Rheumatology Flashcards
What are the X-ray changes seen in rheumatoid arthritis?
Juxta-articular osteopenia
Soft tissue swelling
Joint deformity
Loss of joint space
What are the red flags in a back pain history? 5 things
Night pain History of malignancy Neurological disturbance Abdominal mass Sphincter disturbance Saddle anaesthisia
Name 3 early symptoms of rheumatoid arthritis?
Swelling
Pain
Stiff small joints worse in the morning
Possible tenosynovitis or bursitis
Name 4 late changes of rheumatoid arthritis?
Ulnar deviation of fingers
Boutonnière deformity of fingers
Swan-neck deformity of fingers
Z-deformity of thumb
Give 5 extra-articular signs of rheumatoid arthritis?
Nodules-elbows and lungs Vasculitis Pleural and pericardial effusion Raynauds Carpal tunnel syndrome Osteopororis Fibrosing alveolitis
Which blood test would you take in a suspect rheumatoid patient?
Rheumatoid factor (70%)
Anti-CCP (98%)
FBC-anaemia of chronic disease
ESR/CRP/PV-raised in response to synovitis
What is the diagnostic criteria for rheumatoid arthritis?
4/7 of Morning stiffness (>1 hour lasting >6 weeks duration) Arthritis in >3 joints Arthritis of hand joints Symmetrical arthritis Rheumatoid nodules Positive rheumatoid factor Radio graphic changes
What is the DAS28 and what score is being aimed for?
Disease activity score-assesses tenderness and swelling at 28 joints
Aiming for <3
How can you treat rheumatoid arthritis non pharmacologically? 4 things
MDT approach Support groups Stop smoking Encourage regular exercise Physio OT for aids, splints etc
What is the class of drugs used as first line long term treatment in Rheumatoid arthritis and give 3 examples?
DMARDs
Methotrexate
Sulfasalazine
Hydroxychloroquine
What is a potentially serious SE of DMARDs and how can you avoid it?
Myelosuppression
Regular FBC monitoring is required
If a patient fails to respond to DMARDs in RA, what is the next line of drugs? Give examples?
TNF alpha inhibitors
Infliximab
Etanercept
Adalimumab
If DMARDs and TNF alpha inhibitors fail to control Rheumatoid arthritis, what’s the next line?
Rituximab in combination with Methotrexate
What is the criteria for diagnosing SLE?
>4 of: A RASH POINts an MD •Arthritis (>2 joints) •Renal disorder (proteinuria or cellular casts) •ANA positive •Serositis (pleuritis or pericarditis) •Haematological disorder (anaemia, leukopenia, thrombocytopenia) •Photosensitivity •Oral ulcers •Immunological disorder •Neurological disorder (seizures, psychosis) •Malar rash •Discoid rash
Name 4 seronegative arthropathies?
Ankylosing spondylitis
Enteropathic spondyloarthropathies
Psoriatic arthritis
Reactive arthritis
What is Sjögren’s syndrome?
Autoimmune disease destroying exocrine glands with associated polyarthritis
What tests can be undertaken to monitor the effectiveness of methotrexate? 2 tests
Creatinine
FBC
LFTs
What are the symptoms of polymyalgia rheumatica? 4 things
•Symmetrical aching, tenderness and morning stiffness in shoulders and proximal limb muscles
- Mild polyarthritis
- Tenosynovitis
- Carpal tunnel syndrome
•Fatigue,fever, weight loss, anorexia and depression.
How do you manage Polymyalgia rheumatica?
Prednisalone
Along with PPI and Bisphosphanates (alendronate)
What is polymyalgia rheumatica associated with?
Giant cell arteritis
Name 4 symptoms of temporal arteritis?
Headache Scalp tenderness Jaw claudication Temporary loss of vision in one eye Sudden blindness
How do you treat giant cell arteritis?
Prednisalone (40-60mg PO) immediately
What is Feltys syndrome?
Association of rheumatoid arthritis with splenomegaly and leukopenia
What organisms are commonly responsible for septic arthritis in infants and sexually active adults?
Infants-Haemophilus influenzae
Adults-Neisseria gonorrhoeae
What is the medical term for a sausage shaped toe?
Dactylitis
What is the test used for checking lumbar flexion?
Schober test
Give 4 extra skeletal features that could be present in Ankylosing spondylitis?
Anorexia Fatigue Weight loss Fever Uveitis Aortic incompetence Pulmonary fibrosis
Give 3 ways you could manage Raynauds?
Hand warmers
Battery powered gloves
Oral vasodilators
Sympathectomy
What serological abnormality is found in lupus?
Raised levels of double stranded DNA
Low C3 and C4 complement levels
Give 5 causes of Gout?
Hereditary High dietary purines Alcohol excess Diuretics Leukaemia Renal impairment
What will light microscopy of synovial fluid show in Gout?
Needle shaped Negatively birefringent urate crystals under polarised light
What is the treatment of acute Gout?
Strong NSAID (diclofenac)
Colchicine - if NSAIDs CI
Steroids - if there is renal impairment
How do you prevent Gout?
Lose weight Avoid alcohol excess Avoid purine rich foods Avoid prolonged fasts Use allopurinol after acute attack
What is the difference between Gout and Pseudogout?
