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Rheumatology Flashcards

1
Q

What blood tests can help diagnose SLE?

A

ANA
dsDNA
anti Smith (Type of ENA)

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2
Q

What blood tests are used for SLE monitoring?

A

C3/4
ESR
anti dsDNA

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3
Q

Describe skin manifestations of SLE .

A

Malar rash - Erythematous butterfly rash on face - nasolabial sparing
Discoid - like red scaly ringworm in sun exposed areas
Photosensitivity
Hair loss
Mouth ulcers

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4
Q

Describe the joint manifestations of SLE

A

Asymmetric
Morning stiffness of short duration,
PIP joints
Wrist and knee joints

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5
Q

Describe the symptoms of SLE that are not skin or joint related.

A

Reynauds
Miscarriage
Thrombophilia - anti-phospholipid syndrome

Lung fibrosis
Pleuritis

CKD

Fits
Psychosis

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6
Q

What would you expect to find on a renal biopsy in SLE?

A

Active renal sediment
Red cell or granular casts
(Proteinuria)

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7
Q

How would you treat SLE with MSK involvement only?

A

NSAIDS

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8
Q

How would you treat SLE with MSK and skin involvement.

A

Hydroxychloroquine

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9
Q

When would you consider anticoagulating a patient with SLE?

A

When they have associated antiphospholipid syndrome. Pro thrombotic state.
Warfarin

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10
Q

How would you treat SLE with renal involvement?

A

Cyclophosphomide

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11
Q

Who gets SLE?

A

Afro Caribbean
Female
20s

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12
Q

Which conditions can be associated with Reynaud’s?

A

Scleroderma
SLE
Rheumatoid arthritis

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13
Q

What features of Raynaud’s make it more likely there is an underlying connective tissue disease?

A

Unilateral
Onset post 40

Rash
Arthritis
Calcinosis
Recurrent miscarriage

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14
Q

How is Raynaud’s treated?

A
  1. Handwarmers etc
  2. Ca channel blocker eg nifedipine
  3. IV prostacyclin
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15
Q

What is anti-phospholipid syndrome? Which condition is it associated with?

A

Hyper coagulable state
Recurrent miscarriage

Primary and secondary to SLE

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16
Q

What is Sjrogen’s syndrome? What conditions is it associated with?

A

Dry mucous membranes
Dry eyes - keratoconjunctivitis sicca
Fatigue

Primary or secondary to SLE, RA

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17
Q

Which blood tests can help to diagnose Sjogren’s syndrome?

A

Rheumatoid factor
ANA
anti-Ro
anti- La

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18
Q

What type of malignancy is associated with Sjogren’s syndrome?

A

Lymphoma

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19
Q

How would you treat Sjogren’s?

A

Artificial tears

Pilocarpine for saliva production

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20
Q

What are the symptoms of scleroderma?

A 
C - calcinosis
R - Raynaud's
E - Esophageal dysmotility
S - sclerodactyly
T - telangectasia
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21
Q

Which blood tests might help to diagnose scleroderma?

A

ANA
Rheumatoid factor
Anti - centromere

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22
Q

What is the differential for pain in the proximal muscles(quads, deltoids)?

A

Dermatomyositis/ polymyositis
Polymyalgia rheumatica
Fibromyalgia

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23
Q

How does polymyalgia rheumatica normally present?

A

Pain and morning stiffness in proximal limb muscles (not weakness)
> 60 years old female
usually rapid onset (e.g. < 1 month)

also mild polyarthralgia, lethargy, depression, low-grade fever, anorexia

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24
Q

How is polymyalgia rheumatica treated?

