Rheumatology Flashcards
What are the 4 types of inflammatory arthritis?
Seropositive, seronegative, infectious, crystal induced
What are the 5 types of seropositive arthritis
Rheumatoid arthritis, Lupus, Scleroderma, Vasculitis, Sjorgen’s
What are the types of seronegative arthritis?
Ankylosing spondylitis, psoriatic arthritis, reactive arthtitis, enteropathic arthritis
Define vasculitis
Inflammatory disorder of blood vessel walls causing damage e.g aneurysm, fibrosis, stenosis.
What are the two main types of large vessel arteritis?
Giant cell arteritis (AKA temporal arteritis)
Takayasu’s arteritis (AKA aortic arch syndrome, pulseless disease)
What are the symptoms of Giant cell arteritis
Scalp tenderness, raised temporal artery, headache, fever, jaw claudication and amaurosis fugax
Define amaurosis fugax
A painless temporary loss of vision in one or both eyes described as ‘curtain passing ober the eye’. Usally indicative of transient retinal ischaemia
What are investigations for giant cell arteritis?
Raised ESR and CRP
Temporal artery biopsy to look for granulomatous lesions
What is treatment for giant cell arteritis?
Prednisolone 60mg/ d po for 2 years due to risk of recurrance
Also give PPI and bisphosphonate
What are the three types ofvmedium vessel vasculitis?
Polyarteritis nodosa, Kawasaki disease, buerger’s disease
What is buerger’s disease? (Thromboangiitis obliterans)
Rare condition affecting distal limb vessels , clots in medium sized arteries lead to tisdue ischaemia in fingers and toes. Caused by smoking treated by smoking cessation!
What is polyarteritis nodosa?
Systemic necrotising vasculitis of medium arteries, associated with hep B. Renal disease seen in 70% of cases
What organs does PAN spare?
The lungs
Investigations for PAN?
Raised WCC, ESR, CRP, mild eosinophilia (30%) and anaemia
Renal or mesenteric angiography (check for microaneurisms), renal biopsy.
Treatment for PAN?
Corticosteroids, cyclophosphomide and anti-hypertensives
What is Kawasaki’s disease?
Juvenile form of PAN, children <5, most common type of all vaculitides
What are the symptoms of Kawasaki disease?
Fever resistant to antipyretics > 5 days, strawberry tongue, painful erythema of hsnds and feet, maculopapular rash
What is main complication of kawasaki disease?
Coronary artery aneurysm
How treat kawasaki disease?
IVIG, aspirin and corticosteroids
What are the types of small vessel vasculitis?
ANCA Positive:
granulomatosis with polyangitis
Eosinophilic granulomatosis with polyangitis
Microscopic polyangitis
ANCA Negative:
Henoch-Schonlein purpura, goodpasture’s syndrome
What is ANCA?
Anti-neutrophil-cytoplasmic-antibody. They attack the antigens in the cytoplasm of neutrophils within blood vessels, causing inflammation and/or granuloma formation
Granulomatosis with polyangitis (GPA) affects what with what type of anca?
Nasopharynx, lungs and kidneys
c-ANCA antibodies
Microscopic polyangitis affects what with what type of anca?
Lung and kidneys only
P-ANCA
Eosinophilic Granulomatosis with polyangitis (EGPA) affects what with what type of anca?
Asthma, eosinophilia, vasculitis
P-ANCA
What is goodpasture’s syndrome?
Not ANCA, auto-antibodies (anti-GBM) attack the alpha-3 subunit of type IV collagen. Affects only lung and kidneys
What is treatment for Goodpasture’s Syndrome
Plasmapheresis, steroids, cyclophosphomide, rituximab. Azathioprine for remission
Tell me about Behcet’s disease!
Affects all vessels! Cardinal triad of oral ulcers, genital ulcers and uveitis
Name some connective tissue disorder
Systemic lupus erythematosus
Sjörgen’s syndrome
Idiopathic inflammatory myopathies
Mixed, relapsing polychondritis, behcet’s disease
What are lupus classics?
Butterfly rash, photosensitivity, dry mouth, raynauds phenomenon, nephritis, pleural effusion, protein and hematuria
What is lupus
Autoimmune multisystem connective tissue disease characterised by auto antibodies attacking cell nuclei. ANA then form antigen-antibody complexes that travel around the body depositing in vessels and organs leading to type 3 hypersensitivity reaction
What is management of lupus ?
Focus on preventing flares and reducing their severity
Lifestyle advice to avoid sunlight and other triggers
Limit severity with corticosteroids and immunosuppressants
What is sjögren’s syndrome?
Autoimmune connective tissue disease that is rheumatoid factor positive. Dry mouth and eyes most common
What is systemic sclerosis?
Unknown aetiology, hardened, sclerotic skin. Can be limited, diffuse or without internal organ involvrment
What are the types of arthritis?
Inflammatory, non inflammatory (osteoarthritis), septic, crystal (gout/pseudogout)
Early morning stiffness of >30 minutes suggests what?
Inflammatory arthritis
What does a ‘boggy’ swelling of the joint indicate?
