Rheumatology Flashcards
How would you manage a high calcium?
IV fluids
IV bisphosphonates
if needed give Denosumab and steroid use
What two assessment scales can you do on a patient with suspected osteoporosis?
Which one is said to be better?
DEXA scan
Vertebral fracture assessment
What pathway do bisphosphonates work via?
HMG-CoA pathway
Explain the pharmacology of bisphosphonates?
- Bisphosphonates haven a high affinity for hydroxyapatite so head straight to the bone.
- Osteoclasts when they resorb bone also take up some bisphosphonates.
- The bisphosphonates disable the osteoclast activity. Causes apoptosis and thus reduces bone absorption
Give two significant SE of bisphosphonates?
Oesphagitis
Avascular necrosis of the jaw (happens after months of treatment)
AF
How will high calcium appear on ECG?
Short QT
How will low calcium present on ECG?
Long QT
What will the PTH levels look like in
A. Malignancy
B. Primary PTH
A. Low or normal
B. High
What does having a low Vit D do to the PTH levels?
Increases secondary PTH levels
Leading to increased bone resorption and thus significant risk of osteoporosis
What happens to blood test marker would go up in increased bone turnover?
Alkaline Phosphatase
What is seen on X Ray with someone with Ewing’s sarcoma?
Onion skin appearance
What is seen on X Ray with osteosarcoma ?
Sun burst appearance
What joint deformities will you get in osteoarthritis?
You will get Heberdens (distal) and Bouchard (proximal) nodes
What limb deformities will you get with rheumatoid arthritis?
Boutonnière deformity
Swan Neck deformity
What are two antibodies you will be looking for in the blood of a patient with Rheumatoid arthritis?
- anti CCP
2. RF
What are some of the extra articular joint manifestations of rheumatoid arthritis?
- Subcutaneous skin nodules
- Pleural effusions
- Pericarditis
- Cord compression
- Carpal Tunnel;
What is the first and then the second line treatment for rheumatoid arthritis?
1st line: pain relief + NSAIDs + methotrexate + folic acid
2nd line: biological agent such as infliximab or rituximab
What is a normal T score for a person?
T Score of > -1.0
What is osteomalacia?
The poor mineralisation of bone secondary to Vit D deficiency
What will the levels of calcium and phosphate be like in a patient with osteomalacia?
They will both be low- as in phosphate LOW and calcium LOW
Also increased Alk Phosph and also increased PTH
What is the treatment for osteomalacia?
Adcal
What are the crystals you get in a gout sample?
Monosodium urate crystals
What type of crystals do you get in a pseudo gout sample?
You get calcium pyrophosphate
What is tophaceous gout?
This is when you get monsodium urate crystal deposits in the peripheral joints such as the hands and toes.
These crystals release proteolytic enzymes that break down bone and lead to a punched out appearance to the bone.
What is the management of an acute flare of gout?
Give a steroid injection and an NSAID like colchicine
What are two conditions associated with pseudo gout?
Haemochromatois
Hyper parathyroidism
Diabetes
How do you manage a patient that has a pseudo gout episode?
SAME AS Gout!!
Give steroid injections and also give the patient colchicine
What will an x ray of a pseudo gout joint show?
Chondrocalcinosis
What is the management for Paget’s disease of the bone?
NSAIDs for pain relief
Bisphosphonates
What are 4 Red Flags in a patient with lower back pain?
Younger than 20 or older than 55
Acute onset backache in elderly
Nocturnal pain
History of malignancy
Neuro signs
Is mechanical back pain typically unilateral or bilateral?
Unilateral
How would a mechanical lower back pain present?
Sudden onset
Unilateral
Stiff back and the muscles continuously are spasming
What is lumbar spondylitis?
It is a lesion in the intervertebral disc. This leads to it rotating, shrinking and bending.
Recognised on X Rays as dehydration
Likely for osteophyte formation.
What is the aetiology of polymyositis or dermatomyositis?
Unknown
Just know that dermatomyositis affects the skin
Polymyositis affects the muscle
What is the clinical presentation of polymyositis?
