Rheumatology Flashcards
Anti-dsDNA
Anti-Ro
Anti-La
Anti-Sm
Anti-U1-RNP
Anti-Scl-70
Anti-centromere
Anti-Jo-1
Anti-Mi-2
Ocular manifesations of Rheumatoid arthritis
Keratoconjuncitivitis sicca (most common)
Sjögren’s syndrome (dryness, parotid enlargement)
Episcleritis (erythema)
Scleritis (erythema + pain + swollen)
Felty’s syndrome
Felty’s syndrome
SANTA
Splenomegaly | Arthritis (Rheumatoid) | Neutropaenia | Thrombocytopaenia | Anaemia
Ix for RhA
1st line = Rheumatoid factor (+ve in 70%)
Anti-CCP (high specificity) (+ve in 60%)
These are also poor prognostic factors
X ray changes in RhA
Tip: LESS
- Loss of joint space
- Erosions (justa-articular osteopenia) [often 1st sign]
- Soft tissue swelling
- Soft bones (Osteopenia)
Tx of RhA
S/E of Tx
Acute
- Corticosteroids
Chronic
- (1) DMARD + Bridging Prednisolone
-
Methotrexate
- Folate
- S/E: Hepatotoxic, Agranulocytosis (stop if infection!)
-
Azathioprine
- Check TPMT deficiency beforehand
-
Sulfasalzine
- Safe in pregnancy + breastfeeding
-
Hydroxychlorquine
- Safe in pregnancy + breastfeeding
- *S/E*: Retinopathy
-
Methotrexate
- If refractory –> (2) Biologics
- Anti-TNF (Infliximab, Etanercept, Adalimumab)
- Anti-B cell (Rituximab)
- S/E: Opportunistic infections, reactivation of latent TB
Tx of OA
Tx of OA
1st line
- (1) Oral Paracetamol
- or (1) Topical NSAIDs
- Topical NSAIDs are only indicated in Hand OA or Knee OA
2nd line
- (2) Oral NSAID (+ PPI)
Cause of septic arthritis
< 30 years –> N. gonorrhoea
> 30 years –> S. aureus
Ix + Tx for septic arthritis
Investigations
- Blood culture [1st Ix under new guidelines]
- URGENT joint aspiration –> synovial fluid MC&S
Management
- IV Flucloxacillin
- If pencillin allergic –> IV Clindamycin
Ix for Gout
Ix for Gout
Arthrocentesis with synovial fluid analysis
- -ve birefringent needle-shaped crystals under polarised light [DIAGNOSTIC]
N.B. Urate is normal in 25% of Gout
X-ray (affected joint):
- Periarticular erosions
- Overhanging sclerotic margins / edges
- Well-defined punched out bone lesions
- Soft tissue tophi
Diagnosis?
Gout
Tx for Gout
Acute
- (1) NSAID (C/I in CKD) or Colchicine
- (2) Corticosteroids
Once acute gout resolved
-
Urate lowering therapy
- Xanthine oxidase inhibitor –> Allopurinol
- Uricosuric agents –> Probenecid
- + Colchicine as bridging therapy
Low purine diet (avoid meat + seafood + oily fish)
X-ray Joint: Chondrocalcinosis
Diagnosis?
Ix?
Treatment?
Pseudogout (calcium pyrophosphate crystals)
Arthrocentesis + synovial fluid analysis: +ve birefringent, Rhomboid-shaped crystals
Tx: NSAIDs or Colchicine
DIP swelling + dactylitis
Diagnosis?
Psoriatic arthritis
Early morning gack pain, improves with exercise
Eye pain
Loss of lateral flexion of lumbar spine (1st sign)
Shober’s test +ve
Diagnosis? Ix? X ray changes? Tx?
Ankylosing spondylitis
1st line = X-ray (Pelvis) to look for sacroillitis
X-ray spine –> syndesmophytes, bamboo spine, squaring of vertebra
If X-ray negative –> MRI
Tx: (1) NSAIDs, (2) Biologics
Causes of reactive arthritis
After GI infection –> Post-dysentery
- Salmonella | Campylobacter | Shigella | Yersinia species
After GU infection (Post-STI)–> Urethritis (typically 1-4 weeks after)
- Chlamydia [most common]
Triad of reactive arthritis
Classic triad ==> “can’t see, can’t pee, can’t climb a tree”
- Conjunctivitis
- Urethritis (non-gonococcal)
- Arthritis (post-infectious)
Fever
Arthritis
Salmon-pink rash
Lymphadenopathy
Hepatosplenomegaly
Diagnosis? Ix?
Adult onset Still’s disease
Ferritin: ↑↑↑ (e.g. Ferritin = 4000, NR 15-300)
Amyloidosis
Types + Protein involved
Causes
Presentation
Clot + Thrombocytopenia
Diagnosis?
