Rheumatology Flashcards
Classification of arthritis by number of joints affected?
Monoarthritis = 1
Oligoarthritis = 2-4
Polyarthritis = > 4
Seronegative arthritis feature and examples?
All linked to HLA-B27:
→ ankylosing spondylitis
→ reactive arthritis (Reiter’s)
→ psoriatic arthritis
→ IBD-related arthritis
→ juvenile idiopathic arthritis
Seropositive arthritis feature and examples?
All RF +ve or antibody +ve:
→ rheumatoid arthritis
→ SLE
→ sjogren’s
→ scleroderma
→ vasculitis
Features of rheumatoid arthritis?
Symmetrical arthritis
Main joints are MCPs/PIPs
Morning stiffness improves with activity
Antibodies in rheumatoid arthritis?
Rheumatoid factor
Anti-CCP
X-ray features of rheumatoid arthritis?
Loss of joint space
Juxta-articular osteoporosis
Periarticular erosions
Subluxation
Swan neck vs Boutonniere deformity?
Swan neck = PIP hyperextension, DIP hyperflexion
Boutonniere = PIP hyperflexion, DIP hyperextension
Management of rheumatoid arthritis?
1st line = DMARD +/- short course of prednisolone
2nd line = other DMARD
3rd line = TNF-inhibitor
Felty’s syndrome?
Rheumatoid arthritis + splenomegaly + low WCC
Treatment response monitoring for arthritis?
CRP + DAS28 score
Examples of DMARDs?
Methotrexate
Sulfasalazine
Leflunomide
Azathioprine
Ciclosporin
Hydroxychloroquine
DMARDs unsafe in pregnancy and breastfeeding?
Methotrexate
Leflunomide
Examples of TNF-inhibitors?
Etanercept
Infliximab
Adalimumab
Methotrexate mechanism of action and side effects?
Dihydrofolate reductase inhibitor
Side effects = mucositis, myelosuppresion, pneumonitis, pulmonary fibrosis, liver fibrosis
Methotrexate monitoring requirements?
FBC, U&Es, LFTs weekly until medication stabilised
→ then monitor every 2-3 months
Advice regarding sex and methotrexate?
Women = avoid pregnancy until 6 months post-therapy
Men = use condoms until 6 months post-therapy
What should be co-prescribed with methotrexate?
Folic acid 5mg
Features and management of psoriatic arthritis?
Symmetrical or asymmetrical arthritis
Morning stiffness improves with activity
Psoriatic changes e.g. plaques, nail disease
Management = same as RA, NSAID for mild disease
X-ray features of psoriatic arthritis?
Erosions
New bone formation
“Pencil in cup” appearance
Features and management of reactive arthritis?
Assymetrical arthritis
Within 4 weeks of infection e.g. chlamydia
Urethritis, circinate balanitis, eye disease
Management = NSAID, DMARD for persistent disease
Most common organism and location of septic arthritis?
Organism = staphylococcus aureus
Location = knee
Features, investigation and management of septic arthritis?
Generally unwell e.g. fever
Acute monoarthritis
Investigation = joint aspiration
Management = IV flucloxacillin
Features and management of osteoarthritis?
Asymmetrical arthritis
Main joints are DIPs/PIPs, large joints
Pain worsens upon activity
Management = paracetamol, topical NSAID (knee or hand OA), joint replacement
Features of hand OA?
Herbeden’s nodes (DIPs)
Bouchard’s nodes (PIPs)
Squaring of the thumbs
X-ray features of osteoarthritis?
LOSS:
→ loss of joint space
→ osteophytes
→ subchondral sclerosis
→ subchondral cysts
Osteoporosis vs osteopenia vs osteomalacia?
Osteopenia = low BMD
Osteoporosis = low BMD and structural change
Osteomalacia = low BMD secondary to low vitamin D
Definition of osteoporosis?
Bone mineral density (BMD) < 2.5 standard deviations below the young adult mean density
Who should be screened for osteoporosis and investigations?
Women ≥ 65 and men ≥ 75:
→ FRAX or QFracture score
→ DEXA scan
Management of patients after a fragility fracture?
≥ 75 = oral bisphosphonate, DEXA scan not required
< 75 = DEXA scan
DEXA scan T scores?
> -1.0 = normal
-1.5 to -2.5 = osteopaenia
< -2.5 = osteoporosis
Management of osteoporosis?
1st line = alendronate
2nd line = risedronate, etidronate
3rd line = denosumab, raloxifene etc.
N.B. all should be offered calcium + vitamin D
Bisphosphonate examples, mechanism of action and side effects?
Examples = alendronate, risedronate, etidronate
Mechanism of action = inhibits osteoclasts
Side effects = GI upset, jaw osteonecrosis, atypical stress fractures
Advice for taking bisphosphonates?
- Correct calcium or vitamin D deficiency first
- Take on empty stomach 30 mins before meal
- Stand or sit for 30 mins after ingestion
Calcium, phosphate, ALP and PTH values for osteoporosis, osteomalacia, CKD and Paget’s?
Osteoporosis = all normal
Osteomalacia = decreased calcium and phosphate, increased ALP and PTH
CKD = decreased calcium, increased phosphate and ALP and PTH
Paget’s = normal calcium and phosphate and PTH, increased ALP
Features and management of ankylosing spondylitis?
