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Phase 2

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Phase 2 Harriet Ribbons and Caroline Hoernig The Peer Teaching Society is not liable for false or misleading information – PowerPoint PPT presentation

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Title: Phase 2


1

Rheumatology
  • Phase 2
  • Harriet Ribbons and Caroline Hoernig

The Peer Teaching Society is not liable for false
or misleading information
2
Aims
  • Understand the different types of arthritis
  • Osteoarthritis
  • Rheumatoid Arthritis
  • Seronegative spondyloarthropathies
  • Crystal arthropathies
  • Understand Systemic Lupus Erythematousus (SLE)

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or misleading information
3
Arthritis Introduction
  • Common joint condition
  • Causes pain and inflammation in a joint
  • 10,000 people per year seek help for arthritis
  • Symptoms include
  • Joint pain
  • Joint tenderness
  • Joint stiffness
  • Inflammation around the joints
  • Restricted movement around the joints
  • Warm, red skin over the joints
  • Muscle weakness
  • Muscle wasting

The Peer Teaching Society is not liable for false
or misleading information
4
The Peer Teaching Society is not liable for false
or misleading information
5
JOINT PAIN
INFLAMMATORY
NON-INFLAMMATORY
Autoimmune
Crystal arthritis
Infection
Degenerative
Non-Degenerative
Sports medicine
Rheumatoid arthritis
Vasculitis
Seronegative Spondylarthropathy
Connective tissue disease
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or misleading information
6
Inflammatory Degeneratve
  • Pain eases with use, worst at rest
  • Morning stiffness gt60mins
  • Swelling usually due to joint effusions
  • Joints hot and red
  • Affects younger people
  • Hands and feet
  • Responds to NSAIDS
  • Pain increases with use
  • Morning stiffness lt30mins
  • Bony swelling
  • Not clinically inflamed
  • Affects older patients, prior occupation/sport
  • Knees, hips, CMCP
  • Less convincing response to NSAIDS

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or misleading information
7
INFLAMMATORY
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8
Rheumatoid Arthritis (RA)
  • Affects synovial joints
  • Joints affected
  • (DIP sparing)
  • PIP
  • MCP
  • Wrists
  • Feet
  • Bony erosions on XRay

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9
Hypertrophy synovium -gt New capillary formation
-gt Inflammtion -gt Synovial villi form and grow
into bone -gt PANNUS -gt Cytokines released
10
RA risk factors
  • Increasing age (may occur at any age).
  • Female sex
  • Premenopausal
  • Smoking

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or misleading information
11
RA symptoms
  • Pain
  • Morning stiffness
  • Myalgia
  • Fatigue
  • Weight loss
  • Joint pain
  • Synovitis of small joints
  • Mono/ bilateral arthropathy of the shoulder/
    wrist
  • Tenosynovitis or bursitis
  • Swan neck deformity late on
  • Boutonniere deformity late on
  • Finger drop

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or misleading information
12
RA diagnosis
  • 4 of the following symptoms
  • Morning stiffness gt1 hour gt6 weeks
  • Arthritis gt3 joints
  • Arthritis in hand joints
  • Symmetrical arthritis
  • Rheumatoid nodules
  • Positive RF
  • Radiological changes

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or misleading information
13
Z-Shaped thumb
14
Hypertrophy synovium -gt New capillary formation
-gt Inflammtion -gt Synovial villi form and grow
into bone -gt PANNUS -gt Cytokines released
15
RA Xray changes
  1. Soft tissue swelling
  2. Juxta articular osteopenia
  3. Loss of joint space
  4. Bony erosions

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or misleading information
16
Extra-articular involvement
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or misleading information
17
RA investigations
  • Bloods
  • FBC
  • Anaemia
  • ESR
  • High
  • RF
  • Positive in 80
  • Anti CCP
  • Positive in 80
  • ANA
  • lt50 positive
  • ALL TESTS NEGATIVE IN 20
  • Xray
  • Erosions seen
  • Periarticular osteopenia
  • (Joint space narrowing)

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or misleading information
18
RA treatment
  • NSAIDs
  • Pain relief
  • Glucocorticoids
  • Intramuscular injections
  • Disease Modifying Anti Rheumatic Drugs (DMARDs)
  • Azathioprine, ciclosporin, penicillamine,
    leflunomide, methotrexate and sulfasalazine.
  • Can be used with steroids
  • Reduced damage to joints
  • METHOTREXATE side effects lung fibrosis, liver
    effects.
  • Biological drugs
  • Rituximab (Anti CD20), etanercept (TNF inhibitor)
    and abatacept (T cell stimulator modulator)
  • Inhibits the immune system
  • Surgery

