This document provides an overview of several rheumatological conditions including osteoarthritis, rheumatoid arthritis, systemic lupus erythematosus, and seronegative arthritides such as reactive arthritis, ankylosing spondylitis, and enteropathic arthritis. Key details are provided on the epidemiology, pathology, signs and symptoms, investigations, and management of each condition. The document is intended as a guide for an OSCE station on rheumatology topics.
by Cono Grasso, MD
Jamaica Hospital Medical Center
Presented at the S.L.E. Lupus Foundation's "Get into the Loop!" New York City Lupus Education Series on October 6, 2010.
Know all about psoriasis, its types and treatment options both with allopathic and homeopathic systems of medicines. we detail about the complete aetiology, causes, types, illustrated with pictures, and the allopathic and homeopathic modes of treatment . here we explain how homeopathy helps in controlling and making the skin better in psoriasis and the complete treatment protocols and time required to see favourable results.
by Cono Grasso, MD
Jamaica Hospital Medical Center
Presented at the S.L.E. Lupus Foundation's "Get into the Loop!" New York City Lupus Education Series on October 6, 2010.
Know all about psoriasis, its types and treatment options both with allopathic and homeopathic systems of medicines. we detail about the complete aetiology, causes, types, illustrated with pictures, and the allopathic and homeopathic modes of treatment . here we explain how homeopathy helps in controlling and making the skin better in psoriasis and the complete treatment protocols and time required to see favourable results.
chemical injury to eye by alkali, acids and irritants.
pathophysiology and management.
recent advances in management.
ITS A TRUE EMERGENCY IN OPHTHALMOLOGY
Erythroderma is defined as the scaling erythematous dermatitis involving 90% or more of the cutaneous surface.
Also known as exfoliative dermatitis
Idiopathic exfoliative dermatitis – also known as the “red man syndrome”, is characterized by marked palmoplantar keratoderma, dermatopathic lymphadenopathy,increased IgE.
Increased skin perfusion leads to
Temperature dysregulation >
Resulting in skin loss and hypothermia >
High output state >
Cardiac failure
BMR raises to compensate for heat loss
Increased dehydration due to transpiration (similar to burns)
All lead to negative nitrogen balance and characterized by edema, hypoalbuminemia, loss of muscle mass.
Rheumatology Sheet from Rheumatology Department, Faculty of Medicine, Zagazig University, Egypt.
Disclaimer : not my slide. Just uploading for my personal use..
chemical injury to eye by alkali, acids and irritants.
pathophysiology and management.
recent advances in management.
ITS A TRUE EMERGENCY IN OPHTHALMOLOGY
Erythroderma is defined as the scaling erythematous dermatitis involving 90% or more of the cutaneous surface.
Also known as exfoliative dermatitis
Idiopathic exfoliative dermatitis – also known as the “red man syndrome”, is characterized by marked palmoplantar keratoderma, dermatopathic lymphadenopathy,increased IgE.
Increased skin perfusion leads to
Temperature dysregulation >
Resulting in skin loss and hypothermia >
High output state >
Cardiac failure
BMR raises to compensate for heat loss
Increased dehydration due to transpiration (similar to burns)
All lead to negative nitrogen balance and characterized by edema, hypoalbuminemia, loss of muscle mass.
Rheumatology Sheet from Rheumatology Department, Faculty of Medicine, Zagazig University, Egypt.
Disclaimer : not my slide. Just uploading for my personal use..
2. Objectives
• Go through GALS screen OSCE station
• Cover key Rheum Topics
• Practice SBA
• General Advice
3. Topics to be covered
•Osteoarthritis
•Rheumatoid Arthritis
•SLE
•Seronegative arthopathies
Not covered
Connective tissue diseases (polymyositis, system sclerosis, Sorgjerns syndrome)
Crystal arthropathies (gout, pseudogout)
Vacuities (GCA, polyarteritis nodosa)
Drugs and there side effects! IMPORTANT
Disclaimer: This presentation is just a guide!
4. Osteoarthritis (1)
Mechanical Degeneration of joint cartilage.
Epidemiology: >70yrs,
Risk Factors: Obesity, menopause, smoking, sportsmen, trauma.
Pathology: Damage to cartilage leads to oedema, death of chondrocytes.
Fibrillation and fissuring of cartilage, ulceration and micro fractures occur.
Eventually underlying bone is exposed leading to cyst and osteophytes.
