rheum Flashcards
1
Q
osteoarthritis
A
at synovial joints (hips, knees, DIP, MCP)
cartilage worn down
2
Q
presntation OA
A
joint pain and stiffness worse with activity
weakness
decreased ROM
3
Q
XR OA
A
loss of joint space
osteophytes
subarticular sclerosis
subchondral cysts
4
Q
hand signs OA
A
haberdens nodes at DIP
bouchards nodes at PIP
squaring at CMC thumb
5
Q
diagnosis OA
A
> /= 45
pain on activity
morning stiffness < 30m
6
Q
mx OA
A
wt loss
PT/OT
analgesia: paracetamol, topical nsaids, orial nsaids, opiates
intra-articualr steroid injection
joint replacement
7
Q
RA
A
AI
chronic inflammation of synovial lining, tendon sheaths and bursa
8
Q
genes associated with RA
A
HLA DR4
DLA DR1
9
Q
Ab associated with RA
A
rheumatoid factor
anti-citrullinated cyclic peptid Ab (more snesitive and specific)
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
11
Q
XR features RA
A
joint destruction and deformity
soft tissue swelling
periarticualr osteopenia
bony erosions
12
Q
palindromic rheumatism
A
inflammatory arthritis lasting 1-2d
13
Q
antlantoaxial subluxation
A
can occur due to RA
can cause cord compression
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
15
Q
swan neck deformity
A
hyperextended PIP and flexed DIP
16
Q
boutonnieres deformity
A
hyperextended DIP with flexed PIP
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
18
Q
feltys syndrome
A
(RA, neutropenia, splenomegaly
19
Q
ix RA
A
RF and anti CCP
CRP, ESR
XR
DAS-28 or HAQ
20
Q
mx RA
A
- monotherapy: methotrexate, leflunomide, sulfasalazine, hydroxychloroquine
2.combine - methotrexate and biological therapy (infliximab)
- methotrexate and rituximab
steroids for flare ups
consider surgery
21
Q
methotrexate
A
affects folate metabolism so need folate supplements
22
Q
SE methotrexate
A
mouth ulcers
liver toxicity
pulmonary fibrosis
leukopenia and BM suppression
teratogenic
23
Q
leflunomide
A
interferes with production pyrimidine
24
Q
leflunomide se
A
mouth ulcers
HTN
rash
peripheral neurpathy
liver toxicity
leukopenia and BM suppression
teratogenic
25
sulfasalazine
immunosuppressive and anti-inflammatory
26
sulfasalazine SE
temporary M infertility
BM suppression
27
hydroxychloroquine
interferes with toll like receptors
28
SE hydrpxychloroqeuin
nightmares
decreased visual acuity
liver toxicity
skin pigmentation
29
types anti-TNF
biologics: monoclonal Ab e.g. infliximab
proteins: etanercept
30
SE anti-TNFs
more severe infections
reactivation TB/hep B
31
rituximab
monoclonal Ab to CD20
32
SE rituximab
more severe infections
night sweats
thrombocytopenia
peripheral neuropathy
liver and lung toxicity
33
psoriatic arthritis
seronegative spondyloarthropathy
psoriasis and arthritis
34
features psoriatic arthritis
symmetrical, asymmetrical, spondylitis
nail pitting, oncholysis, dactylitis, enthesitis
conjunctivitis, anterior uveitis,
aortitis
amyloidosis
35
screening for psoriatic arthritis
PEST
36
mx psoriatic arthritis
nsiads
dmards
anti-tnfs
ustekinumab (targets Il12 and 23)
37
XR in psoriatic arthritis
periostitis
ankylosis
osteolysis
dactylitis
'pencil in cup' appearance
38
arthritis mutilans
severe psoriatic arthritis
osteolysis in phalanxes->shortening =telescopic finger
39
reactive arthritis
reiters: acute monoarthritis triggered by infection
40
common infections triggering reactive arthritis
gastroenteritis
STI - chlamydia
41
gene assicaited with reactive arthritish
HLA B27
42
sx reactive arthritis
bilateral conjunctivitis
anterior uveitis
arcinate balanitis
43
mx reactive arthritis
need to rule out septic arthritis
nsaids
steroid injections
dmards
44
