Rheumatology Flashcards
Signs of OA in the hands?
Heberden’s nodes (DIP joints)
Bouchard’s nodes (PIP joints)
Squaring at base of the thumb
What is needed for Dx of OA without Ix? (4)
> 45
Activity related pain
No morning stiffness
No stiffness lasting less than 30mins
OA mx?
- Stepwise analgesia
a) Oral paracetamol, Topical NSAIDs or topical capsaicin
b) Oral NSAIDs + PPI
c) Codeine & morphine - Intra-articular steroid injections
- Joint replacement
Key x-ray changes in OA?
L - Loss of joint space
O - Osteophytes
S - Subchondral sclerosis
S - Subchondral cysts
Genes associated with RA & RF positive patients?
HLA DR1 (RA)
HLA DR4 (RF)
Antibodies in RA?
Anti-CCP (more sensitive and specific)
RF (70%)
Common joints in RA?
PIP and MCP
Wrist and ankle
Can affect larger but less likely
Hand joint and indicative arhtiritis?
DIP = OA
PIP = OA or RA
MCP = RA
Signs of RA in the hands?
- Z shaped deformity to the thumb
- Swan neck deformity
- Boutonnieres deformity
- Ulnar deviation of the fingers at the knuckle
Extra-articular manifestations of RA?
- Pulmonary fibrosis
- Bronchiolitis obliterans
- Felty’ syndrome
- Secondary Sjogren’s
What is the triad of felty’s syndrome?
RA, neutropenia and splenomegaly
Ix for rheumatoid arthritis?
- RF
- If RF -ve -> check anti-CCP
- CRP & ESR
- X-ray hands and feet
Ultrasound joints if needed to evaluate synovitis
RA x-ray changes?
Joint destruction and deformity
Soft tissue swelling
Periarticular osteopenia
Boney erosions
What scoring system is used to monitor RA?
DAS28
Assessment of 28 joints for swelling, tender and ESR.CRP result
RA mx?
Flare ups and bridging - steroids
DMARDS:
1. Hydroxychloroquine, methotrexate, leflunomide or sulfsalazine
2. Combination of two
3. Methotrexate + TNF inhibitor (infliximab)
4. Methotrexate + rituximab
Signs of psioratic arthritis?
- Nail pitting
- Onycholysis (nail separation from nail bed)
- Dactylitis (finger inflammation)
- Enthesitis (entheses inflammation - where tendons insert onto bones)
Psoriatic arthritis x-ray changes?
Pencil-in-cup appearance
Periostitis (thickened and irregular outline of bone)
Ankylosis (bones joining together -> stiffness)
Osteolysis
What is arthritis mutilans?
Severe form of psoriatic arthritis where there is osteolysis of bones around joints in digits -> shortened fingers
Mx of psoriatic arthritis?
NSAIDs for pain
DMARDS
Anti-TNF medications (etancercept, inflixmiad or adalimumab)
Ustekinumab is last line
Common infections which trigger reactive arthritis?
Gastroenteritis
STIs
Triad of reactive arthritis
Bilateral conjunctivitis, anterior uveietis
Balanitis
Arthritis
Can’t see, pee or climb
Emergency rheumatology conditions for prompt hospital admission?
Septic arthritis
Systemic vasculitis
Giant cell arteritis
Rheumatology conditions for urgent referral?
Rheumatoid arthritis
Psoriatic arthritis
Ankylosing spondylitis
Suspected CTD with systemic involvement
Rheumatology conditions for routine refferral?
Suspected CTD without systemic involvement
Polymyalgia rheumatica (PMR)
Crystal arthritis
X-ray changes in AS?
Squaring of the vertebral bodies
Subchondral sclerosis and erosions
Ossification
Joint fusion
Mx of AS?
- NSAIDs
- Anti-TNF (etanercept, infliximab, adalimumab)
- Secukinumab
Steroids during flares
Antibody in SLE?
Anti-nuclear antibodies (ANA) [85%, non-specific]
Anti-dsDNA [70% but more specific]
Antibodies in systemic sclerosis?
Both - ANA
Limited - anti-centromere antibodies
Diffuse - anti-Scl-70
Antibodies associated with Sjogren’s?
Anti-Ro
Anti-La
Antibodies associated with polymyositis and dermatomyositis?
Anti-Jo-1 - polymyositis, sometimes dermatomyositis
Anti-Mi-2 - dermatomyositis
ANA - dermatomyositis
Mx of SLE?
