Medicine - Rheumatology Flashcards
Recall 5 indications for MRI to investigate back pain
Cauda equina
Malignancy
Infection
Fracture
Ankylosing spondylitis
What sort of pain might radiofrequency denervation be useful for?
Joint facet pain
Recall 2 groups of people who are at increased risk of rheumatoid arthritis
Females
Smokers
Recall some HLA associations with rheumatoid arthritis
HLA-DR1
HLA-DR4
Recall some examination findings in the hands in rheumatoid arthritis
Radial deviation at wrists
Ulnar deviation at MCP joints
‘Z thumb’
Boutonniere deformity
Swan neck deformity
What is the boutonniere deformity?
Rupture of central slip allowing proximal inter-phalangeal joint to to prolapse through ‘buttonhole’
What is the swan neck deformity?
Stretching of the volar plate causing proximal inter-phalangeal joint hyperextension –> distal interphalangeal joint flexion
What abnormality might rheumatoid arthritis cause in the neck?
Atlanto-axial subluxation
What is Felty’s syndrome?
Rare triad of:
Rheumatoid arthritis
Neutropaenia
Splenomegaly
Can be remembered using the mnemonic - SANTA:
Splenomegaly
Anaemia
Neutropaenia
Thrombocytopaenia
Arthritis
Recall some useful investigations for rheumatoid arthritis
Positive 'squeeze test' Bloods: - Positive RhF in 70% - Anti-CCP: 80% sensitive - ANA Imaging: XR, USS (synovitis), MRI
How can rheumatoid arthritis disease activity be monitored?
DAS28 (Disease Activity Score 28)
CRP monitoring
What is the 1st line management of rheumatoid arthritis?
Conventional DMARD monotherapy
Short bridging course prednisolone
Recall 4 examples of conventional DMARDs
Methotrexate
Sulfasalazine
Hydroxychloroquine
Mycofenolate mofetil
What monitoring is required for methotrexate?
Regular FBCs and LFTs
Risk of myelosuppression and liver cirrhosis
What monitoring is required for hydroxychloroquine?
Annual visual acuity testing after 5 years’ continuous use
What are the 2nd and 3rd line management options for rheumatoid arthritis?
2nd line: Conventional DMARD combination therapy
3rd line: conventional DMARD + biological DMARD
Give 4 examples of biologics that can be used to manage rheumatoid arthritis
- Etanercept
- Infliximab
- Adalimumab
- Rituximab
How should flare ups of rheumatoid arthritis be managed?
Corticosteroids +/- NSAIDs
How can rheumatoid and osteoarthritis be differentiated using X rays of the hands?
Rheumatoid: loss of joint spaces in the proximal joints
Osteoarthritis: loss of joint spaces in the distal joints
Recall the X ray features of osteoarthritis vs rheumatoid arthritis
Osteoarthritis: LOSS Loss of joint spaces Osteophytes Subchondral cysts Subchondral sclerosis
Rheumatoid arthritis: LESS Loss of joint spaces Erosions (periarticular) Soft tissue swelling Subluxation and deformity
Recall the aetiology of gout
Monosodium urate crystals deposited in and around joints
Systematically recall some causes of gout
Decreased excretion: primary gout, renal impairment
Increased cell turnover: lymphoma, leukaemia, psoriasis, haemolysis, tumour lysis syndrome
Drugs: diuretics, aspirin, EtOH excess
Purine rich foods
Recall some signs and symptoms of gout other than the monoarthritis
Tophi
Radiolucent kidney stone
Interstitial nephritis
What might an X ray show in gout?
Punched out erosions
‘Rat bites’
Recall the management of gout
Acutely: NSAIDs - or colchicine if history of duodenal ulcer/ renal failure
Intra-articular steroid injections may be used if certain it isn’t septic arthritis
Chronic prevention: conservative, or urate-lowering therapy
What conservative measures might be used to prevent gout?
