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ICSM Year 6 > Medicine - Rheumatology > Flashcards

Medicine - Rheumatology Flashcards

1
Q

Recall 5 indications for MRI to investigate back pain

A

Cauda equina

Malignancy

Infection

Fracture

Ankylosing spondylitis

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2
Q

What sort of pain might radiofrequency denervation be useful for?

A

Joint facet pain

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3
Q

Recall 2 groups of people who are at increased risk of rheumatoid arthritis

A

Females

Smokers

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4
Q

Recall some HLA associations with rheumatoid arthritis

A

HLA-DR1

HLA-DR4

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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

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6
Q

What is the boutonniere deformity?

A

Finger deformity seen in RA where the PIPJ is hyperflexed and DIPJ is hyperextended.

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7
Q

What is the swan neck deformity?

A

Stretching of the volar plate causing proximal inter-phalangeal joint hyperextension –> distal interphalangeal joint flexion

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8
Q

What abnormality might rheumatoid arthritis cause in the neck?

A

Atlanto-axial subluxation

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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

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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
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11
Q

How can rheumatoid arthritis disease activity be monitored?

A

DAS28 (Disease Activity Score 28)

CRP monitoring

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12
Q

What is the 1st line management of rheumatoid arthritis?

A

Conventional DMARD monotherapy

Short bridging course prednisolone

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13
Q

Recall 4 examples of conventional DMARDs

A

Methotrexate
Sulfasalazine
Hydroxychloroquine
Mycofenolate mofetil

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14
Q

What monitoring is required for methotrexate?

A

Regular FBCs and LFTs

Risk of myelosuppression and liver cirrhosis

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15
Q

What monitoring is required for hydroxychloroquine?

A

Annual visual acuity testing after 5 years’ continuous use. Should encourage annual testing at opticians though.

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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

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17
Q

Give 4 examples of biologics that can be used to manage rheumatoid arthritis

A
  • Etanercept
  • Infliximab
  • Adalimumab
  • Rituximab
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18
Q

How should flare ups of rheumatoid arthritis be managed?

A

Corticosteroids +/- NSAIDs

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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

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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
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21
Q

Recall the aetiology of gout

A

Monosodium urate crystals deposited in and around joints

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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

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23
Q

Recall some signs and symptoms of gout other than the monoarthritis

A

Tophi
Radiolucent kidney stone
Interstitial nephritis

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24
Q

What might an X ray show in gout?

A

Punched out erosions

‘Rat bites’

