Rheumatology

Question 1

Patient’s shoulder is painful on moving, actively and passively, no swelling/color change.. diagnosis, prevalence and treatment?

Answer 1

Frozen shoulder: External rotation (on both active and passive movement) is classically impaired in adhesive capsulitis
Prevalence: DM
treatment: NSAIDs, physiotherapy, oral corticosteroids and intra-articular corticosteroids

Question 2

A woman having restrictions in moving her knee, without swelling or being hot tender, morning stiffness of 10-15mins. First line?

Answer 2

This patient’s presentation is suggestive of knee osteoarthritis, given her age, gradual onset of pain, functional limitation and lack of significant morning stiffness. NICE guidelines regarding osteoarthritis were updated in 2022 and no longer advocate the use of paracetamol or weak opioids unless they are used infrequently and for short-term relief. First-line management for the knee is the use of topical NSAIDs such as topical ibuprofen.

Question 3

Best diagnosis of ankylosing spondylitis??

Answer 3

sacro-ilitis on a pelvic X-ray

Question 4

Features on XRay for ankylosing spondylitis?

Answer 4

sacroiliitis: subchondral EROSIONS, SCLEROSIS
squaring of lumbar vertebrae
‘bamboo spine’ (late & uncommon)
syndesmophytes: due to ossification of outer fibers of annulus fibrosus
chest x-ray: apical fibrosis

Question 5

What if XRay is negative for AS but there is suspicion of AS??

Answer 5

The next step in the evaluation should be obtaining an MRI. Signs of early inflammation involving sacroiliac joints (bone marrow oedema) confirm the diagnosis of AS

Question 6

Rheumatoid factor?

Answer 6

rheuMatoid faGtor
(Rheumatoid factor is an IgM antibody against IgG)

Question 7

Z-score?

Answer 7

Z-score is helpful in diagnosing secondary osteoporosis and should always be used for children, young adults, pre-menopausal women and men under the age of 50

Question 8

FRAX score??

Answer 8

FRAX tool computes the 10-year probability of hip fracture and/or of major osteoporotic fracture.

Question 9

ORAI??

Answer 9

The Osteoporosis Risk Assessment Instrument (ORAI) uses age, weight, and the use of oestrogen as an aid in selecting postmenopausal patients for bone density testing.

Question 10

QFracture Algorithm??

Answer 10

QFracture is a risk prediction algorithm which calculates an individual’s risk of osteoporotic fracture taking into account their individual risk factors such as age, sex, ethnicity, clinical values and diagnoses.

Question 11

A pregnant SLE pt with anti-Ro (SSA) positive is at a risk of developing which fetal anomaly??

Answer 11

CONGENITAL HEART BLOCK {Fetal bradycardia}

Question 12

HLA-A3??

Answer 12

Hemochromatosis

Question 13

HLA-B51

Answer 13

Behcet disease

Question 14

HLA-B27

Answer 14

PAIR)
Psoriatic arth
AS
Acute Anterior Uveitis
IBD associated arth
Reactive arth

Question 15

HLA-DQ2/DQ8

Answer 15

Celiac disease

Question 16

HLA-DR2

Answer 16

Narcolepsy
Goodpasteur

Question 17

HLA DR3

Answer 17

Dermatitis herpetiformis
Sjogren
PBC

Question 18

HLA DR4

Answer 18

DM-1
RA

Question 19

Treatment algorithm of AS?

Answer 19

1) Encourage exercise eg swimming
2) NSAIDs first line
3) Physio
4) If peripheral joint involvement, then DMARD eg sulphasalazine
5) If high disease activity, then Anti TNF should be given (etanercept, adalimumab)..

Question 20

A pt with hemochromatosis presents with excessive chondrocalcinosis, joint aspiration will show?

Answer 20

{Pseudogout - weakly positively birefringent rhomboid-shaped crystals}
Calcium pyrophosphate deposition (CPPD) disease or pseudogout. The characteristic finding in joint fluid analysis in CPPD disease is the presence of positively birefringent rhomboid-shaped crystals. These crystals are formed due to the deposition of calcium pyrophosphate dihydrate in the joint cartilage, leading to inflammation and pain.

Question 21

Calciphylaxis??

Answer 21

Deposition of calcium within arterioles causing microvascular occlusion and necrosis of the supplied tissue. It most commonly affects the skin and presents as intensely painful, purpuric patches with an area of black necrotic tissue that may form bullae, ulcerate, and leave a hard, firm eschar..

Question 22

What are the RFs of Calciphylaxis??

Answer 22

ESRD, DM, RA, hypercalcemia, hyperphosphataemia and hyperparathyroidism, Warfarin use.

Question 23

How to treat calciphylaxis?

