Medicine - Rheumatology Flashcards
1
Q
Recall 5 indications for MRI to investigate back pain
A
Cauda equina
Malignancy
Infection
Fracture
Ankylosing spondylitis
2
Q
What sort of pain might radiofrequency denervation be useful for?
A
Joint facet pain
3
Q
Recall 2 groups of people who are at increased risk of rheumatoid arthritis
A
Females
Smokers
4
Q
Recall some HLA associations with rheumatoid arthritis
A
HLA-DR1
HLA-DR4
5
Q
Recall some examination findings in the hands in rheumatoid arthritis
A
Radial deviation at wrists
Ulnar deviation at MCP joints
‘Z thumb’
Boutonniere deformity
Swan neck deformity
6
Q
What is the boutonniere deformity?
A
Rupture of central slip allowing proximal inter-phalangeal joint to to prolapse through ‘buttonhole’
7
Q
What is the swan neck deformity?
A
Stretching of the volar plate causing proximal inter-phalangeal joint hyperextension –> distal interphalangeal joint flexion
8
Q
What abnormality might rheumatoid arthritis cause in the neck?
A
Atlanto-axial subluxation
9
Q
What is Felty’s syndrome?
A
Rare triad of:
Rheumatoid arthritis
Neutropaenia
Splenomegaly
Can be remembered using the mnemonic - SANTA:
Splenomegaly
Anaemia
Neutropaenia
Thrombocytopaenia
Arthritis
10
Q
Recall some useful investigations for rheumatoid arthritis
A
Positive ‘squeeze test’
Bloods:
- Positive RhF in 70%
- Anti-CCP: 80% sensitive
- ANA
Imaging: XR, USS (synovitis), MRI
11
Q
How can rheumatoid arthritis disease activity be monitored?
A
DAS28 (Disease Activity Score 28)
CRP monitoring
12
Q
What is the 1st line management of rheumatoid arthritis?
A
Conventional DMARD monotherapy
Short bridging course prednisolone
13
Q
Recall 4 examples of conventional DMARDs
A
Methotrexate
Sulfasalazine
Hydroxychloroquine
Mycofenolate mofetil
14
Q
What monitoring is required for methotrexate?
A
Regular FBCs and LFTs
Risk of myelosuppression and liver cirrhosis
15
Q
What monitoring is required for hydroxychloroquine?
A
Annual visual acuity testing after 5 years’ continuous use
16
Q
What are the 2nd and 3rd line management options for rheumatoid arthritis?
A
2nd line: Conventional DMARD combination therapy
3rd line: conventional DMARD + biological DMARD
17
Q
Give 4 examples of biologics that can be used to manage rheumatoid arthritis
A
- Etanercept
- Infliximab
- Adalimumab
- Rituximab
18
Q
How should flare ups of rheumatoid arthritis be managed?
A
Corticosteroids +/- NSAIDs
19
Q
How can rheumatoid and osteoarthritis be differentiated using X rays of the hands?
A
Rheumatoid: loss of joint spaces in the proximal joints
Osteoarthritis: loss of joint spaces in the distal joints
20
Q
Recall the X ray features of osteoarthritis vs rheumatoid arthritis
A
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
21
Q
Recall the aetiology of gout
A
Monosodium urate crystals deposited in and around joints
22
Q
Systematically recall some causes of gout
A
Decreased excretion: primary gout, renal impairment
Increased cell turnover: lymphoma, leukaemia, psoriasis, haemolysis, tumour lysis syndrome
Drugs: diuretics, aspirin, EtOH excess
Purine rich foods
23
Q
Recall some signs and symptoms of gout other than the monoarthritis
A
Tophi
Radiolucent kidney stone
Interstitial nephritis
24
Q
What might an X ray show in gout?
A
Punched out erosions
‘Rat bites’
25
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
26
What conservative measures might be used to prevent gout?
Weight loss
No EtOH excess
Avoid prolonged fasting
27
Recall the 1st and 2nd line xanthine oxidase drugs that can be used as a urate-lowering therapy
1st: allopurinol
2nd: febuxostat
28
Recall some seronegative spondyloarthropathies
PEAR
Psoriatic arthritis
Enteropathic arthritis
Ankylosing spondylitis
Reactive arthritis
29
Recall some associations of the seronegative spondyloarthropathies
HEADS
HLA-B27
Enthesitis
Axial, asymmetircal oligoarthritis
Dactylitis
Seronegative
30
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
31
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
32
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
33
What is a syndesmophyte?
