Rheumatology and Dermatology Flashcards
What are some possible modes of treatment for atopic dermatitis (eczema)?
- Calcineurin inhibitors: tacrolismus, pimecrolismus
- Topical steroids
- Antibiotics for open lesions
- Antihistamines
- Leukotriene inhibitors: montelukast
- UV light therapy
- Systemic steroids
- Immunosuppressive drugs: methotrexate, cyclosporin, azathioprine
How does one diagnose osteoporosis?
Bone mineral density test (DEXA: dual energy X-ray absorptiometry): T-score <= 2.5
What are the possible complications of osteoporosis?
- Vertebral crush fractures
>> Acute back pain
>> Loss of height
>> Kyphosis - Pathological fractures
>> Femoral neck fracture
>> Distal radius (Colles) fracture
What are the possible treatments for osteoporosis?
>> GO-TO regimen: bisphosphonate +/- SERM
- Bisphosphonates (e.g. risendronate, etidronate, alendronate etc.)
- PTH (e.g. teriparatide) - not to exceed 2 years, and must take bisphosphonate after stopping PTH to maintain BMD
- SERM (e.g. raloxifene)
- Testosterone/conjugated estrogen replacement
- Calcitonin spray - Denosumab
What are the side effects of bisphosphonates?
- Errosive esophagitis: needs to remain upright 30 minutes after drug intake
- Osteonecrosis of the jaw
What are the indications for bisphosphonates?
- Osteoporosis
- Paget’s disease of the bone
- Humoral hypercalcemia of malignancy
What are the possible complications of osteopetrosis?
- Pathological fractures
- Narrowed foramina
>> Cranial nerve impingement
>> Cranial nerve palsies - Marrow infiltration
>> Pancytopenia
>> Extramedullary hematopoiesis
What are some presenting features of Paget disease of bone?
- Increasing HAT SIZE – hats getting too tight
- Narrowing of the auditory foramen: hearing loss
- Bone pain and deformities
- Long bone chalk-stick fractures >> Increased risk for osteosarcoma
What are the stages of Paget disease of bone?
- Lytic: increased osteoclastic activity
- Mixed: increased both osteoclastic/osteoblastic activity
- Sclerotic: increased osteoblastic activity
- Quiescent: minimal osteoclastic/osteoblastic activity
What is the treatment for Paget disease of bone?
Bisphosphonates: alendronate, risendronate etc.
What are the underlying etiologies of osteitis fibrosa cystica?
- Hyperparathyroidism
- Primary pseudohypoparathyroidism (Albright hereditary osteodystrophy)
>> PTH increased >> increased bone turnover with increased osteoclastic activity
What is the defining histological feature of osteitis fibrosa cystica?
“Brown tumours” in bone: cystic spaces lined by osteoclasts filled with fibrous stroma and blood
What are the features of McCune-Albright Syndrome?
- Cafe au lait spots
- Early/Precocious Puberty
- Abnormal Bone: polyostotic fibrous dysplasia (bone is replaced by collagen and fibroblasts with irregular bony trabeculae)
What is the most common type of hip dislocation? What is the most common cause of the above type?
Posterior dislocation of the hip
- Motor vehicle accident: when the knee is flexed and hips slightly abducted –> knee hits the dashboard
What structures can be damaged in a posterior dislocation of the hip?
- Medial circumflex femoral artery
- Lateral circumflex femoral artery
- Femoral vein
- Femoral nerve
- Head of femur
What is the most common cause of the unhappy triad?
Common contact sports injury
- Lateral force applied to a planted leg
What is the unhappy triad?
- MCL
- ACL
- Medial or lateral lemniscus
>> Lateral lemniscus in 56%
>> Medial lemniscus in 44%
Which cell type do chondrocytes originate from? Which cells do they share this origin?
Mesenchymal stem cells
- Osteoblasts
- Adipocytes
What is the leading cause of knee pain in patients under age 45?
Patellofemoral syndrome
What is the treatment for patellofemoral syndrome?
- Strengthening the quadriceps
- Stretching exercises
>> Hamstrings
>> Calves
>> Hip
>> Iliotibial band - Minimize activities that put excessive stress on the knee: squatting, kneeling, jogging, stop and go sports
- Maximize walking and other low-impact exercise
What are the two types of bursitis that can occur at the knee?
