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Year 6 Medicine > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

What are the red flags for back pain?

A 
age <20 or >55
sphincter disturbance
current or recent infection
history of malignancy
morning stiffness
constant or progressive pain
neurological disturbance 
bilateral or alternating leg pain
FLAWS
thoracic back pain
acute onset in elderly people 
nocturnal pain
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2
Q

what does a nerve root lesion at L2 cause?

A

weakness in hip flexion and adduction

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3
Q

what does a nerve root lesion at L3 cause?

A

weakness in knee extension and hip adduction

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4
Q

what does a nerve root lesion at L4 cause?

A

weakness in foot dorsiflexion + inversion + knee extension

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5
Q

what does a nerve root lesion at L5 cause?

A 
weakness in:
great toe dorsiflexion
foot dorsiflexion + inversion
knee flexion
hip extension + abduction
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6
Q

what does a nerve root lesion at S1 cause?

A

weakness in foot plantar flexion + eversion

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7
Q

nerve roots of knee jerk reflex?

A

L3,L4

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8
Q

nerve roots of ankle jerk reflex?

A

S1,S2

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9
Q

Ix lower back pain?

A

MRI only if suspected malignancy, infection, fracture, CES or ank spond
DRE

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10
Q

Mx lower back pain?

A

c: physical activity and exercise
M: NSAIDS + PPI if >45
Other: group exercise programme
manual therapy (techniques such as massage)
radio frequency denervation
epidural injections of Land steroid for acute/severe sciatica

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11
Q

what is rheumatoid arthritis?

A

chronic systemic inflammatory condition characterised by a symmetrical defaming poly arthritis

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12
Q

epidemiology RA?

A

F>M (2:1), 50-60yo, 1% prevalence (higher in smokers)

HLA DR1, DR4

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13
Q

what are some poor prognostic indicators of rheumatoid arthritis?

A 
\+ve RhF
insidious onset
early erosions
HLA DR4
\+ve anti-CCP
extra-articular features
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14
Q

S/S rheumatoid arthritis?

A

swollen, painful small joints in hands and feet
ulna deviation of MCP and radial deviation at wrist
stiffness better with exercise/worse in morn
swan neck, boutonniere, z-thumb

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15
Q

associated features rheumatoid arthritis?

A

eyes - episcleritis, keratoconjunctivitis sicca
neck - Atlanta-axial subluxation (may cause cord compression)
heart -pericarditis
lungs - fibrosis, rheumatoid nodules
hands - de quervains tenosynovitis, CTS, trigger finger
speen -splenomegaly, felty’s syndrome
kidneys - amyloid
all - rheumatoid nodules

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16
Q

what is Felty’s syndrome?

A 
SANTA
Splenomegaly
anaemia
neutropenia
thrombocytopenia
arthritis
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17
Q

Diagnostic criteria for rheumatoid arthritis?

A

American College of Rheumatology Criteria

NICE recommend clinical diagnosis

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18
Q

ix rheumatoid arthritis?

A
  • DAS28 [disease activity score]
  • squeeze test positive (pain across MCPJ or MTPJ)
    Bloods: FBC (anaemia, raised ESR, CRP), RhF (+ve 70%), anti-CCP (90-95% specific, 80% sensitive), ANA(+ve in 30%)
    TJC/SJC
    Imaging: XR (baseline), USS (synovitis), MRI, CXR
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19
Q

what are TJC and SJC

A

tender joint count and swollen joint count (part of DAS28)

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20
Q

What should be monitored in rheumatoid arthritis?

A

DAS28, CRP

if DAS28 >5.1 consider stepping up Mx

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21
Q

Mx rheumatoid arthritis?

A

1st line: conventional DMARD
2nd line: combination cDMARD therapy (2x)
3rd line: biological DMARD + cDAMRD
Surgery: ulna stylectomy, joint prosthesis
Flare ups: corticosteroids (PO, IM methylprednisolone)+/-NSAIDs

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22
Q

Give some examples of cDMARDs?

A 
methotrexate
sulfasalazine
hydroxychloroquine
MMF
cyclophosphamide
azathioprine
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23
Q

Give some examples of bDMARDs?

A 
(TNF-a inhibitors, B cell/T depletion)
EtanercepT (SE demyelination)
Infliximab
Adalimumab
Rituximab
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24
Q

How are methotrexate, sulfasalazine and hydroxychloroquine monitored?

A

M- regular FBC and LFT (risk of myelosuppression and cirrhosis)
S - salicylate so not given if aspirin sensitive
H - annual visual acuity testing. OK IN PREGNANCY.

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25
Q

what joints does OA affect?

A

weight bearing: hip and knee

hands: CMCJ, DIPJ, PIPJ

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26
Q

What joints does RA affect?

A

MCPJ, PIPJ

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27
Q

What is swan neck deformity?

