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Rheumatology Flashcards

1
Q

Rheumatoid Arthritis

what is it

A

an autoimmune condition that causes chronic inflammation of the synovial lining of the joints, tendon sheaths and bursa

it is an inflammatory arthritis

symmetrical polyarthritis

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2
Q

Rheumatoid Arthritis

what does symmetrical polyarthritis mean

A

symmetrical and affects multiple joints

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3
Q

Rheumatoid Arthritis

epidemiology

A

F>M

middle age

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4
Q

Rheumatoid Arthritis

which gene is often present in RF positive patients

A

HLA DR4

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5
Q

Rheumatoid Arthritis

which gene is occasionally present in RA patients

A

HLA DR1

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6
Q

Rheumatoid Arthritis

antibodies

A
  • Rheumatoid Factor (RF)
  • Cyclic citrullinated peptide antibodies (anti-CCP antibodies)
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7
Q

Rheumatoid Arthritis

what is RF

A

an autoantibody that targets the Fc portion of the IgG antibody

which causes activation of the immune system against the patient’s own IgG causing systemic inflammation

RF is most often IgM but can be any class of immunoglobulin

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8
Q

Rheumatoid Arthritis

what are anti-CCP antibodies

A

Cyclic citrullinated peptide antibodies are autoantibodies that are more sensitive and specific to RA than RF

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9
Q

Rheumatoid Arthritis

Key symptoms

A
  • symmetrical distal polyarthropathy
  • joint pain, swelling and stiffness
  • worse after rest but improves with activity
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10
Q

Rheumatoid Arthritis

systemic symptoms

A
  • fatigue
  • weight loss
  • flu like illness
  • muscle aches and weakness
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11
Q

Rheumatoid Arthritis

what is Palindromic Rheumatism

A

self limiting short episodes of inflammatory arthritis with joint pain, stiffness and swelling typically affecting only a few joints

this episode only lasts 1-2d then completely resolves

having positive RF + anti-CCP indicate it will progress to full RA

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12
Q

Rheumatoid Arthritis

which joints are NOT affected

A

distal interphalangeal joints

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13
Q

Rheumatoid Arthritis

common joints affected

A
  • PIP
  • MCP
  • wrist + ankle
  • Metatarsophalangeal joints
  • cervical spine
  • large joints also: knee, hips, shoulders
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14
Q

Rheumatoid Arthritis

what is Atlantoaxial Subluxation

A

occurs in the cervical spine

the axis (C2) and the odontoid peg shift within the atlas (C1)

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15
Q

Rheumatoid Arthritis

what causes Atlantoaxial Subluxation

A

local synovitis and damage to the ligaments and bursa around the odontoid peg of the axis and the atlas

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16
Q

Rheumatoid Arthritis

why is RA relevant in anaesthetics and intubation

A

Subluxation can cause spinal compression

MRI scan can visualise changes in these areas as part of pre-op assessment

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17
Q

Rheumatoid Arthritis

what gives the joints a ‘boggy’ feeling

A

palpation of the synovium in around joints when the disease is active will give this feeling related to inflammation and swelling

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18
Q

Rheumatoid Arthritis

signs in the hands (4)

A
  • Z shaped deformity to the thumb
  • Swan neck deformity
  • Boutonnieres deformity
  • Ulnar deviation of the fingers at the knuckle (MCP joints)
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19
Q

Rheumatoid Arthritis

what is Swan neck deformity

A

hyperextended PIP with flexed DIP

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20
Q

Rheumatoid Arthritis

what is Boutonnieres deformity

A

hyperextended DIP and flexed PIP

due to a tear in the central slip of the extensor component of the finger

the flexor digitorum superficialis tendons (lateral tendons that go around the PIP) pull on the distal phalynx without any other supporting structure

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21
Q

Rheumatoid Arthritis

important extra-articular manifestations (4)

A
  1. pulmonary fibrosis with pulmonary nodules (Caplan’s syndrome)
  2. bronchiolitis obliterans: inflammation causing small airway destruction
  3. Felty’s syndrome: RA, neutropenia, splenomegaly
  4. Secondary Sjogren’s Syndrome aka sicca syndrome
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22
Q

Rheumatoid Arthritis

other extra-articular manifestations (7)

A
  • anaemia of chronic disease
  • CVS disease
  • episcleritis + scleritis
  • rheumatoid nodules
  • lymphadenopathy
  • carpal tunnel syndrome
  • amyloidosis
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23
Q

Rheumatoid Arthritis

inx

A
  • clinical
  • RF
  • if RF -ve, check anti-CCP antibodies
  • CRP, ESR
  • X-ray of hands and feet
  • USS: synovitis
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24
Q