Features?
Tx?
Antiphospholipid syndrome
- Anticardiolipin antibodies: +ve on 2 occasions (12 weeks apart)
- Anti-β2-GPI antibodies: +ve on 2 occasions (12 weeks apart)
- Lupus anticoagulant: +ve on 2 occasions (12 weeks apart)
CLOT
- Clots (arterial + venous)
- Livedo reticularis (mottled rash)
- Obstetric complications (recurrent miscarriage)
- Thrombocytopaenia
Tx: Warfarin (INR 2-3) +/- Aspirin
Shoulder weakness
Raynaud’s phenomenon
Raised CK
Diagnosis?
Polymyositis
Shoulder weakness
Raynaud’s phenomenon
Gottren’s papules
Heloiotrope rash
Shawl sign
Raised CK
Diagnosis?
Dermatomyositis
Definitive diagnosis for dermatomyositis / polymyositis
Muscle biopsy
Tx for dermatomyositis / polymyositis
(1) IV/PO Corticosteroids
(2) IVIG
+ Screen for underlying malingnacy
Joint hypermobility
Elastic + fragile skin
Diagnosis? Cause?
Ehlers Danlos syndrome
Mutation in Type III collagen
Tip: 3hler’s Danlos syndrome (affects Type III Collagen)
Tall
Wrist sign and Thumb sign +ve
High arched palate
Superotemporal ectopia lentis
Aortic regurtation + Mitral regurgitation
Aortic dissection
Pneumothorax
Diagnosis? Cause?
Marfan’s syndrome
Autosomal dominant
Mutations in Fibrillin-1 gene
“Plucked chicken skin” appearance
Retinal angioid streaks
GI Bleeding
Mitral valve prolapse
Diagnosis? Cause? Complications?
Pseudoxanthoma elasticum
Autosomal recessive
↑ risk of ischaemic heart disease
Dry, scaly, erythematous plaques
Follicular keratin plugs [characteristic]
Diagnosis?
Cutaneous discoid lupus erythematosus (DLE) = discoid lupus
Causes of drug-induced lupus
Drugs associated with SLE
- Most common
- Procainamide
- Hydralazine
- Uncommon
- Isoniazid
- Phenytoin
Ix for drug-induced lupus
drug-induced lupus
ANA +ve (100%)
Anti-histone antibodies +ve (90%)
Anti-dsDNA NEGATIVE (usually +ve in SLE)
Causes of Neonatal lupus erythematosus
Presentation
Neonatal lupus erythematosus
Anti-Ro antibodies
Congenital heart block
Tx for SLE
Acute SLE
- High-dose Prednisolone
- IV Cyclophosphamide
Chornic SLE
- Skin symptoms –> Hydroxchlorquine
- Joint symptoms –> NSAIDs
Monitoring for SLE
Monitoring for SLE
- ESR
-
Anti-dsDNA Ab titres
- However, these are not present in all SLE (only present in 70%)
-
C3/C4 levels
- ↓ during active disease as formation of complexes consumes complement
Most common renal manifesation of SLEdiffuse proliferative glomerulonephritis
SLE –> diffuse proliferative glomerulonephritis
Mixed connective tissue disease
What antibody?
Mixed connective tissue disease
Anti-U1-RNP antibodies
Anti-U1 ribonucleoprotein (RNP) antibodies / Anti-RNP: +ve
Sjogren’s syndrome
Antibodies
Presentation
Associations
Sjogren’s syndrome
Anti-Ro + Anti-La
Dry eyes + Dry mouth
Sjogren’s syndrome is associated with
- Primary biliary cirrhosis (70%)
- Rheumatoid arthritis
CREST syndrome
Involves
CREST
- Calcinosis = tender white nodules over extensor surface
- Raynaud’s phenomenon
- oEsophageal dysmotility
- Sclerodactyl = tightening and thickening of skin
- Telangiectasia = blanchable red patches of small vessels
Limited vs Diffuse systemic sclerosis
Bacterial overgrowth syndrome
Investigation?
Associated with?
Systemic sclerosis
Due to reduced peristalsis
Ix: Hydrogen breath test
Most common cause of death in systemic sclerosis
Most common cause of death in systemic sclerosis
Respiratory involvement
- Pulmonary fibrosis
- Pulmonary hypertension
Tx for Raynaud’s phenomenon
CCB (Nifedipine)
Types of vasculitis
Visual symptoms
Jaw claudication
Headache
Scalp tenderness
Polymyalgia rheumatica
Diagnosis? Tx? Complications?
