Rheum Flashcards
1
Q
What is the most common cause of arthritis?
A
Osteoarthritis (OA)
Worldwide, almost 500 million people are affected
2
Q
What is a leading cause of disability worldwide?
A
Osteoarthritis (OA)
3
Q
What are the risk factors contributing to osteoarthritis?
A
- Excess body weight
- Joint mal-alignment
- Peripheral neuropathies
- Joint injury from trauma or repetitive movements
4
Q
What medical conditions predispose individuals to osteoarthritis?
A
- Haemochromatosis
- Septic arthritis
- Haemophilia
5
Q
What genetic factor is associated with osteoarthritis?
A
There appears to be a genetic predisposition, as demonstrated in family history and sibling studies.
6
Q
What are common presentations of osteoarthritis?
A
- Joint pain
- Crepitus
- Warmth, swelling, and erythema are not typically present
7
Q
Which joints are predominantly affected by osteoarthritis?
A
- Hips
- Knees
- Ankles
- Shoulders
- Elbows
8
Q
What imaging findings are typical for osteoarthritis?
A
- Joint space narrowing
- Subchondral sclerosis
- Subchondral cysts
- Osteophytes
9
Q
What is the most common differential diagnosis for large joint osteoarthritis?
A
Pseudogout
10
Q
What lifestyle changes can help manage osteoarthritis?
A
- Weight loss
- Smoking cessation
- Low impact exercise
11
Q
What pharmacological treatments are used for osteoarthritis?
A
- Paracetamol
- NSAIDs
- COX-2 inhibitors (e.g., celecoxib)
12
Q
What is the leading cause of elective joint replacement surgery?
A
Osteoarthritis (OA)
13
Q
What percentage of the world population is affected by rheumatoid arthritis?
A
Close to 1%
14
Q
Which gender is more likely to have rheumatoid arthritis?
A
Females
15
Q
What are the primary presenting complaints of rheumatoid arthritis?
A
Arthritis, typically symmetrical and affecting small joints
16
Q
What are the key features of rheumatoid arthritis?
A
- Morning joint stiffness
- Improvement with movement
- Symmetrical polyarthritis
- Small joint predominance
17
Q
What antibodies are commonly associated with rheumatoid arthritis?
A
- Rheumatoid factor (RF)
- Anti-cyclic citrullinated peptides (anti-CCP)
18
Q
What are the classical extra-articular manifestations of rheumatoid arthritis?
A
- Rheumatoid nodules
- Rheumatoid vasculitis
- Anemia
- Felty’s Syndrome
- Cardiovascular risk
19
Q
What is the primary site of inflammation in rheumatoid arthritis?
A
The synovial membrane
20
Q
What is the role of TNF-alpha in rheumatoid arthritis?
A
It is a major pro-inflammatory cytokine promoting the inflammatory cascade.
21
Q
What is the gold standard DMARD for rheumatoid arthritis?
A
Methotrexate
22
Q
What are common side effects of methotrexate?
A
- Hepatotoxicity
- Pulmonary fibrosis
- Bone marrow suppression
23
Q
What is the role of corticosteroids in rheumatoid arthritis management?
A
Used to dampen inflammation and gain remission
24
Q
What are the commonly used TNF-alpha inhibitors?
A
- Infliximab
- Adalimumab
- Etanercept
25
What is the risk associated with TNF-alpha inhibitors?
Increased risk of infections and autoimmunity
26
What is a characteristic joint deformity associated with rheumatoid arthritis?
Z-deformity of the thumb
27
What is the significance of anti-CCP antibodies in rheumatoid arthritis?
It is the most specific antibody detected in RA, not found in other diseases.
28
What is the main goal of disease-modifying anti-rheumatic drugs (DMARDs)?
To achieve remission and prevent deformity.
29
What is the mechanism of action of Anakinra?
Blocks IL-1 activity
30
What is the role of Tocilizumab in rheumatoid arthritis treatment?
Blocks IL-6 activity
31
What is a common imaging finding in rheumatoid arthritis?
* Joint erosions
* Joint space narrowing
* Periarticular osteopenia
32
What is a common side effect of IL-6 inhibitors like Tocilizumab?
