Rheumatology Flashcards
Gout
- Acute Treatments and Mechanisms
- Chronic Treatments
Chronic
- Allopurinol or FebuXOstat
- Xanthine Oxidase inhibitor
- reduce urate production
- Xanthine Oxidase inhibitor
Acute
- NSAIDs
- Steroid
- PLP ase
- Colchicine
- Plant alkaloid
- Accumulates in WBCs - Canakinumab
- Interleukin-1 inhibitor
- Rasburicase
- In malignancy
Nocturnal pain
- Aetiologies
Nocturnal pains
- Destruction
- Inflammation
- Cancer
Ankle, Elbow, and Wrist pain
- Periarticular causes
Ankle pains
- RA: Tenosynovitis
- PsA:
- Achilles tendinitis
- Lateral epicondylitis - De Quervain’s
- Anatomical snuffbox
Patterns of pain
- Proximal joints only
- Small joint only
- Large joint only
- Large and small joints
- Symmetrical pattern
- Spinal involvement
Pain patterns
- Proximal joints
- PMR - Small joints
- Early RA - Large joints only
- OA - Large and small joints
- RA - Symmetrical
- RA - Spinal
- AS
Monoarthritis
- First DDx
Monoarthritis
- Septic till proven otherwise
Gout vs pseudogout
- Presentation
- Gout
- Men - Pseudogout
- Elderly women
- Severe OA
Chronic monoarthritis
- Infectious cause
Chronic infective monoarthritis
- TB
Chronic monoarthritis
- Non-inflammatory cause
Chronic monoarthritises
- OA
- Traumatic eg. meniscus
- Osteonecrosis
- Prednisolone use - Neuropathic
eg. Charcot’s
DIP Arthritises
DIP Arthritises
- PsA
- Nail dystrophy - OA
- Herbeden’s nodes
Gout
- Speed of swelling
Gout
- Swelling is very fast onset
- Around 1 hour
Fingers
- Bony Swellings?
Bony swellings
- Herbeden’s nodes
- Bouchard’s nodes
Mechanical AM stiffness
- Length
- Activity/rest effect
- Fatigue
- Systemic involvement
Mechanical AM stiffness
- <30 minutes
- Relieved on rest
- Minimal fatigue
- No systemic involvement
Inflammatory AM stiffness
- Length
- Activity/rest
- Fatigue
- Systemic involvement
Inflammatory AM stiffness
- > 1hour
- Better on activity
- Significant fatigue
- Systemic involvement
Rheumatology exam
- Face signs
Rheum Face Ex
- Dry mouth/Eyes
- RA + Sjogren’s - Mouth ulcers
- SLE + IBD + Reactive a. - Iritis
- Spondyloarthropath - Scleritis
- RA, GPA - Visual disurbance
- SLE (retinal vasc.) + GCA
Rheumatology exam
- Skin signs
Rheum Exam - Skin
- PsA
- Plaques, dystrophic nail - SLE
- Raynauds, Digital ulcers, Malar rash, photosensitivity, Livedo r., alopecia - Systemic sclerosis
- Raynaud’s
- Telangiectasia, calcinosis
- Digital ulcers, sclerodactyly - Acute sarcoid
- Erythema nodosum
Rheumatology exam
- GU signs
Rheum Exam - GU
- SLE
- HTN, eGFR,
- N-VH, frothy, miscarriage - Vasculitis
- HTN, eGFR, N-VH, frothy - Gout
- Renal stones - Reactive a.
- Vaginal/urethral discharge
SLE
- Neurologic signs
SLE Neurology
- Headache
- Seizures
- Psychosis
- TIA/CVA
SLE
- Cardio-resp effects
SLE Cardioresp
- SoB
- Pleural effusion
- Pericardial effusion
- Alveolitis - Chest pain
- Pleuritic
GPA
- Cardio-resp effects
Granulomatosis with poly ang.