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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 (xanthine oxidase)
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 systemic 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
148
What is a normal anti-CCP titre?
<7
149
How should a new diagnosis of rheumatoid arthritis be managed?
* Start on steroids (~40mg) then reduce dose incrementally down to 10mg * Wean onto long-term DMARDs * Regular bloods and x-rays to monitor disease progress
150
What must be co-prescribed with steroids, especially if on longer courses?
* Stomach protection (e.g. PPI or H2 antagonist) * Bone protection if on longer courses (e.g. calcium, vitamin D, bisphosphonates)
151
How is methotrexate taken?
* Once a week * Folic acid should be taken once a week alongside it, usually the day after
152
What is the blood monitoring required when starting DMARDs?
* Every 2w for the first 6w * Every month for first three months
153
What is the difference between a large and a medium vessel?
A vessel becomes 'medium' when it penetrates an organ
154
What are some causes of carpal tunnel syndrome?
* Endocrine causes - hypothyroidism, acromegaly, diabetes etc * Rheumatoid arthritis * Repeated use * Idiopathic * Pregnancy
155
What type of hypersensitivity reaction is GCA?
Type 4
156
What feature of GCA is associated with a poor prognosis?
Ischaemic scalp ulcers
157
What are some of the ocular problems you can get in GCA?
* Transient monocular vision loss (amaurosis fugax) * Visual field defects * Complete vision loss
158
What is the management of GCA?
* High dose prednisolone (40-60mg) over 18-24 months * Consider alendronate and vitamin D for bone protection * PPIs for stomach protection * Urgent ophthalmology review if ocular symptoms present
159
What can be given in relapsing GCA disease?
Methotrexate
160
Which interleukin is strongly involved in production of fever?
IL-1
161
What is the role of IL-2?
T cell differentiation
162
How is Takayasu's arteritis diagnosed?
PET-CT
163
What is a significant eosinophil level?
Should be no more than 10% of the total WCC
164
What are some causes of an eosinophilia?
* Atopy and allergies * Worms * Vasculitis * Eosinophilic haematological malignancies * EGPA
165
What is the only lung disease to cause an INCREASE in gas transfer on PFTs?
GPA (Wegner's)
166
Can infliximab be used in pregnancy?
Don't use within 6 months of pregnancy
167
Can methotrexate be used in pregnancy?
No it is teratogenic - wait 3 months after stopping before getting pregnant
168
Can sulfasalazine be used in pregnancy?
It can reduce sperm count so should be advised against in partners of women who want to conceive. However, it is fine to take for the women.
169
What is the pattern of joint involvement in rheumatoid arthritis?
Symmetrical, bilateral and proximal (typically DIPJ-sparing)
170
Which antibody related to RA confers a higher risk of joint erosion/worse disease prognosis?
Anti-CCP antibodies
171
What is the DAS28 based on?
* 28 joint score * CRP/ESR * VAS (visual analogue score)
172
What are the different scores for the DAS28?
>5.1 = severe 3.2-5.1 = moderate 2.6-3.2 = mild <2.6 = in remission
173
What are the different methods of giving steroids and when would each be used?
* Intra-articular - particularly if it is a small number of joints affected (1/2) * Oral - usually if it is more than 2 joints * IM - for multiple, severe joint involvement
174
What is the steroid used in IM steroid injections?
Depomedrone
175
What is an acute complication of methotrexate and what test is done to monitor this?
Acute pneumonitis - this is why a baseline CXR is needed before starting therapy
176
What is a rare complication of sulphasalazine?
DRESS syndrome
177
Can leflonamide be used in pregnancy?
No
178
Can hydroxychloroquine be used in pregnancy?
Yes
179
What screening/baseline tests should be done before starting DMARDs?
* LFTs * FBC * Hep B serology (core and surface) * Latent TB (Quantiferon) * CXR * XR of hands and feet * HIV test
180
When can a patient be stepped up to a biological therapy?
* When they have tried 2x previous DMARDs for 6 months with no success * DAS28 should also be more than 3.2 (moderate or above)
181
What does Rituximab target?
CD20
182
What does Toculizumab target?
IL-6
183
Who should not be given JAK2 inhibitors?
Elderly due to worries over immunosuppression and cancer
184
Aside from joint and nail changes, what other features are seen in psoriatic arthritis?
* Enthesitis * Tendonitis * Dactylitis
185
Is psoriatic arthritis a symmetrical or asymmetrical arthritis?
Asymmetrical typically
186
How is the severity of psoriatic arthritis measured?
PSARC66 (involves 66 joints as well as clinician and patient score)
187
What are the serum urate level targets for gout patents?
Within 1 year of therapy = <300 1 year + = <360
188
How should allopurinol be handled during an acute gout attack?
* Do not start during an acute attack * If already taking, continue to take alongside colcichine
189
When starting allopurinol, what should be co-prescribed?
Colcichine for at least 2 months as there may be a paradoxical effect in first few months of therapy
190
When is CRP and ESR naturally raised?
Obese individuals
191
What marker is almost always raised in vasculitis?
CRP
192
What is the predominant demographic of a GCA patient?
Caucasian, female and >55yo
193
How is ILD secondary to systemic sclerosis managed?
Immunosuppression, usually with mycophenalate mofetil and hydroxychloroquine.
194
What is a rare GI complication of systemic sclerosis?
