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Pass Medicine > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

What drugs cause drug induced lupus?

A 
Hydralazine
Procainamide
Phenytoin
Isoniazid
Minocycline
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2
Q

What are the symptoms of drug induced lupus?

A

Arthralgia
Myalgia
Malar rash
Pleurisy/other chest problems

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3
Q

What tests can we do for drug induced lupus?

A

ANA positive in 100%, dsDNA negative

Anti-histone antibodies positive in 90%

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4
Q

How do we manage drug induced lupus?

A

Stop the drug

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5
Q

What is Felty’s syndrome?

A 
Rare complication of rheumatoid arthritis
Triad of:
Splenomegaly
Neutropenia
Rheumatoid arthritiis
Can use SANTA acronym
Splenomegaly
Arthritis
Neutropenia
Thrombocytopenia
Anaemia
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6
Q

What type of hypersensitivity reaction is SLE?

A

Type 3 hypersensitivity reaction (remember 3 letters in SLE = Type 3 hypersensitivity)

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7
Q

Risk factors for SLE?

A

Female gender (9:1)
Black/Asian ethnicity
Age 20-40

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8
Q

What genes are involved in SLE?

A

HLA B8, DR2 and DR3

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9
Q

What is dactylitis?

A

Inflammation of a digit (finger or toe)

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10
Q

Causes of dactylitis?

A

Spondyloarthropathies

Sickle-cell disease

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11
Q

What is Sjogren’s syndrome?

A

An autoimmune disorder affecting exocrine glands, thus resulting in dry mucosal surfaces.
It is often secondary to RA

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12
Q

What investigations can you do for Sjogren’s?

A

RF +ve
ANA positive (70%)
Anti-Ro antibodies (70%) - remember sjROgren’s
Schirmer’s test - filter paper near conjunctival sac to measure tear formation

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13
Q

How do we manage Sjogren’s?

A

Artificial saliva and tears

Pilocarpine (may stimulate saliva production)

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14
Q

What antibodies are seen in rheumatoid arthritis?

A

Anti-cyclic citrullinated peptide antibodies

Rheumatoid factor

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15
Q

What condition is temporal arteritis associated with?

A

Polymyalgia rheumatica

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16
Q

What do you see histologically with temporal arteritis?

A

Skip lesions

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17
Q

How do we diagnose ankylosing spondylitis?

A

Ankylosing spondylitis needs a radiological feature AND a clinical feature for definitive diagnosis
Key radiological feature is sacroilitis on x-ray

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18
Q

What features would you see on an x-ray in ankylosing spondylitis?

A

Sacroilitis (subchondral erosions, sclerosis)
Squaring of vertebrae
‘Bamboo’ spine
Syndesmophytes: due to ossification of outer fibers of annulus fibrosus

Chest x-ray:
Apical fibrosis

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19
Q

What gene is ankylosing spondylitis associated with?

A

HLA-B27

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20
Q

Is ankylosing spondylitis more common in males or females?

A

3:1 M:F

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21
Q

How do we manage ankylosing spondylitis?

A

Encourage regular exercise (e.g. swimming)
NSAIDs
Physio
DMARDs are only useful if there is peripheral joint involvement
Anti-TNF (in later stages)

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22
Q

What conditions is ankylosing spondylitis associated with?

A 
The A's:
Anterior uveitis
Apical fibrosis
Achilles tendonitis
Aortic regurg.
AV node block
Amyloidosis
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23
Q

What are the features of ankylosing spondylitis?

A 
Back pain/stiffness (reduced lat. flexion of lumbar spine is one of the first signs)
Stiffness usually worse in the morning
Pain and swelling in other parts of body
Extreme tiredness
Anterior uveitis
Loss of lumbar lordosis
Increase in thoracic kyphosis
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24
Q

What is systemic sclerosis?

A

A condition of unknown aetiology in which you get hardened, sclerotic skin and other connective tissues.

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25
Q

What is scleroderma?

A

A tightening and fibrosis of the skin that is autoimmune in nature

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26
Q

What are the 2 types of scleroderma?

A

Localised scleroderma - only affects the skin

Systemic sclerosis - may affect blood circulation and internal organs as well as the skin

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27
Q

What are the 2 types of localised scleroderma?

A

Morphoea:
Discoloured oval patches (plaques) on the skin
Usually itchy
Patches may be hairless and shiny
Improve after a few years and treatment may not be needed

Linear:
Thickened skin occurs in lines along the face, scalp, legs or arms
Occasionally affects underlying bone/muscle
May improve after a few years
Can cause permanent growth problems (e.g. short limbs)

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28
Q

What are the 3 patterns of disease in scleroderma

A

Limited cutaneous systemic sclerosis
Diffuse systemic sclerosis
Localised Scleroderma

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29
Q

What are the features of limited cutaneous systemic sclerosis?

