Rheum / MSK Flashcards
Osteoporosis risk factors
SHATTERED Family
Steroid use >5mg/day prednisolone
Hyperthyroidism; hyperparathyroidism, hypercalciuria
Alcohol and tobacco use
Thin (BMI <22)
Testosterone low (e.g. anti androgen in cancer of prostate)
Early menopause
Renal or liver failure
Erosive/inflammatory bone disease (e.g. RA or myeloma)
Dietary Ca low/malabsorption or Diabetes mellitus type 1
Family history
Back pain history
SOCRATES
Early morning
Red flags
- Feel when wiping
- Urinary retention / incontinence
- Bowel incontinence
- Pain + weakness in legs
Weight loss
Bowel habit
Trauma - even minor falls
OP risk factors
Band like pain round chest or abdo
Infective - Fevers / Night sweats
Social
Alcohol
Smoking
IVDU
PMH
HIV
Immunosupression
Diabetes
Previous back surgery
DH
- Steroids
- Immunosupressives
- Any NSAIDs - important for Ank spond
FH
IBD
Psoriatis
Social
How affecting function and work
Smoking - especially for inflam back pains
Ank spond additional features to ask about
All the other seroneg arthritis (cross over HLA B27)
Skin rash - psoriasis
IBD / bowel symptoms
Recent infection / STI
Anterior uveitis
Enthesitis - Achillies / golfers / tennis elbow / plantar fasciitis
SOBOE
Pain ful red eyes
Frothy urine
pain achilies
AAAAAAs of ank spond
- Anterior uveitis
- Aortitis -> Aortic regurg
- AV block (fibrosis of conduction system)
- Apical pulm fibrosis and reduced chest expansion
- AA Amyloidosis - Nephrotic syndrome
- IgA nephopathy
- Achilles tendonitis + enthesitis eg plantar fasciitis, tennis elbow
Which are the segregative arthritis
HLA B27
Psoriatic arthritis
Enteropathic - IBD
Ank spond
Reactive arthritis
Score for symotoms in Ank Spond
BASDI score
Bath Ank Spond disability index score
Main breathing issue in Ank Spond
Restrictive breathing defect
Exam of inflam back pain eg ank spond? What other bits might you examine?
Hands nail pitting
Squeeze of joints
Spinal movements
Forward / back / side / twist
Schobers test
Spinal palpation
Precuss spine
Listen to heart and lungs
Chest expansion
Hip flexion / extension
How do you do schobers test
Draw a line between dimples
Draw line 10cm above and 5cm below
then bend foward and measure lumbar spine movement
Should increase >10cm
If <5 likely pathological;
5-10cm intermediate
Ank spond Ix
Bedside
* ECG - AV block
* Renal dip - protein -> ACR
Bloods
* FBC / CRP
* Consider HLAB27
* If peripheral arthopathy - CCP / ANA / RF
Imaging
- XR sacroiliac joints
- MRI more sensitive but less specific
- CXR - fibrosis / failure
Management of Ank spond
Physio stretching
Education
NSAIDS x2 -> Anti-TNFa
If peripheral disease - DMARDS eg methotrexate / sulphasalazine
Discitis key risks
IVDU
Immunosuppressed
TB - ever treatment or from endemic area
Brucella - Mild / unpasterised cheese
- Farmers / vets (vets as aerosol from placenta high risk)
Myotonic dystrophy inheritence? what is it? Gene?
Autosomal dominant
-> Muscle weakness and myotonia (Inability of a contracted muscle to relax )
Type 1 - CTG repeat with anticipation
Type 2 - different gene, less anticipation more proximal weakness
What is myotonia
Inability of a contracted muscle to relax
Myotonic dystrophy exam CNs? Limbs? Extra bits?