Temporal arteritis / Giant cell arteritis
Tx: High dose corticosteroids
Complications: anterior ischaemic optic neuropathy –> Blindness
Asian female
Weak/Absent pulses
L + R BP differential
Claudication
Hypertension
Chest pain
Diagnosis? Ix? Tx?
Takayasu arteritis (branches of aortic arch)
Ix: CT angiography
Tx: Corticosteroids
Features of Kawasaki
Ix?
Tx?
Kawasaki’s disease (affects coronary arteries)
- Conjunctivitis
- Rash (maculopapular)
- Adenopathy (cervical lymphadenopathy)
- Strawberry tongue
- Hands and feet (erythema and swollen)
- Fever > 5 days
Ix: TTE to look at coronary arteries
Tx: IVIG + Aspirin
Hepatitis B
Mononeuritis multiplex
Livedo reticularis
Haematuria
Renal failure
Hypertension
Diagnosis? Ix? Tx?
Polyarteritis nodosa (affects skin, renal, mesenteric arteries)
Associated with Hepatitis B
Ix: Angiography (string of beads = Rosary sign)
Tx: Corticosteroids
Smoking
Absence of distal pulses
Rest pain
Raynaud’s phenomenon
Diagnosis? Ix? Tx?
Buerger’s disease (thromboangiitis obliterans)
Associated with smoking
Is: Arterial Doppler + Angiography
Tx: CCB (Nifedipine)
Wegener vs Churg Strauss
What are the new names
Tip: Longer one is for the longer one
Wegener = Granulomatosis with polyangiitis
Churg-Strauss = Eosinophilic granulomatosis with polyangiitis
cANCA vs pANCA
Associations
Targets
Tip: C3PO
-
C-ANCA –> PR3
- Wegener’s
-
P-ANCA –> MPO
- Churg-Strauss
Asthma symptoms
Started Montelukast
Mononeuritis multiplex
Diagnosis? Ix? Tx?
Eosinophilic Granulomatosis with Polyangitis = (Churg-Strauss syndrome)
- pANCA
- Eosinophilia
Tx: Corticosteroids + Cyclophosphamide
Upper respiratory tract involvement (Saddle nose, Sinsitus, Nosebleeds)
Lower respiratory tract involvement (Haemoptysis)
Pauci-immune (rapidly progressive) glomerulonephritis
Diagnosis? Ix? Tx?
Granulomatosis with Polyangiitis (GPA) = (Wegener’s Granulomatosis)
- c-ANCA
- Biopsy: Crescentic glomerulonephritis
Tx: Corticosteroids + Cyclophosphamide
p-ANCA antibodies without evidence of granulomatous disease
Lung + Kidney involvement
No nasopharynx involvement (key difference!)
Diagnosis?
Microscopic polyangiitis
Features of Henon-Schonlein purpura
Renal biopsy findings
+/- Preceding URTI
Palpable purpuric rash (on buttocks and extensor surfaces of arms and legs)
Arthralgia / Arthritis
Abdominal pain
Glomerulonephritis (Haematuria or Proteinuria)
(Peri-articular oedema)
Renal biopsy: mesangial IgA deposition
Behcet’s disease
- features
- complications?
Behcet’s disease
- Triad
- Oral ulcers
- Genital ulcers
- Uveitis
- Erythema nodosum
Complications
- VTE
- Aseptic meningitis
DDx: Wegener’s granulomatosis vs Goodpasture’s syndrome
Cryoglobulinaemia
Triad
Cryoglobulinaemia
-
Triad (PAW)
- Purpura
- Arthralgia
- Weakness
Cryoglobulinaemia
Types + Associations
Acute onset
Shoulder/Hip stiffness or pain
Normal power
Rapid response to corticosteroids
Raised ESR
Diagnosis? Tx? Associations?
Polymyalgia rheumatica
Associated with temporal arteritis / giant cell arteritis
Tx: Corticosteroids
Polymyalgia rhuematica vs Fibromyalgia vs Stain-induced myopathy
Continuous regional pain out of proportion to the severity of the inciting event and beyond the normal time frame expected following the event
Diagnosis? Tx?
Complex Regional Pain Syndrome
Tx: Physiotherapy
Causes + Ix + Tx for osteomyelitis
Osteomyelitis
Causes
- Staph aureus (most common)
- Salmonella spp (most common in sickle cell patients)
Ix: MRI (Bone)
Tx: IV Flucloxacillin +/- Surgical debridgement
Lupus pernio
= Red/Purple raised hard skin lesions on nose, ears, cheeks
Diagnosis? Ix? CXR changes?
Prognosis?
Sarcoidosis
Biopsy = Non-caseating granuloma (diagnostic)
Serum ACE +ve
CXR: bilateral hilar lymphadenopathy
Good prognosis as majority self resolve spontaneously
