Rheumatology Flashcards
Giant cell arteritis
Granulomatous inflammation External carotid artery HLA-DR4 HLA-DRB1 Polymyalgia rhuematica Headaches, claudication, visual disturbances Systemic features
Giant cell arteritis ix
1st: ESR levels
G: temporal artery biopsy with 48hrs of steroids (multiple locations as can be skip lesions)
Giant cell arteritis rx
1st: high dose oral prednisolone (40-60mg/day) immediately
G: titrate prednisolone
Takayasu’s aortitis
Young Japanese females Constitutional upset Head or neck pain Reduced/absent peripheral pulses Hypertension Arm claudication on repetition
Polyarteritis nodosa
Hepatitis B Any age M>F High incidence of aneurysms, thrombosis, embolism Rosary sign (kidney arteries) Thrombosis Infarctions (GI perforations) Hypertension
Kawasaki’s disease
Children Persistent fever >5/7 Fissured lips Swollen hands/feet then desquamation Skin rash Lymphadenopathy 'Strawberry' tongue
Granulomatosis with polyangiitis
cANCA
Triad: upper respiratory, lower respiratory, glomerulonephritis
Saddle shaped nose
Eosinophilic granulomatosis with polyangiitis
pANCA Refractory asthma Eosinophilia Lower respiratory tract (cavitating lesions, haemoptysis) Glomerulonephritis Rash
Microscopic polyangiitis
pANCA
Non-specific with multiple organs affected
Glomerulonephritis (no glomerular Ig deposits)
Henoch-Schönlein Purpura
Purpura on legs and buttocks
Arthritis
Gut symptoms (abdo pain)
Glomerulonephritis with IgA deposition
Mixed essential cryoglobulinaemic vasculitis
Hepatitis C Arthritis Splenomegaly Skin vasculitis Renal disease Cryoglobulins (IgG and IgM mix)
Behçet’s disease
HLA-B51 Triad: recurrent oral ulcers, genital ulcers, uveitis Rash (erythema nodosum) Arthritis Pericarditis Pathergy test
Anti-phospholipid syndrome
Triad: DVT/PE, obstetrics complications, thrombocytopaenia
Anti-cardiolupin
Lupus anticoagulant
Rheumatoid arthritis
HLA-DR1 HLA-DR4 Rheumatoid factor (70%) Anti-CCP (more specific) Cytokines: IL-1, IL-6, TNF-alpha DIP sparing Swan neck deformity (MCP/DIP fixed, PIP extension) Boutonniere deformity (MCP/DIP extension, PIP flexion) Better with movement
Felty’s syndrome
Rheumatoid arthritis
Splenomegaly
Neutropaenia
Osteoarthritis
Heberden’s nodes (DIP)
Bouchard’s nodes (PIP)
X-ray: loss of joint space, osteophytes, subchondral cysts, subarticular sclerosis
Worse with movement
Septic arthritis
Joint aspiration
Acute infection of large joint
Reactive arthritis
Seronegative spondyloarthropathies (HLA-B27)
GI infections (salmonella, shigella, yersinia, campylobacter)
Circinate balanitis
Keratoderma blenorrhagica
Nail dystrophy, hyperkeratosis, onycholysis
Reiter’s syndrome
Reactive arthritis
Urethritis
Conjunctivitis
Gout
Negatively birefringent needle shaped
Uraemic acid increase (increased intake, decreased renal excretion)
Monosodium urate
RF: diuretics, salicylate
Pseudogout
Positively birefringent rhomboid-shaped crystals
Calcium pyraphosphate deposition
RF: age, family history, joint damage, metabolic disturbance
Joint x-ray: linear, radio-opaque deposits in cartilage of joints
Ankylosing spondylitis
Seronegative spondyloarthropathies (HLA-B27) Early morning back stiffness Improves with exercise Psoriasis Iritis & uveitis Enthesis > syndesmophytes > bamboo spine
Schober’s test
Mark at iliac crest level
2nd mark 10cm above
Distance between two marks should increase by >5cm
<5cm = positive
Cervical spondylosis
Osteophyte formation
Radiculopathy and myelopathy
+ve Lhermitte’s sign (crepitus +/- parasthesia down the spine on neck flexion)
