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Week 2 Flashcards

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1
Q

Potential triggers of RA

A

infections, stress, cigarette smoking

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2
Q

Clin pres of RA

A

Pain and swelling in a symmetrical fashion affecting peripheral synovial joints.
Involvement of small joints of hands and feet.
Prolonged early morning stiffness.

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3
Q

Clin signs of RA

A

PIP,MCP,wrist ,MTP synovitis.
Monoarthritis.
Tenosynovitis.
Trigger finger.
Carpal tunnel syndrome.
Palindromic rheumatism.
Systemic symptoms.
Poor grip strength.

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4
Q

Extra-articular manifestations of RA

A

Lungs-Interstitial lung disease, pleural effusion, Rheumatoid nodules.
Heart-Pericarditis, pericardial effusions.
Neurology-Peripheral neuropathy, carpal tunnel syndromes.
Peripheral Rheumatoid nodules.
Cardiovascular disease.
Arterial leg ulcers.

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5
Q

Diag of RA

A

Peripheral ,symmetrical , polyarthritis(more than 5 joints) affecting the small joints of the hands and feet.

Inflammatory markers-usually raised.

Antibody testing - rheumatoid factor, anti-CCP antibodies

Imaging - x-rays, US, MRI

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6
Q

Management of RA

A

Early recognition and diagnosis.
Care by a rheumatologist.
Early treatment with Disease Modifying Anti-rheumatic Drugs for all patients with RA.
Importance of tight control with target of remission or low disease activity.
Use of NSAIDs and steroids only as adjuncts.

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7
Q

Disease-modifying anti-rheum drugs for RA

A

Methotrexate

Sulfasalazine

Hydroxychloroquine-DOES NOT PREVENT EROSIONS.

Combination therapy with MTX,SASP and HCQ.

Leflunomide.

Steroids.

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8
Q

Risks of DMARDs (anti-rheum drugs)

A

Regular monitoring needed.

Bone marrow suppression.

Infection.

Liver function derangement.

Pneumonitis in case of methotrexate.

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9
Q

Biologic agents for RA

A

Anti-TNF - Infliximab,Etanercept,Adalimumab,
Certolizumab,Golimumab
T cell receptor blocker
B cell depletor
IL-6 blocker
JAK 2 inhibitors

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10
Q

DAS 28 scoring for RA

A

<2.6 remission
2.6-3.2 low disease activity
3.2-5.1 mod disease activity
>5.1 active disease
(if >3.2 even with 2 DMARDs -> biologic therapy)

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11
Q

Complication’s of untreated RA

A

Joint damage and deformities-swan necking,Boutonniere`s

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12
Q

Main types of osteoarthritis

A

Localised - hips, knees, finger interphalangeal joints, facet joints of lower cervical and lower lumbar spines.

Generalised - spinal or hand joints and in atleast 2 other joint regions.

Subsets incl DIP joint, thumb bases, etc

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13
Q

Clin pres of OA

A

Extremely variable.

Pain-worse with joint use.

Morning stiffness lasting less than 1 hour.

Inactivity gelling.

Instability.

Poor grip in thumb OA.

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14
Q

Clin signs of OA

A

Joint line tenderness.

Crepitus

Joint effusion

Bony swelling.

Deformity.

Limitation of motion.

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15
Q

What are Heberden’s and Bouchard’s nodes?

A

Heberden’s - squaring of finger joint
Bouchard’s - squaring of thumb

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16
Q

Diag of OA

A

No specific laboratory tests.

Radiological imaging-
Plain X-rays, US, MRI

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17
Q

Management of OA

A

Non-pharma - education, occ therapy, physio
Pharma - analgesia, local intra-art steroid injection, surgery (joint replacement)

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18
Q

Describe chronic gout

A

Chronic joint inflammation
Often diuretic associated
High serum uric acid
Tophi
May get acute attacks

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19
Q

Investigations of gout

A

Serum uric acid raised (may be normal during acute attack)
Raised inflammatory markers
Polarised microscopy of synovial fluid-also helps exclude septic arthritis.
Renal impairment (may be cause or effect)
X-rays

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20
Q

Managment of gout

A

Acute - NSAIDs, CHOLCHICINE, steroid
Preventative - (1w after acute attack)
1)Xanthine oxidase inhibitors-Allopurinol,febuxostat.
2)Uricosuric drugs-Sulfinpyrazone, probenecid,benzbromarone.

