Rheumatology Flashcards
1
Q
Side effects of corticosteroids:
A
Corticosteroids (think CORTICOSTEROIDS):
Cushing’s syndrome
Osteoporosis
Retardation of growth
Thin skin, easy bruising
Immunosuppression
Cataracts and glaucoma
Oedema
Suppression of HPA axis
Teratogenic
Emotional disturbance (including psychosis)
Rise in BP
Obesity (truncal)
Increased hair growth (hirsutism)
Diabetes mellitus
Striae
2
Q
Side effects of corticosteroids:
A
Corticosteroids (think CORTICOSTEROIDS):
Cushing’s syndrome
Osteoporosis
Retardation of growth
Thin skin, easy bruising
Immunosuppression
Cataracts and glaucoma
Oedema
Suppression of HPA axis
Teratogenic
Emotional disturbance (including psychosis)
Rise in BP
Obesity (truncal)
Increased hair growth (hirsutism)
Diabetes mellitus
Striae
3
Q
Side effects of corticosteroids:
A
Corticosteroids (think CORTICOSTEROIDS):
Cushing’s syndrome
Osteoporosis
Retardation of growth
Thin skin, easy bruising
Immunosuppression
Cataracts and glaucoma
Oedema
Suppression of HPA axis
Teratogenic
Emotional disturbance (including psychosis)
Rise in BP
Obesity (truncal)
Increased hair growth (hirsutism)
Diabetes mellitus
Striae
4
Q
Pseudogout tends to affect elderly _____ typically in the wrists/knees and is associated with _____.
A
women
hypothyroidism
5
Q
_____, _____ and _____ antibodies are all associated with systemic sclerosis
A
Scl-70 (Anti-topoisomerase 1)
anticentromere
anti-RNA polymerase III
6
Q
Reactive arthritis describes a triad of ___ , ____, and ____.
A
Arthritis
Urethritis
Conjunctivitis.
Reiter’s Syndrome is a type of Reactive Arthritis
7
Q
Red flags for back pain:
A
New onset age ≤20 or ≥55.
Thoracic or cervical spine pain.
Pain is progressive or not relieved by rest.
Spinal (rather than paraspinal) tenderness.
8
Q
Cancers that commonly metastasise to the bone can be remembered with the mnemonic:
A
BLT with a Kosher Pickle:
Breast
Lung
Thyroid
Kidney
Prostate
9
Q
Felty’s syndrome is a triad of _____, _____ , and _____.
A
rheumatoid arthritis
splenomegaly
neutropenia
Her splenomegaly explains her abdominal discomfort, and her productive cough and coarse crackles suggest a pneumonia, which could be brought on by her neutropenia. Note that splenomegaly can occur in rheumatoid arthritis without Felty’s syndrome, and DMARDs alone can increase susceptibility to infection.
10
Q
____ , usually ____ , are the first-line systemic treatment for Raynaud’s phenomenon.
A
CCBs
Nifedipine
They work because they act as vasodilators, improving blood flow to the digits. It is important to remember that there are other simple interventions that can be taken before trying medications. Smoking cessation is important as smoking has been shown to significantly worsen symptoms. Additionally, encouraging the patient to wear gloves (preferably insulated or self-heating) whenever they are exposed to the cold is important.
11
Q
Before starting biologics, ____ has to be screened for and treated first before starting biologics.
A
TB - mycobacterium tuberculosis
12
Q
The main features of APS can be remembered with the mnemonic _____ :
A
CLOT
Clots - Usually venous thromboembolism (eg. deep venous thrombosis or pulmonary embolism), but arterial embolism (eg. myocardial infarction or stroke) can also occur.
Livedo reticularis - A mottled, lace-like appearance of the skin on the lower limbs.
Obstetric loss - Recurrent miscarriages, pre-eclampsia and premature births can occur.
Thrombocytopenia.
In addition cardiac valve disease can occur, usually aortic and mitral regurgitation ± stenosis.
13
Q
Ankylosing spondylitis is a sero-negative inflammatory arthritis primarily involving the axial skeleton.
Patients often develop Ankylosing spondylitis between the ages of ____ years old. It is three times more common in _____ . It often has strong family history.
A
20-30
males
14
Q
Ankylosing spondylitis is highly associated with _____.
A
acute anterior uveitis
(as with the other seronegative spondylarthropathies), particularly in patients that are also HLA-B27 positive. Acute anterior uveitis itself typically causes a painful red eye, with reduced acuity and a constricted pupil.
Ankylosing spondylitis: 88% of patients are HLA-B27 positive
Acute anterior uveitis: 50-60% are HLA-B27 positive
Reactive arthritis: 50-85% are HLA-B27 positive
Enteric arthropathy (IBD related): 50-60% are HLA- B27 positive
Psoriatic arthritis: 60-70% are HLA- B27 positive
15
Q
_____ is infarction of the posterior ciliary arteries which supply the optic nerve head is the most common mechanism of visual loss in giant cell arteritis.
Classic findings on fundus examination include a swollen, chalky white, optic disc.
A
Anterior ischaemic optic neuropathy
Central retinal artery occlusion is also a possibility in GCA - pale retina and cherry red spot
16
Q
The main side effects of orally taken bisphosphonates such as alendronic acid are _____.
