Rheumatology Flashcards
What is the first line management of an acute monoarthritic join
Joint Aspiration for WCC, gram stain and culture
Name two benefits of joint aspiration
Protects the joint from destruction
Can diagnose
What is the first line management for a patient with prosthetic joint infection
Refer to orthopaedics for full wash out and replacement
Onset of Ankylosing Spondylitis
20-30
What gene is involved in Ankylosing Spondylitis
HLA-B27
Features of AS
Inflammatory back pain: early morning stiffness and tenderness of sacroiliac joint
SPINEACHE:
Sausage digits (dactlitis)
Psoriasis
Inflammatory back pain
NSAID good response
Enthesitis
Arthritis
Chron’s or Colitis elevated CRP]HLA-B27
Eye (uveitis)
Reduced chest expansion and poor lumbar flexion (schober test)
Name some extra-articular features of AS
Upper lobe pulmonary fibrosis
aortitis -> aortic regurgitation
Name four diseases associated with HLA-B27
AS
Reactive Arthritis
Psoriatic Arthritis
Enteric Arthropathy
How can we diagnose Ankylosing Spondylitis
X-Ray showing development of syndesmophytes and BAMBOO SPINE
MRI (MOST SENSITIVE) - shows sacroillitis
What are syndesmophytes
Bony bridges between adjacent vertebrae
Pharmacological treatment of AS
NSAIDs
Second Line: DMARDs (especially if enthesitis is present over axial symptoms)
If someone with AS does not respond to NSAIDs, what is given
Infliximab
What serum should be checked for pernicious anaemia
Intrinsic factor antibodies
Name three antibodies found in coeliac’s
Anti tTg
IgA anti-endomysial
Anti-gliadin
In what condition are antimitochondrial antibodies found in
Primary biliary cirrhosis
In what condition are anti smooth muscle antibodies foundin
Autoimmune hepatitis
What antibodies are found in goodpasture’s syndrome
Antibdodies against collagen IV
What antibodies are found in granulomatosis with polyangitis
cANCA
What is the specific anti bodies found in SLE
Anti-Dsdna and Anti-Smith
What is the most sensitive antibodies for RA
Anti-CCP
What antibodies are found in Sjogren’s
Anti-Ro and Anti-La
What antibody is found in diffuse cutaenous systemic sclerosis
Anti-Scl-70
What autoantibody is found in limited cutaneous systemic sclerosis
Anti-centromere
What autoantibody is found in dermatomyositis
Anti-Jo1
Symptoms of APS
CLOT:
Clots
Livedo Reticularis (lace like mottled rash on lower skin)
Obstetric Loss
Thrombocytopenia
What cardiac symptoms can be found in APl
Aortic and mitral regurgitation
Name three autoantibodies seen in APL
ANti-cardiolipin antibodies
Anti-beta2-GPI antibdoies
Positive lupus anticoagulant
What condition can cause the APL blood tests to be false positive
Syphilis
What should APL be treated
Only when a thromboembolic event has taken place
Name four red flags for back pain
Onset <20 or >55
Thoracic or cervical spine pain
Pain is progressive or not relieved by rest
Spinal tenderness
What improves pain in AS
MOvement
Symptoms of Behcet’s disease
Oral ulcers
Genital ulcers
Erythema nodosum
Gout vs Pseudogout
Gout: negatively birefringent and needle-shaped
Pseudogout: Positively bifringent and rhomboid shaped crystals
What compound causes pseudogout
Pyrophosphate dihydrate crystals
Name two blood tests important to monitor in gout
Uric Acid
Renal Functions
What X-Ray finding is distinctive in pseudogout
Chondrocalcinosis (calcification of cartilage)
Symptoms of dermatomyositis
Purple rash on eyelids
Shawl sign positive
Gottron’s papules (red scaly patches over MCP joint)
Invetsigations for dermatomyositis
CK
EMG
Muscle Biopsy
Risk Factors of Reactive Arthritis
Male
HLA B27
Previous GI or STD
Name a GI species that can cause reactive arthirtis
Shigella
Describe the onset of arthritis in reactive arthirtis