- Prepatellar bursitis: housemaid’s knee
- Infrapatellar bursitis: clergyman’s knee
What are the ligaments most commonly affected in an ankle sprain?
- Anterior talofibular ligament
- Calcaneofibular ligament
- Posterior talofibular ligament
What is the management for ankle sprain?
RICE
- Rest
- Ice: 20 minutes every 2 hours for the first 48 hours
- Compression
- Elevation
How does plantar fasciitis present?
- Pain beneath calcaneus: “Heel pain”
- Pain in the medial arch
- Pain worse with first steps in the morning and after weight-bearing
- Local point tenderness at the medial tubercle of the calcaneus
What is the treatment for plantar fasciitis?
Medications
- NSAIDs
- Local steroid injection
Physiotherapy
- Dorsiflexion with night splints
- Stretching of the plantar fascia and Achilles tendon
- OTC heel inserts
Surgery
- Surgical release of the plantar fascia in severe cases
What are the muscles of the rotator cuff? How does one test their power?
SItS
- Supraspinatus
>> Initial 15 degree abduction of the arm
>> Test: empty beer can test
- Infraspinatus and teres minor
>> External rotation
>> Test: external rotation against resistance
- Subscapularis
>> Internal rotation
>> Test: lift-off test
How does one test for shoulder impingement syndrome?
- Jobe’s test (Empty beer can test) – right-most
- Hawkin’s test – middle
What is the difference between shoulder separation and shoulder dislocation?
Shoulder separation: separation of the clavicle from the acromion and the coracoid process
Shoulder dislocation: separation of the humeral head from the glenoid cavity
What structures can be damaged in an anterior shoulder dislocation? MUST KNOW!
- Axillary nerve: test by testing deltoid cutaneous senses
- Posterior circumflex humeral artery
- Supraspinatus tendon
- Bankart lesion >> Anterior glenohumeral ligament and glenoid labrum separation from the articular surface of the anterior glenoid neck
- Hill-Sachs lesion >> Posterolateral humeral head defect due to abrasion against the anterior rim of the glenoid
What are the two types of epicondylitis?
Lateral epicondylitis
- “Tennis elbow”
- Tears in wrist extensor tendons
Medial epicondylitis
- “Golfer’s elbow”
- Tears in wrist flexor tendons
What is Dupuytren contracture? What is the cause?
Contracture of one or more fingers (usually the ring finger) due to painless thickening and contracture of the tendons of the flexors of the palm
What are the risk factors for Dupuytren contracture?
- Family history
- Age > 40 years
- Male
- Alcoholism
- Smoker
- Diabetes Mellitus
What is the treatment for Dupuytren contracture?
Definitive treatment
- Surgical release
Other forms of treatment
- Radiation
- Bacterial collagenase injection
What is adhesive capsulitis?
Severe shoulder adhesions that lock the shoulder in place, seen with disuse of the shoulder due to pain or prolonged immobilization
What is the treatment for adhesive capsulitis?
Physiotherapy
- Heat
- Analgesia
- Physical therapy to increase range of motion
Medications
- Glenohumeral joint injection
- Subacromial joint injection
Surgery
- Break adhesions under anesthesia (painful!)
Name the carpal bones of the hand.
So Long to Pinky, Here Comes The Thumb!
Proximal row (Lateral to Medial)
- Scaphoid
- Lunate
- Triquetrum
- Pisiform
Distal row (Medial to Lateral)
- Hamate
- Capitate
- Trapezoid
- Trapezium
What condition must one suspect when there is anatomical snuffbox tenderness?
Scaphoid fracture (even if X-ray doesn’t show it)
What are the side effects of NSAIDs?
- Gastric ulcers
- Acute renal failure from renal ischemia
- Acute interstitial nephritis
- Fluid retention
- Aplastic anemia
What are the side effects of aspirin?
- Gastric ulcers and GI bleeding
- Acute renal failure
- Tinnitus
- Hyperventilation
What bon disorder results from excess PTH?
Osteitis Fibrosa Cystica
What are the diagnostic criteria for systemic lupus syndrome?