A
Oesophageal reactions including; oesophagitis, oesophageal ulcers, erosions and strictures which can present as odynophagia, dysphagia or new/worsening dyspepsia.
Other rare, but memorable, side effects for all bisphosphonates include:
Osteonecrosis of the jaw or auditory canal.
Hypocalcaemia.
17
Q
_____ syndrome (now known as eosinophilic granulomatosis with polyangiitis or EGPA) is a rare ____-positive vasculitis.
It is very strongly associated with ____ and the use of leukotriene receptor antagonists (eg. Montelukast). It tends to present with asthmatic or sinusitis-type symptoms with eosinophilia on the blood results. Patients may also have a background of asthma/sinusitis and then present with vague constitutional symptoms.
A
Churg-Strauss
pANCA
asthma
18
Q
The x-ray features of osteoarthritis can be remembered with the mnemonic ____ :
A
LOSS
Loss of joint space.
Osteophytes.
Subchondral cysts.
Subarticular sclerosis.
19
Q
Pseudogout is storngly associated with which biochemical abnormalities ____?
A
Haemochromotosis
Hypomagnesia
Hypophoshotaemia
Hyperparathyroidism
20
Q
Antibodies associated with gastrointestinal diseases
Pernicious anaemia
_____ antibodies are very specific
Coeliac disease
_____ , _____, _____.
_____ are present in 95% of primary biliary cirrhosis patients
High titres of _____ are found in 95% of patients with autoimmune hepatitis
A
Intrinsic factor
Anti-tissue transglutaminase antibodies(IgA),IgA anti-endomysial antibody (IgA), anti-deamidated gliadin peptides (IgG)
Antimitochondrial antibodies (IgM) (remember PBC boys have no energy and so no mitochondrial)
Anti-smooth muscle antibodies (IgG)
(drinking in the sma gives you hepatitis)
21
Q
Side effects of NSAIDs
A
Indigestion
Peptic ulcer disease,
Increased risk of venous thrombo-embolus
Peripheral oedema
Slight increased risk of stroke and heart attack
22
Q
____ and diclofenac make up arthrotec (an NSAID sometimes used to treat joint pain).
A
Misoprostol (prostaglandin analogue)
Misoprostol can cause diarrhoea.
23
Q
_____ antibodies are associated with anti-phospholipid syndrome.
A
Anti-cardiolipin
and
lupus anticoagulant
24
Q
The ____ score is designed to measure disease activity in rheumatoid arthritis.
The doctor looks at ___ joints to decide if they are tender or swollen. Patient also contributes and function is considered.
A
DAS-28 (disease activity score)
28
A patient ‘global health’ assessment from 0 to 100, and either ESR or CRP can also be added into the formula. A low score suggests the patient is in remission, whereas higher scores suggest the patient has more active disease. Using the score allows the rheumatologist to monitor the patient’s progress and response to treatment.
25
Polyarteritis nodosa is associated with which other disease?
Hepatitis B
26
Methotrexate's mechanism of action is to _____ .
Any other anti-folate drug must be therefore avoided, or it will potentiate toxicity. Examples of anti-folate agents include: Methotrexate, \_\_\_\_\_, Permetrexed and Proguan (anti-malarial).
**Impair folate metabolism**
**Trimethoprim**
- if taken togehter can lead to _bone marrow suppression_ and thus _pancytopaenia_
Methotrexate is a competitive inhibitor of the dihydrofolate reductase enzyme, which is involved with catalyzing dihydrofolate to the active tetrahydrofolate.
This is needed for the synthesis of the nucleoside thymidine, and is part of the synthesis of **purine and pyrimidine**. In essence, methotrexate **inhibits the synthesis of DNA and RNA.**
**Folic Acid (5mg) has to be prescribed together with Methotrexate and has to be taken on a separate day to avoid interference with the therapeutic action of Methotrexate.** Depending on the toxicity experienced, Folic Acid can be taken from once a week to six days a week. The standard dose is 5mg once per week, but an alternative is 1mg daily. In either case however, folic acid should not be taken on the same day as methotrexate.
"**Methotrexate Monday**" and "**Folate Friday**" may help you, and patients, remember the once weekly dosing regimen of these drugs.
27
\_\_\_\_\_ are first line for renal hypertensive crises in systemic sclerosis.
ACE-i
28
Anticoagulation with ____ is the mainstay of APS management. If If contraindicated (e.g. in pregnancy), _____ and _____ may be used instead.
**Warfarin**
Low Molecular Weight Heparin
Aspirin
29
Allopurinol is a _____ which reduces serum urate levels which can prevent future attacks of gout.
xanthine-oxidase inhibitor
30
Enteropathic Arthropathy
This is the most likely diagnosis in this patient who presents with bowel symptoms, and an axial pattern of arthritis, as well as erythema nodosum, a skin manifestation of inflammatory bowel disease (IBD).
The dermatological associations are the ulcerative colitis is more likely to feature _____ and Crohn's more likely to feature \_\_\_\_\_.
\_\_\_\_\_ more often presents with peripheral arthritis but there is, of course, a spectrum. Importantly, joint symptoms may precede bowel symptoms in these patients.
