1. For Phase 2a Richard Morris Iain Ruddick The Peer Teaching Society is not liable for false or misleading information…

2. Aetiology / Risk Factors Pathophysiology Epidemiology Clinical Presentation Diagnostic Tests Treatment The Peer Teaching Society is not liable for false or misleading information… Aims

3. Rheumatology – Osteoarthritis – Rheumatoid Arthritis – SLE – Seronegative Spondyloarthropathies – Crystal Arthropathies Bone – Osteoporosis – Paget’s disease – Osteomalacia The Peer Teaching Society is not liable for false or misleading information… Conditions

4. Joint Pain Inflammatory Autoimmune RA Seronegative spondyloarthropathies Connective Tissue Disease Crystal ArthritisInfection Non-Inflammatory Degenerative e.g. Osteoarthritis Non-degenerative e.g. fibromyalgia The Peer Teaching Society is not liable for false or misleading information… Joint Pain

5. Most common type of arthritis Age-related – degenerative Synovial joints affected Risk factors: – Age – Obesity – Local factors Abnormal biomechanics Occupation (farming, footballer…) The Peer Teaching Society is not liable for false or misleading information… Osteoarthritis

6. Symptoms Joint pain Stiffness Gelling Instability Loss of function Worse in evening The Peer Teaching Society is not liable for false or misleading information… Clinical Features of OA Signs Tenderness Swelling Limited ROM Crepitus Joint instability Heberden’s & Bouchard’s Nodes (DIPJ / PIPJ bony swellings) Muscle wasting Altered gait

7. Bloods – ESR normal, CRP may be raised. RF and ANA negative. X-Rays – abnormal only when advanced Arthroscopy Aspiration of synovial fluid – viscous fluid with few leucocytes The Peer Teaching Society is not liable for false or misleading information… Investigations

8. The Peer Teaching Society is not liable for false or misleading information… OA X-Ray shows LOSS Loss of joint space Osteophyte formation Subchondral cysts Subarticular sclerosis

9. The Peer Teaching Society is not liable for false or misleading information… Management of OA Non-Pharmacological Pharmacological Surgical - Low impact activity - Weight loss - Physiotherapy - Analgesia -Regular Paracetamol (1g QDS) -NSAIDs PRN (+PPI if regular) - Joint Injection - Joint Replacement

10. Chronic inflammatory arthritis Symmetrical, peripheral polyarthritis of synovial joints Systemic involvement Risk factors: – Typically female patients aged 30-50 – Smoking – Genetic predisposition The Peer Teaching Society is not liable for false or misleading information… Rheumatoid Arthritis

11. Clinical Features of RA Symptoms Pain & Stiffness worse in morning Tiredness Systemically unwell Disturbed sleep Signs Inflammation Redness Heat Swelling Pain Limited ROM Muscle wasting Deformities

12. The Peer Teaching Society is not liable for false or misleading information… Extra-Articular Features of RA

13. The Peer Teaching Society is not liable for false or misleading information… Investigations -Bloods - Raised ESR - RhF (+ve in 80%) - ANA (+ve in 30%) - Anti-CCP (v.specific) -X-rays - Decreased joint space - Bony erosions - Subluxation - Soft tissue swelling

14. The Peer Teaching Society is not liable for false or misleading information… Management of RA Non-Pharmacological Pharmacological - Regular exercise - Physiotherapy - Occupational therapy - Orthotics (e.g. wrist splint) -NSAIDs - e.g. Ibuprofen + PPI cover - Steroids - Intra-articular - Systemic - DMARDS -Methotrexate & Sulfasalazine -Biologics -e.g. Infliximab (TNF-a inhib) -e.g. Rituximab (anti-CD20 Ab)

15. The Peer Teaching Society is not liable for false or misleading information… RA vs OA

16. The Peer Teaching Society is not liable for false or misleading information… RA vs OA Rheumatoid Arthritis Osteoarthritis PainEases with useIncreases with use StiffnessSignificant (>60 mins) Early morning After rest Not prolonged (<30 mins) Morning/Evening SwellingSynovial +/- bonyBony / None InflammationHot, red jointsNo inflammation DemographicsYoung, FHOlder, occupation Joint distributionSmall joints Hands & feet 1 st CMCJ, DIPJ Knees NSAIDsGood responseLess convincing response

