Rheumatology Flashcards
1
Q
Monitoring of rheumatoid arthritis
A
DAS28 (Disease activity Score) Based on how many tender joints, how many swollen joints, and ESR/CRP results Less than 2.6 = remission 2.6-3.8 = low disease activity 3.8-5.1 = moderate disease activity Over 5.1 = high disease activity
2
Q
X-ray findings in osteoarthritis
A
LOSS Loss of joints space Osteophytes (Heberden/Bouchard nodes) Subchondral sclerosis Subchondral cysts
3
Q
X-ray findings in rheumatoid arthritis
A
LOSED Loss of joint space Osteopenia Soft tissue swelling Erosions Deformities
4
Q
Joints affected in rheumatoid arthritis
A
Symmetrical small joints
EXCUDING: DIPs, 1st MTP/MCP
5
Q
Joints affected in osteoarthritis
A
Females: DIPs, PIPs, 1st CMC
Males: Hip
6
Q
Side effects of MTX
A
GI (stomatitis, n&v, diarrhoea) Photosensitivity Increased risk of infections - especially varicella Miscarriage (make sure on contraception) Bone marrow toxicity Hepatitis/fibrosis Intersitial lung disease
7
Q
Side effects of plaquenil (hydrochloroquine)
A
Similar to MTX (GI symptoms, hair loss)
+ loss of peripheral vision due to fibrosis around macula
8
Q
Side effects of biological DMARDs
A
Infections Malignancy Neurological syndromes (MS, GBS etc) Severe CHF Autoimmune like syndromes Pancytopaeia, aplastic anaemia Raised transanimases Eczema/psoriatic skin rashes
CANNOT GIVE LIVE VACCINATIONS
9
Q
Monitoring while being treated with MTX/other DMARDs
A
CBE, renal function and LFT every 2-4 weeks for first 3 months of treatment
3 monthly thereafter
10
Q
Baseline investigations before beginning MTX or other DMARDs in RA
A
CBE Renal function LFT CXR (in last year) PFTs (in last year) Hep B and C serology (if at high risk)
11
Q
Extra-articular manifestations of RA
A
Neurological symptoms (if C-spine instability)
Nodules on extensor surfaces/pressure points
Eye symptoms (red, itchy, sore)
Constitutional symptoms: mild weight loss, low-grade fevers, fatigue, weakness)
Resp: ILD
Heart: CAD, pericarditis, myocarditis
12
Q
Investigations in RA
A
CBE: anaemia of chronic disease ESR or CRP: raised RF Anti-CCP (very specific, only present in 50%) Plain x-ray
13
Q
Anti-Ro (SS-A) antibody association
A
Sjogren’s syndrome
14
Q
Anti-La (SS-B) antibody association
A
Sjogren’s syndrome
15
Q
Anti-smith antibody association
A
SLE
16
Q
Anti-RNP antibody association
A
Mixed connective tissue disease
17
Q
Anti- Scl70 antibody association
A
Scleroderma
18
Q
Anti-Jo antibody association
A
Dermatomyositis
19
Q
HLA-DR4 association
A
Polymyalgia rheumatica, temporal arteritis
20
Q
HLA-B27 association
A
spondyloarthritides (Ankylosing spondylitis, IBD-associated, reactive arthritis, psoriatic arthritis etc.)
