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4MB Medicine (My version) > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

Describe normal synovial fluid, commenting on appearance, viscosity, white cell count and neutrophils

A

Clear
Normal consistency
WCC less than 200
No neutrophils

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2
Q

Describe osteoarthritic synovial fluid, commenting on appearance, viscosity, white cell count and neutrophils

A

Clear
Increased viscosity
WCC less than 1000
Less than 50% neutrophils

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3
Q

Describe bloody synovial fluid, commenting on appearance, viscosity, white cell count and neutrophils

A

Red/dark brown
Varied viscosity
WCC less than 10 000
Neutrophils less than 50%

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4
Q

Describe inflammatory synovial fluid, commenting on appearance, viscosity, white cell count and neutrophils

A

Yellow/turbid
Reduced viscosity
WCC less than 50 000
Neutrophils vary, should be less than 80%

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5
Q

List the main seropositive inflammatory arthropathies

A 
Rheumatoid
SLE
Scleroderma
Vasculitis
Sjogren's syndrome
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6
Q

List the main seronegative inflammatory arthropathies

A

Ankylosing spondylitis
Reactive arthritis
Psoriatic arthritis
Enteropathic arthritis

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7
Q

List likely aetiology/risk factors for back pain in 15-30 yo

A 
Prolapsed disc
Trauma
Fractures
Ank spond
Spondylolisthesis
Pregnancy
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8
Q

List likely aetiology/risk factors for back pain in 30-50 yo

A

Degenerative spine
Prolapsed disc
Malignancy

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9
Q

List likely aetiology/risk factors for back pain in over 50 yo

A 
Degenerative spine
Osteoporosis
Paget's disease
Malignancy
Spinal stenosis
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10
Q

List red flags for back pain

A 
Age less than 20 or over 55
New onset
Constant, progressive
Worse at night, lying down
Systemic upset
History of cancer
Cauda equina features
Neuro dysfunction
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11
Q

What is osteoarthritis?

A

Wear-and-tear degeneration of bones and joint

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12
Q

List aetiology/risk factors for osteoarthritis

A

Environment (hobbies, occupation, obesity)
Previous injuries/fractures
Genetics/familial
Secondary to disease (Perthes, DDH, arthropathies, malalignment)

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13
Q

List clinical features of osteoarthritis

A 
Pain on movement/worse at end of day
"Background" joint pain
Joint stiffness on waking ~ 30 mins
Instability
Heberden's nodes (DIPJ)
Bouchard's nodes (PIPJ)
Bony tenderness
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14
Q

List XR findings of osteoarthritis

A

Loss of joint space
Osteophyte formation
Subchondral sclerosis
Subchondral cysts

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15
Q

Outline management of osteoarthritis

A 
Exercise to improve muscles and instability
Weight loss
Paracetamol + NSAID
Codeine
IA steroid temporary relief
Joint replacement for pain
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16
Q

List conditions associated with anti CCP antibody

A

Rheumatoid arthritis

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17
Q

List conditions associated with Rheumatoid factor

A 
Rheumatoid arthritis
Sjogren's syndrome
Felty's syndrome
Mixed CTD
SLE
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18
Q

List conditions associated with anti ds DNA antibody

A

SLE

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19
Q

List conditions associated with anti Sm antibody

A

SLE

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20
Q

List conditions associated with anti Ro antibody

A

Sjogren’s syndrome
SLE
Systemic sclerosis
Congenital heart block (placental transfer)

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21
Q

List conditions associated with anti La antibody

A

Sjogren’s syndrome

SLE

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22
Q

List conditions associated with anti-centromere antibody

A

Limited systemic sclerosis

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23
Q

List conditions associated with anti Scl 70 antibody

A

Diffuse systemic sclerosis

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24
Q

List conditions associated with anti RNP antibody

A

Mixed CTD

SLE

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25
Q

List conditions associated with anti Jo 1 antibody

A

Polymyositis

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26
Q

List conditions associated with anti Mi2 antibody

A

Dermatomyositis

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27
Q

What is rheumatoid arthritis?

