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Rheum Flashcards

1
Q

What is polymyositis?

How does it present?

A

Inflammation and destruction of type I and II muscle fibres due to cytotoxic lymphocytes

usually develops over 3-6 months with progressive, symmetrical proximal muscle wasting, tenderness + weakness
symmetrical non-erosive arthritis affects knees, wrists + hands - often morning stiffness

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2
Q

Who is affected by polymyositis? What causes it?

A

affects those in 20s
maybe autoimmune, coxsackie virus has been implicated

can be associated with SLE, RA and Sjogrens
can be non-metastatic complication of malignancy

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3
Q

How does dermatomyositis differ from polymyositis?

A

Cutaneous rash

can affect children

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4
Q

What are the endocrine causes of myopathy?

A

Corticosteroid-induced (Cushing’s or exogenous)
Thyroid (hypo + hyper)
Osteomalacia
B12/ folate deficiency

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5
Q

What are other secondary causes of myopathy?

A

Viral myalgias

Toxic myopathies: alcohol, drugs, statins, lithium

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6
Q

Investigations for widespread MSK pain

A

ESR: high in PMR, inflammatory arthritis, SLE, malign
Serum calcium: low in osteomalacia, high in malign
PTH
Serum ALP: raised in Paget’s and in response to inflamm
Immunology screen

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7
Q

How to approach widespread MSK pain

A

Do the joints look/ move normally? If not, consider inflamm arthritis

If yes, is their proximal myopathy?

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8
Q

How many fibromyalgia trigger points?

A

18

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9
Q

Management of fibromyalgia

A

Education/ reassurance
Physio/ exercise
CBT
Trial TCAs, meds for neuropathic pain

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10
Q

What age does SLE develop?

A

15-40 years

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11
Q

What % SLE sufferers have ANAs?

A

90%

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12
Q

Define SLE

A

Characterised by autoantibody to nuclear material

Widespread vasculitis that can affect most body systems

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13
Q

What involvement of SLE sufferers have skin involvement?

A

75%
malar rash
annular lesions
alopecia

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14
Q

What is drug-induced SLE: causes and presentation?

A

COCP and others
Milder than normal SLE
Kidney-sparing
settles on withdrawal of drug

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15
Q

What are the systemic features of SLE?

A

MSK: arthritis - myalgia - myositis

CNS: headaches - psychosis, depression, anxiety - seizures - neuropathies - chorea

CVS: pericarditis - myocarditis - endocarditis (Libmans-Sacks: non-infective vegetations)

Resp: pneumonitis (mimics pneumonia) - effusion - infarction

Renal: GN (late stages: important to monitor)

Haem: anaemia - thrombocytopenia

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16
Q

What kind of arthritis in SLE?

A

Polyarticular

deformity not due to joint erosion, due to tenosynovitis and fibrosis

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17
Q

What can cause flare-ups in SLE?

A

Stress - skin exposure - infection - COCP - other drugs

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18
Q

What are life-threatening conditions that can be caused by SLE flare-up?

A

Renal failure

Cerebral vasculitis

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19
Q

Investigations for SLE

A

Anti-dsDNA (v specific)
ANA (detected in most)
Anti-histone antibodies: often positive in drug-induced SLE (v specific)
Anti-Ro/La - associated with secondary Sjogens and pulm fibrosis (not v specific)
Antiphospholipid and anticardiolipin antibobodies (positive in 10-20% pts)

Urine for signs of nephritis

FBC: penias
U&Es: renal function
ESR/ CRP: may be high during flare-ups or even when feeling well

Others: skin biopsy, complement C3/4 (low), renal biopsy….

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20
Q

Management of SLE

A

Education: long sleeves, sunscreen

Mild: NSAIDs or anti-malarials

More severe: CS or clever stuff

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21
Q

Features of anti-phospholipid syndrome

A

Venous thrombosis
Arterial thrombosis
Spontaneous miscarriage
Thrombocytopenia (not severe enough to cause haemorrhage)

Others: migraine, epilepsy, chorea, leg ulcers, cardiac valve abnormalities

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22
Q

Management of antiphospholipid syndrome

A

Lifestyle advice to manage risk factors for thrombosis

If no clinical features, dont need to treat
If thrombosis, needs lifelong warfarin

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23
Q

What is Sjogrens?

A

Chronic autoimmune disease charactised by inflammation of exocrine glands: predominantly salivary and lacrimal

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24
Q

What is sicca syndrome?

