Rheumatology Flashcards
What joints are commonly affected in osteoarthritis?
Hips, knees, DIP and PIP joints in hands, CMC joint at the base of the thumb, lumbar spine, cervical spine
What are some risk factors for developing osteoarthritis?
Obesity, age, occupation, trauma, female, family history
What x-ray findings are consistent with osteoarthritis?
Loss of joint space, osteophytes, subarticular sclerosis, subchondral cysts
Where are Heberden’s nodes and Bouchard’s nodes found?
Heberden’s = DIP
Bouchard’s = PIP
How long can morning stiffness last in those with osteoarthritis?
<30 minutes
How is osteoarthritis diagnosed?
Clinical diagnosis if patient is over 45, pain with activity and morning stiffness <30 minutes
How is osteoarthritis managed?
Therapeutic exercise, weight loss, physio
Topical NSAIDs = 1st line
Oral NSAIDs + PPI if more severe
Paracetamol and weak opiates are only recommended for short term infrequent use
What pattern of arthritis is seen in RA?
Symmetrical polyarthritis that tends to affect small joints
What are the risk factors for RA?
Female, middle age, smoking, obesity, family history (HLA DR4)
What antibodies are associated with RA?
Rheumatoid factor and anti-CCP
What is the classic presentation of someone with RA?
Pain and stiffness especially in morning >1 hour, symptoms are worse with rest and improve with activity, may have associated systemic symptoms
What is palindromic rheumatism?
Self-limiting episodes of arthritis affecting a few joints which last a few days and then completely resolve, joints appear normal between episodes
What hand signs are associated with severe RA?
Z shaped deformity of thumb, swan neck deformity, boutonniere deformity, ulnar deviation of the fingers at the MCP
What is atlantoaxial subluxation?
Occurs in the cervical spine due to RA, subluxation can cause spinal cord compression and is an emergency
What are some extra-articular manifestations of RA?
Pulmonary fibrosis, Felty’s syndrome, Sjogren’s syndrome, dry eye, episcleritis, scleritis, rheumatoid nodules, carpal tunnel, caplan syndrome
When should you do an urgent referral to rheumatology for query RA?
What symptoms
Persistent (few weeks) synovitis where there is no other clear cause - arrange baseline bloods and NSAIDs in meantime
What X-ray findings are associated with RA?
Periarticular osteopenia, bony erosions, soft tissue swelling, joint destruction and deformity
What is the initial management of RA?
Short term steroids are used in conjunction with DMARDs at beginning due to having a quicker effect
What DMARDs are most commonly used in RA?
Methotrexate = 1st line
Lefluonomide, sulfasalazine are alternatives
What medication is used to treat RA that is mild or during pregnancy?
Hydroxychloroquine
What gene is associated with spondyloarthropathies?
HLA B27
What extra-articular manifestations are common in psoriatic arthritis?
Uveitis and IBD
What pattern of arthritis is the most common in psoriatic arthritis?
Asymmetrical polyarthritis or very similar to RA (symmetrical polyarthritis)
What hand and nail signs can occur in psoriatic arthritis?
Nail pitting, onycholysis, subungual hyperkeratosis, nail ridging, dactylitis, enthesitis
What x-ray findings are associated with psoriatic arthritis?
Periostitis, ankylosis, osteolysis, dactylitis, pencil in cup appearance
What can be used to manage psoriatic arthritis?
DMARDs such as methotrexate, anti-TNF medications, usetkinumab
What pattern of arthritis is seen in reactive arthritis?
Acute monoarthritis - most commonly knee
What are the common triggers for reactive arthritis?
Chlamydia, gastroenteritis
What are the common features of reactive arthritis?
Bilateral conjunctivitis, hot swollen and painful joint, anterior uveitis, urethritis, fever, fatigue
What investigations need to be done in someone with reactive arthritis?
Synovial fluid for MC+S (high WBC but will not culture anything), blood cultures, stool sample and STI testing to look for source
What is the management of reactive arthritis?
