Lymphoid/Rheum IM Flashcards by John Tan

How to differentiate autoantibodies in testing of rheumatic conditions?

Ab against Nuclear antigens (ANA)
Ab against cytoplasmic antigens (ANCA)

Diagnosis of individual conditions can be further supported by detecting disease-specific ANAs or ANCAs

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Examples of conditions where there are specific ANCAs?

Granulomatosis with polyangiitis (and a few other polyangiitis)
Primary Sclerosing Cholangitis
Ulcerative Colitis

ANCAs observed in especially vasculitides

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Examples of conditions where there are specific ANAs?

SLE = Anti-dsDNA
Systemic Sclerosis (Scleroderma)
Sjögren syndrome
Polymyositis, dermatomyositis

Generally elevated in connective tissue disorders!

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Causes of Reactive neutrophilia?

Reactive is the commonest cause of neutrophilia

Acute bacterial infection
Chronic inflammatory state
Bone marrow stimulation
Drugs
Solid organ tumour

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What is Stevens-Johnson syndrome / Toxic Epidermal Necrolysis?

Skin rxn causing extensive epidermal detachment.

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Is Rheumatoid Factor useful as a marker for seronegative arthropathies?

No. Rheumatoid factors can be raised in up to 20% of seronegative arthropathies. They can be raised in almost any form of autoimmune inflammation.

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How to differentiate mAb drugs, whether human/humanized/chimeric?

Mumab = human
Zumab = humanized
Ximab = Chimeric

Chimeric drugs have higher risk of immune response / hypersensitivity

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Which 2 cancers does RA raise risk of?

Lung cancer
Lymphoma

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How to identify lung pathologies due to RA?

From King Julian tutorials - how to compartmentalize differentials

Go by compartments!
Parenchyma = inflammation, infection, malignancy
Airway = bronchiectasis,** rheumatoid nodules that can cause obstruction and hence atelectasis**
Interstitium = ILD
VEssels = pulmonary vasculitis
Pleura = pleuritis, pleural effusion

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What is Erythema Multiforme?

Inflammation of SubQ fat caused by delayed hypersensitivity rxn.
Associated with infection, autoimmune diseases e.g. sarcoidosis, UC etc, pregnancy, OCP
Firm, erythematous nodular rashes over both LL
Bilateral hilar lymphadenopathy

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Common genes in SLE?

HLA-DR2, HLA-DR3

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Skin manifestations of SLE?

Malar rash sparing nasolabial folds
Raynaud phenomenon
Photosensitivity causing maculopapular rash
Discoid rash
Oral ulcers
Non-scarring alopecia
Periungual telangiectasia

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Common joints affected in SLE?

Fingers, carpal joints, knee.
Usually distal symmetrical polyarthritis

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Which NSAIDs are known to cause psoriasis flares?

Indomethacin and Naproxen

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What heart valvular disease is Ankylosing Spondylitis associated with?

Aortic regurgitation.

Likely due to sclerosing inflammatory process involving aortic root

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What are “B” symptoms? In which conditions?

Systemic symptoms of LOW, fever, night sweats that are a/w lymphomas and leukemias.

Screening vs Diagnostic for SLE?

ANA for screening
dsDNA for diagnostic.
Screen with ANA. If +ve, test Anti-dsDNA
Active SLE has low C3 C4 complement levels

Commonest cutaneous manifestation of sarcoidosis?

Erythema nodosum.
Often comes with bilateral hilar lymphadenopathy

CREST syndrome in Scleroderma?

Calcinosis Cutis
Raynaud phenomenon
Esophageal hypomotility
Sclerodactyly
Telangiectasia

Common triggers of psoriasis?

Infection = URTI, staphs, HIV
Mechanical irritation
Drugs

5 types of psoriasis?

Plaque psoriasis = standard.
Inverse psoriasis = plaques on flexor surfaces
Pustular psoriasis = pustules surrounded by inflamed skin
Guttate psoriasis = small round papules that are raised and sometimes scaly.
Erythrodermic psoriasis = worst type.

Presentation of psoriasis? Excluding arthritic part

Well-demarcated, scaly, pruritic, erythematous plaques/papules with silver-white scaling
Mainly on extensor surfaces, scalp, trunk, elbows.
Auspitz sign = small telangiectasia when scales are scraped off. Removal of scales expose dermal papillae, causing bleeding
Koebner phenomenon = physical stimuli or skin injury can cause appearance of psoriatic skin lesions on previously unaffected skin

Classic DRSAM presentation of Psoriatic arthritis?

DIPJ involvement
RA-like
Spondylitis, sacroilitis
Asymmetric oligoarthritis
Mutilans

Risk factors for RA

HLA-DR4 and HLA-DR1 gene
Smoking
Pre-menopausal women
Infection, obesity, family hx

Hand manifestation of RA?

Symmetrical (usually) pain and swelling of joints Swan neck deformity Boutonniere deformity Z thumb Hitchhiker thumb Ulnar deviation of fingers Piano key sign Hammer toe or claw toe Atlantoaxial subluxation Rheumatoid nodules

Joints commonly affected by RA?

MCPJ, PIPJ Wrist Knee MTPJ

X-Ray findings of RA?

Narrowing of joint space Thickening of subchondral bone Subchondral cyst Osteophytes Marginal erosion of cartilage and bone Osteopenia Soft tissue swelling

Triad of reactive arthritis?

Arthritis Conjunctivitis Urethritis

Presentation of REactive Arthritis?

Latency of 1-4 weeks Arthritis can be symmetrical or asymmetrical. - sacroilitis - Dactylitis - Enthesitis - Arthritis predominantly in lower extremities

Diagnostics of Reactive arthritis?

Send stool culture. Check for STI in case of genitourinary chlamydia (Nucleic acid Amplification Test). Usual bloods e.g. CRP ESR, high TW. Negative rheumatoid factor or anti-CCP Ab. Arthrocentesis will show negative gram stain/cultures, no crystals. Just high WBC.

XR signs of reactive arthritis?

Loss of lumbar lordosis **Ankylosis of costosternal and costovertebral joints Dagger sign Bamboo sign** Shiny corners sign

Skin manifestations of Dermatomyositis?

Heliotrope rash Gotttron's papules V sign Shawl sign Mechanic hands

What is multiple sclerosis?

Chronic degenerative disease of CNS characterized by demyelination and axonal degeneration in brain and spinal cord, caused by an immune-meiated inflammatory process

Diagnosis of Dermatomyositis?

Mostly clinical diagnosis Muscle biopsy showing muscle fibre damage

How to confirm diagnosis of Multiple Sclerosis?

McDonald criteria of both DIT and DIS must be met Dissemination in Time = Appearance of new CNS lesions over time that can be confirmed clinically, with imaging, or with CSF analysis Dissemination in Space = Presence of lesions in different regions of CNS that can be confirmed clinically or in MRI MRI is imaging of choice, showing MS plaques with finger-like radial extensions (Dawson fingers) Contrast-enhancement of active lesions CSF exam showing oligoclonal bands in CSF is highly suggestive of MS