Rheumatoid Arthritis

x-ray changes

A
  • joint destruction and deformity
  • soft tissue swelling
  • periarticular osteopenia
  • bony erosions
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25
Rheumatoid Arthritis when to refer
any adult with persistent synovitis urgent: if it involves the small joints of the hands or feet, multiple joints or symptoms present \>3m
26
Rheumatoid Arthritis diagnostic criteria from ACR/ELAR 2010
Patient scored based on: 1. joints involved (more + smaller joints score higher) 2. RF + CCP 3. ESR + CRP 4. duration of sx (more or less than 6w) score ≥6 = dx of RA
27
Rheumatoid Arthritis what is the DAS28 score
Disease Activity Score based on the assessment for 28 joints useful in monitoring disease activity and response to trx
28
Rheumatoid Arthritis what are the points given for on a DAS28 score
- swollen joints - tender joints - ESR/CRP result
29
Rheumatoid Arthritis what is the Health Assessment Questionnaire (HAQ)
measures functional ability NICE recommend using this at diagnosis to check response to trx
30
Rheumatoid Arthritis what factors make a worse prognosis
- younger onset - male - more joints and organs affected - presence of RF and anti-CCP - erosions seen on x-ray
31
Rheumatoid Arthritis what can be used at 1st presentation and during flare ups to quickly settle the disease
- short course of steroids - NSAIDs + PPI
32
Rheumatoid Arthritis NICE guidelines for DMARDs 1st line
monotherapy with: - methotrexate - leflunomide - sulfasalazine
33
Rheumatoid Arthritis what DMARD can be considered in mild disease (considered the mildest anti-rheumatic drug)
hydroxychloroquine
34
Rheumatoid Arthritis NICE guidelines for DMARDs 2nd line
2 of either: - methotrexate - leflunomide - sulfasalazine
35
Rheumatoid Arthritis NICE guidelines for DMARDs 3rd line
Methotrexate + biological therapy: usually a TNF inhibitor
36
Rheumatoid Arthritis NICE guidelines for DMARDs 4th line
Methotrexate + rituximab
37
Rheumatoid Arthritis why do pregnant women have an improvement in symptoms
probs due to the higher natural production of steroid hormones
38
Rheumatoid Arthritis what DMARDs can be given in pregnancy
Hydroxychloroquine and Sulfasalazine
39
Rheumatoid Arthritis what can biological therapies leads to
immunosuppression : prone to serious infections reactivation of dormant infections: TB + Hep B
40
Rheumatoid Arthritis Biological therapies: name some Anti-TNFs
- adalimumab - infliximab - etanercept - golimumab - certolizumab pegol
41
Rheumatoid Arthritis what is rituximab
a biological therapy (Anti-CD20)
42
Rheumatoid Arthritis how does methotrexate work?
by interfering with the metabolism of folate and suppressing certain components of the immune system
43
Rheumatoid Arthritis how often is methotrexate taken and by which route
injection or tablet once a week
44
Rheumatoid Arthritis what is prescribed alongside methotrexate and when should it be taken
Folic acid 5mg once a week taken on a different day to methotrexate
45
Rheumatoid Arthritis notable SEs of methotrexate (5)
- pulmonary fibrosis - Teratogenic: avoid prior to conception in mothers and fathers - mouth ulcers and mucositis - liver toxicity - bone marrow suppression + leukopenia (low WCC)
46
Rheumatoid Arthritis how does Leflunomide work
an immunosuppressant medication interferes with the production of pyrimidine (an important component of RNA + DNA)
47
Rheumatoid Arthritis side effects of Leflunomide (2)
- Peripheral neuropathy - increased BP
48
Rheumatoid Arthritis how does Sulfasalzine work
immunosuppressive + anti-inflammatory medication mechanism not clear but may be related to folate metabolism
49
Rheumatoid Arthritis what needs to be prescribed alongside Sulfasalzine
folic acid
50
Rheumatoid Arthritis SEs of Sulfasalzine (2)
- temporary male infertility (reduced sperm count) - bone marrow suppression
51
Rheumatoid Arthritis how does hydroxychloroquine work
traditionally an anti-malarial med acts as an immunosuppressive medication by interfering with Toll-like receptors disrupting antigen presentation and increasing the pH in the lysosomes of immune cells
52
Rheumatoid Arthritis SEs of hydroxychloroquine (4)
- nightmares - reduced visual acuity (macular toxicity) - liver toxicity - skin pigmentation
53
Rheumatoid Arthritis how do anti-TNF drugs work
tumour necrosis factor is a cytokine involved in stimulating inflammation blocking TNF reduces inflammation
54
Rheumatoid Arthritis what is the difference between Adalimumab, infliximab, golimumab and certolizumab pegol and Etanercept
the first 4 are monoclonal antibodies to TNF Etanercept is a protein that binds TNF to the Fc portion of IgG and thereby reduces its activity
55
Rheumatoid Arthritis SEs of Anti-TNF drugs
- Vulnerability to severe infections and sepsis - Reactivation of TB and hepatitis B
56
Rheumatoid Arthritis how does Rituximab work
a monoclonal antibody that targets the CD20 protein on the surface of B cells This causes destruction of B cells used for immunosuppression for autoimmune conditions
57
Rheumatoid Arthritis SEs for Rituximab
- Night sweats - thrombocytopenia
58
Myositis what is Polymyositis
autoimmune condition of chronic inflammation of muscles
59
Myositis what is dermatomyositis
an autoimmune connective tissue disorder where there is chronic inflammation of the skin and muscles
60
Myositis what is the key inx to diagnose it
creatine kinase blood test
61
Myositis what is a normal CK
\<300 U/L
62
Myositis what is the CK in polymyositis and dermatomyositis
usually \>1000
63
Myositis what are other causes of raised CK levels
- rhabdomyolysis - AKI - MI - statins - strenuous exercise
64
Myositis what causes a raised CK
inflammation in the muscles cells leads to the release of CK (an enzyme found in muscle cells)
65
Myositis what makes Polymyositis or dermatomyositis a paraneoplastic syndrome
they can be caused by an underlying malignancy: - lung - breast - ovarian - gastric
66
Myositis presentation (4)
- muscle pain, fatigue, weakness - bilateral and typically proximal muscles - mostly shoulder and pelvic girdle affected - develops over weeks
67
Myositis difference in presentation between Polymyositis or dermatomyositis
Polymyositis occurs without any skin features Dermatomyositis has skin features
68
dermatomyositis skin features
- Gottron lesions on the knuckles, elbows and knees - photosensitive erythematous rash on the back shoulders and neck - purple rash on the face and eyelids - periorbital oedema (swelling around the eyes) - subcutaneous calcinosis (Ca deposits in the subcut tissue)
69
Dermatomyositis what are Gottron lesions
scaly erythematous patches found on the knuckles elbows and knees
70
Polymyositis autoantibodies
Anti-Jo-1 antibodies
71
dermatomyositis autoantibodies
Anti-Mi-2 antibodies Anti-nuclear antibodies Anti-Jo-1 antibodies (also in polymyositis)
72
Myositis dx
- definitive: muscle biopsy - clinical presentation - elevated CK - autoantibodies - electromyography (EMG)
73
Myositis mnx
refer to rheumatologist - physio, occupational therapy 1st line: corticosteroids - immunosuppressants (azithioprine) - IV immunoglobulins - Biological therapy (infliximab or etanercept)
74
Osteomalacia what is it
osteo: bone malacia: soft condition where there is defective bone mineralisation causing soft bones results from insufficient vit D
