Rheum Flashcards
What movements are affected in adhesive capsulitis?
External rotation mostly
Internal rotation
Abduction
What renal signs are associated with ANCA vasculitis?
Immune complex glomerulonephritis
Raised creatinine
Haematuria
Proteinuria
ANCA vasculitis CXR findings
Nodular/fibrotic/infiltrative lesions
cANCA target and conditions
Serine proteinase 3 SP3
Granulomatosis with polyangiitis (wegners)
pANCA target and conditions
Myeloperoxidase MPO
Eosinophilic granulomatous with polyangiitis (churg Strauss)
Ulcerative colitis
PSC
Anti GBM
Crohn’s
Can you use ANCA levels for monitoring?
cANCA has some correlation with disease activity
pANCA can’t be used to monitor disease
Ank spond features other than back signs
Atypical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
AV node block
Amyloidosis
Cauda equina, peripheral arthritis
When are DMARDs indicated in ank spond?
Peripheral joint involvement
APTT in antiphospholipid syndrome
Paradoxically rises
Due to lupus anticoagulant antibodies reacting with phospholipids in coag cascade
What is associated with antiphospholipid syndrome?
SLE
Other autoimmune conditions
Lymphoproliferative disorders
Phenothiazines
Investigating antiphospholipid syndrome
Anticardiolipin antibodies
Anti beta 2 glycoprotein I antibodies
Lupus anticoagulant
Thrombocytopenia
Prolonged APTT
Secondary thromboembolism prophylaxis
VTE:
Lifelong warfarin INR 2-3
INR 3-4 if recurrent VTE
Add aspirin if VTE occurred while on warfarin
Arterial:
Lifelong warfarin INR 2-3
Causes of avascular necrosis and how to investigate?
Long term steroids
Chemo
Alcohol XS
Trauma
MRI
How to test for azathioprine toxicity?
TMPT test
How does azathioprine work?
Metabolised to mercaptopurine
Inhibits purine synthesis
Oral ulcers
Genital ulcers
Anterior uveitis
HLA B51
Behcets
How to diagnose behcets?
Clinical findings
Pathergy test: needle prick puncture develops small pustule
How do bisphosphonates work?
Pyrophosphate analogue
Inhibits osteoclasts
Decreases demineralisation in bone
Bisphosphonates side effects
Oesophagitis, oesophageal ulcers
Osteonecrosis of jaw
Atypical stress fractures
Acute phase response (fever, arthralgia, myalgia)
Hypocalcemia
Bisphosphonates duration of treatment
Stop at 5y if
> 75y
Femoral neck T score > - 2.5
Low FRAX/NOGG score
Osteoporosis blood results
Calcium, phosphate, ALP, PTH normal
Osteomalacia blood results
Decreased calcium and phosphate
Increased ALP and PTH
Primary hyperparathyroidism, osteitis fibrosis cystica blood results
Calcium increased
Phosphate decreased
Increased ALP, PTH
CKD, secondary hyperparathyroidism blood results
Calcium decreased
Phosphate increased
ALP increased
PTH increased
Paget’s disease blood results
Calcium, phosphate, PTH normal
ALP increased
Osteoma is associated with what condition
Gardner’s (FAP)
What is the commonest benign bone tumour?
Osteochondroma
Giant cell bone tumour
Benign
Multinucleated giant cells in fibrous stroma
20-40y
Epiphyses of long bones
XR findings of soap/double bubble
Giant cell bone tumour
Locations of osteosarcomas
Mataphyses of long bones before closure
Femur, tibia, humerus
XR sign of codman triangle and sunburst pattern
Osteosarcoma
Mutation associated with osteosarcoma
Rb gene
Osteosarcoma predisposing factors
Rb gene mutations
Paget’s disease
Radiotherapy
Small round blue cell tumour
Ewing’s sarcoma
Malignant bone tumour occuring in pelvis and long bones causing severe pain
Ewing’s sarcoma
Ewing’s sarcoma genetice
T(11:22) translocation
EWS FLI1
Onion skin on XR
Ewing’s sarcoma
Chondrosarcoma affects what areas
Axial skeleton
Physiology of carpal tunnel
Prolongation of action potential for motor and sensory
How does denosumab work?
