate or mycophenylate 2. Maintain remission a. Prevent relapse b. Lower drug toxicities c. More prolonged therapy (2+ years) d. Use azathioprine or methotrexate GCA: Maintain prednisolone 60mg for 1 month Taper to 15mg by 12 weeks. Aim to discontinue corticosteroids by 12- 18 months. Corticosteroid sparing therapy in patients with disease relapse on steroid sparing Mycophenolate Mofetil Methotrexate Tocilizumab (anti-Il-6)

Answer 18

``` MoA: folate antagonism leading to impaired DNA synthesis and cell replication in chemotherapy More subtle MoA in immunosuppression: - adhesion molecules - cytokines - eicosanoids and MMPs - methyl donors - adenosine signalling ``` Indications: - rheumatological disease: - RA - psoriasis or psoriatic arthritis - steroid sparing agent in giant cell arteritis SEs: - GI - N,D+V - hepatitis - stomatitis - Haematological - leukopenia - Others: - frequent infections - pulmonary fibrosis

Answer 19

MoA: - converted into a nucleoside analogue in cells - incorporated into DNA and RNA leading to termination of nucleic acid strands - cell growth and metabolism halts - preferential action in lymphocytes as other cells have purine salvage pathway - given at too low a dose to prevent immune response through cytotoxic effect so other mechanisms must be in play - evidence that inhibits T-cell co-stimulation through interference with CD28 Indications: - most commonly used for inflammatory bowel disease - other severe autoimmune diseases - myasthenia gravis - eczema SEs: - GI; NDV, hepatitis and cholestasis - haematological; leukopenia and thrombocytopenia - frequent infections - can accumulate in 0.2-0.6% who lack TPMT enzyme causing severe toxicity

Answer 20

MoA - small molecule inhibitor of calcineurin - effect of inhibiting signal transduction from the activated TCR complex - profound inhibition of T-cell activation Indications - usually given for organ transplantation; liver, kidney, heart/lung - sometimes used for inflammatory conditions - can be used topically to skin/eye SEs: - nephrotoxicity - hypertension - hepatotoxicity - anorexia and lethargy - hirsutism - parasthesia

Answer 21

TNF inhibitors - Increased risk of TB, particularly disseminated TB - Need to screen for latent TB before prescribing - Also increased risk of salmonella and listeria Rituximab (anti CD20) - Generalised increased risk of serious infection - High risk of hepatitis B reactivation - Need to screen and prophylaxis if necessary Abatacept (anti-CD86) Increased risk of pneumonia and respiratory tract infection. Increased risk of TB but less than TNF blockade. Anti-IL-1 therapy Increased risk of respiratory tract infection and pneumonia. SEs: Hypersensitivity reactions Infusion reactions Mild gastrointestinal toxicity

Answer 22

- onset at any age - variable onset, may be acute - morning stiffness lasting <30 mins - exercise may worsen pain - often improves with rest - may improve overnight - generally worsens with movement or prolonged standing - most common cause is lumbar strain/sprain - examination aim is to exclude other pathologies

Answer 23

Symptoms: - new onset age <16 or >50 - following significant trauma - previous malignancy - systemic=fevers/rigor, general malaise, weight loss - previous steroid use - IV drug abuse, HIV or immunosuppressed - recent significant infection - urinary retention - non-mechanical pain (worse at rest/"night pain") - thoracic spine pain Signs: - saddle anaesthia - reduced anal tone - hip or knee weakness - generalised neurological deficit - progressive spinal deformity

Answer 24

Radiculopathy: - may be acute, increase cough - typically leg > back pain, also known as sciatica - leg pain = dermatomal distribution - straight leg raising test +ve - reduced reflexes - most resolve spontaneously within 12 weeks - wait with investigations -> MRI (x-ray) - <10% need surgery (helps leg, not back pain)

Answer 25

