rheumatology Flashcards
arthropathy definition
disease of a joint
arthritis definition
inflammation of a joint
arthralgia definition
pain in a joint
seropositive condition
auto-antibodies present in serum
anti-CCP antibody
rheumatoid arthritis
anti-nuclear antibody
SLE, Sjorgen’s syndrome, systemic sclerosis, mixed connective tissue disease, autoimmune liver disease
anti-double stranded DNA antibody
SLE
anti-Sm
SLE
anti-Ro
SLE, Sjorgen’s syndrome
anti-La
Sjorgen’s syndrome
anti-centromere antibody
systemic sclerosis (limited)
anti-Scl-70 antibody
systemic sclerosis (diffuse)
anti-RNP antibody
SLE, MCTD, myositis
anti-cardiolopin antibody and lupus anti-coagulant
anti-phospholipid syndrome
anti-neutrophil cytoplasmic antibody (ANCA)
small vessel vasculitis (GPA, EGPA, MPA)
osteoarthritis X-ray signs (LOSS)
loss of joint space osteophytes sclerosis subchondral cysts
the four groups of inflammatory arthropathies
seropositive, seronegative, infectious and crystal deposition arthropathies
osteoarthritis
inflammatory spondylitis
psoriatic arthritis
rheumatoid arthritis
is RA more common in men or women?
women
joints most commonly affected by RA
small joints of the hands and feet
what role does the pannus play in the pathogenesis of RA?
an inflammatory pannus forms and then attacks and denudes the articular cartilage leading to joint destruction
features of inflammatory arthritis
joint pain with associated swelling
morning stiffness
improvement of symtpoms with exercise
synovitis on examination
raised imflammatory markers
extra-articular symptoms
clinical features of RA
symmetrical synovitis, pain, morning stiffness, early involvement of hands and feet
why is the DIP joint not commonly affected in RA?
because RA only affects synovial joints, and the DIP is so small that there is hardly any synovium in it
why can RA result in cervical cord compression?
the atlanto-axial joint can be affected, which can lead to subluxation and eventually cervical cord compression
extra articular manifesations of RA
rheumatoid nodules on extensor surfaces of sites of frefquent mechanical irritation
preural effusions, interstitial fibrosis and pulmonary nodules
keratoconjunctivitis sicca, episcleritis, uveitis and nodulr scleritis
RA investigations
rheumatoid factor, anti-CCP antibody
CRP, ESR and PV are usually raised
xrays often show no abnormality
peri-articular osteopenia and soft tissue swelling
RA treatment
DMARDs (methotrexate, sulphasalazine, hydroxychlorquine, leflunomide)
simple analgesia
NSAIDs
steroids
anti-TNFa injections
disease activity in RA is measured using
DAS28
DAS 28 2.7-3.2
low disease activity
DAS 28 3.3-5.1
moderate disease activity
DAS 28 >5.1
high disease activity
DAS 28 <2.6
remission
patients must have a score of ____ to be eligible for biologic therapy
>5.1 (high disease activity)
operative management of RA
synovectomy, joint replacement, joint excision, tendon transfers, anrthrodesis, cervical spine stabilisation
seronegative arthropathies include
ankylosing spondylitis, psoriatic arthritis, enteropathic arthritis and reactive arthritis
characteristics of seronegative arthropathy
inflammation/arthritic disease of the spine (spondyloarthropathy)
asymmetric oligoarthritis
sacroiliitis
uveitis
dactylitis
enthesopathies
laboratory signs of seronegative arthropathy
HLA-B27 positive
elevated CRP and ESR
who is most commonly affected by ankylosing spondylitis?
males aged 20-40
which joints are affected by AS
spine and sacroiliac joints
AS symptoms
spinal pain and stiffness
knee or hip arthritis
morning spinal stiffness that improves with exercise
gradual loss of spinal movement
development of ‘question mark’ spine (loss of lumbar lordosis and increased thoracic kyphosis)
how do you measure lumbar spine flexion?