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21
Q

Prophylactic therapy with gout?

A

1) One or more attacks of gout in a year inspite of lifestyle modification.
2) Gouty tophi or chronic gouty arthritis.
3) Uric acid calculi.
4)Chronic renal impairment.
5)Heart failure where unable to stop diuretics.
6)Chemo pts with gout.

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22
Q

Management of CPPD

A

NSAIDS
Colchicine
Steroids
Rehydration.

NO PREVENTATIVE TREATMENT AVAILABLE.

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23
Q

What is hydroxyapatite?

A

“Milwaukee shoulder”
Hydroxyapatite crystal deposition in or around the joint.
Release of collagenases, serine proteinases and IL-1
Acute and rapid deterioration.
Females, 50-60 years
Treat w NSAID, inta-art steroid, physio, arthroplasty

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24
Q

Sign of soft tissue rheumatism?

A

Pain should be confined to a specific site e.g. shoulder, wrist etc
(if more generalised soft tissue pain, consider fibro)

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25
Management of soft tissue rheumatism
Clinical history and examination. X-ray - calcific tendonitis Ultrasound scans. MRI if fails to settle. Identify precipitating factors Pain control Rest and Ice compressions PT Steroid injections Surgery
26
Examples of joint hypermobility syndromes and their symptoms
Marfan’s syndrome, Ehlers Danlos syndrome Examples: Joint pains esp. after exercise/physical work. Joint stiffness. Foot and ankle pain. Neck and backache. Frequent sprains and dislocations. Thin stretchy skin.
27
What is the Beighton score?
 >10º hyperextension of the elbows Passively touch the forearm with the thumb, while flexing the wrist. Passive extension of the fingers or a 90º or more extension of the fifth finger Knees hyperextension ≥ 10º) Touching the floor with the palms of the hands when reaching down without bending the knees. Hypermobility if ≥ 4/9
28
Management of hypermobility disorders
Patient education. Physiotherapy. Analgesia as required. Surgery is NOT recommended.
29
Examples of connective tissue disease
Systemic Lupus Erythematosus Sjogrens syndrome Systemic sclerosis Dermatomyositis/Polymyositis Anti-phospholipid syndrome
30
Describe SLE
Immune system attacks cells and tissue resulting in inflammation and tissue damage
31
Management of lupus
sun protection measures hydroxychlororoquine minimise steroid use Monitor disease activity using SLEDAI score
32
Symptoms/signs of Sjogren's disease
Dry eyes-gritty feeling. Dry mouth. Dry throat Vaginal dryness. Bilateral parotid gland enlargement. Joint pains. Fatigue. Unexplained increase in dental cavities (Anti Ro, anti la, raised IgG and plasma vicosity)
33
Describe systemic sclerosis
Multisystem autoimmune disease characterised by vasculopathy, autoimmunity and fibrosis Classic symptoms: - Raynaud’s, Skin thickening, Difficulty swallowing, GORD, telangiectasia, calcinosis, +/-SOB
34
Red flags in systemic sclerosis
Onset of Raynaud’s in mid adulthood Raynaud’s and SOB Raynaud’s and Telangiectasia Digital ulcers/ischaemia Skin tightness/loss of dexterity of hands
35
What are the most significant antibodies in systemic sclerosis?
Anticentromere Antitopoisomerase Anti-RNA polymerase
36
MSK changes in systemic sclerosis
Sclerodactyly Digital ischaemia Myositis
37
What is Raynaud's phenomenon?
Numb/cold extremities in response to stress Triphasic: Blanching – as above (white) Acrocyanosis (purple/blue) Reactive Hyperaemia (redness)
38
