Rheum Flashcards
What is ankylosing spondylitis(AS)
Inflammatory condition mainly affecting the spine that causes progressive stiffness and pain
Conditions associated with HLA B27 gene
Seronegative spondyloarthropathy to include reactive arthritis and psoriatic arthritis
Key joints affected in AS
Sacroiliac joints
Joints of the vertebral column
Presentation of AS
Gradual symptoms
Lower back pain and stiffness and sacroiliac pain
Worse with rest and improves with movement
Worse at night and in the morning
Key complication of AS
Vertebral fractures
Conditions associated with AS
Systemic symptoms such as weight loss and fatigue
Chest pain(costovertebral joints affected)
Ethesitis
Anaemia
Anterior uveitis
IBD
Test used to support diagnosis of AS
Schober’s test
IX for AS
CRP and ESR
HLA B27
Spine X-ray and sacrum
MRI
What might MRI of spine show in AS
Bone marrow oedema early in the disease
X-ray features of AS
Squaring of vertebral bodies Subchondral sclerosis and erosions Syndesmophytes Joints/ligaments ossification Fusion of facet, sacroiliac and costovertebral joints
Mx of AS
NSAIDs
Steroids for flares
Anti-TNF meds(etanercept)
Monoclonal antibodies
General mx of AS outside NSAIDs and steroids
Physio Exercise Smoking cessation Bisphosphonates Treatment of complications Surgery occasionally
What is rheumatoid arthritis(RA)?
Rheumatoid arthritis is an autoimmune condition that causes chronic inflammation of the synovial lining of the joints, tendon sheaths and bursa
RA genetic associations
HLA DR4
HLA DR1
Antibodies present in RA
Rheumatoid factor
Anti-ccp(sensitive to RA)
Presentation of RA
Symmetrical distal polyarthropathy
Pain Swelling Stiffness Fatigue Weight loss
Joints affected by RA
MCP and PIP joints in the hands
Can also present with larger joints affected such as the knees, shoulders and elbows.
What is palindromic rheumatism
involves self limiting short episodes of inflammatory arthritis with joint pain, stiffness and swelling typically affecting only a few joints.
The episodes only last 1-2 days and then completely resolve
What is atlantoaxial subluxation
The axis (C2) and the odontoid peg shift within the atlas (C1). This is caused by local synovitis and damage to the ligaments and bursa around the odontoid peg of the axis and the atlas.
What can atlantoaxial subluxation lead to
SCC
Signs of RA in the arthritis
Z shaped deformity to the thumb
Swan neck deformity (hyperextended PIP with flexed DIP)
Boutonnieres deformity (hyperextended DIP with flexed PIP) Ulnar deviation of the fingers at the knuckle (MCP joints)
What is boutonnieres deformity due to
Is due to a tear in the central slip of the extensor components of the fingers
In RA
Extra-articular manifestations of RA
Pulmonary fibrosis Bronchiolitis obliterans Felty's syndrome Secondary sjogren's syndrome Anaemia of chronic disease
Wrist syndrome associated with RA
Carpel tunnel syndrome
Eye manifestations of RA
Episcleritis and scleritis
IX in RA
Rf
anti-CCP
CRP and ESR
X-rays
X-ray changes in RA
Joint destruction and deformity
Soft tissue swelling
Periarticular osteopenia
Boney erosions
Scoring system used to assess RA
DAS28 - swollen joints, tender joints, ESR/CRP result
Useful in monitoring disease activity and response to treatment
Also HAQ questionnaire to assess response to treatment
Factors causing worse prognosis in RA
Younger onset Male More joints and organs affected Presence of RF and anti-CCP Erosions seen on xray
Mx of RA
Steroids
NSAIDs/COX-2 inhibitors
NICE advice for DMARDs in RA
1st - Methotrexate, leflunomide or sulfasalazine
2nd - 2 of above in combo
3rd - Addition of TNF inhibitor(adalimumab)
What is co-prescribed with methotrexate
Folic acid 5mg
Notable side effects of methotrexate
Mouth ulcers and mucositis Liver toxicity Pulmonary fibrosis Bone marrow suppression and leukopenia Teratogenic
Notable side effects of leflunomide
Peripheral neuropathy
Teratogenic
HTN
Notable side effects of sulfasalazine
Temporary male infertility (reduced sperm count)
Bone marrow suppression
Notable side effects of anti-TNF drugs
Vulnerability to severe infections and sepsis
Reactivation of TB and hepatitis B
Notable side effects of hydroxychloroquine
Nightmares and reduced visual acuity
Notable side effects of rituximab
Night sweats and thrombocytopenia
What type of hypersensitivity reaction is SLE
Type 3 hypersensitivity reaction
Most common disease course in SLE
It often takes a relapsing-remitting course, with flares and periods where symptoms are improved.
SLE presentation
Fatigue Weight loss Arthralgia Myalgia SOB Raynaud's phenomenon Mouth ulcers
Type of rash associated with SLE
Photosensitive malar rash. This is a “butterfly” shaped rash across the nose and cheek bones that gets worse with sunlight.
