Rheumatology Flashcards
What are the 4 key changes on an X-ray of an osteoarthritic joint?
L- Loss of joint space
O- Osteophytes
S- Subchondral sclerosis
S- Subchondral cysts
What is the presentation of oestoarthritis?
Joint pain and stiffness which is worsened by activity
What signs of osteoarthritis are found in the hands?
Heberden’s nodes (DIP)
Bouchard’s nodes (PIP)
How is osteoarthritis diagnosed?
Can be made without any investigations if the pt is >45, has typical activity related pain, stiffness lasting < 30 mins and no morning stiffness
Management of osteoarthritis
Physiotherapy oral paracetamol and topical NSAID Add oral NSAID and PPI ?opiates Intra-articular joint injections joint replacement
What is the distribution pattern of rheumatoid arthritis?
Symmetrical and affecting multiple joints
Which 2 genes is RA often associated with?
HLA DR4
HLA DR1
What type of autoantibody is rheumatoid factor (RF)
It can be any type but is usually IgM
Which 2 antibodies are associated with RA?
Rheumatoid factor (RF) Cyclic citrullinated peptide antibodies (anti CCP)
What is the usual presentation of RA?
Pain and stiffness of small joint of the hands and feet. . Worse in the morning
Better with activity
Associated with fatigue, wt loss
Which joints are almost never affected by rheumatoid arthritis?
DIP joints
What changes can be seen in the hands in RA?
Z shaped thumb
Swan neck deformity
Boutonnieres deformity
Ulnar deviation
What is Caplan’s syndrome?
Pulmonary fibrosis with pulmonary nodules, secondary to RA
Which investigations should be organised in RA?
RF, anti CCP antibodies
CRP, ESR
X-rays of hands and feet
What can be seen on X-ray of a joint in RA?
Joint destruction and deformity
Soft tissue swelling
Periarticular osteopenia
Boney erosions
What is the DAS28 score?
It is a score used in the monitoring of RA. It assesses 28 joints
What is the management of RA?
1st line= monotherapy with methotrexate, lefunomide or sulphasalazine
2nd line= 2 DMARDs in combination
3rd line= methotrexate + biological therapy (usually a TNF inhibitor)
4th line= rituximab
What should be prescribed alongside methotrexate?
Folic acid 5mg to be taken on a different day
What are the notable side effects of methotrexate?
Pulmonary fibrosis
What are the notable side effects of leflunomide?
Hypertension
Peripheral neuropathy
What are the notable side effects of sulfasalazine?
Temporary male infertility
Bone marrow supression
What are the notable side effects of hydroxychoroquine?
Nightmares
Reduced visual acuity
What is the main side effect of anti-TNF medications?
Reactivation of TB and Hep B
What are the main side effects of rituximab?
Night sweats and thrombocytopenia
What are the signs of psoriatic arthritis?
Plaques of psorasis Pitting of nails Onycholysis Dactylitis Enthesitis
How is psoriatic arthritis screened for?
PEST tool
What are the changes seen on X-ray in psoriatic arthritis?
Periostitis Ankylosis Oestolysis Dactylitis Pencil in a cup appearance
What is the management for psoriatic arthritis?
NSAIDs
DMARDs
Anti-TNF
Ustekinumab (monoclonal antibody which targets interleukin 12 and 23)
What is reactive synovitis?
When synovitis occurs in the joints as a reaction to a recent infective trigger
Which infections commonly trigger reactive arthritis?
Gastroenteritis
STI (most often chlamydia)
What are the 3 common associated symptoms of reactive arthritis?
Bilateral conjunctivitis
Anterior uveitis
Circinate balanitis
(cant see, cant pee, cant climb a tree)
What is the management of reactive arthritis?
Aspirate the joint and send for gram staining, culture and sensitivity
NSAIDs
Steriod injections
Which gene is ankylosing spondylitis related to?
