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Y4S2 Medicine > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

List 6 causes of secondary osteoarthritis

A
  1. Haemachromatosis
  2. Wilson’s disease
  3. Ehler’s-Danlos syndrome
  4. Diabetes
  5. Alkaptonuria
  6. Previous injury
  7. Congenital joint disorders
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2
Q

How does joint involvement differ between OA and RA?

A

Involvement of the DIP joint is highly suggestive of OA or psoriatic arthritis, although may occur in RA

RA is more likely to be symmetric

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3
Q

What are Heberden’s nodes and when are they found?

A

Pain and nodular thickening on the dorsal sides of the distal interphalangeal joints

OA

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4
Q

What are Bouchard’s nodes and when are they found?

A

Pain and nodular thickening on the dorsal sides of the proximal interphalangeal joints

OA

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5
Q

What is hallux rigidus and when is it found?

A

Arthrosis of the first metatarsophalangeal joint characterised by hypertrophy of the sesamoid bones

OA

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6
Q

List four radiological signs of OA

A

1. Irregular joint space narrowing

2. Subchondral sclerosis

Dense area of bone (visible on x-ray) just below the cartilage zone of a joint, formed due to a compressive load on the joint

3. Osteophytes

4. Subchondral cysts

Fluid-filled cysts that develop at the surface of a joint due to local bone necrosis induced by the joint stress of osteoarthritis

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7
Q

Which HLA alleles are associated with RA?

A

HLA-DR4, HLA-DR1

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8
Q

What are 3 environmental triggers for RA?

A

Smoking

Infection

Silica dust

Mineral oils

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9
Q

What is a pannus?

A

Growth of granulation tissue from the inflamed synovium into the joint space

Characteristic of RA

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10
Q

How does a pannus cause joint disease?

A

Production of proteinases → destruction of cartilage and ECM

The pannus is composed of inflammatory cells

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11
Q

What is a swan neck deformity?

A

PIP hyperextension and DIP flexion

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12
Q

What is a Boutonniere deformity?

A

PIP flexion and DIP hyperextension

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13
Q

What is trigger finger?

A

Stenosing flexor tenosynovitis

Flexor tendon catches when it glides through a stenotic sheath at the first annular (A1) pulley

(associated with RA and diabetes)

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14
Q

What is a hammer toe?

A

MTP and DIP hyperextension, PIP hyperflexion

A sign of motor neuropathy but can also develop after trauma or rheumatoid arthritis. DM is the most common cause

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15
Q

What is the major complication of RA in the cervical spine?

A

Atlanto-axial subluxation → cervical spinal cord compression

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16
Q

What is the triad of Felty syndrome?

A

Arthritis, splenomegaly, neutropenia

A severe subtype of seropositive RA

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17
Q

When is the peak incidence of RA?

A

Ages 20-50

May occur at any age

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18
Q

Name 4 spondyloarthropathies

A
  1. Ankylosing spondylitis
  2. Psoriatic arthritis
  3. Reactive arthritis
  4. Arthritis of IBD
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19
Q

Reactive arthritis most commonly follows which infections?

A

Enteric - Salmonella, Shigella, Campylobacter

Genitourinary e.g. Chlamydia, mycoplasma

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20
Q

Which connective tissue disease is strongly associated with temporal arteritis?

A

Polymyalgia rheumatica

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21
Q

What are gout crystals composed of?

A

Monosodium urate monohydrate

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22
Q

What is pseudogout?

A

Calcium pyrophosphate deposition disease

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23
Q

What are the differences found on laboratory between monosodium urate and calcium pyrophosphate crystals?

A

Monosodium urate - negative birefringent and needle-shaped

Calcium pyrophosphate - positive birefringent and rhomboid-shaped

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24
Q

Genetic defects impede what process in Ehlers-Danlos syndrome

A

Collagen synthesis

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25
Q

What are 3 clinical features of Ehlers-Danlos syndrome?

A
  1. Hyperextensible skin
  2. Joint hypermobility
  3. Easy bleeding (tissue fragility affecting vasculature)
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26
Q

What is tenosynovitis?

A

Inflammation of a tendon and its sheath

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27
Q

What is the classic triad of reactive arthritis?