Symptoms: Joint Pain, Joint Gelling, Joint instibility Loss of function
6. Osteoarthritis (3)
Management
1. Advice about weight loss, local muscle strengthening exercises
2. Paracetamol and topical NSAIDs are first-line analgesics.
3. Second-line treatment is oral NSAIDs/COX-2 inhibitors, opioids, and intra-
articular corticosteroids.
4. If conservative methods fail then refer for consideration of joint replacement
7. Rheumatoid Arthiritis (1)
A chronic symmetrical inflammatory polyarthititis with systemic
involvement
Epidemiology: F>M 3:1, ages 30-50
Associated with HLA-DR4
Pathology: Autoantibodies (IgM) to Fc of IgG, forming immune complexes
which deposit in joints leading to inflamation.
Symptoms: Pain (decrease with activity), swelling, morning stiffness
>30mins,.
Joint Involvement: MCP, MIP, PIP, MTP SYMETRICAL!
10. Rheumatoid Arthritis (4)
Systemic extra-articular involvement:
Skin: Rhumatoid nodules, synivotendonitis
Lungs: Effusions, nodules, fibroisis, Caplans syndrome: a combination of
pneumoconiosis and RA
Eyes: Sclertis (painful red eye), Episcleritis(non-painful red eye), Sorgjerns
syndrome
Neural: Mononeuritis multiplex, Carpal tunnel
Felty Syndrome: RA with splenomegaly and neutropenia
Normochromic normocytic anaemia
11. Rheumatoid Arthritis (5)
Investigations
ESR, CRP Increased
Possible Anaemia
RF +ve in 70% of cases, Anti-ccp positive in >90% of cases
CXR –Swelling of soft tissue, erosions, joint narrowing, juxto-articular
osteopenia
12.
13. Rheumatoid Arthritis (6)
Management
2009 NICE guidelines it is recommend that patients with newly
diagnosed active RA start a combination of DMARDs (including
methotrexate and at least one other DMARD, plus short-term
glucocorticoids)
1.DMARDS
Methotrexate (s.e derange LFT’s renal, neutopenia, PF, teratogenic)
• Sulfasalazine (s.e infertility, G6PD heamolysis)
• Lefunimide
Others e.g Azathriopine, Gold
(Also add prednisolone)
14. The current indication for a TNF-inhibitor is an inadequate response to
at least two DMARDs including methotrexate
4. Anti TNF alpha, use if DMARDS failed
e.g Entgeracept, Adelumimab , Infliximab
Side effects increase risk of cancer, infection, reversible refulx and
demylinating disease.
If a diagnosis of RA is yet to be made, you can give your patient NSAIDS (if
no contraindication) or a steroid injection
15. Systemic Lupus Erythematosus
SLE an “Systemic, inflammatory, multisystem disorder”
Autoimmune disease in which auto-antibodies and immune complexes
cause damage to organs.
Epidemiology: High prevalence in Afro-carribeans, Peak age of onset 20-
40 years
Aetiology: Hereditary , Genetic, Immune system disorder (Autoantibody
production + impaired tolerance), UV light , Drugs.
