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Year 4 Additional Notes > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

pANCA associations

A

Vasculitis
UC and Crohns (more so UC)
PSC
Anti GBM disease

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2
Q

Features of AS

A

HLAB27 spondyloarthropathy (males, 20-30)

Lower back pain and stiffness of insidious onset
Stiffness worse in morning and improves with exercise
Pain at night- improves on getting up

Exam;

Reduced lateral flexion
Reduced foreword flexion (Schobers)
Reduced chest expansion

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3
Q

Associations of AS

A

The A’s

Apical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendinitis
AV node block
Amyloidosis
Arthritis (peripheral)
And cauda equina

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4
Q

Investigations for AS

A

Spinal exam, observations, spirometry (restrictive disease)
Bloods- ESR, CRP
Imaging- spinal (pelvic) XRay and MRI

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5
Q

X ray changes for AS

A

Early- normal

Later

Sacroilitis (subchondral erosions), loss of joint space
Squaring of lumbar vertebrae
Bamboo spine
Syndesmophytes (from front and side, lumbar vertebrae are connected by bony spurs)
Dagger sign (midline opacification of vertebral column)

Chest X-ray- apical fibrosis

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6
Q

Management of AS

A

Exercise and physio
NSAID
Anti TNF (etanercept) if high disease activity/ peripheral arthritis

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7
Q

Azathioprine

A

Adverse effects

Bone marrow depression
Nausea and vomiting
Pancreatitis
Non melanoma skin cancer

Adverse reaction with allopurinol
Safe in pregnancy

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8
Q

Features of Bechets syndrome

A

20-40 year old men

Oral ulcers, genital ulcers, anterior uveitis
Thrombophlebitis and DVT
Arthritis
Neuro involvement
Erythema nodosum
GI involvement

Pathergy test- needle prick causes inflamed skin pustule

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9
Q

Features of chronic fatigue syndrome

A

4 months of disabling fatigue affecting mental and physical function more than 50% of the time in the absence of other disease

Fatigue
Sleep disturbance eg. Insomnia
Myalgia and arthralgia
Headaches
Cognitive impairment
General malaise

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10
Q

Investigations CFS

A

Bedside- obs and exam and BM urinalysis (bence jones- myeloma)
Bloods- FBC UE LFT glucose HBA1c TFT ESR CRP Ca CK ferritin coeliac haemanitics

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11
Q

Management of CFS

A

CBT
Graded exercise programme
Pain management clinic if pain is a problem
Low dose amitriptyline (if poor sleep)

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12
Q

Denosumab

A

RANKL inhibitor
60mg S/C every 6 months for osteoporosis
120mg given every 4 weeks for prevention of skeletal related events (pathological fractures) in adults with bony metastases

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13
Q

Causes of drug induced lupus

A

Procainamide (anti arrhythmic)
Hydralazine (vasodilator- HTN)
Isoniazid
Phenytoin

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14
Q

Features of drug induced lupus

A

Arthralgia
Myalgia
Skin (malar rash)
Pulmonary involvement eg. Pleurisy
ANA positive, dsDNA negative
Anti histone antibodies

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15
Q

Ehler Danlos syndrome

A

Autosomal dominant
Collagen (type III)

Elastic fragile skin
Joint hyper mobility (dislocation)
Easy bruising
Aortic regurgitation mitral valve prolapse aortic dissection
SAH
Retinal streaks

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16
Q

Fibromyalgia

A

Chronic pain all over (tender spots)
Lethargy
Cognitive impairment eg. Fog
Sleep disturbance (unrefreshed), headaches, dizziness

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17
Q

Management of fibromyalgia

A

Exercise- best evidence
CBT
Medication- pregabalin, amitriptyline

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18
Q

Features of gout

A

Episodes lasting several days where gout flares, symptom free between episodes; significant pain, swelling, erythema, tophi (painless hard nodules)

1st MTP, ankle, wrist, knee

Can get permanent joint destruction

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19
Q

Radiological features of gout

A

Joint effusion
Well defined punched out erosions with sclerotic margins in a juxta articular distribution (and overhanging edges)
Soft tissue tophi may be seen

NB- no loss of joint space

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20
Q

Investigations for gout

A

Bedside- MSK exam, observations
Bloods- uric acid (can be low in acute attack), ESR, CRP, FBC
I&S- X ray, joint aspirate (bifringent light etc.)- would also rule out SA

NB- measure urate 2 weeks after attack

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21
Q

Management of gout

A

Lifestyle- reduce alcohol, lose weight, avoid food high in purines eg. Liver, kidneys, seafood, oily fish, yeast products eg. Marmite

Acute- NSAID or colchicine (diarrhoea). Steroids if these are contraindicated. Keep taking allopurinol.