Transient hepatitis and neutropenia
33
What are IL-6 Inhibitors used for?
They are used as second line to TNF-a inhibitors in the treatment of rheumatoid arthritis (RA)
## Footnote
Tocilizumab is a specific IL-6 inhibitor that blocks IL-6 activity.
34
What is a common side effect of IL-6 inhibitors?
Transient hepatitis and neutropaenia
## Footnote
These side effects are important to monitor during treatment.
35
What is Rituximab?
A monoclonal antibody to CD20 found on B lymphocytes and plasma cells
## Footnote
It is effective in seropositive RA and considered second line to other agents.
36
What major side effect is associated with prolonged treatment with Rituximab?
Hypogammaglobinaemia
## Footnote
This condition places patients at risk of infection.
37
What is the primary goal of surgical procedures in rheumatoid arthritis?
To improve joint stability and function
## Footnote
Surgery does not address the underlying disease process or inflammation.
38
What happens to RA during pregnancy?
RA often enters a quiescent phase due to the immunosuppressed state
## Footnote
However, flares may occur in the post-partum period.
39
What are some contraindicated medications during pregnancy for RA?
Methotrexate and leflunomide
## Footnote
These are potent teratogens and should be avoided.
40
What factors are considered negative prognostic indicators at the time of RA diagnosis?
* Elevated ESR/CRP
* Anti-CCP positive
* Anti-RF positive
* HLA-DR4 mutation
* Early erosive disease
* Extra-articular manifestations
## Footnote
These factors can indicate a more severe disease course.
41
What is the DAS28 score?
A validated measure of disease activity in rheumatoid arthritis
## Footnote
It helps assess the severity and progression of the disease.
42
What is the life expectancy reduction for RA sufferers?
5-10 years
## Footnote
Cardiovascular disease risk is also more than doubled in these patients.
43
What is Ankylosing Spondylitis (AS)?
A rare condition that is the most common form of spondyloarthropathy, affecting around 0.5% of the world population
## Footnote
It accounts for significant disability.
44
What is a key risk factor for Ankylosing Spondylitis?
More than 90% of AS sufferers are HLA-B27 positive
## Footnote
Not all HLA-B27 positive individuals will develop the disease.
45
What are common symptoms of Ankylosing Spondylitis?
* Gradual onset of lumbar or sacroiliac back pain
* Morning stiffness >60 mins
* Nocturnal pain
* Improvement with exercise
## Footnote
These symptoms typically present in individuals under 40 years.
46
What is the Modified New York Criteria used for?
It is a classification system for Ankylosing Spondylitis
## Footnote
It includes clinical and radiological features.
47
What is the first line radiological investigation for AS?
Ray of the pelvis
## Footnote
MRI is used if classical features are absent but suspicion remains high.
48
What are the first line treatment options for Ankylosing Spondylitis?
* NSAIDs
* Stretching exercises
## Footnote
Early treatment is crucial to prevent disease progression.
49
What percentage of patients with non-radiographic AS can spontaneously remit?
Up to 80%
## Footnote
The risk of progression reduces with age.
50
What is the average incidence rate of Psoriatic Arthritis?
1 in 1,000 people
## Footnote
It affects men and women equally.
51
What are common presentations of Psoriatic Arthritis?
* Mono-, oligo-, or polyarticular arthritis
* Asymmetrical joint involvement
* Sausage digits (dactylitis)
## Footnote
MCPJ, PIPJ, and DIPJ involvement is common.
52
What is a characteristic radiological feature of Psoriatic Arthritis?
Pencil-in-cup appearance of phalanges
## Footnote
This feature helps distinguish it from other arthritides.
53
What is the classical triad of Reactive Arthritis?
* Urethritis
* Conjunctivitis
* Arthritis
## Footnote
This triad is often present in cases of reactive arthritis.
54
What is the typical time frame for the onset of Reactive Arthritis after infection?
7-21 days
## Footnote
This time frame helps in diagnosing the condition.
55
What is the most common presentation of Gout?
Acute inflammatory arthritis
## Footnote
Affected joints are typically warm, red, and swollen.
56
What is the pathophysiology of Gout?
Uric acid crystallizes to form deposits in joints
## Footnote
Uric acid is the final metabolite of purine metabolism.