Answer 23

1) Reduce Ca and PO4 levels
2) Treat Hyperparathyroidism
3) Avoid contributing factors like calcium containing subs and warfarin

Question 24

History of back and hip pain and increasing difficulty rising from a chair and combing her hair. She has also found her gait has changed - a friend told her it seemed as though she was ‘waddling’ around. Most helpful in confirming the diagnosis?

Answer 24

Vit D
{Suspect osteomalacia}
Triad of:
1)Bone pain, 2)tenderness
3)proximal myopathy (described by Waddling gait)

Other tests?
-Calcium (low)
-Phosphate (low)
-ALP (High)
-Parathyroid hormone (high)

X-ray:
Translucent bands (Looser’s zones or pseudofractures)

Question 25

Inflammed and hurting DIPs bilaterally?

Answer 25

Inflammatory arthritis involving DIP swelling and dactylitis points to a diagnosis of psoriatic arthritis

Question 25

Associations of Osteomalacia?

Answer 25

CKD Celiac disease Cirrhosis antiConvulsants

Question 26

What are the presentations of psoriatic arthritis?

Answer 26

-Symmetric (Rheumatoid pattern) polyarthritis {MC} {30-40%} -Asymmetrical oligoarthritis {20-30%} -Sacroiliitis -DIP joint disease (10%) -Arthritis mutilans (severe deformity fingers/hand, 'telescoping fingers') -Psoriatic skin lesions -Enthesitis: inflammation at the site of tendon and ligament insertion e.g. Achilles tendonitis, plantar fascitis -Tenosynovitis -Dactylitis (Sausage fingers) -Nail pitting and onycholysis

Question 27

What are the XRay features of psoriatic arthritis?

Answer 27

-Erosive changes and new bone appearance -Periostitis -'pencil-in-cup' appearance

Question 28

How to manage psoriatic arthropathy?

Answer 28

1) Consult Rheumatologist 2) Mild: NSAIDs just 3) Moderate/severe disease: MTX/DMARD 4) Ustekinumab {IL-12/IL-23}(monoclonal AB) and Sekukinumab {IL-17} 5) Apremilast {PDE-4 inhibitor}

Question 29

Positively birefringent rhomboid shaped crystals in?

Answer 29

PSEUDOGOUT: -Haemochromatosis -Hyperparathyroidism -Low magnesium -Low phosphate -Acromegaly -Wilson's disease

Question 30

In which disease does the back pain improves by leaning forward?

Answer 30

SPINAL STENOSIS

Question 31

Cause of lower back pain in marfan syndrome?

Answer 31

DURAL ECTASIA [Ballooning of the dural sac at the lumbosacral level] {with bowel and bladder dysfunction}

Question 32

What are the causes of secondary Raynaud??

Answer 32

Secondary causes of Raynaud's phenomenon connective tissue disorders scleroderma (most common) rheumatoid arthritis systemic lupus erythematosus leukaemia type I cryoglobulinaemia, cold agglutinins use of vibrating tools (Gold mining) drugs: oral contraceptive pill, ergot cervical rib

Question 33

There is pain on the radial side of her right wrist, difficulty gripping objects and her pain worsens when lifting her infant. On examination, there is tenderness over the radial styloid process, and she experiences pain when moving her thumb, particularly when abducting the thumb against resistance. An X-ray demonstrates soft-tissue swelling over the radial styloid only.

Answer 33

"De Quervain's tenosynovitis" [extensor pollicis brevis and abductor pollicis longus tendons] To confirm diagnosis, FINKELSTEIN TEST: "a key diagnostic manoeuvre, performed by grasping the patient’s thumb and ulnar deviating the wrist. Sharp pain along the distal radius confirms the diagnosis, reflecting inflammation of the tendon sheaths."

Question 34

Which factors suggest that underlying condition is a connective tissue disorder?

Answer 34

onset after 40 years unilateral symptoms rashes presence of autoantibodies features which may suggest rheumatoid arthritis or SLE, for example arthritis or recurrent miscarriages digital ulcers, calcinosis very rarely: chilblains

Question 35

How to manage Raynaud's??

Answer 35

Management all patients with suspected secondary Raynaud's phenomenon should be referred to secondary care first-line: calcium channel blockers e.g. nifedipine IV prostacyclin (epoprostenol) infusions: effects may last several weeks/months

Question 36

Which medicine is used for treating Familial Mediterranean fever?

Answer 36

Colchicine { The primary treatment for FMF is Colchicine, which works by reducing inflammation and preventing attacks. It also prevents the complication of systemic amyloidosis which can lead to kidney failure. According to UK guidelines, all patients with FMF should be offered lifelong treatment with Colchicine.}

Question 37

What is FMF and how does it present?

