Rheumatology Flashcards
How would you examine the hands in PACES?
Look: at hands, elbows for nodules, ears for tophi, hairline for psoriasis
Feel: feel systematically
Move: assess power, grip my fingers tightly
FUNCTION: pick up a coin off table, undo button
What the criteria for diagnosing RA?
ACR/EULAR criteria
Joint distribution 1 large joint 0 2-10 large joints 1 1-3 small joints 2 4-10 small joints 3 >10 joints 5
Serology
Negative RF and negative anti-CCP 0
Low positive RF/anti-CCP 2
High positive RF/Anti-CCP 3
Symptom duration
< 6weeks 0
>6 weeks 1
Acute phase reactants
Normal CRP/ESR 0
Abnromal ESR/CRP 1
More than or equal to 6 is RA
What are the signs of RA in hands?
Symmetrical deforming polyarthritis affecting small joints of hands, wrists and elbows, sparing DIP Ulnar deviation of MCP joints Boutounnieres/ swan neck deformities Z thumb Piano key ulnar head Rheumatoid nodules Surgical scars
What are the extra-articular manifestations of RA?
Haematological: anaemia, splenomegaly (Feltys syndrome)
Skin: nodules, vasculitis, pyoderma gangrenosum
Eyes: scleritis, episcleritis, scleroderma perforans
CV: valvular disease, pericarditis, conduction defects, myocardial infarction, myocarditis, HF
Respiratory: pul. fibrosis, pleural effusions, bronchiolitis obliterans
Renal: amyloidosis
Neurological: peripheral neuropathy, mononeuritis multiplex, compression neuropathies, cervical myelopathy-atlanto-axial subluxation, carpal tunnel, ulnar neuropathy
What investigations would you do in somebody with possible RA?
FBC- anaemia, neutropenia
CRP/ESR
Rheumatoid factor: antibodies that recognise the Fc portion of IgG
Anti-CCP- increased specificity, TB can cause false positive
XR signs: periarticular osteopenia, erosions at margins of joints, joint space narrowing, osteopenia, subluxation
Doppler US/MRI for acute synovitis
CXR: pul.fibrosis or nodules
LFTs
HRCT
What are the treatment options for RA?
Exercise, physio, OT, home modification, mobility aids
DMARDS
Methotrexate + at least one other + short term glucocorticois
Others: sulphasalazine, leflunomide, hydroxychloroquine, gold, penicillamine
Biologics
Used if inadequate response to at least 2 DMARDs including methotrexate
- TNF-I: infliximab, adalimumab, golimumab, etanercept
Anti-CD20: rituximab
Anti-IL6: toculizumab
CTLA4 Ig: Abatercept
How would you monitor a patient on a DMARD or anti-TNF?
Specialist review with history and examination
monitor FBC, U+E,. LFT
Infections
What are the side effects of methotrexate?
Hepatitis, alveolitis (pulmonary fibrosis), stomatitis
Pancytopenia/marrow suppression
WHat is the treatment of methotrexate toxicity?
Folinic acid
How do you manage a patient on anti-TNA who presents to A+E with minor infection?
Admit
Stop anti-TNF
IV abx
Seek specialist advice
List the possible causes of anaemia in RA
Anaemia of chronic disease GI bleed due to NSAID or steroid use Feltys syndrome Renal amyloid Marrow suppression- methotrexate Autoimmune haemolytic anaemia Assoc pernicious anaemia
How do you distinguish RA from OA on XR?
RA: juxta-articular osteopenia, erosion, symmetry, deformity
OA: subchondral sclerosis, osteophytes
Both: joint space narrowing, bone cysts
What should you ask about in a person with possible psoriatic arthritis?
FH: if 1st degree relative has it the increases chances x50 Back pain Iritis IBD Enthesitis Plantar fasciitis Dactylitis DIP joint involvement Nail signs
How would you manage somebody with psoriatic arthritis?
NSAIDs mild non-erosive disease
Steroid injection esp enthesitis
DMARD- sulphasalazine or leflonamide
Methotrexate is sig skin disease
AVOID hydroxychloroquine as may worsen skin
Steroid in flares
Consider anti-TNF
Rarely goes into remission so lifelong treatment
How do you differentiate between PsA and RA?
Asymmetry Nail changes Dactylitis Negative anti-CCP/RhF FH/PH of psoriasis
DO you know any HLA assoc of psoriatic arthritis?
