Rheumatology Flashcards
1
Q
Extra articular manifestations of RA
A
rheumatoid nodules, episcleritis, peripheral sensory neuropathy, pericardial effusion (exudate)
2
Q
RA XR
A
LOES: loss of joint space, osteopenia, erosion of bone, swelling of soft tissue
3
Q
FBC & autoantibodies for RA
A
CRP raised +/- ESR. RF (often false positive) & cyclic citrullinated peptide (CCP - rarely false positive, indicates severe disease)
4
Q
how long do DMARDs take to work
A
up to 6 weeks
5
Q
Methotrexate SE
A
given with folate.
nausea, mouth ulcers, diarrhoea, abnormal LFTs, neutropenia, thrombocytopaenia, renal impairment
6
Q
Sulfasalazine SE
A
used in young people & women
drug induced lupus in ANA positive pts
7
Q
hydroxychloroquine SE
A
irreversible retinopathy
8
Q
what does leflunomide do
A
blocks T cell proliferation
9
Q
examples of TNFa blockers
A
infliximab, etanercept, adalimumab
10
Q
why are B cell inhibitors useful in RA
A
they produce RF
e.g. rituximab
11
Q
tissue type that everyone with seronegative arthritis has
A
HLAB27 (chromosome 6)
not everyone with HLAB27 has disease
12
Q
what is enthesitis
A
swelling of bone & tendons
13
Q
seronegative/spondylarthritis mneumonic
A
SPINEACHE Sausage Digits (dactylitis); Psoriasis; Inflammatory back pain; NSAID (works well); Enthesitis (heel); Arthritis; Crohn's/Collitis/elevated CRP; Hlab27; Eye (uveitis)
14
Q
what nail involvement predicts arthritis in patients with psoriasis
A
pitting, onycholysis (white nails lifting off), subungual hyperkeratosis, ridging, thickening, crumbling, colour changes
15
Q
Different presentations in psoriatic arthritis
A
mostly peripheral, DIP & PIP, arthritis mutilans (deforming -> telescoping fingers), dactylitis, asymmetrical large joints; spine; psoriasis
16
Q
bloods in psoriatic a
A
CRP not significantly raised
17
Q
alternative name for reactive arthritis
A
Reiters Disease
18
Q
what infections cause reactive arthritis
A
STIs: chlamydia, gonorrhoea
GI: Salmonella enteritidis, Shigella flexneri, and S. disenteriae, Yersinia enterocolitica, Campylobacter jejuni, Clostridium difficile
19
Q
how long after infection does reactive arthritis peak
A
2-3 weeks (can start 2 days after)
20
Q
what are joints like in reactive arthritis
A
sterile
21
Q
classical presentation for reactive arthritis
A
triad of arthritis, conjunctivitis & sterile urethritis
can also have keratoderma blennorrhagia (brown scaley rash on feet) & circinate balanitis (genital inflamation)
22
Q
what do you get in ankylosing/axial spondylitis
A
syndesmophytes
23
Q
ankylosing/axial treatment
A
anti TNF drugs, IL17 blockers, JAK inhibitors
24
Q
who gets enteropathic arthritis
A
20% IBD pts
25
presentation of enteropathic arthritis
assymetric lower limb, usually reflects bowel activity, typically not erosive
26
joints effected in gout
in order: big toe (1st MTPJ), feet, ankles, knees, elbows, hands. Doesnt effect: shoulders, hips, spine
27
how do urate crystals form
purines -> hypoxanthine -> xanthine -> uric acid -> excreted by kidneys OR monosodium urate crystals.
Xanthine oxidase
28
causes of gout
too high intake (alcohol, fructose, excess meat, shellfish, offal, yeast, or myeloproliferative disease, psoriasis, tumour lysis syndrome etc.
