Rheumatology Flashcards
AS treatment
anti TNFa
sulfasalazine or MTX for peripheral arthritis
diagnosing antiphospholipid
one clinical event (thrombosis or pregnancy complication)
two positive blood tests 3 months apart (lupus anticoagulant or anticardiolipin)
treating antiphospholipid
warfarin INR 2-3
DOAC as alternative but not if triple positive
no treatment required if asymptomatic
aspirin or LMWH for pregnancy
antiphospholipid antibodies
lupus anticoagulant
anticardiolipin
anti beta 2 glycoprotein 1
behcet’s diagnosis
recurrent oral ulcers
plus 2:
- recurrent genital ulcers
- erythema nodosum, aceniform lesions, papulopustular/nodular lesions
- uveitis, hypopyon
- positive pathergy test
- GI symptoms
- DVT, thrombophlebitis (rare)
- seizures, CN palsies, dizziness, memory impairment
RF, ANA, ANCA negative
HLA B51 positive
management of behcet’s
ulcers:
topical steroids
colchicine, oral steroids 1-2y
TNFai 1-2y
eyes:
pred + azathioprine
pred + infliximab/adalimumab
GI/CNS:
pred + infliximab
major vascular:
pred + ciclosporin
charcot
degeneration and bony destruction of joint
> deformity
in people with peripheral neuropathy
dx: weight bearing XR, MRI if inconclusive
presents as erythema, warmth, swelling
joint deformity as a late sign
pain not always present due to neuropathy
dermatomyositis antibodies
anti Mi2 are specific but only present in 30%
ANCA and ANA may be present
dermatomyositis diagnosis
CK, AST, LDH
ANA, anti Mi2, Anti Jo1
muscle biopsy and electromyography
screen for underlying malignancy in adults
diagnosing fibromyalgia
widespread pain both sides of body above and below waist 3/12
or
11 tender points out of 18
antidepressants for fibromyalgia
SSRI best for low mood
TCA best as adjuvant for pain relief
diagnosing GCA
3 of:
age of onset > 50y
new headache
temporal artery tender or reduced pulsation
raised ESR
positive temporal artery biopsy
GCA treatment
40-60mg pred per day and taper
MTX for relapsing
aspirin to reduce stroke risk
GCA complications
visual loss, stroke
aortic aneurysm, dissection
gonococcal arthritis presentation
bacteraemic form:
polyarthritis, tenosynovitis and dermatitis
septic arthritis form:
pain, redness and swelling in one or more joints
goodpasture
HLADR15, HLADRB1
IgG anti GBM against type IV collagen
crescenteric GN
pulm haemorrhages
> plasma exchange, pred, cyclophosphamide
causes of increased uric acid production or reduced excretion
increased production:
purine rich diet (beer, meat)
myelo/lymphoproliferative disorders
acidosis
cytolytic therapy
tumour lysis
reduced excretion:
renal failure
lead intoxication
diuretics, aspirin, cyclosporin
presentations of gout
acute crystal arthritis
gouty nephropathy
chronic tophaceous gout
indications for urate lowering therapy
more than one episode
or
1 attack and :
- tophi
- renal impairment
- uric acid stones
- not possible to stop diuretics
- v young
aim to reduce serum urate < 360 or 300 if tophaceous
use colchicine when starting ULT
granulomatosis with polyangiitis treatment
stage 1:
high dose steroids
cyclophosphamide
plasma exchange in severe cases
stage 2 manintenance:
replace cyclophosphamide with MTX or aza
continue steroids
stage 3 recurrence:
continue steroids or restart cyclo or start rituximab or plasma exchange
HSP tetrad
palpable rash
joint pain
renal and gastro invovlement
HSP antibodies
IgA
OA diagnosis
> 45y with activity related joint pain and less than 30 mins morning stiffness
or
XR