17. Inflammatory multisystem disorder -raised ESR Autoantibodies – antinuclear antibodies (ANA) (95%) – anti-dsDNA antibodies (60%) – RhF +ve (40%) Deposition of immune complexes The Peer Teaching Society is not liable for false or misleading information… Systemic Lupus Erythmatosus

18. Afro-Caribbean / Asian ethnicity Female: Male ratio is 9:1 Peak age onset 20-40 The Peer Teaching Society is not liable for false or misleading information… SLE Epidemiology

19. 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 Immune complex deposition The Peer Teaching Society is not liable for false or misleading information… SLE Pathophysiology

20. The Peer Teaching Society is not liable for false or misleading information… SLE Clinical Features - Great variety! - Most patients: fatigue, arthralgia, skin involvement - Major organ involvement is less common, but more serious - Great variety! - Most patients: fatigue, arthralgia, skin involvement - Major organ involvement is less common, but more serious SKIN >85% of cases “Butterfly” erythema Photosensitivity Malar/Discoid rash Livedo reticularis Raynaud’s Alopecia JOINTS/MUSCLES >90% have joint involvement Like RA – symmetrical small joints Painful but clinically normal Deformity is RARE HEART/CVS 25% of cases Pericarditis Pericardial effusions Myocarditis Cardiomyopathy ↑IHD/Stroke Antiphospholipid syndrome LUNGS >50% of cases Recurrent pleurisy Pleural effusions Pneumonitis Pulmonary fibrosis Intrapulmonary haemorrhage (vasculitis) KIDNEYS 30% of cases Lupus Nephritis Glomerulonephritis NERVOUS SYSTEM 60% of cases Depression Severe psychiatric disturbance Epilepsy Migraines

21. The Peer Teaching Society is not liable for false or misleading information… SLE Clinical Features ORDERHISANAORDERHISANA ORDERHISANAORDERHISANA Oral ulcers Rash (malar) Discoid rash Eye involvement Renal disorders / recurrent abortion Haematological Immunological Serositis Arthritis Neurological involvement Alopecia Oral ulcers Rash (malar) Discoid rash Eye involvement Renal disorders / recurrent abortion Haematological Immunological Serositis Arthritis Neurological involvement Alopecia Diagnostic Criteria 1.Malar (butterfly) rash 2.Discoid rash 3.Photosensitivity 4.Oral ulcers 5.Arthritis 6.Serositis (pleutiris / pericarditis) 7.Renal disorders (persistent proteinuria) 8.CNS disorders (seizures / psychosis) 9.Haematological disorders (haemolytic anaemia, leukopenia, lymphopenia, thrombocytopenia) 10.Immunological disorders (Antiphospholipid antibody, anti-DNA antibody, anti-SM antibody) 11.Antinuclear antibody positive in 95% Diagnostic Criteria 1.Malar (butterfly) rash 2.Discoid rash 3.Photosensitivity 4.Oral ulcers 5.Arthritis 6.Serositis (pleutiris / pericarditis) 7.Renal disorders (persistent proteinuria) 8.CNS disorders (seizures / psychosis) 9.Haematological disorders (haemolytic anaemia, leukopenia, lymphopenia, thrombocytopenia) 10.Immunological disorders (Antiphospholipid antibody, anti-DNA antibody, anti-SM antibody) 11.Antinuclear antibody positive in 95%

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

23. The Peer Teaching Society is not liable for false or misleading information… Management of SLE Non-Pharmacological Pharmacological - Avoidance of sunlight / sunblock -Reduce CV Risk factors -Rheum referral - NSAIDs for arthralgia, serositis - High dose prednisolone for severe episodes. Other immunosuppresives/steroid sparing agents (cyclophosphamide, azathioprine, methotrexate) can be used. - Longterm anticoagulant in APS Surgical - Renal transplant

24. The Peer Teaching Society is not liable for false or misleading information… Prognosis of SLE Episodic relapsing/remitting course 10 year survival 90% – deaths under age 50 usually due to cerebral/renal involvement, or infection – deaths over age 50 usually due to stroke / CAD Fertility usually normal though increased miscarriages

