Rheum Flashcards
Outline the Gel and Coombs hypersensitivity classification with examples
Type 1 - Anaphylactic - IgE binds mast cells
Type 2 - Cell bound - IgM/G binds antigens on cell surface
AIHA, ITP, acute transfusion reactions
Type 3 - Immune complex - Free antigen and antibody combine
SLE, EAA, post strep glomerulonephritis
Type 4 - Delayed - T cells
TB, GvHD, allergic contact dermatitis, GB syndrome
What are the features of dermatomyositis?
Skin: Photosensitive Macular rash Heliotrope rash (periorbital) Gottrons papules
Other: Proximal myopathy Raynauds Respiratory muscle weakness Interstitial lung disease Dysphagia
Which is the most sensitive antibody for dermatomyositis/
ANA (80%)
What is the first line management for ankylosing spondylitis?
NSAIDs and physio/exercise
What are the features of Reiter’s syndrome?
Uveitis
Urethritis
Arthritis
Why are chemo patients at increased risk of developing gout?
Increased urate production (both from drugs and lymphoproliferation in relevant cases)
What are the features of Marfan’s syndrome?
High ape index High arched palate Arachnodactyly Pes planus Pectus excavatum Scoliosis Dilatation of aortic sinuses MV prolapse
Pain pattern in OA?
Better in morning, worse on exercise
Which RA drug can be used safely in pregnancy?
Hydroxychloroquine
What are the features/Ix findings in polymyalgia?
Rapid onset in older patient Aching morning stiffness in proximal muscles WITHOUT weakness May have systemic Fx ESR >40 (V high) CK normal)
What are the risk factors for pseudogout?
Haemochromatosis Hyperparathyroidism Acromegaly Low mag low phos Wilson's disease
Which antibodies are associated with the two forms of systemic sclerosis?
Diffuse = scl70
Limited (central)=centromere
What is the pathology and inheritance pattern of osteogenesis inperfecta?
Collagen metabolism disorder
AutDom
What are the features of osteogenesis imperfecta?
Fractures following minor trauma
Blue sclerae
Deafness secondary to otosclerosis
Dental caries are common
What are the features of Ehler’s Danlos syndrome?
Elastic, fragile skin Joint hypermobility Easy bruising Aortic regurg and other valve disease Subarachs
What is a Beighton score used for?
Used to assess hypermobility - 5/9 marks a positive result
What are the common complications of RA?
IHD (commonest)
Pulmonary fibrosis
Keratoconjunctivitis sicca (dry eyes)
Osteoporosis
What are the 5 different types of psoriatic arthropathy?
AOPSD
Arthritis mutilans - v severe Oligoarthritis Polyarthritis - RA like - commonest Sacroiliitis DIP joint disease
Which radiographic sign is pathognomoic of pseudogout?
Chondrocalcinosis
What should happen with patients already taking allopurinol during an acute attack?
They should continue taking it through the acute inflammation
What is the main side effect of colchicine?
Diarrhoea
When should urate lowering therapy be started/
After the first attack
When should patients taking steroids be offered prophylactic bisphosphonate treatment/
T score < 1.5
WHich medications should be avoided in patients taking methotrexate and why?
Trimethoprim and Co-trimoxazole, as the combination risks bone marrow aplasia
Aspirin should also be avoided due to reduced excretion
What should be coprescribed with methotrexate?
5mg folic acid
You refer a 24-year-old female to rheumatology with intermittent pain and swelling of the metacarpal phalangeal joints for the past 3 months. An x-ray shows loss of joint space and soft-tissue swelling. Rheumatoid factor is positive and a diagnosis of rheumatoid arthritis is made. What initial management is she most likely to be given to help slow disease progression?
Methotrexate and a short course of pred
What are the features of adult onset Still’s disease?
Arthralgia Raised ferritin Salmon pink macpap rash Evening pyrexia LAopathy Seronegative
Allergy to which medication may be a contraindication to Sulfasalazine prescription?
Aspirin
What are the typical features of Behcets?
Oral ulcers Genital ulcers Anterior uveitis Thromboflebitis Arthritis
True or false, CK is raised in polymyalgia rheumatica/
False - it is normal
Aside from recurrent miscarriages, what are the features of antiphospholipid syndrome/
Thrombosis
Livedo reticularis (purple mottling)
Thrombocytopaenia
Which protein is deficient in Marfan’s syndrome?
Fibrillin
What is the first line management of Raynauds?
CCBs e.g. Nifedipine
In which condition might you see periarticular erosions/
RA
What is the main concerning complication of hydroxychloroquine therapy, and therefore what should be done on starting and as monitoring?
Bullseye retinopathy
Baseline opthalmological examination and annual screening is advised
What are the side effects of Azathioprine therapy?
Bone marrow suppression
N/V
Pancreatitis
What test should be done before commencing Azathioprine therapy?
TPMT
What are the 6As of ankylosing spondylitis?
Apical fibrosis AV block Achilles tendonitis Anterior uveitis Aortic regurgitation Amyloidosis
Which clinical test is assocaited with Ank Spon?
Schobers test <5cm
What is the typical presentation of polyarteritis nodosa?