21
Q
Anti-dsDNA antibody association
A
SLE
22
Q
Classic SLE triad
A
fever, joint pain and rash in a woman of childbearing age
23
Q
Erosive osteoarthritis
A
May resemble RA but limited to fingers (DIP, PIP, 1st CMC)
Characterised by CENTRAL erosions (as opposed to marginal erosions in RA) and pseudocysts at DIP and PIP joints
Central subchondral erosions lead to “gull wing” appearance
No soft-tissue swelling or osteopenia
24
Q
Non-pharmacologic therapy of osteoarthritis
A
Patient education and self-management Exercise therapy Weight loss Topical application of cold or heat packs Walking sticks to aid in ambulation Braces
25
Pharmacologic therapy of osteoarthritis
1. Paracetamol 1g QID PRN (or panadol osteo 600mg TDS)
2. NSAID if insufficient pain relief
3. Topical NSAID or capsaicin
4. Intra-articular corticosteroid injection, intra-articular hyaluronan higher cost and slower onset
Glucosamine sulphate and chondroitin sulphate - symptomatic benefit
26
Definition of rheumatoid arthritis
A chronic systemic inflamamtory disease of unknown cause, leading to a chronic symmetrical polyarthritis of both small and large joints and a range of extra-articular manifestations
27
What is pannus
Hypertrophied synovium which causes erosion of contiguous cartilage and bone in RA
28
Management of rheumatoid arthritis
NSAIDs for pain relief
+/- intra-articular steroids
Systemic steroids have shown some disease modifying properties
Non biologic DMARDS:
- start early (irreversible damage occurs within 1-2 years of diagnosis)
- MTX + foilc acid
- Leflunomide
- Sulfasalazine
- Hydroxychloroquine
Biologic DMARDs:
- indicated if DAS28 greater than 3.2 + failed adequate therapy after at least 3-6 months treatment of 2 standard DMARDS of which MTX must have been one
- TNF-a antagonists (etanercept, infliximab, adalimumab)
- Others (abatacept, rituximab)
- MTX must be given with to reduce tolerance
Non-pharmacological:
- Physical therapy and physical activity
- Occupational therapy: exercises, splinting, ergonomics
- patient education and self-management
- surgical (joint replacement, synovectomy etc)
29
Prognosis of rheumatoid arthritis
- most likely to inc. in severity in first 2 years
- Only 5% have rapid progression to total disability
- Life expectancy 3-10 years less than average
- 50% are disabled or unable to work within 10 years of diagnosis
30
What is Felty syndrome
Rheumatoid arthritis + splenomegaly + neutropenia
31
definition of podagra
Acute arthritis involving the first MTP joint
32
Definition of gout
A mono- or oligarthritis of metabolic origin caused by tissue deposition of monosodium urate crystals due to prolonged hyperuricaemia
33
Precipitants of gout episode
```
Stress
Trauma
Infection
Surgery
Crash dieting
Initiation of urate-lowering drugs or drugs than can cause raised urate
```
34
Diagnosis of gout
Serum uric acid level
- not always elevated in acute attack
- chronic hyperuricaemia needs to be treated if over 3 episodes per year (test 2 weeks after resolution of attack)
Joint-fluid analysis:
Monosodium urate crystals:
- needle shaped
- strongly NEGATIVELY birefringent (yellow when parallel to axis of red compensator, blue when aligned across direction of polarisation)
35
Management of Gout
Acute episode:
- Oral NSAID OR colchicine OR prednisolone until symptoms abate (usually 3-5 days)
Life-style modifications:
- low purine diet
- limit alcohol
- limit fructose-containing soft drink
Urate-lowering therapy:
- indicated if recurrent attacks despite lifestyle modifications (over 3 per year)
Allopurinol
36
Mechanism of allopurinol
inhibition of xanthine oxidase - reduced hypoxanthine/xanthine conversion (one of the steps in uric acid production - reduced uric acid prodcution
37
Definition of septic arthritis
Acute infectious inflammation of a joint space requiring urgent diagnosis to prevent rapid joint degeneration
38
Common pathogens in septic arthritis
Kids: kingella (often systemically well)
Young adults: gonorrhoea
Non-gonococcal: S aureus, S pyogenes, S agalictiae, S pneumoniae
Elderly, ISS or IVDU: G-ve (H influenzae, enterobacteriacaea, salmonella, pseudomonas)
39
Diagnosis of septic arthritis
```
Raised WCC, ESR and CRP
Blood culture may indicate organism
Joint fluid analysis:
- yellow colour
- turbid, purulent
- PMNs predominantly
- Synovial fluid:serum glucose ratio less than 0.5
- culture!