- usually <40 years - insidious onset - morning stiffness lasting >30 mins - exercise improves pain/stiffness - no improvement with rest - may wake during second half of night Symptoms in axSpA - fatigue - arthritis in other joints (hip/knees) - enthesitis; achilles tendon, plantar fasciitis - extra-articular inflammation; uveitis, psoriasis, IBD, other (heart/lungs/osteoP) - FHx of extra-articular arthritis

Answer 26

Spondylolisthesis: slip of one vertebra onto the one below; pain may radiate to posterior thigh and increases with extension, only needs surgery if severe Spondylosis: generalised degeneration of vertebral discs Spinal stenosis: anatomical narrowing of spinal canna, congenital and/or degenerative - often presents with claudication in legs/calves - surgery is generally higher risk than no treatment

Answer 27

The pathogenesis of OA involves a degradation of cartilage and remodelling of bone due to an active response of chondrocytes in the articular cartilage and the inflammatory cells in the surrounding tissues. The release of enzymes from these cells break down collagen and proteoglycans, destroying the articular cartilage. The exposure of the underlying subchondral bone results in sclerosis, followed by reactive remodelling changes that lead to the formation of osteophytes and bone cysts. Patients typically present with symptoms that are insidious, chronic, and gradually worsening. Clinical features include pain and stiffness in joints, worsened with activity* and relieved by rest. Prolonged OA results in deformity and a reduced range of movement. Signs of osteoarthritis include localised swelling (e.g. Heberden’s nodes on the DIPJs, Fig. 2) or joint effusion, crepitus, muscle wasting (secondary to disuse), joint malalignment, fixed deformity, and a reduced range of movement.

Answer 28

Management Stage 1- minimal treatment, lifestyle changes Stage 2- physiotherapy, different non-pharmacological therapies, exercise and strength training, braces/knee supports and analgesia as required Stage 3- NSAIDs, intra-articular injections of steroids, may consider prophylactic joint realignment surgery Stage 4- surgery; realignment, replacement, excision, fusion Surgery Take away diseased surface Replace with artificial material that sticks to bone Can fix with uncemeted or cemented, hybrid or reverse hybrid Post Op Mobilisation, discharge, home exercise program

Answer 29

Outcomes 97% happy with surgery General complications- DVT/PE, infection, neurovascular damage, swelling, stiffness, non/partial relief/recurrence Anaesthetic problems Specific hip- dislocation, fracture, leg length, discrepancy, hip noise, implant breakage/failure

Answer 30

Presence of objective arthritis for at least 6 weeks under the age of 16 Most common chronic arthropathy of children Includes several subtypes: - Oligoarticular - presents in one knee, though can be polyarthropathy - Polyarticular - fusion of bones in spine/neck - Systemic onset - systemic symptoms such as fever (high at night and settles in morning), pericarditis, serositis/pleurisy, organomegaly - Psoriatic arthritis - FHx of psoriasis/inflammatory conditions - may have prolonged cradle cap Diagnosis is made clinically; lab and radiography provide prognostic and classification information but not diagnostic Around 10-20% present with asymptomatic uveitis, so must undergo regular ophthalmological examination Treatment with methotrexate and biologics

Answer 31

``` Kawasaki disease: Kawasaki disease (KD) is an acute, febrile, self-limiting, systemic vasculitis of unknown origin that almost exclusively affects young children ``` o Aneurysm formation in medium to large sized arteries o Coronary arteries- myocardial infarction can also have in axillary, iliac and popliteal arteries o Aneurysm formation, high fever, miserable, aseptic meningitis, red eyes and conjunctivitis, morbilliform rash, red, peeling skin o IVIG treatment Henoch-Schonlein purpura: Henoch-Schonlein purpura (HSP) is the most common vasculitis of childhood and affects the small vessels. HSP is characterised by the classic tetrad of rash, abdominal pain, arthritis/arthralgia, and glomerulonephritis o Palpable purpura, tends to be distal and o Arthritis in same joints the rash is over

Week 11 Flashcards

(58 cards)