Peripheral arthritis after 1-4 weeks of infection : Asymmetrical oligoarthritis of the lower limb
Sacroiliac and lumbrosacal arthitis
Keratoderma blenhorragia
Conjunctivities, uveitis
Mucosal ulcers
What is Felty Syndrome
RA
Splenomeglay
Neutropenia
How to manage felty syndrome
Same as RA
Name some medications that can cause gout
Thiazide diuretics
ACEi
Aspirin
What diet can cause gout
Sea food
Why can chemotherapy cause GOUT
Hyperuricaemia in tumour lysis syndrome
What is the first line test for gout
Synovial fluid analysis to EXCLUDE septic arthritis
When should uric acid levels be checked during investigation
2 weeks after the attack as they can be falsely normal
Management of an acute gout attack
NSAID: Indomethacin
Second Line: Colchicine
When shoudl colchicine be given over Indomethacin
When patient has GI side effects, past kidney or heart failure
What is a side effect of colchicine
Diarrhoea
If a patinet is experiencing diarrhoea on Colchicine, what should be done
Administer INtra-articular steroids
When should allopurinol be indicated
PROPHYLAXIS:
Start two weeks after attack
Name the criteria for prophylactic allopurinol
More than 2/3 attacks a year
Tophaceous gout
X-Ray shows joint destructino
Urate nephrolithasis
Polyarticular attacks are disabling
If allopurinol is contraindicated, what can be given
febuxostat
Symptmos of granulomatosis with polyangitis
URTI: Epixstasis, chonric sinusitis or saddle-nose
LRTI: Cough, Haemoptysis, pleuritis
pANCA and c-CANCA positive: Haematuria and proteinuria
X-Ray findings in granulomatosis with polyangitis
Bilateral lung infiltrates
What scoring system is used to determine hypermobility
Beighton score
What beighton score indicates hypermobility
4 or more
Management of hypermobility syndrome
Referral to physio
What histological appearance indicates IgG4 disease
tumefacien lesions with dense lymphocytic infiltrates and storiform fibrosis
Symptoms of IgG4 related disease
swelling of slaivary and lacrimal glands
and ent sinuses
What is a common extraarticular sign in IgG4 disease
Pancreatitis and sclerosing cholangitis
Management of IgG$ disease
Rituximab
How is Marfan’s syndrome inherited
Autosomal dominant
Physical appearance of Marfan’s syndrome
Disproportionately tall and thin with unusually long arms and legs
Arachnodactyly (long spider fingers)
High arch palate
Name some CV features of Marfan’s
Aortic Regurgitation
Aortic root dilatation
Mitral valve prolapse
Abdominal aortic aneurysm
Eye symptoms in Marfan’s Syndrome
Lens Discolouration
Closed angle glaucoma
Medical management of marfan’s
BP control
How often is Methotrexate given
Once a week 2.5mg
How do we increase the dose of methotrexate
Titrate up by 2,5mg a week
Side effects of methotrexate
Cytopenia
Hepatotoxicity
Renal Impairmebt
Pulmonary Fibrosis
Teratogenicity
When should methotrexate be stopped
If LFTs are greater than 3 x from baseline mesaurement
What advice shohuld patients on methotrexate be given regarding contraception
Use while on it and for three months after
Name another antifolate medication other than methotrexate
Trimethoprim
What has to be prescribed alongside methotrexate
Folic Acid
How often is folate acid given alongside methotrexate
Once a week but one DIFFERENT days
What is the antidote for methotrexate
Folinic acid
Signs of microscopic polyangitis
Necrotising glomerulonephirtis
Fevers, weight loss, malaise
Palpable purpura of lower extremities
Mononeuritis multiplex
Alveolar haemorrhage (haemoptysis)
What causes OA pain to worsen
Movement
How long is morning stiffness with OA
Less than 20 mins
X-Ray features of OA
LOSS:
Loss of joint space
Osteophytes
Subchondral cysts
Subchondral sclerosis