Weight loss
No EtOH excess
Avoid prolonged fasting
Recall the 1st and 2nd line xanthine oxidase drugs that can be used as a urate-lowering therapy
1st: allopurinol
2nd: febuxostat
Recall some seronegative spondyloarthropathies
PEAR
Psoriatic arthritis
Enteropathic arthritis
Ankylosing spondylitis
Reactive arthritis
Recall some associations of the seronegative spondyloarthropathies
HEADS
HLA-B27 Enthesitis Axial, asymmetircal oligoarthritis Dactylitis Seronegative
What is the key difference in signs and symptoms between psoriatic arthritis and ankylosing spondylitis?
No signs or symptoms in the hands in ankylosing spondylitis
Recall some associated signs and symptoms of anklosing spondylitis
All the 'A's Anterior uveitis Apical lung fibrosis Aortic regurgitation AV node block Achilles tendonitis Amyloidosis
What is Schober’s test used to diagnose, and what would a positive test be?
Ankylosing spondylitis
- Mark L5
- 1 finger 5cm above and 1 5cm below
- <5cm increase when bending over = positive
What is a syndesmophyte?
Bony growth originating inside a ligament
Recall 3 signs that might be seen on X ray of the lumbar spine in ankylosing spondylitis
- Bamboo spine (squaring of lumbar vertebrae)
- Dagger sign (supraspinous tendon ossification)
- Syndesmophytes
What options for medical management are there in ankylosing spondylitis?
NSAIDs
Anti-TNF
Secukinumab
What condition is the ‘pencil in cup deformity’ most associated with?
Psoriatic arthritis
How can psoriatic arthritis be managed?
NO STEROIDS (can cause flares of psoriasis when tapered)
NSAIDs are first line
–> methotrexate, ciclosporin, sulfasalazine
What is the eponymous name for reactive arthritis?
Reiter’s arthritis
What is reactive arthritis?
Sterile arthritis that develops 1-4 weeks after either urethritis or dysentry
What are the symptoms of reactive arthritis?
"Can't see, can't pee, can't climb a tree" - Conjunctivitis - Urethritis - Lower limb oligoarthritis Also: skin issues --> - keratoderma blenorrhagicum - Circinate balantis - Enthesitis
How should enteropathic arthritis be managed?
Treat underlying IBD
NSAIDs
Local steroids
What condition does RhF have an 100% sensitivity for?
Felty’s syndrome
Which autoimmune connective tissue disorder is associated with anti-dsDNA?
SLE
Which autoimmune connective tissue disorder is associated with anti-CCP?
Rheumatoid arthritis
Which autoimmune connective tissue disorder is associated with anti-histone?
Drug-induced SLE
Which autoimmune connective tissue disorder is associated with anti-centromere?
CREST syndrome
Which autoimmune connective tissue disorder is associated with anti-Jo-1?
Polymyositis
Which autoimmune connective tissue disorder is associated with anti-topoisomerase?
Diffuse stsremic sclerosis
How should Behcet’s disease be managed (broadly)?
Immunosuppression
Recall some symptoms of sjogren’s syndrome
Keratoconjunctivitis sicca
Xerostomia
Dyspareunia
Bilateral parotid swelling
How can eye dryness be tested for in suspected Sjogren’s syndrome?
Schirmer’s test (uses filter paper in the eye)
What is the main danger of sjogren’s in pregnancy?
Antibodies can cross placenta and cause foetal heart block
Recall some symptoms of SLE
SOAP BRAIN MD Serositis Oral ulcers Arthritis Photosensitivity
Blood (pancytopaenia) Renal (proteinuria, haematuria) ANA Immunology (anti-dsDNA, AIHA) Neurological (eg seizures)
Malar rash
Discoid rash
Which drugs can precipitate ‘drug-induced lupus’?
'Hydralazine PIMP' Hydralazine Procainamide Isoniazid Minocycline Phenytoin
In anti-phospholipid syndrome, why would the APTT be falsely prolonged?
