Medicine- rheumatology Flashcards
Most useful investigation for gout and what it would show
Joint aspirate may show negatively birefringent crystals.
Extra-articular features of psoriatic arthropathy
- Skin e.g. psoriasis, nail pitting, onycholysis.
- Eyes e.g. conjunctivitis, uveitis.
The three skin manifestations of SLE
Malar rash
Discoid rash
Photosensitivity
The most sensitive blood test for SLE
ANA -Most sensitive test (98%), not specific, ruling out SLE when negative
SLE demographics
F:M = 10:1 • age of onset in reproductive yr (13-40) • more common and severe in African-Americans and Asians
Who gets a bamboo spine?
Ankylosing spondylitis
Squaring of the vertebral bodies
Vertebral body fusion
Ossification of spinal ligaments
First joints affected in ankylosing spondylitis
The sacroiliac joints
The typical presentation and pain of ankylosing spondylitis
It typically presents before the age of 30 with worsening back pain (initially in the lumbosacral region) and associated morning stiffness.
The back pain typically improves with activity and wakes the patient at night.
Comment on joint stiffness in rheumatoid arthritis
Rheumatoid arthritis is associated with prolonged morning stiffness (usually at least one hour of stiffness before the patient can reach maximum movement).
The small joints of the hands and feet are typically affected in rheumatoid arthritis and it is typically symmetrical in nature.
A condition characterized by dry mucous membranes and the antibodies associated with it
Sjogren’s syndrome
Diagnosis can be via a Schirmer test or by the presence of Anti-Ro and Anti-La antibodies (also ANA + RF)
What’s this? Synovial fluid analysis: weakly positively birefringent crystals under polarising light (calcium pyrophosphate crystals)
Pseudogout
With which disorder/ process is pseudogout associated?
Associated with osteoarthritis and resultant chondrocalcinosis
A 51-year-old Swedish woman presents to A+E with frank haemoptysis. Over the last two months, she has had transitory joint pains mainly in her knees and ankles. She has lost 7 kg in the last two months and has experienced night sweats. She has no history of exotic travel and she has lived in the UK for the last 20 years. She has a significant smoking history. On auscultation, you hear crepitations. You also hear heart sounds: I+II+0. You perform a Mantoux test which is negative. You dip her urine which shows blood +++ and protein ++. A CT scan shows a cavitating lung lesion in the right lung base. A lung biopsy shows granuloma formation and necrosis. What is the most likely diagnosis?
Granulomatosis with polyangiitis (GPA).
Where are Heberden’s nodes?
At the DIPs
Hand signs of OA (3)
Heberdens at the DIPs
Bouchard’s at the PIPs
Thumb squaring
First line treatment for minimal OA
1st line with few joints affected, knee, hand – topical: transdermal NSAIDs preparations, capsaicin
The radiographic hallmarks of OA (4)
- Joint space narrowing
- Subchondral sclerosis
- Subchondral cysts
- Osteophytes
An antibody specific for SLE
Anti-dsDNA
What is the genetic association of RA?
HLA-DR4/DR1 association
Poor prognostic indicators in RA
- young age of onset
- high RF titer
- elevated ESR,
- activity of >20 joints
- presence of extra-articular features
Felty’s syndrome
RA
Splenomegaly
Neutropenia
First line DMARD for RA
Methotrexate (MTX) is the gold standard and is first-line unless contraindicated
Mechanism of action -iniximab, etanercept, adalimumab, golimumab, and certolizumab
These are anti-TNF bDMARDs
Screen RA patients for what kind of diseases?
Cardiovascular. RA assoc with increased mortality It’s the leading cause of death in RA
A renal problem assoc w RA
Amyloidosis
Evaluate all patients with systemic sclerosis for what? And with which tests?
- Pulmonary fibrosis
- Pulmonary artery hypertension
Using:
- High resolution CT
- Lung function tests
- Doppler echocardiography
What are the two forms of systemic sclerosis?
CREST and diffuse SS
What does CREST stand for?
- Calcinosis
- Reynaud phenomenon
- Esophageal dysfunction
- Sclerodactyly
- Telangestasia
Antibodies which are seen in CREST but absent in diffuse SS
Anti-centromere antibodies
Which antibodies are seen in 70% of diffuse SS but rarely in CREST?
Antibodies to Scl-70
Which drug is helpful in systemic sclerosis related pulmonary hypertension?
Bosentan
Investigation to distinguish between primary and secondary Reynaud’s
Nail fold microscopy
Drugs that impair bone mineral density
- Phenytoin
- Glucocorticoids
- Cyclosporine
- Phenobarbital
- Heparin
What is the cause of most of the minor side effects of methotrexate?
Depletion of folate
You can add folic acid and either reduce the methotrexate or adjust the schedule
Which factors are in the immune category for the diagnostic criteria for lupus?
- Antiphospholipid antibodies
- Abnormal serum level of immunoglobulin G or M anticardiolipin antibodies
- Positive lupus anticoagulant test
- False positive syphilis test
What is the NSAID of choice for acute gout?
Indomethacin
The most effective drugs to reduce postmenopausal fracture risk
Bisphosphonates
Which gout Rx can worsen symptoms if you start it during an acute episode?
Allopurinol
Which disorder has no proven treatments?
OA
Typical presentation of polymyalgia rheumatica
Polymyalgia rheumatica typically affects patients over the age of 50 and presents with bilateral shoulder and neck pain
What will you see on temporal artery biopsy in temporal arteritis?
multinucleated giant cells within a granuloma of granulomatous inflammation
Discoid lupus erythematosus can sometimes progress to what?
