Rheumatology Flashcards
Adhesive capsulitis (frozen shoulder) isassociated with
DM
up to 20% of diabetics may have an episode of frozen shoulder
In Adhesive capsulitis (frozen shoulder)
Which is effected more
1- Abduction or external or internal rotation ?
2- active or passive movement?
- external rotation is affected more than internal rotation or abduction
- both active and passive movementis affected
Treatment of Adhesive capsulitis (frozen shoulder)
- NSAIDs
- physiotherapy
- oral corticosteroids and
- intra-articular corticosteroids
Ankylosing spondylitis is associated with a HLA-…..?
HLA-B27
Features of Ankylosing spondylitis ( 7A,C)
- Apical fibrosis
- Anterior uveitis
- Aortic regurgitation
- Achilles tendonitis
- AV node block
- Amyloidosis
- Arthritis peripheral
- cauda equina syndrome
Treatment of Ankylosing spondylitis
encourage regular exercise such as swimming
physiotherapy
NSAIDs are the first-line treatment
the disease-modifying drugs which are used to treat rheumatoid arthritis are only really useful if there is peripheral joint involvement
Antiphospholipid syndrome is associated with
SLE
other autoimmune disorders
lymphoproliferative disorders
phenothiazines (rare)
Investigations of Antiphospholipid syndrome
- anticardiolipin antibodies
- anti-beta2 glycoprotein I (anti-beta2GPI) antibodies
- lupus anticoagulant
- thrombocytopenia
- prolonged APTT
Management of antiphospholipid syndrome
lifelong warfarin with a target INR of 2-3
If recurrent VTE events: if occurred whilst taking warfarin then consider adding low-dose aspirin, increase target INR to 3-4
Causes of Avascular necrosis of the hip
long-term steroid use
chemotherapy
alcohol excess
trauma
What is the the investigation of choice in Avascular necrosis?
MRI
The classic triad of Behcet’s syndrome
- genital ulcers
- oral ulcers
- anterior uveitis
*Goa
Behcet’s syndrome is associated withHLA….?
HLA B51
Investigations of dermatomyositis
- elevated CK
- ANA
- anti-Mi-2 antibodies
- antibodies to signal recognition particle (SRP)
- antibodies against histidine-tRNA ligase (also called Jo-1)
Treatment of dermatomyositis
prednisolone
Drug-induced lupus
Most common causes
procainamide
hydralazine
Less common causes
isoniazid
minocycline
phenytoin
Familial Mediterranean Fever (FMF) is an autosomal ….. disorder
autosomal recessive
Investigations of Polymyositis
- elevated CK
- LDH
- anti-synthetase antibodies
anti-Jo-1 antibodies are seen in pattern of disease associated with lung involvement, Raynaud’s and fever
Management of Polymyositis
high-dose corticosteroids tapered as symptoms improve
azathioprine may be used as a steroid-sparing agent
Which condition is associated with HLA B8, DR2, DR3
SLE
SLE is atype ……?……. hypersensitivity reaction
SLE atype 3 hypersensitivity reaction
neonatal complications due to SLE include
congenital heart block
SLE management
Basics
NSAIDs
sun-block
Hydroxychloroquine
the treatment of choice for SLE
If internal organ involvement e.g. renal, neuro, eye then consider prednisolone, cyclophosphamide
Systemic lupus erythematosus: investigations
ANA
ANTI dsDNA
ANTI Smith
ANTI U1 RNP
ANTI RO (SS-A)
ANTI LA ( SS-B )
Discoid lupus erythematosus is characterised by
follicular keratin plugs
Management of Discoid lupus erythematosus
topical steroid cream
oral antimalarials may be used second-line e.g. hydroxychloroquine
avoid sun exposure
anti-Ro is specific for
Sjogren’s syndrome,
SLE,
congenital heart block
anti-La:specific for
Sjogren’s syndrome
anti-Jo 1: specific for
polymyositis
anti-scl-70 specific for
diffuse cutaneous systemic sclerosis
anti-centromere is specific for
limited cutaneous systemic sclerosis
Carpal tunnel syndrome is caused by compression of ……
compression of median nerve in the carpal tunnel.