A

stretching of the volar plate
PIPJ hyperextension
DIPJ flexion

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28
Q

what is seen on XR in OA?

A 
LOSS
loss of joint space
osteophytes
subchondral cysts
subchondral sclerosis
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29
Q

what is seen on XR in rheumatoid?

A 
LESS
loss of joint space
erosions (periarticular)
soft tissue swelling
subluxation and deformity
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30
Q

aetiology of gout?

A

monosodium urate crystals deposition in and around joints -> erosive arthritis

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31
Q

epidemiology of gout?

A

M>F 5:1

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32
Q

gout associations?

A

HTN
IHD
Metabolic syndrome

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33
Q

Causes of gout?

A

hereditary
drugs (loop diuretics, thiazide diuretics,aspirin,)
decreased excretion (primary gout, renal impairment)
increased cell turnover (lymphoma, leukaemia, haemolysis
ETOH XS
Purine rich foods

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34
Q

S/s gout?

A 
mono arthritis with severe joint inflammation (ankle, foot, hand, wrist elbow)
60% get podagra
trophy 
radiolucent kidney stones 
interstitial nephritis
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35
Q

Ix gout?

A 
polarised light microscopy (-ve birefringent needle shaped crystals)
XR (late; para-articular punched out erosions, reduced joint space)
serum urate (increased OR normal)
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36
Q

Acute Mx gout?

A

Acute:
1st line = colchicine, NSAIDs (not aspirin) +/- PPI
renal impairment = PO steroids (prednisolone 15mg /d)
intraarticular steroid injection

follow up in 4-6w and check BP, HbA1c, serum urate, U&E and lipids -> consider urate lowering therapy

  • do not stop allopurinol if already established
  • do not stop aspirin 75 if for cardioprotective
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37
Q

Chronic mx for gout?

A

conservative: WL, avoid ETOH XS, avoid prolonged fasting
urate lowering therapy: started after inflammation stopped
- XO inhibitors: 1. allopurinol, 2. febuxostat
- uricosuric drugs: probenecid, losartan
- recombinant urate oxidase: rasbicurase

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38
Q

what are the S/S of pseudo gout?

A

mono arthritis (knee, wrist, hip - BIGGER JOINTS)

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39
Q

RFs for pseudo gout?

A 
increased age
OA
DM
hypothyroidism
hyperparathyroidism
hereditary haemochromatosis
Wilsons
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40
Q

Ix pseudo gout?

A

polarised light microscopy (+ve birefringent, rhomboid shaped crystals)
XR chondrocalcinosis

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41
Q

Mx pseudo gout?

A

analgesia
NSAIDs
PO/IM/intra-articular steroids

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42
Q

what are seronegative spondyloarthropathies?

A

a group of inflammatory arthritidies affecting the spine and peripheral joints with no production of rheumatoid factors and associated with HLA-B27 allele

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43
Q

Give some examples of seronegative spondyloarthropathies?

A 
PEAR HEADS
Psoriatic arthritis
Enteropathic arthritis
Ankylosing spondylitis
Reactive arthritis
HLA B27 allele
Enthesitis
Axial, asymmetrical, oligoarthritis
Dactylitis
Seronegative
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44
Q

what is the key difference between ankylosing spondylitis and psoriatic arthritis?

A

lack of hand S/S in AS

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45
Q

What are the S/S of ankylosing spondylitis?

A 
back pain relieved by exercise
anterior chest pain (costochondritis)
SOB (pulmonary fibrosis)
morning stiffness
eye pain
osteoporosis (60%)
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46
Q

epidemiology of ankylosing spondylitis?

A

M>F (6:1); 18-25

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47
Q

Ank Spond associated features?

A 
AAAAAA
anterior uveitis
apical lung fibrosis
aortic regurgitation
AV node block
achilles tenoditis
amyloidosis
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48
Q

Ankylosing spondylitis investigations?

A 
Graded by New York Criteria
Schobers test (<5cm increase = positive)
1st: XR (late changes)
2nd: MRI (if XR normal as more sensitive)
HLA-B27 testing
ESR +/- CRP
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49
Q

what is seen on XR/MRI of ankylosing spondylitis?

A

sacroilitis > vertebrae (corner erosions, syndesmophytes)
scerlosis
ankylosis (fusion)
bamboo sign (squaring of lumbar vertebrae)
dagger sign (supraspinatus ossification)

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50
Q

what is the management of ankylosing spondylitis?

A

conservative: exercise/physiotherapy
medical: NSAID, anti-TNFa (etanercept), secukinumab
surgical: hip replacement to decrease pain and increase mobility

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51
Q

what % of those with psoriatic arthritis are affectedly psoriasis?

A

10-40%

40-60yo

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52
Q

S/S of psoriatic arthritis?

