Rheumatology Flashcards
Contraindication NSAIDS
- chronic kidney disease
- hepatic disease
- peptic ulcer
- adverse drug reaction
Auto Antibody - Rheumatoid Arthritis
- RF intial test ( 70%)
- Anti CCP- conformation (more sensitive and specific )
Auto Antibody - SLE
Ana - intial
Anti Ds DNA - confirming
Anti Smith - confirming
Synovial Fluid Analysis
Rheumatoid Arthritis S/S
- Pain ( decrease during the day)
- Morning stiffness ( >1h)
- Swelling
- Systemic: Fatiquw, weigth loss, Flu like symptomes, Musscle ache weakness
RA - Diagnostic criteria
- Family history of inflammatory arthritis
- Symptoms duration of over six weeks
- Early morning stiffness over an hour
- Arthritis in more than three regions
- Swelling in five or more joins
- Symmetry
- presence of Rheumatoid nodules
- Rheumatoid factor positive
- Raised inflammatory markers in absence of infection
- Anti-CCP positive
- Bony erosions on radiographs of hands and feet uncommon for early diseases
- Strong cardiovascular risk factor
RA- most affected joints
- Metacarpophalangeal (MCP) joints
- Proximal interphalangeal (PIP) joints
- Wrist
- Metatarsophalangeal (MTP) joints (in the foot)
- ankle, knee(mc), shoulder, hip, cervical spine
Symmetrical
Joints : tenderness synovial thickening m
RA - extra articular manifestation
- aggressive treatment
- 40%
- Pulmonary fibrosis
- Felty’s syndrome (a triad of rheumatoid arthritis, neutropenia and splenomegaly)
- Sjögren’s syndrome (with dry eyes and dry mouth)
- Anaemia of chronic disease
- Cardiovascular disease (Pericarditis, Myocarditis, Endocarditis, congestive heart failure)
- Eye manifestations ( keratoconjunctivitis, Scleritis, Ulcerative keratitis)
- Rheumatoid nodules (firm, painless lumps under the skin, typically on the elbows and fingers)
- Lymphadenopathy
- Carpel tunnel syndrome, osteopenia, Osteoporosis
- Renal (Amyloidosis, Glomerolunephritis)
- Bronchiolitis obliterans (small airway destruction and airflow obstruction in the lungs)
- Caplan syndrome (pulmonary nodules in patients with rheumatoid arthritis exposed to coal, silica or asbestos dust)
MC CAUSE OF DEATH : cardiovasular disease
RA - Handsigns
- Z-shaped deformity to the thumb
- Swan neck deformity (hyperextended PIP and flexed DIP)
- Boutonniere deformity (hyperextended DIP and flexed PIP)
- Ulnar deviation of the fingers at the MCP joints
MCP not affected in OA
RA - Atlantoaxial Subluxation
- can cause spinal cord compression
- check pre operative
RA - Dx
- Rheumatoid factor
- Anti-CCP antibodies
- Inflammatory markers, such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR)
- X-rays of the hands and feet for bone changes
- Ultrasound or MRI can be used to detect synovitis (useful when clinical findings are unclear)
RA - Xray changes
- Periarticular osteopenia
- Boney erosions
- Soft tissue swelling
- Joint destruction and deformity (in more advanced disease)
- subluxation
RA - Treatment
- Monotherapy with methotrexate, leflunomide or sulfasalazine
- Combination treatment with multiple cDMARDs
- Biologic therapies (usually alongside methotrexate)
- Lifstyle ( exercise, smoking cessation)
DMARDS
- Hydroxychloroquine may be used in mild disease and palindromic rheumatism. “mildest” DMARD.
- Other cDMARDs : azathioprine, ciclosporin, cyclophosphamide and mycophenolate.