Causes of carpal tunnel syndrome
idiopathic
pregnancy
oedema e.g. heart failure
lunate fracture
rheumatoid arthritis
Treatment of carpal tunnel syndrome
- 6-week trial of conservative treatments if the symptoms are mild-moderate
- corticosteroid injection
- wrist splints at night: particularly useful if transient factors present e.g.pregnancy
- if there are severe symptoms or symptoms persist with conservative management:
- surgical decompression (flexor retinaculum division)
Cubital tunnel syndrome occurs due to compression of
the ulnar nerve as it passes through the cubital tunnel.
In Cubital tunnel syndrome
In which fingers Tingling and numbness occur ?
In the 4th and 5th finger
Treatment of Cubital tunnel syndrome
Avoid aggravating activity
Physiotherapy
Steroid injections
Surgery in resistant cases
Treatment of De Quervain’s tenosynovitis
analgesia
steroid injection
immobilisation with a thumb splint (spica) may be effective
surgical treatment is sometimes required
Ehler-Danlos syndrome is an autosomal …1…..connective tissue disorder that mostly affects type …..2… collagen
- autosomal dominant
- affects type III collagen
- elastic, fragile skin
- joint hypermobility: recurrent joint dislocation
- easy bruising
- aortic regurgitation, mitral valve prolapse and aortic dissection
- subarachnoid haemorrhage
- angioid retinal streaks
Features of which condition
Ehler-Danlos syndrome
Management of fibromyalgia
aerobic exercise: has the strongest evidence base
cognitive behavioural therapy
medication: pregabalin, duloxetine, amitriptyline
In which level of Uric acid is supporting a diagnosis of gout
uric acid level ≥ 360 umol/L
When do you repeat Uric acid level
If Uric acid level is not elevated during a flare and gout is strongly suspected ?
at least 2 weeks after the flare has settled
Drugs causing gout
aspirin
alcohol
pyrazinamide
ciclosporin
cytotoxic agents
diuretics:thiazides, furosemide
Causes of Increased production of uric acid
myeloproliferative/lymphoproliferative disorder
cytotoxic drugs
severe psoriasis
Indications for urate-lowering therapy (ULT)
if:
- > = 2 attacks in 12 months
- tophi
- renal disease
- uric acid renal stones
- prophylaxis if on cytotoxics or diuretics
colchicine inhibits…..
inhibits microtubule polymerization by binding to tubulin, interfering with mitosis. Also inhibits neutrophil motility and activity
Target of s. Uric acid
- < 360 µmol/L
- < 300 µmol/L IF may be considered for patients who have tophi, chronic gouty arthritis or continue to have ongoing frequent flares despite having a uric acid below 360 µmol/L
febuxostat ……………… inhibitor.
xanthine oxidase inhibitor)
Urate-lowering therapy
1. What is the first line ?
- Second line ?
- In refractory cases ?
- allopurinol
- febuxostat
- uricase or pegloticase
Which anti hypertensive drug has a specific uricosuric action?
losartan
Greater trochanteric pain syndromeis due to repeated movement of ………..
the fibroelastic iliotibial band
Features of Greater trochanteric pain syndrome
pain over the lateral side of hip/thigh
tenderness on palpation of the greater trochanter
Adverse effects of Hydroxychloroquine
bull’s eye retinopathy - may result in severe and permanent visual loss
- baseline ophthalmological examinationand annual screening is generally recommened
Causes of iliopsoas abscess
Staphylococcus aureus: most common
Crohn’s (commonest cause in this category)
Diverticulitis, colorectal cancer
UTI, GU cancers
Vertebral osteomyelitis
Femoral catheter, lithotripsy
Endocarditis
intravenous drug use
tennis racket-shaped Birbeck granules on electromicroscopy
Langerhans cell histiocytosis
In Lateral epicondylitis
pain worse on …………….
wrist extension against resistance with the elbow extended or supination of the forearm with the elbow extended
Red flags for lower back pain
age < 20 years or > 50 years
history of previous malignancy
night pain
history of trauma
systemically unwell e.g. weight loss, fever
Sensory loss over anterior thigh
Weak hip flexion, knee extension and hip adduction
Reduced knee reflex
Positive femoral stretch test
Which Site of compression ?