A 
psoriasis
nail (posh = pitting, onycholysis, sublingual hyperkeratosis)
enthesitis
dactylitis
arthritis
affects DIP
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53
Q

what is oligoarthritis ?

A

<= 4 joints

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54
Q

what arthritic features are seen in psoriatic arthritis?

A 
asymmetrical hligoarthritis (20-30%)
distal arthritis of the DIPJ
symmetrical poly arthritis (30-40%, RA but w DIPJ)
arthritis mutilans 
spinal (50%)
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55
Q

what is the investigations for psoriatic arthritis?

A

XR: pencil in cup deformity

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56
Q

Mx psoriatic arthritis?

A 
NSAIDs
methotrexate
ciclosporin
sulfasalazine
anti-TNF
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57
Q

what is reactive arthritis/reiters?

A

sterile arthritis 1-4w after urethritis or dystentery

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58
Q

what causes urethritis?

A

chlamydia, ureaplasma (not gonorrhoea)

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59
Q

what causes dysentery?

A

campylobacter, salmonella, shigella, yersinia

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60
Q

what are the S/S of reactive arthritis?

A

cant see, pee or climb a tree

  • lower limb oligarthritis
  • conjunctivitis/uveitis
  • urethritis
keratoderma blenorrhagicum (plaques on soles/palms)
circinate balanitis (penile ulceration)
enthesitis, mouth ulcers
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61
Q

Ix reactive arthritis?

A

raised ESR
raised crp
stool culture if diarrhoea, urine chlamydia PCR

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62
Q

Mx reactive arthritis?

A

NSAIDs, PO steroids

relapsing -> sulfasalazine

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63
Q

what is enteropathic arthritis?

A

arthritis occurs in 15% of those with UC or Crohn’s

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64
Q

S/S of enteropathic arthritis?

A

asymmetrical lower limb oligoarthritis, sacroilitis

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65
Q

Mx enteropathic arthritis?

A

treat IBD
nsaids
local steroids

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66
Q

what are some autoimmune CTDs?

A 
SLE
Sjogrens
Mixed CTD
systemic sclerosis
myositis
relapsing polychondritis
Behcets
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67
Q

Which conditions are anti rheumatoid factor +ve?

A

sjogrens (50%)
feltys (100%)
RhA (70%)
SLE (20%)

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68
Q

Which conditions are ANA +ve?

A

SLE (99%)
autoimmune hepatitis (75%)
sjogrens (70%)
RhA (30%)

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69
Q

Which conditions are anti dsDNA +ve?

A

SLE (70%)

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70
Q

Which conditions are anti CCP +ve?

A

RhA (80%)

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71
Q

Which conditions are anti histone +ve?

A

drug induced SLE (100%)

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72
Q

which conditions are anti centromere +ve?

A

CREST (limited sclerosis)

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73
Q

which conditions are ENA +ve?

A 
SLE
sjogrens
MCTD
polymyositis
CREST
diffuse systemic sclerosis
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74
Q

which conditions are anti-Ro?

A

SLE, sjogrens (70%), heart block

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75
Q

which conditions are anti-La?

A

SLE

sjogrens (30%)

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76
Q

which conditions are anti-smith?

A

SLE (30%)

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77
Q

which conditions are anti-RNP ?

A

SLE

MCTD

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78
Q

which conditions are anti-jO-1?

A

polymyositis>dematomyositis

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79
Q

which conditions are anti Mi-2?

A

dermatomyositis > polymyositis

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80
Q

which conditions are anti SCL70/topoisomerase?

A

diffuse systemic sclerosis

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81
Q

which conditions are anti RNA pol 1,2,3?

A

diffuse systemic sclerosis

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82
Q

what are the indications for 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

(allopurinol 1st line)

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83
Q

what is atlantoaxial subluxation and how is it screened for?

A

rare complication of rheumatoid arthritis
Anteroposterior and lateral cervical spine radiographs preoperatively screen for this complication
ensuring the patient goes to surgery in a C-spine collar and the neck is not hyperextended on intubation.

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84
Q

What is hyperparathyroidism a risk factor for?

A

development of calcium pyrophosphate dihydrate deposition (CPPD) or pseudogout
chonedrocalcinosis

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85
Q

What is Antisynthetase syndrome?

A

Antisynthetase syndrome is caused by autoantibodies against aminoacyl-tRNA synthetase e.g. anti-Jo1.

It is characterised by

  • myositis
  • interstitial lung disease
  • thickened and cracked skin of the hands (mechanic’s hands)
  • Raynaud’s phenomenon
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86
Q

what is temporal arteritis?

A

Temporal arteritis is large vessel vasculitis which overlaps with polymyalgia rheumatica (PMR) (50%)

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87
Q

what is seen on histology of temporal arteritis?

A

Histology shows changes that characteristically ‘skips’ certain sections of the affected artery whilst damaging others.