The antibodies in the patient’s serum react with the phospholipids in the lab reagent so the patient’s blood does not clot
Recall some signs and symptoms of antiphospholipid syndrome
CLOT Coagulation (venous AND arterial thromboembolism) Livedo reticularis Obstetric complications Thrombocytopaenia
How should antiphospholipid syndrome be managed?
If no previous VTE: low-dose aspirin
If previous VTE: warfarin
Which antibodies should you screen for in SLE?
ANA
Anti-dsDNA
Anti-Smith
How can SLE disease activity be monitored?
Anti-dsDNA titres
C4 and C3 levels (C3 only reduced in extremely severe disease)
ESR
What would characterise a ‘severe flare’ of SLE?
Pericarditis/ nephritis/ AIHA/ CNS disease
How can a severe flare-up of SLE be managed?
Prednisolone + IV cyclophosphamide
What drugs can be used to manage SLE chronically
Hydroxychloroquine + DMARDs + low-dose steroids
What is anti-RNP antibody associated with?
Mixed connective tissue disease
What valve disease is associated with relapsing polychondritis?
Aortic valve disease
What is the triphasic colour change in Raynaud’s?
White –> blue –> red
What does CREST stand for?
Calcinosis, raynaud’s, oesophageal dysmotility, sclerodactyly, telangiectasia
Where is skin involvement limited to in CREST syndrome?
Face, hands and feet
What organ involvement is possible in diffuse systemic sclerosis?
Fibrosis of:
- GIT (causing incontinence, GORD, dysphagia)
- Lung (in 80%)
- Cardiac
- Renal (causing acute hypertensive crisis)
Recall some principles of managing Raynaud’s phenomenon
Conservative (gloves etc)
Nifedipine
PDEV inhibitors (eg sildenafil)
IV iloprost
Recall some signs and symptoms of dermatomyositis and polymyositis
Wasting of shoulder and pelvic girdle
Dysphagia, dysphonia, respiratory weakness
Which malignancies can result in polymyositis as a paraneoplastic syndrome?
Lung
Pancreas
Ovarian
Bowel
Recall some of the dermatological signs of dermatomyositis
Periorbital heliotrope rash
Gottron’s papules
Mechanic’s hands
Macular rash in ‘shawl’ distribution
Which marker in the blood is strongly indicative of polymyositis or dermatomyositis?
Very raised CK
How can polymyositis or dermatomyositis be definitively diagnosed?
Muscular biopsy
What is the ‘myositis panel’ of antibodies?
Anti-Jo1
Anti-Mi2
Anti-SRP
Recall 3 types of ANCA negative small vessel vasculitides
Goodpasture’s
Cryoglobulinaemia
Henoch Schonlein Purpura
Which of the vasculitides is associated with polymyalgia rheumatica?
Temporal arteritis
Recall some signs/symptoms of temporal arteritis
Scalp tenderness
Jaw claudication
Headache
Amaurosis fugax
What is the most useful imaging to investigate temporal arteritis, and what characteristic sign does it show when positive?
USS temporal artery
Halo sign
If imaging is negative but temporal arteritis is still suspected, what more invasive test can be used to make a diagnosis?
Temporal artery biopsy
How should temporal arteritis be managed?
40-60mg PO prednisolone
Followed by PPI + alendronate for 2 years
How should temporal arteritis be managed if there are visual symptoms?
IV methylprednisolone
How should polymyalgia rheumatica be managed?
15mg PO prednisolone
Taper down to 5mg + PPI + alendronate
What are the symptoms of polymyalgia rheumatica?
Pain/stiffness in the shoulder, neck and hips
NO weakness
What are the signs and symptoms of Takasayu’s arteritis?
Weak upper limb pulses, hypertension
Which demographic is polyarteritis nodosa most common in?
Young males (less common in UK)
What is the key association of polyarteritis nodosa?
