musc Flashcards by denise lin

X-ray findings in osteoarthritis

Loss of joint space
Osteophytes
Subchondral cysts
Subchondral sclerosis

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X-ray findings in RhA

Loss of joint space
Soft tissue swelling
Peri-articular osteopenia

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Swan-neck deformity in RhA results from

PIP extension
DIP/MCP flexion

n.b. Boutonnier’s deformity is the opposite

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Malignant melanoma staging

Breslow thickness

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Treatment of hypercalcaemia (i.e. due to mets/multiple myeloma)

IV saline (first-line for dehydration)
Then afterwards give IV bisphosphonates

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Decubitus ulcers

Pressure ulcers

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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

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Sjogren’s syndrome definition

Autoimmune destruction of exocrine glands, especially lacrimal and salivary glands

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Primary AL amyloidosis

Ig light chain

Associated with multiple myeloma

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Secondary AA amyloidosis

Serum amyloid A

Associated with chronic inflammation and infection (IBD)

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Kawasaki’s disease (vasculitis) diagnosis

Echocardiogram

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Rheumatoid arthritis serum markers include

RhF
anti-CCP (MOST SPECIFIC)
ESR
CRP

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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.

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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.

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Types of large vessel vasculitis

Giant cell/temporal arteritis
Polymyalgia rheumatica
Takayasu’s arteritis

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Types of medium vessel vasculitis

Kawasaki’s disease

Polyarteritis nodosa

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Types of small vessel vasculitis with ANCA antibodies

CS disease (eosinophilic granulomatosis with polyangiitis)
WG (granulomatosis with polyangiitis)
Microscopic polyangiitis

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Types of small vessel vasculitis (autoimmune but not ANCA)

Henoch-Schnolein purpura
Anti-GBM disease
Behcet’s disease

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Felty’s syndrome

SANTA mnemonic

Splenomegaly
Arthritis (rheumatoid)
Neutropenia
Thrombocytopenia
Anaemia

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Septic (infective) arthritis causative organisms

<30years - N gonorrhoea

>30years - Staph aureus

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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

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Extra-articular manifestations of spondyloarthropathies

Uveitis
Psoriatic rash
IBD
Aortic valve problems
Ulcers

(see pg 553 OHCM)

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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

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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

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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

1. NSAIDs 2. Intra-articular steroid injection 3. 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.