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Medicine Finals > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

Which condition are anti-histone antibodies associated with?

A

Drug-induced Lupus

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2
Q

Which condition are Anti-Scl-70 antibodies associated with?

A

Diffuse systemic sclerosis

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3
Q

Which condition are anti-centromere antibodies associated with?

A

Limited systemic sclerosis

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4
Q

Which condition are Anti-Ro antibodies associated with?

A

Sjorgen’s syndrome

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5
Q

Which condition are Anti-Jo-1 antibodies associated with?

A

Polymyositis

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6
Q

Which joints are most commonly affected by osteoarthritis?

A

Large joints - hip and knee

Carpometocarpal joints

PIP + DIP

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7
Q

What hand signs are seen in osteoarthritis?

A

Bouchard’s nodes (PIP)

Heberden’s nodes (DIP)

Squaring of the thumb

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8
Q

What are the 4 x-ray signs seen in osteoarthritis?

A

LOSS

Loss of Joint space

Osteophytes

Subchondral cysts

Subchondral sclerosis

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9
Q

How is osteoarthritis managed?

A

First line = oral paracetamol or TOPICAL NSAIDs

2nd line = oral NSAIDS/codeine (remember to co-prescribe PPI)

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10
Q

Which joints are affected by rheumatoid arthritis?

A

Symmetrical distribution

MCP and PIP

Never affects DIP - DIP will be osteoarthritis or psoriatic arthritis

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11
Q

What hand signs are seen in rheumatoid arthritis?

A

Z shaped deformity of the thumb

Swan neck deformity

Boutenniere’s deformity

Ulnar deviation

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12
Q

What x-ray changes are seen in rheumatoid arthritis?

A

Loss of joint space

Juxta-articular osteopororis

Soft tissue swelling

Boney erosions

Periarticular erosions

Subluxation

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13
Q

Which antibodies are associated with rheumatoid arthritis?

A

Rheumatoid factor (non specific but very sensitive)

Anti-CCP antibodies (very specific but not as sensitive)

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14
Q

How is rheumatoid arthritis managed?

A

1st line = DMARD (Methotrexate/Sulfasalazine/Hydroxychloroquine)

2nd line = combination of 2 DMARDs

3rd line = Methotrexate + Inflixamb/Adalimumab

4th line = Methotrexate + Rituximab

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15
Q

How are acute flares of rheumatoid arthritis managed?

A

IM Methylprednisolone

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16
Q

How is rheumatoid arthritis in pregnancy managed?

A

Hydroxychloroquine or Sulfasalazine or Azathioprine

Methotrexate is CI

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17
Q

What is the main adverse effect of Hydroxychloroquine and how is this monitored?

A

Retinopathy

Ophthalmology screening prior to starting and then annually

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18
Q

What is Felty syndrome? What triad is seen? How is it managed?

A

A rare variant of RA

Triad =

Highly active RA

Splenomegaly

Neutropaenia

Management = same as severe RA (methotrexate+pred), also needs to vaccinated against influenza and pneumococcal due to splenomegaly

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19
Q

How does psoriatic arthritis present? What nail changes are seen?

A

Symmetrical polyarthritis is most common but can be asymmetrical

SERONEGATIVE

Sacroilitis (inflammation of pelvis)

Can affect the DIP (unlike RA)

Dactylitis (swelling of the digits)

Nail changes = nail pitting and oncholysis

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20
Q

What x-ray change is seen in psoriatic arthritis

A

Pencil in cup appearance

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21
Q

How is psoriatic arthritis managed?

A

Same as RA

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22
Q

What infections commonly triggers reactive arthritis?

A

Gastroenteritis organisms

Chlamydia

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23
Q

How does reactive arthritis present and what is seen on joint aspiration?

A

Can’t see, can’t pee, cant climb a tree

Acute monoarthritis which presents within 4 weeks of initial infection

Dactylitis

Conjunctivitis and anterior uveitis (can’t see)

Balanitis (can’t pee)

Joint aspiration will be sterile and not grow any organisms

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24
Q

How is reactive arthritis managed?