Symmetrical muscle weakness and wasting of the pelvis and the shoulder muscles
Struggles to walk and raise from a chair can eventually involve the respiratory system.
How does dermatomyositis present?
You get characteristic skin changes
Discolouration on the eyelids
Erythematous plaques on the knuckles
Common to get Raynauds, arthralgia and dysphagia
What are some general symptoms of dermatomyositis and polymyositis?
Fatigue Myalgia Joint pain and stiffness Skin changes Problems catching breath
How would you diagnose dermatomyositis or polymyositis?
Muscle Biopsy
Muscle enzymes: aminotransferase and creatinine kinase will all be raised
ANA and Myositis Specific ANtibodies (MSA) will all be positive
What is the treatment for polymyositis or dermatomyositis ?
Bed rest + prednisolone in flares
Immunosupression via cyclophosphamide in the meantime
What type of hypersensitivity reaction is SLE?
Type 3
What is the pathophysiology of SLE?
Well you get the cells damaged by immune complexes. These cells then undergo apoptosis. Remnants appear on the surface as self antigens containing DNA and histones
Presents theirselves to T cells and B cells and autoantibodies are made.
What are 5 symptoms/signs of SLE?
Fatigue + Fever
Arthralgia (symmetrical and small joints)
Skin: malar and discoid rash, raynauds + photosensitivity
Lungs: recurrent pleural effusions
Heart: pericardial effusions and pericarditis
Kidneys: glomerularnephritis
CNS: psychosis, depression and seizures
Give me 5 things you will see in a patient with SLE’s blood?
ESR raised but CRP normal
Low C3 and C4
ANA positive
anti-dsDNA positive
Anaemia of chronic disease
How would you manage SLE?
High dose steroid + DMARD cyclophosphamide
Use of anti-malarial hydrochloroquine for skin disease and fatigue
What does CLOT stand for in relation to antiphospholipid syndrome?
Coagulation defect (likely clots)
Livedo Reticularis (purple like discolouration of the skin)
Obstetric issues: recurrent miscarriage
Thrombocytopenia
How does APS typically present?
Recurrent DVT or PE or strokes
Miscarriages
Skin abnormalities
Low platelets: and problems relating to this.
What are the 3 blood tests you would like to do on a patient with suspected APS?
Anti-cardiolipin test
Lupus anticoagulant
Anti-B2 glycoprotein test
Need positive test 12 weeks apart x 2
What is the treatment of APS for
- Non pregnant women
- Pregnant women
- long term warfarin - aspirin and clopidogrel can be added
2. LMWH and aspirin
What is the treatment for Raynaud’s disease?
Nifedipine
What is the difference between
Raynaud’s Disease
Raynaud’s Phenomenon?
Raynaud’s Disease: no underlying cause
Raynaud’s phenomenon: underlying cause
What are the two types of systemic sclerosis?
Broadly what are the two ways to categories they’re difference?
- Limited cutaneous scleroderma (CREST) localised to skin
- Diffuse cutaneous scleroderma (DcSSc): skin changes + internal organs. Note the patient will have more progressive condition with this
What symptoms would you expect to see in a patient with Limited cutaneous scleroderma (CREST)?
Calcinosis
Raynauds
Oesphageal Dysmotility
Sclerodactly: thickening of skin at fingers and toes
Telenagiectasis: spider veins
What are the symptoms of Diffuse Cutaneous Scleroderma?
You get CREST + organ involvement
HTN
Nephritis
Pulmonary fibrosis
What antibody will you see in CREST or limited scleroderma?
Anti-centromere antibodies
What antibodies will you see in diffuse scleroderma?
anti RNA polymerase and anti topoisomerase 1 antibodies
If a patient with scleroderma has kidney disease too. What might you see?
- Microangiopathic haemolytic anaemia + protein urine
What can you use nail fold capillaroscopy on? What will it show ?
Scleroderma
Haemorrhages and avascular areas
What antibodies will be positive in Sjogren’s Syndrome?
Anti RO
Anti La
What will be seen in the glands of someone with Sjögren’s syndrome?
