Rheumatology Flashcards
1
Q
Causes of musculoskeletal injuries
A
Contusion: direct blow / compressive force to the muscle
Strain: excessive stretching of the muscles causes microtrauma at the musculotendinous junction
Sprain: excessive stretching / force causing rupture of collagen bundles within a ligament
2
Q
Clinical features of epicondylitis
A
Gradual onset of
Localised epicondyle pain
Normal passive ROM
3
Q
Management of epicondylitis
A
Stop exacerbating action
Conservative: NSAIDs, physio, splints, adjuncts
Medical: steroid injection
Surgical: release incision
4
Q
What is the difference between lateral and medial epicondylitis
A
Lateral (tennis elbow) is inflammation of the common extensor tendon
Medial (golfers elbow) is inflammation of common flexor pronator tendon and ulnar collateral ligament
5
Q
Peak age of tennis elbow (lateral epicondylitis)
A
40-55
6
Q
Peak age of golfers elbow (medial epicondylitis)
A
50-60
7
Q
Risk factors for lateral epicondylitis (tennis elbow)
A
Obesity
Smoking
Carpal tunnel
8
Q
Risk factors for medial epicondylitis (golfers elbow)
A
Manual work
Sports
9
Q
Signs / OE lateral epicondylitis (tennis elbow)
A
Tenderness over medial epicondyle
Pain with resisted wrist flexion and pronation +/- cubital tunnel signs
10
Q
What is de quervains tensynovitis
A
Inflammation of synovial sheaths of thumb tendons
11
Q
Symptoms of de quervains tensynovitis
A
Pain on radial border of wrist / forearm
Swelling around styloid process of radius
12
Q
Management of de quervain’s tenosynovitis
A
Rest, splinting and NSAIDs
Local corticosteroid injections
Surgical release of tendon tunnel (if Sx persist)
13
Q
3 main rotator cuff lesions
A
- Tendon tears
- Calcific tendinitis
- Adhesive capsulitis (frozen shoulder)
14
Q
Signs and symptoms of tendon tears
A
Weakness and pain on shoulder movement (may disturb sleep)
Reduced ROM active > passive in direction of muscle action
15
Q
Signs and symptoms of tendon tears
A
Weakness and pain on shoulder movement (may disturb sleep)
Reduced ROM active > passive in direction of muscle action
16
Q
Management of tendon tears
A
Rest, ice, analgesia
Steroid injections
Physio
Arthroscopic / open surgery: if traumatic tear, if high functional demand, if no improvement in 12w
17
Q
Pathogenesis of calcific tendinitis
A
Deposits of calcium hydroxyapatite crystals
(30-55y)
F>M
18
Q
Signs and symptoms of calcific tendinitis
A
Very severe shoulder pain and stiffness +/- brachial plexus neuritis
Loss of ROM (active and passive)
19
Q
Management of calcific tendinitis
A
Rest and analgesia
Steroid injections
Arthroscopic incision if Sx dont improve
20
Q
Signs and symptoms of adhesive capsulitis (frozen shoulder)
A
Shoulder pain followed by increasing stiffness (no swelling or crepitus)
Loss of ROM esp external rotation
Normal strength
21
Q
Management of adhesive capsulitis (frozen shoulder)
A
Analgesia (NSAID) +/- steroid injections
Physio
Arthroscopic release if no improvement in 12w
22
Q
Risk factors for frozen shoulder
A
Age >40 and female
Following injury / surgery
Shoulder immobility
DM, thyroid disease, CVD, HTN
23
Q
Symptoms of impingement syndrome
A
Pain on shoulder abduction between 45 and 120 degrees
Pain can be present at night and disrupt sleep
+/- arm weakness
24
Q
Causes of impingement syndrome
A
- Subacromial bursitis - inflammed and swollen so narrows space (injury / overuse)
- Supraspinatus tendinitis - inflammed and thickened tendon (injury / overuse)
- Acromioclavicular arthritis - bony spurs narrow joint space (age)
25
Management of impingement syndrome
NSAIDs / physio
Steroid injection
Surgical: remove bony tissue
26
Symptoms of biceps tendon rupture
