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Revision lectures > Rheumatology > Flashcards

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
Q

Ankylosing Spondylitis - buzzword

A

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

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26
Q

Features of Ank Spond

A

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%

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27
Q

Investigation of ank spond

A

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
Q

Management of ank spond

A

NSAIDS
Physio and swimming

DMARD eg sulfasalazine if peripheral joint involvement

Anti TNF if persistently high disease activity despite conventional treatments

29
Q

Antiphospholipid syndrome

A

Predisposition to venous and arterial thrombosis

Recurrent foetal loss

Thrombocytopenia

May be primary or secondary to other conditions e.g. SLE

30
Q

Management of antiphospholipid syndrome

A

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
Q

Still’s Disease

A

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
Q

Types of systemic sclerosis

A

Limited cutaneous systemic sclerosis (includes CREST syndrome)

Diffuse cutaneous systemic sclerosis

Scleroderma (without internal organ involvement)

33
Q

Limited cutaneous systemic sclerosis

A

Raynauds may be first sign

Scleroderma affects face and distal limbs predominantly

Associated with anti centromere antibodies

Subtype of CREST

34
Q

CREST syndrome

A

Calcinosis (white deposits)
Raynauds
Oesophageal dysmotility (dysphagia)
Sclerodactyly (thickened skin on top of hands)
Telangiectasia (excessive number of spider naevi)

35
Q

Diffuse cutaneous systemic sclerosis

A

Scleroderma affects trunk and proximal limbs predominantly

Associated with slc-70 antibodies

Hypertension, lung fibrosis and renal involvement

Poor prognosis

36
Q

Scleroderma

A

Tightening and fibrosis of skin

May be manifest as plaques (morphoea) or linear

37
Q

Dermatomyositis - overview

A

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
Q

Skin features of dermatomyositis

A 
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
Q

Types of psoriatic arthropathy

A 
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
Q

Polymyalgia Rheumatica

A

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
Q

Investigations of PMR

A

ESR under 40
CK and EMG normal
Reduced CD8+ T cells

42
Q

Treatment of PMR

A

Dramatic response with prednisolone 15mg OD

43
Q

Reactive arthritis

A

HLA B27 seronegative spondylarthropathy

Reiters syndrome - urethritis, conjunctivitis, arthritis

Commonly with gonorrhoea/chlamydia

44
Q

Reactive arthritis features

A

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
Q

Sulfasalazine
Cautions and side effects

DMARD

A

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
Q

Hydroxychloroquinine
Adverse effects and monitoring

DMARD

A

Adverse effects
Bulls eye retinopathy

Monitor
Ask about visual symptoms and monitor visual acuity annually

47
Q

Osteoarthritis management

First line for knee/hand

A

Paracetamol and topical NSAIDs (if knee/hand) first line

48
Q

Risk factors for pseudogout

A 
Acromegaly 
Hyperparathyroidism
Hypothyroidism
Haemochromatosis
Low magnesium 
Low phosphate
Wilson's disease
49
Q

Classic Behcets presentation

A

Oral ulcers
Genital ulcers
Anterior uveitis

More common in men, 20-40yrs, eastern Mediterranean

Associated with HLA B5

50
Q

Drug induced lupus - which drugs?

A

Common
Procainamide
Hydralazine

Less Commin
Isoniazid
Minocycline
Phenytoin

51
Q

First line treatment of Raynauds

A

Calcium channel blockers eg Nifedipine

Can also give IV prostacyclin infusions: effects may last several weeks/months

52
Q

Azathioprine

Adverse effects and pre testing

A

Pre test for TPMT deficiency - predisposes to toxicity

Adverse effects
Bone marrow depression
Nausea/vomiting
Pancreatitis

May interact with allopurinol - use lower dose

53
Q

Bisphosponates

Mechanism of action and uses

A

Inhibit osteoclasts

Used in..
Prevention and treatment of osteoporosis
Hypercalcaemia
Pagets
Pain from bony mets
54
Q

Bisphosphonates

Adverse effects

A

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
Q

Side Effect

Methotrexate

A

Myelosuppression
Liver cirrhosis
Pneumonitis

56
Q

Side Effect

Sulfasalazine

A

Rashes
Oligospermja
Heinz body anaemia
Interstitial lung disease

57
Q

Side Effect

Leflunomide

A

Liver impairment
Interstitial lung disease
Hypertension

58
Q

Side Effect

Hydroxychloroquinine

A

Retinopathy

Corneal deposits

59
Q

Side Effect

Prednisolone

A 
Cushingoid features
Osteoporosis
Impaired glucose tolerance 
Hypertension
Cataracts
60
Q

Side Effect

Gold

A

Proteinuria

61
Q

Side Effect

Penicillamine

A

Proteinuria

Exacerbation of myasthenia gravis

62
Q

Side Effect

Etanercept

A

Demyelination

Reactivation of TB

63
Q

Side Effect

Infliximab

A

Reactivation of TB

64
Q

Side Effect

Adalimumab

A

Reactivation of TB

65
Q

Side Effect

NSAIDs

A

Bronchospasm in asthmatics

Dyspepsia/peptic ulceration

66
Q

Typical fibromyalgia presentation

A

Women, 30-50

Chronic pain at multiple sites
Lethargy
Sleep disturbance, headaches, dizziness

Tx = explanation, aerobic exercise, CBT, medication (pregabalin, duloxetine, amitriptyline)

67
Q

Clinical features of Pagets

A

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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