Rheumatology Flashcards
Side effects of corticosteroids:
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
Side effects of corticosteroids:
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
Side effects of corticosteroids:
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
Pseudogout tends to affect elderly _____ typically in the wrists/knees and is associated with _____.
women
hypothyroidism
_____, _____ and _____ antibodies are all associated with systemic sclerosis
Scl-70 (Anti-topoisomerase 1)
anticentromere
anti-RNA polymerase III
Reactive arthritis describes a triad of ___ , ____, and ____.
Arthritis
Urethritis
Conjunctivitis.
Reiter’s Syndrome is a type of Reactive Arthritis
Red flags for back pain:
New onset age ≤20 or ≥55.
Thoracic or cervical spine pain.
Pain is progressive or not relieved by rest.
Spinal (rather than paraspinal) tenderness.
Cancers that commonly metastasise to the bone can be remembered with the mnemonic:
BLT with a Kosher Pickle:
Breast
Lung
Thyroid
Kidney
Prostate
Felty’s syndrome is a triad of _____, _____ , and _____.
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.
____ , usually ____ , are the first-line systemic treatment for Raynaud’s phenomenon.
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.
Before starting biologics, ____ has to be screened for and treated first before starting biologics.
TB - mycobacterium tuberculosis
The main features of APS can be remembered with the mnemonic _____ :
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.
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.
20-30
males
Ankylosing spondylitis is highly associated with _____.
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
_____ 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.
Anterior ischaemic optic neuropathy
Central retinal artery occlusion is also a possibility in GCA - pale retina and cherry red spot
The main side effects of orally taken bisphosphonates such as alendronic acid are _____.
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.
_____ 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.
Churg-Strauss
pANCA
asthma
The x-ray features of osteoarthritis can be remembered with the mnemonic ____ :
LOSS
Loss of joint space.
Osteophytes.
Subchondral cysts.
Subarticular sclerosis.
Pseudogout is storngly associated with which biochemical abnormalities ____?
Haemochromotosis
Hypomagnesia
Hypophoshotaemia
Hyperparathyroidism
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
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)
Side effects of NSAIDs
Indigestion
Peptic ulcer disease,
Increased risk of venous thrombo-embolus
Peripheral oedema
Slight increased risk of stroke and heart attack
____ and diclofenac make up arthrotec (an NSAID sometimes used to treat joint pain).
Misoprostol (prostaglandin analogue)
Misoprostol can cause diarrhoea.
_____ antibodies are associated with anti-phospholipid syndrome.
Anti-cardiolipin
and
lupus anticoagulant
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.
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.
Polyarteritis nodosa is associated with which other disease?
Hepatitis B
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.
_____ are first line for renal hypertensive crises in systemic sclerosis.
ACE-i
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
Allopurinol is a _____ which reduces serum urate levels which can prevent future attacks of gout.
xanthine-oxidase inhibitor
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
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)
_____ 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
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.
______ 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
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
ECG with widespread ST elevation demonstrates _____ and can be associated with _____
Myocarditis
Granulomatosis with Polyangitis (Wegener’s Syndrome)
_____ 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
____ and ____ are autoantibodies specific to Sjogren’s syndrome and can be used to support the diagnosis.
Anti-Ro
and
Anti-La
Side effects of NSAIDs
SAK - Stomach, Asthma, Kidneys.
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.
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
_____ also known as calcium pyrophosphate deposition (CPPD) and pseudogout, is a condition where calcium pyrophosphate crystals build up in the joints.
Chondrocalcinosis
_____ (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
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
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.
Felty’s syndrome is a triad of ____.
rheumatoid arthritis
splenomegaly
neutropenia
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
The second line treatment for gout is ____ , where the most common side effects are ____ .
colchicine
diarrhoea (nausea and vomiting also)
Limited Systemic Sclerosis can be rememebered with the mnemonic ____
CREST
Calcinosis (calcium deposits in the skin)
Raynaud’s Phenomenon
Esophogeal Dysmotility (i.e GORD/Dysphagia etc.)
Sclerodactyly and ulceration
Telangectasia
Clinical features of Behcet’s Disease:
Recurrent oral ulceration
Recurrent genital ulceration
Uveitis
Erythema nodosum
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*
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)
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
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.
Initial tests that should be performed in a patient with suspected gout is arthrocentesis with _____ .
______ 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 Pseudogout and Positive Birefringence* - rhomboid shaped crystals
What is the management of Gout?
____ 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!
Reactive arthritis is associated with which other autoimmune conditions and thus which genetic abnormality?
Psoriasis
Alkylosing spondylitis
HLA-B27
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)
What investigations would you do in inflammatory arthritis?
Radiographic changes in RA?
Pharmacological Management of RA?
COX inhib if patient has gastric symptoms
In addition to bone marrow suppression Methotrexate can cause _____ but importantly it does NOT cause lung fibrosis.
Acute Pneumonitis
Important complications of RA
Osteoporosis
Cardiovascular Disease
Infection
Felty’s syndrome
Psychological impact
Sjogren’s etc
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.)
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.
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.
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
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.
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.
Which test is most likely to confirm a suspected diagnosis of axial spondylarthropathy?
MRI - entire spine and Sacro-Iliac joints
Used to be XRAY
Associations of AS.
5 A’s
Aortic regurgitation
Acute anterior uveitis
Apical Lung fibrosis
AV block
Achilles tendonitis
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.
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)
Renal 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**
Extra-muscular manifestions of myositis?
Interstitial Lung Disease
Arthritis
Mechanics hands (deep fissuring)
Raynaud’s Phenomenon
and
Skin Changes:
A: Gottren’s papules (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)
Life threatening manifestations of myositis?
Dysphagia
Respiratory/breathing compromise
Myositis is associated with ____ and in particular the ____ antibody
Malignancy
TIF1-γ
Sjogrens syndrome is associated with an increased risk of which malignancy?
Lymphoma
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)
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*
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
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)
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
“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!
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)