Schober’s test
AS associated conditions
anterior uveitis, aortitis, pulmonary fibrosis, amyloidosis
xray signs of AS
sclerosis and fusion of SI joints
bony spurs from the vertebral bodies (syndesmophytes) producing a ‘bamboo’ spine
common for xrays to be normal at time of presentation
MRI features of AS
bone marrow oedema
entheitis of the spinal ligaments
laboratory signs of AS
90% of sufferers are HLA-B27 positive
AS treatment
physiotherapy and exercise
NSAIDs
anti-TNF inhibitors for more aggressive disease
DMARDs if peripheral joint inflammation
psoriatic arthritis presentation
asymmetrical oligoarthritis
spondylitis
dactylitis
enthesitis
nail pitting and onycholysis (splitting of nail from nail bed)
psoriatic arthritis treatment
DMARDs (methotrexate)
anti-TNFa therapy for those who don’t repsond to standard therapy
joint replacement in severely affected large joints
DIP fusion
enteropathic arthritis definition
inflammatory arthritis involving the peripheral joints and sometimes spine, in patients with IBD
enteropathic arthritis presentation
large joint asymmetrical oligoarthritis
treatment of enteropathic arthritis
finding medication to manage the underlying condition and the arthritis
reactive arthritis definition
occurs in response to an infection in another part of the body, most commonly GU infection (chlamydia, neisseria) or GI infections (salmonella, campylobacter)
reactive arthritis presentation
large joints become inflamed 1-3 weeks after the infection
(infection triggers autoimmune arthropathy)
Reiter’s syndrome
urethritis, uveitis or conjunctivits and arthritis
SLE mainly involves…
skin, joints, kidneys, blood cells, and nervous system
clinical criteria of SLE
- acute cutaneous lupus
chronic cutaneous lupus
oral or nasa lulcers
non-scarring alopecia
arthritis
serositis
renal
neurologic
haemolyitc anaemia
leukopaenia
thrombocytopaenia
immunologic criteria SLE
ANA
anti-DNA
anti-Sm
antiphospholipid Ab
low complement
direct Coombs’ test
what type of hypersensitivity reaction is SLE
type 3 - immune complex mediated
SLE general symptoms
fever
fatigue
weight loss
SLE MSK symptoms
arthralgia
myalgia
inflammatory arthritis
increased prevalence of AVN, usually of the femoral head
SLE muco-cutaneous symptoms
malar rash
photosensitivity
discoid lupus
subacute cutaneous lupus
oral/nasal ulceration
raynaud’s phenomenon
alopecia
SLE renal symptoms
lupus nephritis
SLE respiratory symptoms
pleurisy
pleural effusion
pneumonitis
pulmonary embolism
pulmonary hypertension
intersitial lung disease
SLE haematological symptoms
leukopaenia
lymphopaenia
anaemia
thrombocytopaenia
SLE neuropsychiatric symptoms
seizures
psychosis
headache
aseptic meningitis
SLE cardiac symptoms
pericarditis
pericardial effusion
pulmonary hypertension
sterile endocarditis
accelerated ischaemic heart disease
SLE GI symptoms
less common
AI hepatitis
pancreatitis
mesenteric vasculitis
SLE investigations
FBC may show anaemia, leukopaenia and thrombocytopaenia
ANA - not specific
Anti-dsDNA - specific
Anti-Sm - specific but low sensitivity
Anti-Ro, Anti-La and Anti-RNP - not specific
C3/4 levels - low when disease active
urinalysis may show signs of glomerulonephritis
imaging for organ involvement
SLE management
skin disease and arthralgia - hydroxychloroquine, topical steroids, NSAIDs
immunosuppression with azothioprine or mycophenolate mofetil
severe disease may need IV steroids and cyclophosphamide
IV Ig and rituximab may be necessary in unresponsive cases
SLE monitoring
anti-dsDNA and complement to monitor disease activity
urinalysis for blood or protein
BP and cholesterol should be monitored
Sjorgen’s syndrome symptoms
dryness of eyes and mouth (sicca)
arthralgia
fatigue
vaginal dryness
parotid gland swelling
Sjorgen’s diagnosis
ocular dryness
positive anti-Ro
positive anti-La
lip gland biopsy
Sjorgen’s management
lubricating eye drops
saliva replacement products
regular dental care
hydroxychloroquine can help with arthralgia and faitgue
systemic sclerosis characteristics
vasomotors distrubances (raynauds)
fibrosis and subsequent atrophy of the skin and subcutaneous tissue
excessive collagen deposition causes skin and internal organ changes
cutaneous involvement of SSc has three stages
1 - oedematous
2 - indurative
3 - atrophic
major features of SSc
centrally located skin sclerosis that affects the arms, face and/or neck
minor features of SSc
sclerodactyly