where is ankylosing spondylitis
sacroiliac joints and vertebral column
45
test for ankylosing spondylitis
schobers
46
main sx ankylosing spondylitis
back pain
47
gene associated with ankylosing spondylitis
HLA B27
48
associations with ankylosing spondylitis
wt loss
chest pain
enthesitis: plantar fasciitis
dactylitis
anaemia
anterior uveitis
aortitis, heart block
restrictive lung disease, pulmonaery fibrosis
IBD
49
XR ankylosing spondylitis
bamboo spine
squared vertebral body
subchondral sclerosis
syndesmophytes
ossification
joint fusion
50
mx ankylosing spondylitis
nsaids
steroids
anti-tnf
secukinumab
51
who is SLE more common in
F
asian
52
what is SLE
inflammatory AI connective tissue disease
53
sx SLE
non specific
photosensitive rash
fatigue
arthralgia
mouth ulcers
raynauds
54
ix SLE
ANA
anti dsDNA
anaemia
decreased C3 and 4
increased CRP and ESR
Ig
proteine:creatinine urine ratio
55
mx SLE
nsaids
pred
hydroxychloroquine
methotrexate
rituximab
56
complications SLE
CVD
infection
anaemia
pericarditis
pleuritis
interstitial lung disease
lupis nephritis
neuropsychiatric SLE
recurrent miscarriage
VTE
57
discoid lupus erythematosus
photosensitive erythematous skin lesions on face, ears, scalp
associated with scarrin galopecia
58
ix discoid lupus erythematosus
skin biopsy
59
mx discoid lupus erythematosus
suncream
steroids
hydroxychloroquine
60
systemic sclerosis
AI inflammatory and fibrotic connective tissue disorder
61
types systemic sclerosis
limited cutaneous
diffuse cutaneous
62
mx systemic sclerosis
steroids and immunosuppresants
63
auto ab in all types systemic sclerosis
ANA
64
sx limited cutaneous systemic sclerosis
CREST syndrome:
calcinosis, raynauds, oesophageal dysmotility, sclerodactyly, telangiectasia
65
auto ab in limited cutaneous systemic sclerosis
anti centromere ab
66
featuers diffuse cutaneous systemic slcerosis
CREST syndrome (calcinosis, raynauds, oesophageal dysmotility, sclerodactyly, telangiectasia)
CV: HTN, CVD
lung: pulmonary HTN, fibrosis
kindey: glomerulonephritis, scleroderma renal crisis
67
auto ab in diffuse cutaneous systemic sclsrosis
anti-scl-70
68
what is polymyalgia rheumatic associated with
GCA
69
features polymyalgia rheumatica
2w bilateral shoulder pain to elbow, bilateral pelvic girdle pain, 45m morning stiffness, worse with movement
systemic sx
pitting oedema
increased inflammatory markers
70
mx polymyalgia rheumatic
steroids (15mg pred) then wean down - can take 1-2y
71
GCA
temporal arteritis
systemic vasculitis of medium and large arterires
72
features GCA
severe unilateral temporal headache
scalp tenderness
jaw claudication
blurred/loss of vision
fever
ache
73
ix GCA
increased ESR]
temporal artery biopsy=multinucleated giant cells
normocytic anaemia
increased ALP, CRP
USS=hypoechoic halo
74
mx GCA
40-60mg pred
aspirin
biopsy
75
complications GCA
early=visual loss, stroke,
late=relapses, stroke, aortitis (->aneurysm/dissection)
76
polymyositis
inflammation muscles
anti-Jo-1 Ab
77
dermatomyositis
inflammation muscles and skin
anti-mi-2, ANA
78
features specific to dermatomyositis
gottron lesions on knucles, elbows and knees
photosensitive erythematous rash
purple rash
periorbital oedema
subcutaneous calcinosis
79
features polymyositis and dermatomyositis
increased CK
bilateral muscle pain and weakness-often shoulder and pelvic girdle
80
mx polymyositis and dermatomyositis
corticosteroids
81
antiphospholipid syndrome
hypercoagulable state
often secondary to SLE
82
auto ab in antiphospholipid syndrome
antiphospholipid ab
lupus anticoag
anticardiolipin
anti-B-2-glycopreotein
83