Treatment of the triggering infection, NSAIDs, steroid injection into affected joint
Which joints are affected in ankylosing spondylitis?
Spine and sacroiliac joints
What is the typical presentation associated with ankylosing spondylitis?
Young adult male in their 20s, gradual onset of symptoms, pain and stiffness in lower back worse with rest and improves with movement, SOB due to restricted chest wall movement
What diseases are associated with ankylosing spondylitis?
Anterior uveitis, aortic regurgitation, AV block, atypical lung fibrosis, anaemia of chronic disease, IBD, achilles tendinopathy
What test can be used to diagnose ankylosing spondylitis?
Schober’s test - two lines 15cm apart, bend forward should be at least 5cm improvement (20cm)
What do X-rays show in ankylosing spondylitis?
Bamboo spine, squaring of the vertebral bodies, subchondral sclerosis and erosions, syndesmophytes, ossification and fusion of facets
What is the most useful investigation for ankylosing spondylitis?
MRI spine as can show bone marrow oedema early in disease before there are XR changes
What is the management for ankylosing spondylitis?
Physio and mobilisation
1st line = NSAIDs
2nd line = anti-TNF e.g. adalimumab
What is the presentation for septic arthritis?
Rapid onset of hot/red/swollen/painful joint, fever, lethargy, limp, refusal to weight bear
What are the most common organisms for septic arthritis?
Staph aureus (most common), neisseria gonorrhoea, H.influenza, E.coli
What is the management for septic arthritis?
Joint aspiration for MC+S, empirical IV antibiotics for 4-6 weeks then oral (IV flucloxacillin = usual 1st line)
What antibodies are associated with SLE?
Anti-nuclear antibodies, anti-dsDNA are highly specific
What symptoms are associated with SLE?
Non-specific symptoms, joint pain, symmetrical small joint arthritis, photosensitive malar rash, lymphadenopathy, mouth ulcers, Raynaud’s phenomenon
What investigations are done in those with SLE? (not including autoantibodies)
FBC - anaemia of chronic disease
CRP and ESR
Urinalysis and urine PCR - lupus nephritis will –> proteinuria
Renal biopsy
What complications can occur due to SLE?
CVD, infections, anaemia, pericarditis, pleuritis, ILD, lupus nephritis, neuropsychiatric SLE, recurrent miscarriage, VTE
What is the management of SLE?
1st line = hydroxychloroquine, NSAIDs, steroids
If resistant or more severe DMARDs and biologics can be used
What are gouty tophi?
SC deposits of uric acid that typically affect the small joints of hands/elbows/ears, usually result of poorly controlled long term gout
What are the risk factors for gout?
Male, obesity, high purine diet (meat and seafood), alcohol, diuretics, existing CKD, family history
What joints are commonly affected in gout?
Base of big toe (MTP), wrist, base of thumb
What crystals are found in aspiration of fluid from the joint in gout?
Negatively birefringent needle shaped crystals made from monosodium urate
What X-ray findings are seen in gout?
Joint space maintained, lytic lesions in bone, punched out erosions with sclerotic borders and overhanging edges
How is an acute flare of gout managed?
NSAIDs = 1st line
Colchicine = 2nd line
Steroids = 3rd line
What prophylaxis can be given to patients to prevent further gout attacks?
Allopurinol 100mg (once acute attack has settled) + lifestyle changes
Which joints are commonly affected in pseduogout?
Knee, shoulder, wrist and hips
What will be seen on synovial fluid aspiration in psuedogout?
Positive birefringent rhomboid shaped calcium pyrophosphate crystals
What are the X-ray changes associated with pseudogout?
Chondrocalcinosis (calcification of cartilage), loss of joint space, osteophytes, subarticular sclerosis, subchondral cysts
What can be done to manage pseudogout?
