Rheumatology Flashcards
1
Q
How should allopurinol be started for treatment of gout?
A
- indicated for all patients after first attack of gout
- delay until inflammation settled (once no longer in pain - no specific time frame)
- initial dose 100mg OD then titrated every few weeks to aim for serum uric acid <360 micromol/L
- colchicine or NSAID cover should be considered
2
Q
What is the initial starting dose of allopurinol for gout?
A
100mg OD then titrate dose every few weeks to aim serum uric acid less than 360 micromol/L
3
Q
Which patients should have a lower target uric acid level (<300 micromol/L)?
A
- those with tophi
- chronic gouty arthritis
- ongoing frequent flares despite uric acid <360
4
Q
How long does the BSR suggest colchicine may need to be continued for when given as cover once allopurinol started?
A
may be needed for 6 months
5
Q
What may be a protective factor from osteoporosis?
A
obesity - can convert androgens into oestrogen, helps maintain bone density
6
Q
What is second-line when allopurinol is not effective?
A
febuxostat (if refractory: uricase, pegloticase)
7
Q
For how long should NSAIDs be used when treating acute gout?
A
until 1-2 days after symptoms have settled
8
Q
What is the mechanism of action of colchicine?
A
inhibits microtubule polymerisation by binding to tubulin (interfering with mitosis); also inhibits neutrophil motility and activity
9
Q
What is the pathophysiology of gout?
A
caused by deposition of monosodium urate monohydrate in the synovium
10
Q
Which foods should be avoided for gout?
A
liver, kidneys, seafood, oily fish (mackerel, sardines), yeast products
11
Q
What drugs can precipitate gout?
A
thiazide diuretics
12
Q
Which antihypertensive may be useful lin gout?
A
losartan - has specific uricosuric action
13
Q
What will the findings of creatinine kinase and EMG be in polymyalgia rheumatica?
A
normal
14
Q
In addition to glucocorticoids what are 6 medications that may worsen osteoporosis?
A
- SSRIs
- antiepileptics
- PPIs
- glitazones
- long term heparin therapy
- aromatase inhibitors e.g. anastrozole
15
Q
What investigations should be requested for patients with osteoporosis?
A
FBC, ESR/CRP, calcium, albumin, creatinine, phosphate, ALP, LFTs, TFTs
DEXA (bone densitometry)
16
Q
What is pseudogout?
A
deposition of calcium pyrophosphate dihydrate (CPPD) in and around joints - especially articular and fibrocartilage
17
Q
What are 5 X-ray changes seen in rheumatoid arthritis?
A
- Loss of joint space
- Juxta-articular osteoporosis
- Subluxation
- Periarticular erosions
- Soft tissue swelling
18
Q
What will radiographic changes show in pseudogout?
A
chondocalcinosis, linear opacification of articular cartilage
19
Q
How many pseudogout present?
A
may be asymptomatic, or acute pseudogout episode or chronic arthritis
20
Q
Which 3 joints are most commonly affected in pseudogout?
A
knees, wrists, hips
21
Q
How is a diagnosis of acute pseudogout made?
A
compensated polarised microscopy on joint aspirate - crystals are rhomboid-shaped and weakly positively birefringent
22
Q
What is the treatment of pseudogout?
A
- aspiration of joint to reduce pain
- NSAIDs
- intraarticular steroid
- systemic steroid
- colchicine if NSAIDs/steroids CI
23
Q
What is one of the most common presenting features of patients with systemic amyloidosis?
A
renal dysfunction
24
Q
How is a diagnosis of amyloidosis made?
A
- Congo red-binding material (bright green fluorescence observed under polarised light after Congo red staining) demonstrated in a biopsy specimen
- biopsies from any affected organ - capillaries in subcutaneous fat often involved + provide sufficient tissue
25
What is the treatment available for amyloidosis?
no specific treatment; therapy aims to suppress underlying plasma cell dyscrasia + supportive measures for organ function
26
What is the definition of reactive arthritis?
arthritis that develops following an infection where the organism cannot be recovered from the joint (urethritis + arthritis +- conjunctivitis)
27
How long after initial symptoms of infection does reactive arthritis tend to develop?
4 weeks
28
How long do symptoms tend to last for in reactive arthritis?
