Rheumatology Flashcards
1
Q
Adhesive capsulitis (frozen shoulder) isassociated with
A
DM
up to 20% of diabetics may have an episode of frozen shoulder
2
Q
In Adhesive capsulitis (frozen shoulder)
Which is effected more
1- Abduction or external or internal rotation ?
2- active or passive movement?
A
- external rotation is affected more than internal rotation or abduction
- both active and passive movementis affected
3
Q
Treatment of Adhesive capsulitis (frozen shoulder)
A
- NSAIDs
- physiotherapy
- oral corticosteroids and
- intra-articular corticosteroids
4
Q
Ankylosing spondylitis is associated with a HLA-…..?
A
HLA-B27
5
Q
Features of Ankylosing spondylitis ( 7A,C)
A
- Apical fibrosis
- Anterior uveitis
- Aortic regurgitation
- Achilles tendonitis
- AV node block
- Amyloidosis
- Arthritis peripheral
- cauda equina syndrome
6
Q
Treatment of Ankylosing spondylitis
A
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
7
Q
Antiphospholipid syndrome is associated with
A
SLE
other autoimmune disorders
lymphoproliferative disorders
phenothiazines (rare)
8
Q
Investigations of Antiphospholipid syndrome
A
- anticardiolipin antibodies
- anti-beta2 glycoprotein I (anti-beta2GPI) antibodies
- lupus anticoagulant
- thrombocytopenia
- prolonged APTT
9
Q
Management of antiphospholipid syndrome
A
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
10
Q
Causes of Avascular necrosis of the hip
A
long-term steroid use
chemotherapy
alcohol excess
trauma
11
Q
What is the the investigation of choice in Avascular necrosis?
A
MRI
12
Q
The classic triad of Behcet’s syndrome
A
- genital ulcers
- oral ulcers
- anterior uveitis
*Goa
13
Q
Behcet’s syndrome is associated withHLA….?
A
HLA B51
14
Q
Investigations of dermatomyositis
A
- elevated CK
- ANA
- anti-Mi-2 antibodies
- antibodies to signal recognition particle (SRP)
- antibodies against histidine-tRNA ligase (also called Jo-1)
15
Q
Treatment of dermatomyositis
A
prednisolone
16
Q
Drug-induced lupus
A
Most common causes
procainamide
hydralazine
Less common causes
isoniazid
minocycline
phenytoin
17
Q
Familial Mediterranean Fever (FMF) is an autosomal ….. disorder
A
autosomal recessive
18
Q
Investigations of Polymyositis
A
- elevated CK
- LDH
- anti-synthetase antibodies
anti-Jo-1 antibodies are seen in pattern of disease associated with lung involvement, Raynaud’s and fever
19
Q
Management of Polymyositis
A
high-dose corticosteroids tapered as symptoms improve
azathioprine may be used as a steroid-sparing agent
20
Q
Which condition is associated with HLA B8, DR2, DR3
A
SLE
21
Q
SLE is atype ……?……. hypersensitivity reaction
A
SLE atype 3 hypersensitivity reaction
22
Q
neonatal complications due to SLE include
A
congenital heart block
23
Q
SLE management
A
Basics
NSAIDs
sun-block
Hydroxychloroquine
the treatment of choice for SLE
If internal organ involvement e.g. renal, neuro, eye then consider prednisolone, cyclophosphamide
24
Q
Systemic lupus erythematosus: investigations
A
ANA
ANTI dsDNA
ANTI Smith
ANTI U1 RNP
ANTI RO (SS-A)
ANTI LA ( SS-B )
25
Discoid lupus erythematosus is characterised by
follicular keratin plugs
26
Management of Discoid lupus erythematosus
topical steroid cream
oral antimalarials may be used second-line e.g. hydroxychloroquine
avoid sun exposure
27
anti-Ro is specific for
Sjogren's syndrome,
SLE,
congenital heart block
28
anti-La: specific for
Sjogren's syndrome
29
anti-Jo 1: specific for
polymyositis
30
anti-scl-70 specific for
diffuse cutaneous systemic sclerosis
31
anti-centromere is specific for
limited cutaneous systemic sclerosis
32
Carpal tunnel syndrome is caused by compression of ......
compression of median nerve in the carpal tunnel.
