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Rheum Flashcards

1
Q

What XR changes are seen in OA?

A

LOSS
- Loss of joint space
- Osteophytes
- Subchondral sclerosis (increased density along joint line)
- Subchondral cysts (fluid filled holes in the bones)

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2
Q

What hand signs suggest OA?

A
  • Heberden’s nodes (DIP joints)
  • Bouchard’s nodes (PIP joints)
  • Squaring of base of thumb at carbo-metacarpal joint
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3
Q

What is the stepwise management of OA?

A
  1. Lifestyle changes and physiotherapy
  2. Oral paracetamol + topical NSAIDs
  3. Add oral NSAIDs + PPI
  4. Intra-articular steroid injections
  5. Joint replacement
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4
Q

What happens in RA?

A

Chronic inflammation of the synovial lining of the joints, tendon sheaths and bursa

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5
Q

How do patients with RA present?

A
  • Symmetrical distal polyarthropathy
  • Pain and stiffness in small joints
  • Pain improves with activity
  • Pain worse in the morning
  • Systemic symptoms - fatigue, wt loss, flu like illness
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6
Q

What joints are rarely affected by RA?

A

DIP joints

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7
Q

What hand signs suggest RA?

A
  • Z shaped deformity to the thumb
  • Swan neck deformity
  • Boutonnieres deformity (opposite of swan neck)
  • Ulnar deviation of the fingers at the MCP
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8
Q

How do you investigate RA?

A
  • Check RF
  • If ^ negative check anti-CCP antibodies (more sensitive and specific)
  • Inflammatory markers
  • XR hands and feet
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9
Q

What XR changes are seen in RA?

A
  • Joint destruction and deformity
  • Soft tissue swelling
  • Periarticular osteopenia
  • Boney erosions
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10
Q

What is the stepwise management of RA?

A

Manage acute flare with short course of steriods

  1. NSAIDS + PPI
  2. Monotherapy with DMARD (methotrexate, leflunomide, sulfasalazine)
  3. 2 DMARDs in conjunction
  4. Methotrexate + biological therapy (TNF inhibitors)
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11
Q

What do you need to consider when prescribing TNF inhibitors?

A
  • Lead to immunosuppression to patients are prone to serious infections
  • Can lead to reactivation of dormant infections e.g. TB, hep B
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12
Q

What are notable side effects of methotrexate?

A
  • Bone marrow suppression
  • Leukopenia
  • Teratogenic
  • Mouth ulcers
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13
Q

What needs to be prescribed with methotrexate?

A
  • Folic acid 5mg
  • Needs to be taken on different day to methotrexate
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14
Q

What needs to be prescribed with methotrexate?

A
  • Folic acid 5mg
  • Needs to be taken on different day to methotrexate
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15
Q

What happens in gout?

A

Chronically high blood uric acid levels -> urate crystals deposited into joints

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16
Q

What joints are most affected in gout?

A
  • Base of big toe (metatarsophalangeal joint)
  • Wrists
  • Base of thumb (carpometacarpal joints)
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17
Q

What are gouty tophi? Where are they found?

A
  • SC deposits of uric acid
  • Small joint and connective tissue of the hands, elbows and ears
  • DIP most common site
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18
Q

What will joint aspiration show in gout?

A
  • Needle shaped crystals
  • Negatively birefringent
  • Monosodium urate crystals
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19
Q

What will joint XR show in gout?

A
  • Joint spaces maintained
  • Lytic lesions
  • Punched out erosions with sclerotic boarders and overhanging edges
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20
Q

What is the stepwise management of an acute gout flare?

A
  1. NSAIDS
  2. Colchicine
  3. Steroids
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21
Q

When are NSAIDs contraindicated for acute gout?

A

In patients with renal impairment or significant heart disease

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22
Q

What is a side effect of colchicine?

A

GI upset -> diarrhoea

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23
Q

What is used for gout prophylaxis? How does it work? What is key when initiating it?

A
  • Allopurinol
  • Xanthine oxidase inhibitor that reduces uric acid levels
  • Don’t initiate until after the acute attack is settled
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24
Q

What is pseudogout caused by?