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88
Q

what are the features of temporal arteritis?

A

typically patient > 60 years old
usually rapid onset (e.g. < 1 month)
headache (found in 85%)
jaw claudication (65%)
visual disturbances:
- amaurosis fugax
- blurring
- double vision
- vision testing is a key investigation in patients with suspected temporal arteritis
- secondary to anterior ischemic optic neuropathy
tender, palpable temporal artery
around 50% have features of PMR: aching, morning stiffness in proximal limb muscles (not weakness)
also lethargy, depression, low-grade fever, anorexia, night sweats

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89
Q

ix temporal arteritis?

A

raised inflammatory markers
ESR > 50 mm/hr (note ESR < 30 in 10% of patients)
CRP may also be elevated, alp raised, plts raised
USS temporal artery (halo sign, if -ve do biopsy)
temporal artery biopsy
skip lesions may be present
note creatine kinase and EMG normal

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90
Q

Mx temporal arteritis?

A
  • urgent high-dose glucocorticoids should be given as soon as the diagnosis is suspected and before the temporal artery biopsy (40-60mg prednisolone) -> PPI AND alendronate for 2y
  • no visual loss: high-dose prednisolone is used
  • evolving visual loss: IV methylprednisolone is usually given prior to starting high-dose prednisolone
  • urgent ophthalmology review same day, visual damage is often irreversible

other treatments:
bone protection with bisphosphonates is required as long, tapering course of steroids is required
low-dose aspirin is sometimes given to patients as well, although the evidence base supporting this is weak

91
Q

What are the 3 patterns of disease for systemic sclerosis?

A
  1. limited cutaneous systemic sclerosis
  2. diffuse cutaneous systemic sclerosis
  3. scleroderma
92
Q

Which antibodies are present in systemic sclerosis?

A

ANA positive in 90%
RF positive in 30%
anti-scl-70 antibodies associated with diffuse cutaneous systemic sclerosis
anti-centromere antibodies associated with limited cutaneous systemic sclerosis

93
Q

Where does limited cutaneous systemic sclerosis affect?

A

face and distal limbs predominately

94
Q

where does diffuse cutaneous systemic sclerosis affect?

A

trunk and proximal limbs predominately

95
Q

What are the adverse effects of methotrexate?

A 
mucositis
myelosuppression
pneumonitis
pulmonary fibrosis
liver fibrosis
96
Q

what should be monitored whilst on methotrexate?

A

FBC, U&E and LFTs need to be regularly monitored.
‘FBC and renal and LFTs before starting treatment and repeated weekly until therapy stabilised, thereafter patients should be monitored every 2-3 months’

97
Q

What should be co-prescribed with methotrexate

A

folic acid 5mg once weekly should be co-prescribed, taken more than 24 hours after methotrexate dose

98
Q

What is antiphospholipid syndrome?

A

Antiphospholipid syndrome is an acquired disorder characterised by a predisposition to both venous and arterial thromboses, recurrent fetal loss and thrombocytopenia

99
Q

What does antiphospholipid commonly occur secondary to

A

SLE

also:
other autoimmune disorders
lymphoproliferative disorders
phenothiazines (rare)

100
Q

features of antiphospholipid?

A 
venous/arterial thrombosis
recurrent fetal loss
livedo reticularis
thrombocytopenia
prolonged APTT
other features: pre-eclampsia, pulmonary hypertension
101
Q

Mx antiphospholipid?

A

primary thromboprophylaxis - low dose aspirin
secondary -
- initial venous thromboembolic events: lifelong warfarin with a target INR of 2-3
- recurrent venous thromboembolic events: lifelong warfarin; if occurred whilst taking warfarin then consider adding low-dose aspirin, increase target INR to 3-4
- arterial thrombosis should be treated with lifelong warfarin with target INR 2-3

102
Q

which autoantibody is most linked to sjogrens

103
Q

What is behcets?

A

rare and poorly understood inflammatory condition that mostly occurs in Turkish, Mediterranean and Japanese

104
Q

what are the S/S of behcets?

A

recurrent oral and or genital ulceration
uveitis
erythema nodosum
VTE

105
Q

Ix behcets?

A

skin pathergy test (pinprick - papule formation)

106
Q

Mx behcets?

A

immunosuppression

107
Q

Epidemiology sjogrens?

A

F>M 9:1 (40-50yo)

108
Q

Types of sjogrens?

A

primary: associated with AI (thyroid, AIH, PBC), MALT lymphoma
secondary: secondary to RhA, SLE, systemic sclerosis

109
Q

S/S sjogrens?

A 
decreased tear production and dry eyes
bilateral parotid swelling 
decreased salivation (xerostomia)
vaginal dryness (dyspareunia)
systemic: polyarthritis, raynaud's, bibasal pulmonary fibrosis, vasculitis, myositis
sensory polyneuropathy
110
Q

Ix sjogrens?

