Title: Phase 2
1 Rheumatology
- Phase 2
- Harriet Ribbons and Caroline Hoernig
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2Aims
- Understand the different types of arthritis
- Osteoarthritis
- Rheumatoid Arthritis
- Seronegative spondyloarthropathies
- Crystal arthropathies
- Understand Systemic Lupus Erythematousus (SLE)
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3Arthritis 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
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4The Peer Teaching Society is not liable for false
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5JOINT 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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6Inflammatory 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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7INFLAMMATORY
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8Rheumatoid Arthritis (RA)
- Affects synovial joints
- Joints affected
- (DIP sparing)
- PIP
- MCP
- Wrists
- Feet
- Bony erosions on XRay
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9Hypertrophy synovium -gt New capillary formation
-gt Inflammtion -gt Synovial villi form and grow
into bone -gt PANNUS -gt Cytokines released
10RA risk factors
- Increasing age (may occur at any age).
- Female sex
- Premenopausal
- Smoking
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11RA 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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12RA 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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13Z-Shaped thumb
14Hypertrophy synovium -gt New capillary formation
-gt Inflammtion -gt Synovial villi form and grow
into bone -gt PANNUS -gt Cytokines released
15RA Xray changes
- Soft tissue swelling
- Juxta articular osteopenia
- Loss of joint space
- Bony erosions
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16Extra-articular involvement
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17RA 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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18RA 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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19DEGENERATIVE
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20Osteoarthritis
- 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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21Radiological changes in OA
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22Clinical features of OA
- Symptoms
- - PAIN
- - POOR MOBILITY
- FUNCTIONAL IMPAIRMENT
- Signs
- ALTERED GAIT
- JOINT SWELLING/TENDERNESS
- CREPITUS
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23Treatment 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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24SERONEGATIVE SPONDYLARTHOPATHY
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25SERONEGATIVE SPONDYLARTHOPATHY
- High rate of HLA-B27
- Rheumatoid factor NEGATIVE.
- Types
- Ankylosing spondylitis
- Psoriatic arthritis
- Reactive arthritis
- Enteropathic arthritis
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26SERONEGATIVE SPONDYLARTHOPATHY
- Ankylosing spondylitis
- Psoriatic arthritis
- Reactive arthritis
- Enteropathic arthritis
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27Ankylosing 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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28AS risk factors
- 20- 30 years
- HLA-B27 linked
- Caucasian
- Men
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29AS 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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316 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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32AS 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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33AS 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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34AS 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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35SERONEGATIVE SPONDYLARTHOPATHY
- Ankylosing spondylitis
- Psoriatic arthritis
- Reactive arthritis
- Enteropathic arthritis
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36Psoriatic 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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37Psoriatic 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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38Psoriatic 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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39Psoriatic arthritis investigations
- Bloods
- ESR
- High
- FBC
- Anaemia
- Xray
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41Psoriatic 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
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42SERONEGATIVE SPONDYLARTHOPATHY
- Ankylosing spondylitis
- Psoriatic arthritis
- Reactive arthritis
- Enteropathic arthritis
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43Reactive 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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44Reactive arthritis Causes
- Shigella
- Chlamydia
- Salmonella
- HIV
- Enterocolli.
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45Reactive arthritis investigations
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46Reactive arthritis treatment
- NSAIDs
- Pain relief
- Steroids
- Used in flare ups
- Antibiotics
- Treat the underlying cause
- (DMARDs)
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47SERONEGATIVE SPONDYLARTHOPATHY
- Ankylosing spondylitis
- Psoriatic arthritis
- Reactive arthritis
- Enteropathic arthritis
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48Enteropathic 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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49(No Transcript)
50CONNECTIVE TISSUE DISEASE
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51Systemic 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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52Clinical 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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53Other manifestations in SLE
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54Investigation 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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55Management
- 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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56Course 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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57CRYSTAL ARTHROPATHY
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58Crystal arthropathies
GOUT -gt hyperuricaemia -gt intra-articular sodium
urate crystals PSEUDOGOUT -gt calcium
pyrophosphate crystals
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59GOUT
- 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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60Acute 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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61Investigating 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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62Treating 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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63Chronic 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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64Pseudogout
- 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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65GOOD LUCK!