- NSAIDs are helpful for pain relief but have associated risks and side effects. ( no paracetamol)
Biological Therapies
- Tumour necrosis factor (TNF) inhibitors (e.g., adalimumab, infliximab, etanercept, golimumab and certolizumab)
- Anti-CD20 on B cells (e.g., rituximab)
- Anti-interleukin-6 inhibitors (e.g., sarilumab and tocilizumab)
- JAK inhibitors (e.g., upadacitinib, tofacitinib and baricitinib)
- T-cell co-stimulation inhibitors (e.g., abatacept)
RA and Pregancy
- sympt can improve or flare
- Hydroxychlorochine or sulfosalazine( plus folic acid) safest
- Tetratogenic Methotrexate and leflunamid
Metotrexat
- Mouth ulcer
- liver toxidity
- bone marrow supression and leukopenia
- Tetratogenic
- interferes with folat metabolism( folic acid 5mg/week)
- Immunsuppresion
- bone marrow suppression ( Macrocystic anaemia)
Sulfosalazine
- Orange urine
- reversible male infertility ( stop before family planing)
- bone marrow supression
Hydroxychloroquin
- Retinal toxicity (reduced visual acuity (macular toxicity)
- Blue-grey skin pigmentation
- Hair lightening (bleaching)
Azathioprim
- thioprin methyltransferase test before medication
- more likely to get bone marrow supression
Feltys syndrom
- complication of longstanding RA
-
3 condtions
1. RA
2. splenomegaly
3. abnormal white blood cell count
Felty sydrom - featutres
- fatigue
- serious infection
- fever
- weight loss
- discoloured patches of the skin
Treatment same as RA
Unique SE for Antirheumatica
- Methotrexate: Bone marrow suppression and leukopenia, and highly teratogenic
- Leflunomide: Hypertension and peripheral neuropathy
- Sulfasalazine: Orange urine and male infertility (reduces sperm count)
- Hydroxychloroquine: Retinal toxicity, blue-grey skin pigmentation and hair bleaching
- Anti-TNF medications: Reactivation of tuberculosis
- Rituximab: Night sweats and thrombocytopenia
Osteoarthritis - RF
- obesity, age
- occupation
- trauma
- female
- family history.
Osteoarthritis - commenly affected joints
- Hips
- Knees
- Distal interphalangeal (DIP) joints in the hands
- Carpometacarpal (CMC) joint at the base of the thumb
- Lumbar spine
- Cervical spine (cervical spondylosis)
Osteoarthritis - Xray Changes
L- loss of joint space
O- Osteophytes
S- subarticular sclerosis
S -subchondral cyst
Osteoarthrits - Presentation
- Bulky, bony enlargement of the joint
- Restricted range of motion
- Crepitus on movement
- Effusions (fluid) around the joint
- symmetrical
- Pain ( worse with activity better at rest)
- Deformity, Instabiltiy an d reduced function
- morning stiffness( <1/2hour)
Osteoarthritis - Sign in hands
- Heberden’s nodes (DIP)
- Bouchard’s nodes (PIP)
- Squaring at the base of the thumb (CMC)
- Weak grip
- Reduced range of motion
Osteoarthritis - Management
- Nsaids
- intraarticular steroids
- Joint replacement
NSAIDS - Adverse Effects
- Gastrointestinal ( gastritis, peptic ulcer)
- Renal (AKI, Chronic kidney disease)
- cardiovascular ( hypertension, heart failure, MI, Stroke)
- excerbating asthma
SLE Diagnostic
CRP/ESR
ANA ( antinuclear) - intial
Anti DsDNA - confirming
Anti Smith - most specific but not sensitive
Antihistone AB - Drug induced lupus
Congenital level C3 4 low
SLE - great pretender
Soap brain MD
S sclerositis ( pleuritis, pericarditis)
0 oral ulcer
A Arthritis.(Non deforming -hand feet )
P photo sensitivity
B blood all low
R Renal (proteinuria,glomerulonephritis)
A Ana
I immunoglobulin (ds dna)
N neurological ( psych seizures)
m malar rush
d discoid rash
Polyarthritis +fatigue +skinlession
Minimal 4 criterias
SLE - Treatment
- treat early to avoid unnecessary steroid use
Mild : Nsaid for atralgia
Moderate skin, joint, serosa - Hydroxychloroquine - Severe kidney involvement - —- corticosteroids,
- immunsupressive drugs(azathioprine, methotrexate- stop progression
- Cytotoxic drugs ( cyclophosphamid)
SLE - Abnormal findings
- Autoantibodies
- Full blood - anaemia of chronic disease, low white cell count and low platelets
- CRP and ESR may be raised with active inflammation
- C3 and C4 levels may be decreased in active disease
- Urinalysis and urine protein:creatinine ratio shows proteinuria in lupus nephritis
- Renal biopsy may be used to investigate for lupus nephritis
Antiphospholipid syndrom
- secondary to SLE
- antiphospolipid antibodies ( anticardiolipin, Antibeta 2 glycoprotein, lupus anticoagulant)
- recurrent fetal loss
- recurrend thrombotic episodes
Antiphospholipid Syndrom - Mx
Thrombosis:
* lifelong anticoagulation ( inr 2.5-3.5)
recurrent fetal loss
* aspirin, heparin +/-Steroids
catastrophic
* high dose steroid
* anticoagulant, cyclophosphamid , plasmapheresis
Secondary Antiphospholipid Syndrome
- SLE, other connective tissue diseases, malignancy, drugs (hydralazine, procainamide, phenytoin, interferon, quinidine),
- infections (HIV, hepatitis C, TB, infectious mononucleosis)
Drug induced SLE
- Atralgia
- Myalgia
- skin
- no renal or nervous system effected
Drug induced SLE - AB
- antihistamin AB
- ANA pos
- Anti DsDNA neg
- Anti Ro and Anti smith 5% pos
Drug induced SLE - Cause
- Phenytoin
- Chlorpromazin
- Proconamid
- Isonazid
- hydralazin
fibromyalgia- Symptoms
– Fatigue and sleep difficulties
– Pain in all 4 Quadrants of the body and the axial skeletal on more or less continuous basis for at least three months.