Answer 37

AR disorder, also called RECURRENT POLYSEROSITIS. (2nd decade) more common in people of Turkish, Armenian and Arabic descent. Features - attacks typically last 1-3 days pyrexia abdominal pain (due to peritonitis) pleurisy pericarditis arthritis erysipeloid rash on lower limbs

Question 38

Minimum steroid intake a patient should be taking before they are offered osteoporosis prophylaxis?

Answer 38

Equivalent of prednisolone 7.5 mg or more each day for 3 months. According to the UK guidelines, patients who are taking a dose equivalent to prednisolone 7.5mg daily for three months or more should be offered osteoporosis prophylaxis. This is because prolonged use of corticosteroids at this dose has been associated with an increased risk of osteoporosis and fractures.

Question 39

What is Management of patients at risk of corticosteroid-induced osteoporosis

Answer 39

The RCP guidelines essentially divide patients into two groups. 1. Patients over the age of 65 years or those who've previously had a fragility fracture should be offered bone protection. 2. Patients under the age of 65 years should be offered a bone density scan, with further management dependent:

Question 40

What is the Mill's test?

Answer 40

Diagnose lateral epicondylitis/Tennis elbow {in de Quervain tenosynovitis} Performed Same as Finkelstein test. Arm flexed and fingers extended in Mills test.

Question 41

INTERSECTION SYNDROME?

Answer 41

Pain and inflammation at the wrist, specifically where the first dorsal compartment (abductor pollicis longus and extensor pollicis brevis) intersects with the second dorsal compartment (extensor carpi radialis longus and brevis).

Question 42

Intersection syndrome vs Arthritis?

Answer 42

>Location of Pain: Intersection syndrome pain: Distal Arthritis: involves joint spaces. >Swelling: Intersection syndrome: Localized swelling, Arthritis: diffuse swelling around joints. >Range of Motion: In arthritis, active range of motion may be limited due to joint stiffness; in intersection syndrome, passive movement may remain intact. >Joint Involvement: Arthritis commonly affects multiple joints (e.g., in rheumatoid arthritis), whereas intersection syndrome is localised to the wrist area.

Question 43

Spurling test?

Answer 43

Cervical radiculopathy resulting from nerve root compression within the cervical spine. Test: head tilting towards the affected side combined with applied downward pressure may reproduce radicular arm sensations if positive for nerve root irritation.

Question 44

What are the drug causes of gout?

Answer 44

-Diuretics: thiazides {indapamide, chlortalidone and bendroflumethiazide}, furosemide -ciclosporin -alcohol -cytotoxic agents -pyrazinamide -aspirin (also prescribe allopurinol)

Question 45

GOUT?

Answer 45

{deposition of monosodium urate monohydrate in the synovium. It is caused by chronic hyperuricaemia (uric acid > 450 µmol/l)}

Question 46

How to manage acute gout?

Answer 46

ACUTE MANAGEMENT: NSAIDs {Max 2 days until after symptoms have settled} and Colchicine (1st line) + PPI -Oral steroids (Pred: 15mg/day) if NSAIDs & colchicine contraindicated. -Intraarticular steroid injection -If already on allopurinol, then continue it.

Question 47

What is the MOA of colchicine?

Answer 47

Binds with Tubulin, then Inhibits microtubules polymerization, and interferes with mitosis. Also inhibits Neutrophil motility and activity. SLOWER ACTION. Reduce the dose if eGFR is 10-50 ml/min and to avoid if eGFR < 10 ml/min. S/E: Diarrhea

Question 48

Indications of URATE LOWERING THERAPY??

Answer 48

Indication MAIN: After 1st attack Other indications: 1) >= 2 attacks in 12 months 2) tophi 3) renal disease 4) uric acid renal stones prophylaxis if on cytotoxics or diuretics

Question 49

URATE LOWERING THERAPY??

Answer 49

"Better delayed until inflammation settled" First line: ALLOPURINOL: Initially, 100mg OD, then titrate to aim serum UA: <360umol/l, if with tophi/chronic gout/frequent flares, then target: <300umol/l Lower the initial dose if reduced eGFR. colchicine cover is required, otherwise use NSAIDs if not tolerated and to be continued for 6 months. 2nd Line: Febuxostat if allo not tolerated Refractory cases: pegloticase (polyethylene glycol modified mammalian uricase), as an infusion once every two weeks.

Question 50

SLE mnemonic?

Answer 50

SOAP BRAIN MD: Serositis: pleurisy or pericarditis Oral ulcers Arthritis Photosensitivity Blood: anaemia, leukopenia, lymphopenia and thrombocytopenia Renal disorder: lupus nephritis - minimal mesangial, mesangial proliferative, focal, diffuse, membranous and advanced sclerosis Antinuclear antibody Immunology: anti-Smith, anti-ds DNA and antiphospholipid antibody Neurologic disorder: seizures or psychosis Malar rash Discoid rash

Question 51

A 34-year-old woman presents with recurrent oral ulcers. On systematic enquiry, she also advises you that she has recurrent genital ulcers, and painful red eyes. What HLA type is associated with the likely underlying diagnosis?

