Phase 2

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Rheumatology

• Phase 2
• Harriet Ribbons and Caroline Hoernig

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Aims

• Understand the different types of arthritis
• Osteoarthritis
• Rheumatoid Arthritis
• Seronegative spondyloarthropathies
• Crystal arthropathies
• Understand Systemic Lupus Erythematousus (SLE)

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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

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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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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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INFLAMMATORY
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Rheumatoid Arthritis (RA)

• Affects synovial joints
• Joints affected
• (DIP sparing)
• PIP
• MCP
• Wrists
• Feet
• Bony erosions on XRay

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Hypertrophy synovium -gt New capillary formation
-gt Inflammtion -gt Synovial villi form and grow
into bone -gt PANNUS -gt Cytokines released
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RA risk factors

• Increasing age (may occur at any age).
• Female sex
• Premenopausal
• Smoking

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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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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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Z-Shaped thumb
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Hypertrophy synovium -gt New capillary formation
-gt Inflammtion -gt Synovial villi form and grow
into bone -gt PANNUS -gt Cytokines released
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RA Xray changes

1. Soft tissue swelling
2. Juxta articular osteopenia
3. Loss of joint space
4. Bony erosions

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Extra-articular involvement
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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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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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DEGENERATIVE
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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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Radiological changes in OA
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Clinical features of OA

• Symptoms
• - PAIN
• - POOR MOBILITY
• FUNCTIONAL IMPAIRMENT
• Signs
• ALTERED GAIT
• JOINT SWELLING/TENDERNESS
• CREPITUS

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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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SERONEGATIVE SPONDYLARTHOPATHY
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SERONEGATIVE SPONDYLARTHOPATHY

• High rate of HLA-B27
• Rheumatoid factor NEGATIVE.
• Types
• Ankylosing spondylitis
• Psoriatic arthritis
• Reactive arthritis
• Enteropathic arthritis

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SERONEGATIVE SPONDYLARTHOPATHY

• Ankylosing spondylitis
• Psoriatic arthritis
• Reactive arthritis
• Enteropathic arthritis

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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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AS risk factors

• 20- 30 years
• HLA-B27 linked
• Caucasian
• Men

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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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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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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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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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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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SERONEGATIVE SPONDYLARTHOPATHY

• Ankylosing spondylitis
• Psoriatic arthritis
• Reactive arthritis
• Enteropathic arthritis

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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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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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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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Psoriatic arthritis investigations

• Bloods
• ESR
• High
• FBC
• Anaemia
• Xray

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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

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SERONEGATIVE SPONDYLARTHOPATHY

• Ankylosing spondylitis
• Psoriatic arthritis
• Reactive arthritis
• Enteropathic arthritis

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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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Reactive arthritis Causes

• Shigella
• Chlamydia
• Salmonella
• HIV
• Enterocolli.

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Reactive arthritis investigations

• Bloods
• ESR
• High
• ECG
• Xray

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Reactive arthritis treatment

• NSAIDs
• Pain relief
• Steroids
• Used in flare ups
• Antibiotics
• Treat the underlying cause
• (DMARDs)

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SERONEGATIVE SPONDYLARTHOPATHY

• Ankylosing spondylitis
• Psoriatic arthritis
• Reactive arthritis
• Enteropathic arthritis

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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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CONNECTIVE TISSUE DISEASE
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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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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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Other manifestations in SLE
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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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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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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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CRYSTAL ARTHROPATHY
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Crystal arthropathies
GOUT -gt hyperuricaemia -gt intra-articular sodium
urate crystals PSEUDOGOUT -gt calcium
pyrophosphate crystals
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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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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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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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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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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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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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GOOD LUCK!