rheumatoid hands/rheumatology Flashcards
EULAR criteria for RA
score 6+ = RA
Symptom Duration (as reported by patient) Points
< 6 weeks 0
> 6 weeks 1
Joint Distribution Points
1 large joint 0
2-10 large joints 1
1-3 small joints (with or without involvement of large joints) 2
4-10 small joints (with or without involvement of large joints) 3
> 10 joints (at least 1 small joint) 5
Serology Points
RF- and CCP- 0
Low RF+ or CCP+ 2
High RF+ or CCP+ 3
Acute Phase Reactants Points
Normal ESR or CRP 0
Abnormal ESR or CRP 1
Hand signs of RA
symmetrical deforming polyarthritis - small joints hands, wrists, elbows, DIP sparing. MCP ulnar deviation Boutonniere's/swan necking Z thumb piano key sign rheumatoid nodules Surgical scars
Extra-articular manifestations of RA
haematological: Felty’s syndrome
skin: nodules, vasculitis, pyoderma gangrenosum
eye: scleritis, episcleritis
CVD: valvular disease, pericardial effusion, myocarditis, heart failure
Resp: pulmonary fibrosis, pleural effusion, bronchiolitis
Renal: amyloidosis
Neurology: peripheral neuropathy, mononeuritis multiplex
Compression neuropathies: carpal tunnel, atlanto-axial subluxation,
Investigation of suspected RA
FBC - anaemia chronic dis, felty’s
CRP/ESR
RhF - 5-10% in normal population 80% of RA
CCP - TB false positive
XR - joints - osteopenia, erosions, joint space narrowing, deformity
CXR - fibrosis or nodules
Lung function tests - restrictive defects
HRCT
Management of RA - options
Conservative: exercise, PT/OT - home and lifestyle modification
NSAIDS
DMARDS - methotrexate, sulphasalazine, leflunomide, hydroxychloroquine
Glucocorticoids
OLD - gold, pencillamine
Biologics
Surgery
Initial management of RA - NICE
new diagnosis: 2 DMARDS inc methotrexate and short-term glucocorticoids.
If disease not responding or disease severity score DAS28 is high - 5.1+
Can give Adalimumab, etanercept, certolizumab pegol or tocilizumab as monotherapy or certolizumab pegol, golimumab, abatacept and tocilizumab with methotrexate if tolerated.
Can continue biologics if there is response
If no response, rituximab and methotrexate in combination
If rituximab contra-indicated/adverse effect - Adalimumab, etanercept, infliximab and abatacept
When stable, reduce as able.
How would you monitor a patient on DMARD/TNF
SPECIALIST REVIEW
clinical - regular review - hx and exam, evidence of infection or complications TB reactivation, pulmonary fibrosis
Bloods - FBC, U&E, LFT - monthly
What are the side effects of methotrexate and how would one treat methotrexate toxicity?
hepatitis alveolitis stomatitis bone marrow suppression/pancytopenia infections due to immunosuppression
Folinic acid
How would you manage a patient in A+E who presents with cellulitis who is taking anti-TNF therapy
admit
stop biologic
IV antibiotics
specialist advice
Causes of anaemia in RA
chronic disease NSAIDS/steroids - causing GI bleeding Felty's renal amyloid myelosuppression secondary to drugs autoimmune haemolytic anaemia
How do you distinguish active from inactive arthritis?
Symptoms - increased pain, fatigue, swelling, joint tenderness, joint temperature, raised ESR
Psoriatic arthritis history
Inflammatory back pain iritis symptoms of IBD enthesitis plantar fasciitis joint distribution - asymmetry ?response to exercise and NSAIDS
Psoriatic arthritis examination
Nails: pitting, onycholysis, transverse ridging, hyperkeratosis, yellowing
Skin: psoriasis - elbows, knees, hairline, back of neck, umbilicus, koebners
Sacroiliitis
Aortic regurgitation
Psoriatic arthritis differentials
DIP involvement - OA
Rheumatoid pattern - RA
ank spond, reactive arthritis, IBD related arthropathy
oligoarthropathy - reactive arthritis, gout, sarcoidosis
dactylitis - gout, reactive, sarcoidosis
If severe and rapid - consider HIV
Investigations psoriatic arthropathy
Plain films
US if radiographs inconclusive
Bloods - fbc anaemia, renal function, CRP and ESR (can be normal in PsA)
HLA-B27
Treating psoriatic arthropathy
conservative: OT/PT
medical: NSAIDS in mild, non erosive disease
DMARDS - sulfasalazine - arthritis
methotrexate - arthritis and skin
leflunomide arthritis > skin
hydroxychloroquine - exacerbates skin disease
Steroids: caution as withdrawal can worsen disease
Local cortisone injections
anti-TNF
will remain on medication indefinitely to control arthritis
How to differentiate between RA and PsA
Asymmetry
nail changes
dactylitis
family hx of psoriasis
negative RhF and CCP
Causes of breathlessness in SLE/connective tissue disorders
PE Pleural effusion pneumonia - (can be due to immunosuppression) pulmonary fibrosis reaction to biologic therapy - ARDS mimic Pericardial effusion Acute MI cardiomyopathy renal failure causing pulmonary oedema myositis/GBS
SLE history
Arthritis - non deforming
