Rheumatology Flashcards
Rheumatoid arthritis - state the following:
- Pathophysiology
- Typical patient
- Presentation
- Investigations
- Management
Pathophysiology:
- Chronic autoimmune inflammatory condition
- Autoantibodies attack the synovial membranes of joints, bursa and tendon sheaths, leading to chronic inflammation (synovitis)
Typical patient:
- Middle age onset
- (3x) F > M
- Family history of RA
Presentation:
- Joint pain / swelling / stiffness, particularly of the small/distal joints
- Symmetrical and affects many joints
- Onset can be sudden or more gradual
- Pain is worse in the morning and worse on rest
- May have some signs in the hands
Systemic symptoms:
- Fatigue
- Weight loss
- Flu-like illness
- Myalgia and weakness
Investigations:
Diagnosis is clinical but want back up of:
- Specific bloods for rheumatoid factor (RF) and then anti-CCP if RF negative
- Routine bloods e.g. FBC, ESR, CRP
- X-rays hands and feet
- Ultrasound of joints to confirm synovitis if unsure
Management:
1. One early DMARD (disease modifying anti-rheumatic drugs) e.g. Methotrexate, Leflunomide or Sulfasalazine
2. Two DMARDs
3. Methotrexate + biologic (e.g. TNF inhibitor Infliximab)
4. Methotrexate + Rituximab (Anti-CD20)
- Use of steroids to settle first presentation and for flares
- Surgery can be used to improve joint complications of RA but not used as much now due to early interventions
List some signs in the hands of someone with established rheumatoid arthritis
- Ulnar deviation of fingers (at MCP joints)
- Bouchard nodes (flexed PIP and extended DIP)
- Swan neck deformity (extended PIP and flexed DIP)
- Z shaped deformity of thumb
+ rheumatoid nodules on elbows
List some extra-articular manifestations of rheumatoid arthritis (3 CAPS)
(3)CAPS
3 C’s:
- Carpal tunnel syndrome
- Cardiovascular disease (increased risk)
- Cord compression (atlanto-axial subluxation)
3 A’s:
- Anaemia of chronic disease (normochromic and normocytic)
- Amyloidosis
- Arteritis
3 P’s:
- Pulmonary disease e.g. fibrosis, bronchiolitis obliterans, bronchiectasis
- Pleural disease
- Pericarditis
3 S’s:
- Sjogren’s syndrome (secondary)
- Scleritis / episcleritis
- Splenomegaly (Felty’s syndrome if with neutropaenia)
List the x-ray changes seen in rheumatoid arthritis
LESS!
Loss of joint space
Erosions
Soft tissue swelling
See-through bones (osteopenia)
Outline the DAS28 score for rheumatoid factor and what it’s used for
DAS 28 score - disease activity score of 28 joints
Points given for:
- Swollen joints
- Tender joints
- ESR / CRP level
Useful for monitoring disease activity and response to treatment
List some side effects of Methotrexate
- GI upset e.g. N&V and diarrhoea
- Pulmonary fibrosis
- Mouth ulcers and mucositis
- Bone marrow suppression / leukopenia
- Thrombocytopenia
- Teratogenic
- Hepatotoxic
List some side effects of NSAIDs
- Indigestion
- Peptic ulcer disease
- VTE e.g. DVT/PE
- Peripheral oedema
- Slight increased risk of stroke and heart attack
List some side effects of corticosteroids e.g. Prednisolone
- Immunosuppression
- Diabetes mellitus
- Osteoporosis
- Suppression of HPA axis
- Teratogenic
- Increased BP
- Cataracts and glaucoma
- Oedema
Cushing’s syndrome
- Thin skin, easy bruising
- Obesity distributed centrally
- Increased hair growth (hirsutism)
- Striae
List some side effects of Sulfasalazine
- Myelosuppression
- Nausea
- Rash
- Oral ulcers
- Infertility / decreased sperm count
List some side effects of Biologic therapy (e.g. Adalimumab)
- Immunosuppression
- Reactivation of TB
- Allergic reaction / reaction at infusion site
Systemic lupus erythematosus (SLE) - state the following:
- Pathophysiology
- Typical patient
- Presentation
- Investigations
- Management
Pathophysiology:
- Systemic autoimmune condition targeting the connective tissue
- Characterised by ANA antibodies (anti-nuclear) against own cell nuclei in proteins
- Often has a relapsing-remitting course
Typical patient:
- Women
- Young-middle age
- Asian
Presentation:
- Usually young-middle aged adults
- F > M and Asians
- Photosensitive malar rash
- Systemic features: fatigue, weight loss, fever
- Hair loss
- Joint pain and inflammatory arthritis
- Myalgia
- Mouth ulcers
- Lymphadenopathy
- Raynaud’s
- SOB
- Chest pain
Investigations:
Criteria used based on clinical features and presence of anti-nuclear antibodies
- Specific bloods for ANA and anti-dsDNA antibodies
- Routine bloods e.g. FBC, ESR, CRP
- Further bloods e.g. C3, C4, immunoglobulins
- Urinalysis and protein:creatitine ratio to test for kidney involvement
- Renal biopsy if lupus nephritis suspected