A

Raynaud’s often the first sign
Scleroderma affecting face/distal limbs
CREST syndrome (a subtype)

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30
Q

What is CREST syndrome?

A 
Calcinosis
Raynaud's phenomenon
oEsophageal dysmotility
Sclerodactyly (tightness of skin on fingers/toes)
Telangiectasia
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31
Q

Which antibodies are limited cutaneous systemic sclerosis associated with?

A

Anti-centromere antibodies

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32
Q

What are the features of diffuse cutaneous systemic sclerosis?

A 
Scleroderma affecting trunk and PROXIMAL limbs predominantly
Interstitial lung disease
Pulmonary arterial hypertension
Renal disease
HTN
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33
Q

Which antibodies are diffuse cutaneous systemic sclerosis associated with?

A

Anti-scl-70 antibodies

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34
Q

How do we manage rheumatoid arthritis?

A

DMARD montherapy +/- short course of bridging prednisolone

Methotrexate is the most widely used DMARD
Sulfasalazine, leflunomide and hydroxychloroquine are others

TNF-inhibitors - given after an inadequate response to 2+ DMARDs, including methotrexate
Examples include: Etanbercept/infliximab

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35
Q

How do we monitor response to treatment in rheumatoid arthritis?

A

CRP and disease activity (DAS28)

36
Q

How do we manage rheumatoid arthritis flares?

A

Corticosteroids - oral or IM

37
Q

What is Schober’s test?

A

A way of testing lumbar spine flexion (for ankylosing spondylitis):

Line 5cm below and 10cm above iliac crests (15cm distance between them)
Patient then flexes (as if reaching for feet) as much as possible and distance is remeasured:
>4cm difference - mild
2-4cm difference - moderate
<2cm difference - severe

38
Q

What causes are there of polyarthritis?

A 
RA
SLE
Seronegative spondylarthropathies
HSP
Sarcoidosis
TB
Pseudogout
Viral infection
39
Q

Rheumatoid arthritis x-ray changes

A

Early:
Loss of joint space
Juxta-articular osteoporosis
Soft-tissue swelling

Late:
Periarticular erosions
Subluxation

40
Q

Paget’s disease of the bone features

A

Only 5% symptomatic

Bone pain (skull, spine, pelvis, long bones)
Isolated raised ALP
Bowing of tibia, bossing of skull
41
Q

What is Paget’s disease of the bone?

A

An increased but uncontrolled bone turnover (primarily a disorder of osteoclasti resorption)

42
Q

How do we treat Paget’s disease of the bone?

A

Bisphosphonates

Calcitonin (less common)

43
Q

What are complications of Paget’s disease?

A 
Deafness
Bone sarcoma
Fractures
Skull thickening
High output cardiac failure
44
Q

What causes Marfan’s?

A

Marfan’s is an autosomal domiinant connective tissue disorder
It is caused by a defect in the FBN1 gene that codes for the protein fibrillin

45
Q

Features of Marfan’s?

A 
Tall statue (arm span to height ratio >1.05)
High arched palate
Arachnodactyly (long slender fingers)
Pectus excavatum
Pes planus
Scoliosis
Dilation of aortic sinuses (seen in 90%)
Repeated pneumothoraces
46
Q

What is the treatment for Marfan’s?

A

Beta-blocker/ACE-inhibitor therapy to reduce risk of aortic aneurysm/dissection/regurgitation

47
Q

What monitoring occurs in Marfan’s?

A

Regular (yearly) echocardiography to monitor for aortic aneurysm, dissection, regurgitation and mitral valve prolapse

48
Q

How do we treat acute reactive arthritis?

A

NSAIDs

Sulfasalazine/methotrexate if symptoms persistent

49
Q

What is reactive arthritis?

A

A HLA-B27 associated seronegative spondyloarthropathy

50
Q

What does Reiter’s syndrome encompass?

A

Urethritis
Conjunctivitis
Arthritis

51
Q

In what condition do you see Reiter’s syndrome?

A

Reactive arthritis

52
Q

What are the most common causes of reactive arthritis?

A

Chlamydia trachomatis is very common in men

Post dysenteric form - e.g. shigella, salmonella, campylobacter etc.

53
Q

What is Behcet’s syndrome?

A

A complex multisystem disorder with presumed autoimmune-mediated inflammation of the arteries/veins

54
Q

What are the features of Behcet’s syndrome?