16. Clinical features
• Musculoskeletal 90% :
-Symmetrical, small joint, arthralgia, - Jaccoud’s arthropathy –Joint
deformity resembling RA – rare
• Cutaneous 75%
-Malar Rash:
-Discoid Lupus
• Neurology 60%
-Cerebral Lupus
• Lungs 50%
-Recurent pleurisy and BILATERAL pleural effusions
- “Shrinking Lung syndrome’
• Renal 30% (Histological changes are frequent)
- Regular screening for urine for blood and protein required
17. Diagnostic Criteria
Criterion Definition/examples
1. Malar rash
Fixed erythema over the malar eminences, tending to spare the nasolabial
folds
2. Discoid rash Erythematosus raised patches, may scar
3. Photosensitivity Skin rash as a result of unusual reaction to sunlight
4. Oral ulcers Usually painless
5. Arthritis Non-erosive: Jaccoud's arthropathy
6. Serositis
a) Pleuritis – pleuritic pain, pleural rub, pleural effusion b) Pericarditis – ECG
changes, rub, pericardial effusion
7. Renal disorder a) Proteinuria (> 3+ or 0.5 g/day) b) Cellular casts in urine
8. Neurological disorder a) Seizures b) Psychosis
9. Haematological disorder
a) Haemolytic anaemia b) Leukopaenia c) Lymphopaenia d)
Thrombocytopaenia
10. Immunological disorder a) Anti-DNA antibodies b) Anti-Sm antibodies c) Anti-phospholipid antibodies
11. Anti-nuclear antibody Exclude drug causes
American College of Rheumatology:
A person is said to have SLE if he/she meets any 4 of these 11 criteria simultaneously or in succession
18. Investigations
• Bloods
FBC: Leucopenia, lymphopenia and/or thrombocytopenia
ESR: Raised
CRP: Normal
U+E: Urea and Creatinine raised in advanced renal disease
• Urine Testing: Protein in urine and RBC Caste
• Complement: Low C3 Low C4
Imaging
• CT– infarcts or haemorrhage with evidence of cerebral atrophy
• MRI – lesions in white matter
19. Serum Antinuclear Antibodies (ANA) Positive >95%
Double stranded DNA Specific for SLE
Positive 60%
ENA: Anti-Ro and Anti-LA Detected
RF Positive in 40% of patients
Anticardiolipin antibodies Present in 35-45% of patients
Serological Syphilis Test False Positive 1/3rd
Investigation-Serology
20. Management
• Symptomatic treatment
-NSAIDS
-Antimalarials: e.g hydroxychloroquine
• Corticosteroids and immunosuppressive drugs
-Single dose I.M corticosteroids for flares
-immunosuppressive drugs for severe thrombocytopenia,
renal and cerebral diseases.
21. Seronegative arthiritis
A seronegative arthritis is an arthritis that is distinguished from rheumatoid arthritis due to
the absence of rheumatoid factor.
• Reactive arthritis
• Ankylosing spondylitis
• Enteropathic arthiritis
• Psoriatic arthritis.
22. Reactive Arthritis (1)
A generic term for a sterile arthritis following an infection (e.g. rheumatic fever, post
viral arthritis etc.)
Aetiology
Onset following an infectious episode either involving the GI or GU tract
GI: Shigella, Salmonella, Campylobacter,
GU: Chlamydia, Mycoplasma species
Acute pattern of clinical course 1-4 weeks post-infection
Epidemiology
• HLA-B27 patients
• axial > peripheral involvement
• M > F
25. Reactive Arthritis (3)
Investigations
• diagnosis is clinical plus laboratory
• lab findings: normocytic, normochromic anemia and leukocytosis
• cultures are sterile
Treatment
Appropriate antibiotics if there is documented infection
NSAIDs, physical therapy, home exercise
Local therapy: Joint protection, intra-articular steroid injection, topical steroid for ocular
involvement
Systemic therapy : Corticosteroids, sulfasalazine, methotrexate (for peripheral joints only)
26.
27. Ankylosing spondylitis (1)
Epidemiology
• incidence 0.2% of general population
• M: F = 5:1; females have milder disease
• 9% HLA-B27 positive in general population
Pathology
• inflammation of ligament where it attaches to bone leading to osteopenia, then erosion,
then ossification
30. Ankylosing spondylitis (3)
Investigations
• x-ray
Symmetric sacroiliitis “pseudowidening” of joint due to erosion with joint sclerosis ’ bony
fusion (late), • x-ray of spine: appearance of “squaring of edges” from erosion and sclerosis
on corners
“bamboo spine” of vertebral bodies leading to ossification of outer fibres of annulus fibrosis
(bridging syndesmophytes), this produces a radiographically
31.
32. Ankylosing spondylitis (4)
Diagnosis
Modified New York Criteria
Clinical criteria
Low back pain >3months, improves on exercise but not relived by rest.
Limitation of lumber spine motion in both the sagittal and frontal planes.
Limitation of chest expansion relative to normal values for age and sex
Radiological criteria
Sarcoiliitis on x-ray
Definite ankylosing spondylitis if the radiological criterion is present plus at
least one clinical criterion.
Probable ankylosing spondylitis if three clinical criteria are present alone, or
if the radiological criterion is present but no clinical criteria are present
33. Ankylosing spondylitis (5)
Management
Conservative
• Early diagnosis is important
• encourage regular exercise such as swimming
• NSAIDs
• Physiotherapy
Medical
• The disease-modifying drugs which are used to treat rheumatoid arthritis (such as
sulphasalazine) are only really useful if there is peripheral joint involvement
• TNF-alpha blockers such as etanercept and adalimumab
34. Enteropathic arthiritis
Arthritis as a result of inflammatory bowl disease
Manifestations of ulcerative colitis and Crohn’s disease
Large joints, asymmetrical, spondylitis, and hypertrophic osteoarthropathy
Symptoms: arthralgia, myalgia, osteoporosis and aseptic necrosis of bone 2º to steroid
treatment of bowel inflammation
Management: If you treat the IDB you treat the arthiritis
Note: NSAIDs should be used cautiously as they may exacerbate bowel disease
35.
