Rheumatology Flashcards
Lateral Epicondylitis Made Worse by ?
Worse on Wrist Extension AGAINST resistance with extended elbow
Supination with elbow extended
Mnemonic - LETS
Lateral epicondylitis, Extension Pain, Tennis Elbow, Supination Pain
Markers of Bone Turnover in Pagets Disease
Procollagen type I N-terminal propeptide (PINP)
serum C-telopeptide (CTx)
urinary N-telopeptide (NTx)
urinary hydroxyproline
Indications for Treatment for Pagets
- Indications
- Investigations
- Complications
1.
a. bone pain
b. skull or long bone deformity
c. fracture
d. periarticular Paget’s
- X ray (Osteolytic –> Mix/Sclerotic Lesions)
Skull Thickening
and osteoporosis circumscripta
NORMAL Vit D and Calcium levels
- Deafness (Cranial Nerve Deafness)
Bone Sarcoma
High Output HF
Dermatomyositis Antibodies ?
ANA - Most Common
Anti Mi-2 is more Specific
Anti Jo 1 - Polymyositis
Hip Pain in Adults Causes
MRCP Specific ones
- Trochanteric Bursitis
- Idiopathic Transient Osteoporosis
- Pubic Symphysis Dysfunction
- Meralgia Paraesthica
Iliotibial Band Pain
Lateral Thigh
50-70 y/o
- 3rd Trimester of Pregnancy
- Pain Radiation to Medial Thigh
Waddling Gait
Causes of Avascular Necrosis ?
- Alcohol Excess
- Chemotherapy
- Steroid Use / Withdrawal
- Trauma
X Ray findings for Avascular Necrosis ?
Is that GOLD Standard though ?
X ray initially normal –> Microfractures, Collapse of Joint Space (Crescent sign) & Osteopenia
MRI is the GOLD STANDARD
Pathophysiology of RA ?
Immune response against Citrullinated Peptides and Synovium
TNF-Alpha binds to p75 and p55 –> induce apoptosis
Active NFkB
Proliferate Fibroblasts –> Activating Collagenase and Protease
Induces the expression of adhesion molecules (SELECTIN) on endothelial cells
Promote osteoclast differentiation and activation –> bone erosion
Osteoporosis vs Glucorticoid Induced
Whats the T score cut off ?
General Population
> -1 : normal
Between -2.5 & -1: Osteopenic
< -2.5: Osteoprosis
- For patients at risk of corticosteroid-induced osteoporosis
- > 65 OR those who’ve previously had a fragility fracture should be offered bone protection.
- Patients under the age of 65 years should be offered a bone density scan, with further management dependent:
T score
> 0: Reassure
Between 0 and -1.5: Repeat bone density scan in 1-3 years
< -1.5: Offer bone protection
The first-line treatment is alendronate. Patients should also be calcium and vitamin D replete.
Osteomalacia ?
- Features
- X ray findings
- Causes
- Bloods ?
- Bone pain + Tenderness + proximal myopathy + Waddling gait –> osteomalacia + Femoral Neck Fractures
- Looser Zone and Pseudofractures
Causes
vitamin D def
CKD
Anticonvulsants
inherited: hypophosphatemic rickets (previously called vitamin D-resistant rickets)
liver disease: e.g. cirrhosis
coeliac disease
- Low PO4 Low Calcium but High ALP and High PTH
Duration of Bisphosphonates ?
Stop at 5 years if :
Age <75
Femoral Neck T score >-2.5
Low FRAX/NOGG
Before Bisphosphonates need to check what ?
Vitamin D and Calcium levels
Calcium only prescribed if low intake
Vit D usually
Which patient does Osteonecrosis of the Jaw happen to ?
IV Bisphosphonate in Cancer Patients
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
Most Common Pathogen for Osteomyelitis ?
Most Common Pathogen in Sickle Cell Patients for Osteomyelitis ?
