Rheumatology Flashcards
Symptoms of gout
pain, swelling, erythema
Joints affected by gout
1st MTP
ankle, wrist, knee
Investigations of gout
fluid: needle shaped negatively birefingement monosodium urate crystals
XR: joint effusion, punched out erosions
Uric acid: check 2 weeks after acute episode
Gout Management
1) NSAIDS/cochicine +PPI
2) PO steroids
3) intra-articular steroids
URT
What is URT
Urate lowering therapy
allopurinol OD titrated until uric acid <360
+ colchicine
When is URT used?
if >=2 attacks in 1 year
tophi
renal disease
uric acid renal stones
What is gout
deposition of monosodium urate monohydrate in synovium caused by chronic hyperuricaemia
causes of gout
decrease uric acid secretion
-diuretics
-CKD
-lead toxicity
Increased production
- myelo/lymphoproliferative disorders
-cytotoxic drugs
-psoriasis
Pseudogout affected joints
knee, wrist, shoulder
pseudogout patho
deposition of calcium pyrophosphate dihydrate crystals in synovium
pseudogout investigations
fluid: +ve birefringement rhomboid shaped crystals
XR: chondrocalcinosis
Pseudogout management
Aspiration
NSAIDS or steroids
SLE epidemiology
women of childbearing age
SLE gene associations
HLA B8 DR2 DR3
Explained SLE pathophysiology
environmental trigger (sun, infection) causes apoptosis, cells aren’t cleared effectively (genetic) so there are XS nuclear antigens which are seen as foreign (genetic) causing immune response-> ANA, deposits in tissues causing inflam
What kind of reaction is SLE
type 3 hypersensitivity reaction
Features for diagnosis of SLE
1) malar rash
2) discoid rash
3) photosensitivity
4) mouth/nose ulcers
5) serositis (pericarditis, pleuritis)
6) arthritis 2+
7) renal disease - abnormal urine protein, glomerulonephritis
8) neuro - seizures, psychosis
9) blood - anaemia, thrombocytopenia
10) ANA
11) other antibody - anti smith, anti dsDNA anti phospholipid
Monitoring SLE
ESR
C3 C4
Management SLE
hydroxychloroquinine
NSAIDS
pred if internal organ involvement
Complications of SLE with pregnancy
neonatal lupus, congential heart block
associated with anti-RO (SSA) antibodies
RA presentation
swollen painful joints hands/feet
morning stiffness
gradual worsening
RA examination
+ve squeeze test
swan neck
boutonniere
Bloods RA
+ve RF (70-80%)
+ anti CCP antibody (70%)
XR RA
loss of joint space
soft tissue swelling
juxta-articular osteoporosis
later
periarticular erosions
subluxation
Management of RA
DMARD monotherapy +/- bridging pred
flares: PO/IM corticosteroids
TNF-inhibs: etanercept, infliximab
Examples of DMARDs
methotrexate: monitor FBC/LFT as risk of liver cirrhosis and myelosuppression
TNF-inhibs e.g infliximab, etanercept
Poor prognostic features of RA
RF +Ve anti CCP antibodies +ve
poor function status
early XR erosions (<2yrs)
extra articular features
HLA DR4
Complications of RA
resp: fibrosis, effusion, nodules
occular: keratoconjunctivitis sicca
OP
IHD
Example of safe and unsafe DMARD in pregnancy
MTX - stop 6/12 prior to conception
safe: sulfasaline, hydroxycholorquine
symptoms of PMR
over 60 and rapid onset
aching and morning stiffness in prox limb muscles
lethargy, low grade fever
Pathophysiology of Reactive Arthritis
following GI or STI infection
Symptoms develop 4 weeks later
What is Reactive Arthritis grouped with
HLA B27 gene, seronegative spondyloarthropathy
How does reactive arthritis present
Cant see cant pee cant climb a tree
1) arthritis - lower joints asymmetrical
2) conjuctivitis, anterior uveitis
3) circinate balanitis, urethritis
last around 4-6 months
Reactive arthritis management
NSAIDs, intra-articular steroids
MTX, sulfsalazine if persistent
Most common organism causing septic arthritis
Staph aureus
Most likely organism causing septic arthritis in sexually active adult
neisseria gonorrhoea
Most common cause of septic arthritis
haematogenous spread
Most common location of septic arthritis
knee
Presentation of septic arthritis
acute swollen joint
warm and fluctuant
fever
Investigations of septic arthritis
synovial fluid aspiration before Abx
blood cultures
imaging
Management of septic arthritis
IV fluxclox (clindamycin)
PO switch after 2 weeks (4-6 weeks Abx total)
needle aspiration to decompress
arthroscopic lavage
What is psoriatic arthritis
seronegative spondyloarthropathy
Psoriatic arthritis epidemiology
10-20% of psorasis patients within 10 years of skin lesions
Presentation of psoriatic arthritis
1) symmetrical: hands, wrists, ankles, DIJ
2) asym: digits
3) spondylitis: back stiffness, sacroilitis
Examination findings of psoriatic arthritis
Skin lesions
nail pitting, onycholysis, dactylitis
enthesis
Ix psoriatic arthritis
XR
- erosive changes + new bone formation
- periostitis
- pencil in a cup appearance
Management of psoriatic arthritis
mild: NSAIDS
mod: MTX
What is ankylosing spondylitis
HLA B27 gene - seronegative spondyloarthropathy
How does ank spon present
young male
gradual onset
back pain and stiffness, worse in the morning improves throughout the day
how do you examine ?ank spon
Schobers test
mark 10cm above and 5cm below L5
if <20cm when bending forward indicates restriction
Investigations ank spon
XR sacroiliac joints
-sacroiliitis
-squaring of lumbar vertebrae
- bamboo spine
MRI if XR -ve but high suspicion
Management ank spon
Regular exercise, PT
NSAIDS
DMARDs if peripheral joint involvement
anti-TNF (etanercept/adalimumam) if persistent
Risk factors for osteoporosis
glucocorticoids
RA
alcohol
Smoking
Low BMI
Hx parental hip #
Meds that increase risk of osteoporosis
*glucocorticoids
SSRI
Anti-epileptic
PPI
Investigations for osteoporosis
DEXA scan T score
<=-2.5 : diagnostic
-2.5->-1: osteopaenia
>-1: normal
Bloods
What is a T score on DEXA scan based on
bone mass of young population
Osteoporosis management
Vit d and calcium supplementation
alendronate -> risedronate if not tolerated
How do you manage risk of OP in patients taking glucocorticoids?