```
40
Management of septic arthritis
Immediate joint aspiration
Antibiotic therapy for 3-4 weeks
Initially IV, should not be switched to oral until clinical improvement
Infected prosthetic joints require longer treatment
41
Definition of psoriatic arthritis
A seronegative chronic asymmetrical oligoarthritis of mainly large joints in patients with psoriasis
42
Epidemiology and timing of psoriatic arthritis
1% of population
Classically 30-55y
Develops in up to 30% of patients with psoriasis
- often lags 20y after onset of skin disease
- may precede rash in up to 40% of children and 15% of adults
HLAB27 in 60%
43
Clinical features of psoriatic arthritis
```
Commonly affects hands
Morning stiffness
Pain, heat, joint tenderness
Nail lesions (in 90%)
- pitting
- ridging
- onycholysis
- subungal hyperkeratosis
Dactylitis
Hand or foot deformity
Painful, red eyes (uveitis)
Rash
Sacroilitis - back stiffness and pain
```
44
X-ray findings in psoriatic arthritis
```
Loss of joint space
Pencil in cup deformities
Bone proliferation (fuzzy bone around affected joint)
Subluxation
Marginal erosions
```
45
Severe form of psoriatic arthritis
Arthritis mutilans
Bony resorption - collapse of soft tissue - telescoping fingers (only in very severe cases)
"Opera glass hands"
46
Management of psoriatic arthritis
```
No cure, symptom control
Non-pharmacological:
- physical therapy
- lifestyle changes
- phototherapy (for rash)
```
Pharmacological:
- NSAIDs
- intra-articular corticosteroids
- DMARDs (MTX, leflunomide)
- TNFa inhibitors (etanercept)
Surgical
47
Which is the most common spondyloarthropathy
Ankylosing spondylitis
48
Definition of ankylosing spondylitis
The most common of the spondyloarthropathies, a chronic systemic inflammatory disease primarily affecting the joints of the spine
49
Symptoms of ankylosing spondylitis
Lower back pain
- begins unilaterally and intermittently
- inc. persistence as progresses
- becomes bilateral
- morning stiffness over 30min
- nocturnal back pain (second half of night)
Symptoms worse in morning or with inactivity
Symptoms improve with exercise/physical activity
Fatigue
Responds to NSAIDs
50
Clinical signs of ankylosing spondylitis
Reduced ROM of lumbar spine (reduced Schober test)
Stooped forward-flexed posture
Tenderness of joints
Increased Thoracic kyphosis
Enthesitis at insertion of Achilles
Uveitis (painful red eye, photophobia, increased tearing, blurred vision)
51
Xray findings in ankylosing spondylitis
SI joint:
- symmetrical bilateral sacroilitis
- joints intially widen - then narrow as progress
- subchondral erosions, sclerosis and proliferation of iliac side of SI joint
- at end stage, SI joint may be a thin line or not visible
SPINE:
- small erosions at corners of vertebral bodies (Romanus lesions of the spine - shiny corner sign)
- vertebral body squaring
- Bamboo spine (fusion of vertebral bodies
- dagger spine (ossification of supraspinous and interspinous ligaments - single central radiodense line)
- calcification of spinal ligaments
52
What are romanus lesions
Small erosions at corners of vertebral bodies
53
Management of ankylosing spondylitis
NSAIDS:
- suppositories in evening will reduce morning pain (indomethacin)
DMARDs:
- sulfasalazine only helps peripheral symptoms
TNF inhibitors:
- for patients with severe AS not responsive to NSAIDs
- Infliximab (IV at 0,2,6w then 6 weekly)
- etanercept (SC 2x/week)
- adalimumab (SC fortnightly)
Non-pharmacologic:
- exercise therapy
- daily stretching
- hydrotherapy or swimming
54
Definition of reactive arthritis
AKA Reiter's syndrome: an uncommon autoimmune condition that develops in response to an infection with a classic triad (in 30%) of non-infectious urethritis, arthritis and conjunctivitis
55
Infections which trigger reactive arthritis
Genitourinary:
- Chlamydia
Gastrointestinal:
- Shigella
- salmonella
- yersinia
- campylobacter
- clostridium difficile
56
Clinical features of reactive arthritis
Transient ASYMMETRIC arthritis of 1 or 2 large joints, distal lower limb most affected
- MTP most common, followed by calcaneus, ankle, knee
- settles within 6 months
```
Fever, malaise, anorexia etc.
