Beruflich Dokumente
Kultur Dokumente
Emma Firth
AIM
To be confident dealing with common rheumatological conditions which you may come across as a junior doctor within multiple settings
Objectives
Refresh bony anatomy of hand Competent joint pain history taking To be confident in the aetiology, features, investigations and management of the know about rheumatological conditions in the core curriculum To get you excited about rheumatology?!!!
Know about:
Osteoarthritis Rheumatoid arthritis Septic arthritis* Gout / Pseudogout Ankylosing Spondylitis Reactive arthritis Polymyalgia rheumatic Temporal arteritis* Vasculitis
Know of:
Seronegative arthritis Fibromyalgia Connective tissue diseases e.g. SLE, scleroderma Not scope to cover the last two today
GROSS ANATOMY
carpometacarpal
HISTORY
SH Occupation
Risks for joint problems Affect of joint problem on work
Systems
CONDITIONS
1. Osteoarthritis
Primary causes
Age Obesity ( pressure) Occupation Golfers 1st MTP joint Footballers knees
Secondary causes
Bone: Pagets, acromegaly Arthritis: RA, gout, chondrocalcinosis Metabolic: hemochromatosis, Wilson's
History / Pattern
DIP + PIP joints of hand Asymmetric large joint involvement Deep ache Triggered by activity, relieved by rest Decreased movement / function Locking / catching +/- myelopathy / spinal stenosis
On examination
Name three clinical signs of osteoarthritis visible on inspection
Look : Osteophytes Heberdens nodes: DIP Bouchards nodes: PIP Squaring (carpo-metacarpal joint) Hip: Fixed flexion Wasting
Feel: Effusions Move: Crepitus Internal rotation of hip Pain on passive movement of hip at end of range
Investigations
Blood tests: -ve Rh factor, ANAs, ESR normal Aspirate: cartilage fragments, viscosity X-ray Name five typical changes that can be seen on xray.
Treatment
Non pharmacological Physiotherapy OT: Assistive devices e.g. sticks, tap turners Low impact aerobic exercise Weight loss Heat / cold packs / TENS for pain relief. Pharmacological 1st : Paracetamol cocodamol 1st : Topical NSAIDs 2nd : Oral NSAIDs, Opioids 2nd : Topical capsaicin 2nd : Intra-articular corticosteroid injections Surgical Athroscopic lavage and debridement (only IF locking) Replacement arthroplasty
Complications:
Cervical / lumbar OA mild myelopathy or radiculopathy Spinal stenosis lower back or leg pain worse back extension Deformity / tendinitis + contractures
2. Rheumatoid arthritis
Pathology
Synovial tissue proliferation = Pannus characteristic pathological lesion in RA. Cells in pannus produce collegenases and proteases cartilage destruction
History / Pattern
What is the typical course of rheumatoid arthritis?
Symmetrical, peripheral polyarthritis PIP joints, MCP, and small foot joints. NOT DIPs Early morning stiffness >30 mins, eased by exercise
On examination
Name four DEFORMITIES OF THE FINGERS / THUMB
Look Subcutaneous nodules Ulnar deviation at MCP joint (i.e. fingers point towards ulnar side) MCP joint swelling
Investigations
Rheumatoid factor Anti- CCP (cyclic citrullinated peptide) antibodies ESR and CRP FBC: Anaemia, thrombocytosis ( platelets) U+E, LFTs (pre treatment) Joint aspirate: Cloudy, can also check for sepsis
Treatment
Non pharmacological Pharmacological Pain: NSAIDs/COX-2 inhibitor Glucortioids: e.g. IM methylprednisolone Disease modifying 1st line: Methotrexate + other +/ST glucocorticoids 2nd line: DMARD monotherapy with fast of dose 3rd line: Anti-TNF- agents e.g. infliximab 4th line: Rituximab (monoclonal antibody against B cells) + methotrexate
Methotrexate
Mechanism Inhibits folic acid reductase Suppresses immune system / inflammation Indications RA; Psoriatic arthritis (licenced) Connective tissue disease: SLE, vasculitides, myositis (unlicensed)
Prescribing It is your first day as an FY1 and a nurse shows you documentation that the consultant on ward round has said Plan: (1) Start methotrexate What else do you know about prescribing methotrexate?