Staph Aureus
Salmonella
OA Management
1st Line for Hand / Knee OA is Topical NSAIDs
2nd Line is Oral NSAIDs + PPI
PCM or Weak Opioids only if other CI OR Short Term Relief
Intra-articular Steroids
Joint Replacement
Biomarker to detect Monitor Severity in SLE ?
Anti dsDNA if not ESR in options
But ESR is best as Anti-dsDNA not present in all
Pseudo Gout
- Causes especially in Young Patients
- Crystals on Bifirengence
- How to differentiate vs Gout ?
- Hereditary Hemochromatosis
Low Calcium Low Mg
Hyperparathyroidism
Acromegaly
Wilsons - Weakly Positive Rhomboid Shape
- X ray - Chondrocalcifications (PSUEDOGOUT>GOUT)
Features of
De Quervain’s tenosynovitis
EPB and APL inflammed
extensor pollicis brevis and abductor pollicis longus tendons
Pain on Thumb Abduction on Resistance
Thumb into fist and Ulnar Deviate –> Pain across Radial side and
- Median Nerve supplied by ?
- Management for Carpal Tunnel Syndrome ?
- Lateral 2 lumbricals
Opponens pollicis
Abductor policis brevis
Flexor policis brevis
THENAR EMINENCE BY MEDIAN
HYPOTHENAR by ULNAR
- 6 weeks conservative management with Wrist Splints and Corticosteroid Injections –> Flexor Retinaculum Division
Ankylosing Spondylitis Imaging Modality
X ray Sacroiliitis –> MRI
Causes of Iliopsoas Abscess ?
Primary
Hematogenous Spread
Secondary
Crohn’s (commonest cause in this category)
Diverticulitis, colorectal cancer
UTI, GU cancers
Vertebral osteomyelitis
Femoral catheter, lithotripsy
Endocarditis
intravenous drug use
Complications of RA memonic
Most Common is IHD
Calcium Homeostasis
Osteoporosis AND Osteopetrosis
Ca/PO4/ALP/PTH all Normal
Always ALP HIGH !!!!
Primary Hyperparathyroidism
Calcium - High
PO4 - Low
ALP - High
PTH - High
Secondary Hyperparathyroidism
Calcium - Low / Normal
PO4 - High
ALP - High
PTH - High / Normal
Tertiary Hyperparathyroidism
Ca - High
PO4 - Low
ALP - High
PTH - VERY HIGH
PseudohypOOOOparathyroidism
Ca - Low
PO4 - High
ALP - High
PTH - High
Osteopetrosis
1. Presentation
2. Treatment
Defective Osteoclast –> Defective Resorption –> Marble Bone Disease
Joint Pain (NOT BONE) and Hearing Loss (Calcification of Auditory Meatus)
Adult Onset Stills Disease
- Presentation Mnemonic
- Investigations
- Managment
- Complications
- FART Hurt
Fever (Quotidian)
Arthralgia
Rashes (Salmon Pink, Comes and Goes with Fever, Proximal Limbs and Trunk, Non Pruritic )
Throat Hurts - Pharyngitis + Lymphadenopathy
- High Ferritin
Anti CCP and RF NEGATIVE - Mild - NSAID (trialed for a week before adding steroids) + Steroids
Severe - Anakinra / Toclizumab (IL6) / Methotrexate
- Macrophage Activation Syndrome (Hemangiocytosic Histiolymphocytosis)
Most Common Cause of Death in AOSD
What Cytokines involved in RA primarily ?
TNF Alpha and IL6
Psoriatic Arthritis
1. Treatment
2.
3. X ray findings
- Mild Axial / Mild Peripheral = JUST NSAIDS
Moderate / Severe = Methotrexate
Ustekinumab (targets both IL-12 and IL-23) AND Secukinumab (targets IL-17)
Apremilast –> PDE4i
Side Effect Suicidal Thoughts
Dermatomyositis ?