SLE
SOAP BRAIN MD: serositis, oral ulcers, arthritis, photosensitivity, blood (haem disorders), renal (proteinuria, urine casts), ANA, immune (anti-dsDNA, anti-Sm, anti-phospholipid), neurological (seizures, psychosis), malar/discoid rash (4/11 = ACR criteria)
SLE antibodies
ANA Anti-dsDNA 60% Anti-Sm 30% Anti-Ro 30% Anti-La 15%
SLE investigations
Skin biopsy: immune deposits at dermal-epidermal junction
Renal biopsy: glomerulonephritis
FBC: anaemia, thrombocytopaenia, leukopaenia/lymphopaenia
Monitoring: complement and ESR
Sjogren’s syndrome
HLA-B8 HLA-DR3 F>M 15-65 yrs Keratoconjunctiva sicca Xerostomia \+/- arthritis, arthralgia, myalgia
Sjogren’s syndrome investigations
Autoantibodies: rheumatoid factor, ANA 60%, anti-La/Ro
Schirmer’s test: +ve <10mm wet in 5mins
Rose Bengal/Fluorescein stain: punctate or filamentary keratitis (cornea)
Pre-scleroderma
Raynaud’s phenomenon, nail-fold capillary changes and ANA
Scleroderma sine scleroderma
1%
Internal organ disease w/o skin changes
Diffuse cutaneous systemic sclerosis
Raynaud’s phenomenon
Skin changes (truncal) and organ involvement (renal, lung, heart, GI)
Anti-scl70/topoisomerase
Anti-RNA polymerase III
Limited cutaneous systemic sclerosis
CREST: calcinosis (deposits), Raynaud/s phenomenon, oesophageal dysmotility, sclerodactyly, telangiectasia)
Anti-centromere antibodies
Antiphospholipid syndrome
Women, multiple miscarriages, young
Triad: obstetric complications, thromboembolic events, thrombocytopaenia
Autoantibodies: lupus anticoagulant, anticardiolupin
CLOT: clotting disorders, livedo reticularis, obstetric complications, thrombocytopaenia
Fibromyalgia
At least 3 months
11 out of 18 points (9 pairs) tenderness immediately elicited: suboccipital muscle insertions, anterior aspects of C5-7, midpoint of upper border trapezius, origin of supraspinatous, 2nd CC, lateral humeral epicondyle, upper outer gluteal quadrant, greater trochanter, knee
Allodynia + hyperesthaesia
Polymyositis
Endomysial inflammation
Preservation of fine motor movements
Proximal weakness (climbing stairs, getting out of chair)
Anti-Jo1
Muscle biopsy: beta-amyloid (Congo red staining)
Dermatomyositis
Petimysial inflammation
Polymyositis + skin changes
Heliotrope rash (eyes), Gottron’s papules (knuckles), shawl sign (shoulders), calcinosis
Anti-Mi2
Muscle biopsy: beta-amyloid (Congo red staining)
Polymyalgia rheumatica
Limited active movement shoulders/hips in the morning (improves throughout day)
No weakness
Tenosynovitis
Ix: ESR (elevated), USS/MRI (joint effusion)
Polymyalgia rheumatica management
Prednisolone + taper down
Osteoporosis prophylaxis: vitamin D, calcium, bisphosphonates
Methotrexate/steroid sparing agents
NSAIDs
Carpal tunnel syndrome
Idiopathic
Secondary ot tenosynovitis, bone, fluid retention, obesity, menopause, diabetes, renal disease
Intermittent hand numbness, difficulty extending the fingers
Carpal tunnel syndrome investigations
Tinel’s test: tap = provokes symptoms
Phalen’s test: flexion of wrist 1min causes symptoms
Osteomyelitis
Infection of bone (s. aureus and s. pygogenes/group A strep)
Young children w/ low grade fever, non specific pain, redness/swelling
Sarcoidosis
Diagnostic: non-caseating granuloms with multi-nucleated Langhans cells, activated epithelioid cells and mononuclear cells Dry, unproductive cough Lupus pernio (red-blue infiltration of cheeks) Erythema nodosum
Lofgren syndrome
Acute sarcoidosis (self-resolving) Fever Erythema nodosum Polyarthralgia/polyarthiritis Bilateral hilar lymphadenopathy
