For Phase 2

1

Rheumatology

• For Phase 2
• Katie Knappett
• Phase 3B

The Peer Teaching Society is not liable for false
or misleading information
2
Aims

• Go over basic sciences from Phase 1
• Aetiology / Risk Factors
• Pathophysiology
• Epidemiology
• Clinical Presentation
• Diagnostic Tests
• Treatment

The Peer Teaching Society is not liable for false
or misleading information
3
Conditions

• Osteoarthritis
• Rheumatoid Arthritis
• SLE
• Seronegative Spondyloarthropathies
• Crystal Arthropathies

The Peer Teaching Society is not liable for false
or misleading information
4
Rheumatology

• Rheumatic diseases
• Joints
• Connective Tissues
• Immunology

The Peer Teaching Society is not liable for false
or misleading information
5
Joint Pain
The Peer Teaching Society is not liable for false
or misleading information
6
Synovial Joints
The Peer Teaching Society is not liable for false
or misleading information
7
Osteoarthritis

• Most common type of arthritis
• Age-related degenerative
• Synovial joints affected
• Epidemiology
• Prevalence increased with age. Uncommon lt45
• Familial

The Peer Teaching Society is not liable for false
or misleading information
8
Risk Factors for OA

• Age
• Sex (FgtM)
• Genetic predisposition (polyarticular)
• Obesity
• Local factors
• Abnormal biomechanics
• Occupation (farming, footballer)

The Peer Teaching Society is not liable for false
or misleading information
9
Pathogenesis of OA

• There is a difference between structural OA and
  symptomatic OA

The Peer Teaching Society is not liable for false
or misleading information
10
Clinical Features of OA

• Symptoms
• Joint pain
• Stiffness
• Gelling
• Instability
• Loss of function
• Worse in evening

• Signs
• Tenderness
• Swelling
• Limited ROM
• Crepitus
• Joint instability
• Bony swelling (Heberdens Nodes, DIPJ)
• Muscle wasting
• Altered gait

The Peer Teaching Society is not liable for false
or misleading information
11
The Peer Teaching Society is not liable for false
or misleading information
12
Investigations

• Bloods ESR normal, hsCRP may be raised. RF and
  ANA negative.
• X-Rays abnormal only when advanced
• MRI subchondral bone changes, early cartilage
  injury
• Arthroscopy
• Aspiration of synovial fluid viscous fluid with
  few leucocytes

The Peer Teaching Society is not liable for false
or misleading information
13
OA X-Ray shows LOSS Loss of joint
space Osteophyte formation Subchondral
cysts Subarticular sclerosis
The Peer Teaching Society is not liable for false
or misleading information
14
Management of OA
Non-Pharmacological
Surgical

• Low impact activity
• Weight loss
• Physiotherapy

• Joint Replacement

Pharmacological

• Analgesia
• Regular Paracetamol (1g QDS)
• NSAIDs PRN (PPI if regular)

The Peer Teaching Society is not liable for false
or misleading information
15
Rheumatoid Arthritis

• Inflammatory
• Autoimmune disease
• Chronic symmetrical, deforming, polyarthritis of
  synovial joints
• Systemic involvement
• Typically female patients aged 30-50

The Peer Teaching Society is not liable for false
or misleading information
16
Risk Factors for RA

• Female sex
• Genetic predisposition
• Smoking

The Peer Teaching Society is not liable for false
or misleading information
17
Pathophysiology of RA

• Widespread persistent synovitis
• Synovial hypertrophy
• Synovial proliferation
• Inflammatory infiltration
• Pannus of inflamed synovium
• Damages underlying articular cartilage by
  blocking nutrition / direct cytokine effect
• Cartilage becomes thinned bone is exposed

The Peer Teaching Society is not liable for false
or misleading information
18
Clinical Features of RA

• Slowly progressive, symmetrical, peripheral
  polyarthritis evolving over weeks months.

