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Martin Edobor, John Lewin
Rheumatology
Objectives
• Go through GALS screen OSCE station
• Cover key Rheum Topics
• Practice SBA
• General Advice
Topics to be covered
•Osteoarthritis
•Rheumatoid Arthritis
•SLE
•Seronegative arthopathies
Not covered
Connective tissue diseases (polymyositis, system sclerosis, Sorgjerns syndrome)
Crystal arthropathies (gout, pseudogout)
Vacuities (GCA, polyarteritis nodosa)
Drugs and there side effects! IMPORTANT
Disclaimer: This presentation is just a guide!
Osteoarthritis (1)
Mechanical Degeneration of joint cartilage.
Epidemiology: >70yrs,
Risk Factors: Obesity, menopause, smoking, sportsmen, trauma.
Pathology: Damage to cartilage leads to oedema, death of chondrocytes.
Fibrillation and fissuring of cartilage, ulceration and micro fractures occur.
Eventually underlying bone is exposed leading to cyst and osteophytes.
Symptoms: Joint Pain, Joint Gelling, Joint instibility Loss of function
Osteoarthritis (3)
Signs: Herberderns Nodes (DIP), Bouchards Nodes (PIP)
Joints affected: DIP (single joint), Hip (unilateral), Knee (usually bilateral)
Investigations: X-Ray Joint Narrowing, Subchondral cyst, Subcondral
sclerosis, osteophyte formation.
Osteoarthritis (3)
Management
1. Advice about weight loss, local muscle strengthening exercises
2. Paracetamol and topical NSAIDs are first-line analgesics.
3. Second-line treatment is oral NSAIDs/COX-2 inhibitors, opioids, and intra-
articular corticosteroids.
4. If conservative methods fail then refer for consideration of joint replacement
Rheumatoid Arthiritis (1)
A chronic symmetrical inflammatory polyarthititis with systemic
involvement
Epidemiology: F>M 3:1, ages 30-50
Associated with HLA-DR4
Pathology: Autoantibodies (IgM) to Fc of IgG, forming immune complexes
which deposit in joints leading to inflamation.
Symptoms: Pain (decrease with activity), swelling, morning stiffness
>30mins,.
Joint Involvement: MCP, MIP, PIP, MTP SYMETRICAL!
Rheumatoid Arthritis (2)
Rheumatoid Arthritis (3)
Rheumatoid Arthritis (4)
Systemic extra-articular involvement:
Skin: Rhumatoid nodules, synivotendonitis
Lungs: Effusions, nodules, fibroisis, Caplans syndrome: a combination of
pneumoconiosis and RA
Eyes: Sclertis (painful red eye), Episcleritis(non-painful red eye), Sorgjerns
syndrome
Neural: Mononeuritis multiplex, Carpal tunnel
Felty Syndrome: RA with splenomegaly and neutropenia
Normochromic normocytic anaemia
Rheumatoid Arthritis (5)
Investigations
ESR, CRP Increased
Possible Anaemia
RF +ve in 70% of cases, Anti-ccp positive in >90% of cases
CXR –Swelling of soft tissue, erosions, joint narrowing, juxto-articular
osteopenia
Year 3 Rheumatology Course
Rheumatoid Arthritis (6)
Management
2009 NICE guidelines it is recommend that patients with newly
diagnosed active RA start a combination of DMARDs (including
methotrexate and at least one other DMARD, plus short-term
glucocorticoids)
1.DMARDS
Methotrexate (s.e derange LFT’s renal, neutopenia, PF, teratogenic)
• Sulfasalazine (s.e infertility, G6PD heamolysis)
• Lefunimide
Others e.g Azathriopine, Gold
(Also add prednisolone)
The current indication for a TNF-inhibitor is an inadequate response to
at least two DMARDs including methotrexate
4. Anti TNF alpha, use if DMARDS failed
e.g Entgeracept, Adelumimab , Infliximab
Side effects increase risk of cancer, infection, reversible refulx and
demylinating disease.
