Rheumatology Flashcards
1
Q
Hand deformities in RA
A
Swan’s neck - DIP flexion, PIP hyperextension
Boutonnière’s - DIP hyperextension, PIP flexion
Z shaped thumb
Ulnar deviation of fingers at the knuckle
2
Q
Antibodies present in RA
A
Rheumatoid factor (RF) Anti-CCP - this is more sensitive and specific
3
Q
Genetic associations with RA
A
HLA DR4
HLA DR1
4
Q
Clinical Presentation of RA?
A
Symmetrical distal polyarthopathy Pain, swelling and stiffness Of joints - worse after rest and better with activity Fatigue Weight loss Muscle aches and weakness
5
Q
Joints typically affected in RA?
A
Small joints of hands and feet, typically wrist, ankle, MCP and PIP
Cervical spine
Knee, hip and shoulders can be affected in later disease
6
Q
What is atlanto axial subluxation
A
Occurs in C2/C1 cervical spine in RA
Local synovitis and damage to ligaments and bursa around the odontoid peg of the axis and atlas
This can lead to spinal cord compression - this is an emergency
Particularly important if patient is having surgery and requiring intubation - this can be checked with MRI scan
7
Q
Extra articular manifestations in RA
A
Pulmonary fibrosis Bronchiolitis obliterens Feltys syndrome (RA, neutropenia and splenomegaly) Sjögren’s syndrome Anaemia of chronic disease Episcleritis Rheumatoid nodules Carpel tunnel Amyloidosis
8
Q
What is felty’s syndrome
A
Triad of:
RA
Neutropenia
Splenomegaly
9
Q
Investigations used to diagnose RA
A
RF, anti-CCP
CRP, ESR
X-rays of hands and feet
10
Q
X ray changes in RA
A
LESS: L - loss of joint space E - bony erosions S - soft tissue swelling S - see through bones (osteopenia)
11
Q
How is disease activity monitored in RA
A
Using DAS28 score Scores joint for: - swollen joints - tender joints - ESR/CRP level
Can also do a health assessment questionnaire (HAQ) to check patients own response to treatment on lifestyle factors
12
Q
Markers of poor prognosis in RA
A
Younger onset Male sex More joints/organs affected Presence of RF and anti-CCP Erosions seen on X-ray HLA DR4
13
Q
Management of RA
A
1st line - DMARD monotherapy (usually methotrexate)
- note that a short course of steroids can be used at first presentation to quickly settle disease
2nd line - add 2nd DMARD e.g, sulfasalazine, leflunomide
3rd line - TNF inhibitor e.g, etanercept, adalimumab, infliximab
14
Q
What blood tests needs to be done prior and during methotrexate treatment and why
A
FBC and LFTs - due to risk of myelosuppression and liver cirrhosis
15
Q
Which DMARDs are safe to use in pregnancy?
A
Sulfasalazine
Hydroxychloroquine
16
Q
Side effects of methotrexate
A
Mouth ulcers and mucositis Liver toxicity Pulmonary fibrosis Bone marrow suppression and leukopenia It is teratogenic in pregnancy
17
Q
What other medication should be co prescribed with methotrexate?
A
Folic acid 5mg
Given on different day (Methotrexate Mondays, folate Fridays)
As methotrexate interferes with metabolism of folate and suppressing certain components of the immune system. Taking folate helps reduces side effects of methotrexate
18
Q
Notable side effects of other DMARDs
A
Leflunomide - peripheral neuropathy
Sulfasalazine - temporary male infertility
Hydroxychloroquine - nightmares
19
Q
What is the main side effect of Anti-TNF medications to remember?
A
Reactivation of TB or Hep B
20
Q
What are the two main patterns of disease in systemic sclerosis?
A
Limited cutaneous systemic sclerosis
Diffuse cutaneous systemic sclerosis
21
Q
What are the features of limited cutaneous systemic sclerosis?
A
CREST syndrome:
C - calcinosis (white spots on fingertips)
R - Raynaud’s phenomenon
E - oesophgeal dysmotility (presents with reflux)
S - sclerodactyly (Hardening of skin which causing finds to curl in and make claw shape)
T - telangiectasia (dilated small blood vessels in the skin)
22
Q
Features of diffuse cutaneous systemic sclerosis
A
CREST symptoms +
Cardiovascular problems - HTN and coronary artery disease
Lung problems - pulmonary hypertension and pulmonary fibrosis
Kidney problems - glomerulonephritis
23
Q
Antibodies in systemic sclerosis?