features antiphospholipid syndrome
VTE
MI
stroke
pregnancy complications
livedo reticularis (purple lace rash)
libmannn sacks endocarditis
thrombocytopenia
84
mx antiphospholipid syndrome
warfarin
85
sjogrens syndrome
AI condition exocrine glands leading to dry mucous membranes
can be secondary to SLE/RA
86
auto ab in sjogrens
anti-Ro
anti-La
87
test for sjogrens
schirmers
88
mx sjogrens
artificial tears/saliva
lubriants
hydroxychloroquine
89
complications sjogrens
conjunctivitis
corneal ulcers
dental cavitis
candida
90
small vessel vasculitis
HSP
eosinophilic granulomatosis with polyangitis-churg strauss
microscopic polyangitis
granulomatosis with polyangitis=wegners granulomatosis
91
HSP features
IgA
purpura
joint pain
renal invovlement
abdo pain
<10y
92
mx HSP
supportive
93
features eosinophilic granulomatosis with polyangitis
p-ANCA
lung and skin problems-asthma
increased eosinophils
94
features microscopic polyangitis
renal failure
sob
haemoptysis
p-ANCA
95
features granulomatosis with polyangitis
c-ANCA
resp tract: epistaxis sinusitis
lungs: cough, wheeze, haemoptysis
glomerulonephritis
96
medium vessel vasculiits
polyarteritis nodosa
churg strauss
kawasaki
97
features polyarteritis nodosa
hep B (+hep c and HIV)
renal impairment
stroke
MI
livedo reticularis
98
features kawasaki
fever >5d
erythematous rash
strawberry tongue
<5y
risk coronary artery aneurysm
99
mx kawasaki
aspirin
IV Ig
100
large vessel vasculitis
GCA
takayasus
101
features takayasus
effects aorta (PA->swell and block=pulselses diseease)
<40y
fever
aches
syncope
102
mx vasculitis
steroids
immunosuppressants (cyclophosphamide, methotrexate)
103
what is behcets disease
relapsing remitting inflammatory disease
HLA B51
104
features behcets disease
mouth and genital ulcers
skin: papules, erythema nodosum
eyes: uveitis, vasculitis
MSK: stiff, arthralgia
GI
CNS: memory, headaches
veins: inflammed, VTE
PA aneurysm
105
behcets ix
pathergy test
106
mx behcets
steroids
colchicine
azathioprine
inliximab
107
gout features
urate crystals in joint (MTP, wrist, CMC) -> pain/red/swollen +/- gouty tophi in DIPgo
108
gout RF
M
obese
meat
seafood
alcohol
diuretics
CVD
fhx
109
ix gout
aspirate=needle shaped negatively birefringent
monosodium urate crystals
110
gout XR
lytic lesions
punched out erosions with sclerotic border
111
mx gout
acute=nsaids, colchicine
prophylacis-allopurinol (xanthine oxidase i)
112
features pseudogout
calcium pyrophosphate crystals ->chondrocalcinosis-hot/swollen/stiff knee/shoulder/wrist/hi
113
ix psuedogout
aspirate=positively birefringent rhomboids
114
XR pseudogout
chondrocalcinosis (white line in joint space)
loss joint space
osteophytes
subarticular sclerlosis
subchondral cysts
115
mx pseudogout
nsaids
colchicine
steroids
joint washout
116
RF osteoporosis
age
F
less mobile
BMI <18.5
RA
alcohol
smoking
long term steroids
SSRI
PPI
anti epileptics
anti oestrogens
post menopausal
117
risk osteoporosis
FRAX - risk # in nect 10y
118
osteoporosis ix
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
mx osteoporosos
vit d and ca (calcichew d3)
bisphosphonates e.g. alendronate, zolendronic acid
denosumab (monoclonal ab)
120
how to bisphosponates work
decrease osteoclast activity
121
SE bisphosphonates
reflux
atypical #
osteonecrosis
122
osteomalaacia
defective bone mineralisation due to vit d deficiency = soft bones
123
features ostemomalacia
fatigue
pain
weakness
#
124
what is rickets
osteomalacia before growth plates close
125
ix osteomalacia
low serum 25-hydroxy vit d
low ca
low phos
high ALP
high PTH
XR=radiolucent bones
126
