musc Flashcards
X-ray findings in osteoarthritis
Loss of joint space
Osteophytes
Subchondral cysts
Subchondral sclerosis
X-ray findings in RhA
Loss of joint space
Soft tissue swelling
Peri-articular osteopenia
Swan-neck deformity in RhA results from
PIP extension
DIP/MCP flexion
n.b. Boutonnier’s deformity is the opposite
Malignant melanoma staging
Breslow thickness
Treatment of hypercalcaemia (i.e. due to mets/multiple myeloma)
IV saline (first-line for dehydration) Then afterwards give IV bisphosphonates
Decubitus ulcers
Pressure ulcers
Patient becomes pyrexic and creps at R lung base while on a course of chemotherapy
Neutropenic sepsis
- blood tests (FBC)
- blood cultures
- give Abx depending on results
- urine MC+S, CXR
Sjogren’s syndrome definition
Autoimmune destruction of exocrine glands, especially lacrimal and salivary glands
Primary AL amyloidosis
Ig light chain
Associated with multiple myeloma
Secondary AA amyloidosis
Serum amyloid A
Associated with chronic inflammation and infection (IBD)
Kawasaki’s disease (vasculitis) diagnosis
Echocardiogram
Rheumatoid arthritis serum markers include
RhF
anti-CCP (MOST SPECIFIC)
ESR
CRP
RhA (chronic inflammatory systemic disease, HLADR1 and DR4).
Presentations and Rx
Worse in the morning.
PIPs, MCPs, wrists, MTPs. Defomities.
Rx: 1. NSAIDs, 2. methotrexate, 3. DMARDs, 4. anti-TNF.
Complications: pulmonary fibrosis.
A 65 year old male undergoing chemotherapy for acute myeloid leukaemia starts to deteriorate on the ward. He complains of a tingling sensation in his fingers and around his lips. He also complains of muscle weakness and appears confused. His biochemistry reveals that he is hyperkalaemic, hyperphosphataemic, hyperuricaemic and hypocalcaemic. His creatinine is elevated to 300umol/L. What is the diagnosis?
Tumour lysis syndrome occurs in patients undergoing chemotherapy for lymphoproliferative malignancies. Lysis of tumour cells leads to the release of large amounts of potassium, phosphate and uric acid into the circulation. Excess phosphate binds to calcium, leading to hypocalcaemia and its clinical features. Patients are also at risk of developing AKI due to the deposition of uric acid and calcium phosphate crystals in renal tubules.
Types of large vessel vasculitis
Giant cell/temporal arteritis
Polymyalgia rheumatica
Takayasu’s arteritis
Types of medium vessel vasculitis
Kawasaki’s disease
Polyarteritis nodosa
Types of small vessel vasculitis with ANCA antibodies
CS disease (eosinophilic granulomatosis with polyangiitis)
WG (granulomatosis with polyangiitis)
Microscopic polyangiitis
Types of small vessel vasculitis (autoimmune but not ANCA)
Henoch-Schnolein purpura
Anti-GBM disease
Behcet’s disease
Felty’s syndrome
SANTA mnemonic
Splenomegaly Arthritis (rheumatoid) Neutropenia Thrombocytopenia Anaemia
Septic (infective) arthritis causative organisms
<30years - N gonorrhoea
>30years - Staph aureus
Spondyloarthropathies are seronegative. Present in M>F. They are associated with HLA-B27 and axial arthritis. Examples of these follow the PEAR mnemonic i.e…..
Psoriatic
Enteropathic
Ankylosing spondylitis
Reactive arthritis
Extra-articular manifestations of spondyloarthropathies
Uveitis Psoriatic rash IBD Aortic valve problems Ulcers
(see pg 553 OHCM)
A 30 year old male has lower back pain that is worse at night and at rest. It is relieved with exercise slightly and he has spinal stiffness. Pain spreads to hip and buttocks. O/E: spinal kyphosis. What is the likely diagnosis?
Ankylosing spondylitis
Bone fusion with abnormal joint stiffening and immobility. There is inflammation of vertebrae
SLE signs and symptoms
SOAP BRAIN MD mnemonic
Serositis Oral ulcers Arthritis Photosensitivity Blood cell def (low Hb, WCC, plts) Renal disorders ANA +ve Immunological disorders (anti-dsDNA, anti-Sm, anti-phospholipid) Neuro disorders Malar rash Discoid rash
SLE antibodies
ANA - most sensitive
dsDNA - most specific
others: anti-Ro
anti-La
anti-Sm
Schirmer’s test (filter paper under lower eyelid measures tear production) is used in which condition
Sjögren’s syndrome (autoimmune destruction of exocrine glands, esp. lacrimal and salivary glands)
Dermatomyositis is an idiopathic inflammatory myopathy. Skin presentations on examination include
Gottren’s papules: discrete erythematous papules over MCP and IP joints
Heliotrope/lilac rash: violet rash on upper eyelids
Shawl sign: diffuse rash over back and shoulders
Periungual telangiectasia: around the nails
Limited systemic sclerosis
CREST features
Skin involvement does not progress beyond forearms ± peri-oral skin
Anti-centromere antibodies
Diffuse systemic sclerosis
CREST features GI disease Interstitial pulmonary disease Renal disease Beaked nose Radial furrowing (puckered mouth) Microstomia (small mouth)
Anti-topoisomerase (Scl70) antibodies
CREST features in systemic sclerosis
Calcinosis Raynaud's Oesophageal dysmotility Sclerodactyl Telangectasia
Chronic tophaceous gout follows repeated attacks of acute gout. Presentations include
Persistent low grade fever
Polyarticular pain
Painful tophi (urate deposits)
Best seen on tendons and pinna of the ear. High serum urate.