- Pathophysiology vs Polymyositis
- Features
- Investigations
- Treatment
- Dermatomyositis -
Cell Mediated CD8+
Polymyositis -
Humoral Immunity B cells and CD4
- Proximal Muscle Weakness
V sign / Shawl Sign
Butterfly Heliotrope Rash
Gottron’s Papules
Periungual Erythema
Holster Sign (Rash over Lateral Thigh)
NO CUTANEOUS FINDING IN POLYMYOSITIS
- ANA
Anti Jo (Anti - Histidine tRNA Ligase)
Anti SNP
Anti Mi 2
SCREEN FOR CANCER !!!! in DERMATOMYOSITIS
(Colon Lung Breast Ovarian )
Muscle Biopsy
1.Dermato - Perivascular / Perimysial Inflammation of Muscle Fibres
- Polymyositits - Endomysial
- Associated with Raynauds , SLE, ILD (Fibrosing alveolitis or organising pneumonia)
Which antibodies are SPECIFIC and SENSITIVE in Dermatomyositis ?
ANA - Sensitive
Anti Mi2 and THEN Anti JO1 (in terms of Specificity)
Anti JO1 predominate Lung Involvement with No Rash
Side Effect of Bisphosphonates ?
Atypical Stress Fractures in Femoral Shaft + Others (Hypocalcemia and Osteonecrosis of Jaw + Esophageal Reactions)
Radial Tunnel Syndrome vs Lateral Epicondylis
Lateral Epicondylitis -
Pain at LATERAL CONDYLE
Wrist extension against Resistance with Flexed Elbow and forearm Supination
Radial Tunnel Syndrome -
PAIN just DISTAL to Lateral Condyle
Pain worse with elbow extension and forearm pronation
SO
Supination - Lateral Condylitis
Pronation - Radial Tunnel Syndrome
X ray Changes in AS ?
Xray changes. ‘S’
Sacroiliitis
Subchondral erosions
Sclerosis
Squaring of lumbar vertebrae
Syndesmophyte
Spine like as bamboo
Apical fibrosis (i remember this as scarring)
Management for AS ?
Swimming
NSAIDs
DMARDs only if Peripheral Involvementt
Psoriatic Arthropathy
Most Common –> Least Common
Rheumatoid pattern –> Oligo –> Spinal –>DIP involvement
Which Rheumatological Conditions more common in MALES ?
AS, Paget and Bechet
RA post STI
Which Rheumatological Conditions EQUALLY affect MALES and FEMALES ?
Psoriatic arthropathy
drug-induced SLE
RA post dysentery form
In Psoriatic Arthritis is it Skin or Arthropathy First ?
Approximately 15% of patients with psoriatic arthritis (PsA) develop arthritis before the onset of skin lesions.
10-20% with skin psoriasis develop PsA.
When to start Bisphosphonates Directly in Osteoporosis ?
1) >75 y/o + fracture
2) <75 y/o –> DEXA first, <-2.5 = bisphosphonates
3) High-risk FRAX Score
4) Post Menopausal Women or Men > 50 with Osteoporotic Vertebral Fracture
When should DEXA Scan be offered directly ?
A DEXA scan should be offered without calculating the fragility risk score in the following situations:
1) > 50 + history of fragility fracture
2) < 40 + a major risk factor for fragility fracture –> these patients should be referred to a specialist depending on the T-score
3) Before starting treatments that may have a rapid adverse effect on bone density (for example, sex hormone deprivation for treatment for breast or prostate cancer)
Patients on Long Term Steroids and Osteoporosis Screening Guidelines
If patient on steroids:
2) aged > 65 no need DEXA
2) aged <65 do DEXA first
- if T score less than - 1.5 -> give alendronate
- If T score more than between 0 to -1.5 ->repeat scan 1-3 yearly
When to stop Bisphosphonates ?