Sudden pop on heavy lifting (pop eye appearance)
27
Risk factors for biceps tendon rupture
Smoking
Steroid use
Elderly
28
Management of biceps tendon rupture
If younger / fit and active: surgery
If older / not fit and active: leave for self resolution -> rest, ice, compression, elevation
29
Symptoms of greater trochanter pain syndrome
Pain over thigh / buttock (worse when lying on side and during exercise)
Localised tenderness to touch
No difficulty putting on shoes / socks
30
Causes of greater trochanter pain syndrome
Gluteal tendinitis / enthesitis
Trochanteric bursitis
31
Management of greater trochanter pain syndrome
2/3 resolve within 1y
Conservative: NSAID, physio, rest
Medical: steroid injection
32
Cause, symptoms and management of patellar bursitis
Cause: prolonged kneeling
Symptoms: localised anterior knee pain and tenderness + fluctuance swelling
Management: avoid kneeling (incision and drainage if infected)
33
Symptoms of Achilles tendinitis
Overuse injury most common in long distance runners
Ache / pain above heel after running / climbing stairs
Morning stiffness
34
Management of Achilles tendinitis
Rest, ice and analgesia
Stretching calf muscles and physio
35
Symptoms of plantar fasciitis
Stabbing pain under heel (worse with first steps after prolonged resting)
Worsened with prolonged standing / exercise
36
Examination findings with plantar fasciitis
Highly localised tenderness at medial tuberosity of calcaneus
Pain exacerbated with active or passive toe dorsiflexion
37
Management of plantar fasciitis
Rest, ice, analgesia (NSAID)
Physio / stretching
Lose weight, change footwear
38
What is subcalcaneal bursitis
Inflammation of bursa between calcaneus and plantar fascia
39
Symptoms of subcalcaneal bursitis
Dull ache under heel that worsens throughout the day
40
Management of subcalcaneal bursitis
Resolves in 6-8w
Rest, ice, analgesia
Comfortable footwear
Orthoptics
41
Management of subcalcaneal bursitis
Resolves in 6-8w
Rest, ice, analgesia
Comfortable footwear
Orthoptics
42
Management of ankle sprain
Rest, ice, compression and analgesia
Early mobilisation and strengthening exercises
43
Function of menisci
Spread load and disperse friction
Inner 75% is avascular so poor healing
44
Causes of meniscal damage
Degenerative tears
Acute tears -> twisting injury
45
Symptoms of meniscal injuries
Pain: intermittent and on knee movement
Locking and giving way
Swelling
46
What are the ottowa ankle rules to rule out fracture
Only X-ray ankle if pain near the malleolus and either
- unable to weight bear immediately after injury and when in ED
Or
Bony tenderness at posterior edge or tip of malleolus
47
Diagnosis of meniscal knee injuries
Hx and examination: Mcmurrays test
X-ray to ro fracture / OA
MRI scan = diagnostic
48
Management of meniscal knee injuries
Arthroscopic repair: if Sx are serious / younger patient
Conservative: activity modification, physio, nsaid (if degenerative tear / OA)
49
Causes of ligamental injuries of the knee
ACL/PCL injuries (rotational injuries when foot is planted eg footballers, skiers)
Isolated PCL injury: RTA (dashboard injury)
Collateral ligament injuries: lateral impact / opposing forces at knee and ankle
50
Symptoms of ACL / PCL injury
Acute swelling (30min) -> hvae to stop activity may be unable to weight bear
Collateral ligament: more insidious swelling
51
Management of ACL/PCL injury
Replacement with hamstring or patellar tendon graft -> dont tend to heal on their own
52
Management of collateral ligament injury
Immobilisation with knee brace and physio
53
Management of collateral ligament injury
Immobilisation with knee brace and physio
54
Neck and back pain red flags that indicate urgent MRI
New onset in <20 or >55