First line:
- NSAIDs
- Steroids
- Hydroxychloroquine
Resistant lupus:
- DMARDs
Severe disease -> biologics
- Rituximab
- Belimumab
Limited systemic sclerosis px?
C - Calcinosis
R - Raynaud’s
E - oEsophageal dysmotility
S - sclerodactyl
T - telangiectasia
Diffuse systemic sclerosis px?
CREST + systemic involvement:
- Hypertension, coronary artery disease (CVD)
- Pulmonary hypertension and pulmonary fibrosis (LUNG)
- Glomerulonephritis, scleroderma renal crisis (kidneys)
Mx of Raynauds?
Nifedipine (CCB)
Polymyalgia rheumatica px?
Pain and stiffness in shoulders, pelvic girdle and neck
PMR Mx?
Prednisolone 15mg then gradually reduced
+ osteoporosis prevention (bisphosphonates, calcium and VitD)
+ gastric protection (PPI)
PMR Ix?
Dx is clinical, excluding other causes and +ve response to oral corticosteroids
Request ESR, PV and CRP
Exclude giant cell arteritis
Px of giant cell arteritis?
Severe unilateral headache
Scalp tenderness when brushing hair
Jaw claudication
Blurred or double vision
Associated symptoms - fever, myalgia, fatigue, weight loss, loss of appetitie, peripheral oedema
Dx of giant cell arteritis?
Clinical presentation
Raised ESR
Temporal artery biopsy -> multinucleated giant cells
Mx of giant cell arteritis?
Immediate steroids (prednisolone 40-60mg) - quick response
Aspirin - decreases visual loss & strokes
PPI
What are myositis, polymyositis and dermatomyositis?
Myositis is inflammation of the muscles
Polymyositis is chronic inflammation of the muscles
Dermatomyositis is inflammation of the skin and muscles
Ix in myositis?
Creatine kinase - is released in muscle inflammation, normally <300 in myositis
> 1000 indicates polymyositis / dermatomyositis
Causes of raised creatine kinase?
Rhabdomyolysis
AKI
M.I
Statins
Exercise
Common cancers which cause polymyositis / dermatomyositis?
Lung
Breast
Ovarian
Gastric
Px of polymyositis?
Muscle pain, fatigue and weakness
Bilaterally, proximal muscles
Shoulder and pelvic girdle
Develops over weeks
Dermatomyositis skin features?
Gottron lesions - scaly red knuckles, elbows and knees
Photosensitive red rash on back, shoulders and neck
Purple rash on face and eyelids
Periorbital oedema
Subcutaneous calcinosis
Definitive dx of polymyositis
Muscle biopsy
Mx of polymyositis / dermatomyositis?
Corticosteroids first line
If steroids inadequate:
- Immunosuppressants (azathioprine)
- IV immunoglobulins
- Biologics (infliximab, etanercept)
What are the anti-phospholipid antibodies?
Lupus anticoagulant
Anticardiolipin antibodies
Anti-beta-2 glycoprotein I antibodies
Antiphospholipid associations?
Venous thromboembolism
Arterial thrombosis
Recurrent miscarriage, pre-eclampsia
Livedo reticularis (purple mottled rash)
Endocarditis
Thrombocytopenia
What is needed for dx of antiphospholipid syndrome?
Hx of thrombosis or pregnancy complications + persistent antibodies
Mx of antiphospholipid syndrome?
Long term warfarin
If pregnant -> LMWH + aspirin
What is Sjogren’s syndrome?
Autoimmune condition affecting exocrine glands -> dryness
Test for Sjogrens?
Schirmer test - filter paper under lower eyelid
Mx of Sjogrens?
Artificial tears
Artificial saliva
Vaginal lubricants
Hydroxychloroquine
What is Henoch-Schonlein purpura?
IgA small vessel vasculitis commonly presenting with purpuric rash affecting lower limbs or buttocks in children.
Triggered by an URTI or gastroenteritis
Features of HSP? (4)
Purpura (100%)
Joint pain (75%)
Abdo pain (50%)
Renal involvement (50%)
Mx of HSP?
Supportive
What is the blood test for vasculitis?
Anti neutrophil cytoplasmic antibodies (ANCA)
What are p-ANCA (MPO antibodies) found in?
Microscopic polyangiitis
Churg-Strauss syndrome / Eosinophilic Granulomatosis with Polyangiitis
What are c-ANCA (PR3 antibodies) found in?
