Rheumatology

Question 1

What is rheumatoid arthritis?

Answer 1

Autoimmune disease resulting in symmetrical polyarthritis, Antibodies to Fc portion of IgG (RF) and anti-CCP

Question 2

How does RA typically present?

Answer 2

Usually middle aged women with progressive, peripheral and symmetrical polyarthritis, Worse in the morning, gets better with use ~30 mins
Can affect any joint, but most often MCP, PIP, MTP

Question 3

What are some extra-articular manifestations of RA?

Answer 3

ILD, Anaemia, Pulmonary disease eg bronchiectasis, Inc CVS risk

Question 4

What are x-ray features of RA?

Answer 4

Loss of joint space, Periarticular erosions, Soft tissue swelling, Subluxation

Question 5

What investigations are done in RA?

Answer 5

Bloods: FBC - microcytic anaemia, raised inflammatory markers
Anti-CCP - more specific to RA
Rheumatoid factor - not specific

Question 6

What is the management of RA?

Answer 6

DMARD therapy - methotrexate, need to also take folate
Steroids for acute flareups; PO, IM or intra-articular
Symptoms control with NSAIDs

Manage risk factors for cardiovascular disease

Question 7

What is SLE?

Answer 7

Autoimmune disease with inadequate T cell activity and increased B cell activity
Autoantibodies made against tissues => immune complexes
These can’t be cleared so there is local inflammation and damage

Question 8

How can SLE present?

Answer 8

Non-specific; fatigue, fever, weight loss, arthralgia

Photosensitivity - malar rash
Renal - glomerulonephritis
Neuro - seizures, psychosis

Question 9

What investigations are done for SLE?

Answer 9

FBC - anaemia, leukopenia
Raised ESR, normal CRP
Urinalysis - proteinuria

Antibodies:
\+ve ANA
Anti-Ro, Anti-La
Anti-dsDNA inc with disease activity 
Low complement

Question 10

How is SLE managed?

Answer 10

Sun protection
Hydroxychloroquine used for rash and arthralgia

Short course of prednisolone for flares

Question 11

What are spondyloarthropathies?

Answer 11

Group of conditions affecting the spine and peripheral joints
Ankylosing spondylitis
Psoriatic arthritis
Reactive arthritis

Question 12

How does ankylosing spondylitis present?

Answer 12

Lower back pain, stiffness which improves throughout the day
Progressive loss of spinal movement

Question 13

What signs are seen in ankylosing spondylitis?

Answer 13

Oft normal
Later stages - loss of lumbar lordosis, exaggerated thoracic kyphosis
Reduced lateral flexion, reduced forward flexion (Schober’s test)

Question 14

What imaging is done for ankylosing spondylitis?

Answer 14

MRI more sensitive

Question 15

What is the management of ankylosing spondylitis?

Answer 15

NSAIDs
Physio
TNF inhibitors - infliximab/etanercept

Question 16

What are extra-articular manifestations of ankylosing spondylitis?

Answer 16

Anterior uveitis
Aortic incompetence
AV block
Apical lung fibrosis

Question 17

What is reactive arthritis?

Answer 17

Sterile synovitis occurring after a distant infection, eg salmonella, chlamydia

Question 18

How does reactive arthritis present?

Answer 18

Asymmetrical lower limb arthritis
Conjunctivitis

Can’t see, can’t pee, can’t bend at the knee

Question 19

What investigations are done in reactive arthritis?

Answer 19

Serology
Raised inflammatory markers
Joint aspirate to rule out septic/crystal arthropathies

Question 20

management

Answer 20

Treat infection
NSAIDs, joint injection
If it doesn’t resolve in 2 yrs => DMARDs

Question 21

How does polymylagia rheumatica present?

Answer 21

Pain and stiffness of shoulder, hips and neck
Decreased ROM, lethargy
Normal muscle strength, but limited by pain

Question 22

What is the management of polymyalgia rheumatica?

Answer 22

15mg prednisolone 1-2 yrs
Should respond fairly quickly
Need to co-prescribe bisphosphonates, vit D, calcium and PPI

Question 23

What is temporal arteritis?

Answer 23

Vasculitis of large cells

Associated with polymyalgia rheumatica

Question 24

How does temporal arteritis present?

Answer 24

Headache, localised over temple
Scalp tenderness
Tongue/jaw claudication due to reduced blood supply
Visual disturbances - blindness, diplopia

Question 25

What investigations are done in temporal arteritis?

Answer 25

Temporal artery biopsy - skip lesions

Bloods - raised inflammatory markers

Question 26

How is temporal arteritis managed?

Answer 26

High dose prednisolone for at least 2 weeks

Acute visual sx => IV methylprednisolone and ophthalmology review