Constant night pain
Progressive motor weakness
Thoracic back pain
Saddle anaesthesia
Bladder / bowel incontinence
Hx of trauma / cancer
Unexplained weight loss
Fever
Steroid use
Recent infection
55
Structural differentials of neck / back pain
Mechanical
Disc prolapse
Spinal stenosis
Spondylolisthesis
56
Inflammatory differentials of neck / back pain
Spondyloarthropathies
Sacroilitis
Polymyalgia rheumatica
57
Destructive differentials of neck and back pain
Malignancy
Infection
58
Metabolic differentials of neck and back pain
Osteoporosis
Osteomalacia
Pagets
59
Neck and back pain as a result of referred pain locations
Major viscera
Uro-genitary
Aorta
Hip
60
What is a radiculopathy
Conditions where pinched nerve roots cause pain, paraesthesia, weakness in a dermatomal distribution (unilateral)
Causes LMN signs (hyporeflexia, hypotonia)
61
What are myelopathies
Conditions where compressed spinal cord causes pain, paraesthesia, weakness bilaterally + other neurological symptoms
- causes UMN signs (hyperreflexia, hypertonia, spasticity)
62
What is cervical spondylosis
Cervical radiculopathy caused by age related degenerative changes to the spine
- ageing causes disc degeneration which reduces shock absorption
- results in osteophyte development
- osteophytes pinch nerve roots as they leave the spinal canal
May develop into myelopathy
63
Symptoms of cervical spondylosis
Pain in neck (radiating down arm)-> brachial neuralgia
Tingling / numbness in one dermatome
+/- weakness in 1 arm
64
OE of cervical spondylosis
Pain reproduced with lateral neck flexion towards affected side
Motor: modest upper muscle weakness
Sensory: reduced pin prick sensation discrimination
LMN: hyporeflexia, hypotonia
65
OE of cervical spondylosis
Pain reproduced with lateral neck flexion towards affected side
Motor: modest upper muscle weakness
Sensory: reduced pin prick sensation discrimination
LMN: hyporeflexia, hypotonia
66
Diagnosis of cervical spondylosis
Neurological examination: myotomes, dermatomes, reflexes
MRI if no improvement / considering surgery
67
Management of cervical spondylosis
Mostly self limiting in 6-12w
1. Conservative: rest, physio, analgesia
Hard collar for neck immobilisation
2. Surgical: ACDF (anterior cervical discectomy and fusion)
68
Who does cervical disc prolapse affect
30-40y
Hx of mild neck trauma
69
Symptoms of cervical disc prolapse
Pain in neck
Tingling / numbness / paraesthesia in one dermatome of arm
+/- weakness in one arm
70
Management of cervical disc prolapse
1. Conservative : rest, physio, analgesia
2. Surgical: microdiscectomy
71
What is cervical canal stenosis
Cord compression
Is more serious than cervical radiculopathy
72
What is cervical canal stenosis
Cord compression
Is more serious than cervical radiculopathy
73
Causes of cervical canal stenosis
Age related degeneration : osteophyte formation and ligament hypertrophy
Disc bulging / herniation: common in younger patients
74
Symptoms of cervical canal stenosis
Gait abnormalities : spastic and ataxic
Loss of fine motor skills
Tingling in fingers
75
OE of cervical canal stenosis
Gait abnormalities : spastic and ataxic
Wasting on shoulder girdle muscles
UMN signs: spasticity, clonus, hyperreflexia, hypertonia
76
Management of cervical canal stenosis
Surgical intervention: laminectomy -> progressive deterioration
77
What is hoffman’s sign
Flick middle finger and watch for reflexive movement of index / thumb
-> positive in UMN pathology eg spinal cord compression
78
Pathology of lumbar disc prolapse
Common in 25-55y
With age increased risk of prolapse through defect in surrounding annulus fibrosus
Results in compression of nerve roots
79
Symptoms of lumbar disc prolapse