- Cardio resp
- Pulmonary infiltrates
- Haemoptysis
- Sinusitis
RA
- Cardio-resp effects
RA Cardio Resp
- Pleural effusion
- Alveolitis
Rheumatological conditions
- Recurrent VTE
- Recurrent cytopenia
Rheumatological conditions
- Anti-phospholipid syndrome
- VTE - SLE
- Recurrent cytopenia
Anti-phospholipid syndrome
- CLOTs
APS (Hughes)
C lots
C oagulation defects L ivedo reticularis - Red/blue 'net' O bstetric (miscarriage) T hrombocytopenia
GALS Assessment
- Components
GALS Assessment
- Gait
- Arms
- Legs
- Spine
Full Rheum Exam
- Shoulder sign
Rheum Shoulder Sign
- Reduced External rotation
- Earliest LoF
Full Rheum Exam
- Early hip signs
Rheum hip signs
- Reduced vastus medialis
- Reduced internal rotation
Rheum exam
- Causes of kyphosis
Rhuem kyphoses
- Long standing AS
- And loss of lumbar lordosis - Osteoporosis
- Fractures
GALS
- Arms (5)
GALS Arm
- Inspect palm and dorsum
- Pincer and power grip
- MCPJ Squeeze
- Forearm movements
5 Shoulder movements
GALS
- Legs (6)
GALS Legs
- Inspect legs
- Hip rotation
- Knee effusion
- Knee movement
- Inspect feet
- MTPJ squeeze
GALS
- Spine (4)
GALS Spine
- Inspect
- Palpate supraspinatus
- Cervical lateral flexion
- Lumbar flexion
- Hip flexion
Two ataxic gaits
Ataxic gaits
- Cerebellar
- Wide staggering
- Arms out for balance - Sensory
- Wide stamping
- Ear and eyes used
Gaits
- Festinant/projectile
- Waddling
Gaits
- Festinant/projectile
- Difficulty intiating
- Shuffling run (festinare)
- Reduced arm swing - Waddling
- Duck-like
- Bilateral muscle weakness
Rheum Exam
- Skin signs
Rheum Skin Exam
- Calcinosis
- SLE
- Systemic sclerosis (s.derma) - Telangiectasia
- Scleroderma
- SLE
- Dermatomysositis - Psoriasis
ANA Association
SLE
SLE ANA
- dsDNA
ANA Association
- SLE and Sjogren’s
SLE and Sjogren’s ANAs
- Anti RO
- Anti-LA
ANA Association
- Systemic sclerosis
Systemic sclerosis ANAs
- Anti-centromere
- Anti-Scl70
ANA Association
- Polymyositis
Polymyositis ANA
- Anti Jo-1
ANCAs
- C ANCA
C ANCA
- GPA
(Granulomatosis w/ PA) - Infection
- Neoplasia
P ANCA
- Association
P ANCA
- MPA
(Microscopic PA) - . Infection
- Neoplasia
HLA association
- B27
HLA B27
- 10% of white people
- AS
- 90% of white people - Iritis
- Juvenile arthritis
Rheum Investigations
- SLE and Vasculitis
SLE & Vasculitis Ix
- Urine dip (protein/blood)
Methotrexate
- 5 ADRs
Methotrexate ADRs
- Nausea
- Oral ulcers, hair thinning
- Hepatitis, cirrhosis
- Pneumonitis
- Bone marrow suppression
Hydroxychloroquine
- 2 ADRs
Hydroxychloroquine ADRs
- GI
- Vision
- Retinal pigmentation
Sulfasalazine
- 4 ADRs
Sulfasalazine ADRs
- GI
- Rash
- Hepatitis
- Bone marros
Cylophosphamide
- 3 ADRs
Cyclophosphamide ADRs
- Marrow suppression
- Infertility
- Cancer risk
Azathioprine
- 2 ADRs
Azathioprine ADRs
- GI
- Marrow supression
Ciclosporin
- 2 ADRs
Ciclosporin ADRs
- Renal impairment
- HTN
RA
- Pathogenesis
RA Pathogensis
- T&B cell anti-bodies
- to Fc of IgG (RF)
- to Citrullinated cyclic p. - Macrophage TNFa
- Synoviocytes
RA Mx
- Chronic
- Acute
RA Mx
- Chronic monotherapy
- Methotrexate - Chronic combination
+ Leflunomide
+ Hydroxychloroquine
+ Sulfasalazine - Acute Steroids
- PO
- IM
- I-art - NSAIDs
- for symptoms
- + PPI
- If not CI’d
RA
- LESS
RA LESS
L oss of joint space
E rosions (periarticular)
S oft tissue swelling
S ubluxation
GCA
- Pathogenesis
GCA
- HLA II Granulomatous vasculitis
- Over 50yrs (72 median)
- Chronic vaculitis
- Large vessels
- Medium vessels - AION
- Anterior ischemic optic neuropathy
- Opthalmic emergency
GCA
- RFs
GCA RFs
- Age
- Female
- PMR (50%)
GCA
- Presentation
GCA S&S
- Headache (70%)
- Localised
- Unilateral
- Boring/lancinating
- Jaw claudication - Constitutional symptoms
- Aching - Scalp tenderness
- Visual disturbance/loss
GCA
- Dx
GCA Dx
- New headache/tenderness
- ESR, CRP, PV
- Visual symptoms
- Biopsy
GCA
- Mx
GCA Mx
- Prednisolone
- PO, OD
- Taper after two weeks - Acute visual
- IV Methylprednisolone
- 1-3 days - Low dose aspirin
PMR
- Presentaton
PMR Pres
- <60 yo
- Proximal limb pain/stiffness
- Neck & shoulders
- Hips - Night time pain
- Systemic (25%)
PMR
- Mx
PMR Mx
- Prednisolone
- PO, OD
- Fast response & slow taper - Methotrexate
- Steroid sparing
Spondyloarthropathies
- Group of 4
Spondyloarthropathies
- AS
- PsA
- Reactive A.