33
Causes of carpal tunnel syndrome
idiopathic
pregnancy
oedema e.g. heart failure
lunate fracture
rheumatoid arthritis
34
Treatment of carpal tunnel syndrome
1. 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
2. if there are severe symptoms or symptoms persist with conservative management:
- surgical decompression (flexor retinaculum division)
35
Cubital tunnel syndrome occurs due to compression of
the ulnar nerve as it passes through the cubital tunnel.
36
In Cubital tunnel syndrome
In which fingers Tingling and numbness occur ?
In the 4th and 5th finger
37
Treatment of Cubital tunnel syndrome
Avoid aggravating activity
Physiotherapy
Steroid injections
Surgery in resistant cases
38
Treatment of De Quervain's tenosynovitis
analgesia
steroid injection
immobilisation with a thumb splint (spica) may be effective
surgical treatment is sometimes required
39
Ehler-Danlos syndrome is an autosomal ...1.....connective tissue disorder that mostly affects type .....2... collagen
1. autosomal dominant
2. affects type III collagen
40
1. elastic, fragile skin
2. joint hypermobility: recurrent joint dislocation
3. easy bruising
4. aortic regurgitation, mitral valve prolapse and aortic dissection
5. subarachnoid haemorrhage
6. angioid retinal streaks
Features of which condition
Ehler-Danlos syndrome
41
Management of fibromyalgia
aerobic exercise: has the strongest evidence base
cognitive behavioural therapy
medication: pregabalin, duloxetine, amitriptyline
42
In which level of Uric acid is supporting a diagnosis of gout
uric acid level ≥ 360 umol/L
43
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
44
Drugs causing gout
aspirin
alcohol
pyrazinamide
ciclosporin
cytotoxic agents
diuretics: thiazides, furosemide
45
Causes of Increased production of uric acid
myeloproliferative/lymphoproliferative disorder
cytotoxic drugs
severe psoriasis
46
Indications for urate-lowering therapy (ULT)
if:
1. >= 2 attacks in 12 months
2. tophi
3. renal disease
4. uric acid renal stones
5. prophylaxis if on cytotoxics or diuretics
47
colchicine inhibits.....
inhibits microtubule polymerization by binding to tubulin, interfering with mitosis. Also inhibits neutrophil motility and activity
48
Target of s. Uric acid
1. < 360 µmol/L
2. < 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
49
febuxostat .................. inhibitor.
xanthine oxidase inhibitor)
50
Urate-lowering therapy
1. What is the first line ?
2. Second line ?
3. In refractory cases ?
1. allopurinol
2. febuxostat
3. uricase or pegloticase
51
Which anti hypertensive drug has a specific uricosuric action?
losartan
52
Greater trochanteric pain syndrome is due to repeated movement of ...........
the fibroelastic iliotibial band
53
Features of Greater trochanteric pain syndrome
pain over the lateral side of hip/thigh
tenderness on palpation of the greater trochanter
54
Adverse effects of Hydroxychloroquine
bull's eye retinopathy - may result in severe and permanent visual loss
* baseline ophthalmological examination and annual screening is generally recommened
55
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
56
tennis racket-shaped Birbeck granules on electromicroscopy
Langerhans cell histiocytosis
57
In Lateral epicondylitis
pain worse on ................
wrist extension against resistance with the elbow extended or supination of the forearm with the elbow extended
58
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
59
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
60
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
61
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
62
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
63
Marfan's syndrome is an autosomal......1....
It is caused by a defect in the ........2...... on chromosome .......3.... that codes for .......4.....
1. autosomal dominant
2. FBN1 gene
3. chromosome 15
4. the protein fibrillin-1
64
McArdle's disease is autosomal .....1.... type ....2..... glycogen storage disease
1. autosomal recessive
2. Type V glycogen storage disease
65
McArdle's disease
caused by .........1....... deficiency
this causes decreased ........2....
1. myophosphorylase deficiency
2. muscle glycogenolysis
66
muscle pain and stiffness following exercise
muscle cramps
myoglobinuria
low lactate levels during exercise
Features of......?
McArdle's disease
67
Heberden’s nodes at the DIP joints seen in
Osteoarthritis (OA) of the hands
68
Osteoarthritis: management
1. weight loss
2. muscle strengthening exercises
3. topical NSAIDs are first-line analgesics ( KNEE & HANDS )
4. second-line treatment is oral NSAIDs
5. intra-articular steroid injections may be tried if standard pharmacological treatment is ineffective
69
Osteogenesis imperfecta is autosomal .......