Conservative management of OA
Weight loss and excercise
Pharmacological management of OA
NSAIDs
Name the triad needed to diagnose OA
> 45
Activity related joint pain
No stiffness lasting for 30 mins or more
What nodes are affected in OA
Heberden’s AND BOucnhard’s
When should topical NSAIDs be considered for OA
People with knee or hand OA
Other than topical NSAIDs what else is an adjunct treatment in hand or knee OA
TOpical capsaicin
If paracetomal or topical NSAIDs are insufficient in controlling hand and knee pain, what is given secondl ine
Oral COX-3 or switch NSAID
When should intraarticular injections be considered in OA
If pain is severe
When should Referral to orthopaedics be done for OA
If significantly affecting ADLs and severe pain, or functional limitation
What disease is associated with polyarteritis nodosa
Hep B
What part of the body is not affwected in Polyarteritis Nodosa
PULMONARY vessels (no lung symptoms)
First line investigation (blood test) for suspected polymyalgia rheumatic/ GCA
ESR (raised)
What is the definitive diagnosis for GCA
Temporal artery biopsy
Management of GCA
60mg OD Prednisolone (high dose)
When should prednisolone be stopped in GCA
over 1-2 years after the attack
What prophylaxis is given for GCA
Low dose aspirin
ONset of polymyalgia rheumatica
50+
Symptoms of polymyalgia rheumatica
Shoulder and hip girdle stiffness for over 1 hour
Low grae fever, reduced appetite and weight loss
Polymyalgia rheumatica vs polymyositis
Myositis: Proximal bilateral weakness with NO PAIN
PR: PAIN and STIFFNESS but no weakness
What ESR threshold indicates polymyalgia rheumatica
> 60
Treatment of polymyalgia rheumatica
First DEXA scan and check history to reduce risk of ulcers.
THEN steroids
Are muscle bulk and reflexes affected in myositis?
No, not until very late in the disease
Extra MSK symptoms of myositis
Later on:
Respiratory failure
Dystonia and dysphagia
Onset of myositis
40-60
Pulmonary sign of myositis
Interstitial lung disease
Name tow CV symptoms of polymyositis
Raynaud’s and myocarditis
Most common malignancy associated with myositis
Lung
First line investigation for polymyositis
CK levels
THEN EMG
THEN Muscle biopsy for definitive diagnosis
What enzyme levels are elevated in polymyostitis
CLAAA
Creatinine Kinase
Lactate Dehydrogenase
Aldolase
ALT
AST
What cancers are dermatomyositis associated with
Gastric, lung, GU and colon cancers
Treatment of Myositis
Steroids (high dose)
What must be monitored to track disease progression on treatment in myositis
CK levels
What is the purpose of hydroxychloroquine in dermatomyositis
Manages skin symptoms
Who should people with myositis be referred to
Physiotherapists
Risk Factors of pseudogout
Hyperparathyroidism
Hypophosphataemia
Hypomagnesemia (stimulates PTh production)
Previous joint surgery
Age
Management of raynaud’s
Nifedipine
When should someone with raynaud’s be referred to hospital
<12
Symptoms not responding to treatment
Severe ischaemia
What is systemic sclerosis
This is increased fibroblast activity resulting in abnormal connective tissue growth and ischaemia
What is limited cutaenous systemic sclerosis
Only affects the face, forearm and lower legs (up to knee)
What is the most common type of systemic sclerosis
Limited (CREST syndrome)
Presentation of Limited SSc
CREST:
Calcinosis
Raynauds
Oesophageal dysmotility
Sclerodactyly
Telangiectasia
WHat autoantibdoy in systemic sclerosis is more likely to cause progression to interstitial lung fibrosis and renal disease in SSc
Anti-scl-70
Name four deformities seen in RA
Swan neck
Z thumb
Ulnar deviation
Boutonierre hand deformity
Wrist subluxation
feet:
Hallux Valgus and hammer toes
Is the aixal spine involved in RA?
