Rheumatology Flashcards
1
Q
risk factors for OA?
A
- obesity
- ageing
- occupation
- trauma
- being female
- FHx
2
Q
LOSS: XR changes seen in OA?
A
- Loss of joint space
- Osteophytes
- Subarticular sclerosis
- Subchondral cysts
3
Q
presentation of OA?
A
- joint pain
- joint stiffness
- worsened by activity
- joint deformity
- atlantoaxial subluxation of C-spine
- reduced ROM
4
Q
commonly affected joints in OA?
A
- hips
- knees
- sacro-iliac joints
- DIPs
- MCP of thumb
- wrist
- C-spine
5
Q
hand signs in OA?
A
- herberden’s nodes at DIPs (never seen in RA)
- bouchard’s nodes at PIPs
- squaring at base of thumb
- weakened grip
- reduced ROM
6
Q
how is OA diagnosed?
A
- clinical diagnosis if >45 and these 2 present:
- activity-related joint pain
- no morning stiffness (or lasts <30 mins)
7
Q
management of OA?
A
- advise to lose weight
- physiotherapy
- occupational therapy
- orthotics
- analgesia
- intra-articular steroid injections
- hip / knee replacements
8
Q
describe the 3 steps in analgesia for OA
A
- PO paracetamol / topical NSAIDs / topical capsaicin
- PO NSAIDs + PPI (omeprazole for gut)
- opiates (codeine, morphine)
9
Q
what is RA?
A
inflammatory, symmetrical polyarthritis
10
Q
genetic associations for RA?
A
- HLA DR4
- HLA DR1
11
Q
antibodies found in RA?
A
- anti-CCP (gold standard)
- RF in 70%
12
Q
presentation of RA?
A
- joint pain, swelling, stiffness
- onset can be as fast as overnight or take months-years
- typically MCPs and PIPs of hands affected (DIP-sparing)
- fatigue
- weight loss
- flu-like illness
- muscle aches and weakness
- short duration if palindromic rheumatism
- atlantoaxial subluxation
13
Q
what is palindromic rheumatism? when would you worry?
A
- short, self-limiting episode of inflamm arthritis
- when anti-CCP present in blood (almost definitely goes on to develop RA)
14
Q
what is atlantoaxial subluxation? what is the main complication?
A
- axis (C2) and atlas (C1) fuse together
- spinal cord compression
15
Q
hand signs in active RA?
A
- “boggy” feeling synovium around joints
- Z-shaped deformity of thumb
- swan neck deformity
- boutonnieres deformity
- ulnar deviation at MCP joints
16
Q
describe swan neck deformity
A
- hyperextended PIP
- flexed DIP
17
Q
describe boutonnieres deformity
A
- hypextended DIP
- flexed PIP
18
Q
systemic signs of RA?
A
- caplan’s syndrome
- bronchiolitis obliterans
- felty syndrome (RA, neutropenia and splenomegaly)
- sjogren’s syndrome
- anaemia of chronic disease
- CVD
- eye signs
- rheumatoid nodules
- lymphadenopathy
- carpel tunnel syndrome
- amyloidosis
19
Q
what is caplan’s syndrome? where is it seen?
A
- pulmonary fibrosis with pulmonary nodules
- RA
20
Q
triad of felty syndrome?
A
- RA
- neutropenia
- splenomegaly
21
Q
eye signs of RA? hint: everything inflamed af
A
- scleritis
- episcleritis
- keratitis (inflamed cornea)
- keratoconjunctivitis sicca (dry conjunctiva and cornea)
- cataracts (due to steroids)
- retinopathy (due to chloroquine)
22
Q
investigations in RA?
A
- bloods (RF, anti-CCP, CRP, ESR)
- XR hands
- XR feet
- USS shows synovitis
23
Q
X-ray changes seen in RA?
A
- joint destruction
- joint deformity
- soft tissue swelling
- periarticular osteopenia
- bony erosions
24
Q
why should patients with persistent synovitis be referred? when does it become urgent?
A
- to rule out RA
- when symptoms have persisted >3m or small joints of hands / feet affected
25
scoring system used in RA diagnosis? how is it calculated? hint: it u
- disease activity score 28 (DAS28)
- looks at tenderness / swelling in 28 joints
- takes ESR and CRP into account too
26
what is the health assessment questionnaire (HAQ) used for? when is it used?