If a diagnosis of RA is yet to be made, you can give your patient NSAIDS (if
no contraindication) or a steroid injection
Systemic Lupus Erythematosus
SLE an “Systemic, inflammatory, multisystem disorder”
Autoimmune disease in which auto-antibodies and immune complexes
cause damage to organs.
Epidemiology: High prevalence in Afro-carribeans, Peak age of onset 20-
40 years
Aetiology: Hereditary , Genetic, Immune system disorder (Autoantibody
production + impaired tolerance), UV light , Drugs.
Clinical features
• Musculoskeletal 90% :
-Symmetrical, small joint, arthralgia, - Jaccoud’s arthropathy –Joint
deformity resembling RA – rare
• Cutaneous 75%
-Malar Rash:
-Discoid Lupus
• Neurology 60%
-Cerebral Lupus
• Lungs 50%
-Recurent pleurisy and BILATERAL pleural effusions
- “Shrinking Lung syndrome’
• Renal 30% (Histological changes are frequent)
- Regular screening for urine for blood and protein required
Diagnostic Criteria
Criterion Definition/examples
1. Malar rash
Fixed erythema over the malar eminences, tending to spare the nasolabial
folds
2. Discoid rash Erythematosus raised patches, may scar
3. Photosensitivity Skin rash as a result of unusual reaction to sunlight
4. Oral ulcers Usually painless
5. Arthritis Non-erosive: Jaccoud's arthropathy
6. Serositis
a) Pleuritis – pleuritic pain, pleural rub, pleural effusion b) Pericarditis – ECG
changes, rub, pericardial effusion
7. Renal disorder a) Proteinuria (> 3+ or 0.5 g/day) b) Cellular casts in urine
8. Neurological disorder a) Seizures b) Psychosis
9. Haematological disorder
a) Haemolytic anaemia b) Leukopaenia c) Lymphopaenia d)
Thrombocytopaenia
10. Immunological disorder a) Anti-DNA antibodies b) Anti-Sm antibodies c) Anti-phospholipid antibodies
11. Anti-nuclear antibody Exclude drug causes
American College of Rheumatology:
A person is said to have SLE if he/she meets any 4 of these 11 criteria simultaneously or in succession
Investigations
• Bloods
FBC: Leucopenia, lymphopenia and/or thrombocytopenia
ESR: Raised
CRP: Normal
U+E: Urea and Creatinine raised in advanced renal disease
• Urine Testing: Protein in urine and RBC Caste
• Complement: Low C3 Low C4
Imaging
• CT– infarcts or haemorrhage with evidence of cerebral atrophy
• MRI – lesions in white matter
Serum Antinuclear Antibodies (ANA) Positive >95%
Double stranded DNA Specific for SLE
Positive 60%
ENA: Anti-Ro and Anti-LA Detected
RF Positive in 40% of patients
Anticardiolipin antibodies Present in 35-45% of patients
Serological Syphilis Test False Positive 1/3rd
Investigation-Serology
Management
• Symptomatic treatment
-NSAIDS
-Antimalarials: e.g hydroxychloroquine
• Corticosteroids and immunosuppressive drugs
-Single dose I.M corticosteroids for flares
-immunosuppressive drugs for severe thrombocytopenia,
renal and cerebral diseases.
Seronegative arthiritis
A seronegative arthritis is an arthritis that is distinguished from rheumatoid arthritis due to
the absence of rheumatoid factor.
• Reactive arthritis
• Ankylosing spondylitis
• Enteropathic arthiritis
• Psoriatic arthritis.
Reactive Arthritis (1)
A generic term for a sterile arthritis following an infection (e.g. rheumatic fever, post
viral arthritis etc.)
