Rheumatology Christopher Leddy 0607165l@student.gla.ac.uk
What we will cover • History • Osteoarthritis • Rheumatoid Arthritis • Sero-ve spondyloarthropathies • Gout and pseudogout
History – Think about • Distribution (one joint/many) • Stiffness, swelling, inflammation • Pattern and duration • Systemic features • Family history • Social factors (employment) • GALS/REMS
Osteoarthritis • A chronic and dynamic disorder characterised by cartilage loss and bone remodelling • Most common arthropathy in adults • Classification • Primary/Idiopathic/Generalised Nodal • Secondary • Normal joint with abnormal load • Abnormal joint with normal load
OA – Clinical features • PAIN AND STIFFNESS • Worse at the END of the day • Stiffness after rest (~30 mins) • Background pain at rest • Joint instability / locking • Thumb carpo-metocarpal • Heberden’s nodes (DIP) • Bouchard’s nodes (PIP)
OA - Investigations • Blood (usu normal) • X-Ray • Loss of joint space • Bone cysts • Osteophyte formation • Subchondral bone sclerosis
OA - XR
OA - Management • Conservative • Exercise (improves joint stability) • Wt loss • Walking aids/appropriate footwear • Physio • Medical/Surgical • Simple analgesia + NSAIDs • Intra-articular steroid injections • Joint replacement
Rheumatoid arthrits A chronic systemic inflammatory disease characterised by a symetrical, deforming, peripheral polyarthritis Pathology • Theory of disordered immunity • Rheum Factor + IgG fixes complement • Inflammation of synovium (pannus) • Pro-inflammatory soup dominated by TNFa • Destructive changes
RA – Clinical features • Women (age of onset 20-40 yrs) • Pain and stiffness • Worse in the MORNING • Symmetrical • Small joints of hands and feet
RA – Swan and Bout
RA – ACR diagnosis • Morning stiffness (>1hr > 6/52) • Arthritis of ≥ 3 joints • Arthritis of hand joints • Symmetrical arthritis • Rheumatoid nodules • +ve RhF • Radiographic changes ≥4 is diagnostic
RA • X-ray Changes • Soft tissue swelling • Juxta-articular osteopenia • Loss of joint space • Bony erosions • Subluxation • Bloods • RhF / anti-CCP / FBC / Coag / ESR / CRP
RA - Management • Pain relief: Simple + NSAIDs and titrate • Steroids: Glucocorticoids • DMARDs • MTX • Sulfasalazine • Hydroxychloroquine • Leflunomide • Gold • Biological / Anti-TNF • Infliximab • Etanercept • Adalimumab
DMARDS - SE MTX – Hepatotoxicity / pneumonitis Sulfasalazine – Reduces sperm count / Rash Hydroxychloroquine – Irreversible retinopathy Leflunomide – Teratogenicity Biologicals Contra-indicated in pregnancy / breast feeding
Seronegative sponds • Ankylosing Spondylitis • Psoriatic arthritis • Reactive arthritis • Seronegative • HLA B27 assoc • Axial Arthritis • Large joint oligoarthritis / monoarthritis • Enthesitis • Dactylitis • Extra-articular manifestations
Ankylosing spondylitis • Young male with low back pain • Morning stiffness relieved by exercise • Worse at night • Pain at sacro-iliac joints • Progressive loss of spinal movements • Treatment • Exercise • NSAIDs • DMARDs
Psoriatic Arthritis • Hx of Psoriasis (10-40%) • Asymmetrical oligoarthritis • DIP joints affected • Skin and nail changes • Treatment • Analgesia + NSAIDs • Steroids • MTX / Sulfasalazine • Anti-TNF agents
Reactive arthritis • Arthritis post infection • Reiters syndrome • Arthritis • Urethritis • Conjunctivitis • Causes • GI: Shigella / Salmonella • GU: Gonorrhoea / chlamydia • Treatment • Treat cause • NSAIDs (self-limiting)
Gout • Crystal arthropathy (monosodium urate) • Commonest inflammatory arthritis in men • Very Painful • Peripheral joints (usu a monoarthropathy) Risk Factors • Alcohol • Thiazide diuretics • High purine diet • Obesity
Gout • Podagra (first metatarsophalangeal joint) • Gouty tophi as disease becomes polyarticular • Gouty nephropathy
Gout - Treatment Acute attack • Simple analgesia • NSAIDs • Colchicine • Steroids Chronic • Lifestyle • Allopurinol • Address risk factors (alcohol/fasting)
Pseudogout • Calcium pyrophosphate dehydrate arthropathy • Risk factors • Age • OA • Neuropathic joints • Haemochromatosis • Wilson’s disease
Pseudogout • Usually spontaneous and self limiting • Typically affects larger joints
Pseudogout Treatment • Analgesia ± NSAIDs • Steroids (IA/IM)
Past paper question A 65-year old obese lady presents with increasing pain in the right groin. Pain is worse on walking and at the end of the day and she volunteers the information that she also gets pain in the right knee at a similar time. What is the most likely diagnosis and which is the joint involved? Osteoarthritis of the right hip
Past paper question A 65-year old obese lady presents with increasing pain in the right groin. Pain is worse on walking and at the end of the day and she volunteers the information that she also gets pain in the right knee at a similar time. You decide to arrange an x-ray. Name 4 features that you would be likely to see in this case. • Loss of joint space • Subchondral bone sclerosis • Osteophyte formation • Boney cysts
Past paper question A 65-year old obese lady presents with increasing pain in the right groin. Pain is worse on walking and at the end of the day and she volunteers the information that she also gets pain in the right knee at a similar time. What is the most appropriate form of management. Name 2 aspects and mark the one you consider to me most important. • Lose weight (most important) • Simple analgesia
Past paper question A 65-year old obese lady presents with increasing pain in the right groin. Pain is worse on walking and at the end of the day and she volunteers the information that she also gets pain in the right knee at a similar time. 6mo later she continues to complain of pain, which is not relieved by your primary treatment. The pain now wakes her at night and you notice a 5o fixed flexion deformity. What procedure would now be indicated? Hemi arthroplasty
Past paper question A 65-year old obese lady presents with increasing pain in the right groin. Pain is worse on walking and at the end of the day and she volunteers the information that she also gets pain in the right knee at a similar time. Her daughter asks you about long-term complications of this surgical procedure. Describe 2 long-term complications that you would tell her about. Loosening of the prosthesis Wearing of the bearing Late infection Peri-prosthetic fracture
Summary Young man – Anky spond Old man – OA / Gout Young woman – RA Old woman – OA Morning stiffness – Sero-/RA Evening stiffness - OA
Summary
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