36. Arthritis associated with psoriasis
M=F
Symptoms
• Pain, swelling, or stiffness in one or more joints. Dactylisis
• Achilles tendinitis, Plantar fasciitis.
• Changes to the nails, such as pitting or separation from the nail bed.
• Pain in the area of the Sacrum (the lower back, above the tailbone).
• Skin changes (plaques on elbows)
Management – Treat similar to rheumatoid
NSAIDS
DMARDS e.g Methotrexate
Biologics e.g Anti-TNFs
Psoriatic Arthritis
37. Practice SBA’s
1. Low levels of which one of the following types of complement are
associated with the development of systemic lupus erythematous?
A.C4
B.C5
C.C6
D.C7
E.C8
38. 2.You review the hands of a 60-year-old man who is complaining of
'arthritis' in his hands:
39. A. Rheumatoid arthritis
B. Systemic Sclerosis
C. Systemic Fungal infection
D. Psoriatic Arthritis
E. Reiter's Syndrome
40. 3. A 25-year-old man presents with back pain. Which one of the following
may suggest a diagnosis of ankylosing spondylitis?
A. Rapid Onset
B. Gets worse following exercise
C. Bone tenderness
D. Pain at night
E. Improves with rest
41. 4. A 57-year-old man presents to his GP due to pain in his right knee. An
x-ray shows osteoarthritis. He has no past medical history of note. What
is the most suitable treatment option for the management of his pain?
A. Oral Doclofenac with omeprazole
B. Oral glucosamine
C. Oral Diclofenac
D. Oral Ibuprofen
E. Oral paracetamol
42. 5. You refer a 24-year-old female to rheumatology with intermittent pain
and swelling of the metacarpal phalangeal joints for the past 3 months.
An x-ray shows loss of joint space and soft-tissue swelling. Rheumatoid
factor is positive and a diagnosis of rheumatoid arthritis is made. What
initial management is she most likely to be given to help slow disease
progression?
A. Infliximab
B. Methotrexate
C. Sulfasalazine
D. Methotrexate + sulfasalazine + short-course of prednisolone
E. Diclofenac
43. 6. A 25-year-old man presents complaining of dysuria and pain in his left
knee. Three weeks previously he had suffered a severe bout of diarrhoea.
What is the most likely diagnosis?
A. Reactive Arthritis
B. Disseminated gonococcal infection
C. Bachet’s syndrome
D. Ulcerative colitis
E. Rheumatoid arthritis
44. 7. A 79-year-old man presents with a history of lower back pain and right
hip pain. Blood tests reveal the following:
What is the most likely diagnosis?
A. Primary hyperparathyroidism
B. Chronic renal failure
C. Osteomalacia
D. Osteoporosis
E. Paget’s disease
Calcium 2.20 mmol/l
Phosphate 0.8 mmol/l
ALP 890 u/L
46. 8. A 40-year-old woman who is known to have systemic lupus
erythematosus is reviewed with an exacerbation of wrist pain. Which one
of the following is the most useful marker for monitoring disease activity?
A. C-reactive protein
B. C2 Levels
C. Anti-nuclear antibody titres
D. Anti-dsDNA titres
E. Anti-Sm Titres
47. 9. Which one of the following is least associated with systemic lupus
erythematous?
A. Anti-nulcear antibodies
B. Anti-Sm Antibodies
C. Elevated ESR
D. Elevated C3 And C4 levels
E. Elevated anti-dsDNA titres in active disease
48. SLE: ANA is 99% sensitive - anti-Sm & anti-dsDNA are 99% specific
C3, C4 are low in SLE not elevated
49. 10. You are doing the annual review of a 50-year-old woman who has
rheumatoid arthritis. Which one of the following complications is most
likely to occur as a result of her disease?
A. Chronic lymphocytic leukaemia
B. Hypertension
C. Colorectal Caner
D. Type 2 diabetes mellitus
E. Ischaemic heart disease