4-6 months
29
What pattern of arthritis is seen in reactive arthritis?
asymmetrical oligoarthritis of lower limbs (+- dactylitis)
30
Which 2 forms of eye disease may be seen in reactive arthritis?
1. conjunctivitis
2. anterior uveitis
31
What are 2 dermatological manifestations of reactive arthritis?
1. circinate balanitis (painless vesicles on coronal margin of prepuce)
2. keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles)
32
When should allopurinol be started after an acute attack of gout?
once inflammation settled and patient no longer in pain (no specific time frame)
33
What is the underlying pathology in gout?
microcystal synovitis caused by deposition of monosodium urate monohydrate in synovium; caused by chronic hyperuricaemia
34
How long should NSAIDs/ colchicine be used for in an acute attack of gout?
until 1-2 days after symptoms have settled
35
What is the main side effect of colchicine?
diarrhoea
36
What treatment may be considered in an acute attack of gout if colchicine and NSAIDs are contra-indicated?
oral steroids e.g. pred 15mg / day
37
What is the mechanism of action of febuxostat?
xanthine oxidase inhibitor
38
Which joint is most commonly affected by gout + in what proportion of cases?
1st metatarsophalangeal (MTP) joint - 70%
39
What does synovial fluid analysis show in gout?
needle-shaped negatively birefringent monosodium urate crystals under polarised light
40
When should uric acid levels be checked in gout?
once acute episode has settled - usually 2 weeks later (may be high, normal or low during attack)
41
What are 6 findings on x-ray in gout?
1. joint effusion (early)
2. punched out erosions with sclerotic margins in juxt-articular distribution + overhanging edges
3. preservation of joint space until late
4. eccentric erosions
5. no periarticular osteopenia (seen in RA)
6. soft tissue tophi
42
What is Schober’s test in ankylosing spondylitis?
line drawn 10cm above and 5cm back dimples (dimples of Venus) - distance between should increase by >5cm on bending - if less test positive
43
What are 3 features on clinical examination of ankylosing spondylitis?
- reduced lateral flexion
- positive Schober’s test
- reduced chest expansion
44
What are 8 additional features of ankylosing spondylitis?
1. Achilles tendonitis
2. Anterior uveitis
3. Aortic regurgitation
4. Apical fibrosis
5. AV node block
6. Amyloidosis
7. Cauda equina syndrome
8. Peripheral arthritis
45
What are 3 side-effects of methotrexate?
1. mucositis
2. myelosuppression
3. liver cirrhosis
4. pneumonitis
5. pulmonary fibrosis
46
What are 4 side effects of sulfasalazine?
1. rashes
2. oligospermia
3. Heinz body anaemia
4. interstitial lung disease
47
What are 3 side-effects of leflunomide?
1. liver impairment
2. interstitial lung disease
3. hypertension
48
What are 2 side effects of hydroxychloroquine?
1. retinopathy
2. corneal deposits
49
What is a key side effect of gold (to treat RA)?
proteinuria
50
What are 2 side effects of penicillamine?
1. proteinuria
2. exacerbation of myasthenia gravis
51
What are 2 side effects of etanercept?
1. demyelination
2. reactivation of tuberculosis
52
What is a side effect of infliximab?
reactivation of tubcerulosis
53
What is a side effect of adalimumab?
reactivation of tubcerulosis
54
What is a side effect of rituximab?
infusion reactions common
55
How useful is serum HLA-B27 for diagnosing ankylosing spondylitis?
not useful - positive in 90% of patients with AS but also 10% of normal patients
56
What is the most useful investigation to establish a diagnosis of ankylosing spondylitis?
plain x-ray of sacroiliac joints
57
What are 5 radiograph changes in ankylosing spondylitis?
1. sacroiliitis - subchondral erosions, sclerosis
2. squaring of lumbar vertebrae
3. bamboo spine (late + uncommon)
4. syndesmophytes - due to ossification fo outer fibres of annulus fibrosus
5. CXR - apical fibrosis
58
What should be done if xray is negative for sacroiliac joints in suspected ankylosing spondylitis, but suspicion is still high?
