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rheum Flashcards

1
Q

osteoarthritis

A

at synovial joints (hips, knees, DIP, MCP)
cartilage worn down

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2
Q

presntation OA

A

joint pain and stiffness worse with activity
weakness
decreased ROM

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3
Q

XR OA

A

loss of joint space
osteophytes
subarticular sclerosis
subchondral cysts

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4
Q

hand signs OA

A

haberdens nodes at DIP
bouchards nodes at PIP
squaring at CMC thumb

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5
Q

diagnosis OA

A

> /= 45
pain on activity
morning stiffness < 30m

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6
Q

mx OA

A

wt loss
PT/OT
analgesia: paracetamol, topical nsaids, orial nsaids, opiates
intra-articualr steroid injection
joint replacement

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7
Q

RA

A

AI
chronic inflammation of synovial lining, tendon sheaths and bursa

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8
Q

genes associated with RA

A

HLA DR4
DLA DR1

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9
Q

Ab associated with RA

A

rheumatoid factor
anti-citrullinated cyclic peptid Ab (more snesitive and specific)

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10
Q

presentation RA

A

symmetrical distal polyarthropathy small joints (PIP, MCP, MTP, wrist, ankle, c-spine)
pain, swelling, morning stiffness, improves with acitvity
systemic sx

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11
Q

XR features RA

A

joint destruction and deformity
soft tissue swelling
periarticualr osteopenia
bony erosions

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12
Q

palindromic rheumatism

A

inflammatory arthritis lasting 1-2d

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13
Q

antlantoaxial subluxation

A

can occur due to RA
can cause cord compression

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14
Q

RA signs in hands

A

feel boggy
z shaped thumb
swan neck (hyperextended PIP and flexed DIP)
boutonnieres (hyperextended DIP with flexed PIP)
ulnar deviation MCP

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15
Q

swan neck deformity

A

hyperextended PIP and flexed DIP

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16
Q

boutonnieres deformity

A

hyperextended DIP with flexed PIP

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17
Q

extra-articular manifestations RA

A

pulmonary fibrosis with pulmonary nodules (caplans)
bronchiolitis obliterans
feltys (RA, neutropenia, splenomegaly)
secondary sjogrens (sicca)
anaemia
CVD
eyes: scleritis, episcleritis, keratitis, keratoconjunctivitis)
rheumatoid nodules
lymphadenopathy
carpal tunnel
amyloidosis

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18
Q

feltys syndrome

A

(RA, neutropenia, splenomegaly

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19
Q

ix RA

A

RF and anti CCP
CRP, ESR
XR
DAS-28 or HAQ

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20
Q

mx RA

A
  1. monotherapy: methotrexate, leflunomide, sulfasalazine, hydroxychloroquine
    2.combine
  2. methotrexate and biological therapy (infliximab)
  3. methotrexate and rituximab

steroids for flare ups
consider surgery

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21
Q

methotrexate

A

affects folate metabolism so need folate supplements

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22
Q

SE methotrexate

A

mouth ulcers
liver toxicity
pulmonary fibrosis
leukopenia and BM suppression
teratogenic

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23
Q

leflunomide

A

interferes with production pyrimidine

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24
Q

leflunomide se

A

mouth ulcers
HTN
rash
peripheral neurpathy
liver toxicity
leukopenia and BM suppression
teratogenic

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25
Q

sulfasalazine

A

immunosuppressive and anti-inflammatory

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26
Q

sulfasalazine SE

A

temporary M infertility
BM suppression

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27
Q

hydroxychloroquine

A

interferes with toll like receptors

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28
Q

SE hydrpxychloroqeuin

A

nightmares
decreased visual acuity
liver toxicity
skin pigmentation

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29
Q

types anti-TNF

A

biologics: monoclonal Ab e.g. infliximab
proteins: etanercept

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30
Q

SE anti-TNFs

A

more severe infections
reactivation TB/hep B

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31
Q

rituximab

A

monoclonal Ab to CD20

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32
Q

SE rituximab

A

more severe infections
night sweats
thrombocytopenia
peripheral neuropathy
liver and lung toxicity

