Rheumatology Flashcards
What auto-antibodies are found in SLE?
What is the initial test?
Anti- dsDNA
Anti-smith
Initial test - ANA *** very sensitive.
What auto-antibodies are found in drug induced Lupus? E.g. Hydralazine
Anti-histone
What auto-antibodies are found in systemic sclerosis
Anti-scl70
What auto-antibodies are found in CREST syndrome/ limited sclerosis?
Anti-centromere
What auto-antibodies are found in polymyositis?
Anti-Jo1
What auto-antibodies are found in Sjogren’s disease
Anti-Ro
Anti-La
What auto-antibodies are found in primary biliary cirrhosis?
Anti- mitochondrial
What auto-antibodies are found in autoimmune hepatitis?
Anti-Smooth muscle
What auto-antibodies are found in Churg strauss, Ulcerative colitis and primary sclerosis group cholangitis?
pANCA
What auto-antibodies are found in wegeners granulomatosis?
cANCA
What auto-antibodies are found in Coeliac disease?
Anti-tissue transglutaminase (TTG)
Anti - gliadin
Anti- endomysial
What auto-antibodies are found in Rheumatoid arthritis?
ANA
Can be found in many other auto-immune diseases
It is also the initial one found in SLE
Screening test & confirmatory test of SLE?
ANA - screening, more sensitive
Anti-dsDNA - specific
= can be used for disease monitoring ( but its not present in all patients*
)
What is SLE?
Multisystem autoimmune disorder
Women >men
Typically appears early adulthood
Remember - +ve ANA, -be ANCA, raised ESR
+/- proteinuria & hematuria - depends on renal involvement
Painful joints and morning stiffness
C3 C4 use in SLE?
C3 C4 - complement levels - LOW during active disease
What is chronic fatigue syndrome?
Features seen?
> /= 4 months of disabling fatigue that affects physical or mental function >50% of the time in absence of other cause
Women > Men
Features =
Sleep problems - lack/excessive
Muscle/joint problems
Headaches
Investigation for chronic fatigue syndrome?
FBC U&E LFT Glucose TFT ESR CRP CK Ferritin Coeliac screening Urinalysis
Management of chronic fatigue syndrome
Cognitive behaviour therapy * very effective
Graded excercise therap
What is polymyositis?
What are its features?
It’s an inflammatory myopathy
Features=
Symmetrical and diffuse muscle weakness = PROXIMAl>DISTAL
Common problems - rising from chair, combing hair, lifting objects, getting out of bath, climbing stairs
Lab investigations for polymyositis
DX??
Creative Kinase - elevated
Anti-Jo1 antibodies
DX- Muscle biopsy
Labs for polymyalgia rheumatica
CK - normal
ESR >30 ** initial test
CRP > 6
Features of polymyalgia rheumatica
Aching and stiffness - proximal
- difficulty getting out of bed, getting up from chair, raising arm above head
50% have temporal arteritis***
Treatment of polymyalgia rheumatica
Prednisolone
What is Sjögren’s syndrome?
Autoimmune disorder affects EXOCRINE glands = dry mucosal surfaces
F>M (9:1)
Can be primary or secondary
Secondary = SLE, RA
Features of Sjögren’s syndrome
Dry eyes - keratoconjunctivitis sicca
= itchy eyes, sandy
= SCHIRMER’s test = decreased tear prod
= Rose Bengal stain - may show corneal ulceration 2ry to dry eyes
Dry mouth - difficulty swallowing food
Recurrent parotitis - BILATERAL enlarge the of parotid glands
Investigations of Sjögren’s syndrome
Schirmer’s test Rose Bengal stain Rheumatoid factor * positive in 100% patients ANti- RO (SSA)70% Anti-LA (SSB) 30%
Management of Sjögren’s syndrome
No cure.
Artificial saliva and tears - HYPERMELLOSE DROPS
What is systemic sclerosis (SCLERODERMA)
Unknown ethology
Hardened sclerotic skin + connective tissue
F>M (4:1)
2 types
Limited - CREST
Diffuse
What is Raynaud’s phenomenon?
Management?
Raynaud’s - pale digits, hands
=due to ischemia — blue when exposed to cold
Due to deoxygentaion - they then become red.
Management -
Nifedipine- only drug licences to treat raynauds
What is CREST syndrome?
Subtype of scleroderma - affects FACE + DISTAL LIMBS
Calcinosis,Raynauds,Esophageal dysmotility,Sclerodactyly,Telangectasia
Raynauds first - slow onset and progression therefore other CREST seen later.
SCL-70 antibodies negative
ANA +ve (mostly)
Associated with anti-centromere antibodies
What is diffuse scleroderma?
Affects TRUNK + PROXIMAL LIMBS Rapid/ fast progression Poor prognosis SCL -70 POSITIVE ANA +ve
Complications and most common cause of death in diffuse systemic sclerosis
Most common cause of death - respiratory involvement
= 80%
- ILD, Pulmonary arterial hypertension (PAH)
Other complications -
Renal disease, HTN
What is giant cell arteritis?
Features?
Temporal cell arteritis - arterial inflammation
LARGE vessel vasculitis
Sometimes associated with PMR (50%)
Features?
>55 y/o
Rapid onset - < 1 month
Headache, blurry vision , jaw claudication, scalp tenderness
Investigations for temporal arteritis
How do you confirm the diagnosis?
