rheumatology Flashcards
signs of rheumatoid arthritis
limited ROM ulnar deviation swan neck boutonniere z thumb rheumatoid nodules
presentation of RA
red hot swollen painful joint with EMS
normally affects symmetrically, the small joints before large
extraarticular
scleritis, episcleritis, sjogren’s
pulmonary effusions, pulmonary fibrosis, pericarditis
splenomegaly, anaemia, amylodosis
investigations for RA
CRP, ESR
RF, anti CCP
x ray (JS narrowing, soft tissue swelling, erosions, periarticular osteopenia)
US for synovitis
management of RA
1st line: methotrexate + infliximab combination therapy
2nd line: triple therapy (methotrexate, hydrochloroquine, sulfasalazine)
adjucts: NSAIDs, corticosteroids
side effects of methotrexate
GI upset, alopecia, risk of infection, nephrotoxic, hepatotoxic
side effects of infliximab
flu like symptoms immune deficiency (risk of legionella and listeria infection)
cause of gout
primary: lesch nyhan syndrome
secondary: renal fairue, thiazide diuretic use, high intake, luekemia
presentation of gout
most commonly the MTP, knee
severe pain, sudden onset
red, hot swollen
investigations for gout
aspirate - negatively birefringent needle shape crystals
serum urate
U&Es
rule out other causes: ANA, RF, antiCCP, x ray
causes of psuedogout
hypo/hyper thyroidism
hyperparathyroidism
hemochromatosis
renal impairment
presentation of pseudogout
commonly knees, wrists, elbows
acute, red, swollen painful joint
investigations for pseudogout
aspirate - positively birefringent rhomboid shaped crystals bone profile (vit D, Ca, PTH)
management of gout
acute: NSAIDs or colchicine (also corticosteroids, anti IL1 biologics)
chronic: lifestyle changes, allopurinol
management of pseudogout
NSAIDs
colchicine
intraarticular dexamethasone
causes of reactive arthritis
virus: rubella, EBV, mumps
GI: salmonella, shigella, campylobacter
chlamydia trachomatis
presentation of reactive arthritis
usually acute symmetrical lower limb
classic trial: arthritis, conjunctivitis, urethritis
keratoderma blennorrhagia
following a diarrhoeal/urinary infection
can cause cardiac complications: aortic regurgitation, aortitis
investigations for reactive arthritis
CRP, ESR, WCC
urinary NAAT, rectal/throat swabs
stool cultures
rule out other causes: RF, ANA, joint aspirate, XRay
management of reactive arthritis
NSAIDs
intraarticular steroids
no evidence for treating underlying infection
self limiting but can be up to 6 months
presentation of inflammatory back pain
age < 40 insidious onset improves with exercise no improvement with rest pain > 3 months
presentation of ankylosing spondylitis
inflammatory back pain uveitis, enthesitis loss of lumbar lordosis reduced flexion (schobers test <5cm) associated with IBD and psoriasis
investigations for ankylosing spondylitis
HLA B27 positive
x ray
spine - vertebral squaring, bamboo spine
pelvis - sacroiliitis
management of ankylosing spondylitis
NSAIDs
TNFa blocker - infliximab
sulphasalazine for peripheral joint involvement
presentation of psoriatic arthritis
asymmetric, common in hands (DIP)
skin changes (scalp lesions, nail dystrophy, psoriatic lesions)
uveitis
investigations for psoriatic arthritis
HLA Cw6
x ray hands DIP erosions lysis of terminal phalanges asymmetry pencil in a cup deformity
what is the CASPAR diagnostic criteria used for
psoriatic arthritis
management of psoriatic arthritis
NSAIDs
intraarticular steroids
infliximab
topical steroids for skin and nails
presentation of enteropathic arthritis
typically knee
abdo pain, diarrhoea, fever, LGI bleed, weight loss
bilateral posterior uveitis
investigations for enteropathy arthritis
HLA B27
CRP, ESR
colonoscopy and faecal calprotectin
presentation of SLE
fever, malaise, fatigue, myalgia
