Rheum II

Question 1

PMR demographics

Answer 1

It usually affects old adults (above 50 years)
More common in women
More common in caucasians

Question 2

Core features of PMR

Answer 2

Bilateral shoulder pain that may radiate to the elbow
Bilateral pelvic girdle pain
Worse with movement
Interferes with sleep
Stiffness for at least 45 minutes in the morning

Question 3

Other features of PMR

Answer 3

Systemic symptoms such as weight loss, fatigue, low grade fever and low mood
Upper arm tenderness
Carpel tunnel syndrome
Pitting oedema

Question 4

Diagnosis of PMR

Answer 4

Clinical presentation and response to steroids

Inflammatory markers (ESR, plasma viscosity and CRP) are usually raised however normal inflammatory markers do not exclude PMR.

Question 5

Treatment of PMR

Answer 5

15mg of prednisolone per day.

Question 6

Symptoms of GCA

Answer 6

Severe unilateral headache typically around temple and forehead
Scalp tenderness my be noticed when brushing hair
Jaw claudication
Blurred or double vision
Irreversible painless complete sight loss can occur rapidly

Question 7

Diagnosis of GCA

Answer 7

Clinical presentation
Raised ESR: usually 50 mm/hour or more
Temporal artery biopsy findings

Question 8

Temporal artery biopsy findings in temporal artery biopsy

Answer 8

: Multinucleated giant cells

Question 9

FBC in GCA

Answer 9

normocytic anaemia and thrombocytosis

Question 10

Mx of GCA

Answer 10

Steroids
Aspirin
PPI

Refer to vascular, rheum, ophthalmologist

Question 11

Late complications of GCA

Answer 11

Relapses of the condition are common
Steroid related side effects and complications
Cerebrovascular accident (stroke)
Aortitis leading to aortic aneurysm and aortic dissection

Question 12

Key ix for diagnosis of myositis

Answer 12

CK blood test

Question 13

Causes of raised CK

Answer 13

Rhabdomyolysis
Acute kidney injury
Myocardial infarction
Statins
Strenuous exercise

Question 14

What can polymyositis or dermatomyositis be caused by

Answer 14

Underlying malignancy. This makes them paraneoplastic syndromes. The most common associated cancers are:

Lung
Breast
Ovarian
Gastric

Question 15

Presentation of dermatomyositis/polymyositis

Answer 15

Muscle pain, fatigue and weakness
Occurs bilaterally and typically affects the proximal muscles
Mostly affects the shoulder and pelvic girdle
Develops over weeks

Question 16

Dermatomyositis skin features

Answer 16

Gottron lesions (scaly erythematous patches) on the knuckles, elbows and knees
Photosensitive erythematous rash on the back, shoulders and neck
Purple rash on the face and eyelids
Periorbital oedema (swelling around the eyes)
Subcutaneous calcinosis (calcium deposits in the subcutaneous tissue)

Question 17

Auto-antibodies present in dermatomyositis

Answer 17

Anti-Jo-1 antibodies: polymyositis (but often present in dermatomyositis)
Anti-Mi-2 antibodies: dermatomyositis.
Anti-nuclear antibodies: dermatomyositis.

Question 18

Definitive diagnosis of dermatomyositis

Answer 18

Muscle biopsy

Question 19

Mx of dermatomyositis/polymyositis

Answer 19

Rheum referral
Corticosteroids
Rule out cancer

Immunosuppressants (such as azathioprine)
IV immunoglobulins
Biological therapy (such as infliximab or etanercept)

Question 20

Autoantibodies associated with antiphospholipid syndrome

Answer 20

Lupus anticoagulant
Anticardiolipin antibodies
Anti-beta-2 glycoprotein I antibodies

Question 21

Mx of antiphospholipid syndrome

Answer 21

Long term warfarin with an INR range of 2-3 is used to prevent thrombosis (3-4 may be used with recurrent thrombosis).

Pregnant women are started on low molecular weight heparin (e.g. enoxaparin) plus aspirin to reduce the risk of pregnancy complications. Warfarin is contraindicated in pregnancy.

Question 22

What is sjogren’s syndrome

Answer 22

This is an autoimmune condition that affects the exocrine glands. It leads to the symptoms of dry mucous membranes, such as dry mouth, dry eyes and dry vagina.

Question 23

Auto-antibodies associated with sjogren’s syndrome

Answer 23

anti-Ro and anti-La antibodies

Question 24

Test used to diagnose sjogren’s syndrome

Answer 24

Schirmer test

Question 25

Mx of sjogren’s syndrome

Answer 25

Artificial tears
Artificial saliva
Vaginal lubricants
Hydroxychloroquine is used to halt the progression of the disease.

Question 26

Complications of sjogren’s syndrome

Answer 26

Eye infections such as conjunctivitis and corneal ulcers
Oral problems such as dental cavities and candida infections
Vaginal problems such as candidiasis and sexual dysfunction

Question 27

General features of all forms of vasculitis

Answer 27

Purpura. These are purple-coloured non-blanching spots caused by blood leaking from the vessels under the skin.
Joint and muscle pain
Peripheral neuropathy
Renal impairment
Gastrointestinal disturbance (diarrhoea, abdominal pain and bleeding)
Anterior uveitis and scleritis
Hypertension

Question 28

What is polyarteritis nodosa

Answer 28

medium vessel vasculitis. It is most associated with hepatitis B but can also occur without a clear cause or with hepatitis C and HIV.

Question 29

Rash associated with polyarteritis nodosa

Answer 29

It is associated with a rash called livedo reticularis. This is a mottled, purplish, lace like rash.

Question 30

What is takayasu’s arteritis

Answer 30

Takayasu’s arteritis is a form of large vessel vasculitis. It mainly affects the aorta and it’s branches. It also affect the pulmonary arteries. These large vessels and their branches can swell and form aneurysms or become narrowed and blocked

Question 31

Presentation of takayasu’s arteritis

Answer 31

It usually presents before the age of 40 years with non-specific systemic symptoms, such as fever, malaise and muscle aches, or with more specific symptoms of arm claudication or syncope