Aetiology
Onset following an infectious episode either involving the GI or GU tract
GI: Shigella, Salmonella, Campylobacter,
GU: Chlamydia, Mycoplasma species
Acute pattern of clinical course 1-4 weeks post-infection
Epidemiology
• HLA-B27 patients
• axial > peripheral involvement
• M > F
Year 3 Rheumatology Course
Reactive Arthritis (2)
Signs and Symptoms
• Musculoskeletal peripheral arthritis, asymmetric pattern, Achilles tendinitis,
dactylitis (“sausage digits”)
• Ophthalmic iritis (anterior uveitis)
• Dermatologic
keratoderma blennorrhagicum (hyperkeratotic skin lesions on palms and soles)
Balanitis circinata (small, shallow, painless ulcers of glans penis and urethral
meatus) are diagnostic
• Gastrointestinal Oral ulcers, diarrhoea
Urethritis + arthritis + conjunctivitis = reactive arthritis
Reactive Arthritis (3)
Investigations
• diagnosis is clinical plus laboratory
• lab findings: normocytic, normochromic anemia and leukocytosis
• cultures are sterile
Treatment
Appropriate antibiotics if there is documented infection
NSAIDs, physical therapy, home exercise
Local therapy: Joint protection, intra-articular steroid injection, topical steroid for ocular
involvement
Systemic therapy : Corticosteroids, sulfasalazine, methotrexate (for peripheral joints only)
Year 3 Rheumatology Course
Ankylosing spondylitis (1)
Epidemiology
• incidence 0.2% of general population
• M: F = 5:1; females have milder disease
• 9% HLA-B27 positive in general population
Pathology
• inflammation of ligament where it attaches to bone leading to osteopenia, then erosion,
then ossification
Ankylosing spondylitis (2)
Symptoms
mid- and low-back stiffness, pain at rest, persistent buttock pain, painful sacroiliac joint
Signs: Decreased Schöber test
Extra-articular manifestations
• ophthalmic: acute anterioruveitis (25-30% patients)
• cardiac: aortitis, aortic regurgitation, pericarditis, conduction disturbances, heart
• failure (rare)
• renal: amyloidosis and IgA nephropathy
• respiratory: apical fibrosis (rare)
• neurologic: cauda equina syndrome (rare)
Year 3 Rheumatology Course
Ankylosing spondylitis (3)
Investigations
• x-ray
Symmetric sacroiliitis “pseudowidening” of joint due to erosion with joint sclerosis ’ bony
fusion (late), • x-ray of spine: appearance of “squaring of edges” from erosion and sclerosis
on corners
“bamboo spine” of vertebral bodies leading to ossification of outer fibres of annulus fibrosis
(bridging syndesmophytes), this produces a radiographically
Year 3 Rheumatology Course
Ankylosing spondylitis (4)
Diagnosis
Modified New York Criteria
Clinical criteria
Low back pain >3months, improves on exercise but not relived by rest.
Limitation of lumber spine motion in both the sagittal and frontal planes.
Limitation of chest expansion relative to normal values for age and sex
Radiological criteria
Sarcoiliitis on x-ray
Definite ankylosing spondylitis if the radiological criterion is present plus at
least one clinical criterion.
Probable ankylosing spondylitis if three clinical criteria are present alone, or
if the radiological criterion is present but no clinical criteria are present
Ankylosing spondylitis (5)
Management
Conservative
• Early diagnosis is important
• encourage regular exercise such as swimming
• NSAIDs
• Physiotherapy
Medical
• The disease-modifying drugs which are used to treat rheumatoid arthritis (such as
sulphasalazine) are only really useful if there is peripheral joint involvement
• TNF-alpha blockers such as etanercept and adalimumab
Enteropathic arthiritis
Arthritis as a result of inflammatory bowl disease
Manifestations of ulcerative colitis and Crohn’s disease
Large joints, asymmetrical, spondylitis, and hypertrophic osteoarthropathy
Symptoms: arthralgia, myalgia, osteoporosis and aseptic necrosis of bone 2º to steroid
treatment of bowel inflammation
Management: If you treat the IDB you treat the arthiritis
Note: NSAIDs should be used cautiously as they may exacerbate bowel disease
Year 3 Rheumatology Course
Arthritis associated with psoriasis
M=F
Symptoms
• Pain, swelling, or stiffness in one or more joints. Dactylisis
• Achilles tendinitis, Plantar fasciitis.
