Rheumatology Flashcards
What are the features of inflammatory arthropathy?
- Early morning stiffness
- Worse after resting, eased by movement
- Soft tissue swelling
What are the features of rheumatoid arthritis? (in a case presentation what would indicate this as top differential)
- Symmetrical, inflammatory arthritis
- Small joints of hands and feet affected (but also hips, elbows and knees)
- Young adults - females 3:1 male
- HLA DR4 associated
- Positive prayer sign
- Soft tissue swelling around MCP joints
- Ular styloid prominent due to palmar subluxation
What can be seen on the dorsal aspect of the hands in rheumatoid arthritis? (4)
- Symmetrical, peripheral destructive arthropathy
- Soft tissue swelling with spindling of proximal joints and loss of valleys between knuckles
- Palmar subluxation and ulnar deviation at the metocarpo-phalangeal joints
- Nodules
What can be seen on the palms of someone with rheumatoid arthritis?
- Palmar erythema
- Wasting of the thenar eminence - carpal tunnel syndrome
- Fixed flexion deformity
- Specific abnormalities - swan neck, button hole, Z thumb
- all due to rheumatoid tenosynovitis
What happens in button hole deformity?
There is rupture of the central slip of extensor expansion - PIP (proximal interphalangeal joint) joint is flexed
What is swan neck deformity?
Rupture of the lateral slip of extensor expansion - so the PIP joint is extended
What is rheumatoid factor?
IgM against your own IgG. Lots of people have it for various reasons.
What is seronegative rheumatoid?
One third of patients are seronegative. 20-30% don’t have IgM autoantibodies.
40% have anti-CCP and if they do, more likely to be rapidly progressive.
What investigations do NICE recommend doing for suspected RA? (6)
- FBC CRP
- Renal and liver function tests
- Rheumatoid factor
- Anti-CCP antibodies
- X-ray hands and feet
- Refer even if all these negative
What are the three first-line drugs used in the treatment of RA?
- Methotrexate
- Lefluomide
- Sulfasalazine
- bridging steroids can also be used - prednisolone
What are the side effects or potential risks associated with methotrexate treatment, which drug cannot be prescribed alongside it?
- Bone marrow suppression - neutropenia/thrombocytopenia
- Liver and renal toxicity
- Pneumonitis and pulmonary fibrosis
- Excretion inhibited by NSAIDs
- Trimethoprim treatment alongside contraindicated due to folate antagonist
What tests/investigations need to be performed before someone is started on biologics?
- Check tuberculin skin test or interferon gamma release assay (IGRA)
- Check radiograph
- If indicated: hep B, hep C and HIV test
- Treat latent TB
What are the TNF inhibitors?
- Infliximab
- Etanercept
- Adalimumab
When are biologics used instead of DMARDS?
After treatment with DMARD doesn’t reduced CRP and active disease, then dual DMARD therapy, if still not working, then biologic. So two DMARDs need to be trialled before biologic offered.
What does methotrexate do?
It stops proliferation of cytotoxic T cells
Why are anaesthetists always cautious and often want an x-ray of the C spine in people with rheumatoid arthritis?
As they can have atlanto-axial subluxation
What happens in atlanto-axial subluxation?
The top of the cervical spine is held together by tendons, which can be weakened by rheumatoid tenosynovitis. If the odontoid peg sublimes backwards over days or weeks, it can compress the upper cervical cord, causing a progressive spastic tetra paresis. If compression is sudden, a rapid output of inhibitory impulses down the vagus can cause cardiac arrest.
What are the differentials for rheumatoid arthritis? (3)
- Psoriatic arthropathy (this is the top one)
- Systemic lupus
- Osteoarthritis with inflammatory component
What are the 5 types of psoriatic arthropathy?
- Oligoarthritis (commonest 70%)
- Distal
- Rheumatoid pattern
- Arthritis mutilans
- Sacroilitis
What are the treatment options for psoriatic arthropathy?
- Sulfasalazine
- Methotrexate
- TNF inhibitors e.g. adalimumab AKA humira - can lead to severe pneumonia
- Ixekizumab (cytokine inhibitor)
- in order of use
What are the two mnemonics to remember what is seen on X-ray in rheumatoid arthritis and osteoarthritis respectively?
RA = SPADES OA = LOSS
What are the findings on X-ray of someone with RA?
S - soft tissue swelling P - peri-articular osteoporosis A - absent osteophytes D - deformity E - erosions S - subluxation
What are the findings on X-ray of someone with OA?
L - loss of joint space
O - osteophytes
S - subchondral cysts
S - subchondral sclerosis
What are the extra-articular manifestations of RA?
FACEBOOKS
F - Felty’s
A - Atlanto-axial subluxation
C - Caplan’s syndrome and pulmonary nodules
E - Effusions
B - Blood - normochromic normocytic anaemia
O - Olecranon bursitis
O - Oral dryness
K - Kidneys (amyloid, gold and penicillamine)
S - Sensory neuropathy and scleromalacia
What is the name for scleroderma hands?
Sclerodactyly - tight waxy skin
What are the features of scleroderma in addition to sclerodactyly? (6)
- Raynauds
- Telangiectasia
- Ulceration on knuckles/finger tips
- Subcutaneous calcification
- Microstomia
- Tethering of the skin over the forehead