Dysuria, UTI symptoms
Mucopurulent vaginal/penile discharge
- uveitis/conjunctivitis
- mouth ulcers
- nail changes
- new murmur
- dactylitis
```
57
Investigations in diagnosis of reactive arthritis
Serology for chlamydia antibodies
Urine PCR for chlamydia
Urine, discharge or stool culture
X-ray: similar to psoriatic
- ill-defined erosions
- bone proliferation
- asymmetric sacroilitis
58
Management of reactive arthritis
NSAIDs
Oral prednisolone for more severe articular and extra-articular disease (daily until symptoms improve, followed by slow dose tapering)
59
Definition of systemic lupus erythematous
A chronic autoimmune connective tissue disease that can affect almost any organ system and follows a relapsing and remitting course
60
Epidemiology of SLE
90% are women
Onset in child-bearing age
Higher incidence in blacks and asian
Family history
61
Arthritis presentation in SLE
Symmetrical (may be asymmetrical)
Polyarticular
Small joints of hands, wrists and knees
62
Dermatologic manifestations specific to SLE
Malar rash
Photosensitivity
Discoid lupus
63
Diagnosis of SLE
CBE: red. WCC and PLT, anaemia of chronic disease
Raised ESR, CRP
ANA- homogenous, speckled or peripheral rim pattern
Anti-dsDNA - more specific for lupus
Anti-smith (highly specific, not sensitive)
Antiphospholipid antibody - 30%
64
Management of SLE
Non-pharm:
- avoid fatigue
- adequate sleep
- broad spectrum sunscreen + slip, slop, slap
Pharm;
- NSAIDs
- Hydroxychloroquine
Topical glucocorticoids for skin lesions
Systemic glucocorticoids (if conservative therapy fails)
Immunosuppressive therapy - cyclophosphamide, AZA, mycophenolate mofetil (for life-threatening manifestations - GN, CNS involvement, thrombocytopenia, haemolytic aneamias)
MTX + folic acid for persistent arthritis (steroid-sparing)
65
Clinical features of disseminated gonococcal infection
May not have symptoms of urethritis/cervicitis by time these symptoms appear
```
Fever
Joint or tendon pain
- migratory polyarthralgia
- Knees, elbows and more distal joints
- single joint in 25%
Skin rash (25%)
- torso, limbs, palms, soles
- painful before visible
- paculopapular or pustular
```
66
Diagnosis of disseminated gonorrhoea
Raised WCC and ESR
| Blood and synovial fluid MCS
67
Management of disseminated gonorrhoea
```
Ceftriaxone 1g IV daily
OR
cefotaxime 1g IV 8-hourly
Continue for 48 hours after abatement of fever, then change to oral regimens based on culture and sensitivity results
Total duration of therapy at least 7d
```
68
Clinical features of sarcoidosis
50% present with chronic respiratory symptoms only
General:
- fatigue, fever, weight loss
- lymphadenopathy
Pulmonary:
- cough
- SOB, wheeze
- chest pain on exertion
Skin rash
Ocular:
- gritty or dry eyes
- misty/blurry vision
- pain, redness
- uveitis
- yellow cnjunctival nodules
Cardiac:
- arrhythmias, palpitations
- syncope or pre-sycnope
- pitting oedema
Rheumatological system
- acute symmetrical oligoarthritis
- large joints of lower limb
69
Which joints are affected in sarcoidosis
Large joints of lower limb
| acute symmetrical oligoarthritis
70
Management of sarcoidosis
Prednisolone +/- steroid sparing agent (e.g. MTX)
71
Definition of mixed connective tissue disease
An autoimmune connective tissue disease with overlapping features of 2 or more connective tissue disease such as SLE, scleroderma, Sjogren syndrome, rheumatoid arthritis and polymyositis
72
Common features of mixed connective tissue disease
Wide range of symptoms, no typical presentation
- nonspecific (fever, arthritis)
- Raynaud phenomenon
- Swollen hands/fingers
- Digital ulcers
- Carpal tunnel syndrome
- Skin involvement (photosensitivity, discoid plaques, malar rash)
```
Muscle weakness
Synovitis
Telangiectasia
Livedo reticularis
Pericarditis or pleuritic features
```
73
diagnostic investigations in mixed connective tissue disease
ANA: high-titre, speckled pattern
| Anti-RNP antibodies
74
Management of mixed connective tissue disease
MTX and hydroxychloroquine
75
Definition of polymyalgia rheumatica
