Rheumatology Flashcards
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
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.
Which part of the body does DAS 28 not include in the monitoring?
Feet
What is the criteria for starting biological therapy:
Failure of:
> 2 DMARDS
- Must include methotrexate unless contraindicated
Severe disease >5.1 DAS28 score
List the seronegative arthropathies:
psoriatic
Ankylosing spondlyitis
Reactive arthritis
Enteropathic arthropathy
JIA
Bechet’s disease
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
What are the renal involvements which can occur with seronegative arthropathies?
Excess use of NSAIDs
- cause damage
IgA nephropathy
Amyloidosis
What is the gold standard for measuring disease activity of ankylosing spondlylitis?
BASDAI
- 6 questions of 5 major symptoms
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
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
What blood vessels have disruption to blood flow causing ischemic optic neuropathy?
Posterior ciliary arteries
What would you expect to find on a biopsy of giant cell arteritis?
Interruption of internal elastic laminae with multi-nucleated inflammatory cells
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
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
Whats a serious complication of Sjorgen’s syndrome and what are some risk factors for it?
Lymphoma:
Parotid enlargement
Positive RF
Palpable purpura
Lymphadenopathy
What is the exclusion criteria for Sjorgens?
Head radiation
Sarcoidosis
AIDS
Anti-cholingeric medication
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
What conditions are associated with pseudogout?
Thyroid dysfunction - both hypo and hyper
Haemochromatosis
Parathyroid dysfunction
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
List some differential diseases that present not to dissimilar to Lupus:
TB
Lyme disease
HIV/ AIDs
What is used to monitor the disease activity of SLE?
SELENA SLEDAI
What laboratory markers may suggest disease activity in SLE?
Anti dsDNA
- rising levels suggest disease activity
Completement:
- falling C3, C4 suggest active disease
What is the management of SLE?
Mild: - Sun Block - Hydroxychloroquine \+/ - Aspirin
Moderate:
- Corticosteroids
- Methotrexate
- Mycophenylate
- Azathioprine
Severe:
- Cyclophospamide - IV
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
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
