Rheumatology Conditions Flashcards
Suggest FOUR things that you may see on examination of a patient with EARLY changes in RA.
- Joint swelling - symmetrical, hand joints
- Thenar wasting
- Rheumatoid nodules - hands, distal to olecranon
- Eye changes - episcleritis, scleritis
- Collapsed arch due to tibilalis posterior tendon (toes don’t sit on floor)
Suggest FOUR things that you may see on examination of a patient with early changes in Psoriatic arthritis. (don’t just have to be joint changes)
- Dactylitis
- Oncolysis of the nails - lifting off the bed
- Iritis (anterior uveitis)
- Achilles tendonitis/plantar fascitis
The early changes of psoriasis (scaly rash on extensors) would be probably be accepted
Name THREE blood tests you would order in a patient you suspect has RA.
- Inflammatory markers - CRP, ESR/PV
- Anti- CCP
- Rheumatoid factor
- FBCs - normocytic anaemia
Name FOUR things you might see on any type of radiograph of a patient with late changes of RA.
- Soft tissue (swelling)
- Erosions
- Decalcifications
- Osteopenia
- Symmetrical joint space narrowing
- Protrusio acetabuli
How should you measure a RA patients response to treatment?
- CRP
- DAS score
- Symptom control - morning stiffness improvement?
- New symptoms?
- ADRs
Name the two main diagnostic criteria for Ankylosing spondylitis. Give a rough outline of the criteria they include.
- Modified New York: \+ Low back pain eased by exercise, not relieved by rest \+ Limitation of lumbar spine \+ Limitation of chest expansion \+ Sacroilitis on X-ray
- ASAS (under 45s with back pain):
+ Bilateral sacroilitis (+/- uveitis)
+ HLA-B27 positive
+ Under 2cm chest expansion
Give THREE symptoms a patient presenting with Ankylosing spondylitis might demonstrate.
- Lumbrosacral pain +/- radiation to buttock eased by exercise, not relieved by rest
- Asymmetrical joint pain/swelling (arthritis)
- Epicondylitis
- Anterior uveitis (iritis)
- Shortness of breath
- Non-specific such as weight loss, fever or fatigue
- Morning joint stiffness
How might you differentiate mechanical back pain from Ankylosing spondylitis via treatment?
NSAIDs - In ankylosing spondylitis, symptoms respond to a course of nonsteroidal anti-inflammatory drugs (NSAIDs) within 48 hours (75%), whereas only around 15% of people with mechanical back pain will respond well.
Suggest THREE things that might be observed on x-ray of a patient with a late presentation of Ankylosing spondylitis.
- Extensive sclerosis in the sacroiliac joints
- Erosions in the sacroiliac joints
- Bony bridging between vertebrae (bamboo spine)
- Ligamentous calcification joining posterior spinous processes
- Erosions and sclerosis in the vertebrae
Name FOUR possible extra-articular manifestations of Ankylosing spondylitis.
- Anterior uveitis (24%-40%)
- CVS (conduction disturbances, aortitis and valvular heart disease)
- Resp (restrictive lung disease and upper lobe fibrosis) - MSK (cauda equina syndrome, C1-C2 subluxation)
What is dactylitis? Suggest THREE conditions in which dactylitis occurs.
Dactylitis is inflammation of a digit that can occur in:
- Psoriatic arthritis
- Ankylosing spondylitis
- Sickle-cell anemia
- Infective causes such as TB, syphilis etc.
Suggest how a clinical diagnosis of SLE might be made. (pretty much how it presents and what you see on investigation)
ACR criteria - need four or more! AIR CRASH:
- Arthritis
- Immunological test derangement
- Rashes (3 types)
- CNS disorders
- Renal
- Apthous oral ulcers
- Serositis/
- Haematological derangement
Describe current management for Systemic Lupus Erythematousus (SLE).
- Conservative:
+ Sun cream - Medical:
+ NSAIDs
+ Corticosteroids - topical/oral
+ DMARDs such as hydroxychloroquine, azathioprine, cyclophosphamide (life threatening disease), methotrexate and mycophenolate mofetil
+ Biologics like rituximab for more severe disease
Suggest THREE things that you may see on examination of a joint of a patient with LATE changes in RA.
- Boutonneire’s
- Swan neck deformity
- Wrist/knuckle subluxation
- Z-shaped thumb
- Ulnar drift
Which joints of the hand are rarely (never) affected in RA?