• Symptoms
• Pain Stiffness typically in the morning
• Tiredness
• Systemically unwell
• Disturbed sleep

• Signs
• Inflammation
• Redness
• Heat
• Swelling
• Pain
• Limited ROM
• Muscle wasting
• Deformities

The Peer Teaching Society is not liable for false
or misleading information
19
Deformities in RA
Boutonniere Swan neck deformities
Ulnar Deviation
Z Thumb
Joint Subluxation (wrist/MCPJ)
Muscle Wasting
The Peer Teaching Society is not liable for false
or misleading information
20
The Peer Teaching Society is not liable for false
or misleading information
21
Rheumatoid Nodules

• Subcutaneous nodules
• Firm, intradermal
• Occur over pressure points (elbows, finger
  joints, Achilles tendon)

The Peer Teaching Society is not liable for false
or misleading information
22
Ring of macrophages and fibroblasts
Necrotic centre
Cuff of connective tissue containing lymphocytes
and plasma cells
23
Extra-Articular Features of RA

• RA is a SYSTEMIC disease

The Peer Teaching Society is not liable for false
or misleading information
24
Investigations

• Bloods
• Raised ESR
• Normocytic anaemia
• RF may be negative at the start, becoming
  positive in 80
• ANA ve in 30
• Anti-CCP
• X-rays
• Decreased joint space
• Bony erosions
• Subluxation
• Carpal destruction

The Peer Teaching Society is not liable for false
or misleading information
25
Management of RA
Non-Pharmacological
Pharmacological

• Regular exercise
• Physiotherapy
• Occupational therapy
• Orthotics (e.g. wrist splint)

• NSAIDs
• Ibuprofen
• Consider COX II selective if needing max doses
  (e.g. Celecoxib)
• PPI cover
• Steroids
• Intra-articular
• Systemic
• DMARDS

Surgical

• Joint replacement
• Pain relief, improve function

The Peer Teaching Society is not liable for false
or misleading information
26
Disease-Modifying Drugs (DMARDs)

• Problem Inflammation
• Solution Stop the inflammation!

Sulfasalazine Methotrexate Ciclosporin Gold Azath
ioprine Penicillamine Hydroxychloroquine

• Biologics
• Anti-cytokine treatments
• Infliximab (anti -TNF-a antibody)
• Etanercept (TNF-a receptor blocker)

The Peer Teaching Society is not liable for false
or misleading information
27
RA vs OA
The Peer Teaching Society is not liable for false
or misleading information
28
RA vs OA
Rheumatoid Arthritis Osteoarthritis
Pain Eases with use Increases with use
Stiffness Significant (gt60 mins) Early morning After rest Not prolonged (lt30 mins) Morning/Evening
Swelling Synovial /- bony Bony / None
Inflammation Hot, red joints No inflammation
Demographics Young, FH Older, occupation
Joint distribution Small joints Hands feet 1st CMCJ, DIPJ Knees
NSAIDs Good response Less convincing response
The Peer Teaching Society is not liable for false
or misleading information
29
Systemic Lupus Erythmatosus

• Inflammatory multisystem
• disorder
• Autoantibody (ANA)
• Deposition of immune
• complexes
• Most common Sx rash arthralgia
• Most serious Sx renal cerebral involvement

The Peer Teaching Society is not liable for false
or misleading information
30
SLE Epidemiology

• Afro-Caribbean / Asian ethnicity
• Female Male ratio is 91
• Peak age onset 20-40

The Peer Teaching Society is not liable for false
or misleading information
31
SLE Aetiology

• ? Cause
• Predisposing Factors
• Genetics (HLA A1, B8, DR3 Complement
  deficiencies, Family history)
• Sex Hormone Status (Premenopausal women, XXY, HRT
  can cause flare up)
• Drugs (hydralazine, isoniazid, penicillmine can
  cause mild SLE)
• EBV ?trigger for SLE

The Peer Teaching Society is not liable for false
or misleading information
32
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
• Abnormal cytokine production

The Peer Teaching Society is not liable for false
or misleading information
33
SLE Pathology

• Skin/Kidneys
• Deposition of complement and IgG antibodies
• ? neutrophils and lymphocytes
• Vasculitis
• Joints
• Immune complexes deposited in synovium

The Peer Teaching Society is not liable for false
or misleading information
34
SLE Clinical Features
- Great variety! - Most patients fatigue,
arthralgia, skin involvement - Major organ
involvement is less common, but more serious
SKIN gt85 of cases Butterfly erythema Photosensi
tivity Malar/Discoid rash Livedo
reticularis Raynauds Alopecia
HEART/CVS 25 of cases Pericarditis Pericardial
effusions Myocarditis Cardiomyopathy ?IHD/Stroke A
ntiphospholipid syndrome
JOINTS/MUSCLES gt90 have joint involvement Like
RA symmetrical small joints Painful but
clinically normal Deformity is RARE
LUNGS gt50 of cases Recurrent pleurisy Pleural
effusions Pneumonitis Pulmonary
fibrosis Intrapulmonary haemorrhage (vasculitis)
KIDNEYS 30 of cases Lupus Nephritis Glomeruloneph
ritis
NERVOUS SYSTEM 60 of cases Depression Severe
psychiatric disturbance Epilepsy Migraines
The Peer Teaching Society is not liable for false
or misleading information
35
SLE Clinical Features
O R D E R H I S A N A
Oral ulcers Rash (malar) Discoid rash Eye
involvement Renal disorders / recurrent
abortion Haematological Immunological Serositis Ar
thritis Neurological involvement Alopecia