HLA B27
Which are the key joints affected in ankylosing spondylitis
Sacroiliac joints and vertebral column
What is the classical X-ray finding in ankylosing spondylitis?
Bamboo spine
How does ankylosing spondylitis present?
Someone in their late teens or twenties Onset > 3months Lower back pain and stiffness Sacroiliac pain Vertebral fractures
Which test in examination can help to confirm a diagnosis of ankylosing spondylitis?
Schober’s test
Which investigations should be done for ankylosing spondylitis?
Inflammatory markers
HLA b27 test
X-ray of the spine and sacrum
MRI of the spine
What is the management of the ankylosing spondylitis?
NSAIDs
Steriods
Anti-TNF
What is the pathophysiology of SLE?
SLE is characterised by anti-nuclear antibodies. They are antibodies to proteins within a person’s own nucleus
How does SLE present?
Fatigue Weight loss Photosensitive malar rash Myalgia and arthralgia lymphadenopathy Raynaud's
Which investigations should be done for SLE?
ANA blood test
Urine protein: creatinine ratio (looking for lupus nephritis)
FBC, CRP, ESR
Which autoantibodies are associated with SLE?
ANA
Anti-dsDNA
How is SLE diagnosed?
SLICC or ACR criteria. Involves confirming the presence of antinuclear antibodies
How is SLE managed?
NSAIDs
Steroids
Hydroxychloroquine
Suncream for rash
How does discoid lupus erthyematosus present?
Photosensitive lesions which are inflamed, dry, crusty and scaling
How can a diagnosis of discoid erthyematosus be confirmed?
Skin biopsy
How is discoid lupus erythematosus managed?
Sun protection
Steriods
Hydroxychloroquine
What is limited cutaneous systemic sclerosis?
Used to be called CREST syndrome C-Calcinosis R-Raynaud's phenomenon E-oEsophageal dymotility S-Sclerodactyly T-Telangiesctasia
What is diffuse cutaneous systemic sclerosis?
Has many features of CREST syndrome but also CV, lung and kidney problems
What is scleroderma renal crisis?
Combination of severe hypertension and renal failure
How systemic sclerosis diagnosed?
using classification criteria from the american college of rheumatology
What are the main treatments for systemic sclerosis?
Steroids and immunosuppressants
Which other rheumatological disease has a strong association with polymyalgia rheumatica?
Giant cell arteritis
Who does polymyalgia rheumatica usually affect?
Caucasian women 50 years old
What are the core features of PMR?
Bilateral shoulder pain which may radiate to the elbow
Bilateral pelvic girdle pain
Worse with movement
Interferes with sleep
Stiffness for at least 45 mins in the morning
How long do symptoms of PMR have to be present for diagnosis?
at least 2 weeks
How is a diagnosis of PMR made?
Clinical presentation and response to steriods
What is the management of PMR?
15mg prednisolone. If no response after one week then stop.
Continue for 4 weeks if there is a good response and slowly taper.
What are the additional steps that should be taken when someone is started on steroid therapy?
DON’T STOP
DON’T- make them aware they will be dependent and mustn’t stop
S-Sick day rules (increase the dose)
T- Treatment card
O- Osteoporosis prevention
P- PPI
What is giant cell arteritis?
It is also known as temporal arteritis. It is a systemic vasculitis of the medium and large arteries
What is the key complication of GCA?
Vision loss
What are the symptoms of GCA?
Severe unilateral headache Scalp tenderness Jaw claudication Blurred or double vision Irreversible painless complete sight loss
What are the diagnostic criteria for GCA?
Clinical presentation
Raised ESR (>50mm/hour)
Temporal artery biopsy
What is found on temporal artery biopsy in GCA?
Multinucleated giant cells
What is seen on duplex ultrasound of temporal artery in GCA?
Hypoechoic halo
What is the management of GCA?
Steroids (prednisiolone 40-60mg)
Aspirin
PPI
What is a LATE complication of GCA?