Bony growth originating inside a ligament
34
Recall 3 signs that might be seen on X ray of the lumbar spine in ankylosing spondylitis
1. Bamboo spine (squaring of lumbar vertebrae)
2. Dagger sign (supraspinous tendon ossification)
3. Syndesmophytes
35
What options for medical management are there in ankylosing spondylitis?
NSAIDs
Anti-TNF
Secukinumab
36
What condition is the 'pencil in cup deformity' most associated with?
Psoriatic arthritis
37
How can psoriatic arthritis be managed?
NO STEROIDS (can cause flares of psoriasis when tapered)
NSAIDs are first line
--> methotrexate, ciclosporin, sulfasalazine
38
What is the eponymous name for reactive arthritis?
Reiter's arthritis
39
What is reactive arthritis?
Sterile arthritis that develops 1-4 weeks after either urethritis or dysentry
40
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
41
How should enteropathic arthritis be managed?
Treat underlying IBD
NSAIDs
Local steroids
42
What condition does RhF have an 100% sensitivity for?
Felty's syndrome
43
Which autoimmune connective tissue disorder is associated with anti-dsDNA?
SLE
44
Which autoimmune connective tissue disorder is associated with anti-CCP?
Rheumatoid arthritis
45
Which autoimmune connective tissue disorder is associated with anti-histone?
Drug-induced SLE
46
Which autoimmune connective tissue disorder is associated with anti-centromere?
CREST syndrome
47
Which autoimmune connective tissue disorder is associated with anti-Jo-1?
Polymyositis
48
Which autoimmune connective tissue disorder is associated with anti-topoisomerase?
Diffuse stsremic sclerosis
49
How should Behcet's disease be managed (broadly)?
Immunosuppression
50
Recall some symptoms of sjogren's syndrome
Keratoconjunctivitis sicca
Xerostomia
Dyspareunia
Bilateral parotid swelling
51
How can eye dryness be tested for in suspected Sjogren's syndrome?
Schirmer's test (uses filter paper in the eye)
52
What is the main danger of sjogren's in pregnancy?
Antibodies can cross placenta and cause foetal heart block
53
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
54
Which drugs can precipitate 'drug-induced lupus'?
'Hydralazine PIMP'
Hydralazine
Procainamide
Isoniazid
Minocycline
Phenytoin
55
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
56
Recall some signs and symptoms of antiphospholipid syndrome
CLOT
Coagulation (venous AND arterial thromboembolism)
Livedo reticularis
Obstetric complications
Thrombocytopaenia
57
How should antiphospholipid syndrome be managed?
If no previous VTE: low-dose aspirin
If previous VTE: warfarin
58
Which antibodies should you screen for in SLE?
ANA
Anti-dsDNA
Anti-Smith
59
How can SLE disease activity be monitored?
Anti-dsDNA titres
C4 and C3 levels (C3 only reduced in extremely severe disease)
ESR
60
What would characterise a 'severe flare' of SLE?
Pericarditis/ nephritis/ AIHA/ CNS disease
61
How can a severe flare-up of SLE be managed?
Prednisolone + IV cyclophosphamide
62
What drugs can be used to manage SLE chronically
Hydroxychloroquine + DMARDs + low-dose steroids
63
What is anti-RNP antibody associated with?
Mixed connective tissue disease
64
What valve disease is associated with relapsing polychondritis?
Aortic valve disease
65
What is the triphasic colour change in Raynaud's?
White --> blue --> red
66
What does CREST stand for?
Calcinosis, raynaud's, oesophageal dysmotility, sclerodactyly, telangiectasia
67
Where is skin involvement limited to in CREST syndrome?
Face, hands and feet
68
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)
69
Recall some principles of managing Raynaud's phenomenon
Conservative (gloves etc)
Nifedipine
PDEV inhibitors (eg sildenafil)
IV iloprost
70
Recall some signs and symptoms of dermatomyositis and polymyositis
Wasting of shoulder and pelvic girdle
Dysphagia, dysphonia, respiratory weakness
71
Which malignancies can result in polymyositis as a paraneoplastic syndrome?