Yes, the cervical spine stabilising ligaments can be detsroyed causing atlanto-axial subluxation
What is the first line managemnt of someone with Ra and nweck pain
CT cervical spine
Name three periarticular features of RA
Carpal tunnel syndrome
Tenosynovitis
Olecranon bursitis
Haematological symptoms of RA
Splenomegaly and amyloidosis
Derm symptoms of RA
Raynaud’s and nodules on the knuckles
OPthalmic features of RA
Episcleritis and scleritis
Respiratory symptom of RA
Pleural effusions and fibrosis
Joint x ray findings in RA
Soft tissue swelling
Periarticular osteoporosis
Juxta-articular erosions
Narrowing of joint space
What scoring system can be used to grade the severity of RA
DAS28
Treatment of RA flares
Intraarticular steroids or oral steroids
When is surgery indicated for RA
If joint is destroyed
At what DAS28 level should DMARDs be givenb
> 5.1
Second line treatment of RA
TWO demards
WIthin what time frame of symptom onset should DMARDs be started
within 3 months
third line management of RA
Infliximab
What vaccine should someone with RA be given
annual influenza and pneumococcal vaccine veery 5 years
WHat steroid sholud be given during pregnancy in those with RA
Prednisolone (oral steroids, not methotrexate) or hydroxychloroquine
Side effects of corticosteroids
CORTICOSTEROIDS:
Cushing’s
Osteoporosis
Retardation of growth
Thin skin
Immunosupression
Cataracts
Oedema
Suppression of HPA axis
Teratogenic
Emotional disturbances (psychosis)
Rise in BP
Obesity
Hirtustism
DM
Striae
Side efefct of hydroxychloroquine
Retinopathy
Side effect of NSAIDs
renal impiarment
GI upset
Asthma exacerbation
How should bisphosphonates be taken
mempty stomach, 30 mins before eating breakfast woth water and stand upright
Signs of adrenal suppresison from corticosteroids
Hyperkalaemic hypotension
How to manage an adrenal crisis from corticosteroids
IV hydrocortisone
How do we prevent an adrenal crisis from corticosteroids
Abruptly stop if course under 3 weeks
>3 weeks = tapering
double dose if unwell
if nil by mouth, move to IV hydrocortisone
What vaccinations are contraindicate din people on corticosteroids
Live vaccinations
What is sicca syndrome
Drying mucous membranes
Investigation for sjogren’s syndrome
Schirmer’s test: <5mm paper wet in 5 minutes
Lip biopsy to demonstrate lymphoid destruction
What other special tests can be used for sjogren’s
rose bengal staining
Salivary flow rate monitoring
Slaivary gland biopsy
Triggers for SLE flares
COCP
UV light
Infections
Stress
Most common cardiac feature of SLE
Pericarditis
What should be moinitored in people with SLE
Renal Function
What two conditions are associated with SLE
Sjogren’s and APL
What drugs can cause lupus
Sulfadiazine
Hydralazine
Procainamide
Isoniazide
Methyldopa
Quindiine
Minocycline
What autoantibody is specific for drug induced lupus
Anti-histones
What is the most specific test for lupus nephritis
Renal biopsy
What antibody dictates prognossis for SLE
Anti dsdna
SYmptoms of SLE
A RASH POINts MD:
Arthalgia
Renal disease
ANA positive
Serositis
Haematological (haemolysis/low platelet count)
Photosensitive rash
Oral ulcers
Immuno tests (antidsdna, anti-smith)
Neuropsychiatric (seizures)
Malar Rash
Discoid Rash
Management of severe SLE flares
Cyclophosphamide
Tretaing renal disease in SLE
ACEi
Treating thrombocytopenia in SLE
IV Ivg
Where is c-ANCA antibodies found
Granulomatosis with polyangitis
Where is p-ANCA found
Microscopic polyangitis