- to measure functional ability in RA
| - done at diagnosis to monitor response to treatment
27
factors indicating a poor prognosis in RA?
- being male
- younger onset
- more joints / organs affected
- RF / anti-CCP antibodies present
- erosions on XR
28
management of RA?
- steroids for initial presentation and acute flare ups
- DMARDs, following ladder
- surgery
29
describe the DMARD ladder in RA?
- 1st line: monotherapy with methotrexate / leflunomide / sulfasalazine / hydroxychloroquine (mild)
- 2nd: add another one of above
- 3rd: methotrexate + TNF inhibitor (e.g. infliximab)
- 4th: methotrexate + CD20 inhibitor (rituximab)
30
examples of TNF inhibitors? important side effect of these?
- adalimumab
- infliximab
- immunosuppression
31
how is methotrexate prescribed? what gets co-prescribed?
- IM / SC injection or weekly tablet
| - 5mg folic acid to be taken weekly, but on a different day
32
side effects of DMARDs?
- mouth ulcers
- liver toxicity
- leukopenia (due to bone marrow suppression)
- teratogenic
33
unique SE of methotrexate?
pulmonary fibrosis
34
unique SEs of leflunomide?
- HTN
| - peripheral neuropathy
35
unique SE of sulfasalazine?
reduces sperm count in men
36
unique SEs of hydroxychloroquine?
- nightmares
| - reduced visual acuity
37
which underlying diseases could be reactivated by anti-TNF therapy?
- TB
| - hep B
38
unique SEs of rituximab?
- night sweats
| - thrombocytopenia
39
what is psoriatic arthritis (PsA)? which group of conditions is it in?
- an inflammatory arthritis associated with psoriasis
| - one of the seronegative spondyloarthropathies
40
what % of psoriasis patients also have PsA?
up to 20%
41
signs of PsA?
- psoriatic plaques on skin
- nail pitting
- onycholysis
- dactylitis
- enthesitis
42
describe onycholysis
nail coming off the nail bed
43
which conditions might be associated with PsA?
- conjunctivitis
- anterior uveitis
- aortitis (inflamed aorta)
- amyloidosis
44
screening tool for PsA? who gets it?
- psoriasis epidemiological screening tool (PEST)
| - all psoriasis patients
45
X-ray changes seen in PsA?
- periostitis
- ankylosis
- osteolysis
- dactylitis
- pencil-in-cup appearance
46
what is arthritis mutilans? which body part is affected? key finding?
- most severe form of PsA
- osteolysis of joints in fingers, causes skin to fold over
- "telescopic finger"
47
management of PsA?
- similar to RA
- NSAIDs for pain
- DMARDs
- anti-TNFs
- last line: ustekinumab (targets IL-12 and IL-23)
48
pathophysiology of reactive arthritis? old name for this?
- synovitis in joints in response to recent infection
| - reiter syndrome
49
presentation of reactive arthritis?
- hot, red, swollen joint
- bilateral conjunctivitis
- anterior uveitis
- circinate balanitis
50
useful acronym for reactive arthritis presentation?
can't see can't pee can't climb a tree
51
key differential of reactive arthritis?
septic arthritis
52
common infective triggers of reactive arthritis?
- any cause of gastroenteritis
- chlamydia is most common STI preceding this
- gonorrhoea more likely to cause gonococcal septic arthritis
53
management of reactive arthritis?
- ABx according to local guidelines until septic arthritis ruled out, then:
- NSAIDs
- steroid injections at joint
- systemic steroids if multiple joints affected
54
investigations for reactive arthritis? why are these done?
- joint aspiration
- gram staining, culture and sensitivity
- to rule out septic arthritis
55
prognosis in reactive arthritis?
- very good
| - most resolve in 6 months and never recur
56
mortality rate in septic arthritis?
10%
57
which procedure increases the risk of septic arthritis?
joint replacement
58
presentation of septic arthritis?
- typically only 1 joint affected
- hot, red, swollen joint
- stiffness
- reduced ROM
- systemic: fever, lethargy, sepsis
59
most common infective organism in septic arthritis?
staph aureus
60
bacterial causes of septic arthritis?