Lung
Pancreas
Ovarian
Bowel
72
Recall some of the dermatological signs of dermatomyositis
Periorbital heliotrope rash
Gottron's papules
Mechanic's hands
Macular rash in 'shawl' distribution
73
Which marker in the blood is strongly indicative of polymyositis or dermatomyositis?
Very raised CK
74
How can polymyositis or dermatomyositis be definitively diagnosed?
Muscular biopsy
75
What is the 'myositis panel' of antibodies?
Anti-Jo1
Anti-Mi2
Anti-SRP
76
Recall 3 types of ANCA negative small vessel vasculitides
Goodpasture's
Cryoglobulinaemia
Henoch Schonlein Purpura
77
Which of the vasculitides is associated with polymyalgia rheumatica?
Temporal arteritis
78
Recall some signs/symptoms of temporal arteritis
Scalp tenderness
Jaw claudication
Headache
Amaurosis fugax
79
What is the most useful imaging to investigate temporal arteritis, and what characteristic sign does it show when positive?
USS temporal artery
Halo sign
80
If imaging is negative but temporal arteritis is still suspected, what more invasive test can be used to make a diagnosis?
Temporal artery biopsy
81
How should temporal arteritis be managed?
40-60mg PO prednisolone
Followed by PPI + alendronate for 2 years
82
How should temporal arteritis be managed if there are visual symptoms?
IV methylprednisolone
83
How should polymyalgia rheumatica be managed?
15mg PO prednisolone
Taper down to 5mg + PPI + alendronate
84
What are the symptoms of polymyalgia rheumatica?
Pain/stiffness in the shoulder, neck and hips
NO weakness
85
What are the signs and symptoms of Takasayu's arteritis?
Weak upper limb pulses, hypertension
86
Which demographic is polyarteritis nodosa most common in?
Young males (less common in UK)
87
What is the key association of polyarteritis nodosa?
Hep B virus
88
What imaging is most useful for investigating polyarteritis nodosa and what sign does it classically produce?
Renal angiogram
Rosary bead sign
89
How can polyarteritis nodosa be managed?
Prednisolone and ciclophosphamide
90
Recall 2 examples of medium vessel vasculitides
Kawasaki disease
Polyarteritis nodosa
91
What are the proper names for Wegener's and Churg Strauss?
Wegener's: granulomatosis with polyangiitis
Churg-Strauss: eosinophillic granulomatosis with polyangiitis
92
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
93
Recall some signs and symptoms of granulomatosis with polyangiitis
URT: rhinitis, saddle-nose
LRT: haemoptysis and cough
Renal: rapidly progressive glomerulonephritis
94
Recall some signs and symptoms of eosinophillic granulomatosis with polyangiitis
- Eosinophilia
- Asthma
- Rapidly progressive glomerulonephritis
95
Recall some signs and symptoms of microscopic polyangiitis
- Palpable purpura
- Rapidly progressive glomerulonephritis
- Haemoptysis
96
What is pANCA directed against?
A myeloperoxidase
97
How should granulomatosis with polyangiitis be managed?
Prednisolone + ciclophosphamide OR rituximab
98
Recall some signs and symptoms of henoch schonlein purpura
Purpuric rash (100%)
Arthralgia with periarticular oedema (70%)
Colicky abdominal pain (60%)
Glomerulonephritis
99
How should henoch schonlein purpura be managed?
Regular follow-up with urine dips and BP measurement
100
How quickly should henoch schonlein purpura usually resolve naturally?
4 weeks
101
What might be seen on a CXR in granulomatosis with polyangiitis?
Lung nodules
102
How should goodpasture's be managed?
Immunosuppression and plasmapheresis
103
What are the 2 types of cryoglobulinaemia, and what is there relative prevalence?
Simple (20%)
Mixed (80%)
104
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
105
Describe the key differences in the symptoms of simple vs mixed cryoglobulinaemia
Simple: visual disturbances, thrombosis, headaches
Mixed: glomerulonephritis, arthralgia, palpable purpura
106
Recall some signs and symptoms of fibromyalgia
Chronic, widespread musculoskeletal pain and tenderness
Fatigue
Sleep disturbance
Morning stiffness
Poor concentration
Low mood
107
Recall some options for management of fibromyalgia
Educate
CBT
Graded exercise programmes
Amitriptyline/ pregabalin/ venlafaxine
108
What is the first line drug used to manage pain in trigeminal neuralgia?