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33
Q

psoriatic arthritis

A

seronegative spondyloarthropathy
psoriasis and arthritis

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34
Q

features psoriatic arthritis

A

symmetrical, asymmetrical, spondylitis
nail pitting, oncholysis, dactylitis, enthesitis
conjunctivitis, anterior uveitis,
aortitis
amyloidosis

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35
Q

screening for psoriatic arthritis

A

PEST

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36
Q

mx psoriatic arthritis

A

nsiads
dmards
anti-tnfs
ustekinumab (targets Il12 and 23)

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37
Q

XR in psoriatic arthritis

A

periostitis
ankylosis
osteolysis
dactylitis
‘pencil in cup’ appearance

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38
Q

arthritis mutilans

A

severe psoriatic arthritis
osteolysis in phalanxes->shortening =telescopic finger

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39
Q

reactive arthritis

A

reiters: acute monoarthritis triggered by infection

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40
Q

common infections triggering reactive arthritis

A

gastroenteritis
STI - chlamydia

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41
Q

gene assicaited with reactive arthritish

A

HLA B27

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42
Q

sx reactive arthritis

A

bilateral conjunctivitis
anterior uveitis
arcinate balanitis

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43
Q

mx reactive arthritis

A

need to rule out septic arthritis
nsaids
steroid injections
dmards

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44
Q

where is ankylosing spondylitis

A

sacroiliac joints and vertebral column

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45
Q

test for ankylosing spondylitis

A

schobers

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46
Q

main sx ankylosing spondylitis

A

back pain

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47
Q

gene associated with ankylosing spondylitis

A

HLA B27

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48
Q

associations with ankylosing spondylitis

A

wt loss
chest pain
enthesitis: plantar fasciitis
dactylitis
anaemia
anterior uveitis
aortitis, heart block
restrictive lung disease, pulmonaery fibrosis
IBD

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49
Q

XR ankylosing spondylitis

A

bamboo spine
squared vertebral body
subchondral sclerosis
syndesmophytes
ossification
joint fusion

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50
Q

mx ankylosing spondylitis

A

nsaids
steroids
anti-tnf
secukinumab

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51
Q

who is SLE more common in

A

F
asian

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52
Q

what is SLE

A

inflammatory AI connective tissue disease

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53
Q

sx SLE

A

non specific
photosensitive rash
fatigue
arthralgia
mouth ulcers
raynauds

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54
Q

ix SLE

A

ANA
anti dsDNA
anaemia
decreased C3 and 4
increased CRP and ESR
Ig
proteine:creatinine urine ratio

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55
Q

mx SLE

A

nsaids
pred
hydroxychloroquine
methotrexate
rituximab

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56
Q

complications SLE

A

CVD
infection
anaemia
pericarditis
pleuritis
interstitial lung disease
lupis nephritis
neuropsychiatric SLE
recurrent miscarriage
VTE

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57
Q

discoid lupus erythematosus

A

photosensitive erythematous skin lesions on face, ears, scalp
associated with scarrin galopecia

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58
Q

ix discoid lupus erythematosus

A

skin biopsy

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59
Q

mx discoid lupus erythematosus

A

suncream
steroids
hydroxychloroquine

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60
Q

systemic sclerosis

A

AI inflammatory and fibrotic connective tissue disorder

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61
Q

types systemic sclerosis

A

limited cutaneous
diffuse cutaneous

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62
Q

mx systemic sclerosis

A

steroids and immunosuppresants

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63
Q

auto ab in all types systemic sclerosis

A

ANA

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64
Q

sx limited cutaneous systemic sclerosis

A

CREST syndrome:
calcinosis, raynauds, oesophageal dysmotility, sclerodactyly, telangiectasia

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65
Q

auto ab in limited cutaneous systemic sclerosis

A

anti centromere ab

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66
Q

featuers diffuse cutaneous systemic slcerosis

A

CREST syndrome (calcinosis, raynauds, oesophageal dysmotility, sclerodactyly, telangiectasia)
CV: HTN, CVD
lung: pulmonary HTN, fibrosis
kindey: glomerulonephritis, scleroderma renal crisis