• Changes to the nails, such as pitting or separation from the nail bed.
• Pain in the area of the Sacrum (the lower back, above the tailbone).
• Skin changes (plaques on elbows)
Management – Treat similar to rheumatoid
NSAIDS
DMARDS e.g Methotrexate
Biologics e.g Anti-TNFs
Psoriatic Arthritis
Practice SBA’s
1. Low levels of which one of the following types of complement are
associated with the development of systemic lupus erythematous?
A.C4
B.C5
C.C6
D.C7
E.C8
2.You review the hands of a 60-year-old man who is complaining of
'arthritis' in his hands:
A. Rheumatoid arthritis
B. Systemic Sclerosis
C. Systemic Fungal infection
D. Psoriatic Arthritis
E. Reiter's Syndrome
3. A 25-year-old man presents with back pain. Which one of the following
may suggest a diagnosis of ankylosing spondylitis?
A. Rapid Onset
B. Gets worse following exercise
C. Bone tenderness
D. Pain at night
E. Improves with rest
4. A 57-year-old man presents to his GP due to pain in his right knee. An
x-ray shows osteoarthritis. He has no past medical history of note. What
is the most suitable treatment option for the management of his pain?
A. Oral Doclofenac with omeprazole
B. Oral glucosamine
C. Oral Diclofenac
D. Oral Ibuprofen
E. Oral paracetamol
5. You refer a 24-year-old female to rheumatology with intermittent pain
and swelling of the metacarpal phalangeal joints for the past 3 months.
An x-ray shows loss of joint space and soft-tissue swelling. Rheumatoid
factor is positive and a diagnosis of rheumatoid arthritis is made. What
initial management is she most likely to be given to help slow disease
progression?
A. Infliximab
B. Methotrexate
C. Sulfasalazine
D. Methotrexate + sulfasalazine + short-course of prednisolone
E. Diclofenac
6. A 25-year-old man presents complaining of dysuria and pain in his left
knee. Three weeks previously he had suffered a severe bout of diarrhoea.
What is the most likely diagnosis?
A. Reactive Arthritis
B. Disseminated gonococcal infection
C. Bachet’s syndrome
D. Ulcerative colitis
E. Rheumatoid arthritis
7. A 79-year-old man presents with a history of lower back pain and right
hip pain. Blood tests reveal the following:
What is the most likely diagnosis?
A. Primary hyperparathyroidism
B. Chronic renal failure
C. Osteomalacia
D. Osteoporosis
E. Paget’s disease
Calcium 2.20 mmol/l
Phosphate 0.8 mmol/l
ALP 890 u/L
Paget's disease - old man, bone pain, raised ALP
8. A 40-year-old woman who is known to have systemic lupus
erythematosus is reviewed with an exacerbation of wrist pain. Which one
of the following is the most useful marker for monitoring disease activity?
A. C-reactive protein
B. C2 Levels
C. Anti-nuclear antibody titres
D. Anti-dsDNA titres
E. Anti-Sm Titres
9. Which one of the following is least associated with systemic lupus
erythematous?
A. Anti-nulcear antibodies
B. Anti-Sm Antibodies
C. Elevated ESR
D. Elevated C3 And C4 levels
E. Elevated anti-dsDNA titres in active disease
SLE: ANA is 99% sensitive - anti-Sm & anti-dsDNA are 99% specific
C3, C4 are low in SLE not elevated
10. You are doing the annual review of a 50-year-old woman who has
rheumatoid arthritis. Which one of the following complications is most
likely to occur as a result of her disease?