- abnormality in type ....... collagen.
autosomal dominant
abnormality in type 1 collagen
70
vertebral osteomyelitis is the most common form of ....... osteomyelitis in adults
haematogenous osteomyelitis
71
The most common cause of osteomyelitis
Staph. aureus
But Salmonella species in patients with sickle-cell anaemia
72
Treatment of osteomyelitis
flucloxacillin for 6 weeks
clindamycin if penicillin-allergic
73
Osteopetrosis is rare disorder of defective .....1...... resulting in failure of normal bone resorption.
2. calcium, phosphate and ALP are ......
3. Treatment
1. defective osteoclast function
2. calcium, phosphate and ALP are normal
3. stem cell transplant and interferon-gamma
74
Medications that may worsen osteoporosis
1. glucocorticoids
2. SSRIs
3. antiepileptics
4. PPi
5. glitazones
6. long term heparin therapy
7. aromatase inhibitors e.g. anastrozole
75
Management of patients at risk of corticosteroid-induced osteoporosis
If T score
1. > 0 ; ........
2. 0 to - 1.5 ; ........
3. < -1.5 ; ........
If T score
1. > 0 ; Reassure
2. 0 to - 1.5 ; Repeat bone density scan in 1-3 years
3. < -1.5 ; Offer bone protection
The first-line treatment is alendronate. Patients should also be calcium and vitamin D replete.
76
Denosumab human monoclonal antibody that inhibits ......?
human monoclonal antibody that inhibits RANK ligand, which in turn inhibits the maturation of osteoclasts
77
6 Risk factors of pseudogout
haemochromatosis
Wilson's disease
hyperparathyroidism
low magnesium,
low phosphate
acromegaly,
78
joint aspiration in pseudogout
weakly-positively birefringent rhomboid-shaped crystals
79
Pseudogout
X Ray finding
chondrocalcinosis
80
Treatment of pseudogout
NSAIDs or intra-articular, intra-muscular or oral steroids as for gout
81
Polymyalgia rheumatica is associated with
temporal arteritis
82
Treatment of Polymyalgia rheumatica
prednisolone 15mg/od
patients typically respond dramatically to steroids, failure to do so should prompt consideration of an alternative diagnosis
83
Predisposing factors of Paget's disease
1. increasing age
2. male sex
3. northern latitude
4. family history
84
the stereotypical presentation of Paget's disease
older male with bone pain and an isolated raised ALP
85
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
86
Complications of Paget's disease
deafness (cranial nerve entrapment)
bone sarcoma (1% if affected for > 10 years)
fractures
skull thickening
high-output cardiac failure
87
Pseudoxanthoma elasticum is an inherited condition usually autosomal ........?
autosomal recessive
88
Cardio features are associated with Pseudoxanthoma elasticum
Mitral valve prolapse
Risk of ischemic heart disease
89
Mycophenolate mofetil inhibits ...............
Inhibits inosine monophosphate dehydrogenase, which is needed for purine synthesis
90
Polyarteritis nodosa (PAN) is a vasculitis affecting ..........sized arteries with necrotizing inflammation leading to aneurysm formation.
medium sized arteries
91
Polyarteritis nodosa (PAN) is associated with
Hepatitis B infection
92
most common organism causing septic arthritis
1. Staphylococcus aureus
2. in young adults who are sexually active, Neisseria gonorrhoeae is the most common organism
93
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
94
RF & ANA in stills disease
Negative
95
Management of Still's disease
1. NSAIDS ; should be used first-line to manage fever, joint pain and serositis
2. Steroids
3. if symptoms persist, the use of methotrexate, IL-1 or anti-TNF therapy can be considered
96
8 Poor prognostic features of RA
1. Female
2. insidious onset
3. poor functional status at presentation
4. extra articular features e.g. nodules
5. rheumatoid factor positive
6. anti-CCP antibodies
7. HLA DR4
8. X-ray: early erosions (e.g. after < 2 years)
97
Rheumatoid arthritis: x-ray changes
1. loss of joint space
2. periarticular erosions
3. juxta-articular osteoporosis
4. subluxation
5. soft-tissue swelling
98
8 conditions associated with a positive RF
1. RA
2. Felty's syndrome
3. SLE
4. systemic sclerosis
5. Sjogren's syndrome
6. infective endocarditis
7. Infections: TB, HBV, EBV, leprosy
8. general population
99
indication for a TNF-inhibitor in RA
an inadequate response to at least two DMARDs including methotrexate
100
Side effects of etanercept
demyelination,
reactivation of tuberculosis
101
Rheumatoid arthritis: management
1. NICE recommend DMARD monotherapy +/- a short-course of bridging prednisolone.
102
choices for initial DMARD monotherapy in RA
1. methotrexate is the most widely used DMARD.
