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Phase 2a Peer Teaching George Fowler Carrie Brain

Learn about RA & OA differences, features, risk factors, diagnosis, and management. Explore autoimmune disorders in rheumatology.

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Phase 2a Peer Teaching George Fowler Carrie Brain

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  1. MSK and Rheumatology Phase 2a Peer Teaching George Fowler Carrie Brain The Peer Teaching Society is not liable for false or misleading information…

  2. Joint Pain The Peer Teaching Society is not liable for false or misleading information…

  3. Patient Case Histories The Peer Teaching Society is not liable for false or misleading information…

  4. Rheumatoid Arthritis • Common chronic inflammatory autoimmune disease • Inflammation of synovial joints (symmetrical) • Extra-articular features include: • Eyes (Sjogren’s syndrome), skin (Felty’s syndrome), Rheumatoid nodules, Neurological, Resp., CVS etc • Typically affects the PIP joints The Peer Teaching Society is not liable for false or misleading information…

  5. Extra-Articular Features of RA The Peer Teaching Society is not liable for false or misleading information…

  6. Rheumatoid Arthritis Risk factors: • Typically female patients aged 30-50 • Smoking • Genetic predisposition The Peer Teaching Society is not liable for false or misleading information…

  7. Rheumatoid Arthritis • Hand deformities (4): • Ulnar deviation • Swan neck deformity • Z-thumbs (deformities) • Boutonnieres deformity The Peer Teaching Society is not liable for false or misleading information…

  8. RA - Clinical Features Symptoms • Pain & Stiffness • Worse in morning • Tiredness • Systemically unwell • Disturbed sleep Signs • Inflammation (Palor, calor, dolor, etc) • Limited ROM • Muscle wasting • Deformities

  9. RA Investigations • Bloods: • Raised ESR • RhF (+ve in 80%) • ANA (+ve in 30%) • Anti-CCP (v.specific) • X-ray: • Decreased joint space • Bony erosions • Subluxation • Soft tissue swelling The Peer Teaching Society is not liable for false or misleading information…

  10. RA Management Non-Pharmacological Pharmacological 1. Regular exercise 2. Physiotherapy 3. Orthotics (e.g. splints) 4. Occupational therapy • NSAIDs • e.g. Ibuprofen + PPI cover • 2. Steroids • Intra-articular • Systemic • 3. DMARDS • Methotrexate & Sulfasalazine • 4. Biologics • e.g. Infliximab (TNF-a inhib) • e.g. Rituximab (anti-CD20 Ab) The Peer Teaching Society is not liable for false or misleading information…

  11. Osteoarthritis – ‘Wear and Tear’ • Most common type of arthritis • Age-related • Degenerative • Synovial joints affected (Knees, hips, hands, etc) Risk factors: • Age • Obesity • Genetics • Local factors (e.g. occupational, recreational) The Peer Teaching Society is not liable for false or misleading information…

  12. Clinical Features of OA Signs Symptoms • Tenderness • Swelling • Limited ROM • Crepitus • Signs on the hands (2): 1. Heberden’s • 2. Bouchard’s Nodes • Joint pain • Stiffness • Loss of function • Worse in evening The Peer Teaching Society is not liable for false or misleading information…

  13. Investigations • Bloods • ESR normal, CRP may be raised. RF and ANA negative 2. X-Rays • Abnormal only when advanced 3. Isotope bone scan (Diagnosis – based on clinical examination) The Peer Teaching Society is not liable for false or misleading information…

  14. OA – X-ray Pathological Features (4) Loss of joint space Osteophyte formation Subchondral cysts Subarticular sclerosis The Peer Teaching Society is not liable for false or misleading information…

  15. Management of OA • Pharmacological • Analgesia (paracetamol, NSAIDs) 2. Non-Pharmacological • Low impact activity • Weight loss • Physiotherapy 3. Surgical (Joint infection, joint replacement) The Peer Teaching Society is not liable for false or misleading information…

  16. RA vs OA The Peer Teaching Society is not liable for false or misleading information…

  17. RA vs OA The Peer Teaching Society is not liable for false or misleading information…

  18. Autoimmune Rheumatological Disorders • SLE • Antiphospholipid syndrome • Sjogrens syndrome (already covered) • CREST syndrome & systemic sclerosis The Peer Teaching Society is not liable for false or misleading information…

  19. Systemic Lupus Erythmatosus Two types of lupus: • Discoid lupus (only affects skin) • SLE (affects skin, joints and internal organs – heart or kidneys) *Autoimmune disease (x9 more common in women) The Peer Teaching Society is not liable for false or misleading information…

  20. SLE Pathophysiology • Cells die by apoptosis; self-antigens presented to immune system for phagocytosis • Antibodies to these self-antigens are produced • Immune system fails to inactivate B and T cells responding to these self-antigens • Autoantibody production • Complement activation • Neutrophil influx • Inflammation • Immune complex deposition The Peer Teaching Society is not liable for false or misleading information…