Often onset during lifting / bending / twisting
Stabbing lower back pain radiating down leg / buttock
Numbness / tingling in one leg
80
OE of lumbar disc prolapse
Pain reproduced with straight leg raise
Motor signs: modest lower muscle weakness
Sensory signs : reduced pin prick sensation discrimination
LMN signs : hyporeflexia, hypotonia
81
Management of lumbar disc prolapse
Conservative : rest, physio, analgesia
Surgical: nerve root block, microdiscectomy (remove piece of prolapsed disc)
82
What is cauda equine syndrome
Compression of cauda equine nerve roots causing pain, paraesthesia and weakness
83
Symptoms of cauda equina syndrome
Bilateral and acute onset
Stabbing lower back and leg pain
Lower limb weakness
Bladder / bowel disturbance
Saddle anaesthesia
Sexual dysfunction
84
Causes of cauda equina syndrome
Herniated lumbar disc = most common
Spinal stenosis
Spinal tumour
Spinal infection
Severe injury to lower back
Congenital malformation
85
Investigations for cauda equina syndrome
Lower limb motor function
Lower limb sensory function
Reflexes
DRE -> sphincter tone
Pre and post micturition bladder scan (>200ml)
MRI
86
Management of cauda equina syndrome
Immediate referral to neurosurgery
-> urgent decompression eg via discectomy
87
What is lumbar canal stenosis
Cauda equina compression causing neurogenic claudication
Usually L4/5 or L5/S1 level
88
Causes of lumbar canal stenosis
Age related degeneration: osteophyte formation and ligament hypertrophy
Disc bulging / herniation : consider in younger patients
89
Symptoms of lumbar canal stenosis
Hx of back pain -> dermatomal distribution
Leg pain / weakness / heaviness that limits walking distance -> distance progressively decreases
Slowly relieved by rest
Feels better by bending forwards / going uphill
90
What is lumbar spondylosis
Stress fractures in pars interarticularis of vertebra (commonly L5)
91
What is spondylolisthesis
Slippage of one vertebra on the one below
92
Causes of spondylolisthesis
Spondylolysis
Age related degeneration
93
Symptoms of spondylolisthesis
Neck / back pain
Radiculopathy
94
Red flag for back pain that could indicate tumour
Bony pain over a single spinal segment
95
What is a syringomyelia
A fluid filled cyst within the spinal cord
96
Causes of syringomyelia
Chiari malformation
Spinal cord tumour
Spinal cord injury
Spinal cord infection eg meningitis
97
Symptoms of syringomyelia
Pain and stiffness in neck, shoulder, arms and back
Muscle wasting and weakness
Loss of sensation and reflexes
Painless burning sensation in fingers
Headaches
98
Management of syringomyelia
Drain syrinx
Correct underlying cause
99
Initial investigations for rheumatoid arthritis
Rheumatoid factor (RF)
Anti cyclic citrullinated peptide antibody - can be detected up to 10yrs before development of RA
X-rays
100
What is high RF levels associated with
Severe progressive disease but not a marker of disease activity
101
What other conditions are associated with positive RF
Felty’s syndrome
Sjögren’s syndrome
Infective endocarditis
SLE
Systemic sclerosis
102
Presentation of rheumatoid arthritis
Swollen painful joints in hands and feet
Stiffness worse in morning
Gradual onset - larger joints become involved
Positive squeeze test - discomfort on squeezing across the metacarpal or metatarsal joints
103
Side effects of methotrexate
Myelosuppression
Liver cirrhosis
Pneumonitis
104
Rheumatoid arthritis X-ray changes
Loss of joint space
Juxta-articular osteoporosis
Soft tissue swelling
Periarticular erosions
Subluxation
105
Initial therapy for RA
Methotrexate (most widely used DMARD) / sulfasalazine / leflunomide
+/- a short course of bridging prednisolone
106
How to manage RA flares