MRI - can show signs of early inflammation involving sacroiliac joints (bone marrow oedema)
59
What may be seen in spirometry in ankylosing spondylitis and why?
restrictive defect - combination fo pulmonary fibrosis, kyphosis, ankylosis of costovertebral joints
60
What is the first line management of ankylosing spondylitis?
encourage regular exercise, physiotherapy, & NSAIDs
61
What is the only time disease-modifying drugs are useful in ankylosing spondylitis and what are examples?
if there is peripheral joint involvement - sulfasalazine
62
What drug is suggested to treat ankylosing spondylitis by EULAR guidelines if disease activity is high despite conventional treatment?
anti-TNF e.g. etanercept, adalimumab
63
What is the management of fragility fractures (e.g. fractured NOF, Colles) aged over 75 vs under 75?
* >75y: start bisphosphonate (e.g. alendronate) without waiting for DEXA
* <75y: DEXA scan - input results into FRAX
64
What is the initial step for management of chronic stable RA?
* **DMARD monotherapy** +- short course of bridging prednisolone: **methotrexate** most common (sulfasalazine/ leflunomide/ hydroxychloroquine)
65
What are 4 examples of DMARDs used for RA?
1. methotrexate
2. sulfasalazine
3. leflunomide
3. hydroxychloroquine
66
What monitoring is essential for patients on methotrexate and why?
* **FBC, U+E + LFT**: risk of myelosuppression + liver cirrhosis
* every week until therapy stabilised, then 2-3 monthly
| other SE: pneumonitis
67
When is hydroxychloroquine considered for initial therapy in RA?
mild or palindromic disease
68
What is used to monitor response to treatment in RA?
CRP + disease activity (using composite score such as DAS28)
69
How is a flare of rheumatoid arthritis managed?
course of corticosteroids - oral or IM
70
What is the indication for TNF-inhibitor use in RA?
inadequate response to at least **2 DMARDs** including **methotrexate**
71
What are 3 examples of TNF-inhibitors that can be used for RA?
1. etanercept
2. infliximab
3. adalimumab
72
How does etanercept work to treat RA?
recombinant human protein, acts as decoy receptor for TNF-alpha. given s/c
73
How does infliximab work to treat RA?
monoclonal antibody, binds TNF-alpha and prevents it from binding with TNF receptors. IV administration
74
How does adalimumab work to treat RA?
monoclonal ab, subcutaneous injection
75
What are 3 types of biological therapies for RA?
* TNF-inhibitors
* rituximab (anti-CD20 monoclonal ab)
* abatacept (influences T lymphocytes)
76
How does rituximab work to treat RA?
anti-CD20, results in B-cell depletion. 2 x 1g IV infusion given 2 weeks apart
77
How does abatacept work to treat RA?
fusion protein that modulates key signal required for activation of T lymphocytes. leads to decrease T-cell proliferation and cytokine production. given as infusion
78
What is the inheritance pattern of Marfan's syndrome?
autosomal dominant
79
What genetic defect is responsible for Marfan's?
defect in FBN1 gene on chromosome 15 - codes for protein fibrillin-1
80
What is the typical arm span to height ratio in Marfan's?
1.05
81
What are 4 heart-related abnormalities seen in Marfan's?
1. Aortic aneurysm
2. Aortic dissection
3. Aortic regurgitation
4. Mitral valve prolapse
82
What are 3 ocular abnormalities seen in Marfan's?
1. Upwards lens dislocation (superotemporal ectopia lentis)
2. Blue sclera
3. Myopia
83
What CNS abnormality may be seen in Marfan's?
dural ectasia - ballooning of dural sac at the lumbosacral level
84
85
What is the mechanism of action of methotrexate?
Antimetabolite that inhibits dihydrofolate reductase, an enzyme responsible for synthesis of purines and pyramidines
86
What is the most common pulmonary manifestation of methotrexate?
Pneumonitis
87
What pattern of pneumonitis is seen with methotrexate use?
Similar to hypersensitivity pneumonitis secondary to inhaled organic antigens
88
How quickly does pneumonitis secondary to methotrexate develop?
Within a year of starting treatment, either acutely or subacutely
89
How does methotrexate induced pneumonitis tend to present?
Non-productive cough, dyspnoea, fever, malaise
90
What is the guidance on avoiding pregnancy and methotrexate use?
Women need to avoid becoming pregnant during and for 6 months after treatment; men should use effective contraception for 6 months after treatment
91
What should be co-prescribed in anyone taking methotrexate?
Folic acid 5mg once weekly (taken >24h after methotrexate dose)
92
What is the starting dose of methotrexate?