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67
Q

auto ab in diffuse cutaneous systemic sclsrosis

A

anti-scl-70

68
Q

what is polymyalgia rheumatic associated with

A

GCA

69
Q

features polymyalgia rheumatica

A

2w bilateral shoulder pain to elbow, bilateral pelvic girdle pain, 45m morning stiffness, worse with movement
systemic sx
pitting oedema
increased inflammatory markers

70
Q

mx polymyalgia rheumatic

A

steroids (15mg pred) then wean down - can take 1-2y

71
Q

GCA

A

temporal arteritis
systemic vasculitis of medium and large arterires

72
Q

features GCA

A

severe unilateral temporal headache
scalp tenderness
jaw claudication
blurred/loss of vision
fever
ache

73
Q

ix GCA

A

increased ESR]
temporal artery biopsy=multinucleated giant cells
normocytic anaemia
increased ALP, CRP
USS=hypoechoic halo

74
Q

mx GCA

A

40-60mg pred
aspirin
biopsy

75
Q

complications GCA

A

early=visual loss, stroke,
late=relapses, stroke, aortitis (->aneurysm/dissection)

76
Q

polymyositis

A

inflammation muscles
anti-Jo-1 Ab

77
Q

dermatomyositis

A

inflammation muscles and skin
anti-mi-2, ANA

78
Q

features specific to dermatomyositis

A

gottron lesions on knucles, elbows and knees
photosensitive erythematous rash
purple rash
periorbital oedema
subcutaneous calcinosis

79
Q

features polymyositis and dermatomyositis

A

increased CK
bilateral muscle pain and weakness-often shoulder and pelvic girdle

80
Q

mx polymyositis and dermatomyositis

A

corticosteroids

81
Q

antiphospholipid syndrome

A

hypercoagulable state
often secondary to SLE

82
Q

auto ab in antiphospholipid syndrome

A

antiphospholipid ab
lupus anticoag
anticardiolipin
anti-B-2-glycopreotein

83
Q

features antiphospholipid syndrome

A

VTE
MI
stroke
pregnancy complications
livedo reticularis (purple lace rash)
libmannn sacks endocarditis
thrombocytopenia

84
Q

mx antiphospholipid syndrome

A

warfarin

85
Q

sjogrens syndrome

A

AI condition exocrine glands leading to dry mucous membranes
can be secondary to SLE/RA

86
Q

auto ab in sjogrens

A

anti-Ro
anti-La

87
Q

test for sjogrens

A

schirmers

88
Q

mx sjogrens

A

artificial tears/saliva
lubriants
hydroxychloroquine

89
Q

complications sjogrens

A

conjunctivitis
corneal ulcers
dental cavitis
candida

90
Q

small vessel vasculitis

A

HSP
eosinophilic granulomatosis with polyangitis-churg strauss
microscopic polyangitis
granulomatosis with polyangitis=wegners granulomatosis

91
Q

HSP features

A

IgA
purpura
joint pain
renal invovlement
abdo pain
<10y

92
Q

mx HSP

A

supportive

93
Q

features eosinophilic granulomatosis with polyangitis

A

p-ANCA
lung and skin problems-asthma
increased eosinophils

94
Q

features microscopic polyangitis

A

renal failure
sob
haemoptysis
p-ANCA

95
Q

features granulomatosis with polyangitis

A

c-ANCA
resp tract: epistaxis sinusitis
lungs: cough, wheeze, haemoptysis
glomerulonephritis

96
Q

medium vessel vasculiits

A

polyarteritis nodosa
churg strauss
kawasaki

97
Q

features polyarteritis nodosa

A

hep B (+hep c and HIV)
renal impairment
stroke
MI
livedo reticularis

98
Q

features kawasaki

A

fever >5d
erythematous rash
strawberry tongue
<5y
risk coronary artery aneurysm

99
Q

mx kawasaki

A

aspirin
IV Ig

100
Q

large vessel vasculitis

A

GCA
takayasus

101
Q

features takayasus

A

effects aorta (PA->swell and block=pulselses diseease)
<40y
fever
aches
syncope

102
Q

mx vasculitis

A

steroids
immunosuppressants (cyclophosphamide, methotrexate)