A

Urethritis

Conjunctivitis

Arthritis

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28
Q

What is the most specific test for RA?

A

Anti-citrullinated peptide antibodies (ACPA)

AKA anti-cyclic citrullinated peptide (anti-CCP)

95% specific

(RF is 85% specific)

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29
Q

What are these?

A

Tophi

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30
Q

Name 4 common causative agents in viral arthritis

A
  1. Parvovirus B19
  2. HBV
  3. HCV
  4. Rubella
  5. HIV
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31
Q

What are 3 clinical tests which can be used in the diagnosis of ankylosing spondylitis?

A
  1. Reduced chest expansion
  2. Mennell sign: tenderness to percussion and pain on the displacement of the sacroiliac joints
  3. FABER test: Flexion, ABduction, External Rotation provoke pain in the ipsilateral hip
  4. Reduced spinal mobility
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32
Q

What is this radiological finding?

A

Syndesmophytes in AS “bamboo spine”

Bony growth originating inside a ligament

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33
Q

What is this radiological finding?

A

Sclerosis of the vertebral ligaments

AS “dagger sign”

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34
Q

Which drug is used in RA if methotrexate is contraindicated or not tolerated?

A

Leflunomide

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35
Q

List 4 management options for ankylosing spondylitis

A

1. Physical therapy

  1. NSAIDs e.g. indomethacin
  2. TNF-alpha inhibitors (do not alter disease progression)
  3. Intra-articular glucocorticoids
  4. DMARDs for peripheral arthritis (no axial effects)
  5. Surgery
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36
Q

3/5 features are required for a diagnosis of psoriatic arthritis.

What are these 5 features?

A
  1. Evidence of psoriasis
  2. Psoriatic nail dystrophy
  3. Negative rheumatic factor
  4. Dactylitis
  5. Radiologic signs
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37
Q

What are 3 treatment options for psoriatic arthritis?

A
  1. NSAIDs (mild)
  2. DMARDs (moderate to severe)
  3. Physical therapy
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38
Q

What are the features of CREST syndrome?

A

C - calcinosis cutis

R - Raynaud’s phenomenon

E - Esophageal hypomotility

S - Sclerodactyly

T - Telangiectasia

(form of systemic sclerosis)

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39
Q

Which test is used to measure tear production?

What is a normal result?

A

Schirmer’s test

Normal: >15mm after 5 minutes (Sjogren <5mm)

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40
Q

What is the triad for disseminated gonococcal infection?

A
  1. Polyarthralgia
  2. Tenosynovitis
  3. Dermatitis
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41
Q

How does disseminated gonococcal infection present if it is not the clinical triad?

A

Purulent gonococcal arthritis

Abrupt inflammation in up to 4 joints (commonly kees, ankles and wrists)

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42
Q

Calcification of synovia and cartilage on ultrasound is characteristic of which disease?

A

Pseudogout

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43
Q

What is the tetrad for HSP?

A
  1. Palpable purpura
  2. Arthritis/arthralgia
  3. GI symptoms
  4. Renal disease
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44
Q

Which purpura characteristically has elevated platelets?

A

HSP

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45
Q

List the 5 major criteria for rheumatic fever

A
  1. Arthritis (migratory polyarthritis primarily involving large joints)
  2. Carditis
  3. Sydenham chorea
  4. Subcutaneous nodule
  5. Erythema marginatum
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46
Q

List the 4 minor criteria for rheumatic fever

A
  1. Aseptic monoarthritis or polyarthralgia
  2. Fever
  3. Elevated acute phase reactants (ESR/CRP)
  4. Prolonged PR interval
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47
Q

What combination of major and minor criteria is required for diagnosis of rheumatic fever?

A

2 major

1 major + 2 minor

3 minor (if recurrent)

ALL + plus evidence of preceding Group A streptococcus infection

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48
Q

What is serum sickness?

A

Type III hypersensitivity reaction in response to anti-toxin or anti-venom administration

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49
Q

What is a serum sickness-like reaction?

