Rheumatology Flashcards by Abi Silcock

What conditions fall in the category of seronegative spondyloarthropathy?

Reactive arthritis
Psoriatic arthritis
Ankylosing spondylitis

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What gene is associated with the development of ankylosing spondylitis?

HLA B27

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What joints are largely affected in ankylosing spondylitis?

Sacroiliac joints

Joints of the vertebral column

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

Bamboo spine

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What is the classical presentation of ankylosing spondylitis?

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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What are they systemic associations of ankylosing spondylitis?

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

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

Modified Shober’s test

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

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

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

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

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Define osteoarthritis

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

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What are the risk factors of developing osteoarthritis?

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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What is the classical presentation of osteoarthritis?

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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In OA, what should ESR and CRP be?

Normal

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

Loss of joint space
Osteophytes
Subchondral cysts
Sub-articular sclerosis

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What is the management of osteoarthritis?

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

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

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Describe the typical presentation of septic arthritis

Single hot, red, swollen painful joint

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What pathogens are associated with septic arthritis?

S.aureus
Streptococci
Neisseria gonorrhoeae
Haemophilus

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What disease can cause an inflammatory arthritis?

Lyme disease (erythema migrans)

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

Bloods - FBC (WBC raised), CRP, ESR

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

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

Flucloxacillin

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

Vancomycin

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Define amyloidosis

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

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What are the three main subtypes of amyloid?

AL
AA
Beta-2 microglobulin

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Define AL amyloid

Light chain deposition in tissues | Associated with multiple myeloma and Waldenstrom's macroglobulinaemia

Define AA amyloid

Complication of chronic inflammatory conditions (RA) and chronic infections (TB, osteomyelitis) Deposition of serum amyloid A protein predominantly in liver, spleen and kidneys

Define Beta-2 microglobulin amyloid

Typically occurs in dialysis patients

How can amyloidosis present?

Cardiac - heart failure esp restrictive cardiomyopathy, arrhythmias Renal failure Gastro - vomiting, GI bleed, diarrhoea, splenomegaly Polyneuropathy Macroglossia

What stain should be used in the diagnosis of amyloidosis?

Apple green birefringence under Congo red staining

How should AL amyloid be managed?

Treat myeloma (chemo/BMT)

How should AA amyloid be managed?

Treat underlying condition to reduce inflammation

What artery is classically affected in giant cell arthritis?

Temporal artery

What other condition is giant cell arthritis strongly linked to?

Polymyalgia rheumatica

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

Caucasian females >50 years

How might giant cell arthritis present?

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

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

``` Fever Muscle aches Fatigue Anorexia and weight loss Peripheral oedema ```

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

Clinical presentation Raised ESR Temporal artery biopsy - multinucleated giant cells

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

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

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

Immediately | Reduces the risk of permanent vision loss

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

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

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

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

What are the complications of giant cell arthritis?

Early (neuro-ophthalmic complications) Vision loss CVA ``` Late: Relapse Complications from steroids CVA Aoritis - aortic aneurysm and aortic dissection ```

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

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

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

ANCA (anti-neutrophil cytoplasmic antibodies)

What are the two types of ANCA blood tests?

p-ANCA (anti-PR3) | c-ANCA (anti-MPO)

In what vasculitis conditions is p-ANCA elevated?

Microscopic polyangiitis | Churg-Strauss Syndrome (eosinophilic granulomatosis with polyangiitis)

In what vasculitis condition is c-ANCA elevated?

Granulomatosis with polyangiitis (Wagener's)

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

Steroids | Immunosuppressants

What immunosuppressants can be used in the management of vasculitis?

Cyclophosphamide Methotrexate Azathioprine Rituximab

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

IgA vasculitis

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

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

What commonly triggers Henoch-Schonein purpura (HSP) ?

Upper airway infections (tonisiitis) | Gastroenteritis

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

``` Purpura Joint pain Abdominal pain Renal involvement (IgA nephritis) ```

How is Henoch-Schonein purpura usually managed?

Supportive - analgesia, fluids and rest

What type of vasculitis is Kawasaki Disease?

Medium vessel vasculitis

How is generally affected by Kawasaki Disease?

Young children, under 5

What are the clinical features of Kawasaki Disease?

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

What is a complication of Kawasaki Disease?

Coronary artery aneurysms

How is Kawasaki disease managed?

Aspirin | IV immunoglobulins

How can eosinophilic granulomatosis with polyangiitis be known as?

Churg-Strauss Syndrome

What type of vasculitis is eosinophilic granulomatosis with polyangiitis?

Small and medium vessel vasculitis

How can eosinophilic granulomatosis with polyangiitis present?

Severe asthma in late teens or adults

What organs can be affected in eosinophilic granulomatosis with polyangiitis?

Lung Skin Kidneys

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

Elevated eosinophil levels

What type of vasculitis is microscopic polyangiitis?

Small vessel vasculitis

What is the main feature of microscopic polyangiitis?

Renal failure | Lungs - SOB and haemoptysis

How can granulomatosis with polyangiitis be known?

Wegener's granulomatosis

What type of vasculitis is granulomatosis with polyangiitis?

Small vessel

What systems are affected in granulomatosis with polyangiitis?

Respiratory tract | Kidneys

What facial feature is associated with granulomatosis with polyangiitis?

Saddle shaped nose (perforated nasal septum)

What symptoms are associated with granulomatosis with polyangiitis?

Epistaxis Crusty nasal secretions Hearing loss Sinusitis Saddle shaped nose Cough Wheeze Haemoptysis Rapidly progressing GN

How might granulomatosis with polyangiitis appear on a CXR?

Consolidation

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

Rapidly progressing GN

What type of vasculitis is polyarthritis nodosa (PAN)?

Medium vessel vasculitis

What is polyarthritis nodosa (PAN) associated with?

Hep B | Hep C and HIV

Where can polyarthritis nodosa (PAN) affect?

``` Medium vessels of the: Skin GIT Kidneys Heart ```

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

Renal impairment CVA MI

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

Livedo reticularis (mottle purplish lace like rash)

What type of vasculitis is Takayasu's arteritis?

Large vessel vasculitis

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

Aorta and branches | Pulmonary arteries

What is the effect of Takayasu's arteritis?

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

How does Takayasu's arteritis commonly present?

Before 40 Non-specific symptoms: Fever Malaise Muscle aches Specific symptoms: Arm claudication Syncope

How can Takayasu's arteritis be diagnosed?

CT/MRI angiography | Doppler US of carotids - carotid disease

Define reactive arthritis

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

What is the typical presentation of reactive arthritis

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

What Ddx needs to be excluded in reactive arthritis?

Septic arthritis

What are the common triggers for reactive arthritis

Gastroenteritis | STIs (chlamydia, gonorrhoea --> gonococcal septic arthritis usually)

What gene potentially predisposes a patient to developing reactive arthritis

HLA-B27

What are the associations of reactive arthritis

Bilateral conjunctivitis Anterior uveitis Circinate balanitis (dermatitis of the head of the penis) "Can't see, can't pee, can't climb a tree'

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

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

How can reactive arthritis be managed?

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

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

6 months

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

DMARDs | Anti-TNF alpha