Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

PTSecrets Rheumatology Part 1: The Painful Joint more informationelow for Maharsh Pandya by:Contents-Part1 Monoarthropathies Softtissuedisorders 01 Septic arthritis, crysta04 Polymositis, Sjorgen’s, arthropathies Dermamyositis Osteo/Rheumatoid SystemicSclerosis 02 Osteoarthritis, 05 Limited and Diffuse Rheumatoid arthritis, JIA Spondyloarthropath ies Q+A 03 Psoriatic, ank spond, 06 15 minutes for any Reactive questionsContents-Part2 BoneProfileTests PMRandLupus 01 What each element 04 Systemic Lupus means Erythrematus Polymyalgia Rheumatica BoneFragility Vasculitis 02 Osteomalacia, pagets 05 Small and large vessel Osteoporosis vasculitis BonePain Osteomyelitis, Q+A 03 hyperparathyroid 06 15 minutes for any cancer questions SBA A61yearoldmanpresentstothe EDwithseverekneepain. A Arthrocentesisoftheknee Itstartedlastweekandworsened since;hehasafamilyhistoryof B Intravenousflucloxacillin goutbutnosurgicalhistory. Hiskneeissignificantlyinflammed C OralNaproxen andisunabletoweightbear Temperature=37.8,otherobsare D Urgentorthopedicassessment normal. Whatisthenextstepin E X-rayoftheKnee management SBA:redhotjoint A61yearoldmanpresentstothe EDwithseverekneepain. A Arthrocentesisoftheknee Itstartedlastweekandworsened since;hehasafamilyhistoryof B Intravenousflucloxacillin goutbutnosurgicalhistory. Hiskneeissignificantlyinflammed C OralNaproxen andisunabletoweightbear Temperature=37.8,otherobsare D Urgentorthopedicassessment normal. Whatisthenextstepin E X-rayoftheKnee management SepticArthritis Presentation Investigations+Management Red, hot, inflammed joint. • Sepsis 6 BUT Pyrexial and systemically unwell • Obtain a synovial fluid sample THEN administer antibiotics Inflamed Joint- typically knee Reduced mobility- not weightbearing • Aspirate to dryness. Kocher Criteria Peads • Prosthetic or inaccessbile joint= • Non-weight bearing orthopedics for sterile • >38.5 arthrocentesis. • ESR >40 • IV abxs for 2 weeks and then oral • WBC > for further. >2 points= high likelihood. • Consider arthroscopic lavage (joint washout) CausativeOrganismsandAntibiotics GonaccocalvsStaphlococcalSepticArthritis StaphAureusor Streptococcal Neisseriagonorrhoeae ● Gram positive ● Gram negative ● 91% of cases- extremes of age ● Young adults ● Investigate a primary source of ● Sexual history of STI/ unprotected infection sex ● Flucloxacillin ● Ceftriaxone Episodicpainfulflaresonaredhotjoint? Gout Pseudogout Urate crystals Calcium pyrophosphate crystals Causes: Causes: • Diuretics (diabetes) • AGE • Alcohol (animals- meat/high • Trauma protein) • Hyperparathyroid • Renal impairment Vs • Haemachromatosis • Trauma • Hypophosphataemia Typically big toe, Tophi lumps can be Typically knee seen SBA ThearthrocentesisandsignificantbloodresultA Allopurinol are: Appearance-yellow SynovialWCC-3,000(<200) B Colchicine %Neutrophil- 57(<25) Needle-shapedcrystals,negativelybifringent SynovialGlucose(%serum)-93 C IV Flucloxacillin Synovialculture-pending U+Es D Methylprednisoloneintraarticular eGFR:25(>60) Whatshouldbedonetotreatthepatient’s E Total knee replacement condition CrystalarthropathyTreatment Gout Pseudogout Investigations: Investigations: X-ray: • peri-articular erosions X-ray: • Subcortical bone cysts • Chondrocalcinosis Synovial Fluid: • Articular meniscal cartilage • Yellow Needles are Negative calcification Management: Vs Synovial Fluid: Conservative: same as pseudogout, • Blue Bricks are Positive address risk factors Management: • Conservative: cool packs and rest Acute: High dose NSAID (Naproxen) or • Acute: same as Gout Colchicine • If severe: Oral and Intraarticular Long term: Address risk factors, if steroids and washouts. recurrent start allopurinol • Long term- Colchicine and NSAIDs can be preventative, joint replacementX-RAYS