A

Calcium pyrophosphate crystals

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25
What joints are commonly affected in pseudogout?
- Knee - Shoulders - Wrists - Hips
26
What will joint aspiration show in pseudogout?
- Calcium pyrophosphate crystals - Rhomboid shaped crystals - Positive birefringent
27
What XR finding is pathognomonic of pseudogout?
- Chondrocalcinosis - Appears as a thin white line in the middle of the joint space caused by calcium deposition
28
What screening tool should patients with psoriasis complete?
Psoriasis epidemiological screening tool (PEST) - Screens for psoriatic arthritis - High score triggers referred to a rheumatologist
29
What is arthritis mutilans?
- Most severe form of psoriatic arthritis - Osteolysis of the bones around the digit - Leads to progressive shortening of the digit - The skin folds as this happens and is called 'telescopic finger'
30
What happens in reactive arthritis?
Infection triggers synovitis in the joints
31
What is another name for reactive arthritis?
Reiter Syndrome
32
What are features of reactive arthritis?
- Arthritis - Bilateral conjunctivitis - Anterior uveitis - Circinate balanitis (dermatitis of the head of the penis) Passmed say: - Oligoarthritis - Conjunctivitis - Urethritis
33
What joints are affected in ankylosing spondylitis?
- Sacroiliac joints - Joints of the vertebral column
34
How does ankylosing spondylitis present?
- Lower back pain and stiffness - Sacroiliac pain in the buttock region - Slow onset >3 months
35
What special test is useful for diagnosing ankylosing spondylitis?
- Schober's test - Distance less than 20cm when bending forward supports a diagnosis of AS
36
What is SLE?
- Systemic lupus erythematosus - Inflammatory autoimmune connective tissue disease
37
How and when does SLE typically present
- Non specific symptoms - Red malar rash - Arthralgia - Myalgia - Hair loss - Mouth ulcers - Raynaud's phenomenon - Lymphadenopathy - Relapsing and remitting course - More common in women and Asians - Presents young to middle age
38
What is the initial step in testing for SLE? What autoantibodies are specific to SLE?
- Anti-nuclear antibodies - present in 85% of patients with SLE - Anti-double stranded DNA
39
How is SLE diagnosed?
- Using specific criteria - Involves confirming the presence of antinuclear antibodies and establishing a number of clinical features of SLE
40
What are 2 key complications of SLE?
- CVD - leading cause of death, chronic inflammation in blood vessels -> HTN and CAD - Infection - more common in patients with SLE and secondary to immunosuppressants
41
What are first line treatments for SLE?
- NSAIDs - Steroids - Hydroxychloroquine (mild DMARD)
42
What is fibromyalgia?
A syndrome characterised by widespread pain throughout the body with tender points at specific anatomical sites
43
What are features of fibromyalgia?
- Chronic pain - Lethargy - Cognitive impairment ('fibro fog') - Sleep disturbance, headaches, dizziness are common
44
What is the management of fibromyalgia?
Lack of evidence + guidelines - Explanation - Aerobic exercise - CBT - Meds - pregabalin, duloxetine, amitriptyline
45
How does Polymyalgia Rheumatica present?
- Rapid onset muscle stiffness - Stiffness is worse in the morning - Affects proximal limb muscles - Weakness is not a feature - Can also present with mild polyarthralgia, lethargy. low grade fever, night sweats
46
What age group is affected by PMR?
Typically patients are >60 yrs
47
What would investigations show in Polymyalgia rheumatica?
- Raised inflammatory markers (ESR >40) - CK and EMG normal
48
What is the management of PMR?
- Prednisolone - Pts typically respond dramatically to steroids - failure may indicate different dx
49
What is antiphospholipid syndrome?
An autoimmune disorder caused by antiphospholipid antibodies
50
What do antiphospholipid antibodies do?
Target proteins that bind to phospholipids on the cell surface -> inflammation and increasing the risk of thrombosis
51
What are the antiphospholipid antibodies?
- Lupus anticoagulant - Anticardiolipin antibodies - Anti-beta-2 glycoprotein I antibodies
52
What are clinical features of antiphospholipid syndrome?
- Livedo reticularis - purple lace-like rash that gives the skin a mottled appearance - Libmann-Sacks endocarditis - non-bacterial endocarditis - Thrombocytopenia
53
What are complications of antiphospholipid syndrome?
- VTE - Arterial thrombosis - Pregnancy related complications - Catastrophic antiphospholipid syndrome (rare complication with rapid thrombosis in multiple organs)
54
What is the management of antiphospholipid syndrome?
- Long term warfarin to prevent thrombosis - LMWH + aspirin in pregnancy
55
What do polymyositis and dermatomyositis present with?
- Gradual onset proximal muscle weakness - May be muscle pain - Dermatomyositis also presents wit skin changes - gottron lesions, heliotrope rash
56
What are causes of polymyositis and dermatomyositis?
Both are autoimmune disorders Possible causes include: - Underlying cancers (making them paraneoplastic syndromes) - Viral infection (HIV, coxsackie A)
57
What is a key investigation in polymyositis and dermatomyositis?
CK - often in the thousands (normal is <300)
58
What antibody is specific to polymyositis?
Anti-Jo-1 antibody
59
What is the management of polymyositis and dermatomyositis?
- Physio - Corticosteroids - first line - Immunosuppressants - IV immunoglobulins
60
What antibodies are associated with Sjogrens syndrome?
- Anti-SS-A (Anti-Ro) - Anti-SS-B (Anti-La)
61
What is Behçet's disease?
- Complex inflammatory condition that affects blood vessels and tissues - Main feature are recurrent oral and genital ulcers
62
What can trigger hyper inflammatory syndrome?
- Autoimmune disease - Cancer - Infection - esp coronavirus
63
What causes hyper inflammatory syndrome?
Immune dysregulation - immune system doesn't 'switch off' once trigger is removed. This leads to: - Macrophage (haemo)phagocytosis - Cytokine release -> uncontrolled T cells -> cytokine storm
64
What are the characteristics of hyper inflammatory syndrome?
3 Fs - Fever (cytokine storm) - Falling counts (haemophagocytosis) - Ferritin highly elevated

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