Rheumatology Flashcards
Red flags in rheumatological/bone pain?
Pain all the time - at rest
Infective
Red flags for back pain
<16, >50 and new pain Hx of cancer Weight loss Recent infection Bladder/bowel symptoms Neurological dysfunction (gait, foot drop)
Why would RA cause cardiomegaly?
Pericardial effusion
How does RA usually affect the kidneys?
Nephrotic syndrome e.g. glomerulonephritis
What blood tests should be given to patients on methotrexate? How often should they be given?
FBC: cytopaenia, macrocytic anaemia
U&E: renal excretion so if there is AKI, methotrexate level will rise
LFT: potential hepatotoxicity
Methotrexate toxicity
Pancyotpaenia (bone marrow suppression due to high methotrexate levels)
GI haemorrhagic enteritis
Pancytopaenia
Macrocytic anaemia
Gum bleeding/ulcers
Hepatotoxicity
Methotrexate alternatives in pregnancy/breastfeeding
Sulfasalazine and hydroxychloroquine
Methotrexate drug interactions that cause bone marrow toxicity?
Trimethoprim (also affects folic acid cycle) or septrin: bone marrow toxicity
Examples of anti-TNFs
Rifliximab
Adalimumab
When should you pause a DMARD?
Before elective surgery
During infection and 2 weeks following the end of antibiotic regimen
When would you stop a DMARD before elective surgery? When would you restart?
Dose frequency +1 week prior to surgery
Start again 2-4 weeks after surgery
Steroid sick day rule?
Double dose and go IV if can’t take orally
Characteristics of ankylosing spondylitis
Young adult male, late teens/20s
> 3 months pain and stiffness in lower back and sacroiliac
Worse in mornings and can be woken at night
Eases on movement
Sacral fractures
What is Schober’s test?
L5 - mark
10cm above and 5 cm below
Bend over
If <20cm gap - restrictive disease
What X-ray changes would you see in ankylosing spondylitis?
Bamboo spine Squaring of vertebral bodies Subchondral sclerosis and erosions Syndesmophytes (bony growths in ligaments) Ossification Joint fusion
Stepwise management of ankylosing spondylitis?
NSAIDs (naproxen/ibuprofen) + physio
Steroids (oral or IM)
Anti-TNF (rifliximab, adalimumab, etanercept)
Secukinumab (anti-IL17)
Avoid smoking
Bisphosphonates
Surgery for deformities
Ankylosing spondylitis investigations
ESR and CRP raised
HLA-B27
MRI shows bone marrow oedema
Xray
Reactive arthritis characteristics
HLA-B27
Gonorrhoea, chlamydia or GI (organism can’t be found in joint)
Urethritis
Asymmetrical oligoarthritis of lower joints
Anterior uveitis/conjunctivitis
Dactylitis
Papules on palms/soles (keratoderma blenorrhagica)
SLE investigations
ANA positive Anti-dsDNA RF (20% patients) Anti-Smith ESR
Elbow pain worse on extension of wrist against resistance - likely diagnosis, characteristics and management?
Lateral epicondylitis (tennis elbow)
45-55 years
Dominant arm
Avoid muscle overload
Simple analgesia
Steroid injection
Physio
What should you take alongside methotrexate? What should be given in methotrexate toxicity?
Folic acid
Toxicity: folinic acid
SLE diagnostic criteria (at least 4)
- Malar rash
- Discoid rash (can scar)
- Photosensitivity
- Ulcers (mouth and nose)
- Serositis (pleuritis, pericarditis) +myocarditis/endocarditis
- Arthritis
- Renal disorder (diffuse proliferative glomerulonephritis)
- Neurological disorders (seizures)
- Blood disorders (anaemia, thrombocytopaenia, leukopaenia)
- Antibodies
Antibodies associated with systemic sclerosis?
ANA (90%)
RF (30%)
Diffuse: Anti-scl-70
Limited: Anti-centomere antibodies
Limited systemic sclerosis characteristics
Raynaud’s phenomenon
Scleroderma of face and hands
Anti-centomere antibodies
Characteristics of diffuse systemic sclerosis
Scleroderma of trunk and proximal limbs
Death caused by interstitial lung disease
Renal disease and HTN
Anti-scl-70 antibodies
CREST syndrome?
Calcinosis - WHITE DEPOSITS Rayndaud's Oesophageal dysmotility - DYSPHAGIA Sclerodactyly - THICKENED HANDS Telangiectasia - SPIDER NAEVI
Drug-induced SLE causes
Hydralazine
Procainamide
Isoniazid
Phenytoin
Antibody in Wegener’s granulomatosis
cANCA
Antibody in Churg-Strauss
pANCA (also seen in SLE, RA, IBD, autoimmune hepatitis)
Investigation and treatment of osteomyelitis?
MRI spine
Flucloxacilin 6 weeks
Clindamycin if allergic