Aortitis leading to aortic aneurysm and aortic dissection
What is polymyositis?
Inflammation in the muscles
What is dermatomyositis?
Connective tissue disorder where there is chronic inflammation in the skin and muscles
What is the key investigation for myositis?
Creatinine kinase blood test. CK should be less than 300U/L, in myositis the result is usually in the thousands
What can cause polymyositis or dermatomyositis?
It can be a paraneoplastic syndrome caused by lung, breast, ovarian or gastric cancers
How does polymyositis and dermatomyositis present?
Muscle pain, fatigue, weakness
Bilaterally
Mostly affects shoulder and pelvic girdle
develops over weeks
What are the skin features of dermatomyositis?
Gottron lesions (knuckles, elbows and knees) Photosensitive erythematous rash
Which autoantibodies are present in dermomyositis and myositis?
Anti-Jo-1 antibodies: polymyositis (but often present in dermatomyositis)
Anti-Mi-2 antibodies: dermatomyositis.
Anti-nuclear antibodies: dermatomyositis.
What is the definitive diagnostic test for dermomyositis?
Muscle biopsy
What is the first line treatment for dermomyositis and myositis?
Corticosteriods
What is antiphospholipid syndrome?
A disorder associated with antiphospholipid antibodies where the patient is in a hypercoagulable state
What are the main associations of antiphospholipid syndrome?
Thrombosis, pregnancy complications and recurrent miscarriage
What are the antiphospholipid antibodies associated with antiphospholipid syndrome?
Lupus anticoagulant
Anticardiolipin antibodies
Anti-beta-2 glycoprotein I antibodies
What is livedo reticularis?
A purple lace like rash which is seen in antiphospholipid syndrome
How is a diagnosis of antiphospholipid syndrome made?
When there is a history of thrombosis or pregnancy plus persistent antibodies
What is the management of antiphospholipid syndrome?
long term warfarin unless pregnant when women are started on LMWH (enoxaparin) plus aspirin
What is Sjogren’s syndrome?
An autoimmune condition which affects the exocrine glands. It leads to the symptoms of dry mucus membranes (mouth, eyes, vagina)
What is the difference between primary and secondary sjogren’s?
Primary is when the condition occurs in isolation, secondary is when it occurs related to SLE or RA
Which autoantibodies are associated with Sjogren’s?
anti-Ro and anti-La
Which test is used to diagnose sjogrens and how is it conducted?
Schirmer’s test. Involves inserting a folded piece of filter paper under the lower eyelid with a strip hanging out. Leave for 5 mins and see how far the tears travel along the strip. Should be 15mm
What is the management of Sjogren’s?
Artificial tears
Artificial saliva
Vaginal lubricants
Hydroxychloriquine is used to halt the progression of the disease
What are the general symptoms of vasculitis?
Purpura joint and muscle pain Peripheral neuropathy Renal impairment HTN
Which tests should be done to test for vasculitis?
Inflammatory markers (CRP and ESR)
ANCA is the antibody present in vasculitis!!
p-ANCA (MPO antibodies): Microscopic polyangiitis and Churg-Strauss syndrome
c-ANCA (PR3 antibodies): Wegener’s granulomatosis
How should vasculitis be managed?
Steroids and immunosuppressants
What type of vasculitis is henoch-schonlein purpura?
IgA vasculitis. Inflammation occurs due to immunoglobulin A deposits in the blood vessels
What are the 4 classic features of henoch-scholein purpura?
Pupura
Joint pain
Abdo pain
Renal involvement
What is the management of HSP?
Analgesia, fluids, rest. Should resolve in 4-6 weeks
What is eosinophillic granulomatosis with polyangiitis?
Used to be known as Churg-Strauss syndrome. It is a small and medium vessel vasculitis which is most associated with lung and skin problems.. Can present with severe asthma and elevated eosinophil levels
What is wegener’s granulomatosis?