A

Reaction clinically identical to serum sickness in response to medications

Pathogenesis unclear

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50
Q

Name 3 conditions people with Sjogren’s are at an increased risk of developing? (one must be non-rheumatological)

A
  1. B cell lymphoma
  2. MALT (mucosa-associated lymphoid tissue) lymphoma
  3. SLE
  4. RA
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51
Q

What is the triad for septic arthritis?

A
  1. Fever
  2. Joint pain
  3. Restricted range of motion
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52
Q

What is a normal white cell count in synovial fluid?

A

< 200/mm3 (cmm)

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53
Q

Synovial fluid containing a range of how many white cells is suggestive of non-inflammatory arthritis?

A

200 - 2000/mm3 (cmm)

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54
Q

Above a threshold of how many white cells in synovial fluid is inflammatory arthritis highly likely?

A

>2000/mm3 (cmm)

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55
Q

What is empiric antibiotic therapy for septic arthritis?

A

Flucloxacillin

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56
Q

List 5 DDx for migratory polyarthritis

A
  1. Gonococcal arthritis
  2. Rheumatic fever
  3. Sarcoidosis
  4. Systemic lupus erythematosus
  5. Lyme disease
  6. Bacterial endocarditis
  7. Whipple’s disease
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57
Q

List 4 causes of symmetrical polyarthritis

A
  1. Rheumatoid arthritis
  2. SLE
  3. Polymyalgia rheumatica
    * (autoimmune connective tissue diseases)*
  4. Viral arthritis
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58
Q

What are 2 highly specific tests for SLE?

A

Anti-dsDNA

Anti-Sm

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59
Q

Which antibody test is most sensitive for SLE?

A

ANA (93% sensitive)

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60
Q

For which diseases is a positive ANA most sensitive?

A

SLE (93%)
Systemic sclerosis/scleroderma (85%)

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61
Q

What is the most specific antibody test for systemic sclerosis?

A

Anti-Scl-70

(anti-topoisomerase)

62
Q

Which two antibodies are together most sensitive for Sjogren syndrome?

A

Anti-Ro/SSA

Anti-LA/SSB

60-80% of patients are positive for one or both antibodies

63
Q

What is the most sensitive antibody for mixed connective tissue disease?

A

Anti-U1 RNP

64
Q

Anti-cytoplasmic antigens (ANCAs) are typical in which group of diseases?

A

Vasculitis

65
Q

Which antibody test can be used to assess disease activity in SLE?

A

Anti-dsDNA

66
Q

Enthesitis is found in which group of diseases?

A

Spondyloarthropathies

67
Q

Parotid gland enalrgement is found in which connective tissue disorder?

A

Sjorgren’s syndrome

68
Q

List 4 foods which can lower serum uric acid

A
  1. Dairy products
  2. Soybeans
  3. Vegetable sources of protein
  4. Cherries
  5. Vitamin C
  6. Coffee
69
Q

What are the two most common causes of avascular necrosis?

A

Glucocorticoid use

Excessive alcohol use

70
Q

How does inflammation/infection affect the viscosity of synovial fluid?

A

Decreases

Proteolytic enzymes released in inflammation decreases the viscosity

71
Q

What is the treatment for polymyalgia rheumatica?

A

Low-dose oral glucocorticoid e.g. prednisolone

RA does not respond rapidly to low-dose corticosteroids

72
Q

What is mixed connective tissue disease?

A

Overlapping symptoms of systemic sclerosis, systemic lupus erythematosus and polymyositis

73
Q

What is polymyositis?

A

Inflammatory myopathy affecting the proximal skeletal muscles

74
Q

What is dermatomyositis?

A

Inflammatory myopathy that presents similarly to polymyositis, with the addition of skin involvement

75
Q

Which two joints are most affected by polymyositis/dermatomyositis?

A

Hip

Shoulder

76
Q

What are two characteristic cutaneous manifestations of dermatomyositis?

A
  1. Gottron papules (extensor surface of the hands)
  2. Helitrope rash (erythematous rash on the upper eyelids)
77
Q

What condition are these characteristic of?

A

Dermatomyositis

Gottron’s papules

78
Q

What condition is this characteristic of?

A

Dermatomyositis

Heliotrope rash

79
Q

What is the difference between limited and diffuse cutaneous systemic sclerosis?

