Week 2 Flashcards
1
Q
What is the definition of rheumatoid arthritis?
A
A chronic systemic inflammatory disease, characterised by potentially deforming symmetrical polyarthritis and extra-articular features (systemic disease)
2
Q
What age group does rheumatoid arthritis tend to develop in and what is the female to male ration?
A
30-50
3:1
3
Q
What genes may contribute to the cause of rheumatoid arthritis?
A
HLA, DR4 and DR1
4
Q
Give two factors which may contribute to rheumatoid arthritis?
A
- Cigarette smoking
2. Infective aetiology
5
Q
Name two differences between a normal joint and a rheumatoid arthritis affected joint?
A
- Tendon sheath becomes inflamed
2. Synovial membrane is inflamed
6
Q
In relation to the pathology of rheumatoid arthritis: what does the synovium become laden with?
A
Macrophages, fibroblasts and multi-nucleated giant cells (resemble osteoclasts)
7
Q
In relation to the pathology of rheumatoid arthritis: what does the synovial membrane do?
A
Expands, actively invades and erodes surrounding bone and cartilage
8
Q
Give four articular symptoms of rheumatoid arthritis?
A
- Joint pain worst on waking and improve with activity
- Stiffness
- Joint swelling
4, malaise and fatigue
9
Q
Give four signs of rheumatoid arthritis?
A
- Swelling
- Tenderness
- Reduced range of movement
- Deformities
10
Q
In teh arthritis classification criteria - what is definite RA defined by (3 things)?
A
- Presence of synovitis in at least 1 joint
- Absence of alternative better diagnosis explaining synovitis
- Achievement of total score of 6 or more
11
Q
In the arthritis classification criteria - what are the 4 point scoring systems?
A
- Number and site of involved joint (0-5)
- Serological abnormality (0-3)
- Elevated acute phase response (0-1)
- Symptom duration (0-1)
12
Q
Give four investigations for rheumatoid arthritis?
A
- Anti CCP (cyclic citrullinated peptide); RF (rheumatoid factor)
- Inflammatory markers - PV, CRP
- Anaemia of chronic disease
- Radiology - ultrasound
13
Q
Give four late complications of RA?
A
- Infection
- Cervical myelopathy
- Interstitial lung disease
- Peripheral neuropathy
14
Q
Is it a good prognosis if you are male and young at age of RA onset?
A
No
15
Q
In RA what is the window of opportunity for treatment?
A
3 months
16
Q
What is the first step treatment for RA?
A
Early initiation of disease modyfyfing drugs (DMARDs) with steroids to cover ‘lag phase’
17
Q
What drugs used for RA are slow avting (weeks to months), reduce rate of joint damage?
A
DMARDs
18
Q
Give a few examples of DMARDs?
A
- Methotrexate
- Sulfasalazine
- Leflumamide
- Hydroxychloroquine
- Penicillamine
19
Q
4 biologic approaches have achieved major impact in RA - what do infliximab, adalimumab and etanercept belongto?
A
Tumour necrosis factor alpha inhibition
20
Q
4 biologic approaches have achieved major impact in RA - what do Rituximab belong to?
A
B cell depletion
21
Q
4 biologic approaches have achieved major impact in RA - what do Abatacept belong to?
A
Disruption of T cell costimulation
22
Q
4 biologic approaches have achieved major impact in RA - what do anankira and tocilizumab belong to?
A
IL-1 inhibition and IL-6 inhibition
23
Q
What four features define osteoarthritis?
A
- Articular cartilage failure
- Subchondral sclerosis
- Loss of joint space
- Subchondral cyst formation
24
Q
What consists of predominantly collagen type 2 fibres linked by covalent bonds, conferring tensile strength?
A
Cartilage
25
In osteoarthritis what is there a loss of and release of?
Loss of matrix, release of cytokines (IL-1, TNF) and mixed metalloproteinases, prostaglandins
26
What occurs once there has been a loss of matrix in OA?
Fibrillation of the cartilage surface and attempted repair with osteophyte formation
27
What is the last stage process of OA?
No cartilage left so synovial fluid goes into bone causing cysts
28
What can previous injury, RA, genetic elements, acromegaly and calcium crystal deposition disease all lead to?
Secondary OA
29
Is OA more common in females or males?
Females
30
Name two occupations more at risk of OA?
Hairdressers and farmers
31
Describe the pain in OA?
Worse on activity and relieved by rest.
32
What is the stiffness like in OA?
Usually morning stiffness lasting less than 30 minutes. Inactivity gelling.
33
What 4 features can be found on examination in a patient with OA?
1. Crepitus
2. Bony enlargements due to osteophytes
3. Joint tenderness
4. Joint effusion
34
What spine segment is OA rarely seen in?
