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PACES > Rheum > Flashcards

Rheum Flashcards

1
Q

Extra articular features of rheumatoid arthritis

A

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
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2
Q

Mx of rheumatoid arthritis

A

MDT - physio, OT
Analgesia, NSAIDs (w PPI)
Steroids with acute flare
DMARDs

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3
Q

DMARD examples

A
  • Methotrexate (inhibits purine synth)
  • Azathioprine

also
• Cyclosporin
• sulfasalazine
• gold

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4
Q

Tell me about Methotrexate

A 
Once weekly DMARD
Inhibits purine synthesis
Must take folic acid replacement
Regular FBC and LFTs
Risk of myelosuppression
agranulocytosis
Avoid pregnancy
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5
Q

causes of anaemia in rheumatoid arthritis

A
  • Anaemia of chronic disease
  • Bleeding from NSAIDs
  • Bone marrow suppression from DMARDs
  • Megaloblastic anaemia
  • Haemolytic anaemia (Autoimmune)
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6
Q

Ehlers Danlos syndrome inheritance

A

absence of collagen autosomal dominant trait, but up to 50% of patients can present as a de novo mutation

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7
Q

features of Ehlers danlos

A
  • skin hyperelasticity
  • hypermobility of joints
  • easy brusing

velvety skin , atrophic scarring
Aortic root dilatation and MR

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8
Q

types of ehlers danlos

A
  • 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)

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9
Q

Joint pain and photosensitive rash

A

SLE

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10
Q

Limited systemic sclerosis features

A
  • Calcinosis
  • Raynaud’s
  • oEsophageal dysfunction
  • Sclerodactyly
  • Telangiectasia
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11
Q

Diffuse systemic sclerosis

A
  • CREST
  • Cardio:
  • hypertension
  • coronary artery disease

• Lung:

  • pulmonary hypertension
  • pulmonary fibrosis.

• Kidney

  • glomerulonephritis
  • scleroderma renal crisis
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12
Q

Antibodies for limited cutaneous systemic sclerosis

A

cutaneous=centromere
Anti-centromere antibodies

Antinuclear antibodies (ANA) are positive in most patients with systemic sclerosis but not specific

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13
Q

Antibodies for diffuse cutaneous systemic sclerosis

A

Anti-Scl-70 antibodies (also associated with more severe disease)

Antinuclear antibodies (ANA) are positive in most patients with systemic sclerosis but not specific

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14
Q

Management of Reynaud’s

A

Nifedipine

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15
Q

SLE features mnemonic

A
  • 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
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16
Q

Myasthenia Gravis antibodies

A

Acetylcholine Receptor Antibodies (80%)

Muscle-specific serum kinase antibodies (10%) (MUSK)

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17
Q

Ehler’s Danlos vs Marfans

A

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

18
Q

Ankylosing spondylitis investigations

A
  • 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

19
Q

Examination of Ankylosing spondylitis

A

• 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

20
Q

What is Felty’s syndrome??

A

combination of

  • rheumatoid arthritis
  • neutropenia
  • splenomegaly

(RaNS)

21
Q

Methotrexate counselling

A

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, )

22
Q

Big red flag to look out for in Sjogrens

A

Weight loss, due to 40-60X increased risk of lymphoid malignancies

23
Q

Antiphospholipid antibodies and important blood test to remember

A
  • Anti-Cardiolipin Antibody (ACL)

* paradoxically raised APPT

24
Q

disease scoring system for rheumatoid arthritis

A

DAS28

25
Q

Extra articular features of rheumatoid arthritis

A
  • CVD is the most common cause of death in RA
  • ILD
  • Felty’s with RA splenomegaly and neutropenia
26
Q

Associated conditions w Ankylosing spondylitis

A
  • 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
27
Q

Patient with RA on methotrexate presents with peripheral oedema, facial oedema and frothy urine

A

nephrotic syndrome

28
Q

uhthoff’s phenomenon

A

worsening of MS symptoms from heat

29
Q

Lhermitte’s sign

A

sudden electric shock down back of neck and spine then radiates to arms and legs

triggered by bending head forwards

30
Q

most common heart problem associated with active lupus

A

Pericarditis

31
Q

Examination for Myasthenia Gravis

A

• 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

32
Q

Age of patients who get diagnosed with Myasthenia Gravis

A
  • Young women (20-35) - usually generalised/acute

* Older men (60-75)- prominent oculobulbar involvement

33
Q

Most important initial investigation in suspected myasthenia gravis

A

FVC

Progressive decline or low (<1.5L) then make ITU aware and measure 4hrly

34
Q

Management of Myasthenia Gravis

A 
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

35
Q

Classic causes of reactive arthritis

A 
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

36
Q

Management of reactive arthritis

A
  • 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)
37
Q

Most common conditions associated with Ankylosing Spondylitis

A 
Most common is  
• IBD (50%) 
• Acute anterior uveitis (35%) 
• Psoriasis (10%) 
• Increased CV risk
38
Q

Ankylosing spondylitis differentials

A
  • 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)
39
Q

New name for pseudogout

A
  • 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
40
Q

Drugs that can induce gout

A
  • Aspirin
  • Diuretics
  • Immunosuppressant agents
  • Xylitol
  • (and renal impairment)
41
Q

What further investigation to offer for Myasthenia Gravis

A

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

42
Q

When would you speak to ITU about patient with myasthenia

A
  • 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

PACES (13 decks)

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