7.5mg once weekly (only one strength of tablet e.g. 2.5mg should be prescribed)
93
What are 2 important interactions of methotrexate?
1. **Trimethoprim** or **co-trimoxazole** - increased risk of marrow aplasia
2. High dose **aspirin** - increases risk of methotrexate toxicity (reduced renal excretion)
94
What is the treatment of choice for methotrexate toxicity?
Folinic acid
95
What are 2 tests that should be performed before starting biologics for RA e.g. adalimumab, etanercept?
* CXR
* tubculin skin test / IGRA
| looking for TB - can cause reactivation
96
Which patients should be assessed using FRAX / QFracture?
* all women over 65, all men over 75
* younger patients in the presence of risk factors (8):
1. previous fragility fracture
2. current use or frequent recent use of systemic glucocorticoid
3. h/o falls
4. FH hip fracture
5. other causes of secondary osteoporosis
6. low BMI <18.5
7. smoking
8. alcohol >14 units / week
97
# [](http://)
Which ages are the FRAX and QFracture tools validated for?
* FRAX: 40-90 years
* Qfracture: 30-99 years
98
What investigation improves the accuracy of the results from FRAX?
bone mineral density
99
When should DEXA scan be performed based on FRAX (without BMD)?
if FRAX shows an intermediate result
100
Which of FRAX and QFracture includes a larger group of risk fractures?
QFracture
101
What are 2 situations when NICE recommend using BMD rather than FRAX?
1. before starting **treatments** that can rapidly affect bone density e.g. **sex hormone deprivation** for treatment for breast/prostate cancer
2. **<40 years** with **major risk factor** e.g. multiple fragility fracture, major osteoporotic fracture, high-dose systemic steroids
102
Waht is considered high-dose systemic glucocorticoid therapy?
more than 7.5 mg prednisolone or equivalent per day for 3 months or longer
103
How is the result of FRAX assessment without bone mineral density interpreted?
* low risk: reassure, lifestyle advice
* intermediate: BMD test
* high risk: offer bone protection
104
How is the management determined by FRAX score with bone mineral density, based on the result?
automatically categorised into
* reassure
* consider treatment
* strongly recommend treatment
105
How is the result from QFracture score interpreted?
not automatically categorised into low/intermediate/high risk - raw data given for 10 year risk, needs to be interpreted alongside local or national guidelines
106
What are 2 situations when the FRAX/QFracture score should be re-calculated?
1. if original risk was in region of intervention threshold for proposed treatment and only after minimum 2 years
2. change in person's risk factors
107
What is usually the first-line antibody test for suspected RA?
Rheumatoid factor (RF)
108
What are 2 tests for Rheumatoid factor?
1. Rose-Waaler test - sheep red cell agglutination
2. Latex agglutination test
109
What are high levels of RF in rheumatoid arthritis associated with?
severe progressive disease (but not marker of disease activity)
110
What are 10 conditions in addition to RA that RF is positive in?
1. Felty's syndrome (around 100%)
2. Sjogren's syndrome (around 50%)
3. infective endocarditis (around 50%)
4. SLE (= 20-30%)
5. systemic sclerosis (= 30%)
6. general population (= 5%)
7. TB
8. HBV
9. EBV
10. leprosy
111
What is the most specific antibody test for RA?
anti-CCP
112
When may anti-CCP be detectable in RA?
may be detectable up to 10 years before development of RA
113
What is the sensitivity of RF and anti-CCP for RA?
both 70-75%
114
What radiology do NICE recommend in all patients with suspected RA?
xray hands and feet
115
What are 4 general features of SLE?
1. fatigue
2. fever
3. mouth ulcers
4. lymphadenopathy
116
What are 6 dermatological manifestations of SLE?
1. malar rash - spares nasolabial folds
2. discoid rash - erythematous, well demarcated rash in sun-exposed areas
3. photosensitivity
4. raynaud's phenomenon
5. livedo reticularis
6. non-scarring alopecia
117
What may be the progression of the discoid rash seen in SLE?
can become pigmented and hyperkeratotic, then become atrophic
118
What are 2 MSK features of SLE?
1. arthralgia
2. non-erosive arthritis
119
What are 2 cardiovasular features of SLE?
1. pericarditis
2. myocarditis
120
What are 2 respiratory features of SLE?
