Rheumatology 2 Flashcards
Osteomalacia
what is it?
Causes (6)
1 Big one with 3 causes within!
2 - condtition
3 drug eg. 1
4- condition
5- condition
6- condition
softening of the bones secondary to low vit D, leads to decreased bone mineral content.
- vitamin D deficiency
- malabsorption
- lack of sunlight
- diet - chronic kidney disease (less conversion of Vit D to active form 1,25-dihydroxyvitamin D
- drug induced e.g. anticonvulsants
- inherited: hypophosphatemic rickets (previously called vitamin D-resistant rickets)
- liver disease: e.g. cirrhosis
6 coeliac disease (malabsorption)
Osteomalacia
Vit D insufficiency =
Vit D deficiency =
Features (4)
1
2
3- where?
4- observe?
Investigations
- what do you see on bloods? (4)
how does this compare to osteoperosis?
Imaging-
-
Vit D insufficiency 20-50ng/ml
Vit D deficiency <12ng/ml
- bone pain
- bone/muscle tenderness
- fractures: especially femoral neck
- proximal myopathy: may lead to a waddling gait
Bloods
1. Low vit D, Low calcium
2. Low phosphate
3. HIGH ALP!
Osteoperosis see NO change in bone profile!
Managment
1. Oral vit d supplementation
- need a loading dose
2. Oral calcium if diet poor
Ricket
- Lower limb abnormalities-
- ## --
-
Features
- aching bones and joints
- Lower limb abnormalities- toddlers genu varum (bow legs)
in older children - genu valgum (knock knees)
- ‘rickety rosary’ - swelling at the costochondral junction
-kyphoscoliosis
craniotabes - soft skull bones in early life
- Harrison’s sulcus- indentation on the chest roughly along the 6th rib
- widening of the wrist joints due to an excess of non-mineralized osteoid at the growth plate
-
-
Drugs which induce SLE
Most common
- think acid (2)
Less common
- Day drinking
Most common
p- procainamide
h- hydralazine
Less common
p- phenytoin
i- isoniazid
m- minocycline
Life-long anticoag for antiphospholipid syndrome with what?
Warfarin! Target INR 2-3
Marfans
The FBN1 gene
on chromosome?
Deficiency of what glycoprotein?
Features
1. CV (2)
2. Resp
3. Eyes (3)
4. Observe/ on insoection (6)
15
Fibrillin
Features
1. CV
- Mitral regurg/ prolapse
- aortic aneurysm of sinus- dissection (also can get regurg)
2. Resp- PTX! seen as primary
3. Eyes
- blue sclera
- myopia (short-sighted )
- upwards lens dislocation
- Observe/ on insoection
- v tall
- high arched palate
- pectus excavatum
- arachnodactyly- long slender fingers
- pes planus- flat foot
- scoliosis
dural ectasia (ballooning of the dural sac at the lumbosacral level)
Bisphosphonates Adverse effects (5)
- GORD- oesophageal reactions: oesophagitis, oesophageal ulcers (especially alendronate)
- osteonecrosis of the jaw
- risk of atypical stress fractures- proximal femoral shaft on alendronate
- acute phase response: fever, myalgia and arthralgia may occur following administration
- hypocalcaemia: due to reduced calcium efflux from bone. Usually clinically unimportant
OA management
1. concserv
2. first line
3. second line
4. non-pharmo
5. last-line
- Conservative- muscle strength
- first-line: paracetamol and topical NSAIDs
- Topical NSAIDs are indicated only for OA of the knee or hand - 2nd line - oral NSAIDs/COX-2 inhibitors, opioids, capsaicin cream and intra-articular corticosteroids + PPI
- TENS machine, supports, braces
- If all fail then surgery
HYPERSENSITIVITES
Type I
Mech-
Example (2)
Type II
Mech-
Example- (4/7)
Type I
Mech- Antigen + IgE bound to mast cells
Example
- anaphylaxis
-Atopgy (asthma, eczema and hayfever)
Type II
Mech- IgG or IgM binds to antigen on cell surface
Example
- Autoimmune haemolytic anaemia
- ITP
- Goodpasture’s syndrome
- Pernicious anaemia
* Acute haemolytic transfusion reactions
* Rheumatic fever
* Pemphigus vulgaris / bullous pemphigoid
HYPERSENSITIVITES
Type III
Mech-
Example (2/4)
Type IV
Mech-
Example (4/7)
Type III
Mech- Free antigen and antibody (IgG, IgA) combine
Example
- Serum sickness
* Systemic lupus erythematosus
* Post-streptococcal glomerulonephritis
* Extrinsic allergic alveolitis (especially acute phase)
Type IV
Mech- T-cell mediated
Example
* Tuberculosis / tuberculin skin reaction
* Graft versus host disease
* Allergic contact dermatitis
* Scabies
* Extrinsic allergic alveolitis (especially chronic phase)
* Multiple sclerosis
* Guillain-Barre syndrome
Ankylosing spondylitis features - the ‘A’s (6)
Apical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
AV node block
Amyloidosis
Fibromyalgia
Features (4)
Mnagement complex and MDT but 4 principles
1
2
3
4- med eg (3)
- chronic pain: at multiple site, sometimes ‘pain all over’
- lethargy
- cognitive impairment: ‘fibro fog’
- sleep disturbance, headaches, dizziness are common
management
1. EXPLAIN!
2. Exercise- best!
3. CBT
4. Med- pregabalin, amytriptylin, duloextine
OA vs RA on hand xray
OA where?
classic
RA 4 signs on XRAY
OA - Distal interphalangeal! Look like pawns in chess
- also carpometacarpal joints
NO RA in DIP!!
also classic LOSS
Loss of joint space
Osteophytes forming at joint margins
Subchondral sclerosis
Subchondral cysts
RA shows
- Juxta-articular osteoporosis/osteopenia (early on)
- loss of joint space
- periarticular erosions
- subluxation
Alport syndrome - defective production of type IV collagen.
features (3)
Mx with..
- glomerulonephritis
- end-stage kidney disease, 3. hearing loss
ACEi
features of DIFFUSE systemic Sclerosis (3)
med 1.
- ILD - how most die
- Pulmonary artery HTN! and HTN
- Renal disease
start on ACEi