Gout shows negative bifringent crystals under microscopy whilst Pseudogout shows positive.
Give 3 risk factors for developing Rheumatoid A?
Smoking
Female
Genetic (HLA DR4)
What is pannus in Rheumatoid A?
A growth which is composed of thick synovial tissue. This produces enzymes which destroy articular cartilage and attract more inflammatory cells => increasing disease severity
How do you treat an acute flare of Rheumatoid Arthritis? 2 things
Steroids - Methylprednisalone
NSAIDs (For symptom control) - Ibuprofen, Diclofenac etc.
What is the test and give 3 antibodies you can test for in SLE?
Immunoflorescence
ANA (Anti-smith and Anti-dsDNA)
Rheumatoid factor
Give 3 ways to monitor disease activity in SLE?
Anti-dsDNA titres Complement levels (decrease in C3/4) ESR (raised)
Give 6 methods to manage SLE starting with simple measures?
High factor sun block creams
NSAIDs - treat minor symptoms
Anti-malarial (hydroxychloroquine) - if NSAIDs aren’t working
Low dose steroids - chronic disease
Azathioprine - maintenance
High dose prednisalone - severe flare ups
What is Antiphospholipid syndrome? 4 things
CLOT
Coagulation defects
Livedo reticularis (capillary dilatation & stasis)
Obstetric complications (recurrent miscarriages)
Thrombocytopoenia
How can you treat Anti-phospholipid syndrome? 2 things
Aspirin
Warfarin - in recurrent thromboses
What is SLE?
Antibodies produced against a variety of antigens. Type 3 hypersensitivity leading to immune complexes that deposits in various organs.
What is Systemic sclerosis ?
Autoimmune disease with increased fibroblast activity => abnormal tissue growth
Characterised by autoantibodies, vascular disease and fibrosis => skin (scleroderma, GI tract & other organs
What are the clinical features of Limited systemic sclerosis? 5 things
CREST
Calcinosis - calcium deposits in subcutaneous tissue
Raynauds phenomenon
Esophageal and gut dysmotility
Sclerodactyly - thick/tight skin of fingers/toes
Telangiectasia
What is the antibody associated with limited systemic sclerosis?
Anti-centromere (ACA)
What is diffuse systemic sclerosis? Which 2 antibodies are associated?
Affects the skin in a difuse pattern
Also fibrosis in lungs, heart and kidneys
Anti-topoisomerase-1 (scl70)
Anti-RNA polymerase
How do you treat systemic sclerosis? 4 things
No cure
Involve physios & OT
Immunosuppression (organ involvement) - IV cyclophosphamide
Treat complications: Raynauds - hand warmers GI - antacids, PPI Cardiac - antiarrythmics Renal - ACEi
Give 6 clinical features of Sjögren’s syndrome?
Lacrimal - Xeropthalmia (low tears), dry eyes
Parotid - Parotid gland swelling, xerostomia, tooth decay
Others - vaginal dryness, dry cough
Systemic features - polyartheritis, raynauds, vasculitis
In Sjögren’s syndrome how can you test for conjuctival dryness?
Schirmer’s test - Strip of filter paper under lower eyelid. Measure distance tears are absorbed. <5mm in 5mins is positive
Who is more likely to present with ankylosing spondylitis and whats the genetic association?
Young (s) males
HLA B27
Give 4 clinical features of ankylosing spondylitis?
Sacroilitis - night back pain, spinal stiffness, loss of movement
Acute anterior uveitits
Enthesitis - pain at tendon/ligament insertion points
Question mark posture
Give 3 ways to treat ankylosing spondylitis?
Intense exercise (OT & Physios)
Pharmo - NSAIDs, local steroid injections, monoclonal antibodies
Surgery -
Give 5 clinical features seen in psoriatic arthritis?
Joints - inflamed, red, tender Psoriasis Nail changes - onycholysis, nail pitting Enthesitis Dactylitis
What X-ray deformity of the hands can be seen in severe Psoriatic arthritis?
Pencil in cup deformity
What is reactive arthritis characterised by? 3 things
Arthritis
Urethritis/Cervicitis
Conjuctivitis
What are the different types of vasculitits? 6 things
Large vessel - Temporal arteritis, Takayasu’s arteritis
Medium vessel - Polyarteritis nodosa, Kawasaki’s disease
Small vessel:
ANCA +ve (Wegener’s, Churg Strauss syndrome)
ANCA -ve (Goodpastures, Henoch Schonlein purpura)
How do you investigate temporal arteritis? If the test is negative should you exclude TA?
Temporal artery biopsy
No, as the disease can manifest in skip lesions
What is polymyositis and give 2 clinical features?
Chronic inflammtory myopathy (inflammation in muscles)
Proximal muscle weakness (unlike PMR which is stiffness) Muscle weakness (dysphagia, dysphonia)
Give 5 clinical features of dermatomyositis?
Macular rash Lilac purple rash Nail fold erythema Gottrons papules (roughened papules over knuckles, elbows and knees) Mechanic's hands (rough skin cracking)
What is the definition of Juvenile idiopathic arthritis?
Persistent arthritis lasting for >6weeks with an onset of <16years old