NSAIDs, colchicine, steroid injections, if severe washouts can be offered
What are the risk factors for osteoporosis?
Older age, post menopausal females, reduced mobility and activity, RA, alcohol and smoking, long term steroids, SSRIs/PPIs/anti-oestrogens
What does the FRAX tool or new fracture tool measure?
Predicts the risk of fragility fracture over the next 10 years - <10% is low risk, high risk if >10%
What does a DEXA scan do?
Measures bone mineral density
What is a Z score?
Represents the number of standard deviations the patient’s bone density falls below the mean for their age
What is a T score?
T score represents the number of standard deviations below the mean for a healthy young adult
What T score represents osteopenia and osteoporosis?
-1 to -2.5 = osteopenia
<-2.5 = osteoporosis
When should the FRAX tool be used?
Women aged >65, men aged >75, younger patients with risk factors
What should be done based on the risk calculated from the FRAX tool?
Low risk - reassure
Intermediate risk - offer DEXA and recalculate
High risk - offer treatment without DEXA
What is the management of osteoporosis?
Vitamin D and calcium, bisphosphonates (denosumab is alternative), lifestyle advice
What are the side effects of bisphosphonates?
Reflux and oesophageal erosions, atypical fractures, osteonecrosis of the jaw and external auditory canal
How often should DEXA scans be repeated?
If low risk every 5 years
If on bisphosphonates every 3-5 years and treatment holiday can be considered
What are the presenting features of GCA?
Unilateral headache, severe pain around temple/forehead, scalp tenderness, jaw claudication, visual changes
What investigations can be performed to confirm diagnosis of GCA?
Raised inflammatory markers, temporal artery biopsy
Gold standard = temporal artery USS (shows halo sign)
What is the management for GCA?
Prednisolone 40-60mg
IV methylprednisolone if visual changes
Steroids continued for 1-2 years
What joints are affected in polymyalgia rheumatica?
Shoulder, pelvic girdle and neck
What are the symptoms of polymyalgia rheumatica?
Pain and stiffness in shoulder, pelvic girdle and neck (muscle aches)
Symptoms worse in morning/after rest and interfere with sleep
Systemic symptoms
What investigations are done in those with polymyalgia rheumatica?
Raised ESR and CRP
Done to rule out differentials only - clinical diagnosis and based on response to steroids
FBC, U+Es, LFTs, calcium, TFTs, serum electrophoresis, CK, antibodies for RA and SLE
What is the management of polymyalgia rheumatica?
15mg prednisolone daily with follow up 1 week later - will have dramatic response
Steroids continued for 1-2 years
What is the presentation of discoid lupus erythematosus?
Photosensitive lesions on face, scalp and ears - dry, red and scaly
Scarring alopecia
What is the management of discoid lupus erythematosus?
Sun protection, topical steroids, hydroxychloroquine
What antibodies are associated with Sjogren’s syndrome?
Anti-Ro and anti-La
What are the symptoms of Sjogren’s syndrome?
Dry mouth, eyes and vagina
What test can be used to help aid diagnosis of Sjogren’s?
Schirmer test - filter paper in eye <10mm = significant
What is the management for Sjogren’s syndrome?
Artificial tears, artificial saliva, vaginal lubricants, pilocarpine can be used to stimulate tear and saliva production
What is the difference between scleroderma and systemic sclerosis?
Scleroderma is a localised version of systemic sclerosis that only affects the skin whereas systemic sclerosis affected other organs as well
What does CREST stand for in CREST syndrome/limited cutaneous systemic sclerosis?
Calcinosis
Raynaud’s phenomenon
Oesophageal dysmotility
Sclerodactyly
Telangiectasia
What can be used to treat raynaud’s and what makes the symptoms worse?
Nifedipine can be used to treat
Beta blockers can worsen the symptoms
What antibodies are associated with systemic sclerosis?
ANA, anti-centromere, anti-Scl-70
What is the management of systemic sclerosis?