1. pleurisy
2. fibrosing alveolitis
121
What are 2 renal features of SLE?
1. proteinuria
2. glomerulonephritis
122
What is the commonest type of glomerulonephritis seen in SLE?
diffuse proliferative glomerulonephritis
123
What are 3 neuropsychiatric features of SLE?
1. anxiety and depression
2. psychosis
3. seizures
124
What is the scale of low glucocorticoid activity/high mineralocorticoid activity to the other end of the scale in terms of specific steroids?
* fludrocortisone
* hydrocortisone
* prednisolone
* dexamethasone
* betmethasone
125
Does an asymmetrical presentation of joint inflammation (e.g. L knee and R MCP joint involvement) suggest rheumatoid arthritis or psoriatic arthritis?
psoriatic
126
What proportion of patients with psoriatic skin lesions develop parthropathy?
10-20%
127
What are 5 different patterns of psoriatic arthropathy?
1. symmetric polyarthritis (30-40%)
2. asymmetrical oligoarthritis (20-30%)
3. sacroiliitis
4. DIP joint disease (10%)
5. arthritis mutilans (telescoping fingers)
128
What are 3 examples of periarticular disease seen in psoriatic arthropathy?
1. enthesitis (Achilles tendonitis, plantar fascitis)
2. tenosynovitis
3. dactylitis
129
What are 3 xray findings in psoriatic arthropathy?
1. erosive changes and new bone formation in coexistence
2. periostitis
3. pencil in cup appearance
130
Who should manage psoriatic arthropathy?
rheumatologist
131
What are 4 features of the management of psoriatic arthropathy that differ from/are similar to RA?
1. mild peripheral arthritis/mild axial disease may be treated with **'just' an NSAID**, rather than all patients being on disease-modifying therapy as with RA
2. if more moderate/severe disease then **methotrexate** is typically used as in RA
3. use of *monoclonal antibodies* such as **ustekinumab** (targets both IL-12 and IL-23) and **secukinumab** (targets IL-17)
4. **apremilast**: phosphodiesterase type-4 (PDE4) inhibitor
132
How does the prognosis of psoriatic arthropathy compare to RA?
better in psoriatic
133
What malignancy is linked to Sjogren's syndrome?
lymphoid malignancy
134
What are 4 blood tests positive Sjogren's syndrome and in what proportion?
1. RF (50%)
2. ANA positive (70%)
3. Anti-Ro (70%)
4. Anti-La (30%)
135
What will histology show in Sjogren's syndrome?
focal lymphocytic infiltration
136
What are 2 aspects of the management of Sjogren's syndrome?
1. Artificial saliva + tear
2. Pilocarpine may stimulate saliva production
137
What are 3 conditions associated with Sjogren's syndrome?
1. Rheumatoid arthritis
2. SLE
3. connective tissue disorders
138
What will bone tests show in Paget's disease?
* raised ALP
* normal calcium, phosphate, PTH
139
What is osteomalacia?
softening of bones secondary to low vitamin D levels, in turn leads to decreased bone mineral content
140
What are 6 causes of osteomalacia?
1. **vitamin D deficiency** - malabsorption, lack of sunlight, diet
2. **chronic kidney disease**
3. **drug-induced** e.g. anticonvulsants
4. **inherited** - hypophosphataemic rickets
5. **liver disease** e.g. cirrhosis
6. **coeliac disease**
141
What are the key features of osteomalacia?
bone pain, muscle tenderness, fractures (femoral neck), proximal myopathy
142
What do bloods show in osteomalacia?
* low vitamin D
* low calcium
* low phosphate
* raised ALP
143
What can be seen on xray in osteomalacia?
translucent bands (Looser's zones or pseudofractures)
144
What is the management of osteomalacia?
vitamin D supplementation (loading dose often used)
calcium supplementation if diet intake inadequate
145
What are 2 groups NICE divide patients into for those at risk of corticosteroid-induced osteoporosis?
1. Patients **>65 years** OR who previously had **fragility fracture** - offer **bone protection**
2. **< 65 y** - offer bone density scan
If > 0: reassure
0 to -1.5: repeat bone desntity scan in 1-3 years
< - 1.5: bone protection
146
What is the management in patients at risk of corticosteroid induced osteoporosis based on the bone density scan?