A

bloods: abs (anti-ro [70%], anti La [30%], RhF [50%], hypergammaglobulinaemia
special: schirmers test, parotid biopsy

111
Q

Mx Sjogrens?

A

artificial tears, saliva replacement
NSAIDS,hydroxychloroquine, immunosuppression

N.B. Abs may cause heart block in baby ->need O&G input

112
Q

Epidemiology SLE?

A

0.2% 9:1 F, child bearing age, afro-carribean, asian

113
Q

S/S SLE?

A 
SOAP BRAIN MD
serositis
oral ulcers, hair loss
arthritis 
photosensitivity
blood (all counts low)
renal (proteinuria, haematuria)
ANA (>95%)
Immunological (anti-dsDNA, AIHA)
neurological (psych, seizures)

malar rash
discoid rash

pulmonary involvement is very common with pleuritic being the most frequent manifestation

114
Q

What are the causes of drug induced lupus?

A 
Hydralazine PIMP
Hydralazine
Procainamide
Isoniazid
Minocycline
Phenytoin
115
Q

S/S of drug induced lupus?

A

arthralgia, myalgia, recent serositis

116
Q

Ix drug induced lupus?

A

anti histone Abs (100%)

117
Q

Classification of APLS?

A

1st (70%)

2nd to SLE (30%)

118
Q

Which antibodies are present in APLS?

A

anti-cardioliptin

lupus anticoagulant

119
Q

S/S of APLS?

A 
CLOTS
Coagulation (venous and arterial thromboembolism; INCREASED APTT)
Livedo reticularis (web like rash)
Obstetric complications
Thrombocytopenia
120
Q

Management of APLS?

A

No prev VTE -> OD low dose aspirin

prev VTE -> OD warfarin

121
Q

Investigations SLE/APLS?

A 
Antibodies:
ANA (99% sensitive, poorly specific)
Anti-dsDNA (99% specific, 70% sensitive)
Anti-smith (99% specific, 70% sensitive)
RF (20% sensitive)

Disease activity monitoring:
Anti-dsDNA titres
C4 reduction (Mod active lupus), C3 reduction (very active lupus)
ESR levels

122
Q

Management of SLE?

A

SEVERE FLARE - prednisolone + IV cyclophosphamide
proteinuria -> ACEi
aggressive lupus nephritis -> immunosuppression

Maintenance:
hydroxychloroquine +/- DMARDs (MMF, azathioprine) +/- low dose steroids
severe disease: biologicals (belimumb, rituximab)
sun protection: sun cream, low dose steroids

123
Q

what is mixed connective tissue disease?

A

SLE, scleroderma, polymyositis, RhA

Ix: anti-RNP

124
Q

what is relapsing polychondritis?

A

an inflammatory disease of the cartilage (tenderness, inflammation and destruction of cartilage)

125
Q

what are the associations with relapsing polychondritis?

A

aortic valve disease
polyarthritis
vasculitis

126
Q

S/S relapsing polychondritis?

A

floppy ears
saddle nose
larynx (stridor)

127
Q

Mx relapsing polychondritis?

A

immunosuppression

128
Q

Aetiology raynaud’s phenomenon?

A

peripheral digit ischaemia precipitated by cold or emotion

129
Q

Classification of raynauds?

A

primary: idiopathic, Raynaud’s disease
secondary: Raynaud’s syndrome
- rheumatological (systemic sclerosis, SLE, RhA, sjogrens)
- haematological (thrombocytosis, pv)
- drugs (COCP, non cardio selective beta blockers)
- congenital (cervical rib -> thoracic outflow syndrome)

130
Q

S/S raynauds?

A

digit pain, triphasic colour change, digital ulceration and gangrene

131
Q

Mx raynauds?

A

gloves/avoid cold
CCB (nifedipine)
PDE V inhibitor (sildenafil)
IV prostacyclin

132
Q

what are the types of systemic sclerosis

A
  1. Limited systemic sclerosis (crest = 70%)

2. diffuse systemic sclerosis (30%)

133
Q

What is CREST?

A 
Calcinosis
Raynaud's
Oesophageal dysmotility
Sclerodactyly
Telangiectasia
Skin involvement (beak nose, microstomia, pul HTN)
 limited to face, hands, feet
134
Q

what is diffuse systemic sclerosis?

A

diffuse skin involvement extends past the wrists and up the arms

135
Q

What are the features of diffuse systemic sclerosis?

A

organ fibrosis
GI: GOR, aspiration, dysphagia, anal incontinence
lung 80%: fibrosis, pul HTN
cardiac: arrhythmias, conduction defects
renal: acute HTN crisis (most common cause of death)

136
Q

Ix Systemic sclerosis?

