Lymphoid/Rheum IM

Question 1

How to differentiate autoantibodies in testing of rheumatic conditions?

Answer 1

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

Question 2

Examples of conditions where there are specific ANCAs?

Answer 2

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

ANCAs observed in especially vasculitides

Question 3

Examples of conditions where there are specific ANAs?

Answer 3

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

Generally elevated in connective tissue disorders!

Question 4

Causes of Reactive neutrophilia?

Reactive is the commonest cause of neutrophilia

Answer 4

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

Question 5

What is Stevens-Johnson syndrome / Toxic Epidermal Necrolysis?

Answer 5

Skin rxn causing extensive epidermal detachment.

Question 6

Is Rheumatoid Factor useful as a marker for seronegative arthropathies?

Answer 6

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

Question 7

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

Answer 7

Mumab = human
Zumab = humanized
Ximab = Chimeric

Chimeric drugs have higher risk of immune response / hypersensitivity

Question 8

Which 2 cancers does RA raise risk of?

Answer 8

Lung cancer
Lymphoma

Question 9

How to identify lung pathologies due to RA?

From King Julian tutorials - how to compartmentalize differentials

Answer 9

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

Question 10

What is Erythema Multiforme?

Answer 10

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

Question 11

Common genes in SLE?

Answer 11

HLA-DR2, HLA-DR3

Question 12

Skin manifestations of SLE?

Answer 12

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

Question 13

Common joints affected in SLE?

Answer 13

Fingers, carpal joints, knee.
Usually distal symmetrical polyarthritis

Question 14

Which NSAIDs are known to cause psoriasis flares?

1

Answer 14

Indomethacin and Naproxen

Question 15

What heart valvular disease is Ankylosing Spondylitis associated with?

Answer 15

Aortic regurgitation.

Likely due to sclerosing inflammatory process involving aortic root

Question 16

What are “B” symptoms? In which conditions?

Answer 16

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

Question 17

Screening vs Diagnostic for SLE?

Answer 17

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

Question 18

Commonest cutaneous manifestation of sarcoidosis?

Answer 18

Erythema nodosum.
Often comes with bilateral hilar lymphadenopathy

Question 19

CREST syndrome in Scleroderma?

Answer 19

Calcinosis Cutis
Raynaud phenomenon
Esophageal hypomotility
Sclerodactyly
Telangiectasia

Question 20

Common triggers of psoriasis?

Answer 20

Infection = URTI, staphs, HIV
Mechanical irritation
Drugs

Question 21

5 types of psoriasis?

Answer 21

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.

Question 22

Presentation of psoriasis? Excluding arthritic part

Answer 22

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

Question 23

Classic DRSAM presentation of Psoriatic arthritis?

Answer 23

DIPJ involvement
RA-like
Spondylitis, sacroilitis
Asymmetric oligoarthritis
Mutilans

Question 24

Risk factors for RA

Answer 24

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

Question 25

Hand manifestation of RA?

Answer 25

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

Question 26

Joints commonly affected by RA?

Answer 26

MCPJ, PIPJ
Wrist
Knee
MTPJ

Question 27

X-Ray findings of RA?

Answer 27

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

Question 28

Triad of reactive arthritis?

Answer 28

Arthritis
Conjunctivitis
Urethritis

Question 29

Presentation of REactive Arthritis?

Answer 29

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

Question 30

Diagnostics of Reactive arthritis?

Answer 30

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.

Question 31

XR signs of reactive arthritis?

Answer 31

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

Question 32

Skin manifestations of Dermatomyositis?

Answer 32

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

Question 33

What is multiple sclerosis?

Answer 33

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

Question 34

Diagnosis of Dermatomyositis?

Answer 34

Mostly clinical diagnosis
Muscle biopsy showing muscle fibre damage

Question 35

How to confirm diagnosis of Multiple Sclerosis?

Answer 35

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