IX in SLE
Autoantibodies FBC(normocytic anaemia) CRP and ESR Immunoglobulins Urinalysis and urine protein-creatinine ratio
Autoantibodies present in SLE
Anti-nuclear antibodies(ANA)
Anti-double stranded DNA(anti-dsDNA) - specific
Criteria for diagnosis of SLE
SLICC Criteria or the ACR Criteria for establishing a diagnosis
involves confirming the presence of antinuclear antibodies and establishing a certain number of clinical features suggestive of SLE
CVS complications of SLE
Cardiovascular disease - HTN, CAD
Pericarditis
Complications of SLE
Infection Anaemia of chronic disease Interstitial lung disease Lupus nephritis Recurrent miscarriage VTE
1st line treatments for SLE
NSAIDs
Steroids (prednisolone)
Hydroxychloroquine (first line for mild SLE)
Suncream and sun avoidance for the photosensitive the malar rash
Options for SLE mx if first line haven’t worked
Rituximab is a monoclonal antibody that targets the CD20 protein on the surface of B cells
Belimumab is a monoclonal antibody that targets B-cell activating factor
Most common causes of drug-induced lupus
Procainamide
Hydralazine
Adverse effects of hydroxycholroquine
Bull’s eye retinopathy
Crystals present in pseudo gout
Crystal arthropathy caused by calcium pyrophosphate crystals - AKA chonedrocalcinosis
Presentation of pseudogout
Hot swollen stiff painful joint - knee, shoulders, wrists and hips
Can affect multiple joints
Can be asymptomatic
What does aspirated fluid show in CPPD
No bacterial growth
Calcium pyrophosphate crystals
Rhomboid shaped crystals
Positive birefringent of polarised light
How does pseudo gout appear on x-ray
Chondrocalcinosis - It appears as a thin white line in the middle of the joint space caused by the calcium deposition
Also LOSS
L – Loss of joint space
O – Osteophytes
S – Subarticular sclerosis
S – Subchondral cysts
Mx of CPPD
NSAIDs Colchicine Joint aspiration Steroid injections Oral steroids
Joint washout(arthrocentesis) in severe cases
What is discoid lupus
Discoid lupus erythematosus is a non-cancerous chronic skin condition.
It is more common in women and usually presents in young adults between ages 20 to 40.
Populations in which discoid lupus is more likely
It is more common in darker-skinned patients and smokers.
What is discoid lupus associated with
It is associated with an increased risk of developing systemic lupus erythematosus, however this risk is still below 5%.
Rarely the lesions can progress to squamous cell carcinoma (SCC) of the skin.
Presentation of discoid lupus
The lesions typically occur on the face, ears and scalp. They are photosensitive, meaning that they are made worse by exposure to sunlight.
They are associated with scarring alopecia (hair loss in affected areas that does not grow back) and hyper-pigmented or hypo-pigmented scars.
Appearance of discoid lupus
Inflamed Dry Erythematous Patchy Crusty and scaling
Diagnosis of discoid lupus
Skin biopsy to confirm diagnosis
Mx of discoid lupus
Sun protection
Topical steroids
Intralesional steroid injections
Hydroxychloroquine
Patterns of psoriatic arthritis
Symmetrical polyarthritis
Asymmetrical pauciarthritis
Spondylitic pattern
Signs of psoriatic arthritis
Plaques of psoriasis on the skin
Pitting of the nails
Onycholysis (separation of the nail from the nail bed)
Dactylitis (inflammation of the full finger)
Enthesitis
Psoriatic arthritis associations
Eye disease (conjunctivitis and anterior uveitis) Aortitis (inflammation of the aorta) Amyloidosis
Screening tool for psoriatic arthritis
PEST tool - high score –> rheum referral
xray changes in psoriatic arthritis x-rays
Periostitis Anklyosis Osteolysis Dactylitis Pencil-in-cup appearance
What is arthritis mutilans
most severe form of psoriatic arthritis. This occurs in the phalanxes. There is osteolysis (destruction) of the bones around the joints in the digits. This leads to progressive shortening of the digit. The skin then folds as the digit shortens giving an appearance that is often called a “telescopic finger”.
Mx of arthritis arthritis mutilans
NSAIDs for pain
DMARDS (methotrexate, leflunomide or sulfasalazine)
Anti-TNF medications (etanercept, infliximab or adalimumab)
Ustekinumab is last line (after anti-TNF medications) and is a monoclonal antibody that targets interleukin 12 and 23
Most common cause of reactive arthritis
Chalmydia
Gonorrhea commonly causes gonococcal septic arthritis
Reactive arthritis associations
Bilateral conjunctivitis (non-infective)
Anterior uveitis
Circinate balanitis is dermatitis of the head of the penis
Can’t see, pee or climb a tree
Mx of reactive arthritis
NSAIDs
Steroid injections into the affected joints
Systemic steroids may be required, particularly where multiple joints are affected
DMARDs or anti-TNF meds for recurrent cases
Auto-antibodies present in systemic sclerosis
ANA
Anti-centromere in limited cutaneous systemic sclerosis
Anti-scl-70 antibodies in diffuse cutaneous systemic sclerosis
Specific examination technique for systemic sclerosis
Nailfold capillaroscopy
Mx of systemic sclerosis
MDT
Steroids
Immunosuppressants
Non-med mx of systemic sclerosis
Avoid smoking
Gentle skin stretching to maintain the range of motion
Regular emollients
Avoiding cold triggers for Raynaud’s
Physiotherapy to maintain healthy joints
Occupational therapy for adaptations to daily living to cope with limitations
Medical mx of systemic sclerosis
Nifedipine can be used to treat symptoms of Raynaud’s phenomenon
Anti acid medications (e.g. PPIs) and pro-motility medications (e.g. metoclopramide) for gastrointestinal symptoms
Analgesia
Antibiotics
Antihypertensives
Treatment of pulmonary artery hypertension
Supportive management of pulmonary fibrosis