A
ANA
Anti centromere - associated with limited diffuse systemic sclerosis
Anti scl-70 - associated with diffuse systemic sclerosis
24
Q
Lupus is more common in which population group?
A
Women of Afro-Caribbean origin
25
Features of lupus
```
Fatigue, weight loss
Arthralgia, myalgia
Photosensitive malar rash
Lymphadenopathy
Mouth ulcers
Raynauds
Livedo reticularis
Glomerulonephritis
Shortness of breath, pleuritic chest pain
```
26
What happens to C3 and C4 in active lupus
Levels decrease
27
Antibodies associated with lupus
ANA
Anti-dsDNA
Others:
Anti-smith (highly specific but not very sensitive)
Antiphospholipid - can occur secondary to SLE
28
Management of SLE?
NSAIDS + steroids
Mild SLE - hydroxychloroquine
Moderate/severe - methotrexate or other DMARD
29
3 types of antiphospholipid antibodies
Lupus anticoagulant
Anticardiolipin antibodies
Anti-beta-2 glycoprotein I antibodies
30
What is livedo reticularis?
Purple lace like rash that gives a mottled appearance to the skin
Found in lupus and antiphospholipid syndrome
31
Features of antiphospholipid syndrome
```
Venous/arterial thrombosis
Recurrent miscarriages
Livedo reticularis
Thrombocytopenia (low platelets)
Prolonged APTT
```
32
Management of antiphospholipid syndrome
Primary thromboprophylaxis - low dose aspirin
| Secondary thromboprophylaxis - lifelong warfarin (target INR 2-3), if recurrent then target INR 3-4
33
Which drugs can cause drug induced lupus?
```
Procainamide
Hydralazine
Isoniazid
Minocycline
Phenytoin
```
34
Criteria used for diagnosis of septic arthritis
```
Kosher criteria:
Fever >38.5
Non weight bearing
Raised ESR
Raised WCC
```
35
Investigations in septic arthritis
Synovial fluid sampling
Blood cultures
Joint X-ray
36
Management of septic arthritis
Obtain synovial fluid for sampling
| IV abx - flucloxacillin (clindamycin if penicillin allergy)
37
Causes of Gout
```
DART:
D - diuretics
A - alcohol
R - renal disease
T - trauma
```
38
Joint aspiration in gout
Monosodium urate crystals
Needle shaped
Negatively birefringent
39
Management of gout
NSAIDS or Cochicine - given for 1-2 days until symptoms settle
40
When should urate lowering therapy be given to patients with gout?
2 weeks after first attack - give allopurinol
Give colchicine cover in first 6 months - as allopurinol can initially trigger gout attacks
Urate lowering therapy can be continued throughout further attacks
41
What lifestyle modifications can people with gout do to limit disease?
Cut back on alcohol
Avoid foods high in purines e.g, meat and seafood
Lose weight if obese
42
What are gouty tophi?
Subcutaneous deposits of uric acid affecting the small joints - most common in DIP
43
Most commonly affected joint in gout
1st metatarsophalangeal joint
44
Diseases associated with pseudogout
Haemochromatosis
Hyperparathyroidism
Acromegaly
Wilson’s disease
45
Joint aspiration in pseudogout
Calcium pyrophosphate dehydrate crystals
Rhomboid shaped
Positively birefringent
46
X-ray findings in pseudogout
Chondrocalcinosis
47
Management of pseudogout
Symptoms usually resolve over several weeks
| NSAIDs for symptomatic relief
48
Population group usually affected by polymyalgia rheumatica
Females
>50 years
More common in Caucasians
49
Features of polymyalgia rheumatica
```
At least a 2 week history of:
Bilateral shoulder pain
Bilateral pelvic girdle pain
Worse with movement
Interferes with sleep
Stiffness for at least 45 minutes in the morning
```
50
Management of polymyalgia rheumatica
15mg prednisolone OD - pts should have good response to this
If after 3-4 weeks a good response has occurs then start a reducing regime:
15mg until symptoms controlled
12.5mg for 3 weeks
10mg for 4-6 weeks
Then reduce by 1mg every 4-8 weeks
51
Measures for people on long term steroids
DON’T STOP
DON’T - don’t stop taking suddenly due to risk of adrenal crises
S - sick day rules (increasing dose)
T - treatment card
O - osteoporosis prevents .eg, bisphosphanates, calcium and vit d
P - PPI for gastric prevention
52
Presentation of giant cell arteritis
Severe unilateral headache around temple/forehead
Scalp tenderness when brushing hair
Jaw claudication
Blurred/double vision
53
Main complication of giant cell arteritis
Painless vision loss (which is irreversible)
54
Findings on temporal artery biopsy in giant cell arteritis
Multinucleated giant cells
Note that there may be skip lesions so a normal biopsy does not rule out diagnosis
55
Diagnostic investigation in giant cell arteritis
Raised ESR >50
56
Management of giant cella arteritis
High dose prednisolone- 40-60mg per day
Review response to steroids within 48 hours
Referral to:
- Vascular surgeons - temporal artery biopsy
- Rheumatology - for same day assessment
- Ophthalmology - if any eye symptoms
57
What is ankylosing spondylitis?