Small vessel vasculitis which affects the respiratory tract and kidneys
What are the features of wegners granulomatosis?
Nose bleeds Crusty nose secretions (ew) hearing loss Saddle shaped nose Cough, wheeze haemoptysis Glomerulonephritis
What does Behçet’s disease present with?
Recurrent oral and genital ulcers
Which gene is Behçet’s disease linked with?
HLA B51
What do the ulcers in Behçet’s disease look like?
Painful and sharply circumscribed with a red halo
What are skin findings in Behçet’s disease?
Erethema nodosum
Papules and pustules
Vasculitic types rashes
What are they investigations for Behçet’s disease?
The pathergy test.
What is the management of Behçet’s disease?
Topical and systemic steroids
Colchicone
immunosupressiants
What causes gout?
High blood urate. This leads to urate crystals being deposited in the joint
What are gouty tophi?
Subcutaneous deposits of uric acid
Which are the classic joints affected by gout?
Base of the big toe
Wrists
Base of thumb
How is gout diagnosed?
Apirate the joint. the fluid will show needle shaped crystals which are negatively bifringent of polarised light
what is seen on X-ray of a gouty joint?
Lytic lesions, punched out erosions, sclerotic borders and overhanging edges
How should a flare of gout be managed?
NSAIDs
Colchicine
What is a notable side effect of colchicine?
diarrhoea
How should gout be prevented?
Allopurinol (xanthine oxidase inhibitor) and lifestyle changes
When should gout prophylaxis be initiated?
After the acute attack
What is pseudogout?
a crystal arthropathy caused by calcium pyrophosphate crystals
What does pseudogout aspirate show?
Rhomboid crystals which are positively birefringent of light
What is the classic xray change seen in pseudogout?
Chondrocalcinosis. A thin white line in the joint space which is caused by calcium deposition
What are the management options for pseudogout?
NSAIDs
Colchicine
Joint aspiration
Steroid injections
What does the FRAX score predict?
A person’s risk of a fragility fracture in the next 10 years
What factors are considered in a FRAX score?
age, BMI, co-morbidities, smoking, alcohol, bone mineral density and FHx
Which joint is the T score measured at in osteoporosis?
The hip
What is the range of T scores suggestive of osteopenia?
-1 to -2.5
What is the T score indicative of osteoporosis?
Less than -2.5
What is the management of osteoporosis?
Bisphosphonates (alendronate 70mg once weekly)
Calcium and vitamin D
What is the potential side effect of bisphosphonates and how is this managed?
Reflux and oesophageal erosions
What is osteomalacia?
there is defective bone mineralisation which results in soft bones Due to insufficient vitamin D
What are the symptoms of vitamin D deficiency?
Fatigue Bone pain Muscle weakness Muscle aches Pathological fractures looser zones
What is the investigation for osteomalacia?
Serum 25-hydroxyvitamin D
What is the treatment and dosing for osteomalacia?
Supplementary vitamin D (colecalciferol)
50,000 IU one weekly for 6 weeks
20,000 IU twice weekly for 7 weeks
4000 IU daily for 10 weeks
What is Paget’s disease of bone?
Excessive bone turnover. This is due to excessive activity of osteoblasts and osteoclasts
Why is there increased risk of pathological fractures in paget’s disease?
There is areas of high and low density bone which results in large and mishapen bones
What does paget’s disease present with?
Bone pain
Bone deformity
Fractures
Hearing loss
What are the key x-ray findings in paget’s disease?
bone enlargment
Osteoporosis circumscripta
Cotton wool appearance of the skull
V shaped defects in the long bones
What is seen on blood tests in paget’s disease?
Raised ALP
Normal calcium and phosphate
What is the management of paget’s disease?
Bisphosphonates
NSAIDs
Calcium and vit D
What are the 2 key complications of paget’s disease?
Osteogenic sarcoma
Spinal stenosis and cord compression