Treatment of Raynaud's/vascuolpathy
Ca blockers (Nifedipine) Others (fluoxetine, ARBs, nitrates) PDE-5 inhibitor Prostacyclcin infusion Endothelin receptor antagonist
39
Which condition has incr risk with anticentromere?
Pulmonary HT
40
Describe spondyloarhtropathy
Family of inflammatory arthritides characterized by involvement of both the spine and joints, principally in genetically predisposed (HLA B27 positive) individuals
41
4 groups of spondyloarthropathy
Ankylosing Spondylitis Psoriatic Arthritis Reactive Arthritis Enteropathic Arthritis
42
Features of all spondyloarthropathyies?
Rheum: Sacroiliac and spinal involvement Enthesitis: inflammation at insertion of tendons into bones Inflam arthritis Dactylitis (“sausage” digits) Extra-art: Ocular inflam Mucocutaneous lesions Aortic incompetenc/heart block No rheum nodules
43
Describe ankylosing spondylitis
Predominantly spine, teens/adults, men Diag: with New York Criteria Clin pres: back pain, enthesitis, periph arthritis, extra art features
44
Why is AS known as A disease?
Axial Arthritis Anterior Uveitis Aortic Regurgitation Apical fibrosis Amyloidosis/ Ig A Nephropathy Achilles tendinitis PlAntar Fasciitis
45
Clin signs of AS
Exam: Tragus/occiput to wall, Chest expansion, Modified Schober test Bloods: inflam perameters, HLA B27 X-ray: sacroiliitis, syndesmophytes, "bamboo" spine (fusion of vert)
46
Spinal differences in AS vs OA
AS: Bone density- normal in early disease, reduced in late disease Shiny corners Flowing Syndesmophytes Fusion (Bamboo spine) OA: Normal bone density Reduced Joint space Subchondral sclerosis Subchondral cyst formation Osteophyte formation Associated with neural foraminal narrowing
47
Describe psoriatic arthritis
Inflammatory arthritis associated with psoriasis, but 10 -15% of patients can have PsA without psoriasis
48
5 subgroups of PsA
1. Confined to distal interphalangeal joints (DIP) hands/feet 2. Symmetric polyarthritis (similar to RA) 3. Spondylitis (spine involvement) with or without peripheral joint involvement 4. Asymmetric oligoarthritis with dactylitis 5. Arthritis mutilans
49
Clin pres of PsA
Nail involvement (Pitting, onycholysis) Dactylitis Enthesitis: Achilles tendinitis, Plantar fasciitis Extra articular features (eye disease)
50
Diag of PsA
Bloods: Inflammatory parameters (raised), Negative Rheum Factor X-ray: Marginal erosions and “whiskering”, “Pencil in cup” deformity, Osteolysis, Enthesitis
51
Describe reactive arthritis
Infection induced systemic illness characterized primarily by an inflammatory synovitis from which viable microorganisms cannot be cultured (symp 1-4w after infection) Most common infections: STI (chlamydia), enterogenic (salmonella, shigella) HLA B27 pos
52
Describe Reiter's syndrome
Form of reactive arth Triad of: Urethritis, Conjuntivitis/Uveitis/Iritis, Arthritis
53
Describe enteropathic arthritis
Associated with inflammatory bowel disease eg. Crohn’s, Ulcerative colitis- 9-20% patients with inflammatory bowel disease Several joints affected, worsening of symptoms during IBD flare-up
54
Clin pres of enteropathic arthritis
GI (loose, watery stool with mucous and blood) Systemic (Weight loss, low grade fever) Eye involvement (uveitis) Skin involvement (pyoderma gangrenosum) Enthesitis (Archilles tendonitis, plantar fasciitis, lateral epicondylitis) Oral (apthous ulcers)
55
Investigations for enteropathic arthritis
Upper and lower GI endoscopy with biopsy showing ulceration/ colitis Joint aspirate- no organisms or crystals Raised inflammatory markers- CRP, PV X ray/ MRI showing sacroiliitis USS showing synovitis/ tenosynovitis