atrophy of the fingertips and bilateral lung fibrosis
what are the CREST symptoms in SSc
Calcinosis
Raynauds
Esophageal dysmotility
Sclerodactyly
Telangiectasia
organ involvement in SSc
pulmonary hypertension, pulmonary fibrosis and accelerated hypertension
gut involvement may lead to dysphagia, malabsorption and bacterial overgrowth of the small bowel
inflammatory arthritis and myositis
limited SSc affects
face, hands, forearms and feet skin changes
late organ involvement
diffuse SSc affects
skin changes to the trunk
early organ involvement
limited SSc antibody
anti-centromere
diffuse SSc antibody
anti-Scl-70
SSc investigations
anti-centromere/anti-Scl-70 antibodies
organ screening
SSc management
raynauds - calcium channel blockers
renal involvement - ACE inhibitors
GI involvement - proton pump inhibitors for reflux
interstitial lung disease - immunosuppression (cyclophospohamide)
mixed connective tissue disease features symptoms seen in other connective tissue diseases, including
raynauds
arthralgia/arthritis
myositis
sclerodactyly
pulmonary hypertension
interstitial lung disease
MCTD antibodies
anti-RNP antibodies
MCTD management
calcium channel blockers for raynauds
immunosuppression if significant muscle or lung disease
antiphospholipid syndrome is a disorder that manifests clinically as…
recurrent venous or arterial thrombosis and/or foetal loss
presentation of anti-phospholipid syndrome
recurrent pulmonary emboli or thrombosis
late spontaneous foetal loss/recurrent foetal loss
migraine
livedo reticularis
APS investigations
thrombocytopaenia
prolongation of APTT
lupus anticoagulant, anti-cardiolipin antibodies and anti-beta 2 glycoprotein may be positive
APS treatment
anti-coagulation if episodes of thrombosis
LMWH in pregnancy if recurrent pregancy loss
gout is caused by
urate crystals within a joint
hyperuricaemia may be due to…
renal underexcretion or excessive intake of alcohol, red meat and seafood
the most common site of gout is
the first metatarsalphalangeal joint (MTP)
gout presentation
intensely painful, hot swollen joint
how long do gout symptoms normally last
7-10 days
what are gouty tophi
painless white accumulations of uric acid in the soft tissues
definitive diagnosis of gout
synovial fluid with polarised microscopy
what shape are uric acid crystals
needle shaped
what type of birefringence do uric acid crystals display
negative
(change from yellow to blue when lined across the direction of polarisation)
treatment of acute gout
NSAIDs
corticosteroids
opioid analgesics
colchicine if cant tolerate NSAIDs
treatment for recurrent gout (or with joint decstruction or tophi)
when should they be started
allopurinol or other urate lowering therapies
should not be started until an acute attack has settled as they can potentiate a further flare
what is pseudogout caused by
pyrophosphate crystals
what is chondrocalcinosis
deposition if calcium pyrophosphate in catilage and other soft tissues in the absence of acute inflammation
calcium pyrophosphate deposition disease tends to affect
the ankle, knee and wrist
calcium pyrophosphate deposition disease can coexist with
hyperparathyroidism
hypothyroidism
renal osteodystrophy
haemochromatosis
Wilson’s disease
treatment of pseudogout
NSAIDs
corticosteroids (systemic and IA)
colchicine
pseudogout prophylaxis?
there is no prophylaxis for pseudogout
characteristics of polymyalgia rheumatica
proximal myalgia of the hip and shoulder girdles
morning stiffness that lasts over 1 hour
symtpoms improve with movement
polymyalgia rheumatica is associated with what type of vasculitis
GCA
polymyalgia rhematica investigations
raised CRP and PV/ESR
polymyalgia rheumatica response to low dose steroids
(diagnostic tool)
symptoms respond very dramatically
polymyalgia rheumatica treatment (and time period)
prednisolone dose reduced over 18 months
(condition resolved in most individuals)
histopathologically, GCA is marked by
transmural inflammation of the intima, media and adventitia of affected arteries
patchy infliltration by lymphocytes, macrophages and multinucleated giant cells
vessel wall thickening in GCA can result in…
arterial luminal narrowing, resulting in subsequent distal ischaemia
GCA presentation
visual disturbances, headache, jaw claudication and scalp tenderness
fatigue, malaise, fever
new onset headache in patients over 50 years with an elevated ESR, CRP or PV?