DIP
Give THREE risk factors for the development of rheumatoid arthritis.
- Female
- 30-50/pre-menopausal
- Smokers (have worse disease, more likely to get extra-articular features)
- Genetics (HLA-DR4/HLA-DW4)
Describe the pathophysiology of rheumatoid arthritis.
- Initiation not understood completely (gun & trigger with genetics as the gun and environment as the trigger)
- Infiltration of the joint space by antibodies that destroy joint surface
- Thickening/inflammation of synovial membrane forms pannus
- Pannus erodes cartilage
Name FOUR possible extra-articular manifestations of rheumatoid arthritis.
- Eyes (episcleiritis, keratoconjuctivitis)
- Skin (thinning/ulceration)
- Cardio-resp (pleural effusion, pericardial effusion, lung fibrosis)
- Peripheral neuropathy
- De quervains tenosynovitis
What scoring system is used to classify/assess rheumatoid arthritis? What are the components?
DAS28 (disease activity score calculator for RA, with 28 being the maximum number of affected joints) with the domains:
- Number of swollen joints
- Number of tender joints
- CRP/ESR
- Patient’s global health rating
Describe how rheumatoid arthritis is diagnosed.
6 points diagnostic:
- Number of small joints involved
- Number of large joints involved
- Rheumatoid factor/anti-CCP
- CRP/ESR
- Duration of symptoms
What are the DAS28 scores that correspond to: remission, low disease activity & high disease activity.
- High disease activity is 5.1+
- Low disease activity <3.2
- Remission achieved with <2.6
Which specific blood tests should be carried out when investigating a patient with suspected SLE?
- Antinuclear antibodies:
+ Anti-SSA (Ro)
+ Anti-SSB (La)
+ Anti-Sm - Anti-dsDNA (useful for disease activity monitoring)
- Anti-histone
- Complement (C3/C4) - decreased as activity of disease use them up
Note: do antiphospholipid protein test to rule out antiphospholipid syndrome
Other than SLE name ONE condition where Anti-SSA (Ro) and/or Anti-SSB (La) may be positive.
- Sjogren’s syndrome
- Scleroderma
What are the main symptoms/signs of scleroderma?
CREST:
- Calcinosis - deposition of calcium in soft tissue
- Raynaud’s phenomenon – reduced circulation to fingers and toes in response to cold
- Esophageal dysmotility – trouble swallowing
- Sclerodactyly – thick and tight skin on fingers and/or toes, may limit joint movement
- Telangiectasia – small dilated blood vessels near the surface of the skin
Sausage fingers, restrictive lung pattern and GORD are also common.
Describe the management of rheumatoid arthritis
- Conservative - analgesia (NSAIDs), education, weight loss, stop smoking, PT, OT (splinting)
- Medical - 1st line MTX (not in pregnancy, 2nd line hydroxychloroquinine or sulfalazine, after combination therapy biologics may be initiated
- Surgical - only in severe long term disease arthroplasty or joint debridement.
Name THREE conditions associated with rheumatoid arthritis.
- Sjogren’s disease
- Pericarditis
- Pulmonary disease
- IBD
It is likely any autoimmune condition would be linked.
Describe when biologic therapy may be initiated in a patient with RA.
DAS score of above 5.1 while on combination therapy with two DMARDs.
Which joints are commonly affected in psoriatic arthritis .
DIP
Describe the management of psoriatic arthritis.
- Conservative - analgesia (NSAIDs) & limited PT/OT
- Medical - DMARDS (MTX/sufalazine - avoid hydroxy), steroids (injection, oral, topical) and vitamin D analogues
- Surgical - joint arthroplasty rare
- Phototherapy - for skin lesions - increased vitamin D
- Coal tar for psoriasis
Psoriatic arthritis commonly occurs alongisde a psoriatic rash. Where does the psoriatic rash commonly occur?
- Extensor aspects
- Scalp
- Naval
- Natal cleft (bum crack)
Under the breasts and thighs - however rash more likely just red rather than scaly
Suggest TWO of the most common causative organism species of septic arthritis.
- Staphylococcus sp.
- Streptococcus sp.
However the second most common ORGANISM (not species as asked) is Neisseria Gonorrhoea
Suggest TWO possible risk factors for the development of septic arthritis.
- Previous join trauma (gout, RA)
- Immunosuppressed patients
- IVDU
- Previous steroid injections
- Diabetes
Compare and contrast the appearance of the synovial fluid aspirate in septic arthritis vs. gout.