A

bedside: urine dip, PCR
bloods: FBC, U&Es, abs
limited CREST -> anti-centromere
diffuse -> anti-SCL70, anti RNA polymerase 1,2,3
imaging:
CXR - cardiomegaly, bibasal fibrosis
Hands - calcinosis
Ba swallow - impaired oesophageal motility
HRCT - fibrosis
Echo - fibrosis
ECG - pulmonary HTN, conduction blocks, arrhythmias

137
Q

Mx systemic sclerosis?

A

Conservative: exercise, skin lubricants, hand warmers
M: immunosuppression
Renal crisis - intensive BP control (ACEi)
oesophageal - PPI, pro kinetics
PHT: sildenafil, bosentan

138
Q

what is polymyositis?

A

striated muscle inflammation

139
Q

S/S myositis?

A

progressive symmetrical proximal muscle weakness (associated myalgia and arthralgia)
wasting of shoulder and pelvic girlde
dysphagia, dysphonia, respiratory weakness
malignancy- paraneoplastic phenomenon (lung, pancreas, ovarian, bowel)

140
Q

what are the features of dermatomyositis?

A

myositis + skin signs

  • periorbital heliotrope rash on eyelids +/- oedema
  • Gottron’s papules on knuckles, elbows, knees
  • mechanics hands
  • macular rash (shawl sign +ve: over back and shoulders)
  • nail fold erythema
  • retinopathy (haemorrhages and cotton wool spots)
  • subcutaneous calcifications
141
Q

What are the extra articular features of dermatomyositis?

A 
fever
arthritis
basal pulmonary fibrosis
raynaud's phenomenon
myocardial involvement: myocarditis, arrhythmias
142
Q

Ix myositis?

A

EMG
Muscle enzymes: Raised CK (in 1000s), raised AST, ALT and LDH
Antibodies: anti-Jo1, Anti-Mi2 [DM>PM], Anti-SRP [PM]
Malignancy screen (tumour markers, CXR, mammogram, USS, CT)

143
Q

Mx myositis?

A

Screen for malignancy

immunosuppression (steroids, cytotoxic agents: azathioprine, methotrexate)

144
Q

which criteria are used to classify vasculitides?

A

Chapel hill criteria

145
Q

Give some large vessel vasculitis?

A

GCA/temporal arteritis

Takayasu arteritis

146
Q

Give some medium vessel vasculitis?

A

Polyarteritis nodosa

Kawasaki disease

147
Q

Give some small vessel vasculitis?

A

p-ANCA: Churg-Strauss (eGPA), microscopic polyangitis
cANCA: Wegener’s granulomatosia (GPA)
ANCA -ve: HSP, good pasture’s, cryoglobulinaemia

148
Q

epidemiology of PMR?

A

> 50yo, association to GCA

149
Q

Which arteries are affected in polymyalgia rheumatica?

A

temporal
maxillary
ophthalmic
central retinal

150
Q

what are the S/S of pMR?

A

pain/stiffness in shoulder, neck and hips (no weakness)

polyarthritis, tenosynovitis, CTS

151
Q

Ix PMR?

A

raised ESR, CRP, ALP, normal CK

152
Q

Mx PMR?

A

15 mg PO prednisolone

taper down to 5 mg + PPI + alendronate

153
Q

What is the epidemiology of takayasu arteritis?

A

Japanese/asian females

20-40yo (granulomatous vasculitis similar to GPA/eGPA)

154
Q

S/S Takayasu arteritis?

A 
weak/unequal upper limb pulses
HTN
Large vessel blockage - COMMONLY AORTA (HF, CRF)
Intermittent limb claudication
AR (20%)
155
Q

mx takayasu?

A

corticosteroids

156
Q

Epidemiology polyarteritis nodosa?

A

young male adults (not common in UK)

157
Q

s/s polyarteritis nodosa?

A 
systemic symptoms
skin (rash)
GIT (melaena, abdo pain)
renal (HTN)
liver dysfunction (HBV)
158
Q

Ix polyarteritis nodosa?

A

HBV serology, rosary bead sign on renal angiogram

159
Q

Mx polyarteritis nodosa?

A

prednisolone and cyclophosphamide

160
Q

Epidemiology Kawasaki?

A

6m-5yo, 8/100000, Japanese and Black Caribbean ethnicity

161
Q

S/S kawasaki?

A 
CRASH and BURN
Conjunctivitis
Rash
Adenopathy
Strawberry tongue
Hands/feet swollen
Fever >5 days
162
Q

Ix Kawasaki disease?

A

clinical (echocardiogram done in OPD)

163
Q

Mx Kawasaki?

A

IVIG and high dose aspirin

164
Q

What are some ANCA +ve conditions?

A

GPA/wegeners
eGPA (Churg-Strauss)
Microscopic polyangitis

165
Q

what are some ANCA negative conditions?

