Rheumatology Flashcards

Question

What are the commonest affected joints in RA?

Answer 1

``` Metacarpophalangeal joints (MCP) Proximal interphalangeal joints (PIP) Wrists Knees Ankles Metatarsophalangeal joints (MTP) ```

Answer 2

Synovial joints Tenosynovium Bursa

Answer 3

Fever, weight loss | Subcutaneous nodules

Answer 4

vasculitis Ocular inflammation e.g. episcleritis Neuropathies Amyloidosis Lung disease – nodules, fibrosis, pleuritis Felty’s syndrome – triad of splenomegaly, leukopenia and rheumatoid arthritis

Answer 5

``` Central area of fibrinoid necrosis surrounded by histiocytes and peripheral layer of connective tissue Occur in ~30% of patients Associated with: Severe disease Extra-articular manifestations Rheumatoid factor ```

Answer 6

Rheumatoid factor | Antibodies to citrulinated protein antigens ACPA

Answer 7

Antibodies that recognize the Fc portion of IgG as their target antigen typically IgM antibodies i.e. IgM anti-IgG antibody! Positive in 70% at disease onset and further 10-15% become positive over the first 2 years of diagnosis

Answer 8

Antibodies to citrullinated peptides are highly specific for rheumatoid arthritis Anti-cyclic citrullinated peptide antibody ‘anti-CCP antibody’ Citrullination of peptides is mediated by enzymes termed: Peptidyl arginine deiminases (PADs)

Answer 9

Treatment goal: prevent joint damage Requires: Early recognition of symptoms, referral and diagnosis Prompt initiation of treatment: joint destruction = inflammation x time Aggressive treatment to suppress inflammation Drug treatment: Disease-modifying anti-rheumatic drugs (‘DMARDs’) = drugs that control the disease process

Answer 10

methotrexate in combination with hydroxychloroquine or sulfasalazine

Answer 11

Biological therapies offer potent and targeted treatment strategies New therapies include Janus Kinase inhibitors : Tofacitinib & Baricitinib Important roles for glucocorticoid therapy (prednisolone) but avoid long-term use because of side-effects. Multidisciplinary approach also important e.g. physiotherapy, occupational therapy, hydrotherapy, surgery

Answer 12

Biological therapies are proteins (usually antibodies) that specifically target a protein such as an inflammatory cytokine

Answer 13

1. Inhibition of tumour necrosis factor-alpha (‘anti-TNF’) antibodies (infliximab, and others) fusion proteins (etanercept) 2. B cell depletion Rituximab – antibody against the B cell antigen, CD20 3. Modulation of T cell co-stimulation Abatacept - fusion protein - extracellular domain of human cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) linked to modified Fc (hinge, CH2, and CH3 domains) of human immunoglobulin G1 4. Inhibition of interleukin-6 signalling Tocilizumab (RoActemra) – antibody against interleukin-6 receptor. Sarilumab (Kevzara) – antibody against interleukin-6 receptor.

Answer 14

Seronegative spondyloarthropathy – no positive autoantibodies Chronic sacroillitis – inflammation of sacroiliac joints Results in spinal fusion – ankylosis Common demographic: 20-30yrs, M Associated with HLA B27

Answer 15

``` Lower back pain + stiffness Early morning Improves with exercise Reduced spinal movements Peripheral arthritis Plantar Fasciitis, Achilles Tendonitis Fatigue ```

Answer 16

Normocytic anaemia Raised CRP, ESR HLA-B27

Answer 17

``` X-Ray MRI Squaring Vertebral bodies, Romanus lesion Erosion, sclerosis, narrowing SIJ Bamboo Spine Bone Marrow Oedema ```

Answer 18

Physiotherapy Exercise regimes NSAIDs Peripheral joint disease - DMARDs

Answer 19

Psoriasis is an autoimmune disease affecting the skin (scaly red plaques on extensor surfaces eg elbows and knees) ~10% of psoriasis patients also have joint inflammation

Answer 20

Unlike RA, rheumatoid factors are not present (“seronegative”)

Answer 21

Classically asymmetrical arthritis affecting IPJs But also can manifest as: - Symmetrical involvement of small joints (rheumatoid pattern) - Spinal and sacroiliac joint inflammation - Oligoarthritis of large joints - Arthritis mutilans

Answer 22

X-rays of affected joints – pencil in cup abnormality MRI – sacroiliitis and enthesitis Bloods – no antibodies as seronegative

Answer 23

DMARDs – methotrexate Avoid oral steroids – risk of pustular psoriasis due to skin lesions

Answer 24

Sterile inflammation in joints following infection especially urogenital (e.g. Chlamydia trachomatis) and gastrointestinal (e.g. Salmonella, Shigella, Campylobacter infections) infections

Answer 25

Enthesitis (tendon inflammation) Skin inflammation Eye inflammation

Answer 26

HIV or HepC infection

Answer 27

Commonly young adults with genetic predisposition (e.g. HLA-B27) and environmental trigger (e.g. Salmonella infection)

Answer 28

1-4 weeks after infection( may be mild infection).

Answer 29

Condition is usually self-limiting – can be managed with NSAIDS or DMARDs if required Reactive arthritis is distinct from infection in joints (septic arthritis)

Answer 30

Lupus = a multi-system autoimmune disease Multi-site inflammation: can affect any almost any organ. Often joints, skin, kidneys, haematology. Also: lungs, CNS involvement Associated with antibodies to self antigens (‘autoantibodies’) Autoantibodies are directed against components of the cell nucleus (nucleic acids and proteins)

Answer 31

1. Antinuclear antibodies (ANA): High sensitivity for SLE but not specific. A negative test rules out SLE, but a positive test does not mean SLE. 2. Anti-double stranded DNA antibodies (anti-dsDNA Abs): High specificity for SLE in the context of the appropriate clinical signs.

Answer 32

F:M ratio 9:1 Presentation 15 - 40 yrs Increased prevalence in African and Asian ancestry populations Prevalence varies 4-280/100,000