Rheumatology Flashcards
Temporal Arthritis (Giant Cell Arthritis) Severe Pain When Comb Touch Scalp .
VASCULITIS OF the large arteries that supply the eyes, optic nerves, and head.
New-onset headache Started After age of 50
BLINDNESS-most feared complication,(prevented by corticosteroids)
Clinical features
• Headache (one or both temples) - most common feature, usually quick onset (1 - 2 days)
• Scalp tenderness - may be described as pain when combing hair
• Jaw claudication
• Decreased vision
may have proximal STIFFNESS of the neck, arms, hips as polymyalgia rheumatica can coexist with temporal arteritis.
Investigations
• Initial - (ESR)
• Definitive - Biopsy of temporal arteries (shows characteristic giant cells)
Treatment
, if ESR↑,START corticosteroids BEFORE a temporal artery biopsy.(to prev blindness)
- Temporal arteritis - Prednisone 60 mg daily with gradually tapering
- Polymyalgia rheumatica - Prednisolone 15 mg daily with gradually tapering
Medication can be added onto corticosteroids for the treatment of TA
Add on LOW-DOSE ASPIRIN
. Aspirin 75 mg daily ↓ visual loss and ischaemic strokes in TA pt
Septic Arthritis
RA patient taking prednisolone for 1 yr present with limited ROM and fever
Any acute monoarthritis is SA unless proven otherwise
Mgx
IV AB x 7 days (untill swelling subsides and blood cultures (-))
then oral AB x 4 weeks
1st line: Fluxocloxacillin 2g QDS
if Allergic to pen : Clindamycin
Vancomycin 2nd or 3rd gen( for MRSA)
G-bacili Gonococcal: cefotaxime or cefta
not responding to AB: repeat aspiration
two organisms: Gono and Staph tests. aspiration and blood cs fever pain and limited motion.
Thats Septic arthritis to remember
Drugs precipitating Gout
pt start left foot swelling and pain (cannot stand) 2 day after taking medications for ht failure
FACT+Niacin
F=Frusemide
A=Alcohol
C=Cytotoxic drug/cyclosporine
T=Thiazide (bendroflumethiazide)* (Indapamide)
Thiazide Diuretics : - Bendroflumethiazide - Chlorthalidone - Cyclopenthiazide - Indapamide - Metolazone - Xipamide
Adverse Effects of Thiazide diuretics:
Hyponatremia, Hypotension, Hypokalemia
Hyper GLUC
(hyperGlycemia, hyperLipidemia, hyperUricemia, hyperCalcemia)
Monoarthritis vs Morning stiffness
In case of Monoarthritis
1/Gout.
2)Pseudgout
Chronic recurrent arthritis(rhomboid-shaped calcium pyrophosphate dihydrate crystals are deposited in joints.)
These crystals show positive birefringence in polarized light.
The most commonly involved joint is the knee.
3)Septic arthritis.
Arthritis is any inflammatory condition of the joints which is characterised by pain, swelling, stiffness, reduced range of motion and deformity.
In case of Morning stiffness
1/RA
2/SLE
3/Ankylosing spondylitis
SLE (Lupus)
diagnosis of SLE- MD SOAP BRAIN M- malar rash D- discoid rash S- serositis (peri/LSacks-endo carditis/ pleuritits) O- oral ulcers A- arthralgia P- photosensitivity B- blood dyscrasias- normochromic normocyticanaemia R- resp-pleurisy, alveolitis// renal// raynauds A- ANA antibodies I- immunologic N-neurologic- depression, anxiety
Important must know features for the exam
Morning stiffness
**Fatigue and tiredness
***Polyarticular and Symmetrical Arthralgia - wrists and small joints of the hands
Remitting and relapsing illness
Mouth ulcers - Large, multiple and painful
Lymphadenopathy
Malar (butterfly) rash: spares nasolabial folds (50% of patient)
Discoid rash: scaly, erythematous, well demarcated rash in sun-exposed areas
Photosensitivity
Raynaud’s phenomenon - one fifth of patients but is often mild
Cardiovascular: pericarditis
Respiratory: pleurisy, fibrosing alveolitis
Renal: glomerulonephritis (nephritis asymptomatic detected by proteinuria, haematuria, hypertension or a raised serum U n C )
Neuropsychiatic: anxiety and depression
Investigation
FBC/ ESR
• Mild normochromic normocytic anaemia is common
• ESR↑
A111 o antibodies :
• **Antinuclear, antibody (ANA) - Screening test with a sensitivity of 95% but not diagnostic in the absence of clinical features. It is a nonspecific antibody that is also p1esent 111 many patients with systemic autoimmune conditions
• **Anti-dsDNA - Highly specific (> 99%), but less sensitive (70%)
• Anti-Smith - Highly specific (> 99%) but even less sensitive (30%-40%)
• Anti-histone - Drug-induced lupus ANA am bodies are often this type
Complement levels (C3, C4) are low during active disease (formation of complexes leads to consumption of complement)
PLABABLE tip for the exam: Pick ANA for: • Most sensitive test • Initial test • Best screening test Pick Anti-dsDNA for • Most specific test • Most discriminative test (usually, Anti-Smith antibody is not given as an option)
Positive ANCA (antineutrophil cytoplasmic antibodies) attack healthy neutrophil by mistake
It includes three main diseases
- Granulomatosis with Polyangiitis (GPA; formerly known as Wegener granulomatosis),