Monoclonal antibody
Prevents development of osteoclasts
Inhibits RANKL
Denosumab uses
60mg injection every 6/12 for osteoporosis
120mg every 4/52 to prevent pathological fractures in PT with bone mets from solid tumours
Denosumab side effects
SOB
Diarrhoea
Hypocalcemia
URTI
Atypical femoral fractures
Dermatomyositis non skin features
Prox muscle weakness/tenderness
Raynaud’s
Resp muscle weakness
Interstitial lung disease
Dysphagia
Dysphonia
Investigating dermatomyositis
ANA 80%
tRNA synthetase antibodies (anti jo-1, anti SRP, anti Mi2)
Elevated CK
EMG
Muscle biopsy
What antibodies are specific to dermatomyositis?
Anti Mi 2
Anti Jo
Mostly polymyositis
Also dermatomyositis with lung involvement, rynauds, fever
Features of drug induced lupus
Arthralgia, myalgia
Macular rash
Pleurisy
ANA
dsDNA negative
Anti histone antibodies
Causes of drug induced luoue
Procainamide
Hydralazine
Isoniazid
Minocycline
Phenytoin
Ehlers danlos features
Elastic fragile skin
Hypermobility and dislocation
Bruising
Aortic regurgitation
Mitral prolapse
Aortic dissection
SAH
Angioid retinal streaks
What nerves may be involved in medical epicondylitis?
Ulnar
Radial tunnel syndrome presentation
Similar to lateral epicondylitis
Pain 4-5 cm distal to lateral epicondyle
Symptoms worsened by extending elbow and pronating
What are extractable nuclear antigens associated with?
ANA positive
Anti Ro associations
Sjogrens
SLE
Congenital heart block
Anti La associations
Sjogrens syndrome
Anti Jo 1 associations
Polymyositis
Anti Scl associations
Diffuse cutaneous systemic sclerosis
Anti centromere associations
Limited cutaneous systemic sclerosis
Familial Mediterranean fever inheritance
Autosomal recessive
Familial Mediterranean fever features
Pyrexia
Abdo pain (peritonitis)
Pleurisy
Pericarditis
Arthritis
Erysipeloid rash lower limbs
Attacks 1-3 days
Managing familial Mediterranean fever
Colchicine
What counts as uricaemia?
> 0.45 mmol/L
Drugs causing gout
Thiazides, furosemide
Ciclosporin
Alcohol
Cytotoxics
Pyrazinamide
Aspirin
Gout- when should you check uric acid levels?
Once acute episode has settled (2/52)
How does colchicine work?
Binds to tubulin and interferes with mitosis
Inhibits microtubule polymerization
So inhibits neutrophil activity and motility
Colchicine and renal impairment
Reduce dose if eGFR 10-50
Avoid if eGFR < 10
What can you give for gout if NSAIDs and colchicine are contraindicated?
15mg prednisolone OD
Intra articular steroid injection
Urate lowering therapy is especially recommended for who?
2 or more gout attacks in 1y
Tophi
Renal disease
Uric acid renal stones
On cytotoxics or diuretics (prophylaxis)
Uric acid level targets
< 0.36 mmol/l
< 0.3 if tophi/chronic gouty arthritis or flares ongoing despite urate <0.36
Urate lowering therapy
Colchicine first line
Febuxostat second line
Uricase
Pegloticase infusion
How does febuxostat work?
Xanthine oxidase inhibitor
Reduces urate levels
Gout predisposing factors
Decreased urate excretion (diuretics, CKD, lead)
Increased urate production (myelo or lymphoproliferative, cytotoxics, psoriasis)
Lesch Nyhan
Lesh Nyhan syndrome
HGPRTase deficiency
X linked recessive
Results in gout, renal failure, neuro deficits, LDS, self mutilation
Transient synovitis of hip
2-10y
Associated with viral infection
Perthes
Avascular necrosis of femoral head
4-8y
Progressive pain
Limo
Hip XR: Widened joint space, decreased femoral head size/flattened femoral head
Perthes
SUFE
10-15y
Obese
Femoral head epiphysis displaces posterio inferiorly
No internal rotation of leg in flexion
Hydroxychloroquine side effects
Bulls eye retinopathy
Secondary causes of iliopsoas abscess
Crohn’s
Diverticulitis, colorectal cancer
UTI
GU cancer
Vertebral osteomyelitis
Femoral catheter, lithotripsy
Endocarditis
IVDU
Diagnosing iliopsoas abscess
Supine, flex knee, externally rotate hip
Ask PT to lift ipsilateral thigh
CT abdo
Osteochondritis dissecans
Pain after exercise
Intermittent swelling and locking
Patellar subluxation
Medial knee pain
Lateral subluxation
Langerhans cell histiocytosis features