- Enteropathic A.
Ankylosing Spondylitis
- Presentation
AS Pres
- Young men
- Teens-mid-thirties - Pain
- Buttock, chest - Later changes
- Positive Schober’s
- Reduced chest expansion
Ankylosing spondylitis
- Mx
AS Mx
- NSAIDs and physio
- TNF inhibitors
- Infliximab/adalimumab/Etanercept - IL-17 inhibitors
- Secukinumab
PsA
- Presentation
PsA Pres
- 10% with Psoriasis
- Oligo-arthrtis
- Symmetrical or mono - Dactylitis
- Pencil-in-cup x-ray
PsA
- Mx
PsA Mx
- NSAIDs
- DMARDs
- Methotrexate
- Ciclosporin - TNFi
- Etanercept
- Infliximab - IL inhibitors
- 17 Secukinumab
- 12/23 Ustekinumab
Reactive arthritis
- Pathogenesis
Reactive arthritis pathogenesis
- Distant infection
- Post dystentery
(Salmonella/shigella/camp.)
- Post urethritis - Acute arthritis
- Lower limb
- Asymmetrical
Reactive arthritis
- Pres
Reactive Arthritis
- Post-infective
- Days - 2 weeks - Acute arthritis
- Lower limb
- Asmmetrical - Can’t see, can’t wee
- Circinate balanitis
- Conjunctivitis
- Uveitis
- Enthesitis
- Tendon joining bone
Reactive arthritis
- Mx
Reactive arthritis Mx
- Treat infection
- NSAIDs
- Joint injections
- Resolve within 2 years
- Refractory (HLA-B27+)
- DMARDs
- Sulfasalazine
Enteropathic arthritis
- Pathophysiology
Enteropathic arthritis
- IBD 10-20%
- 2/3 peripheral
- 1/3 axial - Peripheral Type 1
- Correlates with flares
- Oligoarticular
- Asymmetric - Peripheral Type 2
- Correlates less with flares
- Polyarticular
- Symetrical
Enteropathic arthritis
- Mx
Enteropathic Arthritis Mx
- NSAIDs
- May flare IBD - DMARDs
- TNFi
Ankylosing spondylitis
- 5As
Ankylosing spondylitis
- Anterior uveitis
- Aortic incompetence
- AV Block
- Apical lung fibrosis
- Amyloidosis
SLE
- SOAP BRAIN MD
SLE
S erositis
O ral ulcer
A rthritis
P hotosensitivity
B loods low R enal compromise A NA +ve I mmunologic N eurology (seize/psych)
M alar Rash
D iscoid Rash
SLE
- Mx
SLE Mx
- Lifestyle
- CVS
- Sun protection - Meds
- Hydroxychloroquine
- Prednisolone flares
- Mycophenolate/aza/ritux
Raynaud’s
- Colour changes
Raynaud’s colours
- White
- Low flow - Blue
- Venous stasis - Red
- Hyperaemia
Raynaud’s features
- Incidental Rheumatoid Findings
Rheumatoid Raynaud’s
- Nail-fold capillaries
- Systemic sclerositis
- Dermatomyositis (DM) - Puffy fingers
- Photosensitivity
Raynaud’s
- Rheumatoid associations
Rheumatoid Raynaud’s
- Scleroderma
- SLE
- Dermato/polymyositis
- Sjogren’s
Raynaud’s
- Mechanical causes
Mechanical Raynaud’s
- Vibrating tools
- Cervical rib
Thoracic outlet syndrome - Cryoglobulinaemia
- Sticky blood - Beta-blockers
Raynaud’s
- Management
Raynaud’s Mx
Conservative
- Keep warm
- Smoking cessation
Medical
- CCB
- PDE-5 and prostacyclins
- Sildenaphil
- Iloprost
Vasculitis
- Four small vessel disease