In gout it is a thick crystalline, toothpaste-like substance whereas, in septic arthritis it is a purulent (pus) aspirate.
Compare and contrast the appearance of the crystals in the synovial fluid aspirate in pseudogout vs. gout when examined via polarising microscopy/crystalline birefringency.
- In gout the crystals are monosodium urate crystals which are negatively birefringent
- In pseudogout the calcium pyrophosphate crystals are positively birefringent
Give an overview of what Lyme disease is and how it is transmitted.
Bacterial infection caused by Borrelia burgdorferi transmitted by ticks
Describe how early Lyme disease may present.
- Erythema migrans rash (red circle surrounded by white ring surrounded by a red ring)
- Flu-like symptoms
- Muscular/joint pain
Describe the rash in Lyme disease.
- Around the area of the tick bite after 3-30 days
- Warm
- Rarely itchy/painful
Describe how late Lyme disease may present.
- Headache & neck stiffness
- Arthritis with severe joint pain/swelling
- Swollen knee
- Facial palsy
- Lyme cariditis (palpitations, irregular heart beat)
How may septic arthritis be managed?
- Surgical washout(s) of affected joint
- Antibiotics based on synovial fluid cultures, however, initially broad spectrum
- Percutaneous aspiration
- Joint splinting to allow drainage
Describe how septic arhritis may present.
- Hot, swollen and painful joint - usually monoarticular
- Effusion
- Tender
- NWB if a lower joint
- Reduced range of movement
- Fever (less than half will have this)
What do Kocher’s criteria relate to and what are they?
Kocher’s criteria predict the probability of septic arthritis, the criteria are:
- CRP over 10
- ESR over 40
- WBC over 12 (18 in children)
- Non-weight bearing
If all four and an effusion there is a 98% chance of septic arthritis.
In the advanced of Ankylosing spondylitis what type of posture may patients develop?
Question mark posture:
- Loss of lumbar lordosis
- Exaggerated thoracic kyphosis
Describe the treatment of Ankylosing spondylitis.
- Conservative treatment with physiotherapy
- Mainstay of treatment is NSAIDs
- MTX/Sulfalazine for peripheral involvement however don’t help the spine
- Biologics such as Anti-TNFa
- Surgical management may be required for spinal # repair in later stages
Describe the presentation of Polymyalgia rheumatica.
- Shoulder/neck and/or pelvic girdle (main radiate to upper thigh) pain - describe as a muscular pain
- Upper arm tenderness
- Morning stiffness (over 45 minutes)
- Carpal tunnel syndrome
- Oedema of hands, wrists, feet
- General fatigue, malaise, weight loss
What test can be used to examine the movement of the lower back in Ankylosing Spondylitis?
Schober test
Describe the management of Polymyalgia rheumatica.
- Steroids - mainstay of treatment, low dose for a long time shows a dramatic response
- MTX - some value as a steroid sparing agent
Describe the presentation of SLE with reference to the ACR criteria.
AIR CRASH
ACR Criteria - each worth 1 point:
- Arthritis
- Immunological - anti-DsDNA, Anti-Sm
- Rash - Malar (butterfly), Discoid, Photosensitive
- CNS disorder - seizures or psychosis
- Renal disease - cell casts/persistant proteinuria
- Apthous oral ulcers
- Serositis - pleuritis/pericarditis
- Haematological disorders - leukopenia, lymphopenia, thrombocytopenia
Note: the presentation is often non-specific (fever, malaise, weight loss)
Suggest FOUR things that may be observed on examination of a patient with SLE.
- Hands - Raynaud’s
- Hair may be falling out (alopecia)
- Eyes may be dry
- Face may demonstrate a butterfly (malar) rash
- Mouth may have apthous oral ulcers
- Lymphadenopathy
- Joint arthritis
- Splenomegaly
What are the two main types of lupus?
- SLE (multi-system involvement)
- Discoid (only skin involvement)
Suggest THREE drugs that can cause SLE.
- Chlorpromazine,
- Penicillamine
- Isoniazid
- Sulphasalazine
- Methyldopa
- Procainamide
Suggest THREE conditions in which antinuclear antibodies may occur.
- SLE
- Systemic sclerosis (scleroderma)
- Polymyositis
- Sjogren’s syndrome
Sjogren’s syndrome can either be primary or secondary. Suggest TWO conditions than can cause secondary Sjogrens.
