Rheumatology

Question 1

Describe typical presentation of rheumatoid arthritis

Answer 1

Female, 30 – 50 years old
Symmetrical, affecting MCPs, PIPs, MTPs and typically spares DIPs (can affect any other joint)
History > 6 weeks
Morning stiffness > 30 minutes duration

Question 2

List investigations to do for suspected RA

Answer 2

RF and anti-CCP
FBC
Inflammatory markers
X-ray (changes more apparent in established disease, USS/MRI in early disease)

Question 3

Describe treatment for RA

Answer 3

Initially DMARD monotherapy – methotrexate
Steroids (acutely) – PO/IM or intra-articular
Symptom control with NSAIDs (PPI cover) if no contraindication
If disease still severe after combination DMARDs – biologics (anti-TNFs)
OT/PT, podiatry, psychological

Question 4

List the extra-articular manifestations of RA

Answer 4

3Cs – carpal tunnel syndrome, increased cardiac risk, cord compression
3As – anaemia, amyloidosis, arteritis
3Ps – pericarditis, pleural disease, pulmonary disease
3Ss – Sjogrens, scleritis, splenic enlargement

Question 5

List x-ray features of RA

Answer 5

Loss of joint space
Erosions (periarticular)
Soft tissue swelling
Subluxation

Question 6

Describe polymyalgia rheumatica

Answer 6

Clinical syndrome characterised by pain and stiffness of the shoulder, hip girdles and neck
Average age of onset is 70 years & is associated with GCA

Question 7

Describe the typical presentation of polymyalgia rheumatica

Answer 7

Elderly patients with new sudden onset of proximal limb pain and stiffness (neck, shoulders, hips)
Difficulty rising from chair/combing hair (proximal muscle involvement)
Night time pain
Systemic symptoms – fatigue, weight loss, low grade fever

Question 8

List investigations done for suspected polymyalgia rheumatica

Answer 8

Typical history & examinations
Inflammatory markers – ESR/PV, CRP
Consider temporal artery biopsy if symptoms of GCA

Question 9

Describe the treatment for polymyalgia rheumatica

Answer 9

Dramatic response within 5 days of starting prednisolone (15mg daily)
Has to be tapered very slowly; rapid taper is associated with symptom relapse
Methotrexate can be steroid-sparing in relapsing patients

Question 10

Describe ankylosing spondylitis

Answer 10

Inflammatory disorder of the spine
Radiographic changes at the sacroiliac joints are present

Question 11

Describe the typical presentation of ankylosing spondylitis

Answer 11

Young men (teens – mid-thirties)
Bilateral buttock pain, chest wall & thoracic pain
Prolonged morning stiffness in the lower back and buttocks
Pain and stiffness improve with exercise but not with rest
Progressive loss of spinal movement

Question 12

Describe examination findings for ankylosing spondylitis

Answer 12

Often normal
Later:
1) Loss of lumbar lordosis & exaggerated thoracic kyphosis
2) Schober’s test (mark skin 10cm above and 5cm below PSIS, bend forward with straight legs, distance increase to >20cm is normal)
3) Reduced chest expansion

Question 13

List investigations for suspected ankylosing spondylitis

Answer 13

CRP may be raised but often normal
MRI spine & SI joints

Question 14

List treatment options for ankylosing spondylitis

Answer 14

NSAIDs
Physio
TNF inhibitors
IL-17 inhibitors

Question 15

List extra-articular manifestations of ankylosing spondylitis

Answer 15

Anterior uveitis
Aortic incompetence
AV block
Apical lung fibrosis
Amyloidosis

Question 16

Describe SLE

Answer 16

Multisystemic autoimmune disease
Autoantibodies are made against a variety of autoantigens which form immune complexes
Inadequate clearance of immune complexes results in a host of immune responses which cause tissue inflammation & damage

Question 17

List common signs and symptoms of SLE

Answer 17

Serositis
Oral ulcers
Arthritis
Photosensitivity – malar/discoid rash
Blood disorders
Renal involvement
Autoantibodies – ANA positive in > 90% cases
Immunologic tests
Neurologic disorder – seizures or psychosis

