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Specialities > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

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

A

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

SLE
Sjorgens
PBC
Hep C

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2
Q

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

A

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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3
Q

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

A

Feet

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4
Q

What is the criteria for starting biological therapy:

A

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

Severe disease >5.1 DAS28 score

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5
Q

List the seronegative arthropathies:

A

psoriatic

Ankylosing spondlyitis

Reactive arthritis

Enteropathic arthropathy

JIA

Bechet’s disease

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6
Q

What is the management of reactive arthritis:

A

Treat underlying infection
- must test for STIs

Sexual health review

Rest and NSAIDs
+/-
Steroid injections

*if severe DMARDs

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7
Q

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

A

Excess use of NSAIDs
- cause damage

IgA nephropathy

Amyloidosis

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8
Q

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

A

BASDAI

- 6 questions of 5 major symptoms

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9
Q

Compare and contrast RA vs Psoriatic arthritis:

A
  • 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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10
Q

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

A

It can be falsely low.

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

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11
Q

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

A

Posterior ciliary arteries

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12
Q

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

A

Interruption of internal elastic laminae with multi-nucleated inflammatory cells

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13
Q

What investigations should be done into suspected henoch schonlein?

A

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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14
Q

What are the treatment options for granulomatosis with polyangitis?

A

Induction of remission:
- prednisilone (if mild)

If Severe:

  • Cyclophosphamide
  • Rituxumab

Maintenance of remission:

  • Azathiopurine
  • Methotrexate

**plasma exchange if RPGN

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15
Q

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

A

Lymphoma:

Parotid enlargement
Positive RF
Palpable purpura
Lymphadenopathy

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16
Q

What is the exclusion criteria for Sjorgens?

A

Head radiation

Sarcoidosis

AIDS

Anti-cholingeric medication

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17
Q

What are some clinical findings of Sjorgen’s disease?

A

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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18
Q

What conditions are associated with pseudogout?

A

Thyroid dysfunction - both hypo and hyper

Haemochromatosis

Parathyroid dysfunction

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19
Q

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

A

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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20
Q

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

A

TB

Lyme disease

HIV/ AIDs

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21
Q

What is used to monitor the disease activity of SLE?

A

SELENA SLEDAI

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22
Q

What laboratory markers may suggest disease activity in SLE?

A

Anti dsDNA
- rising levels suggest disease activity

Completement:
- falling C3, C4 suggest active disease

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23
Q

What is the management of SLE?

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

Moderate:

  • Corticosteroids
  • Methotrexate
  • Mycophenylate
  • Azathioprine

Severe:
- Cyclophospamide - IV

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24
Q

When should a Bisphosphonate holiday take place?

A

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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25
Q

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

A

IM methylprednisolone

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26
Q

What is the protein defect in Marfan’s syndrome?

A

Fibrillin-1 - the substrate to elastin

27
Q

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

A

Claudication of the jaw

Claudication of the tongue

28
Q

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

A

CT PET

- shows areas of metabolism as seen with the inflammation

29
Q

List two biomarkers used to assess Lupus:

A

dsDNA

Complement

30
Q

What is the most common side effect of methotrexate?

A

G.I upset

- it is the biggest cause of stopping the meds

31
Q

What is the biggest side effects of steroids?

A

Infection

32
Q

What is the major side effect of hydroxychloroquine?

A

Retinopathy

- should be reviewed yearly by ophthalmology

33
Q

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

A

25 Dihydroxyvitamin D

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

34
Q

Outline the investigations into osteomalacia:

A

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

35
Q

Define and Outline the broad causes of osteomalacia

A

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
36
Q

What is the main treatment for osteomalacia and rickets?

A

Vitamin D
- loading dose then maintenance dose

Calcium
- loading dose for 3 months then maintenance dose

*monitored with vitamin D levels and PTH

37
Q

Discuss the differences in blood results of osteoporosis and osteomalacia:

A

osteoporosis:
- normal Ca
- normal PO4-
- ALP normal
- Urinary Ca normal

Osteomalacia:

  • Low serum Ca
  • PO4- low
  • ALP elevated
38
Q

How is Lupus disease activity monitored?

A

Complement levels

- which usually decrease when disease activity is high

39
Q

In Polymyalgia rheumatica what type of weakness do they have?

A

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

40
Q

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

A

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
41
Q

What are some of the surgical procedures conducted for RA?

A

Synovectomy

Tendon repair
- especially the extensors

Joint replacement

42
Q

What are some poor prognostic factors for RA?

A

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

43
Q

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

A

Tocilizumab
- IL-6

Rituximab:
- CD-20

44
Q

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

A

Hydroxychloroquine

Sulfasalazine

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

45
Q

List some secondary causes of osteoporosis:

A 
Steroid use 
Hyperthyroidism 
Rheumatic disease 
Alcohol abuse 
Warfarin
46
Q

What are the risk factors for osteoporosis?

A

SHATTERED

  • Steroids
  • Hyperthyroidism
  • Alcohol
  • Thin
  • Testosterone reduction
  • Early menopause
  • Renal failure
  • Erosive (RA)
  • Dietary (poor Ca2+)
47
Q

List some drugs which cause osteoporosis:

A 
Steroids 
PPIs 
SSRIs 
Anti-epileptic 
Aromatase inhibitors
48
Q

How is Denosumab given?

A

Sub cut
- twice yearly

Monoclonal Ab against RANK ligand

49
Q

What is the T-score?

A

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

50
Q

List the mechanism by which steroids cause osteoporosis?

A

Increase osteoclast activity

Reduce muscle mass

Reduce Ca2+ absorption from G.I tract

51
Q

Give three examples of bisphosphonates:

A

Alendronate
Risedronate
Ibandronate

52
Q

What is the 1st line treatment for phospholipid syndrome?

A

Low dose aspirin

53
Q

What are some extra-articular manifestations of AS?

A

Eyes:
- Anterior uveitis

Lung:
- Upper zone pulmonary fibrosis

Heart:

  • Aortic regurgitation
  • AV block

MSK:

  • Enthesitis
  • Tenosynovitis
  • neck hyperextension

G.I
- IBD

54
Q

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

A

Squaring of vertebrae

Bamboo spine

Sacroiliitis

Syndesmophytes

55
Q

What is the physical examination for AS?

A

Schober’s test

L5.

  • 10cm above
  • 5cm below

*if no more than <20cm in flexion then suggestive

56
Q

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

A

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
57
Q

How long are antibiotics continued for following Septic arthritis?

A

2 weeks IV

4 weeks PO

minimal 6 weeks in total

*DAIR (debridement, ABx, Implant retained) if <30 days

58
Q

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

A

<30 days:
- likely direct inoculation from surgery

> 30 days
- haematological spread - most commonly from overlying infection

59
Q

Which two antibodies are associated with phospholipid syndrome?

A

Cardiolipin

Lupus anticoagulant

60
Q

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

A

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

61
Q

What are the specific antibodies to lupus?

A

Anti - dsDNA

Extractable nuclear antigen :
- Anti - Smith

62
Q

What is the neurological complication which can occur with AS?

A

Sub-alanto- subluxation

- resulting in cord compression

63
Q

What usually kills you in SLE?

A

Chronic heart failure

Sepsis

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