Rheumatology Flashcards
What joints are most commonly involved in Rheumatoid Arthritis
MCP, PIP joints
What joints are most commonly involved in Osteoarthritis?
Large weight-bearing joints (hip, knee)
Carometacarpal joints
DIP, PIP joints
What is the typical history for Osteoarthritis?
Pain following use, improves with rest
Unilateral symptoms
No systemic upset
What is the typical history for Rheumatoid Arthritis?
Morning stiffness, improves with use
Bilateral symptoms
Systemic upset
X Ray findings of Osteoarthritis?
Loss of joint space
Subchondral sclerosis
Subchondral cysts
Osteophytes forming at joint margins
X-Ray findings of Rheumatoid arthritis?
Loss of joint space
Juxta-articular osteoporosis
Soft tissue swelling
Periarticular erosions
Subluxation
What is the mechanism of action of bisphosphonates?
Pyrophosphate analog which inhibits osteoclast activity
OSCE - a group of drugs used to treat thinning bones, allowing the bones to gain strength over time and ultimately reducing the risk of future fractures.“
How long does it take for bisphosphonates to have an effect?
6 Months
Which antibody is most associated with Sjogren’s syndrome?
ANA
What are some predisposing factors to Paget’s disease of the bone?
Increasing age
Male sex
Northern Latitude
Family History
What are the clinical features of Paget’s disease of the bone?
Only 5% of patients are symptomatic
- The stereotypical presentation is an older male with bone pain and an isolated raised ALP
- Bone pain (e.g. pelvis, lumbar spine, femur)
- Classical untreated features: bowing of tibia, bossing of the skull
What is osteomalacia?
Describes softening of the bones secondary to low vitamin D levels that in turn lead to decreased bone mineral content.
What is HLA-A3 associated with?
Haemachromatosis
What is HLA-B51 associated with?
Behcet’s disease
What is HLA-B27 associated with?
Ankylosing spondylitis
Reactive arthritis
Acute anterior uveitis
Psoriatic arthritis
What is HLA-DQ2/DQ8 associated with?
Coeliac diseaseW
What is HLA-DR2 associated with?
Narcolepsy
Goodpastures
What is HLA-DR3 associated with?
Dermatitis herpetiformis
Sjogren’s syndrome
Primary biliary cirrhosis
What is HLA-DR4 associated with
Type 1 diabetes mellitus*
Rheumatoid arthritis - in particular the DRB1 gene (DRB104:01 and DRB104:04 hence the association with DR4)
Risk factors for Pseudogout?
Pseudogout is strongly associated with increasing age. Patients who develop pseudogout at a younger age (e.g. < 60 years) usually have some underlying risk factor, such as:
haemochromatosis
hyperparathyroidism
low magnesium, low phosphate
acromegaly, Wilson’s disease
Examples of Large vessel vasculitis
- Temporal arteritis
- Takayasu’s arteritis
Examples of medium vessel vasculitis
Polyarteritis nodosa
Kawasaki disease
Examples of small vessel ANCA associated vasculitides
Wegener’s granulomatosis
Churg-Strauss syndrome
Microscopic polyangiitis
Examples of small vessel immune complex small-vessel vasculitis
Henoch-Schonlein purpura
Goodpasture’s syndrome
Cryoglobulinaemic vasculitis
Hypocomplementemic urticarial vasculitis
What is the initial medical management of giant cell arteritis with no visual symptoms or jaw claudication?
40-60mg oral prednisolone daily
What are the characteristic presenting features of Behçet’s disease?
Recurrent oral ulcers
Genital ulcers
Also: Uveitis, Erythema nodosum, Vasculitis, Acneiform lesions
- Superficial thrombophlebitis
What characteristic spinal x-ray appearance is seen in the later stages of ankylosing spondylitis?
A “bamboo spine” with fusion of the sacroiliac and spinal joints
What conditions belong to the seronegative spondyloarthropathy group?
- Psoriatic arthritis
- Reactive arthritis
- Ankylosing spondylitis
What is the key blood test finding in patients with Paget’s disease of bone?
Raised ALP
What is the classic x-ray finding in pseudogout?
