RHEUMATOLOGY
GOUT
Sodium urate crystals – joints (arthritis); soft tissue (tophi); urinary tract (uric acid stones); M5:F1
Acute: recurrent joint pain + swelling, podagra, fever, tenderness, dramatic excruciating pain, wake in night
(sheets pain), mild pyrexia + malaise; sodium monourate deposition in joints attacks
Chronic: subcut tophi on affected joints/ tendons/ bones/ kidnes/ pinna/ hands.
Precip: alcohol, drugs affecting urate metabolism, trauma, fasting, starvation, infxn, diuretics
RF: male, CKD, diuretics, purine-rich diet (Alcohol, meat, seafood), obesity
S&S: tender, erythematous, inflamed joint; commonly 1st metatarsophalangeal joint; arthralgia worse at night. Acute ep lasts 2weeks. Other
features hyperuricaemia: gouty tophi, renal nephrolithiasis
Investigations: Bloods- Inc uric acid (>7.5mg/dL); acute gout: inc ESR, CRP, WCC; X-ray: chronic arthritis – punched out lesions; Synovial fluid:
murky, inc WCC (PMNLs), urate crystals (needle-like); US: double contour signs: 2 hyper-echoic lines
X-ray: soft tissue swelling around single joint; erosions, sclerosis, peri-articular tophi (punched out lesions in bone); NO loss of joint space
Rx: Acute gout: NSAIDs (ibuprofen) or colcichine 1mg PO if C/I; corticosteroids (intra-articular triamcinolone injection); After resolution:
colcichine 0.6mg PO bd; Weeks/months later: normal renal function – probenecid; imp renal function – allopurinol (XO inhibitor); high urinary
urate excretion: allopurinol 300-400mg/d;
Prevention: allopurinol (can paradoxically trigger acute ep of gout so wait 2 weeks after acute attack before starting, and offer NSAID/
colcichine cover for first 1-3months
Advice: purine containing foods (avoid meat + seafood); lose weight; reduce alcohol; avoid diuretics; low dose aspirin
Complications: 2nd OA, uric acid stones (10%), 2nd infections, chronic urate nephropathy, inc risk vascular disease (Esp in women)
DD: pseudogout, septic arthritis: Req synovial fluid aspirations (look for sodium urate crystals (needle shaped) [pseudogout: rhomboid shaped
crystals], SA no crystals) + x-ray findings
PSEUDOGOUT
Calcium pyrophosphate disease; recurrent arthritis long joints + chondrocalcinosis (knees/wrists); >60s
Acute: knee; Chronic: destructive; knee, hips, wrists, shoulders
Investigations: joint aspirate (rhomboid shaped crystals of calcium pyrophosphate crystals), x-ray (symmetrical calcification; OA signs)
Rx: NSAIDs, COX2 inhibitor (colcichine, triamcinolone)
POLYMYOSITIS + DERMATOMYOSITIS
Investigations: EMG, muscle biopsy, skin manifestations; inc se CK + aldolase; inc ALT + AST; anaemia, RF +ve, Normal ESR and CRP; anti-
nuclear autoantibodies (Anti-Jo-1 AB, Anti-Mi-2, Anti-SRP)
Polymyositis: LL, neck muscles, spares face + ocular muscles, muscle pain + tendernessin 25%; late: muscle atrophy, myocarditis, resp failure
Dermatomyositis: myositis features, purple malar rash; Shawl sign; peri-orbital oedema; Gottron sign; periungal erythema, psoriatic like
lesions over scalp
Rx: rest, corticosteorids (prednisolone), 2nd: methotrexate, azathioprine, IV Ig, mycophenolate mofetil
RAYNAUDS
Exaggerated digital arteriolar vasospasm; primary: 60% adults; Hands change colour in cold: white blue red
Rx: avoid exposure to cold/ injuries/ skin cuts; lubricating lotions, stop smoking, ischaemia: CCBs nifedopine/ amlodipine; 2nd lines: ACEIs,
sildenafil. Severe/ resistance: sympathectomy
Prognosis: primary: benign; secondary: ulceration + gangrene
FIBROMYALGIA
3-10% gen pop; F>M; ‘central pain sensitisation’, hypersensitivity of pain fibres
Investigations: Trigger points x18, no lab/ imaging abnormalities; ESR + CRP NORMAL; do not investigate; dg of exclusion
Rx: education, exercise, painkillers ineffective, amitryptiline/ fluoxetine/ gabapentin
POLYMYALGIA RHEUMATICA
Investigations: anaemia, inc ESR + CRP (ESR > 40mm/h); CK normal; Inc Alkphosph
Rx: prednisolone (10-20mg/d + taper); maintenance for 1y; methotrexate reduces RR; OP prophylaxis
GIANT CELL A RTERITIS (TEMPORAL ARTERITIS )
Think if >65y + PUO; high CRP; leukocyte count=N; Systemic pan-arteritis of medium & large vessels; assoc in PR in 25%.
Complications: blindness
Tests: ESR > 100mm/h; Inc ESR + CRP, Alk phosph, plt, low Hb, normocytic normochromic anaemia, thrombocytosis; temporal A bx: inflamm
infiltrate in media + adventitia with cellular infiltrates
Rx: prednisolone (40-60mg/d & taper) + low-dose aspirin; visual loss: IV pulse methylprednisolone
GRANULOMATOSIS WITH POLYANGITIS = WEGENER’S
AI; necrotizing granulomatosis inflammation & pauci-immune vasculitis of small + medium sized vessels (Wegener’s granulomatosis); M=F;
12/milion/yr; peaks 4th + 5th decades
Sites inv: pulm (100%; ALL pt), sinus/ nasopharynx (90%), renal (88%), arthralgia arthritis (60%), neuro cutaneous (50%), ophthalmic (40%)
GOUT
Sodium urate crystals – joints (arthritis); soft tissue (tophi); urinary tract (uric acid stones); M5:F1
Acute: recurrent joint pain + swelling, podagra, fever, tenderness, dramatic excruciating pain, wake in night
(sheets pain), mild pyrexia + malaise; sodium monourate deposition in joints attacks
Chronic: subcut tophi on affected joints/ tendons/ bones/ kidnes/ pinna/ hands.