Acute attack of gout may be triggered by trauma, infection, alcohol, starvation, or withdrawal of hypouricaemic agents. Signs and symptoms include
Sudden excruciating monoarticular pain in MTP joint of big toe
Symptoms peak around 12hrs and resolve in 7-10days
±cellulitis, polyarthritis, serum urate levels can be normal.
Osteoarthritis synovial fluid analysis
Clear
Viscous
Low cell count
Cartilage fragments
Arthritis associated with deposition of calcium pyrophosphate dihydrate (CPPD) crystals in joint cartilage.
Pseudogout
Reactive arthritis typically follow GI or GU infections. What are causative organisms?
GI - Salmonella, Yersinia, Campylobacter
GU - Chlamydia
Keratoderma blenorrhagica (brownish red yellow scales on soles of feet or palms) occurs in
10% reactive arthritis patients.
Reactive arthritis Rx
- NSAIDs
- Intra-articular steroid injection
- Sulfasalazine
Is rheumatoid arthritis (HLA-DR1 and HLA-DR4) asymmetrical or symmetrical?
Symmetrical
deforming polyarthritis
Polyarteritis nodosa (PAN) is a medium vessel vasculitis. It is associated with which other condition?
Hep B
Mixed essential cryoglobulinaemia (MEC) is a small vessel vasculitis. It is associated with which other condition?
Hep C
Microscopic polyangiitis is a small vessel vasculitis. What autoantibody is it associated with?
pANCA
Wegner’s polyangiitis (granulomatosis with polyangiitis) is a small vessel vasculitis. What autoantibody is it associated with?
cANCA
Behcet’s disease is an inflammatory multisystem disease with HLA-B51. Clinical triad is
Orogenital (both) ulcers
Uveitis
Diagnostic test for Behcet’s disease
Pathergy test
±complement levels, FHx
Polymyositis is associated with which type of diseases
Autoimmune connective tissue disorders e.g. scleroderma
Dermatomyositis is associated with which type of diseases
Bronchial, stomach, testicular, breast and ovarian malignancy
Auto-antibodies (anti-Jo-1, anti-Scl, anti-Mi2, HLA-DRW52)
Polymyositis and dermatomyositis both have
Proximal muscle weakness and atrophy affecting both upper and lower limbs
Definitive diagnosis of polymyositis/ dermatomyositis is by
Muscle biopsy
inflammation, vascuolated fibres, amyloid fibrils
Polymyositis and PMR present similarly. Ways to distinguish
PMR has elevated ESR and pain
Myelofibrosis bone marrow aspirate or biopsy results
Aspiration = unsuccessful (‘dry tap’)
Trephine biopsy = fibrotic hypercellular marrow with dense reticulin fibres on silver staining
Criteria for severe aplastic anaemia
<25% normal cells
or <50% normal cells + <30% haemopoietic cells and two of the following:
low neutrophils
low platelets
low reticulocytes
Gout and pseudogout x-ray findings
Gout - none. Uric acid renal stones -> CT KUB
Pseudogout - chondrocalcinosis = linear calcification of cartilage. Signs of osteoarthritis (LOSS)
Stages of sarcoidosis
Stage 1 - BHL
Stage 2 - BHL + pulmonary infiltration + node enlargement
Stage 3 - pulmonary infiltration + fibrosis
Conditions that present with keratoconjunctivitis sicca (dry eyes)
Sarcoidosis
Sjogren’s syndrome
Fluorescein/rose bengal stains in Sjogren’s syndrome may show…
Punctate or filamentary keratitis (clumps of mucus
on cornea)
Sjogren’s syndrome increases the risk of Non-Hodgkin B-cell lymphoma by how many times
40
Other complications: oral candida, conjunctivitis, keratitis, vasculitis, kidney interstitial nephritis, pregnancy congenital heart block.
Anti-cardiolipin antibodies are present in which condition?
Anti-phospholipid syndrome
APL, anti-b2-GPl. demonstrated by ELISA assays
:hermitte’s sign in cervical spondylosis
Neck flexion causes crepitus ±parasthesia down the spine
Cervical spondylosis involves osteoarthritic degeneration of vertebral bodies to produce osteophytes. These compress on nerve roots or anterior spinal cord to cause…
nerve roots - radiculopathy
anterior spinal cord - myelopathy
Macroglossia and purpura around the eyes are both characteristic of which type of amyloidosis?
AL amyloidosis
light chain
Amyloidosis immunochemistry stains
Congo red +ve (only really reliable in AA, poor for AL)
Apple-green bifringence
A 60yr old woman complains of bilateral proximal muscle weakness in the legs and dysphagia. O/E: purple rash on her cheeks. What is the likely diagnosis?
Dermatositis
Autoimmune disease which can have resp and cardio involvement when severe. CK is usually elevated in dermatositis and polymyositis, and EMG shows fibrillation potentials. Rash = heliotropic lilac rash and dysphagia occur.
