Phase 2 Harriet Ribbons and Caroline Hoernig The Peer Teaching Society is not liable for false or...

Phase 2

Harriet Ribbons and Caroline Hoernig

The Peer Teaching Society is not liable for false or misleading information…

• Understand the different types of arthritis:– Osteoarthritis– Rheumatoid Arthritis– Seronegative spondyloarthropathies– Crystal arthropathies

• Understand Systemic Lupus Erythematousus (SLE)


Aims:

• Common joint condition• Causes pain and inflammation in a joint• 10,000 people per year seek help for arthritis• Symptoms include:


Arthritis Introduction:


JOINT PAINJOINT PAIN

INFLAMMATORY NON-INFLAMMATORY

Autoimmune Crystal arthritis Infection Degenerative Non-Degenerative

Rheumatoid arthritis

Seronegative Spondylarthropathy

Connective tissue disease

Sports medicineSports medicine

• Pain eases with use, worst at rest

• Morning stiffness >60mins

• 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

<30mins• Bony swelling• Not clinically inflamed• Affects older patients,

prior occupation/sport• Knees, hips, CMCP• Less convincing response

to NSAIDS


Inflammatory Degeneratve


INFLAMMATORYINFLAMMATORY

• Affects synovial joints• Joints affected:

– (DIP sparing)– PIP– MCP– Wrists– Feet

• Bony erosions on XRay


Rheumatoid Arthritis (RA)Rheumatoid Arthritis (RA)

Hypertrophy synovium -> New capillary formation -> Inflammtion -> Synovial villi form and grow into bone -> PANNUS -> Cytokines released

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


RA risk factors:RA risk factors:

• 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


RA symptoms:RA symptoms:

4 of the following symptoms:

1. Morning stiffness >1 hour >6 weeks

2. Arthritis >3 joints

3. Arthritis in hand joints

4. Symmetrical arthritis

5. Rheumatoid nodules

6. Positive RF

7. Radiological changes


RA diagnosis:RA diagnosis:

Z-Shaped thumb

Hypertrophy synovium -> New capillary formation -> Inflammtion -> Synovial villi form and grow into bone -> PANNUS -> Cytokines released

1.Soft tissue swelling

2.Juxta articular osteopenia

3.Loss of joint space

4.Bony erosions


RA Xray changes:RA Xray changes:


Extra-articular involvement

• Bloods:– FBC

• Anaemia

– ESR• High

– RF• Positive in 80%

– Anti CCP• Positive in 80%

– ANA• <50% positive

– ALL TESTS NEGATIVE IN 20%

• Xray– Erosions seen– Periarticular osteopenia– (Joint space narrowing)


RA investigations:RA investigations:

• 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


RA treatment:RA treatment:


DEGENERATIVEDEGENERATIVE

• 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


Osteoarthritis


Radiological changes in OA


Clinical features of OA• Symptoms;- PAIN- POOR MOBILITY- FUNCTIONAL IMPAIRMENT

• Signs:- ALTERED GAIT- JOINT SWELLING/TENDERNESS- CREPITUS

• 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


Treatment of OA


SERONEGATIVE SERONEGATIVE SPONDYLARTHOPATHYSPONDYLARTHOPATHY

– High rate of HLA-B27

– Rheumatoid factor NEGATIVE.

– Types

• Ankylosing spondylitis

• Psoriatic arthritis

• Reactive arthritis

• Enteropathic arthritis



– Ankylosing spondylitis

– Psoriatic arthritis

– Reactive arthritis

– Enteropathic arthritis



• 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)


Ankylosing Spondylitis (AS):Ankylosing Spondylitis (AS):

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


AS risk factors:AS risk factors:

• 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


AS symptoms:AS symptoms:

- A Atlantic axial instability

- A Atypical lung fibrosis

- A Anterior uveitis

- A Amyloidosis

- A Autoimmune bowel disease and UC

- A Aortic incompetance


6 A’s of AS:6 A’s of AS:

• Aortic incompetence• Cardiomegaly• Amyloidosis• Fractures• Fatigue• Weight loss• Low grade fever• Anaemia• Upper lobe pulmonary

fibrosis• Iritis• Pleuritis• Osteoporosis


AS extra-articular symptoms:AS extra-articular symptoms:

• 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


AS investigations:AS investigations:

• Exercise• Physiotherapy• NSAIDs

– Pain relief• Disease Modifying Anti Rheumatic Drugs (DMARDs):


• Biological drugs:– Rituximab (Anti CD20), etanercept (TNF inhibitor) and abatacept