Oral or IM corticosteroids
107
Indication for a TNF inhibitor with RA
Inadequate response to at least 2 DMARDs including methotrexate
Etanercept / infliximab / adalimumab
108
Ocular manifestations of RA
Keratoconjunctivitis sicca
Episcleritis
Scleritis
Corneal ulceration
Keratitis
109
Poor prognostic factors in RA
RF positive
Anti CCP antibodies
Poor functional status at presentation
X-ray : early erosions
Extra articular features
HLA DR4
Female
110
Cause of carpal tunnel syndrome
Increased pressure on the median nerve as it passes through carpal tunnel at the wrist
111
Risk factors for carpal tunnel syndrome
Pregnancy
DM
Thyroid disease
Wrist fracture
Wrist arthritis
Idiopathic
112
Symptoms of carpal tunnel syndrome
Tingling / pain / numbness in radial 4 digits (not pinky) - may radiate into forearm
Worse at night
Provoked by gripping
Relieved by shaking hand / dangling over side of bed
May have reduced coordination
113
Management of carpal tunnel syndrome
Activity modification
Splint wrist at night
NSAIDs + steroid injection
Optimise underlying conditions eg thyroid
Surgery: if persistent symptoms >6w
114
Benefits of surgery for carpal tunnel syndrome
Without it is likely that wasting and numbness will worsen
Surgery should improve tingling / pain but may take 1y
Muscle weakness unlikely to improve but wont worsen
115
Cause of cubital tunnel syndrome
Increased pressure on the ulnar nerve at the elbow
116
Symptoms of cubital tunnel syndrome
Tingling / pain / numbness in 5th finger -> may radiate into forearm
Exacerbated with prolonged elbow flexion
+/- claw hand
117
Management of cubital tunnel syndrome
Similar to carpal tunnel
- activity modification
- splint
- NSAID + steroid injection
- surgery
118
Cause of Morton’s neuroma
Inflammatory lesion of digital nerve due to irritation / compression eg wearing tight shoes
119
Symptoms of Morton’s neuroma
Pain / burning between toes / ball of foot
Tingling / sensory loss between toes
120
Management of Morton’s neuroma
Offloading insoles
Steroid injection
Surgical incision of digital nerve
121
Clinical presentation of fibromyalgia
Widespread pain
Fatigue
Unrefreshing sleep
122
Functional illnesses associated with fibromyalgia
IBS
Chronic migraine
Chronic pelvic pain
Chronic fatigue syndrome
123
Investigations for fibromyalgia
Screen for comorbidities eg depression
Find / rule out underlying causes eg RA
124
Diagnostic criteria for fibromyalgia
1. Widespread pain involving all 4 quadrants of the body
2. Scoring >7 on the WPI and >5 on SSS or 3-6 on the WPI and >9 on SSS
3. Present for >3m
125
Management of fibromyalgia
Education: reassure, relapsing and remitting, good and bad days, sleep hygiene
Exercise: long term graded exercise programmes
CBT: for pain related depression / anxiety
Pharmacological: sleep low dose TCAs, analgesia
126
Aetiology of gout
Pathological reaction of joint / periarticular tissues to monosodium urate monohydrate crystals
127
What is primary gout
>90% due to inherited defect of uric acid secretion
Usually males >40y
128
What is secondary gout
Chronic hyperuricaemia due to renal impairment or drug therapy
Mainly >65y and post menopausal women
129
Initial presentation of gout
Acute mono arthritis in distal joint
- sudden pain with red, hot, swollen joint
- often wakes patient early in the morning
+/- fever / malaise
130
Presentation of untreated gout
Recurrent attacks with reducing time between
- progressive cartilage and bone erosion
- inflammatory polyarthritis in feet / hands / wrists
- deposition of palpable masses of urate crystals
131
Risk factors for primary gout
Male
Age
FH
Metabolic syndrome: TGs, obesity, HTN, DM
High alcohol intake
High protein diet
