RHEUMATOLOGICAL SYSTEM

OSTEOARTHRITIS

Examine this seventy-two year old lady’s hands and joints and discuss your diagnosis.

CLINICAL EXAMINATION

Classical signs

Heberden’s nodes – bony swellings of the terminal interphalangeal joints

Bouchard’s nodes – bony swellings of the proximal interphalangeal joints

Squaring of the hands – due to subluxation of the first metacarpophalangeal joints

Examine hips and knee joints – crepitus, restricted movement, tender, may be an effusion

Restriction of movement of cervical or lumbar spine

Additional signs:

Make a comment as to the functional status of the individual – are there walking aids, can they do
up buttons etc.

Common discussion topics:

Diagnosis and differentials

Risk factors for osteoarthritis

Complications of OA

Typical x-ray changes

Treatments

Quick revision: Osteoarthritis is a very common disease of synovial joints in older patients,
characterised by painful joints, pain being worse after activity.

Differentials: Consider an inflammatory arthritis in a younger patient with a history of early morning
stiffness as opposed to pain after movement.

Risk factors: older age, female gender, obesity

Complications: peripheral nerve entrapment, cervical spondylosis, deformity leading to loss of

function

X-ray changes: joint space narrowing, subchondral sclerosis –increased bone density, cysts,
osteophytes – bone spurs

Treatment: analgesia, lifestyle changes – weight loss, exercise, surgical treatments

RHEUMATOID ARTHRITIS

Please examine this patient with painful joints.

CLINICAL EXAMINATION

Classical signs

Marked soft tissue swelling of the wrists and metacarpophalangeal joints and proximal
interphalangeal joints

Sparing of the distal interphalangeal joints

Ulnar deviation at the wrist/metacarpophalangeal joints

Swan neck deformities of the fingers (flexed PIP, extended DIP)

Boutoniere deformity of the fingers (extended DIP, flexed PIP)

Z shaped thumbs (flexed MCP, extended IP joint)

Generalised muscle wasting

Palmar erythema

Symmetrical polyarthropathy

Note if active or inactive arthritis – ie if the joints are inflamed

Additional signs:

Vasculitic skin lesions

Rheumatoid nodules at the elbows

Test grip and pincer movements and comment on functional status – eg ability to fasten buttons,
hold cutlery, comb hair, use keys

Signs of carpal tunnel syndrome

Common discussion topics:

Diagnosis and differentials

Other joints which may be affected

Extra-articular features of RA

Criteria for diagnosis

Investigations

Management
Differentials: Psoriatic arthropathy can have a similar presentation, but usually affects nails and the
DIP joints.

Other joints: As well as hand joints, RA can affect the shoulder, elbow, wrist, knee, ankle, foot

Extra-articular manifestations:

Lung: interstitial lung disease, pleural effusions, Caplan’s syndrome: RA with fibrotic nodules in coal-
workers pneumoconiosis

Vasculitis: digital gangrene

Cardiac: pericardial effusion, constrictive pericarditis

Eye: episcleritis, scleritis

Skin: livedo reticularis, pyoderma gangrenosum

Rheumatoid nodules: extensor tendons of the hands, Achilles tendons, lungs, pericardium

Kidney:amyloidosis, proteinuria due to drug therapy – gold salts, pencillamine

Neurological: peripheral neuropathies, carpal tunnel syndrome

Haematological: anaemia of chronic disease, anaemia due to folate deficiency, thrombocytopenia

Felty’s syndrome: Rheumatoid arthritis + leucopenia + splenomegaly

Criteria for Rheumatoid Arthritis

American Rheumatism Association Criteria:

1) Morning stiffness for at least one hour

2) Swelling of at least three joints for six weeks or more
3) Swelling of wrist, metacarpophalangeal or proximal phalangeal joints for 6 weeks or more
4) Symmetrical swelling of joints for 6 weeks or more
5) Rheumatoid nodules
6) Positive rheumatoid factor
7) Radiographic features typical of RA – erosions/periarticular osteopenia

INVESTIGATIONS:

FBC – anaemia of chronic disease, blood loss secondary to NSAIDs

WCC – raised in septic arthritis, neutropenia in Felty’s syndrome

ESR/CRP – indicators of inflammatory activity

Renal function – dipstick for proteinuria

Autoantibodies: Rheumatoid factor – antibodies against the Fc portion of IgG

Anti-CCP (more specific for RA than RhF)

Imaging: Xrays show distinctive changes such as osteopenia, soft tissue swelling, loss of joint space,
bony erosions, subluxation

CXR – lung complications

Arthroscopy – direct view of joint, potential for biopsy

MANAGEMENT

Treatment, including use of DMARDs, is best started early in disease

Treatment goals: control of pain, reduction of inflammation, limitation of joint damage, control of
systemic disease, maintenance of function

NSAIDs: help pain, but do not control inflammation, and serious side effects including gastric
irritation and interstitial nephritis

DMARDs: disease modifying anti-rheumatic drugs; methotrexate, sulfasalazine, gold, penicillamine,

ciclosporin. Delay disease progression and reduce subsequent disability. Combination therapy may
be superior to monotherapy

Biological agents: Infliximab (anti-TNF alpha), etanercept, adalimumab

Indicated if a patient has failed standard therapy with at least two DMARDs

Risks include those of immunopsuppression – reactivation of TB, HIV, malignancy eg lymphoma

PSORIATIC ARTHROPATHY

CLINICAL EXAMINATION

CLASSICAL SIGNS

Nail involvement in 80% - pitting, onycholysis (detachment of the nail from the nail bed),
discolouration, thickening

Five patterns of joint involvement:

Symmetrical joint involvement

Assymetrical joint involvement

Distal interphalangeal arthropathy

Spondylitis with/without sacroiliitis

Arthritis mulilans

Psoriatic plaques at the elbows, scalp, umbilicus

Common discussion topics:

How common is psoriatic arthropathy?

