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Rheumatology Flashcards

1
Q

Specific Articular Deformities in RA

A

Ulnar deviation

Boutonnière deformity (PIP flexion, DIP hyperextension)

Swan neck deformity (PIP hyperextension, DIP flexion)

Baker’s cyst

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2
Q

Extra articular features of RA

A

Fever
Low appetite
Malaise
Weakness

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3
Q

Organ specific features of RA

A

Rheumatoid nodules (usually at pressure points eg elbow)

Increased risk of atherosclerosis

Anaemia

Interstitial Lung Fibrosis

Pleural Effusions

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4
Q

Felty Syndrome

A

RA + Splenomegaly + low WCC

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5
Q

Diagnosis of RA

A

Bloods

  • Rheumatoid Factor
  • Anti CCP Antibody

X-ray

  • decreased bone density - juxta articular osteoporosis
  • soft tissue swelling
  • narrowing of joint space

Late XRay findings

  • periarticular erosions
  • subluxation
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6
Q

Typical RA history

A

Woman, insidious

Swollen, painful, joints - usually MCP and PIP - positive “squeeze” test

Morning stiffness, improves with use

Bilateral symptoms

Systemic upset

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7
Q

Treatment of RA - long term

A

DMARDs - suppress inflammation
- methotrexate, hydroxychloroquinine, sulfasalazine

Biologics 
Abatacept - suppress T cells
Rituximab - suppress B cells
Adalimumab, etanercept, infliximab - block chemokines like TNF
Anakinra - block IL1
Tocilizumab - block IL6
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8
Q

Treatment of RA - acute flare

A

Anti- inflammatories

  • NSAIDs
  • Glucocorticoids (short term)
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9
Q

Poor prognostic features of RA

A 
RF positive
Poor functional status at presentation
HLA DR4
X-ray - early erosions after less than 2yrs
Extra articular features e.g. Nodules
Insidious onset
Anti CCP
Female gender
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10
Q

SLE - typical presentation

A

Female, Afro Caribbean, 20-40yrs

Fever, joint pain, rash

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11
Q

Skin features of SLE

A

Malar (butterfly) rash - spares nasolabial folds
Discoid rash: scaly, erythematous, well demarcated rash in sun exposed areas.
Photosensitivity
Raynauds
Livedo reticularis
Non scarring alopecia

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12
Q

Features of SLE

MSK

A

Arthralgia

Non erosive arthritis

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13
Q

Features of SLE

CVS

A

Pericarditis

Myocarditis

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14
Q

Features of SLE

Resp

A

Pleurisy

Fibrosing alveolitis

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15
Q

Features of SLE

Renal

A

Proteinuria

Glomerulonephritis (diffuse proliferative)

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16
Q

Features of SLE

Neuropsych

A

Anxiety and depression
Psychosis
Seizures

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17
Q

Diagnosing SLE

A

4 criteria

  1. Malar rash
  2. Discoid rash
  3. Photosensitivity
  4. Ulcers (mouth, nose)
  5. Serositis (pericarditis, pleuritis)
  6. Arthritis (2 or more joints)
  7. Renal disease
  8. Neuro disorders
  9. Haematological disorders
  10. Antinuclear antibody - ANA
  11. Other autoantibody - anti-smith, anti-dsDNA (both relatively lupus specific), anti-phospholipid (anti cardiolipin, lupus anticoagulant, anti b2 glycoprotein 1)
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18
Q

Antibodies of SLE

A

Antinuclear antibody - ANA

Other autoantibody
anti-smith, anti-dsDNA (both relatively lupus specific)

anti-phospholipid (anti cardiolipin, lupus anticoagulant, anti b2 glycoprotein 1)

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19
Q

Flares of SLE

A

Corticosteroids

If severe

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20
Q

Gout

A

Red hot tender swollen joint

Hyperuricaemia

1st MTP (Podagra)

Negatively birefringent crystals

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21
Q

Causes of increased uric acid -> gout

A

Increased consumption of purines eg shellfish, red meat
Increased production of purines eg high fructose beverages
Decreased clearance eg dehydration or alcohol consumption
Obesity and diabetes
Chemo and radiation
Genetic
CKD
Medications eg aspirin (ok below 150mg) and thiazides diuretics

