Rheumatology Flashcards
Name some recognised systemic manifestations of SLE
Alopecia Vasculitis Epilepsy Polyneuritis Stroke Chorea Pleurisy Atelectasis Pulmonary fibrosis
In a patient presenting with low back pain, what are 3 important factors to ask about in the history?
Neurological symptoms in legs: weakness, numbness, paraesthesia
Urinary/bowel symptoms: incontinence
FH of ankylosing spondylitis
What are the Calin criteria for inflammatory back pain?
Age of patient at onset: under 40 (1) Insidious onset (1) Morning stiffness (1) Persistence for months: over 3 (1) Response to exercise: improves (1)
HLA B27 test has 90% sensitivity and 90% specificity in a population with chronic back pain for ank spond. In that population 5% will have ank spond. What are the chances of a patient with chronic back pain and a positive HLAB27 having ank spond?
about 30%
200 people with chronic back pain, 10 will have ank spond
Of those 10, 9 will test positive for HLAB27 (sensitivity)
Of the 190 that don’t have it, 10% false positive rate so 19. Out of 200 tests: 9 positives from people with AS, 19 positives from people without AS. So 9/28 chance = around 30%
What blood results would make you suspect that a patient has Paget’s disease of the bone?
Raised alkaline phosphatase
Plasma calcium, phosphate and aminotransferase all normal
What is osgood schlatter disease?
Tension at patella tendon leading to avulsion fracture
Symptoms of pain and swelling over tibial tubercle
What is osgood schlatter disease?
Tension at patella tendon leading to avulsion fracture
Symptoms of pain and swelling over tibial tubercle
What is an enthesis?
Where tendon inserts into bone, where the collagen fibres are mineralised and integrated into bone tissue
What is a bursa?
Fluid filled sac located between a bone and tendon which normally serves to reduce friction between two moving surfaces
How can you differentiate between articular and periarticular problems?
Articular: pain all planes, active = passive, capsular swelling/effusion, joint line tenderness, diffuse erythema/heat
Periarticular: pain in plane of tendon, active > passive, linear swelling, localised tenderness, localised erythema/heat
What is flexor tenosynovitis?
Inflammation of flexor tendon sheaths
Pain and stiffness in flexor finger/thumb, may extend to wrist
Reduced active flexion, crepitus, thickened tender tendon sheaths
May be associated with nodule – trigger finger
Can be associated with RA, Diabetes
What is treatment for flexor tenosynovitis?
Injection hydrocortisone
Surgery
What is de Quervains tenosynovitis? How can you test for it?
Inflammation of tendon sheath containing extensor pollicis brevis and abductor pollicis longus tendons
Pain, swelling radial wrist
Localised tenderness, crepitus, pain worse over radial styloid
Positive Finkelstein’s test
What is Finklesteins test?
With thumb flexed across the palm of the hand, ask patient to move the wrist into flexion and ulnar deviation
Positive if reproduces pain
What is the management for de Quervains tenosynovitis?
Rest from precipitating activity
Splintage
Steroid injection
Surgery
What conditions can precipitate carpal tunnel syndrome?
Diabetes Hypothyroidism RA Pregnancy Acromegaly Vasculitis Trauma Amyloid Sarcoid
What does the median nerve supply in the hand?
Lateral two lumbricals Opponens pollicis Abductor pollicis brevis Flexor pollicis brevis Sensory: Palmar surface thumb, lateral 2 1/2 digits
What are clinical features of carpal tunnel syndrome?
Numbness/parasthesia in median nerve distribution Pain, can radiate up arm Worse at night Hang hand over end of bed Weakness of thumb (abduction) Thenar wasting Positive Tinel’s/Phalen’s
What investigation can be done for carpal tunnel syndrome?
Nerve conduction studies show reduced nerve conduction velocities across wrist
What is the management for carpal tunnel syndrome?
Avoidance of precipitating activity
Night time splints
Local steroid injection
Surgery – division of flexor retinaculum and decompression of carpal tunnel (80% success)
What are tennis and golfers elbows?
