Rheumatology Flashcards
What features in a patient history support a diagnosis of RA?
Family history of RA
Younger (30 - 50 yrs)
MCP + PIP pain + swelling
Multiple small joint swellings
Morning Stiffness (>30mins)
Fatigue
Apart from the hands, what other joints are commonly affected in RA?
Shoulders
Knees
Wrists
What are the classical examination findings in the hands of patients with RA?
Soft tissue swelling + tenderness
Ulnar deviation/Palmar subluxation of MCP
Swan-neck deformity to digits
Rheumatoid Nodules
What are the extra-articular manifestations of RA?
3 C’s:
Carpel Tunnel
CVD Risk
Cord Compression
3 A’s:
Anaemia
Arteritis
Amyloidosis (build of amyloid)
3 P’s:
Pericarditis
Pleural Disease
Pulmonary Disease (bronchiectasis/fibrosis)
3 S’s:
Sjogren’s (attacks glands - mucosal/tear leading to dry eyes and mouth)
Scleritis
Splenomegaly (+ neutropenia is FELTY’S SYNDROME)
What investigations help diagnose RA?
High RF + anti-CCP
FBC (normocytic anaemia - anaemia of CD)
Inflammatory Markers raised
What are the radiological features of RA in the hands?
Loss of joint space
Erosions (Periarticular)
Soft Tissue Swelling
Subluxation
What treatment options are available for RA?
1) Methotrexate
2) DMARD combination therapy (sulfasalazine, hydroxychloroquine, leflunomide)
3) Biologics (Adalimumab, etanercept, rituximab)
Acute Flare up: Steroids
What monitoring is required with RA treatments?
Regular Blood tests
Pregnancy testing (sulfalazine only is safe in pregnancy)
What tests are needed before starting on RA drug therapy and what contraindications are there?
CXR
HIV/TB/Hep B/Hep C status
Bloods
Contraindications:
HIV/Hep B/C
Severe HF
Hx of multiple sclerosis
Cancer
What features distinguish RA from other arthritidies?
No DIP involvement
Morning Stiffness > 30 mins
Activity Improves
Resting worsens
Family History
Younger presentation
Small Joints
What features support a diagnosis of Ankylosing Spondylitis?
Young man (teens-30s)
Back stiffness
Reduced spine movement
Loss of lumbar lordosis
Reduced chest expansion
What is Schober’s Test and what does a +ve one look like?
1) Identify the PSIS on each side
2) Mark the skin in the midline 5cm below PSIS + 10cm above PSIS
3) Ask patient to touch there toes
Distance should increase from 15cm > 20cm
+ve test = Less than 20cm (ankylosing spondylitis)
What symptoms would you ask about if you suspect ankylosing spondylitis?
Back pain > 3 months
Morning Stiffness > 30 mins
Buttock pain
Exercise improves it
No improvement with rest
Pain wakes up at night
EAMs:
Anterior uveitis (acutely painful red eye, photophobia, blurred vision)
Psoriasis
IBD
Genitourinary Infection
AV Block
Aortic incompetence
What investigations would further help with the diagnosis of Ankylosing Spondylitis?
CRP/ESR could be raised
+ve Schober’s test
Spine X-Ray/ MRI Spine
+ve HLA-B27 (GENETICS)
What gene is common in ankylosing spondylitis?
HLA-B27
What are the complications of Ankylosing Spondylitis?
Spinal Fractures
Hip Joint Replacement
Spinal Fusion
Osteoporosis
Anterior Uveitis
Increased CVD risk (arrhythmias/CHF/Valvular Disease)
Lung Fibrosis
How do you manage Ankylosing Spondylitis?
1) NSAIDs + physio
2) TNF Inhibitors (Adalimumab, Etanercept)
3) IL-17 Inhibitors (Brodalumab)
What features support a diagnosis of gout?
> 40 yrs
Male
Sudden, severe, red, tender
Usually one joint, big toe
Tophi nodules
What are the common associations with gout? (Lifestyle and conditions)
Smoking
DM II
CHF
Obesity
High Alcohol intake
Diet (red meat)
Kidney Diseases
What investigations help diagnose gout?
Serum urate/Uric Acid level
Joint aspiration
What treatment options (acute and chronic) are available for patients for gout?