consider GCA
what type of headache is present in GCA
continuous
located in the temporal or occipital areas
focal tenderness on direct palpation
jaw claudication is a result of ischaemia of the ________ artery
maxillary artery
visual symptoms of GCA
unilateral visual blurring or vision loss
occasionally diplopia
GCA diagnosis
raised inflammatory markers
temporal artery biopsy
GCA treatment
corticosteroids (prednisolone 40/60 mg depending on visual symptoms)
TREATMENT SHOULD NOT BE DELAYED FOR BIOPSY
polymyositis causes…
symmetrical proximal muscle weakness
dermatomyositis causes
symmetrical proximal muscle weakness
skin changes
polymyositis is caused by
a T-cell mediated cytotoxic process directed against unidentified muscle antigens
myositis antibodies
anti-Jo-1 and anti-SRP
polymyositis presentation
symmetrical proximal muscle weakness in the upper and lower extermities
insidious onset
myalgia
a poor prognostic sign in polymyositis
dysphagia secondary to oropharyngeal and oesophageal involvement
anti-Jo-1 antibody in polymyositis is associated with
interstitial lung disease
polymyositis investigations
raised inflammatory markers
serum creatine kinase raised
ANA, anti-Jo-1 and anti-SRP
muscle biopsy (exclude other casues)
polymyositis treatment
prednisolone (40 mg)
methotrexate or azathioprine
cutaneous features of dermatomyositis
v-shaped rash over chest
heliotrope rash (eyelids)
purple plaques on bony prominences (Gottron papules on knuckles)
poikiloderma (atrophic, red and brown skin)
dermatomysotis is associated with an increased risk of
malignancy
(breat, ovarian, lung, colon, oesophagus and bladder)
fibromyalgia is thought to be a disorder of
central pain processing or a syndrome of central sensitivity
fibromyalgia is associated with
RA and SLE
fibromyalgia presentation
persistent (>3/12) widespread pain
fatigue
disrupted, unrefreshing sleep
cognitive difficulties
other unexplained symptoms (anxiety, depression, functional impairment of ADLs)
fibromyalgia investigations
rule out other differentials
hypothyroidism
RA
SLE
PMR
fibromyalgia treatment
self-management techniques
graded exercise and activty pacing
amitriptyline, gabapentin and pregabalin
GCA affects what age group
older than 50
Takayasu arteritis affects what age group
under 50
which arteries does GCA normally affect
temporal arteries
early features of large vessel vasculitis
low grade fever
malaise
night sweats
weight loss
arthralgia
fatigue
ANCA associated vasculitis includes
granulomatosis with polangitis
microscopic polyangitis
renal limited vasculitis
Churg-Strauss syndrome
GPA is commonly associated with ENT symptoms such as
nose bleeds
deafness
recurrent sinusitis
nasal crusting
the most important complication of microscopic polyangitis is
glomerulonephritis
investigations for ANCA positive vasculitis
raised ESR, PV and CRP
anaemia of chronic disease
U+E for renal involvement
ANCA
CXR (cavitiating lesions in GPA)
biospy of affected area
management of ANCA associated vasculitis
IV steroids and cyclophosphamide
which of the following is not associated with anti-phospholipid syndrome?
venous thrombosis
livedo reticularis
migraine
recurrent pregnancy loss
thrombocytosis
thrombocytosis
a 69 year old woman complains of pain at the base of her thumbs
on examination, she has bony swelling of her thumb CMC joints and finger DIP joints
postivie ANA and anti-RNP antibody
xray shows loss of joint space, subchondral sclerosis, subchondral cysts and osteophytes
osteoarthritis
a 32 year old man is diagnosed as having a pulmonary embolus with no clinical risk factors
anticardiolipin antibodies are raised
what is the most appropriate anticoagulation treatment?
life long warfarin
a patient has pain in their lower nack and a positive ANA at a titre of 1:160
is this diagnostic of SLE?
no - a diagnosis of SLE needs a combination of clinical and laboratory findings
ANA of this titre is seen in 13% of the normal population
in SLE active complement levels rise when disease is active
true/false
false - complement is consumed in the response to the formation of immune complexes
low levels of complement are a sign of active disease
in SLE, patients will likely be on oral steroids long term
true/false
false - steroids should only be used for short periods to suppress disease activity whilst other agents are introduced
long term steroids are associated with an increased risk of CV disease, T2DM and osteoporosis
when SLE is more active the level of anti-DNA binding antibody is likely to rise
true/false
true
in a patient with SLE which of the following is the least likely to be a cause of chest pain
pneumothorax
pericarditis
pulmonary embolus
pleurisy
MI
pneumothorax
which of the following is not a recognised feature of limited systemic sclerosis
calcinosis
butterfly rash
raynauds
pulmonary HTN
anti-centromere antibody
butterfly rash
which best describes the management of CTDs?