Systemics + arthralgia Wt loss Livedo reticularis Haematuria and renal failure Hep B serology positive in 30%
Which vasculitis is associated with Hep B infection and has no respiratory features?
Polyarteritis nodosa
True or false, the CRP is raised in SLE.
False - its normal
What is referred lumbar spine pain and how do you assess it clinically?
Femoral nerve compression may cause referred pain in the hip
Femoral nerve stretch test may be positive - lie the patient prone. Extend the hip joint with a straight leg then bend the knee. This stretches the femoral nerve and will cause pain if it is trapped
Name some causes of drug induced lupus
Procainamide
Hydralazine
Isoniazid
Phenytoin
What is the management of OA?
Weight loss and exercise Paracetamol and TOPICAL NSAIDs 2nd line is oral NSAIDs, opioids, capsaicin cream and intrarticular corticosteroids \+PPI Can also take glucosamine
What is the cause and presentation of trochanteric bursitis?
Repeated movement of the iliotibial band
Presents with pain and tenderness over the lateral aspect of the thigh
Which of the following is a consequence of TNF alpha (Ertanecept) therapy?
Triggering Granulomatosis with polyangiitis Thrombocytosis Tendonitis Cardiomyopathy Reactivation of TB
Reactivation of TB
Outline the management of RA
Patients should be started on DMARDs as soon as possible
Now recommended a DMARD monotherapy +- short course of pred
Common DMARDs include Methotrexate, sulfasalazine, hydroxychloroquine, leflunomide
TNF inhibitors e.g. etanercept, infliximab, adalimumab
CD20 biologics e.g. Rituximab
Which hand joints are typically affected in osteoarthritis vs. rheumatoid arthritis?
OA: DIPs and carpometacarpals
RA: PIPs and metacarpophalyngeals
What should be advised regarding methotrexate and conception?
Both men and women should stop treatment at least 6 months before considering conception. Hydroxychloroquine is safe for use during pregnancy
What is the earliest clinical sign of AnkSpon/
Reduced lateral lumbar flexion
Combination of Azathioprine with which other drug gives a seriously increased risk of BM suppression?
Allopurinol
Describe the joint aspirate seen in rheumatoid arthritis
High WCC - predominantly PMNs
Yellow and cloudy
Absence of crystals
Which arthropathy is associated with IBD - and what is its serostatus and immunological typing?
Enteropathic arthritis is a seronegative spondyloarthropathy associated with HLA-B27
What is the relationship between alendronate and GFR?
Contraindicated with GFR less than 35
Which therapy is indicated if bisphosphonates not tolerated/CI’d?
Denosumab
Which syndrome is associated with reactive arthritis when there becomes ocular and renal involvement?
Reiter’s - HLA B27 +ve
What are the Xray findings in RA?
Early: Loss of joint space, juxta-articular osteoporosis, soft tissue swelling
Late: Periarticular erosion, subluxation
The concurrent use of methotrexate and which antibiotic may cause a fatal pancytopaenia?
Trimethoprim
Rx of acute reactive arthritis?
NSAIDs
Which cause of joint pain shows the most marked response to steroids, and are thus first line in its management/
Polymyalgia rheumatica
Which cause arthropathy is also known to occur as a paraneoplastic disease, and should therefore be investigated for cancer/
Dermatomyositis
Triad seen in Felty’s sydnrome/
RA
Splenomegaly
Low WCC
What demographic is Buergers disease common in, and what are its features?
Young male smokers
A 32-year-old man presents to the vascular clinic with symptoms of foot pain during exertion. He is a heavy smoker and has recently tried to stop smoking. On examination he has normal pulses to the level of the popliteal. However, foot pulses are absent. A diagnostic angiogram is performed which shows an abrupt cut off at the level of the anterior tibial artery, together with the formation of corkscrew shaped collateral vessels distally.
Allergy to which drug should not be started on sulfasalazine?
Co-trimoxazole
Bisphosphonates should be taken on a full or empty stomach?
Empty
A 25-year-old man presents with a painful, swollen left knee. He returned 4 weeks ago from a holiday in Spain. There is no history of trauma and he has had no knee problems previously. On examination he has a swollen, warm left knee with a full range of movement. His ankle joints are also painful to move but there is no swelling. On the soles of both feet you notice a waxy yellow rash.
What is the most likely diagnosis?
What is the rash?
Reactive arthritis
Keratoderma blenorrhagica
What causes leukonychia?
Hypoalbuminaemia
What can cause dactylitis?
Spondyloarthropathies - psoriactic and reactive arthritis Sickle cell disease TB Sarcoid Syphillis
High or low BMI is a RF for osteoporosis?
Low
What imaging should be done in RA patients pre-op and why?
Lateral and AP cervical spine radiographs due to the risk of atlantoaxial subluxation during surgery - which might lead to cord compression
What is a potential serious complication of penicillamine?
Membranous glomeulonephritis
A 71-year-old woman is diagnosed with polymyalgia rheumatica. She is started on prednisolone 15mg od. What is the most appropriate approach to bone protection?
Start alendronate and ensure calcium and Vit D repletion immediately - as the patient is starting long term steroids
What is second line management in AnkSpon?
TNF therapy
Which class of medication is associated with an increased risk of atypical stress fractures of the femoral shaft?
Bisphosphonates