25. Familial; associated with HLA-B27 No RhF production (“Seronegative”) 3 main conditions: – Ankylosing Spondylitis – Psoriatic Arthritis – Reactive Arthritis The Peer Teaching Society is not liable for false or misleading information… Seronegative Spondyloarthropathies

26. Chronic inflammatory disease of spine & sacroiliac joints Affects young adults Men present earlier – M:F age 16 is 6:1 – M:F age 30 is 2:1 95% are HLA-B27 +ve The Peer Teaching Society is not liable for false or misleading information… Ankylosing Spondylitis

27. The Peer Teaching Society is not liable for false or misleading information… Clinical Features of AS Early Features / Presentation -Typically young male (< age 40) -Low back pain / stiffness -Buttock pain -Worse in the morning; relieved by exercise -Episodic but persistent for 3/12 Early Features / Presentation -Typically young male (< age 40) -Low back pain / stiffness -Buttock pain -Worse in the morning; relieved by exercise -Episodic but persistent for 3/12 Late Features -Kyphosis -Neck hyperextension (question mark posture) -Spino-cranial ankylosis Late Features -Kyphosis -Neck hyperextension (question mark posture) -Spino-cranial ankylosis Associations -Chest pain -Hip involvement -Knee involvement -Enthesitis - Crohn’s/UC/Amyloid -Psoriaform rashes -Iritis / sterile uveitis Associations -Chest pain -Hip involvement -Knee involvement -Enthesitis - Crohn’s/UC/Amyloid -Psoriaform rashes -Iritis / sterile uveitis

28. High sensitivity and specificity 3 out of the following in adults under 50 indicates AS: – Morning stiffness >30 mins – Improvement with exercise but not rest – Awakening due to back pain in the 2 nd half of the night only – Alternating buttock pain The Peer Teaching Society is not liable for false or misleading information… Classification Criteria

29. Clinical diagnosis Radiological findings: – Appear late – Sacroiliitis is earliest feature – Ankylosis & bamboo spine follow The Peer Teaching Society is not liable for false or misleading information… AS Investigations

30. The Peer Teaching Society is not liable for false or misleading information… Management of AS Non-Pharmacological Pharmacological Surgical - Exercise, NOT rest - Intense exercise regimens -NSAIDs for pain / stiffness - Sulfasalazine / Methotrexate help peripheral arthritis / enthesitis -Infliximab if severe -Long term bisphosphonates to help prevent osteoporotic spinal fractures - Hip replacement - Spinal osteotomy

31. Arthritis / Enthesitis in patients with psoriasis or FH of psoriasis – Skin disease may develop after the arthrtitis Pattern: – DIP joints / spinal involvement / arthritis mutilans Associated features: – Dactylitis (due to synovitis/tenosynovitis) – Nail changes – X-ray = erosive changes (‘pencil-in-cup’ deformity) The Peer Teaching Society is not liable for false or misleading information… Psoriatic Arthritis

32. Responds to: – NSAIDs – Methotrexate – Cyclosporin – Anti-TNFα Therapies The Peer Teaching Society is not liable for false or misleading information… Psoriatic Arthritis Treatment

33. Large joint arthritis following an infection – typical triggers: Urethritis (e.g. Chlamydia) Dysentry (e.g. salmonella, shigella & campylobacter) – presents within 1-4wks of infection May be chronic or relapsing The Peer Teaching Society is not liable for false or misleading information… Reactive Arthritis

34. Clinical features – Acute, asymmetrical lower limb arthritis – Enthesitis, iritis & mouth ulcers may occur – “Reiters Syndrome” Can’t See, Can’t Pee, Can’t climb a tree…. Combo of urethritis, arthritis & conjunctivitis Investigations – Raised ESR & CRP – Sexual health review The Peer Teaching Society is not liable for false or misleading information… Reactive Arthritis

35. 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… Reactive Arthritis

36. Gout/Pseudogout 2 main types of crystal involved – Soduim Urate (Gout) – Calcium pyrophosphate (Pseudogout) The Peer Teaching Society is not liable for false or misleading information… Crystal Arthritis

