Rheumatology Flashcards
What disease is pseudogout associated with?
- hyperparathyroidism
- hypothyroidism
- haemochromatosis
- acromegaly
- low magnesium, low phosphate
- Wilson’s disease
what is keratoderma blenorrhagica associated with and what is it?
pustular lesions on palms, soles - seen in reactive arthritis; indistinguishable from palmarplantar pustulosis (bad psoriasis)
risk of developing psoriatic arthritis if have psoriasis
15%; more often skin disease occurs first; 30% have a family hx of psoriasis
HLAc26 a/w psoriasis alone
HLA Dr7 a/w psoriatic arthritis
HLA B27 a/w psoriatic arthritis with spondylitis
MICA-A allele strongly a/w with Psoriatic arthritis
clinical patterns in PsA (joint disease - 6)
predominantly DIP (a/w nail disease) asymmetrical oligoarticular polyarticular small c/w rheumatoid arthritis with spondylitis arthritis mutilans SAPHO syndrome
PsA arthritis treatment
NSAIDs
DMARDs (sulphasalazine MTX - skin only (more irreversible liver fibrosis), ciclosporin, leflunomide) peripheral joints only
anti TNF - skin and all joint (again more liver tox)
ustekinumab IL12/23
SAPHO syndrome
synovitis - sternoclavicular, manubrium acne palmarplantar pustulosis hyperostosis osteitis
HLA B27 in 13%
gonococcal arthritis
dermatitis - pustules esp on hands
tenosynovitis
migratory polyarthritis
NOT a/w HLA B27; due to disseminated gonoccal infx
behcets disease (silk road)
recurrent oral ulceration PLUS 2 of: recurrent genital ulceration eye lesions - panuveitis -> blindness skin lesions - EN, PG, Sweets positive pathergy test (inflammatory response to scratch etc)
ALSO a/w arthritis, thrombosis, vasculitis, CNS (dural sinus thrombosis)
acute rheumatic fever diagnostic criteria
2 major or 1 major; 2 minor
major: carditis, polyarthritis, chorea, erythema marginatum, subcut nodules
minor: fever, arthralgia, PHx rheum fever, raised ESR, CRP, prolonged PR, evidence of GAS infix (ASOT, strep Abs)
antiphospholipid syndrome
aPL X 2 > 12/52 apart AND > 1 thrombosis OR 3 consecutive mc < 10/40 1 mc > 10/40 pre eclampsia < 34/40
aPL = anticardiolipin, lupus anticoagulant, beta2microglobulin
typical EMG findings in myositis
EMG – increased insertional activity, spontaneous fibrillations, abnormal myopathic low amplitude and polyphasic motor potentials, complex repetitive discharges
typical muscle biopsy findings in myositis
muscle degeneration a/w macrophages, internalised nuclei, pale, hyalinised, split fibres, marked variation in fibre size
Anti synthetase syndrome features
- Jo1 antibodies
- Myositis, ILD, arthritis, fever, raynauds, mechanics hands
APS treatment
aPL alone - RFx rx; heparin for travel
> 1 thrombosis + aPL - warfarin
recurrent thrombosis on warfarin - add DMARD
pregnant: no events - aspirin (cease at 34/40)
events - add clexane
avoid warfarin in pregnancy
methotrexate
antimetabolite
SEs: GI, ulcers, hair loss, liver fibrosis (more in PsA), bone marrow suppression, renal toxicity at high dose
AEs: accelerated rheumatoid nodule formation
acute pneumonitis - reversible
B cell lymphomas - regress off MTX
hydroxychloroquine (plaquenil)
retinal toxicity - need 3-5 yearly ophthal review
otherwise well tolerated
OK in pregnancy
sulfasalazine
SEs: rash, headache, BM suppression, hepatotoxicity, haemolysis in G6PD def, reversible oligospermia
Leflunomide
- inhibits pyrimidine synthesis (which are required for T cell proliferation)
- need to wash out with cholestyramine for 11 days pre conception
- SEs: diarrhoea, peripheral neuropathy, LFTs
- CI in pregnancy
cyclosporin
renal toxicity
Azathioprine
- purine analogue
- use in SLE for maintenance
- screen for homozygous deficiency of TMPT enzyme which metabolises 6MP product of azathioprine as these people are at higher risk of bone marrow suppression
- pregnancy cat D
Cyclophosphamide
- alkylating agent
- induction in lupus nephritis
- risk haemorrhagic cystitis, bladder CA
- increases risk of CIN X 3
- age dependent decrease in fertility
- pregnancy cat D
gout
2-60,000 leuks in aspirate
negatively birefringent crystals (in cells at time; can be aspirated between attacks)
aim urate < 0.36mmol/L
xray: -cystic changes, well-defined erosions with sclerotic margins with overhanging bony edges; soft tissue masses
medications affecting urate levels
- allopurinol
- uricosuric agents
- thiazide or loop diuretics
- low-dose aspirin
beer > spirits (wine not a factor)
long term hypouricaemic therapy indicated for gout if:
> 2 attacks; uric acid stones; uric acid > 535umol/L, tophi, chronic gouty arthritis
allopurinol
xanthine oxidase inhibitor - for urate overproducers
side effects: toxic epidermal necrolysis, systemic vascluitis, bone marrow suppression, granulomatous hepatitis, renal failure
- rash, leukopenia or thrombocytopenia, diarrhea, and drug fever
- avoid in Han Chinese and Thai pts if HLAB5801 positive due to high rates of intolerance
Calcium oxalate deposition disease
- primary – rare – death, renal failure, by age 20
- secondary – to ESRF → arthritis
- worse if ascorbic acid supplements as this is metabolised to oxalate which is inadequately cleared in uremia and by dialysis
- bipyramidal crystals
- NSAIDs, colchicine, glucocorticoids, increased dialysis
CPPD pseudogout
precipitants:
- Trauma
- Rapid reduction in calcium levels – surgery (esp parathyroidectomy)
RA diagnosis
Joint involvement - 1 med-large (0) - 2-10 med-large (1) - 1-3 small (2) - 4-10 (3) Duration - 6 weeks (1) RA or CCP - Negative (0) - Low titre (1) - High titre (2) ESR or CRP - Normal (0) - Abnormal (1)
hyperuricaemia
due to decreased renal uric acid excretion
nail fold capillaroscopy
abnormal predicts scleroderma
monitoring in RA
ESR, CRP, stiff joint count
NOT rheumatoid factor!
ANA staining
centromere, nucleolar - scleroderma
homogenous, rim - SLE
speckled - non specific
anti histone Ab
drug induced lupus
anti ribosomal p
highly specific to SLE
FRAX tool
age, weight, height, PHx fracture, FHx NOF, steroids, rheumatoid arthritis, etOH, secondary osteoporosis, smoker
rheumatoid arthritis Rx
rituximab, adalimumab, golimumab, infliximab all better with methotrexate
except tocilizumab
Ab seen from ANA without further testing
anti centromere