Type of spondyloarthropathy (arthritis in spine)
58
Ankylosing spondylitis typically occurs in which population group
Young males
59
What is schober’s test
Test for ankylosing spondylitis
Line drawn 10cm above and 5cm below L5 vertebrae
Get patient to bend forward and measure distance between points
If this distance is <20cm - it suggests restrictions in lumbar movement
60
Joints typically affected in ankylosing spondylitis
Sacroiliac joints
| Joints of vertebral column
61
X-ray findings in ankylosing spondylitis
Sacroilitis - subchondral erosions, sclerosis
Syndesmophytes - ossification of outer fibres of annulus fibrosis
Bamboo spine - due to fusion of spine and sacroiliac joints due to inflammation and stiffness in the joints (Note this only occurs in later disease and is rarely seen in clinical practice)
62
Gene associated with ankylosing spondylitis
HLA-B27
63
Presentation of ankylosing spondylitis
Lower back pain and stiffness - worse with rest and improves with movement
Pain worse at night
>30 mins of stiffness in morning
Symptoms occur in flares
64
Disease associations with ankylosing spondylitis
```
6 A’s:
Anterior uveitis
Atypical fibrosis (Restrictive lung disease)
Aortic regurgitation
Achilles tendinitis
AV node block
Amyloidosis
```
Inflammatory bowel disease
65
Management of ankylosing spondylitis
1st line - NSAIDs
2nd line - steroids
3rd line - ant-TNF medications
66
Features of psoriatic arthritis
Psoriasis
Pitting of nails
Onycholysis
Dactylitis (inflammation of finger)
67
X-ray changes in Psoriatic arthritis
Periostitis - inflammation of periosteum causing thickened and irregular outline of bone
Osteolysis - destruction of bone
Dactylitis - infalmmation of digit and tissue swelling
Pencil in cup appearance- due to central erosions of the bone beside the joints which causes the appearance of one bone in the joint being hollow and one looking like a cup
68
Management of psoriatic arthritis
1st line - NSAIDs
2nd line - DMARDS
3rd line - Anti-TNF
69
Features of reactive arthritis
Can’t see, pee or climb a tree:
Anterior uveitis or bilateral conjunctivitis
Urethritis or cercinate balantis (dermatitis of head of penis)
Arthritis - asymmetrical oligo arthritis of lower limbs
70
What is reactive arthritis
Arthritis that develops following and infection where the organism cannot be recovered from the joint
71
After What infections does reactive arthritis commonly occur
Sexually transmitted infections e.g, chlamydia, gonorrhoea
Also gastroenteritis e.g, campylobacter, salmonella
72
Management of reactive arthritis
1st line - NSAIDS
| 2nd line - DMARDS (used for persistent disease)
73
How long do symptoms of reactive arthritis usually last
Usually around 4-6 months
| Rarely last longer than 12 months
74
What is Sjögren’s syndrome?
Autoimmune condition affecting the exocrine glands
75
Features of Sjögren’s syndrome
Dry mouth
Dry eyes
Dry vagina
76
Antibodies associated with Sjögren’s syndrome
Anti-ro
| Anti -la
77
Management of Sjögren’s syndrome
Artificial tears / saliva
Vaginal lubricants
Hydroxychloroquine - used to halt progression of the disease
78
What disease are patients with Sjögren’s syndrome more at risk of?