Tennis elbow: lateral epicondylitis, inflammation common extensor origin
Golfer’s elbow: medial epicondylitis, inflammation common flexor origin
Pain localised to specific area
Elbow flexion/extension does not cause pain
Pain upon: resisted wrist extension (Tennis)
resisted wrist flexion (Golfer’s)
What is management for tennis and golfers elbows?
Rest from precipitating activity Elbow clasps Local corticosteroid injection Physiotherapy – ultrasound and acupuncture Surgery (often ineffective)
What problems can occur with the rotator cuff?
Supraspinatous tendinitis/rupture Rotator cuff tear Adhesive capsultitis (frozen shoulder) Acute calcific supraspinatous tendonitis Subacromial bursitis Acromioclavicular joint OA
What are the muscles of the rotator cuff and what are their functions?
Supraspinatous - abduction
Infraspinatous – external rotation
Teres minor – external rotation
Subscapularis – internal rotation
What is rotator cuff syndrome? And what test can be done for it?
Spectrum from mild supraspinatus tendinitis to complete tendon rupture
Chronic impingement of cuff under acromial arch
Pain often over acromial area extending into deltoid
Painful mid arc
Impingement test – abducted, flexed and internally rotated
Supraspinatus stress
How can a rotator cuff problem be investigated?
USS
What is the management for rotator cuff syndrome?
Rest, NSAIDs
Local steroid injection around tendon – subacromial space and PT
If chronic/rupture refer to Orthopaedics for surgical opinion
What is acute calcific supraspinatus tendonitis?
Calcium hydroxyapatite deposition near supraspinatus enthesis
Young adults, F>M, acute pain over several hours
Normally resolves over few days
What is the management for acute calcific supraspinatus tendonitis?
Minor – NSAID
Moderate – consider steroid injection
Severe – consider aspirating calcified material
What is adhesive capsulitis (frozen shoulder)?
Progressive pain and stiffness
Global reduction in movement, but particularly external rotation
Three phases: Pain (3-5 months), Adhesive phase (4-12 months), Recovery phase (12-42 months)
Associated with diabetes
Most patients recover by 30 months, but still have reduced movements
What is the management for frozen shoulder?
Analgesia, NSAIDs, Physiotherapy, steroid injection
Surgical opinion in difficult cases (manipulation under anaesthesia)
What are signs/symptoms of acromoclavicular joint OA?
High arc pain
Local tenderness
Adduction painful
Impingement
What is trochanteric bursitis?
Inflammation of superficial and deep bursa that separates gluteus muscles from posterior and lateral side of greater trochanter of the femur
Boring pain over lateral aspect of hip
May radiate down lateral thigh
Worse on walking or lying in bed at night
Localised tenderness upon pressure over greater trochanter
What is the management of trochanteric bursitis?
Rest
Analgesia
Steroid injection
Physio
What is Achilles’ tendonitis?
Inflammation of the achilles tendon
Sometimes at enthesis
Sometimes in middle avascular portion of tendon
Can be seen with seronegatives
Localised pain and swelling of Achilles tendon, with difficulty walking
What is a complication of Achilles’ tendonitis?
Achilles’ tendon rupture
How do you investigate Achilles tendonitis?
USS
What is the management for Achilles tendonitis?
Rest, NSAIDs, physiotherapy
Local steroid injection under U/S guidance into paratenon can help tenosynovitis – if no evidence of tear
What is an Achilles’ tendon rupture? How can you test for it?
Acute rupture – sudden calf pain as if being hit on back of leg
Palpable gap in tendon
Some but little plantarflexion
Squeeze calf whilst prone - no plantarflexion in affected leg (Simmond’s)
What is the management for Achilles’ tendon rupture?
Surgery to repair tendon
Conservative – below knee cast in ankle equinus 6 weeks
What is fibromyalgia? What are symptoms?
All over pain Fatigue Sleep disturbance Depression Anxiety Irritable bowel Tender spots Diagnosis of exclusion
Which conditions can mimic fibromyalgia?