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or misleading information
19
DEGENERATIVE
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20
Osteoarthritis
  • Most common condition affecting synovial joints
  • All joint tissues involved, esp. articular
    cartilage
  • Risk factors
  • Age
  • Sex
  • Genetics
  • Obesity
  • Trauma/occupation
  • ?protective effect of cigarette smoking
  • Knees (esp. medial compartment), hips and hands
    most commonly affected

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or misleading information
21
Radiological changes in OA
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or misleading information
22
Clinical features of OA
  • Symptoms
  • - PAIN
  • - POOR MOBILITY
  • FUNCTIONAL IMPAIRMENT
  • Signs
  • ALTERED GAIT
  • JOINT SWELLING/TENDERNESS
  • CREPITUS

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or misleading information
23
Treatment of OA
  • Education and lifestyle advice eg. lose weight!
  • Analgesia (topical, oral, transdermal)
  • Steroid injections
  • Surgery
  • Uncontrolled pain
  • Significant limitation of function
  • NB. Aim is to relieve pain not increase movement

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or misleading information
24
SERONEGATIVE SPONDYLARTHOPATHY
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25
SERONEGATIVE SPONDYLARTHOPATHY
  • High rate of HLA-B27
  • Rheumatoid factor NEGATIVE.
  • Types
  • Ankylosing spondylitis
  • Psoriatic arthritis
  • Reactive arthritis
  • Enteropathic arthritis

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or misleading information
26
SERONEGATIVE SPONDYLARTHOPATHY
  • Ankylosing spondylitis
  • Psoriatic arthritis
  • Reactive arthritis
  • Enteropathic arthritis

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or misleading information
27
Ankylosing Spondylitis (AS)
  • Sacroilitis
  • Inflammation of one of both of the sacroiliac
    joints
  • Inflammatory back pain
  • Enthesitis
  • Inflammation of the enthesis (where the tendons/
    ligaments enter the bone)
  • (Anterior uveitis)

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or misleading information
28
AS risk factors
  • 20- 30 years
  • HLA-B27 linked
  • Caucasian
  • Men

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or misleading information
29
AS symptoms
  • Back pain in the morning
  • Morning stiffness
  • Ossification of ligament/ tendon
  • Longer than 30 minutes
  • Pain improves with movement
  • Enthesitis
  • Ossification of capsule insertions
  • Synovitis
  • Common at the large peripheral joints
  • Stooped posture
  • Bamboo spine at a late stage
  • Micro-fractures

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or misleading information
30
(No Transcript)
31
6 As of AS
  • A Atlantic axial instability
  • A Atypical lung fibrosis
  • A Anterior uveitis
  • A Amyloidosis
  • A Autoimmune bowel disease and UC
  • A Aortic incompetance

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or misleading information
32
AS extra-articular symptoms
  • Aortic incompetence
  • Cardiomegaly
  • Amyloidosis
  • Fractures
  • Fatigue
  • Weight loss
  • Low grade fever
  • Anaemia
  • Upper lobe pulmonary fibrosis
  • Iritis
  • Pleuritis
  • Osteoporosis

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or misleading information
33
AS investigations
  • Bloods
  • ESR
  • High
  • RF
  • Negative
  • Xray
  • Sacroiliac changes
  • Ascending spread of disease
  • Facet joint involvement
  • Squaring of vertebrae
  • Syndesmophyte (bony growth in the ligament)
  • Ossification
  • Osteitis pubis (inflammation of pubis synthesis)
  • MRI (Gold standard)
  • Joint erosions
  • Fluid

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or misleading information
34
AS treatment
  • Exercise
  • Physiotherapy
  • NSAIDs
  • Pain relief
  • Disease Modifying Anti Rheumatic Drugs (DMARDs)
  • Azathioprine, ciclosporin, penicillamine,
    leflunomide, methotrexate and sulfasalazine.
  • Biological drugs
  • Rituximab (Anti CD20), etanercept (TNF inhibitor)
    and abatacept (T cell stimulator modulator)
  • Inhibits the immune system
  • Local steroid injections

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or misleading information
35
SERONEGATIVE SPONDYLARTHOPATHY
  • Ankylosing spondylitis
  • Psoriatic arthritis
  • Reactive arthritis
  • Enteropathic arthritis