132
Risk factors for secondary gout
Reduced excretion: CKD, thiazide diuretics, NSAIDs, cytotoxic drugs
Increased production: myeloproliferative disorders
133
Aetiology of pseudo gout
Calcium pyrophosphate crystal deposition
Mainly idiopathic
Can be caused by: OA, trauma, dehydration, inherited metabolic disorder
134
Presentation of pseudogout
Usually asymptomatic: incidental finding of chondrocalcinosis on X-ray
Acute attack: similar symptoms to gout mainly in knee
135
Aetiology of calcific periarthritis
Hydroxyapatite deposition in periarticular tissues (muscles, cartilage etc)
136
Presentation of calcific periarthritis
1. Acute attack: spontaneously or following trauma: pain and tenderness, swelling and erythema
137
Diagnosis of crystal arthropathies (gout)
1. Joint aspiration for polarised light microscopy
2. Serum urate levels
3. Determine cause
4. Consider X-ray
138
Management of crystal arthropathies (acute attack)
Do not start allopurinol until acute attack has resolved
Pain relief: fast acting oral NSAIDs
Stop attack: joint aspiration and intra articular steroid injection
139
Long term management of gout
Aim to lower serum urate <360Umol /L
1st: Allopurinol OD
2nd: febuxostat (avoid in CVD)
Monitor serum urate monthly
140
MOA of allopurinol
Xanthine oxidase inhibitor -> reduced urate production
141
Lifestyle factors to manage in gout
1. Reduce alcohol and eat healthily and ensure plenty of fluids
2. Weight management
3. Optimise control of comorbidities
4. Medication review : stop NSIAD, consider alternative diuretic
142
Side effects of allopurinol
Skin rash
N&V
Headaches
Drowsiness
Altered taste
Avoid with azathioprine
143
Indications for long term Tx in gout
Recurrent attacks
Evidence of bone / joint damage
Tophi
Associated renal disease
Severely elevated serum urate
144
Pathophysiology of RA
Common systemic inflammatory disease affecting synovial joint lining to cause symmetrical polyarthritis
Autoimmune destruction of cartilage and bone
145
Risk factors for rheumatoid arthritis
Age (40s)
Female
FH
Smoking
Obesity
146
Extra articular features of RA
1. Lungs: fibrosis, pleural effusions
2. CVS: pericarditis, atherosclerosis
3. Eyes: episcleritis, scleritis, keratoconjunctivitis
4. Vasculitis: splinter haemorrhages, vasculitis ulcers
5. Peripheral neuropathy
147
Investigations for RA
Thorough hx and examination
FBC
RF
ANA antibody
Anti CCP antibodies
X-ray joints: soft tissue swelling, periarticular erosions
148
What is seronegative spondyloarthritis
A group of inflammatory arthropathies
No serum markers but an association with HLA-B27
149
Types of seronegative spondyloarthritis (PEAR)
Psoriatic
Enteropathic (IBD)
Ankylosing spondylitis
Reactive
150
Shared clinical features of seronegative spondyloarthritis
Asymmetrical mono / oligoarthritis of large joints including spine and SIJ
Affects tendons : plantar fasciitis, tendinitis
Extra-articular Sx: iritis, palmar / plantar rashes, dactylitis, mouth ulcers, IBD
151
Clinical presentation of psoriatic arthritis
Stiffness, swelling
Asymmetrical oligoarthritis of weight bearing joints (mimics OA)
Or symmetrical polyarthritis (mimics RA)
Or spondylitis
Or arthritis mutilans
152
Diagnosis of psoriatic arthritis
Clinical features
Lack of RF, ANA, CPP
Bony spurs on xray
153
Management of psoriatic arthritis
Similar to RA: NSAIDs / DMARDs (if peripheral joints)
Biologics
154
Clinical presentation of ankylosis spondylitis
20-30y
Insidious lower back and buttock pain
Morning stiffness and restricted spinal motion
+/- extra articular features
155
Diagnosis of ankylosis spondylitis
MRI : bony bridges between vertebrae
Bloods: mildly raised ESR
156
Management of ankylosis spondylitis