Bone pain (skull, femur)
Cutaneous nodules
Recurrent otitis media/mastoiditis
Tennis racket birbeck granules on electromicroscopy
Langerhans cell histiocytosis
Geographic skull on XR
Punched out scalloped edged lesions
Bevelled edge
Parietal regions
Sign of Langerhans histiocytosis
Leflunomide and pregnancy
Must use contraception during leflunomide treatment and 2y after (women) or 3months (men)
Leflunomide side effects
Diarrhoea
HTN
Weight loss, anorexia
Peripheral neuropathy
Myelosuppression
Pneumonitis
Leflunomide monitoring
FBC
LFT
blood pressure
Leflunomide contraindications
Pregnancy
Caution in liver and lung disease
Facet joint pain features
Worse in morning and on standing
Worse on extension
May be tenderness over facets
L3 compression
Anterior thigh sensory loss
Weak hip flexion, knee extension, hip adduction
Reduced knee reflex
Pos femoral stretch test
L4 compression
Sensory loss anterior knee, medial malleolus
Weak knee extension, hip adduction
Reduced knee reflex
Positive femoral stretch test
L5 compression
Sensory loss dorsum of foot
Weak foot and big toe dorsiflexion
Reflexes intact
Positive sciatic stretch test
S1 compression
Sensory loss posteriolateral leg and lateral foot
Weak plantar flexion
Reduced ankle reflex
Positive sciatic stretch tesr
Spinal stenosis pathology
Intervertebral disc loss of proteoglycan and water content
Increased stress transfer to posterior facet joints
Cartilaginous degeneration, hypertrophy, osteophyte formation
Ligamentum flavum thickening and distortion
Canal narrows
Marfan genetics
Autosomal dominant
FBN1 defect
Chromosome 15
Codes for fibrillin 1
Marfan cardiac associations
Aortic sinus dilatation
Aortic aneurysm/dissection/regurgitation
Mitral valve prolapse
Marfan eye features
Upward lens dislocation
Blue sclera
Myopia
McArdle genetics
Autosomal recessive
McArdle disease
Type V glycogen storage disease
Myophosphorylase deficiency
Decreased muscle glycogenolysis
Muscle pain/stiffness after exercise, cramps, myoglobinuria, low lactate after exercise
Where does lateral femoral cutaneous nerve come from?
L2/3
Where is lateral femoral cutaneous nerve prone to compression?
ASIS and it curves medially and inferiorly
How does MTX work?
Antimetabolite inhibits dihydrofolate reductase
MTX indications
Inflammatory arthritis
Psoriasis
ALL
MTX side effects
Mucositis
Myelosuppression
Pneumonitis
Pulmonary fibrosis
Liver fibrosis
MTX monitorint
FBC, U&E, LFT before starting, then weekly, then 2-3 monthly
MTX interactions
Trimethoprim and cotrimoxazole- marrow aplasia
High dose aspirin- MTX toxicity
Mixed connective tissue disease antibodies
Anti U1 ribonucleoprotein antibodies
Investigating mixed CTD
Exclude other CTD/vasculitis
FBC- anaemia, leucopenia, thrombocytopenia
U&e- renal impairment
Raised CRP, ESR
ANA positive
Anti ds DNA and antiscl70 negative
Managing mixed CTD
Immunosuppression/DMARD
CCB for Raynaud’s
PPI for reflux
Endothelin antagonist/prostacyclin analogue for pHTN
CTD prognosis
1/3 remission
1/3 chronic symptoms
1/3 severe systemic involvement and premature death
How does mycophenolate mofetil work?
Inhibits inosine monophosphate dehydrogenase
Inhibits purine synthesis
Reduces proliferation it T and B cells
Causes of myopathies
Polymyositis
Duchenne, becker, myotonic dystrophy
Cushings
Thyrotoxicosis
Alcohol
Osteogenesis imperfecta genetics and pathology
Autosomal dominant
Decreased synthesis of pro alpha 1 or 2 collagen peptides
–> Type 1 collagen abnormality
Osteogenesis imperfecta features
Fractures after minor trauma
Blue sclera
Osteosclerosis
Dental imperfections
Normal ca, po4, PTH, ALP
Causes of osteomalacia
Vit D deficiency (diet/malabsorption/sunlight)
CKD
Anticonvulsants
Hypophosphatemic tickets (inherited)
Liver disease
Coeliac
Osteomalacia investigations
Low vit d
Low Ca, po4
Raised ALP
XR: translucent bands
Risk factors for haematogenous osteomyelitis
Sickle cell
IVDU
Immunosuppression
Infective endocarditis
Osteomyelitis most common organisms
Staph aureus
Salmonella most common in sickle cell
What conditions predispose to osteoporosis?