– At least 11 out of 18 anatomically specific tender joints. A tender joint hurts at the area where the pressure is applied, and there is no referred pain.
– Normal inflammatory markers CRP, ESR etc.
Congenital Lupus - S/S
- dermatologic
- Cardiac ( 65% -congenital complete heart block- 18/20 SSW)
- hepatic involvement
- splenic abnormalities
Congenital Lupus - AB
- Anti Ro (most likely detected)
- Anti La
- U1 ribonukleid protein
- C4 down
> Transplacental passage
Skleroderma
- Autoimmun
- thickening of skin (accumulation of collagen and injuries of small arteries)
- Localised
- Systemic (limited cutaneous, diffuse cutaneous)
Scleroderma Trias
Fingerdiscomfort + atralgia+ GERD +( Skin tightness)
Localised skleroderma
- does not affect internal organs
- Skin, muscle, joint, bones
- patches on skin mainly trunk (morphea)
- streaks or bands of thick hard skin on arms/legs ( linear scleroderma)
Systemic Sclerosis
- Sausage fingers
- tight and shiny skin
- Arrythmias, pericarditis
- bird like facies
Limited cutaneous systemic sclerosis - CREST
- C calcinosis
- R raynaud phaenomen
- E Oesophagus dismobility
- S Sklerodactyly
- T Teleangiectasia
Diffuse Cutaneous Systemic Sclerosis
- Cardiovascular problems (e.g., hypertension and coronary artery disease)
- Lung problems (e.g., pulmonary hypertension and pulmonary fibrosis)-Late, mcc of death
- Kidney problems (e.g., scleroderma renal crisis)
Systemic sclerosis - Dx
- ESR maybe high
- Anaemia ( normocystic, normochrome)
- ANA ( 90%)
- RF ( 30%)
- Anticentromere Antibodies - specific ( 90% in crest, 5%in diffuse)
- Anti SCL 70 ( Antipoisomerase) - Specific ( just in 20-40% pos)
- Skin biopsy( dermal collagen increast)
Systemic sclerosis - MX
- refer to specialist, pat education
- Analgetics and NSAIDs
- Avoid vasospasm ( no smoking, bblocker, ergotamine)
- Raynaud: CCB( nifedipin)
- RR monitoring
- D-penicillamine(DMARD) if significant systemic or cutaneous involvement
Polymyositis/Dermatomyositis
- autoimmun conective tissue disorder
- symmetrical
- Inflammation of the muscles/skin
Weakness+joint and muscle pain + violaceous facial rash = dermatomysositis
Polymyositis/Dermatomyositis - S/S
- Proximal myopathy
( cant get up from chair/ comb the hair) - Arthralgia
- Dysphagia (50%)
- Rauynaud
- Associated malignancy: lung and ovarys
Dermatomyositis - Skin changes
- Gottron lesions (scaly erythematous patches) on the knuckles, elbows and knees
- Heliotrope rash (a purple rash on the face and eyelids)
- Periorbital oedema (swelling around the eyes)
- Photosensitive erythematous rash on the back, shoulders and neck
Polymyositis/Dermatomyositis - Diagnosis
- Serum CK and aldolase
- Biopsy ( skin and musle) -best
- Emg
- Anti Jo AB ( Polymyosistis)
Differential - CK
Dermatomyosytis/polymyositis
CK and ESR high
Polymyalgia Rheumatica
CK normal and ESR high
Drug induced myositis ( statin, steroids)
CK and ESR normal
Polymyositis/Dermatomyositis - Treatment
- Cortison
- Immunsuppressent
- cytotoxic
- Iv globulin
- Biological ( infliximab,etaercept)
Sjögren
primary
* dry eyes ( keratoconjunctivitis sicca)
* dry mouth
secondary
* dry eyes ( keratoconjunctivitis sicca)