1. Physio and OT
2. Analgesia: strong NSAIDs
3. Anti-TNF-a
4. Surgery : if progressive and affecting QoL
157
What triggers reactive arthritis
Enteric or genitourinary infection (sti)
158
Causative organisms of reactive arthritis
Salmonella, E. coli, campylobacter, shigella
Chlamydia, gonorrhoea
Streptococcus
159
Clinical presentation of reactive arthritis
Acute, symmetrical oligoarthritis of lower limbs / back
Hot swollen joints
Fever and malaise
+/- extra articular features
160
Management of reactive arthritis
Full dose NSAIDs
Intra articular steroid injections
Abx if identified organism
161
Extra articular features in reactive arthritis
Reiter’s triad : conjunctivitis, urethritis, arthritis (can’t see, can’t wee, can’t bend the knee)
Skin rashes / erythema nodosum
162
What are the 2 different types of enteropathic arthritis
Type I: oligoarticular and asymmetrical (+ active IBD)
Type II: polyarticular and symmetrical
163
Management of enteropathic arthritis
1. Treat IBD
2. Treat arthritis
- use NSAIDs with caution as can worsen IBD
- DMARD: sulfasalazine as helps IBD
- anti-TNF - a
164
Examples of multisystem connective tissue disease
SLE
Dm/Pm
Sjogrens
Scleroderma
APS
165
What are multisystem connective tissue disease
Autoimmune conditions (associated with ANA antibody)
Can present with: myalgia, fatigue, rashes, photosensitivity, mouth ulcers, indigestion
166
Characteristic pathological features of multisystem connective tissue disease
1. Inflammation (widespread aches / pains)
2. Fibrosis (skin lesions)
3. Vasospasm (secondary raynauds)
4. Thrombosis (nail infarcts, VTE)
167
Red flags of connective tissue diseases
BP >230/120
Casts in urine
SOB
CNS signs
Severe abdo pain
Ischaemic vasculitis
168
Risk factors for SLE
Female
Afro Caribbean / Asian
FH
UV light
Oestrogens
Stress
169
Clinical presentation of SLE
Relapsing and remitting
Skin: malar rash, discoid rash, mucosal ulcers
Vascular: nail edge infarcts, splinter haemorrhages, raynauds
MSK: symmetrical polyarthritis
Lungs: pleuritis
Heart: pericarditis
CNS: seizures, psychosis, anxiety and depression
Renal: nephritis
Haem: pancytopenia, lymphadenopathy, organomegaly
170
Management of SLE
Skin: topical steroids +/- hydroxychlorquine + vit D
Joints: NSAIDs, hydroxychloroquine, steroids if severe
Severe flares: strong immunosuppression (eg cyclophosphamide)
171
Complications of SLE
Thromboembolic disease
Atherosclerosis
Infection
172
What is antiphospholipid syndrome
Tendency to recurrent thrombosis and / or persistently increased antiphospholipid Abs
173
Clinical presentation of antiphospholipid syndrome (CLOT)
Coagulation defect (arterial or venous thromboembolism)
Livedo reticularis (+/- chronic leg ulcers)
Obstetric issues (recurrent miscarriage)
Thrombocytopenia
174
Management of antiphospholipid syndrome
If antiphospholipid Ab +ve but no clinical thrombosis : low dose aspirin and lifestyle advice (avoid COCP, avoid smoking)
Recurrent miscarriage: low dose aspirin + LMWH
Thrombotic event: lifelong warfarin
175
What is scleroderma
Vascular damage and fibrosis within the skin and organs due to excess collagen
176
Clinical presentation of scleroderma
Skin fibrosis
Fibrosis of GI tract, heart, lungs, kidneys
177
What is limited scleroderma
Peripheral skin involvement (distal to elbows and knees)
Anti centromere antibodies
178
Clinical presentation of limited scleroderma (CREST)
Calcinosis (calcium deposits under skin)
Raynauds
Esophageal dysmotility : heartburn
Sclerodactyly : thick swollen fingers
Telangiectasia
179
Management of scleroderma
Skin: topical steroids
HTN, pulmonary HTN and raynauds: CCBs
Reflux: PPIs
Pain: ibuprofen / paracetamol
180
What is diffuse scleroderma