3.
CASE STUDY
A 53 year old woman presents to A&E with a swollen left painful knee. PMH: RA, being treated with methotrexate and hydroxychloroquine. 2-3 day hx of generally unwell, fever and chills O/E: warm, swollen, decreased ROM, tachycardia, T 37.9
History
Evolves over hrs days Limp / referred pain Exquisite pain Unwell: fever, rigors +/- vomiting
O/E
Systemically septic Swollen, red, tender and warm joint +/- Effusion ROM, held still (pseudoparesis, pseudoparalysis)
Pathogenesis:
1) Haematogenous spread 2) Direct inoculation 3) Direct extension
Risk factors
Prosthetic joint Immunosuppression DM Skin infections / bacteraemia IVDU Trauma
1. 2. 3. 4. 5. 6.
Analgesia Oral antibiotics and discharge Aspiration of knee and injection with steroid Aspiration of knee and send fluid for MC&S Add adaluminab Inform a senior
Investigations
Bloods: raised WCC, CRP +ve Blood cultures USS (cant determine sterile effusion vs pus ) Urgent aspiration in all suspected cases PUS! BUGS! A high leucocyte count of >50,000/ml is highly suggestive even if no organisms are seen Most common organism?
Management
1) IV antibiotics as soon as joint fluid obtained. e.g. Flucloxacillin 2g IV qds & Gentamicin 5mg/kg IV od 2) Prompt surgical washout/drainage +/debridement 3) Joint should be splinted and rested
Complications
Septic shock Osteomyelitis Secondary osteoarthritis Avascular necrosis Growth disturbance in children
4. SERONEGATIVE ARTHROPATHIES
= A group of inflammatory disorders predominantly affecting the spine, sacroiliac joints and larger peripheral joints, characteristically asymmetrical. Rheumatoid factor typically ve. Ass with Human Leukocyte Antigen B27.
Symptoms
Inflammatory back pain: pain and stiffness, lasting >1 hr; worse am/on rest Peripheral arthritis: larger joints, lower limbs usually, 1/3 pts Peripheral enthesitis: Achilles tendonitis, plantar fasciitis, and at tibial tuberosity, 1/3 pt Systemic: fatigue
Signs
spinal flexion (Schobers test*) and neck movements (occiput test*) Excessive thoracic kyphosis + loss of lumbar lordosis (question mark) Crepitations at lung apices LATER: para-spinal wasting, spine #
Complications the 5 As
Investigations
Bloods Raised ESR, Raised/n CRP RF +, anti CCP ve What are the classical signs seen on sacroiliac and lumbar spine xrays?
Treatment
1st: NSAIDs, physio 2nd line: different NSAID 3rd line: anti-TNF e.g. etanercept
4b.
Hans Conrad Julius Reiter German physician convicted of war crimes for medical experiments at concentration camps Wrote a book on racial hygiene Reiter's syndrome was later renamed to Reactive arthritis when his Nazi affiliation came to light
Precipitating infections
GU: Chlamydia trachomatis (>2/3), Gonorrhoea GI: Salmonella, Shigella, Campylobacter and Yersinia Other: Parvovirus B19 (slapped cheek), post-streptococcal
Other than the classical triad, what other features may be present in reactive arthritis?
Investigations
Urethral discharge / stool MC&S Joint aspirate: MC&S ve, giant macrophages on histology RF and anti CCP ve ESR / CRP: /
Treatment
1st = NSAIDs GUM referral
Prognosis
Usually resolves in 6-8 weeks May become recurrent (50%) or lead to chronic symptoms (25%)
Features
1. 2. 3. 4. 5.