L3 nerve root compression
Sensory loss anterior aspect of knee and medial malleolus
Weak knee extension and hip adduction
Reduced knee reflex
Positive femoral stretch test
Which site of compression?
L4 nerve root compression
Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test
Which site of compression?
L5 nerve root compression
Sensory loss posterolateral aspect of leg and lateral aspect of foot
Weakness in plantar flexion of foot
Reduced ankle reflex
Positive sciatic nerve stretch test
Which site of compression?
S1 nerve root compression
Marfan’s syndrome is anautosomal……1….
It is caused by a defect in the ……..2…… on chromosome …….3…. that codes for …….4…..
- autosomal dominant
- FBN1 gene
- chromosome 15
- the protein fibrillin-1
McArdle’s disease is autosomal …..1…. type ….2….. glycogen storage disease
- autosomal recessive
- Type V glycogen storage disease
McArdle’s disease
caused by ………1……. deficiency
this causes decreased ……..2….
- myophosphorylase deficiency
- muscle glycogenolysis
muscle pain and stiffness following exercise
muscle cramps
myoglobinuria
low lactate levels during exercise
Features of……?
McArdle’s disease
Heberden’s nodes at the DIP joints seen in
Osteoarthritis (OA) of the hands
Osteoarthritis: management
- weight loss
- muscle strengthening exercises
- topical NSAIDsare first-line analgesics ( KNEE & HANDS )
- second-line treatment is oral NSAIDs
- intra-articular steroid injections may be tried if standard pharmacological treatment is ineffective
Osteogenesis imperfecta is autosomal …….
- abnormality in type ……. collagen.
autosomal dominant
abnormality in type 1 collagen
vertebral osteomyelitis is the most common form of ……. osteomyelitis in adults
haematogenous osteomyelitis
The most common cause of osteomyelitis
Staph. aureus
But Salmonellaspecies in patients with sickle-cell anaemia
Treatment of osteomyelitis
flucloxacillin for 6 weeks
clindamycin if penicillin-allergic
Osteopetrosis is rare disorder of defective …..1…… resulting in failure of normal bone resorption.
- calcium, phosphate and ALP are ……
- Treatment
- defective osteoclast function
- calcium, phosphate and ALP are normal
- stem cell transplant and interferon-gamma
Medications that may worsen osteoporosis
- glucocorticoids
- SSRIs
- antiepileptics
- PPi
- glitazones
- long term heparin therapy
- aromatase inhibitors e.g. anastrozole
Management of patients at risk of corticosteroid-induced osteoporosis
If T score
1. > 0 ; ……..
- 0 to - 1.5 ; ……..
- < -1.5 ; ……..
If T score
1. > 0 ; Reassure
- 0 to - 1.5 ; Repeat bone density scan in 1-3 years
- < -1.5 ; Offer bone protection
The first-line treatment is alendronate. Patients should also be calcium and vitamin D replete.
Denosumab human monoclonal antibody that inhibits ……?
