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4MB Medicine > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

Describe normal synovial fluid, commenting on appearance, viscosity, white cell count and neutrophils

A

Clear
Normal consistency
WCC less than 200
No neutrophils

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2
Q

Describe osteoarthritic synovial fluid, commenting on appearance, viscosity, white cell count and neutrophils

A

Clear
Increased viscosity
WCC less than 1000
Less than 50% neutrophils

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3
Q

Describe bloody synovial fluid, commenting on appearance, viscosity, white cell count and neutrophils

A

Red/dark brown
Varied viscosity
WCC less than 10 000
Neutrophils less than 50%

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4
Q

Describe inflammatory synovial fluid, commenting on appearance, viscosity, white cell count and neutrophils

A

Yellow/turbid
Reduced viscosity
WCC less than 50 000
Neutrophils vary, should be less than 80%

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5
Q

List the main seropositive inflammatory arthropathies

A 
Rheumatoid
SLE
Scleroderma
Vasculitis
Sjogren's syndrome
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6
Q

List the main seronegative inflammatory arthropathies

A

Ankylosing spondylitis
Reactive arthritis
Psoriatic arthritis
Enteropathic arthritis

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7
Q

List likely aetiology/risk factors for back pain in 15-30 yo

A 
Prolapsed disc
Trauma
Fractures
Ank spond
Spondylolisthesis
Pregnancy
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8
Q

List likely aetiology/risk factors for back pain in 30-50 yo

A

Degenerative spine
Prolapsed disc
Malignancy

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9
Q

List likely aetiology/risk factors for back pain in over 50 yo

A 
Degenerative spine
Osteoporosis
Paget's disease
Malignancy
Spinal stenosis
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10
Q

List red flags for back pain

A 
Age less than 20 or over 55
New onset
Constant, progressive
Worse at night, lying down
Systemic upset
History of cancer
Cauda equina features
Neuro dysfunction
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11
Q

What is osteoarthritis?

A

Wear-and-tear degeneration of bones and joint

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12
Q

List aetiology/risk factors for osteoarthritis

A

Environment (hobbies, occupation, obesity)
Previous injuries/fractures
Genetics/familial
Secondary to disease (Perthes, DDH, arthropathies, malalignment)

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13
Q

List clinical features of osteoarthritis

A 
Pain on movement/worse at end of day
"Background" joint pain
Joint stiffness on waking ~ 30 mins
Instability
Heberden's nodes (DIPJ)
Bouchard's nodes (PIPJ)
Bony tenderness
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14
Q

List XR findings of osteoarthritis

A

Loss of joint space
Osteophyte formation
Subchondral sclerosis
Subchondral cysts

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15
Q

Outline management of osteoarthritis

A 
Exercise to improve muscles and instability
Weight loss
Paracetamol + NSAID
Codeine
IA steroid temporary relief
Joint replacement for pain
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16
Q

List conditions associated with anti CCP antibody

A

Rheumatoid arthritis

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17
Q

List conditions associated with Rheumatoid factor

A 
Rheumatoid arthritis
Sjogren's syndrome
Felty's syndrome
Mixed CTD
SLE
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18
Q

List conditions associated with anti ds DNA antibody

A

SLE

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19
Q

List conditions associated with anti Sm antibody

A

SLE

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20
Q

List conditions associated with anti Ro antibody

A

Sjogren’s syndrome
SLE
Systemic sclerosis
Congenital heart block (placental transfer)