Lymphocytic infilitrates
What is the staining method used for Sjögren’s syndrome?
- Rose Bengal staining
What is a good medication to use to combat fatigue and arthralgia?
Hydroxychloroquine
Is large vessel vasculitis - ANCA positive or negative?
ANCA negative
What classification system do you use for patient with large cell vasculitis?
Chapel Hill classification
Give an example of a large cell vasculitis?
Giant Cell Arteritis
Are small vessel vasculitis positive or negative for ANCA
YES positive for c-ANCA generally
Is small vessel vasculitis more common in men or women?
Give an example of a type?
Men
Wegners , Kawasaki and Henoch Schonelin purpura
What is the management for someone with
A. Large vessel vasculitis
B. Small vessel vasculitis
A. Large Vessel: Steroids
B. Small Vessel: steroids and cyclophosphamide
What are 3 RF for osteomyelitis ?
Sickle Cell anaemia
Diabetes
Peripheral Vascular Disease
What is the method of spread in DM and PVD in relation to osteomyelitis?
Contagious Spread
What is the method of osteomyelitis spread in a patient who has sickle cell ?
Haematogenous
What are 3 causative organisms of osteomyelitis?
Staph Aureus
Staph Epidermidis
Pseudomonas
What investigations would you want to do in someone with suspected osteomyelitis?
Bone Biopsy
Blood Cultures +CRP and WCC
MRI or CT immediately
What are 2 complications of osteomyelitis?
Emphyema
Pericarditis
What two abx would you use to treat osteomyelitis?
IV clindamycin and Ciprofloxacin
What are 3 main causes of septic arthritis?
S Aureus
E.coli
Strep pneumoniae
N gonorrhoea
How long do you have to have symptoms to be diagnosed with CFS?
More than 6 months
Alongside persistent fatigue for more than 6 months. What other 4 criteria do you need to satisfy to get get a diagnosis of CFS?
Swollen lymph nodes
Persistent sore throat
Muscle ache
Brain fog
Polyarthralgia
Post extertional fatigue
Using the American College of Rheumatology Guidelines. How many pain sites need to be satisfied to diagnose fibromyalgia?
11 out of 18
Management: CBT and anti depressants, physio and pain relief
What 6 conditions are associated with the term ankylosing spondylitis?
Juvenile arthritis
Psoriatic Arthritis
Enteripathic arthritis
Reactive arthritis
Anklyosing Spondylitis
Anterior Uveitis
What are some general symptoms of all Ank Spond conditions?
Use the mneumonic SPINECHE
Sausage digits Psoriasis Inflammatory back pain NSAIDs good response Enthestitis Crohns HLA B27 Eye uveitis
What are the two types of bone?
Cortical (hard)
Trabecular (spongy and soft)
What is bone made up of?
Hydroxyapatite
Water
Type 1 collagen
What is a joint’s function?
Weight bear
Move in 3 dimensions
Transfer weight evenly
Give an example of a fibrous joint?
Teeth
Give an example of a cartilagenous joint?
Ribs
Give an example of a synovial joint?
Knee
What are the 4 stages of a fracture?
- Haematoma
- Inflammation + neovascularisation
- Repair
- Remodelling
What investigation would you do in ank spond?
What would you see?
Bamboo spine (synedesmophytes)
Inflammation of sacroiliac joints
Enthestitis
What name is given to the test to determine the flexibility of a patient’s spine. Commonly used in ank spond ?
Scober’s Test
In Ank Spond what will the pattern of pain be?
Radiates to the buttock and hip
Do you get symmetrical or as symmetrical joint involvement in ank spond ?
Assymetrical
What part of the hands are involved in psoriatic arthritis?
DIPJ
What condition causes telescoping of the fingers?
arthritis mutilans
How do you treat psoriatic arthritis?
- Methotrexate
- Methotrexate + ciclosporin
- Methotrexate + ciclosporin + anti TNF entancerpt
What is the management of reactive arthritis?
- NSAIDs and steroid injections
- Treat infection with abx
- Not remitting give methotrexate or sulfalazine
- TNF drug etancerpt (same as psoriatic)