Frontal balding
Bilateral and symmetrical ptosis
Facial muscle weakness
Cataracts
CN exam
-Eye movements usually normal
-Muscles of face tend to be wasted and weak
-Test for myotonia - ask patient to hold eyes tight shut for 10 seconds and they will struggle to re open
- Speech tends to be dysarthria
- Ask about swallowing
Fundoscopy to assess for cataracts
Test visual acuity
Limbs
Tone tends to be reduced
Distal weakness eg footdrop
Ask to grip hand for 5 seconds tight then relax- if myotonia they will struggle
Precussion myotonia - tap thenar eminence -> involuntary thumb flexion
Additionals
Cataracts
Heart -
- Pulse for rate and rhythm - I would like an ECG
- Check for PPM / ICD
Endocrine
- Check for diabetic fingerprick marks
- Check for gynaecomastia
- State would perform scrotal exam for hypoplasia
Myotonic dystrophy differentials of ptosis? Myotonia?
If ptosis unilateral
-> CN III palsy / Horner’s syndrome
Bilateral ptosis
- Myaesthenia / congenital ptosis / senile
Myotonic
Mytonic congenita
Hypokalaemic periodic paralysis
Investigations myotonic dystrophy
Bloods
- CK
- HBA1C
Special
- EMG - ‘dive bomber’ poentials
Genetic testing - gold standard
- DMPK gene for type 1 (CTG repeat) and the CNBP gene for type 2
Complications
* Pulm function for neuromuscular insufficiency
* Cardio complications (conduction block / cardiomyopathy) - ECG + ECHO
* Overnight pulse oximetry / sleep studies
* Screen Thyroid function / diabetes / testosterone
* Visual testing - ref to opthal if cataract
Management of myotonic dystrophy
No cure - MDT conservative
SLT / dietetics
Physiotherapy
Genetic counselling - 50% risk of kids
Palliative care if deteriorating - life expectancy around mid 50s
Annual review
- Test visual function for cataracts
- ECG if abnormal for cardio / PPM if heart block
- OSA
- Evidence of respiratory faiure
- Evidence of diabetes
Drugs
Phenyton / Mexiletine (Na channel blocker) for management of myotonia
Rheum Arthritis painful hands history
Tell me a bit more about it
Early morning stiffness > 1 hour each morning
Duration of symptoms (≥ 6 months)
Pattern of joint involvement (symmetrical / asymmetric, small joint / large joint, oligo/polyarthritis)
expect small joint symmetrical
Constitutional symptoms
-Fever
-Malaise
-Lymphadenopathy
Extra-articular manifestations
Episcleritis (painless) and scleritis
- Have you ever noticed that your eyes are red?
- Have you ever had pain in your eyes?
Interstitial lung disease
-Do you feel breathless when you walk?
- Have you had a cough which has not gone away?
Rheumatoid nodules
- Have you noticed any unusual bumps on your skin?
Raynaud’s phenomenon
- Have you noticed your hands changing colour in the cold?
Glomerulonephritis
- Have you ever noticed blood in your urine?
Systemic vasculitis
- Have you noticed any rashes anywhere on your body?
- Have you noticed any unusual bruises on your body?
- Any skin ulcers?
Mononeuritis / polyneuropathy
- Have you noticed any tingling in your hands or feet?
- Have you noticed any weakness in your hands or feet?
Rule out other disorders
Connective tissue disease
- Systemic lupus erythematosus – mouth ulcers, alopecia
- Mixed connective tissue disease – tightening of skin over digits
Arthritides
- Psoriatic arthritis – itchy plaques on extensors
- Polyarticular gout – asymmetric involvement, precipitants (meat, alcohol, diuretics)
- Osteoarthritis – gets better with activity
- Enteropathic arthritis Change in bowel habit
Screen for complications
[Rhem SOFAA]
Secondary amyloidosis
– nephrotic syndrome
Osteoporosis
- Have you ever fractured a bone?
- How did this happen?
Felty’s syndrome (neutropaenia, splenomegaly + RA, usually > 20 years)
- Have you noticed any fullness in your tummy?
- Do you feel you are getting the flu more often than usual?