Hyperthyroidism, hyperparathyroidism
Hypogonadism
GH deficiency
DM
Multiple myeloma, lymphoma
IBD, malabsorption, gastrectomy, liver disease
CKD
Osteogenesis imperfecta
Homocysteinuria
Meds that may worsen osteoporosis
Glucocorticoids
SSRIs
Anti epileptics
PPI
glitazones
Heparin
Aromatase inhibitors
T score
Based on young person bone mass
> - 1.0 normal
-1.0 - 2.5 osteopenia
< - 2.5 osteoporosis
Z score
T score but adjusted for age, gender, ethnicity
How much prednisolone do you need to take to significantly increase osteoporosis risk?
7.5mg OD for 3 months
How to manage patients at risk of corticosteroid osteoporosis?
Offer bone protection immediately if > 65y or previous fragility #
DEXA if < 65y and no fragility #
Reassure if t > 0
Repeat DEXA if -1.5 < t < 0
Bone protection if t < -1.5
Management of osteoporosis
Alendronate 1st line
Second line alternative bisphosphonates
3rd line strontium ranelate or raloxifene
How does raloxifene work?
Selective oestrogen receptor modulator
Reduces risk of vertebral fractures
Raloxifene adverse effects
May worsen menopausal symptoms
Increased risk VTE
How does strontium ranelate work?
Increases differentiation from pre-osteoblasts to osteoblasts
Inhibits osteoclasts
Strontium ranelate adverse effects
Cardiovascular events
VTE
Skin reactions eg sjs
How does Teriparatide work?
Recombinant PTH
Increases bone density
How does Paget’s disease present?
95% are asymptomatic
Bone pain (pelvis, lumbar, femur)
Bowing of tibia, bossing of skull
Paget’s disease blood results
ALP raised
Normal calcium and po4
Markers of bone turnover
PINP- pro collagen type 1 n terminal propeptide
CTx- serum c telopeptide
NTx- urinary N telopeptide
Urinary hydroxyproline
Complications of pagets
Osteosarcoma
Fractures
Deafness
Skull thickening
High output cardiac failure
What condition is polyarteritis nodosum associated with?
Hep B
Features of polyarteritis nodosa?
Fever, malaise, arthralgia
Weight loss
HTN
Mononeuritis multiplex
Sensorimotor polyneuropathy
Testicular pain
Livedo reticularis
Haematuria, renal failure
20% ANCA
Polymyalgia rheumatica investigations
ESR > 40
EMG and CK normal
Polymyositis is mediated by what type of cells?
T cells
Polymyositis is associated with what condition?
Malignancy
Polymyositis features
Proximal weakness and tenderness
Raynaud’s
Resp muscle weakness
ILD
Dysphagia, dysphonia
Polymyositis investigations
raised CK, LSH, AST, ALT
EMG
muscle biopsy
Anti Jo seen with lung involvement, Raynaud’s, fever
Management of polymyositis
Corticosteroids
Azathioprine as steroid sparing agent
Pseudogout risk factors
> 60y
Haemochromatosis
Hyperparathyroidism
Low mg, po4
Acromegaly
Wilsons
Pseudogout XR
Chondrocalcinosis
Pseudoxanthoma elasticum genetics
Usually autosomal recessive
Features of pseudoxanthoma elasticum
Retinal angioid streaks
Plucked chicken skin appearance
Mitral prolapse
Increased risk IHD
GI haemorrhage
Patterns of psoriatic arthritis
Symmetric polyarthritis
Asymmetrical oligoarthritis
Sacroiliitis
DIP joint disease
Arthritis mutilans
Psoriatic arthritis treatment
NSAIDS for mild disease
MTX
ustrkinumab, secukinumab
Apremilast PDE4 inhibitor
Secondary causes of Raynaud’s phenomenon
Scleroderma, RA, SLE
Leukaemia
Type 1 cryoglobulinemia
Cold agglutinins
Vibrating tools
OCP, ergot
Cervical rib
Raynaud’s treatment
Refer if suspecting secondary Raynaud’s
Nifedipine
IV prostacyclin espoprostenol
Organisms that cause reactive arthritis
Shigella flexneri
Salmonella typhi/enteridis
Yersinia enterocolitia
Campylobacter
Chlamydia trachomatis
Features of relapsing polychondritis
Auricular chondritis, hearing loss, vertigo
Nasal chondritis, saddle nose
Resp tract, hoarse voice, aphonia, wheeze, inspiratory stridor
Episcleritis, scleritis, iritis, keratoconjunctivitis sicca
Arthralgia
Vascular regurgitation, CN palsies, peripheral neuropathies, renal dysfunction
Relapsing polychondritis treatment
Steroids to induce remission
Azathioprine
MTX
Cyclosporine
Cyclophosphamide
Felty syndrome
Rheumatoid arthritis+ splenomegaly + low WCC
Sulfasalazine side effects
Rashes
Oligospermia
Heinz body anaemia
Interstitial lung disease
Hydroxychloroquine side effects
Retinopathy
Corneal deposits
What drug can cause cataracts?