A

Prednisolone - low dose
Dramatic and sudden response
Keep taking for a year (taper)

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25
Which condition is associated with polymyalgia rheumatica?
Giant cell arteritis
26
How is Giant cell arteritis treated?
High dose oral prednisiolone | ASAP to prevent blindness
27
How does dermatomyositis present?
Weakness and pain in proximal muscles (more weakness) Rash - purple red Gottron's papules - red scaly blobs on MCP and PIPs High creatine kinase and LDH (muscle enzymes)
28
How does temporal/giant cell arteritis present?
Lethargy Headaches Recent onset Raised ESR Swollen temporal artery Jaw claudication
29
What does a high titre on a rheumatology blood test indicate?
Positive result 1:160 means they diluted it loads and you could still detect that antibody. Whereas 1:40 could be normal
30
Which conditions are associated with HLA B27?
Ankylosing spondylitis Reiter's syndrome and reactive arthritis Psoriatic arthritis Acute anterior uveitis IBD
31
What is Reiter's syndrome?
Reactive arthritis | Can't see, can't pee, can't climb a tree
32
What are the symptoms of Wegener's granulomatosis?
Triad - renal, lung, upper respiratory
33
What blood test will be positive in vasculitis?
ANCA
34
What blood test will be positive in dermatomyositis?
Jo1
35
What is the differential for a monoarthritis?
``` Septic arthritis Gout Pseudogout Malignancy Trauma ```
36
What type of crystals do you expect in gout?
Urate Needle shaped Negatively birefringent crystals
37
What type of crystals do you expect in pseudogout?
Calcium pyrophosphate Rhomboid Positively birefringent crystals
38
What are the risk factors for gout?
``` Age Male Diabetes High BMI Alcohol Sardines CKD Myeloproliferative disorders Thiazide diuretics ```
39
What are the risk factors for pseudogout?
hyperparathyroidism hypothyroidism haemochromatosis WIlson's disease
40
What do you see on xray in pseudogout?
Chondrocalcinosis
41
What do you see on xray in gout?
Joint effusion is an early sign Well-defined 'punched-out' erosions with sclerotic margins in a juxta-articular distribution, often with overhanging edges no periarticular osteopaenia (in contrast to rheumatoid arthritis) soft tissue tophi may be seen
42
What do you seen on xray in psoriatic arthritis?
Pencil in cup deformity
43
What is the acute management of gout?
NSAIDs Colchicine Continue allopurinol if already taking it but do not start
44
What is the long term management of gout?
Lose weight Cut down alcohol Decrease purine consumption ( Liver, kidneys, seafood, oily fish (mackerel, sardines) and yeast products) Allopurinol 2 weeks after attack has settled
45
When is allopurinol indicated?
2 attacks of gout in one year.
46
What are the xray findings associated with rheumatoid arthritis?
Soft tissue swelling Periarticular erosions Osteopenia Subluxation
47
What bloods will be positive in rheumatoid arthritis?
Rheumatoid factor Anti CCP ESR
48
Which diseases might have a positive rheumatoid factor?
``` Sjogren's syndrome (around 100%) Felty's syndrome (around 100%) infective endocarditis (= 50%) SLE (= 20-30%) systemic sclerosis (= 30%) general population (= 5%) rarely: TB, HBV, EBV, leprosy ```
49
What is needed for a diagnosis of rheumatoid arthritis?
``` Synovitis in at least one joint Small joint involvement At least 4 joints Serology - rhF and anti CCP CRP and ESR Longer than 6 weeks ``` 3 of those
50
What are the joint related symptoms of rheumatoid arthritis?
MCP and PIP involvement Symmetrical Polyarthritis (4 + joints) Morning stiffness Extensor tenosynovitis Carpal tunnel Rheumatoid nodules - ulnar styloid, olecranon, achilles Atlantoaxial subluxation
51
What are the extra-articular symptoms of rheumatoid arthritis?
``` Lung: Pleural effusion ILD Nodules Pericarditis ``` Eyes: Episcleritis Scleritis Keratoconjunctivitis sicca
52
Which joints are commonly affected by rheumatoid arthritis?
MCP and PIP
53
Which joints are commonly affected by osteoarthritis?
DIP and PIP | Carpometacarpal
54
