Rheumatology Flashcards
anti-dsDNA
SLE
anti-centromere
limited cutaneous systemic sclerosis
what is the cardiovascular risk of a patient with rheumatoid arthritis?
2-3 x higher than the normal population
what are the common causes of a monoarthritis?
crystal arthropathy
septic arthropathy
osteoarthritis
trauma (haemarthrosis)
what are the common causes of oligoarthropathy?
crystal arthritis
psoriatic arthritis
reactive arthritis
ankylosing spondylitis/osteoarthritis
what are the 7 clinical features common to all seronegative arthropathies
- seronegative (Rh negative)
- HLA B27 association
- axial arthritis (spine or sacroiliac joints)
- asymmetrical, large joint oligoarthritis
- enthesitis: inflammation at the site of tendon insertion to bone
- dactylitis: inflammation of an entire digit
- extra-articular manifestations: anterior uveitis, psoriaform rash, oral ulceration, aortic regurgitation and inflammatory bowel disease
what is the treatment of pseudogout in acute attacks?
what is the effective prevention for pseudogout?
similar to gout:
- rest, elevation and ice packs
- aspiration and intra-articular steroids
- NSAIDs (+ PPI) and colchicine
prevention: methotrexate and hydroxychloroquine
anti-Ro / anti-La
AKA SSA/SSB
Sjogren (& SLE)
what are the nail changes associated with psoriatic arthritis?
how frequently do they occur?
in 80% of patients
- onycholysis
- nail pitting
- subungual keratosis
what are the surgical options for the management of septic arthritis?
surgical arthrocentesis, washout and debridement
prosthetic septic arthritis should always be referred to the surgeons for consideration of replacing the prosthesis because medical therapy will not penetrate the joint space effectively
what is the global prevalence of osteoarthritis?
>10% of people >60 years old
what are are the radiographic features of osteoarthritis?
‘LOSS’
- loss of joint space
- osteophites
- subarticular sclerosis
- subchondral cysts
what are two pathognemonic feature of ank spond on plain film of the spine?
vertebral syndesmophytes
bamboo spine - calcification of spinal ligaments
what are some suitable biologic agents for the control of rheumatoid arthritis?
what must be checked before starting any of these biologics?
- anti-TNF-alpha: infliximab
- B-cell depletion: rituximab
- IL-1 and IL-6 inhibition: tocilizumab
- anti-T cell: abatacept
always a change to reactivate latent TB and hepatitis B, so all patients must be screened.
anti-Sm
SLE
what blood tests are best for monitoring SLE disease activity?
- anti-dsDNA titres
- c3 and c4
- ESR (clasically normal CRP though)
can also monitor BP, red cell casts in urine, urine protein
what tests should be run on a synovial fluid sample?
cytology - white cell count
micro - Gram stain and culture
biochem - polarised light microscopy
other than DMARDs and biologics, what is the management strategy for rheumatoid arthritis?
- physiotherapy, exercise, OT and rehab
- NSAIDs for breakthrough pain
- steroids for acute flares, systemic > intra-articular
- surgery: relieve pain and improve functioning (joint fusion), prevent deformity
- managing cardiovascular and cerebrovascular risk factors
- atherosclerotic process is sped up in RhA patients
- smoking worsens symptoms of RhA, so encouraging them to stop
what are the extra-articular manifestations of rheumatoid arthritis?
nodules
- elbows
- lungs
- heart
- brain/meningies
- lymphadenopathy
lungs
- pleurisy
- interstitial fibrosis
cardiac
- ischaemic heart disease
- pericarditis/pericardial effusion
eye
- episcleritis
- scleritis
- keratoconjunctivitis sicca
other
- splenomegaly (not always Felty syndrome)
- RA, splenomegaly, neutropenia
- osteoporosis
- amyloidosis
- anaemia of chronic disease
- carpel tunnel syndrome
what are the common causes of polyarthritis?
symmetrical
- rheumatoid arthritis
- osteoarthritis
asymmetrical
- reactive arthritis
- psoriatic arthritis
what is the typical pattern of back pain experienced in ank spond?
low back pain that gradually gets worse throughout the night, peaks in the morning and gets better with exercise
pain radiates from the back to the buttocks/hips
how do you monitor disease activity in rheumatoid arthritis?
using the DAS28 score
palmo-plantar pustulosis is associated with what disease?
psoriatic arthritis
what is a suitable choice of medication to control blood pressure in severe lupus nephritis flare?
ace-i
along with drugs to control the underlying disease process such as immunosuppression with high-dose steroids, MMF or cyclophosphamide
how would you investigate dermatomyositis?
- muscle enzymes (CK, aldolase, ALT, AST, LDH)
- associated auto-antibodies (Anti-Jo1, anti-Mi2)
- EMG - classic fibrilation potentials
- muscle biopsy
- MRI - muscle oedema
anti-Scl70
diffuse cutaneous systemic sclerosis
which is the most commonly affected joint by septic arthritis?
knee, in >50% of cases
what are some differentials for proximal myopathy?