Systemic lupus erythematosus (SLE) Hypothyroidism Polymyalgia rheumatica Malignancy Myopathy Metabolic bone disease
What is the management for fibromyalgia?
Patient education: About condition, Reassure that no serious pathology, No harm in exercising
Cognitive behavioural therapy (CBT)
Low dose amitriptyline
Graded aerobic exercise regime
What are the criteria for the classification of RA?
Morning stiffness >1 hour >6 weeks Arthritis of 3 or more joints >6 weeks Arthritis of hand joints: wrist, PIP, MCP >6 weeks Symmetric arthritis Rheumatoid nodules Positive rheumatoid factor Radiographic changes 4 present - refer
What baseline investigations are useful in RA?
ESR/PV/CRP FBC U&E/LFT RhF Anti CCP ANA Urine dip Radiology
What deformities occur in the hand in RA?
Swan neck and boutonnière
Z shaped thumb
Ulnar deviation (MCP)
Volar subluxation (wrist)
What deformities happen in the foot in RA?
Hammer, overlapping and claw toes
Splay foot, valgus deviation (MTP)
MTP head subluxation
Pes planus, valgus hind foot
What deformity can happen in the spine in RA?
Atlantoaxial subluxation
What are extra articular features of RA?
Systemic: weight loss, fever, lymphadenopathy, fatigue
Ocular: keratoconjunctivitis sicca, scleritis, episcleritis
Pulmonary: alveolitis, fibrosis, nodules, pleural effusions,
Cardiac: carditis, conduction disturbance, coronary arteritis
Vasculitis: ischaemia and infarction
Feltys syndrome
Amyloidosis: nephrotic syndrome, cardiac, malabsorption
Anaemia
Osteoporosis
Who might be involved in the management of a patient with RA?
GP Rheumatologist Nurse specialist Physio Occupational therapist Podiatrist Orthotist Surgeons
What surgery can be done for a patient with RA?
Joint arthroplasty
Tendon repair
Synovectomy
C spine stabilisation
What toxic effects can DMARDs have?
Bone marrow toxicity: thrombocytopenia, leucopenia, pancytopenia
Liver toxicity: >2x increase AST or ALT or lowered albumin
Renal toxicity and hypertension: >1+ blood and or protein, >30% rise creatinine
Pulmonary: dry cough and dyspnoea
What risks do TNF alpha biologics have?
Infections esp TB
Malignancy
MS
CCF
Which inflammatory cells are found in sacroiliac joints of patients with ankylosing spondylitis?
CD4 and CD8 T cells and macrophages
What is the diagnostic criteria for ankylosing spondylitis?
Radiologic criteria: sacroiliitis grade 2 bilaterally or 3-4 unilaterally
Clinical criteria: LBP and stiffness >3 months improved with exercise and not relieved by rest, limitation of L spine motion in frontal and saggital planes, limitation of chest expansion
Diagnosis requires radiologic criteria and at least one clinical
What is schobers test?
Mark level L5
Mark 5cm below and 10cm above this point
Patient touch toes while keeping knees straight
If distance between two points doesn’t increase by 5cm, sign of restriction in lumbar flexion - ankylosing spondylitis
What are axial features of ankylosing spondylitis?
Early: Romanus lesion
Advanced: bony ankylosis
What are peripheral features of ankylosing spondylitis?
Hip and shoulder disease
Peripheral enthesopathy
What are possible complications of ankylosing spondylitis?
Fracture: C5/6, C6/7, C7/T1
Spondylodiscitis
What are extra articular features of ankylosing spondylitis?
Uveitis Psoriasis Inflammatory bowel Aortic regurgitation Conduction defects Upper lobe fibrosis Neurological: fracture dislocation - cauda equina syndrome, Atlanto-axial disease Renal: amyloidosis, IgA nephropathy
What investigations should be done for a patient with ankylosing spondylitis?
L spine and sacroiliac joint X-ray
CRP and ESR
HLA B27
What are treatment options for ankylosing spondylitis?