Squamous cell carcinoma (SCC) of the skin
Infliximab mechanism of action
Infliximab works via TNF-α inhibition. It belongs to a class of drugs called ‘biologics’. These are the second line of treatment for rheumatoid arthritis (RA), following disease modifying anti-rheumatoid drugs (DMARDs). Biologics are a type of targeted therapy. They suppress specific factors involved in the inflammatory cascade to reduce the inflammation seen in RA.
What is the relationship between HLA B27 and AS?
There is a strong association between HLA-B27 and developing AS. Around 8% of Caucasians have this gene, but only around 1-2% will develop AS. However, not everyone with AS has the HLA-B27 allele (around 90% have it). Therefore it cannot be used diagnostically
Best initial test for AS
X-Rays
Best initial therapy AS
NSAIDs and exercise (TNF inhibitors in refractory cases)
Deposition of which type of crystal is characteristic of gout?
Gout is characterised by an inflammatory response to the deposition of monosodium urate crystals, following extracellular urate supersaturation.
Rheumatoid arthritis is associated with which antibodies? (4)
HLA DR1
HLA DR4
Anti CCP
ACPA (can be positive or negative).
SLE is associated with which antibodies? (5)
HLA DR2, HLA DR3
Antinuclear antibodies (ANA)
Anti Smith
Anti dsDNA.
Polymyositis antibodies (2)
Anti Jo 1
Anti Mi 2
Scleroderma antibodies (2)
Anti-Scl-70
ANA.
Typical presentation of reactive arthritis
Typically presents 2-4 weeks after a urinary tract or gastrointestinal infection. A single lower limb joint is typically affected and there is often systemic symptoms of malaise and fever. Conjunctivitis and urethritis can also be present and are referred to as Reiter’s triad.
The core features of polymyalgia rheumatica
Bilateral shoulder pain which may radiate to the elbow
Bilateral pelvic girdle pain
Worse with movement
Sleep interference
Stiffness for at least 45 minutes in the morning
Pitting oedema, carpal tunnel syndrome, fatigue and weight loss are all other features associated with polymyalgia rheumatica.
What is deposited in the joint in pseudo gout
Deposition of calcium pyrophosphate dihydrate (CPPD) in the joint tissue
Typical presentation of dermatomyositis
History of progressive proximal muscle weakness with a facial rash, in addition to the findings of muscle tenderness and a raised creatinine kinase
What type of rash is present in dermatomyositis?
Heliotrope rash- a violaceous periorbital rash
Best initial Ix in polymyositis and dermatomyositis
Look for raised CK and anti-Jo-1 antibodies
Risk factors for giant cell arteritis
Polymyalgia rheumatica
Female
>50
Best initial test for temporal arteritis and most definitive test (2)
- ESR (>50) 2. Temporal artery biopsy
A Middle Eastern man with oral ulcers, uveitis and genital ulcers: name the syndrome
Behcet syndrome. Rx Steroids.
Young Japanese woman with aortic claudication, differential BP in both upper extremities and an absence of pulses: name the syndrome
Takayasu arteritis. Rx steroids
Mrs Jones lives alone and is currently in remission from breast cancer. She presents to her GP with progressive muscle pain, fatigue and weakness in her shoulders over the past few weeks. Upon examination, you notice periorbital oedema, a purple rash on her eyelids and erythematous patches on her elbows which you suspected to be Gottron lesions. In order to confirm your suspicions, you order several investigations which show: Anti-nuclear antibodies positive Anti-Mi-2 antibodies positive Elevated creatine kinase levels What would be your first-line treatment?
Mrs Jones is presenting with classic symptoms of dermatomyositis. It shares similar features with polymyositis plus skin involvement. These two conditions can be caused by paraneoplastic syndromes, therefore it is critical that Mrs Jones is also assessed for a potential cancer re-occurrence. Corticosteroids are the first-line Rx for both conditions. If the response to corticosteroids is inadequate then immunosuppressants, IV immunoglobulins or biological therapies
Which drug is useful to treat intestinal dysmotility in scleroderma?
Ocreotide
Antibodies associated with limited cutaneous systemic sclerosis
Anti-centromere
Antibodies associated with diffuse cutaneous systemic sclerosis
Anti-scl-70
Treatment of polymyalgia rheumatica
The value of glucocorticoids like prednisone is well established in the treatment of polymyalgia rheumatica. Nearly everyone with PMR improves, even with longstanding symptoms, and sometimes after only 1 or 2 doses. NSAIDS have no role in PMR ***
You can diagnose osteoarthritis clinically if which three things are present?
- Age >45
- Morning stiffness <30 minutes
- Persistent usage related joint pain in one or few joints ***
Back pain exacerbated by standing and walking and relived by sitting down
Spinal stenosis
Elderly lady with painful stiff shoulders who can’t lift her arms above her head. Labs show anemia and raised ESR
Polymyalgia rheumatica
Complication of scaphoid fracture
Avascular necrosis
Heliotrope rash
Dermatomyositis
Bamboo spine
Ankylosing spondylitis
Ehlers Danlos syndrome
Kawasaki disease
Arthritis mutilans: An extremely severe form of chronic rheumatoid or psoriatic arthritis characterized by resorption of bones and the consequent collapse of soft tissue. When this affects the hands, it can cause a phenomenon sometimes referred to as ‘telescoping fingers’.