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21
Q

List conditions associated with anti La antibody

A

Sjogren’s syndrome

SLE

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22
Q

List conditions associated with anti-centromere antibody

A

Limited systemic sclerosis

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23
Q

List conditions associated with anti Scl 70 antibody

A

Diffuse systemic sclerosis

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24
Q

List conditions associated with anti RNP antibody

A

Mixed CTD

SLE

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25
List conditions associated with anti Jo 1 antibody
Polymyositis
26
List conditions associated with anti Mi2 antibody
Dermatomyositis
27
What is rheumatoid arthritis?
Chronic seropositive inflammatory arthritis caused by antibodies to Fc fragment of IgG and synovial fluid, resulting in a symmetrical deforming polyarthritis
28
List aetiology/risk factors for rheumatoid arthritis
``` Women Smoking Age 35-50 yo Genetics, familial Trauma Autoimmune conditions ```
29
List clinical features of rheumatoid arthritis
``` Symmetrical swollen painful joints Usually MCP and PIP / small joints Early morning stiffness Pain/stiffness eases with exercise Tenosynovitis, bursitis Extensor tendon rupture Rheumatoid nodules Boutonniere deformity (PIPJ flexion, DIPJ extension) Swan-neck deformity (PIPJ extension, DIPJ flexion) Ulnar deviation of fingers Z thumb Lymphadenopathy Systemic upset ```
30
What investigations would you do for rheumatoid arthritis?
XR may be normal or show peri-articular osteopenia and erosions Raised CRP ESR PV Antibodies (RhF, CCP)
31
Outline management of rheumatoid arthritis
``` DMARD within 3 months of onset: methotrexate/sulfasalazine/hydroxychloroquine + steroid for lag phase and flares NSAID for symptom relief Physiotherapy, OT Biologics if unresponsive to 2 DMARDs ```
32
Which biologic is an anti-TNF agent?
Infliximab | Etanercept
33
Which biologic is an anti-CD20 (B-cell) agent?
Rituximab
34
Which biologic is an anti- T-cell agent?
Abatacept
35
Which biologic is an anti- IL-6 agent?
Tociluzimab
36
Which biologic is an anti- IL-1 agent?
Anakinra
37
What is ankylosing spondylitis?
Chronic seronegative inflammatory arthritis of spine and sacroiliac joints
38
Which HLA is associated with most seronegative arthropathies?
HLA B27
39
List clinical features of ankylosing spondylitis
``` Gradual onset back pain, worse at night Relieved by NSAIDs Morning stiffness, better with exercise Reduced lumbar lordosis Increases thoracic kyphosis Acute uveitis Enthesitis Paraspinal muscle wasting ```
40
What investigations would you do for ankylosing spondylitis?
XR shows syndesmophytes, fused bones (bamboo spine) | Schobert's test
41
Outline management of ankylosing spondylitis
Physiotherapy/exercise NSAID for symptoms Biologics if severe Local steroid injection
42
What are the patterns of psoriatic arthritis?
Usually asymmetrical oligoarthritis | Can be symmetrical polyarthritis
43
What does psoriatic arthritis look like on XR?
Pencil-in-cup deformity
44
What type of pattern does enteropathic arthritis usually present with?
Large joint asymmetrical oligoarthritis
45
What is reactive arthritis?
Sterile arthritis occuring in response to infection in other body area
46
List aetiology for reactive arthritis
``` GU infection (Chlamydia, Neisseira) GI infection (Salmonella, Campylobacter) ```
47
List clinical features of reactive arthritis
Reiter's triad (urethritis, uveitis, arthritis) Large joint inflammation Mouth ulcers Enthesitis Keratoderma blenorrhagica (brown raised papules) Circinate balanitis (painless penile ulceration)
48
Outline management of reactive arthritis
``` Rest Self-limiting (4 weeks) Treat infection NSAID Steroid injection ```
49
What is systemic lupus erythematosus (SLE)?
Multisystem autoimmune condition involving antibodies against body sites
50
List aetiology/risk factors for SLE
``` Women Afro-Caribbeans HLA DR2/DR3 EBV can be a trigger Drugs (isoniazide, hydralazine, chlorpromazine, phenytoin, OCP) ```