A

Limited (CREST) - Raynaud’s precedes other symptoms, skin involvement limited to the hands, fingers and face

Diffuse - widespread skin findings, extracutaneous organ manifestations

80
Q

What are 4 extracutaneous manifestations of diffuse systemic sclerosis?

A
  1. Arthralgia and myalgia
  2. Dysphagia and reflux (oesophageal dysmotility)
  3. Constipation, bloating, gas (small bowel dysmotility)
  4. Pulmonary hypertension
  5. Interstitial lung disease
  6. Prerenal kidney failure (collagen deposits in renal arterioles)
81
Q

Which antibodies are most specific for limited SSc?

A

Anti-centromere antibodies (ACA)

82
Q

Which antirheumatic drug may cause a reactivation of latent TB?

A

TNF alpha inhibitors

TNF alpha plays a key role in containing TB within granulomas

83
Q

What is the most specific antibody for SLE?

A

Anti-Smith

84
Q

Name 3 TNF-alpha antagonists used in rheumatology

A
  1. Adalimumab
  2. Etanercept
  3. Infliximab
85
Q

List 6 adverse effects of methotrexate

A
  1. Gastrointestinal (stomatitis, nausea, diarrhoea, bleeding)
  2. Rash
  3. Hepatotoxicity
  4. Interstitial pneumonitis and pulmonary fibrosis
  5. Bone marrow suppression
  6. Nephrotoxicity
  7. Increased risk of lymphoproliferative disorders
  8. Teratogenicity
  9. Alopecia
86
Q

What are contraindications to methotrexate use?

A

Significant liver or kidney disease

Heavy alcohol intake

Pregnancy

Lactation

87
Q

Name 4 conventional synthetic disease-modifying antirheumatic drugs (csDMARDs)

A
  1. Methotrexate
  2. Leflunomide
  3. Hydroxychloroquine
  4. Sulfasalazine
  5. Cyclosporine
  6. Azathioprine
88
Q

What is the mechanism of cyclosporine?

A

Calcineurin inhibitor

Inhibits T cell activation (prevents production of IL-2 and other cytokines which stimulate T cell proliferation and differentiation)

89
Q

Name 3 classes of biologic disease-modifying antirheumatic drugs (bDMARDs)

A
  1. TNF-alpha inhibitors e.g. adalimumab
  2. Janus kinase inhibitors e.g. tofacitnib
  3. B cell depletors e.g. rituximab
  4. Selective T cell costimulation modulator e.g. abatecept
  5. Interleukin-1 receptor antagonist e.g. anakinra
90
Q

Why are NSAIDs used for acute gout?

A

They have uricosuric effects at high doses

91
Q

Why is aspirin use a risk factor for gout?

A

Inhibits uric acid excretion

92
Q

What is the mechanism of colchicine?

A

Anti-inflammatory

NOT analgesic, but can reduce pain due to less inflammation

93
Q

A patient with gout initiates a new medication and develops diarrhoea. Which drug is most likely to have this effect?

A

Colchicine

Near 100% with high doses

94
Q

What is the mechanism of allopurinol?

What effect does it have on uric acid?

A

Xanthine oxidase inhibitor

Reduces uric acid production

95
Q

List 2 notable side effects of allopurinol

A
  1. Hypersensitivity syndrome (rash, fever, nephritis, hepatitis, eosinophilia)
  2. Toxic epidermal necrolysis/Steven-Johnson syndrome
  3. GI intolerance
  4. Neutropenia, thrombocytopenia
96
Q

Why has allopurinol traditionally been avoided during acute attacks of gout?

A

The frequency of acute flares increases in the first months of allopurinol use

BUT do not discontinue during acute attacks

97
Q

What is the mechanism of febuxostat?

A

Xanthine oxidase inhibitor

Used when allopurinol is not tolerated

98
Q

What is the mechanism of rituximab?

A

CD-20 monoclonal antibody

Binds to and lyses B cells (not plasma cells - does not significantly lower immunoglobulin levels, but inhibits the formation of new IgM antibodies)

Used for RA

99
Q

Anti-histone antibodies are suggestive of which disease?

