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Medicine finals > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

What conditions fall in the category of seronegative spondyloarthropathy?

A

Reactive arthritis
Psoriatic arthritis
Ankylosing spondylitis

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2
Q

What gene is associated with the development of ankylosing spondylitis?

A

HLA B27

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3
Q

What joints are largely affected in ankylosing spondylitis?

A

Sacroiliac joints

Joints of the vertebral column

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4
Q

What is the classical appearance of ankylosing spondylitis seen on spinal XR?

A

Bamboo spine

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5
Q

What is the classical presentation of ankylosing spondylitis?

A

Young adult male

Lower back pain and stiffness - improves on exercise, worse at night and in the morning

Pain takes at least 30 minutes to improve on the morning

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6
Q

What are they systemic associations of ankylosing spondylitis?

A

Apical fibrosis
Anterior uveitis
Aortic regurgitation
Enthesitis - achilles tendonitis, plantar fasciitis

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7
Q

What clinical examination is important in identifying patients with ankylosing spondylitis?

A

Modified Shober’s test

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8
Q

What treatments can be used in the management of ankylosing spondylitis?

A

Morning exercises
NSAIDs
Local steroid injections
TNF alpha blocker - if failed on >2 NSAIDs

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9
Q

What features might be evident on spinal XR which are indicative of ankylosing spondylitis?

A

Bilateral sacroiliac erosion - more suggestive than HLA B27
Squaring of vertebral bodies
Syndesmophytes

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10
Q

Define osteoarthritis

A

A disease of synovial joints characterised by cartilage loss and accompanying periarticular change

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11
Q

What are the risk factors of developing osteoarthritis?

A

Increasing age
Female sex
Abnormal joint
External joint stress (obesity, occupational stress on joints, trauma)
Internal joint stress (crystal deposits, previous joint infection)

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12
Q

What is the classical presentation of osteoarthritis?

A

Joint pain exacerbated by exercise and relieved by rest

Joint stiffness
ROM
Joint swelling
Signs of synovitis (warmth, effusion)
Tenderness around joint
Crepitus
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13
Q

In OA, what should ESR and CRP be?

A

Normal

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14
Q

What are the classical features seen on XR in a joint with osteoarthritis?

A

Loss of joint space
Osteophytes
Subchondral cysts
Sub-articular sclerosis

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15
Q

What is the management of osteoarthritis?

A

Conservative:
Exercise/physio
Weight loss

Pharmaceutical:
Regular paracetamol
Topical NSAIDs
Topical capsaicin
Oral NSAIDs (gastro-protection)
Consider intra-articular steroids

Surgical:
Arthroscopy & debridement
Joint replacement

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16
Q

In what group of patients, can a diagnosis of osteoarthritis be made without requiring further investigation?

A

Over 45
Typical activity related pain
No morning stiffness or stiffness that lasts less than 30 minutes

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17
Q

Describe the typical presentation of septic arthritis

A

Single hot, red, swollen painful joint

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18
Q

What pathogens are associated with septic arthritis?

A

S.aureus
Streptococci
Neisseria gonorrhoeae
Haemophilus

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19
Q

What disease can cause an inflammatory arthritis?

A

Lyme disease (erythema migrans)

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20
Q

What investigations should be instigated in a patient with suspected septic arthritis?

A

Bloods - FBC (WBC raised), CRP, ESR

Blood cultures
Joint aspirate
Swabs - skin, throat, sputum, urine
XR

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21
Q

If a patient presents with septic arthritis with no risk factor of atypical organisms, what antibiotic should be initiated?

A

Flucloxacillin

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22
Q

If a patient has suspected septic arthritis and has a risk of MRSA, what antibiotic should be used?

A

Vancomycin

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23
Q

Define amyloidosis

A

Deposition of a normally soluble protein in a tissue that disrupts normal function

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24
Q

What are the three main subtypes of amyloid?

A

AL
AA
Beta-2 microglobulin

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25
Q

Define AL amyloid

A

Light chain deposition in tissues

Associated with multiple myeloma and Waldenstrom’s macroglobulinaemia

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26
Q

Define AA amyloid

A

Complication of chronic inflammatory conditions (RA) and chronic infections (TB, osteomyelitis)

Deposition of serum amyloid A protein predominantly in liver, spleen and kidneys

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27
Q

Define Beta-2 microglobulin amyloid

A

Typically occurs in dialysis patients

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28
Q

How can amyloidosis present?

A

Cardiac - heart failure esp restrictive cardiomyopathy, arrhythmias

Renal failure

Gastro - vomiting, GI bleed, diarrhoea, splenomegaly

Polyneuropathy

Macroglossia

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29
Q

What stain should be used in the diagnosis of amyloidosis?