Urate lowering therapy (ULT)- 2-4 weeks after first attack of gout (allopurinol or febuxostat). May need colchicine of NSAID cover whilst starting (<300), as allopurinol can trigger gout initially

NB- stop thiazides, losartan is better if HTN, increase vitamin C

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22
Q

Causes of hyperuricaemia

A

Diuretics (thiazides)
CKD
Lead toxicity
Cytotoxic drugs/chemotherapy
Myeloproliferative disorder
Gout

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23
Q

HLA A3

A

Haemochromatosis

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24
Q

HLA B51

A

Bechets

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25
Q

HLA B27

A

AS
Reactive arthritis
Anterior uveitis
Psoriatic arthritis
Enteric arthritis

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26
Q

HLA DQ2/8

A

Coeliac

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27
Q

HLA DR3

A

Dermatitis herpetiformis
Sjögren’s syndrome
PBC

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28
Q

HLA DR4

A

T1DM
RA

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29
Q

Hydroxychloroquine

A

May cause bulls eyes retinopathy (can cause severe and permanent visual loss- baseline ophthalmological examination and annual screening reccomended)

Safe in pregnancy

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30
Q

Langerhans cell histiocytosis

A

Childhood bony lesions

Bone pain (skull and proximal femur)
Cutaneous nodules
Recurrent otitis media and mastoiditis
Tennis racket shaped Birbeck granules on electron microscopy

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31
Q

Lateral epicondylitis

A

AKA tennis elbow (caused by painting, tennis etc.)

Pain and tenderness localised to lateral epicondyle
Pain worse on wrist extension against resistance or supination, with elbow extended

Analgesia
Steroid injections
Physiotherapy

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32
Q

Features of Marfan’s syndrome

A

Defects in fibrillin 1

Tall stature- arm span to height ratio >1.05
Arachnodactylyl (wrap fingers around joints)
hyperextendable joints
High arched palate
Pectus excavatum
Pes planus (flat feet)
Scoliosis
Dilation of aortic sinuses
Dural ectasia (ballooning of dural sac at lumbosacral level)

Complications;
Aortic aneurysm, aortic dissection, regurgitation, mitral valve prolapse
Pneumothoraces
Upward lens dislocation

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33
Q

Management of Marfan’s syndrome

A

Beta blockers and ACE-I to control HTN and heart pathology
Physio for reducing hyper mobility issues
Genetic counselling- screen family members
Regular echocardiograms (1 year) and ophthalmology reviews, 5 yearly MR/CT aorta (complications)

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34
Q

Adverse effects of methotrexate

A

Hair loss
Mucositis
Myelosupression
Pnueomonitis
Pulmonary fibrosis
Liver fibrosis

Avoid pregnancy, and 6 months afterwards (men should use contraception for 6 months after finishing it too)

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35
Q

Methotrexate interactions

A

Avoid trimethoprim or co trimoxazole
High dose aspirin may increase risk of toxicity

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36
Q

Causes of myopathy

A

Proximal muscle weakness

Inflammatory eg. Polymyositis
Inherited- DMD
Endocrine- cushings, thyrotoxicosis
Alcohol

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37
Q

Management of OA

A

Supportive- weight loss, muscle strengthening exercises, physiotherapy, TENS device
Medical- paracetamol and topical NSAID eg. Ibuprofen gel, then oral NSAID (PPI) and opioids and intra articular steroids
Surgical- joint replacement when other measures fail

NB- topical NSAIDs only for hand/knee OA

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38
Q

Osteogenesis imperfecta

A

Autosomal dominant

Presents in childhood
Fractures following minor trauma
Blue sclera
Osteosclerosis causing deafness
Dental imperfections