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22
Q

Managing Gout - acutely

A

If already on allopurinol then continue

NSAIDs
Corticosteroids
Colchicine (can give diarrhoea)

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23
Q

Managing gout - long term

A

Diet
Xanthine oxidase inhibitors eg allopurinol

Allopurinol - start 2 weeks after acute attack settled, NSAID or colchicine while starting, initial dose 100mg od and titrate

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24
Q

Pseudogout

A

Weakly positive birefringent rhomboid shaped crystals

Knee, wrist, shoulder

X-ray - chondrocalcinosis

Aspirated to rule out septic arthritis
NSAIDs or steroids

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25
Ankylosing Spondylitis - buzzword
20-30 yr old male HLA B27 Seronegative spondyloarthropathy so RF negative Young man with lower back pain and stiffness of insidious onset. Worse in morning, improves in exercise, pain at night. Reduced lateral and forward flexion and chest expansion Bamboo spine
26
Features of Ank Spond
Reduced lateral flexion Reduced forward flexion - Schobers - draw line 10cm above and 5cm below dimples of Venus. Forward flexion doesn't increase by more than 5cm Reduced chest expansion Others - apical fibrosis, anterior uveitis, aortic Regurgitation, Achilles tendinitis, av nose block, amyloidosis, cauda equina, peripheral arthritis in 25%
27
Investigation of ank spond
Can have raised ESR and CRP Plain XRay - can be normal in early disease, later changes include... Sacroilitis: subchondral erosions, sclerosis Squaring of lumbar vertebrae Bamboo spine Syndesmophytes: due to ossification of outer fibres of annulus fibrosis Apical fibrosis on CXR
28
Management of ank spond
NSAIDS Physio and swimming DMARD eg sulfasalazine if peripheral joint involvement Anti TNF if persistently high disease activity despite conventional treatments
29
Antiphospholipid syndrome
Predisposition to venous and arterial thrombosis Recurrent foetal loss Thrombocytopenia May be primary or secondary to other conditions e.g. SLE
30
Management of antiphospholipid syndrome
Initial venous thromboembolic events - warfarin INR 2-3 for 6 months Recurrent - warfarin lifelong and if occurred whilst on warfarin increase to 3-4 Arterial thrombosis - lifelong warfarin INR 3-4
31
Still's Disease
16-35yrs Arthralgia, elevated serum ferritin, salmon pink maculopapular rash, pyrexia (worse in late afternoon), lymphadenopathy NSAIDs then steroids after a week If symptoms persist consider methotrexate, IL1 or anti-TNF RF and ANA negative
32
Types of systemic sclerosis
Limited cutaneous systemic sclerosis (includes CREST syndrome) Diffuse cutaneous systemic sclerosis Scleroderma (without internal organ involvement)
33
Limited cutaneous systemic sclerosis
Raynauds may be first sign Scleroderma affects face and distal limbs predominantly Associated with anti centromere antibodies Subtype of CREST
34
CREST syndrome
Calcinosis (white deposits) Raynauds Oesophageal dysmotility (dysphagia) Sclerodactyly (thickened skin on top of hands) Telangiectasia (excessive number of spider naevi)
35
Diffuse cutaneous systemic sclerosis
Scleroderma affects trunk and proximal limbs predominantly Associated with slc-70 antibodies Hypertension, lung fibrosis and renal involvement Poor prognosis
36
Scleroderma
Tightening and fibrosis of skin | May be manifest as plaques (morphoea) or linear
37
Dermatomyositis - overview
Inflammatory disorder Symmetrical proximal muscle weakness Characteristic skin lesions Idiopathic or associated with malignancy Other features - Raynauds, resp muscle weakness, ILD, dysphagia, dysphonia ANA positive usually Anti-Jo
38
Skin features of dermatomyositis
``` Photosensitive Macular rash over back and shoulder Heliotrope rash in periorbital region Gottrons papilla - roughened red papilla over extensor surfaces of fingers Nail gold capillary dilatation ```
39
Types of psoriatic arthropathy
