Rheumatology Flashcards
Xray features in ankylosing Spondylitis
Plain Xray of sacro iliac spine is most useful investigation in ankylosing spondylitis. Findings include
- Sclerosis
- Subchondral erosions
- Bamboo spine
- Syndesmophytes
- Squaring of Lumbar vertebrae
CXR - Apical Fibrosis
Treatment:
Regular exercise
Physiotherapy
NSAIDS
Disease modifying drugs eg Sulphasalazine, if there is peripheral joint involvement
Treatment of Gout
ACUTE:
NSAIDS or Colchicine is 1st line
Next line is prednisolone
Intrarticular steroids
Urate reducing drug in order of preference -
Allopurinol
Febuxostat
Uricase
Pegloticase
Life style modification
- Avoid purine rich foods
- Switch Thiazides to Losartan (Uricosuric)
- Avoid alcohol during attacks
- Weight loss
- Increased Vitamin C
MOA of Colchicine
Binds to tubulin to inhibit microtubule polymerization and inhibit Mitosis
Warm autoimmune hemolytic anaemia
Occurs at room temperature.
Involves IgG. causes extravascular hemolysis
Causes - Idiopathic, SLE, lymphoma, CLL, methyldopa,
Treatment
Steroids +/- Rituxumab
Cold Autoimmune Hemolytic anaemia
Occurs at -4 degrees.
Involves IgM. causes Intravascular hemolysis.
Seen in acrocyanosis and raynaud’s phenomenon
Causes - Mycoplasma, EBV, SLE, lymphoma,
What is double contor sign
A hyperechoic, irregular band over the superficial margin of the joint cartilage.
Seen in Gout and caused by deposition of monosodium urate crystals.
Different from deposition of calcium pyrophosphate which causes hyperechoic, irregular band in middle layer of the cartilage.
Familial mediterranean fever
It is also called recurrent Polyserositis.
Autosomal recessive inheritance.
More common in turkish, armenian and arabic people.
Feature - Pericarditis, arthritis, Pleuritis, pyrexia, erysipeloid rash on lower limbs.
Treatment - Colchine may be helpful
Difference between Rheumatoid arthritis and Psoriatic arthritis based on affected joints
PIP - Rheumatoid arthritis
DIP - Psoriatic arthritis
Radiological findings specific to particular diseases
Pepper pot skull - Hyperparathyroidism
Rain drop skull - Multiple myeloma
Double contour sign - Gout
Pencil in cup appearance - Psoriatic arthritis
Treatment of Psoriatic arthritis
Mild disease - NSAIDS
Moderate/severe disease - Methotrexate, Monoclonal antibodies, Apremilast (Phosphodiesterase inhibitor)
Prognosis is better than RA
Features of ankylosing spondylitis
Back pain, worse in the morning, improving with exercise
Reduced forward flexion (Schober’s test) and lateral flexion.
The As - Aortic regurgitation, anterior uveatis
Reactive arthritis
Constellation of Urethritis, Conjuctivitis, Arthritis.
Formerly called Reiter’s syndrome
Treatment -
- NSAIDS, Intrarticular steroids
- Persistent disease - Methotrexate, Sulphasalazine
-
Pathognomic skin features of reactive arthritis
circinate balanitis (painless vesicles on the coronal margin of the prepuce)
keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles)
features of Psoriatic arthritis
Symmetric polyarthritis
Asymmetric Oligoarthritis
DIP disease
Sacroilitis
Arthritis mutilans
Other features of Psoriatic arthritis:
Periarticular - Dacylitis, Tenosynovitis
Skin - Psoriasis
Nail - pitting, Onycholysis
Risk factors of pseudogout
Hyperparathyroidism
Haemochromatosis
Wilson’s disease
Low Mg, Low PO4
Acromegaly
ANCA associated vasculitis
Includes Granulomatosis with polyangitis, Eosinophilic Granulomatosis with polyangitis and Microscopic polyagitis
cANCA - Granulomatosis with polyangitis (Wegener’s ganulomatosis)
pANCA - Churgstrauss disease and microscopic polyangitis
Symptoms include Renal symptoms, respiratory symptoms, systemic symptoms and upper respiratory tract symptoms.
Investigation: FBC, U&E, CXR, ANCA screening, CRP Urinalysis
Treated with immunosuppressive medications
Conditions associated with pANCA
Ulcerative colitis
Crohn’s disease
Primary sclerosing cholangitis
Anti GBM disease
Antibodies and their most associated conditions
ACh receptors - Myaesthenia gravis
Anti gliadin - Celiac disease
cANCA - Granulomatosis with polyangitis (Wegener’s ganulomatosis)
pANCA - Churg strauss disease and microscopic polyangitis
dsDNA/ anti SSA - SLE
Anti-CCP - Rheumatoid arthritis
TSH antibodies and thyroid peroxidase - Graves disease
Anti centromere - Limited cutaneous systemic sclerosis
Anti Scl 70 - Diffuse Cutaneous systemic sclerosis
Anti mitochondrial antibodies - Primary biliary cirrhosis
Anti mi 2 antibodies - Dermatomyositis
Anti jo - Myositis
Anti cardiolipin - Primary phospholipid syndrome
Anti-U1RNP - Mixed connective tissue disease.
Avascular necrosis of the femur : Causes and investigation
Causes:
Chemotherapy
Long term steroids
Alcohol excess
Trauma
Investigation:
MRI of the joint - best option
Plain X-ray - may show osteopenia and microfractures, Crescent sign
Treatment:
Joint replacement
Dermatomyositis
inflammatory disorder characterized by characteristic skin lesions and proximal limb weakness.
associated with some malignancies and connective tissue diseases
Skin:
Photosensitive rash
Heliotrope rash, Gottron papules, Mechanic hands, nail bed capillary dilatation.
Investigation - Anti Mi, Anti-jo 1, Anti SRP
Check creatine kinase, muscle biopsy
Treatment
Check for cancer
physiotherapy/OT
Corticosteroids - 1st line
Immunosuppresant - Methotrexate, azathioprine
Triad of Interstitial lung disease, inflammatory arthritis and Myositis
Anti-synthase syndrome
Mixed connective tissue disease
Also called sharp’s syndrome
wide range of symptoms similar to SLE, myosistis, systemic sclerosis.
Raynaud’s phenomenon is often the 1st symptom.
Mostly associated with Anti-U1RNP, ANA
Cryoglobulinemia
Type I - Monoclonal, RF/ANA - negative. Associated with multiple myeloma and waldenstrom macroglobulinemia.
Type II - Mixed monoclonal and polyclonal, RF - Positive. associated with Hep C, Rhematoid arthritis, lymphoma, Sjogren’s disease.
Type III - Polyclonal. RF - Positive. Associated with Sjogren’s syndrome, RA
Investigation - High ESR, Low C4
Treatment -
Immunosuppressives
Plasmaoharesis
A combination of Neurological symptoms + Jaundice
Likely Wilson’s disease
Copper accumulationon tissues eg Basal ganglia, Liver, eyes, kidney.
Autosomal recessive inheritance of defective ATP7B gene on chromosome 13.
Ist symptom in children - Liver dx, while it is neurological symptoms in adult.
Investigation
Reuced ceruloplasmin, reduced serum copper (Bound). raised free serum copper,
Treatment
Chelation with penicillamine / Trietine hydrochloride
