Rheumatology Flashcards
What are classed as the seropositive arthritides?
Rheumatoid arthritis
SLE
Scleroderma
Vasculitis
Sjogren’s syndrome
What are classed as seronegative arthritides?
Ankylosing spondylitis
Psoriatic arthritis
Reactive arthritis
IBD arthritis
What are the crystal-induced arthritides?
Gout
Pseudo-gout
What makes a condition seropositive?
When autoantibodies within the serum can be associated with disease presence.
Which antibody is associated with rheumatoid arthitis?
Anti-CCP
ANA, anti-dsDNA, anti-Sm, anti-Ro, and anti-RNP are all associated with which condition?
Systemic lupus erythematous
What antibodies are associated with Sjogren’s syndrome?
ANA
Anti-Ro
Anti-La
ANA, and anti-centromere antibody are associated with which condition?
LIMITED systemic sclerosis
Anti-Scl-70 is associated with which condition?
DIFFUSE systemic sclerosis
Which antibody is associated with myositis?
Anti-Jo-1
What antibodies are associated with anti-phospholipid syndrome?
Anti-cardolipin
What are features of inflammatory arthritis?
Joint pain with associated swelling
Morning stiffness (>30mins)
Improvement with exercise
Raised inflammatory markers
Extra-articular symptoms
Which is commonly positive in seronegative patients?
HLA-B27
Will be accompanied by raised CRP and ESR.
What is the most common form of arthritis?
Osteoarthritis
What x-ray findings may be observed in osteoarthritis?
Loss of joint space
Osteophytes
Sclerosis
Subchondral cysts
Think ‘LOSS’
How should osteoarthitis be treated?
Manage pain with analgesia
Give physiotherapy
Advise weight loss
What is the most prevalent seropositive inflammatory arthropathy?
Rheumatoid arthritis
How is rheumatoid arthritis treated?
Very aggressively - give a DMARD.
Methotrexate is first-line.
What is a side-effect of DMARD therapy?
Bone marrow suppression
If DMARDs are ineffective in rheumatoid arthritis, what may be used instead?
Biologics
What is a risk in those taking biologics?
Reactivation of latent TB
Perform a CXR prior to commencing therapy.
What scoring system is used to decide whether biologics are indicated in rheumatoid arthritis?
DAS28
Indicated if shown to have high disease activity.
What is ankylosing spondylitis?
A chronic inflammatory disease of the spine and sacro-iliac joints.
May lead to fusion of the intervertebral and sacro-iliac joints.
In which condition are 90% of patients HLA-B27 positive?
Ankylosing spondylitis
How may ankylosing spondylitis present on an X-ray?
Sclerosis and fusion of the SI joints and the formation of syndesmophytes (bony spurs) on the vertebral bodies.
Often dubbed a ‘bamboo spine’.
How is ankylosing spondylitis treated first-line?
Physiotherapy
Exercise therapy
NSAIDs
If first-line therapy is ineffective, what is indicated as second-line in ankylosing spondylitis?
Anti-TNF inhibitors
Important to note that DMARDs do not have any impact on spinal disease.
Can surgery be used in ankylosing spondylitis?
Only in those with hip/knee disease.
Surgery too risky on the spine to be a viable option.
How prevalent is psoriatic arthritis?
Occurs in 30% of patients with psoriasis.
How does psoriatic arthritis present?
Asymmetrical symptoms
Spondylitis
Dactylitis
Enthesitis
How is psoriatic arthritis treated?
DMARDs (usually give methotrexate)
If no response, give anti-TNF.
What is enteropathic arthritis?
An inflammatory arthritis involving the peripheral joints.
Tends to be asymmetrical.
Affects 10-20% of IBD patients.
What is reactive arthritis?
A form of arthritis that occurs n response to an infection - commonly of urinary/GI/sexual origin.
Presents with a triad of: uveitis/conjunctivitis, urethritis, and arthritis.
Think ‘can’t see, can’t pee, can’t climb a tree’.
How is reactive arthritis treated?
Treated underlying infection, and provide symptomatic relief (e.g. steroids).
How is SLE treated?
Manage the manifestations of the individual.
In skin disease/arthralgia give hydroxychloroquine, topical steroids or NSAIDs.
If organ involvement, or symptoms of inflammatory arthritis, give immunosuppression (e.g. azathioprine).
How is SLE monitored?
Continuously check anti-dsDNA and complement levels.
What is Sjogren’s syndrome?
An autoimmune disorder characterised by lymphocytic infiltration of the exocrine organs.
How does Sjogren’s syndrome present?
Dryness of the eyes and mouth is most common.
May also have arthralgia, fatigue, vaginal dryness, and parotid gland swelling.
How is Sjogren’s syndrome diagnosed?
Positive Schirmer’s test (identifies ocular dryness)
Presence of anti-La, and anti-Ro
Positive lip biopsy
How is Sjogren’s syndrome treated?
Lubricating eye drops
Saliva replacement
Regular dental check ups (as increased risk of cavities)
Hydroxychloroquine
Where is affected in limited systemic sclerosis?
Skin of the face, hands, forearms, and feet.
What antibody is linked to limited systemic sclerosis?
Anti-centromere antibody
How does ankylosing spondylitis impact the spine?
Loss of movement through decreased lumbar lordosis and increased thoracic kyphosis.
