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Year 5 > Rheum - clinical > Flashcards

Rheum - clinical Flashcards

1
Q

Which joints does RhA most commonly affect?
Which joints does it never affect?
Common presentation in the hands?

A

MCPs and PIPs
Never affects DIPs (this is osteoarthritis)
Symmetrical, swollen, painful stiff joints

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2
Q

Extra-articular features of RhA?

A 
rheumatoid nodules
pericaridal/pleural effusion
scleritis
fibrosing alveolitis
vasculitis
carpal tunnel syndrome
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3
Q

What is Felty’s syndrome?

A

RhA + splenomegaly + neutropenia

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4
Q

On examination of RhA hands, what might you find?

What scar patterns on observation might you find?

A

Early - swollen/synovitis of MCP, PIP, wrist (symmetrical)
Later - ulnar deviation of fingers, dorsal wrist subluxation, Boutonniere, swan-neck deformities of fingers, Z-deformity of thumbs
Scars: palmar surface hand - carpal tunnel release; over MCP joints from joint replacement; Darrachs procedure (removal of ulnar styloid)

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5
Q

In what conditions might RF be raised?

A

RhA

Sjogren’s syndrome

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6
Q

Treatment for new diagnosis of RhA?

A

Aggressive + early treatment with DMARDs eg methotrexate

COMBINATION OF DMARDS USED AS FIRST LINE

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7
Q

What antibiotic should be avoided with methotrexate? Why?

A

Trimethoprim

Both act on folate pathway leading to pancytopenia

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8
Q

What should patients avoid whilst on anti-TNF therapy?

A

Live vaccines eg MMR, yellow fever, polio, BCG

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9
Q

What diagnostic classifications are used for RhA?

A

ACR and EULAR

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10
Q

ACR diagnostic criteria?

A 
4 out of 7 of:
morning stiffness (>1 hour lasting >6 weeks)
arthritis of >=3 joints
arthritis of hand joints
symmetrical arthritis
rheumatoid nodules
\+ve rheumatoid factor
radiographic changes
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11
Q

What does a direct Coombs test test for?

A

AIHA

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12
Q

5 hallmarks in the joints of psoriatic arthritis?

A

1) spondyloarthropathy (joint disease of vertebral column)
2) rheumatoid-like arthropathy
3) large joint monoarthritis
4) oligoarthritis (between 1 and 4 joints)
5) seronegative arthritis

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13
Q

Extraarticular features of psoriatic arthritis?

A

Enthesitis (eg palmar fascitis)
Uveitis
Nail change - pitting, onycholysis
dactilytis (“swollen like sausages”) - whole digit swells up

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14
Q

Who can you assess sacroilitis of spine clinically?

A

Scherber’s test (10cm above dimples of Venus and 5 cm below, then ask patient to bend forward to touch toes without bending knees - movement of greater than 5cm = normal. less than 5cm = sacroilitis)

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15
Q

Risk factors for gout?

A

Ingesting lots of uric acid
Kidney failure
Diuretics (loop and thiazide; interfere with excretion of uric acid in distal tubules)
Chemotherapy (increased purine metabolism from DNA breakdown as lots of cell lysis - often given medication prophylacticly)
Psoriasis - incerased cell turnover

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16
Q

Crystals appear negatively birefringent under microscopy. What is the disease?

A

Gout

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17
Q

Patient presents with hot, red, inflamed big toe. Pain = 10/10, so great is the pain that they don’t want the bedsheets over it. How would you treat initially?

A

Colchicine or NSAIDs (if no kidney disease)

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18
Q

Chronic treatment for gout?

A

allopurinol

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19
Q

Patient started on sulfasalazine for worsening rheumatoid arthritis. They develop a fever, sore throat and fatigue around a week after they start the drug. Extremely painful ulcers appear in the mouth, lips, genital and anal regions.

What is the problem? Describe the pathophysiology. Give 2 other examples of drugs which might cause a similar reaction?

A

Stevens-Johnson Syndrome, a form of toxic epidermal necrolysis (TEN)
Keratinocyte apoptosis mediated by CTL (CD8) causes epidermis to separate from dermis at the epidermal-dermal junction. (Delayed hypersensitivity reaction)
eg anticonvulsants, antibiotics, antifungals, antretrovirals, azathioprine, allopurinol, corticosteroids.
Manage: optimal wound care, nutrition, critical care, pain management

20
Q

Colour changes seen in hand of Raynaud’s?

A

white then blue then red

21
Q

What diseases are associated with secondary Raynaud’s?

A

Connective tissue disease (especially scleroderma: limited cutaneous systemic sclerosis (CREST)/ diffuse cutaneous systemic sclerosis)
Vasculitis
Malignancy
Peripheral vascular disease

22
Q

Symptoms of limited cutaneous systemic sclerosis?

