Rheumatology Flashcards
Rheumatoid arthritis respiratory complications
- pulmonary fibrosis
- pleural effusion, pleurisy
- pulmonary nodules
- bronchiolitis obliterans
- methotrexate pneumonitis
- caplan syndrome (RA + massive lung fibrosis with pneumoconiosis e.g. coal worker’s lung, berylliosis, asbestosis, silicosis)
Ocular features of rheumatoid arthritis
- keratoconjunctivitis sicca (most common)
- episcleritis/scleritis
- corneal ulceration
- keratitis
- steroid-induced cataracts
- chloroquine retinopathy
Neuromuscular complications of rheumatoid arthritis
- vasculitis: nail fold infarcts, mild sensory neuropathy, (rarer: cutaneous ucleration, mononeuritis multiplex, mesenteric / cerebral / coronary artery involvment)
- entrapment neuropathies (e.g. CTS)
- osteoporosis
- ligamentous laxity (atlantoaxial subluxation, subaxial subluxation i.e. lower cervical spine)
- tenosynovitis
Reactive arthritis features
- asymmetrical oligoarthritis of lower limbs
- dactylitis
- urethritis
- eye: conjunctivitis (seen in 50%), anterior uveitis
- skin: circinate balanitis (painless vesicles on the coronal margin of the prepuce), keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles)
Mx
- treat precipitating infection
- NSAIDs -> intra-articular steroid -> systemic steroid
Relapsing polychondritis mx
1) Steroids to induce
2) Maintenance with azathioprine / methotrexate / ciclopsorin
Takayasu arteritis clinical features
- large vessel vasculitis, varying pattern
- systemic features of a vasculitis e.g. malaise, headache
- unequal blood pressure in the upper limbs. May have subclavian steal syndrome
- carotid bruit
- intermittent claudication, especially arm
- aortic regurgitation (around 20%)
- assoc w/ RAS
Takayasu arteritis Ix
- angiography
- ANCA not associated
Takayasu arteritis mx
1) steroids
2) immunosuppression
Polyarteritis nodosa features
Medium-sized artery vasculitis
- general: fever, weight loss, malaise
- mononeuritis multiplex
- large joint arthralgia
- GI: abdo pain, GI haemorrhage
- renal: haematuria, renal failure, hypertension
- livedo reticularis
Polyarteritis nodosa ix & mx
- pANCA 20%
- hep B 30%
- angiography
Mx
- prednisolone
- cyclophosphamide
Scleroderma renal crisis
Mx: ACEi
- > ramipril if moderate
- > captopril (fast acting) if severe
Management of systemic sclerosis associated ILD
MMF or cyclophosphamide
Adult onset still’s disease features
- arthralgia
- pink maculopapular rash
- pyrexia which is worse when pain / rash is worst
- LNs
- RF / ANA -ve
Mx adult onset still’s disease
1) NSAIDs +/- steroids
2) Methotrexate
3) Biologics
- Etanercept (anti-TNF)
- anakinra, canakinumab (IL1 inhib),
- Tocilizumab (anti-IL6)
4) Rituximab
Psoriatic arthritis features
- 10-20% psoriasis get arthropathy
Patterns
- RA
- sacroilitis
- DIPJ
- asymmetrical oligoarthritis
Ix
- DIPJ pencil in cup
- RF 10%
- low ANA+ve
Psoriatic arthritis mx
- as for RA including steroids for flares
1) NSAIDs
2) DMRARDs - MTX if co-existant psoriasis
- sulfasalazine, leflunomide, ciclosporin
3) Biologics e.g. anti-TNF - infliximab, etanercept
Discoid lupus
- erythematous rash
- face, neck, ears, scalp
- scarring alopecia and pigmentation
- photosensitive
- <5% progress to SLE
Mx:
topical steroids
hydroxychloroquine
Lupus pernio
- cutaneous sarcoidosis
- purplish lesions nose / cheeks
Systemic sclerosis general features
- raynaud’s
- arthritis / arthralgia
- ILD, pulmonary HTN
- scleroderma renal crisis
- scleroderma
- reflux, SIBO, malabsorption
Limited scleroderma
- ANA+ve
- anti-centromere abs
- sleroderma limited to face, neck, limbs distal to knee, elbow
Diffuse systemic sclerosis
- ANA +ve
- anti scl70
- internal organ involvement more common
- 50% 10 year survival
- scleroderma also involves trunk and proximal limbs
Polymyositis features
- proximal muscle weakness +/- tenderness
- raynaud’s
- ILD
- dysphagia
- elevated CK
- assoc with some cancers: cervix, lung, ovarian, bladder, stomach, pancreas
Polymyositis abs
anti-Jo
Polymyositis mx
1) steroids
2) azathioprine
3) MTX
4) infliximab / etanercept (anti-TNF)
Relapsing polychondritis mx
1) Induce remission: steroids
2) Maintenance: azathioprine, methotrexate, cyclosporin, cyclophosphamide
SLE Mx
ALL
- NSAIDs
- sun-block
- hydroxychloroquine
Mild-mod
- short term pred
Mod
- short term pred + aza/mtx
Severe
- IV steroids
- cyclophosphamide / rituximab
Nephritis
- MMF
- > azathioprine in pregnancy
Pericarditis
- NSAIDs, colchicine, hydroxychloroquine
Myocarditis
- steroids
- cyclophosphamide
- hydroxychloroquine
- mx as HF
Treatment and monitoring paget’s disease of the bone
- bisphosphonate
- 6 monthly ALP to monitor
Mx of gout in warfarinised patient with egfr <30
- avoid NSAIDs
- avoid colchicine as egfr <30 and it can increase inr
- steroids orally or intra-articularly can help
Causes of drug induced lupus
- procainamide
- hydralazine
- penicillamine
- isoniazid
- phenytoin, cabemazapine
- lamotrigine (cutaneous features only)
Features of drug induced lups
- as for SLE but renal / CNS involvement rare
- ANA +ve
- dsDNA -ve
- anti-histone +ve
(anti-Ro / Sm +ve 5%)
Henoch-Schonlein purpura
- IgA small vessel vasculitis
- follows infection
- usually children
- rash over buttocks
- abdo pain
- polyarthritis
- haematuria / renal failure may occur
Mx: analgesia, steroids for arthropathy
Course is usually self limiting. Good prognosis if no nephropathy. 1/3 relpase
Takayasu’s arteritis
- large vessel vasculitis affecting aorta and its branches
- female predominance
- fever, malaise, weight loss
- TIAs
- limb claudication
- angina
- AR
- mesangial proliferative GN
- Mx: steroids -> aza / MTX
Dermatomyositis abs
anti Mi-2
Indications for steroids in sarcoidosis
- infiltrates on CXR with significant symptoms
- significant hypercalcaemia
- eye, heart, neuro involvement
- erythema nodosum failing to respond to NSAIDs
- lofgren’s (if unresponsive to NSAIDs) - EN + migratory polyarthritis