physio and surgery to stabilise joints
immunosuppression to normalise antibody levels
high dose steroids on diagnosis
treat symptomatically and monitor for major complications
treat symptomatically and monitor for major complications
the nail changes associated with psoriatic arthritis are
pitting and onycholysis
oligoarthritis, sacroiliitis, spondylitis, dactylitis and enthesitis commonly occur in which type of arthritis
psoriatic arthritis
which of the following are included in the spondyloarthopathies
ankylosing spondylitis
gout
psoriatic arthritis
reactive arthritis
rheumatoid arthritis
AS, psoriatic arthrtitis and reactive arthritis
following 2 months of joint pain, a 38 year old lady is diagnosed with RA
which of the following treatments is recommended first?
azathioprine
methotrexate
anti-IL6 therapy
anti-TNF therapy
diclofenac
methotrexate
which of the following is an xray finding indicative of gout
subchondral cyst formation
peri-articular erosion
chondrocalcinosis
loss of joint space
peri-articular osteopaenia
chondrocalcinosis
(calcium pyrophosphate in the soft tissue in the absence of inflammation)
a 24 year olf patient, just diagnosed with RA, is about to commence DMARD therapy, but wants to start a family
what treatment is most appropriate
leflunomide
sulphasalazine
methotrexate
rituximab
cyclophosphamide
sulphasalazine
ideally, she should delay her pregnancy until her disease has improved
a patient has had successful treatment of acute gout but has had 4 flares this year
the most appropriate treatment to prevent further flares is
prednisolone
colchicine
allopurinol
sulphasalazine
naproxen
allopurinol
which of the following is not useful in a patient who presents with symmetrical, small joint swelling
on examination there is a nodule on his elow but there are no other skin changes
systemic examination reveals features of pulmonary fibrosis
hand and feet xrays
PV and/or CRP
anti-CCP antibody
CXR
anti-dsDNA antibody
anti-dsDNA antibody
(useful in diagnosis of SLE but not RA)
anti-CCP antibody is associated with RA
true/false
true
bamboo spine is an early radiographic change of AS
true/false
false
what are the features of Reiter’s triad?
reactive arthritis, urethritis and uveitis
PMR principally affects patients over the age of 50
true/false
true
which of the following is not a common xray finding in osteoarthritis
subchondral cyst formation
periarticular erosion
loss of joint space
osteophyte formation
subchondral sclerosis
periarticular erosion
which of these tests is the initial investigation of choice for detecting renal involvement in vasculitis?
urea
urinalysis
renal ultrasound scan
creatinine
glomerular filtration rate (GFR)
urinalysis
anti-TNF agents are more effective in combination with standard DMARDs
true/false
true
biological agents are associated with a higher risk of infection than synthetic DMARDs
true/false
true
all patients with inflammatory arthritis should be given biological agents
true/false
false
anti-TNF agents are 1.5 times more effective than standard synthetic DMARDs
true/false
true
biological agents are generally more expensive than synthetic DMARDs
true/false
true
methotrexate and azathioprine can be used as remission maintaining agents in vasculitis
true/false
true
patients who are going to be on long term steroids should always be assessed for bone protection
true/false
true
steroids are the mainstay of treatment in the early stages of vasculitis
true/false
true
cyclophosphamide is always indicated in vasculitis
true/false
false
which of the following is not a recognised treatment for OA
methotrexate
topical analgesics
NSAIDs
joint replacement
physiotherapy
methotrexate
in a patient with PMR, the development of a headache should make you consider…
GCA
allopurinol should be tritiated until target serum urate is achieved (below 360 micromol/L)
true/false
true
allopurinol should be stopped during acute gout flares
true/false
false
steroids can be used to reduce inflammation in acute gout
true/false
true
in patients with new onset RA, DMARDs should be commeced within 3 months of onset of symptoms
true/false
true
DMARDs require regular blood monitoring to ensure safety
true/false
true
DMARDs are slow acting
true/false
true - up to 8-12 weeks to take effect
DMARDS can reduce the rate of progression of joint damage
true/false
true
DMARDs can reduce inflammation in joints and reduce pain
true/false
false - patients will still need analgesia alongside the DMARD