SynovialFluidanalysisCheatsheet Colour Clarity Viscosity WCC PMN Glucose Crystals Bacteria (per (%) (% mm3 serum) Normal Clear Clear High <200 <25 90-100 None None Septic- Yellow/g opaque variable >50,0 >75 <50 None Gram +ve* Staph/Strep reen 00 Gout Yellow/w cloudy Low 2- 50-75 80-100 Urate, None hite 50,00 yellow, 0 needle Pseudogout Yellow cloudy Low 2- 50-75 80-100 CPP, None 50,00 blue, 0 brick Septic- Gonn Yellow/g Opaque variable >50,0 >75 <50 None Gram –ve* reen 00 Osteoarthritis Straw/ye Clear/clo Medium 200- <25 90-100 None None llow udy 2000 Haemoarthrosis Red/yell Opaque variable 200- 50-75% 90-100 None None ow 2000 SBA Question: A Intraarticularmethylpred A 59 year old lady presents with bilateral finger pain. B Methotrexate Over the past 2 years the pain has worsened and particularly for 15 C OralIbuprofen minutes after she wakes up, before then improving. A hand X-ray is given. What is the most appropriate D Referraltohandsurgeon management option for her condition? E Topicaldiclofenac OsteovsRheumatoid Osteo-typical Rheumatoid Joints typically involved Joints typically involved: DIP, PIP, CMC and Knee ● PIP, MCP- NO DIP Characteristic hand signs Characteristic Hand signs ● Heberden’s and Bouchard’s nodes ● Swannecking and Z-shaping Typical pattern: Typical pattern • Short-lasting morning stiffness, • Long-lasting morning stiffness, worse with movement, improves improves with movement Vs Distinguishing features with rest ● Bilateral and symmetrical Distinguishing features ● Asymmetrical ● Inflammation ● Crepitus Demographics Demographics ● More common in women ● Same in men and women ● Younger to middle aged ● Middle aged and older OsteovsRheumatoid Osteo-typical Rheumatoid X-ray: Use American College of Rheumatology Loss of joint space Criteria for diagnosis ≥6= diagnosis: Osteophytes • Joint Distribution: (5) Subchondral cysts • Serology: Anti-CCP and RF (3) Subchondral sclerosis • Symptom duration: >6 weeks- (1) Conservative Management: ESR and CRP (1) Keep moving the joint X-ray: Vs Physiotherapy Loss of joint space Muscle strengthening Juxta-articular osteoporosis Low impact exercise (swimming) Periarticular erosions SubluxationOsteoarthritisImagingRheumatoidArthritisImaging Extraarticularmanifestations:NOFingCROCs N=nodules, typically on elbows, ulcers and vasculitis. O= osteoporosis, inflammation and steroids. Felty’s syndrome: RA with low WCC and splenomegaly, Infection- with immunosuppression. Treat the RA whilst monitoring for infection Cardiac: IHD, pericarditis, Respiratory: pulmonary fibrosis pleural effusion, disease + methotrexate Ocular: Episcleritis, conjunctivitis, keratoconjunctivitis sicca Carpal Tunnel: Other neuropathies Methotrexate Drugcheatsheet MoA: Folic acid synthesis inhibitor, acts on Dihydrofolate reductase Prescribing: Taken weekly, monitor FBCs, U+Es and LFTs weekly to optimise dose, then repeat 2-3 months. Side effects: Narrow therapeutic index! Respiratory: Mucositis + pulmonary fibrosis. Haem: myelosuppression, esp. agranulocytosis. Hepatic: liver fibrosis. Renal: Renal impairment Prescribing concerns: Avoid trimethoprim- is also a folate inhibitor. Co-prescribe folic acid. Contraception: Strongly advise to take contraception. Men and women should stay on contraception for up to 6 months following cessation of methotrexate. OsteoarthritisMedicalandsurgicaltreatment Tips Surgery Add PPI to NSAIDS or Joint correction/replacement4 steroids in >45 to Good luck post covid. prevent GI ulcers Opiates/IAsteroids Oral Codeine up to 03 Oramorph IA prednisolone Oralparacetamol/ NSAIDS Ibuprofen/naproxen 02 TopicalNSAIDS Topical diclofenac or 01 ibuprofen RhematoidarhrTreatment Surgery Joint correction/replacement Very rare Use DAS-28 to 04 Immunotherapies* monitor disease st progression 1ndnfliximab 2rdituximab 3 Abatacept 03 Relief NSAIDS- analgesia Steroids- 02 inflammation DMARDMonotherapy* Hydroxychloroquine- mild 01 Sulfasalazine Methotrexate- severe JuvenileIdiopathicArthropathy Aetioloigy Presentation IxandMx Criteria History Investigations ● Swelling pain or ● All diagnostic criteria ● FBCs, LFTs etc.