57
What dietary factors contribute to hyperuricaemia and Gout?
* Alcohol
* Seafood
* Fructose-sweetened soft drinks
* Meat
## Footnote
Total protein consumption does not increase risk.
58
What condition can be mistaken for osteomyelitis or septic discitis due to difficulty in diagnosis?
Spinal gout
## Footnote
Spinal gout is a recognized entity where gout crystals may deposit in the spine.
59
What is the final metabolite of purine metabolism?
Uric acid
## Footnote
Uric acid results from the catabolism of nucleotides, nucleosides, and bases.
60
What triggers an inflammatory response in gout?
Free crystals
## Footnote
The presence of monosodium urate crystals in joints leads to inflammation mediated by the inflammasome and caspase pathways.
61
What pH and temperature conditions promote crystal precipitation in gout?
Acidosis or cooler temperatures
## Footnote
Crystal precipitation is influenced by pH and temperature, among other factors.
62
What is the pathological level of urate thought to be in gout?
Greater than 0.408 umol/L
## Footnote
This level is associated with an increased risk of gout development.
63
What diagnostic method is used to identify monosodium urate crystals?
Polarised light microscopy
## Footnote
This method reveals needle-shaped crystals with negative birefringence in synovial fluid.
64
What are the clinical features used for gout classification criteria?
* More than one attack of arthritis
* Maximal pain and inflammation in less than 24 hours
* Monoarthritis
* Erythema over the affected joint
* 1st metatarsophalangeal joint involved
* Presence of a tophus
* Hyperuricaemia
* Radiological features
* Joint aspirate negative for septic arthritis
## Footnote
These features are part of the American College of Rheumatology (ACR) or European League Against Rheumatism (EULAR) criteria.
65
What types of management are recommended for patients with gout?
* Non-pharmacological management
* Pharmacological management
## Footnote
Non-pharmacological management includes dietary counseling and weight loss, while pharmacological management involves treating acute attacks and preventing future attacks.
66
What is a common first-line treatment for acute gouty arthritis?
* Corticosteroids
* Colchicine
* Non-steroidal anti-inflammatory drugs (NSAIDs)
## Footnote
All these agents can be used to manage acute flares, with no single agent being superior.
67
What is the mechanism of action of allopurinol?
Inhibition of xanthine oxidase enzyme
## Footnote
This action reduces uric acid production in the body.
68
What is the contraindication for using allopurinol?
CrCl < 30 mL/min and hypersensitivity
## Footnote
Allopurinol should not be used in patients with severely reduced renal function or known hypersensitivity.
69
What are the common clinical features of pseudogout?
* Asymptomatic in most cases
* Mild joint pain
* Acute inflammatory arthritis
## Footnote
Pseudogout often presents with knee involvement and can be mistaken for osteoarthritis.
70
What type of crystals are identified in pseudogout?
Calcium pyrophosphate
## Footnote
These crystals are rhomboid-shaped and exhibit positive birefringence under polarized light microscopy.
71
What is the gold standard for diagnosing polymyositis?
Muscle biopsy
## Footnote
The biopsy shows primary inflammation with T lymphocyte predominance.
72
What are the distinguishing features of dermatomyositis compared to polymyositis?
* Heliotrope rash
* Shawl sign
* Gottron's papules
* Mechanics hands
## Footnote
These skin symptoms are characteristic of dermatomyositis.
73
What is the typical age of onset for polymyositis?
6th decade of life
## Footnote
The condition affects 2-10 people per million population with a female predisposition.
74
What is a common treatment for inflammatory myopathies?
Immunosuppression with corticosteroids
## Footnote
Other treatments may include cyclosporine, cyclophosphamide, or rituximab for relapsed disease.
75
What is the primary inflammation finding in muscle biopsy for dermatomyositis?
CD4 lymphocyte predominance
## Footnote
The biopsy typically shows perimysial and perivascular inflammation without infiltrating muscle fibers.
76
What is the role of hydroxychloroquine in dermatomyositis management?
Effective for rash
## Footnote
Hydroxychloroquine helps manage skin symptoms associated with dermatomyositis.
77
What is the gold standard for identifying inflammation and targeting muscle biopsies?
