Rheumatology Flashcards
What type of arthritis is associate with skin and nail changes?
Psoriatic arthritis
What type of nail changes are seen in psoriatic arthritis?
Pitting and ocholyosis?
What is ocholyosis?
When nail separates from skin
Which joints are usually affected in rheumatoid ?
Metacarpophalangeal joints
Which joints are affected in psoriatic arthritis?
Distal interphalangeal joints
What is 1st line management for ankylosing spondylitis?
NSAID’s
What is treatment for ankylosing spondylitis after NSAIDs? Specifically for peripheral joint disease NOT spinal inflammation?
DMARDS - methotrexate and sulfasalazine
What is management for ankylosing spondylitis in cases of spinal inflammation?
Anti tnf biologics - Adalimumab
What is the definition of ankylosing spondylitis?
Seronegative inflammatory arthritis primarily involving the axial skeleton
What’s the common presentation of ankylosing spondylitis?
Younger man with early morning lower back stiffness - gets better with activity
Sacroiliac joint tenderness
Enthesis’s - Achilles tendonitis and plantar fasciitis
Anterior uveitis
What bedside test can be done in ankylosing spondylitis?
Modified schober’s test - if distance on forward flexion is less than 5cm it indicates restricted forward flexion
What investigations are needed in ankylosing spondylitis?
Pelvic x-ray
Lumbar xray
MRI is mot sensitive
What may be seen on lumbar x-ray in ankylosing spondylitis?
Bamboo spine - fusion of vertebral column - the vertebral bodies may become square looking
If pt has severe heart failure should nsaids be given?
No - they’re contraindicated
Should warfarin be used in pregnancy?
No - use LMWH and low dose aspirin
What is given in miscarriage prevention?
Low dose aspirin and LMWH
What ‘s the dose of aspirin that should be taken in anti-phospholipid syndrome pregnancy?
75-150mg daily from 12 weeks gestation till delivery
What cells are low in SLE?
Lymphopenia - low lymphocyte count
Which HLA is associated with a poor prognosis of rheumatoid?
HLA-DR4
Which antibodies are found in churg strauss syndrome (eosinophilic granulomacytosis)?
P-ANCA
How does churg strauss syndrome present?
Polyneuropathy
Adult onset asthma
Small vessel vasculitis in lower extremeties
Eosinophilia
Which antibodies are positive in diffuse systemic scelorosis?
Anti-topoisomerase antibodies
How does diffuse systemic scleorosis present?
Raynaud’s
Vascular complications like ischaemic digital ulcers
Hypertensive crisis
Pulmonary arterial hypertension
Fibrosing complications involving lung and heart and GI tract
What antibodies are found in dermatomyosisits?
Anti-Mi-2 antibodies
Which antibodies are seen in CREST syndrome - limited systemic sclerosis?
Anti-centromere antibodies
How does limited systemic sclerosis present?
Raynauds
Calcinosis
Telengiectesia
Intestinal hypomotility
Dysphagia - swallowing of solids an issue and then liquids
Sclerodactyly
Which antibodies are present in rheumatoid?
Anti-CCP
Which marker is most specific for SLE?
Anti-dsDNA and anti-Sm
What is granulomatosis with polyangiitis? (Wegener granulomatosis)
Rapidly progressing glomerunephritis and pulmonary haemorrhage
Patient will be systemically unwell and there is a background of recurrent sinusitis or chronic cough
Nasal septum deformity
Rash
Joint symptoms
Haemoproteinuria
C-ANCA positive
How is granulomatosis with polyangiitis confirmed?
Renal biopsy
What is first line treatment for SLE?
hydroxychloroquine
What is the presentation of behcets disease?
Anterior uveitis@ painful red eye, photophobia, blurred vision and hypoyon
Genital and oral ulcers
Erythema nodosum
Pulmonary artery aneurysm
Which HLA is Behcet’s assocaited with?
HLA-B51
Which antibodies are present in APS?
Anticardiolipin and lupus anticoagulant and anti-beta glycoprotein 1 - APL can cause miscarriages
What is presentation of polymyalgia rheumatica?
Bilateral shoulder, hip and girdle pain with morning stiffness
What is first line treatment for polymyalgia rheumatica?
Low dose oral prednisolone
What is takayasu’s arteritis?
Granulomatous vasculitis mainly in young women
How does takayasu’s arteritis present?
New onset headaches
Visual changes
Arm claudication
BP difference between each arm
What would be the presentation difference between takayasu’s arteritis and fibromuscular dysplasia?
Fibromuscular dysplaisa affects renal and carotid arteries
What is pathergy?
Formation of a papule at the site of trauma (for example cannula insertion_ - specific feature of behcet’s disease
What antibodies are positive in granulomatosis with polyangitis (wegener’s)
c-anca
Which HLA are found in ankylosing spondylitis?
HLA-B27
What pathogen causes septic arthritis in IV drug users?
Pseudomonas
What is the polymyositis and dermatomyosisits?
