Rheumatology COPY Flashcards
Best way to distinguish primary and secondary raynauds
Nailfold Capilloroscopy - normal in primary raynauds
Why is febuxistat second line to allopurinol in gout prophylaxis?
Inhibits both reduced and oxidised forms of Xanthine Oxidase making it more potent but with higher risk of CVD and all-cause mortality
Treatment GCA
High dose steroids
Methotrexate
Tocilizumab (anti-IL6)
Anti-TNF inhibitors NOT recommended
Inclusion Body Myositis distribution
Asymmetrical Proximal and Distal weakness
- Quadracips
- Finger flexors - distinguishing factor
- Ankle dorsiflexion
- Cricopharyngeal involvement with dysphagia
Investigation findings inclusion body myositis
- Normal or mildly raised CK
- Biopsy;
1. Endomysial inflammation
2. Rimmed Vacuoles
3. Proteinaceous inclusions - EMG showing mixed myopathic and neuropathic process
Management of OA
Weight loss
Exercise
CBT
Proper footwear
NSAIDS
Duloxetine
Intra-articular steroids
Joint replacement
Renal transporters of uric acid
ABCG2 - excretion at proximal tubule (and gut)
URAT1 - reabsorption
ANCA Vasculitis types
- Granulomatosis with polyangitis (Wegners) - cANCA/PR3 - GN, Lung, Sinus, ENT
- Microscopic polyangitis - pANCA, MPO - GN and Lung
- Eosinophilic polyangitis Granulomatosis (Churg-Strauss) - pANCA - Asthma, Nasal polyps, atopy, GN
Anti-synthetase syndrome
- Anti-tRNA Ab - Anti-Jo and Anti-PL12
- Dermatomyositis
- Interstitial Lung Disease
- Raynauds
- Non-Erosive Arthritis
Diagnostic criteria for PMR
Must have;
Age > 50
Bilateral shoulder aching
Abnormal CRP or ESR
Plus > 4 of;
Morning stiffness > 45 minutes (2 points)
Hip pain/limited ROM
Absence of RF or Anti-CCP (2 points)
Absence of other joint involvement
USS findings of shoulder or hip bursitis/synovitis
Antibody associated with limited Scleroderma
Anti-Centromere
Antibodies associated with diffuse scleroderma
Anti-topoisomerase 1 (Scl-70)
Anti- RNA polymerase - increased risk of renal cell crisis and malignancy
Antibody associated with scleroderma renal crisis
Anti-RNA polymerase
Antibody associated with scleroderma interstitial lung disease
Anti-topoisomerase (Anti Scl-70)
Definition ‘Extensive’ scleroderma ILD
> 20% lung involvement on HRCT
FVC < 70%
DLCO < 55%
Treatment of Scleroderma renal crisis
ACE inhibitors
Due to RAAS blockade which leads to resolution of malignant HTN
Rheumatoid arthritis diagnostic criteria
- Number of joints
- Seropositivity (RF +/- Anti-CCP)
- CRP or ESR
- Duration of symptoms > 6 weeks
Feltys syndrome
Neutropenia
Splenomegaly
Rheumatoid arthritis
Leg Ulcers
Imaging findings in RA
Symmetrical
Sparing of DIP
Joint space narrowing with Ankylosis
Erosions
Periarticular ostopenia
Soft-tissue swelling
Subluxation
Major cause of death in RA
Cardiovascular disease (associated with higher CRP levels at baseline)
Abatacept
CTLA receptor agonist which inactivates CD4 cells.