Granlomatosis with polyangitiis
Young Asian woman with weak pulse in one arm?
Takayasu’s arteritis
Hepatitis B positive vasculitis?
Polyarteritis nodosa
Bizarre asthma in adults vasculitis?
Chrug-Strauss syndrome / Eosinophilic granulomatosis with polyangiitis
Epistaxis, crusty nasal secretions, sinusitis, URTI, rapidly progressing glomerulonephritis vasculitis?
Wagner’s granulomatosis / granulomatosis with polyangiitis
Behcet’s disease px?
Recurrent oral and genital ulcers
- Oral ulcers >3 year, they have a red halo
- Genital ulcers often develop on two opposing surfaces facing each other (kissing ulcers)
What is the pathergy test?
Used in Ix of Behcet’s disease
Abrasion created to look for a wheal forming
Typical joints for gout?
Base of big toe (metatarsophalangeal joint)
Wrists
Base of thumb (carpometacarpal joints)
Large joints - Knee and ankle
What causes gout?
Chronically high uric acid levels -> urate crystals deposited in joint
Dx of gout?
Aspiration of joint fluid showing:
- Needle shaped crystals
- Negatively birefringent of polarised light
- Monosodium urate crystals
What would a joint x-ray of gout show?
Lytic lesions of bone
Punched out erosions
Joint space maintained
Gout Mx during a flare?
- NSAIDs
- Colchine
- Steroids
Gout prophylaxis?
Allopurinol + lifestyle changes
(lose weight, stay hydrated, less alcohol, less meat/seafood)
What causes pseudogout?
Calcium pyrophosphate crystals deposited in joint (chondrocalcinosis)
Common joints for pseudogout?
Knees
Shoulders
Wrists
Hips
Chronic condition and can affect multiple joints
Dx of pseudogout?
Aspiration of synovial fluid will show?
- Calcium pyrophosphate crystals
- Rhomboid shaped crystals
- Positive birefringent of polarised light
What is seen on x-ray of pseudogout?
Chondrocalcinosis - thin white line in joint space showing calcium deposition
+ LOSS
Mx of pseudogout?
Self-limiting over several weeks
Symptomatic mx:
- NSAIDs
- Colchine
- Steroid injection
- Oral steroids
Severe -> joint washout
Medications which increase Rx of osteoporosis?
Steroids, SSRIs, PPIs, ant-epileptics and anti-oestrogens
Bone mineral density and T-score?
More than -1 = normal
-1 to -2.5 = osteopenia
Less than -2.5 = osteoporosis
Mx of osteoporosis?
Calcium + VitD + bisphosphonates
If bisphosphonates contraindicated:
- Denosumab
- Strontium ranelate
- HRT
Examples of bisphosphonates?
Alendronate (once weekly, oral)
Risedronate (once weekly, oral)
Zoledronic acid (one yearly, IV)
Bisphosphonate side effects?
Reflux and oesophageal erosions
Atypical fractures
Osteonecrosis of the jaw
Osteonecrosis of the external auditory canal
What is osteoporosis and osteopenia?
Osteoporosis is when there is a reduction in the density of bones
Osteopenia is a less severe reduction in bone density
What is osteomalacia?
This is when there is defective bone mineralisation causing “soft” bones. Due to inadequte VitD.
Mx for osteomalacia?
VitD supplements (colecalciferol)
What is Paget’s disease?
Excessive bone turnover due to excessive activity of osteoblasts and osteoclasts -> patches of sclerosis and lysis
Causes enlarged, misshaped bones
X-ray findings of Paget’s disease?
Bone enlargement and deformity
Well defined osteolytic lesions
Cotton wool appearance of the skull
V-shaped defects in long bones
Mx of Paget’s disease?
Bisphosphonates
+ calcium & VitD
+ NSAIDs for bone pain
Monitor ALP
Two key complications of Paget’s disease?
Osteosarcoma
Spinal stenosis and spinal cord compression (Dx - MRI)
Side effects of methotrexate? (5)
Bone marrow suppression & leukopenia
Liver toxicity
Pneumonitis
Mouth ulcers and mucositis
Highly teratogenic
Side effects of sulfasalazine? (2)
Male infertility
Bone marrow suppression
Side effects of hydroxychloroquine? (4)
Reduced visual acuity
Nightmares
Liver toxicity
Skin pigmentation