HLA-B27 with sacroilitis
HLA-DR4 with RA distribution
HLA- B38/39- peripheral distal arthritis
What are the 11 criteria in SLE?
ACR criteria in diagnosis of SLE
- Malar rash: butterfly-shaped rash across cheeks and nose
- Discoid (skin) rash: raised red patches
- Photosensitivity: skin rash as result of unusual reaction to sunlight
- Mouth or nose ulcers: usually painless
- Arthritis (nonerosive) in two or more joints, along with tenderness, swelling, or effusion. With nonerosive arthritis, the bones around joints don’t get destroyed.
- Cardio-pulmonary involvement: inflammation of the lining around the heart (pericarditis) and/or lungs (pleuritis)
- Neurologic disorder: seizures and/or psychosis
- Renal (kidney) disorder: excessive protein in the urine, or cellular casts in the urine
- Hematologic (blood) disorder: hemolytic anemia, low white blood cell count, or low platelet count
- Immunologic disorder: antibodies to double stranded DNA, antibodies to Sm, or antibodies to cardiolipin
- Antinuclear antibodies (ANA): a positive test in the absence of drugs known to induce it.
Requires at least 4 criteria
What might you find on examination in patient with SLE?
Lymphadenopathy or fever Arthritis: Jaccoud's arthropathy (deformity at rest) which resolves on making fist Malar rash Discoid lupus Vasculitis SCarring alopecia Mouth ulcers Livedo reticularis Libman-Sacks endocarditis- AR/MR Pulmonary fibrosis/effusions Nephrotic syndrome or signs of RRT CN lesions, mononeuritis Cushingoid from steroids
What are the key features of Sjorgrens syndrome?
Dry eyes
Dry mouth
Bilateral parotid gland enlargement (differentials are lymphoma, sarcoidosis, parotid tumour, mumps)
What are the investigations for Sjorgrens syndrome?
Schirmers test- filter paper in lower eyelid and close eyes, normal >15mm
ENA antibodies: anti Ro/La
If antibodies negative then salivary gland biopsy
What is the management of Sjorgrens?
If primary require long term follow up as risk of lymphoma is 40x
Tear and salvia replacement
How would you investigate somebody with possible SLE?
Immunological tests:
- ANA
- DsDNA
- ENA: Ro, La, Smith, RNP
- C3, C4
- Antiphospholipid antibodies
FBC: anaemia, thrombocytopenia, lymphopenia, coombs test
Urine: dip and casts
CXR
ECHO
Skin biopsy
How do you manage SLE?
Simple analgesics , NSAIDs (caution)
Steroids
Hydroxychloroquine
Cyclophosphamide- reserved for life threatening disease- lupus nephritis, vasculitis, cerebral disease
Mycophenolate mofetil- as effect as cyclophosphamide with lower risk ovarian failure
Azathioprine
Biologics have been used
IVIg and plasma exchange in life threatening disease
Renal disease: ACE-I/ARB
Anti-phospholipid syndrome: warfarin/LMWH
What are the chances of passing SLE to offspring?
Genetic factors important but chances are low
What investigations help to determine if a patients lupus is active?
Urinalysis for blood and protein Urine cytology for red cell casts U+E ESR FBC- cytopenia Anti-dsDNA C3, C4
What are the major risks of cyclophosphamide therapy and what can be done to prevent them?
Infection
- reactivation of latent TB, HIV, hep B/C
- bone marrow suppression
- septrin prophylaxis
Bladder toxicity- haemorrhagic cystitis, use mesna
Malignancy
Infertility- freeze sperm, ovarian protection
Nausea, vomiting, alopecia, teratogenicity
What is scleroderma?
A spectrum of disease encompassing:
- Raynauds phenomonen: 2nday to systemic sclerosis, SLE, Sjorgrens, MCTD, dermatomyositis
- Localised scleroderma- Morphoea, Linear scleroderma, En Coup de Sabre
- Systemic sclerosis- limited or diffuse (CREST)
What are your screening questions for connective tissue diseases?
Do you have any rashes? Worse in sun? Are you losing hair? Do you suffer with mouth ulcers? Do you have dry eyes and mouth? Are you short of breath? (pul.htn) Do you have difficulty swallowing/heartburn? Do you have diarrhoea/weight loss? Are your muscles painful/ weak? Do you have difficulty rising from a chair?
