Rheumatology Flashcards
- What are the early and late radiologic finding of patient with RA?
- And what is the earliest finding????
Early ( non-specific)
- soft tissue swelling (earliest)
- synovial joint distension
- periarticular edema
- periarticular (juxta-articular) osteopenia (early)
Late
- cartilage space narrowing and erosions
-joint sublaxation
What is the effect of RA on vertebrae???
And dont forget it is life-threatening 😱
C1-2 or atlanto-axial sublaxation
Patient know case of RA come with
Dry eyes
Burning or itching sensation; see also “Clinical features of conjunctivitis.”
Blurred vision
Slit-lamp examination findings may include:
Conjunctival injection (usually symmetric and bilateral)
Punctate epithelial erosions (superficial punctate keratitis)
Epithelial filaments on the corneal surface (filamentary keratitis)
Symptoms of connective tissue disorders may also be present.
Etiology:
part of Sjögren syndrome, rheumatoid arthritis (RA), or systemic lupus erythematosus (SLE or lupus).
Contact lens and vit A deficiency
Diagnosis:
Schirmer test and tear breakup test (TBUT)
Patient known case of RA and come with:
Triad of
Splenomegaly + arthritis +neutropenia
What is the dx????
This patient is at particular risk of what malignancy??
Felty syndrome
Clinical triad consisting of arthritis, splenomegaly, and neutropenia
Other features
Skin ulcers of the lower limbs (indicating vasculitis)
Hepatomegaly
Fever
Chest pain (indicating pleuritis or pericarditis)
Associated with increased risk of non-Hodgkin lymphoma
Ttt: methotrexate
RA spares which joints??? Mention 3
DIP
1st MTC
1st CMC
Abx choice in case of -ve gram stain septic arthritis ?
Abx choice in case of +ve gram stain septic arthritis ?
-ve = MCC MRSA =vancomycin
+ve = ceftriaxone or cefotaxime =3rd generation cephalosporin
For 4-6 weeks
Drugs induce gout???
And best antihypertensive agent in gout patient?
See pic
Lorsartan
TB drug cause gout»_space; pyrazinamide
Mention gout prophylaxis and indication
Alloperinol (xanthine oxidase inhibitor)
Indication
2 or more flares per year
Hyperuricemia (>9)
Urate kidney stone + chronic kidney disease
30 years old male with back pain, that is severe at night prevent him form sleep🥲
With stifness for 2, get better with exercise
+ dactylitis + achilles tendon infalmmation
X ray spine shows bambo sign
Dx?
Most specific test?
Mx?
Ankylosing spondylitis
Sacral MRI
First-line : Physical therapy + NSAID for 6m
then adilmumab
🚨 if mention skin inflammation»_space;> poriatic arthritis ( axial or peripheral arthritis + skin psoriasis + nail changes + enthesitis + dactylitis
Dx???
Most common organism?
Reactive arthritis ( reiter syndrome)
MCC after chlamydia
Tx: short-term NSAID, long-term SULFASALAZINE
Mention drugs that cause of drug-induced lupus
And what is the most common one???
MCC hydralazine
Remeber, these drug, It Provoke Mean, Hurtful, Condition =SLE
I= INH
P= procainamide + quinidine
M= methyldopa, minocycline
C= carpamazapine + diltazem
You suspect lupus? Next step???
ANA = انا لوبس 😂
عشان يقولك “انا SLE “
If -ve we can exclude SLE !!
Most specficic anti-smith
For diesease activity > anti ds-DNA
for neonatal lupus > anti Ro La
Most common symptoms in SLE ?
MSK symptoms (90%)
-arthralgia (MC) : symmetrical small joint arthralgia (resembling RA)
-myalgia
rarely , jaccouds arthropathy (reversible in contrast with RA whichis permenant damage)
Then in 2nd place comes the Skin symptoms ( rash, rynoud, levido reticularis )
Most common system affected by SLE??
CNS ❤️🥰😍😘 (60%) (mild depression, migraine)
Then hematology (59%) ( Autoimmune hemolytic anemia =+ve comb +spherocyte+hemolysis) (cytopenias )
Then pulmonary (50%) (pleurisy, pleural effusion, fibrosis)
Mention 3 causes of non-infective endocarditis ?
SLE patient
microscopy of renal biopsy shows focal proliferative neohritis, which class and what is mx?
3
pregnant SLE patient
And baby is at risk (=positive anti-Ro/La) of congenital heart block
What to do???
Drug managemnt of mild, moderate , severe SLE
Can you remember 🤨
Very good 👏
Most important symptoms or signs that present in nearly all patient of scleroderma ?
1- skin fibrosis
2- raynoud
What are the signs of limited systemi sclerosis ???
CREST syndrome
Remeber here pulmonary hypertension whereas in systemic is lung fibrosis + nephrotic crisis
Limited = involves skin of forearm + legs (distal limbs ) + pulmonary hypertension and GI obstruction
Limited vs diffuse scleroderma serology?
Middle age female with dry eye and dry mouth
Nexst step???
What are the associated antibodies?
How to confirm the diagnosis?
And what is the tx?