A

HSP
Goodpastures
Cryoglobulinaemia

166
Q

what are the S/S of wegeners/GPA?

A

URT - rhinitis, epistaxis, saddle nose
LRT - haemoptysis, cough
Renal - rapidly progressive glomerulonephritis (RPGN), nephritic syndrome

167
Q

what are the Ix for GPA?

A

cANCA (pr3)
dipstick (p+, h+)
CXR (nodules)

168
Q

what is eGPA/Churg Strauss?

A

rare disease occurs in atopic individuals

169
Q

What are the S/S of eGPA?

A

eosinophilia
asthma (late onset)
vasculitis (incl. RPGN)

170
Q

What are the Ix for eGPA?

A

pANCA (MPO n.b. also +ve in UC/TB)

171
Q

What are the S/S of microscopic polyangitis?

A

RPGN
palpable purpura
haemoptysis

172
Q

Ix for microscopic polyangitis?

A

pANCA (MPO)

173
Q

What are the features of HSP?

A

Most common childhood vasculitis

often preceded by URTI (2-3 days)

174
Q

S/S HSP?

A 
purpuric rash (urticarial, maculopapular, spares trunk)
arthralgia (and periarticular oedema, large joints)
Abdominal pain (haematemesis, melena, intussusception)
Glomerulonephritis (micro/macroscopic haematuria, nephrotic syndrome (rare))
175
Q

Ix hsp?

A

Urinalysis (RBCs, protein, casts)

FBC, clotting screen, U&E,

176
Q

Mx HSP?

A 
follow up (weekly for 1m, 2 weekly for 2m, 3m, 6m, 12m)
BP measurements 
Urine dip (haematuria)
Most cases will resolve spontaneously within 4 weeks
177
Q

what is good pastures?

178
Q

What are the S/S of good pastures?

A

RPGN

haemoptysis

179
Q

what are the investigations for good pastures?

A

Anti-gbm antibody

CXR (bilateral lower zone infiltrates)

180
Q

Mx goodpastures?

A

immunosuppression + plasmapheresis

181
Q

What is simple cryoglobulinaemia?

A 
Monoclonal IgM -hyperviscosity:
visual disturbances
bleeding from mucous membranes
thrombosis
headaches and seizures
182
Q

What is mixed cryoglobulinaemia?

A 
Polyclonal IgM - immune complex mediated disease
GN
palpable purpura
arthralgia
peripheral neuropathy
183
Q

aetiology of simple cryoglobulinaemia?

A

20%

secondary to: myeloma, CLL, Waldenstroms macroglobulinaemia

184
Q

aetiology of mixed cryoglobulinaemia?

A 
80%
secondary to SLE
sjogrens
HCV
mycoplasma
185
Q

epidemiology of fibromyalgia?

A

10% of new rheumatology referrals

F>M (10:1)

186
Q

RFs fibromyalgia?

A 
neurosis (depression, anxiety, stress)
work dissatisfaction
overprotective family/lack of support
middle age
low income
divorced 
low educational status
187
Q

Associations fibromyalgia?

A

chronic fatigue syndrome
IBS
chronic headache syndrome

188
Q

S/S fibromyalgia?

A 
chronic widespread musculoskeletal pain and tenderness
fatigue
sleep disturbance
morning stiffness
poor concentration 
low mood
189
Q

Ix fibromyalgia

A

all normal

190
Q

Mx fibromyalgia?

A

educate
CBT
graded exercise programmes
amitriptyline, pregabalin, venlafaxine

191
Q

Management of chronic pain?

A

all diabetics get peripheral neuropathy

Amitriptyline Duloxetine Gabapentin Pregabalin

192
Q

1st line for neuropathic pain?

A

amitriptyline, pregabalin

193
Q

1st line for diabetic neuropathy?

A

duloxetine

tramadol as rescue therapy

194
Q

1st line for trigeminal neuralgia?

A

carbamazepine

195
Q

Epidemiology still’s disease?

A

15-25yo, 35-45 yo

196
Q

S/S stills disease?

A

Arthralgia
Salmon pink rash (maculopapular)
Pyrexia (rises in late evening in daily pattern alongside arthralgia)

197
Q

Investigations Stills disease?

A

RhF, ANA -ve
Raised ferritin
Yamaguchi criteria (sensitivity of 93.5%)

198
Q

Management of Still’s disease?

A

1st line: NSAIDs (for fever, joint pain, serositis)
2nd line: after 1 week of NSAIDs + steroids
3rd line: methotrexate, IL-1, anti-TNF

199
Q

Epidemiology of pagets?

A

Paget’s disease is common (UK prevalence 5%) but symptomatic in only 1 in 20 patients.

200
Q

which bones are affected in Paget’s?

A

The skull, spine/pelvis, and long bones of the lower extremities

201
Q

Paget’s RF?

