Rheumatology Flashcards
Describe the signs/symptoms in the joints of rheumatoid arthritis
- Swollen, painful, stiff joints
- Small joints of hand, wrist, feet and cervical spine
- Symmetrical
- Worse in the morning or after prolonged inactivity
- Digital ulnar deviation
- Dorsal wrist subluxation (radial)
- Loss of knuckle guttering
- Finger deformities
- Swan neck (PIPJ extention, DIPJ flexion)
- Boutonniere (PIPJ flexion, DIPJ extension)
- Z deformity of thumb
Name some extra-articular signs of rheumatoid arthritis
- Skin - rheumatoid nodules, vasculitis, Raynauds
- Lungs - fibrosis, pleural effusion, nodules
- Kidneys - amyloid, immune-complexes
- Liver - hepatomegaly
- Blood - normocytic anaemia, neutropenia
- Neuro - peripheral neuropathy
- Atherosclerosis
- Eyes - episcleritis/scleritis, dryness
- Carpal tunnel syndrome
- Osteoporosis
Describe the diagnostic criteria of RA
At least 4 criteria for 6 weeks:
- Morning stiffness > 1 hour
- Involvement of hand joints
- Arthritis >/= 3 joints
- Symmetrical arthritis
- Rheumatoid nodules
- Serum rheumatoid factor
- X-ray changes
Name some investigations into RA
- Bloods - inc ESR/CRP, dec Hb, dec WCC, inc platelets, inc LFTs (ALP), dec albumin
- Rheumatoid factor (70%)
- Anti-CCP antibody (95%)
- X-ray
- Soft tissue swelling
- Loss of joint space
- Erosions
- Subluxation
- Carpal destruction
How is RA managed?
- Regular exercise
- Physiotherapy
- Wrist splints
- NSAIDs (ibuprofen 400mg/8hr) + PPI
- Steroid injection
- Glucocorticoids for acute flare ups (prednisolone 7.5mg/d)
- DMARDs ASAP (methotrexate)
- Anti-TNF (infliximab)
- Surgery - joint replacement, tenosynovectomy, carpal tunnel decompression
Name the common DMARDs, their mechanism of action and their side effects
- Hydroxychloroquine - eye exam (ocular toxicity)
- Methotrexate/anti-tnf - CXR (pulmonary fibrosis)
- Ciclosporin/mycophenolate - urinanalysis
What advice should be given when prescribing NSAIDs?
- Not to asthmatics, peptic ulcer
- For relief of symptoms only - not needed all the time
- Side effects - GI bleeding, headaches/dizziness, hypertension, fluid retention allergic reaction, constipation, diarrhoea
- Stop taking if experiencing abdo pain or black stools and report to doctor
- Don’t supplement with other NSAIDs over the counter
- Smoking and alcohol increase side effect risk
What is the Disease Activity Score?
DAS28: A tool used to measure the activity or control of RA. Questions include:
- Number of swollen joints (/28)
- Number of tender joints (/28)
- ESR/CRP value
- Patient global health score (/10)
Number between 0-10 based on severity of disease activity
Describe the signs/symptoms of psoriatic arthritis
- Asymmetrical oligoarthritis (inflammation affecting 1-4 joints during 1st 6 months)
- Mainly DIPs
- Pain, swelling, stiffness, redness, warmth
- Dactylitis (sausage finger)
- Nail pitting / oncholysis (nail separation)
- Enthesitis (inflammation of tendon insertion)
- Spondylitis (back)
Describe the x-ray features of psoriatic arthritis
- Asymmetrical
- Osteolysis (pencil in a cup appearance)
- Proliferative erosions
- Periosteal reaction
- DIP disease
How is psoriatic arthritis investigated?
- Bloods - U+Es, LFTs
- NO rheumatoid factor
- Hands and feet x-ray
- US/MRI of achilles tendon
How is psoriatic arthritis treated?
- Physiotherapy
- Refer to dermatology for psoriasis
- NSAIDs
- DMARDs - methotrexate, leflunomide, ciclosporin, azathioprine
- Anti-TNF (infliximab)
- Intra-articular steroids
What is reactive arthritis?