What is the mechanism of action of allopurinol?
Xanthine oxidase inhibitor
55
What is the mechanism of action of bisphosphonates?
Pyrophosphate analog which inhibits osteoclasts
56
What is the pathophysiology of Marfan's?
Fibrillin 1 mutation
57
What is the pathophysiology of ehlers danlos?
Abnormality in types 3 and 5 collagen
58
Describe the management of rheumatoid arthritis.
1. Symptomatic - NSAIDS or oral prednisolone if severe plus 2. Long term - methotrexate plus one other DMARD (eg hydroxychloroquine/sulfasalazine Biologicals if DMARDs have no effect
59
What are the indications for use of infliximab in rheumatoid arthritis?
Severe disease - on DAS 28 | Failed with intensive therapy of a number of different DMARDs (must include methotrexate)
60
Which scale is used to grade severity of rheumatoid arthritis?
DAS 28
61
What are the extra articular symptoms of seronegative arthropathies?
``` Nail pitting (psoriatic) Psoriasis ``` Dactylitis - sausage fingers Enthesistis - achilles tendonitis Plantar fasciitis Can't see pee or climb a tree (reactive) Uveitis Iritis Dysuria Frequency Heart block Aortic regurg
62
What is the mechanism of action of corticosteroids?
Acts on the glucocorticoid receptor on the nucleus to block expression of transcription factors of: prostaglandins, histamine and T-lymphocytes Therefore antiinflammatory and immunosuppressive effects
63
When are steroids a first line treatment?
Giant cell arteritis - high dose | Polymyalgia rheumatica - low dose
64
What are the side effects of glucocorticoids?
``` Cushings: Weight gain Striae Moon face Parotid swelling Thin skin Bruising ``` ``` Fluid retention Osteoporosis Osteonecrosis Peptic ulcers Pancreatitis Cataracts ``` Increased wbcs
65
What should you prescribe alongside a long term steroid?
Bisphosphonate | PPI
66
What should happen to a steroid dose perioperatively?
If over 10mg daily Minor surgery - 25 mg hydrocortisone at induction of anaesthesia and then resume normal medication postoperatively. Moderate surgery - usual dose of steroids pre-operatively and then 25 mg of hydrocortisone intravenously (IV) at induction, followed by 25 mg IV every 8 hours for 24 hours. Usual pre-operative dose is then continued. Major surgery - usual dose of steroids pre-operatively, then a bigger 50 mg of hydrocortisone IV at induction, followed by 50 mg IV every 8 hours for 48-72 hours. Continue this infusion until the patient has started light eating, then restart the normal pre-operative dose.
67
What is the mechanism of action of methotrexate in RA?
Potentiates adenosine to reduce inflammation
68
What is the mechanism of action of methotrexate in cancer?
Inhibits DHFR enzyme that synthesises folate This is required in the s phase of the cell cycle for DNA synthesis. Therefore targets rapidly dividing cells.
69
What advice must be given with methotrexate?
``` Take weekly Take folate supplements Abortive - avoid pregnancy till 3 months after stopping Interacts with trimethoprim Immunosuppressant ```
70
What are the side effects of methotrexate?
Nausea Photosensitivity Ulcers Hepatitis Pneumonitis Nephrotoxic Abortive Decreased bone marrow (myelosuppression) therefore Immunosuppressant
71
What monitoring is required with methotrexate?
FBC, U&E and LFTs For infection from myelosuppression, nephrotoxicity and hepatitis/cirrhosis Baseline and weekly till stable then every 3 months
72
What monitoring is required with azathioprine?
Check TPMT enzyme levels before prescribing, as required for metabolism of this drug
73
What is a problem with the anti tnf drugs?
Reactivation of TB
74
What blood test tends to be positive in sarcoidosis?
ACE
75
Which conditions are associated with ankylosing spondylititis?
Apical fibrosis Aortic regurgitation AV node block Achilles tendonitis Amyloidosis Anterior uveitis
76
What complications are associated with rheumatoid arthritis?
Ischaemic heart disease Osteoporosis Depression
77
What blood test indicates anti phospholipid syndrome?
Paradoxical raised aptt

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