Rheumatology 1 Flashcards
ANCA are associated with which type of disease?
Give three examples
Small vessel vasculitis
1. Granulomatosis with polyangitis (Wegener’s)
2. Eosinophilic granulomatosis with polyangitis (Churg-Strauss)
3. Microscopic polyangitis
Type of ANCA
Granulomatosis with polyangitis/ Wegener’s?
cANCA
Type of ANCA
Eosinophillic granulomatosis/ Churg Strauss?
pANCA
Type of ANCA
Microscopic polyangitis?
pANCA
Other pANCA conditions (4)
UC (70%)
PSC (70%)
AntiGBM (25%)
Crohn’s (20%)
Ankylosing spondylitis HLA
HLA B27
What is Schober’s test?
a line is drawn 10 cm above and 5 cm below the back dimples (dimples of Venus). The distance between the two lines should increase by more than 5 cm when the patient bends as far forward as possible
Features of ank spond (7)
Apical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
AV node block
Amyloidosis
Cauda equina
Ank spond O/E: (3)
Reduced lateral flexion, forward flexion, chest expansion
Ank spond Ix of choice
If negative then which Ix
Plan XR - sacroiliac joints
MR
Findings on sacroiliac joint (4) and CXR (1) for ank spond
MR findings (1)
Bamboo spine
Sacroilitis
Subchondral erosions
Syndesmophytes
Apical fibrosis
Bone marrow oedema
Ank spond Mx (4)
Exercise e.g swimming
NSAIDs
Physio
DMARDS if peripheral joint involvement
Features of antiphospholipid syndrome (5)
Recurrent fetal loss
Recurret VTE/ arterial thrombosis
Thrombocytopenia
Prolonged APTT
Livedo reticularis (mottled skin)
Antiphospholipid syndrome is associated with which condition?
SLE
Antiphospholipid syndrome Mx
Primary thromboprophylaxis
Secondary
INR range
Recurrent VTE mx (2)
Primary thromboprophylaxis: Low dose aspirin
Secondary thromboprophylaxis:
Initial VTE or aterial: warfarin INR 2-3
Recurrent VTE INR 3-4 + aspirin
Which test should be used to check for azathioprine toxicity?
TPMT test
Triad of symptoms for Behcet’s syndrome?
Oral ulcers
Genital ulcers
Anterior uveitis
Behcet’s
What is it?
Ethnicity
Gender
Age
HLA
Automimmune vasculitis all sizes large, medium and small vessel
Turkish
M>F
20-40yo
HLA B51
What it the pathergy test?
Puncture site following needle prick becomes inflamed with small pustule forming/ ulcer formation = test for Behcet’s
Bisphosphonates counselling
‘Tablets should be swallowed whole with plenty of water while sitting or standing; to be given on an empty stomach at least 30 minutes before breakfast (or another oral medication); patient should stand or sit upright for at least 30 minutes after taking tablet’
When do you stop bisphosphonates? (3)
Stopped after 5 years if:
Patient <75yo
Femoral neck T score >2.5
Low risk FRAX
Osteoporosis
Ca
Phos
ALP
PTH
Ca normal
Phos normal
ALP normal
PTH normal
Osteomalacia
Ca
Phos
ALP
PTH
Ca low
Phos low
ALP normal
PTH normal
Primary hyperparathyroidism
Ca
Phos
ALP
PTH
Ca high
Phos low
ALP high
PTH high
Secondary hyperparathyroidism (CKD)
Ca
Phos
ALP
PTH
Ca low
Phos high
ALP high
PTH high
Paget’s
Ca
Phos
ALP
PTH
Ca normal
Phos normal
ALP high
PTH normal
Osteopetrosis
Ca
Phos
ALP
PTH
Ca normal
Phos normal
ALP normal
PTH normal
XR double bubble/ soap bubble appearance is keeping with which benign tumour?
What age group?
Where does it commonly occur?