A. Chronic lymphocytic leukaemia
B. Hypertension
C. Colorectal Caner
D. Type 2 diabetes mellitus
E. Ischaemic heart disease
Advise
Questions?

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Year 3 Rheumatology Course

  • 1. Martin Edobor, John Lewin Rheumatology
  • 2. Objectives • Go through GALS screen OSCE station • Cover key Rheum Topics • Practice SBA • General Advice
  • 3. Topics to be covered •Osteoarthritis •Rheumatoid Arthritis •SLE •Seronegative arthopathies Not covered Connective tissue diseases (polymyositis, system sclerosis, Sorgjerns syndrome) Crystal arthropathies (gout, pseudogout) Vacuities (GCA, polyarteritis nodosa) Drugs and there side effects! IMPORTANT Disclaimer: This presentation is just a guide!
  • 4. Osteoarthritis (1) Mechanical Degeneration of joint cartilage. Epidemiology: >70yrs, Risk Factors: Obesity, menopause, smoking, sportsmen, trauma. Pathology: Damage to cartilage leads to oedema, death of chondrocytes. Fibrillation and fissuring of cartilage, ulceration and micro fractures occur. Eventually underlying bone is exposed leading to cyst and osteophytes. Symptoms: Joint Pain, Joint Gelling, Joint instibility Loss of function
  • 5. Osteoarthritis (3) Signs: Herberderns Nodes (DIP), Bouchards Nodes (PIP) Joints affected: DIP (single joint), Hip (unilateral), Knee (usually bilateral) Investigations: X-Ray Joint Narrowing, Subchondral cyst, Subcondral sclerosis, osteophyte formation.
  • 6. Osteoarthritis (3) Management 1. Advice about weight loss, local muscle strengthening exercises 2. Paracetamol and topical NSAIDs are first-line analgesics. 3. Second-line treatment is oral NSAIDs/COX-2 inhibitors, opioids, and intra- articular corticosteroids. 4. If conservative methods fail then refer for consideration of joint replacement
  • 7. Rheumatoid Arthiritis (1) A chronic symmetrical inflammatory polyarthititis with systemic involvement Epidemiology: F>M 3:1, ages 30-50 Associated with HLA-DR4 Pathology: Autoantibodies (IgM) to Fc of IgG, forming immune complexes which deposit in joints leading to inflamation. Symptoms: Pain (decrease with activity), swelling, morning stiffness >30mins,. Joint Involvement: MCP, MIP, PIP, MTP SYMETRICAL!
  • 10. Rheumatoid Arthritis (4) Systemic extra-articular involvement: Skin: Rhumatoid nodules, synivotendonitis Lungs: Effusions, nodules, fibroisis, Caplans syndrome: a combination of pneumoconiosis and RA Eyes: Sclertis (painful red eye), Episcleritis(non-painful red eye), Sorgjerns syndrome Neural: Mononeuritis multiplex, Carpal tunnel Felty Syndrome: RA with splenomegaly and neutropenia Normochromic normocytic anaemia
  • 11. Rheumatoid Arthritis (5) Investigations ESR, CRP Increased Possible Anaemia RF +ve in 70% of cases, Anti-ccp positive in >90% of cases CXR –Swelling of soft tissue, erosions, joint narrowing, juxto-articular osteopenia
  • 13. Rheumatoid Arthritis (6) Management 2009 NICE guidelines it is recommend that patients with newly diagnosed active RA start a combination of DMARDs (including methotrexate and at least one other DMARD, plus short-term glucocorticoids) 1.DMARDS Methotrexate (s.e derange LFT’s renal, neutopenia, PF, teratogenic) • Sulfasalazine (s.e infertility, G6PD heamolysis) • Lefunimide Others e.g Azathriopine, Gold (Also add prednisolone)
  • 14. The current indication for a TNF-inhibitor is an inadequate response to at least two DMARDs including methotrexate 4. Anti TNF alpha, use if DMARDS failed e.g Entgeracept, Adelumimab , Infliximab Side effects increase risk of cancer, infection, reversible refulx and demylinating disease. If a diagnosis of RA is yet to be made, you can give your patient NSAIDS (if no contraindication) or a steroid injection
  • 15. Systemic Lupus Erythematosus SLE an “Systemic, inflammatory, multisystem disorder” Autoimmune disease in which auto-antibodies and immune complexes cause damage to organs. Epidemiology: High prevalence in Afro-carribeans, Peak age of onset 20- 40 years Aetiology: Hereditary , Genetic, Immune system disorder (Autoantibody production + impaired tolerance), UV light , Drugs.
