Rheum Flashcards
What is monoarthritis
1 joint involved
What is oligoarthritis
<= 5 joints affected
What is polyarthritis
> 5 joints affected
Give examples of monoarthritis
gout
septic
osteo
Give examples of oligoarthritis
reactive psoriatic gout osteo ankylosing spondylitis
Give examples of polyarthritis
symmetrical:
RA
osteo
asymmetrical
reactive
psoriatic
What conditions is Raynaud’s present in
SLE
polumyositis
dermatomyositis
State some signs in the hands that are typical of RA
Z deformity of thumb ulnar deviation swan neck deformity boutonniere deformity nail pitting nail fold vasculitis
What is Z deformity of the thumb
MCP flexion
IP hyperextension
What is swan neck deformity
PIP hyperextension
DIP flexion
What is Boutonniere deformity
PIP flexion
DIP extension
What are the key investigations in suspected RA?
Bloods: FBC, CRP, ESR, U+E, LFT, RF, ANA, anti-cyclic citrullinated peptide antibodies
Imaging: XR hands and feet, CXR, US/MRI joints
What can happen to CRP and ESR in RA?
inflammatory markers, so raised
Does a raised RF diagnose RA?
no!
can be raised in other infam diseases and in healthy!
What can a raised ANA (antinuclear antibodies) suggest?
SLE
RA
healthy!
What are the systemc problems causes in RA
lympadenopathy
pulmonary fibrosis
peripheral nerve entrapment
What vaccines need to be given to those taking DMARDs?
influenza - annual
pneumococcal - 10y
live vaccines contraindicated
Does RF or anti-CCP antibodies have a greater specificity for RA?
anti-CCP antibodies
What factors indicate a poor prognosis for RA?
rheumatoid factor positive poor functional status at presentation HLA DR4 X-ray: early erosions (e.g. after < 2 years) extra articular features e.g. nodules insidious onset anti-CCP antibodies
What complications can methotrexate cause?
liver cirrhosis
pneumonitis
myelosupression
What complications can prednisolone cause?
Cushingoid features Osteoporosis Impaired glucose tolerance Hypertension Cataracts
What monitoring needs to happen in methotrexate treatment
Monitoring of FBC & LFTs is essential due to the risk of myelosuppression and liver cirrhosis
How long does is take for DMARDs to produce a full response
2-6m
Why are DMARDs the best treatment for inflammatory arthritis
suppress disease progress
control the signs and symptoms
limit joint damage.
What treatment should be initiated in newly diagnosed active rheumatoid arthritis,
combination of DMARDs (including methotrexate and at least one other DMARD)
a short-term corticosteroid,
within 3 months of the onset of persistent symptoms.
When should you consider changing DMARD for a patient?
If a disease-modifying anti-rheumatic drug does not lead to an objective benefit within 6 months, it should be replaced by a different one.
When can a TNF inhibitor be prescribed in RA
an inadequate response to at least two DMARDs including methotrexate
What type of hypersensitivity reaction is SLE?
type III
What are someof the risk factors for SLE?
afro-caribbean
exposure to sunlight
drugs:
EBV
What are the key initial features of SLE?
fever rash mouth ulcers joint pain lympadenopathy
What are key immunological findings in SLE?
antinuclear antibody (ANA) ds-DNA antibody RF anti-Smith: anti-U1 RNP, SS-A (anti-Ro) and SS-B (anti-La)
Which immunological finding is most sensitive for SLE?
ANA (95%)
ds-DNA (70%)
anti-Smith 30%
Which immunological finding is most specific for SLE?
ds-DNA (90%)
anti-Smith (90%)
ANA
What systems are affected with symptoms of SLE?
skin serosa mucosa joints kidneys brain blood immune!