Acute:
NSAIDs
Oral/IM Steroids
Colchine
Chronic:
Regular Exercise
Diet Modification
Reduce Alcohol
Smoking Cessation
Urate Lowering Therapy:
Allopurinol
Febuxostat
What does crepitus in a joint represent?
Loss of Cartilage
Does OA or RA improve with rest?
OA - improves with rest
RA - improves with movement
What are type of joint swellings are and what do these signify?
Hard - boney - Heberden’s, Bouchard’s nodes in OA
Soft/non-tender - inflammatory disease
What are the 2 tests for carpel tunnel syndrome?
Phalen’s Test:
wrists together flexed with dorsal surfaces of each hand touching each other for 1 minute
Tinel’s Test:
Tap the median nerve with index and middle finger for 30 secs-1min
Should get numbers in lateral 3 digits
What scan is used for osteoporosis and what result is significant?
DEXA Scan
T score of > -2.5cm
What patient factors make osteoporosis more likely?
Low BMI
Tall
What patient factors can cause low bone density?
Genetics
Low testosterone
Thyroid issues
Smoking
Alcohol
Low BMI
Physical inactivity
What disease are associated with osteoporosis?
CKD
Cushing’s
Thyrotoxosis
Malabsorption (coeliac e.g.)
RA
What drugs are linked to osteoporosis?
LONG TERM STEROID USE
Thyroxine
What score is used to asses fracture risk in osteoporosis/
FRAX
High then treatment is required
What is the basics of osteoporosis management?
1) Biphosphonates (10yrs use max)
2) s.c. PTH
3) Denosumab
Vit D!
What are some side effects of biphosphonates?
Osteonecrosis of jaw
Atypical femur fracture
What does the pneumonic SOAP BRAIN stand for in SLE?
Serositis (pleurisy, pericarditis)
Oral ulcers
Arthritis
Photosensitivity
Blood disorders (low WCC, lymphopenia)
Renal involvement (glomerulonephritis)
Autoantibodies (ANA +ve)
Immunologic tests
Neurologic disorder (seizures, psychosis)
What are the clinical features of SLE?
Painful hands (arthritis)
Raynaud’s phenomenon
Alopecia/hair thinning
Pleuritic chest pain/SOB
Butterfly rash
Fatigue
Sunlight Sensitivity
What examination findings will you look for in SLE?
Malar Rash
Mouth Ulcers
Alopecia
Raynauds (cold hands)
Pain in joints
Pleural Rub
Splenomegaly
What investigations would you request for SLE?
FBC (anaemia of CD, thrombocytopenia, leukopenia)
Raised ESR/CRP (CRP can be =)
Urine Dip (proteinuria in lupus nephritis)
Autoantibodies:
ANA (Anti-Nuclear Antibodies)
Anti-dsDNA (Anti-double stranded DNA)
Anti-Ro + Anti-La (Sjögren’s syndrome)
Low C3/C4 (compliment proteins)
What is the diagnostic criteria for SLE?
Constitutional:
Fever
Hematologic:
Leukopenia
Thrombocytopenia
Autoimmune Hemolysis
Neuropsychiatric:
Delirium
Psychosis
Seizures
Mucocutaneous:
Non-scarring alopecia
Oral Ulcers
Discoid Lupus
Serosal:
Pleural/Pericardial Effusion
Pericarditis
MSK:
Joint involvement
Renal:
Protenuria
Kidney biopsy showing lupus nephritis changes
Immunological:
Anti-dsDNA
Anti-Smith Antibody
Low C3/C4
Antiphospholipid antibodies
> 10 = SLE (each category ranges from 2-10 points each)
What features would suggest SLE active disease (a flare up)?
Symptoms returning or worsening of symptoms already present
Ongoing Fever
Painful/swollen joints
Worsened Fatigue
Rashes
Leg swelling
Pleuritic chest pain
What management is available for SLE?
- Sun protection
- Reduce CVS RFs
- Hydroxychloroquine (gold standard)
- NSAIDs
- Azathioprine, Mycophenolate mofetil
- Biologics (rituximab, belimumab)
Flares:
Short course of prednisolone
What monitoring is required with SLE and it’s treatments long term?
