Rheumatology Flashcards
What is the pathology of RA?
synovitis, thickened synovial lining, infiltration by inflammatory cells and generation of new blood vessels
RF for RA?
women, family history, HLA-DR4 (genetics)
X ray features for RA?
LESS - LOSS of joint space EROSIONS SOFT tissue swelling SOFT bones (osteopenia)
Hand signs of RA?
ulnar deviation, swan neck deformity, boutonierre deformity
Features of RA?
symettrical polyarthritis (typically affects the small joints of hands and feet.)
- morning stiffness >30 minutes
- as deteriorates, larger joints get involved
- positive MCP squeeze test
- weakened joint capsules - deformities, unstable joints, subluxation
Name some non articular manifestations of RA?
SYSTEMIC - fever, fatigue, weight loss
EYES - sjogrens, scleritis, episcleritis
NEURO - carpel tunnel, cord compression, polyneuropathy
HAEM - lymphadenopathy, splenomegaly, anaemia
PULM - effusion, fibrosis, nodules
HEART - pericarditis, effusion
Ix for RA?
Bloods - FBC/UE/CRP/ESR
ABs - anti CCP/RF antibodies
Xray the affected joints
synovial fluid sample
Which antibodies are positive in RA?
RF, anti-CCP
Name some poor prognostic RA factors?
rheumatoid factor positive poor functional status at presentation HLA DR4 X-ray: early erosions (e.g. after < 2 years) extra articular features e.g. nodules insidious onset anti-CCP antibodies
How do you manage RA? give a few treatments?
NSAIDS - reduce pain and stiffness
Paracetamol - pain
Steroids - reduce disease activity. Systemic vs injection
DMARDS - inhibit inflammatory cytokines e.g. synlfasalazine Methotrexate
Biological DMARD - TNFa inhibitor e.g. Infliximab
List some side effects of commonly used RA drugs
NSAIDS/prednisolone/methotrexate
NSAIDS - bronchospasm in asthmatics, peptic ulcers, dyspepsia
Prednisolone - cushingoid, osteoporosis, HTN, impaired glucose tolerance
Methotrexate - myelosuppression, liver cirrhosis, pneumonitis
Features of ankylosing spondylitis? who is the patient group most commonly affected?
pain and stiffnesss in lower back/buttocks. Pain improves with exercise and there is progressive reduced spinal movement
Commonly affects young men (early 20s)
What do you find on examination with a patient with ankylosing spondylitis?
reduced lordosis and increased kyphosis, reduced L spine mobility and reduced spine flexion, chest does not expand as well
Ix for ankylosing spondylitis?
Increased ESR/CRP levels
X ray - erosions and sclerosis
MRI - sacroilitis
HLAB27 testing
Mx for ankylosing spondylitis?
exercises in the morning for mobility and posture
NSAIDs
TNFa blocking drugs/methotrexate
Name some seronegative spondyloarthropathies?
ankylosing sponydilitis
psoriatic arthritis
reactive arthritis
enteropathic arthritis (Chrons/UC)
Features of psoriatic arthritis?
asymetrical affect on small DIP hand joints
arthritis mutilans
sacroiliitis
dactylitis
Ix for psoriatic arthritis?
routine bloods/ESR
X-ray - pencil cup deformity
Mx of psoriatic arthritis
analgesia, NSAIDS, IA corticosteroids, methotrexate
What infections can cause reactive arthritis?
GI - shigella, salmonella, campylobacter
STI - chlamydia
Features of reactive arthritis?
typically affects knees/ankles/feet
CIRCINATE BALANITIS RASH
acute anterior uveitis
plantar fasciitis
What is reiters syndrome?
urethritis, reactive arthritis, conjunctivitis
Ix of reactive arthritis?
clinical diagnosis
synovial fluid aspirate - sterile, high neutrophils
Mx of reactive arthritis?
NSAIDS, local corticosteroid injections
What is enteropathic arthritis?
large joint asymmetrical oligoarthritis occuring in patients with UC/CD. parrallels the activity of the IBD.
What sort of crystals are in joints with gout?
intra-articular sodiium urate crystals (due to hyperuricaemia)
Causes of hyperuricaemia?
reduced excretion - CKD/thiazide diuretics/HTN
increased production - high purine turnover/polycythemia/leukaemia
Features of gout?
commonly affects MTP joint in big toe. Significant pain, swelling, erythema.
Precipitating factors for an attack of gout?
diet/alcohol/thiazide diuretic/dehydration
Ix for gout?
joint fluid microscopy - long needle shaped crystals (-ve bifringent under polarised light)
X ray - joint effusion, punched out erosions
Serum uric acid raised
Acute management of gout?
NSAIDS, colchicine (SE = diarrhoea), IA corticosteroids
Chronic management of gout?
allopurinol (xanthine oxidase inhibitor) low purine diet stop thiazide diuretics reduce alcohol reduce weight
What antibodies are positive in SLE?
ANA, dsDNA
Blood results in SLE?
FBC (anaemia), UE, Cr, raised ESR, normal SLE, low C3 and C4. Positive ANA and dsDNA antibodies
IgG deposition in kidneys
Multisystem features of SLE
MSK - arthralgia/myalgia
GENERAL - tired, fever, depressed, weight loss
SKIN - butterfly rash, vasculitis, alopocia, UV sensitivity
BLOOD - anaemia, leucopenia, thrombocytopenia
LUNGS - pleural effusions
HEART - pericarditis, myocarditis
KIDNEYS - glomerulonephritis
Mx of SLE?
NSAIDS, chloriquine/hydroxychloroquine corticosteroids immunosuppressant - azathioprine rituximab (anti - CD20)
Features of antiphospholipid syndrome?
thrombosis, recurrent miscarriages
Arteries - TIA/stroke/MI
Placenta - recurrent miscarriages
Other - migraine, thrombocytopenia, renal impairment, accelerated atheroma
Mx of antiphospholipid syndrome?
lifelong anti-coagulation
What causes systemic sclerosis?
autoimmune activation, proliferation of fibroblasts and production of connective tissue = thickened vascular walls
Features of systemic sclerosis?
CREST SYNDROME
calcinosis, raynauds, oesophagus, sclerodactyl, telangiectasia
What is polymyositis?
inflammation and necrosis of skeletal muscle fibres
Features of polymyositis?
symmetrical progressive weakness, muscle wasting of proximal muscles, difficulty squatting, NO pain
Ix for polymyoisitis?
muscle biopsy = shows muscle inflammation and necrosis
increased CK, ESR normal
Positive anti JO abs
MRI
Mx of polymyositis?
prednisolone
Features of polymyalgia rheumatica?
Pt with GCA. Abrupt stiffness and pain in the neck and shoulder muscles. malaise/fever/weight loss. AION
