Rheumatology for AMK

Abhinav Singh PMS

Objectives
Talk through presentation, diagnosis and

management of core rheumatology. RA, OA, SPA, CA, SA.

Tackle 3 AMK style questions.

Connective tissue diseases, metabolic

bone diseases and MSK examinations not covered.

Rheumatoid arthritis
Chronic systemic disease, primarily

affecting the synovial joints.

Typically presents as an insidious

polyarthritis.
Inflammatory changes in the synovial

membrane and articular surfaces causes deformity / pannus.

 1 % incidence. M:F = 1:3. Typical onset between 40 and 70.

However, JA is also recognised.

Aetiology considered multifactorial, yet

60% of a populations predisposition is genetic.

Environmental contribution not yet clear

and hormonal influences may also exist.

Clinical presentation
Articular manifestations-

Local pain, swelling and erythema

Stiffness following inactivity Z thumb, swan-neck deformity Extra- articular manifestations-

Nodules
Vasculitis / Neuropathy Sjogrens syndrome

Diagnosis and Management

X rays Soft tissue swelling, narrow joint

spaces, peri/juxta-articular erosion

RF Anti-CCP.
WHO-analgesia ladder Paracetamol, NSAIDS, Steroids,

DMARDS, Biological agents

Osteoarthritis
Synovial joint disease characterised by

loss of articular cartilage and overgrowth of underlying bone.

Considered to be a degenerative joint

disease.
OA is multifactorial, active disease which

usually begins in middle age.

 10 % of all x-rays have OA.

M:F = 1:2. Higher incidence in elderly.

The correlation between radiographic findings and symptoms is poor.

Risk factors include obesity and past sports injuries.

Clinical presentation
Pain is usually aching or burning in nature,

worsening over years, localised to the joint itself or the one below.
Pain is worse after activity, improved by

rest.
Hyperplasia of the synovium leads to

deformity (Heberdens & Buchard nodes). Chondral destruction causes varus

Diagnosis and Management

Diagnosis is usually clear from history and

examination.
X-ray shows classical changes- LOSS. No cure for OA therefore the aim is to

reduce pain and conserve function. Analgesia commonly used with the surgical option being joint replacement.

Spondyloarthropathies
SPA describes a group of related and

overlapping inflammatory conditions.

Characterised by enthesitis and

synovitis. Sero ve.

All types are associated with HLA-B27

(MHC class 1 anatigen). Most prevalent in ankylosing spondylitis (85-95%).

Ankylosing spondylitis
Recurrent enthesitis leads to fibrosis

and ossification. Incidence of 1%, occurs mid-20s.

Outer fibres of vertebral discs become

inflamed where they attach to vertebral body.

Over time this causes squaring,

syndesmophyte production and fusing of

Clinical presentation
MSK features-

Lower back pain and stiffness, improves

with exercise Schrobers test- Dimples of venus, ? posture

Extra skeletal features Anterior uveitis Aortic incompetence / aortitis

Apical lung fibrosis

Diagnosis and Management

Raised ESR, CRP. FBCs, Genotyping

for RA is expensive.
X-rays- Bamboo spine. Physiotherapy, Drugs (NSAIDS-

Indomethacin; DMARDS; local steroids; biological agents), Surgery (osteotomy).

Reactive arthritis
Aseptic arthritis that develops after an

anatomically distant infection.

Shigella, Salmonella- GI; Chlamydia-

GU.
Symptoms start a few weeks after

infection.

Clinical presentation
MSK features Typically asymmetrical and oligoarticular Dactylitis- sausage fingers Extra skeletal features Conjunctivitis Urethritis Skin and mucosal lesions- Circinate

balanitis Reiters syndrome- arthritis, urethritis and

Diagnosis and Management

Raised ESR, CRP. FBCs, serological

antibody tests, GU tests (cervical swab, MSU).

Exclude septic arthritis- synovial fluid

drain.
Drugs (NSAIDS, local steroid, DMARDS

in severe disease).

Enteropathic arthritis
Arthritis associated with IBD. 10-20% of patients with Crohns disease

and ulcerative colitis.