- > 65 + previous fragility #: offer bone protection
- <65: DEXA T score
>0: reassure
0-> -1.5: repeat scan 1-3 years
-<1.5: bone protection
Risk factors for osteoarthritis
Age, female
occupation
high BMI
trauma
FHx
XR findings osteoarthritis
Loss of joint space
Osteophytes
Subarticular sclerosis
Subchondral cysts
Do not correlate to disease severity
Presentation of osteoarthritis
joint pain and stiffness (lasting less than 30mins in the morning)
worse on exercise
Joints commonly affected by osteoarthritis
Knee, hip, sacroiliac, c spine
DIP, CMC, wrist
Examination findings of osteoarthritis
Haberdens nodes (DIP)
Bouchards nodes (PIP)
Squaring at thumb base (CMC)
Decreased grip and decreased ROM
Diagnosis of osteoarthritis
clinical
Management of osteoarthritis
lifestyle
PT/OT/Orthotics
Analgesia: PCM/topical NSAIDS -> PO NSAIDS -> opiods
IA steroid injections
joint replacement
Osteomyelitis causes
staph aureus mainly
salmonella if sickle cell
Osteomyelitis investigations
MRI
Osteomyelitis management
6/52 Abx - fluclox (clinda)
RF for osteomyelitis
haematogenous: SS, IVDU, IE, immunosuppression
non-haematogenous: DM, diabetic foot ulcers, PAD
Pathophysiology of antiphospholipid syndrome
genetic factor: HLA DR7
environmental trigger: infection, drugs
anti-beta 2 glycoprotein1 and anti-cardiolipin encourage clot formation
Features of antiphospholipid syndrome
arterial/venous thrombosis
recurrent fetal loss
pre-eclampsia
investigations of antiphospholipid syndrome
antibodies: anti beta 2 glycoprotein 1, anti cardiolipin, lupus anticoagulant
thrombocytopenia
increased APTT
Antiphospholipid syndrome management
primary thromboprophylaxis: low dose aspirin
secondary - warfarin target 2-3
if further episode target 3-4 +aspirin
What is avascular necrosis of hip
death of bone tissue secondary to loss of the blood supply
Causes of avascular necrosis of hip
Steroids
Chemo
Alcohol
Trauma
features of avascular necrosis of hip
asymptomatic -> pain
Investigations of avascular necrosis of hip
XR - crescent sign, collapse of articular surface
MRI
Management of avascular necrosis of hip
joint replacement
Carpal Tunnel Cause
compression of median nerve
carpal tunnel symptoms
pain/pins and needles, thumb, middle finger, index finger
shaking hand improves symptoms
Examination findings of carpal tunnel
Tinnels: tapping
Phalens: flexion of wrist
weakness thumb abduction
wasting of thenar eminence
Diagnosis of carpal tunnel
electrophysiology - prolonged action potential
Management of carpal tunnel
6/52 conservative
- corticosteroid injection
- splint
If persists
- decompressive surgery
What is chronic fatigue syndrome
more than 3 months disabling fatigue affecting mental and physical function >50% of the time
How does chronic fatigue present
Fatigue
post exertional malaise
unrefreshing sleep
cognitive difficulties
Chronic fatigue investigations
full bloods inc coeliac
Chronic fatigue management
specialist referral
CBT
What is Cubital tunnel syndrome
compression of ulnar nerve in cubital tunnel
How does Cubital tunnel syndrome present
tingling/numbness 4th and 5th fingers
intermittent->constant->weakness and wasting
How is cubital tunnel syndrome diagnosed
clinical
can use NCS
How is cubital tunnel syndrome managed
PT, steroid injections, surgery
What is De Quervain’s tenosynovitis
sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflamed.
