Rheum Flashcards
Extra articular features of rheumatoid arthritis
CVD is the most common cause of death in RA
- Episcleritis and scleritis
- Pleural effusions and fibrosis
- Pericarditis (restrictive or constrictive)
- Splenomegaly (Felty’s syndrome)
- Nephrotic syndrome
- Carpal tunnel
- Anaemia
Mx of rheumatoid arthritis
MDT - physio, OT
Analgesia, NSAIDs (w PPI)
Steroids with acute flare
DMARDs
DMARD examples
- Methotrexate (inhibits purine synth)
- Azathioprine
also
• Cyclosporin
• sulfasalazine
• gold
Tell me about Methotrexate
Once weekly DMARD Inhibits purine synthesis Must take folic acid replacement Regular FBC and LFTs Risk of myelosuppression agranulocytosis Avoid pregnancy
causes of anaemia in rheumatoid arthritis
- Anaemia of chronic disease
- Bleeding from NSAIDs
- Bone marrow suppression from DMARDs
- Megaloblastic anaemia
- Haemolytic anaemia (Autoimmune)
Ehlers Danlos syndrome inheritance
absence of collagen autosomal dominant trait, but up to 50% of patients can present as a de novo mutation
features of Ehlers danlos
- skin hyperelasticity
- hypermobility of joints
- easy brusing
velvety skin , atrophic scarring
Aortic root dilatation and MR
types of ehlers danlos
- Most common is hypermobile EDS (mainly joints)
- Next most common is classical, where skin is mostly affected
These account for >90%
• Another type is vascular type, higher risk of internal haemorrhage (risk of reduced life expectancy)
Joint pain and photosensitive rash
SLE
Limited systemic sclerosis features
- Calcinosis
- Raynaud’s
- oEsophageal dysfunction
- Sclerodactyly
- Telangiectasia
Diffuse systemic sclerosis
- CREST
- Cardio:
- hypertension
- coronary artery disease
• Lung:
- pulmonary hypertension
- pulmonary fibrosis.
• Kidney
- glomerulonephritis
- scleroderma renal crisis
Antibodies for limited cutaneous systemic sclerosis
cutaneous=centromere
Anti-centromere antibodies
Antinuclear antibodies (ANA) are positive in most patients with systemic sclerosis but not specific
Antibodies for diffuse cutaneous systemic sclerosis
Anti-Scl-70 antibodies (also associated with more severe disease)
Antinuclear antibodies (ANA) are positive in most patients with systemic sclerosis but not specific
Management of Reynaud’s
Nifedipine
SLE features mnemonic
- Serositis – Pleurisy, pericarditis
- Oral ulcers
- Arthritis
- Photosensitivity rash
- Blood disorders (Neutropenia , thrombocytopenia, lymphopenia, anaemia)
- Renal involvement (Lupus nephritis)
- Antinuclear antibodies
- Immunologic phenomena
- Neurologic disorder
- Malar rash
- Discoid rash
Myasthenia Gravis antibodies
Acetylcholine Receptor Antibodies (80%)
Muscle-specific serum kinase antibodies (10%) (MUSK)
Ehler’s Danlos vs Marfans
multisystemic disorders that primarily affect the soft connective tissues
EDS - skin hyperextensibility, atrophic scarring, joint hypermobility and generalized tissue fragility
MFS - aortic root dilation/dissection, ectopia lentis and bone overgrowth
Ankylosing spondylitis investigations
- CRP and ESR may be raised (normal doesn’t exclude)
- HLA B27 +ve in 90% of AS, but +ve in 10% gen pop
Xray of sacroiliac joint
• sacralilitis (erosion / sclerosis)
• sqauring of sacroiliac joint
• bamboo spine is late sign
Examination of Ankylosing spondylitis
• Reduced flexion in the lumbar spine
——–> Schober’s test - measure 10cm vertically, then normal is >15cm following maximal forward flexion of the spine
• Increased extension at cervical spine
——–> Increased occiput to wall distance
• Reduced chest expansion
• Reduced rotation
What is Felty’s syndrome??