Giant cell tumour
20-40yo
Epiphyses of long bones
Where does an osteoma commonly occur?
Associated with which syndrome?
Skull
Gardner’s syndrome (variant of familial adenomatous polyposis)
What is the most common benign bone tumour?
Gender
Age
Osteochondroma -cartilage-capped bony projection on the external surface of a bone
M>F
Age <20yo
What is the most common primary malignant bone tumour?
Where does it occur?
Age range
Osteosarcoma
Long bones - femur, tibia, humerus
Children and adolesents
Osteosarcoma is associated which conditions (2)?
Retinoblastoma
Paget’s disease of the bone
What is the Codman triangle?
Seen in which condition?
XR finding seen in osteosarcoma
Sunburst appearance
Which type of bone malignancy would you see an onion skin appearance on XR?
Ewing’s sarcoma
Which malignant bone tumour is most common in middle aged?
Chondrosarcoma
(Malignant tumour of cartilage)
CFS Mx (5)
- CBT
- Graded exercise
- Pacing
- Low dose amitriptyline
- Pain management clinic
Causes of dactylitis (6)
Psoariatic arthritis
Reactive arthritis
Sickle cell
TB
Sarcoidosis
Syphillis
How often is denosumab given for treatment of osteoporosis?
SC 60mg every 6 months
Mx of osteoporosis (2)
- Bisphosphonates - alendronate if not tolerated then alternative risedronate or etidronate
- Raloxifene
What is dermatomyositis?
Inflammatory disorder causing symmetrical proximal muscle weakness and skin lesions
Usually an underlying malignancy
What are Gottron’s papules?
Which condition are they found in?
Dermatomyositis
Roughened red papules over extensor surfaces of fingers
Name five skin features of dermatomyositis
Macular papular rash across chest and back
Heliotrope rash in periorbital region
Gottron’s papules
Dry and scaly hands
Photosensitivity
Dermatomyositis auto-antibody positive (3)
80%
30% 30%
ANA (80%)
anti-Jo1 anti Mi-2 (30%)
Discoid lupus
Gender
Does it progress to SLE?
Characterised by?
F>M
Rarely progresses to SLE
Follicular keratin plugs
Discoid lupus is commonly found where?
Describe the lesion
Healing lesions can cause?
Face, scalp, ears, neck
Erythematous, raised rash, scaly
Scarring alopecia and pigmentation
Discoid lupus Mx (3)
- Topical steroid cream
- Anti-malarials e.g hydroxychloroquine
- Avoid sun exposure
Ehler Danlos
AD or AR
Affects which type of collagen?
Associated with which conditions? (4)
AD
Type III
Aortic regurg, MV prolapse, aortic dissection, SAH
What drugs can cause drug induced lupus? (3)
Hydralazine
Isoniazid
Phenytoin
Mx fibromyalgia (3)
Name three medications that can be used
Explanation
Aerobic exercise
CBT
Pregabalin, duloxetine, amitriptyline
Gout synovial fluid analysis
When do you check urate levels?
Negatively birefringent crystals
2 weeks after the acute attack
Gout radiological findings (5)
Joint effusion
Punched out erosions
Eccentric erosions
Soft tissue tophi
Preservation of joint space
Gout mx
Acute (3)
What should happen to allopurinol?
- NSAIDs/ colchicine - until D2 post symptoms have resolved +/- PPI
- Pred 15mg OD/ intra-articular steroid
Continue allopurinol
When should you offer ULT? (urate lowering therapy e.g allopurinol) (5)
=>2 attacks in last year
Tophi
Renal disease
Uric acid renal stones
As prophylaxis if on diuretics or cytotoxics
How should allopurinol be titrated?
What should you give with allopurinol?
100mg OD, up titrated every few weeks until serum uric acid <300
Colchine cover or NSAIDs –> may need to be continued for 6 months
What can you give if allopurinol is not tolerated?
Febuxostat (xanthine oxidase inhibitor)
Which drug can cause gout?
Thiazide diuretics
