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
Lady with RA going for lap chole surgery, what investigation is needed to be done beforehand and why?
Anteroposterior and lateral cervical spine radiographs
Why?
Atlantoaxial subluxation is a rare complication of rheumatoid arthritis, but important as it can lead to cervical cord compression.
Ensuring the patient goes to surgery in a C-spine collar and the neck is not hyperextended on intubation.
Hip pain which is referred from the lumbar spine can be elicited with what exam finding?
How do you do the test?
Femoral nerve stretch test Aka Ely Test may be positive
- Lie the patient prone. Extend the hip joint with a straight leg then bend the knee. This stretches the femoral nerve and will cause pain if it is trapped
Gout
When are you offered prophylaxis treatment + with what?
Particular recommnded if: (5)
When should you start it?
First line:
Class
Dose and titrate until…
Why would some people start at a lower dose?
Second-line-
In refractory cases-
Urate lowering therapy to all patients after their first attack!
Particular recommnded if:
- >=2 attacks in 12 months
- tophi
- renal disease
- uric acid renal stones
- prophylaxis if on cytotoxics or diuretics
- Delay until inflam has settled
First-line: Allopurinol (xanthine oxidase inhibitors) 100mg OD and titirated until serum uric acid is <300
- Start at lower dose if reduced eGFR
Second-line- febuxostat
Refractory cases- pegloticase (polyethylene glycol modified mammalian uricase) can achieve rapid control of hyperuricemia.
Antiphospholipid syndrome
Management
- Never had a clot before =
- If had previous clots =
- Never had a clot before = low-dose aspirin
- Previous clots = Warfarin, target INR 2-3
What is Polyarteritis nodosa (PAN)?
Assoc. with what infection?
Features (7)
Antibody in 20%?
vasculitis affecting medium-sized arteries with necrotizing inflammation leading to aneurysm formation
hepatitis B infection
- fever, malaise, arthralgia
- weight loss
- hypertension
- mononeuritis multiplex, sensorimotor polyneuropathy
- testicular pain
- livedo reticularis
- haematuria, renal failure
perinuclear-antineutrophil cytoplasmic antibodies (ANCA)
Which TB drug can cause drug induced lupus?
and what is the antibody assoc with drug induced lupus?
Isoniozid
Antihistone antibodies
Rotator cuff muscles
Name them and their movement
Supraspinatus- AB (does the first 20 degrees then deltoid takes over)
Infraspinatous- External rotation
Subscapularis- Internal rotation
Teres minor (basically just helps infraspinatous and does ext. rotation)
Side effect of IFN-alpha (2) for Hep C
- Flu-like symp
- Depression
What is the triad of Feltys Syndrome
- RA
- Low WCC
- Splenomegaly
Ank Spond XRay findings (4)
One chest xray finding
- sacroilitis: subchondral erosions, sclerosis
- squaring of lumbar vertebrae
- Bamboo spine
- syndesmophytes: due to ossification of outer fibers of annulus fibrosus
chest x-ray: apical fibrosis
What antibody would you associate with any vasulitis?
General antibody =
1)…..- 2 vasculiditis
2) ……- 1 vasculitis
ANCA!
p-ANCA (MPO antibodies):
- Microscopic polyangiitis (Good-pastures, also anti-GBM)
- Churg-Strauss syndrome aka eosinophilic granulomatosis polyangiitis
c-ANCA (PR3 antibodies): Granulomatosis with polyangiitis aka Wegners Syn.
Reactive arthritis features
classic triad
others:
- Hands
- skin (2)
Reiters syn; Cant see, cant pee cant climb a tree
1) urethritis
2) conjunctivitis or ant. uvietitis
3) arthritis
- Dactylitis (seen in psoriatic too ofc.)
Skin: - circinate balanitis (painless vesicles on the coronal margin of the prepuce)
- keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles)
SLE what blood test can be monitored in ACTIVE flare up and is it low or high?
Compliment levels are usually low during active disease - may be used to monitor flares
Describe how you should take Bisphosphonates
Take at least 30 mins before breakfast with plenty of water and sit upright for 30 mins
Diffuse systemic sclerosis management for renal disease and respiratory disease
Renal disease- ACEi to decrease BP
systemic sclerosis-associated interstitial lung disease- IV cyclophosphamide
GCA if have negative biopsy (very possible due to skip lesions) when should the biopsy be retaken?
Within 7 days
Salfasalazine
is it safe in preg?
STEM! - caution in who? (2)
SE:
(5)
Yes- but need to take folic acid 5mg
Max dose if preg is 2g/day and need folic acid supp ofc.
Caution- if aspirin sensitivity or sulphonamide sensivity
Caution - G6PD def
SE
1. Can colour tears
2. Steven-Johnson syn
3. Temporary male infertility
4. Myelosurpression- can get heinz body anaemia (obvs would make G6PD wrose)
5. Pneumonitis/ fibrosis
Leflunamide
SE (6)
- Hypertension
- peripheral neuropathy
- Tiatrogenic
- BM surpression
- Mouth ulcers
6 Rash
Methotrexate
MOA-
Route-
What prescribed with it?-
When is this given?-
NEVER PRESCRIBE WITH… (2)
ANOTHER KEY DRUG INTERACTION
Treatment for methotrexate toxiticity?
MOA- Anti-folic metabolsim
Route- IM or tablet once a week
What prescribed with it?- 5 mg Folic acid
When is this given?- 24hrs after
NEVER
- Trimethoprim
- Co-trimoxazole, both lead to myelosurpression
- High dose aspirin as can cause toxity of methotrexate secondary to decreased extertion
Follinic acid
Methotrexate
SE (5)
Monitoring rules?
Methotrexate baseline investigations? (3)
Preg rules (2)
- Tiatrogenic
- Mouth ulcers
- BM suppression
- Pulmonary fibrosis
- Liver cirrhosis
Monitor- baseline before, weekly, then when stable every 2/3 months
Baseline:
1. CXR- TB
2. FBC, U+E, LFT,
3. Sometimes pulmonary function tests
Preg
- M+F should stop 6 months before tryig to conceive
- Effective contraception 6 months after stopping
