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amc > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

Contraindication NSAIDS

A
  • chronic kidney disease
  • hepatic disease
  • peptic ulcer
  • adverse drug reaction
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2
Q

Auto Antibody - Rheumatoid Arthritis

A
  • RF intial test ( 70%)
  • Anti CCP- conformation (more sensitive and specific )
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3
Q

Auto Antibody - SLE

A

Ana - intial
Anti Ds DNA - confirming
Anti Smith - confirming

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4
Q

Synovial Fluid Analysis

A
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5
Q

Rheumatoid Arthritis S/S

A
  • Pain ( decrease during the day)
  • Morning stiffness ( >1h)
  • Swelling
  • Systemic: Fatiquw, weigth loss, Flu like symptomes, Musscle ache weakness
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6
Q

RA - Diagnostic criteria

A
  • 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
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7
Q
A
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8
Q

RA- most affected joints

A
  • 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

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9
Q

RA - extra articular manifestation

A
  • 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

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10
Q

RA - Handsigns

A
  • 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

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11
Q

RA - Atlantoaxial Subluxation

A
  • can cause spinal cord compression
  • check pre operative
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12
Q

RA - Dx

A
  • 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)
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13
Q

RA - Xray changes

A
  • Periarticular osteopenia
  • Boney erosions
  • Soft tissue swelling
  • Joint destruction and deformity (in more advanced disease)
  • subluxation
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14
Q

RA - Treatment

A
  1. Monotherapy with methotrexate, leflunomide or sulfasalazine
  2. Combination treatment with multiple cDMARDs
  3. Biologic therapies (usually alongside methotrexate)
  4. Lifstyle ( exercise, smoking cessation)
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15
Q

DMARDS

A
  • 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)
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16
Q

Biological Therapies

A
  • 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)
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17
Q

RA and Pregancy

A
  • sympt can improve or flare
  • Hydroxychlorochine or sulfosalazine( plus folic acid) safest
  • Tetratogenic Methotrexate and leflunamid
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18
Q

Metotrexat

A
  • Mouth ulcer
  • liver toxidity
  • bone marrow supression and leukopenia
  • Tetratogenic
  • interferes with folat metabolism( folic acid 5mg/week)
  • Immunsuppresion
  • bone marrow suppression ( Macrocystic anaemia)
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19
Q

Sulfosalazine

A
  • Orange urine
  • reversible male infertility ( stop before family planing)
  • bone marrow supression
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20
Q

Hydroxychloroquin

A
  • Retinal toxicity (reduced visual acuity (macular toxicity)
  • Blue-grey skin pigmentation
  • Hair lightening (bleaching)
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21
Q

Azathioprim

A
  • thioprin methyltransferase test before medication
  • more likely to get bone marrow supression
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22
Q

Feltys syndrom

A
  • complication of longstanding RA
  • 3 condtions
    1. RA
    2. splenomegaly
    3. abnormal white blood cell count
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23
Q

Felty sydrom - featutres

A
  • fatigue
  • serious infection
  • fever
  • weight loss
  • discoloured patches of the skin

Treatment same as RA

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24
Q

Unique SE for Antirheumatica

A
  • 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
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25
Q

Osteoarthritis - RF

A
  • obesity, age
  • occupation
  • trauma
  • female
  • family history.
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26
Q

Osteoarthritis - commenly affected joints

A
  • Hips
  • Knees
  • Distal interphalangeal (DIP) joints in the hands
  • Carpometacarpal (CMC) joint at the base of the thumb
  • Lumbar spine
  • Cervical spine (cervical spondylosis)
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27
Q

Osteoarthritis - Xray Changes

A

L- loss of joint space
O- Osteophytes
S- subarticular sclerosis
S -subchondral cyst

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28
Q

Osteoarthrits - Presentation

A
  • 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)
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29
Q

Osteoarthritis - Sign in hands

A
  • Heberden’s nodes (DIP)
  • Bouchard’s nodes (PIP)
  • Squaring at the base of the thumb (CMC)
  • Weak grip
  • Reduced range of motion
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30
Q

