Rheumatology Revision Clare 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 1 A 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?

What might you find on examination? What are you looking for? 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?

May be none… or…. Subchondral sclerosis Joint space narrowing Osteophytes Z-deformity May also get subchondral cysts in late/severe OA.

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? What else should you look for/check? 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 Boutonniere = button hole = because of tendon injury/damage Swan neck = because hyperextension of PIP and flexion of DIP = caused by a lax volar plate http://www.3pointproducts.com/Portals/30688/images//Boutonnierrelabel.jpg http://www.3pointproducts.com/Portals/30688/images//SwanNecklabel.jpg

Other bony features? C- spine Feet 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? Patient is concerned that she has been late to work recently because of disruption to her morning routine

SO WHAT ARE YOU GOING TO DO FOR HER? Investigations Bloods FBC, U+E, LFTs, ESR, CRP, RF, anti-CCP Imaging X-ray findings?

“Pencil in cup” deformity Loss of joint space Deformity Soft tissue swelling “Pencil in cup” deformity Bony erosion Periarticular osteopaenia

Management Conservative Medical Surgical Weight loss, smoking cessation Support - “MDT approach” Medical Analgesia, steroids, DMARDs, Biologics NICE guidance = early DMARDS Surgical Joint fusions, joint replacement, carpel tunnel decompression

Check baseline U+E, FBC, LFTs & urine analysis DMARDs Check baseline U+E, FBC, LFTs & urine analysis Methotrexate Sulfasalazine Gold Penicillamine Side effects? Folic acid suppression, deranged LFTs Myelosuppression; pneumonitis (rare) Nephrotic syndrome (Gold & Penicillamine)

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!