DMARDs and biologics can be used in widespread disease
Physio and OT
Whats the difference between polymyositis and dermatomyositis?
Dermatomyositis involves characteristic skin changes - Gottron papules and heliotrope rash around eyelids - where polymyositis has no skin involvement
What are the symptoms of polymyositis and dermatomyositis?
Gradual onset, symmetrical proximal muscle weakness causing difficulties standing from a chair, climbing stairs or lifting overhead
What test is done in dermatomyositis/polymyositis?
Creatine kinase will be significantly raised
Electromyography, muscle biopsy and MRI may also be done
What antibodies are present in polymyositis?
Anti-Jo-1
What is the management for polymyositis/dermatomyositis?
Corticosteroids = 1st line
Alternatives = methotrexate, IV immunoglobulins and biologic therapy
What are the symptoms of fibromyalgia?
Chronic pain at multiple sites not commonly affected with pain, lethargy, cognitive impairment, sleep disturbance, headaches, dizziness
What is the management of fibromyalgia?
MDT approach - aerobic exercise, CBT, pregabalin, duloxetine, amitriptyline
What is osteomalacia?
Defective bone mineralisation causes soft bones due to insufficient vitamin D (rickets in children)
Why does low vitamin D lead to poor bone mineralisation?
Low vitamin D leads to low serum calcium and phosphate due to poor absorption from kidneys and poor bone turnover
What is the bone profile of someone with osteomalacia?
Low calcium, low phosphate, high ALP, high PTH
What is the management for osteomalacia?
Cholecalciferol - loading regime (4000IU daily) and then maintenance dose (800-2000IU)
What is Paget’s disease?
Paget’s disease of the bone involves excessive bone turnover due to increased osteoclast and osteoblast activity which leads to patchy areas of high density and low density bones
What is the presenting features of Paget’s disease?
May be asymptomatic, bone pain, bone deformity, fractures, hearing loss
What can be seen on x-ray in someone with Paget’s disease?
Osteoporosis circumscripta, cotton wool appearance of skull, V-shaped osteolytic defects
What is the management for Paget’s disease?
Bisphosphonates - check ALP levels for monitoring (should normalise)
What is HSP, how does it present and how is it treated?
IgA small vessel vasculitis, presents with purpura, joint pain, abdominal pain and IgA nephritis, management is supportive
What is microscopic polyangitis and how does it present?
Small vessel vasculitis, causes renal failure due to glomerulonephritis and diffuse alveolar haemorrhage causing haemoptysis
What is granulomatosis with polyangitis and how does it present?
Small vessel vasculitis that affects the lungs and kidneys leads to cough, wheeze, haemoptysis and glomerulonephritis
What is eosinophilic granulomatosis with polyangitis and how does it present?
Small vessel vasculitis that primarily affects the lungs and skin, presents with severe asthma in middle age
What is polyarteritis nodosa and how does it present?
Medium vessel vasculitis that leads to renal impairment, hypertension, tender erythematous skin nodules, MI, stroke
What is Kawasaki disease, how does it present and what is the management?
Medium vessel vasculitis that affects children under 5, presents with high fever (>5 days), widespread rash, skin peeling of the palms and soles, bilateral conjunctivitis and a strawberry tongue, treatment is with aspirin and IV immunoglobulins
What is takayasu’s arteritis, how does it present?
Large vessel vasculitis that affects aorta and its branches, these vessels can swell and form aneurysms or becomes narrows and blocked, presents with fever, malaise and claudication
What are the symptoms of Ehlers-Danlos?
Hypermobility, joint pain, easy bruising, poor wound healing, chronic pain, headaches, POTS, GI reflux, IBS, period issues, urinary incontinence, TMJ dysfunction
Why are those with dermatomyositis/polymyositis screened for malignancy?
Dermatomyositis is commonly a paraneoplastic syndrome
What are the blood test findings of someone with Paget’s disease?
An isolated rise in ALP