A

Chronic seropositive inflammatory arthritis caused by antibodies to Fc fragment of IgG and synovial fluid, resulting in a symmetrical deforming polyarthritis

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28
Q

List aetiology/risk factors for rheumatoid arthritis

A 
Women
Smoking
Age 35-50 yo
Genetics, familial
Trauma
Autoimmune conditions
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29
Q

List clinical features of rheumatoid arthritis

A 
Symmetrical swollen painful joints
Usually MCP and PIP / small joints
Early morning stiffness
Pain/stiffness eases with exercise
Tenosynovitis, bursitis
Extensor tendon rupture
Rheumatoid nodules
Boutonniere deformity (PIPJ flexion, DIPJ extension)
Swan-neck deformity (PIPJ extension, DIPJ flexion)
Ulnar deviation of fingers
Z thumb
Lymphadenopathy
Systemic upset
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30
Q

What investigations would you do for rheumatoid arthritis?

A

XR may be normal or show peri-articular osteopenia and erosions
Raised CRP ESR PV
Antibodies (RhF, CCP)

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31
Q

Outline management of rheumatoid arthritis

A 
DMARD within 3 months of onset: methotrexate/sulfasalazine/hydroxychloroquine
\+ steroid for lag phase and flares
NSAID for symptom relief
Physiotherapy, OT
Biologics if unresponsive to 2 DMARDs
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32
Q

Which biologic is an anti-TNF agent?

A

Infliximab

Etanercept

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33
Q

Which biologic is an anti-CD20 (B-cell) agent?

A

Rituximab

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34
Q

Which biologic is an anti- T-cell agent?

A

Abatacept

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35
Q

Which biologic is an anti- IL-6 agent?

A

Tociluzimab

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36
Q

Which biologic is an anti- IL-1 agent?

A

Anakinra

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37
Q

What is ankylosing spondylitis?

A

Chronic seronegative inflammatory arthritis of spine and sacroiliac joints

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38
Q

Which HLA is associated with most seronegative arthropathies?

A

HLA B27

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39
Q

List clinical features of ankylosing spondylitis

A 
Gradual onset back pain, worse at night
Relieved by NSAIDs
Morning stiffness, better with exercise
Reduced lumbar lordosis
Increases thoracic kyphosis
Acute uveitis
Enthesitis
Paraspinal muscle wasting
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40
Q

What investigations would you do for ankylosing spondylitis?

A

XR shows syndesmophytes, fused bones (bamboo spine)

Schobert’s test

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41
Q

Outline management of ankylosing spondylitis

A

Physiotherapy/exercise
NSAID for symptoms
Biologics if severe
Local steroid injection

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42
Q

What are the patterns of psoriatic arthritis?

A

Usually asymmetrical oligoarthritis

Can be symmetrical polyarthritis

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43
Q

What does psoriatic arthritis look like on XR?

A

Pencil-in-cup deformity

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44
Q

What type of pattern does enteropathic arthritis usually present with?

A

Large joint asymmetrical oligoarthritis

45
Q

What is reactive arthritis?

A

Sterile arthritis occuring in response to infection in other body area

46
Q

List aetiology for reactive arthritis

A 
GU infection (Chlamydia, Neisseira)
GI infection (Salmonella, Campylobacter)
47
Q

List clinical features of reactive arthritis

A

Reiter’s triad (urethritis, uveitis, arthritis)
Large joint inflammation
Mouth ulcers
Enthesitis
Keratoderma blenorrhagica (brown raised papules)
Circinate balanitis (painless penile ulceration)

48
Q

Outline management of reactive arthritis

A 
Rest
Self-limiting (4 weeks)
Treat infection
NSAID
Steroid injection
49
Q

What is systemic lupus erythematosus (SLE)?

A

Multisystem autoimmune condition involving antibodies against body sites

50
Q

List aetiology/risk factors for SLE

A 
Women
Afro-Caribbeans
HLA DR2/DR3
EBV can be a trigger
Drugs (isoniazide, hydralazine, chlorpromazine, phenytoin, OCP)
51
Q

List clinical features of SLE

A 
Fever
Fatigue
Weight loss
Malaise - relapsing and remitting
MSK: arthralgia, myalgia, arthritis, AVN
Skin: malar rash, photosensitivity, alopecia, Raynaud's
Resp: pleurisy, pleural effusion, PE, ILD
Haem: cytopenia
Lymphadenopathy
Endocarditis
Migraine
Eye problems
52
Q

What investigations would you do for SLE?

A 
Antibodies: ANA, anti-ds-DNA, anti-Sm
Anti-histone ab for drug-induced
Low C3/C4 levels when disease active
Urinalysis for glomerulonephritis
Greater than 4 criteria (at least 1 clinical + 1 lab) or biopsy-proven nephritis and antibody
53
Q

Outline management of SLE

A

Acute flare: IV cyclophosphamide + prednisolone
Maintainence: NSAID, hydroxychloroquine, low-dose steroid
Nephritis: immunosuppression
Unresponsive: IV Ig, rituximab

54
Q

What is Sjogren’s syndrome?