51
List clinical features of SLE
``` Fever Fatigue Weight loss Malaise - relapsing and remitting MSK: arthralgia, myalgia, arthritis, AVN Skin: malar rash, photosensitivity, alopecia, Raynaud's Resp: pleurisy, pleural effusion, PE, ILD Haem: cytopenia Lymphadenopathy Endocarditis Migraine Eye problems ```
52
What investigations would you do for SLE?
``` Antibodies: ANA, anti-ds-DNA, anti-Sm Anti-histone ab for drug-induced Low C3/C4 levels when disease active Urinalysis for glomerulonephritis Greater than 4 criteria (at least 1 clinical + 1 lab) or biopsy-proven nephritis and antibody ```
53
Outline management of SLE
Acute flare: IV cyclophosphamide + prednisolone Maintainence: NSAID, hydroxychloroquine, low-dose steroid Nephritis: immunosuppression Unresponsive: IV Ig, rituximab
54
What is Sjogren's syndrome?
Autoimmune lymphocytic infiltrate of exocrine organs (lacrimal/salivary glands) causes dryness and irritation
55
List aetiology/risk factors for Sjogren's syndrome
May be primary disease Secondary: rheumatoid, SLE, other autoimmunity Lymphoma
56
List clinical features of Sjogren's syndrome
``` Dry eyes Dry mouth Parotid swelling Dysphagia Arthralgia Vaginal dryness ```
57
What investigations would you do for Sjogren's syndrome?
Schirmer test for conjunctival dryness Antibodies: anti-Ro, anti-La Parotid biopsy
58
Outline management of Sjogren's syndrome
Eye drops/gels/ointments for dryness Pilocarpine NSAID + hydroxychloroquine for arthralgia
59
What is systemic sclerosis?
Autoimmune abnormality of excess collagen deposition
60
List clinical features of systemic sclerosis
Limited: calcinosis, Raynaud's, esophageal dysmotility, sclerodactyly, telangiectasia, may have skin involvement Diffuse: whole body involvement, organ fibrosis
61
What investigations would you do for systemic sclerosis?
Antibodies: anti-centromere (limited), anti-scl-70 (diffuse) | Organ screening
62
Outline management of systemic sclerosis
IV cyclophosphamide for organ involvement/progression | Ca ch blockers
63
Which antibody is associated with mixed CTD?
Anti-RNP antibody
64
What is antiphospholipid syndrome?
Autoimmune recurrent thrombosis
65
List clinical features of antiphospholipid syndrome
``` Increased frequency of stroke/MI Sterile endocarditis PE Migraine Spontaneous miscarriages in second/third trimester Livedo reticularis ```
66
What investigations would you do for antiphospholipid syndrome?
Lupus anticoagulant + anti-cardiolipin antivody Anti-beta-2-glycoprotein antibody Thrombocytopenia Prolonged APTT
67
Outline management of antiphospholipid syndrome
Lifelong anticoagulation | LMWH during pregnancy
68
What is gout?
Deposition of monosodium urate crystals in and around joints due to increased serum uric acid
69
List aetiology/risk factors for gout
``` High purine diet (seafood) Alcohol excess Hereditary Thiazide diuretics Leukaemia Renal impairment Haem disorder ```
70
List clinical features of gout
``` Acute monoarthropathy, usually 1st MTPJ Intense pain Red hot swollen joint Nausea Gouty tophia - accumulation of uric acid ```
71
What investigations would you do for gout?
Synovial aspirate shows -ve birefringence (yellow-blue) needle-shaped crystals
72
Outline management of gout
Acute: NSAID, colchicine, steroid if NSAID not tolerated Prophylaxis: allopurinol/febuxostat
73
What is pseudogout?
Deposition of calcium pyrophosphate crystals in and around joints Chondrocalcinosis occurs if no inflammation
74
List aetiology/risk factors for pseudogout
``` Idiopathic Old age Hyperparathyroidism Hypothyroidism Diabetes Haemochromatosis Wilson's disease Surgery, trauma ```
75
List clinical features of pseudogout
Acute monoarthropathy typically affecting larger joints | Chronic destructive changes
76
What investigations would you do for pseudogout?
Synovial aspirate shows +ve birefringence rhomboid-shaped crystals
77
Outline management of pseudogout
NSAID Steroid Colchicine Hydroxychloroquine for prophylaxis
78
List clinical features of polymyalgia rheumatica
