Rheumatology Flashcards
Classification Criteria for SLE
Needs 4 and at least one from either group
Clinical Criteria
- acute or subacute cutaneous lupus
- chronic cutaneous lupus
- oral or nasal ulcers
- non scarring alopecia
- synovitis of two or more joints
- serositis
- renal involvement
- neurological involvement
- haemolytic anaemia
- leukopenia <4
- thrombocytopenia <100
Immunological Criteria
- ANA
- anti ds-DNA
- Anti- Smith
- low complement
- direct Coombs positive
- anti phospholipid antibodies
Mechanism of ustekinumab
IL 12/23 inhibitor
Abatacept Mechanism
CD80/86 inhibitor preventing T cell activation
Tofacitinib mechanism
JAk STAT inhibitor
What HLA is associated with the development of anti-HMG antibodies?
HLA DRB1 11:01
What is the main cell found in the synovial fluid of a patient with RA?
Neutrophil
What proportion of patients with RA are seronegative?
One third
What are the radio graphic features of RA of the hands?
Juxtaarticular osteoporosis
Joint space narrowing
Marginal erosions
DIP sparring
Radiographic hand X-ray findings of Gout.
- joint effusion
- joint space preservation
- punched out erosions
- tophi
- DIP joint involvement
Hand X-ray findings in SLE?
Normal
Preserved joint spaces
Can have passively correctable deformity (secondary to tendon damage)
Hand xray changes in psoriatic arthritis?
DIP joints involved Pencil in cup deformity Dactylitis Periostitis Arthritis mutilans
Hand X-ray changes in scleroderma.
Acro-osteolysis Subcutaneous calcification Joint space narrowing Juxtaarticular osteoporosis Erosions First CMC joint subluxation
What is the main contraindication to abatacept?
Bowel perforation
Diverticulitis
What are the criteria for inflammatory back pain?
4/5 of the following
- age <40
- insidious onset
- improvement with exercise
- no improvement with rest
- pain at night with improvement on movement
What is the differential diagnosis of dactylitis.
Reiters Syndrome Sarcoidosis Psoriatic arthritis Flexor tendon sheath infections Gout
What are the features of sacroilitis?
Early
- sclerosis
- joint space narrowing
- small erosions
Late
- severe sclerosis
- joint space widening
- large erosions
- fusion (very late)
Clinical criteria for Ankylosing spondylitis?
- Clinical Criteria (need 1)
- lower back pain and stiffness for >3 months which improves with exercise
- limitation of lumbar spine motion
- limitation of chest expansion - Radiologic Criteria (need 1)
- sacroiliitis of grade 2 bilaterally
- or 3 unilaterally
Radiographic findings of ankylosing spondyliitis of the spine?
Shiny corners (Romanus Lesion) Syndesmophyte formation Bamboo spine (fusion of bodies by syndesmophytes) Dagger spine (calcification of interspinous ligaments)
What are the different types of spondyloarthritis?
Ankylosing spondylitis
Psoriatic Arthritis
Reactive Arthritis
Enteropathic Arthritis
What are the five clinical patterns of psoriatic arthritis?
Distal Arthritis Asymmetric Oligoarthritis Symmetric Polyarthritis Arthritis mutilans Spondyloarthritis
What proportion of patients with psoriatic arthritis have a history of psoriasis?
70-85%
Treatment of psoriatic arthritis?
NSAIDs
Dmards (methotrexate, sulphasalazine, hydroxychloroquine)
Biological agents
Small molecules (apremilast)
Mechanism of sekukinumab?
IL 17 inhibitor
What is the expected clinical course for reactive arthritis?
70% resolve in 6 months
Chronic course in 25%
Destructive arthritis 5%
What medication can precipitate scleroderma real crisis?
Prednisone
Cyclosporine
What is the treatment of secondary raynauds?
- Cold avoidance
- Amlodipine/Nifedipine
- Topical GTN Or PDE 5 inhibitors or IV prostanoids
Mechanism of belimumab?
B lymphocyte stimulator protein inhibitor.
What are the histological features of Polymyositis and Inclusion body myositis?
Scattered necrotic muscle fibres with CD8 infiltration
What are the histological features of dermatomyositis?
Perifascicular atrophy and fibrosis with CD4 infiltration
What is the median survival of limited sclerosis with pulmonary hypertension?
11 months
What is the strongest genetic factor for Behçet’s disease?
HLA B 51
What is the most common ILD pattern in scleroderma?
NSIP
What is the treatment of scleroderma associated lung disease
- MMF preferred
- Cyclo and azathioprine can also be used
- Rituximab And experimental agents (if refractory)
- Lung transplantation
What are the predictors of mortality for pulmonary hypertension related to scleroderma?
Right heart failure Low DLCO Male Age >60 Poor exercise capacity Anti U1RNP negative Pericardial effusion
What is the treatment of WHO class 2-3 SSc PAH?
- Combination oral therapy (ambrisentan and tadaladil)
- Atrial Septostomy (bridge to lung tx)
No role for Calcium channel blocker.
What is the management of WHO class 4 SSc PAH?
- Combination IV prostanoid and oral therapy
- Atrial Septostomy (bridge to lung tx)
- Lung transplantation
No role for Calcium channel blocker.
What is the treatment of SSc associated raynauds ulcers?
Iloprost infusion
Cessation of agents which worsen disease (beta blockers)
How do you treat scleroderma associated skin disease?
- MMF
2. Methotrexate second line
What is topoisomerase 1?
Scl-70
How does duration of raynauds inform on the likely subtype of scleroderma?
Long standing - likely limited Scleroderma
Short history - likely diffuse scleroderma
Diagnostic criteria for sjogrens.
- Ocular dryness - schooner and Saxon test
2. Blood/histo evidence of autoimmunity - anti Ro or anti La or anti centromere or salivary biopsy
What is the most specific US imaging finding of Gout?
Double contour sign
Mechanism of raburicase?
recombinant urate-oxidase enzyme, which converts uric acid to allantoin
What is the serum urate aim for 1) non tophaceous gout and 2) tophaceous gout?
1) <0.36
2) <0.3
What is the treatment of psoriatic arthritis?
- NSAIDs
- DMARDS (methotrexate, leflunomide)
- TNF alphas
- Anti interleukins
What clinical presentation of RA is associated with a good prognosis?
Acute onset arthritis in a few large joints
What are the negative prognostic factors in RA?
Age <20 or >60 High titre RF Anti CCP positive Early erosive joint disease High inflammatory markers
What is the most common extraarticular manifestation of Ank Spon.
Uveitis
What is the most common first site of disease in knee OA?
Patellofemoral joint
What are the features of rheumatoid arthritis related arthropathy?
MCP joint involvement
Hook like osteophytes
Squared off bone ends
Joint space loss
What are the extra-articular features of AS?
Anterior Uveitis Av Node Block Aortic Regurg Apical Fibrosis Amyloidosis Achilles tendinitis
What is the HLA associated with RA?
HLA DR4
Ehlers Danlos is most commonly associated with a defect in which type of collagen?
Type 3
What are anti srp antibodies associated with?
Polymyositis
