Rheumatology Flashcards by John Darlington

What is the rheumatoid factor against and list some examples of diseases its present in:

Is an antibody typically IgM which targets the Fc Portion of the IgG antibody

SLE
Sjorgens
PBC
Hep C

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Out with medications what is an important part of the management of RA and why?

Referral to specialist.

The majority of disease damage occurs within early onset of the disease.
therefore initial specialist input is needed.

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Which part of the body does DAS 28 not include in the monitoring?

Feet

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What is the criteria for starting biological therapy:

Failure of:
> 2 DMARDS
- Must include methotrexate unless contraindicated

Severe disease >5.1 DAS28 score

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List the seronegative arthropathies:

psoriatic

Ankylosing spondlyitis

Reactive arthritis

Enteropathic arthropathy

JIA

Bechet’s disease

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What is the management of reactive arthritis:

Treat underlying infection
- must test for STIs

Sexual health review

Rest and NSAIDs
+/-
Steroid injections

*if severe DMARDs

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What are the renal involvements which can occur with seronegative arthropathies?

Excess use of NSAIDs
- cause damage

IgA nephropathy

Amyloidosis

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What is the gold standard for measuring disease activity of ankylosing spondlylitis?

BASDAI

- 6 questions of 5 major symptoms

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Compare and contrast RA vs Psoriatic arthritis:

Auto-antibodies present
Synovial lining hypertrophy
Erosion of new bone
Lack of dactylics
Usually sparing of the SI lumbar joints
More likely to be symmetrical

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What is an important point to remember when measuring uric acid levels in acute gout attacks?

It can be falsely low.

usually measure 2-3 weeks after the initial flare has settled

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What blood vessels have disruption to blood flow causing ischemic optic neuropathy?

Posterior ciliary arteries

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What would you expect to find on a biopsy of giant cell arteritis?

Interruption of internal elastic laminae with multi-nucleated inflammatory cells

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What investigations should be done into suspected henoch schonlein?

Bloods:

FBC
Blood film - rule out leukaemia, ITP
U&Es
Blood cultures (for meningitis/ sepsis)
LFTs (for albumin)
RF
ANA, ANCA

Orifices:
- Urinalysis - assess for protein/ blood - IgA?

very important to exclude other diseases which can include it:
virus
malignancy
autoimmune

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What are the treatment options for granulomatosis with polyangitis?

Induction of remission:
- prednisilone (if mild)

If Severe:

Cyclophosphamide
Rituxumab

Maintenance of remission:

Azathiopurine
Methotrexate

**plasma exchange if RPGN

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Whats a serious complication of Sjorgen’s syndrome and what are some risk factors for it?

Lymphoma:

Parotid enlargement
Positive RF
Palpable purpura
Lymphadenopathy

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What is the exclusion criteria for Sjorgens?

Head radiation

Sarcoidosis

AIDS

Anti-cholingeric medication

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What are some clinical findings of Sjorgen’s disease?

Dry eyes
- keratoconjunctivitis sicca

Dry mouth

Dry vagina

Renal tubular acidosis type I (DCT)

Raynaud’s

Coeliac disease
- 10x more common

Primary biliary cirrhosis

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What conditions are associated with pseudogout?

Thyroid dysfunction - both hypo and hyper

Haemochromatosis

Parathyroid dysfunction

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What doses of Allopurinol should be given with regard to renal function?

Normal:
- 100mg. Recheck urate in 6 weeks. >300, increase to 200mg.

CKD 3-4:
- 50mg. Recheck urate in 6 weeks. >300, increase to 100mg.

CKD 5:
- discuss with renal team

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List some differential diseases that present not to dissimilar to Lupus:

Lyme disease

HIV/ AIDs

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What is used to monitor the disease activity of SLE?

SELENA SLEDAI

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What laboratory markers may suggest disease activity in SLE?

Anti dsDNA
- rising levels suggest disease activity

Completement:
- falling C3, C4 suggest active disease

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What is the management of SLE?

Mild: 
- Sun Block 
- Hydroxychloroquine 
\+/
- Aspirin

Moderate:

Corticosteroids
Methotrexate
Mycophenylate
Azathioprine

Severe:
- Cyclophospamide - IV

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When should a Bisphosphonate holiday take place?

After 5 years a FRAX score and DEXA scan should be done.

If they are not high risk (>75, on steroids, previous hip fracture, T score <2.5) then they can discontinued on the bisphosphonates for 2 years and re-reviewed

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What is the drug of choice for managing acute flares of RA?

IM methylprednisolone

What is the protein defect in Marfan's syndrome?

Fibrillin-1 - the substrate to elastin

Specifically what type of pain is in the jaw and mouth with GCA?

Claudication of the jaw | Claudication of the tongue

Out with an US and biopsy what other investigation can be done for GCA?

CT PET | - shows areas of metabolism as seen with the inflammation

List two biomarkers used to assess Lupus:

dsDNA Complement

What is the most common side effect of methotrexate?

G.I upset | - it is the biggest cause of stopping the meds

What is the biggest side effects of steroids?

Infection

What is the major side effect of hydroxychloroquine?

Retinopathy | - should be reviewed yearly by ophthalmology

What is the biochemical test of choice for investigating low Vitamin D?