Calcium, phosphate, PTH, ALP normal

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39
Q

Causes of osteomalacia

A

Vitamin D deficiency (malabsorption, lack of sunlight, diet)
CKD
Anticonvulsant

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40
Q

Features of osteomalacia

A

Bone pain and tenderness
Fractures
Proximal myopathy (waddling gait)

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41
Q

Investigations and management of osteomalacia

A

Bloods- low vitamin D, low calcium and phosphate, raised ALP
Imaging- translucent bands

Vitamin D supplementation, calcium supplementation if dietary intake is inadequate

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42
Q

Risks for Pagets disease of bone

A

Increased age
Male sex
FH

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43
Q

Features of Paget’s disease of bone

A

Skull, spine, pelvis, long bones of lower extremities are most commonly affected

Bone pain
Pathological fractures
Isolated raised ALP (calcium and phosphate normal)
Bony deformities eg. kyphosis, OA, enlarged maxilla, frontal bossing of skull, bowed femur and tibia

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44
Q

Investigation for Paget’s disease of bone

A

Bedside- obs and exam
Bloods- FBC UE CRP LFT bone profile
Imaging- X ray, isotope bone scan

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45
Q

Management of Paget’s disease of bone

A

Conservative- lifestyle measures, physiotherapy
Medical- Bisphosphonate (if pain, skull or long bone deformity, fracture, periarticular Paget’s), analgesia (NSAID), ensure adequate vitamin D and calcium
Surgery- correction of deformities

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46
Q

Polyarteritis nodosa association

A

Hepatitis B

47
Q

Differentials for a polyarthritis

A

RA
OA
Psoriatic arthritis
SLE
AS
TB
Gout
Virus eg. HIV

48
Q

Features of poly myalgia rheumatica

A

60+
Rapid onset (less than 1 month)
Aching, morning stiffness in proximal limb muscles (pelvic and shoulder girdle)
Worse with movement
Weakness not a symptom
Mild poly arthralgia, lethargy, depression

49
Q

Investigations and management for PR

A

Raised ESR
CK and EMG normal

Activity modification, Prednisolone (usually respond dramatically), methotrexate if unsuitable

50
Q

Risk factors for pseudo gout

A

Increasing age
Haemochromatosis
Hyperparathyroidism
Acromegaly
Wilson’s disease
Low magnesium and phosphate

51
Q

Features of pseudo gout

A

Calcium pryophosphate dehydrate crystals

Mono arthritis, rarely oligoarthritis (gouty attack, red swollen, tender, painful)
Knee wrist and shoulders commonly affected
Joint aspirate- positively bifringent rhomboid crystals
Chondrocalcinosis on XRay

52
Q

Management of pseudo gout

A

Aspirate joint fluid to exclude septic arthritis
NSAIDs or intra articular/oral steroids
(Colchicine during acute attack- not first line)

NB- no prophylaxis between attacks eg. Allopurinol

53
Q

Features of psoriatic arthritis

A

Either a symmetric poly arthritis or an asymmetric oligoarthritis (few joints)
Sacroiltiis
DIP joint disease
Arthritis mutilans (telescope fingers)
Psoriatic skin lesions
Periarticular disease (tenosynovitis, enthetitis, dactylitis)
Nail changes eg, pitting, onchylosis

54
Q

X ray changes psoriatic arthritis

A

Erosive changes and new bone formation
Periostitis
Pencil in cup appearance

55
Q

Management of psoriatic arthritis

A

Similar to RA, but if just mild, can try NSAID without the DMARD

56
Q

Raynaud’s disease

A

Young women with bilateral symptoms

57
Q

Secondary causes of raynauds phonomenon

A

Connective tissue disorders- scleroderma, RA, SLE
Leukaemia
Cold agglutins
Vibrating tools
OCP
Cervical rib

58
Q

Management of raynauds

A

If suspected secondary raynauds, refer to secondary care
Calcium channel blockers eg, nifedipine, or IV prostacyclin (epoprostenol)

59
Q

Reactive arthritis

A

Preceding GI or STD illness 4 weeks before

Conjunctivitis, urethritis, arthritis
Also balantitis and sores on soles of feet (Keratoderma blennorrhagica

NB- young person with single, swollen joint, think gonococcal SA first rather than reactive arthritis, need to rule this out first