A

Autoimmune lymphocytic infiltrate of exocrine organs (lacrimal/salivary glands) causes dryness and irritation

55
Q

List aetiology/risk factors for Sjogren’s syndrome

A

May be primary disease
Secondary: rheumatoid, SLE, other autoimmunity
Lymphoma

56
Q

List clinical features of Sjogren’s syndrome

A 
Dry eyes
Dry mouth
Parotid swelling
Dysphagia
Arthralgia
Vaginal dryness
57
Q

What investigations would you do for Sjogren’s syndrome?

A

Schirmer test for conjunctival dryness
Antibodies: anti-Ro, anti-La
Parotid biopsy

58
Q

Outline management of Sjogren’s syndrome

A

Eye drops/gels/ointments for dryness
Pilocarpine
NSAID + hydroxychloroquine for arthralgia

59
Q

What is systemic sclerosis?

A

Autoimmune abnormality of excess collagen deposition

60
Q

List clinical features of systemic sclerosis

A

Limited: calcinosis, Raynaud’s, esophageal dysmotility, sclerodactyly, telangiectasia, may have skin involvement
Diffuse: whole body involvement, organ fibrosis

61
Q

What investigations would you do for systemic sclerosis?

A

Antibodies: anti-centromere (limited), anti-scl-70 (diffuse)

Organ screening

62
Q

Outline management of systemic sclerosis

A

IV cyclophosphamide for organ involvement/progression

Ca ch blockers

63
Q

Which antibody is associated with mixed CTD?

A

Anti-RNP antibody

64
Q

What is antiphospholipid syndrome?

A

Autoimmune recurrent thrombosis

65
Q

List clinical features of antiphospholipid syndrome

A 
Increased frequency of stroke/MI
Sterile endocarditis
PE
Migraine
Spontaneous miscarriages in second/third trimester
Livedo reticularis
66
Q

What investigations would you do for antiphospholipid syndrome?

A

Lupus anticoagulant + anti-cardiolipin antivody
Anti-beta-2-glycoprotein antibody
Thrombocytopenia
Prolonged APTT

67
Q

Outline management of antiphospholipid syndrome

A

Lifelong anticoagulation

LMWH during pregnancy

68
Q

What is gout?

A

Deposition of monosodium urate crystals in and around joints due to increased serum uric acid

69
Q

List aetiology/risk factors for gout

A 
High purine diet (seafood)
Alcohol excess
Hereditary
Thiazide diuretics
Leukaemia
Renal impairment
Haem disorder
70
Q

List clinical features of gout

A 
Acute monoarthropathy, usually 1st MTPJ
Intense pain
Red hot swollen joint
Nausea
Gouty tophia - accumulation of uric acid
71
Q

What investigations would you do for gout?

A

Synovial aspirate shows -ve birefringence (yellow-blue) needle-shaped crystals

72
Q

Outline management of gout

A

Acute: NSAID, colchicine, steroid if NSAID not tolerated
Prophylaxis: allopurinol/febuxostat

73
Q

What is pseudogout?

A

Deposition of calcium pyrophosphate crystals in and around joints
Chondrocalcinosis occurs if no inflammation

74
Q

List aetiology/risk factors for pseudogout

A 
Idiopathic
Old age
Hyperparathyroidism
Hypothyroidism
Diabetes
Haemochromatosis
Wilson's disease
Surgery, trauma
75
Q

List clinical features of pseudogout

A

Acute monoarthropathy typically affecting larger joints

Chronic destructive changes

76
Q

What investigations would you do for pseudogout?

A

Synovial aspirate shows +ve birefringence rhomboid-shaped crystals

77
Q

Outline management of pseudogout

A

NSAID
Steroid
Colchicine
Hydroxychloroquine for prophylaxis

78
Q

List clinical features of polymyalgia rheumatica

A 
Proximal symmetrical myalgia
Muscle stiffness (NOT weakness)
Tenderness
Morning stiffness lasting over 1h, improves with the day and movement
Fatigue
Weight loss
Anorexia
Depression
Temporal pain in 15% of pts
79
Q

What investigations would you do for polymyalgia rheumatica?