What is Schober’s test?
A test used in the diagnosis of ankylosing spondylitis.
Involves measuring 5cm below the posterior superior iliac crests, and 10cm above, whilst patient is standing upright.
Upon bending forward, in normal movement, gap between should be >20cm.
What conditions may occur alongside ankylosing spondylitis?
Anterior uveitis
Pulmonary fibrosis
Amyloidosis
What is involved in diffuse systemic sclerosis?
Significant early progression to organ damage.
Which antibody is linked to diffuse systemic sclerosis?
Anti-Scl-70 antibody development
What antibody is linked to mixed connective tissue disease?
Anti-RNP
What can be used to treat Raynaud’s phenomenon?
Calcium channel blockers
What is antiphospholipid syndrome?
A disorder resulting in recurrent arterial/venous thrombosis/fetal loss.
What condition may present alongside anti-phospholipid syndrome?
SLE
How is anti-phospholipid syndrome treated in those with no previous thrombosis?
Low-dose aspirin
If patient has suffered a VTE, how is antiphospholipid syndrome managed?
Lifelong warfarin therapy
What is gout?
A crystal arthropathy caused by the deposition of urate crystals within a joint.
Results from hyperuricaemia.
What form of crystals are involved in gout?
Urate
What condition is associated with ‘pencil in cup’ appearance on X-ray, and ‘sausage fingers’?
Psoriatic arthritis
Which rheumatological condition may produce a malar rash?
SLE
Finding is also associated with mitral stenosis.
What is an important differential to exclude in gout?
Septic arthritis
Both present with an intensely painful, red, hot, swollen joint.
How is gout diagnosed?
Sampling of the synovial fluid.
Will show negatively birefringent, needle-shaped uric acid crystals.
How is an acute episode of gout treated?
Colchicine or NSAIDs are first-line.
Always give gastro-protection if giving NSAIDs.
What medication may be used to prevent gout reoccurence?
Allopurinol
What is pseudo-gout?
A form of acute arthritis caused by calcium pyrophosphate crystals.
How does pseudo-gout present in the synovial fluid?
Weakly positive birefringent rhomboid-shaped crystals.
How is an acute attack of pseudo-gout treated?
NSAIDs or steroids.
What is polymyalgia rheumatica?
A common chronic inflammatory disease characterised by proximal myalgia of the hip and shoulder girdles.
How does polymyalgia rheumatica present?
Proximal myalgia of the hip/shoulder girdles
Morning stiffness lasting less than 1 hour
What condition is associated with polymyalgia rheumatica?
Giant cell arteritis
How is polymyalgia rheumatica treated?
Low dose steroids (15mg prednisolone)
Take this daily and taper dose over 18 months.
What is the most common form of systemic vasculitis?
Giant cell arteritis
How is Giant cell arteritis investigated?
Inflammatory markers (e.g. ESR, CRP)
Temporal artery biopsy - definitive
Important to note that creatine kinase and EMG will be normal.
What are symptoms of temporal arteritis?
Visual symptoms
Headache
Jaw claudication
Scalp tenderness
Fatigue
Malaise
What is a potential complication of GCA?
Visual loss
How is GCA treated?
High-dose corticosteroids (prednisolone)
If no visual involvement then 40mg, although if visual involvement is present then 60mg.
Lower dose over a 2-year period.
What is polymyositis?
An idiopathic inflammatory myopathy causing symmetrical muscle weakness.
What antibodies are specific to polymyositis?
anti-Jo-1
anti-SRP
How can PMR and polymyositis be differentiated?
Polymyositis will have raised inflammatory markers AND elevated creatine kinase.
Polymyalgia rheumatica will have raised inflammatory markers ONLY.
How is polymyositis diagnosed?
Inflammatory markers (elevated)
Creatine kinase level (elevated)
Abnormal EMG
Muscle biopsy
How is polymyositis treated?
Prednisolone
Immunosuppression
What is dermatomyositis?
A condition similar to polymyositis, although the skin is involved.
Associated with other connective tissue disorders, or underlying malignancy.
What skin features are seen in dermatomyositis?
Heliotrope rash
V-shaped rash over the chest
Gottron’s papules
What may cause dermatomyositis?
Idiopathic
Connective tissue disorders
Underlying malignancy
Due to risk, screen for malignancy at the time of diagnosis.
What cancers are commonly linked to dermatomyositis?
Ovarian
Breast
Lung
What is fibromyalgia?
An unexplained condition causing widespread muscle pain and fatigue.
Most commonly seen in middle-aged women.
What is vasculitis?
Inflammation of the blood vessels, leading to the thickening, stenosis, occlusion and eventual ischaemia.
What are the 2 main forms of large vessel vasculitis?
GCA
Takayasu arteritis
How is large vessel classified?
Due to it predominately affecting the aorta and its major branches.
In which age-group is GCA mostly seen?
Before 50 years of age.
In which age-group is Takayasu arteritis mostly seen?
Under 50 years of age.
How are forms of large-vessel vasculitis treated?
High-dose corticosteroids
How can small vessel vasculitis be treated?
ANCA positive
ANCA negative
What are examples of small vessel vasculitis?
GCA
Eosinophilic GPA
Microscopic polyangiitis
Henoch-Schonlein Purpura
