Rheumatology

Question 1

Newly diagnosed RA… What drug management?

Answer 1

Initial therapy of methotrexate and another DMARDs, and short term Prednisolone

Question 2

List the vaccines that a patient who is immunosuppressed cannot have (5)

Answer 2

• BCG
• MMR
• Yellow fever
• Oral typhoid
• oral polio

Question 3

Give osce description of RA findings…

Answer 3

The patient has bilateral arthropathy, mainly affecting the small joints but sparing the DIP. RA is three times more common in women and also more common in smokers.

Question 4

Complications of ankylosing spondylitis

Answer 4

O/E: shrobers (?) Thoracic kyphosis and loss of lumbar lordosis… Complications: Anterior uveitis Apical lung fibrosis AOrtic regurge IgA Nephropathy Cervical myelopathy Osteoporosis

Question 5

Management of reynauds

Answer 5

Primary if fam Hx, long standing and no ulceration/gangrene Management: ➡️Avoid cold etc ➡️Can give GTN cream ➡️ ca channel blockers

Question 6

Gout vs pseudogout microscopy

Answer 6

Gout:

• Needle-shaped monosodium urate crystals
• displaying negative birefringence under polarized light.

​Pseudogout

• Rhomboid-shaped calcium pyrophosphate dihydrate crystals,
• showing Positive birefringence in polarized light.

Question 7

Mechanism of allopurinol

Answer 7

Xanthene oxidase inhibitor

Question 8

Investigations in Sjogrens

Answer 8

100% RF 70% ANA 70% anti Ro 30% anti La

Question 9

Abx to avoid if on methotrexate

Answer 9

Avoid trimethoprim (or cotrimoxazole) as it increases bone marrow aplasia. Manage with folic rescue

Question 10

Big red flag to look out for in Sjogrens

Answer 10

Weight loss, due to 40-60X increased risk of lymphoid malignancies

Question 11

This rash with symmetrical, proximal muscle weakness

Answer 11

Dermatomyositis (with periorbital heliotrope rash)

• may be idiopathic or associated with connective tissue disorders or underlying malignancy (typically lung cancer, found in 20-25% - more if patient older)
• polymyositis is a variant of the disease where skin manifestations are not prominent
• Also get macular rash on back and shoulders

Question 12

Antibody associated with polymyositis

Answer 12

Jo1

Question 13

Antibody associated with limited cutaneous scleroderma

Answer 13

Antibody associated with limited cutaneous scleroderma: Centromere

Question 14

cANCA and pANCA

three ‘other’ causes of positive ANCA

Answer 14

cytoplasmic ANCA:

• Wegener’s granulomatosis (positive in > 90%)

perinuclear ANCA:

• Churg-Strauss syndrome (positive in 60%)
• primary sclerosing cholangitis (positive in 60-80%)

Other causes of positive ANCA (usually pANCA)

• IBD (UC > CD)
• RA, SLE, Sjogren’s
• autoimmune hepatitis

Question 15

Which ANCA can you use to correlate with disease severity??

Answer 15

• some correlation between cANCA levels and disease activity
• none with pANCA

Question 16

Most specific antibody for SLE

Answer 16

• anti-dsDNA: highly specific (> 99%), but less sensitive (70%)
• 99% are ANA positive

Question 17

Antiphospholipid antibodies and important blood test to remember

Answer 17

• Anti-Cardiolipin Antibody (ACL)
• paradoxically raised APPT

Question 18

Investigations for ankylosing spondylitis

Answer 18

Reduced lateral and forward flexion (under 5cm Schober’s)

reduced chest expansion

May have reduced lumbar lordosis,

• CRP and ESR may be raised (normal doesn’t excclude)
• HLA B27 +ve in 90% of AS, but +ve in 10% gen pop

Xray of sacroiliac joint

• sacralilitis (erosion / sclerosis)
• sqauring of sacroiliac joint
• bamboo spine is late sign

Question 19

What is Felty’s syndrome??

Answer 19

combination of

• rheumatoid arthritis
• neutropenia
• splenomegaly

rans

Question 20

What is adult onset Stills disease

Answer 20

classic triad of

• persistent high spiking fevers
• joint pain
• distinctive salmon-colored bumpy rash

w/ High Ferritin

Question 21

MOST specific antibody for SLE

Answer 21

• anti-Smith: most specific (> 99%), sensitivity (30%)
• anti-dsDNA: highly specific (> 99%), but less sensitive (70%)