Any 4 of the following 11 (MD SOAP BRAIN):
M: Malar rash
D: Discoid rash
S: Serositis - pleuritis, pericarditis
O: Oral ulcers (PAINLESS!)
A: Arthritis (non-erosive, non-destructive, at least involving 2 joints)
P: Photosensitivty
B: Blood - hemolytic anemia, leukocytopenia, lymphocytopenia, thrombocytopenia
R: Renal - lupus (nephritic – diffuse proliferative glomerulonephritis; nephrotic – membranous glomerulonephritis)
A: ANA (anti-nuclear antibody) positive
I: Immunological markers - anti-dsDNA Ab, anti-Smith Ab, anti-phospholipid Abs
N: Neurlogical symptoms - seizures, psychosis
What are the common causes of death in patients with systemic lupus erythematosus?
- Cardiovascular disease
- Renal disease
- Infections
List the immunological markers for SLE and their value in diagnosis and disease management.
ANA: sensitive, very non-specific
Anti-dsDNA antibody: specific, poor prognosis (esp. for renal disease)
Anti-Smith antibody: specific, no known prognostic value
Anti-histone antibody: suggests drug-induced lupus
Anticardiolipin antibody: causes hypercoagulable state
C3, C4 levels: decreased –> leads to immunosuppression
What are the drugs that can cause drug-induced lupus erythematosus?
SHIPP
- Sulfonamides
- Hydralazine
- Isoniazid
- Phenytoin
- Procainamide
What are the possible causes for a positive ANA result?
- SLE
- Rheumatoid arthritis
- Juvenile idiopathic arthritis
- Polymyositis
- Dermatomyositis
- Scleroderma
- Mixed connective tissue disease
- Sjogren’s syndrome
What is the main underlying pathophysiology of scleroderma?
Diffuse systemic progressive sclerosis
- Skin tightening with no wrinkles
- Digital pitting
- Distal ulcerations
- Characteristic facies: mask-like face, tight lips, beak nose and radial perioral furrows
What are the possible systemic manifestations of scleroderma?
Gastrointestinal
- Dysphagia
- Loss of LES function: GERD, ulcerations and strictures
- Small bowel hypomotility: diarrhea, bloating, cramps, malabsorption, weight loss
- Large bowel hypomotility: wide mouth diverticuli on barium study (pathognomonic)
Renal
- Hypertension
- “Scleroderma renal crisis”: malignant arterial hypertension, oliguria and microangiopathic hemolytic anemia
Pulmonary
- Interstitial fibrosis
- Pulmonary hypertension
- Pleurisy
- Pleural effusions
Cardiac
- Left ventricular dysfunction
- Pericarditis
- Pericardial effusion
- Arrhythmias
Musculoskeletal
- Polyarthralgias
- Resorption of distal tufts
- Low grade myopathy
Endocrine
- Hypothyroidism
What are the two types of scleroderma and what are their characteristics?
Diffuse scleroderma
- Rapid progression
- Early systemic involvement
- Widespread skin involvement
- Anti-DNA topoisomerase I/Anti-Scl 70 antibody
Localized scleroderma (CREST syndrome)
- Limited skin involvement confined to fingers and face
- C: calcinosis
R: Raynaud’s phenomenon
E: Esophageal dysmotility
S: Sclerodactyly
T: Telangiectasia
- More benign clinical course
- Anti-centromere antibody
What is the classical presentation of Sjogren’s syndrome?
Can’t see, can’t spit, can’t climb up shit. (Note: Sicca symptoms)
- Dry eyes: xerophthalmia
>> Dryness
>> Conjuncitivits
>> A feeling of sand in eyes - Dry mouth: xerostomia
>> Dysphagia
>> Difficulty in swallowing - Arthritis
+ Bilateral enlarged parotid glands
+ Dental caries (due to dry mouth)
+ Increased risk for MALT lymphomas
List two complications of Sjogren’s syndrome.
- Dental caries
- MALT (mucosa-associated lymphoid tissue) lymphoma
What are the immunological markers for Sjogren’s syndrome?
- Anti-Ro (anti-SS-A) antibody
- Anti-La (anti-SS-B) antibody
- Rheumatoid factor
What are the “sicca symptoms”?
