Download File - Sheffield Peer Teaching Society

MSK and Rheumatology
Phase 2a Peer Teaching
George Fowler
Carrie Brain
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Joint Pain
Joint Pain
Inflammatory
Autoimmune
RA
Crystal Arthritis
Non-Inflammatory
Infection
Degenerative e.g.
Osteoarthritis
Non-degenerative e.g.
fibromyalgia
Seronegative
spondyloarthropathies
Connective Tissue
Disease
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Patient Case Histories
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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
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Extra-Articular Features of RA
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Rheumatoid Arthritis
Risk factors:
– Typically female patients aged 30-50
– Smoking
– Genetic predisposition
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Rheumatoid Arthritis
Hand deformities (4):
1. Ulnar deviation
2. Swan neck deformity
3. Z-thumbs (deformities)
4. Boutonnieres deformity
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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
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
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RA Management
Pharmacological
1. 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)
Non-Pharmacological
1. Regular exercise
2. Physiotherapy
3. Orthotics (e.g. splints)
4. Occupational therapy
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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)
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Clinical Features of OA
Symptoms
Signs
•Joint pain
•Stiffness
•Loss of function
•Worse in evening
•Tenderness
•Swelling
•Limited ROM
•Crepitus
•Signs on the hands (2):
1. Heberden’s
2. Bouchard’s Nodes
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Investigations
1. 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)
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OA – X-ray Pathological Features (4)
Loss of joint
space
Osteophyte
formation
Subchondral
cysts
Subarticular
sclerosis
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Management of OA
1. Pharmacological
- Analgesia (paracetamol, NSAIDs)
2. Non-Pharmacological
- Low impact activity
- Weight loss
- Physiotherapy
3. Surgical (Joint infection, joint replacement)
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RA vs OA
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RA vs OA
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Autoimmune Rheumatological Disorders
1. SLE
2. Antiphospholipid syndrome
3. Sjogrens syndrome (already covered)
4. CREST syndrome & systemic sclerosis
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Systemic Lupus Erythmatosus
Two types of lupus:
1. Discoid lupus (only affects skin)
2. SLE (affects skin, joints and internal organs –
heart or kidneys)
*Autoimmune disease
(x9 more common in women)
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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
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Systemic Lupus Erythmatosus
Symptoms:
• Joint pain
• Skin rash
• Fatigue (extreme tiredness)
• Fever
• Weight loss
• Headache
• Hair loss
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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)
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Management of SLE
Non-Pharmacological - Avoidance of sunlight / sunblock
-Reduce CV Risk factors
-Rheum referral
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
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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)
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CREST Syndrome
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Osteoporosis
• Characterised by reduced bone mass and micro-architectural
deterioration of bone tissue
• Bone more fragile and susceptible to fracture
Osteoporotic (fragility) fractures - fractures that result from
mechanical forces that would not ordinarily result in 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)
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Conditions
Rheumatology
• Rheumatoid Arthritis
• Seronegative
Spondyloarthropathies
• Crystal Arthropathies
• Connective tissue
disorders (e.g. SLE,
CREST syndrome)
Bone
• Osteoporosis
• Osteomalacia
• Infections
• Back pain red flags
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Crystal Arthritis
• Gout & Pseudogout
• 2 main types of crystal involved
– Monosoduim Urate (Gout)
– Calcium pyrophosphate (Pseudogout)
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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
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Gout
Uric acid pathway:
Dietary purines
Xanthine
oxidase
Uric acid in bloodstream
excreted by
kidneys
monosodium urate crystals in tissues
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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
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
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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)
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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.
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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
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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
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Pseudogout Risk Factors
•
•
•
•
•
•
•
•
Dehydration
Intercurrent illness
Hyperparathyroidism
Diabetes
Low Phosphate or magnesium
Osteoarthritis
Haemochromotosis
Acromegaly
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Pseudogout
• Diagnosis
- X-ray: chondrocalcinosis
– Synovial fluid microscopy:
• Positively birefringent rhomboidal crystals
• Purulent aspirate
– Bloods
• Raised ESR, CRP and WCC
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Pseudogout Treatment
• Aspiration reduces pain
• NSAID/Colchicine as with gout
• Intra-articular steroid injection
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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
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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)
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Seronegative Spondyloarthropathies
• May be axial (ankylosing spondylitis)
• Or peripheral (reactive/psoriatic/enteropathic)
• Key clinical manifestations?
1)Spinal inflammation
2)Peripheral arthritis
3)Peripheral enthesitis
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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
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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
Late Features
-Kyphosis
-Neck hyperextension (question mark posture)
-Spino-cranial ankylosis
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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
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
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AS Investigations
• Radiological findings:
– Appear late
– Sacroiliitis is earliest feature
(inflammation, narrowing
and sclerosis of the sacroiliac joints)
– Vertebral syndesmophytes
– Ankylosis & bamboo spine
follow (spinal fusion).
