Rheumatology Flashcards
What are the antibodies associated with rheumatoid arthritis?
Rheumatoid Factor, Anti-CCP
What are the antibodies associated with SLE and Drug-induced Lupus?
ANA
Anti-DSDNA, Anti-Sm, Anti-phospholipid
Drug-induced lupus: Anti-histone antibodies
What are the antibodies associated with Sjogren’s Syndrome?
ANA
Anti-Ro and Anti-La
What are the antibodies associated with Anti-phospholipid syndrome?
Anti-cardiolipin, Lupus anticoagulant and Anti-B2 glycoprotein 1
What are the antibodies associated with Systemic Sclerosis?
ANA
Anti-centromere, Anti-RNA polymerase III, Anti- Scl 70
What are the antibodies associated with Dermatomyositis and Polymyositis?
ANA
Anti-Jo1 in both
Anti-Mi2 in polymyositis
What is the blood marker associated with seronegative inflammatory arthritis?
HLA-B27
What are the 4 types of seronegative inflammatory arthritis?
Psoriatic Arthritis
Reactive Arthritis
Enteropathic Arthritis
Ankylosing Spondylitis
What is the classic pattern of joint involvement in seropositive arthritis?
Symmetrical
Small joint
Polyarthritis
What is the classic pattern of joint involvement in seronegative arthritis?
Asymmetrical
Larger joint
Mono/oligo arthritis
What is the classic pattern of joint involvement in crystal arthropathy?
Asymmetrical
Small-Large joint
Monoarthropathy
Most commonly affecting 1st MTP joint first and moving proximally with disease progression.
What is the classic pattern of joint involvement in Osteoarthritis?
Symmetrical
Large and Small Joint
Oligo/Polyarthritis
What would you expect to find on examination in Rheumatoid Arthritis?
Rheumatoid Nodules Ulnar Drift Boutonneire Deformity Swan neck Deformity Palmar Subluxation Joint Stiffening, Swelling Hammer Toe Deformity
What would you expect to find on examination in lupus?
Butterfly/Malar Rash or Discoid Rash Raynaud's Photosensitivity Non-scarring alopecia Oral Ulcers
What drugs are associated with causing lupus?
Sulfa-drugs Phenytoin Isoniazid Methyldopa TNFa inhibitors
What would you expect to find on examination in Sjogren’s Syndrome?
Dry eyes and Dry mouth Raynaud's May also have vaginal dryness Vasculitic rash Parotid gland swelling
What is Schirmer’s Test?
Test used in Sjogren’s syndrome to measure tear production.
What are the key symptoms of anti-phospholipid syndrome?
Recurrent vascular thrombosis / unprovoked VTE Recurrent Miscarriage Livedo Reticularis Prolonged APTT Thrombocytopenia
What would you expect to find on examination in dermatomyositis?
Heliotrope Rash Gottron's Papule's Shawl sign over upper chest Holster sign on lateral thigh Periungal erythema
Raynaud’s and photosensitivity
What would you expect to find on examination in polymyositis?
Heliotrope Rash
Raynaud’s
Proximal muscle weakness
Dysphagia/aspiration
What would you expect to find on examination in systemic sclerosis?
Raynaud's Thickening of skin over fingers Taught, shiny skin with pigment change Sclerodactyl Oesophageal involvement - dysphagia, GORD/dyspepsia
What would you expect to find on knee aspiration of gout?
Negatively birefringent, yellow, needle shaped crystals
What would you expect to find on joint aspiration in pseudo gout?
Weakly positively birefringent, blue, rhomboid shaped crystals - calcium pyrophosphate
What would you expect to see on joint x-ray in a person with osteoarthritis?
Loss of joint space
Osteophytes
Subchondral cysts
Subcondral sclerosis
What would you expect to see on joint x-ray in gout?