NSAIDS, intra articular steroids if one joint, oral steroids if several joints
Sulfalazine and methotrexate often used

60
Q

Extra articular manifestations and complications of RA

A

Pulmonary fibrosis, pleural effusion, bronchiolitis, pleurisy
Keratoconjunctivitis sicca, epislceritis, scleritis, corneal ulcers
Osteoporosis
IHD
Infection risk
Depression
Felty syndrome (RA and Splenomegaly)
Carpal tunnel syndrome
Amyloidosis

61
Q

Initial investigations for suspected RA

A

Rheumatoid factor (anti CCP if negative as more specific)
X-rays of hands and feet
USS suspected joints (synovitis)

62
Q

Rheumatoid arthritis management

A

Refer to rheumatology
First presentation- steroids, NSAID (PPI), DMARD
Continued therapy- 2x DMARD if one insufficient, NSAIDs or paracetamol if continued pain
Flare ups- IM corticosteroids (or PO/articular)
Supportive- physio, occupational therapy, orthotics, surgery for joint deformities

CRP and DAS28 to monitor response to treatment

63
Q

Features of rheumatoid arthritis

A

Swollen painful joints in hands and feet
Can come in rapidly (days), or over months to years
Stiffness worse in morning, improves with activity
Insidious development over months
Positive squeeze test- discomfort on squeezing across metacarpal or metatarsal joints)
Nodules
Extrarticular manifestations
Hand deformities are late signs, as is Atlantio axial subluxation

NB- no erythema (this is either gout, pseudogout, or SA)

64
Q

Poor prognostic factors in RA

A

RF or antiCCP positive
Poor functional status at presentation
Early erosions on XRay
Extra articular features eg. Nodules

65
Q

Rheumatoid arthritis x ray findings

A

Loss of joint space
Periarticular osteopenia (early finding)
Soft tissue swelling
Marginal erosions
Subluxation (late finding)

Not seen in early disease- can take 6-24 months

66
Q

Pathophysiology of septic arthritis

A

Staph aureus
Neisseria gonorrhoea in young sexually actively adults

Haematogenous spread eg. abscess
Knee

67
Q

Features of SA

A

Acute red swollen joint
Restricted movements
Warm to touch, fluctuating
Fever

68
Q

Investigations for SA

A

Bedside- obs, MSK exam
Bloods- 2 cultures from 2 sites, FBC UE ABG CRP ESR LFT
I&S- US guided joint aspirate- microscopy and culture and sensitivities (crystal microscopy too- gout and pseudo gout), imaging

NB- crystal arthritis (gout) and septic arthritis can co exists (may get crystals with bacterial growth)

NB- if a patient develops a staph aureus bacteraemia, they should undergo a TTE to exclude endocarditis

69
Q

Management of SA

A

Sepsis 6
MicroGuide for local policy on which ABX to use- IV flucloxacillin and rifampicin (clindamycin if allergy) for 6-12 weeks
May need arthroscopic lavage
NSAIDs and physiotherapy input

70
Q

Features of Sjögren’s syndrome

A

Can be primary or secondary to RA or SLE

Keratoconjunctivitis sicca
Dry mouth
Dry vagina
Arthralgia
Raynauds
Myalgia
Polyneuropathy
Parotitis

Increased risk of lymphoid malignancy

71
Q

Investigations and management of Sjögren’s

A

ANA and RF (if secondary to RA and SLE)
Anti RO Anti La
Schrimers tear test (less than 10mm- bad)

Artificial saliva and tears (vaginal lubricants) and regular dental check ups
May use hydroxychloroquine

72
Q

Features of stills disease

A

Arthralgia
Myalgia
Pharyngitis
Serum ferritin raised, leukocytosis
Salmon pink maculopapular rash
Pyrexia (worse in afternoon evening)
Lymphadenopathy
RF and ANA negative

73
Q

Management of Stills disease

A

NSAIDs
Add Steroids
Add DMARD

74
Q

Cautions with sulfalazine

A

G6PD deficiency
Allergy to aspirin or sulphonamides (eg. Glicazide, co trimazole)

75
Q

Adverse effects of sulfalazine

A

Oligospermia
Steve’s Johnson syndrome
Pneumonitis and lung fibrosis
Myelosupression (anaemia)
Coloured tears (stained contact lenses)