After 5 years and continue if :
- > 75y/o
- on steroids
- prev hip/vertebral fracture
- high risk FRAX
- T score <2.5 still
Osteoporotic Medications
Pathophysiology
Fill more
Bisphosphonates - Inhibit Osteoclasts
Denosumab - Human monoclonal antibody to RANKL
(ONLY for primary prevention of OFF in postmenopausal women who have osteoporosis (T-score <-2.5)
Raloxifene - Selective oestrogen receptor modulators (SERM) -
Osteoporotic Drugs and Step up’s
PO bisphosphonate (switch if dysphagia),
2nd IV zol,
3rd denosumab
SERMs can be considered if spinal #s
Polyarteritis Nodosa Diagnostic Criteria ?
Young Patient with Thrombotic Event
≥ 16 years + Need 3/10
- LOW >4kg
- Livedo reticularis
- Testicular pain
- Myalgia
- Mononeuritis Multiplex
6 New onset DBP > 90mmHg - Elevated urea >14.3//creatinine >133
- Hepatitis B
- Arteriogram – dilated arteries/constricted by arteritis
- Granulocyte/mixed leukocyte infiltrate in arterial wall biopsy
Post Prandial Abdominal Pain
Which Arteries are spared by Polyarteritis Nodosa ?
Pulmonary and Glomerular
Whats the Treatment for PAN ?
Prednisolone
Cyclophosphamide
Antiviral for Hepatitis B
Pathophysiology of PAN
Focal segmental necrotising leukocytoclastic vasculitis –>
Inflammation damages vascular endothelium & predisposes formation of arterial thrombosis
AND
Fibrinoid Necrosis
Kawasaki Disease Features Mnemonic
Conjuctivitis Bilateral
Rash Polymorphous
Adenopathy
Strawberry Tongue
Hands (Desquamation and Oedema)
Burn - Fever > 5 days
Kawasaki Disease Investigations and Treatment ?
Urinalysis - Sterile Pyuria
Echo - Coronary Angiogram in first 6 weeks time
High Dose Aspirin
IVIG to reduce risk of Coronary Aneurysm
Need to give in first 10 days
PAN Nodosa Investigations
C3/C4 Low if Heb B
C3/C4 Elevated if Idiopathic
Thrombocytosis / Anaemia / Leukocytosis
What is Anti-
Synthetase Syndrome also called as ?
Dermatomyositis
Marfan Syndrome Mutation ?
FBN1 Gene on C15
Sequestrates TGF-Beta and Protects Elastin
Marfan - Defect in Glycoprotein that wraps around Elastin
Marfan Features ?
Pectus Carinatum / Pectus Excavatum
Dural Ectasia
Lens Dislocation Up and Out (unlike __________)
Blue Sclera
Dilatation of Aortic Sinuses
(Aortic Regurgitation / MVP)
Intellect Intact !!! unlike Homocystinuria
Antiphospholipid Syndrome
- Features
- Investigations
- Treatment
- CLOT
Clots - Arterial/Venous
Liverdo Reticularis
Obstetric Loss
Thrombocytopenia
- Anti-Lupus Anticoagulant
Cardiolipin
B2 Glycoprotein Antibodies
Positive on 2 occasions 12 weeks apart
Do Treponema Serology to Avoid FALSE POSITIVES
Mixing Studies and no correction of APTT o PT
- Primary Prophylaxis - Low Dose Aspirin
If Thrombotic Event then Wafarin (2-3) –> IF Thrombotic despite on Wafarin –> Wafarin (3-4) + Low Dose Aspirin
Which antibody is good for Diagnosing APLS vs Predicting Future Thrombosis ?
ACL better for diagnosis, LAC better for predicting risk of future thromboses
Features of Osteogenesis Imperfecta ?
BDSM:
Blue sclera
Dental imperfection
Sensorineural hearing loss
Multiple fractures
Which Collagen Type is Impaired in Osteogenesis Imperfecta ?