What type of osteogenesis imperfect is the most deadly
Type 2
Management of osteogenesis imperfecta
Oral rusendronnate daily i
What is Arthritis Mutilans
Found in psoriatic arthritis: Telescopic fingers from bone shortening
When does a DEXA scan become first line management in osteoporosis
When there is an intermediate risk (so if the person has immediate risk factors but hasn’t yet fallen)
When does denosumab become first line management of osteoporosis
In young people to defer bisphsophonate use
What is Paget’s disease of the bone
Increased osteoclastic bone resorption followed by compensatory increase in new bone formation
This causes an excess in woven bone over lamellar bone growth which is weaker
What is the distinctive investigation finding that indicates Paget’s disease of the bone
Increased ALP with normal serum calcium levels
Just an isolated rise in ALP
Osteomalacia vs Paget’s findings
Low ALP AND Low Serum Calcium vs Low ALP only
Management of a patient with a T-score <-1.5 and going to be on steroids
Prophylactic bisphosphonates
A lack of which substance causes marfan’s
Fibrillin
Initial management of reactive arthritis
Ibuprofen
What pulmonary feature would be seen on a chest X Ray for ankylosing spondyltitis (late)
Apical Fibrosis
Appearance of RA on a joint aspiration
Raised WBC and yellow appearance (similar to septic)
Complication of parathyroidism
Pseudogout
What should all NSAIDs in osteoarhritis be prescribed with
PPIs
What T score is diagnostic of osteoporosis
<-2/5
What defines osteopenia
T score bweetn -1 and -2.5
First line management of osteoarthritis
Paracetomal + topical NSAIDs
When are calcium supplements indicated for osteoporosis
Only if dietary intake is inadequate
What type hypersensitivity is SLE
Type 3
Management of GCA when there are eye signs
IV methylperdnisolone
NOrmally Prednisolone oral otherwise
What substance (lack of) causes osteomalacia
Lack of vit D
Symptoms of osteomalacia
Proximal muscle weakness
Joint Pain
Increased risk of fractures
Symptoms of rickets
Craniotabes
Delayed closure of the fonatenelles
Rachitic rosary
Genu Varum (bow legs)
Lab results of osteomalacia
Low Vit D
Low blood calcium levels
Raised ALP
Role of Vit D
Bone mineralisation (so in osteomalacia and rickets, bones can’t be mineralised and become soft)
What is osteomyelitis
Inflammation of the bone
How do organisms reach the bone to cause osteomyelitis
Haematogenously
Causative species for osteomyelitis
Staph Aureus
What is sequestrum
When dead bone in osteomyelitis detahces from the healthy bone
WHat is involucrum
Viable periosteum that seperated from the underlying bone
Presentation of osteomyelitis
Swelling are eryhtmea
Bone pain + immobile
Pain exacerbated by movement
Risk Factors for osteomyelitis
Blunt trauma history
What is pott’s disease
Vertebral osteomyelitis from miliary TB (haematoginously spreadings)
Signs of vertebral osteomyelitis
Urinary retention, back pain and fever
What is chronic osteomyelitis
Asymptomatic but localised bone pain or decreased range of motion
Gold standard diagnosis of osteomyelitis
Bone Cultures
Is paracetamol routinely offered for osteoarthritis
No
When should someone be referred to orthopaedic surgery
If they are complaining about dialy activtities
What treatment can be given while waiting for DMARDs to kick in
Bridging steroids
Flares:
Intra-articular steroids
then IM Steroids
then oral
What diet should be recommended to people with RA
Meditteranean