Clinical presentation
Peripheral arthritis
Asymmetrical, mono or oligoarticular can

develop Worsens with severity of bowel disease

Spondylitis and sacroiliitis Not to do with arthritis but a marker of

IBD
Enthesopathy

Diagnosis and Management

GI tests to confirm flare, stool samples

etc.
X-ray changes can be typical of AS. Manage flare with steroids, sulfasalazine

and biological agents. No NSAIDS.

Psoriatic arthropathy
Inflammatory arthritis associated with

psoriasis.
1-3% of the population get psoriasis and

10% of these patients get PA.

More common with nail involvement.

Clinical presentation
PA may precede diagnosis of psoriasis.

Check scalp and natal cleft.

MSK features Distal arthritis of DIPJ Asymmetrical oligoarthritis Symmetrical polyarthritis like RA Spondylitis Arthritis mutilans- reabsorption of

metacarpals and phalanges

Diagnosis and Management

Raised ESR, CRP. FBCs, RF is absent. X-rays- erosion with proliferation of

adjacent bone, reabsorption of terminal phalanges, pencil-in-cup deformity, periostitis.

Physiotherapy, drugs (NSAIDS, local

steroid, DMARDS in severe disease).

Crystal arthropathies- Gout

Gout is a consequence of

hyperuricaemia and uric acid crystal formation.

Classified as acute and chronic.
Uric acid is a breakdown product of

purine bases. Nucleic acid hypoxanthine xanthine Uric acid (xanthine oxidase).

Clinical presentation
Acute Extremely painful, accelerating

monoarthritis (1 MTP). Can also affect the olecranon bursae (elbow).

Chronic Gouty tophi leads to deformity through

destruction of joint cartilage. Renal disease through deposition in

Diagnosis and Management

Raised serum uric acid is not diagnostic.

Normally ESR, CRP and WBC counts are raised.

X-rays- No changes appear until

recurrent gout attacks. Crystal analysisNeedle shaped crystals with negative bifringence.
Acutely- NSAIDS, colchicine and

corticosteroids. Prophylaxis- Allopurinol

Psuedogout
Deposition of calcium pyrophosphate

dihydrate crystals leading to acute synovitis.

Less common than gout, predominance

in elderly and slightly higher in females.

Deposition on cartilage, synovium and

joint capsule.

Clinical presentation
Acute Monoarthritis commonly of the knee
Swollen, erthematous joint which

resolves in a week
Chronic Many similarities to OA- pain, stiffness and loss of function Wrist, elbows and ankles affected unlike OA

Diagnosis and Management

Raised serum uric acid is not diagnostic.

Normally ESR, CRP and WBC counts are raised.

X-rays- Chondrocalcinosis and OA like

changes. Crystal analysis- Rhomboid or rod shaped crystals with positive bifringence.
Physiotherapy, analgesics, NSAIDS and

Septic arthritis
A medical emergency! Seen more often in children, young

adults and elderly.

Infection reaches to the synovial joint via

haematogenous route.
N. gonorrhoeae is most likely causative

organism.

Clinical presentation
Acutely hot and swollen joint (hip and

knee). Fever and systemically unwell.

All movement causes intense pain and

weight bearing is not possible.

Passive examination is not possible.

Diagnosis and Management

Raised ESR, CRP and WBC counts. X-rays- Initially normal and later show

joint destruction. US is more useful in looking joint effusion (if cloudy, send for MC&S).
Conservative- Analgesia, splinting and

antibiotic therapy. Surgical- emergency drainage.

Questions
An elderly woman presents with symmetrical swollen

and painful wrists. Pain is affecting her functionality and she has also noticed and unsightly swelling around her elbow.
A 22 year old male develops lower back pain &

stiffness, which is worse in the morning & is relieved by exercise.

Following an acute attack of dysentery, a 46 year old

male develops heel pain and pustular sores on the soles of his feet & a right knee joint effusion.
A rugby player has a traumatic dislocation of his knee.

Few days later he presents with acute pain in the