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AS Investigations
• Clinical examination:
- reduced lateral flexion (use the MODIFIED
SCHOBER TEST)
- reduced forward flexion
- reduced chest expansion
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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
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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)
Psoriatic Arthritis Treatment
• Responds to:
– NSAIDs
– Intra-articular corticosteroid injections
– DMARDS e.g. Methotrexate, sulfasalazine
– Anti-TNFα Therapies e.g. etanercept, adalimumab
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Reactive Arthritis
• Sterile joint arthritis following a gut or sexual
infection
– typical triggers:
• Urethritis (e.g. Chlamydia)
• Dysentry (e.g. salmonella, shigella & campylobacter)
– presents within 1-4wks of infection
• May be chronic or relapsing
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Reactive Arthritis
– Acute, asymmetrical lower limb arthritis
– Enthesitis, dactylitis, uveitis & mouth ulcers may occur
– “Reiters Syndrome”
• Can’t See, Can’t Pee, Can’t climb a tree….
• Combo of urethritis, arthritis & conjunctivitis
Investigations?
– Raised ESR & CRP
– Sexual health review
– Urethral swab, stool culture
– May need to aspirate joint to exclude septic arthritis
Reactive Arthritis
• Management:
– NSAIDs / Steroids
– Intra-articular corticosteroid injections
– Consider sulfasalazine / Methotrexate if chronic
– Tetracycline in chlamydia infection
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Enteropathic Arthritis
• Episodic peripheral synovitis in patients with
IBD e.g. Crohns.
• Asymmetric lower limb arthritis
• Usually reflects disease activity
• Remission occurs with bowel disease
suppression
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Infections
• Bone infections – osteomyelitis
• Joint infections – septic arthritis
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Osteomyelitis
• Infection localised to the bone
• Risk factors? Diabetes, peripheral vascular
disease & pre-existing joint problems.
• How does the infection spread? 1 of 3 ways:
1) Direct inoculation after trauma to the bone
2) Soft tissue spread
3) Haematogenous spread from the blood
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Osteomyelitis
• Likely organism? Staph aureus
• S&S? tenderness, inflammation, fever, malaise,
sweats, may be aggravated by movement.
• Investigations:
- Raised WCC, ESR & CRP
- Imaging e.g. X-ray – erosion, soft tissue swelling
from 1-2 weeks. MRI shows changes within 3d.
- Bone biopsy
- Blood cultures
Osteomyelitis
Treatment:
- immobilisation
- Antibiotics tailored to culture & sensitivity from
biopsy and blood cultures
- Surgical debridement
Septic Arthritis
• MSK emergency! Can destroy a joint in 24h.
• Consider in all pts with acute joint pain + fever/
raised WCC.
• >50% of cases joint affected is the knee
• Rf: pre-existing joint disease,
immunosuppression e.g. DM, IVDU, prosthetic
joints.
• Again, usually staph aureus.
Septic Arthritis
• Investigations?
- Synovial fluid aspiration & culture
- Blood cultures
- X-ray
- Bloods e.g CRP, ESR, WCC.
• Treatment?
- IV abx e.g. flucloxacillin
- analgesia
- splinting and rest
- joint washout if no improvement
Back Pain
• SUPER COMMON complaint esp in general practice
• Majority is mechanical – use analgesia and rest.
• BUT remember other causes too! E.g.
– Degenerative
– Infection (immunosuppression, steroids, diabetes)
– Tumors (previous hx cancer, other suggestive symptoms like
weight loss)
– Fractures (pathological in steroid use/osteoporosis/cancer)
– Rheumatological
– Non-spinal e.g. AAA
Back Pain
RED FLAGS in back pain
-
under 20/over 50
Persistent and severe
Worse at night/wakes pt at night
Associated with systemic illness e.g. wt loss, night
sweats.
Neurological signs e.g. bladder/bowel incontinence
Thoracic pain (?cancer with lung mets?) + abdo pain
(AAA).
Significant PMH e.g. HIV/cancer.
Trauma
Back Pain
– Mechanical history
Stiff back, muscular spasms, pain lessens with sitting
or lying down. Pain relief/physio helpful. Age 20-50,
lumbrosacral region, varies with activity and time.
Patient well. 90% recover in 6 wks.
- Neurological back pain history e.g. lumbar
prolapse/spinal stenosis
Severe and acute pain in lower back that may radiate
down the buttock and leg, paraesthesia in the leg. Pain
relieved by rest
Back Pain
Don’t forget cauda equina!
Emergency needing urgent spinal decompression
Hx perianal numbness, bladder/bowel incontinence,
paralysis, pain/paraesthesia in BOTH legs…
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