Thoracic
35
Name three joints in the hand affected by OA?
DIP, PIP and 1st CMC
36
In OA of the hands - where might bony enlargements be seen?
DIPs (Heverdens nodes)
| PIPs (Bouchards nodes)
37
Give 2 features of OA in the knee?
Genu varus and valgus deformities
| Bakers cysts
38
Give three features of the hip in OA?
1. pain may be felt in groin or radiating to knee
2. pain felt in hip may be radiating from the lower back
3. hip movements restricted
39
In OA of the spine - what might osteophytes impinge on and what might happen in the lumbar section?
Nerve roots
| Can cause spinal stenosis if encroach on spinal canal
40
What three pharmacological measures are done for OA?
1. Analgesia
2. NSAIDS
3. Pain modulators - tricyclics
41
Name two intra-articular mananagements for OA?
Steroids and hyaluronic acid
42
What is the most effective treatment for OA?
Joint replacement
43
What is inflammation in the joint triggered by uric acid crystals?
Gout
44
Is gout more common in males or females?
Males
45
What stage in life is gout common to occur in?
After menopause
46
At what level of uric acid does it become insoluble?
>0.42 mmol/l
47
What do inherited enzyme defects, myeloproliferative disorders, psoriasis, haemolytic disorders, alcohol and high dietary purine intake (red meat, seafood, corn)?
Increased urate production
48
What does chronic renal impairment, volume depletion (heart failure), hypothyroidism, diuretics and cytotoxics (cyclosporin)?
Reduced urate excretion
49
What three joints does acute gout present in?
1st MTP > ankle > knee
50
Does gout settle without treatment?
10 days without treatment
| 3 days with treatment
51
What condition is chronic joint inflammation, often diuretic associated and involves high serum uric acid?
Chronic tophaceous gout
52
What is tophi - found in chronic tophaceous gout?
Swelling in fingers and toes
53
What two things are raised in chronic tophaceous gout?
1. Serum uric acid raised - may be normal during acute attack
2. Raised inflammatory markers
54
What is the key investigation for chronic tophaceous gout?
Polarised microscopy of synovial fluid
55
What does chronic tophaceous gout look like on an x-ray?
Dense shadow streching from base of DIP to middle of pharynx
56
What are the three treatments for acute gout?
1. NSAIDs
2. Colchicine
3. Steroids
57
What two drugs are used for the prophylaxis of gout?
Allopurinol
| Febuxostat
58
When should you start prophylaxis treatment for gout?
2-4 weeks after acute attack
59
What condition is commoner in the elderly, chondrocalcinosis increases with age, is related to osteoarthritis and affects fibrocartilage - knees, wrists and ankles?
Calcium pyrophosphate deposition disease
60
What is another name for calcium pyrophosphate deposition disease?
Pseudo-gout
61
What are acute attacks of pseudo-gout due to?
Calcium pyrophosphate crystals
62
What is the difference between uric acid crystals and pseudogout crystals?
Pseudogout - envelope shaped
| Uric acid - long, sharp, needle like
63
What are four treatments of psuedogout?
1. NSAIDS
2. Colchicine
3. Steroids
4. Rehydration
64
What condition is Milwaukee shoulder associated with?
Hydroxyapatite
65
In hydroxyapatite what is released?
Collagenases, serine proteinases and IL-1
66
What are four treatments for hydroxyapatite?
NSAIDs
Intra-articular steroid injection
Physioltherapy
Partial or total arthroplasty
67
What is the general term to describe pain that is caused by inflammation/damage to ligaments, tendons, muscles or nerve near a joint rather than either the bone or cartilage?
Soft tissue rheumatism
68
What is the term for more generalised soft tissue pain?
Fibromyalgia
69
Where is the commonest area for soft tissue pain?
Shoulder
70
Where does cubital tunnel syndrome occur?
In elbow
71
Where does de-quervains tenosynovitis occur?
Wrist
72
Name two joint hypermobility syndromes?
Marfan's
| Ehlers Danlos
73
What is the modified beighton score used for?
hyperextension and flexion
74
What type of cause of muscle disease are polymyositis, dermatomyositis, inclusion body myositis, polymyalgia rheumatica?
Inflammatory
75
What type of cause of muscle disease are hypo/hyperperthyroidism, cushings, hyperparathyroidism and diabetes mellitus?
Endocrine
76
What type of cause of muscle disease are hypokalaemia, hypocalcaemia and hyponatraemia?
Electrolyte disorders
77
Name a non-inflammatory cause of muscle disease?
Fibromyalgia
78
Name two idiopathic inflammatory myopathies?