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or misleading information
36
Psoriatic arthritis
  • Joints affected
  • DIP
  • Spine
  • Nail involvement
  • Sacroiliac joints
  • In people with psoriasis or family history of
    psoriasis
  • Less severe than RA

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or misleading information
37
Psoriatic arthritis types
  • Distal interpharyngeal arthritis (DIPJs)
  • Most typical form
  • Nail dystrophy
  • Seronegative symettrical polyarthritis
  • Similar to RA eg knees, wrists, DIPs (not MCPs)
  • Arthritis mutilans
  • 5 affected.
  • Xray shows periarticular osteolysis and bone
    shortening
  • Unilateral or bilateral sacroilitis
  • 15 affected.
  • Affects the cervical spine
  • Assymetrical arthritis
  • Warm red tender joints
  • Dactylitis in hands and feet
  • Juvenille onset
  • 20 childhood arthritis

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or misleading information
38
Psoriatic arthritis symptoms
  • Stiffness and pain
  • Joint involvement
  • DIP joint
  • Asymmetrical oligoarticular arthritis
  • Symmetrical polyarthritis
  • Arthritis mutilans (degeneration of joint)
  • Sacroilitis
  • Psoriasis (some cases)
  • Scalp
  • Perineum
  • Umbilicus
  • Nail lesions
  • Pitting
  • Onchyolysis
  • Splinter haemorrhages
  • Skin lesions
  • Erythematous lesions
  • Pus

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or misleading information
39
Psoriatic arthritis investigations
  • Bloods
  • ESR
  • High
  • FBC
  • Anaemia
  • Xray

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or misleading information
40
(No Transcript)
41
Psoriatic arthritis treatment
  • Exercise
  • NSAIDs
  • Pain relief
  • Disease Modifying Anti Rheumatic Drugs (DMARDs)
  • Azathioprine, ciclosporin, penicillamine,
    leflunomide, methotrexate and sulfasalazine.
  • Biological drugs
  • Rituximab (Anti CD20), etanercept (TNF inhibitor)
    and abatacept (T cell stimulator modulator)
  • Inhibits the immune system

The Peer Teaching Society is not liable for false
or misleading information
42
SERONEGATIVE SPONDYLARTHOPATHY
  • Ankylosing spondylitis
  • Psoriatic arthritis
  • Reactive arthritis
  • Enteropathic arthritis

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or misleading information
43
Reactive arthritis (Reiters)
  • Triad of symptoms
  • Cant see (Conjunctivitis)
  • Cant pee (Urethritis)
  • Cant climb a tree (Arthritis)
  • Common in 18-30
  • Commoner in lower extremities
  • 30 chronic.
  • Majority resolve within 3-24 months

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or misleading information
44
Reactive arthritis Causes
  • Shigella
  • Chlamydia
  • Salmonella
  • HIV
  • Enterocolli.

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or misleading information
45
Reactive arthritis investigations
  • Bloods
  • ESR
  • High
  • ECG
  • Xray

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or misleading information
46
Reactive arthritis treatment
  • NSAIDs
  • Pain relief
  • Steroids
  • Used in flare ups
  • Antibiotics
  • Treat the underlying cause
  • (DMARDs)

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or misleading information
47
SERONEGATIVE SPONDYLARTHOPATHY
  • Ankylosing spondylitis
  • Psoriatic arthritis
  • Reactive arthritis
  • Enteropathic arthritis

The Peer Teaching Society is not liable for false
or misleading information
48
Enteropathic arthritis
  • Occurs in 10-15 of all IBD cases (Ulcerative
    colitis and Crohns)
  • HLA B27 linked in 50 of cases
  • Asymetrical arthritis
  • Mainly affects the lower limbs
  • Remission of IBD leads to improvement in symptoms
  • TREAT IBD TO TREAT ARTHRITIS

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or misleading information
49
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50
CONNECTIVE TISSUE DISEASE
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or misleading information
51
Systemic lupus erythematosus
  • Inflammatory, multisystem autoimmune disorder -gt
    autoantibodies which form immune complexes/bind
    to tissues
  • 90 occurs in females
  • Peak onset 20-40yrs
  • Predisposing factors
  • Heredity
  • Genetics
  • Sex hormone status (pre-menopausal)
  • Drugs (hydralazine, isoniazid, penicillamine)
  • UV light

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or misleading information
52
Clinical features of SLE
  • Most suffer from
  • FATIGUE
  • ARTHRALGA (gt90) -gt symmetrical, small joints,
    deformity and erosions rare
  • SKIN PROBLEMS (85) -gt butterfly rash, vasculitic
    lesions, photosensitivity, raynauds
  • But can affect any organ
  • Lungs, heart, nervous system, eyes, GI system
  • DIAGNOSIS -gt based on ACR criteria, must have
    gt4/11