A

Drug-induced lupus

100
Q

Anti-Jo-1 antibodies are suggestive of what?

A

Idiopathic inflammatory myopathies

Polymyositis, dermatomyositis

101
Q

Name 2 calcineurin inhibitors

A

Cyclosporine

Tacrolimus

Inhibits IL-2 and other cytokines which normally stimulate T cell proliferation and differentiation

102
Q

What is the major adverse effect of cyclosporine?

A

Nephrotoxicity

103
Q

How does antiphospholipid syndrome lead to a hypercoagulable state?

A

Antibodies form complexes with anticoagulant proteins e.g. protein C, S, antithrombin III

Antibodies activate platelets and vascular endothelium

→ hypercoagulable state → increased risk of thrombosis and embolism

104
Q

What are the clinical features of antiphospholipid syndrome?

A

C - clotting (arterial and venous)

L - livedo reticularis

O - obstetric problems

T - thrombocytopenia

105
Q

Which ophthalmological condition is associated with rheumatoid arthritis?

A

Episcleritis

106
Q

Which alleles are associated with SLE?

A

HLA-DR2 and HLA-DR3

107
Q

Which antibodies are associated with drug-induced lupus?

A

Anti-histone

anti-dsDNA is not associated with drug-induced lupus

108
Q

What are 3 poor prognostic markers in SLE?

A
  1. High serum anti-dsDNA
  2. Fall in complement (CH50, C3, C4)
  3. Diagnosis before 25
  4. Renal, vascular or neurological involvement
  5. Low C1q (lupus nephritis)
109
Q

Which medication is used in all patients with lupus?

A

Hydroxychloroquine or chloroquine

110
Q

Which medications most commonly cause drug-induced lupus?

A

Sulfa drugs (drugs containing a sulfonamide group)

+ hydralazine, isoniazid, phenytoin, TNF-alpha inhibitors

111
Q

Which organs are unaffected in drug-induced lupus but affected by idiopathic SLE?

A

Oral mucosa

Brain

Kidneys

112
Q

What is the prognosis for drug-induced lupus erythematosus?

A

Remission after discontinuation

113
Q

How are complement levels affected by SLE?

A

Low C3 and C4

114
Q

What is the most important prognostic factor for SLE?

A

Lupus nephritis

(immune complex-mediated glomerulonephritis)

115
Q

Which two autoantibodies are most strongly associated with antiphospholipid syndrome?

A

Anticardiolipin

Lupus anticoagulant

116
Q

How does lupus anticoagulant influence aPTT

A

In vitro (lab) → prolonged aPTT

In vivo (body) → short aPTT

117
Q

Which laboratory test does the presence of anticardiolipin autoantibodies alter?

A

False positive syphilis (cardiolipin is used for syphilis testing)

118
Q

What is behcet syndrome?

A

Systemic vasculitis that can affect arteries and veins of all sizes

119
Q

What is the classic triad of behcet syndrome?

A
  1. Painful mouth ulcers
  2. Painful genital ulceration
  3. Uveitis
120
Q

What is unique about the vegetations in Libman-Sacks endocarditis?

A

Sterile

On both sides of the valve

Vegetations are easily dislodged and embolisation is common

Emboli are particularly large

121
Q

Which drug is used for gout if allopurinol is not tolerated?

A

Febuxostat

122
Q

What are 5 extra-cutaneous manifestations of SLE?

A
  1. Myalgia
  2. Serositis (pleuritis, pericarditis)
  3. Nephritis
  4. Libman-Sacks endocarditis
  5. Pneumonitis
  6. Interstitial lung disease
  7. Oesophagitis
  8. Hepatitis
  9. Pancreatitis
  10. Raynaud’s phenomenon
  11. Thromboembolism
  12. Seizures
  13. Personality changes
  14. Autoimmune haemolytic anaemia
123
Q

What is the mechanism of anakinra?

A

Interleukin-1 receptor antagonist

124
Q

What is the role of environmental antigens in the pathophysiology of RA?

A

Cause modification (e.g. citrullation) of proteins (e.g. type II collagen)

Susceptibility genes predispose someone to view these modified proteins as antigenic

125
Q

Why does RA accelerate osteoporosis?