56
Management of spondyloarthropathies
Pharma: NSAIDs, corticosteroids, TS eyedrops, DMARDs, anti-TNF if severe/unresponsive, secukinumab (PsA, AS)
56
Management of spondyloarthropathies
Pharma: NSAIDs, corticosteroids, TS eyedrops, DMARDs, anti-TNF if severe/unresponsive, secukinumab (PsA, AS) Non-pharma: physio, OT, orthotics/chiropody
57
4 key features of spondyloarthropathies
Associated with HLA B27 Affect Spine/Joints Enthesitis Extra articular features
58
Mono, oligo vs polyarthritis?
Mono - one joint, gout, septic arth Oligo - 1-4 joint, serum neg spondylo (PsA, reactive) Poly - >4 joint, (OA, RA)
59
How can we characterise 3 main muscle diseases?
Inflammatory myopathies - weakness Polymyalgia Rheumatica - pain and stiffness Fibromyalgia - pain and fatigue
60
Describe myopathy
Musc fibres don't function properly -> muscle weakness
60
Describe myopathy
Musc fibres don't function properly -> muscle weakness
61
Describe inflammatory myopathies
Polymyositis and Dermatomyositis AI, female, 40-50y
62
Clin pres of inflammatory myopathies
Musc weakness Insidious onset, worsens over months Symmetrical proximal msucs Spec problems e.g. brushing hair Myalgia (25-50%)
63
Clinical signs of dermatomyositis
Grotton's sign Heliotrope rash Shawl sign
64
Systemic involvement in inflammatory myopathy
Lung: Interstitial lung disease (10%), Respiratory muscle weakness Oesophageal: Dysphagia Cardiac: Myocarditis Other: Fever, weight loss, Raynauds phenomenon, inflammatory arthritis
65
Management for inflam myopathy
Investigations: Bloods for musc enzymes, electrolytes, autoantibodies EMG, Musc biopsy, MRI Treatment: Corticosteroids, immunosuppression (azathioprine, methotrexate, ciclosporin, IgG)
66
Describe polymyalgia rheumatica
>50, northern region, assoc with temproal arteritis Clin pres: Symmetrical ache in shoulder/hip girdle Morning stiffness Fatigue, anorexia, weight loss,fever Reduced movement of shoulders, neck, hips Normal musc strength
67
Describe temporal arteritis/giant cell arteritis
Granulomatous arteritis of large vessels Clin pres: Headache Scalp tenderness Jaw claudication Visual loss (amaurosis fugax) Tender, enlarged, non-pulsatile temporal arteries
68
Investigation/diag of polymyalgia rheumatica
Raised ESR, plasma viscosity, CRP Temporal artery biopsy Temporal artery USS
69
Treatment of polymyalgia rheumatica
Low dose steroids!!!!!!!! - PMR - prednisolone 15mg daily - GCA - prednisolone 40-60mg daily Reduce over 18-24months
70
Describe fibromyalgia
Common cause of MSK pain, not inflammation!!!! < women, 22-50, post-trauma
71
Clin manifestations of fibromyalgia
CNS - headaches, sleep, dizzy Musc - myofascial pain, fatigue Joints - morning stiffness Systemic symptoms - pain, weight gain Urinary, eyes, jaw, skin, chest, repro issues
72
Diagnosis of fibromyalgia
Widespread pain + assoc symptoms 3 or more months No other condition explaining pain
73
Management of fibromyalgia
Education, MDT, exercise, CBT, homeopathic, anti-depressants, analgesia, gabapentin/pregabalin
74
Describe vasculitis
- inflammation of blood vessels - arteries, arterioles, veins, venules, or capillaries. - can often lead to inflammation, ischemia and /or necrosis of tissue - clinical manifestations are diverse - primary or secondary (2nd - caused by infection/drug/toxin/part of another inflam disorder/cancer)
75
Clin pres of vasculitis
Very variable depending on organ Systemic symtoms - fever, malaise, WL, fatigue
76