Safe in pregnancy and breast feeding

NB- Sulfalazine (4 S’s- sperm, SJS, stains contacts, safe in pregnancy)

76
Q

Features of SLE

A

Type 3 hypersensitivity reaction
More common in women and people of black/Asian origin

General- fatigue, fever, mouth ulcers, lymphadenopathy, arthralgia

Skin- malar rash (not nasolabial folds), discoid rash, photosensitive, raynauds, livedio reticularis, alopecia

Resp- pleurisy, fibrosing alveolitis

Renal- diffuse proliferative glomerulonephritis

Neuropsychiatric- anxiety, depression, psychosis, seizures

77
Q

Investigations for suspected SLE

A

Bedside- observations, examination (check lungs), urinalysis
Bloods- FBC UE ABG antibodies (ANA, anti dsDNA) ESR (monitoring- CRP can be normal, if raised= underlying infection), complement levels (C4 low in active disease so good for monitoring)
Imaging- CXR (lung involvement), joint x rays and kidney biopsy (symptom dependent)

78
Q

SLE management

A

Refer to rheumatology
NSAIDs, vaccines before immunosuppression
Sun block
Hydroxychloroquine
May need steroids if renal or neuro involvement, more severe disease may also require methotrexate (folic acid), azathioprine, ciclosporin etc.

79
Q

Limited cutaneous systemic sclerosis

A

Raynauds
Scleroderma of face and distal limbs
Subtype is CREST- calcinosis, raynauds, esophageal dysmotility, sclerodactyly, telangiectasia

80
Q

Diffuse cutaneous systemic sclerosis

A

Scleroderma of face and proximal limbs
Interstitial lung disease and pulmonary artery HTN
Renal involvement- HTN and AKI

81
Q

Scleroderma

A

Without internal organ involvement
Tightening and fibrosis of skin

82
Q

Features of temporal arteritis (GCA)

A

60+
Rapid onset (less than 1 month)
Headache (exacerbated by combing hair eg.)
Jaw claudication
Visual disturbance- amaurosis fugax, blurring double vision
Tender palpable temporal artery
Features of PMR (ask about these)
Lethargy, depression, low grade fever, night sweats (vasculitis)

83
Q

Investigations for temporal arteritis

A

Bedside- ophthalmology exam, observations
Bloods- FBC UE ESR (raised), CRP
I&S- temporal artery biopsy (skip lesions)

NB- GCA can cause Anterior ischemic optic neuropathy - fundoscopy typically shows a swollen pale disc and blurred margins

84
Q

Treatment of temporal arteritis

A

Urgent high dose corticosteroids before biopsy- no visual loss, Prednisolone, visual loss (or ischaemic anterior neuropathy), IV methylprednisolone before Prednisolone
If visual loss- urgent ophthalmology review same day

NB- give bone protection (bisphosphanate) and PPI when giving these steroids (will be taking them for a while)

85
Q

DAS 28 scoring

A

<2.6- remission

2.6-3.2 - low

3.2-5.1 - moderate

> 5.1 - severe

86
Q

Leflunomide

A

HTN and peripheral neuropathy

87
Q

Sulfalazine

A

Male infertility (oligospermia), SJS, stained contacts

88
Q

Hydroxychloroquine

A

Nightmares and reduced visual acuity

89
Q

Anti TNF a

A

Reactivation of TB or hepatitis B

90
Q

Rituximab

A

Night sweats and thrombocytopenia

91
Q

DMARDs in pregnancy

A

Sulfalazine and hydroxychloroquine

92
Q

Causes of anaemia in RA

A

Anaemia of chronic disease
Iron deficiency anaemia secondary to use on non steroidals
Feltys syndrome- anaemia leukopaenia and enlarged Splenomegaly
Pernicious anaemia
Haemolytic anaemia

Platelet count will go up as part of the inflammatory process (also raised LFTs and ferritin)

93
Q

Tophi

A

Seen in gout not pseudo gout

94
Q

Light microscopy findings of gout synovial fluid

A

Negative bifringent needles

95
Q

Gout vs pseduogout

A

On history alone, gout tends to affect big toe, pseudo gout affects the knee

96
Q

Fibromyalgia associations

A

Functional somatic syndromes (IBS, CFS, migraines)
Psychiatric disorders eg. Depression, GAD
Sleep disorders- restless leg syndrome
Inflammatory rheumatoid conditions eg. SLE, RA