PMR
polymyositis, dermatomyositis
hypothyroidism
primary muscle disease (muscular dystrophy)
osteoarthritis (cervical spondylosis/shoulder OA)
spinal stenosis
apart from the joints, what other features of rheumatoid arthritis are common in the hands?
(extensor) tenosynovitis and bursitis
extensor tendor nodularity or rupture
what are some suitable DMARDs for rheumatoid arthritis?
what are their major side effects?
best control is usually achieved with a combination of
- methotrexate (pulmonary and liver fibrosis, myelosuppression, teratogenic)
- hydroxychloroquine - retinopathy, eye screening yearly
- sulfasalazine - rash, oligospermia, oral ulcers, GI upset
other option
- leflunomide - teratogenic (M & F), oral ulcers, hypertension, hepatotoxic
what is the difference between NSAIDs and colchicine in the management of acute gout?
what patients are both CI? what is the next treatment option?
NSAIDs are preferred - but CI in many cases (GI, cardio, renal)
colchicine has a slower onset of action but still effective
CKD/renal disease - then use steroids (po, im, intra-articular)
anti-RNP
mixed CTD
what are the radiographic features of rheumatoid arthritis?
juxta-articular osteopenia
joint subluxation and loss of joint space
soft tissue swelling (better appreciated on USS)
erosions
anti-histone
drug-induced SLE
what are the features of gout arthropathy on plain radiograph?
periarticular erosions
soft tissue swelling (best appreciated on USS)
normal joint space (until late in disease course)
no evidence of sclerosis
dermatomyositis is associated with?
is a paraneoplasitc phenomenon from a visceral organ solid tumour
investigate for
- gastric CA (1/3rd patients)
- lung
- pancreas
- ovarian
- bowel
what is the typical course of antimicrobials in septic arthritis?
typically 2 weeks IV as an inpatient, then 2-4 weeks oral when discharged
how do you manage ank spond?
what are the biologic agents of use?
- intense, specialist physio-led exercise program
-
Pain
- NSAIDs
- local steroid injections
-
biologics
- TNF-alpha blocker = etanercept, adalimumab
-
surgery
- hip replacement (if mobility is affected)
- spinal-osteotomy (rarely)
- osteoprotection with bisphosphonates
what are the common causative organisms for septic arthritis?
- N gonorrhoeae*
- Staph. aureas*
- Strep. pneumo*
Gram -ve bacilli
what are some causes of secondary osteoarthritis?
obesity and occupation (kneeling, squatting, climbing, lifting)
haemochromatosis
what are the signs of dermatomyositis?
heliotrope rash around the eyes with oedema
nail fold erythema
macular rash - ‘shawl sign’ when distributed over shoulders
Gottron’s papules over knuckles, elbows and knees
beyond acute gout, what are the features of hyperuricaemia seen in long-term gout sufferers?
gouty tophi
interstitial nephritis
urate renal stones
what are the signs of cauda equina compression?
alternating or bilateral lower limb pain
saddle (perianal anaesthesia)
urinary retention and faecal incontinence
erectile dysfunction
why is it important to examine the spine of a rheumatoid arthritis patient?
atlanto-axial joint subluxation can threaten the cord
always check the C-spine
risk factors for rheumatoid arthritis
- smoking
- F>M
- 5th-6th decade of life
- HLA DR4/DR1 genotype
what are the features of reactive arthritis?
- arthritis, enthesitis
- keratoderma blenorrhagica
- circinate balanitis
- conjunctivitis/iritis
- mouth ulcers
anti-Jo-1, anti-Mi-2
polymyositis and dermatomyositis
anti-phospholipid / anti-cardiolipin
antiphospholipid syndrome / SLE
a high RF is associated with…
severe disease & extra-articular manifestations
what are the clinical features of APLS?
‘CLOT’
- coagulation defects (arterial and venous thrombosis)
- livedo reticularis
- obstetric (recurrent miscarriage)
- thrombocytopenia
what are some common agents precipitating drug-induced lupus?
procainamide, hydralazine
isoniazid, minocycline, phenytoin
what are the associated features of ankylosing spondylitis?
the A’s of ank spond
- anterior uveitis
- achilles tendonitis
- aortic regurgitation
- apical fibrosis
- AV nodal block
- amyloidosis
- and cauda equina
which antibiotic is associated with achilles tendon disorders?
ciprofloxacin
besides the skin, what are the other organ systems involved in systemic sclerosis?
which is the most important cause of mortality in these patients?
- renal - malignant hypertension, glomerulonephritis
- msk - arthritis, polymyositis
- lung - pulmonary fibrosis, pleural effusions
- heart - restrictive cardiomyopathy, pericarditis, pulmonary hypertension
- gi - dysphagia, GORD, dysmotility, PBC
most common cause of death is renal failure
what is the difference in features of limited and diffuse systemic sclerosis?
limited
invovles skin of the hand, face and maybe neck. renal crises rarely occur. late involvement of the lungs, manifesting as pulmonary hypertension.
diffuse
diffuse skin involvement, including trunk and proximal limbs. early involvement of the lungs, kidney, gut and heart.
what are the features of APLS?
CLOTs
- coagulation (venous and arterial)
- livedo reticularis
- obstetric (recurrent miscarriage)
- thrombocytopenia
