Rheumatology Flashcards
Temporal arteritis (giant cell arteritis) visual
Common >50 y/o (if <50 then think Takasayu)
Large vessel-sized vasculitis
External carotid arteries
Assoc with polymyalgia rheumatica
Sx: headache, temporal artery/scalp tenderness, jaw claudication, acute unilateral blindness
Complications: irreversible visual loss (due to optic nerve ischaemia)
Ix:
FBC (normochromic/normocytic anaemia, increased platelets)
Increased transaminases
Temporal artery biopsy (if negative, biospy other side) as skip lesions can occur (granulomatous inflammation, multinucleated giant cells)
Tx:
oral prednisolone
IV methylprednisolone (if visual loss)
Maintenance:
prednisolone (around 1 yr), aspirin, PPI, calcium (prevent OP)
Vasculitis
Large sized vessels: Temporal arteritis, Takasayu arteriitis
Medium: Kawasaki
Small: ANCA vasculitis (Granulomatosis with polyangiitis, esoinophilic granulamtosis with polyangiitis - Churg strauss), Goodpasture’s, Henoch Schonlein Pupura
Takasayu arteritis
Granulomatous inflammation of aorta and major branches (causing stenosis aneurysms)
Women (20-40 y/o)
Sx: dizziness, upper/lowerlimb claudication
Sx: hypertension (due to renal stenosis), weak arm pulses, carotid bruit, low grade fever
Complications: aortic regurgitation, aortic aneurysm
Ix:
CT angiogram
MR angiogram
Tx:
Prednisolone
Methotrexate
Medium vessel vascilitis (involves muscular arteries e.g. renal arteries)
Polyarteritis nodosa
Necrotising vasulitis
Involves most organs but lung spared
Sx:
hypertension (renal a)
abdo pain, malaena (mesenteric a)
skin lesions
Ix:
Hep B serology (Hep B sAG)
Biopsy: transmural necrotising inflammation
Tx: prednisolone + cyclophosphamide + methotrexate
Kawasaki disease
Children, Asian, male
Signs: Fever, maculopapular rash, conjuctivitis, strawberry tongue, unilateral cervical lymphadenopathy, hardening of palms and soles
Usually involves coronary artery, can lead to MI
Ix:
Echo (coronary aneurysms)
Tx:
1st line: IV Ig + aspirin (high dose) - (usually not given in children with viral illness due to Reye syndrome)
2nd line: prednisolone + aspirin
Small vessel vasculilitis
Granulomatosis with polyangiitis
Systemic vasculitis involves upper+lower resp tract and rapidly progressive glomerulonephritis
Sx: upper airways: epistaxis, saddle nose deformity, oral ulcers lower airways: SOB, cough renal: haematuria, oedema, hypertension weight loss, fever, night sweats
Ix:
Urinalysis + microscopy (haematuria, proteinuria)
CT chest (lung nodules)
cANCA + EIA (levels of cANCA correlates with disease activity)
Biopsy: necrotising granulmatous inflammation with multi nucleated giant cells
Tx: cyclophosphamide + prednisolone
Esoinophilic granulomatosis with polyangiitis
Necrotising granulomatosis with eosinophils
Involves heart, lungs
Assoc. with asthma and peripheral esoinophilia
Sx: peripheral neuropathy, rhinits, petechiae legs, wheeze (asthma)
Ix:
p-ANCA + MPO
PFR/Spirometry: obstructive reversible airway obstruction
Tx: prednisolone + methylprednisolone
Henoch Schonlein pupura
Vasculitis due to IgA deposition
Polymyalgia rheumatica
> 50 y/o
Assoc. with temporal arteritis
Sx: subacute onset bilateral pain/ morning stiffness in shoulders, hips and proxmial limb muscles (difficulty getting up from chair), fatigue
No weakness
Ix:
Alk phos: increased
Creatinine kinase + EMG normal
US: bursitis
DDx: RA, OA, polymyositis
Tx: prednisolone (fast repsonse)
OP
Low bone density leading to increased bone fragility and risk of fractures
Risk fx: female, age, lower BMI, steroid use, alcohol, hyperthyroidism, Vit D deficiency
Sx: asymptomatic, back pain, kyphosis (vertebral fracture)
Ix:
DXA
-1 to -2.5: osteopenia
-2.5 or worse: OP
X-ray
Ca2+, Alk Phos, PTH (normal)
Tx:
Lifestyle: smoking, alcohol, weight bearing exercises, home-based fall prevention programme
1st line: Bisphosphonates (inhibits osteoclasts)
Aledronic acid (taken in morning, 30 mins before eating and remain upright)
SE: joint pain, osteonecrosis jaw
Calcium, Vit D
2nd line: Raloxifene (selective oestrogen receptor modulator)
3rd line: Terparatide (recombiant PTH, which increases osteoblast activity). Increased risk of renal malignancy.