Type 1
DEXA screening where vs Diagnosing where
Calcaneum for Screening
Hip for Diagnosing
Discoid Lupus Erythematosus Quick Facts !!!
Rarely Progresses to SLE
Young Females Commonly
Causes SCARRING ALOPECIA
Photosensitive
Carpet Sign - Peel lesion and look underneath Follicular Keratin Plugs
Temporal Arteritis Ophthalmological Findings
Occlusion of the posterior ciliary artery –> AION - Swollen Pale Disc and Blurred Margins
GCA Triad
Anemia
ESR Elevated
Fever
Unique Investigations Specific to GCA
ALP
IgG
CK not elevated (vs Dermatomyositis)
Temporal Artery Biopsy
(Serial Sectioning ever 3-5 cm of Temporal Artery) if Negative DOESNT RULE OUT GCA !!!!!!
Which Enzyme does Leflunomide Inhibit ?
Dihydroorotate Dehydrogenase
Which Enzyme Inhibited by Mycophenolate Mofetil
Inosine Monophosphate Dehydrogenase
BehCets Disease
- HLA ?
- Features
- Investigations
- Diagnostic Criteria
HLAB51
- Middle Eastern / Mediterranean –> Male Predominance
Korean / Japanese –> Female Predominance
- Oral Ulcers
Genital Ulcers
Uveitis (70% with 1/4 going blind)
Thrombophlebitis
Erythema Nodosum
Neuro - Aseptic Meningitis
Cerebral Venous Sinus Thombosis
Abdomen - Ileocecal Valve involvement
- Recurrent Oral Ulcer (3 or more in 12 months)
+ 2 of
Recurrent Genital Ulcers
Ocular
Cutaneous -
(Erythema Nodosum , Psuedofolliculitis and Acneiform )
Positive Pathergy Test
(puncture site following needle prick becomes inflamed with small pustule forming)
Pregnancy Safe DMARDs
C
Azathioprine
Sulfasalazine
Hydroxychloroquine
Why should NSAIDs be avoided in 3rd Trimester ?
Premature Closure of PDA
Avoid after 32 weeks
Discoid Lupus Treatment
Steroids Topical –> Oral Hydroxychloroquine
Poor Prognostic Factors for RA ?
RA 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
When do we X ray Ankles ?
ankle x-ray is required only pain Mid foot + 1 of the following
1.Tenderness in the 5th metatarsal zone
2.Tenderness in the Navicular zone
3. inability to walk 4 steps with weight bearing immediately or in the ED
Target for cANCA and pANCA ?
cANCA - Serum Protease 3
pANCA - MPO
What Risk Factor for Adhesive Capsulitis ?
T2DM
Reactive Arthritis
1. Causative Agent
2. Treatment
- Post Dysentery
Shigella flexneri
Salmonella typhimurium
Salmonella enteritidis
Yersinia enterocolitica
Campylobacter
Post STI
Chlamydia trachomatis
- From Aspirate –>
No organism found = Reactive = No antibiotics
**START NSAIDs and REFER to Rheumatology **
Organisms isolated = Septic = IV Flocloxacillin
Treatment for RA
Mild -
Hydroxychloroquine
Moderate - Severe
(Extra articular / RF Anti CCP + / Radiological Erosions)
1st Line –> Methotrexate with Bridging Steroids
(FBC LFT HepB/C Mantoux Test before starting)
2nd Line –> S/H/L
STEP UP - DMARD + DMARD
STEP UP - BIOLOGICS !!!
When ?
If two trials of DMARDs (1st monotherapy + 2nd combination therapy) still can’t achieve remission .
Each trial lasts 6 months. Combination therapy must include methotrexate.
Severe: DAS-28 >5.1
When do we start Biologics in RA ?
If two trials of DMARDs (1st monotherapy + 2nd combination therapy) still can’t achieve remission .