75
Osteomalacia what is rickets
osteomalacia in children prior to their growth plates closing
76
Osteomalacia why is vit D deficiency common in CKD
the kidneys are essential in metabolising vit D to its active form
77
Osteomalacia what is vit D essential for
- calcium and phosphate absorption from the intestines and kidneys - bone turnover
78
Osteomalacia what causes defective bone mineralisation
inadequate levels of vit D --\> low ca and phosphate in blood ca and phosphate are required for construction of bone
79
Osteomalacia why does low calcium cause secondary hyperparathyroidism
parathyroid gland tries to raise ca levels by secreting parathyroid hormone which increases reabsorption of ca from the bones
80
Osteomalacia symptoms
may not have any - fatigue - bone pain - muscle weakness - muscle aches - pathological or abnormal fractures
81
Osteomalacia what are looser zones
fragility fractures that go partially through the bone
82
Osteomalacia RFs
RFs for Vit D deficiency - darker skin - low exposure to sunlight - live in colder climates - spend majority of time indoors
83
Osteomalacia what is the lab inx for vit D
serum 25-hydroxyvitamin D
84
Osteomalacia interpretation of Serum 25-hydroxyvitamin D \<25 nmol/L
vitamin D deficiency
85
Osteomalacia interpretation of Serum 25-hydroxyvitamin D 25 – 50 nmol/L
vitamin D insufficiency
86
Osteomalacia interpretation of Serum 25-hydroxyvitamin D 75 nmol/L or above
optimal
87
Osteomalacia inx results
- low serum ca - low serum phosphate - Serum alkaline phosphatase may be high - PTH may be high - X-Ray: may show osteopenia (more radiolucent bones) - DEXA scan shows low bone mineral density
88
Osteomalacia trx
Colecalciferol with one of the following regimes: - 50,000 IU once weekly for 6 weeks - 20,000 IU twice weekly for 7 weeks - 4000 IU daily for 10 weeks A maintenance supplementary dose of 800 IU or more per day should be continued for life after the initial treatment.
89
Osteomalacia trx for pts with only vitamin D insufficiency
started on the maintenance dose without the initial treatment regime
90
SLE what is it
Systemic Lupus Erythematosus an inflammatory autoimmune connective tissue disease
91
SLE whom is it more common in
women and Asians
92
SLE when does it present
in young to middle aged adults but can present later in life
93
SLE what are the leading causes of death
CVD and infection
94
SLE pathophysiology
inflammatory response to anti-nuclear antibodies
95
SLE symptoms
- photosensitive malar rash. Butterfly shaped rash across nose and cheek bones that gets worse with sunlight - hair loss - SOB - splenomegaly - joint pain - lymphadenopathy - myalgia - fatigue - weight loss
96
SLE which antibodies are associated with it
anti-nuclear antibodies (ANA) anti-double stranded DNA (anti-dsDNA)
97
SLE inx
- autoantibodies (ANA, anti-dsDNA) - FBC: normocytic anaemia - C3+4: low - CRP+ESR: high - Immunoglobulins: raised - Urinalysis: proteinuria in lupus nephritis - renal biopsy: lupus nephritis
98
SLE what are ANA
anti-nuclear antibodies antibodies against normal proteins in the cell nucleus not specific
99
SLE what are anti-dsDNA
specific to SLE. Useful for monitoring disease activity
100
SLE which type of ANA is highly specific to SLE but not very sensitive
Anti-Smith
101
which type of ANA is associated with systemic sclerosis
Anti-Scl-70
102
which type of ANA is associated with Sjogren’s syndrome
Anti-Ro and Anti-La
103
which type of ANA is associated with limited cutaneous systemic sclerosis
Anti-centromere antibodies
104
SLE what can occur secondary to SLE
Antiphospholipid antibodies and antiphospholipid syndrome associated with an increased risk of VTE
105
SLE what do you use to establish a diagnosis
the SLICC Criteria or the ACR Criteria involves confirming the presence of ANA and establishing a certain number of clinical features
106
SLE complications: why does it cause CVD
chronic inflammation in the blood vessels --\> HTN + coronary artery disease
107
SLE complications: why is infection more common
part of the disease process and secondary to immunosuppressants.
108
SLE complications: why is anaemia of chronic disease more common
It affects the bone marrow causing a chronic normocytic anaemia can also get low WCC, neutrophils and platelets
109
SLE complications: why does lupus nephritis occur
inflammation in the kidney. it can progress to end-stage renal failure
110
SLE 1st line trx
anti-inflammatory and immunosuppression - NSAIDs - steroids (prednisolone) - hydroxychloroquine -
111
SLE what is 1st line trx for mild SLE
hydroxychloroquine
112
SLE other commonly used immunosuppressants in resistant or more severe lupus
Methotrexate Mycophenolate mofetil Azathioprine Tacrolimus Leflunomide Ciclosporin
113
SLE what is considered for patients with severe disease or where patients have not responded to other treatments.
Biological therapies: - Rituximab - Belimumab
114
SLE how does Belimumab work
monoclonal antibody that targets B-cell activating factor
115
what needs to be tested before giving azathioprine
Thiopurine methyltransferase enzyme activity
116
why does the activity of thiopurine methyltransferase need to be tested before starting azathioprine
metabolism + elimination of azathioprine and its metabolites involve xanthine oxidase and thiopurine methyltransferase (TPMT) ​ azathioprine should not be prescribed to patients with absent TPMT activity ​ ​
117
Psoriatic Arthritis what is it
an inflammatory arthritis associated with psoriasis
118
Psoriatic Arthritis what is arthritis mutilans
most severe form of psoriatic arthritis osteolysis (destruction) of the bones around the joints in the digits. This leads to progressive shortening of the digit. The skin then folds as the digit shortens giving an appearance that is often called a “telescopic finger”.
119
Psoriatic Arthritis what group of conditions is it part of
seronegative spondyloarthroapathy
120
Psoriatic Arthritis name 3 patterns of it
1. Symmetrical polyarthritis 2. Asymmetrical pauciarthritis 3. Spondylitic pattern
121
Psoriatic Arthritis describe the symmetrical polyarthritis pattern
- similar to RA presentation - more common in women - hands, wrists, ankles, DIP joints are affected - MCP joints are less commonly affected (unlike rheumatoid)
122
Psoriatic Arthritis describe the asymmetrical pauciarthritis pattern
- affects mainly digits and feet - pauciarthritis: only affects a few joints
123
Psoriatic Arthritis describe the spondylitic pattern
- more common in men - back stiffness - sacroilitis - atlanto-axial joint involvement
124
Psoriatic Arthritis what other areas can be affected (not the patterns)
- spine - achilles tendon - plantar fascia
125
Psoriatic Arthritis signs (5)
1. plaques of psoriasis on skin 2. pitting of the nails 3. onycholysis 4. dactylitis 5. enthesitis
126
Psoriatic Arthritis what is onycholysis
separation of the nail from the nail bed
127
Psoriatic Arthritis what is dactylitis
inflammation of the full finger
128
Psoriatic Arthritis what is enthesitis
inflammation of the entheses (points of insertion of tendons into bone)
129
Psoriatic Arthritis other associations (3)
- eye disease: conjunctivtiis + anterior uveitis) - aortitis (inflammation of the aorta) - amyloidosis
130