103
Q

what is behcets disease

A

relapsing remitting inflammatory disease
HLA B51

104
Q

features behcets disease

A

mouth and genital ulcers
skin: papules, erythema nodosum
eyes: uveitis, vasculitis
MSK: stiff, arthralgia
GI
CNS: memory, headaches
veins: inflammed, VTE
PA aneurysm

105
Q

behcets ix

A

pathergy test

106
Q

mx behcets

A

steroids
colchicine
azathioprine
inliximab

107
Q

gout features

A

urate crystals in joint (MTP, wrist, CMC) -> pain/red/swollen +/- gouty tophi in DIPgo

108
Q

gout RF

A

M
obese
meat
seafood
alcohol
diuretics
CVD
fhx

109
Q

ix gout

A

aspirate=needle shaped negatively birefringent
monosodium urate crystals

110
Q

gout XR

A

lytic lesions
punched out erosions with sclerotic border

111
Q

mx gout

A

acute=nsaids, colchicine
prophylacis-allopurinol (xanthine oxidase i)

112
Q

features pseudogout

A

calcium pyrophosphate crystals ->chondrocalcinosis-hot/swollen/stiff knee/shoulder/wrist/hi

113
Q

ix psuedogout

A

aspirate=positively birefringent rhomboids

114
Q

XR pseudogout

A

chondrocalcinosis (white line in joint space)
loss joint space
osteophytes
subarticular sclerlosis
subchondral cysts

115
Q

mx pseudogout

A

nsaids
colchicine
steroids
joint washout

116
Q

RF osteoporosis

A

age
F
less mobile
BMI <18.5
RA
alcohol
smoking
long term steroids
SSRI
PPI
anti epileptics
anti oestrogens
post menopausal

117
Q

risk osteoporosis

A

FRAX - risk # in nect 10y

118
Q

osteoporosis ix

A

DEXA
z-score is age adjusted
t-score is sd below young: -1 to -2.5 is osteopenia, <-2.5 is osteoporosis, <-2.5 and # is severe osteoporosis

119
Q

mx osteoporosos

A

vit d and ca (calcichew d3)
bisphosphonates e.g. alendronate, zolendronic acid
denosumab (monoclonal ab)

120
Q

how to bisphosponates work

A

decrease osteoclast activity

121
Q

SE bisphosphonates

A

reflux
atypical #
osteonecrosis

122
Q

osteomalaacia

A

defective bone mineralisation due to vit d deficiency = soft bones

123
Q

features ostemomalacia

A

fatigue
pain
weakness
#

124
Q

what is rickets

A

osteomalacia before growth plates close

125
Q

ix osteomalacia

A

low serum 25-hydroxy vit d
low ca
low phos
high ALP
high PTH
XR=radiolucent bones

126
Q

mx osteomalacia

A

vit d -colecalciferol

127
Q

pagets disease

A

excessive bone turnover (increase osteoclast and osteoblast activity)=pathy sclerosisand lysis=bone pain, deformity, #

128
Q

ix pagets

A

increased ALP
XR=deformity, osteroporosis, circumscripta, cotton wool skull, v shaped long bones

129
Q

mx pagets

A

bisphosphonate

130
Q

complications pagets disease

A

osteosarcoma
spinal stenosis and cord compression

130
Q

where does pagets often effect

A

axial skeleton

131
Q

What is inflammatory response driven by

A

Cytokines

132
Q

Features inflammatory response and cause

A

Hot: capillary widening leading to increased blood flow
Red and swollen: Increased permeability leading to fluid release
Tender: leukocytes go to injury site
Pain: systemic response leading to fever and more leukocytes

133
Q

Normal Inflammation pathway

A

Macrophages activated (for phagocytosis)
Release IL-1
Activate other macrophages
Response shut down by NK cells and CTL