A

Acute mono arthritis needs to be managed under local hot joint policy

Urgent joint aspiration (gram staining and C+S) to exclude septic arthritis

When reactive arthritis has been diagnosed it is treated w/ NSAIDs

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25
Q

What is ankylosing spondylitis and how does it present?

A

HLA-B27 associated spondyloarthropathy (seronegative)

Usually presents in young men

Inflammation of the sacroiliac joints and the joints of the vertebral column

Progresses to fusion of the joints

Lower back pain and stiffness - inflammatory pattern (worse in morning, improves with movement)

Reduced lateral flexion of the spine

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26
Q

What x-ray findings are seen in ankylosing spondylitis?

A

Spine X-ray:

Squaring of the lumbar vertebrae

Bamboo spine (later stages)

Syndesmophytes

Pelvic x-ray = Sacroilitis

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27
Q

What is the best diagnostic test for ankylosing spondylitis?

A

Pelvic x-ray showing sacroilitis

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28
Q

How is ankylosing spondylitis managed?

A

NSAIDs

Exercise/physio

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29
Q

What other organ systems can ankylosing spondylitis affect other than the spine and pelvis?

A

Chest pain due to fusion/inflammation of costosternal joints and costovertebral joints

Plantar fasciitis

Anterior uveitis

Pulmonary fibrosis

Inflammatory bowel disease

Heart block

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30
Q

What is systemic lupus erythematosus? How does it present?

A

Inflammatory autoimmune connective tissue disorder

Relapsing-remitting

Photosensitive malar rash

Arthralgia

Myalgia

Fever

Fatigue

Mouth ulcers

Splenomegaly

Lymphadenopathy

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31
Q

Which autoantibodies are associated with SLE?

A

Anti-nuclear antibodies (not as specific but more sensitive)

Anti-dsDNA (more specific)

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32
Q

How is SLE managed?

A

1st line = Hydroxychloroquine (safe in pregnancy)

can also try other immunnosuppressants - Methotrexate/Azathioprine

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33
Q

What is the association between SLE and complement levels?

A

Complement levels are usually low during active disease

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34
Q

What are complications of SLE?

A

Cardiovascular disease

Recurrent miscarriage

Antiphospholipid syndrome

Lupus nephritis

Pericarditis

Pleuritis

Anaemia of chronic disease

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35
Q

What is discoid lupus erythematosus and how does it present? How is it treated?

A

Chronic skin condition

More common in women with darker skin

Slightly increased risk of SLE

Photosensitive lesions on the face/ears/scalp - lesions are inflamed dry/patchy/crusty

Associated with scarring alopecia

Management = topical steroids

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36
Q

What antibodies are associated with drug-induced lupus?

A

Anti-nuclear antibodies

Anti-histone antibodies

37
Q

What drugs most commonly cause drug induced lupus?

A

Procainamide

Hydralazine

Isoniazid

Minocycline

Phenytoin

38
Q

What is systemic sclerosis and what are the two types?

A

Autoimmune inflammatory connective tissue disorder

2 types = Limited and Diffuse

Limited = CREST

Calcinosis

Raynaud’s

Oesophageal dysmotility

Sclerodactyly

Telangiectasia

+ Scleroderma just on face and below elbows.

Diffuse =

Scleroderma which affects trunk and proximal limbs.

Also affects cardiovascular (HTN and coronary artery disease), lungs (pulmonary HTN and pulmonary fibrosis) and the kidney (glomerulonephritis and scleroderma renal crisis)

39
Q

What is seen on nail fold capillaroscopy in systemic sclerosis?

A

Abnormal capillaries

Avascular necrosis

Micro-haemorrhages

40
Q

How can you differentiate Raynaud’s which is secondary to systemic sclerosis and primary Raynaud’s?

A

Nailfold capillaroscopy

41
Q

Which autoantibodies are associated with systemic sclerosis?

A

Limited = Anti-centromere

Diffuse = Anti-Scl-70

42
Q

What is antiphospholipid syndrome and how can it present?

A

An autoimmune disorder characterised by - arterial and venous thrombosis and adverse pregnancy outcomes

CLOT

Clots (both venous and arterial)

Livedo reticular (mottled lace like appearance of veins on lower limbs)

Obstetric loss

Thrombocytopaenia

43
Q

What is seen on clotting bloods in antiphospholipid syndrome?