**pyoderma gangrenosum**
**erythema nodosum**
**Crohn's**
31
A normal temporal artery biopsy does not exclude GCA as the vasculitis appears in \_\_\_\_\_.
skip lesions
However a postive result is diagnostic. (i.e poor sensitivity and high specificity)
32
\_\_\_\_\_ is the antibody present in patients with granulomatosis with polyangiitis (GPA) which is what this clinical picture describes.
GPA can have upper (sinusitis, crusting, nasal discharge) and lower respiratory tract features (shortness of breath, haemopytisis, chest pain).
**c-ANCA**
33
Side effects and monitoring of methotrexate:
**Cytopenia** - Monitor full blood count and advise patients to report suspected infections and bruising.
**Hepatotoxicity** - Monitor liver function tests. Mild elevation is normal, but discontinue if they rise to more than 3x normal.
**Renal impairment** - Monitor renal function.
**Acute Pneumonitis - (but NOT Pulmonary fibrosis)** - Take a baseline CXR. Advise patients to report any respiratory symptoms eg. dyspnoea/dry cough.
**Teratogenicity** - Advise patients to use contraception while taking methotrexate, and for 3 months after use. Beware prescribing other folate antagonists.
34
\_\_\_\_\_\_ is an ____ and is the mainstay of treatment of milder SLE symptoms such as skin and joint involvement alone (in addition to NSAIDs).
Immunosuppressants are usually reserved for more severe symptoms or when there is evidence of organ involvement.
**Hydroxychloroquine**
**antimalarial**
35
Infliximab is an _____ biologic treatment.
Biologics like infliximab slow the progression of rheumatoid arthritis, improve symptoms and are very effective for certain patients.
They are expensive and can cause significant immunosuppression among other side effects and so are reserved for cases when patients have severe disease (with a DAS28 score above \_\_\_\_) despite combination DMARD therapy (ex. methotrexate/sulfasalazine)
**anti-TNFa**
**5.1**
36
ECG with widespread ST elevation demonstrates _____ and can be associated with \_\_\_\_\_
**Myocarditis**
**Granulomatosis with Polyangitis** (Wegener's Syndrome)
37
\_\_\_\_\_ are positive in over 95% of SLE patients.
**Anti-nuclear antibodies** (ANA)
Anti-double stranded DNA (dsDNA) autoantibodies are a subgroup of ANA. **dsDNA is more specific** but **only positive in around 60%** of SLE patients - thus less sensitive
Note: ANA is positive in most CT disease
38
\_\_\_\_ and ____ are autoantibodies specific to Sjogren's syndrome and can be used to support the diagnosis.
**Anti-Ro**
and
**Anti-La**
39
Side effects of NSAIDs
**SAK** - **S**tomach, **A**sthma, **K**idneys.
_GI side effects_
Dyspepsia and upper GI ulceration.
The risk is especially high in patients with a PMH of dyspepsia or GI ulceration, excessive alcohol intake or concomitant aspirin usage.
If they are unavoidable in patients at a high risk, consider co-prescribing a PPI or using a COX-2 inhibitor instead.
_Respiratory side effects_
A minority of asthma patients experience a deterioration with NSAIDs, so they should be used with caution in this group.
_Renal side effects_
Nephrotoxicity - NSAIDs are most associated with pre-renal injury as they cause afferent arteriole vasoconstriction in the kidneys, though they can rarely cause acute interstitial nephritis. They should be withheld in AKI.
_Other side effects_
Increased risk of cardiovascular events.
Minor antiplatelet effect (should be avoided in active bleeding where possible).
Differences between NSAIDs and COX-2 inhibitors
COX-2 inhibitors, also known as **coxibs**, such as celocoxib are a newer alternative to traditional NSAIDs like ibuprofen or naproxen. Coxibs selectively inhibit COX-2 which confers a lower risk of GI ulceration and so may be preferred in patients at high risk of GI ulceration.
However, shortly after they were first released, the coxib 'rofecoxib' was discontinued because it was found to increase the risk of cardiovascular events to a significantly higher extent than regular NSAIDs. This lead to a lack of uptake in coxib use, but more recent research has found that other coxibs, particularly moderate dose celocoxib, confers an equivalent cardiovascular risk to normal NSAIDs and are therefore safe to use in place of regular NSAIDs where necessary.
40
Name the four main features of a rheumatoid hand
**Swan neck deformity**: flexed distal interphalangeal point, hyperextended proximal interphalangeal joint
**Boutonniere's deformity**: hyperextended distal interphalangeal joint, flexed proximal interphalangeal joint
**Ulnar deviation**: the metacarpophalangeal joints are deviated towards the ulna
**Z-thumb deformity**: flexed carpometacarpal joint, hyperextended metacarpophalangeal joint, flexed interphalangeal joint
41
\_\_\_\_\_ also known as calcium pyrophosphate deposition (CPPD) and pseudogout, is a condition where calcium pyrophosphate crystals build up in the joints.
**Chondrocalcinosis**
42
\_\_\_\_\_ (inflammation where tendons, ligaments or joint capsules insert into bone) can occur in any of the seronegative spondylarthropathies, but is especially prominent in AS. The ____ is an especially common site of this and is the likely cause of his ankle pain.
