Rheumatology Flashcards
Swan neck = hyperextension at PIP and flexion and DIP
Boutonnière = flexion at PIP and hyperextension at DIP
For RA diagnosis you need 4/7 of RF RISES?
R - rheumatoid factor
F -finger/ hand joint involvement
R - rheumatoid nodules I - Involvement of 3 + joints S - Stiffness (early morning) E - Erosions/ decalcification of x-rayI S- Symmetrical
Which bloods should you do in RA?
WBC ESR/ CRP Auto- antibodies (Rh/ CCP) Albumin (low = increasing disease severity) Neutropenia is seen in Felty’s syndrome)
What are the 3 types of biological drugs used in RA?
IL-1 receptor antagonists e.g. Anakinra
TNF alpha antagonists e.g. etanercept
Cytotoxic e.g. azathioprine
Extra-articular RA
Eyes = kerato-conjunctivitis sicca, episcleritis, scleritis CVS = endocarditis, pericarditis, myocarditis CNS = carpal tunnel, peripheral neuropathies Respiratory = pulmonary nodules, bronchiolitis obliterates , pleural effusions Skin = rheumatoid nodules
X-ray features of RA
Soft tissue swelling e.g. joint effusion, oedema, tenosynovitis
Osteoporosis
Joint space narrrowing
Erosions
Reiters syndrome = triad of…
Seronegative asymmetrical arthritis
Conjunctivitis
Urethritis
Treat with bed-rest, intra-articulation steroids and NSAIDs
To be diagnosed with lupus you need 4/7 of
ORDER HER ANA
O - Oral ulcers R - rash (malar) D - disorder rash E - exaggerated photosensitivty R - renal disease and raynauds
H - haematological abnormality (low lymphocytes, platelets and neutrophils)
I - immunological abnormality (low C3/ C4,
S - serositis
A - ANA (Anti- dsDNA, anti- Ro/ La)
N - neurological
A - arthralgia
Minor SLE = NSAIDs, hydroxychloroquine and low dose steroids
Major SLE = high dose steroids and immunosuppressants
What is Libyan-Sacks endocarditis?
A non-bacterial form of endocarditis which typically affects this mitral valve
APTT is increased in anti-phospholipid syndrome
Platelets may be low
Initially treated with aspirin
STart warfarin in VTE develops
Anti-centromere antibody
Limited systemic sclerosis
Anti-Scl70
Diffuse cutaneous systemic sclerosis
Systemic sclerosis is also called CREST syndrome - what are the features?
C = calcinosis R = raynauds E = oesophageal dysmotility S = sclerodactyly (thickening of skin on finders and hands) T = telangiectasia
Early stage systemic sclerosis = treat with immunosuppressants
Late stage = treat with anti-fibrotics e.g. penicillamine
Don’t forget CCB e.g. nifidepine for raynauds
Psoriatic arthritis usually causes an asymmetrical arthritis with prominent axial skeleton involvement
DIP joints are often affected - unlike in RA
Rh and ANA -ve
Extra-spinal features of ank spon?
Anterior uveitis
Enthesitis - tendon involvement
Aortic regurgitation
Apical pulmonary fibrosis
Skin features of dermatomyositis
Helitrope rash
Periorbital oedema
Gottron’s papule (red, scaly patches on dorsum of hand) and periungul telangiectasia
Shawl sing
Immunology of dermatomyositis
High CK and ANA
Anti-Jo +ve
Sjogrens is associated with RhF, ANA, anti-Ro and anti-La. What are the complications?
Pancreatitis Nephrogenic DI Renal tubular acidosis Glomerulonephritis Neuropathy
What is polyarteritis nodosa?
- Necrotizing vasculitis of small and medium blood vessels
- Rapid renal failure can occur, as well as weight loss, fever, malaise, myalgia, polyarthritis
- livedo reticularis is common
- Arteriography will show multiple small aneurysms
- associated with HBV, HIV, CMV etc
PMR = proximal stiffness, ESR raised but power normal and CK normal
Unlike polymyositis which causes high CK
Wegners granulomatosis
- necrotizing granulomas in respiratory tract + kidneys
- purpura, cough, bloody nasal discharge, haematuria
- cANCA
Young female with systemic illness and tenderness over palpable arteries + bruits. May be claudication pain….
Takayasu arteritis
Large vessel vasculitis
Treat with steroids +/- immunosuppressant
Beware renovascular hypertension
Behçet’s disease is more common in Turkey. What are the features?