Polyarteritis indistinguishable from RA (MCPs, PIPs) Asymmetrical oligoarthritis affecting large + small joints Predominant sacroiliitis and spondylitis (mimics ank spond) DIP joint arthritis Arthritis mutilans (1%): pencil and cup appearance from telescoping
Investigations Blds: 5-10% RF +ve, Anti CCP ve Synovial fluid: no crystals X-ray: Erosions, Minimal juxta-articular osteopenia, Pencil-in-cup deformity
Treatment Physio Steroids for flares but not LT 1st line: DMARD methotrexate 2nd line: NSAIDs, other DMARDs e.g. sulfasalazine / Anti-TNF e.g. etanercept, Infliximab
Features
Hx of IBD Peripheral arthritis: Usually asymmetrical, lower limbs, larger joints, Often transient and migratory Sacroilitis/spondylitis Ocular disease: anterior uveitis, conjunctivitis, scleritis, episcleritis
Investigations
RF and anti CCP ve ESR and CRP / X-rays (MRI in the young): spine/sacroiliac joints (as for ank spond) Investigation for IBD: colonoscopy etc
Management
Control IBD DMARDs Anti-TNF if severe
5. CRYSTAL ARTHROPATHIES
5a. GOUT
URATE
Purines hypoxanthine * xanthine *urate
[2/3 excreted renally; 1/3 intestinally CO2 + NH3] *enzyme xanthine oxidase; uricase
Risk factors
Idiopathic in uric acid excretion CKD Thaizides Alcohol Beer, shellfish, bacon Dehydration
Features
Sudden onset *Acutely* painful Monoarthritis Able to weight bear Swollen, hot, red
Investigations
Blds: Urate, FBC, U+E, CRP, BC? USS / Xray Aspiration and fluid MC&S
Management
Risk reduction: Dietary advice Diuretics r/v Pharmacological Acute: 1st NSAIDs, 2nd Colchicine Preventer: ALLOPURINOL
5b. PSEUDO-GOUT aka Calcium pyrophosphate dehydrate (CPPD) crystal deposition disease
Pathology
Calcium pyrophosphate deposition in cartilage
Features
Risk factors
Bone: OA, acromegaly Endo: Hyperparathyroidism, hypothyroidism, LT steroids Metabolic: Haemochromatosis
Usually affects knee / wrist / shoulder and ankle joints Similar presentation to gout acute joint pain and swelling
Investigations
Bloods: FBC (WCC), RF and anti-CCP ve, U+E, LFTs, cutlure Uric acid levels if suggests gout Xray: chondrocalcinosis, hook osteophytes on medial side of joints Aspiration: MC&S What do you see on aspiration?
Management Joint aspiration response rate to DMARDs but try: hydroxychloroquine, sulphazalazie Low dose colchicines prevention NSAIDs
6. VASCULITIS
Causes
Primary Large vessel: Polymyalgia rheumatica, Takayasu's, Temporal arteritis Medium vessel: Polyarteritis nodosa, Kawasakis, Buergers disease Small vessel: Behet's syndrome, ChurgStrauss syndrome, HSP, Wegener's granulomatosis Secondary RA, SLE, ank spond, dermatomyosits, malignancy e.g. lymphoma, infection e.g. hepatitis C, certain drugs
Features
Unexplained ischaemia: claudication, angina, TIA/CVA, mesenteric/cutaneous/limb ischaemia, MI, gangrene, HTN General symptoms: Fever, weight loss Skin: Palpable purpura Muscles and joints: Myalgia or myositis, arthralgia Nervous system: Mononeuritis multiplex, headache, stroke, tinnitus, reduced visual acuity, acute visual loss Respiratory tract: Epistaxis, haemoptysis GI tract: Abdominal pain, PR bleeding Kidneys: Glomerulonephritis
Buergers disease
Investigations
Raised ESR, CRP, WCC, eosinophils Anaemia ANCA +ve: Wegener's granulomatosis, ChurgStrauss syndrome, microscopic polyangiitis Biopsy of affected organ Angiogram
Treatment
Dependent on type / progression Steroids Immunosuppressants
6a)
A 60 year old woman presents non-specifically unwell with fever and weight loss. She feels pain and stiffness in her shoulders and hips. She has also noticed she has a temporal headache and she has noticed her scalp tender when brushing her hair. What is the most likely diagnosis?