Atlanto-axial subluxation
- Is there any pain at the back of the head or neck?
- Have you ever experienced the room spinning around you?
Anaemia
- Do you feel tired?
- Do you get any chest pain or short of breath when you walk?
Carpal tunnel syndrome
- Do you notice any tingling in your thumb or index finger?
- Do you have any problems using your thumb?
Functional status
- How is this affecting your life?
- Make sure you ADDRESS CONCERNS
- Are you able to do things like unlock a door with a key or uncap a bottled drink?
- Do you have any difficulty with buttons?
Social history
- Smoking - makes much worse
- Alcohol - consider gout
DH
- Tried any thing to help?
- Gp prescribed anything?
Familty historu
- Any inflammatory conditions / arthritis
Common drugs used for Rheum A and thier main complications? Best for pregnancy?
Steroids – exogenous Cushing’s, osteoporosis, cataracts, weight gain
Methotrexate – pulmonary fibrosis, marrow suppression
Sulphasalazine – rash, funny coloured secretions eg eye / urine…
- Best for pregnancy
Hydroxychloroquine – retinitis, need screening within 6 months
Leflunomide - Hangs in body for 2 years -> may need to have cholestryramine washout if pregnant
Biologics – opportunistic infections
AntiTNFa - inflix, adalib, etaercept
AntiCD20- Rituxumab
Anti-IL6 - Toculizumab
Some METH SUccers Hyde LEFtover Biftas
hEYEdroxycloroquine
Difference in joints affected in hand of psoriatic vs rheum arthritis
Rhem more MCP and PIP
Psoriatic more DIP
Rheum patient presents with breathlessness. Key things to screen in history?
Extra articular pulm fibrosis
Methotrexate therapy
Anaemia
- Chronic disease
- NSAIDs / GI symotoms
Infection
Immunosupressed
- Felty syndrome
- Medication related
Lymphoma
- Fever weight loss night sweats
Rheumatoid hand exam? What else would you examine if time permits?
Ask if any particular pain first
Inspection:
- Vasculitic lesions
- Nail fold infarcts
- Wasting of the small muscles of the hand
- Swollen joints and their distribution
- Symmetry
- Deformities of rheumatoid hand:
- Rheumatoid nodules (usually over extensor surfaces of elbow and finger joints)
- Scars suggesting previous decompression of carpal tunnel / tendon release
- Look for active synovitis
- Ulnar deviation at MCP / swan neck / Boutonnier
Palpate
- Ask if any joints are painful again
- Examine each small joint of the hand, then the other joints in turn
Function
Power
- Make a fist
- Squeeze my fingers as tight as possible
- Make a ring with index and thumb and then I do same and pull
Function
- Do up a button
- Write with a pen
- Prayer sign / reverse prayer sign
- Put your hands behind your head
Extra-articular manifestations
- Look at eyes for scleritis / episcleritis
- Listen for fine basal crepitations of interstitial lung disease
- Listen for aortic regurgitation
Complications
- Conjunctival pallor
- Test forward flexion and extension of the cervical spine
- Look for evidence of exogenous Cushing’s
- Check for cataracts secondary to steroid use
- Tinnel’s test for carpal tunnel syndrome
What are the deformities seen in rheumatoid hand
Swan neck deformity: hyperextension of PIPJ with flexion at DIPJ and MCPJ
Boutonnier’s deformity: flexion at PIPJ with hyperextension of DIPJ and MCPJ
Z deformity of thumb: hyperextension of IPJ, fixed flexion and subluxation of MCPJ
Ulnar deviation of fingers
Subluxation of MCPJ
Rheum differentials
Small joint symmetrical polyarthritis
- Rheum most likely
- Consider SLE / psoriatic
Seronegative
- Psoriatic, more likely DIP + nail changes
- Enteropathic - GI symptoms / mount ulcers usually affects a larger joints
- Reactive - Eye signs, urethitis (though 50% dont get symptoms
- Ank spond - Alternating buttock pain
- Gout - especially big toe and tophi
- Calciumpyrophospate deposition
Osteoarthitiis
- Especially if lack of inflammatory symptoms
Rheum Athritis investigations
FBC
- Anaemia
- Raised platelets (inflammation)
- Neutropenia eg felty
ESR / CRP
- U&E / LFTs - drugs
- Rheumatoid factor + Anti-CCP (disease progression)
- Consider ANA / ANCA especially if rash on face / connective disease symptoms
- Consider HLA B27 if history unclear
Protein Dip / Albumin creatinine ratio
Plain XRs of hands and feet as baseline
- May affect how aggressive treatment if erosions
Rheumatoid factor is what
IgM antibody to FC portion of IgG
-Not specific, and actually more prevelant in sjorgrens syndrome
though it does correlate with progression
Management of Rheumatoid? How to monitor symptoms?
