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Junior blocks > Rheumatology > Flashcards

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
Q

Which condition is associated with polymyalgia rheumatica?

A

Giant cell arteritis

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26
Q

How is Giant cell arteritis treated?

A

High dose oral prednisiolone

ASAP to prevent blindness

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27
Q

How does dermatomyositis present?

A

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)

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28
Q

How does temporal/giant cell arteritis present?

A

Lethargy
Headaches
Recent onset

Raised ESR
Swollen temporal artery
Jaw claudication

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29
Q

What does a high titre on a rheumatology blood test indicate?

A

Positive result

1:160 means they diluted it loads and you could still detect that antibody.
Whereas 1:40 could be normal

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30
Q

Which conditions are associated with HLA B27?

A

Ankylosing spondylitis
Reiter’s syndrome and reactive arthritis
Psoriatic arthritis

Acute anterior uveitis
IBD

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31
Q

What is Reiter’s syndrome?

A

Reactive arthritis

Can’t see, can’t pee, can’t climb a tree

32
Q

What are the symptoms of Wegener’s granulomatosis?

A

Triad - renal, lung, upper respiratory

33
Q

What blood test will be positive in vasculitis?

34
Q

What blood test will be positive in dermatomyositis?

35
Q

What is the differential for a monoarthritis?

A 
Septic arthritis
Gout 
Pseudogout
Malignancy
Trauma
36
Q

What type of crystals do you expect in gout?

A

Urate
Needle shaped
Negatively birefringent crystals

37
Q

What type of crystals do you expect in pseudogout?

A

Calcium pyrophosphate
Rhomboid
Positively birefringent crystals

38
Q

What are the risk factors for gout?

A 
Age
Male
Diabetes
High BMI
Alcohol
Sardines
CKD
Myeloproliferative disorders
Thiazide diuretics
39
Q

What are the risk factors for pseudogout?

A

hyperparathyroidism
hypothyroidism
haemochromatosis
WIlson’s disease

40
Q

What do you see on xray in pseudogout?

A

Chondrocalcinosis

41
Q

What do you see on xray in gout?

A

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
Q

What do you seen on xray in psoriatic arthritis?

A

Pencil in cup deformity

43
Q

What is the acute management of gout?

A

NSAIDs
Colchicine
Continue allopurinol if already taking it but do not start

44
Q

What is the long term management of gout?

A

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
Q

When is allopurinol indicated?

A

2 attacks of gout in one year.

46
Q

What are the xray findings associated with rheumatoid arthritis?

A

Soft tissue swelling
Periarticular erosions
Osteopenia
Subluxation

47
Q

What bloods will be positive in rheumatoid arthritis?

A

Rheumatoid factor
Anti CCP
ESR

48
Q

Which diseases might have a positive rheumatoid factor?

A 
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
Q

What is needed for a diagnosis of rheumatoid arthritis?

A 
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
Q

What are the joint related symptoms of rheumatoid arthritis?

A

MCP and PIP involvement
Symmetrical
Polyarthritis (4 + joints)
Morning stiffness

Extensor tenosynovitis
Carpal tunnel
Rheumatoid nodules - ulnar styloid, olecranon, achilles
Atlantoaxial subluxation

51
Q

What are the extra-articular symptoms of rheumatoid arthritis?

A 
Lung:
Pleural effusion
ILD
Nodules
Pericarditis

Eyes:
Episcleritis
Scleritis
Keratoconjunctivitis sicca

52
Q

Which joints are commonly affected by rheumatoid arthritis?

A

MCP and PIP

53
Q

Which joints are commonly affected by osteoarthritis?

A

DIP and PIP

Carpometacarpal

54
Q

What is the mechanism of action of allopurinol?

A

Xanthine oxidase inhibitor

55
Q

What is the mechanism of action of bisphosphonates?

A

Pyrophosphate analog which inhibits osteoclasts

56
Q

What is the pathophysiology of Marfan’s?

A

Fibrillin 1 mutation

57
Q

What is the pathophysiology of ehlers danlos?

A

Abnormality in types 3 and 5 collagen

58
Q

Describe the management of rheumatoid arthritis.

A
  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
Q

What are the indications for use of infliximab in rheumatoid arthritis?

A

Severe disease - on DAS 28

Failed with intensive therapy of a number of different DMARDs (must include methotrexate)

60
Q

Which scale is used to grade severity of rheumatoid arthritis?

61
Q

What are the extra articular symptoms of seronegative arthropathies?

A 
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
Q

What is the mechanism of action of corticosteroids?

A

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
Q

When are steroids a first line treatment?

A

Giant cell arteritis - high dose

Polymyalgia rheumatica - low dose

64
Q

What are the side effects of glucocorticoids?

A 
Cushings:
Weight gain
Striae
Moon face
Parotid swelling
Thin skin 
Bruising
Fluid retention
Osteoporosis
Osteonecrosis
Peptic ulcers
Pancreatitis
Cataracts

Increased wbcs

65
Q

What should you prescribe alongside a long term steroid?

A

Bisphosphonate

PPI

66
Q

What should happen to a steroid dose perioperatively?

A

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
Q

What is the mechanism of action of methotrexate in RA?

A

Potentiates adenosine to reduce inflammation

68
Q

What is the mechanism of action of methotrexate in cancer?

A

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
Q

What advice must be given with methotrexate?

A 
Take weekly
Take folate supplements
Abortive - avoid pregnancy till 3 months after stopping
Interacts with trimethoprim
Immunosuppressant
70
Q

What are the side effects of methotrexate?

A

Nausea
Photosensitivity
Ulcers

Hepatitis
Pneumonitis
Nephrotoxic

Abortive
Decreased bone marrow (myelosuppression) therefore Immunosuppressant

71
Q

What monitoring is required with methotrexate?

A

FBC, U&E and LFTs

For infection from myelosuppression, nephrotoxicity and hepatitis/cirrhosis
Baseline and weekly till stable then every 3 months

72
Q

What monitoring is required with azathioprine?

A

Check TPMT enzyme levels before prescribing, as required for metabolism of this drug

73
Q

What is a problem with the anti tnf drugs?

A

Reactivation of TB

74
Q

What blood test tends to be positive in sarcoidosis?

75
Q

Which conditions are associated with ankylosing spondylititis?

A

Apical fibrosis
Aortic regurgitation
AV node block

Achilles tendonitis
Amyloidosis
Anterior uveitis

76
Q

What complications are associated with rheumatoid arthritis?

A

Ischaemic heart disease
Osteoporosis
Depression

77
Q

What blood test indicates anti phospholipid syndrome?

A

Paradoxical raised aptt

Junior blocks (12 decks)

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