- Eosinophilic Granulomatosis with Polyangiitis (EGPA; previously known as Churg-Strauss syndrome),
- Microscopic polyangiitis (MPA)
Sjogren Syndrome (Previous RA patient develop dry eye )
Autoimmune disorder affecting exocrine glands
Female: Male (9:1)
Presentation:
● Enlargement of parotid and lacrimal glands
● Dry eyes - Sandy feeling under the eyes
● Dry mouth - Difficulty swallowing
● Associated with: RA, SLE and scleroderma
Investigations ● Schirmer’s test: Decreased tear production Rose Bengal Stain (corneal ulceration) ● Anti Ro and Anti La antibody + ****** ● RF + (38%) ● ANA + Management ● Artificial tears ● Plenty of water and artificial saliva
Gout
NSAID(naproxen)= causes RENAL insufficiency GASTRIC problems(gastritis) lung (aggravate ASTHMA)
if gastric problem only = NSAID+PPI
if renal or asthma= CORTICOSTERIODS
Risk factors: ● Diet: Meat and alcohol ● Tumour cell lysis (chemotherapy) ● Chronic kidney disease ● Diuretics
first metatarsal phalangeal joint
Diagnosis
Presence of MSU crystals in the synovial fluid
↑ Uric acid level in serum/urine (not definitive)
Treatment Acute: ● NSAIDs (naproxam) Low dose Aspirin- precipitate gout ● Colchicine ● Corticosteroids
Prevention:
● Allopurinol and febuxostat - decreased
formation of uric acid
Allopurinol → First line urate lowering agent
Febuxostat → Second-line urate lowering agent
Polymyalgia Rheumatica
Presentation
● Bilateral pain and morning stiffness of the
shoulder, neck and pelvic girdle
● Difficulty in getting out of bed, or raising the arm
to brush the hair
● Associated with GIANT CELL ARTHERITIS(50%)
● Mean age >50 yrs
Investigation
● ↑ ESR / CRP
● Normal creatine kinase
Treatment
● Steroids (oral prednisolone)
Differential Diagnosis
Myositis - weakness > pain + ↑CK
Polymyalgia - pain > weakness + normal CK
Plabable’s Tip
Remember the letter P
Polymyalgia = Pain (not weakness)
Muscles are tender with no true weakness!
How to differentiate Churg Strauss Versus Wegner ??
Both may present with
Hemoptysis , Hematuria and URT(Sinusitis and Polyps)
since both affect vessels of Respiratory system and kidneys.
But each has its specific Clinchers:
CS: Asthma , Eosinophilia , sinusitis , polyposis ,rhinitis.
Inv- CT-Ground Glass Attenuation
WG: Nasal bleeding , Nasal Crusting , Nassl septum perforation.
** I think what makes them feel typically the same is
Sinusitis, Polyps , Renal affection
Raynaud’s phenomenon
Raynaud = nifedipine (Quick onset CCB) SAH = nimodipine
Raynaud’s phenomenon is episodic vasospasm of
the arteries or arterioles in the extremities which
leads to colour change.
Fingers or toes which are exposed to cold usually
turn pale, followed by cyanosis and/or rubor.
Seronegative Spondyloarthropathies (SpA) Sero(-) = negative Rheumatoid Factor Arthritis of Axial Skeleton(Skull, hyoid bone, ribcage , Vertebral column, sacroiliac joint)
RAPE ReA (Reactive arthritis ) AS (Ankylosing spondylitis) PsA (Psoriatic arthritis) IBD (Inflammatory bowel disease) Enterohepatic
**Men*Ankylosing Spondylitis (joint and tendon insertion area inflammation and fusion)
Pt with chronic diarrhoea 1yr (aphthus ulcers/ perianal skin tags) / redness and painful eye / lower back pain/ stiffness wakes him up early morning / ESR< 30
A- ankylosing spondylosis, anterior uveitis , age<30 , Male:female 6:1 B- back pain C- crohn's disease D- diarrhoe (due to crohn's) E- ESR raised / CRP ↑
Most appropriate Inv - Xray sacroiliac joint for SACROILIATIS(earliest sign)
HLA-B27 associated ( 10% of HLA-B27 pt will develop AS)
Lower back pain / stiffness wakes him up in the morning
time to get out of bed > 30 min
Tenderness in SACROILIAC JOINT / limited range of spinal motion
Age < 30
Aortic Regurgitation
30-50% of Anterior Uveitis (painful red eye / severe photophobia)pt will develop AS
20-30% of AS will have Anterior Uveitis
AS is 10-20 times common in IBD
Chronic diarrhoea / apthous ulcers / perianal skin tags
Test - Schobers test - <20cm Blood Results CP- NNA ESR<30 Dx MRI- Vertebral syndesmophytes Sacroiliac joint Vertebra - Bamboo spine
Mgx
First line- NSAID / steroid injection
Second Line - Anti-TNF therapy
Supportive - Physio(exercise not rest
)
Female*Polymyositis(muscle destruction= CK↑ )
Vs Polymyalgia rheumatica(pain only no muscle loss= ESR or CEO↑)
POLYMYOSITIS:
- -immune-mediated striated muscle inflammation
- -common in females –50-70 years age
–c/p: symmetric proximal muscle weakness;
advanced case: dyspnea, dysphagia
–associated with breast/ lung CA
–inv: high CK ********
positive anti Jo-1 antibodies
–t/t: steroids
POLYMYALGIA RHEUMATICA: --inflammatory --common in females --age: >50 --c/p: pain + stiffness of shoulders & pelvic muscles; difficult to get out of chair; difficult to lift arms above head; fever, weight loss --associated with Temporal Arteritis
–inv: high ESR >30 mm/hr ******
CRP>6 mg/ml****
; anemia
–t/t: steroids