Denosumab: monoclonal antibody to RANKL. SC twice yearly.
Seronegative spondyloarthropathies
Psoriatic arthritis, enteropathic arthritis, reactive arthritis
HLA-B27
Ankylosing spondylitis
Chronic progressive inflammatory arthropathy
Develops early 20s, male
Sx: inflammatory back pain early morning back stiffness, improvement of stiffness with exercise, age of onset <40, pain lasts >3 mnths
Reduced lateral flexion
Anterior unveitis, apical fibrosis, aortic regurg, achilles tendonitis
Signs: bamboo spine
Ix: pelvic XR (sacroilitis)
MRI (inflammation, erosions)
cervical/lumbar/thoracic XR
- (romanus lesions (erosions)
- vertebral syndesmophytes (bony growth in the ligament)
- bamboo spine (fusion of vetebral bodies due to calcification of ligaments)
- spinal fractures
Tx: NSAIDs, exercise, physiotherapy
Sulfasalazine (if severe: peripheral joint involvement)
Psoriatic arthritis
Mono/Oligoarticular (one/few joints) arthritis (compared to Polyarticular (multiple) in RA)
DIP joints of hand
Dactilytis, scaroilitis
Skin (psoriatic plaques), nail changes (pitted nails, onychomycosis (separation of nail from nail bed)
Ix:
XR hands + feet (erosion in DIP joint, pencil cup deformity)
RF/Anti- CCP (negative)
Joint aspiration (exclude gout)
Tx:
NSAIDS, physiotherapy, intra-articular steroid injections
DMARDs
Reactive arthritis
Arthritis due to autoimmune response to infection
Causes: GI (Campylobacter, salmonella, shigella), Genitourinary (Chlamydia trachomatis) infections
Sx:
starts 1-4 weeks after infection
asymmetrical oligoarticular (few joints) arthritis (usually lower large joints)
Enthesistis (achilles tendon)
Keratoderma blenorrhagica (brown raised plaques on soles/palms)
Circinate balantis (painless ulcer on penis)
Triad of conjuctivitis, urethritis, arthritis, - Reiter’s syndrome) “can’t see, pee, climb a tree)
Ix: Stool culture Sexual health review Joint aspiration (exclude gout) XR (asymmetrical sacroilitis)
Tx:
NSAIDs
Corticosteroids
Autoimmune connective tissue disorders
SLE
Multisystem autoimmune disease. Autoantibodies against autoantigens forming immune complexes which deposit in tissues causing damage.
Female. HLA DR2/3
Drug induced lupus: isoniazid, hydrazaline, procainimide, phenytoin. Assoc. with antihistone antibodies.
Ix: Anti-histone antibodies
Sx:
Malar/butterfly rash, photosensitive lupus rash, discoid rash (coin-shaped), alopecia, oral ulcers, synovitis, seizures
Signs: haemolytic anaemia, leucopenia, thrombocytopenia, Jaccoud’s arthropathy (joint disorder)
Ix: ANA (antinuclear antibody) (most sensitive) Anti-dsDNA Anti-Smith Anti-phospholipid Low complement (C3/C4) \+ve Direct Coombs test Raised ESR, but not CRP Urinalysis (proteinuria, casts- lupus nephritis) Skin/renal biopsies
Tx: Hydroxychloroquine (DMARD)
Azathioprine - steroid sparing agent
Maintenance - NSAIDs (unless renal disease) and hydoxychloroquine
Severe: haemolytic anaemia, lupus nephritis: high dose steroids, rituximab
Lupus nephritis: Hydroxychloroquine+ prednisolone+cyclophosphamide
Anti-phospholipid syndrome
Increased antiphosphlipid antibodies (anticardiolipin, lupus anticoagulant, anti B2 glycoprotein I)
Assoc with SLE
Sx: thrombotic tendency, recurrent miscarriage, thrombocytopenia
Ix: antiphospholipid antibodies
Tx: anticoagulants
Sjogren’s syndrome
Systemic autoimmune disorder characterised by dry eyes and dry mouth due to lymphocytic infiltration into the lacrimal and salivary glands
Risk fx: SLE, RA, female
Sx: dry mouth, eyes, skin, throat
Ix: Anti-Ro and Anti-La
Schirmer’s test (measures tears)
Tx:
Artificial tears
Ophthalmic ciclosporin drops
Polymyositis and dermatomyositis
Progressive symmetrical proximal muscle weakness and autoimmune-mediated striated muscle inflammation
Sx: myalgia, arthalgia, dysphagia, dysphonia
Dermatomyositis
Myositis + skin changes
Sx: malar rash, shawl sign (malar rash on back), heliotope (lilac) rash on eyelids, red papules on knuckes/elbows
Usually from paraneoplastic from lung, pancreas, ovarian, bowel
Both: fever, Raynaud’s, interstitial lung fibrosis
Ix:
CK (high)
Muscle biopsy
Anti-Mi2, ANA
DDx: muscular dystrophy, rhabdomyolysis Tx: oral prednisolone, methotrexate IV steroids (if severe)
Paget’s disease of the bone
Bone remodelling disorder characterised by increase bone resorption due to hyperactive osteoclasts, bone formation and remodelling
Usually affects femur, pelvis, skull
Hyperactive osteoclasts. Increase bone turnover leading to deposition of abnormal bone and microfractures.