A

Prolonged APTT

Low platelets

44
Q

How is antiphospholipid syndrome managed?

A

Primary prophylaxis = Low dose Aspirin (75mg) –> In pregnancy this should be Aspirin + LMWH

Secondary prophylaxis (when there has been an episode of VTE) = Lifelong warfarin (switch to LMWH during pregnancy and when trying to conceive).

45
Q

What autoantibodies are seen in antiphospholipid syndrome?

A

Lupus anticoagulant

Anticardiolipin antibodies

Anti-beta-2 glycoprotein 1 antibodies

46
Q

Which condition is associated with anticardiolipin antibodies?

A

Antiphospholipid syndrome

47
Q

How can temporal arteritis/GCA present?

A

Headache (around temples)

Jaw claudication

Visual disturbances - amaurosis fugax, blurring, double vision, relative afferent pupillary defect

Palpable temporal artery

Tenderness around temporal artery

Around 50% have symptoms of polymyalgia rheumatic - morning stiffness of the shoulders and pelvic girdle

48
Q

What investigations should be conducted in temporal arteritis/GCA?

A

Raised ESR > 50

Temporal artery biopsy - shows multinucleated giant cells

Other results which may be abnormal:

Raised ALP

Raised CRP

Normocytic anaemia

Raised platelets

49
Q

How is suspected temporal arteritis/GCA managed?

A

Send for inflammatory markers

40mg prednisolone (start treatment before biopsy results are back)

If jaw symptoms - 60mg prednisolone

If visual symptoms - IV Methylprednisolone

50
Q

How does polymyalgia rheumatic present? How is it managed?

A

Morning pain and stiffness of the shoulders, neck and pelvic girdle (including thighs)

NO WEAKNESS - just pain!!

Strong association with GCA

Managed with 15mg prednisolone then tapered down

51
Q

Which autoimunne connective tissue disorder causes a raised creatine kinase?

A

Polymyositis/ Dermatomyositis

52
Q

How does polymyositis present?

A

Muscle pain, fatigue and WEAKNESS!!

Muscle weakness of the shoulders and pelvic girdle

53
Q

How does dermatomyositis present?

A

Gottron lesions (red or violet bumps that form on the knuckles/knees/elbows)

Photosensitive rash on back/shoulders/neck

Periorbital oedema

Purple rash around eyes

54
Q

What autoantibodies are associated with polymyositis and dermatomyositis?

A

Polymyositis –> Anti-Jo-1

Dermatomyositis –> Anti-Mi-2 and ANA

55
Q

How is polymyositis and dermatomyositis diagnosed?

A

Clinical presentation + Elevated CK

Autoantibodies

Electromyography + Muscle biopsy

56
Q

What condition is associated with a raised CK in malignancy?

A

Polymyositis (Can be a paraneoplastic syndrome in lung cancer)

57
Q

What is the differential diagnosis of a hot swollen joint?

A

Septic arthritis

Reactive arthritis

Gout

Pseudogout

58
Q

Which joint is usually affected by gout?

A

1st MTP (base of big toe)

59
Q

What is seen on joint aspiration in gout?

A

Monosodium urate crysals

Needle-shaped

Negatively bifringent of polarised light

60
Q

How is gout managed?

A

Acute management = NSAIDs or Colchicine (Continue Allopurinol during acute attacks)

Prophylaxis = Allopurinol (wait until initial acute attack has settled before prescribing for first time)

61
Q

What is seen on joint aspiration in pseudo gout?

A

Calcium pyrophosphate

Rhomboid shaped

Weakly-positively bifringent to polarised light

62
Q

What is seen on x-ray in psueodgout?

A

Chondrocalcinosis (calcium in the cartilage)

63
Q

How is pseudo gout managed?

A

Manage acute attacks with NSAIDs or colchicine

64
Q

What is Sjorgen’s syndrome and how does it present?

A

Autoimmune conditions of the EXOCRINE glands

Dry eyes, dry mouth, vaginal dryness

65
Q

Which malignancy has an increased risk in Sjorgen’s syndrome?