If > 0: reassure
0 to -1.5: repeat bone desntity scan in 1-3 years
< - 1.5: bone protection
147
Which patients are deemed at risk of corticosteroid-induced osteoporosis
daily steroid equivalent to > 7.5 mg prednisolone / day for 3 months or more
148
What are 4 adverse effects of azathioprine?
1. bone marrow depression
2. nausea / vomiting
3. pancreatitis
4. increased risk of non-melanoma skin cancer
149
Which drug can azathioprine have a significant reaction with and what should be done?
allopurinol - use lower doses of azathioprine
150
Is azathioprine safe to use in pregnancy?
yes
151
What are 6 key adverse effects of bisphosphonates?
1. oesophageal reactions - oesophagitis, ulcers
2. osteonecrosis of the jaw
3. atypical stress fractures of proximal femoral shaft
4. acute phase response - fever, myalgia, arthralgia
5. hypocalcaemia
152
What is the guidance for how to take bisphosphonates?
* swallowed whole with water, sitting or standing
* take on empty stomach at least 30 minutes before breakfast or oral medication
* stand or sit upright for at least 30 minutes after taking tablet'
153
What should always be checked before giving bisphosphonates?
check for + correct hypocalcaemia + vitamin D deficiency
| ca only prescribed if dietary intake inadequate - vit D normally given
154
What is the duration of bisphosphonate therapy?
stop at 5 years if the following apply:
* patient is < 75-years-old
* femoral neck T-score of > -2.5
* low risk according to FRAX/NOGG
155
What are 7 causes of raised ALP?
1. **liver**: cholestasis, hepatitis, fatty liver, neoplasia
2. **Paget's**
3. **osteomalacia**
4. **bone metastases**
5. **hyperparathyroidism**
6. **renal failure**
7. **physiological**: pregnancy, growing children, healing fractures
156
What are 6 skin features of dermatomyositis?
1. photosensitive
2. macular rash over back and shoulder
3. **heliotrope** rash in the periorbital region
4. **Gottron's papules** - roughened red papules over extensor surfaces of fingers
5. 'mechanic's hands': extremely dry and scaly hands with linear 'cracks' on the palmar and lateral aspects of the fingers
6. nail fold capillary dilatation
157
What are 4 blood test markers which may be present in dermatomyositis?
1. ANA (80%)
aminoacyl-tRNA synthetases (anti-synthetase) antibodies (30%):
2. anti-Jo1
3. anti-SRP
4. anti-Mi-2
158
What are 2 drugs recommended if patients cannot tolerate bisphosphonates?
strontium ranelate and raloxifene
159
What type of drug is raloxifene?
selective oestrogen receptor modulator (SERM)
160
What are 2 risks of raloxifene?
1. may worsen menopausal symptoms
2. increased risk of thromboembolic events
161
What type of cancer may raloxifene decrease the risk of?
breast cancer
162
What is the mechanism of action of strontium ranelate?
dual action bone agent: increases deposition of new bone by osteoblasts (promotes differentiation of pre-osteoblast to osteoblast) and reduced resoprtion of bone by inhibiting osteoclasts
163
When should strontium ranelate be used for osteoporosis?
only when no other treatments that can be used due to concerns regarding safety profile
164
What are 3 risks of strontium ranelate?
1. increased risk of cardiovascular events
2. increased risk of thromboembolic events
3. serious skin reactions e.g. SJS
165
What is the mechanism of denosumab?
human monoclonal antibody that inhibits RANK ligand - this inhibits maturation of osteoclasts
166
Which antibodies are a good indicator of diffuse cutaneous systemic sclerosis?
Anti-Scl-70
167
Which antibodies are a good indicator of limited cutaneous systemic sclerosis?
anti-centromere antibodies
168
What is another name for CREST syndrome?
limited cutaneous systemic sclerosis
169
What type of antibody is rheumatoid factor?
IgM
170
What is the only type of antibody that can cross the placenta?
IgG
171
What are 6 conditions that anticardiolipin antibodies are present in?
1. antiphospholipid syndrome
2. SLE
3. ITP
4. RA
5. psoriatic arthritis
6. Sjogrens syndrome
172
What is Felty syndrome?
occurs in some cases of rheumatoid arthritis
SANTA mnemonic:
S: splenomegaly
A: anaemia
N: neutropenia
T: thrombocytopenia
A: arthritis (rheumatoid)