Osteoarthritis - Management

A
  • Nsaids
  • intraarticular steroids
  • Joint replacement
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31
Q

NSAIDS - Adverse Effects

A
  • Gastrointestinal ( gastritis, peptic ulcer)
  • Renal (AKI, Chronic kidney disease)
  • cardiovascular ( hypertension, heart failure, MI, Stroke)
  • excerbating asthma
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32
Q

SLE Diagnostic

A

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

33
Q

SLE - great pretender

A

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

34
Q

SLE - Treatment

A
  • 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)
35
Q

SLE - Abnormal findings

A
  • 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
36
Q

Antiphospholipid syndrom

A
  • secondary to SLE
  • antiphospolipid antibodies ( anticardiolipin, Antibeta 2 glycoprotein, lupus anticoagulant)
  • recurrent fetal loss
  • recurrend thrombotic episodes
37
Q

Antiphospholipid Syndrom - Mx

A

Thrombosis:
* lifelong anticoagulation ( inr 2.5-3.5)

recurrent fetal loss
* aspirin, heparin +/-Steroids

catastrophic
* high dose steroid
* anticoagulant, cyclophosphamid , plasmapheresis

38
Q

Secondary Antiphospholipid Syndrome

A
  • SLE, other connective tissue diseases, malignancy, drugs (hydralazine, procainamide, phenytoin, interferon, quinidine),
  • infections (HIV, hepatitis C, TB, infectious mononucleosis)
39
Q

Drug induced SLE

A
  • Atralgia
  • Myalgia
  • skin
  • no renal or nervous system effected
40
Q

Drug induced SLE - AB

A
  • antihistamin AB
  • ANA pos
  • Anti DsDNA neg
  • Anti Ro and Anti smith 5% pos
41
Q

Drug induced SLE - Cause

A
  • Phenytoin
  • Chlorpromazin
  • Proconamid
  • Isonazid
  • hydralazin
41
Q

fibromyalgia- Symptoms

A

– 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.

42
Q

Congenital Lupus - S/S

A
  • dermatologic
  • Cardiac ( 65% -congenital complete heart block- 18/20 SSW)
  • hepatic involvement
  • splenic abnormalities
43
Q

Congenital Lupus - AB

A
  • Anti Ro (most likely detected)
  • Anti La
  • U1 ribonukleid protein
  • C4 down

> Transplacental passage

44
Q

Skleroderma

A
  • Autoimmun
  • thickening of skin (accumulation of collagen and injuries of small arteries)
  • Localised
  • Systemic (limited cutaneous, diffuse cutaneous)
45
Q

Scleroderma Trias

A

Fingerdiscomfort + atralgia+ GERD +( Skin tightness)

46
Q

Localised skleroderma

A
  • 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)
47
Q

Systemic Sclerosis

A

  • Sausage fingers
  • tight and shiny skin
  • Arrythmias, pericarditis
  • bird like facies
48
Q

Limited cutaneous systemic sclerosis - CREST

A
  • C calcinosis
  • R raynaud phaenomen
  • E Oesophagus dismobility
  • S Sklerodactyly
  • T Teleangiectasia
49
Q

Diffuse Cutaneous Systemic Sclerosis

A
  • 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)
50
Q

Systemic sclerosis - Dx

A
  • 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)
51
Q

Systemic sclerosis - MX

A
  • 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
52
Q

Polymyositis/Dermatomyositis

A
  • autoimmun conective tissue disorder
  • symmetrical
  • Inflammation of the muscles/skin

Weakness+joint and muscle pain + violaceous facial rash = dermatomysositis

53
Q

Polymyositis/Dermatomyositis - S/S

A
  • Proximal myopathy
    ( cant get up from chair/ comb the hair)
  • Arthralgia
  • Dysphagia (50%)
  • Rauynaud
  • Associated malignancy: lung and ovarys
54
Q

Dermatomyositis - Skin changes

A
  • 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
55
Q

Polymyositis/Dermatomyositis - Diagnosis

A
  • Serum CK and aldolase
  • Biopsy ( skin and musle) -best
  • Emg
  • Anti Jo AB ( Polymyosistis)
56
Q