Bacterial overgrowth in small bowel - due to poor peristaltic function of the bowel, resulting in bacteria building up in the gut
195
When would pain be worse in disc prolapse?
On flexion
196
When would pain be worse in joint facet pain?
On extension
197
How does spinal stenosis typically present?
Bilateral calf pain, with the symptoms being alleviated by leaning forwards or on something
198
What is anterior uveitis?
An acutely red, painful eye with a dilated pupil
199
What is Apremilast?
PD4 inhibitor (weak immunosuppressant) - good for patients where immunosuppression is a worry e.g. elderly patients, lymphoma/myeloma patients * Doesn't need much monitoring * Tablet form
200
Why can ankylosing spondylitis cause T2 respiratory failure?
Due to costo-vertebral fusion of the ribs
201
What can ankylosing spondylitis cause in the heart?
AV node heart block due to fibrosis of the conduction pathway
202
What would be seen on examination of an ankylosing spondylitis patient?
* Reduced chest expansion (<3cm) * Loss of lumbar lordosis * Increased thoracic kyphosis * Stooped posture * Positive Schobers test
203
What are Romanis lesions and when are they seen?
Vertebral endplate sclerosis seen in ankylosing spondylitis
204
What scoring system can be used to determine severity of ankylosing spondylitis?
BASDAI
205
What is the management of ankylosing spondylitis?
* Stretching/physiotherapy * NSAIDs * Biologics
206
When would someone be stepped up to biological therapy in ankylosing spondylitis?
4/10 BASDAI + 4/10 pain + 2x failed NSAIDs (1 month) --> biologics
207
What is the evidence base for physiotherapy and NSAIDs as first line for ankylosing spondylitis?
Both have been shown to slow progression as well as regular NSAIDs resulting in radiographic regression
208
How is zolendronate given?
As a yearly IV infusion
209
Are PPIs required alongside zolendronate?
No as it is an IV infusion so it does not damage the stomach lining
210
How is Denosumab given?
6-monthly subcutaneous injections
211
What does Denosumab target?
RANKL
212
What bone marker can be used to measure response to anti-restorative/anabolic therapies in osteoporosis?
PINP (pro-collagen type 1 N-terminal propeptide)
213
What is the P1NP target for post-menopausal women (not on HRT)?
20-76mg/dl
214
What part of the joint is affected first in osteoarthritis and rheumatoid arthritis respectively?
Osteoarthritis = medial RA = lateral
215
Is osteoarthritis a distal or proximal disease?
Distal
216
Is rheumatoid arthritis a distal or proximal disease?
Proximal (classically DIPJ-sparing)
217
What condition is a 'gull-wing' appearance seen in the metacarpals?
OA
218
What is the classical pattern of joint involvement in RA?
Bilateral and symmetrical
219
What condition are 'opera glass hands' appearance seen in the metacarpals?
Psoriatic arthritis - although very uncommon nowadays due to improved treatments
220
What is acro-osteolysis?
Shortening and resorption of bone at the distal end of a finger/toe
221
Where does ankylosing spondylitis typically affect first?
Sacro-iliac joints
222
What are some x-ray features seen in ankylosing spondylitis?
* Bamboo cervical spine * Fused sacra-iliac joint * Dagger sign
223
What are some MRI features seen in ankylosing spondylitis?
* Shiny corners (on T2 weighted images) * Fused SIJs
224
What are ankylosing spondylitis patients particularly at risk of?
Severe spinal fractures (even when minor trauma involved)
225
What causes the 'bamboo spine' in AS?
Ossification of the anterior and posterior longitudinal ligaments
226
What causes the 'dagger sign' in AS?
Ossification of the interspinous ligament
227
What is DISH?
Diffuse idiopathic skeletal hyperostosis is a condition characterised by continuous ossification of ligaments and enthuses, mainly in the axial skeletal but can also occur in peripheral joints
228
How is DISH diagnosed?
When at least four thoracic vertebrae have developed osteophytes
229
Which part of the skeleton is mainly affected by DISH?
Thoracic vertebra
230
What is the incidence of DISH?
Quite common - around 10%, incidence increases with age (but usually found incidentally)
231
What age is required for a diagnosis of JIA to be made?
Must be present before age of 16
232
Which area of the body is typically spared from ossifications in DISH?
Areas near the aorta due to pulsatile effect so most ossifications will be right-sided
233
What is the adult form of JIA known as?
Stills disease
234
Below what eGFR are bisphosphonates contraindicated?
<35
235
How long should symptoms have been present before a diagnosis of chronic fatigue syndrome can be made?
3 months
236
Is azathioprine safe to use in pregnancy?
Yes
237
What are some EARLY x-ray findings in RA?
* Juxta-articular osteopenia * Loss of joint space * Soft tissue swelling
238
What drug cannot be co-prescribed alongside allopurinol?
Azathioprine - it can cause bone marrow suppression
239
What initial investigation can be used to confirm a diagnosis of ankylosing spondylitis?
Pelvic XR
240
What other drug can methotrexate not be used alongside?
Trimethoprim (and co-trimoxazole) - can cause bone marrow suppression and severe/fatal pancytopenia
241
What form of NSAIDs are first line for knee osteoarthritis?
Topical
242
How are the renal complications of systemic sclerosis managed?
ACE inhibitors
243
If a man is found to have osteoporosis, what should be checked?
Testosterone
244
What ongoing Mx should be given to patients aged > 75 who suffer a fragility fracture?
Bisphosphonates started immediately (no need for DEXA scan)
245
What should be considered in an elderly patient presenting with dermatomyositis?