A 
Oral ulcers
Genital ulcers
Anterior uveitis
Thrombophlebitis
Arthritis
Erythema nodosum

Associated with HLA B51

55
Q

Which rheumatological condition is antiphospholipid syndrome associated with?

A

SLE

56
Q

What are the risk factors for pseudogout?

A 
Haemochromatosis
Hyperparathyroidism
Acromegaly
Low magnesium/phosphate
Wilson's disease
57
Q

What do you see on joint aspiration in pseudogout?

A

Weakly-positively birefringent rhomboid-shaped crystals

Calcium pyrophosphate dihydrate crystals

58
Q

How do we treat pseudogout?

A

Aspiration of joint fluid (to exclude septic arthritis)

NSAIDs (or oral steroids)

59
Q

Which condition are patients more likely to get whilst undergoing chemotherapy?

A

Gout (increased urate production)

60
Q

What class of drugs increase the risk of TB reactivation?

A

TNF alpha

And I guess any other immunosuppressive drugs

61
Q

What are the features of Still’s disease?

A

Arthralgia
Salmon-pink maculopapular rash
Pyrexia (rises in the later afternoon/early evening - with worsening joint symptoms/rash)

62
Q

How do we treat Still’s disease?

A 
NSAIDs
Steroids (if NSAIDs don't adequately manage)
63
Q

What on x-ray will distinguish pseudogout from gout?

A

Chondrocalcinosis (present in pseudogout)

64
Q

Which types of complement are low in SLE?

A

C3 and C4

65
Q

What is osteogenesis imperfecta?

A

A group of disorders of collagen metabolism

66
Q

What are some features of osteogenesis imperfecta?

A 
Presents in childhood
Fractures following minor trauma
Blue sclera
Deafness secondary to otosclerosis
Dental imperfections
67
Q

What is polymyalgia rheumatica?

A

Polymyalgia overlaps with temporal arteritis. There is a vasculitis with giant cells which characteristically ‘skip’ certain sections of affected artery whilst damaging others. In polymalgia rheumatica it is the muscle bed arteries which are affected most

68
Q

What are the features of polymyalgia rheumatica?

A

Typically older patients >60
Usually rapid onset (<1 month)
Aching
Morning stiffness in proximal limb muscles (NOT weakness)
Mild polyarthralgia, lethargy, depression, anorexia, night sweats, low-grade fever

69
Q

How do we treat polymyalgia rheumatica?

A

Prednisolone

70
Q

What investigation findings would you see in polymyalgia rheumatica?

A

ESR >40

CK and EMG normal

71
Q

What is Takiyasu’s arteritis?

A

A vasculitis that primarily affects the aorta and its branches

72
Q

What are the features of Takayasu’s arteritis?

A

F>M
Symptoms include upper limb claudication
Diminished/absent pulses
ESR affected in the acute phase

73
Q

What is Buergers disease?

A

A vasculitis with thrombotic occlusions of the small/medium sized lower limb vessels

74
Q

Features of Buergers disease

A

Proximal pulses usually present but pedal pulses lost
Common in young male smokers
Causes pain in the lower limb (e.g. feet)

75
Q

What is polyarteritis nodosa?

A

A systemic necrotising vasculitis affectiing small and medium sized muscular arteries

76
Q

What organs are often affected in polyarteritis nodosa?

A

Kidneys (70% of cases)

77
Q

What is Wegener’s granulomatosis?

A

A vasculitis affecting small/medium sized arteries

78
Q

How do we tend to treat vasculitides?

A

Smoking cessation

Immunosuppression

79
Q

How do we assess hypermobility?

A

Beighton score (5/9 is +ve in adults, 6/9 for children)

80
Q

What is Ehler-Danlos syndrome?

A

An autosomal dominant connective tissue disorder that mostly affects type III collagen

81
Q

What are the features of Ehler-Danlos syndrome?

A 
Elastic, fragile skin
Joint hypermobility
Easy bruising
Aortic regurgitation, dissection and mitral valve prolapse
Subarachnoid haemorrhage
82
Q

How do we treat psoriatic arthritis?

A

Same as rheumatoid arthritis (methotrexate, bridging prednisolone, anti-tnf etc.)

83
Q

Is rheumatoid factor positive in psoriatic arthritis?

A

No, it’s negative

84
Q

How do we treat Raynaud’s syndrome?

A

Nifedipine (a calcium channel blocker)

85
Q

Churg-strauss (eosinophilic granulomatosis with polyangiitis [EPGA])

A

pANCA associated small vessel vasculitis

86
Q

Features of Churg-strauss

A 
Asthma
Eosinophilia
Paranasal sinusitis (nasal polyps too)
Mononeuritis multiplex
Petechial rash
pANCA positive

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