A

Apple green birefringence under Congo red staining

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30
Q

How should AL amyloid be managed?

A

Treat myeloma (chemo/BMT)

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31
Q

How should AA amyloid be managed?

A

Treat underlying condition to reduce inflammation

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32
Q

What artery is classically affected in giant cell arthritis?

A

Temporal artery

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33
Q

What other condition is giant cell arthritis strongly linked to?

A

Polymyalgia rheumatica

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34
Q

What group of patients have the highest risk of developing giant cell arthritis?

A

Caucasian females >50 years

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35
Q

How might giant cell arthritis present?

A

Severe unilateral headache typically around the temporal/forehead
Scalp tenderness
Jaw claudication
Blurred/double vision
Irreversible painless complete sight loss

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36
Q

What are some of the potential systemic symptoms of giant cell arthritis?

A 
Fever
Muscle aches
Fatigue
Anorexia and weight loss
Peripheral oedema
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37
Q

How can a definitive diagnosis of giant cell arthritis be made?

A

Clinical presentation
Raised ESR
Temporal artery biopsy - multinucleated giant cells

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38
Q

What additional investigations should be performed in giant cell arthritis and what may they show?

A

FBC - normocytic anaemia and thrombocytosis
LFT - raised Alk Phos
CRP - raised
Duplex ultrasound of the temporal artery - hyperechoic halo sign

39
Q

In a patient with suspected giant cell arthritis, when should steroids be started and why?

A

Immediately

Reduces the risk of permanent vision loss

40
Q

Along with steroids, what other medications should be prescribed in patients with giant cell arthritis and why?

A

Aspirin - reduce risk of vision loss and strokes
PPI - gastroprotection against steroids
Bisphosphonates and Calcium and Vit D supplements - osteoporosis prevention

41
Q

If a patient presents with potential giant cell arthritis, where should they be referred to?

A

Vascular surgeons - temporal artery biopsy
Rheumatology - specialist diagnosis and management
Ophthalmology - emergency same day appointment if they have visual changes

42
Q

What are the complications of giant cell arthritis?

A

Early (neuro-ophthalmic complications)
Vision loss
CVA

Late:
Relapse
Complications from steroids
CVA
Aoritis - aortic aneurysm and aortic dissection
43
Q

What are some of the features that suggest a possible vasculitis?

A 
Purpura - purple-coloured non-blanching rash 
Joint and muscle pain
Peripheral neuropathy
Renal impairment
GI disturbances
Anterior uveitis and scleritis
Hypertension
44
Q

What type of blood test is key in the diagnosis of vasculitis?

A

ANCA (anti-neutrophil cytoplasmic antibodies)

45
Q

What are the two types of ANCA blood tests?

A

p-ANCA (anti-PR3)

c-ANCA (anti-MPO)

46
Q

In what vasculitis conditions is p-ANCA elevated?

A

Microscopic polyangiitis

Churg-Strauss Syndrome (eosinophilic granulomatosis with polyangiitis)

47
Q

In what vasculitis condition is c-ANCA elevated?

A

Granulomatosis with polyangiitis (Wagener’s)

48
Q

What treatment classes can be used in the management of vasculitis?

A

Steroids

Immunosuppressants

49
Q

What immunosuppressants can be used in the management of vasculitis?

A

Cyclophosphamide
Methotrexate
Azathioprine
Rituximab

50
Q

What type of vasculitis is Henoch-Schonein purpura (HSP)?

A

IgA vasculitis

51
Q

How does Henoch-Schonein purpura (HSP) commonly present?

A

Purpuric rash affecting the lower limbs and buttocks of children (under 10)

52
Q

What commonly triggers Henoch-Schonein purpura (HSP) ?

A

Upper airway infections (tonisiitis)

Gastroenteritis

53
Q

What are the four classical features of Henoch-Schonein purpura?

A 
Purpura
Joint pain
Abdominal pain
Renal involvement (IgA nephritis)
54
Q

How is Henoch-Schonein purpura usually managed?

A

Supportive - analgesia, fluids and rest

55
Q

What type of vasculitis is Kawasaki Disease?

A

Medium vessel vasculitis

56
Q

How is generally affected by Kawasaki Disease?

A

Young children, under 5

57
Q

What are the clinical features of Kawasaki Disease?

A 
Persistent fever for > 5 days
Erythematous rash
Bilateral conjunctivitis
Erythema and desquamation of palms and soles
Strawberry tongue
58
Q

What is a complication of Kawasaki Disease?

