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1. MSK Rheum Flashcards

1
Q

Pattern of joint involvement in RA:

A

Hands and feet
Sparing of the DIPs
Larger joint involvement as it progresses

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2
Q

Classic signs and symptoms of RA:

A

Swollen painful joints in hands and feet
Stiffness worse in the morning
Bilateral symptoms

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3
Q

25% of patients have ocular manifestations of RA, what are they?

A

Keratoconjunctivitis sicca
Episcleritis (just erythema)
Scleritis (erythema and pain)
Corneal ulceration
Keratitis

Iatrogenic
Chloroquine retinopathy
Steroid-induced cataracts

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4
Q

Investigations for RA:

A

Rheumatoid Factor
Anti-CCP - most specific for RA
ESR and CRP
XR of hands and feet

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5
Q

Poor prognostic factors in RA:

A

RF +ve
Anti-CCP +ve
Poor functional status at presentation
XR showing early erosions
Extra-articular features e.g. nodules
HLA-DR4
Insidious onset

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6
Q

Diagnosis of RA:

A

ACR criteria:
Target population is definite clinical synovitis, without a more fitting diagnosis.

Adding category scores, needs 6/10 to qualify.

Categories are joint involvement, serology, acute phase reactants and duration of symptoms >/<6wks.

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7
Q

Monitoring of RA:

A

CRP and DAS28 score

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8
Q

First line management RA:

A

Monotherapy with DMARD e.g. MTX, leflunomide, sulfasalazine
+ short term bridging treatment with prednisolone

Hydroxychloroquine for mild or palindromic RA.

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9
Q

Treatment of RA flare:

A

intra-articular glucocorticoid injection, or oral
+ ?NSAIDs

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10
Q

Second line management of RA, if combinations of DMARDs have been tried:

A

Biologic drugs:
TNF-alpha inhibitors e.g. infliximab
Rituximab

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11
Q

Hydroxychloroquine action and side effects:

A

Inhibits TLRs

Bull’s eye retinopathy - severe permanent visual loss. More common than previously thought.
+ GI disturbances etc.

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12
Q

Methotrexate action and side effects:

A

Anti-folate mechanism - must take folate too.

Mucositis, pulmonary fibrosis, liver fibrosis, pneumonitis and myelosuppression.

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13
Q

Sulfasalazine action and side effects:

A

Unclear mechanism

Arthralgia, cough, diarrhoea, dizziness, fever, GI discomfort, headache, leucopenia, skin reactions, vomiting

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14
Q

Contraindications to methotrexate:

A

Pregnancy

Trimethoprim or co-trimoxazole - marrow aplasia

High dose aspirin increases risk of toxicity due to decreased excretion

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15
Q

Environmental factors in RA (3:)

A

Smoking
Infection
Hormonal - female sex

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16
Q

Extra-articular complications of RA (minus ocular and respiratory):

A

osteoporosis
ischaemic heart disease
increased infection risk
depression

Rare = Felty’s syndrome (RA + splenomegaly + low wcc) and amyloidosis

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17
Q

Respiratory complications of RA:

A

Pulmonary fibrosis
Pleural effusions
Pulmonary nodules
Bronchiolitis obliterans
MTX pneumonitis
Pleurisy

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18
Q

What are the 4 seronegative arthritides?

A

Psoriatic arthritis
Ankylosing spondylitis
Enteropathic arthritis
Reactive arthritis

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19
Q

Define seronegative spondyloarthropathy:

A

Disease involving the axial skeleton, expressing a variety of extra-skeletal signs and symptoms.

Commonly associated with HLAB27, RF negative (‘seronegative’).

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20
Q

Ocular manifestations of RA:

A

25% have eye complications

Keratoconjunctivitis sicca (dry eyes)
Episcleritis
Scleritis
Corneal ulcer
keratitis

Also from medications - steroid induced cataracts, chloroquine retinopathy.

Annual screening programme recommended for chloroquine!

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21
Q

4 spondyloarthropathies, and some extra-articular manifestations:

A

Ankylosing spondylitis;

Enteropathic arthritis

Reactive arthritis

Psoriatic arthritis

Achilles tendonitis, aortic regurg, plantar fasciitis, uveitis, upper zone fibrosis, amyloidosis

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22
Q

Ank spond is HLAB27 and typically presented in males aged 20-30 years old. Give features of the presenting complaint, and examination features:

A

Lower back pain and stiffness, improves with exercise.
Insidious onset.
Pain at night, improves on getting up.

Reduced lateral and forward flexion, Schober’s test positive. Reduced chest expansion.

Enthesitis, tendonitis, peripheral arthritis

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23
Q

The ‘A’s of ankylosing spondylitis (other features):

A

Anterior uveitis
Achilles tendonitis
Arthritis
Aortic regurgitation
AV node block

Cauda equna syndrome,

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23
Q

HLAB27 is NOT useful in making a diagnosis of AS. What is the most useful investigation?

