arthropathies amp Vasculitis Dr Emma Hodgkins FY1 Gastroenterology What were cramming into 25 minutes Psoriatic arthritis Ankylosing spindylitis Reactive arthritis Enteropathic spondyloarthropathy ID: 697148
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Finals revision 2014:Seronegative arthropathies& Vasculitis
Dr Emma Hodgkins, FY1, GastroenterologySlide2
What we’re cramming into 25 minutesPsoriatic arthritisAnkylosing spindylitisReactive arthritisEnteropathic spondyloarthropathyExtra-articular featuresTypes of VasculitisWith a couple of cases….Slide3
Case scenario: A 45 year old man comes to see you because of increasing pain in the small joints of his hands. They have been troubling him for the last few months but have gotten worse over the last few weeks. They are painful and stiff first thing in the morning, more on the right than the left. They get better after an hour and moving them. The joint occasionally swell and it is disrupting his morning routine and making him late for work. He works as a builder. He suffers from Psoriasis which is well managed with coal tar. He does not smoke and drinks socially. On exam he has obvious scaling of his elbows and behind his ears. He has pitting of his nail beds and he has tender, swollen MCPs and PIP joint, worse on the right than the left. He has good function in both hand and can do buttons and write his name.
What are your differentials for this man?
How will you investigate him?
What are the different patterns of psoriatic
arthropathy
?
How would you manage this gentleman?
What are the extra articular features of ankylosing spondylitis?What the different types of seronegative arthropathies?Slide4
Case scenario: A 45 year old man comes to see you because of increasing pain in the small joints of his hands. They have been troubling him for the last few months but have gotten worse over
the last few weeks. They are painful and stiff first thing in the morning
, more on the right than the left. They get better after an hour and moving them. The joint occasionally swell and it is disrupting his morning routine and making him late for work. He works as a builder. He
suffers from Psoriasis
which is well managed with coal tar. He does not smoke and drinks socially. On exam he has obvious scaling of his elbows and behind his ears. He has
pitting of his nail beds
and he has tender, swollen MCPs and PIP joint, worse on the right than the left. He has good function in both hand and can do buttons and write his name.
What are your differentials for this man?How will you investigate him?What are the different patterns of psoriatic arthropathy?How would you manage this gentleman?
What are the extra articular features of ankylosing
spondylitis?
What the different types of
seronegative
arthropathies
?Slide5
Psoriatic arthritisAffects 10% of those with psoriasisCan precede skin symptomsRheumatoid factor negative5 patternsPolyarthritis – RA-likeSpinal – can mimic ankylosing spondylitisDIP joint onlyOligoarthritisPsoriatic mutilans – rare, severe deformitySlide6
PA: InvestigationsBloods : FBC, Inflammatory markers, RhF, HLA-B27XrayErosions, Periarticular oseoporosis‘pencil-in-cup’ deformity (whittling & cupping of phylanges)Slide7
PA: ManagementConservative: physio, splintsMedicalNSAIDSDMARDs- Methotrexate, ciclosporinAnti-TNF drugsIntra-articular steroidsSurgical – when all else fails – fusion etcSlide8
Ankylosing Spondylitis Chronic inflammatory disease of the spine and sacroiliac jointsYoung men commonest affectedSymptoms and signsGradual onset lower back pain and stiffness worse at night, relieved by exercisereduced range of spinal movementReduced hip rotationquestion mark postureSchrobers test positiveSlide9
Ankylosing Spondylitis Investigations (Diagnosis is clinical)
Bloods – exclude other causes – FBC, ESR, CRP, RF
Imaging – pelvic xray, MRI (more sensitive) – erosions and sclerosisBamboo or rugger jersey spine is rare
now
Management
Conservative – weight loss, exercise!!