Small Vessel Disease
- MPA
- GPA
- Wegener’s - EGPA
- Churg-Strauss - IgA
- Henoch-Schonlein Purpura
Vasculitis
- Two medium vessel diseases
Medium vessel disase
- PAN
- Polyarteritis nodosa - KD
- Kawasaki disease
Vasculitis
- Two large vessel disease
Large vessel disease
- GCA
- TAK
- Takayasu arteritis
Vasculitis
- Commonest aetiology
Vasculitis
- Commonly Secondary
- Infection
- Drugs
- Malignancy
- Ct disease
Vasculitis
- Mx
Vasculitis Mx
Secondary
- R/O infection
- Stop drugs
Medical
3. CSTs
- Second line
- Cytotoxic
- Immunomodulatory
- Biologics
Myositis
- Presentation
- DM
- PM
DM and PM Pres
- 40-50
- Proximal muscle weakness
- Painless
- SoB
- Rash
- Dorsal hand (Gottron’s)
- Pigmentation change - Mechanic’s Hands
- Cracked palms
- Cracked fingers - Raynaud’s
Myositis
- Mx
DM and PM Mx
Lifestyle
1. Sun protection
Medical
2. CSTs
- DMARDs long-term
- Methotrexate
- Azathioprine
- HCQ for rash - Second line
- Rituximab
- IVIG
Systemic Sclerosis
(Scleroderma)
CREST
Scleroderma CREST
C alcinosis cutis R aynaud's E osophageal dysmotility S clerodactyly T elangiectasia
Systemic Sclerosis
(Scleroderma)
- Mx
Systemic sclerosis Mx
- No ‘cure’
Conservative
1. Psychological support
Medical
2. Raynaud’s management
- Skin thickening
- Methotrexate
- Mycophenolate - HTN
- ACEi - Flares
- Short prednisolone - GI
- PPI
Sjogren’s
- MAD FRED
Sjogren’s MAD FRED
M yalgia
A rthralgia
D ry mouth
F atigue
R aynaud’s
E nlarged parotids
D ry eyes
Sjogren’s
- Mx
Sjogren’s Mx
Conservative
1. Avoid dry/smoky areas
Medical
2. Artificial tears
- Artificial saliva
- Gum/pastilles
- Sugar free - Emolients
- Skin
- Lubrication - Rarely Immuno/steroids
Sjogren’s
- Associations
Sjogren’s Associations
- RA and SLE
- Coeliac, PBC, Thyroid
- 5-10% Lymphoma risk
- Fetal
- Loss
- Heartblock
- Lupus syndrome
Hypermobility spectrum
- S&S
HSD S&S
- Soft tissue rheumatism
- Epicondylitis - Skin
- Thin, striated
- Papyraceous
- Hyperextensible - Marfanoid
- Myopia, drooping lids
- Hernias and prolapses
Hypermobility
- Management
Hypermobility Mx
- Strengthening exercises
- Subluxation - Specialist pain mx
- Splinting/surgery
Fibromyalgia
- S&S
Fibromyalgia S&S
- Stiffness
- Profound fatigue
- Numbness
- Headaches
- IBS
- Depression and anxiety
- ‘Fibrofog’
Fibromyalgia
- Mx
Fibromyalgia Mx
- Pain
- Amitryptyline
- Pregabalin - CBT
Osteoporosis
- Ix
OP Ix
- DEXA
- Dual energy absorbiometry - T-score from age range
- OP is >2.5 SDs
- Osteopenia is 1-2.5 SDs - Z-Score age and gender
Osteopenia
- Mx
Osteopenia Mx
Conservative
- Weight-bearing exercise
- Alcohol and smoking
- Dietary calcium
Medical
2. Vit D3
Osteoporosis
- Mx
Osteoporosis Mx
- Vit D
- Oral bisphosphonate
- Or IV - Second line
- Denosumab
- Teriparatide (PTH)