* dry mouth
* + arthralgia ( RA)
Sjögren - S/S
- fatigue
- Sicca
- difficulty swalloing
- salivary gland enlargement
- Xerotrachea (chronic dry cough, hoarsness)
- Dyspareunia
- non erosive Arthritis
-
can transform in non hodgkin (44xrisk)
*
Sjögren- Dx
- Autoantibodies - pos ANA, RO, LA
- Schirmer test
- Sialogram
- Biopsy if parotid gland enlargement ( goldstandard)
Sjögren- Mx
- refer
- symptomatic ( eg pilocarpin)
- NSAIDs , hydroxychloroquin, steroid for arthritis
Raynaud - primary
- not associated with other diseases
*
Classification Vasculitis
Small vessel
NON-ANCA-ASSOCIATED
* Predominantly cutaneous vasculitis
* Henoch-Schönlein purpura
* Essential cryoglobulinemic vasculitis
ANCA-ASSOCIATED
* Wegener’s granulomatosis
*Churg-Strauss vasculitis
* Microscopic polyangiitis
Medium-sized vessel
* Polyarteritis nodosa
* Kawasaki’s disease
Large vessel
* Giant Cell Arteritis (Temporal Arteritis)
* Takayasu’s
Major vasculitides
-polyarteritis nodosa (PN),
-giant cell arteritis (GCA)& polymyalgia rheumatica
-Takayasu arteritis,
-Behcet syndrome,
-Churg-Strauss vasculitis
-Wegener granulomatosis (WG)
Polyarthritis nodosa
- necrotising vasculitis
- young/middle aged man
- association - drugabuser, HepB/C, Bcell lymphoma
Polyarthritis nodosa - S/S
- fever, malaise, myalgia, weight loss
- migratory arthralgia/polyarthritis
- subcutaneous noduls, skin ulcer
- abdominal pain, rectal bleeding
- kidney impairment
- hypertension
- Cardiac disorders: arrythmia, failure infarction
Polyarthritis nodosa- Dx/Mx
- ESR raised, CRP raised
- renal biopsy or affected organ ( best)
MX
* Corticosteroid, immunsuppressants
Giant Cell Arthritis
- associated with polymyalgia rheumatica
- sudden vision loss with temporal headache, jaw. claudication
- ESR high (100) , temporal art biopsy
- MX iv Corticosteroid
Polymyalgia rheumatica
malaise +painful shoulder girdle +morning stiffness( over 50)
Polymyalgia rheumatica
- pain, stiffness- shoulder/pelvic girdle, cervical spine
- symmetrical
- 60 -70a
- weight loss malaise anorexia
Polymyalgia rheumatica/temporal arthritis
non complicated:
Prednisolone
Complicated ( e.g vision loss)
iv methylprednisolone
other: Methotrexate, Azathioprin cortison sparing agent
Behçet syndrome
- affects all veins and arteries of all size
- Mediterran, middle east, east asia
- R reccurent oran/genital ulcer
- U uveitis
- S skin damage
- T Test Pathergy
Behçet syndrome - S/S
- Arthritis (knee)
- ulcer
- Occular sign ( pain, reduced vision, floaters)
–>refer to Ophtalmologist
Behçet syndrome- Dx
Dx
- Pathergy Test
- Inflammatory markers
- HLAB51
Mx
corticosteroid
colchicin
Immunsuppressive drugs
colchecine - Kidney impairment
no or reduced
Allopurinol
- If >1 attack in 12 month
- not in acute attack ( after 6 week)
- Adverse effect: rash, lower in KI
- drug interaction amoxicillin, azathioprin
- dont touch in flare
Chronic use of methotrexate can cause following side effects:
1-Hepatotoxicity
2-Folic acid deficiency
3-Myelosuppression with low platelet and white cell count.
4-Interstitial pneumonitis
5-Fatigue
6-Nausea and vomiting
7-Stomatitis or mouth ulcers.
Ankylosing Spondylytis - Treatment
