Rheumatology 1 Flashcards
Most common anti-body +ve in antiphospholipid syndrome?
3 main features of antiphospholipid syndrome?
anticardiolipin antibody
- Arterial/venous thrombosis
- miscarriage
- livedo reticularis - mottled skin thought to be due to spasms of the blood vessels
Management of GCA if visual loss and if no visual loss?
Visual loss
methylprednisolone IV
No visual loss
Oral prednisolone high dose
Anti-antiphospholipid syndrome complications CLOTs
APS causes CLOTs
Clots in arteries and veins
Livedo reticularis
Obstetric problems/miscarriages
Thromobocytopaenia (and paradoxical prolonged APTT)
What is the antibody for:
Diffuse cutaneous systemic sclerosis
Limited cutaneous systemic sclerosis
Diffuse cutaneous systemic sclerosis is associated with anti Scl-70 antibodies
Limited- Anti-centromere
Inflammatory arthritis involvinf DIP swelling and all fingers being completely swollen?
Psoriatic arthritis
- DIP swelling and dactylitis points to a diagnosis of psoriatic arthritis (sausage fingers)
Triad for Behcet’s disease
Oral ulcers + genital ulcers + anterior uveitis
Which joint is most commonly affected in gout?
first metatarsophalangeal joint of the first toe
What clinical exam findings would you see in ankylosing spondlysis
1)
2) + Test
3)
4)
1) reduced lateral flexion
2) reduced forward flexion - 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
3) reduced chest expansion
4) tragus wall test/ occiput wall test/ Flesche Test- Test thoracic kyphosis and abnormality is occiput not touching the wall.
Explain what you would see in a joint aspiration of both gout and pseudo-gout (4 each)
- No bacterial growth
- Needle shaped crystals
- Negative birefringent monosodium urate crystals
- No bacterial growth
- Rhomboid/ brick shaped crystals
- Positive birefringent calcium pyrophosphate deposition
4.
Padgets disease 3 STEM features
+ extra STEM
- Old man
- Bone pain (AXIAL BONES- skull, spine, pelvis but also femur and tibia)
- Raised ALP
STEM- deafness (cranial nerve entrapment)
Hydroxychloroquine side effect (4)
Safe in preg?
1) Bulls eye retinopathy
2) Nightmares
3) Skin pigmentation
4) Liver toxicity
Yes safe in preg!
If a patient is taking Sulfasalazine what drug allergies should they be CAUTIOUS about? (2)
also what underlying condition?
allergy to aspirin or sulphonamides (cross-sensitivity)
Sulphonamide eg. Co-trimoxazole
G6PD Def!!!
Features in history of Systemic juvenile idiopathic arthritis (3 + Rash description)
- Gradual onset
- Morning stiffness and spiking fevers.
- May also be a history of school absences or avoidance of physical activities.
- Rash= A flat, pale pink rash may appear.
Dermatomyositis
STEM THAT YOU MUST DO…
Presentation: non skin (5)
Presentation skin features (5)
STEM: CHeck for underlying malignancy such as ovarian, breast, lung
Presentation
- Prox muscle weakness +_ tenderness
- Raynauds
- Resp. muscle weakness
- ILD- Fibrosing alveolitis or organising pneumonia
- dysphagia- dysphonia
Skin features
- photosensitive
macular rash over back and shoulder
- Heliotrope rash periorbit
- Gottron’s papules - roughened red papules over extensor surfaces of fingers
- ‘mechanic’s hands’: extremely dry and scaly hands with linear ‘cracks’ on the palmar and lateral aspects of the fingers
- nail fold capillary dilatation
What does a T score of -2.5 mean on a DEXA scan?
T scores describe one’s bone density as a standard deviation (SD) score in comparison to the mean value derived from a reference population of young healthy adults - usually 30 years old
What condition is diagnosed with:
+ve cANCA
+ve pANCA
+ve cANCA = granulomatosis with polyangiitis
pANCA = eosinophilic granulomatosis with polyangiitis (Churg-Straus) microscopic polyangiitis or Goodpasture’s disease.