mx osteomalacia
vit d -colecalciferol
127
pagets disease
excessive bone turnover (increase osteoclast and osteoblast activity)=pathy sclerosisand lysis=bone pain, deformity, #
128
ix pagets
increased ALP
XR=deformity, osteroporosis, circumscripta, cotton wool skull, v shaped long bones
129
mx pagets
bisphosphonate
130
complications pagets disease
osteosarcoma
spinal stenosis and cord compression
130
where does pagets often effect
axial skeleton
131
What is inflammatory response driven by
Cytokines
132
Features inflammatory response and cause
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
Normal Inflammation pathway
Macrophages activated (for phagocytosis)
Release IL-1
Activate other macrophages
Response shut down by NK cells and CTL
134
What happens when the immune system doesn't switch off in inflammation
Continuous macrophage activation
Cytokine storm/hyperinflammation leading to organ damage
135
Cytokine storm/HLH triggers
Infection: viral, coronations
Cancer: often haem
AI
immunotherapy
Individual susceptibility
136
What is HLH
Haemophagocytic lymphohistiocytosis
Immune disregulation
Hyperinflammation
137
Features HLH
Fever
Falling blood counts
Ferritin highly elevated (>10,000)
Unwell patients and CRP falling
High TG, reduced fibrinogen, abnormal LFTs)
138
What to do if suspect HLH
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
Mx HLH
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
feltys syndrome
(RA + splenomegaly + low white cell count)
141
SE and risks nsaids
Peptic ulcer
Renal failure
Exacerbate asthma
MI and stroke- particularly diclofenac
142
Aim urate lowering therapy
Uric acid under 300
143
Febuxostat
Xanthine oxidase inhibitors
2nd line urate lowering therapy in gout due to cost
144
SE DMARDS
Suppress bone marrrow: low WCC AND platelets
Abnormal LFTs
Mouth ulcers
Hair loss
Nausea
Diarrhoea
Teratogenic other than sulfasalazine and azathioprine
145
Monitoring DMARDS
FBC, U AND E, LFT
Initially monthly for 3m, then every 3m
146
Methotrexate
6-8w to work
Anti folate therefore need folic acid
Restric alcohol
Need 3m off before pregnant
147
Leflunomide
Less well tolerated than methotrexate due to GI SE
148
Sulfasalazine
Well tolerated but less effective
149
Anti TNF drugs
Infliximab
Etanercept
Adalimumab
Certolizumab
Golimumab
150
How are biological drugs given
INFUSION or injection
Can't take orally as would destroy
151
Rituximab
Anti CD20 = ANTI b cell
152
Abatercept
Anti t cell
153
Tocilizumab
Anti IL6
154
JAK i
Baricitinib
Tofacitinib
Oral as work on intracellular pathway
155
SE anti TNF
Increased risk infection and work infection
Ab against so reduced effect
Infection injection site
Increase risk ca - skin
156
What is rituximab good for
Ab mediated disorders
157
Important SE riuximab
Reduces Ab response to vaccines, as given 6m -18mnthly usually give vaccine then wait 6w before give rituximab
158
SE tocilizumab
Reduces CRP so it won't rise in infection
159
Are JAK I biologics
No!
160
How to biological work
Outside cekk to stop cytokines binding to receptors
161
JAK i SE
Short half life in comparison to biologics
Increased risk infection - shingles
Increased risk DVT and PE
Possible risk malignancy
162
sx allopurinol sensitivity
lymphadenopathy
eosinophilia
fever
skin rash
163
medications causing lymphadenopathy
allopurinol
phenytoin
atenolol
carbamazepine
164
sx dermatomyositis
unwell
arthralgia
wt loss
heliotrope rash
purple scaly patches on elbows
muscle weakness - particularly proximal upper limbs
165
blood results dermatomyositis
ANA positive
CK: very high - 50x normal
anti-mi-2 ab