A 
CREST + scleroderma (tightness of skin) limited to hands
Calcinosis
Raynaud's
oEsophgeal dysmotility
Sclerodactyly
Telangiectasia
23
Q

What is the most common cause of mortality secondary to scleroderma?

A

Pulmonary hypertension

24
Q

What antibodies are associated with diffuse cutaneous systemic sclerosis?

A

Anti-Scl70 antibodies (anti-topoisomerase I) = a form of anti-nuclear antibody (ANA)
[I think there may be more as well…]

25
Q

What antibodies are associated with limited cutaneous systemic sclerosis?

A

Anti-centromere antibodies

26
Q

What might steroids precipitate in a patient with scleroderma?

A

Renal crisis

27
Q

What condition is associated with “bamboo spine” on x-ray?

Describe the appearance.

A

Ankylosing spondylitis
Vertebral body fusion by marginal syndesmophytes (calcification or heterotopic ossification inside a spinal ligament or annulus fibrosus)
Radiographic appearance thin, curved, radio-opaque spicules that completely bridge adjoining vertebral bodies

28
Q

What is associated with “dagger spine” appearance on x-ray? What is the cause?

A

Ankylosing spondylitis

Interspinous ligament calcification

29
Q

Treatment for ankylosing spondylitis? How would the regimen be changed with peripheral involvement?

A

Physiotherapy + NSAIDs or anti-TNF therapy.

Add DMARDs - they are useless for spinal changes

30
Q

How is the severity and progression of ankylosing spondylitis assessed?

A

Using the BASDAI, subjective measurement by patient

31
Q

What is the most common gene abnormality in ankylosing spondylitis?

A

HLA-B27 (around 90% of Caucasians with AS have HLA-B27 abnormality)

32
Q

Thoracic spine symptoms (pain and stiffness) and elderly age of onset (60/70 year old), what is the most likely diagnosis.
What changes are likely to be seen on x-ray?

A

diffuse idiopathic skeletal hyperostosis (DISH)
NOT ANKYLOSING SPONDYLOSIS - usually younger age of onset and affecting lumbar spine.
Flowing ossification (florid, flowing ossification along the anterior or right anterolateral aspects of at least 4 contiguous vertebrae)

33
Q

34 year old man presents with tender, red lumps on his shins with bilateral ankle arthritis
Most likely diagnosis?
What investigations required?

A

Sarcoidosis (the skin appearnce is erythema nodosum [panniculitis - inflammation of subcutaneous adipose tissue])
CXR (bilateral hilar lymphadenopathy), lung function, serum ACE (can be used as a treatment marker)

34
Q

What is lupus pernio?

A

Cutaneous sarcoid on the face

35
Q

Antibody for SLE?

A

anti-dsDNA

36
Q

When would CRP IN ADDITION TO ESR be raised in someone with lupus?

A

concurrent infection

In the presence of pleurisy or pericardial involvment

37
Q

When would complement be most usefully investigated in the management of SLE?

A

Follow response to treatment and predictor of flair-up

38
Q

What is Libman-Sacks endocarditis? What causes it?

A

Inflammatory vegetations on cardiac valves, typically the mitral valve
SLE

39
Q

Difference between Jaccouds arthritis and RhA?

A

Deforming non-erosive arthropathy characterised by ulnar deviation of the fingers.
non-erosive; tendon inflammation and tendon contractures only, no bone involvement

40
Q

What rashes may be seen in a 40 year old with proximal muscle weakness?

A

(Dx is dermatomyositis)
Gottron’s papules - discrete erythematous papules overlying the MCP and PIP joints
Heliotrope rash - purple coloured rash over upper eyelids

41
Q

What antibodies are most strongly associated with dermatomyositis?

A

Anti-MI-2 antibodies

42
Q

What antibodies are most strongly associated with polymyositis?

A

Anti-JO-1 antibodies

43
Q

What complication should be screened for at presentation and annually for 3 years in a patient diagnosed with dermatomyositis?

A

Malignancy. Most common are GI and ovarian

44
Q

What is the difference between myositis, polymyalgia rheumatica and fibromyalgia?

A

INFLAMMATORY MARKERS, CLINICAL MUSCLE WEAKNESS, PAIN, CREATINE KINASE

myositis and PMR are inflammatory conditions with raised inflammatory markers
CK rise in myositis - autoimmune destruction of muscle fibres
PMR - no actual weakness on examination, pain and stiffness predominate
myositis - muscle weakness apparent but often no pain
fibromyalgia - pain (neuropathic) and perceived weakness but no raised inflammatory markers

45
Q

diagnostic criteria for myositis?

A

2 of 3 from: muscle biopsy (autoimmune destruction of muscle fibres), EMG, MRI (muscle oedema)

Year 5 (9 decks)

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