- Rheumatoid arthritis
- Scleroderma
- SLE
Describe the management of scleroderma.
- Conservative - PT/OT, patient education and regular monitoring
- Medical - DMARDs (cyclophosphamide, mycophenalate mofetil, azathioprine and MTX) and nifedipine for Raynauds
- Surgical - contracture release, removal of calcinosis
Suggest THREE complications of scleroderma.
- GI (malnutrition due to oesophageal dysmotility, obstruction)
- Renal crisis (accelerated HTN leading to renal failure)
- Cardiac (MI, arrythmias, pericarditis, fibrosis)
- Pulmonary (aspiration pneumonia)
Describe how scleroderma can be diagnosed.
Score 9 or more:
- Skin thickening proximal to MCP (9 points)
- Fingers:
+ Sclerodactyly (4 points)
+ Puffy fingers (2 points)
- Fingertips:
+ Pitting scars (4 points)
+ Ulcers (2 points)
- Telangiectasia (2 points)
- Abnormal nail fold capillaries (2 points)
- Raynaud’s (3 points)
- Scleroderma related antibodies (3 points)
- Pulmonary arterial hypotension and/or interstitial lung disease (2 points)
Describe the presentation of Behcet’s disease.
- Apthous ulcers (mouth, genitals)
- Uveitis +/- hypopyon, retinal vasculitis/haemorrhage
- Erythema nodosum
- Arthritis
- Pericarditis
- Non-specific (fever, malaise, tiredness)
Describe the management of Behcet’s disease.
- Medical management includes steroids (both topical and oral), DMARDS (for eye disease) and NSAIDs
- Surgical management GI perforation/peritonitis, aneurysm repair and eye repair (catracts, retinal detachment)
Describe the presentation of gout.
- Sudden, severe joint pain (commonly big toe or thumb)
- Swelling, redness and tenderness around the affected joint
Describe the management of pseudogout.
- Conservative - lifestyle measures, joint elevation and rest
- Symptom relief - NSAIDs, steroids, ice packs
- Medical - colchicine (remission) and allopurinol (maintenance) and STOP DIURETICS
Describe the management of fibromyalgia.
- No cure
- Conservative - muscle strengthening, aerobic exercise to reduce fatigue.
- Medical - paracetamol, weak opioids and TCAs such as amitryptilline can be used for control of pain and mood
Describe how a diagnosis of fibromyalgia is made.
- Exclude other causes via history, examination, investigations
- Severe pain in 11/18 specific sites of the body when applying light pressure (blanch examiner’s thumbnail)
Name TWO types of large vessel vasculitis.
- Takayasu arteritis
- Giant Cell Arteritis
Name TWO types of medium vessel vasculitis.
- Kawasaki
- Polyarteritis nodosa.
Define the category of disorders that both osteoporosis and osteopenia belong to.
Conditions where the bone mineral density is lower than normal, leading to an increased risk of fracture
Compare and contrast T and Z scores derived from DEXA scans.
Both are scores measuring the bone density of an individual as compared to a general, healthy population:
- T-Score is a YOUNG, normal, healthy individual
- Z-Score is a normal healthy individual OF THEIR AGE
What range of T scores correspond to osteopenia.
-1.0 to -2.5
What range of T scores correspond to osteoporosis
-2.5 and under
Describe the main possible causes/risk factors for the development of secondary osteoporosis.
Decreased osteoblast/increased osteoclast activity FRACTURES:
- Family history
- Rheumatoid arhritis and other inflammatory conditions
- Alcohol
- Corticosteroids
- Thin - eating disorders, coeliac
- Ulcerative colitis and Crohn’s
- Reduction in oestrogen (as it usually suppresses osteoclasts) or mobility
- Endochrinopathoes (hyperthyroidism, hyperparathyroidism)
- Smoking
Describe the parameters of FRAX (the WHO fracture risk assessment tool)
Suggests when people will need DEXA scan monitoring and their risk of a #:
- Menopause
- # history
- Smoking/alcohol history
- Oral steroid use
- RA
Give an overview of the management of osteoporosis.
The decision to initiate treatment is clinical dependent on risk of falls etc.
- Treat underlying cause
- Lifestyle - increase exercise, increase Vit D/calcium intake, stop smoking/drinking alcohol
- Medical - bisphonates which you should give with calcium, SERMs (selective oestrogen receptor modulators) are an alternative, parathyroid hormone peptide drugs and HRT for those secondary to menopause