• Diagnostic Criteria
• Malar (butterfly) rash
• Discoid rash
• Photosensitivity
• Oral ulcers
• Arthritis
• Serositis (pleutiris / pericarditis)
• Renal disorders (persistent proteinuria)
• CNS disorders (seizures / psychosis)
• Haematological disorders (haemolytic anaemia,
  leukopenia, lymphopenia, thrombocytopenia)
• Immunological disorders (Antiphospholipid
  antibody, anti-DNA antibody, anti-SM antibody)
• Antinuclear antibody positive in 95

The Peer Teaching Society is not liable for false
or misleading information
36
SLE Investigations
Routine Bloods Low WCC (neutophils and
lymphocyres) Low platelets Normocytic
anaemia/ Haemolytic anaemia Raised ESR Normal
CRP Raised Urea and Creatinine in renal
involvement
Autoantibodies ANA Anti-dsDNA Anti-Ro Anti-La
Anti-SM Antiphospholipid antibodies (in
APS) Complement ? C3 and C4
Histology Skin/Renal biopsy deposition of IgG
and complement complexes Imaging CT Head
infartcs/ Haemorrhage/ cerebral atrophy
The Peer Teaching Society is not liable for false
or misleading information
37
Management of SLE

• Avoidance of sunlight / sunblock
• Reduce CV Risk factors
• Rheum referral

Non-Pharmacological
Pharmacological

• NSAIDs for arthralgia, serositis
• Hydroxychloroquine for joint/skin problems if
  NSAIDs insufficient.
• High dose prednisolone for severe episodes.
  Other immunosuppresives/steroid sparing agents
  (cyclophosphamide, azathioprine, methotrexate)
  can be used.
• Longterm anticoagulant in APS

Surgical

• Renal transplant

The Peer Teaching Society is not liable for false
or misleading information
38
Prognosis of SLE

• Episodic relapsing/remitting course
• 10 year survival 90
• Deaths ltage 50 usually due to cerebral/renal
  involvement, or infection
• gt50, deaths due to stroke / CAD
• Increased lymphoma risk
• Fertility usually normal though increased
  miscarriages

The Peer Teaching Society is not liable for false
or misleading information
39
Seronegative Spondyloarthropathies

• Familial HLA-B27
• Different distribution of joint involvement
• Spine/Sacroiliac joints
• Asymmetrical large joint oligo- or
  monoarthropathies
• Enthesitis (inflammation of site of attachment of
  tendon/ligament to bone)
• Extra-articular features
• No RF production (Seronegative)

The Peer Teaching Society is not liable for false
or misleading information
40
Seronegative Spondyloarthropathies

• 3 main conditions
• Ankylosing Spondylitis
• Psoriatic Arthritis
• Reactive Arthritis

The Peer Teaching Society is not liable for false
or misleading information
41
Ankylosing Spondylitis

• Inflammatory spinal disorder
• Affects young adults
• Men present earlier
• MF age 16 is 61
• MF age 30 is 21
• 95 are HLA-B27 ve

The Peer Teaching Society is not liable for false
or misleading information
42
Clinical Features of AS

• Early Features / Presentation
• Typically young male
• Low back pain / stiffness
• Buttock pain
• Worse in the morning relieved by exercise
• Episodic but persistent for 3/12

• Associations
• Chest pain
• Hip involvement
• Knee involvement
• Enthesitides plantar faciitis
• Crohns/UC/Amyloid
• Psoriaform rashes
• Iritis / sterile uveitis

• Late Features
• Kyphosis
• Neck hyperextension (question mark posture)
• Spino-cranial ankylosis

The Peer Teaching Society is not liable for false
or misleading information
43
Classification Criteria

• High sensitivity and specificity
• 3 out of the following in adults under 50
  indicates AS
• Morning stiffness gt30 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
44
AS Investigations