How does SLE affect the skin
malar rash - butterfly, does not affect nasolabial folds
discoid rash
photosensitivity
How does SLE affect the mucosa
ulcers in mouth, nose, vagina
Describe the discoid rash in SLE
in sun exposed areas
scaly, erythematous, well demarcated rash
Lesions may progress to become pigmented and hyperkeratotic before becoming atrophic
How does SLE affect the serosa
serositis!
eg. pleuritis
pericarditis
How does SLE affect the joints
arthralgia
non-erosive arthritis - >=2 peripheral joints
How does SLE affect the kidneys
proteinuria
glomeulonephritis
How does SLE affect the blood
anaemia (haemolytic)
thrombocytopenia
leukopaenia
How does SLE affect the brain
seizures
psychosis
anxiety and depression
How does SLE affect the immune system
ANA
anti ds-DNA
anti-Smith
anti-phospholipid
What are the diagnostic criteria of SLE?
4 of the following present:
malar rash dicoid rash photosensitivity oral ulcers serositis proteinuria/glomerulonephritis joint problems CNS problems haematological problems immuniological probs (anti ds-DNA, anti-Smith) ANA
What tests can be used in monitoring SLE?
anti ds-DNA -
complement levels - low C3/C4 in active disease due to formation of immune complexes
ESR raised in flare up
Which drugs can cause SLE?
chlorpromazine, methyldopa, hydralazine, isoniazid, d-penicillamine
Describe the treatment of SLE if there is no major organ involvement
anitmalarials - hydroxychloroquine
low dose steroids
azathioprine/methotrexate
Describe the treatment of SLE if there is major organ involvement
cyclophosphamide
mycophenylate mofetil
calcineurin inhibitors eg. ciclosporin/tacrolimus
What diseases is there an increased risk of in SLE?
cardiovascular disease
osteoporosis
What is antiphospholipid syndrome?
antibodies affect coagulation leading to pro-thrombotic state
What problems are caused by antiphospholipid syndrome
CLOTS
Coagulation defect
Livedo reticularis
Obstetric - miscarriage
Thrombocytopenia
What is livedo reticularis
mottled reticulated vascular pattern that appears as a lace-like purplish discoloration of the skin. The discoloration is caused by swelling of the venules owing to obstruction of capillaries by small blood clots.
What joints does ankylosing spondylitis most commonly affect?
sacroiliac
spine
Which HLA is most commonly associated with ank spond?
HLA B27
Is ankylpsing spondylitis sero negative or positive?
sero negative
What is the typical presentation of ankylosing spondylitis
20/30y male
gradual onset back pain and stiffness
worse at night, improves with movement
pain radiates to thighs and buttocks
Why is there a progressive loss of spinal movement in ank spond?
spinal fusion!
What are some features of ank spond on spinal examination?
reduced lateral flexion of lumbar spine reduced forward flexion Schober's test <5cm decreased thoracic expansion sacroilitis
neck hyperextension
thoracic kyphosis
question mark posture
What are some systemic symptoms of ank spond?
apical lung fibrosis, Acute iritis Aortic regurgitation Achilles tendonitis AV node block Amyloidosis and cauda equina syndrome onycholysis, fatigue,
What is Schober’s test? What disease is it used to test in?
line is drawn 10 cm above and 5 cm below L5/the back dimples (dimples of Venus). The distance between the two lines should increase by more than 5 cm when the patient bends as far forward as possible
Ankylosing spondylitis
What is the first feature of ankylosing spondylitis on xray?
sacroilitis - subchondral erosions, sclerosis
What are the later features of ank spond on xray?
squaring of lumbar vertebrae
‘bamboo spine’ (late & uncommon)
syndesmophytes:
apical fibrosis on CXR
What is the management of ank spond?
Exercise!
physio - maintain posture and mobility
NSAIDs for pain
TNF alpha inhibitors in severe cases which failed to respond to NSAIDs
What can spirometry show in ankylosing spondylitis?
a restrictive defect due to a combination of pulmonary fibrosis, kyphosis and ankylosis of the costovertebral joints.
What are syndesmophytes?
calcification between corners of vertebrae due to ossification of outer fibers of annulus fibrosus
What are the signs of systemic sclerosis in the hands?