common causative organism of OM in IVDU
pseudomonas
osteomyelitis abx
fluclox + fusidic acid
or vanc + cefotaxime
IV 2 weeks then 4-6 weeks PO
Brodie’s abscess
subacute abscess in long bone metaphysis
painful
cultures may be negative
DEXA T scores
osteoporosis: T < - 2.5
normal: T > 1.0
osteopenia: T -1 to -2.5
arrange DEXA if FRAX > 10%
give bisphosphonate if T < -2.5
causes of secondary osteoporosis
multiple myeloma, carcinomatosis, leukaemia
heparin
CTx
corticosteroids, anticonvulsants
alcohol
hyperPTH, thyroid disorders, hypogonadism, pituitary tumours, addisons, T1DM
vit C and D def
RA, AS, TB, CKD
thalassaemia, sickle cell
when to perform DEXA
- women > 65y and men > 75y with suspected OP
- > 50y with fragility fracture or steroids or falls of BMI < 18.5 or smoker or alcohol > 14 units
- < 50y with steroids, fragility fracture or untreated premature menopause
when to start OP treatment
minimal trauma hip/vertebral fracture
minimal trauma fracture and T < -1.5
T < -2.5
bisphosphonates contraindications
hypocalcaemia
uveitis
delayed oesophageal emptying
bisphosphonate alternatives
strontium- risk of VTE, SJS
calcitonin
teriparatide- synthetic PTH
denosumab- risk of osteonecrosis of jaw
stages of paget’s disease
- osteolytic
- reparative
- inactive
paget’s
presentation in 40s
coarse trabeculae, weak hypervascularised bone
prone to pathological fracture
> bisphosphonates (zolendronate first line)
calcitonin if bisphosphonates not tolerated
teriparatide contraindicated (risk of osteosarcoma)
polyarteritis nodosa
medium sized arteries vasculitis
assoc w/ hep B, (also C, HIV)
subcut nodules, livedo reticularis, necrotic ulcers, HTN, ischaemic abdo pain, haematuria, mononeuritis multiplex
ANCA neg
rosary sign- microaneurysms
tx: steroids and cyclophosphamide/aza
managing PMR
- low dose pred + calcium, vit D, bisphosphonate
- MTX + folic acid
- tocilizumab
diagnosing polymyositis
ANA positive, muscle enzymes raised (also in dermato)
anti-Jo seen more in pt with pulm fibrosis, arthritis, raynauds
ESR, RF
dx: EMG (short polyphasic potentials, spontaneous fibrillation) and muscle biopsy (necrosis and regeneration)
creatinine phosphokinase and aldolase raised, can be used to monitor
need to rule out malignancy (CTTAP)
MSA and MAA to differentiate underlying malignancy
PMR aetiology/associations
myaesthenia gravid
raynauds, systemic sclerosis
hashimotos
malignancy
polymyositis treatment
high dose steroids, taper
add aza or ciclosporin if needed
wean steroids and add maintenance DMARD
lung involvement: steroids and ciclosporin or tacrolimus and cyclophosphamide
pseudogout associations
hyperparathyroidism
hypothyroidism
haemochromatosis
dialysis, trauma, reduced magnesium
psoriatic arthritis
HLA B27 in 20%
tx: DMARD (leflunomide, sulfasalazine, MTX, ciclosporin) or anti TNFa
progressive course, prognosis worse for those with arthritis mutilans
environmental causes of Raynauds
smoking
trauma, vibration, frostbite
heavy metals, vinyl chloride
beta blockers
malignancy, infection, haem/endocrine disorders
raynauds treatment options
nifedipine
sildenafil
prostaglandins for incipient gangrene
bosentan for extreme cases
seronegative spondyloarthropathies
psoriatic
reactive
ank spond
reactive arthritis complications
(rare)
heart block
aortic incompetence
pericarditis
extra-articular features of reactive arthritis
conjunctivitis, uveitis
urethritis
keratoderma blennorrhgaicum, circinate balantis