Blood Pressure (CVS risk)
Urinalysis
U+Es
FBCs
LFTs
Steroids:
Hyperglycaemia (blood glucose monitoring)
DMARDs:
FBC (bone marrow suppression)
What are some complications of SLE?
CVD
Infection (from disease and drugs used)
Anaemia of CD
Pericarditis
Pleuritis
ILD
Lupus Nephritis
What is the typical presentation of Giant Cell Arteritis (GCA)?
Older white patients (50yrs+)
Unilateral headache (temple/forehead)
Jaw claudication
Scalp tenderness
Burred/double vision
Temporal artery inflamed with reduced or absent pulsation
What investigations can be used to aid your diagnosis of GCA?
Raised ESR (CRP)
Temporal artery biopsy (necrotising arteritis)
How is GCA treated? What if there is visual disturbance?
Oral prednisolone for 2 weeks then titre down
+ aspirin 75mg
+ PPI (protective w/ steroids)
Symptomatic/visual disturbance:
IV methylprednisolone
What is Polymyalgia rheumatica?
Inflammatory condition causing pain/stiffness in shoulders, pelvic girdle and neck
What is the typical presentation in polymyalgia rheumatica?
Older white patients
Sudden onset (<2weeks) of pain/stiffness in shoulders, neck, pelvic girdle
Reduced ROM but normal strength
Worse in morning or after rest
Weight loss/fatigue/fever
GCA association
Carpel tunnel
How is diagnosis of polymyalgia rheumatica made?
Clinical presentation
Raised ESR/CRP
How is polymyalgia rheumatica treated?
Daily prednisolone 15mg
RAPID IMPROVEMENT WITHIN DAYS
IF NOT: WRONG DIAGNOSIS
What signs will be present in psoriatic arthritis?
Psoriasis plaques
Nail pitting
Oncholysis (separation of the nail from nail bed)
Dactylitis (inflammation of finger)
Enthesitis (entheses - point of tendon insertion into bone)
How do you treat psoriatic arthritis?
- NSAIDs
- DMARDs (methotrexate)
- Anti-TNF (etanercept, infliximab, adalimumab)
What is reactive arthritis and how does it present? How can we treat it?
Synovitis following infection elsewhere
(dysentery, urethritis, cervicitis)
CAN’T SEE (Conjunctivitis)
CAN’T WEE (Urethritis)
Raised inflammatory markers
Normal joint aspiration
Treat underlying infection
NSAIDs if needed
What is enteropathic arthritis and how can it be treated?
EIM of IBD
TNF-i (etanercept, infliximab, adalimumab) treat arthritis and IBD
DMARDs
(NSAIDs can flare IBD)
What is Raynaud’s phenomenon and what does the colour of the hand represent?
Vasospasm of digits
Painful episodes lasting minutes
White - inadequate blood flow
Blue - venous stasis
Red - re-warming hyperaemia
What diseases/meds are associated with Raynaud’s phenomenon?
SLE
Sjogren’s
Scleroderma
Polymyositis
B Blockers
What is the treatment for Raynaud’s?
- Avoid smoking
- Keep warm (cold triggers it)
- Ca channel blockers
How will a patient with vasculitis present?
Dependant on what organ is involved
MSK:
Arthralgia
Myalgia
CNS:
Headaches
CVS:
Pericarditis
Angina
Resp:
Haemoptysis
Dyspnoea
Cough/Chest pain
GI:
Abdo pain
Diarrhoea
Renal:
Haematuria
General:
Fatigue
Fever
Night sweats
Weight loss
Anaemia
What could vasculitis show on examination?
Necrotic skin ulcers
Purpura
Abdo:
Tenderness
Organomegaly
Cardiopulmonary:
Crackles
Pleural rubs
What investigations would you order with suspected vasculitis?
CRP/ESR^
Urine Dip (GLOMERULONEPHRITIS)
Anti-neutrophil cytoplasmic antibodies (ANCA)
CXR
What are some conditions that can cause secondary vasculitis?
Malignancy (blood)
Connective Tissue Disorders
Infection (viruses)
Drugs
What is the management for vasculitis?
- Rule out infection. Stop offending medication
- Corticosteroids
- Cyclophosphamide, Rituximab
What are the small-vessel vasculitis and describe them briefly?