A sterile inflammatory arthritis precipitated by a distant infection (HLA-B27 associated)
- Urethritis
- Acute diarrhoea
- Chlamydia trachomatis
- Campylobacter
- Shigella
- Salmonella
- Rubella
- HIV
- Hep B/C
Name some signs/symptoms of reactive arthritis
- Reiter’s syndrome = arthropathy (knee, SI joint), conjunctivitis + urethritis/cervicitis
- ‘Can’t wee, can’t see, can’t climb up a tree’
- GI - ileitis/colitis
- Mucocutaenous - oral ulcers, keratoderma blenorrhagium (small hard nodules on soles of feet)
- General - malaise, fatigue, weight loss
- Enthesopathy (attachment of tendon/ligament)
How is reactive arthritis investigated?
- Bloods - FBC, U+Es, LFTs, CRP/ESR
- Aspirate knee - M, C + S
- Stool culture
- urethral swabs
- PCR of early morning urine (chlamydia)
How is reactive arthritis treated?
- Antibiotics
- NSAIDs
- Intra-articular corticosteroid injection
- DMARDs if no improvement
What is ankylosing spondylitis?
Autoimmune inflammation of the axial skeleton, typically the SI joint.
- HLA-B27 associated
- Predominantly affects males
- Between 15-40
What are the signs and symptoms of ankylosing spondylitis?
- Chronic dull pain in lower back/gluteal region
- Worse in the morning
- Better with exercise
- Insertional tendonitis (Achilles, intercostal, plantar fascia etc)
- Synovitis (hip/knee)
- Uveitis (inflammation of anterior eye chamber)
- Systemic - weight loss, fatigue, fever
- Question mark posture in late disease
- CVS - Aortic regurgitation, cardiomegaly, aortic valve disease
- Respiratory - upper lobe, bilateral pulmonary fibrosis
Additional features (As) = arthitis, anterior uveitis, aortic regurgitation, AV node block, achilles tendonitis, apical pulmonary fibrosis, amyloidosis and cauda equina
How is ankylosing spondylitis investigated?
- Schober’s test - flexion of lumbar spine (abnormal if < 5cm)
- Wall-tragus measurement (kyphosis)
- Bloods - HLA-B27, anaemia, raised inflammatory markers
- MRI of sarco-iliac joints
- Erosions
- Sclerosis
- X-ray of spine = squaring and ossification
- Syndesmophyte = longitudinal fibrous band
- Symmetrical SIJ changes
How is ankylosing spondylitis treated?
- Education - sleeping flat on a firm mattress
- Exercise and physiotherapy
- Hydrotherapy
- Stop smoking
- NSAIDs / opioids
- DMARDs
- Sulfasalazine
- TNF-alpha blocker (infliximab)
- Acute flare ups - intra-articular steroid injection
- Steroid eye drops for uveitis
- Surgery
- Joint replacement (hip)
What is SLE?
Autoimmune-mediated, systemic inflammation/connective tissue disorder that can affect multiple organs
- Classically affects women aged 20-40
- More common in non-white communities
Name some signs and symptoms of SLE
- Rashes
- Malar - spares nasolabial folds
- Discoid - erythematous papules with scaling on head/neck
- Photosensitive
- Raynauds
- Oral/nasopharyngeal ulcers (painless)
- Arthritis > 2 joints (non-erosive)
- Serositis - pleural / pericardial / peritoneal
- Renal disease
- Cardiovascular disease
- CNS - seizures, psychosis, headache
- Haematological - haemolytic anaemia, leucopenia, lymphopenia
- Systemic - weight loss, maliase, fever, myalgia, alopecia
Describe the criteria for diagnosing ankylosing spondylitis
Describe the criteria for diagnosing SLE
SOAP BRAIN MD
- Serositis (pleurits, pericarditis)
- Oral ulcers
- Arthritis
- Photosensitivity
- Blood - anaemia, leukopenia, thrombocytopenia
- Renal - protein
- ANA
- Immunology - dsDNA
- Neurology - psych, seizures
- Malar rash
- Discoid rash
How is SLE investigated?