Chondrocalcinosis
What name is given to osteoarthritic bony lumps in the distal interphalangeal joints?
What about similar lumps in the proximal interphalangeal joints?
Heberden’s nodes
Bouchard’s nodes
What pathology in the cervical spine can cause spinal cord compression in patients with rheumatoid arthritis?
Atlantoaxial subluxation
What risks are associated with not following the specific procedure when taking oral bisphosphonates?
Reflux
Oesophageal erosions
Why is irreversible blindness in one eye a potential complication in Giant Cell arteritis?
The Temporal Artery supplies the Ophthalmic artery
How is swan neck in a rheumatoid hand formed?
Swan-neck is due to the rupture of the lateral slips and so, the PIPJ hyper-extends
What are the most commonly affected bones in Paget’s disease?
The most commonly affected bones are the pelvis, vertebrae, skull, femur and tibia.
What is the typical fracture caused by Paget’s disease?
Transverse fracture, perpendicular to the cortex
What is the rare malignant complication of Paget’s disease?
Osteosarcoma
What is the pathophysiology of Paget’s disease?
In Paget’s disease there is increased osteoclast activity at first and followed by increased osteoblast activity resulting in disorganised bone breakdown and formation.
What is Behcets disease?
A rare multi-organ disease caused by a systemic vasculitis. The cause is unknown
How do you Diagnose Behcets disease?
- There is no specific test more done to rule out other causes
- RF
- ANA
- ANCA
- HLAB51
What is the classical triad of Adult Onset Stills Disease?
- Arthritis
- Spiking fevers
- A fleeting maculopapular salmon-pink rash
How do you manage mild Adult onset Stills disease?
NSAIDs and Aspirin
What is ankylosing spondylitis?
It is a seronegative inflammatory arthritis affecting the axial skeleton
What are the key clinical features of Ankylosing Spondylitis?
- Inflammatory back pain
- Enthesitis (Achilles Tendonitis, Plantar Fasciitis)
- Peripheral arthritis may occur
What are the extra-articular manifestations of Ankylosing Spondylitis?
- Anterior Uveitis
- Aortitis which can lead to aortic regurgitation
- Upper lobe pulmonary fibrosis
- IgA nephropathy
What would you see on a PELVIC Xray in someone with ankylosing spondylitis?
Sacroilitis may be seen
In advanced disease there is Ankylosis or fusion of the joint
What would you see on a LUMBAR X-Ray in Ankylosing Spondylitis?
- The vertebral bodies may become ‘squared’
- In later stages, bony bridges called syndesmophytes form between adjacent vertebrae and there is ossification of spinal ligaments
- In late disease there may be complete fusion of the vertebral column which is known as bamboo spine
What antibodies are associated with drug-induced SLE?
Anti-Histone
What antibodies are associated with SLE?
- Anti-dsDNA
- Anti-SM
- ANA
What can you use for the long-term management of gout in patients that cannot tolerate Allopurinol?
Febuxostat
What is Felty’s syndrome?
Rheumatoid arthritis + splenomegaly+Low white cell count
What is Dermatomyositis?
An inflammatory disorder causing symmetrical, proximal muscle weakness and characteristic skin lesions
What are the causes of dermatomyositis?
Idiopathic
Associated with connective tissue disorders
Underlying malignancy (Ovarian, breast and lung cancer)
SCREEN FOR MALIGNANCY IF NEW DIAGNOSIS OF DERMATOMYOSITIS
What are the signs of dermatomyositis?
- Photosensitive
- Macular rash over back and shoulder
- Heliotrope rash in the periorbital region
- Gottron’s papule - roughened red papules over extensor surfaces of fingers
What are some commonly associated conditions with pseudogout?
- Haemochromatosis
- Hyperparathyroidism
- Low magnesium, low phosphate
- Acromegaly
- Wilsons disease
What features might you see in a patient with Marfans Syndrome?
- Tall stature
- High-arched palate
- Arachnodactyly
- Pectus Excavatum
- Pes planus
- scoliosis
What is the antibody test for anti-phospholipid syndrome?
Anti-cardiolipin antibodies
Can also do Anti-Beta2 glycoprotein I or lupus anticoagulant
What are the XRay findings in Psoriatic arthritis?