**Enthesitis**
**Achilles tendon**
43
List the autoantibodies associated with:
Rheumatoid \_\_\_\_
Sjogrens \_\_\_\_
SLE \_\_\_\_
Polyarteristis nodosa \_\_\_\_
Poly/dermatomyositis \_\_\_\_
Wegener's granulomatosis (granulomatosis w/ polyangiitis) \_\_\_\_\_
Eosinophilic granulomatosis w/ polyangiitis \_\_\_\_
Diffuse Cutaneous Systemic sclerosis \_\_\_\_\_
Limited Cutaneous Systemic Sclerosis \_\_\_\_\_
Drug Induced SLE \_\_\_\_
Rheumatoid: **Anti-RF and Anti-CCP**
Sjogrens: **Anti-Ro and Anti-La**
SLE: **Anti-dsDNA**
Polyarteristis nodosa: **None**
Poly/dermatomyositis : **Anti-Jo1**
Wegener's granulomatosis (granulomatosis w/ polyangiitis): **cANCA**
Eosinophilic granulomatosis w/ polyangiitis : **pANCa**
Diffuse Cutaneous Systemic sclerosis: **Anti-SCL70**
Limited Cutaneous Systemic Sclerosis: **Anti-Centromere**
Drug Induced SLE: **Anti-Histone**
44
Relapsing-remitting ____ and ____ ulceration is the hallmark of Bechet's disease
**oral**
and
**genital**
**Uveitis**
**Erythema nodosum**
Erythema and arthritis are also consistent, as is a **positive family history** (seen in **\>30%**). While Bechet's is classically associated with **Turkey and the Mediterranean** basin, it is also more common **Japanese** patients.
45
Felty's syndrome is a triad of \_\_\_\_.
**rheumatoid arthritis**
**splenomegaly**
**neutropenia**
46
\_\_\_\_ test can be used to evaluate whether or not the eyes are dry. A strip of filter paper is inserted under the eyelid. If \<5mm of the paper is wet after 5 minutes, this is very suggestive of dry eyes and sjogren's syndrome.
Schirmer's
47
In septic arthritis, white cells in the synovial fluid are usually above \_\_\_\_/mm3 and may be as high as \_\_\_\_/mm3. Neutrophil levels are \>\_\_\_%.
10,000/mm3
100,000/mm3
90
48
Patients with reactive arthritis tend to present with ____ , \_\_\_\_, \_\_\_\_.
**Dysuria**
**Arthralgia**
**Iritis/Conjunctivits**
49
Eosophageal (or oesophageal) dysmotility is a very frequent feature of systemic sclerosis. It occurs in over \_\_\_\_% of patients of all systemic sclerosis patients, and this is what the 'E' stands for in CREST syndrome.
90%
50
\_\_\_\_\_ syndrome is a rare syndrome. Also known as rheumatoid pneumoconiosis and is characterised by _____ in people with rheumatoid arthritis and a known exposure to dust particles (e.g. coal [anthracite], asbestos and silica). It can cause shortness of breath. The patient used to work in the construction industry and thus may have been exposed to asbestos. The symmetrical pain and stiffness in the hands is suggestive of rheumatoid arthritis.
Caplan's syndrome
intrapulmonary nodules
51
Microscopic polyangitis is one of the more common forms of arteritis affecting smaller arteries, characterised by ___ disease, _____ disease and ____ antibody directed against myeloperoxidase.
**renal**
**pulmonary disease**
**pANCA**
52
She is manifesting the classical triad of primary Sjogren syndrome: ____ , ____ and \_\_\_\_. While active arthritis may be seen, arthralgia is more common. ____ test confirms the extent of the patient's dry eyes.
**dry mucosa** (especially eye and mouth)
**fatigue**
**joint pain** (arthralgia)
**\*Schirmer's\***
53
Note that polyarteritis nodosa has _____ with ANCA antibodies.
no association
54
The second line treatment for gout is ____ , where the most common side effects are ____ .
**colchicine**
**diarrhoea** (nausea and vomiting also)
55
Foot eversion is weak in ____ nerve root lesions and the ankle jerk is affected.
S1
56
Which medication makes raynaud's worse?
Beta Blockers (ex.propanalol)
57
Lupus nephritis is usually treated with a combination of high dose **corticosteroids** _AND_ a ____ drug.
\_\_\_\_ is usually very effective and preferred, though tacrolimus (calcineurin inhibitor and immunosuppressant - also used in eczema) and mycophenylate are alternatives.
**Cytotoxic**
**Cyclophosphamide**
58
Limited Systemic Sclerosis can be rememebered with the mnemonic \_\_\_\_
**CREST**
**C**alcinosis (calcium deposits in the skin)
**R**aynaud's Phenomenon
**E**sophogeal Dysmotility (i.e GORD/Dysphagia etc.)
**S**clerodactyly and _ulceration_
**T**elangectasia
59
\_\_\_\_\_\_ is the treatment of choice in a patient with temporal arteritis and visual impairment. If the patient _did not have significant visual symptoms_ then giving _oral prednisolone_ would be an appropriate initial treatment.
**IV methylprednisolone (500mg)**
60
Treatment of Ankylosing spondylitis?
**Exercise**, **NSAIDs,** and _if severe_ - **Biologics** (ex. Infliximab - TNFa Inhibitor)
\*\*\****DMARDS** are _not used_ in AS\*\*\**
**Non-pharmacological treatment**
Treatment options for ankylosing spondylitis are limited and there are no treatments known to reduce remission or significantly delay the progress of the disease.
