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AUTOIMMUNE INFLAMMATORY ARTHRITIS AND SPONDYLOARTHRITIDES (RHEUMATOID…

- - - - stiff small joints of hands and feet
      - worse in the morning. This can fluctuate and larger joints may become involved.
      - painful
      - Symmetrical swollen
    - - Sudden onset, widespread arthritis.
      - Recurring mono/polyarthritis of various joints (palindromic ra)
      - Persistent monoarthritis (knee, shoulder, or hip).
      - Systemic illness with extra-articular symptoms, eg fatigue, fever, weight loss, pericarditis, and pleurisy, but initially few joint problems (commoner in ♂).
      - Polymyalgic onset—vague limb girdle aches.
      - Recurrent soft tissue problems (eg frozen shoulder, carpal tunnel syndrome, de Quervain’s tenosynovitis).
  - - - Look for tenosynovitis (inflammation of the fluid-filled sheath (called the synovium) that surrounds a tendon, typically leading to joint pain, swelling, and stiffness) or bursitis (The bursa is a sac filled with lubricating fluid, located between tissues such as bone, muscle, tendons, and skin, that decreases rubbing, friction, and irritation.)
      - Swollen mcp, pip, wrist, or mtp joints (often symmetrical)
      - Inflammation, no joint damage
    - - Ulnar deviation and subluxation of the wrist and fingers.
      - Boutonnière and swan-neck deformities of fingers or z-deformity of thumbs occur.
      - (Joint damage, deformity.)
      - Hand extensor tendons may rupture
      - Foot changes are similar
      - Larger joints can be involved
      - Atlanto-axial joint subluxation may threaten the spinal cord (rare).
    - - Lungs
        
        interstitial fibrosis
        
        bronchiolitis obliterans
        
        Pleural disease
        
        organizing pneumonia
      - Cardiac
        
        pericardial effusion
        
        carpal tunnel syndrome
        
        pericarditis
        
        peripheral neuropathy
        
        IHD
        
        splenomegaly (seen in 5%; only 1% have Felty’s syndrome: ra + splenomegaly + neutropenia
      - Nodules
        
        lungs
        
        cardiac
        
        Elbows
        
        cns
        
        lymphadenopathy
        
        vasculitis
      - Eye
        
        scleromalacia
        
        keratoconjunctivitis sicca
        
        scleritis
        
        Episcleritis
        
        osteoporosis
        
        amyloidosis is rare
  - - - Later there may be bony erosions, subluxation, or complete carpal destruction
      - show soft tissue swelling, juxta-articular osteopenia and ↓joint space
    - - L – loss of joint space
        
        E – erosions
        
        S – soft tissue swelling
        
        S – soft bones (osteopenia)
  - - - Best results are often achieved with a combination of methotrexate, sulfasalazine, and hydroxychloroquine. Leflunomide is another option.
      - Immunosuppression is a potentially fatal se of treatment (especially in combination with methotrexate) which can result in
        
        pancytopenia
        
        ↑susceptibility to infection (including atypical organisms)
        
        neutropenic sepsis
      - can take 6–12 weeks for symptomatic benefit
      - 1st line and should ideally be started within 3 months of persistent symptoms
      - Hydroxychloroquine
        
        can cause retinopathy; pre treatment and annual eye screen required.
      - Sulfasalazine
        
        rash, ↓sperm count, oral ulcers, gi upset.
      - Methotrexate
        
        pneumonitis (pre treatment cxr), oral ulcers, hepatotoxicity, teratogenic.
        
        myelosuppression
      - Leflunomide
        
        teratogenicity (♂ and ♀), oral ulcers, ↓bp, hepatotoxicity.
    - - Rapidly reduce symptoms and inflammation
      - Useful for acute exacerbations, eg im depot methylprednisolone 80–120mg
      - Intra-articular steroids have a rapid but short-term effect
      - Oral steroids (eg prednisolone 7.5mg/d) may control difficult symptoms, but side effects preclude routine long-term use.
    - - good for symptom relief
      - no effect on disease progression
      - Paracetamol and weak opiates are rarely effective.
    - - Initiated by specialists, for patients with active disease despite adequate trial of at least 2 dmards.
      - Pre treatment screening for tb, hepatitis b/c, hiv essential.
      - 2 b -cell depletion:
        
        used in combination with methotrexate and approved by nice for severe active ra where dmards and a tnfα‎ blocker have failed
        
        Eg rituximab
      - 1 tnfα‎ inhibitors:
        
        Eg infliximab, etanercept, adalimumab, are approved by nice as 1st-line agents.
        
        Where methotrexate is contraindicated, can be used as monotherapy.
        
        Clinical response can be striking, with improved function and health outcomes, although response may be inadequate/unsustained
      - 3 il -1 and il-6 inhibition:
        
        Monitor for hypercholesterolaemia.
        