Question 18

List investigations for suspected SLE

Answer 18

Raised ESR or plasma viscosity
Anaemia & leukopenia are common
Anti-Ro, anti-La, anti-dsDNA, antiphospholipid antibodies
C3 and C4 fall with disease activity
Urinalysis – detecting renal disease
Skin biopsy
Renal biopsy

Question 19

Describe the treatment for SLE

Answer 19

Sun protection
Healthy lifestyle – increased CVS risk
Hydroxychloroquine – helpful for rash and arthralgia
Mycophenolate mofetil, azathioprine and rituximab
Prednisolone – for flares

Question 20

Describe the management for osteoarthritis

Answer 20

Non-drug therapy: strengthening & range of movement exercises, weight loss, walking stick
Pharmacological therapy: regular paracetamol, NSAIDs short term, intra-articular corticosteroids can be offered
Surgery: if nothing else has worked, surgery can be considered

Question 21

Describe fibromyalgia

Answer 21

Common disorder if central pain processing characterised by chronic widespread pain in all 4 quadrants of the body
Allodynia, a heightened and painful response to innocuous stimuli is often present

Question 22

List symptoms and signs of fibromyalgia

Answer 22

Pain
Joint/muscle stiffness
Profound fatigue
Unrefreshed sleep
Numbness
Headaches
IBS
Depression & anxiety

Question 23

List treatment options for fibromyalgia

Answer 23

Should be specifically tailored based on pain intensity, function and associated features
Low dose amitriptyline
Pregabalin may be effective
Opiates NOT recommended
CBT

Question 24

Describe osteoporosis

Answer 24

Characterised by low bone mass, deterioration of bone tissue & disruption of bone architecture -> compromised bone strength & increased risk of fracture

Question 25

List investigations for suspected osteoporosis

Answer 25

Dual energy x-ray absorptiometry (DEXA) of lumbar spine and hip = gold standard
T-score (number of SDs from the mean bone density of persons of same gender at age of peak density): minus 2.5 or less

Question 26

Describe the treatment for osteoporosis

Answer 26

Vitamin D +/- calcium supplementation plus:
1st line – oral bisphosphonates/IV if oral not tolerated
2nd line – denosumab or teriparatide

Question 27

Describe the pathogenesis of gout

Answer 27

Inflammatory arthritis related to hyperuricaemia
Deposition of monosodium urate crystals -> accumulate in joints and soft tissues, result in acute and chronic arthritis, soft-tissue masses (tophi), urate nephropathy & uric acid nephrolithiasis

Question 28

List risk factors for gout

Answer 28

Non-modifiable: age > 40 years, male gender
Modifiable: increased purine uptake, alcohol intake, high fructose intake, obesity, CCF

Question 29

Describe the treatment for gout

Answer 29

General prevention – maintain optimal weight, regular exercise, diet modification
First line treatment in acute gout – NSAIDs, oral/IM steroids, colchicine
Chronic cases – urate lowering therapy: allopurinol & febuxostat

Question 30

Describe osteomalacia

Answer 30

Normal amount of bone but decreased mineral content
Occurs after fusion of the epiphyses (rickets if this process occurs during the period of bone growth)

Question 31

List signs and symptoms of osteomalacia

Answer 31

Bone pain and tenderness
Fractures (esp. femoral neck)
Proximal myopathy due to decreased phosphate & vit D deficiency

Question 32

List investigations for suspected osteomalacia

Answer 32

Calcium, phosphate, ALP, PTH, 25(OH)-vitamin D
Bone biopsy – shows incomplete mineralisation
X-ray – loss of cortical bone

Question 33

List treatment options for osteomalacia

Answer 33

Vitamin D
Vitamin D2/calcitriol (malabsorption or hepatic disease)
Alfacalcidol/calcitriol (renal disease or vitamin D resistance)
Monitor plasma Ca2+, initially weekly, and if nausea/vomiting