Differential - CK

A

Dermatomyosytis/polymyositis
CK and ESR high
Polymyalgia Rheumatica
CK normal and ESR high
Drug induced myositis ( statin, steroids)
CK and ESR normal

57
Q

Polymyositis/Dermatomyositis - Treatment

A
  • Cortison
  • Immunsuppressent
  • cytotoxic
  • Iv globulin
  • Biological ( infliximab,etaercept)
58
Q

Sjögren

A

primary
* dry eyes ( keratoconjunctivitis sicca)
* dry mouth

secondary
* dry eyes ( keratoconjunctivitis sicca)
* dry mouth
* + arthralgia ( RA)

59
Q

Sjögren - S/S

A
  • fatigue
  • Sicca
  • difficulty swalloing
  • salivary gland enlargement
  • Xerotrachea (chronic dry cough, hoarsness)
  • Dyspareunia
  • non erosive Arthritis
  • can transform in non hodgkin (44xrisk)
    *
60
Q

Sjögren- Dx

A
  • Autoantibodies - pos ANA, RO, LA
  • Schirmer test
  • Sialogram
  • Biopsy if parotid gland enlargement ( goldstandard)
61
Q

Sjögren- Mx

A
  • refer
  • symptomatic ( eg pilocarpin)
  • NSAIDs , hydroxychloroquin, steroid for arthritis
62
Q

Raynaud - primary

A
  • not associated with other diseases
    *
63
Q

Classification Vasculitis

A

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

64
Q

Major vasculitides

A

-polyarteritis nodosa (PN),
-giant cell arteritis (GCA)& polymyalgia rheumatica
-Takayasu arteritis,
-Behcet syndrome,
-Churg-Strauss vasculitis
-Wegener granulomatosis (WG)

65
Q

Polyarthritis nodosa

A
  • necrotising vasculitis
  • young/middle aged man
  • association - drugabuser, HepB/C, Bcell lymphoma
66
Q

Polyarthritis nodosa - S/S

A
  • fever, malaise, myalgia, weight loss
  • migratory arthralgia/polyarthritis
  • subcutaneous noduls, skin ulcer
  • abdominal pain, rectal bleeding
  • kidney impairment
  • hypertension
  • Cardiac disorders: arrythmia, failure infarction
67
Q

Polyarthritis nodosa- Dx/Mx

A
  • ESR raised, CRP raised
  • renal biopsy or affected organ ( best)

MX
* Corticosteroid, immunsuppressants

68
Q

Giant Cell Arthritis

A
  • associated with polymyalgia rheumatica
  • sudden vision loss with temporal headache, jaw. claudication
  • ESR high (100) , temporal art biopsy
  • MX iv Corticosteroid
69
Q

Polymyalgia rheumatica

A

malaise +painful shoulder girdle +morning stiffness( over 50)

70
Q

Polymyalgia rheumatica

A
  • pain, stiffness- shoulder/pelvic girdle, cervical spine
  • symmetrical
  • 60 -70a
  • weight loss malaise anorexia
71
Q

Polymyalgia rheumatica/temporal arthritis

A

non complicated:
Prednisolone
Complicated ( e.g vision loss)
iv methylprednisolone

other: Methotrexate, Azathioprin cortison sparing agent

72
Q

Behçet syndrome

A
  • 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
73
Q

Behçet syndrome - S/S

A
  • Arthritis (knee)
  • ulcer
  • Occular sign ( pain, reduced vision, floaters)
    –>refer to Ophtalmologist
74
Q

Behçet syndrome- Dx

A

Dx
- Pathergy Test
- Inflammatory markers
- HLAB51

Mx
corticosteroid
colchicin
Immunsuppressive drugs

75
Q

colchecine - Kidney impairment

A

no or reduced

76
Q

Allopurinol

A
  • 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
77
Q

Chronic use of methotrexate can cause following side effects:

A

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.

78
Q

Ankylosing Spondylytis - Treatment

A

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