Rheumatology Flashcards

1
Q

If suspect RA on a hand exam, what else to examine?

A
  • Other joints including C spine
  • Blood pressure (overall CV risk)
  • Extra-articular manifestations of disease
    • Face: conjunctival pallor for anemia, eyes (Sjogren’s)
    • Lungs: fibrosis (RA-ILD, MTX-ILD), pleural effusions, Caplan’s syndrome / rheumatoid pneumoconiosis (nodular condition in RA when exposed to dust)
    • Heart: pericardial rubs (pericarditis)
    • Abdomen - splenomegaly (Felty’s), HSM (RA is a/w increased risk of lymphoma), injection sites (biologics)
    • Lower limbs - pyoderma gangrenosum, neuropathy, feet
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2
Q

Who gets rheumatoid nodules in RA?

And where are rheumatoid nodules, typically?

A

Rh factor +ve patients only

(Nothing to do with CCP)

Elbows (but can be anywhere)

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3
Q

What are the lung manifestations of RA?

A
  • ILD
    • Usually UIP
  • Pleural effusion
    • Exudative (high protein, LDH)
    • Low glucose (<2.2, rule out empyema & malignancy)
    • pH < 7.2 (rule out empyema, oesophageal rupture)
  • Lung nodules
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4
Q

Which single autoantibody is most specific for RA?

Which is more sensitive?

A

Anti-CCP / ACPA (specificity 95%)

RhF is more sensitive (but only 70%)

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7
Q

What are markers of poor prognosis in RA?

A

Early erosions on XR (the strongest)

RhF / Anti CCP

HIgh levels of inflammation (ESR and CRP)

HLA DRB1*04

Smoking

Extra articular features

Alfred lecture also said: high number of swollen and tender joints, functional limitation

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8
Q

What is this?

A

Remitting, seronegative, symmetric synovitis with pitting edema (RS3PE)

An atypical presentation of RA

A tenosynovitis

Might be a paraneoplastic pheneomenon

Very good response to low dose glucocorticoids

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9
Q

What are the features of OA on XR?

A

L: loss of joint space

O: osteophytes

S: subchondral cysts

  • can be mistaken as erosions

S: subchondral sclerosis

  • NB in RA there is periarticular osteopenia
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10
Q

What is the cause of this?

A

Psoriatic artthritis

  • Pencil in cup deformity
  • Ankylosis
  • Subluxation
  • Periostitis
  • Absence of periarticular osteopenia (differentiates from RA)
  • Arthritis mutilans
  • Hand joint involvement:
    • DIP, PIP
  • Other joints:
    • Feet, sacroiliac, spine
    • Knee, elbow, ankles, shoulders much less common

Remember: tends to effect ‘ray’ not ‘row’ in PsA

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11
Q

What is the cause of this?

A

Rheumatoid arthritis

  • Soft tissue swelling
  • Juxta-articular osteopenia
  • Joint space narrowing
  • Marginal erosions
  • Subchondral cysts
  • Subluxation and deformity - ulnar deviation MCP, boutonniere and swan neck, hitchhiker thumb
  • Hand joint involvement:
    • PIP and MCP (esp. MCP 2-3)
    • Ulnar styloid
    • Triquetrum
    • DIP spared
  • Other joints:
    • Feet (PIP, MTP esp 4-5)
    • Shoulder, hip, knee, C-spine
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12
Q

What are the causes of a positive rheumatoid factor?

A
  • SLE (~30%)
  • Sjogren’s (<100%)
  • Scleroderms (30%)
  • MCTD (50%)
  • Mixed cryoglobulinemia (100%)
  • Certain infections (malaria, rubella, Hep C, TB)
  • Malignancy
  • Healthy subjects (5-10%)
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13
Q

Can you use RhF or anti-CCP to monitor disease activity in RA?

A

No

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14
Q

What is palindromic rheumatism?

A

Atypical presentation of RA

  • Articular or sometimes periarticular pain, then swelling and erythema
  • Symptoms worsen for hours to a few days
  • Symptoms resolve in reverse sequence (think palindrome) with no residua
  • 50% will go on to develop RA - ACPA +vity helpful in predicting

Treatment: hydroxychloroquine (may reduce risk of progression to RA)

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20
Q

Who tends to get nodal generalised osteoarthritis?