First presentation- probably NAD
Chronic disease- periarticular erosion
joint effusion is an early sign well-defined 'punched-out' erosions relative preservation of joint space until late eccentric erosions no periarticular osteopenia soft tissue tophi may be seen
What is the management for osteoarthritis?
Conservative: weight loss, exercise, assistive devices and aids
- Paracetamol
- Topical NSAIDs - > oral
- Intra-articular steroid injection
- Joint replacement
What would you expect to see on x-ray in rheumatoid arthritis?
Loss of joint space
Erosions
Periarticular osteopenia
Joint deformity
Which DMARD is safest in pregnancy?
Sulfasalazine
What is the management for Gout?
- NSAIDs to settle acute attack + PPI
a. Colchicine if renal impairment
b. Oral steroids also alternative - Allopurinol long term (initiated 2w after acute attack settles) + colchicine cover <6m
a. Febuxostat = alternative in renal impairment
Lifestyle advice: reduction in red meat and alcohol consumption, stop smoking, exercise/lose weight
Medication review e.g. stopping thiazides
What is the management of pseudogout?
Oral NSAIDs and PPI
Intra-articular steroid injection
Systemic steroids
What are the associated symptoms with reactive arthritis?
Conjunctivitis and Urethritis
Can’t see, can’t pee, Can’t climb a tree
What are the symptoms associated with ankylosing spondylitis?
Lower back pain and stiffness - worst on waking, better with activity
Anterior Uveitis / Iritis
Usually presents in late teens/early 20s
What is the test for ankylosing spondylitis?
Schober’s test
Which condition is most commonly associated with polymyalgia rheumatica?
Giant cell arteritis
Where does polymyalgia rheumatic most commonly affect?
Shoulders
Neck
Pelvic Girdle
Worse with movement and interrupt sleep
Which test discriminates between myositis and polymyalgia rheumatica?
Creatine Kinase
- levels raised in true myositis, not in PR
What are the key symptoms of GCA?
Scalp tenderness
Jaw claudication
Visual disturbance (unilateral)
Amaurosis Fugaux
What is the diagnostic test for GCA?
Temporal artery biopsy
What is the management for GCA?
High dose oral prednisolone
IV methylprednisolone if visual changes developing
PPI + bisphosphonates to protect stomach and bones.
What are the key symptoms of takayasu’s arteritis?
Limb claudication on exertion Dizziness on upper limb exertion Unequal BP in the arms Absent pulses Associates with aortic regurgitation
What are the key symptoms of Kawasaki Disease?
Child <4/5yo >5 day history of fever Strawberry tongue Vasculitic rash- polymorphic, maculopapular, erythematous Conjunctivitis Unilateral cervical lymphadenopathy
What is the management for Kawasaki disease?
IVIG + high dose aspirin
Z score determines whether aspirin continued
Only scenario where aspirin is given to children
What is the classic triad of EGPA?
Eosinophilia
Granulomatous inflammation
Vasculitis
ie. associated with asthma, allergic rhinitis, sinusitis
What is the classic triad of GPA/Wegener’s?
Nasal symptoms, haemoptysis and haematuria
Upper respiratory tract, lower respiratory tract and glomerulonephritis
URT: nasal crusting, epistaxis, otorrhoea/otalgia, ulcers, saddle nose
LRT: SOB, cough, haemoptysis, dyspnoea
GN: haematuria
What are the 4 key symptoms of HSP?
Purpuric Rash
Abdominal Pain
Arthritis/arthralgia
Glomerulonephritis
Which conditions are associated with C and P-ANCA?
C-ANCA: GPA/Wegener’s
P-ANCA: EGPA, microscopic polyangiitis, Ulcerative colitis, Primary sclerosing cholangitis
What are the systemic features associated with ankylosing spondylitis?
The A's: Apical fibrosis Anterior uveitis Aortic regurgitation Achilles tendonitis AV node block Amyloidosis and cauda equina syndrome peripheral arthritis (25%, more common if female)
What is the management for anti-phospholipid syndrome?