A

Plain XR of sacro-iliac joints.

Looking for fusion, squaring of the lumbar vertebrae, bamboo spine and syndesmophytes. Dagger sign.

Also CXR, showing apical fibrosis

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24
If the XR is negative but high suspicion remain, what is next line investigation?
MRI If sacro-iliitis not present yet then MRI can show early signs of inflammation
25
Spirometry in AS may show a restrictive deficit due to?
Combination of: Pulmonary fibrosis Enthesitis/ involvement of costovertebral joints Kyphosis
26
Dagger sign on XR in AS:
Single central radiodense line = ossification of supraspinous and interspinous ligaments, usually late sign. Bamboo spine - fusion of anterior and psoterior spine
27
What are syndesmophytes due to and how are they seen on an XR?
Calcification of the outer fibres of the annulus fibrosus - calcified lateral margins of intervertebral discs.
28
Management of ankylosing spondylitis, 1st and 2nd line:
Lifestyle - exercise e.g. swimming, avoid smoking, bisphosphonates given. 1. NSAIDs + physio 2. Etanercept / infliximab / adalimumab? anti-TNF if persistent disaese despite activ terament. DMARDs only given if peripheral joint involvement.
29
Additional symptoms of AS:
Dactylitis Enthesitis SOB due to restricted chest wall Vertebral fracture
30
3rd line AS management:
MABs against IL-17 secukinumab JAKi = ?Intraarticular steroid injection
31
Differences in joints affected between RA and PsA:
PsA - DIPs and axial skeleton RA = these are not involved.
32
5 recognised patterns of psoriatic arthritis, indicating the most common:
Symmetrical Asymmetrical (1-4 joints) DIP predominant Spondylitis Arthritis mutilans (severe osteolysis, telescoping)
33
What tool is used to screen for PsA in patients with existing psoriasis?
PEST tool (Psoriasis Epidemiological Screening Tool) Asks about joint pain, swelling, Hx of arthritis and nail pitting
34
Characteristic x-ray findings in psoriatic arthritis:
Periostitis, juxta-articular DIPs! Ankylosis fixation / fusion of bone at joint Osteolysis Dactylitis - soft tissue swelling seen on xr Pencil in cup - late stage, osteolysis - arthritis mutilans
35
Treatment of PsA is similar to RA; what are some notable differences?
Not everyone gets MTX first line. If mild peripheral / axial disease can treat with just NSAIDs. MABs ustekinumab, secukinumab Apremilast is a PDE4 inhibitor, limits inflamamtion Better prognosis than RA
36
Reactive arthritis usually causes acute monoarthritis. Which joint is typically affected, and give some common triggers.
Knee Triggers: Gastroenteritis Chlamydia
37
Extra-articular features of reactive arthritis:
Conjunctivitis Urethritis Dactylitis Circinate balanitis
38
Time course of reactive arthritis, with recurrence and chronicity rates:
Develops 4 weeks after initial infection Symptoms last for about 4-6 months 25% recurrent 10% chronic
39
What needs to be excluded in patients with reactive arthritis?
Septic arthritis Also, HIV
40
Septic arthritis must first be excluded with joint aspiration, microscopy, culture and sensitivity testing, and crystal examination for gout and pseudogout. What is the management of reactive arthritis once septic arthritis has been excluded?
Treat existing infection e.g. chlamydia NSAIDs Intra-articular steroids ?systemic steroids if multiple joints are affected
41
Discuss the pathophysiology of SLE:
SLE is a type III hypersensitivity Autoimmune disease HLA b8, DR2, 3 Immune system dysregulation leading to immune complex formation
42
Skin features of SLE:
Malar rash Discoid lesions Photosensitivity Raynauds disease Livedo reticularis
43
Neuropsychiatric features of SLE:
Depression Anxiety Psychosis Seizures
44
Pericarditis is the most common cardiac manifestation of SLE. What renal complications exist, and what would a renal biopsy show of the most common type?
Lupus nephritis: can result in CKD. Proteinuria Must be monitored by urinalysis at regular check up. Renal biopsy should be done, glomeruli show endothelial and mesangial proliferation. Capillary wall thickening secondary to immune complex deposition.
45
WHO classification of lupus nephritis:
I = normal II = mesangial GN III = focal prolif IV = Most common, most severe. diffuse proliferative GN V = membranous VI = sclerosing
46
High sensitivity can rule something OUT if it is negative. Describe what 99% sensitivity for ANA means in SLE.
99% sensitivity: 99% of people with SLE will have a positive ANA, therefore easier to rule OUT if the ANA is negative
47
Discuss the antibodies tested for in SLE:
ANA 99% sens RF 20% postiive dsDNA 99% specific, but less sensitive 70% Anti-Smith 99% spec, 30% sens Also anti-Ro and La
48
Other blood tests in SLE:
ESR ! CRP may be normal durng active disease Complement C3 and C4 may be low during activity = classic sign anti-dsDNA is good for monitoring disease
49
Treatment of choice + lifestyle factors in SLE:
SLE treatment of choice = Hydroxychloroquine Sun block and NSAIDs
50
Give the most commonly associated disease for each of the following antibody: Centromere/Scl-70 Ro La Jo-1 RNP Smith ANticardiolipin
Centromere/Scl-70 = Local / Diffuse Systemic sclerosis Ro = Primary Sjogren's 70% La = Primary sjogren's 30% Jo-1 = dermatomyositis RNP = SLE and MCTD (higher in this) Smith = SLE Anti-cardiolipin = APS
51
Systemic sclerosis is characterised by hardened skin and other connective tissues. There are 3 patterns of disease. Discuss limited cutaneous systemic sclerosis.
Limited cutaneous systemic sclerosis: Raynaud's is often the first sign. Affects FACE AND DISTAL LIMBS with scleroderma. Subtype = CREST syndrome
52
What is CREST syndrome?
Calcinosis Raynauds Esophageal dysmotility Sclerodactyly Telangiectasia
53
Systemic sclerosis is characterised by hardened skin and other connective tissues. There are 3 patterns of disease. Discuss diffuse cutaneous systemic sclerosis.
Diffuse: Trunk and proximal limbs Anti-scl70 > anticentromere Presence of these abs are assocaited with higher risk of ILD Renal disease and hypertension are other involvement features. Poor prognosis for diffuse cutaneous systemic sclerosis
54
Most common cause of mortality in diffuse cutaneous systemic sclerosis:
Interstitial lung disease / respiratory involvement. Pulmonary fibrosis, pulmonary arterial hypertension.
55
What is the term for systemic sclerosis without internal organ involvement, and what are the types?
Scleroderma - hardened sclerotic skin. Plaque or linear are the types
56
A patient with systemic sclerosis has renal disease. What drug should they be started on?
Captopril Quick action, short half life, able to titrate quickly. Targets mechanism by reducing efferent arterial vasoconstriction, and limiting RAAS activation.
57
Non-medical management of systemic sclerosis:
Physio / stretching of skin periodically Stop smoking Regular emollients Avoid cold triggers Physio Occupational therapy
58
Autoantibodies positive in systemic sclerosis:
Anti-centromere (limited) Anti-Scl-70 (diffuse) ANA = non specific
59
Medical management of systemic sclerosis focuses on treating symptoms and complications
E.g. nifedipine for Raynaud's Captopril for renal involvement + hypertension PPI for acid reflux Analgesia for joint pain
60
What are steroids associated with in systemic sclerosis?
Steroids are associated with scleroderma renal crisis. Only use if no other options
61
Sjogren's can be split into primary and then secondary to another CTD, where it would usually develop 10 years after the initial diagnosis. What does Sjogren's syndrome affect?
Sjogren's affects the exocrine glands, leading to dry mucosal surfaces.
62
Which malignancy is there an increased risk of with Sjogren's syndrome?
Lymphoid malignancy
63
Features of Sjogren's syndrome:
Dry Eyes Dry skin Vaginal dryness Arthralgia Raynaud's Sensory polyneuropathy Parotitis recurrent Subclinical RTA
64
Investigations of Sjogren's including antibodies that are positive:
RF positive in 50% Anti Ro 70% Anti La 30% ANA 70% Schirmer's test for tear duct Histology = focal lymphocytic infiltration Also hypergammaglobulinaemia and low C4
65
Management of Sjogren's:
Artifical saliva and tears Pilocarpine may increase saliva production
66
Dermatomyositis is an inflammatory disorders causing symmetrical, proximal muscle weakness and skin lesions. Can be associated with underlying malignancy; which ones?
Ovarian Breast Lung There is an underlying malignancy in 20-25%, higher risk if older.
67
Describe the cutaneous involvement in dermatomyositis:
Heliotropic rash covering periorbital region Macular rash over back and shoulders Photosensitivity Gottron's papules - roughened red papules over extensor surfaces Mechanics hands - extreme dry scaly cracked + nail fold capillary dilatation
68
Discuss the extra-cutaneous features of dermatomyositis:
Proximal muscle weakness and tenderness, NOT stiffness Raynaud's Respiratory muscle weakness ILD Dysphagia Dysphonia
69
Discuss antibody results in dermatomyositis compared to polymyositis
Dermato = ANA positive, and anti-JO-1 positive in 30% In polymyositis there is Jo-1 positive if there is lung involvement
70
Polymyositis is a variant of dermatomyositis without cutaneous manifestations. What investigations should be done, other than antibody testing:
CK - elevated Renal function Muscle enzymes e.g. LDH, AST AND ALT are all elevated. EMG Muscle biopsy
71
Management of polymyositis:
High dose steroids Taper as improving Azathioprine can be used as steroid sparing agent

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