- Often have the unusual combination of coexistence of erosice changes and new bone formation
- Periostitis
- ‘Pencil-in-cup’ appearance
What can be used to manage acute flares of rheumatoid arthritis?
Methylprednisolone IM
What points should you mention when counselling someone starting methotrexate about side effects?
- Oesophageal irritation
- Abdominal pain/nausea/GI upset
- Joint and muscle pain
- Osteonecrosis of the jaw
What are some common drugs implicated in drug induced lupus?
Isoniazid, procainamide, hydralazine, minocycline and phenytoin
What can help distinguish gout from pseudogout?
Chondrocalcinosis
What is a useful rule out test in SLE?
ANA
Which autoantibody is most associated with Primary Sjogren’s syndrome?
Anti-Ro
What is the most common joint for septic arthritis?
Knees
What are the risk factors for pseudogout?
- Haemochromatosis
- Hyperparathyroidism
- Low magnesium, low phosphate
- Acromegaly, Wilson’s disease
What is osteogenesis imperfecta?
A group of disorders of collagen metabolism resulting in bone fragility and fractures.
What is the inheritance of osteogenesis imperfecta?
- Autosomal dominant
Abnormality in type 1 collagen due to decreased synthesis of pro-alpha 1 or pro-alpha 2 collagen polypeptides
What are the features of osteogenesis imperfecta?
- Presents in childhood
- Fractures following minor trauma
- Blue Sclera
- Deafness secondary to otosclerosis
- Dental imperfections are common
What are the features of osteomalacia?
- Bone pain
- Bone/muscle tenderness
- Fractures: especially femoral neck
- Proximal myopathy: may lead to waddling gait
What is the first line drug for management of Raynaud’s phenomenon?
Calcium channel blockers e.g., nifedipine
What should you warn a patient about when starting hydroxychloroquine?
Bull’s eye retinopathy
What blood results would you expect in osteomalacia?
Low serum calcium, low serum phosphate, raised ALP and raised PTH
What should be ruled out before starting Azathioprine?
Thiopurine methyltransferase deficiency
What are the four seronegative spondyloarthropathies?
- Ankylosing spondylitis
- Reactive Arthritis
- Psoriatic Arthitis
- IBD associated Arthritis
What crystals would you see in gout?
Monosodium urate
What crystals would you see in pseudogout?
Calcium pyrophosphate
What signs signs might you see in Rheumatoid Arthitis?
Ulnar deviation of MCP joints
Swan neck deformity
Boutonniere deformity
Z shape deformity of thumbs
MCP joint swelling
MCP joint subluxation
Muscle wasting
Ulnar deviation
Joint swelling
What is Sarcoidosis?
A chronic graulomatous disorder. Granulomas are inflammatory nodules full of macrophages.
What is Lofgren’s syndrome
Lofgren’s syndrome refers to a specific presentation of sarcoidosis with a classic triad of symptoms:
- Erythema nodosum
- Bilateral hilar lymphadenopathy
- Polyarthralgia (joint pain in multiple joints)
What blood tests should you do for Sarcoidosis?
- Raised Angiotensin-converting enzyme (ACE)
- Raised Calcium (Hypercalcaemia)
What is the management of Sarcoidosis?
Conservative management
Oral steroids (for 6-24 months) are usually first-line where treatment is required
- Bisphosphonates to protect against osteoporosis
- Methotrexate
What are the complications of Sarcoidosis?
Pulmonary fibrosis and pulmonary hypertension
What is Osteomalacia?
Where defective bone mineralisation causes “Soft bones”
What is Paget’s disease due to?
Excessive bone turnover due to increased osteoclast and osteoblast activity
How might a person with Paget’s disease of the bone present?
Bone pain
Bone deformity
Fractures
Hearing lossW
What is the main treatment of Paget’s disease of the Bone?
Bisphosphonates
How should you monitor Paget’s disease?
Monitor the serum Alkaline phosphatase
Indications for a Thoracotomy?
Indications for thoracotomy include loss of more than 1.5L blood initially or ongoing losses of >200ml per hour for >2 hours
