Clinical Questions - Rheumatology Flashcards
Name 4 Seronegative arthropathies
Ankolysing spondylitis
Psoriatic arthritis
Reactive arthritis
Enteropathic arthritis
Name 5 seropositive arthropathies
RA, SLE, Scleroderma, vasculitis, sjogrens
What types of cells infiltrate the synovium in RA?
Multinucleated giant cells Macrophages Lymphocytes Cytokines Fibroblasts
Describe briefly the pathogenesis of RA
- Inflammation and thickening of the synovium (+ infiltration of inflammatory cells)
- Erosion of the surrounding cartilage as the infiltrate spreads on the surface and creates a pannus that eventually destroys the cartlilage.
- Destruction of the bone due to the pannus. This can lead to osteoporosis and joint deformity.
Describe a pannus
A layer of chronically inflamed fibrous tissue
What would the histology show in RA?
- Intense inflammation (presence of inflammatory cells)
- Redundant layers of synovial lining
- accumulation of mononuclear cells
A 24 year old lady present to your clinic with pain in her MCP and PIP joints. She reports feeling generally unwell and on inspection her joints are swollen and tender.
Rheumatoid arthritid
In a patient you suspect to have RA, what two autoantibodies would you want to look for?
Rheumatoid factor
Anti CCP
Is the joint involvement usually symmetrical or non symmetrical in RA?
Symmetrical
What nerve problem can occur as a result of RA?
Carpal tunnel syndrome
What is the window of oppertunity in arthritis before their is irreversible joint damage?
Three months
Name 2 deformities that are seen in patients with RA
Ulnar deviation
Swan neck deformity
How would you treat a patient with newly diagnosed RA?
- NSAIDS
- Low dose oral corticosteroids
- Methotrexate/ sulfasalazine
Frequent early review
What biologic would you use in RA?
Anti TNF (infliximab, adalimimub)
Why should you initially prescribe corticosteroids alongside DMARDs?
They have a lag phase of weeks/months
What would your next step be for a patient who was not responding to initial DMARD treatment?
Combination therapy with other DMARDs
What are you suspecting to show up in the FBC of a patient with rheumatoid arthritis?
Raised ESR and CRP
What drug, used in RA causes B cell depletion?
Rituximab
What four DMARDs might you prescribe in combination for a patient with early RA?
Methotrexate
Sulfasalazine
Hydroxychloroquine
Corticosteroids
What vascular problem is associated with RA?
Vasculitis
What four x ray findings are associated with osteoarthritis?
Loss of joint space
Osteophyte formation
Subchondral sclerosis
Subchondral cysts
What are some causes of secondary osteoarthritis?
Injury, RA, acromegaly, gout
What is dactilysis?
Inflammation of an entire digit
What joints are most common;y affected by psoriatic arthritis?
DIP joints of the hands and feet
A 20 year old boy presents to your clinic with pain in his buttock and lower back and stiffness. He reports that the pain gets better when he walks/
Ankolysing spondylitis
How do you perform schobers test and what does it show?
- With the patient standing straight upright, find venous dimples and mark the midpoint between them.
- Use a tap measure to put another mark 5cm below this.
- The measure 10cm about the midline of the venous dimples (15cm between the marks)
- Get the patient to bend forwards and touch their toes without bending their knees and measure the difference between the top and bottom dots.
- If the difference between these readings is less than 5cm then this implies stiffness.
How would you treat a patient newly diagnosis with ankolysing spondylitits?
- A regimen of exercises to stop the syndesmophytes from forming.
- NSAIDS
- Methotrexate is good for peripheral disease but not for spinal disease
- Biologics - adalimimub and etanercept
What different patterns of joint involvement could you see in a patient with psoriatic arthritis?
- Monoarthritis
- Polyarthritis than is almost identical to RA
- Ankolysing spondylitis
- DIP joints of the hand and feet (most common)
- Arthritis multilans causes marker periarticular osteolysis and bone shortening
What type of arthritis shows a pencil-in-cup appearance on radiographs? Why is this?
Psoriatic arthritis. This occurs because the erosions is the joint are central, not juxta articular.
What treatments would you initiate for a patient with psoriatic arthritis?
NSAIDS Corticosteroids (injected) DMARDS Anti TNF Physiotherapy
What problems would there be with prescribing corticosteroids for a patient with psoriatic arthritis?
Rebound flare of skin disease
What percentage of patients with IBD go on to get enteroptahic arthritis?
10 - 15%
What two patterns does enteropathic arthritis usually follow?
- Large joint monoarthritis.
2. Asymmetrical oligoarthritis
How do you treat enteropathic arthritis?
Treatment of the IBD. In UC colectomy will cure the arthritis usually
An overweight lady presents to you with severe pain on movement in both hips, worst on the right side.
Osteoarthritis
What are bony enlargments at the DIP joints called?
Hebredens nodes
What are bony enlargements at the PIP joints called?
Bouchards nodes
What is genu valgum?
“knock-knee”, is a condition in which the knees angle in and touch one another when the legs are straightened.)
What is genu varum?
bow-leggedness,, is a physical deformity marked by (outward) bowing of the leg in relation to the thigh, giving the appearance of an archer’s bow. Usually medial angulation of both femur and tibia is involved. Varus - airus
What treatments would you consider in osteoarthritis?
Physiotherapy Weight loss Sensible shoes Walking stick NSAIDS Pain modulatirs Intra articular steroids Joint replacement
What kind of crystals are deposited in the joints in gout?
Urate crystals which are negatively bifringenet and needle shaped
What foods would you advice someone who suffers from bad gout to avoid?
Red met, seafood, wine/beer, corn syrup
What chronic disease can make you more at risk of gout?