134
Q

What happens when the immune system doesn’t switch off in inflammation

A

Continuous macrophage activation
Cytokine storm/hyperinflammation leading to organ damage

135
Q

Cytokine storm/HLH triggers

A

Infection: viral, coronations
Cancer: often haem
AI
immunotherapy
Individual susceptibility

136
Q

What is HLH

A

Haemophagocytic lymphohistiocytosis
Immune disregulation
Hyperinflammation

137
Q

Features HLH

A

Fever
Falling blood counts
Ferritin highly elevated (>10,000)

Unwell patients and CRP falling
High TG, reduced fibrinogen, abnormal LFTs)

138
Q

What to do if suspect HLH

A

Quick screen: FBC, TG, U &E, LDH, LFT, ferritin, fibrinogen, clotting
Review imaging: hepatosplenomegaly , lymphadenopathy
H- score: if over 169 give 1g IV methylpred, MDT, rheum, haem, HDU
Consider triggers

139
Q

Mx HLH

A

Steroids: IV methylpred, treats trigger, may be enough to tx if catch early
If no response 48h: anakinra (blocks IL1), etoposode (proapoptotic), tocilizumab/baricitimab (block IL6 and JAC - used in covid 19)

140
Q

feltys syndrome

A

(RA + splenomegaly + low white cell count)

141
Q

SE and risks nsaids

A

Peptic ulcer
Renal failure
Exacerbate asthma
MI and stroke- particularly diclofenac

142
Q

Aim urate lowering therapy

A

Uric acid under 300

143
Q

Febuxostat

A

Xanthine oxidase inhibitors
2nd line urate lowering therapy in gout due to cost

144
Q

SE DMARDS

A

Suppress bone marrrow: low WCC AND platelets
Abnormal LFTs
Mouth ulcers
Hair loss
Nausea
Diarrhoea
Teratogenic other than sulfasalazine and azathioprine

145
Q

Monitoring DMARDS

A

FBC, U AND E, LFT
Initially monthly for 3m, then every 3m

146
Q

Methotrexate

A

6-8w to work
Anti folate therefore need folic acid
Restric alcohol
Need 3m off before pregnant

147
Q

Leflunomide

A

Less well tolerated than methotrexate due to GI SE

148
Q

Sulfasalazine

A

Well tolerated but less effective

149
Q

Anti TNF drugs

A

Infliximab
Etanercept
Adalimumab
Certolizumab
Golimumab

150
Q

How are biological drugs given

A

INFUSION or injection
Can’t take orally as would destroy

151
Q

Rituximab

A

Anti CD20 = ANTI b cell

152
Q

Abatercept

A

Anti t cell

153
Q

Tocilizumab

A

Anti IL6

154
Q

JAK i

A

Baricitinib
Tofacitinib

Oral as work on intracellular pathway

155
Q

SE anti TNF

A

Increased risk infection and work infection
Ab against so reduced effect
Infection injection site
Increase risk ca - skin

156
Q

What is rituximab good for

A

Ab mediated disorders

157
Q

Important SE riuximab

A

Reduces Ab response to vaccines, as given 6m -18mnthly usually give vaccine then wait 6w before give rituximab

158
Q

SE tocilizumab

A

Reduces CRP so it won’t rise in infection

159
Q

Are JAK I biologics

A

No!

160
Q

How to biological work

A

Outside cekk to stop cytokines binding to receptors

161
Q

JAK i SE

A

Short half life in comparison to biologics
Increased risk infection - shingles
Increased risk DVT and PE
Possible risk malignancy

162
Q

sx allopurinol sensitivity

A

lymphadenopathy
eosinophilia
fever
skin rash

163
Q

medications causing lymphadenopathy

A

allopurinol
phenytoin
atenolol
carbamazepine

164
Q

sx dermatomyositis

A

unwell
arthralgia
wt loss
heliotrope rash
purple scaly patches on elbows
muscle weakness - particularly proximal upper limbs

165
Q

blood results dermatomyositis

A

ANA positive
CK: very high - 50x normal
anti-mi-2 ab

finals (31 decks)

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