Muscle biopsy
## Footnote
Muscle biopsy is essential for diagnosing conditions like dermatomyositis (DM) and inclusion body myositis (IBM).
78
What type of lymphocyte predominance is seen in primary inflammation in dermatomyositis?
T lymphocyte predominance
## Footnote
Specifically, there is a predominance of CD4 lymphocytes.
79
What are the characteristic features of muscle biopsy in dermatomyositis?
Perimysial and perivascular inflammation, normal muscle cells
## Footnote
Infiltration does not occur within muscle fibers.
80
What is the treatment approach for dermatomyositis?
Glucocorticoids, steroid-sparing immunosuppressants, hydroxychloroquine
## Footnote
Options include azathioprine, mycophenylate, and cyclosporine.
81
Is there a cure for dermatomyositis?
No cure
## Footnote
Lung involvement in DM carries a worse prognosis.
82
What are the clinical aspects of Inclusion Body Myositis (IBM)?
Weakness of distal muscle groups, hand and forearm involvement, progressive disease
## Footnote
Affects all muscle groups and can impact bulbar muscles and respiratory function in late stages.
83
What is the main diagnostic feature of IBM in muscle biopsy?
Inclusions of plaques in rimmed vacuoles within muscle fibers
## Footnote
There is a relative paucity of inflammation.
84
What is the common cause of statin-induced muscle injury?
Rhabdomyolysis
## Footnote
Occurs in 1 in 10,000 people using statins.
85
What are the risk factors for rhabdomyolysis in statin therapy?
Older age, concomitant fibrate use, lipophilic drugs
## Footnote
Atorvastatin and simvastatin have a higher risk compared to hydrophilic drugs like pravastatin.
86
What is the management for statin-induced muscle injury?
Drug withdrawal, immunosuppression
## Footnote
The condition generally persists for much longer than 2 months.
87
What characterizes Steroid Induced Myopathy?
Proximal weakness affecting hip flexors and quadriceps
## Footnote
Patients can lose as much as 1% of power per day on high-dose glucocorticoids.
88
What is the recommended treatment for Polymyalgia Rheumatica (PMR)?
Low dose glucocorticoids
## Footnote
There is usually a good early response within a few days.
89
What is the hallmark of fibromyalgia?
Widespread pain and chronic fatigue
## Footnote
Allodynia is always present.
90
What is the primary theory regarding the pathophysiology of fibromyalgia?
Central sensitization change to sensory inputs
## Footnote
Peripheral sensation is transmitted at a heightened level.
91
What is the diagnostic criterion for fibromyalgia?
Tenderness at 11 of 18 pressure points
## Footnote
Increased tenderness at key pressure areas is assessed.
92
What are the two major types of ANCA-associated vasculitides?
p-ANCA and c-ANCA
## Footnote
p-ANCA targets myeloperoxidase (MPA, EGPA) and c-ANCA targets proteinase 3 (GPA).
93
What is the classic symptom of Giant Cell Arteritis?
Unilateral temporal headache
## Footnote
Jaw claudication is the most specific symptom.
94
What is the gold standard test for diagnosing Giant Cell Arteritis?
Temporal artery biopsy
## Footnote
Histological findings include panarteritis with inflammatory infiltrates.
95
What characterizes Takayasu arteritis?
Patchy granulomatous inflammation of the aorta
## Footnote
Symptoms may resemble flu-like illness.
96
What is the management strategy for Polyarteritis Nodosa (PAN)?
Immunosuppression with corticosteroids
## Footnote
Steroid-sparing agents may include mycophenylate, cyclophosphamide, and methotrexate.
97
What are the clinical features of Kawasaki disease?
High-grade fever, conjunctivitis, strawberry tongue
## Footnote
Cardiac involvement can lead to myocarditis and pericarditis.
98
What is the management for Kawasaki disease?
Intravenous immunoglobulin (IVIG), high dose aspirin
## Footnote
Care should be taken in children due to the risk of Reye's Syndrome.
99
What is the defining histological feature of Granulomatosis with Polyangiitis (GPA)?
Granulomas on histological assessment
## Footnote
Significant respiratory tract involvement is also a hallmark.
100
What is the main treatment for Eosinophilic Granulomatosis with Polyangiitis (EGPA)?