- staph aureus (commonest)
- gonococcus
- strep pyogenes (and other group A streptococci)
- H. influenza
- E. coli
61
differentials for septic arthritis?
- reactive arthritis
- gout
- pseudogout
- haemoarthrosis
62
management of septic arthritis? which ABx would you choose?
- empirical IV ABx initially
- continued for 3-6 weeks
- e.g. flucloxacillin + rifampicin 1st line
- vancomycin if penicillin allergy / MRSA / prosthetic joint
- joint aspirate for staining, microscopy, culture and sensitivities
- then tailor ABx to sensitivities
63
what is ankylosing spondylitis? which group is it in?
- inflammatory arthritis affecting spine, causing stiffness and pain
- seronegative spondyloarthropathies
64
what groups the seronegative spondyloarthropathies together?
all linked to HLA B27 gene
65
which conditions come under seronegative spondyloarthropathies?
- ankylosing spondylitis
- IBD-related (enteropathic) arthritis
- reactive arthritis
- psoriatic arthritis
- undifferentiated spondylitis
66
typical demographic affected by ankylosing spondylitis?
- young male in teens / 20s
| - M:F = 3:1
67
presentation of ankylosing spondylitis?
- lower back pain
- lower back stiffness
- sacroiliac pain
- pain worsened by rest, improves on movement
- pain may wake patient at night, gets better throughout day
68
key complication in ankylosing spondylitis?
vertebral fractures
69
non-spinal signs of ankylosing spondylitis?
- systemic (weight loss, fatigue)
- chest pain (from costovertebral joints)
- plantar fasciitis, achilles tendonitis (from enthesitis)
- dactylitis
- anaemia
- anterior uveitis
- aortitis
- heart block
- restrictive lung disease
- pulmonary fibrosis in 1%
- IBD
70
X-ray findings in ankylosing spondylitis?
- X-ray of spine shows:
- "bamboo spine" (all fused together)
- squaring of vertebral bodies
- subchondral sclerosis and erosions
- syndesmophytes
- ossification
- fusion of facet, sacroiliac and costovertebral joints
71
useful test to assess spine mobility in ankylosing spondylitis?
- schober's test
- mark 2 points on lumbar spine and see how much they move apart on lumbar flexion
- if difference is <20cm, this is restricted
72
investigations for ankylosing spondylitis?
- bloods (CRP, ESR)
- HLA B27 gene test
- X-ray of spine and sacrum
- MRI spine
73
what does MRI spine show early on in ankylosing spondylitis?
- bone marrow oedema
| - comes up before any x-ray changes do
74
drug management for ankylosing spondylitis?
- NSAIDs
- steroids
- anti-TNF (etanercept) or infliximab
- last line: secukinumab (anti IL-17)
75
non-drug management of ankylosing spondylitis?
- physiotherapy
- exercise
- stop smoking
- bisphosphonates for any osteoporosis
- surgery for joint deformities
76
what is SLE?
inflammatory autoimmune connective tissue disease
77
leading causes of death in SLE patients?
- CVD
| - infection
78
antibodies found in SLE?
antinuclear antibodies
79
presentation of SLE? hint: there's a lot
- non-specific
- fatigue
- weight loss
- joint pain, non-erosive arthritis
- muscle pain
- fever
- malar rash
- lymphadenopathy
- splenomegaly
- SOB
- pleuritic chest pain
- mouth ulcers
- hair loss
- raynaud's phenomenon
80
describe the skin changes seen in SLE
- photosensitive malar rash
- made worse by sunlight
- "butterfly" distribution across nose and cheekbones
81
investigations and findings in SLE?
- autoantibodies (ANA present in 85%)
- FBC (anaemia of chronic disease)
- C3 and C4 (low in active disease)
- CRP and ESR (raised in active disease)
- immunoglobulins (raised)
- urine protein : creatinine ratio
- renal biopsy
82
why are urinalysis and renal biopsy done as SLE investigations?
to check for lupus nephritis
83
which antibodies are most specific to SLE? what does this mean?
- anti-double stranded DNA (anti-dsDNA)
- anyone who doesn't have SLE is very unlikely to have these antibodies
- 2nd most specific are anti-Smith
84
which condition is associated with anti-Ro and anti-La antibodies?
sjogren's syndrome
85
which condition might develop secondary to SLE?
antiphospholipid syndrome
86
complications of SLE?