  • 16. Clinical features • Musculoskeletal 90% : -Symmetrical, small joint, arthralgia, - Jaccoud’s arthropathy –Joint deformity resembling RA – rare • Cutaneous 75% -Malar Rash: -Discoid Lupus • Neurology 60% -Cerebral Lupus • Lungs 50% -Recurent pleurisy and BILATERAL pleural effusions - “Shrinking Lung syndrome’ • Renal 30% (Histological changes are frequent) - Regular screening for urine for blood and protein required
  • 17. Diagnostic Criteria Criterion Definition/examples 1. Malar rash Fixed erythema over the malar eminences, tending to spare the nasolabial folds 2. Discoid rash Erythematosus raised patches, may scar 3. Photosensitivity Skin rash as a result of unusual reaction to sunlight 4. Oral ulcers Usually painless 5. Arthritis Non-erosive: Jaccoud's arthropathy 6. Serositis a) Pleuritis – pleuritic pain, pleural rub, pleural effusion b) Pericarditis – ECG changes, rub, pericardial effusion 7. Renal disorder a) Proteinuria (> 3+ or 0.5 g/day) b) Cellular casts in urine 8. Neurological disorder a) Seizures b) Psychosis 9. Haematological disorder a) Haemolytic anaemia b) Leukopaenia c) Lymphopaenia d) Thrombocytopaenia 10. Immunological disorder a) Anti-DNA antibodies b) Anti-Sm antibodies c) Anti-phospholipid antibodies 11. Anti-nuclear antibody Exclude drug causes American College of Rheumatology: A person is said to have SLE if he/she meets any 4 of these 11 criteria simultaneously or in succession
  • 18. Investigations • Bloods FBC: Leucopenia, lymphopenia and/or thrombocytopenia ESR: Raised CRP: Normal U+E: Urea and Creatinine raised in advanced renal disease • Urine Testing: Protein in urine and RBC Caste • Complement: Low C3 Low C4 Imaging • CT– infarcts or haemorrhage with evidence of cerebral atrophy • MRI – lesions in white matter
  • 19. Serum Antinuclear Antibodies (ANA) Positive >95% Double stranded DNA Specific for SLE Positive 60% ENA: Anti-Ro and Anti-LA Detected RF Positive in 40% of patients Anticardiolipin antibodies Present in 35-45% of patients Serological Syphilis Test False Positive 1/3rd Investigation-Serology
  • 20. Management • Symptomatic treatment -NSAIDS -Antimalarials: e.g hydroxychloroquine • Corticosteroids and immunosuppressive drugs -Single dose I.M corticosteroids for flares -immunosuppressive drugs for severe thrombocytopenia, renal and cerebral diseases.
  • 21. Seronegative arthiritis A seronegative arthritis is an arthritis that is distinguished from rheumatoid arthritis due to the absence of rheumatoid factor. • Reactive arthritis • Ankylosing spondylitis • Enteropathic arthiritis • Psoriatic arthritis.