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or misleading information
53
Other manifestations in SLE
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54
Investigation of SLE
  • FBC
  • Often pancytopenia (low WBC, anaemia,
    thrombycytopenia)
  • Raised ESR
  • U Es
  • Urea and creatinine elevated in advanced disease
  • Autoantibodies
  • ANA (but 10 of normal population ve!)
  • Anti dsDNA (useful prognostic indicator)
  • Anti-Ro, Anti-La, Antiphospholipid Ab
  • Complement -gt C3 and C4 often decreased in active
    disease

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or misleading information
55
Management
  • Avoid sunlight exposure
  • Decrease cardiovascular risk factors
  • NSAIDS -gt for arthritis, fever
  • Antimalarials -gt chloroquine, hydroxychloroquine
  • Corticosteroids -gt for severe flares, IMI, higher
    doses in renal/cerebral disease
  • Cyclophosphamide, Mycophenoate, Azathioprine, MTX
  • Severe flares, not controlled by steroids
  • Biologics -gt RITUXIMAB (Anti-CD20)

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or misleading information
56
Course and prognosis of SLE
  • Usually episodic with exacerbations and
    remissions
  • Can be chronic and persistent
  • Early deaths are due to renal/cerebral disease
  • Deaths later on are due to CAD and stroke
  • Recurrent miscarriages can occur

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or misleading information
57
CRYSTAL ARTHROPATHY
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or misleading information
58
Crystal arthropathies
GOUT -gt hyperuricaemia -gt intra-articular sodium
urate crystals PSEUDOGOUT -gt calcium
pyrophosphate crystals
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or misleading information
59
GOUT
  • Increased prevalence in developed countries diet
    important!
  • MF 101
  • Prevalence in older female is increased by
    diuretic use
  • Pathology
  • Hypoxanthine gt Xanthine gt Uric acid
  • Xanthine Oxidase
  • Uric acid levels depend on the balance beween
    purine synthesis and ingestion and elimination of
    urate by the kidney/gut
  • Serum uric acid levels increase with age,
    obesity, western diet, DM, IHD, HTN, FHx

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or misleading information
60
Acute gout
  • Ingestion of sodium urate crystals by polymorphs
    causing release of cytokines and complement
    activation in a joint
  • Typically in middle-aged men
  • Sudden onset of pain, swelling and redness of a
    joint, typically the 1st MTPJ
  • Triggers too much food/alcohol, dehydration,
    starting a diuretic

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or misleading information
61
Investigating gout
  • Clinical picture often diagnostic gout should
    always be on your list of differentials for a
    red, hot, swollen joint (along with septic
    arthritis!)
  • Joint fluid microscopy
  • Gout negatively birefringent sodium urate
    crystals
  • Serum uric acid
  • Usually gt600umol/L
  • Serum urea/creatinine/eGFR
  • Monitored for renal impairment

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or misleading information
62
Treating acute gout
  • High dose NSAIDS or COXIBS
  • eg. Naproxen, Diclofenac, Indomethacin
  • In renal impairment
  • Colchicine or corticosteroids
  • Dietary advice
  • Reduce alcohol esp. beer and reduce
    calories/cholesterol and avoid shellfish
  • Reduce serum uric acid levels to lt360um/L
  • ALLOPURINOL
  • Blocks xanthine oxidase
  • Given for frequent attacks despite change in
    diet/if patient cant tolerate NSAIDS/if renal
    impairment present/tophi

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or misleading information
63
Chronic tophaceous gout
  • Occurs if uric acid levels very high
  • Sodium urate forms tophi in skin around joints
    and on ears, fingers.
  • Punched-out bone cysts on Xray
  • Superimposed acute attacks can occur
  • Often associated with renal impairment
  • /- diuretic use
  • Treatment
  • Stop diuretics or swap
  • Allopurinol

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or misleading information
64
Pseudogout
  • Calcium pyrophosphate deposits in hyaline or
    fibrocartilage
  • Similar to acute gout butmore common in elderly
    women, usually affects knee and wrists
  • DIAGNOSIS
  • - Appearance of chondrocalcinosis on XRay
  • - Joint aspirate -gt rhomboidal, weakly positive
    birefringent crystals
  • Treatment
  • Joint aspiration
  • NSAIDS or COLCHICINE

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or misleading information
65
GOOD LUCK!
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