Psoriatic Arthritis what screening tool is recommended by NICE to use in patients with psoriasis
Psoriasis Epidemiological Screening Tool (PEST) to screen for psoriatic arthritis
131
Psoriatic Arthritis what does the Psoriasis Epidemiological Screening Tool (PEST) involve
questions asking about joint pain, swelling, a history of arthritis and nail pitting. A high score triggers a referral to a rheumatologist.
132
Psoriatic Arthritis x-ray changes (6)
1) pencil in cup appearance 2) periostitis 3) ankylosis 4) osteolysis 5) dactylitis
133
Psoriatic Arthritis x-ray changes: what is pencil in cup
central erosions of the bone beside the joints this causes the appearance of one bone in the joint being hollow and looking like a cup whilst the other is narrow and sits in the cup.
134
Psoriatic Arthritis x-ray changes: what is periostitis
inflammation of the periosteum causing a thickened and irregular outline of the bone
135
Psoriatic Arthritis x-ray changes: what is ankylosis
bones joining together causing joint stiffening
136
Psoriatic Arthritis x-ray changes: what is osteolysis
destruction of bone
137
Psoriatic Arthritis x-ray changes: what is dactylitis
inflammation of the whole digit appears on the xray as soft tissue swelling
138
Psoriatic Arthritis mnx
- NSAIDs for pain - DMARDS (methotrexate, leflunomide or sulfasalazine) - Anti-TNF medications (etanercept, infliximab or adalimumab) - Ustekinumab (last line)
139
Psoriatic Arthritis what is last line mnx and what is it
Ustekinumab: a monoclonal antibody that targets interleukin 12 and 23
140
Gout what are gouty tophi
subcutaneous deposits of uric acid typically effecting the small joints and connective tissues of the hands, elbows and ears
141
Gout which joint in the hands is most effected by gouty tophi
the DIP joints
142
Gout presentation
single acute hot swollen and painful joint
143
Gout RFs (7)
- male - obese - high purine diet (meat+seafood) - alcohol - diuretics - existing CVD or kidney disease - FH
144
Gout which typical joints are affected
- Base of the big toe (metatarsophalangeal joint) - Wrists - Base of thumb (carpometacarpal joints)
145
Gout Dx
clinically or by aspiration of fluid from the joint
146
Gout what will aspirated fluid show
- no bacterial growth - needle shaped crystals - negatively birefringent of polarised light - monosodium urate crystals
147
Gout what will x-ray show
- joint space maintained - lytic lesions - punched out erosions: sclerotic borders overhanging edges
148
Gout acute flare mnx
1st line: NSAIDs 2nd line: colchicine 3rd line: steroids
149
Gout when is colchicine used
during an acute flare when NSAIDs are inappropriate: renal impairment or significant heart disease
150
Gout common SE of colchicine
diarrhoea (dose dependent)
151
Gout prophylaxis mnx
allopurinol lifestyle changes
152
Gout what is allopurinol
a xanthine oxidase inhibitor used for the prophylaxis of gout: it reduces uric acid levels
153
Antiphospholipid Syndrome what is it
a disorder associated with antiphospholipid antibodies where the blood becomes prone to clotting. The patient is in a hyper-coagulable state.
154
Antiphospholipid Syndrome main associations
- thrombosis - recurrent miscarriages
155
Antiphospholipid Syndrome can occur secondary to which condition
SLE
156
Antiphospholipid Syndrome which antiphospholipid antibodies is it associated with
- lupus anticoagulant - Anticardiolipin antibodies - Anti-beta-2 glycoprotein I antibodies
157
Antiphospholipid Syndrome what do the antiphospholipid antibodies do
interfere with coagulation and create a hypercoagulable state where the blood is more prone to clotting.
158
Antiphospholipid Syndrome what is the rash that you get called
livedo reticularis
159
Antiphospholipid Syndrome what is livedo reticularis
a purple lace like rash that gives a mottled appearance to the skin
160
Antiphospholipid Syndrome what is Libmann-Sacks endocarditis
a type of non-bacterial endocarditis where there are growths (vegetations) on the valves of the heart mitral valve is most commonly affected associated with SLE and antiphospholipid syndrome.
161
Antiphospholipid Syndrome blood results
thombocytopenia (low platelets)
162
Antiphospholipid Syndrome dx
hx of thrombosis or pregnancy complication AND persistent antibodies: - lupus anticoagulant - anticardiolipin antibodies - anti-beta-2 glycoprotein I antibodies
163
Antiphospholipid Syndrome mnx if not pregnant
- long term warfarin (INR 2-3)
164
Antiphospholipid Syndrome mnx if pregnant
LMWH (enoxaparin) + Aspirin
165
Pseudogout which crystals are present
calcium pyrophosphate crystals
166
Pseudogout common joint affected
knee, shoulders, wrists and hips
167
Pseudogout Typical presentation
an older adult with a hot, swollen, stiff, painful knee.
168
Pseudogout Definitive diagnostic inx
joint aspiration for synovial fluid
169
Pseudogout what will aspiration fluid show
- no bacterial growth - calcium pyrophosphate crystals - rhomboid shaped crystals - positive birefringent of polarised light
170
Pseudogout what is the classic xray change in pseudogout (pathognomonic)
chondrocalcinosis
171
Pseudogout what is chondrocalcinosis
x-ray finding: thin white line in the middle of the joint space caused by the calcium deposition.
172
Pseudogout x-ray changes
chondrocalcinosis similar to osteoarthritis: Loss of joint space Osteophytes Subarticular sclerosis Subchondral cysts
173
Pseudogout symptomatic mnx
NSAIDs Colchicine Joint aspiration Steroid injections Oral steroids usually resolves over several weeks
174
Pseudogout mnx in severe cases
Joint washout (arthrocentesis)
175
Ankylosing Spondylitis what group of conditions is it in
seronegative spondyloarthropathy group of conditions relating to the HLA B27 gene.
176
Ankylosing Spondylitis what key joints are affected
sacroiliac joints joints of the vertebral column
177
Ankylosing Spondylitis what causes the classical 'bamboo spine'
fusion of the spine
178
Ankylosing Spondylitis which gene is it strongly associated with
HLA B27 gene
179
Ankylosing Spondylitis main presenting features
lower back pain and stiffness sacroiliac pain in the buttock region. worse with rest and improves with movement
180
Ankylosing Spondylitis at least how long does it take for stiffness to improve in the morning
30 min
181
Ankylosing Spondylitis typical exam presentation
young adult male with lower back pain slow onset \>3m
182
Ankylosing Spondylitis key complication
vertebral fractures
183
Ankylosing Spondylitis what tests how much mobility there is in the spine
Schober’s Test
184
Ankylosing Spondylitis what result in the Schober test helps diagnosis Ankylosing Spondylitis
If the distance with them bending forwards is less than 20cm
185
Ankylosing Spondylitis what does the Schober's test involve
mark a point 10cm above and 5cm below the L5 vertebrae pt bends down as far as they can and measure the distance between the points
186
Ankylosing Spondylitis inx
- CRP and ESR may be raised - HLA B27 genetic test - X-ray spine and sacrum - MRI: bone marrow oedema
187
Ankylosing Spondylitis x ray changes (6)
1. bamboo spine 2. squaring of vertebral bodies 3. Subchondral sclerosis and erosions 4. Syndesmophytes 5. Ossification 6. fusion of the facet, sacroiliac and costovertebral joints
188
Ankylosing Spondylitis xray: what is Syndesmophytes
