RHEUMATOLOGY REVISIONClare Hunt FY2

The plan Overview of Osteoarthritis and Rheumatoid

arthritis

Case scenarios 1 and 2 Symptoms and signs Clinical findings Epidemiology/ Risk factors Management

CASE SCENARIO 1A 67 year old lady comes to see you complaining of increasing pain in her hands

What do you do? History Examination Management

HISTORY Mostly affects her thumbs but also the small joints of

her fingers.

Pain is worse at the end of the day and after she has been gardening.

Noticed slight swelling of her joints. Pain eased by paracetamol when at its worst.

PMH - Hypertension (amlodipine 5mg.)

No alcohol; doesn’t smoke. Retired secretary.

DIFFERENTIAL DIAGNOSES?

CONTINUED

What might you find on examination?

What are you looking for?

LOOK

FEEL

MOVE

EXAMINATION FINDINGS Hands are not grossly deformed although she

does have a mild Z shaped deformity of the thumb

No skin lesions at her elbows or behind the ears.

Generally tender over all PIPs and DIPs with some hard swellings

She can do up buttons and write her name, although this causes some discomfort

WHAT ARE YOUR DIFFERENTIAL DIAGNOSES?

Osteoarthritis Rheumatoid arthritis

WHAT INVESTIGATIONS WOULD YOU LIKE?

Bloods – ESR? X-ray

What x-ray changes would you expect?

Joint space narrowing

Subchondral sclerosis

Osteophytes

May be none… or….

May also get subchondral cysts in late/severe OA.

Z-deformity

OA OF HANDS Usually as part of nodal osteoarthritis Mainly women > 40s or 50s Usually base of the thumb and DIPs Joints may be swollen and tender

Function usually good Linked with increased risk OA knee. Nodal OA likely to be passed mother to daughter. http://www.arthritisresearchuk.org/arthritis-information/conditions/osteoarthritis/which-joints-are-affected/

hands.aspx#sthash.peJPKKJ0.dpuf http://images.rheumatology.org/image_dir/album75691/md_05-04-0068.jpg

OSTEOARTHRITIS IN GENERAL

Weight bearing joints – knees, hips

Use – shoulders, hands

Spine (especially C-spine)

WHO? > late 40s - “wear and tear” Female Family hx OA Overweight Previous joint injury/operation Physically demanding job – repetitive

movements Joint abnormality eg Perthes’ PMH – gout, Rheumatoid arthritis

MANAGEMENT Lifestyle changes – weight loss NSAIDS Intra-articular steroid injections

Surgery

Summary of OA Degenerative disease of increasing age Mainly weight-bearing/high use joints Pain, swelling, stiffness – evening > morning Management – lifestyle, symptom control,

surgery

CASE SCENARIO 2 A 34 year old lady comes to see you giving

an 8 week history of pain affecting the small joints of her hand.

What do you want to know?

CONTINUED Pain and stiffness worst first thing in the morning Improves after about 1hour General malaise Noticed her hands are slightly swollen

PMH – nil DH – OCP

What else do you want to know? Smokes 10/day; <14units alcohol/week Occupation = Secretary Grandmother had problems with her hands

EXAMINATION What might you find?

Slight swelling over MCP and PIP joints both hands

Tender on palpation

No obvious deformity

What else should you look for/check? Temp 37.5 No skin changes elbows or scalp Right eye slightly red around cornea – not painful

DIFFERENTIAL DIAGNOSES? Rheumatoid arthritis

Septic arthritis Gout Osteoarthritis SLE Psoriatic arthritis

WHAT IS RHEUMATOID ARTHRITIS? Definition

“a multisystem autoimmune inflammatory condition that typically affects the small

joints of the hands and feet”

SYMPTOMS AND SIGNS Differentiate OA from RA

Worse in morning Morning stiffness Small joints of hand Symmetrical MCPs and PIPs > DIPs

TYPICAL HAND SIGNS? Ulnar deviation of fingers DIPs spared Guttering of MCPs Wasting of intrinsic hand muscles Carpal tunnel syndrome

http://www.3pointproducts.com/Portals/30688/images//Boutonnierrelabel.jpghttp://www.3pointproducts.com/Portals/30688/images//SwanNecklabel.jpg

OTHER BONY FEATURES? C- spine

Cervical subluxation Neck pain Atlanto-axial instability

Feet Subluxation of metatarsal heads Claw toes

Diagnostic criteria of RA Diagnosis can be made if these are all

present:

Inflammatory arthritis involving three or more joints.

Positive RF and anti-CCP Raised CRP or ESR Duration of symptoms > six weeks Excluded similar diseases:

Psoriatic arthritis Acute viral polyarthritis Gout/psuedogout SLE

EXTRA-ARTICULAR MANIFESTATIONS

Weight loss, fever, malaise common Skin – Rheumatoid nodules – elbows & forearms

Heart – pericarditis, pericardial effusion Lungs – Rheumatoid nodules, pulmonary fibrosis,

pleural effusion, bronchiectasis

Eyes – episcleritis/scleritis

Neuro – peripheral neuropathy, carpal tunnel syndrome

Felty’s syndrome

WHAT DOES THE PATIENT WANT?

I – what does she think it is?

C – what is she worried/concerned about/how is it affecting them?

E – what does she want from you today?

SO WHAT ARE YOU GOING TO DO FOR HER? Investigations

Bloods FBC, U+E, LFTs, ESR, CRP, RF, anti-CCP

Imaging X-ray findings?

Soft tissue swelling

Deformity

Loss of joint space

Bony erosionPeriarticular

osteopaenia

“Pencil in cup” deformity

Management

Conservative Weight loss, smoking cessation Support - “MDT approach”

Medical Analgesia, steroids, DMARDs, Biologics NICE guidance = early DMARDS

Surgical Joint fusions, joint replacement, carpel tunnel

decompression

DMARDS Methotrexate Sulfasalazine Gold Penicillamine

Side effects? Folic acid suppression, deranged LFTs Myelosuppression; pneumonitis (rare) Nephrotic syndrome (Gold & Penicillamine)

Check baseline U+E, FBC, LFTs & urine

analysis

Biologics (after failure to respond to 2 DMARDS)

Anti-TNF alpha Infliximab, Adalimumab, Etanercept

What test should be done prior to starting biologics?

Side effects Allergic reactions; TB reactivation; increased risk

infection

SUMMARY

MULTIDISCIPLINARY APPROACH!