Immunosuppression with corticosteroids
## Footnote
Plasmapheresis may be used in severe cases.
101
What is the previous term for Eosinophilic Granulomatosis with Polyangiitis (EGPA)?
Churg-Strauss Syndrome
102
What predisposition is commonly associated with EGPA?
Atopic predisposition
103
What are the three major stages of EGPA?
* Allergic Prodrome
* Eosinophilic
* Vasculitic
104
What symptoms are commonly present during the Allergic Prodrome stage of EGPA?
* Long standing atopy
* Asthma
* Allergic rhinitis
* Sinusitis
105
What occurs during the Eosinophilic stage of EGPA?
Peripheral blood eosinophilia occurs
106
What is a potential consequence of eosinophils in the Eosinophilic stage?
End-organ disease
107
What is a significant characteristic of the Vasculitic stage of EGPA?
Significant vasculitis of small arterial vessels
108
What are common complications associated with the Vasculitic stage of EGPA?
* Stenosis
* Thrombosis
* Ischaemia of end-organ tissue
109
Which organs are predominantly affected in the Vasculitic stage of EGPA?
* Lungs
* Kidneys
110
What are the classical findings in EGPA?
* Eosinophilia
* p-ANCA positivity
* Pulmonary infiltrates
* Mononeuritis
111
What is the treatment approach for EGPA?
* Immunosuppression
* High-dose corticosteroids for induction
* Cyclophosphamide in severe cases
* Long-term steroid-sparing agents like azathioprine or mycophenylate
112
What is a common cause of Cryoglobulinaemic Vasculitis?
Hepatitis C infection
113
What is the primary treatment for Cryoglobulinaemic Vasculitis if Hepatitis C is the cause?
Treatment of the underlying cause
114
What are common symptoms of Henoch-Schonlein Purpura?
* Rash affecting buttocks or ankles
* Renal involvement
115
What laboratory findings are associated with Henoch-Schonlein Purpura?
* Elevated inflammatory markers
* Normal platelets
116
What is the typical age demographic for Thromboangiitis obliterans?
Young adults who smoke
117
What is the main management strategy for Thromboangiitis obliterans?
Smoking cessation
118
What is the incidence of Systemic Lupus Erythematosus (SLE) in North America?
23-240 per 100,000 people
119
Which ethnic groups have higher incidence rates of SLE?
* African descendants
* Lower in Caucasians
120
What is the female to male ratio for SLE prevalence?
10:1
121
What environmental factors are associated with an increased risk of SLE?
* Smoking
* UV light exposure
* Low vitamin D levels
122
What role does abnormal cell death play in SLE?
It is involved in the pathophysiology of SLE
123
What is a significant immunological feature of SLE?
Presence of antinuclear antibodies (ANA)
124
What are the histological classes of renal involvement in SLE?
* Class I - minimal disease
* Class II - mesangial proliferation
* Class III - focal proliferative GN
* Class IV - diffuse proliferative GN
* Class V - membranous GN
125
What are common neurological manifestations of SLE?
* Aseptic meningitis
* Seizures
* Demyelination
* Peripheral neuropathy
126
What is the first-line treatment for all SLE patients?
Hydroxychloroquine
127
What are the side effects of long-term corticosteroid use in SLE?
Common side effects include weight gain and osteoporosis
128
Which drug is typically used for mild to moderate SLE?
Methotrexate
129
What is a major side effect of Mycophenolate mofetil (MMF)?
Diarrhoea
130
What is the role of Belimumab in SLE treatment?
Approved in addition to standard therapy
131
What is a prominent side effect of certain lupus treatments?
Photosensitivity
## Footnote
Photosensitivity is a common adverse effect seen in lupus patients undergoing certain treatments.
132
What is Mycophenolate mofetil (MMF) used for?
Moderate to severe lupus
## Footnote
MMF is beneficial for both induction and maintenance therapy.
133
What is the predominant side effect of Mycophenolate mofetil (MMF)?
Diarrhoea
## Footnote
Diarrhoea is the most common adverse effect associated with MMF.
134
What does the EXPLORE Trial indicate about Rituximab?
