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-
- ## --
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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
What IL is triggered in sepsis causing hypotension?
IL-1 - causes big vasodilation and fever
WHat is the most common manifestation of systemic lupus erythematosus (SLE)
pericarditis
myocarditis also assoc.
Management of PMR
1.
what marker is rained and what is not raised?
prednisolone e.g. 15mg/od
patients typically respond dramatically to steroids, failure to do so should prompt consideration of an alternative diagnosis
ESR increased
CK NOT raised, EMG normal
SLE management
Basics (2)
Med-
if internal organ involvement (2 options)
NSAIDs
sun-block
HYDROXYCHLOROQUINE!
Internal
- prednisolone
- cyclophosphamide
Anti-citrullinated protein antibody is for?
highly specific test for rheumatoid arthritis
Ank Spond- How many different NSAID drugs must this patient have failed to respond to before anti-TNF alpha inhibitors- if predominantly axial!!
2
what blood test/ condition is a risk factor for pseudo-gout
Raised calcium, low phosphate and a raised parathyroid hormone which is typical of primary hyperparathyroidism.
calcium pyrophosphate dihydrate deposition (CPPD) or pseudogout
Chemotherapy patients are at increased risk of what rheumatology condition?
Gout- from increased urate production
Cytotoxic drugs cause an increase in the breakdown of cells, releasing products that are degraded into uric acid. Hyperuricaemia is a known risk factor for gout.
Which blood test is the best for ruling out SLE
ANA- its the most sensitive,most will have
What is a difficult situation when prescribing a bisphosphinate? and what should be done?
BNF states bisphosphonates are contraindicated if the eGFR is less than 35!! even IV
therefore consider denosumab
DEXA scan get T score but also Z score-what does this acocunt for? (3)
- age
- gender
- ethnic factors