Bilateral and proximal muscle weakness and in case of dermatomyositis - skin rashes
How does polymyositis present?
Bilateral and proximal hip and shoulder and girdle muscle weakness
As disease progresses:
Pharyngeal or oesophageal muscles weaken leading to dysphonia and dysphagia
Resp muscles can lead to type 2 resp failure
How can dermatomyositis present?
Muscular features present in polymyositis but also heliotrope rash (lilac discolouration of eyelid skin + periorbital oedema)
Gottron’s papules: scaly and erythematous papules over knuckles, and extensor surfaces
V-sign rash - rash affecting anterior chest and neck
Shawl sign - when rash affects upper arms and shoulders
What is amyotrophic dermatomyositis?
Characteristic skin changes but not muscle involvement
Which markers are raised in both dermatomyositis and polymyositis?
They turn your muscles into clay (CLAAA)
C - creatine kinase
L lactate dehydrogenase
A - Aldolase
ALT
AST
What is treatment for dermatomyositis and polymyositis?
Corticosteroids - moitor CK to know tapering dose
Additional immunosuppressants - methotrexate or mycophenolate if needed
How is a diagnosis of APL made?
Positive antibody result on 2 seperate occasions with at least 12 week interval between them
Which antibodies are positive in psoriatic artheritis?
None - it’s a seronegative arthropathy so negative rheumatoid antibody screen
What is achilles tendon enthesopathy a feature of?
Psoriatic arthritis
Which gene mutation is present in Marfaan’s?
Fibrillin 1 gene
What is gold standard investigation for ankylosing spondylitis?
MRI
How can osteoarthritis present?
Pain in join during or after use
Stiffness esp in mornings or after a period of inactivity
Loss of flexible and range of motion
Grating sensation or feeling of bone rubbing on bone
Heberden’s nodes
Bouchard’s nodes
Where are heberden’s nodes vs bouchard’s nodes?
Heberden’s: swelling of distal interphalangeal joint
Bouchard node: swelling of proximal interphalangeal joint
What’s the acronym to diagnose osteoarthritis?
LOSS
L- loss of joint space - cartilage thinning
O - osteophytes - bone spurs - new bone around joint margins
S - subchondral sclerosis - Increased bone density - so areas look whiter on x-ray
S - subchondral cysts
What is a common side effect of ciclosporin?
Diarrhoea
What is mechanism of action of ciclosporin?
Lowers activity of T lymphocytes by inhibiting calcineurin
What is first line treatment of trochanteric bursitis?
Rest and ice
How does trochanteric bursitis present?
Inflammation over bursa as lateral hip pain and swelling with positive Trendelenburg test.
What are the signs of methotrexate toxicity? and which medications can exarcebate this?
Fatigue
Mouth sores
Shortness of breath
- trimethoprim
How does livedo reticularis look like?
Mottled lace like appearance on legs
What is IgG4 related disease?
Chronic inflammatory condition characterized by tissue infiltration with lymphocytes and IgG4-secreting plasma cells, various degrees of fibrosis - can present as recurrent worsening episodes of autoimmune pancreatitis - seen with new onset diabetes diagnosing and suasage pancreas sign ( diffuse thickening of pancreas)
What is familial Mediterranean fever?
Familial Mediterranean fever (FMF) is a genetic autoinflammatory disorder that causes recurrent fevers and painful inflammation of your abdomen, chest and joints.
What is first line treatment of raynauds?
CCB usually nifedipine - they are vasodilators
What are the main side effects of alendronic acid (oral bisphosphonates)?
Oesophageal reactions like oesophagitis
Ulcers
Erosions
Strictures
Can presents as odynophagia
Dysphagia
New or worsening dyspepsia
Which antibodies are present in sjogren’s?
Anti ro and anti-La
Which medication can be used as an alternative to nsaid’s in GI bleed patients and why is this medication effective?
Celocoxib : selective COX-2 inhibitor - they have a lower risk of GI ulceration than regular NSAID’s because they inhibit COX-1 to a lesser extent and COX 1 is protective for gastric mucosa
Which rash is associated with antiphospholipid syndrome?
Livedo reticularis - mottled lace like rash found on lower limbs
What is a known side effect to be careful of with hydroxychlorquine?
Retinal toxicity - presenting with poor central vision, difficulty breating or accomodating objects and change in colour vision
What type of toxicity is common in methotrexate?
Neutropenia
Folate deficiency anaemia
Liver
What can cause false positive for APL ?
Syphilis that’s why it’s important to do a treponemal serology
What is triad of felty syndrome?
Long standing rheumatoid arthritis
Idiopathic neutropenia
SplenomegaLy
What is enteropathic arthritis a complication of?
IBD
What is first line treatment for behcet’s?
Steroids or colchicine
Other than eosinophilic granulomatosis with polyangiitis what can present with positive pANCA?
Microscopic polyangiitis - presents with respiratory, renal and generalised symptoms
What is most common associated side effect of methotrexate and why?