Widespread skin changes
Anti Scl-70 antibodies
181
Clinical presentation of diffuse scleroderma
Heart (arrhythmia)
Lungs (SOB, pulmonary HTN)
Kidneys (AKI and HTN)
182
What is Sjögren’s syndrome
Autoimmune destruction and fibrosis of exocrine glands
183
Clinical presentation of Sjögren’s syndrome
Dry eyes, mouth, vagina, skin
Dry throat / sinuses - cough
Parotid swelling
184
Extra glandular features of Sjögren’s syndrome
Polyarthritis / arthralgia
Raynauds / rashes
Vasculitis
Nephritis
Peripheral neuropathy
Increased risk of lymphoma
185
Investigations for Sjögren’s syndrome
Schirmer’s test: blotting paper inside lower eyelid to measure amount of moisture produced in 5 mins
Antibodies : anti Ro, anti La, ANA
186
Management of Sjögren’s syndrome
Artificial tears and saliva (+/- muscarinic agonists)
Frequent drinks, sugar free pastilles
187
What conditions are classed as idiopathic inflammatory myopathies
Polymyositis
Dermatomyositis
Inclusion body myositis
188
Clinical presentation of idiopathic inflammatory myopathies
Proximal muscle weakness
Characteristic rash in dermatomyositis
189
Investigations for idiopathic inflammatory myopathies
FBC (anaemia and increased ESR)
CK = elevated
ANA, RF and MSAs = often positive
Electromyograph = spontaneous muscle fibrillation
Muscle biopsy
MRI
190
Management of idiopathic inflammatory myopathies
High dose corticosteroids (1m prednisolone)
Immunosuppressants
191
What is systemic vasculitis
Inflammation of vessel walls
May cause aneurysm / rupture or occlusion and organ damage
Can be primary or secondary to underlying disease / drug induced
Classified based on size of smallest vessel involved
192
Systemic symptoms of systemic vasculitis
Malaise
Myalgia
Arthralgia / arthritis
Headache
Fever
Weight loss
193
Cutaneous symptoms of systemic vasculitis
Purpura
Infarct
Ulcer
gangrene
194
Mucosal symptoms of systemic vasculitis
Ulcers
Conjunctivitis / scleritis / episcleritis / uveitis
Retinal haemorrhage
195
ENT symptoms of systemic vasculitis
Epistaxis
Nasal crusting
Stridor
Hearing loss
196
Resp symptoms of systemic vasculitis
Dyspnoea
Haemoptysis
197
CV symptoms of systemic vasculitis
Pericarditis
Angina
MI
Thrombosis
Bruits
198
GI symptoms of systemic vasculitis
Abdo pain
Bloody diarrhoea
Perforation
199
Renal symptoms of systemic vasculitis
HTN
Proteinuria
Haematuria
Casts
Renal failure
200
Neuro symptoms of systemic vasculitis
Stroke
Seizures
Confusion
201
Management of systemic vasculitis
Large vessel - steroids usually enough
Medium / small vessel - IV cyclophosphamide + steroids
202
Vessels involved in large vessel vasculitis
GCA
Takayasu’s arteritis
203
Medium vessels involved in vasculitis
Kawasakis disease
Polyarthritis Nodosa
204
Small vessels involved in vasculitis
Granulomatosis with polyangitis
Churg Strauss syndrome
HSP
205
Clinical features of polymyalgia rheumatica
Acute onset of:
- bilateral stiffness and aching of proximal joints (shoulders, hips)
- morning stiffness >45 mins
- acute phase response: ESR, fatigue, fever, night sweats, weight loss
206
What is a common emergency in polymyalgia rheumatica
Giant cell arteritis
- headache
- jaw pain
- needs urgent high dose corticosteroids
207
Management of polymyalgia rheumatica
1. Low dose prednisolone (10-20mg for 2w then wean down to maintenance dose for 1-2y)
2. Co-prescribe bone protection (PPI) with long term steroids
3. Follow up
208
Risk factors for pseudogout
Hyperparathyroidism
Haemochromatosis
Low Mg, low P
Acromegaly
209
What are the side effects of hydroxychloroquine
Retinopathy
Can be used in pregnant women
210
How to differentiate between gout and pseudogout
Pseudogout will show chondrocalcinosis on xray