aphthous ulcers, erythema nodosum
IBD symptoms
RA XR changes
early:
may be no change
juxta articular osteoporosis, osteopenia
intermediate:
joint space narrowing
late:
bone and joint destruction
subluxation
diagnosing RA
RhF positive in 70%
anti CCP more specific
ESR and CRP may reflect disease activity
factors associated with poor prognosis in RA
RhF, anti CCP, HLA DR4
smoking
extra articular features
female
early erosions
severe disability at presentation
sarcoid histopathology
granulomas composed of macrophages, lymphocytes, epithelioid histiocytes
> fuse to form multinucleate giant cells
sarcoid presentation
lung and skin most commonly involved
-erythema nodosum, skin plaques, subcut nodules, lupus pernio
- uveitis
-painless rubbery lymphadenopathy
- splenomegaly, deranged LFTs
- CN palsies, meningitis, hydrocephalus, SOLs
- arrhythmias, BBB, CHB
- hypercalcaemia
- bone cysts
Heerfordt-Waldenstrom syndrome
sarcoidosis with:
- parotid enlargement
- uveitis
- fever
- CN palsies
Lofgren syndrome
sarcoid:
BHL + erythema nodosum + fever + arthralgia
managing sarcoid
steroids if hypercalcaemia and hypercalciuria, ophthal or CNS involvement
pred, weaning after 4 weeks to maintenance dose
MTX or azathioprine next line
Still’s disease
polyarthritis, rash, intermittent fever
systemic JIA
IL-1, IL-6 involvement
ANA positive is correlated to uveitis
10% develop macrophage activation syndrome MAS
macrophage activation syndrome MAS
fever
organomegaly
cytopaenias, coagulopathy
raised ferritin, TGs
reduced fibrinogen
drug induced lupus
M > F
resolves on stopping drug
CNS and renal disease rare
ANA pos, dsDNA neg
procainamide, isoniazid, hydralazine
SLE
type III hypersensitivity
antibodies react with antigen
> complexes accumulate in small blood vessels
> attacked by neutrophils and complement
> damage to endothelium
> reduced supply to the organ
SLE blood tests
ANA in 95%
antidsDNA, low complement, anti Smith
anti-Ro/La, antiRNP (non specific)
antiphospholipid should be tested
CRP rises in joint disease and serositis
low C3, C4 may suggest lupus nephritis
SLE treatment
steroids
DMARDS for arthritis
steroids, MTX, azathioprine for vital organ involvement
plasma exchange and biologics for refractory disease
primary Raynauds vs Raynauds in systemic sclerosis
digital ulcers and calcinosis unusual in primary
scleroderma renal crisis
malignant HTN
rapid renal impairment
onion skin vasculature
limited vs diffuse sclerosis
limited:
face, neck , distal limbs
Calcinosis, Raynauds, oEsopheageal dysmotility, Sclerodactyly, Telangiectasia
anti centromere
pulm HTN more likely than renal crisis
diffuse:
includes proximal limbs
anti Scl
renal crisis more likely than pulm HTN
scleroderma without organ disease
plaques, linear
SS antibodies
RhF in 30%
ANA in 90%
anti centromere (limited), anti Scl70 (diffuse)
SS management, screening
-annual echo and PFTs (pHTN and fibrosis)(
-BP and creatinine
-avoid steroids due to risk of renal crisis
-steroids are needed for pulm fibrosis, myositis
-PPI for reflux
-abx for SIBO
- iloprost for digital ischaemia
-ACEi for renal crisis
takayasu pathophysiology
CD4 and CD8 mediated
transmural fibrosis
> alternating areas of dilatations (pseudoaneurysms)
AKA pulseless disease
thromboangiitis obliterans/Buerger disease
affects limbs
mostly in young male smokers
HLA B5
ANCA antibody associations
cANCA- anti PR3
pANCA- anti MPO
treating kawasaki
steroids are contraindicated due to risk of coronary aneurysms