Features of De Quervains tenosynovitis
pain on the radial side of the wrist
tenderness over the radial styloid process
abduction of the thumb against resistance is painful
Examination of De Quervains tenosynovitis
Finkelstein’s test
thumb in fist, deviate hand towards ulnar side, if pain at radial side +ve test
Management of De Quervains tenosynovitis
Analgesia
steroid injection
split
surgery
How would dermatomyositis present
symmetrical prox muscle weakness (shoulder/hip)-> wasting
fever, weight loss, fatigue
Gottrons papules - purple lesions tops small joints of fingers
Heliotrope rash - bilat discolouration around eyes
Investigation findings of dermatomyositis
ANA +ve
Anti Jo 1, Anti Mi 2
Increased CK
How do you manage dermatomyositis
pred
How do you manage discoid lupus erythema?
Top steroids
PO Anti malarials
avoid sun
How does discoid lupus erythema present
erythematous raised rash on neck/face/scalp/ears
when healing scars cause alopecia
Commmon causes of drug induced lupus
procainamide
hydralazine
What Is Ehlers-Danlos
Autosomal dom connective tissue disorder affecting type III collagen
Presentation of Ehlers Danlos
Hypermobility (joint dislocation), elastic fragile skin (Easy brusing)
Cardiac association with Ehlers Danlos
aortic regurgitation, mitral valve prolapse and aortic dissection
Diagnosis: lateral epicondyle pain,
worse on resisted wrist extension or forearm supination when elbow extended acute episode 6-12 weeks
Lateral epicondylitis (tennis elbow)
episodes late 6months - 2 years
Diagnosis: medial epicondyle pain, worse on wrist flexion and pronation, accompanied by numbness/tingling 4th and 5th finger
Medial epicondylitis (golfers elbow) tingling due to ulnar nerve involvement
Diagnosis: pain 4-5cm from lateral epicondyle, worse by extending elbow and pronating forearm
Radial tunnel syndrome
due to overuse
Diagnosis: swelling over posterior aspect of elbow in middle aged man
olecranon bursitis
Diagnosis: tingling 4th 5th finger progressing to numbness, worse when elbow resting on firm surface or flexed for periods of time
Cubital tunnel syndrome
compression of ulnar nerve
Familial Mediterranean Fever epidemiology, presentation and management
Ex: turkish, armenian, arabic
Px: fever, abdo pain, pleurisy, pericarditis, lower limb rash
Mx: colchicine
Fibromyalgia symptoms and epidemiology
women 30-50
pain at multiple sites
fatigue, sleep disturbance, cog impairment
Fibromyalgia management
education, exercise, CBT
pregabalin, duloxetine, amitriptyline
Pathophysiology Marfans
autosomal dominant CTD
defect in FBN1 gene on chromosome 15
Symptoms Marfans
tall
long fingers
high arched palate
heart: aortic sinus dilation -> aneurysm, mitral valve prolapse
pneumothorax
eyes: blue sclera, myopia
Marfans management
ECHO monitoring
B blockers/ACE inhibs
What is Pagets disease of the bone
Increased osteoclastic resorption
How does Pagets disease of bone present
older male with bone pain and increased ALP
Common areas for Pagets disease of bone to affect
pelvis, lumbar spine, femur
bowing of tibia, bossing of skull
Investigtaions Pagets
Increased ALP
XR: osteolysis -> mixed lytic/sclerotic lesions
skull XR: thickened vault, osteoporosis circumsciptia
Management of Pagets
PO risedronate IV zoledronate if
bone pain
skull or long bone deformity
fracture
periarticular Paget’s
what is Raynauds?
exaggerated vasoconstriction to cold or emotional stress
causes of Raynauds
primary
secondary: connective tissue disorder (scleroderma), leukaemia, OCP
Management of Raynauds
nifedipine
IV prostacyclin
What is Sjogrens syndrome?
Autoimmune affecting exocrine glands ->dry mucosal surfaces
Causes of Sjogrens syndrome
primary; Sicca syndrome
secondary: RA, CTD
Presentation of Sjogrens syndrome
middle aged women
dry eyes blurred vision
dry mouth
dry skin and vagina
Investigations of Sjogrens syndrome
ANA +ve 70%
RF +ve 50%
Anti Ro, Anti La
Histology: focal lymphocytic infiltration
Management of Sjogrens syndrome
Artificial tears and saliva
Pilocarpine
What is temporal arteritis
medium and large vessel vasculitis ?cause
How does temporal arteritis present?
> 60 year old, rapid <1month
headache
jaw claudication
tender palpable temporal artery
visual loss
50% PMR
Why can you get visual loss in temporal arteritis
occlusion of posterior ciliary artery -> ischaemia of optic nerve head
Investigations of temporal arteritis
increased ESR
temporal biopsy: skip lesions
fundoscopy: swollen pale disc, blurred margins
Management of temporal arteritis
no visual loss: high dose pred
visual loss: IV Methylpred
urgent opthal review
bisphosphonates