- CVD
- infection
- anaemia of chronic disease
- leukopenia, neutropenia, thrombocytopenia
- pericarditis
- pleuritis
- interstitial lung disease, then pulmonary fibrosis
- lupus nephritis
- neuropsychiatric SLE
- recurrent miscarriage
- VTE
87
pregnancy complications associated with SLE?
- recurrent miscarriage
- IUGR
- pre-eclampsia
- pre-term labour
88
2 neuro complications of SLE?
- optic neuritis
| - transverse myelitis
89
psych complication of SLE?
psychosis
90
1st line treatments for SLE?
- hydroxychloroquine (1st line where mild)
- NSAIDs
- prednisolone
- sun cream for rash
91
when are immunosuppressants and biological therapies used in SLE? give some examples
- when it is either anti-inflammatory resistant or more severe
- immunosuppressants: methotrexate, azathioprine, tacrolimus
- biologics: rituximab, belimumab
92
main types of med used in SLE?
- anti-inflammatories
- immunosuppressants
- biological therapies
93
typical demographic affected by discoid lupus erythematosus (DLE)?
- female
- aged 20-40
- dark skinned
- smoker
94
prognosis of DLE?
- 5% go on to develop SLE
| - rarely progresses to SCC
95
distribution of skin lesions in DLE?
- face
- ears
- scalp
96
describe the presentation of lesions in DLE?
- inflamed
- dry
- erythematous (red)
- patchy
- crusty
- scaly
97
what skin changes can DLE cause?
- lesions
- scarring alopecia
- hyper or hypopigmented scars
98
how is DLE diagnosed?
usually done clinically, but can be confirmed with skin biopsy
99
management of DLE?
- sun protection
- topical steroids
- intralesional steroid injections
- hydroxychloroquine
100
what is systemic sclerosis?
autoimmune inflammatory, fibrotic connective tissue disease
101
distribution of skin lesions in systemic sclerosis?
all over
102
what are the 2 main patterns of disease in systemic sclerosis?
- limited cutaneous (CREST syndrome)
| - diffuse cutaneous
103
CREST: features of limited cutaneous systemic sclerosis?
- Calcinosis
- Raynaud's phenomenon
- oEsophageal dysmotility
- Sclerodactyly
- Telangiectasia
104
features of diffuse cutaneous systemic sclerosis?
CREST plus:
- heart: HTN, CAD
- lungs: pulmonary HTN, pulmonary fibrosis
- kidneys: glomerulonephritis, scleroderma renal crisis
105
what is calcinosis? where is it typically found?
- calcium deposits under the skin
| - fingertips
106
where is oesophageal dysmotility seen? describe some features
- seen in systemic sclerosis
- swallowing difficulties
- acid reflux
- oesophagitis
107
features of scleroderma renal crisis?
- severe HTN
| - renal failure
108
antibodies found in systemic sclerosis?
- antinuclear antibodies
- anti-centromere antibodies (limited)
- anti-Scl-70 antibodies (diffuse)
109
investigation done in raynaud's phenomenon to rule out systemic sclerosis?
nailfold capillaroscopy
110
non-medical management of systemic sclerosis?
- stop smoking
- skin stretching
- emollients
- gloves (raynaud's)
- physiotherapy for joints
- OT
111
medical management of systemic sclerosis?
- nifedipine (for raynaud's)
- PPIs, metoclopramide (for GI signs)
- analgesia (joint pain)
- ABx (skin infections)
- antihypertensives
112
distribution of joint pain and stiffness in polymyalgia rheumatica (PMR)?
- shoulders
- pelvic girdle
- neck
113
which condition is PMR strongly associated with?
GCA
114
describe PMR
inflammatory condition causing pain and stiffness in certain joints
115
typical demographic affected by PMR?
Caucasian women aged >50
116
NICE criteria for diagnosing PMR?
the following present for >2 weeks:
- bilateral shoulder pain
- bilateral pelvic girdle pain
- pain worse on movement
- pain interfering with sleep
- 45 mins or more of morning stiffness
117
other, non-diagnostic features of PMR?
- systemic (weight loss, fatigue, fever, low mood)
- upper arm tenderness
- carpal tunnel syndrome
- pitting oedema
118
differentials of PMR?
