Rheumatology Flashcards
Which condition are anti-histone antibodies associated with?
Drug-induced Lupus
Which condition are Anti-Scl-70 antibodies associated with?
Diffuse systemic sclerosis
Which condition are anti-centromere antibodies associated with?
Limited systemic sclerosis
Which condition are Anti-Ro antibodies associated with?
Sjorgen’s syndrome
Which condition are Anti-Jo-1 antibodies associated with?
Polymyositis
Which joints are most commonly affected by osteoarthritis?
Large joints - hip and knee
Carpometocarpal joints
PIP + DIP
What hand signs are seen in osteoarthritis?
Bouchard’s nodes (PIP)
Heberden’s nodes (DIP)
Squaring of the thumb
What are the 4 x-ray signs seen in osteoarthritis?
LOSS
Loss of Joint space
Osteophytes
Subchondral cysts
Subchondral sclerosis
How is osteoarthritis managed?
First line = oral paracetamol or TOPICAL NSAIDs
2nd line = oral NSAIDS/codeine (remember to co-prescribe PPI)
Which joints are affected by rheumatoid arthritis?
Symmetrical distribution
MCP and PIP
Never affects DIP - DIP will be osteoarthritis or psoriatic arthritis
What hand signs are seen in rheumatoid arthritis?
Z shaped deformity of the thumb
Swan neck deformity
Boutenniere’s deformity
Ulnar deviation
What x-ray changes are seen in rheumatoid arthritis?
Loss of joint space
Juxta-articular osteopororis
Soft tissue swelling
Boney erosions
Periarticular erosions
Subluxation
Which antibodies are associated with rheumatoid arthritis?
Rheumatoid factor (non specific but very sensitive)
Anti-CCP antibodies (very specific but not as sensitive)
How is rheumatoid arthritis managed?
1st line = DMARD (Methotrexate/Sulfasalazine/Hydroxychloroquine)
2nd line = combination of 2 DMARDs
3rd line = Methotrexate + Inflixamb/Adalimumab
4th line = Methotrexate + Rituximab
How are acute flares of rheumatoid arthritis managed?
IM Methylprednisolone
How is rheumatoid arthritis in pregnancy managed?
Hydroxychloroquine or Sulfasalazine or Azathioprine
Methotrexate is CI
What is the main adverse effect of Hydroxychloroquine and how is this monitored?
Retinopathy
Ophthalmology screening prior to starting and then annually
What is Felty syndrome? What triad is seen? How is it managed?
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
How does psoriatic arthritis present? What nail changes are seen?
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
What x-ray change is seen in psoriatic arthritis
Pencil in cup appearance
How is psoriatic arthritis managed?
Same as RA
What infections commonly triggers reactive arthritis?
Gastroenteritis organisms
Chlamydia
How does reactive arthritis present and what is seen on joint aspiration?
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
How is reactive arthritis managed?
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
What is ankylosing spondylitis and how does it present?
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
What x-ray findings are seen in ankylosing spondylitis?
Spine X-ray:
Squaring of the lumbar vertebrae
Bamboo spine (later stages)
Syndesmophytes
Pelvic x-ray = Sacroilitis
What is the best diagnostic test for ankylosing spondylitis?
Pelvic x-ray showing sacroilitis
How is ankylosing spondylitis managed?
NSAIDs
Exercise/physio
What other organ systems can ankylosing spondylitis affect other than the spine and pelvis?
Chest pain due to fusion/inflammation of costosternal joints and costovertebral joints
Plantar fasciitis
Anterior uveitis
Pulmonary fibrosis
Inflammatory bowel disease
Heart block
What is systemic lupus erythematosus? How does it present?
Inflammatory autoimmune connective tissue disorder
Relapsing-remitting
Photosensitive malar rash
Arthralgia
Myalgia
Fever
Fatigue
Mouth ulcers
Splenomegaly
Lymphadenopathy
Which autoantibodies are associated with SLE?
Anti-nuclear antibodies (not as specific but more sensitive)
Anti-dsDNA (more specific)
How is SLE managed?
1st line = Hydroxychloroquine (safe in pregnancy)
can also try other immunnosuppressants - Methotrexate/Azathioprine
What is the association between SLE and complement levels?
Complement levels are usually low during active disease
What are complications of SLE?
Cardiovascular disease
Recurrent miscarriage
Antiphospholipid syndrome
Lupus nephritis
Pericarditis
Pleuritis
Anaemia of chronic disease
What is discoid lupus erythematosus and how does it present? How is it treated?
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
What antibodies are associated with drug-induced lupus?
Anti-nuclear antibodies
Anti-histone antibodies
What drugs most commonly cause drug induced lupus?
Procainamide
Hydralazine
Isoniazid
Minocycline
Phenytoin
What is systemic sclerosis and what are the two types?
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)
What is seen on nail fold capillaroscopy in systemic sclerosis?
Abnormal capillaries
Avascular necrosis
Micro-haemorrhages
How can you differentiate Raynaud’s which is secondary to systemic sclerosis and primary Raynaud’s?
Nailfold capillaroscopy
Which autoantibodies are associated with systemic sclerosis?
Limited = Anti-centromere
Diffuse = Anti-Scl-70
What is antiphospholipid syndrome and how can it present?
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
What is seen on clotting bloods in antiphospholipid syndrome?
Prolonged APTT
Low platelets
How is antiphospholipid syndrome managed?