Schirmer’s test
Dx is by history + schirmer test , is still in dout , confirm by lip biopsy
Treatment is supportive ( artificial tears )
Patient with signs and symptoms of
Polymyositis + scleroderma + SLE
What antibody will be high ?
Mixed conncetive tissue disease
Anti-RNP
ارنب
Gradual onset of proximal muscle weakness + intact EMG
Dx?
Most sensitive test : CK
diagnostic gold standard : muscle biopsy
50 years female with
Headache+ scalp tenderness+ blurry vision+ jaw claudication
Lab : ESR 120😨
Next step?
Steroid
Then biopsy 2cm in length (DONT BE TRICKED: -ve biopsy doesnt exclude due to skip lesion)
Maintenance: 60mg predinsolone daily then taper to 10mg + Tociluzumab
Young asian female with constitutional symptoms + pulselesness 😨 of brachial artery + aortic regurgitation, Dx?
Best or confirmatory ?
Then how to treat?
Takawaso arteritis
MRA: best initial , CTA is alternative
Never biopsy ! How to take biopsy from major artery 🤣 only done in kig khalid hospital
Tttt: intial high dose steroid +DMARDs
Lests test If you are superhero
What is the dx?
Most important risk factor?
Best to diagnose?
Polyartertis nodusa = poly micro aneurysms everywhere ! + constitutional symptoms
Hepatitis B
Dx: biopsy or visceral angiography showing micro-aneurysm
Treatment of polyarteritis nodusa??.
Mention 3 conditions causes very high ESR 100-120 (normal:20) ?
Very few
1- infective endocarditis
2- gaint cell arteritis
3- malignancy
Patient with saddle nose + hemoptysis + hematuria ???
CXR shows multiple nodules
Dx?
What antibody you will found?
granulomatosis with polyangiitis (wegener disease)
C-ANCA
Most ocular abnormality found in GPA disease?
Proptosis
Wegener disease has brother with p-ANCA what is his name??.
Microscopic polyangiitis
Adult onset + difficult to control asthma , dx??
EGPA
Patient with
Severe recurrent ulcer and severe acne 😣😢
What test will help you in diagnosis?
Pathergy test
Ddx of pulomonary - renal syndrome?
= alveolar hemorrhage + hemturia or glumerulonephritis
There is 4 deformity of RA. hand, cant you remember it all ??
What is the ttt of RA flare and long-term treatment?
Radiological finding of osteoarthritis?
Osteophyte + subchondral sclerosis +
Mlst common rout of infection in septic arthritis + MC organism?
Hematogenous
S.Aureus
Ttt of gout? Flare and maintenance?
Flare: DOC indomethacin , or clochicine , Contraindicated is allopurinol
Maintenance: allopurinol or probenicid
Typical presentation of pseudogout?
Eldery women + in knee or wrist joint + with hemochromatosis or hyperparathyroidism + marked improvement after joint aspiration
Tx: NSAID or clochicine
Before starting any DMARDS you should screen for ?
TB : TST, IGRA
Hep B, C
HIV
Autoantibody test part1
Antibody» found in > importance
ANCA»_space;>? >?
AntiDs antibody >. >
AntiSmith >. >
Anto Ro/SSA+AntiLa/SSB >. >
Antiribosomal P >. >
Antihistone antibody>. >
ANA > SLE > most sensitive, if negative rule out SLE
AntiDs-DNA antibody > SLE. > monitor disease activity
AntiSmith > SLE > Most sepcific
Anto Ro/SSA+AntiLa/SSB > SLE > high risk of neinatal lupus
Antiribosomal P > SLE > CNS lupus or lupus hepatitis
Antihistone> Drug induced SLE
High titer of Anti U1-RNP. dx?
MCTD
Positive anti scl70 , dx?
Systemic scleroderma
Anti-centromere antibodies found in ?
Limited scleroderma
Dx?
P-ANCA
C-ANCA
P-ANCA > MPA, EGPA
C-ANCA> wegener (GPA)
Anti-CCP diagnose?
RA
Difference of RA. And ankylosing spondyltis and osteoarthritis in Xray?
Pathophysiology of SLE ?
type III hypersensitivity reactions (Immuune- complex with complement activation)
2nd line treatment if patient Sle has no respose to hydroxychloroquine?
Add methotrexate
What is the most important prognostic factor in SLE patient ?
Renal involvement
SLE patient with proteinuria+ low C3 C4
next step?
Dx?
Ttt?
Renal biopsy
Dx Lupus nephritis by renal biopsy is suspected renal involvement ( proteinuria, RBC cast, acanthocyte )
Ttt:
IV cyclophosphamide followed by oral mycophenolate + aggressive BP control to preserve kidney
SLE patient with refractory seizure and no signs of meningitis or any CNS infection
Mx?
IV methypredisolone + IV cyclophosphamide ( collect ova and store it first )
Young female with multiple first trimetster abortion + upper limb thrombus + recurrent DVT + livido reticularis
dx?
Long-term Mx?
Antiphospholipid syndrome
Screen for SLE
mx: lifelong warfarin
MCC of death in SLE patient?
CVS (pericarditis )
Whenever you suspect SLE , next step ????