- OA, RA
- SLE
- myositis
- cervical spondylitis
- adhesive capsulitis (of both shoulders)
- thyroid dysfunction
- osteomalacia
- fibromyalgia
119
investigations in PMR? hint: mostly to rule out differentials
- ESR, plasma viscosity and CRP all raised (inflammation)
- FBC, UEs, LFTs to rule out other causes
- Ca (raised in hyperPT / cancer, low in osteomalacia)
- serum protein electrophoresis (myeloma)
- CK (myositis)
- rheumatoid factor (RA)
- ANA (SLE)
- anti-CCP (RA)
- urinary bence jones protein (myeloma)
- CXR (lung abnormalities)
120
treatment of PMR?
- 15mg prednisolone per day for a week
- if no improvement after 1 week, PMR ruled out
- there should be a 70% improvement in 3-4 weeks
- if this is the case, start a reducing regime
- more severe: refer to rheum
121
DON'T stop: advice for patients on long-term steroids?
- DON'T: they should not stop taking steroids suddenly because of risk of adrenal crisis
- Sick day rules: reduce dose if feeling ill
- Treatment card: carry it
- Osteoporosis: consider bisphosphonates, Ca and vit D to prevent this
- PPI: consider omeprazole for stomach lining protection
122
what is giant cell arteritis (GCA)?
systemic vasculitis which affects the medium and large arteries
123
which condition is GCA strongly associated with?
PMR
124
key complication of GCA?
vision loss
125
presentation of GCA?
- headache
- scalp tenderness on brushing hair
- jaw claudication
- blurred / double vission
- systemic signs
- irreversible painless complete vision loss
126
nature of headache in GCA?
- severe
- unilateral
- affects temple and forehead
127
which systemic signs may be seen in GCA?
- fever
- muscle aches
- fatigue
- loss of appetite / weight
- peripheral oedema
128
how is GCA diagnosed?
- clinical presentation
- ESR >50mm/h (raised)
- temporal artery biopsy findings
129
investigations in GCA?
- bloods (raised ESR and CRP, FBC may show anaemia + thrombocytosis)
- temporal artery biopsy
- LFTs (raised ALP)
- duplex USS of temporal artery
130
what is found on temporal artery biopsy in GCA?
multinucleated giant cells
131
what is found on duplex USS of the temporal artery in GCA?
hypoechoic halo sign
132
management of GCA?
- start high-dose steroids before confirming diagnosis
- 40-60mg pred per day
- aspirin 75mg (decreases vision loss / stroke risk)
- PPI for gastric protection
133
why should high-dose steroids be started before a diagnosis of GCA is confirmed?
to reduce risk of permanent vision loss
134
which antibodies are found in antiphospholipid syndrome?
- lupus anticoagulant
- anticardiolipin antibodies
- anti-beta-2 glycoprotein I antibodies
135
key complication in women with antiphospholipid syndrome?
recurrent miscarriage
136
describe the pathophysiology of antiphospholipid syndrome
- antiphospholipid antibodies interfere with the clotting cascade
- pt is in hypercoagulable state
- thrombosis occurs
137
which condition can antiphospholipid syndrome occur secondary to?
SLE
138
complications of antiphospholipid syndrome? hint: 3 of them are pregnancy-related
- VTE (DVT, PE)
- arterial thrombosis
- recurrent miscarriage
- stillbirth
- pre-eclampsia
- Libmann-Sacks endocarditis
139
rash seen in antiphospholipid syndrome? what does it look like?
- livedo reticularis
| - purple lace like rash, makes skin look mottled
140
what is Libmann-Sacks endocarditis? which conditions is it seen in?
- non-bacterial vegetations on mitral valve
| - SLE and antiphospholipid syndrome
141
how is antiphospholipid syndrome diagnosed?
- Hx of thrombosis / recurrent pregnancy complications
| - PLUS: presence of any of the 3 antibodies
142
management of antiphospholipid syndrome?
- long-term warfarin (aim for INR 2-3) to prevent VTE
- LMWH (enoxaparin) + aspirin in pregnancy to reduce complication risk
- remember NO warfarin in pregnancy!
143
eye signs seen in RA?