(T cell stimulator modulator) – Inhibits the immune system

• Local steroid injections


AS treatment:AS treatment:

• Joints affected:– DIP– Spine– Nail involvement – Sacroiliac joints

• In people with psoriasis or family history of psoriasis

• Less severe than RA


Psoriatic arthritis:Psoriatic arthritis:

- 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


Psoriatic arthritis types:Psoriatic arthritis types:


Psoriatic arthritis symptoms:Psoriatic arthritis symptoms:

• Bloods:

– ESR

• High

– FBC:

• Anaemia

• Xray


Psoriatic arthritis investigations:Psoriatic arthritis investigations:

• Exercise• NSAIDs

– Pain relief• Disease Modifying Anti Rheumatic Drugs (DMARDs):


• Biological drugs:– Rituximab (Anti CD20), etanercept (TNF inhibitor) and

abatacept (T cell stimulator modulator) – Inhibits the immune system


Psoriatic arthritis treatment:Psoriatic arthritis treatment:

• Triad of symptoms:– Can’t see (Conjunctivitis)– Can’t pee (Urethritis)– Can’t climb a tree (Arthritis)

• Common in 18-30• Commoner in lower extremities• 30% chronic.• Majority resolve within 3-24

months


Reactive arthritis (Reiter’s):Reactive arthritis (Reiter’s):

• Shigella• Chlamydia• Salmonella• HIV• Enterocolli.


Reactive arthritis Causes:Reactive arthritis Causes:

• Bloods:

– ESR

• High

• ECG

• Xray


Reactive arthritis investigations:Reactive arthritis investigations:

• NSAIDs

– Pain relief

• Steroids

– Used in flare ups

• Antibiotics

– Treat the underlying cause

• (DMARDs)


Reactive arthritis treatment:Reactive arthritis treatment:

• 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


Enteropathic arthritis:Enteropathic arthritis:


CONNECTIVE TISSUE DISEASECONNECTIVE TISSUE DISEASE

• Inflammatory, multisystem autoimmune disorder -> 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


Systemic lupus erythematosus

• Most suffer from…- FATIGUE- ARTHRALGA (>90%) -> symmetrical, small joints,

deformity and erosions rare- SKIN PROBLEMS (85%) -> butterfly rash, vasculitic

lesions, photosensitivity, raynauds• But can affect any organ…

– Lungs, heart, nervous system, eyes, GI system

• DIAGNOSIS -> based on ACR criteria, must have >4/11


Clinical features of SLE


Other manifestations in SLE

• FBC– Often pancytopenia (low WBC, anaemia,

thrombycytopenia)– Raised ESR

• U + E’s– 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 -> C3 and C4 often decreased in active disease


Investigation of SLE

• Avoid sunlight exposure• Decrease cardiovascular risk factors• NSAIDS -> for arthritis, fever• Antimalarials -> chloroquine, hydroxychloroquine• Corticosteroids -> for severe flares, IMI, higher doses in

renal/cerebral disease• Cyclophosphamide, Mycophenoate, Azathioprine, MTX

– Severe flares, not controlled by steroids

• Biologics -> RITUXIMAB (Anti-CD20)


Management

• 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


Course and prognosis of SLE


CRYSTAL ARTHROPATHYCRYSTAL ARTHROPATHY


Crystal arthropathies

GOUT-> hyperuricaemia-> intra-articular sodium urate crystals

PSEUDOGOUT-> calcium pyrophosphate crystals


GOUT

• Increased prevalence in developed countries; diet important!

• M:F = 10:1• Prevalence in older female is increased by diuretic use• Pathology;

Hypoxanthine ===> Xanthine ===> 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


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


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 >600umol/L

• Serum urea/creatinine/eGFR– Monitored for renal impairment


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 <360um/L*ALLOPURINOL*– Blocks xanthine oxidase– Given for frequent attacks despite change in diet/if patient can’t

tolerate NSAIDS/if renal impairment present/tophi


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


Pseudogout• Calcium pyrophosphate deposits in hyaline or fibrocartilage• Similar to acute gout but…more common in elderly women,

usually affects knee and wrists• DIAGNOSIS;- Appearance of chondrocalcinosis on XRay- Joint aspirate -> rhomboidal, weakly positive birefringent

crystals• Treatment- Joint aspiration- NSAIDS or COLCHICINE

GOOD LUCK!

Phase 2 Harriet Ribbons and Caroline Hoernig The Peer Teaching Society is not liable for false or...

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