areas of bone growth where the ligaments insert into the bone
189
Ankylosing Spondylitis medical mnx
- NSAIDs - Steroids - Anti-TNF (etanercept) or inflixamb final line: Secukinumab (monoclonal antibody against interleukin-17)
190
Ankylosing Spondylitis additional mnx
- Physiotherapy - Exercise and mobilisation - Avoid smoking - Bisphosphonates to treat osteoporosis - Treatment of complications - Surgery is occasionally required for deformities to the spine or other joints
191
Reactive Arthritis what is it
synovitis occurs in the joints as a reaction to a recent infective trigger
192
Reactive Arthritis what did it used to be known as
Reiter Syndrome
193
Reactive Arthritis difference between septic and reactive arthritis
reactive: no infection in joint
194
Reactive Arthritis what are the most common infections that trigger it
- gastroenteritis - Chlamydia
195
what do gonorrhoea commonly cause
gonococcal septic arthritis
196
Reactive Arthritis what group of conditions is it part of
seronegative spondyloarthropathy group of conditions
197
Reactive Arthritis what gene is it linked to
HLA B27
198
Reactive Arthritis associations
- bilateral conjunctivitis - anterior uveitis - circinate balanitis
199
Reactive Arthritis what is the common saying used to remember the features of reactive arthritis
can't see can't pee or climb a tree
200
Reactive Arthritis presentation of joint
acute monoarthritis, most often the knee warm, swollen and painful joint.
201
Reactive Arthritis what is circinate balanitis
dermatitis of the head of the penis
202
Reactive Arthritis mnx to exclude septic arthritis
- abx - aspirate for C+S and send for crystal examination
203
Reactive Arthritis mnx when septic arthritis is excluded
- NSAIDs - steroid injections into the affected joints - systemic steroids may be needed
204
Reactive Arthritis prognosis
most resolve within 6m and don't recur Recurrent cases may require DMARDs or anti-TNF medications.
205
Vasculitis Types of Vasculitis Affecting The Small Vessels (4)
- Henoch-Schonlein purpura - Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss syndrome) - Microscopic polyangiitis - Granulomatosis with polyangiitis (Wegener’s granulomatosis)
206
Vasculitis Types of Vasculitis Affecting The Medium Sized Vessels (3)
- Polyarteritis nodosa - Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss syndrome) - Kawasaki Disease
207
Vasculitis Types of Vasculitis Affecting The Large Vessels (2)
- Giant cell arteritis - Takayasu’s arteritis
208
Vasculitis what is the blood test to remember for vasculitis
Anti neutrophil cytoplasmic antibodies (ANCA)
209
Vasculitis what are the 2 types of ANCA blood tests
p-ANCA aka anti-MPO antibodies c-ANCA aka anti-PR3 antibodies
210
Vasculitis which vasculitis is p-ANCA (MPO antibodies) associated with
Microscopic polyangiitis and Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss syndrome)
211
Vasculitis which vasculitis is c-ANCA (PR3 antibodies) associated with
Granulomatosis with polyangiitis (Wegener’s granulomatosis)
212
Vasculitis usual mnx
steroids + immunosuppressants
213
Vasculitis what steroids may be used for mnx
- Oral (i.e. prednisolone) - Intravenous (i.e. hydrocortisone) - Nasal sprays for nasal symptoms - Inhaled for lung involves (e.g. Churg-Strauss syndrome)
214
Vasculitis what immunosuppressants may be used for mnx
- Cyclophosphamide - Methotrexate - Azathioprine - Rituximab and other monoclonal antibodies
215
Vasculitis how does Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss syndrome) present
- severe asthma in late teenage years or adulthood - elevated eosinophil levels
216
Vasculitis what organs does Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss syndrome) mainly effect
lung and skin
217
Vasculitis what sized vessels does Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss syndrome) affect
small and medium vessel vasculitis
218
Vasculitis what sized vessels does Microscopic polyangiitis affect
small vessel vasculitis
219
Vasculitis main features of Microscopic polyangiitis
- RENAL FAILURE - SOB - haemoptysis
220
Vasculitis what sized vessels does Granulomatosis with polyangiitis (Wegener’s granulomatosis) affect
small vessel vasculitis
221
Vasculitis what organs does Granulomatosis with polyangiitis (Wegener’s granulomatosis) affect
respiratory tract and kidneys
222
Vasculitis resp tract presentation of Granulomatosis with polyangiitis (Wegener’s granulomatosis)
- epistaxis - crustal nasal secretions - hearing loss - sinusitis - saddle shaped nose due to perforated nasal septum - cough, wheeze, haemoptysis
223
Vasculitis what may the CXR show in Granulomatosis with polyangiitis (Wegener’s granulomatosis)
consolidation and it may be misdiagnosed as pneumonia
224
Vasculitis renal presentation in Granulomatosis with polyangiitis (Wegener’s granulomatosis)
rapidly progressing glomerulonephritis
225
Vasculitis what sized vessels does Polyarteritis Nodosa affect
medium vessel vasculitis.
226
Vasculitis what is Polyarteritis Nodosa most associated with
Hep B also hep c and HIV
227
Vasculitis Polyarteritis Nodosa presentation
- livedo reticularis - renal impairment - strokes - MI
228
Vasculitis what sized vessels does Takayasu’s arteritis affect
large vessel vasculitis.
229
Vasculitis which part of the body does Takayasu’s arteritis mainly affect
the aorta and its branches also the pulmonary arteries
230
Vasculitis why is Takayasu’s arteritis aka 'pulseless disease'
large vessels and their branches can swell and form aneurysms or become narrowed and blocked.
231
Vasculitis Takayasu’s arteritis presentation
- before 40y - fever, malaise, muscle aches - arm claudication, syncope
232
Vasculitis Takayasu’s arteritis diagnostic inx
CT or MRI angiography
233
Sjogren's Syndrome what is it
autoimmune conditions that affects the exocrine glands
234
Sjogren's Syndrome presentation
dry mucous membranes: - dry mouth - dry eyes - dry vagina
235
Sjogren's Syndrome what is Primary Sjogren’s
the condition occurs in isolation
236
Sjogren's Syndrome what is Secondary Sjogren’s
the condition occurs related to SLE or rheumatoid arthritis.
237
Sjogren's Syndrome what antibodies is it associated with
anti-Ro anti-La
238
Sjogren's Syndrome what is the Schirmer Test
inserting a folded piece of filter paper under the lower eyelid with a strip hanging out over the eyelid leave for 5min distance along the strip hanging out that becomes moist is measured
239
Sjogren's Syndrome Schirmer Test results if the pt has Sjogren's Syndrome
The tears should travel 15mm in a healthy young adult. \< 10mm is significant.
240
Sjogren's Syndrome mnx
- Artificial tears - Artificial saliva - Vaginal lubricants - Hydroxychloroquine: to halt the progression of the disease.
241
Sjogren's Syndrome complications of the eye
conjunctivitis and corneal ulcers
242
Sjogren's Syndrome complications of the mouth
dental cavities and candida infections
243
Sjogren's Syndrome complications of the vagina
candidiasis and sexual dysfunction
244
Sjogren's Syndrome rare complications
- Pneumonia and bronciectasis - Non-Hodgkins lymphoma - Peripheral neuropathy - Vasculitis - Renal impairment
245
Behçet’s Disease what is it
a complex inflammatory condition. It characteristically presents with recurrent oral and genital ulcers.
246
Behçet’s Disease what gene is it linked to