Aetiology
Subacute granulomatous inflammation - Vasculitis
Epidemiology
Age >50 years usually 3F:1M 50% of pts with GCA also have polymyalgia rheumatica 15% of pts with polymyalgia rheumatic also have GCA
Symptoms
Unilateral throbbing/boring pain Constant Temporal artery tenderness: Pain when combing hair Jaw claudication B symptoms: Fever, Weight loss, night sweats, lethargy, depression, arthralgia Visual problems: amaurosis fugax, diplopia, sudden loss of vision.
Signs
Thickened, tender or nodular with pulsation temporal and/or facial artery Proximal myalgias
Investigations
Bloods: ESR (usually >30, but may be normal) +/- normocytic anaemia Temporal artery biopsy: giant cell arteritis Exclude other diagnoses e.g. malignancy, RA, myeloma. When would you biopsy? What if the biopsy was negative for giant cell arteritis?
Complications
Blindness due to involvement of ophthalmic artery (Anterior ischaemic optic neuropathy)
Management
No ocular symptoms: Prednisolone 40-60mg daily Tapering dose Monitor ESR Treatment should not need to be continued for more than a year Ocular symptoms / vision loss: 1mg/kg prednisolone (6080mg) or IV methylprednisolone Same day ophthalmology referral emergency!
Features
Symptoms: Aching, and morning stiffness > 1 hr Pattern: Proximal, symmetrical Systemic: fatigue, fever, weight loss, anorexia and depression Onset: days 2 weeks
Diagnosis if >3 of the following: Bilateral shoulder pain or stiffness Morning stiffness lasting >1hr Bilateral tenderness in the upper arms Weight loss and/or depression Age 65 Onset of illness <2wk ago Initial ESR >40mm/h
Investigations
ESR and CRP FBC : anaemia Alkaline phosphatase, BG, creatinine, lipids, BMD, TB testing USS of hip and shoulder
Management
Physiotherapy Oral corticosteroids e.g. prednisolone 15-20mg daily Tx for initially ~3 years then trial slow withdrawal over 6 months
Plenary
Refreshed gross anatomy of hand Reviewed joint pain history taking Covered all the know about conditions in the curriculum, and the seronegative arthropathies in the know of conditions and seronegative arthritides Equipped to deal with common rheumatological conditions which you may come across as a junior doctor within A&E, GP, dermatology, colorectal/gastroenterology, GUM, ID including rheumatological emergencies Rheumatology is not just about joint pain!!
Question 1
A 24 year old male presents with knee pain, red watery eyes and dysuria. He has also noticed plaques on his hands. What is the most likely diagnosis?
Question 2
Which of the following is an xray feature in rheumatoid arthritis? a) b) c) d) e) Loosers zones Widened joint space Periarticular osteopenia Osteophytes Lytic lesions
Question 3
In a patient with rheumatoid arthritis, what is the most likely cause of a low haemoglobin with a normal MCV, normal WCC and platelet count? a) Iron deficiency b) Feltys syndrome c) Methotrexate d) Anaemia of chronic disease e) Hypothyroidism
Question 4
A 65 year old female presents with a painful right knee. An xray of the knee shows linear calcification of the articular cartilage and lateral meniscus. Given the diagnosis, what would you find on aspiration of the joint? a) Pus b) Positively birefringent crystals c) Negatively birefringent crystals d) No abnormality e) Raised leucocyte count
Question 5
A 62 year old man presents to his GP practice with joint pain affecting his knee and wrist and feeling generally unwell. On examination there is generalised lymphadenopathy and a rash on his shin
What diagnosis do you suspect? How would you confirm it?