Physio NSAIDs DMARDs and steroids TNF alpha blockers Surgery
What is the peak age of onset for psoriatic arthritis?
35-50 years
What are the 5 clinical subgroups of psoriatic arthritis?
Symmetrical polyarthritis Asymmetrical oligoarthritis DIP disease Spondylitis Arthritis mutilans
What is treatment for psoriatic arthritis?
NSAIDs DMARDs Steroids TNF alpha OT/physio Surgery Dermatology
Who gets reactive arthritis?
Young adults, equal sex
Post urethritis/cervicitis or infectious diarrhoea
What are sero positive features of reactive arthritis?
Conjunctivitis
Balanitis
Oral ulcers
Pustular psoriasis
What are treatments for reactive arthritis?
NSAIDs
Steroids - intra articular
Antibiotics - chlamydia
DMARDs
What cultures might you take from a patient with reactive arthritis?
Throat
Urine
Stool
Urethra/cervix
What can reiters syndrome be precipitated by?
Chlamydia Salmonella Campylobacter Shigella Yersinia
What criteria are required for diagnosis of Behçet’s disease?
Oral ulceration plus two of: Genital ulcers Defined eye lesions Defined skin lesions Positive skin pathergy test
What conditions are associated with pseudogout?
Haemochromatosis Hyperparathryoidism Hypomagnesaemia Hypophosphatasia Hypothyroid Familial hypocalciuric hypercalcaemia
What pathogens usually precipitate a reactive arthritis?
Chlamydia trachomatis Yersinia Salmonella Shigella Campylobacter C diff Chlamydia pneumoniae
What factors predict a poor prognosis for progression in early RA?
Age Female Symmetrical small joint involvement Morning stiffness over 30 mins More than 4 swollen joints CRP >20 Positive RF and anti CCP
What are some complications of RA?
Ruptured tendons Ruptured joints (bakers cysts) Joint infection Spinal cord compression Amyloidosis
What deformities of the feet might be seen in RA?
Foot broadens and a hammer toe develops
Exposure of metatarsal heads to pressure by forward migration of protective fibrofatty pad causes pain
Ulcers or calluses may develop under metatarsal head and dorsum of toes
Flat medial arch and loss of flexibility of foot
Valgus deformity of ankle
Give some non articular manifestations of RA
Scleritis Sjögren's syndrome Lymphadenopathy Pericarditis Bursitis Nodules Tendon sheath swelling Tenosynovitis Amyloidosis Sensorimotor polyneuropathy Pleural effusion Fibrosing alveolitis Anaemia Carpal tunnel syndrome Nail fold lesions of vasculitis Splenomegaly (feltys syndrome) Leg ulcers Ankle oedema
What are risk factors for developing carpal tunnel syndrome?
Obesity
Repetitive wrist work
Pregnancy
RA
What is the mechanism of action of azathioprine?
Cytotoxic agent
Metabolised to mercaptopurine
Acts as purine analogue to inhibit DNA synthesis
What are serious complications of azathioprine therapy?
Renal failure
Bone marrow suppression
What enzyme activity needs to be checked before commencing a patient on azathioprine therapy?
TPMT - thiopurine methyltransferase
What are features of Behçet’s disease?
Oral ulcers Genital ulcers Erythema nodosum Uveitis Inflammatory reaction when skin is pricked with a fine needle
What are treatment options for acute gout?
NSAIDs
Colchicine
Systemic glucocorticoids
Intra articular glucocorticoids
Which antibody is present in polyarteritis nodosa?
pANCA
What are features of polyarteritis nodosa?
Malaise Weight loss Anaemia Fever Non specific pains Acute renal failure Livedo reticularis
What is polyarteritis nodosa?
Medium sized artery vasculitis with a predominance for renal vasculature
Which antibody is associated with primary biliary cirrhosis?
Anti mitochondrial antibody
In which conditions might ANA antibodies be present?
SLE
Autoimmune hepatitis
Post infection
Inflammatory bowel disease
What is the treatment for acute gout?
NSAIDs: indomethacin
Colchicine