2. sulfasalazine
3. leflunomide
4. hydroxychloroquine
103
Side effects of Adalimumab
Reactivation of tuberculosis
104
Side effects of Methotrexate
Myelosuppression
Liver cirrhosis
Pneumonitis
105
Side effects of Sulfasalazine
Rashes
Oligospermia
Heinz body anaemia
Interstitial lung disease
Stevens-Johnson syndrome
106
Side effects of Leflunomide
Liver impairment
Interstitial lung disease
Hypertension
107
Side effects of Hydroxychloroquine
Retinopathy
Corneal deposits
108
2 Side effects of Penicillamine
Proteinuria
Exacerbation of myasthenia gravis
109
Which DMARD are safe in pregnancy
sulfasalazine and hydroxychloroquine are considered safe in pregnancy
110
In Sjogren's syndrome
There is a marked increased risk of ............?
lymphoid malignancy
111
Management of Sjogren's syndrome
artificial saliva and tears
pilocarpine may stimulate saliva production
112
Rotator cuff muscles
SItS - small t for teres minor
Supraspinatus
Infraspinatus
teres minor
Subscapularis
113
CREST syndrome is
subtype of limited systemic sclerosis
1. Calcinosis,
2. Raynaud's phenomenon,
3. OEsophageal dysmotility,
4. Sclerodactyly,
5. Telangiectasia
114
Which pattern of systemic sclerosis is associated with anti-centromere antibodies
Limited cutaneous systemic sclerosis
115
Which is the first sign of Limited cutaneous systemic sclerosis?
Raynaud's
116
Which condition is associated with anti scl-70 antibodies ?
Diffuse cutaneous systemic sclerosis
117
What is the most common cause of death in Diffuse cutaneous systemic sclerosis?
interstitial lung disease (ILD) and
pulmonary arterial hypertension (PAH)
118
Patients with Diffuse cutaneous systemic sclerosis complicated by renal disease and hypertension, should be started on ......?
an ACE inhibitor
119
Which one is associated with poor prognosis
Limited or diffuse cutaneous systemic sclerosis?
Diffuse cutaneous systemic sclerosis
120
Temporal arteritis affects ............sized vessels arteries.
medium and large-
121
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 is evolving visual loss IV methylprednisolone is usually given prior to starting high-dose prednisolone
urgent ophthalmology review
122
Secondary causes of Raynaud's phenomenon
1. scleroderma (most common)
2. RA
3. SLE
4. Leukaemia
5. type I cryoglobulinaemia, cold agglutinins
6. cervical rib
7. drugs: oral contraceptive pill, ergot
8. use of vibrating tools
123
Management of Raynaud's
all patients with suspected secondary 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
124
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.
125
Treatment of Relapsing polychondritis
Induce remission: steroids
Maintenance: azathioprine, methotrexate, cyclosporin, cyclophosphamide
126
Reactive arthritis is a triad of
urethritis, conjunctivitis and arthritis
127
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
128
Treatment of reactive arthritis
symptomatic: analgesia, NSAIDS, intra-articular steroids
sulfasalazine and methotrexate are sometimes used for persistent disease
129
Treatment of Psoriatic arthropathy
treatment is similar to that of rheumatoid arthritis
130
Methotrexate inhibits..........
dihydrofolate reductase, an enzyme essential for the synthesis of purines and pyrimidines
131
Methotrexate & pregnancy
women should avoid pregnancy for at least 6 months after treatment has stopped
132
Interactions of methotrexate with
1. trimethoprim
2. co-trimoxazole
* increases risk of marrow aplasia
3. high-dose aspirin increases the risk of methotrexate toxicity secondary to reduced excretion
133
Treatment of Methotrexate toxicity
the treatment of choice is folinic acid
134
Azathioprine increase risk of .............cancer
risk of non-melanoma skin cancer
135
Azathioprine in pregnancy
Safe to use
136
4 Side effects of Azathioprine
1. bone marrow depression
2. pancreatitis
3. nausea/vomiting
4. increased risk of non-melanoma skin cancer
137
Bisphosphonates inhibit ........
osteoclasts by reducing recruitment and promoting apoptosis.