Swelling (non-pitting oedema) of fingers and toes
Skin becomes hard and thickened - this may limit joint movement or cause joint contractures
Swelling and sclerosis reduce hand movements, so patients may be unable to make a fist, or to place the palmar surfaces together - the ‘prayer sign’.
Fingertips may have pitting, ulcers or loss of bulk from finger pads.
Raynaud’s phenomenon.
What are the key pathophysiological features of systemic sclerosis?
excessive collagen deposition by fibroblasts
damages blood vessels
What are the first features of systemic sclerosis
skin thickening and hardening in hands or face
Raynaud’s
oesophageal symptoms
What are the three kinds of systemic sclerosis?
limited
diffuse
scleroderma
Describe the features of limited systemic sclerosis
affects face, hands and feet CREST slow onset, slow progression affects internal organs anti-centromere antibodies
What does CREST stand for? What does this mean?
Calcinosis - calcium deposits in skin
Raynaud’s
Esophageal dysmotility
Sclerodactyly - tightening of skin in fingers
Telangiectasia - dilation of capillaries in skin
Describe the features of diffuse systemic sclerosis
affects upper arm, trunk and thighs
more rapid onset and progression
scl-70 antibodies
Describe scleroderma
no multi organ involvement
localised thickening of areas of skin - plaques or linear
What are the facial features of systemic sclerosis
Tightening of facial skin. Tight lips (microstomia)
If systemic sclerosis is suspected, which antibodies should be tested for?
scl-70
anti-centromere
Anti-RNA polymerase III
How is systemic sclerosis managed?
exercise/physio
DMARDs: methotrexate, mycophenolate mofetil or cyclophosphamide
monitor BP and renal function
ACEi if renal failure
Which joints does psoriatic arthritis commonly affect
DIP
symmetrical polyarthritis
sacroilitis
What percentage of people with psoriasis develop arthropathy?
10%
What changes occur in the hands in psoriatic arthritis>
pitting
onycholysis
dactylitis - sausage fingers
How is psoriatic arthritis managed?
NSAIDs
methotrexate or ciclosporin if skin disease alsoproblemaic
resistant = anti-TNF
local steroid injections to reduce joint inflammation
What is Sjogren’s syndrome
autoimmune disorder affecting exocrine glands resulting in dry mucosal surfaces.
What are the symptoms of sjogren’s
dry eyes: keratoconjunctivitis sicca
dry mouth
vaginal dryness
What immunological findings are associated with sjogren’s?
RF - 100%
ANA - 70%
anti-Ro - 70%
Anti-La - 30%
What is Schirmer’s test?
holding filter paper near conjunctival sac to measure tear production
What is the pathophysiology of Gout
deposition of monosodium urate crystals in the synovium due to hyperuricaemia
What are some factors that increase the risk of gout
increased production
- cytotoxic drugs,
- psoriasis
- eating liver, kidneys, oily fish, yeast
decreased exretion
- diuretics (thiazide and loop)
- CKD
what is the differential diagnosis for gout
septic arthritis reactive arthritis pseudogout trauma cellulitis
what are the symptoms of gout
acute severely painful swollen joint (peak at 12hrs, lasts for 6-10d)
What can trigger an attack of gout
alcohol
stress
trauma
exercise
what are some signs of chronic gout
urate tophi
uric acid renal stones
what investigations should be carried out in suspected gout
FBC
joint aspiration - MC+S
xray joint
What are the signs of gout on xray
subcutaenous tissue swelling
punched out juxta articular erosions with sclerotic margins
preserved joint space
no periarticular osteopaenia
why do you need to do an FBC in gout?
a myeloproliferative disorder could be the cause - increased cell turnover
What is the treatment for an acute episode of gout?
NSAIDs, steroid injection
colchicine
What is the treatment for the prophylaxis of gout?
not started until 2 weeks since resolution of flare up
allopurinol
What are the indications for prophylaxis of gout
two episodes within a year tophi renal disease renal stones prophylaxis if taking cytotoxins or diuretics
