rheum Flashcards
rheumatoid arthritis, splenomegaly and low WCC
felty’s syndrome
test when starting on azathioprine
Thiopurine methyltransferase (TPMT) deficiency is present in about 1 in 200 people and predisposes to azathioprine related pancytopaenia
nausea/vomiting
pancreatitis
increased risk of non-melanoma skin cancer
A significant interaction may occur with allopurinol and hence lower doses of azathioprine should be used.
causes of dactylitis
spondyloarthritis: e.g. Psoriatic and reactive arthritis
sickle-cell disease
other rare causes include tuberculosis, sarcoidosis and syphilis
DAS 28
disease activity score in 28 joints fo rRA
meds to avoid with methotrexate
Trimethoprim and co-trimoxazole, anti-folate antibiotics
mx of gout
acute: nsaids and colchicine +- PPI
long term: allopurinol 2nd line febuxostat
ix for osteomalacia
low 25(OH) vitamin D (in 100% of patients, by definition) raised alkaline phosphatase (in 95-100% of patients) low calcium, phosphate (in around 30%) x-ray: children - cupped, ragged metaphyseal surfaces; adults - translucent bands (Looser's zones or pseudofractures)
mx of ankspond
encourage regular exercise such as swimming
NSAIDs are the first-line treatment
physiotherapy
the disease-modifying drugs which are used to treat rheumatoid arthritis (such as sulphasalazine) are only really useful if there is peripheral joint involvement
the 2010 EULAR guidelines suggest: ‘Anti-TNF therapy should be given to patients with persistently high disease activity despite conventional treatments’ (2 NSAIDS)
research is ongoing to see whether anti-TNF therapies such as etanercept and adalimumab should be used earlier in the course of the disease
drugs and antibodies in drug induced lupus
procainamide
hydralazine
Less common causes
isoniazid
minocycline
phenytoin
antihistone antibodies
causes of positive anca
cANCA - granulomatosis with polyangiitis (Wegener’s granulomatosis)
pANCA - Churg-Strauss syndrome + others (see below)
Other causes of positive ANCA (usually pANCA)
inflammatory bowel disease (UC > Crohn’s)
connective tissue disorders: RA, SLE, Sjogren’s
autoimmune hepatitis
marfans abnormalirty
chromosome 15 that codes for the protein fibrillin-1
acromegaly pts can get
pseudogout
antibodies is most specific for limited cutaneous systemic sclerosis?
anticentromere
comlication of chemotherapy
Chemotherapy patients are at increased risk of gout from increased urate production
dermatomyositis associated with
breast, ovarian and lung ca
dermatomyositis antibodies
antibodies against histidine-tRNA ligase (also called Jo-1)
antibodies to signal recognition particle (SRP)
anti-Mi-2 antibodies
t score for bisphosphonates if on steroids
t -1.5
more than 7.5mg pred for 3 months
mx of reactive arthritis
symptomatic: analgesia, NSAIDS, intra-articular steroids
sulfasalazine and methotrexate are sometimes used for persistent disease
symptoms rarely last more than 12 months
mx of OA
- weight loss advice
- paracetamol +-topical NSAIDS
- 2lin: oral NSAIDs
- supports, shock absorbers
- joint replacement
features of antiphospholipid syndrome
venous/arterial thrombosis recurrent fetal loss livedo reticularis thrombocytopenia prolonged APTT other features: pre-eclampsia, pulmonary hypertension
ehlers danlos
type 3 collagen
elastic, fragile skin
joint hypermobility: recurrent joint dislocation
easy bruising
aortic regurgitation, mitral valve prolapse and aortic dissection
subarachnoid haemorrhage
angioid retinal streaks
(paradoxically) prolonged APTT + low platelets
antiphospholipid syndrome
s/e of hydroxychloroquine
bull’s eye retinopathy - may result in severe and permanent visual loss
recent data suggest that retinopathy caused by hydroxychloroquine is more common than previously thought and the most recent RCOphth guidelines (March 2018) suggest colour retinal photography and spectral domain optical coherence tomography scanning of the macula
baseline ophthalmological examination and annual screening is generally recommened
A contrast to many drugs used in rheumatology, hydroxychloroquine may be used if needed in pregnant women.
ank spond dx criteria
Sacroilitis on imaging* plus 1 or more spondyloarthritis features†
or
HLA-B27 plus 2 or more other spondyloarthritis feature
polyarteritis nodosa fx
fever, malaise, arthralgia
weight loss
hypertension
mononeuritis multiplex, sensorimotor polyneuropathy
testicular pain
livedo reticularis
haematuria, renal failure
perinuclear-antineutrophil cytoplasmic antibodies (ANCA) are found in around 20% of patients with ‘classic’ PAN
hepatitis B serology positive in 30% of patients
behcets features
classically: 1) oral ulcers 2) genital ulcers 3) anterior uveitis
thrombophlebitis and deep vein thrombosis
arthritis
neurological involvement (e.g. aseptic meningitis)
GI: abdo pain, diarrhoea, colitis
erythema nodosum
different spondyloarthropathies
ankylosing spondylitis
psoriatic arthritis
Reiter’s syndrome (including reactive arthritis)
enteropathic arthritis (associated with IBD
mx RA
DMARD monotherapy +/- a short-course of bridging prednisolone. In the past dual DMARD therapy was advocated as the initial step.
poor response to 2 DMARDS- tnf inhibitors
measure with DAS28 and CRP
pencil and cup dips and pips
plantar spur
psoriatic arthritis
Antisynthetase syndrome fx
autoantibodies against aminoacyl-tRNA synthetase e.g. anti-Jo1.
It is characterised by myositis interstitial lung disease thickened and cracked skin of the hands (mechanic's hands) Raynaud's phenomenon
how to test if hip pain is referred from back
femoral nerve stress test
complication of RA in surgery
atlantoaxial subluxation, screen with 2 view c spine x rays
complication of penicillamine (chelating agent for wilsons)
membranous glomerulonephritis (nephrotic syndrome)
bisphonsphonate holidays not allowed if
ge >75 Glucocorticoid therapy Previous hip/vertebral fractures Further fractures on treatment High risk on FRAX scoring T score
ank spond associations
Apical fibrosis Anterior uveitis Aortic regurgitation Achilles tendonitis AV node block Amyloidosis
RA XRAY
Early x-ray findings
loss of joint space
juxta-articular osteoporosis
soft-tissue swelling
Late x-ray findings
periarticular erosions
subluxation
score to assess hypermobility
beighton score
patients who are allergic to x may also react to sulfasalazine
aspirin
reactive artritis aspirate appearance
cloudy yellow, culture negative, no crystals, WCC 20,000/mm3
interferon features and uses
Interferon-alpha
produced by leucocytes
antiviral action
useful in hepatitis B & C, Kaposi’s sarcoma, metastatic renal cell cancer, hairy cell leukaemia
adverse effects include flu-like symptoms and depression
Interferon-beta
produced by fibroblasts
antiviral action
reduces the frequency of exacerbations in patients with relapsing-remitting MS
Interferon-gamma
predominately natural killer cells. Also by T helper cells
weaker antiviral action, more of a role in immunomodulation particularly macrophage activation
may be useful in chronic granulomatous disease and osteopetrosis
osteogenesis imperfecta
Overview
autosomal dominant
abnormality in type 1 collagen due to decreased synthesis of pro-alpha 1 or pro-alpha 2 collagen polypeptides
Features presents in childhood fractures following minor trauma blue sclera deafness secondary to otosclerosis dental imperfections are common
