Rheumatology 1 Flashcards by Lucy Searle

When is the peak incidence of rheumatoid arthritis?

40s

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What are the risk factors for rheumatoid arthritis?

Genetic (HLA DR4 and DR1)
Female
Smokers
RF and anti-CCP

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What are the constitutional symptoms of RA?

Fatigue
Sweat
Weight loss
Fever

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What type of arthritis is RA?

Insidious symmetrical polyarthritis

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What typical joints are involved in RA?

PIP
MCP
Wrist and ankle
MTP
Elbow and knee
Cervical spine

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Name three deformities seen in aggressive or untreated RA?

Ulnar deviation at the wrist
Palmar subluxation at the MCP and wrist
Z Thumb
Boutonniere's
Hammer toe

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What is Boutonniere’s deformity?

Fixed flexion of digit

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What are the signs of active rheumatoid?

Heat, redness, swelling, pain, stiffness >30 minutes in the morning

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What is the name of the form of RA, where joint inflammation is episodic and resolves with no lasting damage?

Palindromic

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Name three systemic features of RA?

Secondary Sjogren's syndrome
Episcleritis
Rash
Rheumatoid nodules
Pulmonary fibrosis
Serositis

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What is Felty’s syndrome?

RF positive RA
Neutropenia
Splenomegaly

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Why are RA patients at risk of osteoporosis?

Consequence of long term steroids

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What are the components of the DAS28 score?

CRP/ESR
Global VAS - how has the patient’s RA been over the last week
Number of tender joints
Number of swollen jionts

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What is found on FBC and acute phase reactants in a patient with active rheumatoid?

Raised ESR and CRP
Normochromic normocytic anaemia
Reactive thrombocytosis
Raised ferritin but low serum iron

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What percentage of the normal population have a positive RF?

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What is anti-CCP and why is it sometimes better to use than RF?

Anti-cyclic citrullinated peptide

More specific than RF

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What is seen on X-Ray in RA?

Soft tissue swelling and synovitis
Periarticular osteopenia
Loss of joint space
Erosions

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What is the treatment of a newly diagnosed rheumatoid arthritis patient?

IM depomedrone (tides patient over until methotrexate kicks in)
Methotrexate and another DMARD such as hydroxychloroquine or sulfasalazine

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When might methotrexate not be started in a newly diagnosed RA patient?

Patient is breastfeeding
Patient is trying to conceive/pregnant
Disease is very mild

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Name three anti-TNF biological DMARDs

Infliximab
Etanercept
Adalimumab

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What is the mechanism of rituximab?

Anti-CD20

Binds to B cells and triggers cell apoptosis

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What is the main side effect of methotrexate?

Nausea (decreased with folic acid)

Abnormal liver function

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If a patient is intolerant to methotrexate why can’t they have rituximab?

Rituximab must be taken with methotrexate as there is a higher risk with this biologic that antibodies will form against the biologic. Methotrexate decreases the chance of this happening

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What is tocilizumab?

Anti-IL6

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What is abatacept?

T-cell co-stimulator modulator

What is baracitinib?

JAK inhibitor

What is the DAS28 threshold to signify uncontrolled disease and possibly the changing of medication?

DAS28>5.1

What factors convey a poor prognosis in RA?

Male Diagnosed less than 30 years Large number of joints involved Extra-articular manifestations

What is SLE?

A heterogenous, inflammatory, multi-system autoimmune disease

What are the risk factors for SLE?

Female Afro-Caribbean/SE Asian/Chinese ethnicity HLA DR2/DR3

What is the most common cause of SLE?

Idiopathic

Name three drugs that can induce lupus

``` Chlopromazine Methyldopa Isoniazid d-penicillamine Minocycline ```

What are the signs and symptoms of SLE?

``` Inflammatory arthritis Systemic features Oral ulcers Dry eyes and mouth Alopecia Malar butterfly rash Pleurisy and fibrosis Raynaud's ```

What is the malar butterfly rash of lupus?

Photosensitive Erythematous, raised, pruritic Spares the naso-labial folds

What other rashes feature in SLE?

Discoid lupus Livedo reticularis Alopecia Vasculitic rashes

How is lupus nephritis diagnosed?

Routine monitoring of hypertension, proteinuria, haematuria, raised urea or creatinine

What type of anaemia is common in SLE?

Haemolytic | But normochromic normocytic anaemia is common

What antibodies are found in SLE?

``` Anti-dsDNA Anti-SM Antiphospholipid ANA Anti-histone if drug induced ```

How is haemolytic anaemia diagnosed?

direct Coombs' test | Reticulocytes, bilirubin, blood film

What complement levels are seen in SLE?

Low C3 and C4 | High C3d

What malignancy is associated with SLE?

non-Hodgkin's lymphoma

Name some drugs used to treat various symptoms of SLE.

Hydroxychloroquine Mycophenolate mofetil Azathioprine Cyclophosphamide

Which drug is first line for mild SLE?

Hydroxychloroquine

Name some risk factors for fibromyalgia

``` Stress Chronic fatigue Women Depression PTSD ```

Name some symptoms of fibromyalgia.

Chronic widespread pain and stiffness Fatigue and poor sleep Poor memory and concentration Paraesthesias

Which conditions may co-exist with fibromyalgia?

IBS Tension headaches Irritable bladder TMJ syndrome

How many tender points are required to diagnose fibromyalgia?