  • 22. Reactive Arthritis (1) A generic term for a sterile arthritis following an infection (e.g. rheumatic fever, post viral arthritis etc.) Aetiology Onset following an infectious episode either involving the GI or GU tract GI: Shigella, Salmonella, Campylobacter, GU: Chlamydia, Mycoplasma species Acute pattern of clinical course 1-4 weeks post-infection Epidemiology • HLA-B27 patients • axial > peripheral involvement • M > F
  • 24. Reactive Arthritis (2) Signs and Symptoms • Musculoskeletal peripheral arthritis, asymmetric pattern, Achilles tendinitis, dactylitis (“sausage digits”) • Ophthalmic iritis (anterior uveitis) • Dermatologic keratoderma blennorrhagicum (hyperkeratotic skin lesions on palms and soles) Balanitis circinata (small, shallow, painless ulcers of glans penis and urethral meatus) are diagnostic • Gastrointestinal Oral ulcers, diarrhoea Urethritis + arthritis + conjunctivitis = reactive arthritis
  • 25. Reactive Arthritis (3) Investigations • diagnosis is clinical plus laboratory • lab findings: normocytic, normochromic anemia and leukocytosis • cultures are sterile Treatment Appropriate antibiotics if there is documented infection NSAIDs, physical therapy, home exercise Local therapy: Joint protection, intra-articular steroid injection, topical steroid for ocular involvement Systemic therapy : Corticosteroids, sulfasalazine, methotrexate (for peripheral joints only)
  • 27. Ankylosing spondylitis (1) Epidemiology • incidence 0.2% of general population • M: F = 5:1; females have milder disease • 9% HLA-B27 positive in general population Pathology • inflammation of ligament where it attaches to bone leading to osteopenia, then erosion, then ossification
  • 28. Ankylosing spondylitis (2) Symptoms mid- and low-back stiffness, pain at rest, persistent buttock pain, painful sacroiliac joint Signs: Decreased Schöber test Extra-articular manifestations • ophthalmic: acute anterioruveitis (25-30% patients) • cardiac: aortitis, aortic regurgitation, pericarditis, conduction disturbances, heart • failure (rare) • renal: amyloidosis and IgA nephropathy • respiratory: apical fibrosis (rare) • neurologic: cauda equina syndrome (rare)
  • 30. Ankylosing spondylitis (3) Investigations • x-ray Symmetric sacroiliitis “pseudowidening” of joint due to erosion with joint sclerosis ’ bony fusion (late), • x-ray of spine: appearance of “squaring of edges” from erosion and sclerosis on corners “bamboo spine” of vertebral bodies leading to ossification of outer fibres of annulus fibrosis (bridging syndesmophytes), this produces a radiographically
  • 32. Ankylosing spondylitis (4) Diagnosis Modified New York Criteria Clinical criteria Low back pain >3months, improves on exercise but not relived by rest. Limitation of lumber spine motion in both the sagittal and frontal planes. Limitation of chest expansion relative to normal values for age and sex Radiological criteria Sarcoiliitis on x-ray Definite ankylosing spondylitis if the radiological criterion is present plus at least one clinical criterion. Probable ankylosing spondylitis if three clinical criteria are present alone, or if the radiological criterion is present but no clinical criteria are present
  • 33. Ankylosing spondylitis (5) Management Conservative • Early diagnosis is important • encourage regular exercise such as swimming • NSAIDs • Physiotherapy Medical • The disease-modifying drugs which are used to treat rheumatoid arthritis (such as sulphasalazine) are only really useful if there is peripheral joint involvement • TNF-alpha blockers such as etanercept and adalimumab
  • 34. Enteropathic arthiritis Arthritis as a result of inflammatory bowl disease Manifestations of ulcerative colitis and Crohn’s disease Large joints, asymmetrical, spondylitis, and hypertrophic osteoarthropathy Symptoms: arthralgia, myalgia, osteoporosis and aseptic necrosis of bone 2º to steroid treatment of bowel inflammation Management: If you treat the IDB you treat the arthiritis Note: NSAIDs should be used cautiously as they may exacerbate bowel disease