Carbamazepine
109
What is the first line drug used to manage pain in diabetic neuropathy?
Duloxetine
110
What are the 2 first line drugs used to manage pain in neuropathic pain?
Amitriptyline
Pregabalin
111
What criteria are used to diagnose Still's disease?
Yamaguchi criteria
112
What might be raised in the blood in Still's disease?
Ferritin
113
Recall some signs and symptoms of Still's disease
Arthralgia
Salmon-pink rash
Pyrexia (rises alongside arthralgia in the late evening)
114
What is the first line in managing Still's disease?
NSAIDs, after 1 week --> steroids
115
What type of crystal is involved in pseudogout?
Calcium pyrophosphate dehydrate
116
Recall 4 associations of pseudogout
Hypothyroidism
Chondrocalcinosis
Haemochromatosis
Hyperparathyroidism
117
Recall 4 possible complications of steroid use
Cataracts
Avascular necrosis
Osteoporosis
Diabetes mellitus
118
Recall 6 causes of erythema nodosum
Sarcoidosis
Post-streptococcal infection
TB
IBD
COCP
Idiopathic
119
How should erythema nodosum be treated?
- Can be managed symptomatically with NSAIDs
- If in setting of sarcoidosis with lung changes --> prednisolone
120
Recall 5 associations of axial spondyloarthropathy
Aortic regurgitation
Cauda equina
Psoriasis
IBD
Anterior uveitis
121
Recall 3 side effects of ciclosporin
Hypertension
Tremulousness
Gingival hypertrophy
122
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
123
How long does morning stiffness need to last in order to be a significant history for inflammatory arthritis?
>30 mins
124
What needs to be done before DMARDs are started to check for contraindications?
Comprehensive metabolic panel + hep B and C serology
125
Recall 4 DMARDs that can be used in rheumatoid arthritis treatment
Methotrexate
Leflunamide
Sulphasalazine
Hydroxychloroquine
126
What shoud be done prior to starting any biologic treatment?
Test for latent TB
127
Recall 3 common symptoms of septic arthritis
Joint effusion
Joint pain
Decreased ROM
128
What is the most commonly implicated pathogen in septic arthritis?
Staphylococcus aureus
129
How should septic arthritis be managed?
Timely joint aspiration coupled with IV abx
130
What is the most likely comorbidity in a person who has pseudogout?
Osteoarthritis
131
Recall 4 drugs/drug classes that increase serum uric acid
Thiazides
Furosemide
Low-dose aspirin
Cyclosporine
132
How would synovial fluid examination differ between acute and chronic gout?
Acute: intracellular crystals
Chronic: extracellular crystals
133
Which cytokine is most associated with acute flares of gout?
IL 1
134
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)
135
What is the difference between Heberden's and Bouchard's nodes?
Heberden's: DIP
Bouchard's: PIP
136
What is anti-RPP (ribosomal P protein) highly specific for?
SLE with neuropsychiatric manifestations
137
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
138
Does lupus nephritis produce the nephrotic or nephritic syndrome when symptomatic?
The nephrotic syndrome
139
What are the most a)concerning and b) common pulmonary sequelae of SLE?
a) Diffuse alveolar haemorrhage
b) Pleuritis
140
What is the most common cardiac manifestation of SLE?
Pericarditis
141
Recall some important lifestyle changes for SLE patients
Always wear sunscreen
Stop oestrogen-containing medication
Avoid smoking
Start exercise programme
142
Which DMARD has the best evidence base for treating SLE?
Hydroxychloroquine
143
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
144
How should an acute inflammation of gout be treated in patients with CKD that contraindicates NSAIDs?
Oral prednisolone
145
3 blood tests for monitoring SLE activity:
ESR
dsDNA
C3 + C4
146
What is lupus pernio and what causes it?
Disfiguring purple facial rash (not painful)
Caused by sarcoidosis (not lupus, despite the name)
147
Following an acute asthma attack, what PEF is required for safe discharge?
>75% of predicted