Non-pharmacological treatments including exercise and physiotherapy which is critical to improve and maintain posture, flexibility and mobility.
**Pharmacological treatment**
NSAIDs first line often prescribed with a protein pump inhibitor
Disease- modifying-anti-rheumatic- drugs (DMARDs) such as sulfasalazine and methotrexate are more useful in patients with enthesitis than axial symptoms, so are given in addition to analgesia in patients with concomitant peripheral disease. These drugs do not improve spinal inflammation.
Local steroid injections can be used as an adjunct
Patients who have failed to control symptoms with NSAIDs/ have severe disease may be offered TNF-alpha inhibitors such as Infliximab.
There is good evidence that Inflixmab can improve both clinical and X-ray outcomes in ankylosing spondylitis.
61
Anti-tuberculous treatment with ____ and ____ is known to reduce renal urate excretion and precipitate particularly troublesome attacks of gout.
Chemotherapy resulting in _____ also precipitates gout due to the high levels of \_\_\_\_, ____ , \_\_\_\_.
**pyrazinamide**
**ethambutol**
**Urate**
**Phosphate** (chelates and thus lowers serum Ca)
**Potassium**
62
In Giant Cell Arteritis, Patients are 17 times more likely to develop _____ and 2.4 times more likely to develop _____ , compared with unaffected people of the same age and sex.
**Thoracic aortic aneurysms**
**Isolated abdominal aortic aneurysms**
63
A pulmonary-renal syndrome with acute/sub-acute onset of symptoms, is classic of \_\_\_\_\_.
The classic presenting symptom is _____ followed \_\_\_\_\_. The age of the patient also fits a diagnosis of Goodpasture's - the age distribution is bi-modal, 20-30 years and 60-70 years.
**Goodpasture's syndrome (aka anti-GBM syndrome)**
Haemoptysis
by deterioration in renal function
64
**Goodpasture's syndrome**
\_\_\_\_\_\_ antibodies against type 4 collagen found within glomerular and alveolar basement membranes
**Anti-glomerular basement membrane**
65
**Granulomatosis with polyangiitis** (Wegener's)
\_\_\_\_\_ antibodies
**Churg-Strauss** (Eosinophilic Granulomatosis w/ polyangiitis)
\_\_\_\_\_ antibodies
**Cytoplasmic anti-neutrophil cytoplasmic** (cANCA)
**Peri-nuclear anti-neutrophil cytoplasmic** (pANCA)
66
A patient in a scleroderma renal crisis presents with a rapid decline in renal function, usually with marked ____ which can cause ____ and seizures.
The mainstay of treatment is to rapidly reduce the hypertension. _____ are used first-line for this purpose.
Short acting ACE-inhibitors such as ____ may be used initially before being converted to long acting ones such as ramipril.
\_\_\_\_\_ are used second line if necessary, with ____ reserved for those that fail to respond.
**Hypertension**
**Headaches**
**ACE-inhibitors**
**Captopril**
**Calcium channel blockers**
**Dialysis**
67
Polymyalgia Rheumatica (PMR) classically presents in those over ____ with bilateral apparent ____ muscle weakness which is caused by pain and stiffness and sometimes a ____ .
**50**
**proximal**
**low-grade fever**
68
In Churg Strauss syndrome, patients present with late-onset ___ , eosinophilia and rapidly progressive _____ with a palpable rash and \_\_\_\_.
asthma
glomerulonephritis
GIT bleeding (ex. Melaena)
69
For a RA patient hoping to get pregnant which combination of drugs can be used to replace methotrexate?
**Hydroxychloroquine a**nd **Sulfasalazine** with **concomitant folate supplementation** can be continued throughout pregnancy.
70
Diabetic foot
Charcot's Arthropathy presents with the 6Ds (destruction, deformity, degeneration, dislocation, dense bones and debris).
Classically, it affects the ____ joints. The most common underlying aetiology is diabetes. Diabetes leads to microvascular disease, autonomic neuropathy and peripheral neuropathy which synergistically leads to cumulative damage to the joints. Rarer causes includes _____ , alcohol and ____ . ____ is the main differential diagnosis to rule out.
**tarsometatarsal**
syringomyelia (fluid filled cyst aka syrinx in spinal cord that damages and compresses spinal cord)
syphilis
Osteomyelitis
71
\_\_\_\_\_ is the commonest pattern of psoriatic arthritis.
**Asymmetrical oligoarthritis**
There are 5 main patterns of joint involvement:
**Distal arthritis**
**Asymmetric oligoarthritis (60%)**
**Symmetric polyarthritis**
**Spondyloarthritis (axial involvement)**
**Arthritis mutilans (5%).**
_30% of patients with psoriasis also develop psoriatic arthritis_ - these patients usually have nail changes and dactylitis (inflammation of an entire digit).
72
\_\_\_\_\_ is contraindicated in patients with psoriatic arthritis as it is known to worsen Psoriasis.
Hydroxychloroquine
73
Clinical features of Behcet's Disease:
**Recurrent oral ulceration**
**Recurrent genital ulceration**
**Uveitis**
**Erythema nodosum**
74
In an acutely hot tender joint what are your 3 top differentials and which investigations should you to make a diagnosis?