- Bloods
- ANA / ENA / ds DNA antibody
- FBC - dec neutrophils, dec lymphocytes, inc ESR, dec C3/C4
- NB: not necessarily raised CRP
- Urine dip - inc urea, inc creatinine, protein
What is anti-phospholipid syndrome?
A hypercoagulable state caused by antiphospholipid antibodies
- Can be secondary to SLE
- Causes thrombosis and obstetrical complications
- Miscarriage, pre-eclampsia, congenital heart block
- Treated with hydroxychloroquine
What advice should be given to someone with SLE?
- Rest as appropriate
- Avoid over-exposure to sunlight
- Wear sun cream (> SPF 30)
- CVS risk factors
- BMI
- Smoking / alcohol
- Exercise
- Take calcium / vit D supplements to maintain bone health
- Avoid oestrogen pill
What pharmacological treatment is recommended for SLE?
- NSAIDs
- Hydroxychloroquine (if uncontrolled by NSAIDs)
- Risk of retinopathy (need annual opthalmology check)
- Prednisolone for severe episodes
- Azathioprine, methotrexate, ciclopsorin if not controlled by HCQ
- Rituximab
What is Wegener’s Granulomatosis / GPA?
A systemic vasculitis that affects small and medium sized blood vessels. This typically affects the lungs, kidneys and ENT.
Name some clinical features of Wegeners
- Kidneys - glomerulonephritis
- Nose - saddle-nose, pain, stuffiness, nosebleeds
- Ears - conductive/sensorineural hearing loss
- Oral cavity -ulcers, strawberry gingivitis
- Eyes - scleritis, conjunctivits, uveitis
- Lungs - nodules, cavitis. infiltrate, haemorrhage
- Arthritis
- Chronic sinusitis
How is Wegeners investigated?
- CXR - nodules, cavities, infiltrate
- Urine dip - microscopic haematuria, red cell casts
- Biopsy of kidney/sinus - granulomatous inflammation of arterial walls
- Nasal/oral inflammaion
- Bloods
- ANCA
- FBC
- CRP/ESR
What is the criteria for diagnosing Wegeners?
How is Wegeners treated?
- Cyclophosphamide for induction
- Azathioprine, methotrexate, trimethoprim for remission maintenance
- Rituximab
- Prednisolone for acute flare ups
What are the signs and symptoms of dermatomyositis/polymyositis?
- Muscle weakness
- Symmetrical
- Diffuse
- Starts proximally
- Breathlessness (diaphragmatic weakness)
- Skin
- Gottron’s papules = erythematous papules over MC/IPJ
- Macular rash over back (shawl sign)
- Heliotrope / lilac rash over eyelids
- Telangiectasia (spider veins)
- Mechanics hands
- Raynauds
What is dermatomyositis?
Inflammation of the skin and muscles that can also affect the joints, oesophagus, lungs and heart
How is dermatomyositis/polymyositis investigated?
- Inc creatine kinase / ALP
- Alteration in electromyograph activity
- Muscle biopsy / skin biopsy
- Malignancy markers - FBC, CXR, CRP, abdo US, PSA
- Anti-Mi-2 antibodies
Describe the signs and symptoms of polymyalgia rheumatica
- Symmetrical aching and morning stiffness in shoulders and proximal limb muscles for > 1 month
- Polyarthritis
- Tenosynovitis (carpal tunnel)
- Depression
- Fatigue
- Fever
- Weight loss
How is PMR investigated?
- Inc ALP
- Inc ESR
How is PMR treated?
- Prednisolone
- Decrease dose slowly
- Bisphosphonates
Name some signs and symptoms of Giant Cell Arteritis/temporal arteritis?
- Headache
- Worse with chewing/brushing hair
- Scalp and temporal artery tenderness
- Jaw claudication
- Sudden blindness in one eye
- Prominent/pulsatile temporal artery
How is GCA investigated?
