Rheumatology Flashcards
What antibody is found in drug-induced lupus?
Anti-ANA (100%)
Anti-Histone (80-90%)
What skin features are seen in reactive arthritis?
Circinate balanitis (painless vesicles on the coronal margin of the prepuce)
Keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles)
What are the symptoms of lateral epicondylitis?
Pain is worse on resisted wrist extension/suppination whilst elbow extended
What are the symptoms of medial epicondylitis?
aka Golfer’s elbow
Pain is worse on flexion and pronation of the wrist.
What should you do before giving bisphosphonates in osteomalacia?
Correct calcium levels
What is needed following a diagnosis with dermatomyositis?
Screening for malignancy as it can be found in 25% of patients, especially if they are older
In which condition are “pencil-in-cup” appearances seen on x-ray?
Psoriatic arthritis - you see distal interphalangeal joint pain and swelling + dactylitis
They are caused by periarticular erosions and bone resorption
What are rat-bite erosions (erosions with overhanging edges) associated with?
Gouty tophi
What are features of Behcet’s syndrome?
- classically: 1) oral ulcers 2) genital ulcers 3) anterior uveitis
- thrombophlebitis and deep vein thrombosis
- arthritis
- neurological involvement (e.g. aseptic meningitis)
- GI: abdo pain, diarrhoea, colitis
- erythema nodosum
What are early and late x-ray changes of rheumatoid arthritis?
Early x-ray findings
* loss of joint space
* juxta-articular osteoporosis
* soft-tissue swelling
Late x-ray findings
* periarticular erosions
* subluxation
What are skin signs seen in dermatomyositis?
- macular rash over back and shoulder
- heliotrope rash in the periorbital region
- Gottron’s papules - roughened red papules over extensor surfaces of fingers
- ‘mechanic’s hands’: extremely dry and scaly hands with linear ‘cracks’ on the palmar and lateral aspects of the fingers
- nail fold capillary dilatation
What is used to manage acute flare-ups of rheumatoid arthritis?
Glucocorticoids oral or injections such as methylprednisolone acetate and triamcinolone acetonide
According to NICE, what should you do for a patient over 65 years starting on long-term corticosteroids?
A bisphosphonate, such as alendronate, to prevent glucocorticoid-induced osteoporosis
In addition, ensuring adequate intake of calcium and vitamin D is important to support bone health
What are examination findings of ankylosing spondylitis?
- Reduced lateral flexion
- Reduced forward flexion
- Reduced chest expansion
What is antisynthetase syndrome?
Antisynthetase syndrome is caused by autoantibodies against aminoacyl-tRNA synthetase e.g. anti-Jo1.
It is characterised by
* myositis
* interstitial lung disease
* thickened and cracked skin of the hands (mechanic’s hands)
* Raynaud’s phenomenon
What are causes of primary hyperparathyroidism?
- Parathyroid adenoma (80%)
- Parathyroid hyperplasia (15%)
- Parathyroid carcinoma (1%)
How is vision affected in temporal arteritis?
Anterior ischemic optic neuropathy: occlusion of the posterior ciliary artery (a branch of the ophthalmic artery) → ischaemia of the optic nerve head (swollen pale disc and blurred margins on fundoscopy)
What are the main features of polymyalgia rheumatica?
- typically patient > 60 years old
- usually rapid onset (e.g. < 1 month)
- aching, morning stiffness in proximal limb muscles
- also mild polyarthralgia, lethargy, depression, low-grade fever, anorexia, night sweats
*weakness is not considered a symptom of polymyalgia rheumatica
What is the main investigation finding of polymyalgia rheumatica?
Raised ESR
Creatinine kinase and EMG are normal
What is the treatment of polymyalgia rheumatica?
Prednisolone e.g. 15mg/od
*Patients typically respond dramatically to steroids, failure to do so should prompt consideration of an alternative diagnosis
What is seen on x-ray in pseudogout?
Chondrocalcinosis (visible calcification of cartilage)
What should you ideally do before administering broad-spectrum antibiotics in septic arthritis?
Perform synovial fluid sampling
What is the preferred antibiotic regimen for septic arthritis?
Flucloxacillin 4-6 weeks
If penicillin-allergic, consider clindamycin
If MRSA, consider vancomycin or teicoplanin
If gonococcal arthritis or Gram-negative infection, consider cefotaxime or ceftriaxone
What is Felty’s syndrome?
Triad of: splenomegaly, neutropenia and rheumatoid arthritis
*Hypersplenism results in destruction of blood cells which classically results in neutropenia but can also cause pancytopenia
What is the treatment for Raynaud’s phenomenon?
first-line: calcium channel blockers e.g. nifedipine
IV prostacyclin (epoprostenol) infusions: effects may last several weeks/months
What drugs can cause drug-induced lupus?
Most common causes:
* procainamide
* hydralazine
Less common causes:
* isoniazid
* minocycline
* phenytoin
What is the management of reactive arthritis?
Analgesia + NSAIDS
If NSAIDS do not work, consider intra-articular steroids
If steroids do not work, consider methotrexate or sulfasalazine
What is a side effect of hydroxychloroquine?