Hep B virus
What imaging is most useful for investigating polyarteritis nodosa and what sign does it classically produce?
Renal angiogram
Rosary bead sign
How can polyarteritis nodosa be managed?
Prednisolone and ciclophosphamide
Recall 2 examples of medium vessel vasculitides
Kawasaki disease
Polyarteritis nodosa
What are the proper names for Wegener’s and Churg Strauss?
Wegener’s: granulomatosis with polyangiitis
Churg-Strauss: eosinophillic granulomatosis with polyangiitis
Recall the type of ANCA associated with:
- Granulomatosis with polyangiitis
- Eosinophillic granulomatosis with polyangiitis
- Microscopic polyangiitis
- Granulomatosis with polyangiitis: cANCA
- Eosinophillic granulomatosis with polyangiitis: pANCA
- Microscopic polyangiitis: pANCA
Recall some signs and symptoms of granulomatosis with polyangiitis
URT: rhinitis, saddle-nose
LRT: haemoptysis and cough
Renal: rapidly progressive glomerulonephritis
Recall some signs and symptoms of eosinophillic granulomatosis with polyangiitis
- Eosinophilia
- Asthma
- Rapidly progressive glomerulonephritis
Recall some signs and symptoms of microscopic polyangiitis
- Palpable purpura
- Rapidly progressive glomerulonephritis
- Haemoptysis
What is pANCA directed against?
A myeloperoxidase
How should granulomatosis with polyangiitis be managed?
Prednisolone + ciclophosphamide OR rituximab
Recall some signs and symptoms of henoch schonlein purpura
Purpuric rash (100%)
Arthralgia with periarticular oedema (70%)
Colicky abdominal pain (60%)
Glomerulonephritis
How should henoch schonlein purpura be managed?
Regular follow-up with urine dips and BP measurement
How quickly should henoch schonlein purpura usually resolve naturally?
4 weeks
What might be seen on a CXR in granulomatosis with polyangiitis?
Lung nodules
How should goodpasture’s be managed?
Immunosuppression and plasmapheresis
What are the 2 types of cryoglobulinaemia, and what is there relative prevalence?
Simple (20%)
Mixed (80%)
Describe the key differences in the aetiologies of simple vs mixed cryoglobulinaemia
Simple: monoclonal IgM secondary to myeloma/ CLL/ Waldenstrom’s macroglobulinaemia –> hyperviscosity
Mixed: polyclonal IgM secondary to SLE/ Sjogren’s/ hep C/ mycoplasma –> immune complex-mediated disease
Describe the key differences in the symptoms of simple vs mixed cryoglobulinaemia
Simple: visual disturbances, thrombosis, headaches
Mixed: glomerulonephritis, arthralgia, palpable purpura
Recall some signs and symptoms of fibromyalgia
Chronic, widespread musculoskeletal pain and tenderness Fatigue Sleep disturbance Morning stiffness Poor concentration Low mood
Recall some options for management of fibromyalgia
Educate
CBT
Graded exercise programmes
Amitriptyline/ pregabalin/ venlafaxine
What is the first line drug used to manage pain in trigeminal neuralgia?
Carbamazepine
What is the first line drug used to manage pain in diabetic neuropathy?
Duloxetine
What are the 2 first line drugs used to manage pain in neuropathic pain?
Amitriptyline
Pregabalin
What criteria are used to diagnose Still’s disease?
Yamaguchi criteria
What might be raised in the blood in Still’s disease?
Ferritin
Recall some signs and symptoms of Still’s disease
Arthralgia
Salmon-pink rash
Pyrexia (rises alongside arthralgia in the late evening)
What is the first line in managing Still’s disease?
NSAIDs, after 1 week –> steroids
What type of crystal is involved in pseudogout?