Aspirin low-dose = primary thromboprophylaxis
Secondary= lifelong warfarin with target INR 2-3
What are the common adverse effects of azathioprine?
bone marrow depression
nausea/vomiting
pancreatitis
increased risk of non-melanoma skin cancer
Thiopurine methyltransferase (TPMT) test may be needed to look for individuals prone to azathioprine toxicity
What are the common features of Behcet’s syndrome?
Oral ulcers + genital ulcers + anterior uveitis
thrombophlebitis and deep vein thrombosis
arthritis
neurological involvement (e.g. aseptic meningitis)
GI: abdo pain, diarrhoea, colitis
erythema nodosum
What are adverse effects of bisphosphonates?
Risk of gastritis
Increased risk of jaw osteonecrosis
Increased risk of femoral shaft fractures
acute phase response: fever, myalgia and arthralgia may occur following administration
What is denosumab?
Second-line treatment for OA
It is a human monoclonal antibody that prevents the development of osteoclasts by inhibiting RANKL
What is Ehler-Danlos Syndrome?
autosomal dominant connective tissue disorder that mostly affects type III collagen
Features:
elastic, fragile skin
joint hypermobility: recurrent dislocation
easy bruising
aortic regurgitation, mitral valve prolapse and aortic dissection
subarachnoid haemorrhage
angioid retinal streaks
What is Marfan’s syndrome?
Autosomal dominant connective tissue disorder- defect in FBN1 gene which codes for fibrillin.
What are the features of Marfan syndrome?
Tall stature High-arched palate Arachnodactyly Pectus excavatum Scoliosis Flatfoot (pes Planus) Dilation of aortic sinuses, aortic aneursym, aortic regurge Mitral valve prolapse in 75% Repeated pneumothoraces Blue sclera
What are the prescribing considerations for methotrexate?
Taken weekly
Folic acid should be taken alongside 5mg weekly
FBC, U&E and LFTs need to be regularly monitored- weekly until stabilised, then every 2-3m
Avoid prescribing alongside trimethoprim or cotrimoxazole
In the case of methotrexate toxicity, folinic acid should be given
What is osteogenesis imperfecta?
Disorders of collagen metabolism resulting in bone fragility and fractures
Type 1 = most common
Autosomal dominant inheritance
presents in childhood fractures following minor trauma blue sclera deafness secondary to otosclerosis dental imperfections are common
What is osteomalacia?
Softening of the bones due to low vitamin D levels -> decreased bone mineral content
Causes: Vit D deficiency (diet/malabsorption/lack of light) CKD Anticonvulsants Liver cirrhosis
What are symptoms of osteomalacia?
bone pain
bone/muscle tenderness
fractures: especially femoral neck
proximal myopathy: may lead to a waddling gait
Bloods show: low vis D, calcium, phosphate but raised ALP and PTH
Translucent bands on x-ray
How is osteomalacia managed?
Vitamin D supplements
Calcium supplements
How do you assess patients with osteoporosis?
If >75 and have a fragility fracture- start bisphosphonate without need for DEXA
If <75, DEXA scan should be arranged and used in a FRAX score
How should osteoporosis be managed?
DEXA scan and FRAX score if appropriate
Vitamin D and calcium supplementation should be offered to all women unless confident it is unnecessary
Alendronate = first line
If can’t tolerate: risedronate or etidronate
Strontium ranelate and raloxifene are recommended if patients can’t tolerate bisphosphonates
HRT can also help reduce risk of post-menopausal osteoporosis
What are features of polymyositis?
proximal muscle weakness +/- tenderness Raynaud's respiratory muscle weakness interstitial lung disease: e.g. fibrosing alveolitis or organising pneumonia dysphagia, dysphonia
What is first line treatment for Raynaud’s?
Nifedipine
What triad of features make up Felty’s syndrome?
RA + splenomegaly + low WCC
