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Phase 2
Harriet Ribbons and Caroline Hoernig
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Aims:
• Understand the different types of arthritis:
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Osteoarthritis
Rheumatoid Arthritis
Seronegative spondyloarthropathies
Crystal arthropathies
• Understand Systemic Lupus Erythematousus
(SLE)
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Arthritis Introduction:
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Common joint condition
Causes pain and inflammation in a joint
10,000 people per year seek help for arthritis
Symptoms include:
o Joint pain
o Restricted movement
o Joint tenderness
around the joints
o Joint stiffness
o Warm, red skin over
o Inflammation around
the joints
the joints
o Muscle weakness
o Muscle wasting
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The Peer Teaching Society is not liable for false or misleading information…
JOINT PAIN
INFLAMMATORY
Autoimmune
Crystal arthritis
NON-INFLAMMATORY
Infection
Degenerative
Non-Degenerative
Sports medicine
Seronegative Spondylarthropathy
Vasculitis
Rheumatoid arthritis
Connective tissue disease
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Inflammatory
Degeneratve
• 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
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INFLAMMATORY
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Rheumatoid Arthritis (RA)
• Affects synovial joints
• Joints affected:
– (DIP sparing)
– PIP
– MCP
– Wrists
– Feet
• Bony erosions on XRay
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Hypertrophy synovium -> New capillary formation -> Inflammtion ->
Synovial villi form and grow into bone -> PANNUS -> Cytokines released
RA risk factors:
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Increasing age (may occur at any age).
Female sex
Premenopausal
Smoking
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RA symptoms:
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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
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RA diagnosis:
 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
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Z-Shaped thumb
Hypertrophy synovium -> New capillary formation -> Inflammtion ->
Synovial villi form and grow into bone -> PANNUS -> Cytokines released
RA Xray changes:
1.Soft tissue swelling
2.Juxta articular osteopenia
3.Loss of joint space
4.Bony erosions
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Extra-articular involvement
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RA investigations:
• Bloods:
– FBC
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Anaemia
– ESR
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High
– RF
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Positive in 80%
– Anti CCP
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Positive in 80%
– ANA
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<50% positive
– ALL TESTS NEGATIVE IN 20%
• Xray
– Erosions seen
– Periarticular osteopenia
– (Joint space narrowing)
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RA treatment:
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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
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DEGENERATIVE
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Osteoarthritis
• 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
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Radiological changes in OA
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Clinical features of OA
• Symptoms;
- PAIN
- POOR MOBILITY
- FUNCTIONAL IMPAIRMENT
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Signs:
ALTERED GAIT
JOINT SWELLING/TENDERNESS
CREPITUS
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Treatment of OA
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Education and lifestyle advice eg. lose weight!
Analgesia (topical, oral, transdermal)
Steroid injections
Surgery
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Uncontrolled pain
Significant limitation of function
NB. Aim is to relieve pain not increase movement
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SERONEGATIVE
SPONDYLARTHOPATHY
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SERONEGATIVE SPONDYLARTHOPATHY
– High rate of HLA-B27
– Rheumatoid factor NEGATIVE.
– Types
• Ankylosing spondylitis
• Psoriatic arthritis
• Reactive arthritis
• Enteropathic arthritis
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SERONEGATIVE SPONDYLARTHOPATHY
– Ankylosing spondylitis
– Psoriatic arthritis
– Reactive arthritis
– Enteropathic arthritis
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Ankylosing Spondylitis (AS):
• 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)
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AS risk factors:
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20- 30 years
HLA-B27 linked
Caucasian
Men
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AS symptoms:
• 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
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6 A’s of AS:
- A Atlantic axial instability
- A Atypical lung fibrosis
- A Anterior uveitis
- A Amyloidosis
- A Autoimmune bowel disease and UC
- A Aortic incompetance
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AS extra-articular symptoms:
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Aortic incompetence
Cardiomegaly
Amyloidosis
Fractures
Fatigue
Weight loss
Low grade fever
Anaemia
Upper lobe pulmonary fibrosis
Iritis
Pleuritis
Osteoporosis
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AS investigations:
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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
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AS treatment:
• Exercise
• Physiotherapy
• NSAIDs
– Pain relief
• Disease Modifying Anti Rheumatic Drugs (DMARDs):
– Azathioprine,
ciclosporin,
penicillamine,
leflunomide,
methotrexate and sulfasalazine.
• Biological drugs:
– Rituximab (Anti CD20), etanercept (TNF inhibitor) and abatacept
(T cell stimulator modulator)
– Inhibits the immune system
• Local steroid injections
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SERONEGATIVE SPONDYLARTHOPATHY
– Ankylosing spondylitis
– Psoriatic arthritis
– Reactive arthritis
– Enteropathic arthritis
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Psoriatic arthritis:
• Joints affected:
– DIP
– Spine
– Nail involvement
– Sacroiliac joints
• In people with psoriasis or family history of
psoriasis
• Less severe than RA
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Psoriatic arthritis types:
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Distal interpharyngeal arthritis (DIPJs)
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Most typical form
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Nail dystrophy
Seronegative symettrical polyarthritis
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Similar to RA eg knees, wrists, DIPs (not MCPs)
Arthritis mutilans
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5% affected.
