Rheumatology Flashcards
Common causes of monoarthritis, oligo-arthritis and polyarthritis
Mono - Gouty or septic arthritis
Oligo (under 4) - Spondyloarthritis (e.g. Ankylosing spondylitis) and Enteropathic arthritides
Poly (>5 joints) - RA, SLE
Joints involved in spondyloarthritis
Axial joints and peripheral joints
Back pain and dactylitis
Sequence of hand examination
Ask questions about getting dressed, showering, working in kitchen
Ask patient to move hands/ joints in all directions - assess range of active movement
Palpate for joint tenderness, signs of inflammation
Palpate for any crepitation in joints casued by joint effusion
Test for grip strength by squeezing
Define all deformities: valgus/varus/ ulnar/ radial …etc
Look for extra-articular features:
- Episcleritis, nodules, vasculitis for RA
- Skin and nail lesions for psoriasis
- Iritis, mucocutaneous lesions and cardiac complications in ankylosing spondylitis
- Tophus deposition in gout
- Septic vesicular lesions in gonococcal arthritis
Locations of small vessel vasculitis?
Ulnar aspect of elbows
Nail fold, bed and edge
Lower limbs
Fundi
Define Raynaud’s phenomenon
Raynaud’s phenomenon is a problem that causes
decreased blood flow to the fingers, ears, toes, nipples, knees, or nose due to spasms of blood vessels in those areas
Fingers that turn pale or white then blue when exposed to cold, or during stress or emotional upset
Hands that may become red, swollen and painful when warmed
Interpret:
Liliac/ purple rash around the eyes and face
Puffiness around eyes
Redness around neck at sun-exposed areas
Scaly, red, violaceous rash on the MCP and PIP joints
Raynaud’s phenomenon
+/- muscle tenderness
Finger tip black and scaly
What other peripheral signs?
Dermatomyositis
Liliac/ purple rash around the eyes and face - HELIOTROPIC RASH
Puffiness around eyes - PERIORBITAL EDEMA
Redness around neck at sun-exposed areas - PHOTOSENSITIVE RASH
Scaly, red, violaceous rash on the MCP and PIP joints - GOTTRON’S PATCHES
Raynaud’s phenomenon
+/- muscle tenderness
Finger tip black and scaly - DIGITAL VASCULITIS
Cardiac arrhythmia
Aspiration pneumonia and pulmonary fibrosis
Proximal muscle weakness***
Causes of dermatomyositis
Majority idiopathic
Juvenile or adult onset
Asso. with underlying connective tissue disorder
Asso. with malignancy, esp. NPC
D/dx of polymyositis without skin lesions
Drug and toxin induced myopathies (e.g. statins)
Rhabdomyolysis
Metabolic myopathies (hyper or hypothyroidism, acromegaly)
Infective myositis
Investigations for dermatomyositis
Creatinine kinase, Aspartate transaminase, LDH
Electromyography
MRscles
Anti-nuclear Ab, Anti-MDA Ab, Anti-Jo-1 Ab
Interpret:
Uremic features
Nodules on ear lobe, interphalangeal and metatarsophalangeal joints
Large first MTP joint nodule with signs of inflammation
Dx?
Causes?
Gouty arthritis
Under-secretion of uric acid: primary or secondary to drugs (diuretics, pyrazinamide)
Over production of uric acid: primary or secondary to excessive dietary intake, alcohol use or lymphoproliferative diseases, psoriasis, cytotoxic drugs
Ddx of gouty tophi
Rheumatoid nodule: also found at extensor surfaces, firmer, more discrete and smaller
Xanthomata: over large tendons e.g. Achilles’ tendon
Ddx for acute arthritis
Septic arthritis
Traumatic arthritis
Tests for gouty arthritis
Uric acid, renal function, CBC
Joint fluid: cell count, culture, microscopy: birefringent uric acid needle- shaped crystals**, increased WBC counts
X-ray: soft tissue swelling, erosive lesions if chronic
Precipitating factors of gout
Trauma
Dietary excess
Alcohol
Starvation
Interpret:
bony articular nodules at PIP and DIP, firm, no signs of inflammation
Tender on palpation
Limited ROM
Knee crepitation
Dx?
Causes?