Order ANA
Mention 3 autoantibodies associated with antiphospholipid syndrom?
Lupus anticoagulant
Anti-cardiolipin
Anti-B2 glycoprotein
Antineural antibody 😡😡😡 found in which disease? Indicate what?
SLE patient pregnant and got DVT
She has +ve APLS antibodies
What is the ttt?
Note: if the disease is controlled with <5mg warfarin , keep it . If more switch to LMWH
Becuase > 5mg warfarin is teratogenic , while less than 5 is not
Golden slide for SLE 🤩
SLE patient with UTI
what is the drug that used in UTI treatment but causes SLE flare??.
Or what drug you should avoid in treating this patient?
And sulpha-containing drug
As Bactrim
what types of vaccine are contraindicated in SLE patient?
Live attenuated due to DMARDs usage will decrease immunity
Key words of polyarthritis in a golden slide
Do you know that there is syndrome called pseudo-felty syndrome!!
He is not SANTA he is thief will steal your 🎁
🔑: lymphocytosis
RA patient with severe disease not responding well to methotrexate and hydroxychloroquine what to add?
Adilumamb
Treatment of RA in brief Do not delay administration of Methotrexate Steroid is giving as a bridging until Methotrexate start to act
If both failed to control symptoms D Adalimumab (Anti-TNF)
N.B: Caution for liver, lung, kidney and bone marrow toxicity with using Methotrexate Before starting Adalimumab you should test for hepatitis profle, HIV and screen for latent TB (risk of reactivation)
32-year-old female diagnosed with severe RA, rheumatologist decided to start TNF inhibitor as a treatment of choice, which diseases is a high risk this patient to get it as a recurrence?
TB
Old age patient known case of osteoarthritis, HTN, DM and CKD, came asking for pain medication of joint pain, what to give? A- Celecoxib B- Ibuprofen C- Tramadol D- Prednisone
Tramadol
Antibodies found in
Diffuse scleroderma vs limited scleroderma (CREST)
Anti-scl 70 (topoisomerase) vs anticentromere
70-year-old male patient came to your clinic complaining of bilateral shoulder pain in addition to bilateral hip pain, upon examination, power is 5 out of 5, on systemic review he gave history of unilateral headache at temple area, what is he most likely diagnosis?
Polymyalgia rheumatica
Old age+ gaint cel arteritis + bilateral shoulder and hip stifness
Dx: biopsy
Next step : high dose steroid
what type of RTA found in sogren disease
ادعي ربك ماتنسين الجواب او مايجيك السؤال ذا
لان ماله الادعاء لا نيمونيك ولا تفسير منطقي يقدر عليه
RTA1(distal RTA)
Middle age female + fever+ salmon rash + high ferittin (>2500) + arthritis ??dx and managment
Adult still disease
First line :NSAID , if no response > steroid
Patient with spetic arthritis you started empric vancomycin abx then the culture appear with MSSA (methcillin sensitive staph) what to do?
Switch to oxacillin , fluxacillin
How to know if SLE patient is in disease flare ? What is the soecial symptoms of SLE flare ?
Fever amd weight loss with mild lymphadenopathy
Most specific type of endocarditis for SLE patient
Libman-sack endocarditis
Is present search for antiphospholipid syndrome
How to monitor SLE disease activity ? By what labs?
The triad of
Skin lesion (purpura or nodules ) + mononeuroitis complex + esophilia
EGPA
Goodpasture syndrome attack which type of collagen?
Type 4
How to confirm diagnosis of polyangitis nodusa
Patient with saddle nose + swelling of ear pinna , dx?
Relapsing polychondritis
Patient with saddle nose + swelling of ear pinna , dx?
Relapsing polychondritis
Patient with saddle nose + swelling of ear pinna , dx?
Relapsing polychondritis
After dx of bechet disease what to do?
Screen for pulmonary aneurysm by CTA chest
After dx of bechet disease what to do?
Screen for pulmonary aneurysm by CTA chest (Pulmonary CTA)
Golden slide for rheumatology
Patient with SLE
she is suffering from persistent refrqctory arthritis that are not responding to NSAID what to add?
First add low-dose corticosteroid in no improvement add methotrexate in no response add azathioprine
The preferred immunosuppressive agent for SLE during pregnancy is ?
Azathioprine
SLE pregnant with postivie antiRo /La , what you will expect in baby
Rash and congenital heart block
Is anti-dsDNA and anti-smith support the diagnosis of MCTD or SLE?😅
DONT BE TRICKED
Positive anti-Sm or anti-dsDNA antibodies supports the diagnosis of SLE, not MCTD
Patient with refractory tophaceous gout , what is the best chronic treatment ?
RA patient with drop foot, dx?
Patient with suspected ankylosing spondylitis , next step + most appropriate
Next is sacroiliac X-ray
Best is MRI sacroiliac
Patient with glumerulonephritis + hemoptysis + positive anti-GBM , Dx?
Goodpasture
RA patient on methotrexate, but now developed abnormal LFT, what to do
STOP methotrexate (hepatotoxic) and replase it with leflunomide
🟠patient with know liver disease avoid MTX and leflunomide and use sulphasalazine