37. Inflammatory arthritis Hyperuricaemia Intra-articular sodium urate crystals VERY painful The Peer Teaching Society is not liable for false or misleading information… Gout

38. 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… Precipitants of Gout Attack

39. 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… Clinical Features of Gout

40. 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 (>600µmol/L) The Peer Teaching Society is not liable for false or misleading information… Investigations of Gout

41. 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… Management of Acute Gout

42. 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… Recurrent Gout

43. 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… Pseudogout

44. Dehydration Intercurrent illness Hyperparathyroidism Myxoedema Low Phosphate or magnesium Osteoarthritis Haemochromotosis Acromegaly The Peer Teaching Society is not liable for false or misleading information… Pseudogout Risk Factors

45. 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… Pseudogout

46. Aspiration reduces pain NSAID/Colchicine as with gout Intra-articular steroid injection The Peer Teaching Society is not liable for false or misleading information… Pseudogout Treatment

47. Septic Arthritis Systemic Scerosis Polymyalgia Rheumatica Vasculitis Polymyositis / Dermatomyositis The Peer Teaching Society is not liable for false or misleading information… Other Rheumatology not covered

48. Characterised by compromised bone strength, predisposing to an increased risk of fracture The Peer Teaching Society is not liable for false or misleading information… Osteoporosis Risk factors -FH -Elderly -Steroid use -Alcohol & Tobacco -Early menopause Presentation -Pain -Reduced mobility -Height loss -Kyphosis -Fracture

49. The Peer Teaching Society is not liable for false or misleading information… Osteoporosis Investigations – DXA Measures BMD Measured as a T-score – > -1 = no evidence of osteoporosis – -1 to -2.5 = osteopenia – < -2.5 = osteoporosis Management – Conservative Smoking & alcohol Weight-bearing exercise – Pharmacological Bisphosphonates Calcium & Vit.D Denosumab HRT (in post-menopause)

50. The Peer Teaching Society is not liable for false or misleading information… Paget’s disease Epidemiology – Incidence rises with age Rare under 40 – Men > Female – Genetic component Pathophysiology – Increased rate of bone turnover – Leads to disordered architecture – Results in loss of strength & elasticity Disease stages: – Osteolysis Osteoporosis circumscripta on X-ray – Mixed phase Osteolysis & osteosclerosis – Osteosclerosis Bones v.white on X-ray

51. The Peer Teaching Society is not liable for false or misleading information… Paget’s disease Presentation – Symptoms 70% asymptomatic Bone pain Bony deformity & enlargement Bones warm (increased vascularisation) – Complications Fracture Spinal cord compression Secondary OA Investigations – X-ray Bony deformity/enlargement Sclerosis & osteolysis – Alk phos markedly raised Treatment – Analgesia – Physical aids – Bisphosphonates – Surgery (joint replacement & osteotomy)

52. The Peer Teaching Society is not liable for false or misleading information… Osteomalacia & Rickets Impaired bone mineralisation – results in the accumulation of unmineralised osteoid & softening of bone Osteomalacia – Bone pain / fracture Rickets – Osteomalacia in a child – Effects are seen at the growth plate Growth plate widened, cupped & frayed Valgus & varus deformities

53. The Peer Teaching Society is not liable for false or misleading information… Osteomalacia & Rickets Causes – Vitamin D deficiency Malabsorption Poor diet Lack of sunlight – Hypophosphataemia – Drug-induced Presentation – Osteomalacia Bone pain & tenderness Fractures Proximal myopathy – Rickets Growth retardation Hypotonia Valgus & varus deformities

54. The Peer Teaching Society is not liable for false or misleading information… Osteomalacia & Rickets Investigations – Bloods Low calcium, phosphate & vitamin D High alk phos & PTH – Bone biopsy Incomplete mineralisation – X-ray Pseudofractures Widened, cupped & frayed growth plates in Rickets Treatment – Vitamin D

55. Vertebral disc degeneration Bone tumours Fibromyalgia Mechanical lower back pain Infection The Peer Teaching Society is not liable for false or misleading information… Other Bone/MSK not covered