Septic Arthritis / Gout / Pseudogout
\*remember synovial fluid analysis can take time so **remember to request _urgent cell count_, _gram stain_ and _crystals_** as these can be done **within an hour**\*
75
What are the risk factors for developing septic arthritis?
**AGE**: Elderly \> 65 or Young Children \<5
**Immunocompromised** (ex. steroids etc)
**IVDU**
**Damaged joint** (OA/RA)
**Prosthetic Joints** (NEVER ASPIRATE PROSTHETIC JOINT - THEATRE)
**Chronic Disease** (Renal failure/Diabetes/Liver Cirrhosis/Alcoholism)
76
Most common causative organisms of septic arthritis?
**Staph**
**Gonnococcal** (most common cause \< 30 yo)
Rarely **syphillis** can cause SA but usually in concomittant HIV/Chlamydia Infection
77
What is the management of septic arthritis?
**IV Antibiotics 2/52 followed by oral 4/52**
Successful treatment requires identification of causative
organism – **ALWAYS ASPIRATE THE JOINT PRIOR TO GIVING
ANTIBIOTICS**
Choose antibiotic based on _clinical situation_ and _local guidelines_ (ie most likely
causative organism, and local Ab resistance profile)
Always involve the microbiologist.
Adjust antibiotics when culture
results available.
78
Initial tests that should be performed in a patient with suspected gout is arthrocentesis with _____ .
## Footnote
\_\_\_\_\_\_ confirm gout and differentiate it from pseudogout, and the fluid should also be sent for gram stain and culture to rule out septic arthritis.
Synovial fluid analysis
**Needle-shaped monosodium urate crystals with negative birefringence** (yellow when parallel to light - blue when at 90 degrees)
\*Remember **P** for **P**seudogout and **P**ositive Birefringence\* - _rhomboid shaped_ crystals
79
What is the management of Gout?
80
\_\_\_\_ is a form of Reactive arthritis and consists of which triad of symptoms?
**Reiter's Syndrome**
**Arthritis**
**Urethritis**
**Conjunctivitis**
**CANT SEE!
CANT PEE!
CANT BEND THE KNEE!**
81
Reactive arthritis is associated with which other autoimmune conditions and thus which genetic abnormality?
Psoriasis
Alkylosing spondylitis
HLA-B27
82
Rheumatoid Factor is typically an IgM antibody that binds to the Fc portion of the ___ antibody.
RF is better used as a ____ marker as it has a low sensitivity and specificity.
**IgG**
\*RF and IgG join to form immune complexes that contribute to the disease process\*
**Prognostic** (can be used to monitor disease and is associated with worse prognosis)
83
What investigations would you do in inflammatory arthritis?
84
Radiographic changes in RA?
85
Pharmacological Management of RA?
COX inhib if patient has gastric symptoms
86
In addition to bone marrow suppression Methotrexate can cause _____ but importantly it does NOT cause lung fibrosis.
Acute Pneumonitis
87
Important complications of RA
**Osteoporosis**
**Cardiovascular Disease**
**Infection**
Felty's syndrome
Psychological impact
Sjogren's etc
88
HLA-B27 and Ankylosing Spondylitis are particularly associated with which other auto-inflammatory/ spondylarthropathy diseases?
**Uveitis**
**Psoriatic arthritis**
**IBD**
**Reactive Arthritis**
**Behcet's disease** (resembles other spondyloarthropathies in certain respects but in other ways is quite distinct. It is associated with **HLA-B51** rather than HLA-B27.)
89
Management of AS?
_Non-pharmacological:_
**Physiotherapy**! - most important
**Exercise**
_Pharmacological:_
_1st line_ - **NSAIDs** (Naproxen) + a protein pump inhibitor
**COX inhib** (Etoricoxib)
Disease- modifying-anti-rheumatic- drugs (DMARDs) such as _sulfasalazine and methotrexate are more useful in patients with enthesitis_ than axial symptoms, so are given in addition to analgesia in patients with concomitant peripheral disease. These drugs do not improve spinal inflammation.
Local steroid injections can be used as an adjunct - improve symptoms but do not prevent skeletal and thus radiographic changes.
Patients who have failed to control symptoms with NSAIDs/ have severe disease may be offered **TNF-alpha inhibitors** such as **Infliximab**.
There is good evidence that Inflixmab can improve both clinical and X-ray outcomes in ankylosing spondylitis.
90
Whilst RA is an autoimmune disease that results in the inflammation of the synovium, the pathophysiology of spondylarthropathies (i.e AS / Reactive, Psoriatic+ Enteric arthritis / Uveitis) primarily involves inflammation of the \_\_\_\_
**Entheses** (_enthesitis_) - where tendon or ligaments insert onto bone.
The unifying features of the spondyloarthropathies is inflammation involving entheses: enthesopathy. This is strongly associated with HLA-B27.
Remember presentation of heel and sole pain - due to plantar fasciiitis.
91
Dactylitis is inflammation of the entheses that develops into the swelling of the ____ and thus a 'sausage like' swelling of the entire finger.
Remember Psoriatic arthritis is a heterogeneous disease in that it can be polyarticular, oligoarticular, DIP (mimicking OA), can can have RA at same time etc.
Tendon Sheath
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Psoriatic Arthritis has classical radiographic features such as "\_\_\_\_\_" .
**Pencil cup erosion**
Severe version on the right is where fingers telescope into themselves is known as _arthritis mutilans_ - now very rare due to improvements in treatment options.