Each trial lasts 6 months. Combination therapy must include methotrexate.
+
Severe: DAS-28 >5.1
What’s the DAS-28 cut offs for RA ?
DAS-28
<2.6 = remission
2.6-3.2 = low disease activity
3.2-5.1 = moderate disease activity
>5.1 = severe disease activity
Ask Emily Whats this on RA management
DAS28 >3.2 (MODERATE RA) –> + biologics // biologics alone if MTX contraindicated
*IL6: after inadequate response to 1 or more DMARD
*Abatacept for pt with non-tuberculous mycobacterial lung disease
*Rituximab after inadequate response to TNFa
*Rituximab for pt with lymphoproliferative disorder
*JAK inhibitor only if cannot tolerate TNFa
How is Pagets Disease Treated ?
Oral or IV Bisphosphonates
Rheumatoid Factor
IgM against Fc Portion of IgG
Meet and Greet !!!!
T3 HSN !!!
Medications Causing Osteoporosis ?
DRUGS that CAUSES osteoporosis :
She developed Breast cancer (anastrazole), admitted in hospital (gave her DVT prohylaxis Heparin), PPI cover was also given, she developed hospital acquired psychosis and was given (SSRI)
In Systemic Sclerosis
Where is PAH common and ILD Common ?
Limited - PAH
Diffuse - ILD and Scleroderma Renal Crisis
What Medication should Patients with Scleroderma Renal crisis be started on
ACEi Captopril
Mixed Connective Tissue Disease
- Features
- Investigations
- Treatment
- Its a Collection of Diseases
Severely –> SLE
Punished –> Polymyositis
Due to –> Dermato
Severed –. Scleroderma
RNP –> Anti U1RNP
Raynaud’s Usually Precedes
Dactylitis
- Anti U1 RNP
Antibodies against SnRNP70 which is a component of the SPLICESOME
ANA + but ScL70 - and DsDNA - (If they are positive then they are sensitive to those diseases)
- Treat Symptoms of the Collective Diseases
Cutaneous Findings in Reactive Arthritis ?
- circinate balanitis (painless vesicles on the coronal margin of the prepuce)
- keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles)
Spinal Stenosis Presentation ?
Associated with OA
Spinal stenosis –>
Brought upon by Walking in LEGS !!! (w or w/o backpain) AND
relived by bending forward.
facet pain –> pain on standing and back extention.
Causes behind Raynauds Phenomenon ?
Mnemonic
COLD HAND
Cryoglobulins
Obstruction
Lupus
DM/Drugs - BB/OCP/Migraine
Hematological (PRV)
Atherosclerosis
Neurological
Disease of Unknown (Idiopathic)
Azathioprine MOA ?
Purine Synthesis Inhibitor
TPMT Test to check patients prone to Azathioprine Toxicity
Side Effects of Azathioprine
Non Melanoma Skin Cancer
Pancreatitis
Bone Marrow Supression
Familial Mediterranean Fever (FMF)
- Inheritance
- Pathophysiology
- Complication to keep an eye out for ?
- Treatment
- Autosomal Recessive
Armenian Greek Turkish
2nd Decade of Life
2.
MEVR Gene Mutation on C16 Nonsense Mutation
Produce Pyrin
Mutation Causes Uninhibited Pyrin Production –> Increase IL1
Fever (lasts 6 hours to 4 days)
Peritonitis
Pleuritis
Arthritis
Pericarditis
erysipeloid rash on lower limbs
- Secondary Amyloidosis –> CKD
So check UE - Colcohicine
Anakinra
T score compared to what ?
Z score compared to what ?
T score: based on bone mass of young reference population
Z Score : Matched for Age Sex and Ethnic
Pagets
Osteoporosis
Osteopetrosis
Is it increased or decreased Osteoclast ?