HLA B51 gene. This is a prognostic indicator of severe disease.
247
Behçet’s Disease Ddx
- Simple aphthous ulcers are very common - IBD (esp Crohn’s) - Coeliac disease - Vit deficiency (B12, folate or iron) - Herpes simplex ulcers - Hand, foot and mouth disease (coxsackie A virus) - Squamous cell carcinoma
248
Behçet’s Disease presentation of mouth ulcers
- at least 3 episodes of oral ulcers/year - painful, sharply circumscribed erosions with a red halo - occur on the oral mucosa - heals over 2-4 weeks
249
Behçet’s Disease presentation of genital ulcers
“Kissing ulcers” ulcer develops on two opposing surfaces so that they are facing each other.
250
Behçet’s Disease skin findings (3)
1. Erythema nodosum 2. Papules and pustules (similar to acne) 3. Vasculitic type rashes
251
Behçet’s Disease eye manifestations
- Anterior or posterior uveitis - Retinal vasculitis - Retinal haemorrhage
252
Behçet’s Disease MSK presentation
- Morning stiffness - Arthralgia - Oligoarthritis often affecting the knee or ankle. This causes swelling without joint destruction.
253
Behçet’s Disease inflammation and ulceration can occur through which part of the GI tract
- ileum - caecum - ascending colon
254
Behçet’s Disease how does it affect the veins
veins can become inflamed and this can lead to vein thrombosis. Eg: - Budd Chiari syndrome - DVT - thrombus in pulmonary veins - cerebral venous sinus thrombosis
255
Behçet’s Disease how may the lungs be affected
Pulmonary artery aneurysms can develop
256
Behçet’s Disease which particular inx is used
the pathergy test
257
Behçet’s Disease what is the pathergy test
- tests for non-specific hypersensitivity in the skin - needle creates a SC abrasion on forearm - reviewed 24-48h later to look for a weal ≥5mm
258
Behçet’s Disease which conditions it the pathergy test positive in
- Behçet’s disease - Sweet’s syndrome - pyoderma gangrenosum
259
Behçet’s Disease mnx
- Topical steroids to mouth ulcers (e.g. soluble betamethasone tablets) - Systemic steroids (i.e. oral prednisolone) - Colchicine: anti-inflammatory to treat symptoms - Topical anaesthetics for genital ulcers (e.g. lidocaine ointment) - Immunosuppressants e.g. azathioprine - Biologic therapy e.g. infliximab
260
Behçet’s Disease prognosis
- relapsing remitting condition - normal life expectancy - increased mortality with haemoptysis, neuro involvement and other major complications
261
Osteoarthritis RFs
- obesity - age - occupation - trauma - female - FH
262
Osteoarthritis pathophysiology
an imbalance between the cartilage being worn down and the chondrocytes repairing it leading to structural issues in the joint
263
Osteoarthritis what are the 4 key xray changes
LOSS Loss of joint space Osteophytes Subchondral sclerosis Subchondral cysts
264
Osteoarthritis what is subchondral sclerosis
increased density of the bone along the joint line
265
Osteoarthritis what is subchondral cysts
fluid-filled holes in the bone, aka geodes
266
Osteoarthritis presentation
- joint pain + stiffness - worsened by activity - deformity, instability + reduced function in the joint
267
Osteoarthritis commonly affected joint s
- Hips - Knees - Sacro-iliac joints - Distal-interphalangeal joints in the hands (DIPs) - The CMC joint at the base of the thumb - Wrist - Cervical spine
268
Osteoarthritis signs in the hand
- Heberden’s nodes - Bouchard’s nodes - Squaring at the base of the thumb at the carpo-metacarpal joint - Weak grip - Reduced range of motion
269
Osteoarthritis which joints do Heberden's nodes affect
the DIPs
270
Osteoarthritis which joints do Bouchard's nodes affect
the PIPs
271
Osteoarthritis what kind of joint is the carpo-metacarpal joint at the base of the thumb
a saddle joint
272
Osteoarthritis diagnosis
NICE: no inx if: - pt\>45y - has typical activity related pain - has no morning stiffness or stiffness lasting \<30min
273
Osteoarthritis conservative mnx
- weight loss - physio - occupational therapy + orthotics
274
Osteoarthritis stepwise analgesia
1. PO paracetamol + top NSAIDs or top capsaicin (chilli pepper extract) 2. add PO NSAIDs (+PPI) 3. consider opiates: codeine + moprhine
275
Osteoarthritis what mnx provides a temporary reduction in inflammation and improve symptoms.
Intra-articular steroid injections
276
Osteoarthritis what can be used in severe cases
joint replacement
277
Osteoporosis what is it
a reduction in the density of the bones
278
Osteoporosis what is osteopenia
a less severe reduction in bone density than osteoporosis
279
Osteoporosis RFs
- Older age - Female - Reduced mobility and activity - Low BMI (\<18.5 kg/m2) - Rheumatoid arthritis - Alcohol and smoking - Long term corticosteroids. - SSRIs, PPIs, anti-epileptics and anti-oestrogens
280
Osteoporosis what dose of long term corticosteroids increase the risk significantly
\>7.5mg prednisolone/day for \>3m
281
Osteoporosis why are post-menopausal women at risk
Oestrogen is protective against osteoporosis postmenopausal women have less oestrogen and older and often have other risk factors
282
Osteoporosis what is the FRAX tool
gives a prediction of the risk of a fragility fracture over the next 10 years
283
Osteoporosis what is the 1st step in assessing someone's risk of osteoporosis
FRAX Tool
284
Osteoporosis what information is inputted in the FRAX tool
- age - BMI - co-morbidities - smoking - alcohol - family history - bone mineral density (from DEXA scan)
285
Osteoporosis the FRAX tool gives results as a % 10 year probability of?
- major osteoporotic fracture - hip fracture
286
Osteoporosis how is the bone mineral density calculated
using dual-energy xray absorptiometry (DEXA scan) they measure how much radiation is absorbed by the bones, indicating how dense the bone is.
287
Osteoporosis where is the DEXA scan reading done on the skeleton
the hip
288
Osteoporosis DEXA scan: what is the Z score
the number of standard deviations the patients bone density falls below the mean for their age
289
Osteoporosis DEXA scan: what is the T score
the number of standard deviations the patients bone density falls below the mean for a healthy young adult
290
Osteoporosis DEXA scan: which is the most clinically important outcome, the T or Z score
T score at the person's hip
291
Osteoporosis what is the bone mineral density if T score at the hip is \> -1
normal
292
Osteoporosis what is the bone mineral density if T score at the hip is -1 to -2.5
ostepenia
293
Osteoporosis what is the bone mineral density if T score at the hip is
osteoporosis
294
Osteoporosis what is the bone mineral density if T score at the hip is
severe osteoporosis
295
Osteoporosis who do you perform a FRAX assessment on
patients at risk of osteoporosis: - F\>65 - M\>75 - younger pts with RFs: previous fragility fracture, hx of falls, low BMI, long term steroids, endocrine disorders, RA
296
Osteoporosis FRAX outcome without a BMD result will suggest one of three outcomes:
Low risk – reassure Intermediate risk – offer DEXA scan and recalculate the risk with the results High risk – offer treatment
297
Osteoporosis FRAX outcome with a BMD result will suggest one of two outcomes:
- Treat - Lifestyle advice and reassure
298
Osteoporosis mnx
- lifestyle changes - vit D + calcium - bisphosphonates
299
Osteoporosis what lifestyle changes can be made