Kidney disease
Why are serum urate levels not useful to measure during an acute attck of gout?
They will most likely be normal as uric acid is deposited in the joint
What drug can cause gout?
Diuretics
What are the treatments for an acute gout flare up?
NSAIDS
Colchine
Steroids
What are the treatments for chronic gout?
Allopurinol
Febuxostat
What is pseudo gout?
A crystal arthropathy where there is deposition of calcium pyrophosphate crystals (positively bifringenet needles)
How do you treat an attack of pseudo gout?
NSAIDs
Colchine
Steroids
Rehydration
How would you distinguish between gout and pseudo gout?
Joint fluid microscopy
What is dactylitis?
Sausage digits
What two articular symptoms are seronegative arthropathies associated with?
Enthesitis
Dactylitis
What could be the possible extra articular features of ankolysing spondylitis?
Uveitis Cardiovascular problems Pulmonary fibrosis Mucosal inflammation Amylodisis
What is amylodosis?
Deposits of abnormal protein, called amyloid, in tissues and organs throughout the body. It can lead to organ failure
What biologic drugs would you give in ankolysing spondylitis?
Infliximab, adalimimub
Give 4 features of an xray you would expect to see in psoriatic arthritis
Marginal erosions/whiskering
Pencil in cup
Osteolysis
Enthesitis
What biologic drug would you use in psoriatic arthrtisi?
Anti TNF (etanercept)
What is reiter’s syndrome?
A form of reactive arthritis with the triad of symptoms; arthritis, urethritis, conjuntivitis
What would you expect the blood results to look like in reactive arthritis?
Raised ESR, CRP
How do you treat reactive arthritis?
NSAIDs
Corticosteroids (intra articular, oral or eye drops)
Antibiotics
DMARDS
What is the definition of vasculitis?
The presence of leukocytes/immune complexes in the vessel wall with reactive damage to mural structures
A women presents to your clinic with weakness of her legs. She has started to find it impossible to climb up the stairs. She reports feeling generally unwell and having lost weight.
Polymyositis
A women presents to your clinic with weakness of her legs. She has started to find it impossible to climb up the stairs. She reports feeling generally unwell and having lost weight. On examination she has a purple rash over her eyelids and across her knuckles.
Dermatomyositis
What antibody is associated with polymyositis?
Anti Jo 1
How would you treat someone with polymyositis?
Prednisolone
DMARDs
IV immunoglobulin
What antibody is most associated with mixed connective tissue disease?
Anti RMP antibody
A women presents to you because she has had three miscarriages. She has also had two DVTs in the past.
Anti phospholipid syndrome
How would you treat someone with anti phospholipid syndrome?
Lifelong anti coagulation with warfarin
What antibody is positive in anti phospholipid syndrome?
Anti cardiolipin
What three tests could you do to test for antiphospholipid syndrome?
- Anticardiolipin test (this detects the antibodies that bind the negatively charged phopholipid)
- Lupus anticoagulant test which detects changes in the ability of the blood to clot in a test tube.
- The anti beta 2 glycoprotein 1 test.
What is a positive result for the lupus anticoagulant test?
In the presence of aPl antibodies their will be an anticoagulant effect. This is the opposite from the procoagulant effect to aPl antibodies in the blood.
What is the diagnostic criteria for antiphospholipid syndrome?
A positive test result on two occasions 12 weeks apart.
How would you treat a pregnant women with anti phospholipid syndrome who has previously been on warfarin?
Oral aspirin and subcutaneous heparin
What is oliogarthritis?
Arthritis affecting 1 - 4 joints in the first six months of disease
What are the five major criteria of mixed connective tissue disease?
Severe myositis Pulmonary involvement Raynuads Swollen hands Sclerodactyly Anti RNP antibodies
What is soft tissue rheumatism?
Pain caused by inflammation/damage to ligaments, tendons, muscles or nerves near a joint.
Briefly describe the pathology of sjogens syndrome?
An autoimmune conditions where there is lymphocyte infiltration of exocrine glands causing a dry mouth and dry eyes.
What treatments can you give for someone with sjogrens
Eye drops/punctual plugs Saliva replacements Pilocarpine Hydroxychloroquine Steroids and immunosuppression Attention to CVS risk factors
Briefly describe the pathology of systemic sclerosis.
There is increasing activity of fibroblasts which means more collagen is produced and this causes fibrosis of the dermis and the internal organs.
There is also widespread vascular damage involving small arteries, arterioles and capillaries.
What clinical feature is seen in almost 100% of systemic sclerosis cases?
Raynauds
A women presents to you complaining that her fingers get very cold and white. She also complains of a tightness of the face on her face, hands and feet. She has found she is also getting increasingly bad heartburn.
Limited systemic sclerosis
A women presents to you with stiff joints and tight skin across her whole body. She complains of dysphagia and heartburn and described feeling generally unwell.
Diffuse systemic sclerosis
What antibody do you expect to find in limited systemic sclerosis?
Anti centromere
ANA
What antibody do you expect to find in diffuse systemic sclerosis?
Anti topoisomerase
ANA
Why would you look for proteinuria in a patient with systemic sclerosis?
Check renal function (hypertensive renal crisis can occur)
What would be raised if a patient with systemic sclerosis had an acute kidney injury?
Urea and creatinine
What drugs would you use to treat raynauds in systemic sclerosis?
ACE inhibitors or calcium channel blockers
What might improve heartburn and reflux in systemic sclerosis?
PPIs such as omeprazole
What drugs would you prescribe to lower the chance of kidney damage in a patient with systemic sclerosis?
ACE inhibitors
How would you treat pulmonary hypertension is a patient with systemic sclerosis?
Oral vasodilators, oxygen and warfarin