Disease Activity Score for symptoms to help direct management / response to treatment
MDT from begining
- Physio for joint function
- OT (50% not in same job at 2 years)
- Scoring systems
- Patient groups / support groups
Medications
- Usually trial of NSAIDs + PPI / paracetamol
- Steroids especially if symptoms for 3 months already
DMARDS
- Methotrexate (or sulphasalazine) first line usually + folic acid
- Anti-TNFa
Patient treated for rheum A comes in after treatment for UTI completely run down ….
Given trimethropim and on methotrexate -> myelosupression
DMARD best for preg and breast feeding in rheum A
Sulphasalazine
Biologics in Rheum? screening?
Anti- TNF
- Etanercept, Adalidumab, Infliximab
- Screening for TB / BBV / varicella
- High risk for infection
- Keep vaccines eg flu / pneumococcus updated
Anti CD20
- Rituxumab
Anti - IL6
- Toculizamab
Renal impairment in Rheum arthritis - what might be the cause?
Use of NSAIDs -> intersitial nephritis
Renal toxicity in DMARDs eg Methrexate (may need dose reduction)
Glomerulonephritis in other autoimmune disease
AA Amyloidosis due to chronic inflammation
What would signify poor prognosis in Rheum A
RF / CCP / HLA-DR4 positive
Erosive disease early
Female
Systemic sclerosis history
Think about skeening the affected symptoms
Raynauds
- Are your fingers more sensitive to the cold. Do you get any skin colour changes
- May affect toes / ears / nose
Skin
- Sclerodactyly - skin thickening
- Puffy fingers
- Calcium nodules
- Telangectasia New red vessles on hands
GI - replacement of luminal wall with fibrosis
- Oesophageal dysmotility- Reflux / vomiting
- Gastroparesis
- Small bowel overgrowth - bloating / diarrhoea
Pulmonary fibrosis / pulm HTN
- Worsening SOBOE
- Dry cough
Cardiac
- Syncope - (fibrosis -> conduction disturbance)
- Angina - accelerated atherosclerosis
- Sob / swelling of ankles secondary to pulm hypertension
Erectile dysfunction
Renal
- Any rise in usual blood pressure
Arthralgia / muscle pain
Social
- How does raynauds affect work / life
- Increased in silicon mining etc
- Smoking - much more rapid fibrosis / vascular disease
PMH
- Autoimmune / Ca
DH
- Other autoimmune eg levothyroxine
- Prev cytotoxic
- Any other drug use eg cocaine
FH
- Autoimmiune
Causes of raynauds
Primary idiopathic
Autoimmune
Carpal tunnel
Cushings
Hypothyroidism
Drugs
- Cytotoxic chemo microvascular damage
- Drugs for ADHD
Primary vs secondary raynauds
Primary
- Starts around menarche
Secondary
- Features of autoimmune
- Later in life 20+
- involves thumb
3 main Antibodies in sclerosis
Anti-centromere
- Limited cutaneous
- More vascular injury / raynauds / ulceration
- Pulm HTN
Anti SCL-70
- Significant lung fibrosis
- less Pulm HTN
RNA polymerase 3
- Ealy rapidly progressive diffuse
- Lots of liung fibrosis
- Highest risk for renal crisis
Unilateral raynauds?