A

Raised CRP, ESR, PV
Normal CK
Temporal artery biopsy if GCA

80
Q

Outline management of polymyalgia rheumatica

A 
Oral prednisolone 15mg reducing over 18 months
with gastric (PPI) and bone (bisphosphonate) protection
81
Q

What is polymyositis?

A

Idiopathic inflammatory myopathy thought to be caused by T-cell mediated cytotoxicity against muscle cells

82
Q

List clinical features of polymyositis

A 
Symmetrical proximal muscle weakness
Dysphagia
Interstitial lung disease, resp weakness
Dysphonia
Raynaud's
Arthralgia
Arrhythmia
83
Q

What investigations would you do for polymyositis?

A

Very elevated CK, raised inf markers
EMG shows fibrillation
Antibodies: ANA, anti-Jo-1, anti-SRP
Muscle biopsy confirms diagnosis

84
Q

Outline management of polymyositis

A

Prednisolone 40mg

Immunosuppression if resistant (azathioprine, methotrexate, cyclophosphamide)

85
Q

List clinical features of dermatomyositis

A 
Myositis features
V-shaped rash
Gottron's papules
Heliotrope rash
Skin cracks
86
Q

There is increased risk of malignancy with dermatomyositis. True/False?

87
Q

List clinical features of fibromyalgia

A 
Chronic pain (over 3 months) that is widespread in absence of inflammation
Fatigue
Unrefreshed sleep
Unexplained symptoms
Tender points
Low threshold for pain and other stimuli
88
Q

Outline management of fibromyalgia

A

Education, self-help and coping strategies
CBT
Exercise
Neuropathic analgesia (amitryptilline, gabapentin)
Venlafaxine

89
Q

What is vasculitis?

A

Inflammation of blood vessels that may cause stenosis and thickening

90
Q

What are the main large vessel vasculitides?

A 
Giant cell arteritis (in over 50yo)
Takayasu arteritis (in under 50yo)
91
Q

List clinical features of large vessel vasculitis (mainly GCA)

A 
Intense pain around temporal artery
Scalp tenderness
Jaw claudication
Amaurosis fugax
Fever
Weight loss
Arthralgia
92
Q

What investigations would you do for large vessel vasculitis?

A

Raised CRP, ESR, PV
MR angiography
Temporal artery biopsy shows multinucleated giant cells (may be -ve due to skip lesions)

93
Q

Outline management of large vessel vasculitis

A

40-60mg prednisolone with gradual reduction

+/- immunosuppression

94
Q

What are the main medium vessel vasculitides?

A

Polyarteritis nodosa

Kawasaki disease

95
Q

List clinical features of medium vessel vasculitis

A

Systemic upset
Skin rashes, punched out ulcers
Coronary aneurysms
Renal failure is main cause of death

96
Q

Outline management of medium vessel vasculitis

A

Control BP
Steroid
Cyclophosphamide

97
Q

What are the main small vessel vasculitides?

A

Granulomatous polyangitis (GPA)
Microscopic polyangitis (MPA)
Eosinophilic granulomatous polyangitis (EGPA)
Henoch-Schonlein purpura

98
Q

What is GPA?

A

Multisystem necrotising granulomatous inflammation with predilection for upper resp tract and kidneys

99
Q

List clinical features of GPA

A 
Nosebleeds
Recurrent sinusitis, nasal crusting
Nasal cartilage collapse (saddle-nose)
Deafness
Haemoptysis
Skin purpura
Renal disease (rapidly progressive GN)
100
Q

What investigations would you do for GPA?

A

cANCA, PR3
Urinalysis, renal biopsy
XR

101
Q

Outline management of GPA

A

IV steroid + cyclophosphamide

Cotrimoxazole prophylaxis

102
Q

What is EGPA?

A

Late onset asthma + eosinophilia + granulomatous vasculitis

103
Q

Which antibody is associated with EGPA?

104
Q

Which antibody is associated with MPA?

105
Q

What is Henoch-Schonlein purpura?

A

IgA-mediated vasculitis usually in kids

106
Q

List clinical features of Henoch-Schonlein purpura

A 
Generalised purpuric rash over buttocks and lower limbs
Joint pain
Abdo pain
Vomiting
Preceding URTI (Group A Strep)
Glomerulonephritis
107
Q

Which ANCA is associated with Henoch-Schonlein purpura?

A

None!

It is ANCA -ve

108
Q

Henoch-Schonlein purpura is usually self-limiting. True/False?

4MB Medicine (My version) (19 decks)

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