        Eg tocilizumab (il-6 receptor blocker), approved by nice in combination with methotrexate where tnfα‎ blocker has failed (or is contraindicated).
      - Inhibition of t-cell co-stimulation:
        
        Eg abatacept—licensed for active ra where patients have not responded to dmards or tnfα‎ blocker.
      - SIDE EFFECTS
        
        worsening heart failure
        
        hypersensitivity
        
        reactivation of tb (∴ screen and consider prophylaxis) and hepatitis b
        
        injection-site reactions and blood disorders
        
        Serious infection
        
        ana and reversible sle-type illness may evolve
        
        no increased risk of solid organ tumours but skin cancers may be more common
        
        tnf inhibitors do not appear to be associated with a further increase in the already elevated lymphoma occurrence in ra
- - - - Men present earlier: ♂:♀~6:1 at 16yrs old, and ~2:1 at 30yrs old.
      - ~90% are hla b27 +ve
      - 0.25–1%.
    - - progressive loss of spinal movement (all directions)—hence ↓thoracic expansion
      - The disease course is variable; a few progress to kyphosis, neck hyperextension (question-mark posture), and spino-cranial ankylosis.
      - Other features include enthesitis, especially Achilles tendonitis, plantar fasciitis, at the tibial and ischial tuberosities, and at the iliac crests
      - Pain radiates from sacroiliac joints to hips/buttocks, and usually improves towards the end of the day.
      - Anterior mechanical chest pain due to costochondritis and fatigue may feature.
      - typical patient is a man <30yrs old with gradual onset of low back pain, worse during the night with spinal morning stiffness relieved by exercise.
      - Acute iritis occurs in ~⅓ of patients and may lead to blindness if untreated (but may also have occurred many years before, so enquire directly).
      - AS is also associated with osteoporosis (up to 60%), aortic valve incompetence (<3%), and pulmonary apical fibrosis.
      - FUNKY WAY TO REMEMBER (ALL A'S)
        
        Other features - the 'A's
        
        Apical fibrosis
        
        Anterior uveitis
        
        Aortic regurgitation
        
        Achilles tendonitis
        
        AV node block
        
        Amyloidosis
        
        and cauda equina syndrome
        
        peripheral arthritis (25%, more common if female)
    - - Diagnosis is clinical, supported by imaging
      - x-rays can show si joint space narrowing or widening, sclerosis, erosions, and ankylosis/fusion.
      - mri allows detection of active inflammation (bone marrow oedema) as well as destructive changes such as erosions, sclerosis, and ankylosis.
      - Vertebral syndesmophytes are characteristic (often t11–l1 initially): bony proliferations due to enthesitis between ligaments and vertebrae.
        
        These fuse with the vertebral body above, causing ankylosis.
      - In later stages, calcification of ligaments with ankylosis lead to a ‘bamboo spine’ appearance.
      - BLOODS
        
        ↑esr,
        
        ↑crp,
        
        fbc (normocytic anaemia),
        
        hla b27 +ve (+ve in 90–95% of cases but only 5% of patients hla b27 +ve have AS).
    - - Exercise, not rest, for backache, including intense exercise regimens to maintain posture and mobility—ideally with a specialist physiotherapist. nsaids usually relieve symptoms within 48h, and may slow radiographic progression
      - tnf α‎ blockers (eg etanercept, adalimumab) are indicated in severe active AS
      - Local steroid injections provide temporary relief.
      - Surgery includes hip replacement to improve pain and mobility if the hips are involved, and rarely spinal -osteotomy.
      - ↑risk of osteoporotic spinal fractures (consider bisphosphonates).
    - - Prognosis is worse if esr >30; onset <16yrs; early hip involvement or poor response to nsaids
      - There is not always a clear relationship between the activity of arthritis and severity of underlying inflammation (as for all the spondyloarthritides).
  - - - Arthropathy often improves with the treatment of bowel symptoms (beware nsaids). Use dmards for resistant cases.
      - coeliac and Whipple’s disease
      - gi bypass,
      - Inflammatory bowel disease,
  - - - • dip joints
      - • asymmetrical oligoarthritis
      - • symmetrical polyarthritis (like ra)
      - • spinal (similar to as)
      - • psoriatic arthritis mutilans (rare, ~3%, severe deformity).
    - - Associated with nail changes in 80%, synovitis (dactylitis),
      - acneiform rashes and palmo-plantar pustulosis.
      - Erosive changes, with ‘pencil-in-cup’ deformity in severe cases.
    - - methotrexate
      - Anti-tnf agents are also effective
      - sulfasalazine
      - nsaids
  - - - circinate balanitis (painless penile ulceration secondary to Chlamydia),
      - mouth ulcers,
      - keratoderma blenorrhagica (brown, raised plaques on soles and palms),
      - enthesitis.
      - Iritis,
      - Patients may present with a triad of urethritis, arthritis, and conjunctivitis (Reiter’s syndrome). CANT SEE PEE OR CLIMB A TREE???
    - - Culture stool if diarrhoea. Infectious serology.
      - Sexual health review.
      - ↑esr & ↑crp.
      - x-ray may show enthesitis with periosteal reaction.
    - - There is no specific cure.
      - treat with nsaids or local steroid injections
      - Splint affected joints acutely;
      - Consider sulfasalazine or methotrexate if symptoms >6 months
      - Treating the original infection may make little difference to the arthritis