Mucocutaneous lesions - butterfly pattern rash, light sensitive, alopecia, mouth ulcers
Cardioresp. involvement - SOB, CP, syncope, haemoptysis
Renal disease - oedema, renal biopsies, RRT
Myositis
Neuropsychiatric
Haematological - thrombotic events - antiphospholipid syndrome
Obstetric - recurrent miscarriage, pre-eclampsia
ACR SLE diagnostic criteria
4 of
Malar Rash
discoid rash
photosensitivity
oral ulcers
non erosive arthritis
serositis - pleuritis, pleural effusion or percarditis
renal disorder - proteinura, cellular casts
neurological disorder - seizures, psychosis, transverse myelitis
haematological disorder - haemolytic anaemia, leucopenia, lymphopenia, thrombocytopenia
anti-nuclear antibodies
other autoantibodies - antiphospholipid syndrome, anti SM, anti dsDNA
SLE examination
lymphadenopathy or fever
arthritis
mucocutaneous - discoid rash, malar rash, mouth ulcers, vasculitis, alopecia,
cardiac involvement - AR or MR
respiratory - fibrosis, pleural effusions, consolidation
Hypertension
urinalysis - nephritic picture
renal disease - oedematous, nephrotic syndrome, RRt, AV fistula, renal transplant
Evidence of thrombotic events
Iatrogenic - cushingoid appearance
Neurological
Sjogrens - hx, exam, ix
Seen in combination with RA or SLE
dry eyes, dry mouth
bilateral enlarged parotid glands
schirmer’s test - filter paper, measure distance of moisture spread
anti Ro and anti La, may be seen in RhF and anti CCP positive, if antibodies -ve - parotid biopsy
High risk of lymphoma - 40x
SLE investigations
Determined by disease pattern
urine cytology - cell casts
elevated ESR, sometimes elevated CRP due to acute process
FBC - haemolytic anaemia, thrombocytopenia, lymphopenia
Immunological tests
ANA - positive in 95%
dsDNA usually positive
anti ro and la
low C4 and low C3
antiphospholipid antibodies
CK - myositis
Pulse oximetry +/- ABG CXR - effusions, fibrosis, cardiomegaly (can be sign of pericardial effusion)
CTPA - ?PE
Echo - if valvular lesion - incompetence, vegetations, pericardial effusion
renal biopsy
Treating SLE - medication
Steroids - pred - long term antimalarials immunosuppressants - azathioprine, cyclophosphamide, MMF, methotrexate biologics - rituximab IVIg plasmapheresis
SLE - anticoagulation
Risks of cyclophosphamide
Infection:
reactivation of previous infection - Hep B, Hep C, TB and HIV screen prior
myelosuppression
immunosuppression - PCP prophylaxis given
haemorrhagic cystitis - MESNA
Malignancy - all forms assoc with increased doses
Infertility
Oral cyclophosphamide has a higher risk than puled IV equivalent
Tell me about systemic sclerosis
systemic sclerosis is a CTD causing thickening and fibrosis in the skin with heterogenous other organ involvement. It is 3x more common in women. No ethnic bias.
Tell me about the scleroderma spectrum
This increases in severity from Reynaud’s phenomenon, localised scleroderma, limited cutaneous systemic sclerosis (CREST) scleroderma distal to elbows), diffuse cutaneous (proximal to elbows)
This patient has reynaud’s phenomenon, what are the causes and the differentiating features
SYSTEMIC SCLEROSIS
Scleroderma
SOB leading to Pulmonary fibrosis or PAH
Dysphagia, dyspepsia, diarrhoea
SLE
malar rash/photosensitivity/scarring alopecia
Jaccoud’s arthropathy
Oral ulceration
DERMATOMYOSITIS
Heliotrope rash
Proximal rash
MIXED CONNECTIVE TISSUE DISEASE
features of SLE
features of scleroderma
features of polymyositis
SJOGREN’S SYNDROME
Xerophthalmia
Fatigue
Non-erosive small joint polarthropathy
Examination features of connective tissue disorders - ?CREST
HANDS sclerodatyly arthritis jaccoud's arthropathy (severe rheumatoid appearance) digital ulcers subcutaneous calcinosis cutaneous vasculitis periungal erythema gottrons papules
FACE
telangiectasia
microstomia
Cardiorespiratory
fibrosis
PAH
(pulmonary causes are largest cause of mortality)
Investigations of Reynauds/systemic sclerosis and management
Positive ANA - 90% Scl70 dcSSc anticentromere lcSSc nailfold capillaroscopy lung function tests HRCT Echo
Treatment
calcium antagonists and iloprost - Reynauds
methotrexate, MMF - skin
cyclophosphamide - skin and lungs
Gout triggers
alcohol purine ingestion haemorrhage infection trauma surgery radiotherapy dehydration
Gout precipitating conditions
Renal impairment hypothyroidism myelo/lympho-proliferative conditions PCV hyperparathyroidism diabetes mellitus diabetes insipidus barter's syndrome sarcoidosis psoriasis hyperlipidaemia obesity
Drugs that increase urate level
thiazide diuretics aspirin theophylline ciclosporin levodopa ethambutol
Note losartan and fenofibrate reduce levels.
Investigations in gout
Bedside - blood pressure (HTN due to renal impairment)
obs - low grade pyrexia
Lab
urate, lipids, thyroid and renal dysfunction
Imaging
plain films - punched out erosions
joint space preservation
no osteopenia