A

Coronary artery aneurysms

59
Q

How is Kawasaki disease managed?

A

Aspirin

IV immunoglobulins

60
Q

How can eosinophilic granulomatosis with polyangiitis be known as?

A

Churg-Strauss Syndrome

61
Q

What type of vasculitis is eosinophilic granulomatosis with polyangiitis?

A

Small and medium vessel vasculitis

62
Q

How can eosinophilic granulomatosis with polyangiitis present?

A

Severe asthma in late teens or adults

63
Q

What organs can be affected in eosinophilic granulomatosis with polyangiitis?

A

Lung
Skin
Kidneys

64
Q

What is the characteristic finding on the FBC in eosinophilic granulomatosis with polyangiitis?

A

Elevated eosinophil levels

65
Q

What type of vasculitis is microscopic polyangiitis?

A

Small vessel vasculitis

66
Q

What is the main feature of microscopic polyangiitis?

A

Renal failure

Lungs - SOB and haemoptysis

67
Q

How can granulomatosis with polyangiitis be known?

A

Wegener’s granulomatosis

68
Q

What type of vasculitis is granulomatosis with polyangiitis?

A

Small vessel

69
Q

What systems are affected in granulomatosis with polyangiitis?

A

Respiratory tract

Kidneys

70
Q

What facial feature is associated with granulomatosis with polyangiitis?

A

Saddle shaped nose (perforated nasal septum)

71
Q

What symptoms are associated with granulomatosis with polyangiitis?

A

Epistaxis
Crusty nasal secretions
Hearing loss
Sinusitis

Saddle shaped nose

Cough
Wheeze
Haemoptysis

Rapidly progressing GN

72
Q

How might granulomatosis with polyangiitis appear on a CXR?

A

Consolidation

73
Q

What type of renal condition is associated with granulomatosis with polyangiitis?

A

Rapidly progressing GN

74
Q

What type of vasculitis is polyarthritis nodosa (PAN)?

A

Medium vessel vasculitis

75
Q

What is polyarthritis nodosa (PAN) associated with?

A

Hep B

Hep C and HIV

76
Q

Where can polyarthritis nodosa (PAN) affect?

A 
Medium vessels of the:
Skin
GIT
Kidneys
Heart
77
Q

What are the potential effects of polyarthritis nodosa (PAN)?

A

Renal impairment
CVA
MI

78
Q

What type of rash is polyarthritis nodosa (PAN) associated with?

A

Livedo reticularis (mottle purplish lace like rash)

79
Q

What type of vasculitis is Takayasu’s arteritis?

A

Large vessel vasculitis

80
Q

What blood vessels are mainly affected in Takayasu’s arteritis?

A

Aorta and branches

Pulmonary arteries

81
Q

What is the effect of Takayasu’s arteritis?

A

Large arteries and branches can:
Swell - aneurysms
Narrowed and blocked - pulseless disease

82
Q

How does Takayasu’s arteritis commonly present?

A

Before 40

Non-specific symptoms:
Fever
Malaise
Muscle aches

Specific symptoms:
Arm claudication
Syncope

83
Q

How can Takayasu’s arteritis be diagnosed?

A

CT/MRI angiography

Doppler US of carotids - carotid disease

84
Q

Define reactive arthritis

A

Synovitis occur in the joints as a reaction to a recent infective trigger

85
Q

What is the typical presentation of reactive arthritis

A

Acute mono arthritis - in the lower limb, most often the knee
Warm, swollen, painful joint

86
Q

What Ddx needs to be excluded in reactive arthritis?

A

Septic arthritis

87
Q

What are the common triggers for reactive arthritis

A

Gastroenteritis

STIs (chlamydia, gonorrhoea –> gonococcal septic arthritis usually)

88
Q

What gene potentially predisposes a patient to developing reactive arthritis

A

HLA-B27

89
Q

What are the associations of reactive arthritis

A

Bilateral conjunctivitis
Anterior uveitis
Circinate balanitis (dermatitis of the head of the penis)

“Can’t see, can’t pee, can’t climb a tree’

90
Q

In reactive arthritis, what should the joint aspirate be sent off for?

A

Gram staining, culture and sensitivity - exclude septic arthritis
Crystal examination - exclude gout and pseudogout

91
Q

How can reactive arthritis be managed?

A

NSAIDs
Steroid infections into affected joint
Systemic steroids - esp if multiple joints affected

92
Q

How long does it take for most cases of reactive arthritis to resolve?

A

6 months

93
Q

If a patient has recurrent cases of reactive arthritis, how can they managed?

A

DMARDs

Anti-TNF alpha

Medicine finals (12 decks)

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