Underlying malignancy as it can be a paraneoplastic syndrome (ovarian/breast/lung tumours)
246
How might acute pneumonitis present?
New onset dyspnoea, low grade fever, cough and scattered crepitations
247
How long is antibiotic therapy required for septic arthritis?
4-6 weeks (2 weeks IV, 2-4 weeks PO)
248
When is monitoring vs bone protection offered in relation to DEXA T scores?
249
How long do you need to wait after stopping methotrexate before attempting to conceive?
6 months (male and female)
250
What is the typical biochemistry of osteomalacia?
Low Ca Low phosphate High ALP High PTH
251
What protein is affected in Marfan's syndrome?
Fibrillin
252
What movement typically makes lateral epicondylitis pain worse?
Worse on resisted wrist extension/suppination whilst elbow extended
253
What would be a typical joint aspirate in RA?
Yellow fluid No crystals No culture growth but high WBC
254
What needs to be corrected before starting bisphosphonates?
Vitamin D and calcium levels (as bisphosphonates can worsen calcium levels)
255
What type of fracture do bisphosphonates increase the risk of?
Atypical stress fractures - typically in the proximal femoral shaft
256
What is the maximum steroid dose advised in the Mx of poly myalgia rheumatica?
20mg - if no improvement with this, should be referred to a specialist to consider alternate diagnoses
257
What is the classic triad seen in Behcet's disease?
* Oral ulceration * Genital ulcers * Anterior uveitis
258
Aside from the classical triad, what other symptoms are seen in Behcet's disease?
* Thrombophlebitis * DVT * Arthritis * Erythema nodosum * GI symptoms - abdo pain, diarrhoea, colitis
259
Which HLA allele is Behcet's associated with?
HLA B51
260
What is the epidemiology of Behcet's disease?
* More common in men * More common in eastern Mediterranean populations (e.g. Turkey) * Tends to affect younger people * 30% will have a positive FHx
261
How should bisphosphonates be taken and why?
First thing in the morning on an empty stomach with plenty of water. This is to prevent an oesophageal reaction due to retention as the bisphosphonates can react with the oesophageal lining if retained, resulting in oesophagitis.
262
Pain and stiffness around the base of the thumb points towards which rheumatological condition?
Osteoarthritis
263
What further investigation should be ordered for an elderly patient presenting with symptoms of dermatomyositis/polymyositis?
Malignancy screen
264
What are the four rotator cuff muscles and what do they do?
* Subscapularis - positioned anteriorly on your chest, helps with internal rotation of shoulder *Supraspinatus - positioned on top of your shoulder and runs parallel to your deltoid. Needed for the first 20° of shoulder abduction, then the rest of abduction is done by the deltoid *Infraspinatus - positioned posteriorly on the superior aspect of your back, helps with external rotation of shoulder *Teres minor - positioned posteriorly on the superior aspect of your back, helps with external rotation of shoulder
265
What should be checked before starting a patient of sulfasalazine?
If they are sensitive to aspirin and patients who are allergic to aspirin may also react to sulfasalazine due to cross reactivity in their similar structures
266
What is greater trochanteric pain syndrome?
Hip pain (pain and tenderness over the lateral side of thigh) due to repeated movement of the fibroelastic iliotibial band
267
Who is greater trochanteric pain syndrome most commonly seen in?
Most common in women aged 50-70 years
268
What is anotehr name for greater trochanteric pain syndrome?
Trochanteric bursitis (old name)
269
What antibody is dermatomyositis associated with?
Anti-Jo-1
270
What is typically seen on fundoscopy in GCA?
Engorged and pale optic disc with blurred margins due to oedema
271
What factors does a Z score take into account?
Age, gender and ethnicity
272
What is the treatment for methotrexate toxicity?
Folinic acid
273
When should bisphosphonate treatment be re-evaluated?
After 5 years of bisphosphonate therapy, treatment should be re-assessed for ongoing treatment depending on their risk (high or low), with an updated FRAX score and DEXA scan.
274
What are some features that would put a patient into the high-risk group requiring bisphosphonate therapy?
Age >75 Glucocorticoid therapy Previous hip/vertebral fractures Further fractures on treatment High risk on FRAX scoring T score <-2.5 after treatment
275
If an osteoporosis patient is deemed low risk after their 5-year reevaluation, what should be done next?
If any of the high risk criteria apply, treatment should be continued indefinitely, or until the criteria no longer apply. If they are in the low risk group however, treatment may be discontinued and re-assessed after two years, or if a further fracture occurs.
276
What is one of the most serious comorbidities associated with RA?
IHD
277
What is the difference between Gottron's papule and Gottron's sign?
*Gottrons papules* - these are small violaceous papules, often seen on the proximal interphalangeal and metacarpophalangeal joints. *Gottron's sign* - this refers to violaceous macules, sometimes with associated oedema, over the knees and elbows. Both are seen in dermatomyositis.
278
A positive result of which test would suggest referred pain from the lumbar spine resulting in hip pain?
Femoral nerve stretch test
279
What are the typical biochemistry results seen in osteogenesis imperfecta?
Usually all normal

ICSM Year 6 (21 decks)

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