``` Rheumatoid like polyarthritis Asymmetrical olioarthritis Sacroilitis DIP joint disease Arthritis mutilans (telescoping) (pencil in cup) ``` Treat as rheumatoid but better prognosis Occurs in 10-20% patients with skin lesions
40
Polymyalgia Rheumatica
Typically over 60 yrs Rapid onset (under 1 month) Aching, morning stiffness in proximal limb muscles Mild poly arthralgia, lethargy, depression, low grade fever, anorexia, night sweats Overlaps with temporal arteritis
41
Investigations of PMR
ESR under 40 CK and EMG normal Reduced CD8+ T cells
42
Treatment of PMR
Dramatic response with prednisolone 15mg OD
43
Reactive arthritis
HLA B27 seronegative spondylarthropathy Reiters syndrome - urethritis, conjunctivitis, arthritis Commonly with gonorrhoea/chlamydia
44
Reactive arthritis features
Within 4 weeks of initial infection, symptoms generally last 4-6months Asymmetrical oligoarthritis of lower limbs Can see can't pee can't bend the knee
45
Sulfasalazine Cautions and side effects DMARD
Cautions - GP6D deficiency - allergy to aspirin or sulphonamide Adverse effects Oligospermia SJS pneumonitis/lung fibrosis Myelosuppression, Heinz body anaemia, megaloblasgic anaemja May colour tears -> stained contact lenses
46
Hydroxychloroquinine Adverse effects and monitoring DMARD
Adverse effects Bulls eye retinopathy Monitor Ask about visual symptoms and monitor visual acuity annually
47
Osteoarthritis management First line for knee/hand
Paracetamol and topical NSAIDs (if knee/hand) first line
48
Risk factors for pseudogout
``` Acromegaly Hyperparathyroidism Hypothyroidism Haemochromatosis Low magnesium Low phosphate Wilson's disease ```
49
Classic Behcets presentation
Oral ulcers Genital ulcers Anterior uveitis More common in men, 20-40yrs, eastern Mediterranean Associated with HLA B5
50
Drug induced lupus - which drugs?
Common Procainamide Hydralazine Less Commin Isoniazid Minocycline Phenytoin
51
First line treatment of Raynauds
Calcium channel blockers eg Nifedipine Can also give IV prostacyclin infusions: effects may last several weeks/months
52
Azathioprine | Adverse effects and pre testing
Pre test for TPMT deficiency - predisposes to toxicity Adverse effects Bone marrow depression Nausea/vomiting Pancreatitis May interact with allopurinol - use lower dose
53
Bisphosponates | Mechanism of action and uses
Inhibit osteoclasts ``` Used in.. Prevention and treatment of osteoporosis Hypercalcaemia Pagets Pain from bony mets ```
54
Bisphosphonates | Adverse effects
Oesophageal reactions - oesophagitis, oesophageal ulcers (esp alendronate) Osteonecrosis of the jaw Increased risk of apical stress fracture of proximal femoral shaft (alendronate) Acute phase response - fever myalgia and arthralgia may occur Hypocalcaemia - due to reduced calcium efflux from bone. Usually clinically unimportant
55
Side Effect Methotrexate
Myelosuppression Liver cirrhosis Pneumonitis
56
Side Effect Sulfasalazine
Rashes Oligospermja Heinz body anaemia Interstitial lung disease
57
Side Effect Leflunomide
Liver impairment Interstitial lung disease Hypertension
58
Side Effect Hydroxychloroquinine
Retinopathy | Corneal deposits
59
Side Effect Prednisolone
``` Cushingoid features Osteoporosis Impaired glucose tolerance Hypertension Cataracts ```
60
Side Effect Gold
Proteinuria
61
Side Effect Penicillamine
Proteinuria | Exacerbation of myasthenia gravis
62
Side Effect Etanercept
Demyelination | Reactivation of TB
63
Side Effect Infliximab
Reactivation of TB
64
Side Effect Adalimumab
Reactivation of TB
65
Side Effect NSAIDs
Bronchospasm in asthmatics | Dyspepsia/peptic ulceration
66
Typical fibromyalgia presentation
Women, 30-50 Chronic pain at multiple sites Lethargy Sleep disturbance, headaches, dizziness Tx = explanation, aerobic exercise, CBT, medication (pregabalin, duloxetine, amitriptyline)
67
Clinical features of Pagets
5% symptomatic Bone pain Classical, untreated features: bossing of skull, bowing of tibia RAISED ALP - calcium and phosphate normal Skull XRay: thickened vault, osteoporosis circumscripta Tx = bisphosphonate

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