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Rheumatology Revision Everything you need to know in one hour!

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Likely exam situations Rheumatology History Hand examination (knee, ankle and foot) Common Rheumatology referrals Back pain- prevalence, approach to Ix and Mx, differentiating inflammatory vs non-inflammatory Connective Tissue Diseases Rheumatology Emergencies- septic joint, vasculitis, lupus flare.

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A quick reminder of joint names

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History taking Presenting Complaint Pain - SOCRATES Arthritis Inflammatory or non-inflammatory Redness, heat, swelling, early morning stiffness Symmetrical or asymmetrical Mono/oligo/polyarthritis

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Associated features RA: Raynauds, fever, malaise, chest symptoms, dry eyes and mouth Seronegative: red sore eyes, back pain, rash, diarrhoea CTD: same as RA + consider alopecia, muscle pain/weakness, difficulty swallowing, rash

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Osteoporosis risk factors Fibromyalgia Sleep pattern Associated conditions IBS, migraine

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PMH Any arthritic conditions Any autoimmune conditions (thyroid disease most common) Inflammatory bowel disease Psoriasis DH In a patient with a known diagnosis of inflammatory arthritis, take a full DMARD hx Think about diuretics and antihypertensives if suspecting gout

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FH Same as for PMH Maternal hip fracture for osteoporosis SH Cigarettes and alcohol Functional status at home and at work System Enquiry

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Joint pain Arthritis Inflammatory Arthritis Non inflammatory Arthritis Metabolic Vitamin D Pagets Osteoporosis Soft Tissue Rheumatism Fibromyalgia Regional Pain syndromes

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Fibromyalgia Middle aged women Widespread myalgias and arthralgias Trigger points Associated sleep disturbance

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Also associated with IBS Migraine Depression and anxiety Chronic fatigue syndrome (part of a spectrum) A DIAGNOSIS OF EXCLUSION!

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Osteoarthritis Classification By site By cause By features Risk factors Obesity, sex, genetics, hypermobility Trauma, inflammation, sepsis, AVN, slipped epiphysis, obesity, occupation

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Osteoarthritis clinical features Hand Heberdens (DIPJ) and Bouchards (PIPJ) nodes 1st CMC squaring Generalised wasting Knee: Quadriceps wasting Crepitus Cool effusion Valgus/varus deformity Instability Hip: Reduced rotation (internal) Trendelenburg +

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Osteoarthritis X-rays Sclerosis Osteophytes Loss of joint space Cysts

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Osteoarthritis - treatment Lifestyle modification (weight, exercise) Footwear Physiotherapy Quadriceps exercises Occupational therapy Complementary therapies Intra-articular steroid Drugs Simple analgesia NSAIDs be aware of side effects COX-2 inhibitors controversy about cardiovascular side- effects Glucosamine controversy whether it works. Great placebo effect!

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Which of the following statements regarding rheumatoid arthritis is correct? A. A negative anti CCP antibody confers a worse prognosis B. Rheumatoid nodules only occur in seropositive disease C. Men are affected more frequently than women D. 1 in 1000 of the population are affected E. Prednisolone is the first line therapy

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Rheumatoid Arthritis Symmetrical inflammatory polyarthritis Propensity to affect small joints +ve rheumatoid factor (80-90%) Rheumatoid nodules 1% of adult population Female to male 3:1 Peak onset age 35-45

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Chronic Inflammation in the Rheumatoid Synovium Pannus PMN Cytokine Bone Activated T cells Macrophage B cell Inflamed synovial membrane Eroding cartilage

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RA extra-articular problems Raynauds Sicca syndrome Pericarditis Pleuritis/ Pulmonary Fibrosis Subcutaneous Nodules Ocular Inflammation Neuropathies Vasculitis Increased cardiovascular risk

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Primer on the Rheumatic Diseases. 12 th ed. Atlanta, Ga: The Arthritis Foundation; 2001: 225-231. Induce remission Reduce pain and inflammation Improve physical function Retard/halt joint destruction Improve survival Goals of Therapy in RA