Pagets: Increased Osteoclast
Osteoporosis : Increased osteoclast
Osteopetrosis : Reduced osteoclast
TNF secreted by which cells primarily in humans ?
Macrophages
Antiphospholipid Syndrome Picture ?
High APTT and Low PLT
vs
Activated Protein C Resistance causes Shortened APTT
LESS vs LOSS
Loss of Joint Space
Erosions
Soft Tissue Swelling
Juxta articular Osteopenia
Loss of Joint Space
Osteophytes
Subchondral Cysts
Subchondral Sclerosis
Gout Radiological Features
Double Contour Sign on USS
Juxta-articular distribution ‘punched out lesion’
Soft Tissue Swelling
Overhanging Sclerotic Margins
no periarticular osteopenia (in contrast to rheumatoid arthritis)
Chondrocalcinosis seen in Pseudogout
Gout - Soft tissue swelling, punched-out bone lesions and overhanging sclerotic margins
L4 compression
Loss of Knee Jerk
Weak Knee Extension and Hip Adduction
Sensory loss anterior aspect of knee and medial malleolus
Positive Femoral Stretch
L4 and L3 Compression
Positive Femoral Stretch Test
Reduced Knee Reflex for L3 and L4
L5 and S1 (ankle Reflex reduced only in S1 compression)
Positive Sciatica Strech Test
Myotome for
L3/L4/L5 and S1
L3- Weak hip flexion, knee extension and hip adduction
L4- Weak knee extension and hip adduction
L5- Weak Big toe dorsiflexion
S1- Weakness on Plantar Flexion
Dermatome for L3/L4/L5 and S1
L3 = parasthesia over anterior thigh
L4 = same as L3 in terms of parasthesia over anterior thigh, but also over the knee
L5 = weakness of dorsiflexion of big toe and foot
S1 = weakness of PLANTAR flexion of foot and small toe pinky
Pseudoxanthoma elasticum features !!!
retinal angioid streaks
‘plucked chicken skin’ appearance - small yellow papules on the neck, antecubital fossa and axillae
cardiac: mitral valve prolapse, increased risk of ischaemic heart disease
gastrointestinal haemorrhage
Sulfasalazine
1. MOA
Prodrug for 5ASA –>
Decreasing neutrophil chemotaxis & suppressing proliferation of lymphocytes and pro-inflammatory cytokines
Sulfasalazine
1. Cautions
2. Side Effects
Cautions
G6PD deficiency
allergy to aspirin or sulphonamides (cross-sensitivity)
Adverse effects
- oligospermia
- Stevens-Johnson syndrome
- pneumonitis / lung fibrosis
- myelosuppression,
- Heinz body anaemia 6. Megaloblastic anaemia
- may colour tears → stained contact lenses
Avascular Necrosis Precipitants ?
Long Term Steroids Previous Chemo
Alcohol Excess
Trauma
Secondary Causes of Osteoporosis ? Menmonic ?
SLE Antibody Specific and Sensitive ?
Specific - Anti dsDNA and Anti Smith
Sensitive - ANA
Drug Induced Lupus Mnemonic
SHIMP:
1.Sulphonamides
2.Hydralazine (renal involvement)
3. Isoniazid
4. Minocycline
5. Phenytoin, Penicillin, Procainamide
What Antibody for Drug Induced Lupus ?
Anti - Histone
Rickets Pathophysiology ?
Excess Non Mineralized Osteoid at Growth Plates
Rickets Features ?
Swollen Wrists
Rickety Rosary
Harrisons Sulcus
Toddlers - Genu valRUM
Children - Genu valGUM
Craniotabes - Soft Cranial Bones
Biochemically - Hypocalcemia , Raised ALP and Low Vitamin D
Rickets X ray features
frying-widening and irregularity of the growth plate
splaying-widening of the metaphysical end of the bone
cupping-concavity of the metaphysis
In Sjogren Syndrome what drug can help wet mouth ?