Chronic inflammatory condition on unknown aetiology that affects elderly individuals, characterised by proximal myalgia of the hip and shoulder girdles with accompanying morning stiffness for more than 1h and full response to corticosteroid therapy
76
Epidemiology of polymyalgia rheumatica
```
0.5% prevalence
Median age 72
Rare below 55y
15% will develop GCA
50% of patients with GCA have associated PMR
HLA-DR4 haplotype
```
77
Clinical feautres of polymyalgia rheumatica
Abrupt onset (50%)
Symmetrical aching and stiffness of shoulders, neck and hip girdle
- difficulty combing hair, getting up from chair etc
Stiffness after inactivity, especially at night (inability to turn in bed, difficulty arising), improves with activity or hot shower
May begin unilateral but will become bilateral within a few weeks
78
Diagnostic investigations in polymyalgia rheumatica
ESR (higher than 40)
ALP mildly increased
CK= NORMAL
RF, ANA, Anti-CCP normal
79
Core inclusion criteria required for the diagnosis of polymyalgia rheumatica
Bilateral shoulder and/or pelvic girdle aching
Morning stiffness for over 45 min
Age over 50
Duration over 2w
Evidence of acute phase response (ESR/CRP)
80
Management of polymyalgia rheumatica
If no features of GCA: low-dose daily prednisolone
(if fails to respond promptly, reconsider diagnosis)
If features of GCA without visual complications: high dose oral prednisolone + aspirin
If GCA with visual symptoms: IV methylprednisolone for 3 days, then prednisolone as above + aspirin
81
Typical features of giant cell arteritis
New headache, new visual symptoms, jaw claudication
Superficial temporal artery inflammation on palpation (tender, thickened, erythematous)
Scalp tenderness!
82
Criteria for diagnosis of giant cell arteritis
Temporal artery biopsy findings:
- Intimal proliferation with luminal stenosis
- disruption of internal elastic lamina by a mononuclear cell infiltrate
- invasion and necrosis of media progressing to involvement of entire vessel wall
- giant cell formation with granulomata within mononuclear cell infiltrate
- intravascular thrombosis
83
Definition of Sjogren's syndrome
An autoimmune disease characterised by the immune-mediated destruction of exocrine glands, particularly salivary and lacrimal (may affect pancreatic function, respiratory secretions - dry cough, and vaginal dryness)
84
Epidemiology of Sjogren's syndrome
Prevalence 0.5-2% of women
Increase with age
occurs in 10-25% of patients with SLE
30-50% of patients with RA
85
Clinical features of Sjogren's syndrome
```
Constitutional: fatigue, low-grade fever
Xerophthalmia (dry eyes)
- itchy
- gritty feeling
- increased sensitivity to irritants e.g. smoke
- eyelid symptoms
```
Xerostomia (dry mouth)
- difficulty swallowing
- recurrent and unique dental infections
- pain eating salty or spicy foods
- difficult talking
- oral erythematous thrusu
URT and LRT symptoms
- dry cough
- tracheobronchitis
Painless enlargement of salivary glands
- begins unilaterally
- generally absent unless RA
Neurological: peripheral and cranial neuropathies (MS 'Look-alike')
Skin:
- palpable or non-palpable purpura
- papules
- urticarial lesions
- annular lesions
- xerosis
- Raynaud's phenomenon
86
Diagnostic investigations in Sjogren's syndrome
Schirmer test (measuring wetting of standardised tear strips applied between eyeball and lateral inferior lid)
ANA: homogenous or speckled patterns
Anti-Ro (60-75%) - SS-A
Anti-La (40%) - SS-B
87
Management of Sjogren syndrome
Symptomatic relief only
For dry eyes;
- sodium eye drops
- polyvinol alcohol + povidone eye drops
For dry mouth:
- chewing gum or lozenges can stimulate saliva production
- artificial saliva
- mouthwash and toothpaste
- mouth gel
For vaginal dryness:
- lubricant jellies
- post-menopausal women: intravaginal oestradiol pessary or cream
88
Definition of Raynaud's disease
The primary idiopathic form of Raynaud phenomenon, a vasospastic disorder characterised by episodic ischaemia and triphasic colour change of the digits of the hands and feet when exposed to cold or emotional distress.