25 Dihydroxyvitamin D Reflects true stores of vitamin D as opposed to 1,25 DOHD which can fluctuate

Outline the investigations into osteomalacia:

Bloods: - LFTS - Alkaline phosphatase (elevated due to osteoblast activity) - PTH (usually elevated) - 25 dihydroxyvitamin D3 (low) - FGF-23 (tumour induced) Plain x-rays Gold standard is tetracycline- labelled bone biopsy but this is rarely done

Define and Outline the broad causes of osteomalacia

A disease of failure to mineralise the newly laid down bone, resulting in soft bone. Vitamin D deficiency: - poor diet - absorption (Crohn's, coeliacs, short bowel) Calcium deficiency - poor diet - absorption - vitamin D Defective vitamin D activation - liver disease - CKD - Vitamin D dependent rickets type I Low levels of phosphate - renal tubular defects - hypophosphatamia vitamin D resistant rickets

What is the main treatment for osteomalacia and rickets?

Vitamin D - loading dose then maintenance dose Calcium - loading dose for 3 months then maintenance dose *monitored with vitamin D levels and PTH

Discuss the differences in blood results of osteoporosis and osteomalacia:

osteoporosis: - normal Ca - normal PO4- - ALP normal - Urinary Ca normal Osteomalacia: - Low serum Ca - PO4- low - ALP elevated

How is Lupus disease activity monitored?

Complement levels | - which usually decrease when disease activity is high

In Polymyalgia rheumatica what type of weakness do they have?

Weakness is due to pain inhibition. It is not true weakness

What are some of the extra-articular manifestation of RA?

Eyes: - Episcleritis - Keratoconjunctivitis Skin: - Rheumatoid nodules Respiratory: - pulmonary fibrosis - Rheumatoid nodules - Bronchiolitis obliterans Heart: - pericarditis - pericardial effusion Haematological: - Anaemia of chronic disease - Felty's syndrome (splenomegaly +neutropenia) Neurological: - carpal tunnel syndrome - Peripheral neuropathy

What are some of the surgical procedures conducted for RA?

Synovectomy Tendon repair - especially the extensors Joint replacement

What are some poor prognostic factors for RA?

Early onset Positive serology (Rh factor and Anti - CCP) Early joint erosion HLA DR4

Name two biological agents that reduce activity of B cells and how they work:

Tocilizumab - IL-6 Rituximab: - CD-20

Which DMARDs are safe during pregnancy? and does pregnancy usually make RA worse or better?

Hydroxychloroquine Sulfasalazine Pregnancy usually reduces symptoms of RA as there is an overall reduction in immune response

List some secondary causes of osteoporosis:

``` Steroid use Hyperthyroidism Rheumatic disease Alcohol abuse Warfarin ```

What are the risk factors for osteoporosis?

SHATTERED - Steroids - Hyperthyroidism - Alcohol - Thin - Testosterone reduction - Early menopause - Renal failure - Erosive (RA) - Dietary (poor Ca2+)

List some drugs which cause osteoporosis:

``` Steroids PPIs SSRIs Anti-epileptic Aromatase inhibitors ```

How is Denosumab given?

Sub cut - twice yearly Monoclonal Ab against RANK ligand

What is the T-score?

It is bone mineral density measured against that of a young healthy adult. Each move number represents a standard deviation away from this norm. 0 to -1: normal -1 to -2.5: osteopenia >2.5: osteoporosis

List the mechanism by which steroids cause osteoporosis?

Increase osteoclast activity Reduce muscle mass Reduce Ca2+ absorption from G.I tract

Give three examples of bisphosphonates:

Alendronate Risedronate Ibandronate

What is the 1st line treatment for phospholipid syndrome?

Low dose aspirin

What are some extra-articular manifestations of AS?

Eyes: - Anterior uveitis Lung: - Upper zone pulmonary fibrosis Heart: - Aortic regurgitation - AV block MSK: - Enthesitis - Tenosynovitis - neck hyperextension G.I - IBD

What features may be seen on x-ray of AS?

Squaring of vertebrae Bamboo spine Sacroiliitis Syndesmophytes

What is the physical examination for AS?

Schober's test L5. - 10cm above - 5cm below *if no more than <20cm in flexion then suggestive

Management and How are you going to monitor someone with Henoch Scholien syndrome and what is the prognosis?

Management: - Conservative +/- steroid use (reserved for sever disease) Urine analysis - to monitor for worsening kidney involvement BP monitoring Prognosis: - 1/3rd will relapse - Small proportion will develop end stage renal failure

How long are antibiotics continued for following Septic arthritis?

2 weeks IV 4 weeks PO minimal 6 weeks in total *DAIR (debridement, ABx, Implant retained) if <30 days

What timelines are suggestive of where an infection came from in Prosthetic Septic arthritis?

<30 days: - likely direct inoculation from surgery >30 days - haematological spread - most commonly from overlying infection

Which two antibodies are associated with phospholipid syndrome?

Cardiolipin Lupus anticoagulant

What is a risk factor of Sjorgen's syndrome in a woman of child baring age?

Passing on of Anti- Ro and Anti - La in crease risk of congenital heart block

What are the specific antibodies to lupus?

Anti - dsDNA Extractable nuclear antigen : - Anti - Smith

What is the neurological complication which can occur with AS?

Sub-alanto- subluxation | - resulting in cord compression

What usually kills you in SLE?

Chronic heart failure Sepsis