Precip: alcohol, drugs affecting urate metabolism, trauma, fasting, starvation, infxn, diuretics
RF: male, CKD, diuretics, purine-rich diet (Alcohol, meat, seafood), obesity
S&S: tender, erythematous, inflamed joint; commonly 1st metatarsophalangeal joint; arthralgia worse at night. Acute ep lasts 2weeks. Other
features hyperuricaemia: gouty tophi, renal nephrolithiasis
Investigations: Bloods- Inc uric acid (>7.5mg/dL); acute gout: inc ESR, CRP, WCC; X-ray: chronic arthritis – punched out lesions; Synovial fluid:
murky, inc WCC (PMNLs), urate crystals (needle-like); US: double contour signs: 2 hyper-echoic lines
X-ray: soft tissue swelling around single joint; erosions, sclerosis, peri-articular tophi (punched out lesions in bone); NO loss of joint space
Rx: Acute gout: NSAIDs (ibuprofen) or colcichine 1mg PO if C/I; corticosteroids (intra-articular triamcinolone injection); After resolution:
colcichine 0.6mg PO bd; Weeks/months later: normal renal function – probenecid; imp renal function – allopurinol (XO inhibitor); high urinary
urate excretion: allopurinol 300-400mg/d;
Prevention: allopurinol (can paradoxically trigger acute ep of gout so wait 2 weeks after acute attack before starting, and offer NSAID/
colcichine cover for first 1-3months
Advice: purine containing foods (avoid meat + seafood); lose weight; reduce alcohol; avoid diuretics; low dose aspirin
Complications: 2nd OA, uric acid stones (10%), 2nd infections, chronic urate nephropathy, inc risk vascular disease (Esp in women)
DD: pseudogout, septic arthritis: Req synovial fluid aspirations (look for sodium urate crystals (needle shaped) [pseudogout: rhomboid shaped
crystals], SA no crystals) + x-ray findings
PSEUDOGOUT
Calcium pyrophosphate disease; recurrent arthritis long joints + chondrocalcinosis (knees/wrists); >60s
Acute: knee; Chronic: destructive; knee, hips, wrists, shoulders
Investigations: joint aspirate (rhomboid shaped crystals of calcium pyrophosphate crystals), x-ray (symmetrical calcification; OA signs)
Rx: NSAIDs, COX2 inhibitor (colcichine, triamcinolone)
POLYMYOSITIS + DERMATOMYOSITIS
Investigations: EMG, muscle biopsy, skin manifestations; inc se CK + aldolase; inc ALT + AST; anaemia, RF +ve, Normal ESR and CRP; anti-
nuclear autoantibodies (Anti-Jo-1 AB, Anti-Mi-2, Anti-SRP)
Polymyositis: LL, neck muscles, spares face + ocular muscles, muscle pain + tendernessin 25%; late: muscle atrophy, myocarditis, resp failure
Dermatomyositis: myositis features, purple malar rash; Shawl sign; peri-orbital oedema; Gottron sign; periungal erythema, psoriatic like
lesions over scalp
Rx: rest, corticosteorids (prednisolone), 2nd: methotrexate, azathioprine, IV Ig, mycophenolate mofetil
RAYNAUDS
Exaggerated digital arteriolar vasospasm; primary: 60% adults; Hands change colour in cold: white blue red
Rx: avoid exposure to cold/ injuries/ skin cuts; lubricating lotions, stop smoking, ischaemia: CCBs nifedopine/ amlodipine; 2nd lines: ACEIs,
sildenafil. Severe/ resistance: sympathectomy
Prognosis: primary: benign; secondary: ulceration + gangrene
FIBROMYALGIA
3-10% gen pop; F>M; ‘central pain sensitisation’, hypersensitivity of pain fibres
Investigations: Trigger points x18, no lab/ imaging abnormalities; ESR + CRP NORMAL; do not investigate; dg of exclusion
Rx: education, exercise, painkillers ineffective, amitryptiline/ fluoxetine/ gabapentin
POLYMYALGIA RHEUMATICA
Investigations: anaemia, inc ESR + CRP (ESR > 40mm/h); CK normal; Inc Alkphosph
Rx: prednisolone (10-20mg/d + taper); maintenance for 1y; methotrexate reduces RR; OP prophylaxis
GIANT CELL A RTERITIS (TEMPORAL ARTERITIS )
Think if >65y + PUO; high CRP; leukocyte count=N; Systemic pan-arteritis of medium & large vessels; assoc in PR in 25%.
Complications: blindness
Tests: ESR > 100mm/h; Inc ESR + CRP, Alk phosph, plt, low Hb, normocytic normochromic anaemia, thrombocytosis; temporal A bx: inflamm
infiltrate in media + adventitia with cellular infiltrates
Rx: prednisolone (40-60mg/d & taper) + low-dose aspirin; visual loss: IV pulse methylprednisolone
GRANULOMATOSIS WITH POLYANGITIS = WEGENER’S
AI; necrotizing granulomatosis inflammation & pauci-immune vasculitis of small + medium sized vessels (Wegener’s granulomatosis); M=F;
12/milion/yr; peaks 4th + 5th decades
Sites inv: pulm (100%; ALL pt), sinus/ nasopharynx (90%), renal (88%), arthralgia arthritis (60%), neuro cutaneous (50%), ophthalmic (40%)