138
Side effects of bisphosphonates
1. oesophagitis
2. osteonecrosis of the jaw
3. hypocalcaemia
4. acute phase response: fever, myalgia and arthralgia may occur following administration
139
Denosumab Inhibits
RANKL
140
the two most common side effects of denosumab
Dyspnoea and diarrhoea
141
cANCA is found in which condition
Granulomatosis with polyangiitis
142
pANCA is found in which conditions
1. Eosinophilic granulomatosis with polyangiitis
2. Microscopic polyangiitis
3. Ulcerative colitis
4. Primary sclerosing cholangitis
5. Crohn's disease
6. Anti-GBM disease
143
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
144
Azathioprine - check ................. before treatment
thiopurine methyltransferase deficiency (TPMT)
145
APTT and platelet in antiphospholipid syndrome
prolonged APTT and thrombocytopenia make antiphospholipid syndrome the most likely diagnosis
146
Inflammatory arthritis involving DIP swelling and dactylitis points to a diagnosis of
psoriatic arthritis
147
What indicates a poor prognosis In Polymyositis ?
interstitial lung disease
148
SLE - antibodies associated with congenital heart block
anti-Ro
149
Paget's disease - increased serum and urine levels of
hydroxyproline
150
Which cells secretes the majority of tumour necrosis factor in humans?
Macrophages
151
HLA DRB1 has been implicated in ......?
SLE
152
HLA DR4 is associated with
RA
153
HLA DQ2 is associated with .....
coeliac disease
154
HLA B51
Behcet's disease
155
Which autoantibody is most specific for dermatomyositis ?
Anti-Mi-2 antibodies
156
Which autoantibody is most common +ve for dermatomyositis ?
ANA
157
Approximately what percentage of patients with psoriasis develop an associated arthropathy?
10-20%
158
4 signs associated with carpal tunnel syndrome?
1. weakness of thumb abduction (abductor pollicis brevis)
2. wasting of thenar eminence (NOT hypothenar)
3. Tinel's sign: tapping causes paraesthesia
4. Phalen's sign: flexion of wrist causes symptoms
159
Bone pain, tenderness and proximal myopathy (→ waddling gait) seen in
osteomalacia
160
What are the blood tests can be used for disease monitoring in SLE ?
1. complement levels (C3, C4) are low during active disease
2. anti-dsDNA titres can be used for disease monitoring (but note not present in all patients)
161
Patients who are allergic to aspirin may also react to
sulfasalazine
162
What should be monitored during treatment with Leflunomide ?
CBC
LFT
BP
163
Rheumatoid factor is an Ig..?.. antibody against Ig..?..
Rheumatoid factor is an IgM antibody against IgG
164
Which antibodies are most specific for systemic lupus erythematous?
anti-Sm & anti-dsDNA are 99% specific
165
What is the most common cardiac defect seen in Marfan's syndrome
dilation of the aortic sinuses which may predispose to aortic dissection
166
Which connective tissue disease is most strongly associated with Raynaud's phenomenon?
systemic sclerosis
167
Patients with carpal tunnel syndrome often get relief from ...
shaking their hands
168
What is Heberden’s nodes?
Seen in which condition?
- Painless nodes (bony swellings) at the DIP joints
- osteoarthritis
169
Looser's zones x-ray are most characteristically associated with
Osteomalacia
170
Diagnosis of ankylosing spondylitis can be best supported by ........... on a pelvic X-ray
sacro-ilitis
171
What is the greatest predictor of future thrombosis in patients with anti-phospholipid syndrome?
Lupus anticoagulant
172
Which vasculitis is associated with hepatitis B infection ?
Polyarteritis nodosa
173
Anti-Jo 1 antibodies are more commonly seen in .......... than ............
Anti-Jo 1 antibodies are more commonly seen in polymyositis than dermatomyositis
174
Patients with Sjogren's syndrome are at an increased risk of which malignancy?
Non-Hodgkin's lymphoma
175
Which drug is associated with an increased risk of atypical stress fractures of the proximal femoral shaft?
Alendronate
176
TNF is key in pathophysiology of ......
RA
177
Apremilast is
PDE4 inhibitor