Polymyositis and dermatomyositis
79
Are Polymyositis and dermatomyositis more common in females or males and what age group?
Females
| 40 - 50 years
80
What is the most common presenting feature of polymyositis and dermatomyositis?
Muscle weakness - insidious onset, worsening over months, usually symmetrical and proximal muscles
81
Name a cutaneous disease that has Gottrons sign, shawl sign and heliotrope rash?
Dermatomyositis
82
Name a lung disease, oesophageal problem, cardiac disease associated with dermatomyositis?
Interstitial lung disease
Dysphagia
Myocarditis
83
What is there a 15% incidence of in dermatomyositis?
Malignancy - risk greatest in men over 45 (ovarian, breast, stomach, lung etc)
84
What two drugs can influence dermatomyositis?
Steroids and statins
85
Is Raynauds indicative of dermatomyosiits?
Yes
86
Name two examinations used to help diagnose dermatomyositis?
Confrontational testing - power
| Isotonic testing - 30 second sit to stand test
87
What investigation is mainly used for diagnosis of dermatomyositis?
Blood tests
88
What four things are looked for in blood tests for dermatomyositis?
Muscle enzymes - CK
Inflammatory markers
Electrolytes, calcium, PTH, TSH
Autoantibodies
89
What two autoantibodies are looked for in dermatomyositis?
ANA, Anti-Jo-1
90
What other test (involves a probe) can be used to help diagnose dermatomyositis?
Electromyography - increased fibrillations, abnormal motor potentials, complex repetitive discharges
91
In diagnosing dermatomyositis - what test is definitive and shows perivascular inflammation and muscle necrosis?
Muscle biopsy
92
What investigation for dermatomyositis shows muscle inflammation, oedema, fibrosis and calcification?
MRI
93
Give 5 treatments for dermatomyositis?
1. Glucocorticoids
2. Azathioprine
3. Methotrexate
4. Ciclosporin
5. IV immunoglobulin
94
What can be misdiagnosed in patients over 50 as polymyositis, is commoner in men and involves distal muscle weakness?
Inclusion body myositis
95
Give two points on weakness in inclusion body myositis?
1. Weakness wrist and finger flexors, quadriceps and anterior tibial muscles in legs
2. Often asymmetrical weakness
96
Are CK levels higher in polymyositis or inclusion body myositis?
Higher in PM
97
What does a muscle biopsy for inclusion body myositis show?
Inclusion bodies and rimmed vacuoles
98
What skin findigns are found in polymyositis?
None
99
What is the difference between classic muscle biopsy findings in poly and dermatomyositis?
Poly - CD8 T cells
| Derm - CD4 T cells
100
What muscle disease occurs almost exclusively in >50s and is associated with temporal arteritis/giant cell arteritis?
Polymyalgia Rheumatica
101
What is normal in polymyalgia rheumatica?
Muscle strength
102
Where is ache felt in polymyalgia rheumatica?
In shoulder and hip girdle
103
Give 5 clinical manifestations of temporal arteritis and giant cell arteritis?
1. Headache
2. Scalp tenderness
3. Jaw claudication
4. Visual loss
5. Tende, enlarged, non-pulsatile temporal arteries
104
What two conditions invole granulomatous arteritis of large vessels?
Temporal arteritis and giant cell arteritis
105
What is raised in polymyalgia rheumatica?
Raised ESR, plasma viscosity and CRP
106
How is polymyalgia rheumatica diagnosed?
Exclusion of other diagnoses
107
How is polymyalgia rheumatica treated?
With low dose steroids - higher dose if temporal arteritis
108
What is a common cause (more common in women) of chronic musculoskeletal pain and is not associated with inflammation?
Fibromyalgia
109
What might fibromyalgia begin after?
Emotional or physical trauma
110
What do fibromyalgia symptoms worsen on?
Exertion, fatigue and stress
111
What are some clinical manifestations of fibromyalgia?
Pins and needles, headaches, depression, abdo pain (IBS), poor concentration anad memory
112
Give two clinical findings of fibromyalgia?
1. Excessive tenderness on palpitation of soft tissues
| 2. 11/18 tender points
113
What is the definition of spondyloarthropathy?
Family of inflammatory arthritides characterised by involvement of both the spine and joints, principally in genetically predisposed (HLA B27) individuals.
114
What are the four subgroups of spondyloarthropathy?
1. Ankylosing spondylitis
2. Psoriatic arthritis
3. Reactive arthritis (Reiter's)
4. Enteropathic arthritis
115
What is the difference between mechanical and inflammatory back pain?
Mechanical - worse on activity, worse at end of day, better with rest
Inflammatory - worse with rest, better on activity, early morning stiffness
116
What is dactylitis? - it is shared by all spondyloarthropathies
Inflammation of entire digit
117
Other than dactylitis - what three other features are shared by the spondyloarthropathies?