Medical – NSAIDs, Steroids, DMARDS, Biologics
Surgical – little beyond hip replacements if involvedSlide10
Reactive arthritisA sterile arthritis occuring after an extra-articular infection
Causative infection is usually…
Gastrointestinal (salmonella, shigella, campylobacter
)
Urogenital (
chlamydia
– 60%)
Reiter’s syndrome = arthritis, urethritis & conjunctivitisMay present with Pain in large jointslow back pain (sacroliliitis
)Painful heels (enthesitis
/plantar fasciitis)
Dysuria
Conjuctivitis
Oral ulceration
Keratoderma
blenorrhagica
(10%) macules on soles & palmsSlide11
Reactive arthritisInvesigationsFBC, ESR, CRP, HLA-B27 (70-80%) Stool & urine cultures, Urethral swabs
Management
Initially rest, NSAIDs (indomethacin)Mobilise with 2 weeks course of NSAIDs/sulfasalazineTreat the underlying infection
Topical antibiotics to prevent secondary infection of conjunctivitisSlide12
Extra-articular features of inflammatory diseasesSlide13
Enteropathic arthritisAssociated with Crohn’s disease and UCWhich are also associated with…
Primary sclerosing
cholangitisPyoderma gangrenosum
Uveitis
Erythema
nodosum
Thyroid disease
Usually an oligoarthritisTreat with disease modifying treatment for IBDSlide14
And breath…almost there!
Just time for one more case!Slide15
A 45 year old man comes to see you with a stuffy nose for the last 5 months. He is troubled by recurrent sinusitis and runny nose. He also feels his nose has changed shape, as if it has “caved in”. He has felt generally unwell with aches and tiredness for the last 3 months. The reason he has come today is that he coughed up blood yesterday and is worried it means he has cancer. On examination his temp is 37.3. He has mild conjunctival pallor and a saddle shaped deformity of his nose. Systemic examination is otherwise unremarkable. You send off some routine bloods and his urea come back at 17 and his creatinine at 350.
What are your main differentials for this man?
How will you investigate him?How will you manage him?What is the classification for vasculitis? Give examples of each group
What are the ANCA positive
vasculitides
?Slide16
A 45 year old man comes to see you with a stuffy nose for the last 5 months. He is troubled by recurrent sinusitis and runny nose. He also feels his nose has changed shape, as if it has “caved in”. He has felt generally unwell
with aches and tiredness for the last 3 months. The reason he has come today is that he coughed up blood
yesterday and is worried it means he has cancer. On examination his temp is 37.3. He has mild conjunctival pallor and a saddle shaped deformity of his nose. Systemic examination is otherwise unremarkable. You send off some routine bloods and his urea come back at 17 and his
creatinine at 350
.
What are your main differentials for this man?
How will you investigate him?
How will you manage him?What is the classification for vasculitis? Give examples of each groupWhat are the ANCA positive vasculitides?Slide17
VasculitisClassified by vessels affectedLarge vesselGiant cell/Temporal arteritis – associated with PMRTakayasu’s arteritis – rare, hypertension with absent peripheral pulses
Medium vessel
Polyarteritis Nodosum – don’t need to know
Kawasaki’s disease – affects
children- strawberry tongue
Small vessel
Churg
Straus Syndrome – asthma, eosinophilia, systemic vasculitis*Wegener’s Granulomatosis – Upper & lower resp symptoms, renal impairment*Microscopic
polyangitis – don’t need to know*Henoch
Schonlein
Purpura
– affects children, post URTISlide18
General symptoms of any/alll vasculitidies
General symptoms
Kidneys
Gi system
Joints
Lungs
Heart
Eyes
SkinSlide19
General symptoms of any/alll vasculitidiesGeneral symptomsFever, weight loss, night sweats
malaise
KidneysGlomerulonephritis
Renal failure
Gi
system
Abdominal pain
UlcerationDiarrhoeaJointsArthritis
LungsDyspnoea, cough,
haemoptysis
Heart
Pericarditis
Myocarditis
Coronary arteritis
Eyes
Cotton-wool spots
Retinal haemorrhages
Skin
Vasculitic
/
purpuric
/
maculopapular
rashSlide20
And a few specific onesSlide21
All done!Think
inflammatoryThink
systemicThink steroidsThink
DMARDs
Think
MDTSlide22
Good luck!