A

Dry eyes/ mouth due to non-immune causes, eg smoking

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25
Causes of Sjogrens
Primary or secondary in association with RA, SLE, systemic sclerosis, polymyositis, PBC, chronic active hepatitis
26
Symptoms of Sjogrens
Keratoconjunctivitis, often bacterial infections Xerostomia, caries Vaginal dryness Low GI mucus: gastritis, oesophagitis Primary Sjogrens is systemic and can develop symptoms similar to SLE
27
Investigations for Sjogrens
RhF, and ANA often raised Sometimes antiphospholipids raised Anti-Ro/La and Ig often v high
28
Vasculitis with different BP in both arms
Takayasu arteritis
29
Presentation of osteogenesis imperfecta
V varying degrees
30
What is osteopetrosis?
Marble bone disease Failure of osteoclasts to resorb bones (bone marrow transplant is curative)
31
What is the T score?
Bone mineral density (osteoporosis)
32
Describe the histology in osteoporosis?
Increased osteoclastic resorption slowed osteoblast formation thinning of bone cortex trabeculae are attenuated with big Heversian canals
33
Modifiable risk factors for osteoporosis
poor calcium and vit D lack of exercise smoking alcohol excess
34
Non-modifiable risk factors for osteoporosis
``` Age Race (Caucasian, Asian) Female Early menopause Small size Family hx ```
35
Meds that can cause osteoporosis
CS, anticonvulsants, heparin
36
What does DEXA scan measure?
Bone density of lumbar spine and proximal femur | need 30% loss before seen on radiograph
37
What does serum biochemistry show in osteoporosis?
No abnormalities
38
Mx osteoporosis
Lifestyle Bisphosphonates other clever stuff
39
Rarer cause of rickets
Phosphate depletion (renal disease, liver failure, others)
40
Causes of vit D deficiency
low dietary intake, insufficient sun exposure, deranged liver or kidney metabolism, malabsorption (coeliac disease, small bowel resection)
41
Clinical features of rickets
Bowing of legs Overgrowth of costochondral junctions (forming a 'rachitic rosary') Widened epiphyses Flattened 'bossed' square skull or craniotabes (skull snaps back when pressed)
42
Clinical features of osteomalacia
Muscle and bone pain Spontaneous incomplete fractures in long bone and pelvis Proximal myopathy with waddling gait and Gower's sign
43
Biochem in Pagets
Raised ALP (ca, phos normal) Hydroxyproline in urine
44
Mx of Pagets
Bisphosphonates if symptomatic Maybe surgery (v vascular)
45
10% Pagets leads to which ca?
Osteosarcoma | poor prognosis, may need to amputate/ chemo
46
Why can Pagets lead to high-output HF?
New blood vessels forming shunts
47
Most common bug cause of osteomyelitis? | Others
Staph aureus (also strep spp, haemophilus influenzae) If immunocompromised: E.coli, Klebsiella, Pseudomonas etc.
48
How is osteomyelitis usually caused?
haematogenous spread | can also occur from infected wounds, open fractures, surgery
49
How to investigate for osteomyelitis?
Blood cultures Inflammatory markers Pus should be aspirated for MC&S x-ray may look normal for 7-10 days
50
What is Pott's disease?
TB osteomyelitis in thoracic or lumbar vertebrae
51
Causes primary OA
idiopathic | general wear and tear
52
How does OA appear o/e?
Swelling and effusion Joint deformity Creps on movement Wasting of supporting muscles due to limited use of joints
53
How does RA show on x-ray?
Soft tissue swelling, narrowing of joint spaces, subchondral cysts, juxta-articular erosions, may have osteopenic adjacent bone
54
Mx ank spond
NSAIDs | DMARDs have no place
55
What is reactive arthritis?
Aseptic, in response to infection at different site GI, urinary, Reite's...
56
What is enteropathic arthritis?
Related to IBD (20% pts) Peripheral asymmetrical mono-oligoarthritis Varies with severity of disease (eg bowel resection improves sx) Most x-rays/ bloods are normal mx by improving IBD Different to sacroilitits where unrelated to disease severity
57
Why do crystal arthropathies cause swelling?
neutrophils attack crystals
58
Causes of secondary gout?
``` Increased production of uric acid (increased cell turnover in ca, leukaemias after chemo) Impaired excretion (renal failure, chronic booze, diuretics) High dietary intake of purines ```
59
Where does urate come from?
Breakdown of DNA
60
What is chronic gouty arthritis?
After recurrent attacks - cartilage degeneration, synovial hyperplasia, secondary OA
61
Gout: Mx Prophylaxis
NSAIDs, eg colchine | allopurinal is prophylaxis
62
Describe crystals of pseudogout
Brick-shaped crystals that are positively bifringe...wotevs | gout are needle-shaped
63
Mx pseudogout
Pain relief | Joint aspiration/ CS
64
Where is the pain in De Quervain's tenosynovitis?
Radial styloid
65
What causes mallet finger?
Extensor tendon damage - DIP cannot fully extend
66
What causes dropped finger?
Extensor tendon rupture at wrist, so MCP cannot extend | primary or secondary to RA
67
Which elbow: tennis and golfer's
Tennis: lateral epicondylitis Golfers: medial (GM)
68
MoA bisphosphonates
Osteoclast inhibition
69
mx OA
lifestyle paracetamol and topical NSAIDs (knee, hand) oral NSAID/ PPI CS injection surgery
70
what can be reactivated with biological agents?
TB, hep B
71
what should be given for gout in renal disease?
CS
72
keratoderma blenorrhagica and circinate balanitis are associated with what
reactive arthritis
73
mx reactive arthritis
NSAIDs
74
which malignancy linked with SLE
non--Hodgkins
75
CREST
``` calcinosis raynauds oesophageal dysmotility sclerosis telangiectasia ``` this is limited sclerosis. also diffuse systemic sclerosis
76
antibodies associated with CREST
ant-centromere
77
antibodies associated with diffuse systemic sclerosis
anti-Scl-70
78
Raynaud disease vs syndrome
Disease is idiopathic | syndrome part of underlying condition
79
bloods to arrange in raynauds
ANA (90%) anti-centromere (CREST) Anti Scl-70 (diffuse) Anti-RNA polymerase III (increased risk of renal crises)
80
antibodies in polymyositis
anti-Jo-1 | and elevated CK
81
p-ANCA
Churg-Strauss (associated with asthma)

Medicine (30 decks)

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