A

post-menopausal females

usually have female family history of same

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21
Q
  • Compare the XR findings, specifically:*
  • -erosions*
    • joint space*
    • bone density*
  • in:*

Gout

RA

PsA

A

Gout

Punched out erosions, joint space preservation, tophi

RA

Juxta articular cortical erosions, joint space narrowing, osteopenia

Psoriatic arthritis

Pencil in cup, bony proloferation / periostitis, DIPJ involvement

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22
Q

What tests would you like to order if you suspect RA?

A
  • FBE (anaemia related to disease e.g. chronic disease / Felty’s or related to treatment eg bleeding due to NSAIDs / steroids, folate deficiency / cytopenia related to MTX)
  • ESR / CRP
  • RhF (not specific, do NOT monitor for disease activity)
  • Anti-CCP (specific, do NOT monitor for disease activity)
  • Hand XR

Other / wholistic tests

  • Imaging of the other joints including lateral C spine XR to rule out atlanto-axial subluxation
  • CXR /CT chest if suspect ILD / effusions / Caplan’s syndrome / nodules
  • TTE if suspect pericarditis
  • Lipids / HbA1c for CV risk
  • Vitamin D / calcium / DEXA if suspect OP (due to treatment / steroid exposure or RA on its own)
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23
Q

What are the causes of a symmetrical, deforming polyarthopathy?

A
  • Rheumatoid arthritis
  • Psoriatic arthritis or enteropathic arthritis (other spondyloarthopathies eg. reactive arthritis tend to cause a mono arthritis)
  • Osteoarthritis [although usually asymmetrical or a mono/oligo arthritis]
  • Polyarticular gout / chronic tophaceous gout [although gout / CPDD usually asymmetrical or a mono/oligo arthritis]
  • Jaccoud’s arthropathy of SLE
  • ??Systemic sclerosis
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24
Q

What are the XR features of RA

A

L - loss of joint space

O - osteopenia

S - soft tissue swelling

E - erosions (juxta/periarticular, but intra-articular in severe)

D - deformity

25
Q

Spiel for assessing disease activity

A

Number of tender / swollen joints

in conjunction with inflammatory markers

+ in a SpA may also examine for activity of eye / bowel / skin involvement which can mimic disease activity

26
Q

Types of PsA?

A

Types of psoriatic arthritis

  1. Symmetrical-deforming polyarthritis sparing the DIPJs (rheumatoid-like)
  • Most common
  • Very similar to RA but usually sero-negative
  1. Asymmetrical oligoarthritis involving the DIPJs
  • Second most common
  • associated with dactylitis (soft tissue swelling)
  1. DIP arthritis
  • Second-least common
  • Associated with nail changes
  1. Spondylitis / sacroiliitis
    * Third most common
  2. Arthritis mutilans
  • Least common
  • Severe osteolysis / pencil in cup
27
Q

OTHER EXAMINATION IF SUSPECT PSA?

A

Other joints

Including back exam for axial disease (and perform Schober’s test)

Including enthesopathy (achilles tendons and plantar fascia)

Skin - scalp, navel, natal cleft and behind the ears for evidence of psoriasis

Face - uveitis, episcleritis

Lung - apical lung fibrosis in AS

Heart - murmur of aortic regurgitation

Abdomen - tenderness due to association with IBD

28
Q

What are the XR changes of PsA?

A

Osteolysis & pencil in cup deformity

Periostitis (to make ‘mouse ears’ and ‘fluffy’ appearance)

Involvement of DIPJs

(DDx erosive OA)

29
Q

Tests to order in a symmetrical deforming polyarthopathy

A

FBE (anaemia related to disease e.g. chronic disease)

ESR / CRP

RhF, Anti-CCP (although the former not specific to RA)

ANA, anti-dsDNA, anti-Smith (if suspect SLE / Jaccoud’s Arthopathy)

U1RNP if suspect MCTD

Anti-centromere Ab, RNA-polymerase III, scl-70

HLAB27

Uric acid level

Hand XR

Other / wholistic tests

Imaging of the other joints including lateral C spine XR to rule out atlanto-axial subluxation, spine/SIJ if suspect lumbar spine involvement in SpA

CXR /CT chest if suspect ILD / effusions / Caplan’s syndrome

TTE if suspect pericarditis

Lipids / HbA1c for CV risk

Vitamin D / calcium / DEXA if suspect OP (due to treatment / steroid exposure or RA on its own)

Urinylasis if suspect Jaccoud’s arthopathy / SLE

30
Q

What is the features of gout on synovial fluid analysis?