Subclavian steal possiblity
Limied vs diffuse sclerosis? Why differentiate
Limited
- Skin changes limited to face, fingers and hands
Diffuse
- Proximal to elbows / knees
Prognosis is different
- Diffuse tend to have more significant GI / pulmonary fibrosis
- Limited more severe hand disease eg raynauds -> ulcerating / pulm HTN
Systemic sclerosis management
Conservative
- Patient education
- Avoiding smoking
- Gentle skin stretching to maintain the range of motion
- Avoiding cold triggers for Raynaud’s
- Physiotherapy to help maintain healthy joints
- Occupational therapy for adaptations to daily living
- Regularly meaure blood pressure - monitor for renal crisis
- Yearly echo / ECG
Medical
- Regular emollients
- raynauds - nifedipine
- reflux - PPI
- Slowed Gi transit - metoclopramide
- antihypertensive - ACE
- pulm htn sildenafil, bosentan (Endothelin receptor antagonist)
Try and avoid steroids - risk of renal crisis
Dmards
- Usually Methotrexate / hydroxycloriquine
- If pulm fibrosis- mycophenolate mofetil
- rituxumab anti cd20
- toculizumab - anti il-6
Don’t use anti tnfa in connective tissue disease
Surgical
Consider stem cell transplant in early aggressive disease
Systemic sclerosis exam
Hands
- Feel temp of hand towards finger tips
- Sclerodactyly / ppuffy
- Evicence previous ulcers (pits on end of fingers)
- Telangectasia - small dilated capilaries (grow in areas of localised hypoxia)
- calcinosis lumps on palpation
- Look in nail folds for dilated capilaries
Feel bilat pulses
- Unilateral would include large vessle vasculitis
BP - renal crisis
Neck
JVP
Face
- Ask to examine things on face
- Ask for mouth opening
Lungs auscultaion
- Fibrosis
Heart auscultate - Pulm HTN (tricuspid regurg / loud P2)
Feet
- Leg swelling
- Ulcers on toes
Consider skin changes indicating diffuse
Systemic slcerosis differentials if raynauds / pulm fibrosis
Raynauds + pulm fibrosis
- Rheum arthritis - Often a clinical overlap between too
- Polymyositis / dermatomyositis - Significant myositis / weakness
- Lupus - Malar rash
Unilateral raynauds
- Thoracic outlet obstruction
- Large vessle vasculitis
Signifcant smoking history
- Beurgers disease
Systemic sclerosis investigations
Bedside
- BP / urine dip - renal crisis
- Oxygen sats - especially on exertion
- ECG - conduction disturbance / RHS
Bloods
- FBC (anaemia), renal funcion, thyroid function, inflammatory markers, CK if muscles
- Consider ProBNP if ?pulm htn
- ANA / antibody profile (centromere, scl-70, RNA polymerase)
Imaging
- Consider CXR
- pulm fibrosis - HRCT
- Lung funciton tests
- Echo if RHS
Special
- Nailfold capiliroscopy - Few areas on body where you can directly visulise capilaries*
- Unlikely go for barium swallow / OGD unless refractory symptoms
Get signifcant capilary drop out and large capilaries
Systemic sclerosis management
Patient education
MDT
- Dietician / palliative care
- Resp / GI / cardio input
Yearly monitoring
- Echo
- Pulm function tests
Medical
Reflux - PPI
Small bowel overgrowth - cyclical Abx
Raynauds - nifedipine
Pulm HTN - sildenafil (also works for raynauds)
Fibrosis - immunomodulatory (anti cd20 - rituxumab, anti IL6 - Toculizumab) + ninetanib
Early diffuse high risk disease
- Consider stem cell transplant (10% mortalty)
Pulm function tests in Pulm HTN?