- Inc ESR/CRP
- Inc platelets
- Inc ALP
- Dec Hb
- Temporal artery biopsy
- Fundoscopy - pale swollen optic disc
- Visual acuity
Name some causes of gout
- Diuretics - reduced renal excretion
- Obesity / hyperlipidaemia
- Hyperparathyroidism
- High purine intake
- Red meat, beer, offal
- Ischaemic heart disease
- Renal impairment
- Hypothyroidism
- Drugs - pyrazinamide / ethanol
Name some precipitants of gout
- Trauma
- Starvation
- Alcohol
- Surgery
- Infection
Describe some clinical signs and symptoms of gout
Urate crystals deposited in synovium, connective tissues and kidneys
- Pain, redness and swelling of the joint
- MTP of big toe
- Knee
- Elbow
- Ankle
- Olecranon bursitis
- Tophus deposits in digits, ear, bursae, tendon sheaths
- Nephropathy
- Uric acid stones in urinary tract
How is gout diagnosed?
- Synovial fluid analysis
- Polarised light microscopy
- Gram stain / culture (exclude infection)
- Serum urate (not always inc)
- CRP/ESR, FBC
- X-ray
- Soft tissue swelling
- Opacities
- Erosions
How is gout managed?
- NSAIDs (CI in renal disease)
- Corticosteroids
- Lifestyle changes
- Avoid fasting
- Reduce alcohol intake
- Reduce food high in purines
- Lose weight
- Avoid aspirin
- Allopurinol (3 weeks after attack) 100-300 mg/day
- Adjust with urate levels
What is Sjogrens syndrome?
Chronic autoimmune disorder, characterised by lymphocytic infiltration exocrine glands resulting in dry mucous membranes
- More common in females
- Between 30-60 years
- Can be secondary to RA or SLE
What are the clinical features of Sjogrens
- Dry mucous membranes - mouth, eyes, vagina, resiratory tract
- Mouth - difficulty eating, dental caries, candidal infections
- Repiratory tract - hoarseness, infections
- Dry skin
- Eyes - corneal ulcers, keratoconjunctivitis
- Signs and symptoms of a secondary cause
- Arthralgia
- Parotid gland swelling
- Raynauds
- Lymphadenopathy
How is Sjogrens investigated?
- Routine bloods tests - anaemia
- Inc amylase and inflammatory markers
- +ve ANA and RF
- +ve anti-Ro and anti-La
- Schirmer test (strips of filter paper) - dry eyes
- Can perform biopsy of salivary gland or lower lip
How is Sjogrens managed?
- Education
- Promotion of oral hygiene
- Artifical tears/lubricating gels
- Artifical saliva sprays/mouthwashes
- Pilocarpine - stimulate saliva and tear production
- Hydroxychloroquine if skin/joint problems
- Analgesia
- Emollients for dry skin
Name the important immunological blood tests and what they diagnose
- Rheumatoid factor (IgM) - 70% RA, 90% Sjogrens
- Anti-CCP antibody - RA
- ANA - SLE, 75% Sjogrens
- Anti-ds DNA - SLE
- Extractable Nuclear Antigens
- Anti-Ro - Sjogrens
- Anti-La - Sjogrens
- Anti-Jo1 - polymyositis
- ANCA - vasculitis
- ACLA - anti-phospholipid syndrome
Name some examples of seronegative arthropathies
- Reactive arthritis
- Ankylosing spondylitis
- Psoriatic arthritis
- Enteropathic arthritis
What test may be useful before starting azathioprine/mecaptocurine?
Serum TPMT - enzyme that is involved in the metabolism of azathioprine
- If deficient - can develop severe and life-threatening bone marrow toxicity
What is GCA/temporal arteritis?
- Large vessel vasculitis
- Segmental granulomatous inflammation of external carotid artery and branches
- Superficial temporal
- Opthalmic
- Maxillary
- Pain over thickened, tender, non-pulsatile temporal arteries
- Visual loss / amaurosis fugax (25%)
- Jaw claudication
- Associated with PMR
What are the main 4 features of anti-phospholipid syndrome?
CLOT
- Clotting disorder (thrombosis)
- Livedo reticularis
- Obstetric complications
- Recurrent 1st trimester miscarriage
- Thrombocytopenia
30% of SLE
Describe the difference between RA and OA in terms of:
- Symmetry
- Morning stiffness
- Agrravating and relieving factors
- Age of onset
- Speed of deterioration
- Systemic involvement
How is GCA diagnosed?
- Raised ESR
- Temporal artery biopsy
How is GCA managed?
Prednisolone 60mg/day until ESR decreases