human monoclonal antibody that inhibits RANK ligand, which in turn inhibits the maturation of osteoclasts
6 Risk factors of pseudogout
haemochromatosis
Wilson’s disease
hyperparathyroidism
low magnesium,
low phosphate
acromegaly,
joint aspiration in pseudogout
weakly-positively birefringent rhomboid-shaped crystals
Pseudogout
X Ray finding
chondrocalcinosis
Treatment of pseudogout
NSAIDs or intra-articular, intra-muscular or oral steroids as for gout
Polymyalgia rheumatica is associated with
temporal arteritis
Treatment of Polymyalgia rheumatica
prednisolone 15mg/od
patients typically respond dramatically to steroids, failure to do so should prompt consideration of an alternative diagnosis
Predisposing factors of Paget’s disease
- increasing age
- male sex
- northern latitude
- family history
the stereotypical presentation of Paget’s disease
older male with bone pain and an isolated raised ALP
Management of Paget’s disease
indications for treatment include
indications for treatment
1. bone pain
2. skull or long bone deformity
3. fracture
4. periarticular Paget’s
bisphosphonate(either oral risedronate or IV zoledronate)
calcitonin is less commonly used now
Complications of Paget’s disease
deafness (cranial nerve entrapment)
bone sarcoma (1% if affected for > 10 years)
fractures
skull thickening
high-output cardiac failure
Pseudoxanthoma elasticum is an inherited condition usually autosomal ……..?
autosomal recessive
Cardio features are associated with Pseudoxanthoma elasticum
Mitral valve prolapse
Risk of ischemic heart disease
Mycophenolate mofetil inhibits ……………
Inhibits inosine monophosphate dehydrogenase, which is needed for purine synthesis
Polyarteritis nodosa (PAN) is a vasculitis affecting ……….sized arteries with necrotizing inflammation leading to aneurysm formation.
medium sized arteries
Polyarteritis nodosa (PAN)is associated with
Hepatitis B infection
most common organism causing septic arthritis
- Staphylococcus aureus
- in young adults who are sexually active,Neisseria gonorrhoeaeis the most common organism
Treatment of septic arthritis
flucloxacillin or clindamycin if penicillin allergic
antibiotic treatment is normally be given for several weeks (BNF states 4-6 weeks)
patients are typically switched to oral antibiotics after 2 weeks
RF & ANA in stills disease
Negative
Management of Still’s disease
- NSAIDS ; should be used first-lineto manage fever, joint pain and serositis
- Steroids
- if symptoms persist, the use of methotrexate, IL-1 or anti-TNF therapy can be considered
8 Poor prognostic features of RA
- Female
- insidious onset
- poor functional status at presentation
- extra articular features e.g. nodules
- rheumatoid factor positive
- anti-CCP antibodies
- HLA DR4
- X-ray: early erosions (e.g. after < 2 years)
Rheumatoid arthritis: x-ray changes
- loss of joint space
- periarticular erosions
- juxta-articular osteoporosis
- subluxation
- soft-tissue swelling
8 conditions associated with a positive RF
- RA
- Felty’s syndrome
- SLE
- systemic sclerosis
- Sjogren’s syndrome
- infective endocarditis
- Infections: TB, HBV, EBV, leprosy
- general population
indication for a TNF-inhibitor in RA
an inadequate response to at least two DMARDs including methotrexate
Side effects of etanercept
demyelination,
reactivation of tuberculosis
Rheumatoid arthritis: management
- NICE recommendDMARDmonotherapy+/- a short-course of bridging prednisolone.
choices for initial DMARD monotherapy in RA
- methotrexateis the most widely used DMARD.
- sulfasalazine
- leflunomide
- hydroxychloroquine
Side effects of Adalimumab
Reactivation of tuberculosis
Side effects of Methotrexate
Myelosuppression
Liver cirrhosis
Pneumonitis
Side effects of Sulfasalazine
Rashes
Oligospermia
Heinz body anaemia
Interstitial lung disease
Stevens-Johnson syndrome
Side effects of Leflunomide
Liver impairment
Interstitial lung disease
Hypertension
Side effects of Hydroxychloroquine
Retinopathy
Corneal deposits
2 Side effects of Penicillamine
Proteinuria
Exacerbation of myasthenia gravis
Which DMARD are safe in pregnancy
sulfasalazine and hydroxychloroquine are considered safe in pregnancy
In Sjogren’s syndrome
There is a marked increased risk of …………?