Pure fibrosis ?
Pulm HTN
- FVC preseved
- TLco reduced
Pulm firbosis
- Restrictive
- TLco falls with FVC
Critical distal ischemia / pulm HTN drug
IV ilaprost
Systemic sclerosis - what immunomodulary drug do you avoid
STEROIDS
- may precipitate renal crisis
- especially if anti-rna polymerase 3
What causes renal crisis in systemic sclerosis? Rx?
Vasospasm of renal arteries
-> kidneys produce lots of renin to raise BP
-> viscious cycle
Treat with ACEi
GCA history key bits
HPC
- Explore general headache questions
- Unilateral headache subacute onset
- Pain on palpation of side of head
- Fever / rash / night sweats
- Jaw claudication / tongue pain
- Any changes in vision
PMH
- polymyalgia rheumatica - early morning pain in shoulders / hips
DH
- Steroids for other reasons
Family history
- increased risk if first degree
Social history
- Smoking bad
- Alcohol
- Work / function
GCA investigations
GCAPS risk score
Bedside
- Observations including BP in both arm
Bloods
- FBC (anaemia / thrombcytosis) / LFTs (often rise in ALP) / renal function
- Inflam markers espectially ESR
- Consider myeloma screen
- consider vasculitis screen
- Calcium, vit D, HBA1C if for long term steroids
Imaging
Temporal artery US
Special
Temporal artery biopsy - if unclear / negative US with suspicious history
Focused exam in GCA
Palpate temporal arteries
Cranial nerves especially eyes
Palpate pulses BP both sides
Consider Auscultate heart
- AR in dissection
GCA differential diagnosis
Classic history of GCA
Mimick
- Tempomandibular joint dysfunction
- Migraine (unusual in elderly)
Infection
Fever - any infective / neoplastic cause
US of temportal artery in GCA
Non compressible halo sign
- marker of inflammation
[May mimmick if atherosclerosis]
GCA management how long steroids? Additional management?
Any visual involvement
- Opthalmology review prior to rheum
Acute
- PPI + Pred 40mg / day.
- If opthal / jaw claudication / tongue claudication / prominent temporal arteries - > 60mg
- would expect response around 24-36 hours
- Likely for 12-18 months
Adcal d3 + alendronic acid (bone protection long term steroids)
GCA relapse on Pred next steps
Consider methotrexate / leflunomide
[-> anti-IL6 eg toculizumab]
How swollen monoarthropathy key differentials - additionals in history
Time frame
Septic / crystal
- Fevers, CRP and pain are not specific for either
Reactive
- urethitis
- Uveitis
- Sexual history
- Recent illness
Psoriatic - CRP often very low
- History of rashes
- Often previous joint
Haemarthorsis
- Hx trauma
DH
- Anticoagulation
- Diuretics
- Immunocompromised
PMH
- Joint replacement or metalwork eg heart valves anywhere in the body
- Recent infection/catheter (bacteraemia)
- CKD
- Immunocompromised
SH
- Smoking
- Meat, shellfish, fizzy drinks, alcohol
- Overweight - biggest risk factor for gout
- IVDU
Hot swollen joint exam
Examine the joint
Then examine elbow - tophi
Hands / behind ears - tophi / psoriasis
How swollen joint what is your differential
Septic arthritis most important
Gout pseudogout
Reactive arthritis
Autoimmune - psoriatic
Consider TB and haemarthrosis
Would be very unlikely to be rheumatoid
How swollen joint investigations
Joint aspiriation is the most important investigation ideally before antibiotics
Bedside set of obs fever / septic
Bloods - inflam markers including platelets
Blood culutres
Uric acid - if raised likely to be significant as usually reduced in inflammation. Low does not rule out gout
[Consider RF & ccp, HLAB27 (reactive/psoriatic/ank spond),]
Xrays - calcification / destruction
What would make you not want to aspirate a hot swollen knee?