Pilocarpine Muscarinic Agonist
Relapsing Polychondritis features
Ears: auricular chondritis, hearing loss, vertigo
Nasal: nasal chondritis → saddle-nose deformity
Respiratory tract: e.g. hoarseness, aphonia, wheezing, inspiratory stridor
Ocular: episcleritis, scleritis, iritis, and keratoconjunctivitis sicca
Joints: arthralgia
Recurrent Polychondritis + Behcets Disease
MAGIC
Mnemonic for TNF Alpha inhibitors
I-AGE
I - Infliximab (also IV)
AGE (Adalimumab, Golimumab, Etanercept) = all S?C
Osteomalacia X ray features ?
Psuedofractures or Looser Zone Translucency
Waddling Gait + Bony Tenderness with Proximal Myopathy – > THIN WHAT ??
OSTEOMALACIA !!!!
Vs Polymyalgia (mostly >50) + NO Weakness
Hand OA Joint Involvement
Carpometacarpal and distal interphalangeal joint
Lateral Epicondylitis Examination Findings ?
Pain on Wrist Extension and Supination against Resistance when Elbow Bent
If Medial Epicondylitis then
Wrist Flexion and Pronation pain on resistance when elbow bent
Leflunomide Side Effects
gastrointestinal, especially diarrhoea
hypertension
weight loss/anorexia
peripheral neuropathy
myelosuppression
pneumonitis
What to measure for Leflunomide then ?
Blood Pressure !!!!
Every 2 weeks for the first 6 months and then 8 weekly
Contraceptive Guidance for Leflunamide
Contraception for at least 2 years for Women and 3 months after treatment for Men
Long Wash Out Period so coupled with Cholestyramine to excrete
Carpal Tunnel Syndrome Features and Treatment
Wasting of THENAR Eminence
APB Muscle weakness cant pinch
Treatment -
1. 6 weeks conservative
2. Corticosteroid Injections
3. Wrist Splints useful if Transient Exacerbating Factors like Pregnancy
4. Flexor Retinaculum Division
Gonococcal Arthritis Presentation ?
Arthritis-dermatitis syndrome
Allergy to what drug can cross react with Sulphasalazine ?
Aspirin
De Quervain Thyroiditis
Pain over Radial Styloid
Abduction of the thumb against resistance is painful
Urinary Markers
Urinary hydroxyproline - Paget’s disease of bone.
Urinary porphobilinogen - acute intermittent porphyria
Urinary uroporphyrin - porphyria cutanea tarda
Urinary coproporphyrin - Dubin-Johnson syndrome
Mneumonic CHUP (Markers) DPPA (diseases)
When is RA Flare Up Common vs When is SLE Flare up Common ?
Conditions worse during Pregnancy:
SLE
Myasthenia Gravis
Conditions improve during pregnancy:
RA
Multiple sclerosis
Raised PTH in Osteomalacia ? yes or no
Yes
X ray Early and Late changes for RA
Rheumatoid arthritis
1. Early x-ray findings: loss of joint space, juxta-articular osteoporosis, soft-tissue swelling
- Late x-ray findings: periarticular erosions, subluxation
Pseudogout Causes
haemochromatosis
hyperparathyroidism
low magnesium,
low phosphate
acromegaly,
Wilson’s disease
So check
PTH level, TFTs, Serum Mg/PO4, IGF1 level etc…
Transferrin not Ferritin as Acute Phase Reactant
Discoid Lupus Treatment
Topical steroids → Oral Hydroxychloroquine
Most Common Echo finding in
Pseudoxanthoma Elasticum
MVP
Medications causing
Gout
Cover gout with A Cool PAD
Cover gout with A Cool PAD
Ciclosporin, Alcohol, Cytotoxic agents, Pyrazinamide, Aspirin, Diuretics.
Ciclosporin, Alcohol, Cytotoxic agents, Pyrazinamide, Aspirin, Diuretics.