A

increasing age
male sex
northern latitude
family history

202
Q

Clinical features of Paget’s?

A 
only 5% of patients are symptomatic
the stereotypical presentation is an older male with bone pain and an isolated raised ALP
bone pain (e.g. pelvis, lumbar spine, femur)
classical, untreated features: bowing of tibia, bossing of skull
203
Q

Ix pagets?

A

bloods:
raised alkaline phosphatase (ALP)
calcium and phosphate are typically normal. Hypercalcaemia may occasionally occur with prolonged immobilisation

other markers of bone turnover include:
procollagen type I N-terminal propeptide (PINP)
serum C-telopeptide (CTx)
urinary N-telopeptide (NTx)
urinary hydroxyproline

x-rays:
osteolysis in early disease → mixed lytic/sclerotic lesions later
skull x-ray: thickened vault, osteoporosis circumscripta

bone scintigraphy:
increased uptake is seen focally at the sites of active bone lesions

204
Q

Management of paget’s?

A 
indications for treatment include:
bone pain
skull or long bone deformity
fracture
periarticular Paget's

bisphosphonate (either oral risedronate or IV zoledronate)
calcitonin is less commonly used now

205
Q

Complications of Paget’s?

A 
deafness (cranial nerve entrapment)
bone sarcoma (1% if affected for > 10 years)
fractures
skull thickening
high-output cardiac failure
206
Q

What is Marfan’s and what is it caused by?

A

Marfan’s syndrome is an autosomal dominant connective tissue disorder
defect in the FBN1 gene on chromosome 15 that codes for the protein fibrillin-1

207
Q

What are the features of Marfan’s?

A

tall stature with arm span to height ratio > 1.05
high-arched palate
arachnodactyly
pectus excavatum
pes planus
scoliosis of > 20 degrees
heart: dilation of the aortic sinuses (seen in 90%) which may lead to aortic aneurysm, aortic dissection, aortic regurgitation, mitral valve prolapse (75%),
lungs: repeated pneumothoraces
eyes: upwards lens dislocation (superotemporal ectopia lentis), blue sclera, myopia
dural ectasia (ballooning of the dural sac at the lumbosacral level)

208
Q

leading causes of death in marfan’s?

A

aortic dissection

209
Q

Mx Marfan’s?

A

regular echocardiography monitoring and beta-blocker/ACE-inhibitor therapy

210
Q

Blood results in osteogenesis imperfect?

A

Adjusted calcium, PTH, ALP and PO4 results are usually NORMAL in osteogenesis imperfecta

211
Q

Features of osteogenesis imperfecta?

A 
presents in childhood
fractures following minor trauma
blue sclera
deafness secondary to otosclerosis
dental imperfections are common
212
Q

What is the management for secondary prevention for osteoporotic fractures in post menopausal women?

A

start a bisphosphonate before waiting for a DEXA

  • vitamin D and calcium supplementation should be offered to all women unless the clinician is confident they have adequate calcium intake and are vitamin D replete
  • alendronate is first-line
  • around 25% of patients cannot tolerate alendronate, usually due to upper gastrointestinal problems. These patients should be offered risedronate or etidronate
  • strontium ranelate and raloxifene are recommended if patients cannot tolerate bisphosphonates
213
Q

Interpretation of DEXA?

A 
T = no of SDs away from youthful average
Z = no of SDs away from age matched average

T>-1 = normal
T-1 - -2.5 = osteopenia
T

214
Q

what is ANA antibody seen in?

A

(SSSA)

systemic lupus erythematous (SLE)
systemic sclerosis
autoimmune hepatitis
Sjogren’s syndrome

215
Q

What is AMA antibody raised in?

A

primary biliary cholangitis
autoimmune hepatitis
idiopathic cirrhosis

216
Q

What is anti-GBM seen in?

A

Good pastures

217
Q

What is pANCA seen in?

A

eosinophilic granulomatosis with polyangiitis
microscopic polyangiitis
Goodpasture’s disease.

218
Q

Features of rheumatoid arthritis?

A 
LESS
Loss of joint space
Erosions
Subchondral Cysts
Subchondral sclerosis

ie erosions differentiate from rheumatoid

219
Q

What is HLA-B27 associated with?

A

Reactive arthritis
Ankylosing spondylitis
seronegative spondyloarthropathies

220
Q

What HLA is behcets associated with?

221
Q

What is HLA-DQ2 associated with?

222
Q

what is HLA-DR3 associated with?

A 
Addison's disease
systemic lupus erythematosus
type 1 diabetes mellitus
Grave's disease
myasthenia gravis
dermatitis herpetiformis
Sjogren's syndrome
primary biliary cirrhosis
223
Q

What is HLA-DR1 associated with?

Year 6 Medicine (18 decks)

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