or too low excretion: renal impairment, thiazide diuretics, aspirin, certain drugs
29
why does alcohol increase gout
alcohol competes with uric acid for excretion
30
gout on microscopy
negatively birefringent needle shaped crystals
31
chronic gout prevention
allopurinol (xanthine oxidase inhibitor) or febuxostat. increases gout initially so coprescribe with NSAIDs/cochicine (SE: diarrhoea) for 6 months)
32
crystal in pseudogout
pyrophosphate
33
joints in pseudogout
knees > wrists > shoulders > ankle > elbows
34
risk factors pseudogout
haemochromotosis, hyperparathyroidism, hypophosphatasia, hypomagnesaemia, hypothyroidism, acromegaly
35
microscopy for pseudogout
weakly positive birefringent rhomboid shaped crystals
36
antibody in connective tissue diseases
ANA
37
bloods in SLE
ESR raised, CRP not. CRP only goes up if interpretive infection
blood counts tend to be low
38
antibodies in SLE
ANA (sensitive), dsDNA (specific but not present in all)
39
SLE complication
lupus nephritis (nephrotic syndrome & renal failure
40
radiological signs of osteoarthritis
JOSSA
Joint space narrowing, osteophytes, subchondral (& periarticular) sclerosis, subchondral cysts; abnormalities of bone contour
41
signs of osteoarthritis on hands
Heberden's nodes (DIP) & bouchards nodes (PIP)
42
what changes do you see in bone structure with age
decreased trabecular thickness, decrease in connections between horizontal trabeculae, decrease in trabecular strength, remodelling frequency increases
43
why is Cushing's a risk factor for osteoporosis
cortisol increases resorption & osteoblast apoptosis
44
antiresorbative treatment for osteoporosis
bisphosphonates (inactivate osteoclasts) e.g. alendronate, zoledronate
Denosumab - monoclonal antibody that inhibits RANKL
45
anabolic osteoporosis treatments
increase osteoblast activity & formation
| teriparatide (PTH analogue). 2nd line, expensive
46
where is haematogenous seeding most common in children vs adults
children: long bones
adults: vertebra
47
why is haematogenous seeding most common in the metaphesis (when in long bones)
blood is slower, absent basement membrane, lacking/inactive phagocytic lining.
even more blood flow in children (with age, vertebra get more blood flow too)
48
most common causative organism for spine infection (osteomyelitis)
staph aureus (can survive inside macrophages)
49
common osteomyelitis causative organisms in healthy people
staph aureus, coagulase negative staph, aerobic gram negative bacilli
50
osteomyelitis causative organism in sickle cell
salmonella
51
osteomyelitis causative organisms in IVDU
P. aeruginosa & serratia marcescens
52
XR signs of osteomyelitis
bony destruction, abnormal bone density, digital vascular calcification, cortical erosion, periosteal reaction, mixed lucency, sclerosis, sequestera, soft tissue swelling
On MRI - increased white signal = inflammation
53
septic arthritis common organisms
same as osteomyelitis. used to be haemophilus influenza in children under 2, now vaccinated
54
common joints for septic arthritis
knee>hip>shoulder. 90% monoarthritis
55
antibiotics for staph aureus
flucloxacillin, erythromycin, doxy/tetracycline
56
most common bacteria in prosthetic joint infection
coagulase negative staph, staph aureus
57
where does osteosarcoma occur
metaphysis of long bones (often knee, proximal humerus)
58
where does osteosarcoma metastasize to
lung
59
what staging system do primary bone tumours use
Enneking System
60
what staging system do primary bone tumours use
Enneking System (IA-> III)
61
what does Mirel's scoring system show
chance of periprosthetic fracture within 12 months
62
what is osteomalacia
weak bones, due to defective mineralisation of newly formed bone matrix (osteoid) usually due to vitamin D deficiency
63
Diagnostic criteria for RA
RF RISES
Rheumatoid factor positive; Finger/hand/wrist involvement; Rheumatoid nodules present; Involvement of >3 joints; Stiffness in morning for >1hr; Erosions on XR; Symmetrical involvement.
Need >4 of above for >6 weeks
64
Sensitivity vs specificity
Sensitivity: ability of a test to correctly identify those with a disease
Specificity: ability of a test to correctly identify those without a disease
(In context: hightly sensitive: few false negatives highly specific: few false positives)
65
What is felty syndrome
Rheumatoid arthritis + splenomegsly & granulocytopenia
| Treat RA and it will help the rest of the triad
66
Bisphosphonates side effects
Oesophagitis, jaw necrosis
| Give meds in morning then stand up straight to make sure goes into stomach
67
Advantage of zoledronate over alendronate
Zol can be given once a year as an injection
68
What type of hypersensitivity is SLE
Type 3
69
What is antiphospholipid syndrome
Antibody mediated acquired thrombopholia characterised by thrombosis and or recurrent miscarriages.