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Xray shows periarticular osteolysis and bone shortening
Unilateral or bilateral sacroilitis
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15% affected.
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Affects the cervical spine
Assymetrical arthritis
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Warm red tender joints
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Dactylitis in hands and feet
Juvenille onset
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20% childhood arthritis
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Psoriatic arthritis symptoms:
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Stiffness and pain
Joint involvement:
– DIP joint
– Asymmetrical oligoarticular
arthritis
– Symmetrical polyarthritis
– Arthritis mutilans
(degeneration of joint)
– Sacroilitis
Psoriasis (some cases):
– Scalp
– Perineum
– Umbilicus
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Nail lesions
– Pitting
– Onchyolysis
– Splinter haemorrhages
Skin lesions:
– Erythematous lesions
– Pus
– Erythroderma
Enthesitis
Dactylitis (sausage digits)
Synovitis
Subcutaneous nodules
Conjunctivitis and uveitis
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Psoriatic arthritis investigations:
• Bloods:
– ESR
• High
– FBC:
• Anaemia
• Xray
The Peer Teaching Society is not liable for false or misleading information…
Psoriatic arthritis treatment:
• Exercise
• NSAIDs
– Pain relief
• Disease Modifying Anti Rheumatic Drugs (DMARDs):
– Azathioprine, ciclosporin, penicillamine, leflunomide,
methotrexate and sulfasalazine.
• Biological drugs:
– Rituximab (Anti CD20), etanercept (TNF inhibitor) and
abatacept (T cell stimulator modulator)
– Inhibits the immune system
The Peer Teaching Society is not liable for false or misleading information…
SERONEGATIVE SPONDYLARTHOPATHY
– Ankylosing spondylitis
– Psoriatic arthritis
– Reactive arthritis
– Enteropathic arthritis
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Reactive arthritis (Reiter’s):
• 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
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Reactive arthritis Causes:
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Shigella
Chlamydia
Salmonella
HIV
Enterocolli.
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Reactive arthritis investigations:
• Bloods:
– ESR
• High
• ECG
• Xray
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Reactive arthritis treatment:
• NSAIDs
– Pain relief
• Steroids
– Used in flare ups
• Antibiotics
– Treat the underlying cause
• (DMARDs)
The Peer Teaching Society is not liable for false or misleading information…
SERONEGATIVE SPONDYLARTHOPATHY
– Ankylosing spondylitis
– Psoriatic arthritis
– Reactive arthritis
– Enteropathic arthritis
The Peer Teaching Society is not liable for false or misleading information…
Enteropathic arthritis:
• 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
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CONNECTIVE TISSUE DISEASE
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Systemic lupus erythematosus
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Inflammatory, multisystem autoimmune disorder ->
autoantibodies which form immune complexes/bind to
tissues
90% occurs in females
Peak onset 20-40yrs
Predisposing factors
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Heredity
Genetics
Sex hormone status (pre-menopausal)
Drugs (hydralazine, isoniazid, penicillamine)
UV light
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Clinical features of SLE
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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…
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Lungs, heart, nervous system, eyes, GI system
• DIAGNOSIS -> based on ACR criteria, must have >4/11
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Other manifestations in SLE
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Investigation of 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
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Management
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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
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Severe flares, not controlled by steroids
• Biologics -> RITUXIMAB (Anti-CD20)
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Course and prognosis of SLE
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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
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CRYSTAL ARTHROPATHY
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Crystal arthropathies
GOUT
-> hyperuricaemia
-> intra-articular sodium urate crystals
PSEUDOGOUT
-> calcium pyrophosphate crystals
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GOUT
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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*
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Serum uric acid levels increase with: age, obesity, western
diet, DM, IHD, HTN, FHx
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Acute gout
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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
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Investigating gout
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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
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Gout; negatively birefringent sodium urate crystals
• Serum uric acid
– Usually >600umol/L
• Serum urea/creatinine/eGFR
– Monitored for renal impairment
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Treating acute gout
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High dose NSAIDS or COXIBS
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eg. Naproxen, Diclofenac, Indomethacin
In renal impairment;
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Colchicine or corticosteroids
• Dietary advice
– Reduce alcohol esp. beer and reduce calories/cholesterol and avoid
shellfish
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Reduce serum uric acid levels to <360um/L
*ALLOPURINOL*
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Blocks xanthine oxidase
Given for frequent attacks despite change in diet/if patient can’t
tolerate NSAIDS/if renal impairment present/tophi
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Chronic tophaceous gout
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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
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Pseudogout
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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
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GOOD LUCK!