Raised ESR , CRP may be elevated
Dx - temporal artery biopsy
note - CK and EMG = normal
Treatment temporal arteritis
High dose Prednisolone
Urgent ophthalmic review
Added on med -
aspirin - decrease stroke and visual loss
Bisphosphonates - high doses of steroids can cause osteopenia and osteoporosis
Features of gout
Gout - form of inflammatory arthritis
Main features- pain swelling erythema
70% of presentation affect 1st MTP - big toe - podagra
Others - ankle wrist knee
Medications that can cause gout
Thiazides diuretic - bendroflumethiazide
Loop diuretics - furosemide
Alcohol
How do you diagnose gout
Synovial fluid aspiration and analysis
= negative birefringent
*send for culture only if feverish
Serum Uric acid - normal/low in acute gout
- measure 4-6 weeks after acute stage is relieved
Management of acute attack of gout
Long term management
1st line - NSAID - ibuprofen, Naproxen
2nd line - Colchicine
Long term -after 2 weeks of acute attack
Allopurinol + NSAIDs + colchicine
When should you think of septic arthritis?
Mono arthritis - single joint involvement (knee common, shoulder)
+ fever, pain, swelling, limited movement, hotness
+ RF = DM steroid HIV RA
Commonest causative organism of septic arthritis?
Staph aureus
Commonest causative organism of septic arthritis in young sexually active ?
N.Gonorrhoea
Diagnosis of septic arthritis
Aspiration of synovial fluid - culture + sensitivity
Blood culture
Management of septic arthritis?
** IV antibiotic 1 week until BC negative and swelling resolves
Oral antibiotics 4 weeks
Flucloxacillin - 4-6 weeks = 1st line
If allergic to penicillin - Clindamycin
If organism is Gonorrhoea - Cefotaxime, Ceftriaxone
Not responding — repeated percutaneous aspiration
What is reactive arthritis?
Seronagtive spondyloarthritis
Asymmetric
= migratory oligoarthritis of LL (knees. Ankles)
+ back pain
+ extraarticular features - Reiters triad + skin (maculopapular rash)
Young adults, typically no fever
Follows STI or GI infection (dysentery cell illness)
Reiters triad
Extraarticular features of reactive arthritis
- conjunctivitis, uveitis
- urethritis
- arthritis
Can’t see, can’t pee, can’t climb a tree
Management of reactive arthritis
Symptomatic
Persistent disease
-Symptomatic - analgesia, NSAIDs, intractable-articulate steroids
= symptoms rarely last > 10 months
-Sulfasalzine+ methotrexate for persistent disease
What is De Quervain’s disease?
Gamer thumb/mummy thumb
Pain under root of thumb
Common after pregnancy - RSI of extensor pollicis brevis +abductor pollicis longus
Tennis elbow
Lateral epicondylitis
Wrist extension affected
Golfer’s elbow
Medial epicondylitis
Finger flexors and pronation are affected
- baseball,construction,plumber injury
Features of Churg Strauss/ Eosinophilic Granulomatosis w/ polyangiitis
Asthma + nasal polyps+allergic rhinitis
Eosinophilia
+other organs = purpurin, glomerluonephritis, HF, skin nodules
Lab and imaging findings Churg Strauss
CT - ground glass attenuation
Eosinophilia
Raised ESR CRP IgE
**pANCA
Features of Wegener’s granulomatosis / Granulomatosis w/ polyangiitis
URT - sinusitis/ nasal septum perforation/epistaxis/nasal crusting
+ hematuria/hemoptysis
Bleeding = nose, lung, kidney
*** c-ANCA
Rheumatoid arthritis - management
DMARD mono therapy - methrotrexate +/- short course prednisolone
NSAIDs for severe joint pain
Feature of ankylosing spondylitis
Morning stiffness
Uveitis (painful eye)
Low back pain - worse in morning, improves with excercise
Tenderness of SI joint
ankylosing spondylitis
To diagnose -
Treatment
NSAIDs — 1st line
Anti-TNF - 2nd line
Dx - X-RAY of SI joint **
Lab investigations ankylosing spondylitis
Raised WBC ESR
+/- Anemia
HLA-B27 - positive in 10%, has strong association
ankylosing spondylitis - associations
Anterior uveitis
Aortic regurgitation
What is Schober’s test?
assesses the amount of lumbar flexion
Features of Sarcoidosis
Erythema nodosum. - tender red nodules over shins
Bilateral hilar lymphadenopathy - common on CXR
Polyarthralgia
Hypercalcemia,fever.
> 2 or more = consider sarcoidosis
3 Syndromes associated with sarcoidosis
1.Lofgren’s - acute form of sarcoidosis
= bilateral hilar lymphadenopathy + erythema nodosum, fever, polyarthralgia
-excellent prognosis
- Mikulicz - parotid enlargement + lacrimal gland enlargement
= dry mouth, face swelling
- due to sarcoidosis, TB, lymphoma - Heerfordt’s syndrome
Uveoparotid fever - parotid enlargement + fever + uveitis 2ry to sarcoidosis
Diagnostic criteria of Rheumatic Fever
RF - immunological reaction to recent strept pyogene infection (2-6 is)
Criteria =
2 major or
1 major + 2 minor
Evidence of recent strept infection - raised antibodies /+ throat swab/+ group A strept antigen test
Major criteria of RF (5)
Erythema marginatum - pink annular rash trunk limbs =seen in 10% children, rare in adults Sydenham chorea - late Poly arthritis Pancarditis Subcutaneous nodules
** J♥️NES
Minor criteria of RF (4)
Raised ESR CRP
Fever
Arthralgia
Prolonged PR
Labs in RF
raised ESR - most likely to be abnormal
Most SPECIFIC = ASO antibodies (antistreptolysin O antibodies)
- the most appropriate test
Management of RF
Antibiotics - Oral penicillin V
Anti-inflammatory- NSAIDs 1st line
Treatment of complications