Management:
First line:
- Hydroxychloroquine
- NSAIDs
- Prednisolone (steroids)
- Skin protection e.g. suncream
If not responding/severe:
- Immunosuppressants e.g. Methotrexate, Mycophenolate mofetil
- Biologics e.g. Rituximab
List some complications of SLE
Cardiovascular disease (HTN and coronary artery disease) = LEADING CAUSE OF DEATH
- Infection (disease + immunosuppressants)
- Lupus nephritis (inflammation in kidneys)
- Anaemia of chronic disease (bone marrow suppression)
- Pericarditis
- Pleuritis
- Interstitial lung disease (fibrosis)
- Neuropsychiatric (optic neuritis, transverse myelitis or psychosis)
- Recurrent miscarriages
- Antiphospholipid syndrome, leading to VTE
Gout - state the following:
- Pathophysiology
- Typical patient
- Presentation
- Investigations
- Management
Pathophysiology:
- Crystal arthropathy which occurs as a result of chronic hyperuraemia
- Sodium urate crystals are deposited in the joint causing joint to become painful, swollen and hot
Typical patient:
- Male
- Obese
- Family history
- Existing cardiovascular or renal disease
Presentation:
- Single painful, swollen and hot joint
- Acute, severe onset
Key differential should be septic arthritis
Investigations:
- Diagnosed clinically or by joint aspiration
- X-ray of affected joint
KEY = exclude septic arthritis
Management:
Acute attack
- NSAIDs
- Colchicine
- Steroids
Prophylaxis/prevention
- Allopurinol (only once acute attack has resolved)
- Lifestyle changes e.g. lose weight, hydration, limit alcohol and limit purine-based foods
List some risk factors for gout (modifiable and non-modifiable)
Modifiable
- Alcohol intake / high purine diet
- Obesity
- Diuretics
Non-modifiable
- Male
- Family history
- Existing cardiovascular or renal disease
List some typical joints that are affected in gout
- Base of the big tole (MTP)
- Base of thumb (MCP)
- Bigger joints e.g. knee and ankle
List 3 things seen in a joint aspiration from a gouty joint
- Monosodium urate crystals (needle-shaped)
- Negative birefringent of polarised light
- Absence of bacteria
List 2 things that x-ray of a gout joint will show
- Punched out erosions (with overhanging edges and sclerotic margins)
- Lytic bone lesions
Joint space is generally maintained
Outline how pseudogout differs from gout
Pseudogout involves calcium pyrophosphate (rather than monosodium urate) crystals being deposited into joints
Osteoporosis - state the following:
- Pathophysiology
- Typical patient
- Presentation
- Investigations
- Management
Pathophysiology:
- Reduced density of bones (low bone mass) leading to reduced bone strength
- Increased risk of fractures
Typical patient
- Post-menopausal women
- White / south asian
Presentation:
- Generally not symptomatic
- Often discovered upon an unusual fracture e.g. low energy fracture
Investigations:
- FRAX assessment to assess risk
- DEXA scan to confirm (dual energy x-ray absorptiometry)
Management:
Based on results from a FRAX prediction or DEXA scan
Conservative
- Weight bearing exercise
- Limit alcohol intake
- Stop smoking
- Increase dietary calcium
Medical
- Vitamin D and calcium supplements (AdCal D3)
- Oral bisphosphonates (IV if not tolerated)
- Then Denosumab 2nd line
List the risk factors for developing osteoporosis (modifiable and non-modifiable)
Modifiable:
- Low mobility (non-weight bearing)
- Low calcium diet / low sun exposure (vitamin D deficiency)
- Smoking
- Excess alcohol intake
- Low BMI/weight
- Corticosteroids
Non-modifiable:
- Female
- Post-menopausal
- Family history of osteoporosis
- Increased age
- White or south asian
- Premature menopause
Outline how a DEXA scan is used to diagnose osteoporosis
DEXA scan is gold standard for diagnosis of osteoporosis
- Assesses the bone mineral density using x-rays
- Measures how much radiation is absorbed by the bones, which indicates how dense the bones are
- Reading taken at the hip is key
- T score used (can also use Z score)
T score < - 2.5 = osteoporosis
T score > -1 = normal
T score between those two is osteopenia
Briefly outline how the FRAX score is calculated and it’s use in osteoporosis
FRAX score gives a risk of fragility fracture in the next 10 years (assess risk of osteoporosis)
Performed on individuals at risk of osteoporosis
- Women over 65
- Men over 75
- Anyone at increased risk e.g. low BMI, long-term steroids
Calculated using information e.g. age, BMI, co-morbidities, smoking, alcohol and family history
Can also enter results of a DEXA scan for a more accurate result
Overall gives a 10 year risk of having either:
- Major osteoporotic fracture
- Hip fracture