Can lead to normal CRP in patients despite infection or inflammation
Side effect of hydroxychloroquine
Retinopathy
Hyperpigmentation
Rheumatoid Factor - False positives
- Chronic infection (most common)
- Other Rheumatological pathologies
- Hep B and C
- Cryoglobulinemia
- Endocarditis
- Malignancy
- Primary Biliary cirrhosis
- 4% young population
Rheumatoid factor negative conditions
- Ankylosing spondylitis
- Psoriatic arthritis
- Enteropathic arthritis
- PMR
Best predictor of RA severity
Early bony erosions on imaging
Indicator of disease activity in RA
CRP
NOT anti-CCP or RF
Note: indictor of disease severity is early erosive bone disease
Rescue Rx for MTX toxicity
Folinic acid - utilisation of reduced folates for nucleic acid synthesis
Treatment of Latent Tb pre-TNF inhibitor use
9 months Isoniazid
4 months Rifampicin
3 months Isoniazid and Rifampicin
First line DMARD for Rheumatoid
Methotrexate
Adult Onset Still’s disease
Young adults, often during pregnancy
Fever
Pharyngitis
Salmon coloured rash
Adenopathy
Hepatosplenomegaly
Lymphadenopathy
High Ferritin
Inflammatory arthritis
negative Rheumatoid and ANA
Reiters syndrome
Reactive Arthritis - asymmetrical oligoarthriritis of lower limbs
Urtheritis
Conjunctivitis
Serological marker indicating disease severity in Lupus
- Low complement levels
- dsDNA indicative of severity of renal disease
ANA does not indicate severity
Serological marker of mixed connective tissue disorder
Anti - RNP
Serological markers of Sjogrens
Anti-Ro
Anti- La
Serological marker drug-induced lupus
Anti- Histone
All serological markers of Lupus
ANA (Nuclear)
dsDNA (Homogenous)
Anti-histone - drug induced (homogenous)
Anti-Smith
Anti-Ro
Anti-lupus Anticoagulant
Anti-ribosomal P
Anti-beta-glycoprotein 1
DISH - diffuse idiopathic skeletal hyperostosis
> 4 Vertebral ossification
50, Men, Diabetic
No involvement of SI joints
HLA-B27 negative
Treatment of Ankylosing Spondylitis
Exercise
NSAIDs
Smoking cessation
If failed after 12 weeks -
Anti-TNF (do not slow radiological progression in AS, but do in psoriatic arthritis)
Anti-IL17- Secukinumab
Methotrexate has no effect in AS
Pencil-in-cup XR appearance
Characteristic for psoriatic arthritis
Behcets Syndrome
Systemic Vasculitis
Oral Ulcer > 3 times/1 year
Genital Ulcers
Pathergy (Inflammatory response to skin prick with a sterile needle)
Erythema Nodosum
Inflammatory arthriris
Uveitis
Elevated ESR
Occurs along “Silk Road” demographic
Small vessel vasculitis associations with Hepatitis
Polyarteritis Nodosum - Hepatitis B
Cryoglobulinemic vasculitis - Hepatitis C
Urate transporters
ABCG2 - excretion at kidneys and gut
URAT1 - reabsorption at kidneys
Imaging findings of OA
Joint space narrowing
Subchondral cysts
Osetophytes
Sclerosis
Gull wing deformity of DIP
Rheumatoid Arthritis HLA associations
HLA DRB1-04
How does smoking increase RA risk?
Increased conversion arginine -> citrulline -> target for anti-CCP
Stimulants for RA
- Smoking
- Periodontal infection via Porphyromonas Gingivalis
- Gut bacteria
Convert Arginine to citrulline which up regulates Anti-CCP
Mechanism of action of Leflunomide
- Blocks DHODH which is required in pyrimidine synthesis
- Reversed by Cholecystyramine if severe side effects of ILD or hepatitis
Best TNF-inhibitor in pregnancy
Certolizumab
Risk factors scleroderma renal crisis
- Anti- RNA polymerase and Anti-topoisomerase (Scl-70)
- Steroid use
- Tendon Friction rub
- Cyclosporins
Most common ILD pattern in diffuse scleroderma
Non-specific interstitial pneumonia - diffuse
(RA = UIP, basal, AS = apical, Sjogrens = lymphoid)
Treatment ILD associated with Scleroderma
Cyclophosphomide or Mycophenolate
Nail change in psoriatic arthritis
Nail pitting/Onychodystrophy
Jaccoud Arthropathy
Non-erosive arthritis as a result of recurrent joint inflammation from other forms of arthritis.
It is distinguished from RA because it is non-erosive and reversible
Uric acid level targets in gout
< 0.3 if tophi
< 0.36 if no tophi
Most common ILD pattern in diffuse scleroderma
Non-specific interstitial pneumonia
Treatment of Latent Tb pre-TNF inhibitor use
9 months Isoniazid
4 months Rifampicin
3 months Isoniazid and Rifampicin
Treatment of Scleroderma renal crisis
ACE inhibitors
Due to RAAS blockade which leads to resolution of malignant HTN
Serology of drug-induced lupus
- ANA (without anti-dsDNA. Anti-smith, Anti-Ro)
- Anti-histone
