Rheumatology Flashcards
Which joints are never/rarely involved in RA?
- Lumbar spine
2. DIPJ
10 extra articular features of RA
- Skin - raynauds phenomenon, leg ulcers
- Eyes - scleritis, sjogrens syndrome, cataracts secondary to steroids
- Cricoarytenoid joint disease (sore throat, hoarse voice, neck pain), recurrent headaches at the base of the skull or arm tingling from C1-2 subluxation
- Lungs - ILD, pleural effusion, pleuritis
- Heart - pericarditis, valve disease due to rheuamtoid nodules, ACS
- Renal - drug use, amyloid (all rare)
- Nervous system - peripheral neuropathy, entrapment neuropathy, mononeuritis multiplex
- Blood - ACD, felty’s syndrome
- Systemic - fevers, weight loss, fatigue
- vasculitis - digital arteritis, ulcers, pyoderma gangrenosum
4 side effects of MTX
- Hepatic toxicity
- Pulmonary fibrosis
- Thrombocytopenia
- Leukopenia
3 side effects of leflunomide
- Diarrhoea
- Alopecia
- Liver toxicity
3 side effects of HCQ
- Nausea
- Pigmentation
- Retinopathy - needs regular ophthalmological review
5 side effects of sulfasalazine
- Rash
- Nausea
- Haematological abnormalities
- LFT derangements
- Reversible oligospermia
5 differential diagnosis of deforming, symmetrical, chronic polyarthropathy
- Rheumatoid arthritis
- Psoriatic arthropathy or other seronegative arthropathies
- Chronic tophaceous gout (rarely symmetrical)
- Primary generalized osteoarthritis
- SLE - usually but not always non-deforming
4 causes of arthritis and nodules
- SEROPOSITIVE RA
- SLE - rare
- Rheumatic fever - very rarely
- Amyloid arthropathy in conjunction with myeloma
4 criteria for diagnosis of RA according to 2010 ACR/EULAR RA criteria
- Number of joints involved
- Serology (RF, ACPA)
- Acute phase reactant (CRP, ESR)
- Duration of symptoms - <6 weeks or >6 weeks
Anti-CCP antibodies
More specific at 97%
Associated with more severe disease course and erosive disease
Rheumatoid factor
70% of patients are seropositive
Positive especially if they have rheumatoid nodules or associated vasculitis
Xray changes to look for in RA
- Soft tissue swelling
- Symmetrical joint space narrowing - in OA the narrowing are asymmetrical
- Juxtaarticular osteoporosis
- Marginal joint erosions
Action of leflunomide
Pyrimidine antagonist which inhibits the proliferation of T cells
2 major poor prognostic markers in RA
Large number of joints involved at the outset
Significant abnormalities in the inflammatory markers
Causes of drug induced SLE
- Procainamide
- Hydralazine
- Isoniazid
- Methyldopa
- Penicillamine
For both procainamide and hydralazine, most patients are ANA positive within 1 year.
5 clinical features of GPA
- Nasal congestion
- Rhinorrhoea
- Bloody ansal discahrge
- Cough with haemoptysis
- Breathlessness
Disease association with polyarteritis nodosa
Hepatitis B - 1/3 of cases
5 clinical features of EGPA
- Asthma
- Allergic rhinitis, nasal polyps, saddle nose
- Eczema
- Cough and breathlessness
- PNS disease such as symemtrical peripheral neuropathy or mononeuritis multiplex
Asthma occurs before peripheral eosinophilia
4 features of mixed essential cryoglobulinaemia
- Palpable purpura of the extremities
- Raynauds disease
- Arthritis
- Neuropathy
Concurrent Hep C is common
Differential diagnosis of livedo reticularis
- ANCA vasculitis
- Cholesterol atheroembolism after vascular procedure
- APLS
5 year survival rate for scleroderma
70%
Which patient group have higher incidence of diffuse disease and of ILD?
Asian patients
Manifestations of scleroderma:
Dermatological: Arthritis: GI: Renal: Respiratory: Cardiac: Others:
Dermatological: Raynauds (commonly the first symptom), tight skin, sclerodactyly
Arthritis: arthropathy in rheumatoid distribution, carpal tunnel syndrome
GI: dysphagia, heart burn (oesophagitis), diarrhoea causing malabsorption
Renal: HTN, CKD
Respiratory: ILD, pleurisy, PTHN
Cardiac: Pericarditis, arrhythmias, dilated cardiomyopathy
Others: Erectile dysfunction, hypothyroidism, non-melanoma skin cancers
Differential diagnosis to manifestations of scleroderma
- Eosinophilic fasciitis
- Diabetic cheiroarthropathy
- Nephrogenic systemic fibrosis
Screening for ILD and pulmonary hypertension
- Lung function test
- HRCT
- Echocardiogram to check for PHTN
- If high suspicion for PHTN, R heart catheterization and 6MWT.
2 rules for use of biological agents in treatment of RA
- Failure of at least 6 months of treatment with traditional DMARD
- Treatment must include MTX and combination of HCQ, LEF, or sulfasalazine
What is the role of nailfold capillaroscopy?
Presence of dilated tortuous nailfold capillaries with drop outs are suggestive of underlying connective tissue disease and can help to distinguish between primary raynauds vs secondary raynauds phenomena
Poor prognostic factors in scleroderma
Good prognostic factors?
- Asian patients - more ILD and diffuse disease
- Men
- Renal manifestations
- Late onset disease
Good prognostic factors include those with skin/gut involvement without other organ disease
Management of scleroderma
Symptomatic treatment - avoid vasospasm by stopping smoking, beta blockers, cold weather
Aggressive treatment of reflux with PPIs to prevent oesophageal stricture
Nifedipine, prazosin or methldopa for raynauds phenomena
Artificial tears for dry eyes
Malabsorption - suspect and treat bacterial overgrowth with antibiotics
D-penicillamine for skin disease may be helpful (immunosuppressant which interferes with collagen cross linking)
Cyclophosphamide for 9 months if progressive lung disease
Treat pulmonary hypertension with ERA, PDE5 inhibitors, IV prostaglandins.
ACEI for preventing hypertensive renal crisis.
What to expect when asked to examine the hands in the introductory stem…
- Arthropathy
- Acromegaly
- Peripheral nerve lesion
- Myopathy
- Neuropathy