• Clinical diagnosis
• Radiological findings
• Early Normal, or erosions/sclerosis affecting
  both sides of lower sacroiliac joints
• Late Squaring of vertebra,
• bamboo spine

The Peer Teaching Society is not liable for false
or misleading information
45
Management of AS
Non-Pharmacological

• Exercise, not rest
• Intense exercise regimens

Pharmacological

• NSAIDs for pain / stiffness
• Sulfasalazine / Methotrexate help peripheral
  arthritis / enthesitis
• Infliximab
• Long term bisphosphontes to help prevent
  osteoporotic spinal fractures

Surgical

• Spinal osteotomy

The Peer Teaching Society is not liable for false
or misleading information
46
Psoriatic Arthritis

• Arthritis / Enthesitis in patients with psoriasis
  or FH or psoriasis
• Skin disease may develop after the arthrtitis
• Asymmetrical arthritis involving DIPJ and spine
• Dactylitis (due to synovitis/tenosynovitis)
• Arthritis mutilans

The Peer Teaching Society is not liable for false
or misleading information
47
Psoriatic Arthritis Treatment

• Responds to
• NSAIDs
• Methotrexate
• Cyclosporin
• Anti-TNFa Therapies

The Peer Teaching Society is not liable for false
or misleading information
48
Reactive Arthritis

• Large joint mono- or oligoarthritis occurring
  following an infection
• Men gt Women
• Typical triggers
• NSU e.g. Chlamydia trachomats
• Gut infections salmonella, shigella, yersinia

The Peer Teaching Society is not liable for false
or misleading information
49
Reactive Arthritis

• May be chronic or relapsing
• Management
• Rest
• Splint joints
• NSAIDs / Steroids
• Consider sulfasalazine / Methotrexate
• Treating original infection has little benefit

The Peer Teaching Society is not liable for false
or misleading information
50
Reactive Arthritis

• Reiters Syndrome
• Cant See, Cant Pee, Cant climb a tree.
• Reactive Arthritis
• Urethritis
• Conjuncivitis

The Peer Teaching Society is not liable for false
or misleading information
51
Crystal Arthritis

• Gout/Pseudogout
• 2 main types of crystal involved
• Soduim Urate
• Calcium pyrophosphate

The Peer Teaching Society is not liable for false
or misleading information
52
Gout

• Inflammatory arthritis
• Hyperuricaemia
• Intra-articular sodium urate crystals
• VERY painful

The Peer Teaching Society is not liable for false
or misleading information
53
Hyperuricaemia

• Uric acid is the end product of purine metabolism
• Blood levels depend on purine synthesis, dietary
  purines and elimination of urate by the
  kidney/intestine
• Risk factors for hyperuricaemia (. Gout!)
• Renal function
• Body weight
• Blood pressure
• Alcohol intake

The Peer Teaching Society is not liable for false
or misleading information
54
Precipitants of Gout Attack

• Aggressive induction/cessation of hypouricaemic
  therapy (Allopurinol)
• Alcohol / shellfish binges
• Sepsis / MI / Acute severe illness
• Truma / Surgery / Dehydration (diuretics)

The Peer Teaching Society is not liable for false
or misleading information
55
Clinical Features of Gout

• Middle aged older men
• Sudden onset (ususally during the night)
• Agonising pain
• Red, shiny joint (polished apple)
• Tender
• Chronic gout urate deposits
• (tophi) found in peripheries

The Peer Teaching Society is not liable for false
or misleading information
56
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 (gt600µmol/L)

The Peer Teaching Society is not liable for false
or misleading information
57
Management of Acute Gout

• Strong NSAID e.g. naproxen
• Or
• Colchicine
• Or
• Steroids
• Prevent future attacks by avoiding high purine
  foods, alcohol XS, weight loss

The Peer Teaching Society is not liable for false
or misleading information
58
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
59
Pseudogout

• AKA Calcuim Pyrophosphate Dihydrate (CPPD)
  arthropathy
• 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
60
Pseudogout Risk Factors

• Dehydration
• Intercurrent illness
• Hyperparathyroidism
• Myxoedema
• Low Phosphate or magnesium
• Osteoarthritis
• Haemochromotosis
• Acromegaly

The Peer Teaching Society is not liable for false
or misleading information
61
Pseudogout

• Diagnosis
• 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
62
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
63
Other Rheumatology not covered

• Septic Arthritis
• Systemic Scerosis
• Polymyalgia Rheumatica
• Vasculitis
• Polymyositis / Dermatomyositis

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