Answer 51

Behcet's syndrome is associated with HLA B51 CLASSICAL TRIAD BEHCETS DISEASE: oral ulcers, genital ulcers and anterior uveitis.

Question 52

TNF inhibitors?

Answer 52

-Infliximab -Golimumab -Etanercept -Adalimumab

Question 53

Rituximab, daratumumab, anakinra, secukinumab????

Answer 53

Ritux: CD 20 antagonist Dara: CD 38 antagonist Anakinra: IL-1 inhibitor {A-1} Secukinu: IL-17A inhibitor {secu staran}

Question 54

Dermatomyositis antibodies?/

Answer 54

ANA most common, anti-Mi-2 most specific

Question 55

What are the investigations and management of dermatomyositis?

Answer 55

-elevated creatine kinase -EMG -muscle biopsy -ANA positive in 60% -anti-Mi-2 antibodies are highly specific for dermatomyositis, but are only seen in around 25% of patients -anti-Jo-1 antibodies are not commonly seen in dermatomyositis - they are more common in polymyositis where they are seen in a pattern of disease associated with lung involvement, Raynaud's and fever Rx: Prednisolone

Question 56

What are the guidelines about treating temporal arteritis??

Answer 56

The American College of Rheumatology 1990 criteria requires 3 of the following for GCA diagnosis: 1. Age >50 y/o 2. New onset localised headache 3. Temporal artery tenderness or decreased pulsation 4. ESR >50mm/hr 5. Temporal artery biopsy positive Uncomplicated GCA (no visual involvement and/or jaw/tongue claudication) should be treated with oral prednisolone 40-60mg daily until symptoms and investigations normalise. Complicated GCA (with visual involvement and/or jaw/tongue claudication), as in this scenario, should be given IV methylprednisolone 500-1000mg for 3 days before starting oral prednisolone. As GCA requires long-term steroid therapy bone sparing agents (a bisphosphonate and vitamin D) and a gastroprotective drug (e.g omeprazole) should be prescribed. Also, low dose aspirin should be considered as it has been shown to reduce the rate of visual loss and cerebrovascular accidents in GCA.

Question 58

What are the features of rheumatoid arthritis??

Answer 58

Early x-ray findings loss of joint space juxta-articular osteoporosis soft-tissue swelling periarticular erosions subluxation

Question 59

Bull's eye retinopathy with severe and permanent visual loss?

Answer 59

HYDROXYCHLOROQUINE

Question 60

When do you suspect Chronic Fatigue Syndrome/Myalgic Encephalomyelitis?

Answer 60

All of these symptoms should be present and would be present for 3 months: Debilitating fatigue that is worsened by activity, is not caused by excessive cognitive, physical, emotional or social exertion, and is not significantly relieved by rest. Post-exertional malaise after activity in which the worsening of symptoms: is often delayed in onset by hours or days is disproportionate to the activity has a prolonged recovery time that may last hours, days, weeks or longer. Unrefreshing sleep or sleep disturbance (or both), which may include: feeling exhausted, feeling flu-like and stiff on waking broken or shallow sleep, altered sleep pattern or hypersomnia. Cognitive difficulties (sometimes described as 'brain fog'), which may include problems finding words or numbers, difficulty in speaking, slowed responsiveness, short-term memory problems, and difficulty concentrating or multitasking.

Question 62

Female with APTT raised and low platelet?

Answer 62

APLA

Question 63

How to manage APLA?

Answer 63

Management - based on EULAR guidelines -primary thromboprophylaxis low-dose aspirin -secondary thromboprophylaxis --initial venous thromboembolic events: lifelong warfarin with a target INR of 2-3 --recurrent venous thromboembolic events: lifelong warfarin; if occurred whilst taking warfarin then consider adding low-dose aspirin, increase target INR to 3-4 --arterial thrombosis should be treated with lifelong warfarin with target INR 2-3

Question 64

Antibodies in APLA?

Answer 64

-anticardiolipin -antibodies anti-beta2 glycoprotein I (anti-beta2GPI) antibodies -lupus anticoagulant

Question 65

Poor prognostic factors in RA??

Answer 65

-rheumatoid factor positive -anti-CCP antibodies -poor functional status at presentation -X-ray: early erosions (e.g. after < 2 years) -extra articular features e.g. nodules -HLA DR4 -insidious onset

Question 66

MOA of Medication of fragility fractures?

Answer 66

Bisphosphonates inhibit osteoclasts (modulation of the receptor activator of nuclear factor-κB (RANK) ligand.)