Rheumatology Flashcards
What is the first-line treatment for osteoporosis?
A bisphosphonate, alendronic acid with calcium and vitamin D supplements
What is calcitriol?
The man-made, active form of vitamin D
What is Behcet’s disease?
Auto-immune mediated inflammation of the arteries and veins i.e. systemic vasculitis
What is the classic triad of Behcet’s disease?
Oral ulcers, genital ulcers and anterior uveitus
What is the treatment for Behcet’s disease?
Symptom management
What is the classic epidemiology of Behcet’s disease?
- Common in eastern Mediterranean
- More common and severe in men
- Affects younger adults 20-40
What are the classic preceding events before reactive arthritis?
- History of gastrointestinal or genitourinary infection
- Infection in the last 1-4 weeks
What are the presenting features of reactive arthritis?
- Fever
- Arthritis
- Enthesitis (inflammation where tendons insert into bones)
- Conjunctivitis and iritis
- Skin lesions
What joins are usually affected in reactive arthritis?
Large joints of the lower limb, tend to be asymmetrical
What is the treatment for reactive arthritis?
NSAIDs and corticosteroids
What is rheumatic fever?
An autoimmune condition that affects the heart, joints, muscles, skin and brain
What is the cause of rheumatic fever?
Group A streptococcal throat infection e.g. Streptococcus pyogenes in the last 2-6 weeks
What are the major diagnostic criteria for rheumatic fever?
- Erythema marginatum
- Chorea
- Polyarthritis
- Carditis
- Subcutaneous nodules
What is the cause of chronic rheumatic heart disease?
Chronic changes to heart valves as a result of carditis seen in rheumatic fever
What is the treatment for rheumatic fever?
IM antibiotics (benzathine benzylpenicillin, erythromycin in pen allergic) and symptom management
What are the key diagnostic factors for rheumatoid arthritis?
- Active symmetrical arthritis lasting >6 weeks
- Age 50-55
- Female
- Joint pain and swelling
- Morning stiffness
What joints are commonly affected in rheumatoid arthritis?
MCP, PIP and MTP joints
What are the investigations for suspected RA?
- Rheumatoid factor (+ve in 60-70%)
- Anti-CCP (anti-cyclic citrullinated peptide antibody) (+ve in 70%)
What is the treatment for mild RA in patients not planning pregnancy?
DMARD e.g. hydroxychloroquine
What is a DMARD?
Disease-modifying anti-rheumatic drug
What is the primary treatment option for patients with RA that are pregnant or planning a pregnancy?
Prednisolone
What is the treatment for poorly controlled RA?
Methotrexate plus biological agent or DMARD
How are flares of rheumatoid arthritis managed?
With oral or IM corticosteroids
What can be used to monitor SLE flares?
Complement - they are usually low during active disease
What are the classic signs and symptoms of SLE?
- Malar (butterfly) rash
- Photosensitive rash
- Discoid rash
- Mouth ulcers
- Fatigue
- Arthralgia
- Unexplained fever
99% of patients with SLE are ___ ________.
ANA positive
What blood results would you see in patients suspected of having SLE?
- Anaemia
- Leukopenia
- Thrombocytopenia
- Elevated urea, creatinine ESR and CRP
- Positive ANA
What is the treatment of choice for SLE?
Hydroxychloroquine
What is the first line treatment for SLE patients with lupus nephritis?
Induction therapy, hydroxychloroquine and corticosteroids e.g. cyclophosphamide and prednisolone
What is gout characterised by?
Acute onset of severe joint pain, with swelling, effusion, warmth, erythema, and or tenderness of the involved joint(s).
What is the difference between gout and pseudogout when analysing the synovial fluid?
Gout = strongly negative birefringent needle-shaped crystals under polarised light
Pseudogout = positively birefringent rhomboid-shaped crystals under polarised light
The joint most affected (70% of cases) in gout is the _____ ___ joint. However, the _____, _______, ______, _____, _____ and _____ are also commonly affected.
First MTP
Foot, ankle, knee, fingers, wrist and elbow
What are strong risk factors for gout?
- Male sex
- Older age
- Post-menopausal
- High consumption of meat, seafood and alcohol
- Use of diuretics, ciclosporin and pyrazinamide
What is the cause of gout?
Chronic hyperuricaemia (uric acid > 0.45 mmol/l)
What is the first-line treatment for acute gout?
NSAID plus corticosteroid plus colchicine
What is the first-line treatment for recurrent gout 2-3 weeks post acute episode?
Allopurinol and suppressive therapy (NSAID or low dose colchicine)
What is allopurinol?
Urate-lowering therapy used to treat gout
What is pseudogout also known as?
Calcium pyrophosphate arthritis (CPP)
The prevalence of CPP _______ with each decade after the age of __ years.
Doubles
60
What are the strong risk factors for pseudogout?
- Old age
- Injury new or previous to joints
- Hyperparathyroidism
- Hemochromatosis
- Hypomagnesemia
- Hypophosphatasia
What is the first-line treatment for pseudogout?
Intra-articular corticosteroids (preferably triamcinolone hexacetonide) with paracetamol
What is the first-line treatment for pseudogout when injections are not possible/tolerated?
NSAIDs
What type of arthritis is psoriatic arthritis?
Seronegative inflammatory spondyloarthropathy
What are the key differences seen in psoriatic arthritis that differentiates it from rheumatoid arthritis?
- Mono- or oligoarticular
- DIP joint involvement
- Dactylitis
- Sacroiliitis
- History of psoriasis
- Nail changes (pitting)
What is the treatment for psoriatic arthritis?
A combination of DMARDs, NAIDS, physiotherapy and intra-articular corticosteroid injections
What are patients with psoriatic arthritis at increased risk of?
Myocardial infarction, angina, and hypertension
Regard a hot, swollen, acutely painful joint with restriction of movement as ______ ________ until proven otherwise, even in the absence of fever and irrespective of microbiology and blood test results.
Septic arthritis
What are the most common organisms seen in septic arthritis?
Staphylococci or streptococci
What tests should you do on the synovial fluid of a patient with suspected septic arthritis?
- Fluid microscopy
- Gram stain
- Polarising microscopy
- Culture and sensitivities
- White cell count
Should you aspirate a joint suspected of being infected before or after starting antibiotic therapy?
Before unless more urgent treatment is indicated
What is your management for a suspected infection in prosthetic joint(s) and why?
Refer to orthopaedics because aspiration needs to be done in a sterile operating theatre environment
What is the treatment for septic arthritis in an accessible joint with no systemic involvement?
- Empirical IV antibiotics e.g. flucloxacillin/clindamycin
- Aspirate the joint to dryness
- Analgesia
What is the most common cause of septic arthritis in young adults who are sexually active?
Neisseria gonorrhoeae
What is Sjögren’s syndrome?
An autoimmune disease characterised by dry eyes and dry mouth (xerostomia) as a consequence of lymphocytic infiltration into lacrimal and salivary glands
What antibodies are associated with Sjögren’s syndrome?
- ANA
- Anti-60 kD (SS-A) Ro
- Anti-La auto-antibodies
What is polymyalgia rheumatica characterised by?
Pain and morning stiffness in the neck, shoulder girdle and/or pelvic girdle. There is also a rapid response (24-72 hours) to corticosteroids.
What condition is polymyalgia rheumatica associated with?
Giant cell arteritis
What are the pathological changes seen in bursitis?
- Synovial thickening
- Bursal adhesions
- Villus formation
- Tags
- Deposition of chalky deposits