- keratoconjunctivitis sicca (most common)
- episcleritis (red, no pain)
- scleritis (red and painful)
- corneal ulceration
- keratitis
144
key features of sjogren's syndrome?
dry mucous membranes:
- dry eyes
- dry mouth
- dry vagina
145
which conditions might sjogren's syndrome occur secondary to?
- SLE
| - RA
146
which antibodies are associated with sjogren's syndrome?
- anti-RO
| - anti-La
147
which condition is the schirmer test used to diagnose? what does this involve?
- sjogren's syndrome
- putting a dry folded piece of paper under the lower eyelid
- wait 5 mins
- measure distance travelled by tears
- 15mm in healthy adult
- <10mm in sjogren's
148
management of sjogren's syndrome?
- artificial tears and saliva
- vaginal lube
- hydroxychloroquine to halt progression
149
complications of sjogren's syndrome? hint: all relate to areas of dryness
- corneal ulcers
- dental cavities
- sexual dysfunction
- oral or vaginal candidiasis
150
which other organs might be affected in sjogren's?
- lungs (pneumonia, bronchiectasis)
- lymph nodes (NHL)
- nerves (peripheral neuropathy)
- vessels (vasculitis)
- kidneys (renal impairment)
151
which types of vasculitis affect small vessels?
- HSP
- eosinophilic granulomatosis with polyangiitis
- microscopic polyangiitis
- wegener's granulomatosis
152
which types of vasculitis affect medium-sized vessels?
- polyarteritis nodosa
- eosinophilic granulomatosis with polyangiitis
- kawasaki disease
153
which types of vasculitis affect large vessels?
- GCA
| - takayasu's arteritis
154
presentation of vasculitis? hint: there's a LOT
- purpura, non-blanching
- joint / muscle pain
- peripheral neuropathy
- renal impairment
- GI disturbance (diarrhoea, abdo pain, bleeding)
- anterior uveitis + scleritis
- HTN
- systemic (fever, weight loss, fatigue, anorexia, anaemia)
155
blood tests and findings in vasculitis?
- CRP and ESR (raised)
| - ANCA (positive)
156
in which conditions will p-ANCA be positive?
- microscopic polyangiitis
| - eosinophilic granulomatosis with polyangiitis
157
in which condition will c-ANCA be positive?
wegener's granulomatosis
158
management of vasculitis?
- specialist referral
- steroids (prednisolone, hydrocortisone)
- immunosuppressants (cyclophosphamide, methotrexate)
159
describe the pathophysiology of HSP
there are IgA deposits in certain blood vessels which give symptoms in the affected areas
160
which demographic is most commonly affected by HSP?
children under 10
161
4 classic features of HSP?
- purpura
- joint pain
- abdo pain (for first few days)
- renal impairment (IgA nephritis in 50%)
162
prognosis of HSP?
- most fully recover in 4-6 weeks
- 1 in 3 have it again within 6 months
- 1% get ESRF
163
key finding on bloods in eosinophilic granulomatosis with polyangiitis?
raised eosinophils on FBC
164
presentation of wegener's granulomatosis?
- nosebleeds
- crusty nasal secretions
- hearing loss
- sinusitis
- O/E saddle shaped nose (perforated nasal septum)
- cough
- wheeze
- haemoptysis
- glomerulonephritis
165
CXR findings in wegener's granulomatosis?
- consolidation
| - often mistaken for pneumonia!
166
which infection is polyarteritis nodosa most associated with? which others might it be associated with?
- hep B
| - HIV, hep C
167
features of polyarteritis nodosa?
- renal impairment
- stroke
- MI
- livedo reticularis rash
168
describe livedo reticularis. which condition is it seen in?
- mottled, purple, lacy rash
| - polyarteritis nodosa
169
typical demographic affected by kawasaki disease?
children under 5
170
features of kawasaki disease?
- persistent high fever for >5 days
- erythematous rash
- bilateral conjunctivitis
- redness and desquamation of soles of palms / soles
- strawberry tongue
171
key complication of kawasaki disease?
coronary artery aneurysm
172
treatment of kawasaki disease?
- aspirin
| - IV immunoglobulins
173
which named arteries are mainly affected in takayasu's arteritis? what does it cause?
- aorta and pulmonary arteries
- they swell and aneurysms form
- may become blocked
- "pulseless disease"
