Rheumatology Flashcards
Antibody associated with drug induced SLE
anti-histone antibody
What drug should everyone with SLE be on
hydroxychloroquine
Biggest cause of mortality is well-controlled lupus
Cardiovascular disease (but uncontrolled lupus is still the biggest killer)
Adverse effect of hydroxychloroquine
retinopathy
1st line for lupus nephritis
mycophenolate
antiphospholipid syndromes venous vs arterial INR target range
target INR 2.0 to 2.5 for venous 3.0 to 3.5 for arterial clots esp CNS
Most likely cardiopumonary manifestation of SLE
Pleurisy, pericarditis, effusions (30-50%)
What ANA is associated with pericarditis in SLE
Anti-Sm
Antihypertensive for gout
Losartan
Gout synovial fluid findings
Monosodium urate crystals = needle shaped crystals which are STRONGLY NEGATIVELY birefringent on polarised light microscopy
Uric acid treatment aims (no tophi vs tophi)
No tophi 0.36; tophi 0.3
After allopurinol what other drugs are available for management of gout?
Febuxostat - newer xanthine oxidase inhibitor (not a purine analogue) Probenecid - inhibits URAT1 to block retention of urate in kidneys → weak uricosuric agent
Risk factors for avascular necrosis
HIV, steroids, excessive ETOH use, sickle cell, transplantation (likely secondary to corticosteroids)
Most common chronic inflammatory arthritis
rheumatoid arthritis
What allele in the MHC confers the greatest risk of RA
HLA-DRB1
Most reproducible environmental risk factor for rheumatoid arthritis
smoking (antibody positive)
Most common cervical spine joint affected in RA
Atlantoaxial joint
Felty’s syndrome
triad of neutropenia, splenomegaly and nodular RA
Specific immunological marker for rheumatoid arthritis
Anti-CCP (associated with erosive disease)
Infliximab
Anti-TNF
Anakinra
IL-1 receptor antagonist
Rituximab
CD20 monoclonal antibody
Tocilizumab
mAb agains IL-6
Tofacitinib
Inhibits JAK1 and JAK3
DMARDS for RA in pregnancy
Hydroxychloroquine and sulfasalazine
What renal disease is associated with poor disease control in rheumatoid arthritis
Secondary amyloidosis
What is HLA27 most commonly associated with
Ank spond
What features would inflammatory back pain have
4 out of 5 of the following: -Age <40 years -Lack of improvement at rest -Pain at night -Improve with exercise -Insidious onset
What is enthesis
Inflammatory at the insertion of the tendon to the bone
Ank spond extra articular abnormalities
Uveitis (30%) Aortic valve disease Cardiac conduction abnormalities Restrictive lung disease Also atherosclerotic cardiovascular disease
Bug most commonly assocaited with reactive arthritis
Yersinia But also Chlamydia Ureaplasma urealyticum Campylobacter E coli Salmonella Shigella
ANA pattern associated with limited sclerosis
Centromere - indicates anti-centromere antibody
Treatment for scleroderma renal crisis
ACE-I
What inflammasome and interleukin are involved in the initiation of acute gout flares?
NLRP3 inflammasome and interleukin 1beta. Monosodium urate crystals interact with resident macrophages to form and activate the NLRP3 inflammasome. Caspase 1 processes pro-interleukin 1beta into mature interleukin 1-beta
What is the dominant cause of hyperuricaemia
Underexcretion
What are the most common comorbidities associated with gout?
Hypertension - 74% CKD - 71% Obesity - 53% Diabetes - 26%
When is urate lowering therapy indicated?
recurrent gout flares >1 flare a year tophi stage 2 or worse CKD or kidney stones Not recommended for people with asymptomatic hyperuricaemia
What HLA is associated with allopurinol hypersensitivity syndrome
HLA-B*5801
What gout drugs can lead to myelosuppression with azathioprine?
Xanthine oxidase inhibitors - allopurinol, febuxostat Due to azathioprine increasing 6-mercaptopurnie concentrations
6 ddx of acute knee monoarthritis
septic arthritis crystal arthritis other inflammatory monoarthritis traumatic arthritis osteoarthritis avascular necrosis
benefit of uric acid
antioxidant if someone if profoundly hypouricaemic, it is thought that the rate of neurodegenerative diseases can increase
what temperature causes precipitation of uric acid
lower temperatures
Why does premenopausal women rarely have gout
estrogenic is uricosuric
What skin condition is associated with gout
psoriasis due to high skin turnover
What drives elevated ESR in inflammation
Fibrinogen
Ultrasound of uric acid deposition
Double contour sign
Ultrasound of gout joint effusion
“Snowstorm appearance”
What diet for gout
DASH diet (dietary approaches to stop hypertension)
adverse effect of febuxostat
all cause mortality and cardiovascular mortality were higher with febuxostat - do not use in patients with IHD or congestive heart failure
What statins don’t interact with colchicine
Atorvastatin, simvastatin Ok to use pravastatin and rosuvastatin CYP3A4 inhibitor and P-glycoprotein inhibitors Also interacts with ritonavir
Mean time of allopurinol rash onset after starting drug
30 days (90% within 6 months)
RIsk factors for allopurinol hypersensitivity syndrome
Female Age Renal impairement Diuretic use HLA B*58:01
How is activity in RA defined by
1) joint activity 2) how many active joints 3) CRP and ESR
When should DMARDS be commenced in RA
at diagnosis
Poor prognostic factors in RA
RF positivity, anti-CCP positivity Functional limitation Number of joints (synovitis) Early erosions High ESR or CRP
Biggest cause of mortality in RA
Cardiovascular disease (RA has same independent risk to diabetes)
How early can erosions be detected on MRI in RA
4 months
What cell causes bony erosions in RA
osteoclast relevant for bone scans
At what doses does prednisolone increase osteoporosis
>7.5mg
Which TNF inhibitor does not work in inflammatory bowel disease
etanercept
What infection does JAK inhibitors predispose you to more than the other DMARDS
shingles cannot have vaccine because it’s a live vaccine
What infection does IL-17 inhibitors predispose you to more than the other DMARDS
candidasis
What DMARD should not be used in demyelination
TNF inhibitors
Which DMARD should not be given in heart failure
anti-TNF
What vaccinations are live
shingles, MMR, yellow fever, BCG
What organisms in septic arthritis is associated with drug abuse?
pseudomonas aeruginosa, serratia percescens
What organisms in septic arthritis is associated with haemoglobinopathies
streptococcus pneumonia, salmonella
diagnostic test of reflex sympathetic dystrophy
bone scintigraphy
which area of the foot does diabetic arthropathy most commonly affect
mid foot
patient on dialysis XR diagnosis
dialysis related amyloidosis
differences between HD related amyloidosis and other amyloidosis
less visceral invovlement
mainly joints
increases with duration of HD
where are syndesmophytes most commonly seen in ank spond
thoraco-lumbar
what condition is assos with non-marginal syndesmophytes
psoriatic spondylitis
which side of the sacroiliac joint does ank spond affect more
iliac side
what arthritis is most associated with enthesitis
reactive arthritis
gout erosions vs rheumatoid erosions vs infective
gout has bigger erosions - if you few a circle with the erosion the circle woud mainly be outside the bone but in gout more of the erosion is in the bone
in infective, the border of the erosion isn’t as smooth
what joint is most suggestive of haemochromatosis
MCP (next test ferritin)