- Dry mouth
- Dry eyes
- Nasal dryness
- Vaginal dryness
- Chronic bronchitis
- Reflux esophagitis
Those with sicca symptoms do NOT necessarily have Sjogren’s syndrome.
What is fibromyalgia?
Excess muscle tenderness in 11 of 18 particular spots
- Low cervical
- Second rib
- Lateral epicondyle
- Knee
- Occiput
- Trapezius
- Supraspinatus
- Gluteus
- Greater trochanter
>> Benign course
What are some clinical features suggestive of or specific to psoriasis? Name 3.
- Plaques and papules with silvery scaling
- Auspitz sign: bleeding spots from broken scales/plaques/papules
- Pitting of the nails (similar to a golf ball)
>> 1/3rd of patients with psoriasis will have psoriatic arthritis, which is a type of seronegative spondyloarthropathy that is associated with asymmetric and patchy involvement mainly in the fingers (DIP joints – VS. no DIP joint involvement in RA), spine and sacroiliac joints. Psoriatic arthritis is also associated with dactylitis and the “pencil in cup” deformity on X-ray.
What are the clinical characteristics of seborrheic keratosis?
- Flat
- Greasy
- Pigmented
- Tortoise-shell like
- Horn cysts
- Looks “stuck-on”
>> Common benign neoplasm of older people
>> Also known as senile warts
Name the lesion.
- Very superficial
- Honey-coloured crusting
- Highly contagious
Impetigo
>> Staphylococcus aureus
>> Streptococcus pyogenes
>> Lips and nose, especially in children
Name the lesion.
- Dermis infection
- Acute
- Painful
Cellulitis
>> Staphylococcus aureus
>> Streptococcus pyogenes
Name the lesion.
- Deep tissue injury
- Rapidly spreading
- Extremely tender, even beyond the area of obvious inflammation
- Crepitus upon palpation
Necrotizing fasciitis
- Streptococcus pyogenes
- Anaerobic bacteria (Clostridium perfringes, Vibrio vulnificus)
Name the lesion.
- White, painless plaques on the tongue
- Cannot be scraped off
- Associated with EBV infection
- Commonly seen in immunosuppressed individuals (e.g. HIV-positive patients)
Oral hairy leukoplakia
What are the presenting features of staphylococcal scalded skin syndrome (SSSS)?
- Fever
- Generalized erythematous rash
- Sloughing of the upper layers of the epidermis
- Heals completely
>> Commonly seen in infants and children
What are the classical features of pemphigus vulgaris?
DAMN is a vulgar word.
- Desmosomes
- Acantholysis
- Mouth lesions
- Nikolsky’s sign positive
>> Flaccid intraepidermal bullae caused by acantholysis with involvement of the oral mucosa
>> Nikolsky’s sign: separation of epidermis upon manual stroking of the skin
What is the gold standard for diagnosis of pemphigus vulgaris?
Punch biopsy of the skin for direct immunofluorescence: reticular/net-like pattern around epidermal cells
Name the lesion.
Erythema multiforme
- Associated with:
>> Drugs
>> Infections
>> Cancers
>> Autoimmune disease - Target-like lesions with multiple rings and dusky centre showing epithelial disruption
What are the classical features of SJS?
- Fever
- Bulla formation and necrosis
- Sloughing of the skin
- Rash similar to erythema multiforme
- Involvement of at least 2 mucous membranes
Name the lesion.
- Premalignant to squamous cell carcinoma of the skin
- Sand-paper like on palpation
- Treat with 5-fluorouracil (5-FU)
Actinic keratosis
Describe the appearance lichen planus.
- *The 6 Ps of Lichen Planus**
- Pruritic
- Purple
- Polygonal
- Planar
- Plaques
- Papules
+ Wickham striae (reticular white lines)
+ Sawtooth infiltrate of WBCs in histology at the dermal-epidermal junction
Name the lesion.
- Herald patches, usually on the trunk and back
- Christmas tree distribution of rash
- Self-limiting within 6-8 weeks
- Helped by sunlight exposure
Pityriasis rosea
Name the lesion.
- Rolled edge with central ulceration
- Pearly nodules
- Telangiectasia
- Palisading nuclei
Basal cell carcinoma
What are the common locations for tophi in a patient with gout?
- External ear
- Olecranon bursa (elbow)
- Achilles tendon