Lymphoid malignancy e.g, non Hodgkin’s lymphoma
79
What is osteoarthritis
Wear and tear in the joints leads to pain and stiffness
80
X Ray changes in osteoarthritis
```
LOSS:
Loss of joint space
Osteophytes
Subchondral cysts
Sub articular sclerosis
```
81
Features of osteoarthritis
Joint pain and stiffness
| Worsening with activity
82
Commonly affected joints in osteoarthritis
```
Large joints usually affected:
Hips
Knees
Sacro-iliac joints
DIPs (note this is different to RA as these aren’t affected)
MCP
Wrist
Cervical spine
```
83
Signs in hands for osteoarthritis
```
Haberdens nodes (DIPs)
Bouchard nodes (PIPs)
Squaring of thumb
Weak grip
Reduced range of motion
```
84
Management of osteoarthritis
Weight loss, physiotherapy
Analgesia - oral paracetamol and topical NSAIDs
Steroid injections
Joint replacement - for severe cases
85
What is osteomalacia
Normal bone tissue but decreased mineral content resulting from insufficient vitamin D
86
Presentation of osteomalacia
Fatigue
Bone pain
Muscle weakness
87
Investigation results in osteomalacia
Reduced calcium
Reduced phosphate
Raised Alkalaine phosphatase
88
Management of osteomalacia
Supplementary vitamin D (colecalciferol)
89
Risk factors for low vitamin D
Cold climates
Darker skin
Reduced exposure to sunlight - e.g. spending lots of time indoors
90
What is the risk of osteomalacia in young children?
Rickets
91
Risk factors for osteoporosis
```
Older age
Female
Reduced mobility and activity
Low BMI
Rheumatoid arthritis
Alcohol/smoking
Long term steroid use
Other medications - SSRIs, PPIs, anti-oestrogens
```
92
What is the FRAX tool
Gives a prediction of the risk of a fragility fracture over the next 10 years
This is usually the first step in assessing someone’s risk of osteoporosis
93
What is osteoporosis
Reduced bone density of the bones (which increases risk of fractures as bones aren’t as strong)
94
What is a DEXA scan
Duel energy XRay absorptiometry
| Measures bone mineral density - classically done at the hip
95
Difference between Z and T score
Z scores - BMD compared to mean for their age
| T score - BMD compared to that of a young healthy adult
96
Interpretation of T scores
>-1 = normal
| -1 - -2.5 = osteopenia
97
When would you perform a FRAX assessment?
On patients at risk of osteoporosis
Women >65
Men >75
Younger patients with risk factors e.g, Hx of falls, low BMI, longe term steroid use , RA
98
When would you perform a DEXA scan?
If the FRAX score comes back as intermediate risk
| Note if FRAX is high risk then start treatment straight away
99
Lifestyle management of osteoporosis
Activity and exercise
Maintain healthy weight
Adequate calcium and vit D
Stop smoking/alcohol
100
Medical management of osteoporosis
Calcium/vit D supplements - if have inadequate calcium
Bisphosphonates - which prevent osteoclast activity
1st line - alendronate
2nd line - risedronate
3nd line - denoxumab (if bisphosphonates not tolerated)
101
Side effects of bisphosphonates
Reflux and oesophageal erosions
Atypical fractures
Osteonecrosis of jaw
102
How should patients take bisphosphonates
Taken once a day
30 mins before food in the morning
Sitting upright for 30 minutes before moving or eating
103
When would patients with osteoporosis have a treatment holiday
Assess FRAX and DEXA after 3-5 years on bisphosphonate treatment
If BMD has improved and not suffered any fractures - then they may have a break from treatment of 18 months - 3 years before repeating assessment
104
What is Paget’s disease of the bone
Increased but uncontrolled bone turnover
105
Which bones does Paget’s disease of the bone usually affect?
Skull, lumbar spine, pelvis and long bones
| Can be remembered by drawing imaginary line down centre of patient
106
Investigation findings in Paget’s disease
Calcium and phosphate are normal
| Isolated raised alkaline phosphatase
107
Antibodies in Granulomatosis with polyangitis (GPA)
CANCA and PR3
108
Antibodies in eosinophilic granulomatosis with Polyangitis
PANCA and MPO