Recurrent aphthous stomatitis Sterile pustules at site of trauma Genital ulceration Large joint arthritis Intestinal ulceration Epididymitis Uveitis
Treat with steroids/ ciclosporin
Podagra
1st MCP - most commonly affected in gout
Don’t forget gouty tophi on the pinnae and hands and arthritis can be a feature of chronic gout
Treat with NSAID/ colchicine
Allopurinol to reduce recurrence
Positively bifringent crystals
Pseudogout
Calcium pyrophospahte crystals
Diabetes, hyperparathyroidism, haemochromatosis, hypothyroid etc are RF
Pagets typically affects the pelvis, lumbar spine, femur and skull. Pain, fractures and nerve compression
ALP is raised but Ca normal
Treat with bisphosphonate such as aledronate for active disease and calcitonin for pain
Osteomalacia is defective bone mineralisation. It presents with bone pain and deformity + proximal myopathy. Bloods show Low Ca, phosphate and vit D with high ALP and PTH. Give some causes
Poor diet
Malabsorption
Chronic pancreatitis
Chronic renal failure
‘Looser’s zone’ on bones e.g. femur
Marfan’s associated with dilated aortic sinuses or mitral valve prolapse. Pectus excavatim and arachnodactlyl. Which protein is mutated?
Fibrillation
Arachnodactyly means fingers and long and spider like
Osteopenia = T score -1 to -2.5
Osteoporosis T score
< -2.5
Think Still’s disease in a patient with a fever which worsens in the afternoon/ evening then improves each morning
There is usually gradually worsening joint pain and a rash (typically salmon pink)
NSAIDs are mainstay of treatment
Remember there should be a dramatic response with steroids when treating PMR.
If there is not a sudden improvement then the diagnosis is probably not correct
What is the cause of visual loss in temporal arteritis?
Anterior ischaemic optic neuropathy
Typically described as ‘large, dark shadow coming down’
1st line management of OA
Lifestyle
Paracetemol +/- topical NSAID (if hands/ knee affected)
Remember limited (central) systemic sclerosis = anti-centromere
Diffuse (spread) systemic sclerosis = Anto-Scl70
High impact exercise, Black ethnicity and late menopause are all protective against osteoporosis
Having RA is a risk factor, included in the FRAX tool
Sjogrens may be primary or secondary to RA/ SLE etc. What important complication should you be aware of?
Vastly increased risk of lymphoma
Offer allopurinol to all patient who present with acute gout
It should be started at least 2 week after gout has settles as if started to early it can precipitate other atacks
BUT if patients are already taking allopurinol they should continue to take it - even if they have an acute attack
Bone protection for patient started on long -term steroids?
> 65 or previous fragility # = start aledronate + ensure adequate Ca/ Vit D
<65 = do bone density scan and act accordingly
Bisphosphonates are associated with osteonecrosis of the jaw and atypical femoral shaft #
Also risk of oesophageal reactions such as ulcers
Management of Ank Spon?
Regular exercise therapy e.g. swimming
Physio
NSAIDs
5key features of anti-phospholipid syndrome
1) Prolonged APTT
2) Thrombocytopenia
3) Recurrent arterial/ venous thrombosis
4) Recurrent pregnancy loss
5) Livedo reticularis
Ank spon = all the A’s
Apical fibrosis Anterior uveitis Aortic regurgitation Achilles tendinitis AV node block Amyloidosis
Patient on leflonumide need their FBC, LFT and BP measure. Myelosupression and pneumonitis are important side effects
Very long half-life so women need effective contraception for at least 2years after treatment
Who is the classic patient affected by Takayasau vasculitis?
Large vessel vasculitis which affects Asian women aged <40
Affects brachial of the arch of aorta
—> head/ arms pain/ symptoms
What is the commonest type of vasculitis?
Kawasaki
Fibrinoid necrosis and ‘string of beads’ on angiogram?
Polyarteritis nodosa
Symptoms depend on location:
Renal —> HT
Mesenteric —> mesenteric Ischaemia etc
Buerger’s disease is notorious for causing…
Clots in the vessels supplying the fingers and toes —> ulcers and necrosis
Usually young men who smoke
How do you differentiate between granulomatosis with polyangitis (Wegners) and microscopic polyangitis?
Microscopic polyangitis affects lungs and kidneys only (NOT NOSE). There are NO granuloma and it is p-ANCA
Wegner’s is cANCA
p-ANCA
Churg Strauss or microscopic polyangitis was
What are the different types of psoriatic arthritis?
- distal psoriatic arthritis
- psoriatic spondylitis
- rheumatoid-like
- arthritis mutilans
- asymmetrical oligoarthritis
The lung has a dual blood supply from the:
- pulmonary arteries
- bronchial arteries
