Rheumatology

Question 1

Which joints are never/rarely involved in RA?

Answer 1

1. Lumbar spine

2. DIPJ

Question 2

10 extra articular features of RA

Answer 2

1. Skin - raynauds phenomenon, leg ulcers
2. Eyes - scleritis, sjogrens syndrome, cataracts secondary to steroids
3. Cricoarytenoid joint disease (sore throat, hoarse voice, neck pain), recurrent headaches at the base of the skull or arm tingling from C1-2 subluxation
4. Lungs - ILD, pleural effusion, pleuritis
5. Heart - pericarditis, valve disease due to rheuamtoid nodules, ACS
6. Renal - drug use, amyloid (all rare)
7. Nervous system - peripheral neuropathy, entrapment neuropathy, mononeuritis multiplex
8. Blood - ACD, felty’s syndrome
9. Systemic - fevers, weight loss, fatigue
10. vasculitis - digital arteritis, ulcers, pyoderma gangrenosum

Question 3

4 side effects of MTX

Answer 3

1. Hepatic toxicity
2. Pulmonary fibrosis
3. Thrombocytopenia
4. Leukopenia

Question 4

3 side effects of leflunomide

Answer 4

1. Diarrhoea
2. Alopecia
3. Liver toxicity

Question 5

3 side effects of HCQ

Answer 5

1. Nausea
2. Pigmentation
3. Retinopathy - needs regular ophthalmological review

Question 6

5 side effects of sulfasalazine

Answer 6

1. Rash
2. Nausea
3. Haematological abnormalities
4. LFT derangements
5. Reversible oligospermia

Question 7

5 differential diagnosis of deforming, symmetrical, chronic polyarthropathy

Answer 7

1. Rheumatoid arthritis
2. Psoriatic arthropathy or other seronegative arthropathies
3. Chronic tophaceous gout (rarely symmetrical)
4. Primary generalized osteoarthritis
5. SLE - usually but not always non-deforming

Question 8

4 causes of arthritis and nodules

Answer 8

1. SEROPOSITIVE RA
2. SLE - rare
3. Rheumatic fever - very rarely
4. Amyloid arthropathy in conjunction with myeloma

Question 9

4 criteria for diagnosis of RA according to 2010 ACR/EULAR RA criteria

Answer 9

1. Number of joints involved
2. Serology (RF, ACPA)
3. Acute phase reactant (CRP, ESR)
4. Duration of symptoms - <6 weeks or >6 weeks

Question 10

Anti-CCP antibodies

Answer 10

More specific at 97%

Associated with more severe disease course and erosive disease

Question 11

Rheumatoid factor

Answer 11

70% of patients are seropositive

Positive especially if they have rheumatoid nodules or associated vasculitis

Question 12

Xray changes to look for in RA

Answer 12

1. Soft tissue swelling
2. Symmetrical joint space narrowing - in OA the narrowing are asymmetrical
3. Juxtaarticular osteoporosis
4. Marginal joint erosions

Question 13

Action of leflunomide

Answer 13

Pyrimidine antagonist which inhibits the proliferation of T cells

Question 14

2 major poor prognostic markers in RA

Answer 14

Large number of joints involved at the outset

Significant abnormalities in the inflammatory markers

Question 15

Causes of drug induced SLE

Answer 15

1. Procainamide
2. Hydralazine
3. Isoniazid
4. Methyldopa
5. Penicillamine

For both procainamide and hydralazine, most patients are ANA positive within 1 year.

Question 16

5 clinical features of GPA

Answer 16

1. Nasal congestion
2. Rhinorrhoea
3. Bloody ansal discahrge
4. Cough with haemoptysis
5. Breathlessness

Question 17

Disease association with polyarteritis nodosa

Answer 17

Hepatitis B - 1/3 of cases

Question 18

5 clinical features of EGPA

Answer 18

1. Asthma
2. Allergic rhinitis, nasal polyps, saddle nose
3. Eczema
4. Cough and breathlessness
5. PNS disease such as symemtrical peripheral neuropathy or mononeuritis multiplex

Asthma occurs before peripheral eosinophilia

Question 19

4 features of mixed essential cryoglobulinaemia

Answer 19

1. Palpable purpura of the extremities
2. Raynauds disease
3. Arthritis
4. Neuropathy

Concurrent Hep C is common

Question 20

Differential diagnosis of livedo reticularis

Answer 20

1. ANCA vasculitis
2. Cholesterol atheroembolism after vascular procedure
3. APLS

Question 21

5 year survival rate for scleroderma

Answer 21

70%

Question 22

Which patient group have higher incidence of diffuse disease and of ILD?

Answer 22

Asian patients

Question 23

Manifestations of scleroderma:

Dermatological:
Arthritis:
GI:
Renal:
Respiratory:
Cardiac:
Others:

Answer 23

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

Question 24

Differential diagnosis to manifestations of scleroderma

Answer 24

1. Eosinophilic fasciitis
2. Diabetic cheiroarthropathy
3. Nephrogenic systemic fibrosis

Question 25

Screening for ILD and pulmonary hypertension

Answer 25

1. Lung function test 2. HRCT 3. Echocardiogram to check for PHTN 4. If high suspicion for PHTN, R heart catheterization and 6MWT.

Question 26

2 rules for use of biological agents in treatment of RA

Answer 26

1. Failure of at least 6 months of treatment with traditional DMARD 2. Treatment must include MTX and combination of HCQ, LEF, or sulfasalazine

Question 27

What is the role of nailfold capillaroscopy?

Answer 27

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

Question 28

Poor prognostic factors in scleroderma Good prognostic factors?

Answer 28

1. Asian patients - more ILD and diffuse disease 2. Men 3. Renal manifestations 4. Late onset disease Good prognostic factors include those with skin/gut involvement without other organ disease

Question 29

Management of scleroderma

Answer 29

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.

Question 30

What to expect when asked to examine the hands in the introductory stem...

Answer 30

1. Arthropathy 2. Acromegaly 3. Peripheral nerve lesion 4. Myopathy 5. Neuropathy