  21. Systemic Lupus Erythmatosus Symptoms: • Joint pain • Skin rash • Fatigue (extreme tiredness) • Fever • Weight loss • Headache • Hair loss The Peer Teaching Society is not liable for false or misleading information…

  22. SLE – Diagnosis and Treatments Diagnosis: 1. Autoantibodies • antinuclear antibodies (ANA) (95%) • anti-dsDNA antibodies (60%) • RhF +ve (40%) 2. ESR / LFTs / FBC etc Treatment: 1. NSAIDs (reduce inflammation), steroid (e.g. prednisolone), DMARDs (e.g. methotrexate), antimalarials (e.g. hydroxychloroquine), biological therapies (e.g. rituximab) The Peer Teaching Society is not liable for false or misleading information…

  23. Management of SLE • Avoidance of sunlight / sunblock • Reduce CV Risk factors • Rheum referral Non-Pharmacological Pharmacological • NSAIDs for arthralgia, serositis • High dose prednisolone for severe episodes. Other immunosuppresives/steroid sparing agents (cyclophosphamide, azathioprine, methotrexate) can be used. Surgical Renal transplant The Peer Teaching Society is not liable for false or misleading information…

  24. Systemic Sclerosis • Autoimmune disease of connective tissue • Characterized by thickening of the skin • Accumulation of collagen, and by injuries to the smallest arteries • Can cause vascular damage and fibrosis • No cure (control symptoms + prevent complications) • 2 types of systemic sclerosis: • 1. Limited cutaneous systemic sclerosis • (old term – CREST syndrome) • (Face, forearms and lower legs) • 2. Diffuse cutaneous systemic sclerosis • (upper arms, thighs or trunk) The Peer Teaching Society is not liable for false or misleading information…

  25. CREST Syndrome The Peer Teaching Society is not liable for false or misleading information…

  26. Osteoporosis • Characterised by reduced bone mass and micro-architectural deterioration of bone tissue • Bone more fragile and susceptible to fracture • Risk factors: increasing age, female, low BMI, smoking, alcohol… • Diagnosis: DEXA scan • Management: • General – lifestyle, nutrition, exercise, smoking cessation etc • Medical – bisphosphonates (first-line, e.g. alendronate) Osteoporotic (fragility) fractures - fractures that result from mechanical forces that would not ordinarily result in fracture The Peer Teaching Society is not liable for false or misleading information…

  27. Conditions Rheumatology • Rheumatoid Arthritis • Seronegative Spondyloarthropathies • Crystal Arthropathies • Connective tissue disorders (e.g. SLE, CREST syndrome) Bone • Osteoporosis • Osteomalacia • Infections • Back pain red flags The Peer Teaching Society is not liable for false or misleading information…

  28. Crystal Arthritis • Gout & Pseudogout • 2 main types of crystal involved • Monosoduim Urate (Gout) • Calcium pyrophosphate (Pseudogout) The Peer Teaching Society is not liable for false or misleading information…

  29. Gout • Inflammatory arthritis • Hyperuricaemia – high levels of uric acid in the blood stream • Gets deposited as intra-articular sodium urate crystals in the tissues • VERY painful The Peer Teaching Society is not liable for false or misleading information…

  30. Gout Uric acid pathway: Xanthine oxidase Dietary purines excreted by kidneys Uric acid in bloodstream monosodium urate crystals in tissues The Peer Teaching Society is not liable for false or misleading information…

  31. Precipitants of Gout Attack • Aggressive induction/cessation of hypouricaemic therapy (Allopurinol) • Increased intake: Alcohol/red meat/shellfish/high fructose intake e.g. sugary drinks • Cell damage: Acute severe illness/ Trauma / Surgery • Reduced renal excretion: Dehydration • Cell death: Chemotherapy • High cell turnover: psoriasis • Also Insulin therapy & diuretics

  32. Clinical Features of Gout • Middle aged – older men • Sudden onset (ususally during the night) • Agonising pain • Red, shiny joint (“polished apple”) – any joint, classically the big toe in exam qs! • Tender • In chronic gout: urate deposits (tophi) found in peripheries The Peer Teaching Society is not liable for false or misleading information…

  33. Investigations of Gout • Clinical picture is diagnostic, as is the response to treatment • Joint Aspiration & Microscopy of Synovial fluid – Sodium Urate seen which is “negatively birefringent needles under polarised light” • X-Ray – soft tissue swelling, periarticular erosions, normal joint space • Bloods – raised serum uric acid (>360µmol/L) The Peer Teaching Society is not liable for false or misleading information…

  34. Management of Acute Gout • Strong NSAID e.g. naproxen/diclofenac Or • Colchicine Or • Steroids • Prevent future attacks by avoiding high purine foods, stopping diuretics, avoid alcohol, weight loss. The Peer Teaching Society is not liable for false or misleading information…

  35. Recurrent Gout • Reduction of serum urate with long-term Allopurinol (Inhibitor of Xanthine oxidase which converts Xanthine to Urate) • Start alongside NSAID/Colchicine as initiation can precipitate acute attack • Check serum urate levels and adjust dose accordingly The Peer Teaching Society is not liable for false or misleading information…