``` Proximal symmetrical myalgia Muscle stiffness (NOT weakness) Tenderness Morning stiffness lasting over 1h, improves with the day and movement Fatigue Weight loss Anorexia Depression Temporal pain in 15% of pts ```
79
What investigations would you do for polymyalgia rheumatica?
Raised CRP, ESR, PV Normal CK Temporal artery biopsy if GCA
80
Outline management of polymyalgia rheumatica
``` Oral prednisolone 15mg reducing over 18 months with gastric (PPI) and bone (bisphosphonate) protection ```
81
What is polymyositis?
Idiopathic inflammatory myopathy thought to be caused by T-cell mediated cytotoxicity against muscle cells
82
List clinical features of polymyositis
``` Symmetrical proximal muscle weakness Dysphagia Interstitial lung disease, resp weakness Dysphonia Raynaud's Arthralgia Arrhythmia ```
83
What investigations would you do for polymyositis?
Very elevated CK, raised inf markers EMG shows fibrillation Antibodies: ANA, anti-Jo-1, anti-SRP Muscle biopsy confirms diagnosis
84
Outline management of polymyositis
Prednisolone 40mg | Immunosuppression if resistant (azathioprine, methotrexate, cyclophosphamide)
85
List clinical features of dermatomyositis
``` Myositis features V-shaped rash Gottron's papules Heliotrope rash Skin cracks ```
86
There is increased risk of malignancy with dermatomyositis. True/False?
True
87
List clinical features of fibromyalgia
``` Chronic pain (over 3 months) that is widespread in absence of inflammation Fatigue Unrefreshed sleep Unexplained symptoms Tender points Low threshold for pain and other stimuli ```
88
Outline management of fibromyalgia
Education, self-help and coping strategies CBT Exercise Neuropathic analgesia (amitryptilline, gabapentin) Venlafaxine
89
What is vasculitis?
Inflammation of blood vessels that may cause stenosis and thickening
90
What are the main large vessel vasculitides?
``` Giant cell arteritis (in over 50yo) Takayasu arteritis (in under 50yo) ```
91
List clinical features of large vessel vasculitis (mainly GCA)
``` Intense pain around temporal artery Scalp tenderness Jaw claudication Amaurosis fugax Fever Weight loss Arthralgia ```
92
What investigations would you do for large vessel vasculitis?
Raised CRP, ESR, PV MR angiography Temporal artery biopsy shows multinucleated giant cells (may be -ve due to skip lesions)
93
Outline management of large vessel vasculitis
40-60mg prednisolone with gradual reduction | +/- immunosuppression
94
What are the main medium vessel vasculitides?
Polyarteritis nodosa | Kawasaki disease
95
List clinical features of medium vessel vasculitis
Systemic upset Skin rashes, punched out ulcers Coronary aneurysms Renal failure is main cause of death
96
Outline management of medium vessel vasculitis
Control BP Steroid Cyclophosphamide
97
What are the main small vessel vasculitides?
Granulomatous polyangitis (GPA) Microscopic polyangitis (MPA) Eosinophilic granulomatous polyangitis (EGPA) Henoch-Schonlein purpura
98
What is GPA?
Multisystem necrotising granulomatous inflammation with predilection for upper resp tract and kidneys
99
List clinical features of GPA
``` Nosebleeds Recurrent sinusitis, nasal crusting Nasal cartilage collapse (saddle-nose) Deafness Haemoptysis Skin purpura Renal disease (rapidly progressive GN) ```
100
What investigations would you do for GPA?
cANCA, PR3 Urinalysis, renal biopsy XR
101
Outline management of GPA
IV steroid + cyclophosphamide | Cotrimoxazole prophylaxis
102
What is EGPA?
Late onset asthma + eosinophilia + granulomatous vasculitis
103
Which antibody is associated with EGPA?
pANCA
104
Which antibody is associated with MPA?
pANCA | MPO
105
What is Henoch-Schonlein purpura?
IgA-mediated vasculitis usually in kids
106
List clinical features of Henoch-Schonlein purpura
``` Generalised purpuric rash over buttocks and lower limbs Joint pain Abdo pain Vomiting Preceding URTI (Group A Strep) Glomerulonephritis ```
107
Which ANCA is associated with Henoch-Schonlein purpura?
None! | It is ANCA -ve
108
Henoch-Schonlein purpura is usually self-limiting. True/False?
True

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