A

Inflammatory cytokines increase RANKL expression on T cells –> T cells bind to RANK on osteoclasts

126
Q

What is the sensitivity and specificity of rheumatoid factor for RA?

A

Sensitivity: 70%

Specificity: 85%

127
Q

What is the sensitivity and specificity of anti-CCP for RA?

A

Sensitivity: 67% (RF is better)

Specificity: 95%

128
Q

What type of hypersensitivity reaction is RA?

129
Q

What type of hypersensitivity reaction is reactive arthritis/Reiter’s syndrome?

130
Q

Which group is most affected by reactive arthritis?

A

Young men

20-40

M > F post-urethral

M=F post-enteric

131
Q

What is TNF-alpha?

A

A cytokine involved in inflammatory and immune responses and in the pathogenesis of rheumatoid arthritis, psoriasis and inflammatory bowel disease

132
Q

What causes a pleural friction rub in RA?

A

Inflammation of the pleura secondary to a systemic inflammatory state

133
Q

Which feature best distinguishes a malar rash from rosacea?

A

The butterfly rash spares the nasolabial folds

134
Q

Why may patients with lupus exhibit livedo reticularis?

A

Thrombosis → blockage of the venous or arteriolar system → increased discoloured deoxygenated blood + venular dilation

135
Q

When are biologic DMARDs indicated?

A

Moderate or severe disease activity after 3 months of csDMARD therapy

Do not cease csDMARD

136
Q

What is the sensitivity of ANA in lupus?

A

93% (very sensitive)

137
Q

What is the sensitivity of anti-dsDNA and anti-Sm antibodies in SLE?

A

Anti-dsDNA: 70% (prognostic plus associated with renal disease)

Anti-Sm: 30% (but highly specific)

138
Q

Which antibodies are extractable nuclear antigens (ENA)?

A

Anti-Sm (SLE)

Anti-U1-RNP (MCTD)

Anti-Ro (Sjogren)

Anti-La (Sjogren)

139
Q

What are the radiological features of RA?

A

Loss of joint space
Erosions
Soft tissue swelling
Soft bones (osteopenia)

(LESS)

140
Q

How is the incidence of reactive arthritis affected by gender?

A

Post-enteric: equal

Post-urethritis: M > F

141
Q

What are the classic pathology findings of myocardial tissue in rheumatic heart disease?

A

Aschoff bodies (granuloma of rheumatic inflammation)

Antischkow cells (large, elongated cells found in Aschoff bodies)

142
Q

How does ankylosing spondylitis affect males and females differently?

A

Male to female; 3:1

143
Q

What are the ocular manifestations of reactive arthritis?

A

Conjunctivitis

Iritis

144
Q

What are 3 risk factors for pseudogout

A
  1. Joint trauma
  2. Haemachromatosis
  3. Gout
  4. Hyperparathyroidism
  5. Hypophosphatemia/hypomagnesemia
    * Most commonly idiopathic*
    * Damaged cartilage releases an enzyme, nucleoside triphosphate pyrophosphohydrolase which leads to CPPD crystal formation​*
145
Q

4/11 features are required for a diagnosis of lupus

Name as many of these 11 as you can

146
Q

What ANA titre is considered positive?

147
Q

Which arthritis’ may present with DIP involvement?

A

AS

Psoriatic arthritis

OA

Sarcoidosis

148
Q

How do calcineurin inhibitors work?

A

Inhibit T cell activation (prevents the production of IL-2 and other cytokines which stimulate T cell proliferation and differentiation)

149
Q

How does rituximab affect B cells/plasma cells?

A

Binds to and lyses B cells (not plasma cells - does not significantly lower immunoglobulin levels, but inhibits the formation of new IgM antibodies)

CD-20 monoclonal antibody

Used for RA

150
Q

Bull’s eye maculopathy is associated with which rheumatological drug?

A

Hydroxychloroquine

151
Q

Which antibodies are elevated in drug-induced lupus?

A

Anti-histone

152
Q

How are acute gout attacks managed?

A
  1. NSAIDs
  2. Colchicine if contraindicated
  3. Glucocorticoids (oral or intra-articular)

Y4S2 Medicine (18 decks)

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