Henoch-Schonlein Purpura/ IgA Vasculitis:
IgA deposits in vessels in children
Purpura + IgA nephritis
Microscopic Polyangiitis:
Glomerulonephritis
Diffuse alveolar haemorrhage (haemoptysis)
Granulomatosis with Polyangiitis (Wegner’s granulomatosis):
Nose bleeding
Sinusitis
Cough
Wheeze
Haemoptysis
Glomerulonephritis
Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss):
HIGH Eosinophils
Severe asthma in middle age
What are the medium-vessel vasculitis and describe them briefly?
Polyarteritis Nodosa:
Renal impairment
HTN
Skin nodules
MI/stroke
Post HEP B
Kawasaki Disease:
Children under 5yrs
Widespread erythematous maculopapular rash
Bilateral conjunctivitis
Strawberry tongue
What are the large-vessel vasculitis and describe them briefly?
Giant Cell Arteritis
Takayasu’s Arteritis:
Limb claudication
Pulseless limbs
What is systemic sclerosis? What investigations would you ask for?
Increased fibroblast activity resulting in abnormal connective tissue growth causing vascular damage and fibrosis
ANA +ve
X-ray hands (calcinosis)
CXR/PFT
ECG/Echo
What are the 2 types of systemic sclerosis?
Limited Scleroderma:
Calcinisis (white calcium deposits on fingertips)
Raynaud’s
Esophageal dysmotility
Sclerodactyly (hand skin tightening/ reduced ROM)
Telangiectasia (dilated blood vessels in skin, on the face)
Anti-centromere antibodies
Diffuse Scleroderma:
Sudden onset of skin thickening
Proximal to elbows/knees
Systemic/pulmonary arterial HTN
Anti-Scl-70 antibodies
What is the management for systemic sclerosis?
Psychological support
Ca antagonist/sidenafil for Raynaud’s
Methotrexate - skin thickening
ACE-i
Prednisolone - flares
What are the common symptoms of Sjögren’s syndrome?
Fatigue
Dry Mouth
Dry eyes
Myalgia
Arthralgia
Raynauds
Huge Parotid glands
What investigations are there for Sjogren’s and how do we manage it?
Schirmer Test - measures tear volume
Anti-Ro
Salivary gland biopsy
Artificial tears/saliva
Vaginal lubricants
What is hypermobility spectrum disorder and how does it present? What treatment is available?
Joints moving beyond normal limits due to laxity of ligaments, capsules + tendons
Pain is from micro trauma?
Pain around joints (worsening after activity)
+ve Beighton score
Strengthening exercises to reduce subluxation
What is the aetiology of OA?
Loss of articular cartilage accompanied by new bone formation and capsular fibrosis
Resulting from overuse, excessive loading, injury and genetics
What are the risk factors for getting OA?
Female
Obesity
Age
Trauma/joint malalignment
What are the commonly effecting joints in OA?
Hip
Knees
Spine
DIP
Carpometacapral joint (thumb)
What do x-rays show with OA?
Loss of joint space
Osteophytes (bone spurs)
Subarticular sclerosis (increased bone density across joint line)
Subchondral cysts (fluid-filled holes in bone)
What are signs of OA in the hands?
Heberden’s nodes (DIP)
Bouchard’s nodes (PIP)
Squaring at the base of the thumb (CMC)
What treatment is available for OA?
1) Strengthening + ROM exercises
2) Paracetamol
3) NSAIDs short spells (topical best)
4) Surgical joint replacement
What is the pathophysiology behind fibromyalgia?
Disorder of central pain processing
Pain in all 4 quadrants of the body
Heightened response to not harmful stimuli
Reduced REM sleep found??!! maybe this causes heightened response + pain
What are the symptoms and signs of fibromyalgia?
Joint/muscle stiffness
Fatigue
Unrefreshed sleep
Numbness
Headache
IBS
Depression/Anxiety
Poor concentration
What is the typical presentation of fibromyalgia?
Female 40s
Chronic fatigue + joint tenderness post emotional/physical stimuli
How can we manage fibromyalgia?
- Education (helps symptoms most)
- Sleep advice + ^exercise
- Low dose amitrypytiline/pregabalin
- CBT
What is the triad of Felty’s syndrome?
Rheumatoid arthritis
Splenomegaly
Neutropenia
