Rheumatology Flashcards
Name some medications that might precipitate gout
Thiazide and loop diuretics (reduce excretion of uric acid)
Certain chemotherapy agents
Inflammatory arthritides can be classified as either seropositiv, seronegative, infectious or crystal-induced
What are the seropositive arthropathies?
Rheumatoid arthritis
Juvenile RA
SLE
Scleroderma
Vasculitis
Sjogren’s
Inflammatory arthritides can be classified as either seropositiv, seronegative, infectious or crystal-induced
What are the seronegative arthropathies?
Ankylosing spondylitis
Psoriatic arthritis
Reiter’s syndrome (reactive arthritis)
Inflammatory bowel disease arthritis
When considering gout as a diagnosis, what important past medical history questions might you ask a patient?
History of gout
History of renal disease
History of renal stones
Heart failure or hypertension managed with diuretics
Other than the affected joint in question, where else would you look on a patient with suspected gout?
Appearance of gouty tophi which indicate chronic hyperuricaemia (pinnae of the ears and fingers)
May also have olecranon bursitis
Suspect gout? What investigations would you perform?
Joint aspirate for microscopy, gram-staining and culture - most important investigation, confirms diagnosis of gout or pseudogout and culture will help to rule out septic arthritis
FBC - usually shows neutrophilia and raised inflammatory markers
Serum uric acid - may be raised, but normal in 25-40% of patients with acute attack
Blood cultures sent at the same time as aspirate cultures
Acute gout diagnosed! How do you treat it?
Attacks can be very painful and last 5-7 days. Best managed with COX-2 inhibitors and NSAIDs - Diclofenac, Naproxen and Indomethacin can all be used
For some patients e.g. renal failure, the above may not be appropriate, so Colchicine can be used (500 micrograms 4 times/day)
Steroids are also useful - once SA excluded, intra-articular steroid injections can prove useful in monoarticular disease
Once acute attack has passed, allopurinol can be commenced to lower uric acid levels
What condition would the following bloods indicate?
Anti-dsDNA - raised
Anti-Ro - raised
Anti-La - normal
SLE
Anti-dsDNA is associated with SLE
Anti-Ro may also be raised, as well as in Sjogren’s, but anti-La is much more specific for Sjogren’s
SLE has numerous associated complications
What investigations would you perform to explore these?
Urinalysis - glomerulonephritis (GN) in SLE often presents with proteinuria and/or haematuria before any derangement in U&Es. Presence of red cell casts indicates GN
Baseline CXR and pulmonary function tests - done to exclude interstitial lung disease
Baseline echocardiogram - pulmonary hypertension may be seen in severe autoimmune disease
How is SLE treated?
Based on degree of organ involvement
Hydroxychloroquine is started in every patient - reduces photosensitivity, fatigue, arthralgia and reduces likelihood of progression to other organ involvement
Short courses of steroids/IM steroids can be given to patients with synovitis
NSAIDs can be used to treat arthralgia
Long-term steroids should be reserved for patients with major organ involvement
In a patient with SLE, what advice would you give them regarding pregnancy?
Active disease? Avoid pregnancy as associated with poor maternal and foetal outcomes
Immunosuppressive therapy? Methotrexate and Mycophenolate are highly teratogenic - should be stopped for at least 3 months prior to conception
Does she have antiphospholipid antibodies? If so, she should be given aspirin and LMWH once pregnancy confirmed
Does she have anti-Ro antibodies? Associated with congenital heart block in 2-5% of foetuses
Woman in her 60s presents with new-onset pain in her arms for the last 6 weeks, and some weight loss. Recently started on a statin for high cholesterol
What questions do you ask?
Establish if muscular pain or joint pain
Muscular diseases are characterised by pain, weakness and wasting of muscles. Generally there is no stiffness in the joint Examples include polymyositis, dermatomyositis, inclusion body myositis, limb girdle muscle dystrophy or statin-induced necrotising myositis
Able to get up from a chair?
Stiffness in the morning?
Swelling/stiffness in the small joints of the hands?
Anyone in the family with a muscle disease?
Systemic Enquiry - difficulty swallowing? Regurgitation? SoB? Chest pains etc.
What are Gottron’s papules?
What condition are they associated with?
Red bumps forming on the ouside of the joints of the hand
Seen in dermatomyositis
What is one of the telling features of polymyalgia rheumatica that separates it from muscle diseases?
What bloods are classically raised in the acute phase?
Muscle diseases exhibit muscle weakness, but there is no muscle weakness in PMR, it is a disease of the joints
ESR/CRP will be elevated
What blood test is really important when trying to establish if a patient is suffering from a muscle disease?
Creatinine Kinase
Inflammatory pain and stiffness is usually worse in the morning/evening and after activity/inactivity
Inflammatory pain is usually worse in the morning and in inactivity
It usually gets better as the day progresses, as opposed to mechanical back pain which gets worse as the day progresses
Back pain that radiates down the legs indicates an inflammatory/mechanical source
Parasthesia, bowel and bladder symtoms indicate an inflammatory/mechanical source
Mechanical source
Again, mechanical source
Inflammatory back pain responds very well/poorly to NSAIDs
Mechanical back pain responds very well/poorly to NSAIDs
Inflammatory - very well to NSAIDs
Mechanical - poorly to NSAIDs
Seronegative spondylarthropathies are more commonly symmetric/asymmetric poly/oligoarthropathies
More commonly oligoarthropathies (fewer than 4 joints involved), and more commonly asymmetric
Can DIP joints be affected in seronegative spondyloarthropathies?
Yes - useful to differentiate from RA which doesn’t affect DIPs
What are the two most common organisms associated with reactive arthritis in the UK?
Campylobacter
Chlamydia
What is the gold standard investigation of choice when investigating a patient presenting with back pain deemed likely to be the result of a seronegative spondyloarthropathy?
MRI of Spine and SI joints
Also HLA typing - HLA-B27 is present in 95% of patients with ank. spond. and is also v. high in patients with reactive arthritis
How is ankylosing spondylitis best treated?
NSAIDs and physiotherapy for spinal disease. There is no role for steroids or DMARDs
For peripheral disease, IA or IM steroids, short courses of oral steroids or DMARDs such as sulfasalazine, methotrexate and leflunomide
According to the Chapel Hill Consensus Critera, what are the types of large cell vasculitis?
Takayasu arteritis
Giant cell arteritis
According to the Chapel Hill Consensus Critera, what are the types of medium cell vasculitis?
Polyarteritis nodosa
Kawasaki disease
According to the Chapel Hill Consensus Critera, what are the types of small cell vasculitis (ANCA-associated)?
Microscopic polyangiitis
Granulomatosis with Polyangiitis (formerly Wegener’s)
eosinophilic Granulomatosis with Polyangiitis, (formerly Churg-Strauss)
According to the Chapel Hill Consensus Critera, what are the types of immune complex small cell vasculitis?
Henoch-Schonlein purpura aka IgA Vasculitis
Cryoglobulinaemic vasculitis
Hypocomplemenetemic Urticarial vasculitis