lymphoid malignancy
Management of Sjogren’s syndrome
artificial saliva and tears
pilocarpine may stimulate saliva production
Rotator cuff muscles
SItS- small t for teres minor
Supraspinatus
Infraspinatus
teres minor
Subscapularis
CREST syndrome is
subtype of limited systemic sclerosis
1. Calcinosis,
2. Raynaud’s phenomenon,
3. OEsophageal dysmotility,
4. Sclerodactyly,
5. Telangiectasia
Which pattern of systemic sclerosis is associated withanti-centromere antibodies
Limited cutaneous systemic sclerosis
Which is the first sign of Limited cutaneous systemic sclerosis?
Raynaud’s
Which condition is associated withanti scl-70 antibodies ?
Diffuse cutaneous systemic sclerosis
What is the most common cause of death in Diffuse cutaneous systemic sclerosis?
interstitial lung disease (ILD) and
pulmonary arterial hypertension (PAH)
Patients with Diffuse cutaneous systemic sclerosis complicated by renal disease and hypertension, should be started on ……?
anACE inhibitor
Which one is associated with poor prognosis
Limited or diffuse cutaneous systemic sclerosis?
Diffuse cutaneous systemic sclerosis
Temporal arteritis affects …………sized vessels arteries.
medium and large-
Treatment of Temporal arteritis
urgent high-dose glucocorticoids should be given as soon as the diagnosis is suspected
if there is no visual loss then high-dose prednisolone is used
if there isevolving visual loss IV methylprednisoloneis usually given prior to starting high-dose prednisolone
urgent ophthalmology review
Secondary causes of Raynaud’s phenomenon
- scleroderma (most common)
- RA
- SLE
- Leukaemia
- type I cryoglobulinaemia, cold agglutinins
- cervical rib
- drugs: oral contraceptive pill, ergot
- use of vibrating tools
Management of Raynaud’s
all patients with suspectedsecondary Raynaud’s phenomenon should be referred to secondary care
first-line: calcium channel blockers e.g.nifedipine
IV prostacyclin (epoprostenol) infusions: effects may last several weeks/months
Which is the most common part of the body affected in Relapsing polychondritis ?
the ears,
- can affect other parts of the body such as the nose and joints.
Treatment of Relapsing polychondritis
Induce remission: steroids
Maintenance: azathioprine, methotrexate, cyclosporin, cyclophosphamide
Reactive arthritis is a triad of
urethritis, conjunctivitis and arthritis
the organisms that are most commonly associated with reactive arthritis:
Post-STI form : Chlamydia trachomatis
Post-dysenteric form:
1. Shigella flexneri
2. Salmonella typhimurium
3. Salmonella enteritidis
4. Yersinia enterocolitica
5. Campylobacter
Treatment of reactive arthritis
symptomatic: analgesia,NSAIDS, intra-articular steroids
sulfasalazine and methotrexate are sometimes used for persistent disease
Treatment of Psoriatic arthropathy
treatment is similar to that of rheumatoid arthritis
Methotrexate inhibits……….
dihydrofolate reductase, an enzyme essential for the synthesis of purines and pyrimidines
Methotrexate & pregnancy
women should avoid pregnancy for at least 6 months after treatment has stopped
Interactions of methotrexate with
- trimethoprim
- co-trimoxazole
- increases risk of marrow aplasia
- high-dose aspirin increases the risk of methotrexate toxicity secondary to reduced excretion
Treatment of Methotrexate toxicity
the treatment of choice is folinic acid
Azathioprine increase risk of ………….cancer
risk of non-melanoma skin cancer
Azathioprine in pregnancy
Safe to use
4 Side effects of Azathioprine
- bone marrow depression
- pancreatitis
- nausea/vomiting
- increased risk of non-melanoma skin cancer
Bisphosphonates inhibit ……..
osteoclastsby reducing recruitment and promoting apoptosis.