- Activity and exercise - Maintain a healthy weight - Adequate calcium intake - Adequate vitamin D - Avoiding falls - Stop smoking - Reduce alcohol consumption
300
Osteoporosis who does NICE recommend calcium + vit D to
in patients at risk of fragility fractures with an inadequate intake of calcium
301
Osteoporosis what does Calcichew-D3 contain
- 1000mg of calcium - 800 units of vit D (colecalciferol).
302
Osteoporosis what should pts with adequate Ca intake but lack of sun exposure take
vit d
303
Osteoporosis what is the 1st line trx
bisphosphonates
304
Osteoporosis how do bisphosphonates work
interfering with osteoclasts and reducing their activity, preventing the reabsorption of bone
305
Osteoporosis SE's of bisphosphonates
- Reflux and oesophageal erosions - Atypical fractures (e.g. atypical femoral fractures) - Osteonecrosis of the jaw - Osteonecrosis of the external auditory canal
306
Osteoporosis example of bisphosphonates
- Alendronate 70mg once weekly (oral) - Risedronate 35 mg once weekly (oral) - Zoledronic acid 5 mg once yearly (intravenous)
307
Osteoporosis other options if bisphosphonates are CId, not tolerated or not effective
- Denosumab - Strontium ranelate - Raloxifene - HRT
308
Osteoporosis what is denosumab
a monoclonal antibody that works by blocking the activity of osteoclasts.
309
Osteoporosis what is Strontium ranelate
a similar element to calcium that stimulates osteoblasts and blocks osteoclasts but increases the risk of DVT, PE and myocardial infarction.
310
Osteoporosis what is Raloxifene
used as secondary prevention only. a selective oestrogen receptor modulator that stimulates oestrogen receptors on bone but blocks them in the breasts and uterus
311
Osteoporosis what should low risk pts not on trx be given
lifestyle advice and followed up within 5 years for a repeat assessment.
312
Osteoporosis when should pts on biphosphonates have a repeat FRAX and DEXA scan
3-5 years treatment holiday should be considered if their BMD has improved and they have not suffered any fragility fractures
313
Osteoporosis what is a treatment holiday
a break from treatment of 18 months to 3 years before repeating the assessment.
314
Paget’s Disease of Bone pathophysiology
excessive bone turnover due to excessive activity of osteoblasts and osteoclasts not coordinated, leading to patchy areas of high density (sclerosis) and low density (lysis).
315
Paget’s Disease of Bone presentation
older adults: - bone pain - bone deformity - fractures - hearing loss
316
Paget’s Disease of Bone key inx
- x ray - LFTs, ca, phosphate
317
Paget’s Disease of Bone xray findings
- Bone enlargement and deformity - “Osteoporosis circumscripta” - “Cotton wool appearance” of the skull - “V-shaped defects” in the long bones
318
Paget’s Disease of Bone xray: what is Osteoporosis circumscripta
well defined osteolytic lesions that appear less dense compared with normal bone
319
Paget’s Disease of Bone xray: what is “Cotton wool appearance” of the skull
patchy areas of increased density (sclerosis) and decreased density (lysis)
320
Paget’s Disease of Bone xray: what is “V-shaped defects” in the long bones
V shaped osteolytic bone lesions within the healthy bone
321
Paget’s Disease of Bone what will biochemistry show
- raised ALP (other LFTs normal) - normal calcium - normal phosphate
322
Paget’s Disease of Bone what is the main trx
bisphosphonates
323
Paget’s Disease of Bone other mnx apart from biphosphonates
- NSAIDs for bone pain - Ca + Vit D - surgery for fractures, deformity or arthritis
324
Paget’s Disease of Bone what does monitoring involve
ALP and review sx .Effective treatment should normalise the ALP and eliminate symptoms.
325
Paget’s Disease of Bone 2 key complications
Osteogenic sarcoma (osteosarcoma) Spinal stenosis and spinal cord compression
326
Paget’s Disease of Bone what is osteosarcoma
a type of bone cancer with a very poor prognosis
327
Paget’s Disease of Bone how does osteosarcoma present
increased focal bone pain, bone swelling or pathological fractures
328
Paget’s Disease of Bone how is spinal stenosis diagnosed
with an MRI scan
329
Paget’s Disease of Bone how is spinal stenosis usually treated
bisphosphonates
330
Discoid Lupus Erythematosus what is it
a non-cancerous chronic skin condition.
331
Discoid Lupus Erythematosus who is it more common in
- women - aged 20-40 - darker-skinned pts - smokers
332
Discoid Lupus Erythematosus what is there an increased risk of developing
SLE (\<5%) rarely, lesions can progress to SCC of the skin
333
Discoid Lupus Erythematosus where do lesions typically present
on the face, ears and scalp
334
Discoid Lupus Erythematosus appearance of lesions
- Inflamed - Dry - Erythematous - Patchy - Crusty and scaling - hyper or hypo-pigmented scars.
335
Discoid Lupus Erythematosus are the lesions photosensitive
yes
336
Discoid Lupus Erythematosus what is scarring alopecia
hair loss in affected areas that does not grow back
337
Discoid Lupus Erythematosus diagnostic inx
skin biopsy
338
Discoid Lupus Erythematosus trx
- Sun protection - Topical steroids - Intralesional steroid injections - Hydroxychloroquine
339
Systemic Sclerosis what is it
an autoimmune inflammatory and fibrotic connective tissue disease
340
Systemic Sclerosis what is scleroderma
hardening of the skin. most patients with scleroderma have systemic sclerosis
341
Systemic Sclerosis what are the 2 main patterns of disease
- Limited cutaneous systemic sclerosis - Diffuse cutaneous systemic sclerosis
342
Systemic Sclerosis what did Limited cutaneous systemic sclerosis used to be called
CREST syndrome
343
Systemic Sclerosis features of limited cutaneous systemic sclerosis
Calcinosis Raynaud's phenomenon Esophageal dysmotility Sclerodactyly Telangiectasis
344
Systemic Sclerosis what is Diffuse cutaneous systemic sclerosis
includes the features of CREST syndrome plus: - CVD problems - lung problems - kidney problems
345
Systemic Sclerosis Diffuse cutaneous systemic sclerosis: what CVD problems are there
HTN + coronary artery disease
346
Systemic Sclerosis Diffuse cutaneous systemic sclerosis: what lung problems are there
pulmonary hypertension and pulmonary fibrosis
347
Systemic Sclerosis Diffuse cutaneous systemic sclerosis: what kidney problems are there
glomerulonephritis scleroderma renal crisis
348
Systemic Sclerosis what is the appearance of scleroderma
hardening of the skin shiny, tight skin without the normal folds in the skin. most notable on the hands and face.
349
Systemic Sclerosis what is sclerodactyly
the skin tightens around joints it restricts the range of motion in the joint and reduces the function of the joints. fat pads on the fingers are lost. Skin can break + ulcerate
350
Systemic Sclerosis what is calcinosis and where is it commonly found
calcium deposits build up under the skin fingertips
351
Systemic Sclerosis what is Raynaud’s phenomenon
fingertips go completely white and then blue in response to even mild cold.
352
Systemic Sclerosis what causes Raynaud's phenomenon
vasoconstriction of the vessels supplying the fingers
353
Systemic Sclerosis what is Oesophageal dysmotility caused by
connective tissue dysfunction in the oesophagus
354
Systemic Sclerosis what sx are in oesophageal dysmotility
swallowing difficulties acid reflux oesophagitis
355
Systemic Sclerosis what is systemic and pulmonary HTN caused by
