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