No benefit in inducing remission or maintenance
## Footnote
The EXPLORE Trial found that Rituximab does not help in achieving remission for lupus.
135
What is Belimumab approved for?
Poorly controlled disease
## Footnote
Belimumab is a BLys inhibitor that can be used alongside standard therapy.
136
In lupus nephritis, when is treatment indicated?
Class III-IV lupus nephritis
## Footnote
Treatment is specifically indicated for these classes of lupus nephritis.
137
What is the role of intravenous corticosteroids in lupus treatment?
Induce remission
## Footnote
Intravenous corticosteroids are often combined with Mycophenolate or Cyclophosphamide for severe cases.
138
What is the recommended management for maintaining lupus treatment?
Weaning corticosteroid dose slowly with continued Mycophenolate or Cyclophosphamide
## Footnote
Maintenance therapy typically involves a gradual reduction of corticosteroids while keeping other medications.
139
What is a significant risk of pregnancy with active lupus disease?
Life-threatening and high mortality
## Footnote
Active disease during pregnancy poses serious health risks to both mother and child.
140
What kind of contraception is contraindicated in antiphospholipid syndrome?
Oestrogen containing contraception
## Footnote
This type of contraception can increase the risk of thrombosis in patients with antiphospholipid syndrome.
141
What is the average onset age for scleroderma?
35-50 years old
## Footnote
Scleroderma typically presents in this age range.
142
What is the female to male ratio for scleroderma prevalence?
3:1
## Footnote
Scleroderma is more common in females compared to males.
143
What are the risk factors for developing scleroderma?
* Genetic predispositions
* Family history
* Environmental exposures (e.g., silica, vinyl chlorides)
## Footnote
Various genetic and environmental factors contribute to the risk of developing scleroderma.
144
What is the pathophysiology of scleroderma primarily associated with?
Upregulation of TGF-b
## Footnote
This leads to excessive collagen production and fibrosis.
145
What are the clinical features of limited scleroderma, previously referred to as CREST?
* Calcinosis
* Raynaud's phenomena
* Esophageal dysmotility
* Sclerodactyly
* Telangiectasia
## Footnote
These features characterize limited scleroderma.
146
What complication can arise from Raynaud's phenomenon in scleroderma?
Digital ischaemia resulting in ulcers
## Footnote
Complications of Raynaud's can lead to serious tissue damage.
147
What distinguishes diffuse scleroderma from limited scleroderma?
Skin involvement extends beyond the elbow to the trunk
## Footnote
Diffuse scleroderma has a more aggressive onset and broader skin involvement.
148
What is the management approach for pulmonary hypertension in scleroderma?
* Sildenafil
* Bosentan
* Ambrisentan
* Macitentan
* Iloprost
* IV Epoprostenol
## Footnote
Various agents are used to manage pulmonary arterial hypertension in scleroderma.
149
What is a poor prognostic indicator for scleroderma?
Male gender
## Footnote
Men generally have a worse prognosis in scleroderma compared to women.
150
What characterizes Mixed Connective Tissue Disease?
Presence of features from scleroderma, myositis, lupus, and rheumatoid arthritis
## Footnote
This overlap syndrome is defined by the presence of Anti-U1-RNP antibodies.
151
What is Sjogren's Syndrome characterized by?
Sicca symptoms (dry eyes and mouth)
## Footnote
It affects the exocrine glands and is more common in women.
152
What is the typical age of onset for Sjogren's Syndrome?
35-50 years of age
## Footnote
Most patients present within this age range.
153
What antibodies are most specific for Sjogren's Syndrome?
* Anti-SSA/Ro
* Anti-SSB/La
## Footnote
These antibodies are commonly associated with Sjogren's Syndrome.
154
What is the purpose of Schirmer's test?
Diagnose Sjogren's Syndrome
## Footnote
It measures the moisture level of tears to assess dry eyes.
155
What is often revealed by a biopsy of glandular tissue in Sjogren's Syndrome?
Lymphocytic infiltrates
## Footnote
This finding supports the diagnosis, although biopsy is not always required.
156
What is a major risk during pregnancy for patients with anti-SSA/Ro antibodies?
Neonatal lupus and congenital heart block
## Footnote
These complications can arise due to maternal antibodies affecting the fetus.