malar rash, discoid rash, photosensitivity, oral ulcers
renal disease (nephritis/ESRF)
CNS disease (headaches, seizures, anxiety)
haemotalogical disease: anaemia, TTP
serositis: pluerisity, pleural effusions, pericarditis
arthritis
investigations for SLE
ANA, anti dsDNA, anti SM, antiphospholipid, anti Ro, anti La, anti RNP
high ESR but normal CRP
complement decreased
urinalysis, serum creatinine, urine PCR, renal biopsy
x ray joints(arthritis), chest (serositis)
management of SLE
smoking cessation topical steroids/sunblock for skin NSAIDs methotrexate cyclophosphamide rituximab
presentation of Giant cell arteritis
temporal headache amaurosis fugax jaw claudication polymyalgia rheumatica malaise, fatigue, fever
investigations for temporal arteritis
raised CRP and ESR
temporal artery USSS - halo
temporal artery biopsy
management of temporal arteritis
prednisolone
methotrexate
tocilizumab
presentation of polymyalgia rheumatica
shoulder/hip pain - worse in morning, symmetrical
morning stiffness lasting >1hr
fatigue, wt loss, fever
management of polymyalgia rheumatica
prednisolone
what is takayasu arteritis
a large cell arteritis affecting the aorta and its major branches can result in aortic regurgitation stenosis aneurysm formation hypertension
presentation of henoch schonlein purpura
purpuric rash commonly on the thigh and buttocks, associated with other skin changes (urticarial rash, confluent petechiae, ecchymoses)
arthralgia/arthritis
GI - abdo pain, bleeds, diarrhoea, intussusception
small vessel arteritis and their ANCA association
granulomatosis with polyangitis - cANCA and PR3
microscopic polyangitis - pANCA and MPO
HSP - ANCA negative
presentation of GPA
URT: rhinitis, sinusitis, septal perforation
LRT: dyspnoea, haemoptysis
renal: RPGN (haematuria, oliguria, hypertension)
constitutional: fatigue, fever, myalgia
presentation of MPA
necrotising vasculitis resulting in RPGN and pulmonary haemorrhage
Presentation of scleroderma
limited cutaneous = CREST + mainly distal extremties, later onset of visceral involvement
diffuse cutaneous = distal, proximal, trunk, face, early visceral involvement
CREST syndrome
calcinosis raynaud's eosophageal involvement sclerodactyly telangiectasia
visceral involvement of scleroderma
vascular: raynaud’s
skin: digital ulceration, oedematous
MSK: polyarthritis
GI: reflux, malabsorbtion and wt loss, constipation
resp: interstitial fibrosis, pulmonary hypertension
cardiac: pericarditis, HF, arrhythmias
Renal: glomerulosclerosis
investigations for scleroderma
FBC, ESR, U&Es urinalysis ANA anti Scl 70 (diffuse) anticentromere (limited)
management of scleroderma
raynauds - amlodipine
digital ulcers: phosphodiesterase 5 inhibitor
oesophageal involvement: PPI
arthritis: methotrexate
presentation of polymyositis
Proximal muscle weakness Muscle atrophy dysphagia dyspnoea In dermatomyositis, characteristic heliotrope rash and gottron's papules
investigations for polymyositis
elevated CK, LDH, adolase ESR ANA, anti Jo 1 (associated with interstitial lung disease) MRI EMG muscle biopsy
management of polymyositis
prednisolone
methotrexate/azathioprine
IVIG, plasmapheresis, biologics
risk of pregnancy and CTD
anti Ro/anti La - neonatal lupus syndrome
anti Ro - congenital heart block
antiphospholipid antibodies - miscarriage
SLE - pre-eclampsia, feotal growth retardation, prematurity
presentation of sjogren’s
dry eyes (itchy, FB sensation) dry mouth (swallowing difficulty, decreased taste) fatigue
Less common (dry skin, vaginal dryness, arthralgia, myalgia)
investigations for sjogrens
schirmer test
Anti Ro, anti La
management of sjogrens
artificial tears salivary substitutes ciclosporin eye drops pilocarpine NSAIDs for MSK pain