97
Q

Investigations for fibromyalgia

A

Clinical- 3 months of widespread pain in muscles and joints, and 11/18 tender points (bloods still good to do to rule out an inflammatory process, and joint USS if swelling reported)

98
Q

Steroids and DONT STOP

A

Don’t stop taking abruptly- have to be tapered down

S- sick day rules (double)
T- treatment card
O- osteoporosis prevention
P- PPI

99
Q

Drug induced lupus

A

Doesn’t typically affect the oral mucosa, CNS, or kidneys

100
Q

Urate lowering therapy

A

The British Society of Rheumatology Guidelines now advocate offering urate-lowering therapy to all patients after their first attack of gout. ULT is particularly recommended if:
• >= 2 attacks in 12 months
• tophi
• renal disease
• uric acid renal stones
• prophylaxis if on cytotoxics or diuretics

101
Q

Investigations for systemic sclerosis

A

Bedside- observations, physical exam, ECG, urinalysis
Bloods- ANA and anti-scl 70 for diffuse, anti centromere for limited, antibodies, organ involvement eg. echocardiogram, UE
Imaging- hand x ray (calcinosis), CXR (fibrosis), echocardiogram (fibrosis)

102
Q

Management of systemic sclerosis

A

No cure
Usual lifestyle modification measures
Symptomatic treatment- GI (PPI), Raynaud’s (nifedipine)
Preventative- lung fibrosis (immunosuppressant), renal crises (low dose ACE)

103
Q

What test needs to be done prior to starting a biologic

A

chest X-ray to look for TB prior to starting biologics for rheumatoid arthritis as they can cause reactivation

104
Q

Antibodies for systemic sclerosis

A

Limited cutaneous systemic sclerosis: anti-centromere

Diffuse cutaneous systemic sclerosis: anti-scl-70

105
Q

Management of Bechet’s disease

A

Topical steroids to mouth ulcers (e.g. soluble betamethasone tablets), topical anaesthetics for genital ulcers (e.g. lidocaine ointment), colchicine can also be used acutely
Maintain remission- systemic steroids (i.e. oral prednisolone), immunosuppressants such as azathioprine, biologic therapy such as infliximab

106
Q

X ray findings of Paget’s

A

Bone enlargement and deformity
“Osteoporosis circumscripta” describes well defined osteolytic lesions that appear less dense compared with normal bone
“Cotton wool appearance” of the skull describes poorly defined patchy areas of increased density (sclerosis) and decreased density (lysis)
“V-shaped defects” in the long bones are V shaped osteolytic bone lesions within the healthy bone

107
Q

Complications of Paget’s

A

Osteogenic sarcoma (osteosarcoma)
Spinal stenosis and spinal cord compression

108
Q

CRP and ESR in SLE

A

CRP normal (if raised, possible infection)
ESR raised (used for monitoring along with complement)

109
Q

What score can investigate hypermobility

A

Beighton score
Beighton score is positive if at least 5/9 in adults, or at least 6/9 in children

110
Q

Live vaccines

A

Live influenza vaccine
Measles, Mumps and Rubella (MMR) vaccine
Rotavirus vaccine
Shingles vaccine
BCG vaccine
Oral typhoid vaccine
Varicella vaccine
Yellow Fever vaccine

111
Q

Who cant have a live vaccine

A

Haematological malignancy
HIV/AIDS
SCID
Stem cell transplant
Chemotherapy or radiotherapy
Immunosuppressive treatment eg. biologics, DMARDs (eg.methotrexate), steroids

112
Q

What medication should you not prescribe alongside allopurinol

A

Azathioprine

Azathioprine and allopurinol have a severe interaction causing bone marrow suppression

113
Q

What imaging do patients with RA require pre-operatively?

A

Anteroposterior and lateral cervical spine radiographs

The neck cannot be hyperextended during intubation

Atlanto-axial subluxation

114
Q

Organisms causing arthritis

A

SA- staph aureus, young: gonorrhoea

Reactive A- E. coli, young: chlamydia

Year 4 Additional Notes (17 decks)

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