What is the features of pseudogout on synovial fluid anlaysis?

A

The true purist would say you need to see intracellular (intra-neutrophil) crystals; you can see uric acid crystals in a joint with OA!

  • Monosodium urate (gout)
    • Brightly, negatively birefringent in polarized light, needle-shaped
    • Negatively birefringent = turn yellow when aligned parallel to the light source, turn blue when perpendicular

can remember: yeLLow when paraLLel

  • Calcium pyrophosphate dehydrate (pseudogout)
    • Weakly, positively birefringent, rhomboid or rectangular
    • Positively birefringent = turn blue when aligned parallel to the light source, turn yellow when perpendicular
31
Q

How should gout be diagnosed?

A
  • Definitive diagnosis requires the identification of monosodium urate crystals under polarised microscopy in synovial (or bursal) fluid or tophi
  • Once have a definitive diagnosis, diagnostic aspiration is not required for recurrent attacks unless infection is suspected
32
What is the target serum uric acid concentration of patients on uric-acid lowering therapy? What is a normal uric acid level?
* Target serum uric acid **\< 0.36 mmol/L** (6 mg/dL) for patients with non-tophaceous gout * Target serum uric acid **\< 0.30 mmol/L** (5 mg/dL) for patients with tophaceous gout * *The presence of tophi indicates a higher urate load* **Normal uric acid is \<0.41**
33
On synovial fluid analysis, what WCC is typical of a non-inflammatory cause of an arthopathy?
200 - 2,000
34
On synovial fluid analysis, what WCC is typical of an inflammatory cause of an arthopathy?
2,000 to 50,000 - 100,000
35
On synovial fluid analysis, what WCC is typical of an infective cause of an arthopathy?
\> 50,000
36
Differntial diagnosis of monoarthritis
* Septic arthritis * Bacterial, non-gonoccal arthritis * Gonococcal arthritis * Crystal * Gout (monosodium urate crystals) * Pseudogout (calcium pyrophsophate deposition disease) * Sondyloarthopathies * OA
37
Xray changes in pseudogout
Chondrocalcinosis radiographic calcification in hyaline and/or fibrocartilage
38
What are the sites of CPDD?
Wrist Knee
39
Hand and face findings in systemic sclerosis?
_Hands_ Dilated nail fold capillaries Nail dystrophy Sclerodactyly **Ask them to put the pulps of their fingers on their MCPs, not make a fist** Loss of finger pulps and pseuoclubbing Raynauds Digital ulceration Calcinosis _Face_ Telangiectasia (in the mouth also) Perioral puckering Reduced mouth apeture
40
Systemic sclerosis other things to examine?
Chest and abdomen to see if sclerodactyly involvement there Blood pressure & _urine disptick_ renal exam for SRC Resp exam - evidence of ILD Cardiac exam - pericardial rub (_pericarditis_), pulmonary hypertension Gastrointestinal exam and examination of oral cavity for dental hygeine (reflux and reduced mout aperture)
41
Invetsigations for scleroderma
ANA Anti-centromere antibody Scl-70 (topoisomerase) RNA polymerase HRCT / TTE Urine dipstick UEC
42
Colour changes in Raynauds
White then blue then red
43
What are some differntials for nodules?
Gouty tophi Rheumtoid nodules Calcinosis cutis CPDD can also cause nodules Tenodon xanthelmatas
44
IF YOU DON'T SEE OBVIOUS DEFORMITY THINK OF
Systemic sclerosis Dermatomyositis / Polymyositis
45
DIfferentials for a rash in a rheum exam
Psoriasis Rash of Still's disease Telangiactasia Mechanic's hands Gottren's papules Heliotrope rash Shawl sign
46
Ix in dermatimyositis / polymyositis
CK ANA ENA 'Myositis specific antibodies' EMG MRI Skin / Muscle biopsy
47
What other examination in dermatomyositis / polymyositis?
Proximal muscle strength Respiratory exam for anti-synthetase syndrome (anti-Jo1) Examine for LAD and abdomen given increased risk of cancer (adenocardinomas)
48
49
Xray PsA vs erosive OA
Both involve DIPJ PsA - pencil in cup, periosititis, M=F erosive OA - gull wing, post menopausal females