Typical joints affected
Nodal OA
Idiopathic, associated with aging and chronic use of joints
CMC, MTP, Knee, cervical and lumbar spine, DIP, PIP
Ddx of nodal OA?
Rheumatoid arthritis: spares DIP, mainly MCP, symmetrical and inflammatory
Spondyloarthritis e.g. psoriatic arthritis: Inflammatory signs, nail changes, skin changes
Interpret:
Cutaneous, silvery areas at extensor surfaces of limbs, scalp, umbilicus and lower back
Pitting nails
Signs of inflammation and pain at isolated joints, not symmetrical
Additional signs?
Dx?
Typical joints affected?
Psoriatic arthritis
Tendonitis
Uveitis
Dactylitis
Psoriatic arthritis
- 5% spinal disease
- 10% DIP disease
- 35% symmetrical/ asymmetrical polyarthritis
- 50% Asymmetrical oligoarthritic
Causes of psoriatic arthritis
Familial predisposition
Up to 75% with HLA-B27 positive
Ddx of psoriatic arthritis?
Rheumatoid arthritis: symmetrical polyarthritis
Ankylosing spondylitis with sacroilliitis
Inflammatory bowel disease associated arthritis
Interpret:
Smooth, shiny and tight skin on face and hands
Raynaud’s phenomenon +ve
Finger ulcers
Flexion contracture
Additional classical signs?
Dx?
Ddx?
Scleroderma
Reduced oral aperture Associated pulmonary fibrosis Arthritis Beaked nose Sclerodactyly
Systemic sclerosis with overlapping symptoms
Describe Raynaud’s phenomenon
Causes?
Triphasic color changes:
ischemia in white
Cyanosisi in blue
reactive hyperthermia for red
Scleroderma Dermatomyositis Polymyositis Atherosclerosis Buerger's disease
Tests for scleroderma
Anti-nuclear Ab
Anti- Scl 70 Ab
Chest X-ray with pulmonary fibrosis
Lung function test with restrictive pattern
Barium swallow with esophageal immobility
What causes finger ulceration in Scleroderma
Which joints are typically infected in systemic sclerosis
Severe Raynaud’s phenomenon causes digital ulceration
Infection possible
Systemic sclerosis: affecting joints distal to MCP only
Interpret:
Dry eyes with gritty/ sand sensation Dry mouth with complications MCP and PIP joints inflammation Lymphadenopathy Raynaud's phenomenon Gland swelling
Which oral complications and what is the name of the classical dry mouth sign?
Which glands swell?
Dx?
Sjogren syndrome
Cracker sign + dental carries, peri-odontitis and oral candidiasis
Parotid and submandibular gland swelling
Ddx of Sjogren syndrome
Lymphoma
Amyloidosis
Parotid tumor: Adenoid cystic or pleomorphic adenoma
Tests for dry eyes in Sjgoren syndrome + 3 lab tests
Schirmer’s test for dry eyes
Serum electrolyte: Secondary renal tubular acidosis causing hypoK
Immune markers: Anti-nuclear Ab, Anti-Ro and Anti-La
Salivary gland biopsy
Interpret:
Polyarthritis in hands and hip Malar rash Tired-looking Cutaneous vasculitic lesions on both palms Pleural rub
Most likely Dx?
What other systemic involvements?
SLE
Lupus nephritis
Lupus serositis causing chest pain
Anemia and thrombocytopenia
Hand deformities in RA
Bilateral ulnar deviation of Metacarpophalangeal joints
Swan neck deviation/ Z-shape deformity of index and little finger
Thenar and intrinsic hand muscle wasting
Systemic complications of long-standing RA
MSS: tendon rupture, joint deformities, septic arthritis
Lung: pleural effusion, nodules and fibrosing alveolitis
Pericarditis
Keratoconjunctivitis
Splenomegaly, anemia, amyloidosis
Neurological: mononeuritis, entrapment neuropathies e.g. CTS
Features seen in RA patients with long term immunosuppression
Steroids:
Cushingoid features: Acne, Hirsutism, Buffalo hump, central obesity
Diabetes, Hypertension, cataracts, glaucoma
Increase susceptibility to infections
Gastric ulcers
Osteoporosis, avascular necrosis of hip joint