89
Epidemiology of Raynaud's DISEASE
More common than secondary Raynaud phenomenon
F:M 4:1
More common in the young (under 40y)
5-15% though to have primary Raynaud disease will subsequently develop a secondary cause (frequently a connective tissue disorder)
90
Clinical features of Raynaud's disease
usually more mild than secondary Raynaud's
Well demarcated triphasic digit discolouration associated with cold exposure (white - blue - red - normal)
+/- sensations of cold, numbness in pallor/cyanosis phases
Throbbing, painful sensation may accompany hyperaemic phase
Fingers more often affected than toes, thumbs rarely affected
Sclerodactyly develops in 10%
Normal nail-fold capillary pattern
No pitting scars, ulceration or gangrene of fingers or toes
91
Management of Raynaud's disease
Lifestyle:
- stress reduction
- avoid cold exposure
- warm clothing
- techniques to terminate an attack (hands in warm water, rotating arms like windmill etc.)
- avoid smoking and sympathomimetic drugs
Pharm:
- not generally necessary for primary Raynaud as mild disease
- Nifedipine
- Prazosin (sympatolytic)
- topical nitroglycerin
92
Definition of polyarteritis nodosa
Polyarteritis nodosa (PAN) is a relatively rare systemic vasculitis characterised by necrotising inflammatory lesions that affect medium-sized and small muscular arteries, preferentially at vessel bifurcations
93
Risk factors for polyarteritis nodosa
```
Male gender
40-60y
Hep B or C infection
IVDU
Hairy cell leukaemia
```
94
Clinical features of polyarteritis nodosa
```
Constitutional symptoms
Cutaneous symptoms
- most commonly on legs
- can be painful
- rash
- purpura
- gangrene
- nodules
- cutaneous infarcts
- livedo reticularis
- Raynaud phenomenon
```
GI:
- abdo pain (sometimes post-prandial)
- Nausea/vomiting
- GI bleeding
Renal (60%)
- flank pain
CNS
- amaurosis fugax
PNS: (60%) - various peripheral neuropathies
GU:
- pain over testicular or ovarian area
- testicular infarction
Cardiac (35%)
- Chest pain, SOB, palpitations, MI, CHF
95
What is livedo reticularis
Mottled reticulated vascular pattern appears as a lace-like purplish discolouration of the skin (caused by swelling of venules causing obstruction of capillaries by thrombi)
96
Diagnosis of polyarteritis nodosa
Conventional angiograpy
| Aneurysms and/or stenosis of medium sized vessels (most commonly in kidney, liver and mesenteric arteries)
97
Diagnostic criteria for systemic sclerosis
A. MAJOR CRITERION: Proximal scleroderma: symmetrical thickening, tightening and induration of the skin of the fingers and the skin proximal to the MCP or MTP joints
B. MINOR CRITERIA:
1. Sclerodactyly (loss of skin creases, joint contractures and sparse hair limited to the fingers)
2. Digital pitting scars or loss of substance from the finger pad
3. Bibasilar pulmonary fibrosis
Presence of major criterion or 2+ minor criteria
98
Definition of scleroderma
A group of conditions linked by the presence of thickened, sclerotic skin lesions - either systemic or localised.
99
Classifications of systemic sclerosis
Limited cutaneous scleroderma (CREST syndrome)
Diffuse cutaneous scleroderma
etc.
100
CREST syndrome components
```
Calcinosis cutis
Raynaud phenomenon
Esophageal dysmotility
Sclerodactyly
Telangiectasia
```
101
What is calcinosis cutis
The deposition of calcium in the skin.
Appear as firm whitish/yellowish papules, plaques or nodules on the surface of the skin. Most likely to be multiple lesions. May become tender and ulcerated, discharging chalk-like creamy material of mainly calcium phosphate with a small amount of calcium carbonate.
102
Anti-centromere antibody association
CREST syndrome 95% specificity
103
Auto-antibody associated with CREST syndrome
Anti-centromere antibody