Bull’s eye retinopathy - may result in severe and permanent visual loss
What is the first-line treatment of ankylosing spondylitis?
NSAIDS
When do you consider TNF-alpha treatment in ankylosing spondylitis?
Anti-TNF alpha inhibitors should be used in axial ankylosing spondylitis that has failed on 2 different NSAIDS and meets criteria for active disease on 2 occasions 12 weeks apart. Physio should be used throughout the treatment.
What is the preferred management for antiphospholipid syndrome?
Primary thromboprophylaxis: low-dose aspirin
Secondary thromboprophylaxis: warfarin (target INR = 2-3 if initial VTE or arterial thrombosis; target INR = 3-4 if recurrent VTE)
What is treatment of choice for methotrexate toxicity?
Folinic acid
What is the guidance for taking bisphosphonates?
Take at least 30 minutes before breakfast with plenty of water + sit-upright for 30 minutes following.
It has poor oral bioavailability, which can be further reduced by food or drink (other than plain water). Furthermore, due to its potential for causing oesophageal irritation and ulceration, it is recommended that patients remain upright (sitting or standing) for at least 30 minutes after ingestion to facilitate passage through the oesophagus
What are important risk factors for osteoporosis according to the FRACxtool?
- history of glucocorticoid use
- rheumatoid arthritis
- alcohol excess
- history of parental hip fracture
- low body mass index
- current smoking
What would you see on joint aspiration of gout?
Negatively (yellow) birefringent needle-shaped crystals under polarised light
What would you see on joint aspiration of pseudogout?
Positively (blue) birefringent rhomboid-shaped crystals under polarised light
What test should you do if you suspect osteoporosis in men?
Measure testosterone
*Low testosterone levels are associated with higher bone turnover therefore osteoporosis.
What are the features of Takayasu’s arteritis?
Large vessel vasculitis which typically causes occlusion of the aorta. It is more common in younger females (e.g. 10-40 years) and Asian people.
Features
* systemic features of a vasculitis e.g. malaise, headache
* unequal blood pressure in the upper limbs
* carotid bruit and tenderness
* absent or weak peripheral pulses
* upper and lower limb claudication on exertion
* aortic regurgitation (around 20%)
It is associated with renal artery stenosis.
Investigations include MRA or CTA
Management = steroids
What Schober’s test result is indicative of ankylosing spondylitis?
Schober’s test <5cm is suggestive of ankylosing spondylitis
What are different types of seronegative spondyloarthropathies?
These are associated with HLA-B27:
* Ankylosing spondylitis
* Psoriatic arthritis
* Reactive arthritis
* Enteropathic arthritis (associated with IBD)
What is the first-line medical management for osteoarthritis?
Topical NSAIDs if OA of hand or knee
*If topical is insufficent, move to oral NSAIDs. Paracetamol and opioids are no longer offered regularly.
How do you manage patients at risk of corticosteroid-induced osteoporosis?
Patients >65yrs or previous hx of fragility fracture: direct bone protection
Patients <65yrs should be offered DEXA scan:
* T>0 - reassure
* -1.5<T<0 - repeat DEXA in 1-3yrs
* T<-1.5 - bone protection
Bone protection is with alendronate. Also ensure calcium and Vit D levels are replenished.
What should you do if patients fail to respond to steroids in PMR?
Refer to specialist for consideration of other diagnoses
What is the management of antiphospholid syndrome?
Primary thromboprophylaxis: aspirin
Secondary thromboprophylaxis: lifelong warfarin
How does loss of joint space differ in osteoarthritis to rheumatoid arthritis?
Osteoarthritis - eccentric, non-uniform loss of space
Rheumatoid arthritis - uniform, symmetrical
Which joints are more commonly affected in osteoarthritis?
DIPJs
PIPJs
STTJ (Scaphoid, Trapezium and Trapezoid Joint)
CMCJ (thumb base)
Which joints are more commonly affected in rheumatoid?
Carpal bones
MCPJs
PIPJs
What is polyarteritis nodosa associated with?
Hepatitis B infection
What should you do when a patient first starts allopurinol?
Prescribe a NSAID or colchicine cover
*Allopurinol is a xanthine oxidase inhibitor which reduces the production of uric acid and it is used in the prophylactic treatment of gout to reduce deposition of urate in joints. However starting allopurinol can in itself trigger an acute flare up of gout.
What are features of plantar fasciitis?
Most common cause of heel pain seen in adults - pain is usually worse around the medial calcaneal tuberosity. The pain is exacerbated by walking on tip toes.
Management:
* rest the feet where possible
* wear shoes with good arch support and cushioned heels
* insoles and heel pads may be helpful
What is the most common organism causing septic arthritis?
Overall is Staphylococcus aureus
However, in young adults who are sexually active, Neisseria gonorrhoeae is the most common organism (disseminated gonococcal infection)
Which muscles/tendons are inflammed in De Quervain’s tenosynovitis?
Extensor pollicis brevis and abductor pollicis longus tendons
What are some associations of pseudogout?
Haemochromatosis
Hyperparathyroidism
Low magnesium, low phosphate
Acromegaly
Wilson’s disease