Asymptomatic.
Sx: Pain at bone/joint, pathological fractures, hearing loss (skull involvement which affects CN VIII), spinal cord compression, cardiac failure
Signs: bone bowing, frontal bossing (pronounced forehead)
Ix: XR (lytic changes) Bone scan Alk phos (raised), normal Ca, normal PTH serum CTX (bone resorption)
Tx:
Analgesia - NSAIDs
Bisphosphonates
Physiotherapy
Complications: osteosarcoma, fractures
Bone tumours and mets
Primary:
Benign Malignant
Osteoid osteoma Osteosarcoma
Chondroma Chondrosarcoma
Giant cell tumour Ewing’s tumor
Osteoid osteoma
Small, benign osteoblastic proliferation
Adolescents
Pain worse at night, relieved by aspirin
Osteosarcoma (most common) 10-25 y/o Malignant tumour which cells form osteoid or bone Metaphysis long bones, knee Signs: mass, antalgic gait (limp) Lung mets
Tx: chemo + surgery
Chrondroma
Mass of cartilage in medulla
Hands/feet, long bones
Osteocartilagenous exostosis
Benign outgrowth of cartilage with endochondral ossification
Adolescence
Metaphysis of long bones
Chondrosarcoma
De novo or from chondroma or exostosis
Middle aged/elderly
Ewing’s sarcoma
5-15 yrs
Long bones, flat bones of limb girdles
Early mets to lungs, breasts
Mets
Lytic (more common)
Sclerotic - Prostate, Breast Ca, Carcinoid
Solitary bone mets - thyroid, renal
RA and OA
Autoimmune condition involving polyarthritis, usually PIP, MCP joints
HLA-DR4
Inflammation of synovium leads to influx of macrophages, B and T cells, plasma cells. Pannus is formed which is invasive to local tissue and cartilage.
Sx: symmetrical joint stiffness which lasts >30 mins in morning, better throughtout day
Signs: Boutinere’s, swan neck deformity, ulnar deviation, rheumatoid nodules (fingers/elbows)
Extra-articular sx: pericarditis, pleural effusion (exudative), felty’s syndrome (RA, splenomegaly, neutropenia)
Ix:
Anti-RF/CCP
XR affected joint (LESS)
DAS-28
Tx:
DMARDs (methotrexate, sulfasalazine, leflunomide)
Biologics
Anit-TNFs: Infliximab, Etanercept (increased risk TB)
Tocilizumab (Anti-IL6)
Abatacept (Anti-CTLA4. T cell) Risk of resp infections
Rituximab (Anti-CD20 B cell) Risk of Hep B.
OA
Degenerative joint disorder characterised by degradation of articular cartilage
Primary: unknown cause.
Secondary: trauma, RA, gout
Sx: joint pain/stiffness, loss of function
Signs: Heberden’s nodes (nodes near DIP joint), Bouchard’s nodes (nodes near PIP joint), crepitus
Ix: XR affected joints (LOSS)
CRP
Tx: 1st line: topical capsaicin + physio \+ intra-articular corticosteroid joint injections 2nd line: paracetamol + topical 3rd line: NSAIDs+ paracetamol + topical Duloxetine: inhibits NA+serotonin
Surgery: hip/knee replacement
Osteomalacia
Normal bone but decreased mineral content
Rickets in children
Causes: Vit D deficiency Renal failure Drug induced anticonvulsants Liver disease - cirrhosis
Ix: Alk phos (increased) Low Ca2+, low phosphate, Vit D High PTH XR: adults (looser's pesudofractures)
Tx:
Cholecalciferol + Calcium carbonate