  • 36. Arthritis associated with psoriasis M=F Symptoms • Pain, swelling, or stiffness in one or more joints. Dactylisis • Achilles tendinitis, Plantar fasciitis. • Changes to the nails, such as pitting or separation from the nail bed. • Pain in the area of the Sacrum (the lower back, above the tailbone). • Skin changes (plaques on elbows) Management – Treat similar to rheumatoid NSAIDS DMARDS e.g Methotrexate Biologics e.g Anti-TNFs Psoriatic Arthritis
  • 37. Practice SBA’s 1. Low levels of which one of the following types of complement are associated with the development of systemic lupus erythematous? A.C4 B.C5 C.C6 D.C7 E.C8
  • 38. 2.You review the hands of a 60-year-old man who is complaining of 'arthritis' in his hands:
  • 39. A. Rheumatoid arthritis B. Systemic Sclerosis C. Systemic Fungal infection D. Psoriatic Arthritis E. Reiter's Syndrome
  • 40. 3. A 25-year-old man presents with back pain. Which one of the following may suggest a diagnosis of ankylosing spondylitis? A. Rapid Onset B. Gets worse following exercise C. Bone tenderness D. Pain at night E. Improves with rest
  • 41. 4. A 57-year-old man presents to his GP due to pain in his right knee. An x-ray shows osteoarthritis. He has no past medical history of note. What is the most suitable treatment option for the management of his pain? A. Oral Doclofenac with omeprazole B. Oral glucosamine C. Oral Diclofenac D. Oral Ibuprofen E. Oral paracetamol
  • 42. 5. You refer a 24-year-old female to rheumatology with intermittent pain and swelling of the metacarpal phalangeal joints for the past 3 months. An x-ray shows loss of joint space and soft-tissue swelling. Rheumatoid factor is positive and a diagnosis of rheumatoid arthritis is made. What initial management is she most likely to be given to help slow disease progression? A. Infliximab B. Methotrexate C. Sulfasalazine D. Methotrexate + sulfasalazine + short-course of prednisolone E. Diclofenac
  • 43. 6. A 25-year-old man presents complaining of dysuria and pain in his left knee. Three weeks previously he had suffered a severe bout of diarrhoea. What is the most likely diagnosis? A. Reactive Arthritis B. Disseminated gonococcal infection C. Bachet’s syndrome D. Ulcerative colitis E. Rheumatoid arthritis
  • 44. 7. A 79-year-old man presents with a history of lower back pain and right hip pain. Blood tests reveal the following: What is the most likely diagnosis? A. Primary hyperparathyroidism B. Chronic renal failure C. Osteomalacia D. Osteoporosis E. Paget’s disease Calcium 2.20 mmol/l Phosphate 0.8 mmol/l ALP 890 u/L
  • 45. Paget's disease - old man, bone pain, raised ALP
  • 46. 8. A 40-year-old woman who is known to have systemic lupus erythematosus is reviewed with an exacerbation of wrist pain. Which one of the following is the most useful marker for monitoring disease activity? A. C-reactive protein B. C2 Levels C. Anti-nuclear antibody titres D. Anti-dsDNA titres E. Anti-Sm Titres
  • 47. 9. Which one of the following is least associated with systemic lupus erythematous? A. Anti-nulcear antibodies B. Anti-Sm Antibodies C. Elevated ESR D. Elevated C3 And C4 levels E. Elevated anti-dsDNA titres in active disease
  • 48. SLE: ANA is 99% sensitive - anti-Sm & anti-dsDNA are 99% specific C3, C4 are low in SLE not elevated
  • 49. 10. You are doing the annual review of a 50-year-old woman who has rheumatoid arthritis. Which one of the following complications is most likely to occur as a result of her disease? A. Chronic lymphocytic leukaemia B. Hypertension C. Colorectal Caner D. Type 2 diabetes mellitus E. Ischaemic heart disease