Side effects of bisphosphonates
- oesophagitis
- osteonecrosis of the jaw
- hypocalcaemia
- acute phase response: fever, myalgia and arthralgia may occur following administration
Denosumab Inhibits
RANKL
the two most common side effects of denosumab
Dyspnoea and diarrhoea
cANCA is found in which condition
Granulomatosis with polyangiitis
pANCA is found in which conditions
- Eosinophilic granulomatosis with polyangiitis
- Microscopic polyangiitis
- Ulcerative colitis
- Primary sclerosing cholangitis
- Crohn’s disease
- Anti-GBM disease
How to take Bisphosphonates to avoid oesophageal problems
Take at least 30 minutes before breakfast with plenty of water + sit-upright for 30 minutes following
- 30 before & 30 after
Azathioprine - check …………….. before treatment
thiopurine methyltransferase deficiency (TPMT)
APTT and platelet in antiphospholipid syndrome
prolonged APTT and thrombocytopenia make antiphospholipid syndrome the most likely diagnosis
Inflammatory arthritis involving DIP swelling and dactylitis points to a diagnosis of
psoriatic arthritis
What indicates a poor prognosis In Polymyositis ?
interstitial lung disease
SLE - antibodies associated with congenital heart block
anti-Ro
Paget’s disease - increased serum and urine levels of
hydroxyproline
Which cells secretes the majority of tumour necrosis factor in humans?
Macrophages
HLA DRB1 has been implicated in ……?
SLE
HLA DR4 is associated with
RA
HLA DQ2 is associated with …..
coeliac disease
HLA B51
Behcet’s disease
Which autoantibody is most specific for dermatomyositis ?
Anti-Mi-2 antibodies
Which autoantibody is most common +ve for dermatomyositis ?
ANA
Approximately what percentage of patients with psoriasis develop an associated arthropathy?
10-20%
4 signs associated with carpal tunnel syndrome?
- weakness of thumb abduction (abductor pollicis brevis)
- wasting of thenar eminence (NOT hypothenar)
- Tinel’s sign: tapping causes paraesthesia
- Phalen’s sign: flexion of wrist causes symptoms
Bone pain, tenderness and proximal myopathy (→ waddling gait) seen in
osteomalacia
What are the blood tests can be used for disease monitoring in SLE ?
- complement levels (C3, C4) are lowduring active disease
- anti-dsDNA titres can be used for disease monitoring (but note not present in all patients)
Patients who are allergic to aspirin may also react to
sulfasalazine
What should be monitored during treatment with Leflunomide ?
CBC
LFT
BP
Rheumatoid factor is an Ig..?.. antibody against Ig..?..
Rheumatoid factor is an IgM antibody against IgG
Which antibodies are most specific for systemic lupus erythematous?
anti-Sm & anti-dsDNA are 99% specific
What is the most common cardiac defect seen in Marfan’s syndrome
dilation of the aortic sinuses which may predispose to aortic dissection
Which connective tissue disease is most strongly associated with Raynaud’s phenomenon?
systemic sclerosis
Patients with carpal tunnel syndrome often get relief from…
shaking their hands
What is Heberden’s nodes?
Seen in which condition?
- Painless nodes (bony swellings) at the DIP joints
- osteoarthritis
Looser’s zones x-ray are most characteristically associated with
Osteomalacia
Diagnosis of ankylosing spondylitis can be best supported by ……….. on a pelvic X-ray
sacro-ilitis
What is the greatest predictor of future thrombosis in patients with anti-phospholipid syndrome?
Lupus anticoagulant
Which vasculitis is associated withhepatitis B infection ?
Polyarteritis nodosa
Anti-Jo 1 antibodies are more commonly seen in ………. than …………
Anti-Jo 1 antibodies are more commonly seen in polymyositis than dermatomyositis
Patients with Sjogren’s syndrome are at an increased risk of which malignancy?
Non-Hodgkin’s lymphoma
Which drug is associated with an increased risk of atypical stress fractures of the proximal femoral shaft?
Alendronate
TNF is key in pathophysiology of ……
RA
Apremilast is
PDE4 inhibitor