93
Treatment of Psoriatic arthritis is very similar to RA except that we need to be careful of ____ as these can cause _____ .
Steroids
Pustular Psoriasis or flare of skin psoriasis.
94
Which test is most likely to confirm a suspected diagnosis of axial spondylarthropathy?
**MRI** - **entire spine and Sacro-Iliac** joints
Used to be XRAY
95
Associations of AS.
**5 A's**
**Aortic regurgitation**
**Acute anterior uveitis**
**Apical Lung fibrosis**
**AV block**
**Achilles tendonitis**
96
Clinical features of systemic sclerosis (i.e organ systems affected)
**Cardiovascular**
* Raynaud's phenomenon.
* Pericarditis.
* Myocardial fibrosis which can cause heart failure and arrhythmias.
**Gastrointestinal**
* Oesophageal dysmotility. This can cause dysphagia or dyspepsia.
* Gastroparesis and Bowel hypomotility. This can cause bacterial overgrowth in the small bowel, or constipation in the large bowel.
**Respiratory**
* Pulmonary fibrosis (ILD)
* Pulmonary hypertension. This causes a picture of right heart failure, with exertional dyspnoea and fatigue or weakness with signs of right heart failure (eg. raised venous pressure, peripheral oedema, cardiac heave).
It can be asymptomatic for a long time before becoming rapidly apparent and so should be monitored for regularly with echocardiogram or diffusing capacity (DLco).
\*_***Pulmonary hypertension*** is more common in ***limited*** cutaneous SSc_, while pulmonary fibrosis and renal crises are more common in diffuse SSc\*
**Renal**
* _Scleroderma renal crisis_. This causes a rapidly progressive renal failure, usually with hypertension which can cause headaches and seizures.
\*\*Unlike renal disease in systemic lupus erythematosus and rheumatoid arthritis, scleroderma renal crisis is _not due to glomerulonephritis_, and so nephritic or nephrotic syndromes do not usually occur\*\*
Blood pressure and renal function should be frequently monitored.
97
Clinical Features of SLE
\*\***SOAP BRAIN MD**\*\*
**S** erositis (pleuritis, pericarditis – leads to \*\*Libbman Sacks\*\* endocarditis – *clot/vegetation at mitral valve*)
**O** ral ulcers
_**A** rthritis (\> 2 Joints)_ - \*similar picture to RA but arthritis is reversible unlike RA and patients can make a fist\*
**P** hotosentivity
**B** lood disorders (ex. haemolytic anaemia**)
R**enal disease (**glomerulonephritis -** proteinuria/haematuria)
**A** NA positive (antinuclear antibodies) – non-specific (most of the population have positive ANA – but if not present unlikely to be lupus)
**I** mmunological features (ex. Anti – dsDNA is a test used to help diagnose SLE)
**N** eurologic disease (ex. _seizures_ and _psychosis_ and _neuropathy_)
* *M** alar rash
* *D** iscoid rash
\*can also get livedo reticularis like APS\*
* Rare in children
* _More common in adolescent/reproductive age females_ (10X women: 1X men) – *Remember Czech patient Sara*. After menopause (2:1) – oestrogen thought to play a role
* Mainly \*\***Type 3 hypersensitivity**\*\* reaction **(antibody- nuclear antigen complex deposits in tissue**)
\*\*Remember whilst ESR is raised in SLE, **_CRP can be normal_**\*\*
98
Extra-muscular manifestions of myositis?
**Interstitial Lung Disease**
**Arthritis**
**Mechanics hands** (deep fissuring)
**Raynaud's Phenomenon**
and
**_Skin Changes:_**
A: **Gottren's papule**s (erythema over MCP/PIP/DIP) - **pathognomonic sign of DM**.
B: Dilated nail fold capillary (Many CT diseases)
C: **Heliotrope rash** is a violaceous (violet) peri-orbital erythema, with or without edema of the eyelids.
D: Calcinosis (more common in SS)
99
Life threatening manifestations of myositis?
Dysphagia
Respiratory/breathing compromise
100
Myositis is associated with ____ and in particular the ____ antibody
**Malignancy**
**TIF1-γ**
101
Sjogrens syndrome is associated with an increased risk of which malignancy?
Lymphoma
102
Visual symptoms in GCA?
Diplopia (double vision)
Amaurosis Fugax
Vision loss
103
GCA can be associated with polymyalgia rheumatica features such as \_\_\_\_.
**Shoulder** or **Pelvic Girdle** pain and stiffness
## Footnote
**Early Morning stiffness**
104
Potential complications of GCA include:
Stroke
Vision loss (permanent)
105
Management of GCA
* **IV prednisolone**
(**40mg** if no visual symptoms or jaw/tongue claudication
**or**
**60mg** if visual symptoms or tongue/jaw claudication)
Consider _IV Methylpredisolone_ (500-1000mg) if visual loss or stroke symptoms
* **Refer to ophthamology and rheumatology**
* **Urgent ESR/CRP** _(prognostic)_
106
Investigations in GCA?
**History/Examination**
**ESR/CRP**
**Temporal artery ultrasound**
**Temporal artery biopsy** (important to remember does not rule out GCA due to skip lesions in artery).
\*if evidence of large vessel vasculitis - MRI/CTA\*
107
Long term management of GCA following IV prednisolone in emergency.