What are the hallmark radiological features

Treatment

Quick revision: Psoriatic arthropathy is a seronegative spondylarthropathy – ie lacks rheumatoid

factor positivity and is associated with HLA B27. It affects up to 10% of people with psoriasis and can
be debilitating.

Radiological features

Destruction of small joints

Periostitis

‘pencil and cup’ apprearance in arthritis mutilans

Treatment

NSAIDs, DMARDS Biological agents (infliximab, etanercept)

ANKYLOSING SPONDYLITIS

Please examine this patient’s back and comment on your findings.

CLINICAL EXAMINATION

How to examine: (Hasan do not copy – this section is taken word for word from Baliga)

Ask the patient to look to either side – the whole body turns when the patient is asked to do so.

Examine the cervical, thoracic and lumbar spine – cervical spine involvement occurs later in disease
and results in pain on movement of the neck

Measure the occiput-wall distance – inability to make contact when heel and back are against the
wall

Perform Schober’s test – mark points 10cm above and 5cm below a line joining the ‘dimple of Venus’
on the sacral promontory. An increase in the separation of less than 5cm during forward flexion
indicates limited spinal mobility

Examine for distal arthritis (in 30%) esp shoulders and knees

Note any iritis/anterior uveitis

Listen for aortic regurgitation

Listen for apical fibrosis

Classical signs

‘Question mark’ posture due to loss of lumbar lordosis, fixed kyphoscoliosis of the thoracic spine
Restriction of spinal movements in all directions (extension, lateral flexion, rotation)

Schober’s test positive: mark points 10cm above and 5cm below a line joining the Dimple of Venus.
In apatient with ankylosing spondylitis there is an increase in the separation of less than 5cm during
forward flexion – indicates spinal mobility

Patient unable to make contact between occiput and wall when heels lined up against wall (indicates
upper spinal involvement)

Arthritis in the peripheral joints

Additional signs:

Iritis/uveitis

Early diastolic murmur of arotic regurgitation

Apical fibrosis

Common discussion topics:

Tell me about Ankylosing spondylitis

Extra-articular manifestations of disease

Investigations

Management

Quick revision: Ankylosing spondylitis is a seronegative spondylarthropathy alongside psoriatic

arthritis, reactive arthritis and Reiter’s syndrome. HLA B27 is characteristically positive. Male to
female ratio is 4:1. The main clinical criteria for diagnosis include low back pain of at least three
months duration with inflammatory features – eg relieved by exercise, limitation of spinal mobility in
two planes, limitation of chest expansion.

Extra-articular manifestations:

Apical fibrosis, Anterior uveitis, Aortic regurgitation, Atrioverntricular heart block, Amyloidosis,
Achilles tendonitis

Investigations:

Diagnosis is clinical

XR imaging of sacro-iliac joints and lumbar spine – erosions, sclerosis, syndesmophytes, bamboo
spine

HLA-B27 testing

MANAGEMENT

Encourage exercise
NSAID’s

Surgical therapy to vertebrae is sometimes performed.

Genetic counselling to siblings/children

SCLERODERMA

Please examine this patient’s hands and come to a diagnosis.

CLINICAL EXAMINATION

Classical signs:

Smooth, tight skin over the fingers

Sclerodactyly (finger pulp atrophy)

Pseudoclubbing

Telangiectasia (dialted nail-fold capillaries)

Tight skin over face with beaking of the nose and microstomia

Additional signs:

Raynaud’s phenomenon

Vitiligo

Dry gritty eyes (Sjogrens)

Subcutaneous calcification – fingers, elbows, extensor aspect of forearm

SOB/ fine inspiratory crackles (lung fibrosis)

Arthritis

Common discussion topics:

What is scleroderma?

Investigations

Tell me about complications of scleroderma

Management

Quick revision: Sclerodactyly is localized thickening and tightness of the fingers. It is commonly
accompanied by atrophy of the underlying skin.

What is scleroderma?
Systemic sclerosis is a multisystem autoimmune disease characterised by a vasculopathy, diffuse
fibrosis of the skin and various internal organs and a number of immune abnormailities.

The clinical manifestations of this disease are extremely varied and several subsets have been
developed. The two major types of scleroderma are localised and systemic scleroderma.

Localised scleroderma: Affect the skin without any internal organ involvement. Involves limited or
generalised morphoea, linear scleroderma.

Systemic scleroderma: has two subtypes

Limited cutaneous systemic sclerosis: formerly called CREST syndrome

Calcinosis, Raynaud’s phenomenon, Eosophageal dysmotility, Sclerodactyly, Telangiectasia

Diffuse cutaneous systemic sclerosis: Sclerosis proximal to the knees or elbows or involving the
trunk. Significant incidence of interstitial lung disease, renal failure, GI disease, myocardial
involvement.

INVESTIGATIONS

Antibodies:

Anti-centromere antibodies occur in limited cutaneous systemic sclerosis

Anti-topoisomerase antibodies and anti RNA polylerase antibodies occur in both limited cutaneous
and diffuse cutaneous systemic sclerosis.

Scleroderma renal crisis is the acute onset of renal failure and hypertension in a patient with
scleroderma. An ACE inhibitor is the treatment of choice.

MANAGEMENT

Raynaud’s phenomenon: vasodilators such as calcium channel blockers

Skin changes – calcinosis topical emollients

Lung – interstitial lung disease – LTOT, diuretics for cor pulmonale

GI tract – prokinetic agents

Kidney – ACE inhibitors

Early phase of diffuse form: immunosuppressive drugs – cyclophosphamide, methotrexate