connective tissue dysfunction in the systemic and pulmonary arterial systems worsened by renal impairment
356
Systemic Sclerosis which condition can occur in severe systemic sclerosis
pulmonary fibrosis (gradual onset dry cough and SOB)
357
Systemic Sclerosis what is scleroderma renal crisis
acute severe HTN + renal failure
358
Systemic Sclerosis which autoantibodies are positive in most patients
Antinuclear antibodies (ANA) but not specific to systemic sclerosis
359
Systemic Sclerosis which antibodies are most associated with limited cutaneous systemic sclerosis
Anti-centromere antibodies
360
Systemic Sclerosis which antibodies are most associated with diffuse cutaneous systemic sclerosis
Anti-Scl-70 antibodies they are associated with more severe disease.
361
Systemic Sclerosis what is nailfold capillaroscopy
a technique where the nailfold is magnified and examined
362
Systemic Sclerosis nailfold capillaroscopy: what will indicate systemic sclerosis
Abnormal capillaries, avascular areas and micro-haemorrhages
363
Systemic Sclerosis how to differentiate patients with primary Raynaud’s and Systemic Sclerosis
patients with primary Raynaud’s will have normal nailfold capillaries
364
Systemic Sclerosis what is dx based on
meeting a number of criteria for clinical features, antibodies and nailfold capillaroscopy.
365
Systemic Sclerosis mnx for diffuse disease and complications such as pulmonary fibrosis
- MDT - steroids + immunosuppressants
366
Systemic Sclerosis non-medical mnx
- Avoid smoking - Gentle skin stretching to maintain range of motion - Regular emollients - Avoiding cold triggers for Raynaud’s - Physio + occupational therapy
367
Systemic Sclerosis what medical trx for Raynaud's
Nifedipine
368
Systemic Sclerosis medical trx
focuses on treating symptoms and complications: e.g analgesia, PPIs, abx, ACEi
369
what is enteropathic arthritis
seronegative spondylarthropathy occurring in 10-20% of patients with inflammatory bowel disease (IBD)
370
what is associated with Polyarteritis nodosa
Hep B
371
Polymyalgia Rheumatica which condition is this strongly associated with
giant cell arteritis
372
Polymyalgia Rheumatica demographics
\>50y women Caucasians
373
Polymyalgia Rheumatica what are the core features
- Bilateral shoulder pain that may radiate to the elbow - Bilateral pelvic girdle pain - Worse with movement - Interferes with sleep - Stiffness for at least 45 minutes in the morning
374
Polymyalgia Rheumatica how long should core features be present for
at least 2w
375
Polymyalgia Rheumatica other features
- Systemic symptoms: weight loss, fatigue, low grade fever, low mood - Upper arm tenderness - Carpel tunnel syndrome - Pitting oedema
376
Polymyalgia Rheumatica how is dx made
- clinically - response to steroids - exclude other conditions
377
Polymyalgia Rheumatica what inx should you do to exclude other conditions
- FBC, U&Es, LFTs. TFTs - Ca (hyperparathryoidism, osteomalacia) - Serum protein electrophoresis (myeloma) - CK (myositis) - RF - urine dipstick
378
Polymyalgia Rheumatica what are pts initially started on
15mg prednisolone/day assess 1w after. Stop if poor response
379
Polymyalgia Rheumatica when you assess 3-4w later after starting steroids, what would you expect to see in PMR
a 70% improvement in symptoms and inflammatory markers to return to normal
380
Polymyalgia Rheumatica If 3-4 weeks of steroids has given a good response, what regime should you start
a reducing regime with the aim of getting the patient off steroids can take 1-2y
381
Polymyalgia Rheumatica additional measures for pts on long term steroids
Don't STOP Don't: risk of adrenal crisis if steroids are abruptly withdrawn Sick day rule: increase dose if unwell Treatment card: to alert others they are steroids dependent Osteoporosis: consider bisphosphonates, Ca + Vit D PPI: consider gastric protection
382
what needs to be screened for first before starting biologics like infliximab?
TB due to the SE of it being reactivated
383
why is hydroxychloroquine CI'd is psoriasis
SE: it worsens it
384
what is Still's disease
an idiopathic autoinflammatory condition
385
pyrexia (often very high and of uncertain origin at first) , arthralgia and a fine nonpruritic salmon pink rash, elevated serum ferritin. What is it?
Still's disease
386
Giant Cell Arteritis aka
temporal arteritis
387
Giant Cell Arteritis which condition is it strongly linked with
polymyalgia rheumatica
388
Giant Cell Arteritis which patients are at higher risk
white females \>50y
389
Giant Cell Arteritis key complication
vision loss
390
Giant Cell Arteritis sx
- Severe unilateral headache typically around temple and forehead - Scalp tenderness noticed when brushing hair - Jaw claudication - Blurred or double vision
391
Giant Cell Arteritis diagnosis
- Clinical presentation - Raised ESR: usually 50 mm/hour or more - Temporal artery biopsy findings
392
Giant Cell Arteritis what is found on temporal artery biopsy
Multinucleated giant cells
393
Giant Cell Arteritis what is it
a systemic vasculitis of the medium and large arteries.
394
Giant Cell Arteritis what may FBC show
normocytic anaemia and thrombocytosis (raised platelets)
395
Giant Cell Arteritis what may LFTs show
raised ALP
396
Giant Cell Arteritis result of c reactive protein
usually raised
397
Giant Cell Arteritis what will duplex US of the temporal artery show
hypoechoic halo sign
398
Giant Cell Arteritis initial mnx
high dose steroids immediately before confirming diagnosis
399
Giant Cell Arteritis what other meds should you consider apart from prednisolone
- aspirin 75mg daily - PPI for gastric protection whilst on steroids
400
Giant Cell Arteritis ongoing mnx
- continue high dose steroids (40-60mg) until the symptoms have resolved - slowly wean off steroids (can take several years)
401
Giant Cell Arteritis early complications
- vision loss - stroke
402
Giant Cell Arteritis late complications
- relapses - steroids SEs - stroke - aortitis --\> aortic aneurysm --\> aortic dissection
403
which is more sensitive or more specific for RA? anti-CCP RF
RF - most sensitive anti-CCP - most specific
404
(PIP) joints are hyper-extended but this is reducible when she extends her fingers from a fist position. what is it
Jaccoud's arthropathy in SLE
405
young footballer, lower back pain worse in morning. pain in his buttocks which alternates from left to right. He has a localised pain over his right achilles tendon what is it
sacroilitis
406
what is in arthrotec (an NSAID sometimes used to treat joint pain)
Misoprostol and diclofenac
407
what SE can misoprostol cause
diarrhoea
408
does SLE cause low and high complement
low
409
does SLE cause exudative or transudative pleural effusions
exudative
410
what needs to be screened for and treated first before starting biologics
TB
411
which cancer is dematomyositis associated with
lung
412
What anatomical area is inflamed in the joints of an inflammatory arthritis
Synovium (synovial fluid and membrane)
413
red hot swollen joint. Gram stain negative. No crystals. Temperature and WCC high. What is it and how to treat
septic arthritis gram stain is positive in 50%, so a negative gram stain does not mean there is no infection. IV antibiotics should be started pending culture results.

Finals (47 decks)

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