  36. Pseudogout • AKA Calcuim Pyrophosphate Dihydrate (CPPD) arthropathy • Calcium pyrophosphate deposits in joints. • Similar to gout but affects different joints; mainly wrist/knee • More common in Women The Peer Teaching Society is not liable for false or misleading information…

  37. Pseudogout Risk Factors • Dehydration • Intercurrent illness • Hyperparathyroidism • Diabetes • Low Phosphate or magnesium • Osteoarthritis • Haemochromotosis • Acromegaly The Peer Teaching Society is not liable for false or misleading information…

  38. Pseudogout • Diagnosis - X-ray: chondrocalcinosis • Synovial fluid microscopy: • Positively birefringent rhomboidal crystals • Purulent aspirate • Bloods • Raised ESR, CRP and WCC The Peer Teaching Society is not liable for false or misleading information…

  39. Pseudogout Treatment • Aspiration reduces pain • NSAID/Colchicine as with gout • Intra-articular steroid injection The Peer Teaching Society is not liable for false or misleading information…

  40. Seronegative Spondyloarthropathies • A family of related diseases • Familial; associated with HLA-B27 • No RhF production, hence “Seronegative”. • 4 main conditions: • Ankylosing Spondylitis • Psoriatic Arthritis • Reactive Arthritis • Enteropathic Arthritis The Peer Teaching Society is not liable for false or misleading information…

  41. Seronegative Spondyloarthropathies • These conditions involve the PERIPHERAL joints and the SPINE (Spondylo = spinal column). • They also affect the EYES, SKIN and GUT • Characteristic features are enthesitis (inflammation where ligaments/tendons insert into bone)and dactylitis (sausage fingers) The Peer Teaching Society is not liable for false or misleading information…

  42. Seronegative Spondyloarthropathies • May be axial (ankylosing spondylitis) • Or peripheral (reactive/psoriatic/enteropathic) • Key clinical manifestations? • Spinal inflammation • Peripheral arthritis • Peripheral enthesitis The Peer Teaching Society is not liable for false or misleading information…

  43. Ankylosing Spondylitis • Chronic inflammatory disease of spine & sacroiliac joints • Progressive loss of spinal movement • Affects young adults – late teens/early 20s • Males 5x more common than females • 95% are HLA-B27 +ve The Peer Teaching Society is not liable for false or misleading information…

  44. Clinical Features of AS • Early Features / Presentation • Typically young male (< age 40) • Low back pain / stiffness • Buttock pain • Worse at night, disturbs sleep, morning stiffness • Episodic but persistent for 3/12 Associations • Chest pain • Hip involvement • Knee involvement • Enthesitis • -arthritis and dactylitis • Crohn’s/UC/Amyloid • Rashes • Iritis / sterile uveitis • -low grade fever • -malaise • -weight loss Late Features • Kyphosis • Neck hyperextension (question mark posture) • Spino-cranial ankylosis The Peer Teaching Society is not liable for false or misleading information…

  45. Classification Criteria • High sensitivity and specificity • 3 out of the following in adults under 50 indicates AS: • Morning stiffness >30 mins • Improvement with exercise but not rest • Awakening due to back pain in the 2nd half of the night only • Alternating buttock pain The Peer Teaching Society is not liable for false or misleading information…

  46. AS Investigations • Radiological findings: • Appear late • Sacroiliitis is earliest feature (inflammation, narrowing and sclerosis of the sacro-iliac joints) • Vertebral syndesmophytes • Ankylosis & bamboo spine follow (spinal fusion). The Peer Teaching Society is not liable for false or misleading information…

  47. AS Investigations • Clinical examination: - reduced lateral flexion (use the MODIFIED SCHOBER TEST) - reduced forward flexion - reduced chest expansion The Peer Teaching Society is not liable for false or misleading information…

  48. Management of AS Non-Pharmacological • Exercise, NOT rest • Intense exercise regimens Pharmacological • NSAIDs for pain / stiffness • local corticosteroid injections • Anti-TNF if severe Surgical • Hip replacement • Spinal osteotomy The Peer Teaching Society is not liable for false or misleading information…

  49. Psoriatic Arthritis • Arthritis in patients with psoriasis or FH of psoriasis • Skin disease may develop after the arthritis • Pattern: • DIP joints / spinal involvement / arthritis mutilans • Associated features: • Dactylitis (due to synovitis/tenosynovitis) & enthesitis (e.g. at Achilles tendon) • Nail pitting • X-ray = erosive changes (‘pencil-in-cup’ deformity)

  50. Psoriatic Arthritis Treatment • Responds to: • NSAIDs • Intra-articular corticosteroid injections • DMARDS e.g. Methotrexate, sulfasalazine • Anti-TNFα Therapies e.g. etanercept, adalimumab The Peer Teaching Society is not liable for false or misleading information…

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