combination of
- rheumatoid arthritis
- neutropenia
- splenomegaly
(RaNS)
Methotrexate counselling
Take weekly
Blood test for blood, liver and kidneys - Before+during treatment
CXR before treatment
Not advised if • pregnant/trying or breastfeeding • severe liver, kidney, or blood disease • active infection • mouth, stomach or duodenal ulcer • due to have a "live" vaccine
Folic acid weekly, day after your methotrexate
Drug contraindications (NSAIDs, trimethoprim, cotrimoxazole, )
Big red flag to look out for in Sjogrens
Weight loss, due to 40-60X increased risk of lymphoid malignancies
Antiphospholipid antibodies and important blood test to remember
- Anti-Cardiolipin Antibody (ACL)
* paradoxically raised APPT
disease scoring system for rheumatoid arthritis
DAS28
Extra articular features of rheumatoid arthritis
- CVD is the most common cause of death in RA
- ILD
- Felty’s with RA splenomegaly and neutropenia
Associated conditions w Ankylosing spondylitis
- Atlanto-axial subluxation
- Anterior uveitis
- Apical fibrosis
- Aortic regurgitation
- Amyloidosis (renal)
- Achilles involvement (enthesitis)
Most common is • IBD (50%) • Acute anterior uveitis (35%) • Psoriasis (10%) • Increased CV risk
Patient with RA on methotrexate presents with peripheral oedema, facial oedema and frothy urine
nephrotic syndrome
uhthoff’s phenomenon
worsening of MS symptoms from heat
Lhermitte’s sign
sudden electric shock down back of neck and spine then radiates to arms and legs
triggered by bending head forwards
most common heart problem associated with active lupus
Pericarditis
Examination for Myasthenia Gravis
• Ocular myasthenia
—–>Sustained upgaze and repeated blinking
• Limb weakness
—–>Lift arms to 90deg, check shoulder ab- and adduction. Then move one arm up and down 20 times, and retest ab- and adduction
• Central/bulbar involvement
—–>Power of head/neck flexion and extension (fatigue this movement as above)
Ask the patient to take a deep breath and count out loud as many numbers as they can
Age of patients who get diagnosed with Myasthenia Gravis
- Young women (20-35) - usually generalised/acute
* Older men (60-75)- prominent oculobulbar involvement
Most important initial investigation in suspected myasthenia gravis
FVC
Progressive decline or low (<1.5L) then make ITU aware and measure 4hrly
Management of Myasthenia Gravis
Conservative • Patient education • Patient alert card • MDT • Optometry • SALT
Medical
• Pyridostigmine
• Low dose PO steroid
• Steroid sparing with Azathioprine (check TPMT levels)
ACUTELY
• IVIG and/or plasma exchange
• Steroids (methylpred or pred) -uptitrate slowly as can make worse
Surgical
• Thymectomy (can cause remission in 80%!) even if they don’t have thymoma
Classic causes of reactive arthritis
Typically preceded by 4-8 weeks by infection of : • Chlamydia • Salmonella • Campylobacter • Streptococcus
Gonococcal can cause but more likely to cause Septic arthritis
HLA B27 is +ve in 50% of Reactive A
Management of reactive arthritis
- Rule out other causes
- ESR >30 is worse prog
- HLA B27 is +ve in 50% of Reactive A
- Typically self-limiting without steroids
- BASHH recommends Tx infection (but not “lengthy” course, unlike some trusts)
Most common conditions associated with Ankylosing Spondylitis
Most common is • IBD (50%) • Acute anterior uveitis (35%) • Psoriasis (10%) • Increased CV risk
Ankylosing spondylitis differentials
- Rule out cancer red flags
- IBD-related spondyloarthropathy (Which came first?)
- Mechanical back pain (improves with rest)
- Lumbar spinal stenosis (Typically >60y)
- RA (predom periph)
New name for pseudogout
- Acute calcium pyrophosphate deposition arthritis (CPPD)
- 50% of adults develop radiographic changes typical of CPPD by the age of 80
- linear opacification of articular cartilage
Drugs that can induce gout
- Aspirin
- Diuretics
- Immunosuppressant agents
- Xylitol
- (and renal impairment)
What further investigation to offer for Myasthenia Gravis
Bedside tests like
• Ice pack test to reverse fatigable ptosis
• FVC to check not in respiratory compromise
• Measure severity on MG composite scale
• Speech and language input
• Ask for optometry input if ophthalmeplegia
Bloods
• Acetylcholine Receptor Antibodies (80%)
• Muscle-specific serum kinase antibodies (10%) (MUSK)
• ?Lambert Eaton - Voltage gated calcium channel
• Thyroid antibodies as 10% also have autoimmune thyroid disease
Electromyography EMG
• Decrement on repetitive stimulation
CT to look for thymoma
Can offer tensilon test, but not if signif cardiac cormorb
When would you speak to ITU about patient with myasthenia
- Looks unwell
- Can’t finish sentence
- Can’t lift head off pilow
- Can’t manage secretions
- Can no longer count up to 20 in one breath
- Low or declining FVC