**Steroid tapering**
**Bone Prophylaxis** (bisphosphonates)
**PPI**
**Blood sugar monitoring** (diabetes risk)
**Symptom monitoring**
**ESR/CRP monitoring**
**Steroid sparing** - (*_Tocilizumab_* IL-6 receptor antibody can be used effectively in steroid sparing/refractory/relapsing/confirmed disease)
Methotrexate and Leflunomide **(**inhibits urate metabolism) have also been shown to be effective steroid sparing agents
108
Clinical Features Small Vessel Vasculitis (i.e Granulomatosis w/polyangiitis or Esoinophilic granulomatosis w/ polyangiitis)
**Lung:**
Interstitial Lung Disease (both)
Wegener's - Cavitating lesions
Eosinophilic granulomatosis w/ polyangiitis - Asthma and pneumonitis/blood
**Renal** impairment
**Skin** (Rashes) - purpuric and palpable
**ENT (deafness)**
Wegener's - Erosive (saddle nose) / Ulceration and crusting/ Septal deviation/erosion)
Chrugg strauss or Eosinophilic - Allergic
**Neuro**
Peripheral neuropathy (both)
109
Risk Factors for Septic Arthritis
** Advancing age** (_particularly \> 80_)
** Joint prosthesis** / foreign material
** Immunosuppression** - medication, HIV infection
** Diabetes mellitus**
** Existing joint disease**, e.g. osteoarthritis, rheumatoid arthritis
** Causes of transient bacteraemia**, e.g. intravenous drug use **(IVDU)**
** Joint instrumentation**, e.g. intra-articular injection, arthroscopy
110
Investigations for an acute large joint monoarthritis that is erythematous/hot/swollen?
**Bloods:**
** Inflammatory markers** - FBC, ESR and CRP are all useful. In septicarthritis, you would expect the CRP to be higher than the ESR.
** Renal profile** - think about sepsis-related AKI and nephrotoxics. Also,CKD might be a risk factor for crystal arthropathy.
** Clotting** - useful to have prior to joint aspiration; deranged clotting may highlight risk of haemarthrosis.
** Serum uric acid** - a raised level may alert you to possible gout (but can be normal in approximately 1 in 3 patients).
** Blood cultures** - useful in most patients presenting with a febrile illness, particularly if there is going to be a delay to diagnostic joint aspiration.
**Imaging:**
** Plain x-ray** - this is particularly pertinent in a patient with a history of trauma, but can also be helpful to look for chondrocalcinosis in patients with calcium pyrophosphate deposition (see below).
** Other imaging** - students may read about the use of ultrasound. This can certainly aid aspiration of smaller joints and there are some specific signs that can be detected in acute gout. That said, its diagnostic utility is limited here. The same applies to other imaging modalities, e.g. CT and MR.
** Joint aspiration** - this is the gold standard test here. Ideally, aspiration should be performed before antibiotics are given. In practice, there is often a delay but this should be avoided if at all possible! That said, it’s worth highlighting that prosthetic joints should ordinarily be aspirated by an orthopaedic surgeon in theatre, which can cause some delay.
Joint fluid should be examined for:
o Cell count - **white cell count \> 50,000 cells/mm3 is strongly suggestive of septic arthritis**
o Differential cell count - predominantly neutrophils (polymorphs) present in bacterial joint infection
o Gram stain
o Culture
o Polarised light microscopy - looking for crystals
111
Differential Diagnosis of CPPD?
The differential diagnosis for the chondrocalcinosis seen in this case can be remembered by the mnemonic "HOGWASH."
Hyperparathyroidism
Ochronosis (alkaptonuria)
Gout
Wilson's disease
Arthritides (any)
(P)Seudogout: CPPD
Hemochromatosis.
Of the entities associated with chondrocalcinosis CPPD is by far the most common to affect the medial and lateral compartments of the knee.
https://medpix.nlm.nih.gov/case?id=e873f611-563c-4795-a978-509460a25243
112
“Gram positive cocci in clusters” is a typical description of ____ .
**Staph Aureus**
Other infecting organisms include:
Coagulase negative Staphylococci, particularly in prosthetic joints.
Gram negative bacilli, e.g. **E coli. - more common in elderly** patients, can be associated with **urinary tract infections**.
**Neisseria gonorrhoeae** - causes a different pattern of disease (typically a migratory oligoarthritis / tenosynovitis)
Atypical infections, e.g. tuberculosis, Lyme disease, fungal infections - these
are rare!
113
Clinical Triad of Disseminated Gonoccocal Infection? (DGI)
**Migratory Oligoarthritis** (usually of the small joints of the hands)
**Tenosynovitis** (2/3 of patients)
**Dermatitis** (Non specific - can be Maculopapular/Vesicular)
114
Management Septic Arthritis?
** Conservative -** rest, splinting, analgesia, early physio intervention as things improve, stopping immunosuppressive medications (methotrexate, biologic).
** Medical -** supportive fluid therapy, antibiotics as per local guidelines (typically two weeks intravenous and four weeks oral).
** Surgical -** washout is often required (sometimes repeatedly) to control the infection. This is because only the synovium is vascular so a septic arthritis behaves much like an abscess - antibiotics penetrate relatively poorly into the infected fluid.