Lots of overlying cellulitis
Previous replacement - as if introduce infection will likely need a whole re-do
Uncontrolled anticoagulation
If the joint aspirate has crystals does this rule out septic arthritis
NO
Septic arthritis affects damaged joints eg gout
Please present this patient (myotonic dystrophy)
- This patient has myotonic facies
- There is muscle wasting affecting the face and distal muscle groups.
- There is frontal balding and lens opacification in keeping with cataracts
- Power is reduced in the muscles of facial expression and bulbar muscles.
- In keeping with this the patient has slurred speech
- Tendon reflexes are absent
- Myotonia was demonstrated when the patient made a fist.
- Precussion myotonia was also demonstrated over the thenar eminence
I think this patient has a myotonic dystrophy.
I would like to go on to examine the cardiovascukar and respiratory systems as well as looking for evidence of hypogonadism and perform a urine dip for glucose.
Bar muscles what else found in myotonic dystrophy
- Cataracts
- frontal balding
- conduction defects in heart
- Endocrine - hypogonadism and diabetes
- Cognitive abnormalities
When do the musclular dystophies present
Mytonic dystrophy - early adulthood
Duchennes / bekkers - childhood
Fascioscapular musculodystrophy - Adulthood
How to perform precussion myotonia
Tap the thenar eminence, or the area just under the thumb, with a rubber hammer
Observe the thumb’s adduction and flexion, and its slow return
The dimple may also take longer to resolve
Why does myotonia occur
- Abnormality if sodium / cloride channels
- causes a prolonged period of electrical discharge
Why does myotonia disappear in later stages of myotonic dystrophy
Muscle wasting and weakness there is a reduction of the contracting muscle
Duchenne vs becker vs myotonic dystrophy
Gene?
Symptoms?
Diagnosis?
Complications
Duchenne vs becker vs myotonic dystrophy
Gene?
Symptoms?
Diagnosis?
Complications
Diagnosis ank spond
At least 1 of 3 clinical critetia
- Low back pain present for more than 3 months and improved by expersise
- Limitation of lumber spine motion
- Limitation of chest expansion
AND radiological
- Presence of sacroilitis on XR
Spinal xr findings ank spond name 3
- Squaring of the vertebrae: [Inflammation and bone deposition can cause the vertebral bodies to appear squared, especially on lateral X-rays ]
- Romanus lesions: Small erosions and reactive sclerosis at the corners of the vertebrae, also known as “shiny corner signs”
- Sacroiliitis: Inflammation of the sacroiliac joints
Late findings
-Bamboo spine: A classic finding in late-stage AS, where the vertebral bodies fuse together, resembling a bamboo stem
- Ankylosis: Fusion of the facet joints of the spine
- Calcification: Calcification of the anterior longitudinal ligament, supraspinous ligaments, and interspinous ligaments, which can appear as a “dagger sign” on frontal radiographs
Sclerodema with fibrosis key dmard to use
Mycofenolate mofetil
When do you have to avoid if ANA positive in rheumatological conditions? why? What should you use?
Anti-TNFa and Sulphasalazine
- risk of inducing lupus (SLE)
Then use rituxumab / toculizumab
ANA positive connective tissue disease loosey choice of dmards
Methotrexate, hydroxycloriquine, mycophenolate
Mabs - rituxumab, toculizumab
ANA positive connective tissue disease loose dmards
Methotrexate, hydroxycloriquine, mycophenolate
Mabs - rituxumab, toculizumab
Present limited cutaenous systemic sclerosis?
Diffuse?
Limited
- There is telangectasia over the face and microstomia
- There is sclerodactlyly (and ulceration)
- There are diulated nail fold capiliaries
- There are palpable nodules consistent with calcinosis over the fingers and elbows
- There is an inibility to make a fist secondary to a reduction in range of movement
Diffuse
- There is tight skin over the face arms, trunk and legs with areas of hyper and hypopigmentation