Calcium pyrophosphate dehydrate
Recall 4 associations of pseudogout
Hypothyroidism
Chondrocalcinosis
Haemochromatosis
Hyperparathyroidism
Recall 4 possible complications of steroid use
Cataracts
Avascular necrosis
Osteoporosis
Diabetes mellitus
Recall 6 causes of erythema nodosum
Sarcoidosis Post-streptococcal infection TB IBD COCP Idiopathic
How should erythema nodosum be treated?
- Can be managed symptomatically with NSAIDs
- If in setting of sarcoidosis with lung changes –> prednisolone
Recall 5 associations of axial spondyloarthropathy
Aortic regurgitation Cauda equina Psoriasis IBD Anterior uveitis
Recall 3 side effects of ciclosporin
Hypertension
Tremulousness
Gingival hypertrophy
Describe the broad mechanism of synovitis development in rheumatoid arthritis
- Cellular immune activation of T lymphocytes
- Plasma cell production of RF, anti-CCP (not necessarily required for development of RA)
- Macrophage production of inflammatory cytokines and chemokines: eg TNF, IL1 and IL6
- Cartilage and bone destruction by MMPs and osteoclasts
How long does morning stiffness need to last in order to be a significant history for inflammatory arthritis?
> 30 mins
What needs to be done before DMARDs are started to check for contraindications?
Comprehensive metabolic panel + hep B and C serology
Recall 4 DMARDs that can be used in rheumatoid arthritis treatment
Methotrexate
Leflunamide
Sulphasalazine
Hydroxychloroquine
What shoud be done prior to starting any biologic treatment?
Test for latent TB
Recall 3 common symptoms of septic arthritis
Joint effusion
Joint pain
Decreased ROM
What is the most commonly implicated pathogen in septic arthritis?
Staphylococcus aureus
How should septic arthritis be managed?
Timely joint aspiration coupled with IV abx
What is the most likely comorbidity in a person who has pseudogout?
Osteoarthritis
Recall 4 drugs/drug classes that increase serum uric acid
Thiazides
Furosemide
Low-dose aspirin
Cyclosporine
How would synovial fluid examination differ between acute and chronic gout?
Acute: intracellular crystals
Chronic: extracellular crystals
Which cytokine is most associated with acute flares of gout?
IL 1
Recall 3 uricosuric agents that may be used as urate-lowering therapies in patients with chronic gout
Probenecid
Losartan (useful in patients with HTN)
Fenofibrate (useful in patients with hyperlipidaemia)
What is the difference between Heberden’s and Bouchard’s nodes?
Heberden’s: DIP
Bouchard’s: PIP
What is anti-RPP (ribosomal P protein) highly specific for?
SLE with neuropsychiatric manifestations
What is Jaccoud arthropathy?
Appears similar to swan neck deformity on examination, but is actually a reversible sign of SLE that results from joint capsule and ligament laxity
Does lupus nephritis produce the nephrotic or nephritic syndrome when symptomatic?
The nephrotic syndrome
What are the most a)concerning and b) common pulmonary sequelae of SLE?
a) Diffuse alveolar haemorrhage
b) Pleuritis
What is the most common cardiac manifestation of SLE?
Pericarditis
Recall some important lifestyle changes for SLE patients
Always wear sunscreen
Stop oestrogen-containing medication
Avoid smoking
Start exercise programme
Which DMARD has the best evidence base for treating SLE?
Hydroxychloroquine
How should lupus nephritis be treated?
Induction with high dose methylprednisolone and a steroid-sparing agent (eg cyclophosphamide or MMF)
Follow with steroid-sparing maintenance therapy
How should an acute inflammation of gout be treated in patients with CKD that contraindicates NSAIDs?
Oral prednisolone
3 blood tests for monitoring SLE activity:
ESR
dsDNA
C3 + C4
What is lupus pernio and what causes it?
Disfiguring purple facial rash (not painful)
Caused by sarcoidosis (not lupus, despite the name)
Following an acute asthma attack, what PEF is required for safe discharge?
> 75% of predicted