Ankylosing spondylitis management
1. First line concservative
2. + First line med
3. Conservative
4. Med
5. Maybe?
- Encourage regular exercise such as swimming
- First line med- NSAIDs are the first-line treatment
- Physiotherapy
- DMARD BUT if peripheral joint involvement- sulphasalazine)
- Maybe Anti-TNF therapy should be given if persistently high disease activity- adilimumab or etenercept
Still’s Disease
STEM-
Presentation (stem +3)
Investigations- Bloods (1 rule in, 2 to rule out)
STEM- Salmon pink rash on back
- arthralgia
- rash: salmon-pink, maculopapular
- pyrexia- typically rises in the late afternoon/early evening in a daily pattern and accompanies a worsening of joint symptoms and rash
- lymphadenopathy
- elevated serum ferritin
- rheumatoid factor (RF) and anti-nuclear antibody (ANA) negative
Stills Disease
Name of criteria to diagnose
Management
1.
2.
3.
Yamaguchi criteria
Management
1. NSAIDs- trial for atleast a week before…
2. steroids
may control symptoms but won’t improve prognosis
3. if symptoms persist, the use of methotrexate, IL-1 or anti-TNF therapy can be considered
Spot diagnosis antibodies
Anti-La and Anti-Ro
Anti-Scl-70
Anti-CCP and Rh F
anti-centromere antibodies and ANA
Anti-Jo-1(2)
Anti-Smith antibody
Anti-La and Anti-Ro
- Sjogren’s syndrome ( dry mouth and eyes and parotid gland swelling.)
Anti-Scl-70
- diffuse cutaneous systemic sclerosis (diffuse scleroderma (thickening of the skin), CREST symptoms AND systemic organ involvement)
anti-centromere antibodies (more sensitive) and ANA- Limited cutaneous systemic sclerosis JUST CREST
Anti-CCP and Rh F
- RA
Anti-Jo-1
- dermatomyositis (proximal muscle weakness and a blue-purple heliotrope rash, often found on the face, upper eyelids and trunk.)
- ALSO +ve in polymyositis
Anti-Smith antibody- specific for SLE
Osteoperosis in a male
Cause?
Key blood test?
Physiology of how this impacts bone formation? (2)
Hypogonadism- either hypergonadotropic (primary gonadal failure) or hypogonadotropic (secondary to a defect in the hypothalamic-pituitary axis) hypogonadism.
Tesosterone
- First, androgens stimulate bone formation during puberty.
- Second, androgens prevent bone resorption during and after puberty.
Methotrex causes pneumonitis and pulmonary fibrosis but what is the difference?
pneumonitis- presents as cough, dyspnoea, malaise, and fever and typically develops within a year of starting treatment
pulmonary fibrosis- scaring of lung parenchyma, develops due to long-term exposure to methotrexate, restrictive picture on spirometry.
Osteoperosis by long-term steroid medication.
What is the over-arching rule?
When deciding, go for age governed rules.
T scores explained (3)
If you are giving bone protection:
First line =
But check… first
Give prophylactic use if going to be taking the equivalent of prednisolone 7.5mg a day for 3 or more months
- Patients over the age of 65 years or those who’ve previously had a fragility fracture should be offered bone protection.
- Patients under the age of 65 years should be offered a bone density scan, with further management dependent:
T score
> 0 = reassure
0 to -1.5 = Repeat bone density scan in 1-3 years
< -1.5 = Offer bone protection
Management
First line = alendronate.
But ensure calcium and vitamin D replete first
Pagets disease
Indications for treatment: 4
Management
first line =
Oral =
IV eg =
- bone pain
- skull or long bone deformity
- fracture
- periarticular Paget’s
first line = bisphosphonate (either oral risedronate or IV zoledronate)
calcitonin is less commonly used now