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RA - treatment Physiotherapy Occupational therapy DMARDs Methotrexate Sulfasalazine Gold Anti TNF drugs Etanercept Adalimumab Certolizomab B cell inhibitors T cell co stimulator inhibitors IL6 inhibitors

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RA hands 1 Look Typical rheumatoid deformities Joint swelling,subluxation, swan neck, Boutonnieres, ulnar deviation Muscle wasting Rheumatoid nodules (remember elbows) Rash Palmar erythema Purpura (and skin thinning) 2ndary to steroids Livedo reticularis / skin mottling (associated with Raynauds) Nailfold infarcts / splinter haemorrhages (rheumatoid vasculitis)

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RA hands 2 Feel Is the arthritis active? Move Assess function Grip strength Writing Buttons Other bits Consider further muscle and neurological assessment

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OA hands Look Heberdens nodes Bouchards nodes Squaring of hand (OA of 1 st CMCJ) Check elbows (you shouldnt see anything!) Feel Is there active inflammation? Move Assess function

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Your final statement Come up with a diagnosis Explain how you got to the diagnosis Comment on function

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Asymmetrical inflammatory oligoarthritis Tends to affect large joints HLA B27 +ve Distinctive features Sacroiliitis Dactylitis Uveitis Seronegative inflammatory arthritis

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R eactive Post infection, esp diarrhoea or STD Reiters classic triad of arthritis, urethritis and uveitis A nkylosing spondylitis Classically young men with inflammatory back pain Can also get peripheral arthritis Sero ve subtypes (RAPE)

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RAPE continued P soriatic arthritis Can develop before onset of psoriasis 5 different patterns (oligoarticular, RA-like, sacroiliitis, DIPJ and nail involvement only, arthritis mutilans) E nteropathic arthritides Associated with inflammatory bowel disease

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Crystal Arthritides Gout Inflammatory response to monosodium urate monohydrate crystals (needle shaped, negatively birefringent) Associations: age, sex, alcohol, hypertension, renal impairment, diuretics

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Acute Rapid onset 90% monoarticular 1 st MTPJ in >50% of first attacks Usually settles within 7-10 days Chronic Gouty tophi Urate nephropathy

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Urate

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More crystal arthritides Pseudogout Calcium pyrophosphate crystal deposition in joints (rhomboid positively birefringent) Mainly elderly, F>M, ubiquitous Acute self-limiting synovitis Chronic arthropathy strong assoc / overlap with OA

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Pyrophosphate

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Septic Arthritis Predisposing factors immunosuppression pre-existing joint damage iv drug abusers age indwelling catheters 80% monoarthritis, 20% oligo or polyarthritis S. aureus, gram ve organisms, Neisseria gonorrhoeae

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Connective Tissue Diseases Rheumatoid arthritis SLE Sjogrens Scleroderma Polymyositis Dermatomyositis Polyarteritis Nodosa Wegeners Granulomatosis

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Connective tissue diseases Common factors Raynauds General malaise ANA +ve Raised inflammatory markers Secondary Sjgrens Lung fibrosis

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Autoantibodies RARheumatoid factor SLE ANA, dsDNA, antiphospholipid antibodies (anticardiolipin, lupus anticoagulant) SSc Anticentromere antibody (limited) Scl-70 (diffuse) MyositisAnti-Jo-1 WegenersANCA SjogrensAnti-Ro, Anti-La (part of ENA) Overlap syndromesAnti-RNP (part of ENA)

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Young women Blacks and Hispanics 12/100,000 in UK

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SLE diagnostic criteria 4 out of 11 of: Malar rash Discoid rash Photosensitivity Oral ulcers Arthritis Serositis (pleurisy, pericarditis, peritonitis) Renal proteinuria >0.5g/24h or 3+ cellular casts Neurological Seizures or psychosis Haematological Haemolytic anaemia or low WCC (