Prednisolone
Gold side effects
Proteinuria
Penicillamine side effects
Proteinuria
Exacerbation of myasthenia gravis
Etanercerpt side effects
Demyelination
TB reactication
What drugs can cause reactivation of TB?
Etanercerpt
Infliximab
Adalimumab
Rituximab side effects
Infusion reactions
How does rheumatoid factor act?
Usually IgM
Reacts with Fc portion of IgG
How can RF be detected?
Rose Waaler test (sheep red cell agglutination)
Latex agglutination (less specific)
Conditions associated with positive RF
RA
Feltys
Sjogrens
Infective endocarditis
SLE
systemic sclerosis
RA initial management
DMARD and bridging prednisolone
When do you give a TNF inhibitor for RA?
Insufficient response to 2 DMARDs including MTX
How does entacerpt work?
Recombinant human protein
Acts as decoy receptor for TNFalpha
How does infliximab work?
Monoclonal antibody
Binds to TNF alpha
Prevents it from binding with TNF receptors
What route of administration is entacerpt given?
SC
What route of administration is infliximab given?
IV
What route of administration is adalimumab given?
SC
How does rituximab work and how is it given?
CD 20 monoclonal ab
B cell depletion
Two 1g IV infusions 2 weeks apart
How does abtacept work?
Modulates signal required for T cell activation
Decreased T cell proliferation and cytokine production
What RA drugs are safe in pregnancy?
Sulfasalazine
Hydroxychloroquine
Low dose steroids
NSAIDS up to 32weeks
What rotator cuff muscle adducts arm?
Teres minor and subscapularis
What rotator cuff muscle rotates arm laterally?
Infraspinatus
Teres minor
What rotator cuff rotates arm medially?
Subscapularis
Sjogrens is associated with an increased risk of what?
Lymphoid malignancy
Investigating sjogrens
RF 50%
ANA 70%
Anti Ro 70%
Anti La 30%
Schirmers test (tears)
Histo (lymphocytic infiltration)
Hypergammaglobulinaemia
Low C4
Features of stills disease
Arthralgia
High ferritin
Salmon pink maculopapular rash
Pyrexia (afternoon/evening)
Lymphadenopathy
Stills disease RF and ANA
Negative
When is sulfasalazine contraindicated?
G6PD deficiency
Aspirin/sulfonamide allergy
What type of hypersensitivity is involved in SLE?
Type 3
SLE is associated with what markers?
HLA B8
HLA DR2
HLA DR3
ANA positive
Anti dsDSNA
Anti Smith
Anti U1, Ro, La
Complement levels in SLE active disease
C3, C4 low
Neonatal SLE complications
Congenital heart block
Anti centromere antibodies
Limited cutaneous systemic sclerosis
CREST syndrome
Calcinosis
Raynaud’s
oEsophageal dysmotility
Sclerodactyly
Telangiectasia
Anti Scl 70
Diffuse cutaneous systemic sclerosis
What does tumour necrosis factor do?
Activates macrophages and neutrophils
Acts as costimulator for t cell activation
Mediates response to gram negative septicaemia
Anti tumour effect
Phospholipase activation
TNF binds to what?
P55 and p75 receptors to induce apoptosis
Systemic effects of TNF
Pyrexia
Increased acute phase proteins
Disordered metabolism, cachexia
Examples of TNF inhibitors
Infliximab
Etanercerpt
Adalimumab
Golimumab
How does rheumatoid factor work?
IgM against Fc of IgG
What antibody does pANCA target?
MPO
Drug induced lupus antibodies
ANA positive
dsDNA negative
Antihistone usually positive
SLE antibodies associated with congenital heart block
Anti Ro
Types of collagen and disorders
1: osteogenesis imperfecta
2: achondroplasia
3: ehlers danlos
4: alports, antiGBM
5: ehlers danlos
Dermatomyositis antibodies
80% are ANA positive
Anti mi2
