Rheumatology

Question 1

What is MCP subluxation towards the palm referred to as?

Answer 1

Volar subluxation

Question 2

What’s this?

Answer 2

Swan neck deformity

Question 3

What’s this?

Answer 3

Boutenniere’s deformity

Question 4

What’s this?

Answer 4

Z thumb deformity

Question 5

What’s this?

Answer 5

Sclerodactyly

Question 6

What are distal interphalangeal joint osteroarthritic nodules called?

Answer 6

Heberden’s node

Question 7

What are proximal interphalangeal joint osteroarthritic nodules called?

Answer 7

Bouchard’s nodes

Question 8

What two causes of arthritis typically cause symmetrical polyarthropathy with DIP sparing?

Answer 8

Rheumatoid arthritis and SLE arthropathy

Question 9

What abnormality is seen in this XR?

Answer 9

Erosions of the MCPs and the ulnar styloid

Question 10

What are the abnormalities in this XR?

Answer 10

Pencil in cup at the DIPs

Question 11

What are these deformities typical of?

Answer 11

Osteoarthritis

Question 12

What are the lumber spine findings in patients with ankylosing spondylitis?

Answer 12

Loss of lumber lordosis
Squaring of vertebrae
Syndesmophytes
Bamboo spine
Apophyseal (facet/intervertenral) joint fustion

Question 13

What is a syndesmophyte?

Answer 13

Annulus fibrosus and ligamentous ossficiation at the junction of adjacent vertebral bodies.
Syndesmophytes originate from the connective tissue, osteophytes (though appearing similar radiographically) originate from the bone.

Question 14

What is meant by facet joint fusion?

Answer 14

Literal fusion of the vertebral bodies.

Question 15

What are the extraaxial joint manifestations of anklyosing spondylitis?

Answer 15

Arthritis: ankles, hips, knees, shoulders, and sternoclavicular joint.s
Enthesitis: especially at the achilles tendon
Dactylitis - diffuse swelling of toes or fingers

Question 16

What the extraarticular manifestations of ankylosing spondylitis?

Answer 16

Acute anterior uveitis
Inflammatory bowel disease
Psoriasis
Apical lung fibrosis
Aortitis and aortic valve disease

Question 17

What is the differential for Jaccoud’s arthropathy?

Answer 17

Rheumatic fever
SLE
Parkinson’s disease
Hypocomplementemic vasculitis
HIV

Question 18

What is the significance of an anti-smith antibody?

Answer 18

Most specific SLE antibody, but not the most common. Also seen in mixed connective tissue diseae however.

Question 19

What antibody is typically seen in drug-induced lupus?

Answer 19

Anti-histone antiboides.

Question 20

Most common causes of drug induced lupus?

Answer 20

Procainamide, hydralazine, isoniazid, quinidine, chlorpromazine, methyldopa, pheytoin, carbamazepine, sulphonamides, OCP, tetracycline

Question 21

What type of heart disease is associated with lupus?

Answer 21

Libman-Sacks endocarditis - non-infective vegetations form heart valves. Most commonly the aortic and mitral valves. Often see diffuse thickenings on the vavles. Can cause stenosis or regurgitatant murmurs, which can eventuate in cardiac failure. These non-infective lesions can also embolise.

Question 22

What are the features seen in anti-centromere ANA pattern scleroderma?

Answer 22

Limited systemic sclerosis
Pulmonary arterial hypertension

Question 23

What are the features seen in anti-RNA polymerase III antibody sceleroderma?

Answer 23

ANA nucleolar pattern
Diffuse systemic sclerosis
Hand disability
Renal crisis with higher blood pressure

Question 24

What the features seen in anti-Scl70 autoantibody scleroderma?

Answer 24

Fine speckled ANA
Diffuse systemic sclerosis
Progressive lung fibrosis
Digital ulcers
Hand disability

Question 25

What is the thing about anti-Ro60 and SLE?

Answer 25

It's the pathogenic antibody in a significant number of 'ANA negative' lupus presentations. It has to be tested for seperate to ANA. Also crosses the placenta like Ro52 and causes neonatal lupus.

Question 26

What are the clinical features of antisynthetase syndrome?

Answer 26

Acute onset Myositis Reynaud's phenomenon Non-erosive arthritis 'Mechanics hands' - thickened finger tips Interstitial lung disease Anti-Jo1 positive

Question 27

What's the thing about antiribosomal P antibody and SLE?

Answer 27

Also a cytoplasmic antibody associated with SLE that, like Ro60, is not readily seen on ANA/ENA. Has been associated with neuropsychiatric SLE in more cases than other abs.

Question 28

What is anti-Jo1 ab associated with?

Answer 28

Anti-synthetase syndrome

Question 29

What are the antibodies that are associated with dermatomyositis? What is each myositis phenotype

Answer 29

Anti-MDA5 (amyopathic dermatomyositis) Anti-TIF1 gamma (malignancy associated, red on white patches, ovoid palatal patch, hyperkeratotic palmar patches) Anti-Mi-2 (rapid onset, low risk of associated malignancy) Anti- SRP (necrotising rapidly progressive myopathy with minimal inflammation) Anti-Jo1 (antisynthetase syndrome) Anti-NXP-2 (young onset disease, calcinosis and dysphagia prominant features) Anti-SAE - (dysphagia heavy) Anti-HMGCR (immune mediated necortising myositis, 50% have used statins previously)

Question 30

What does anti-MDA5 dermatomyositis look like?

Answer 30

Amyopathic! No muscle involvement. Rapidly progressive ILD however, arthritis, and skin involvement. This includes Gottron papules, shawl sign, painful palmar papules and macules, oral ulcerations and non-scaring alopecia.

Question 31

What antibody is often seen in patients with inclusion body myositis?

Answer 31

anti-NT5C1A

Question 32

What are the clinical features of inclusion body myositis?

Answer 32

Insidious onset of weakness (over about 5 years) Old > young Males > female Proximal > distal leg weakness Distal upper limb weakness - particularly flexor muscles Facial muscle (especially obicularis occulis) Globally decreased reflexes Dysphagia

Question 33

What is the autoantibody seen in all patients with mixed connective tissue disease?

Answer 33

Anti-U1RNP

Question 34

What is the combination of features that make MCTD the most likely diagnosis compared with SLE or SSc?

Answer 34

Raynaud phenoenon AND dactylitis The absence of severe kidney or CNS disease Severe arthritis Insidious onset pulmonary hypertension without ILD Anti-U1 RNP ab positive

Question 35

List all the autoantibodies associated with SLE

Answer 35

Anti-DS DNA Anti-Sm (smith) Anti-ribosomal P Anti-Ro52/60 (SSA)

Question 36

What type of myopathy has this patient most likely got?

Answer 36

Inclusion body myositis. Note the classic finding of forearm muscle wasting.