- movement reduction ● Pyrexia- systemic screen for MAS ● In 1 or more joint ● Pink trunkal rash- ● ANA- if positive, ● >6 weeks systemic investigate for Uveitis ● In those <16 years old Management Subtypes Systemic: RiskFactors 1 IV or oral methyl pred. ● Systemic (non- nd specific) ● Female 2 immunologics ● Pauciarticular (<4 ● <6 years old Pauci- 1 IA steroids joints) ● Associated HLA 2ndmethotrexate/ immunologics ● Polyarticular (>4 ● Family history Poly- joints) 1 DMARD ● Others nd 2 Immunologics, steroids SBA A24yearoldmanpresentedtotheGP withrecurrant lowerbackpain.Thepain A Hydroxychloroquine isnotmanaged,particularlyworsewhen causinghimtowakehimatnightand B Infliximab earlyinthemorning.despite physiotherapyandtrailing Naproxen C NaproxenandIndometacin andibuprofen. ApreviousX-rayhadconfirmed sacroiliitis. D Prednisoloneoral Whatongoingtherapywouldbemost E Rituximab appropriatetomanagehisconditionHLA-27Spondyloarthropathies Psoriaticarthritis Background Presentation Treatment Pathophysiology Signs Investigations A varied disease that can • Telescoping of the X-ray: pencil in cup be Rheumatoid-like, or fingers (arthritis deformity in severe cases more oligoarthritic. RF- negative multicans) Must have psoriasis or • Dactylitis (sausage CASPAR classification family history of psoriasis finger) Nail Changes: Management History • onycholysis (separation ● 5 types: of the nail from the nail ● Start on NSAIDs ● Polyarticular bed) ● Consider DMARDs if ● Spondyloarthritic • Nail pitting polyarticular ● Oligoarticular • Nail loss ● If still severe: ● Distal • Hyperkeratosis TNF alpha blocker ● Arthritis multicans IA steroid injections AnkylosingSpondylitis Aetiology Presentation Treatment Pathophysiology Signs Investigations ● X-ray ● Initially inflammation ● Reduced forward ● HLAB-27 of the SI joints ● Works up the spine flexion- Schober’s ● MRI spine ● Fusion of the Test positive ● CXr- apical fibrosis vertebral bodies= ● Increased: Cervical bamboo spine flexion, thoracic kyphosis and loss of Management lumbar lordosis. Legs ● NSAIDS History will be bent to ● Physiotherapy compensate. ● BASDAI Test to assess ● Young, male ● DMARDs for peripheral ● Morning stiffness, ● Reduced cervical disease Sacroilitis spinal movements. ● Steroid injections and ● Improves with Immunologics for excercise inflammation. AScomplication RemembertheAs Apical fibrosis Anterior uveitis Aortic regurgitation Achilles tendonitis AV node block Amyloidosis peripheral Arthritis And cauda equina syndrome ReactiveArthritis Background Presentation Treatment History Symptoms Investigations 3-4 weeks following GI or Can’t see, pee or climb a • Rule out other GU infection tree Rheumatological • Post Dysentery: • See- conjunctivitis conditions Shingella, • Pee- urethritis (rheumatoid) Campylobacter, • Climb a tree- Management Salmonella oligoarthritis, typically • Post STI- Chylamidia- asymmetrical in large Self resolves but can more common in men lower limb and SI develop to chronic with joints. symptoms lasting up to 12 months Treat with NSAIDS (Naproxen) and/or steroids SBA A39yearoldwomanpresentswith dysphagia,dryeyesand A AntiLa arthralgia,alongsideparotid swelling.Shehasnomedical B AntiRo historyofnote.Whatinvestigation willconfirmthediagnosis C OGD D Rheumatoidfactor E Schwirmer’s Sjogren’s Aetiology Presentation Treatment Pathophysiology Signs Investigations Schirmer’s test- filter Autoimmune attack of • Keratoconjunctivitis paper in conjunctival sac exocrine glands sicca (dry eyes) for 5 mins Either primary or • Xerostomia (dry Anti- Ro and Anti La secondary to RA, SLE and mouth)- can lead to systemic sclerosis dysphagia or Rheumatoid and SLE Typically in young or post dysarthria, dental bloods menopausal women problems. Management • Vaginal dryness • Artificial Tears and saliva • Arthralgia • Pilocarpine • Glandular swelling • Treat secondary cause • Most resolve after 1 year. Myositis Presentation Presentation Treatment Pathophysiology Signs Management • Striated muscle • Muscle enzymes: CK, Initial inflammation ESR, ALT, AST, LDH, • High dose IV pred over a few days, then • Proximal muscle Aldolase high dose oral tapered weakness • EMG • Screen for cardiac or • MRI- muscle oedema nd over months respiratory • Muscle biopsy 2 line: involvement- can • Anti jo-1 antibodies- azathioprine/methotrexat spread to these. particularly in resp e, (Palpitations or signs disorders 3 line: IV IG, of lung fibrosis) • Anti MI-2 immunologics • Anti ANA PolymyostosisvsDermomyostosis Poly Derm ● Associated with malignancy ● ANA positive ● Nailfold erythema ● Associated with malignancy- lung, ● Affects middle-aged females Vs pancreatic, bowel, ovarian ● Heliotrope rash ● Gottren’s papules ● Majority anti ANA positive SBA Apatientpresentswith numbnessinherfingersand A Cetirizine toesandhasdevelopedthis conditionoverthepast3 months.Onexaminationshe B GTN hasmultiplespidernaevi C Oxygentherapy acrosshertorsoandabdomen bloodtestshows: AntiCentromer-+ve D Prednisolone Giventhelikelydiagnosiswhat canbegiventomanagethe E Sidenafil patient’ssymptoms SystemicSclerosis Limited Diffuse Approach Presentation Presentation Management • Only hands, feet and • Whole body • Sidenafil for face. Involvement raynaulds, keep • Look for pulmonary • Anti- scl70, anti rna extremities warm. HTN • Worse prognosis • Monitor BP alongside • Anti Centromere • Scleroderma renal antibodies crisis: high BP, anuria, ACEi, echos, AKI. Worsened with spirometry CREST steroids • No curative treatment, • Calcinosis monitor and treat • Raynaulds • More lung and cardiac complications • Oesophageal dysmotility fibrosis • Sclerodactyl • Worse arthraligia. • Telangectasia Immunologictablesummary Example name(s) Use* MoA TNF-A blockers Infliximab, Adalimumab, IBD, RA, AS, PA, Prevents TNF A mediated certolizumab, Psoriasis immune response thereby golimumab reducing inflammation. Anti-IL1 Anakinra RA Binds to IL-1, preventing granulocyte activation + recuruitment Anti-IL6 Tocilizumab RA, GCA, Binds to IL-6, preventing lymphocyte recruitment JAK inhibitors Tofacitinib, Baricitinib,RA, PA, IBD, Ezcema Prevents bound interleukens from Upadacitinib, causing their action, preventing WCC action. anti CD20 Rituximab RA, NHL, GPA, MPA, Prevents B-cell activation and PV proliferation. soluble receptor for TNF Etanercept RA, AS, PA, Psoriasis Same as TNF-A blockers but less pronounced side effects Anti B-lymph stimulator Belimumab SLE Binds to BLyS to prevent profileration CTLA-4 activator Abatacept RA, PA Activates CTLA-4 receptors inhibiting T-cell function. HighYieldFactSummary Red hot joint with fever= septic arthritis until proven otherwise, Aspirate ASAP then give Abx. Old, Oligo arthropathy, worse with movement= osteo, Younger woman, symmetrical polyarthropathy improving with movement= Rheum, weird combo with psoriasis or fam hist of psoriasis= psoariatic SI inflammation in young men= Ank Spond, give NSAIDS Dry mouth and eyes with autoimmune history= sjorgens, give tears and lubricants Myositis with rash= dermo, without= poly, give Pred! Thank you! Please fill in the feedback form : https://app.medall.org/training/feedback/anonymous?organisation=cardiff-university- 1d35ee05-c72b-48f9-840c-abb1560ca666&keyword=656e9412673cec8dce419717 Email: pandyamk@cardiff.ac.uk Followoursocials! chips_cardiff Cardiff Healthcare International PerspectiveS