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).
What autoantibodies are seen in antiphospholipid syndrome?
Lupus anticoagulant
Anticardiolipin antibodies
Anti-beta-2 glycoprotein 1 antibodies
Which condition is associated with anticardiolipin antibodies?
Antiphospholipid syndrome
How can temporal arteritis/GCA present?
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
What investigations should be conducted in temporal arteritis/GCA?
Raised ESR > 50
Temporal artery biopsy - shows multinucleated giant cells
Other results which may be abnormal:
Raised ALP
Raised CRP
Normocytic anaemia
Raised platelets
How is suspected temporal arteritis/GCA managed?
Send for inflammatory markers
40mg prednisolone (start treatment before biopsy results are back)
If jaw symptoms - 60mg prednisolone
If visual symptoms - IV Methylprednisolone
How does polymyalgia rheumatic present? How is it managed?
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
Which autoimunne connective tissue disorder causes a raised creatine kinase?
Polymyositis/ Dermatomyositis
How does polymyositis present?
Muscle pain, fatigue and WEAKNESS!!
Muscle weakness of the shoulders and pelvic girdle
How does dermatomyositis present?
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
What autoantibodies are associated with polymyositis and dermatomyositis?
Polymyositis –> Anti-Jo-1
Dermatomyositis –> Anti-Mi-2 and ANA
How is polymyositis and dermatomyositis diagnosed?
Clinical presentation + Elevated CK
Autoantibodies
Electromyography + Muscle biopsy
What condition is associated with a raised CK in malignancy?
Polymyositis (Can be a paraneoplastic syndrome in lung cancer)
What is the differential diagnosis of a hot swollen joint?
Septic arthritis
Reactive arthritis
Gout
Pseudogout
Which joint is usually affected by gout?
1st MTP (base of big toe)
What is seen on joint aspiration in gout?
Monosodium urate crysals
Needle-shaped
Negatively bifringent of polarised light
How is gout managed?
Acute management = NSAIDs or Colchicine (Continue Allopurinol during acute attacks)
Prophylaxis = Allopurinol (wait until initial acute attack has settled before prescribing for first time)
What is seen on joint aspiration in pseudo gout?
Calcium pyrophosphate
Rhomboid shaped
Weakly-positively bifringent to polarised light
What is seen on x-ray in psueodgout?
Chondrocalcinosis (calcium in the cartilage)
How is pseudo gout managed?
Manage acute attacks with NSAIDs or colchicine
What is Sjorgen’s syndrome and how does it present?
Autoimmune conditions of the EXOCRINE glands
Dry eyes, dry mouth, vaginal dryness
Which malignancy has an increased risk in Sjorgen’s syndrome?
MALT Lymphoma
What autoantibodies are associated with Sjorgen’s syndrome?
Rheumatoid factor
Anti-nuclear antibodies
Anti-Ro antibodies
Anti-La
How can Sjorgen’s syndrome be diagnosed?
Schirmer’s test
How is Sjorgen’s syndrome managed?
Artificial saliva/tears
Vaginal lubricant
Which organisms most commonly cause Septic Arthritis and how does it present?
Staph aureus, but can also be Gonorrhoea in sexually active patients
hot, red, swollen painful joint
systemic symptoms - fever
What is Behcet’s disease, how does it present?
Inflammatory conditon
Triad = Recurrent oral ulcers and genital ulcers
and Anterior uveitis
Also…
Erythema nodosum
Morning stiffness + arthralgia
What is polyarteritis nodosa? How does it present?
Vasculitis which affects medium-sized vessels
Fever, malaise, arthralgia
Mononeuritis
Livedo reticularis
Haematuria
Renal failure
Necrotic ulcers
What conditions can cause secondary Raynaud’s?
Systemic scleross
Polycythaemia rubra vera
SLE
How is Raynaud’s managed?
Nifedipine
What are features of Marfan syndrome?
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
What are features of Ehler-Danlos syndrome?
Elastic/fragile skin
Joint hypermobility
Easy bruising
Aortic regurg
Aortic dissection
Mitral valve prolapse
Subarachnoid haemorrhage
What is osteoporosis and how is it diagnosed?
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
How is osteoporosis managed?
Bisphosphonates e.g. Alendronate
Calcium + vitamin D
What are risk factors for osteoporosis?
Old age
Post-menopause
Low BMI
Long term steroids
Smoking
What is osteomalacia and what is the cause?
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
How does osteomalacia present?
Fatigue
bone pain
Muscle weakness/aching
Abnormal fractures
What investigations can be used to diagnose osteomalacia?
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
How is osteomalacia managed?
Vitamin D (colecalciferol)
What is Paget’s disease?
Excessive osteoclast action and increased osteoblast action
Uncontrolled bone turnover
What is seen on skull x-ray in Paget’s disease?
Thickened vault
Osteoporosis circumscripta (Cotton-wool appearance)
Which blood marker is raised in Paget’s disease?
ALP
Calcium and phosphate are normal
Bone disease: decreased calcium, decreased phosphate, increased ALP, increased PTH
Osteomalacia
Bone disease: increased calcium, decreased phosphate, increased ALP, increased PTH
Primary hyperparathyroidism
Bone disease: normal calcium, normal phosphate, increased ALP, normal PTH
Paget’s disease
Which conditions are associated with pANCA ? (Not just rheum)
GPA
Ulcerative colitis
Primary sclerosing cholangitis