Lower back pain
Sacroiliac joint tenderness
Reduced lateral and forward flexion
Morning stiffness improves with activity
Enthesitis, anterior uveitis, pulmonary fibrosis
Management = exercise, NSAID, DMARD
X-ray features of ankylosing spondylitis?
Sacroiliitis
Squaring of lumbar vertebrae
“Bamboo spine” appearance
Features and management of SLE?
Multisystem manifestations
→ general e.g. fatigue
→ msk e.g. arthritis
→ skin e.g. malar rash
→ kidneys e.g. GN
→ heart e.g. pericarditis
→ lungs e.g. pleurisy
Management = hydroxychloroquine (1st line), prednisolone (2nd line), cyclophosphamide (3rd line)
Antibodies in SLE vs drug-induced SLE?
SLE = ANA, anti-dsDNA, anti-smith
Drug-induced = anti-histone
Monitoring markers for SLE?
Anti-dsDNA
ESR
C3 and C4 (low in active disease)
Features and management of Sjögren’s syndrome?
Keratoconjunctivitis sicca
Dry mouth
Vaginal dryness
Arthralgia
Management = artificial tears/saliva, pilocarpine
Antibodies in Sjögren’s syndrome?
ANA
Anti-Ro
Anti-La
Complication of Sjögren’s syndrome?
40-60 fold increased risk of lymphoid malignancy
Features of gout?
Painful, swollen joint
Localised erythema
Typically affects 1st MTP
Synovial fluid feature of gout?
Needle shaped negatively birefringent monosodium urate crystals
When should uric be measured after a gout attack and why?
After episodes has settled (around 2 weeks)
→ may be low, normal or high during attack
Acute vs long-term management of gout?
Acute = NSAID or colchicine (1st line), prednisolone (2nd line)
Long-term = allopurinol (1st line), febuxostat (2nd line)
Conditions associated with pseudogout?
Haemochromatosis
Hyperparathyroidism
Wilson’s disease
Acromegaly
Synovial fluid feature of pseudogout?
Rhomboid shaped positively birefringent crystals
List examples of small vs medium vs large vessel vasculitides?
Small = wegener’s, churg-strauss, microscopic polyangiitis, HSP, goodpasture’s
Medium = kawasaki, polyarteritis nodosa
Large = giant cell (temporal), takayasu’s
ANCA associated vasculitides and antibody sub-type?
Granulomatosis with polyangiitis (cANCA)
Eosinophillic granulomatosis with polyangiitis (pANCA)
Microscopic polyangiitis (pANCA)
Features and management of ANCA associated vasculitis?
Generally unwell e.g. fever
Glomerulonephritis
Respiratory disease
Sinusitis
Vasculitis rash (minority)
Management = immunosuppressants
Features and management of temporal (giant cell) arteritis?
Headache
Jaw claudication
Visual disturbance
Tender temple region
PMH polymyalgia rheumatica
Management = oral prednisolone (no visual loss), IV methylprednisolone (visual loss)
Investigation for temporal arteritis and feature?
Temporal artery biopsy
Skip lesions
Most common optic manifestation of temporal arteritis and fundoscopy features?
Anterior ischaemic optic neuropathy
Fundoscopy = pale disc and blurred margins
Features and management of polymyalgia rheumatica?
Achy, stiff proximal limb muscles
NO weakness!
Polyarthralgia
Fatigue
Raised ESR
Management = prednisolone
Features and management of fibromyalgia?
Chronic pain at specific points
Brain fog
Fatigue
Management = exercise, pain management
Polymyalgia vs fibromyalgia?
Polymyalgia = > 60, raised ESR, morning stiffness, no tender points
Fibromyalgia = 30-50, normal ESR, no morning stiffness, tender points e.g. shoulders
Timescale for chronic fatigue syndrome?
Symptoms must be present for at least 3 months to be referred to CFS specialist
Features and management of polymyositis?
Proximal muscle weakness
Raynaud’s
Interstitial lung disease
Management = prednisolone
Features and management of dermatomyositis?
Proximal muscle weakness
Raynaud’s
Interstitial lung disease
Heliotrope rash
Shawl sign
Gottron’s papules
Management = prednisolone
Investigations for polymyositis and dermatomyositis?
Creatine kinase (CK)
EMG
Muscle biopsy
Antibody in polymyositis and dermatomyositis?
Anti-Jo-1
Additional screening test for polymyositis and dermatomyositis?
Check for underlying malignancy
Most commonly breast, ovarian or lung
Disease patterns of systemic sclerosis?
Limited cutaneous systemic sclerosis
Diffuse cutaneous systemic sclerosis
Scleroderma (no internal organ involvement)
CREST syndrome and features?
Sub-type of limited cutaneous systemic sclerosis:
→ calcinosis
→ raynaud’s
→ oesophageal dysmotility
→ scerlodactyly
→ telangiectasia
Antibody in limited vs diffuse systemic sclerosis?
Limited = anti-centromere
Diffuse = anti-scl-70
Features and management of antiphospholipid syndrome?
Venous/arterial thrombosis
Recurrent miscarriages
Pre-eclampsia
Levido reticularis
Management = low-dose aspirin, lifelong warfarin (if PMH thrombotic event)
Blood test features of antiphospholipid syndrome?
Thrombocytopaenia
Prolonged APTT
Anti-cardolipin antibodies
Features of Behcet’s syndrome?
Triad of:
→ oral ulcers
→ genital ulcers
→ anterior uveitis
Arthritis with a salmon-pink rash?
Still’s disease