Sacroiliac and spinal involvement
Enthesitis
Inflammatory arthritis
118
What is enthesitis?
Inflammation at insertion of tendons into bones - achilles tendinitis, plantar fasciitis
119
Give four shared extra-articular features of spondyloarthropathies?
1. Ocular inflammation (anterior uveitis, conjuntivitis)
2. Mucocutaneous lesions
3. Rare aortic incompetence or heart block
4. No rheumatoid nodules
120
What is the definition of ankylising spondilitis?
Chronic systemic inflammatory disorder that primarily affects the spine.
121
What is the hallmark of ankyolising spondilitis?
Sacroiliac joint involvement (sacroiliitis)
122
What disorder invilves peripheral arthritis (uncommon), enthesopathy, is more common in men and occurs in late adolescence or early adulthood?
Ankylosing spondilytis
123
What is the 5 criteria for diagnosis of ankylosing spondylitis?
1. Limited lumbar motion
2. Lower back pain for 3 months - improved with movement
3. Reduced chest expansion
4. Bilateral sacroiliitis
5. Unilateral sacroillitis
124
Is amyloidosis a clinical feature of ankylosing spondylitis?
Yes
125
Ankylosing spondylitis is the 'A' disease - give the 7 relations.
```
Axial arthritis
Anterior uveitis
Aortic regurgitation
Apical fibrosis
Amyloidosis
Achilles tendinitis
plAntar fasciitis
```
126
Give three examinations for ankylosing spondylitis?
1. Tragus/occiput to wall
2. Chest expansion
3. Modified Schober test
127
What bloods are checked in ankylosing spondylitis?
ESR, CRP, PV
| HLA B27
128
What three things are looked for on an x-ray of ankylosing spondylitis?
Sacroiliitis
Syndesmophytes
Bamboo spine
129
What four drug treatments are used for treating AS?
1. NSAID
2. Disease modifying drugs
3. Anti TNF
4. Corticosteroids
130
What drug is used in severe AS (BASDAI>4)?
Etanercept
131
Give the definition for psoriatic arthritis?
Inflammatory arthritis associated with psoriasis, but 10-15% can have PsA without it
132
Is psoriatic arthritis RF negative? and does it have rhematoid nodules?
It is negative
| No nodules
133
In Psoriatic arthritis - what happens to nails?
Pitting
| Onycholysis
134
Give four x-ray features of psoriatic arthritis.
1. Marginal erosions and whiskering
2. Pencil in cup deformity
3. Osteolysis
4. Enthesitis
135
Give four treatment options for psoriatic arthritis.
1. NSAIDS
2. Corticosteroids
3. Disease modifying drugs
4. Anti-TNF
136
What is an infection induced systemic illness characterised primarily by an inflammatory synovitis from which viable micro-organisms cannot be cultured?
Reactive arthritis (Reiter's)
137
In reactive arthritis - when do the symptoms occur?
1-4 weeks after infection
138
Name four most common infections in reactive arthritis?
Urogenital - chalmydia
| Enterogenic - salmonella, shigella, yersinia
139
What is the triad for Reiter's syndrome?
Urethritis
Conjuctivitis/uveitis/iritis
Arthritis
140
In reactive arthritis is it symmetrical or asymmetrical monoarthritis?
Asymmetrical
141
Name four musculocutaneous lesions in reactive arthritis?
1. Keratodema
2. Circinate balanitis
3. Painless oral ulcers
4. Hyperkeratotic nails
142
Name two ocular clinical features of reactive arthritis?
1. Conjuntivitis
| 2. Iritis
143
Name two visceral manifestations of reactive arthritis?
1. Mild renal disease
| 2. Carditis
144
In reactive arthritis - how is it diagnosed?
```
Inflammatory parameters (ESR, CRP, PV)
Cultures - blood, urine, stool
Joint fluid analysis
```
145
In what time frame can reactive arthritis spontaneously resolve?
6 MONTHS
146
Name the main treatment for reactive arthritis?
NSAIDS
147
What type of arthritis is associated with IBD?
Enteropathic arthritis
148
What will 20% of patients with Crohns have in relation to enteropathic arthritis?
Sacroiliitis
149
Give 5 ways to investigate enteropathic arthritis?
1. GI endoscopy with biopsy
2. Joint aspirate
3. Raised CRP, PV
4. X-rray showing sacroiliitis
5. USS showing synovitis
150
What should not be used to treat enteropathic arthritis?
NSAIDS
151
Give three pharmacological treatments for enteropathic arthritis?
1. Steroids
2. DMRDS
3. Anti-TNF