Associated with SLE in 20-30%
70
Antiphospholipid syndrome s&s
Coagulation defects - dvt, MI etc
Livedo reticularis - discolourisation of leg
Obstetric issues
Thrombocytopenia
71
Antiphospholipid diagnosis
```
1 clinical (vascular event, pregnancy morbidity)
1 lab (anticardiolipin, lupus anticoagulant, anti beta 2 glycoproteins 1 antibody)
```
72
Antiphospholipid treatment
Lifestyle - no smoking etc
Warfarin long term
Manage clots etc
73
S&s sjogrens
Dry eyes, parotid gland enlargement, joint pain, raynauds, systemic features
74
Sjogrens diagnosis
Schirmer tear test, rose Bengal staining & slit lamp exam. Rheumatoid factors, ANA, anti Ro, anti La
75
What is systemic sclerosis
Autoimmune disease with increased fibroblast activity (increased collagen deposition) resulting in abnormal growth of connective tissue. High mortality
76
Systemic sclerosis s&s
Limited: skin involvement - hands, face, feet, forearms; beak like nose, small mouth, microstomoa
& diffuse: widespread skin changed, raynauds, gi, renal, lung involvement
77
Polymyositis
Rare muscle disorder with inflammation and necrosis of skeletal muscle. Defmatomyositis get skin involvement too
78
Polymyositis signs
Proximal muscles of shoulder and pelvic girdle effected, pain & tenderness uncommon. Can lead to resp failure if respiratory muscles involved
79
Dermatomyositis sigsn
Heliotrope (purple) discolouration of eyelids. Scaly erythematous plaques over knuckles (gottron lesions)
80
Polymyositis diagnosis
Serum creatinine kinase etc
| ANA, ant jo1, anti mi2
81
Pagets
Localised disorder of bone remodelling - increased resorption and increased formation of weaker bone. Rare Under 40
82
Pagets signs
Bowed tibia
Skull changes (can cause deafness & hydrocephalus)
(Bone pain etc)
83
Pagets diagnosis
Increased ALP, urinary hydroxyproline
84
Pagets treatment
Bisphosphonates
| Nsaids
85
Hyperuricaemia definition (values)
>420umol/l in men
| > 360umol/l in women
86
1st line investigation for gout
Bloods
87
Gold standard investigation for gout
Joint aspiration (incase of septic arthritis)
88
First line treatment for gout
Colchicine & nsaids
89
What is osteomyelitis
Infection of bone marrow
90
Joint effected in ank spon
Sacroiliac joint
91
Reactive arthritis mnemonic
Can’t see (uveitis)
Can’t pee (urethritis)
Can’t climb a tree (enthesitis)
92
Psoriatic arthritis xr sign of telescope fingers
Pencil in cup
93
Treatment for all hlab27
```
Pain management (very responsive to nsaids) or corticosteroids
Biological therapy - infliximab
```
94
Neuropathic pain relief drugs
TCA, gabapentin, pregabalin
95
What cancer do you see onion skin in
Ewing’s sarcoma
96
Secondary bone tumours
```
Lead kettle (PBKTL)
Prostate, breast, kidneys, thyroid, lungs
```
97
Wegeners granulomatosos
```
cANCA positive
Hearing loss, sinusitis, nose bleeds
Saddle shaped nose
Treated with steroids and immunosuppressants
Aka granulomatosis with polyangitis
```
98
SLE complications
CVD, infection, anaemia, pericarditis, pleuritic, ILD, lupus nephritis, neuropsychiatric SLE, recurrent miscarriage, VTE
99
Skull appearance on XR in pagets
Cotton wool appearance
100
RA treatment 1st - 4th line
1. DMARD
2. 2 dmards
3. + biologic (usually anti tnf)
4. Rituximab
101
Polymyalgia rheumatica
Inflammatory disorder causing pain stiffness and inflammation in the shoulders, neck and hip muscles
102
Causes of raises creatinine kinase
```
Dermato/polymyositis
Rhabdomyolysis
AKI
MI
Statins
Strenuous exercise
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