Rheumatology Flashcards
Urate targets in gout treatment
Low disease burden <0.36 mmol/L High disease burden <0.3 mmol/L
What is this?
Double conture sign
Seen in gout due to a layer of crystals on the surface of the cartilage
Sens 44% Spec 99%
What type of crystal is seen in gout?
Monosodium urate
Strongly negatively birefringent needle shapped crystals:
‘Yellow when parrallel to the polariser’
What is the HLA association with allopurinol hypersensitivity?
HLA -B*58:01
Test Han Chinese, Thai, Korean
What are the key inflammatory components of gout attack?
Inflammasone assembly
IL1 production
Phagocytosis by macrophages
What non-traditional urate lowering drugs can lower serum urate?
Losartan
Fenofibrate
What are the XR changes seen in osteoarthritis?
L - Loss of joint space
O - Osteophytes
S - Subchondral cysts
S - Subchondral sclerosis
What is the HLA association with rheumatoid arthritis?
Increased risk with HLA-DRB1
Felty syndrome is associated with HLA DR4
What pattern is rheumatoid associated interstitial lung disease?
Usually UIP, worse prognosis than NSIP
What is Felty Syndrome?
Triad of persistant rheumatoid arthritis, splenomegaly and neutropenia
Can have other extra-articular manifestations
Associated with HLA-DR4
What are the key cytokines seen in RA?
TNF-a
IL-6
IL-1
What is the classification of lupus nephritis?
What are the principles of the 2019 EULAR-ACR SLE classification criteria?
Must have ANA > 1:80 at any point in time
Must have at least 1 clinical criteria and total score >10
The clinical criteria contain - fever, cutaneous, arthritis, neurological, serositis, haematological and renal manifestations
Immunological criteria - anti-phospholipid, complement, dsDNA, anti-SM
If there is a renal biopsy demonstrating lupus nephritis this is diagnostic
What are the changes in complement seen in SLE?
Low C3 C4 in active disease
How is disease acitvity in lupus monitored?
Clinically
ESR>CRP
dsDNA
Complement levels
Proteinuria
Disease activity scoring systems
What is the management of lupus nephritis?
- General measures with ACEI, BP management, CVD management, hydroxychloroquine
- Immunosuppress class III, IV and possibly V
- Induction with steroids + mycophenolate or cyclophosphamide
- Maintance with low dose steroids + mycophenolate or azathioprine
What are anti-Ro and anti-La antibodies associated with?
Sjogrens
Sjogren manifestations in SLE
Congentital heart block, neonatal lupus
What antibodies are associated with neurolupus?
Anti-ribosomal P
What are the risk factors for poor pregnancy outomes in SLE?
Disease activity in preceeding 6 months
Stopping hydroxychloroquine
Serological activity
Lupus nephritis
Anti-phosopholipid syndrome
Organ damage
Anti Ro and Anti La (SSA and SSB)
What are the antibodies seen in scleroderma and whar are they associated with?
Centromere - limited, Pul HTN
Topoisomerase 1 (Scl-70) - ILD
RNA polymerase III - diffuse, renal involvement
What antibody is associated with mixed connective tissue disease?
ANA speckled
ENA - U1RNP
What is the classic clinical feature of mixed connective tissue disease?
Puffy hands
What types of rash are seen in dermatomyositis?
Gotrans patches - over knuckles of hands
Shawl sign - back of neck/shoulders
Heliotrope rash - eye lids
What is the muscle involvement pattern with inclusion body myositis?
Distal upper limb
Proximal lower limb
Can be asymmetric
What is the HLA association with immune mediated necrotizing myopathy? What is the antibody?
HLA DRB1*11:01
ANti0HMGCR antibodies highly specific
What is anti-synthetase syndrome?
ILD
Raynauds
Mechanics hands
Arthritis
Myositis
Most commonly Jo-1 positive
What is Lofgren syndrome?
A particular sarcoidosis syndrome
- hilar lymphadenopathy
- Joint pain - often ankle
- Erythema nodosum
What are the key inflammatory drivers of ankylosing spondylitis?
IL-23 driving Th17 picture which produces IL-17 and TNFa
What are the cardiac manifestations of ankylosing spondylitis?
Ischaemic heart disease
Conduction defects
Aortic regurgitation
What types of lung disease is seen in ankylosing spondylitis?
Restrictive lung defect from reduced chest wall expansion
Interstitial fibrosis - in the upper lobes
What is the treatment for ankylosing spondylitis?
1st - NSAID (continous) and physio, education, smoking cessation
**Extra-axial disease - local steroid injections, MTX, sulfasalazine
2nd - anti-TNFa or secukinumab (anti-IL17)
In ankylosing spondylitis what agents should not be used in co-existing IBD?
Etanercept (anti-TNF) - not effective in IBD
Secukinumab (anti-IL17) - not effective, may be harmful
What forms of arthritis affect the DIP joints?
Osteoarthritis
Psoriatic arthritis
Gouty arthrtitis
What are the radiographic features of psoriatic arthritis?
Pencil in cup deformity
Marginal erosions with adjacent proliferation
Small joint ankylosis
Asymmetric sacroiliitis
What antibody is associated with inclusion body myositis?
Anti-5NT1A
Highly specific but not sesnitive
Associated with more severe disease
Which dermatomyositis anibody is associated with highest malignancy risk?
TIF gamma antibody
NXP2
Anti-P155
What are the common ANA patterns? What are they associated with?
Homogenous - dsDNA, histone, chromatin
Rim or peripheral staining - dsDNA, sclerosis
Speckled - most eg SS-A, SS-B
Nucleolar - sclerosis, polymyositis
Centromere - sclerosis, primary biliary cirrhosis