Oral ulceration - due to methotrexate interfering with folate metabolism which leads to mucosal damage which can manifest as mouth sores
What infection is polyarteritis nodusa strongly associated with?
Hep B infection
Which organs does polyarteritis nodusa not affect?
Lungs
Which antibodies are positive in limited cutaneous systemic sclerosis?
Anti-centromere
In Diffuse cutaneous systemic sclerosis what antibodies are positive?
Anti - scl -70
What is main management of sjogren’s?
Topical and targeted symptomatic relief - for example Hypromellose - used as artificial tears and applied as eye drops
What can differentiate polymyositis from polymyalgia rheumatica?
In PR there is proximal bilateral muscle PAIN but weakness is not a prominent feature unlike in polymyositis where weakness is a prominent feature
Which malignancy is highly associated with dermatomyositis?
Lung - which can cause progressive breathlessness - esp if this new onset of muscle weakness
Why are NSAID’s nephrotoxic?
They cause vasoconstriction of afferent renal arterioles
What gland becomes swollen in sjogrens?
Parotid gland
If a young man presents with achilles tendonitis and back pain what should you start thinking?
Ankylosing spondylitis
Which HLA is associated with Behcets?
HLA-B51
What is dural ectasia?
As the membrane expands, it can press on the vertebrae in your lower back, which can cause: backache. headache. numbness or pain in your legs. - commonly associated with marfan’s
Which type of lens dislocation is common in marfans?
Superior lens dislocation
What bone related issue can anti-epileptics like phenytoin cause? and why?
Osteoporosis
Osteomalacia
Rickets
Due to their cytochrome P450 enzyme inducing effects - increases conversion of vitamin D to it’s inactive form
Phenytoin also stimulates osteoclasts inhibiting osteoblasts and reduces intestinal calcium absorption
What’s the difference between buerger’s and raynauds?
Buerger’s Disease is a serious, tobacco-related condition characterized by vessel inflammation and clotting, while Raynaud’s Disease involves vasospasms often triggered by cold or stress, with the primary form being less severe and secondary form associated with systemic diseases.
What’s the diagnostic first line for takayasu’s?
CT angiogram
What type of anaemia is caused by folate deficiency?
Macrocytic anaemia
What antibody is positive in dermatomyositis?
Anti-Jo1
What creatinine clearance level would indicate alendronate can’t be used?
Under 35
How often should methotrexate be taken?
Once weekly
Which tests should be done before commencing methotrexate?
Baseline liver function
Renal function
FBC
Chest x-ray - as methotrexate can cause pneumonitis
What’s the most common cause of acute septic arthritis?
Staph aureus
What could mean gonorrhoea causes acute septic arthritis?
Young male
Presence of necrotic pustules
What type of lymphoma is sjogren’s associated with?
MALT - mucosa associated lymphoid tissue low grade B cell non hodgkin lymphoma
What happens with the pulses in takayasu’s arteritis?
Radial pulses may be absent
Bruits may be audible over the carotids
What is first line investigation for polymyositits?
Creatinine kinase
2nd line is the EMG
What is most definitive test for polymyositis?
Muscle biopsy
What is good pasture’s syndrome?
Anti-glomerular basement membrane antibodies against type 4 collagen found within the glomerular and alveolar basement membranes
What is juxta -articular erosions and what are they an early sign of?
Erosions near joint space
Rheumatoid
What is an adverse effect of leflunomide (RA drug) to be monitored at each review?
Blood pressure as it can cause hypertension - if after hypertensive medication BP is still uncontrolled then stop the leflunomide
What is still’s disease?
Idiopathic autoinflammatory condition characterised by:
1. Pyrexia
Arthralgia
Salmon pink rash
Elevatedferritin -exceeding 10,000
Increase liverenzymes
What is treatment for still’s disease?
NSAIDS and aspirin first line
Low dose cortticosteroids next
with antiIL1 agents
What eye issue is a side effect of corticosteroid use?
Glaucoma
What are gottron’s papules?
Erythematous papule and patches with scaling over dorsal metacarpophalangeal and interphalangeal joints - one of the cutaneous signs for dermatomyositis
What is the commonest form of rheumatoid factor antibody?
IgM against IgG
What is the quantiferon test?
Diagnostic tool for TB - important to do before starting biologics as they can reactivate latent TB
Which type of respiratory failure is polymyositis more likely to lead to?
Chronic type 2
Under what circumstance can a patient have their steroids stopped abruptly?
2 week course of 20mgoral pred a day - basically if the oral course is less than 3 weeks. BUT if the course was more than 40mg pred then it needs slow withdrawal
What is a common extra-muscular manifestation associated with polymyositis?
Interstitial lung disease
How does staph aureus present on histology?
Gram positive cocci in grape like clusters
What effect can sulfasalazine have on male fertility?
Reversible azoospermia
What is most definitive test for sjogren’s?
Salivary labial gland biopsy
Which clotting test is prolonged in APL?
Activated partial thromboplastin time - aPTT
