Rheumatology Flashcards
Symptoms of inflammatory arthropathy
Early morning stiffness > 20 mins
worse after resting, eased by movement
soft tissue swelling, loss of knuckle valleys
raised ESR, CRP
Features of RA
symmetrical, peripheral destructive Arthropathy
small joints of hands or feet
also hips, elbows, knees
palmar subluxation and ulnar deviation at MCP
rheumatoid nodules
active synovitis- red, swollen joints
young adults 3:1 female:male
HLA DR4 associated
Palmar features of RA
Palmar erythema
wasting of thenar eminence- carpal tunnel
fixed flexion contracture
specific Abnormalities- swan neck, button hole, z-thumb
rheumatoiod tenosynovitis
Anatomy of boutonnière deformity
Anatomy of swan neck deformity
What is rheumatoid factor?
IgM against your own IgG
3% of healthy
high titres associated with progressive disease- DMARDs early
Seronegative rheumatoid?
Identical disease presentation to seropositive
1/3 are seronegative
most unlikely to have nodules/ extra-articular
less likely to be rapidly progressive
most have non-classical rheumatoid factors
usually IgG vs IgG
Extra-articular features of RA
FACEBOOKS
Felty’s syndrome
Atlanto-axial subluxation
Caplans syndrome and pulmonary nodules
Effusions (pleural exudates)
Blood – normochromic normocytic anaemia
Olecronon bursitis
Oral dryness (sicca syndrome)
Kidneys (amyloid, gold and penicilliame)
Sensory neuropathy and scleromalacia
DMARDs
Methotrexate- folate antagonist, single weekly dose
sulfasalazine- Inhibits TNF and cytokines production
leflunomide- inhibits B and T cell function
biologicals
steroids
Side effects of methotrexate
Pulmonary fibrosis- spirometry
liver toxicity- LFTs
bone marrow suppression- FBCs
interaction- excretion inhibited by NSAIDs- toxicity
Trimethoprim is contraindicated- another folate antagonist
folic Acidosis rescue often given as a single weekly dose on non-MTX day - decrease symptoms
Differential diagnosis of RA
RA
psoriatic arthropathy
SLE
osteoarthritis with inflammatory component
5 types of psoriatic arthropathy
oligoarthritis 70%
distal (classical) 15%
rheumatoid pattern 15%
arthritis mutilans
sacroilitis may be a feature
Psoriatic arthropathy: treatment options
Radio graphic features of RA
SPADES
Soft tissue swelling
Peri-articular osteoporosis
Absent osteophytes
Deformity
Erosions
Subluxation
XRay features of OA
LOSS
Loss of joint space
Osteophytes
Subchondral cysts
Subchondral Sclerosis
Examination features of scleroderma
Hands- sclerodactyly- tight waxy skin, telamgiectasia, raynaud’s, evidence of ulceration
temperature, skin thethering, subcutaneous calcification (extensor aspects)
‘function of hands
face, upper arms, chest- diffuse
three finger test for microstomia
Features of diffuse cutaneous scleroderma
More extensive together with internal organ involvement (lung, GI, heart, Renal)
mask like face, waxy skin around a small mouth
tethering of skin over nose
interstitial pulmonary fibrosis (restrictive)
renal involvement (hypertension, impaired renal function)
atonic oesophagitis (reflux and aspiration)
1/3 ANA+ve
anti-Scl70 in 1/3
RNA polymerase
Features of limited cutaneous Sclerosis
CREST
Calcinosis
Raynaud’s
Esophageal involvement
Sclerodactyly
Telangiectasia
Questions to ask in scleroderma
Do your hands change colour in the cold?
do you get breathless ?
do you get indigestion or heartburn?
Scleroderma management
Raynaud’s- nifedipine
digital ulcers- bosentan or IV prostanoids
skin- methotrexate (?cyclophosphamide, mycophenylate)
GI- PPI
renal Crisis- ACEi
Pulmonary hypertension- bosentan, sildenafil
Anti- CCP
95% specificity
70% sensitivity
antigen derived from collagen
40% of seronegative RA
Features of seronegative arthritis
Different from seronegative rheumatoid arthritis
psoriatic, Reiter’s, post-dysentery, enteropathic, ankylosing spondylitis
asymmetrical oligoarthritis often associated with sacroiliitis
underlying pathophysiology is an enthesopathy
HLA B27 associated
anyerior uveitis is associated
Features of SLE
immune complexes
non-specific presentation e.g. fever, weight loss, anaemia
light sensitive rash
nail fold vasculitis
splinter haemorrhages
small joint arthritis
Complications of SLE
Hypertension
renal impairment
nephrotic syndrome
pleurisy/pericarditis
cerebral lupus