A

MALT Lymphoma

66
Q

What autoantibodies are associated with Sjorgen’s syndrome?

A

Rheumatoid factor

Anti-nuclear antibodies

Anti-Ro antibodies

Anti-La

67
Q

How can Sjorgen’s syndrome be diagnosed?

A

Schirmer’s test

68
Q

How is Sjorgen’s syndrome managed?

A

Artificial saliva/tears

Vaginal lubricant

69
Q

Which organisms most commonly cause Septic Arthritis and how does it present?

A

Staph aureus, but can also be Gonorrhoea in sexually active patients

hot, red, swollen painful joint

systemic symptoms - fever

70
Q

What is Behcet’s disease, how does it present?

A

Inflammatory conditon

Triad = Recurrent oral ulcers and genital ulcers
and Anterior uveitis

Also…

Erythema nodosum

Morning stiffness + arthralgia

71
Q

What is polyarteritis nodosa? How does it present?

A

Vasculitis which affects medium-sized vessels

Fever, malaise, arthralgia

Mononeuritis

Livedo reticularis

Haematuria

Renal failure

Necrotic ulcers

72
Q

What conditions can cause secondary Raynaud’s?

A

Systemic scleross

Polycythaemia rubra vera

SLE

73
Q

How is Raynaud’s managed?

A

Nifedipine

74
Q

What are features of Marfan syndrome?

A

Tall stature

High arched palate

Pectus excavatum (sunken breastbone)

Pes planus (flat foot)

Dilation of the aortic sinuses - which can cause complications such as aortic regurg/aortic dissection/aortic aneurysm/mitral valve prolapse

Upwards lens dislocation

Dural ectasia

75
Q

What are features of Ehler-Danlos syndrome?

A

Elastic/fragile skin

Joint hypermobility

Easy bruising

Aortic regurg

Aortic dissection

Mitral valve prolapse

Subarachnoid haemorrhage

76
Q

What is osteoporosis and how is it diagnosed?

A

Low bone mineral density

Bone mineral density can be calculated by doing a DEXA scan which gives a T score

T score = -1 or more = normal, -1 to -2.5 = osteopenia, less than -2.5 is osteoporosis

If a fracture in a pt aged 75 or older - treat as osteoporosis w/o scan

77
Q

How is osteoporosis managed?

A

Bisphosphonates e.g. Alendronate

Calcium + vitamin D

78
Q

What are risk factors for osteoporosis?

A

Old age

Post-menopause

Low BMI

Long term steroids

Smoking

79
Q

What is osteomalacia and what is the cause?

A

Defective bone mineralisation causing soft bones

Due to insufficient vitamin D

Insufficient vitamin D causes decreased calcium reabsorption

Decreased calcium reabsorption causes secondary hyperparathyroidism which increases osteoclast action

80
Q

How does osteomalacia present?

A

Fatigue

bone pain

Muscle weakness/aching

Abnormal fractures

81
Q

What investigations can be used to diagnose osteomalacia?

A

Low vitamin D

Low calcium

Low phosphate

However calcium and phosphate may be normal if this has been compensated by a raised PTH

Raised ALP

82
Q

How is osteomalacia managed?

A

Vitamin D (colecalciferol)

83
Q

What is Paget’s disease?

A

Excessive osteoclast action and increased osteoblast action

Uncontrolled bone turnover

84
Q

What is seen on skull x-ray in Paget’s disease?

A

Thickened vault

Osteoporosis circumscripta (Cotton-wool appearance)

85
Q

Which blood marker is raised in Paget’s disease?

A

ALP

Calcium and phosphate are normal

86
Q

Bone disease: decreased calcium, decreased phosphate, increased ALP, increased PTH

A

Osteomalacia

87
Q

Bone disease: increased calcium, decreased phosphate, increased ALP, increased PTH

A

Primary hyperparathyroidism

88
Q

Bone disease: normal calcium, normal phosphate, increased ALP, normal PTH

A

Paget’s disease

89
Q

Which conditions are associated with pANCA ? (Not just rheum)

A

GPA

Ulcerative colitis

Primary sclerosing cholangitis

Medicine Finals (32 decks)

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