Describe large vessel vasculitis
Granulomatous infiltration of the walls of the large vessels. Main causes - TA and GCA Inv - ESR, plasma viscosity, temp art biopsy, US, CT Treatment - 40-60mg prednis, steroid sparing e.g. leflunamide/metho, tocilizumab
77
Describe Takayasus arteritis
<40y, females, Asian Claudication, bruit, BP diff in extremities Inv with angiogram
78
Describe the classification of small vessel vasculiis
ANCA - Wegner's granulomatosis, microscopic polyangitis, Churg-Strauss Non-ANCA - Henoch-Schnlein purpura, serum cryoglobulin
79
Describe GPA (Wegner's)
< north Euro, males, 35-55y Constitiutional symptoms and athralgia
80
Describe the different symptoms of GPA
ENT - sinusitis, epistaxis, ulcers, saddle nose, deafness Ocular - conjunctivitis, uveitis, optic nerve vasc Resp - cough, haemop, pulm infiltrates, cavitation Cutaneous - palp purpura, ulcers Renal - necrotsising glomerulonephritis Nervous - cranial nerve palsy, mononeuritis multiplex
81
Main diff between GPA and EGPA
EGPA has late onset asthma, high eosinophil count, ANCA specificity
82
Describe Henoch-Schonlein purpura (HSP)
Acute IgA mediated, most commin in kids (2-11) Generalized vasculitis involving the small vessels of skin, GI tract, kidneys, joints, andlungs and CNS
83
HSP is secondary to....
75% preceding URTI, pharyngeal, GI infection - most commonly group A strep - precedes by 1-3w
84
Clin pres of HSP
Purpuric rash typically over buttocks and lower limbs Colicky abdominal pain Bloody diarrhoea Joint pain +/- swelling Renal involvement (50%)
85
Main drugs in rheumatology
Analgesics e.g. paracetamol, opiates NSAIDs DMARDs Biologics Gout therapy Corticosteroids
86
Indications and SEs for NSAIDs
Inflammatory arthritis Mechanical musculoskeletal pain Pleuritic / pericardial pain SEs: - ulcers, dyspepsia, renal impairment, incr CV event, wheeze
87
Describe DMARDS
Slow acting, e.g. methotrexate, sulphasalazine, leflunomide Anti-inflam, not analgesic Reduce rate of joint damage Reg monitoring for SEs
88
Use of DMARDs in which arthritic conditions?
RA, Psoriatic arthritis, Connective Tissue Disease and Vasculitis
89
SEs of SMARDs
Metho/leflu: Leucopenia / thrombocytopenia Hepatitis / cirrhosis (alcohol intake must be limited) Pneumonitis Rash / mouth ulcers Nausea / diarrhoea Needs monitoring of FBC and LFTs Spec: sulph Hepatitis Reversible oligozoospermia Others etc.. gold -> bone marrow suppression Teratogenic (no use 3 months before conception)
90
Describe anti-TNFs in arthritis
Etanercept Adalimumab, Certolizumab, Infliximab, Golimumab Biosimilars: Benepali, Amgevita SEs: - infection esp TB - risk of malignancy esp skin - contraindications (pulm fibrosis, HF)
91
Treatement of gout, acute vs phrophylactic?
Acute - colchicine (SE: diarrhoea) - NSAIDs - steroids Prophylactic (lower urate) - allopurinol (exac gout, rash, azathiprine interaction) - febuxostat (renal imp, avoid in IHD) - uricosurics
92
Indications for corticosteroids in arthritis
Inflammatory arthritis Polymyalgia rheumatica / giant cell arteritis Vasculitis
93
SEs of coritcosteroids in arthritis
Weight gain - centripetal obesity Muscle wasting, Skin atrophy, Osteoporosis, Avascular necrosis of the femoral head Diabetes, Hypertension Cataract, Glaucoma Fluid retention, Adrenal Suppression Immunosuppression *reduce toxicity via low dose for short time, consider steroid sparing*
94
Unique feature of each type of vertebrae...
Cervical - Thoracic - Lumber -

Musculoskeletal (8 decks)

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