Suggestive of synovitis which occurs in inflammatory arthritis
What joints does rheumatoid arthritis normally effect?
Wrists, metacarpal phalanges, and proximal interphalangeal joint (not distal). Involve the is usually symmetrical
Describe swan neck deformities and in what condition they are found
Hyper extension of proximal interphalangeal joint and flexion of the distal interphalangeal joint. Rheumatoid arthritis
Describe Boutonniere deformity and what condition causes it
Flexion of the proximal interphalangeal joint and hyperextension of the distal interphalangeal joint. Rheumatoid arthritis
Define guttering
Muscle wasting seen over the dorsum of the hand
If you’re a GP and you think someone has rheumatoid arthritis what do you do?
Prescribe analgesia for symptomatic relief and refer urgently to rheumatology. Rapid treatment improves long term outcomes, by maintaining function and quality of life
What blood tests would you complete to confirm rheumatoid diagnosis?
Rheumatoid factor and anti-CCP antibody. Antinuclear antibody may ) di Cate connective tissue disease
Baseline blood tests (FBC, U&E, LFTs), TFTs, plain radiographs of the hands and feet
How is rheumatoid arthritis diagnosed
By a rheumatologist and according to ACR classification criteria
Basically duration, number and type of joints involved, antibody tests and CRP and ESR
How’s is disease activity in rheumatoid arthritis monitored?
Using the disease activity score - DAS28
What is the treatment for active rheumatoid arthritis?
Combination of DMARDs (disease monitoring anti-rheumatic drug), normally methotrexate and hydroxychloroquine, AND with a corticosteroid
Names some DMARDs
Methotrexate and hydroxychloroquine are the most common
Others include leflunomide and sulphasalazine
What are some of the known complication of rheumatoid arthritis?
Carpal tunnel syndrome, haemolytic anaemia
Felty’s syndrome (combination of RA, splenomegaly and neutropenia)
What is the onset for psoriatic arthritis?
Mono arthritis that gradually gets worse
What are the crystals found in gout?
Monosodium urate that are needle shaped and strongly negatively birefringent- yellow under polarized light
Describe the crystals found in pseudo gout I
CPPD crystals positively birefringent rhomboid crystals - blue under polarized light
What tests do you need to do if you suspect gout?
FBC, U&E, LFTs, CRP AND ESR (helps monitor response to treatment esp in septic arthritis), serum urate (low/normal does not rule out gout). Joint aspiration and synovial fluid analysis microscopy-GOLD STANDARD!
Is warfarin a contraindication for joint aspiration?
No
How is an acute attack of gout treated?
Naproxen - but not in renal impairment, and may need gastroprotectors
Colchicine, start asap when NSAIDs don’t work. Start at low dose to avoid diarrhoea
Prednisolone intra-articular v effective if not responding to other treatment - but not in diabetics!
What are the conditions necessary to begin patient on prophylactic treatment for gout?
Established diagnosis of gout AND one of: Two or more gout attacks per year Tophus by clinical imaging study CKD Stage 2 or worse Urolithiasis
What is the aim of prophylactic gout therapy?
To maintain a lower serum uric acid (sUA)<300 micromoles/L
Lower the sUA greater chance of dissolution of tophi
When should urate lowering therapy be introduced following. An acute attack of gout?
2-4 weeks after attack has subsided
What is the prophylactic treatment for gout?
Allopurinol- a xanthine oxidase inhibitor and first drug of choice
Start at 100mg then work up until sUA at desired levels
Continue lifelong, alternative is febuxostat
What are the sideffects of allopurinol?
May cause early increase in gout attacks- therefore give colchicine for two weeks before starting
10% develop rashes
Allopurinol hypersensitivity syndrome (mortality 20-25%)
What are the lifestyle advice for people with gout?
Weight loss, avoid alcohol, avoid sugar sweetened drinks , avoid heavy meals and excessive intake of meat and seafood
Eat low- fat diary produce, vitamin C and exercise regularly
For how long must a patient be on prophylactic colchicine along side allopurinol?
6 months
Define fibromyalgia
Chronic widespread pain >3months in duration
Both sides of the body, above and below waist and along axial spine
What are alternative diagnosis and things to look out for in patient you may think has fibromyalgia?
Hypothyroidism - hair thinning, weight gain
SLE - malar rash, photosensitvity
Addison’s disease- hyper pigmentation
Lymphoma/infection- posterior cervical lymph node enlargement
What tests would you do to rule out anything that isn’t fibromyalgia?
TSH, 25-hydroxy vitamin D level, vitamin B12 level, iron studies,
Magnesium, ESR/CRP
What is the treatment for fibromyalgia?
Exercise- the only management option with strong evidence
CBT, Hydrotherpy, acupuncture
Screen for anxiety and depression
Duloxetine, pregabalin, tramadol
What are the risk factors for fibromyalgia?
Low household income, lack of further education, female, FH of fibromyalgia, going through a traumatic event, rheumatoid arthritis
What are the x-ray changes of rheumatoid arthritis?
Loss of joint space Junta-articular osteoporosis Soft-tissue swelling periarticulat erosions Subluxation
