Rheumatology

Question 1

XR features of RA

Answer 1

Juxta-articular osteopaenia
Marginal erosions
Joint space narrowing

Ulnar deviation & Subluxation MCP
Ankylosis

Question 2

Classic Clinical Features of RA

Answer 2

Boutonierre’s Deformity
Swan Neck
Z joint derformity

Question 3

Extra-articular Manifestations of RA

Answer 3

Rheumatoid Nodules (only if RF positive)
Vasculitis
Tenosynovitis (inflammation of the tendon sheath resulting in trapping of the tendon = trigger finger)
Nerve entrapment, 2o synovitis of the tendons - carpal tunnel
Episcleritis (not painful) / Scleritis (painful)
C/Sp - atlantoaxial subluxation
Haematological - Anaemia, Neutropaenia (Felty’s)
Pulmonary - effusions, pulmonary fibrosis
Heart - pericarditis, murmurs
Skin - pyoderma gangrenosum
Abdomen - splenomegaly (Felty’s), hepatomegaly (amyloidosis)
Kidneys - nephrotic syndrome
Nervous System - mononeuritis multiplex

Question 4

Serological Testing for RA

Answer 4

FBC - anaemia (chronic illness), neutropaenia (Felty’s), neutrophilia (inflammation)
Inflammatory markers - CRP + ESR
RF
Anti-cyclic citrullinated peptide (specific)

Question 5

Poor prognostic factors in RA

Answer 5

RF positivity
anti-CCP positivity
early radiological evidence or erosive disease
impaired functional status
persistently active synovitis

Question 6

Management Principles of RA

Answer 6

DMARD - MTX, Leflunomide, Sulfasalazine, HCQ
Biologicals - TNF (entanercept, adalimumab), CTLA4 (abatacept), anti-IL6 (tocilizumab), CD20 (Rituximab), JAK inhibitor (tofacitinib)

Vaccinations - if possible prior to starting immunosuppresion (avoid live vaccines after starting biologics)

Question 7

Non-pharmacological Mx RA

Answer 7

Physiotherapy - hand exercises
OT - adaptive equipment and aides
Smoking Cessation
Bone Protection - osteoporosis

Question 8

Presentation of RA findings

Answer 8

Bilateral
Symmetrical
Deforming
Polyarthritis - involving wrists, MCP, PIP (DIP sparing)

Limitation of Function
Extra-articular manifestations

Question 9

XR features of Psoriatic Arthritis

Answer 9

Erosive disease with bone proliferation
Pencil in Cup
Osteolysis
Dactylitis
Arthritis Mutilans
Asymmetrical Sacroilitis

Question 10

5 different patterns of Psoriatic Arthritis

Answer 10

1. Assymetric oligo/mono-arthritis
2. Symmetrical Polyarthritis (same as RA)
3. Axial disease +/- sacroilitis
4. DIP + nail changes
5. Arthritis Mutilans

Question 11

Extra-articular Manifestations of Psoriatic Arthritis

Answer 11

Skin - plaques and rashes (extensor surfaces, scalp and ears)
Enthesitis - achilles and plantar fascia
Nails - pitting, onycholysis, traverse ridging
Dactylitis - inflammation of the tendon sheath and the soft tissues
Cardiovascular - aortitis and AR murmur
Pulmonary - apical lungfibrosis
Eyes - conjunctivitis, uveitis

Question 12

Blood testing for PsA

Answer 12

HLA B27

Question 13

Pharmacologic Management PsA

Answer 13

NSAIDs - continuous
Intra-articular Steroid Injection
DMARDs (MTX and Sulphsalazine) - useful in skin and peripheral joint manifestations
Biologicals - TNF (infliximab, adalimumab), Secukinumab (IL-17), Ustekinumab (IL12/23)

Question 14

Contraindications to TNF

Answer 14

CCF
Demyelinating Disease
Active Bacterial Infection

Question 15

Diagnosis of Ankylosing Spondylitis

Answer 15

1 clinical 
(Back pain, morning stiffness >1hr, pain relieved by exercise)
\+
1 radiographic
(Sacroilitis)

Question 16

Extra-articulation/Systemic Manifestations of AR

Answer 16

Anterior Uveitis
Aortic Regurgitation
AV conduction defects
Apical Lung fibrosis
Atlanto-axial subluxation
Achilles Tendonitis
Amyloidosis

IBD
Osteopaenia

Question 17

Seronegative Arthritis

Answer 17

PEAR
Psoriatic Arthritis
Enteropathic Arthritis
Ank Spondylitis
Reactive Arthritis

Question 18

Investigations for Ank spondylitis

Answer 18

HLAB27 (95%)
Pelvic XR - sacroilitis
Lumbar Spine - squaring, shiny corners, bridging syndesmophytes (bamboo spine)