11/18

What medications are used to treat the pain of fibromyalgia>

Opioids NSAIDs Amitriptyline and duloxetine Pregabalin and gabapentin`

Name some large vessel vasculitides.

Giant cell arteritis | Takayasu's arteritis

Describe the facial pain of GCA.

Recent onset Temporal/occipital Scalp tenderness Jaw claudication

What percentage of GCA patients have cerebral, systemic, and both cerebral and systemic involvement?

Both - 30% Systemic only - 5% Cerebral only - 65%

What percentage of RA patients are RF positive, and what percentage of the normal population are RF positive?

RF positive RA - 80% | RF positive non-RA - 20%

What are the visual symptoms of GCA?

Amaurosis fugax Diplopia Blurred vision

What is the cause of amaurosis fugax?

Ischaemic optic neuritis due to vasculitic involvement of the ophthalmic artery.

What is the main complication of GCA?

Subclinical aortic root involvement leading to aneurysms

What is the name of the syndrome where vasculitis affects the aortic arch vessels, causing brain ischaemia?

Subclavian steal syndrome

Name four consequences of long term steroids

Osteoporosis Steroid myopathy Bruising Hypertension

What is the different in treatment response between GCA and PMR?

PMR is exquisitely sensitive to steroids and does not relapse once in remission GCA is less sensitive and may relapse

How is GCA diagnosed?

Pulseless temporal artery Bruit over carotid, axillary, or brachial arteries Elevated ESR Temporal artery biopsy

What is seen on temporal artery biopsy in GCA?

Vasculitis with skip lesions Mononuclear cells Granulomas

What are three differentials of GCA?

Migraine or tension headache Trigeminal neuralgia Takayasu's arteritis

What is the treatment of GCA?

Immediate PO prednisolone

In what circumstances is IV methylprednisolone given in GCA?

If visual symptoms are present

What does joint hypermobility mean?

Joints easily move beyond their normal expected range

What is the main risk factor for benign joint hypermobility?

Family history

Why does hypermobility sometimes lead to exercise related pain?

When the body is deconditioned, tissue laxity leads to soft tissue injury. Exercise avoidance means a worsening spiral is set up.

What are some other symptoms of hypermobility?

Hand writing pain Fatiguability Generalised tiredness Posture related muscle pains

Is stiffness present in hypermobility syndrome?

Yes, after activity | Often for several days

What other conditions is hypermobility associated with?

Postural orthostatic tachycardia syndrome (POTS) Hernias Uterine or rectal prolapse Joint dislocation

How is POTS diagnosed?

Tilt table test

What criteria scores hypermobility?

Beighton

What are the components of the Beighton scores?

Little fingers - passive dorsiflexion beyond 90 Thumbs: passive dorsiflexion to forearm Elbows: hyperextension beyond 10 Knees: hyperextension beyond 10 Trunk: palms on the floor with knees fully extended

What Beighton score corresponds to hypermobility?

4-6 | Young adult

What are the differentials of hypermobility?

Type 3 Ehlers Danlos JIA/RA Fibromyalgia AS

How is hypermobility managed?

Physio - strengthening muscle groups | Progressive resisted exercise programme

What is the cause of gout?

Deposition of monosodium urate crystals within joints causing acute inflammation and eventual tissue damage

What is the typical threshold of serum uric acid for recurrent attacks of gout?

>360umol/L

What are the risk factors of gout?

``` Male Meat/seafood/alcohol Diuretics Obesity Hypertension ```

Name 3 protective factors for gout

Dairy products Coffee Vitamin C

What are the symptoms of gout?

``` Acute pain Swelling Tender Erythema Fever Inability to bear touch/walk ```

What is the most common joint to be affected by gout?

First MTP

Name three differentials of uric acid gout?

Septic arthritis Calcium pyrophosphate deposition disease Chronic tophaceous RA

What investigations are required in gout?

Joint aspiration Serum uric acid (in an asymptomatic period) X-Ray Fasting glucose and lipids

What is seen in joint aspiration in gout?>

Negatively birefringent needle shaped crystals

What are the X-Ray findings in chronic gout?

Punched out lesions Sclerosis Tophia

Why is it important to do fasting glucose and lipids?

Gout is commonly associated with metabolic syndrome

What is the treatment of an acute attack of gout?

Elevation and ice NSAIDs Colchicine

What is the prophylactic treatment of gout?

Allopurinol | Febuxistat

When is gout prophylaxis indicated?

>1 attack per 12 months

Which foods are high in purines and therefore intake should be reduced?

Red meat Liver and kidneys Herring, sardines, and mussels

Which drugs can cause hyperuricaemia?

Diuretics Aspirin Ciclosporin Chemotherapy

What type of drug is allopurinol?

Xanthase oxidase inhibitor that lowers urate

When should gout prophylaxis be initiated?

1-2 weeks after an acute attack

What crystals are associated with pseudogout?

Calcium pyrophosphate dihydrate

Attacks of pseudogout can be precipitated by...

Dehydration Illness Surgery or trauma RF: haemochromatosis

What is the most common joint affected in pseudogout?

Knee and wrist

How do the symptoms of pseudogout compare with uric acid gout?

Similar but milder

What does aspiration of a pseudogouty joint show?

Intracellular and extracellular weakly positive birefringent rhomboid crystals

What is the treatment of gout?

Symptomatic | Ice packs, NSAIDs, therapeutic aspiration

What are the causes of drug-induced lupus?

Procainamide Hydralazine Isoniazid