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BRS YR2 > Rheumatology Diagnostics > Flashcards

Rheumatology Diagnostics Flashcards

1
Q

What are the diagnostic tests available for rheumatology?

A
  • blood tests
  • joint (synovial) fluid analysis
  • imaging tests
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2
Q

What imaging is available for rheumatology?

A
  • x-rays
  • US
  • CT
  • MRI
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3
Q

What blood tests are done for rheumatology?

A
  • FBC
  • U+Es
  • LFTs
  • Bone profile
  • ESR
  • CRP
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4
Q

What are the main types of arthritis?

A
  • osteoarthritis
  • inflammatory arthritis
  • septic arthritis
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5
Q

What would you see on an FBC with inflammatory arthritis?

A 
Hb = anaemia or normal
MCV = normal
WCC = normal
Platelet = normal/raised
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6
Q

What would you see on an FBC with osteoarthritis?

A 
Hb = normal
MCV = normal
WCC = normal
Platelet = normal
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7
Q

What would you see on an FBC with septic arthritis?

A 
Hb = normal
MCV = normal
WCC = increased/leucocytosis
Platelet = normal/increased
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8
Q

What does a higher creatinine?

A

worse renal clearance (indicating kidneys problem)

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9
Q

What is the effect of systemic lupus erythematous on the kidneys?

A

lupus nephritiis

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10
Q

What is the effect of vasculitis on the kidneys?

A

nephritis

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11
Q

What is the effect of chronic inflammation on the kidneys?

A
  • high levels of serum amyloid A (SAA) protein

- SAA deposits in organs (AA amyloidosis)

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12
Q

What does a low albumin reflect?

A
  • problem of synthesis (in liver)

- problem of leak from kidney (eg in lupus nephritis)

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13
Q

What is the effect of Disease Modifying anti-rheumatic drugs on the liver?

A

can cause liver damage

- pts on methotrexate need regular blood tests (every 8 weeks)

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14
Q

What is tested in a bone profile?

A
  • Calcium
  • Phosphate
  • Alkaline phosphatase
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15
Q

What is Paget’s disease?

A

an abnormality of high bone turnover

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16
Q

What are the clinical features of Paget’s disease?

A
  • bone pain
  • excessive pain growth
  • fracture in areas of abnormal bone
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17
Q

What can be seen in a bone profile if the patient has Paget’s disease?

A

raised ALP

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18
Q

What is osteomalacia?

A

soft bones due to vitamin D deficiency

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19
Q

How does osteomalacia present on a bone profile?

A

ALP: normal or raised

Ca and PO4: normal or low

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20
Q

What is osteoporosis?

A

low bone density

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21
Q

How does osteoporosis present on a bone profile?

A

Calcium, phosphate and ALP normal

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22
Q

What can cause a raised ESR?

A
  • inflammation
  • elevated immunoglobulin level
  • paraprotein (myeloma)
  • anaemia
  • increasing age
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23
Q

How does SLE present on an inflammation profile?

A

ESR: high
CRP: normal

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24
Q

When can CRP be high in SLE?

A
  • significant synovitis

- inflammatory pleural/pericardial effusion

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25
Q

What should be done if there is an elevated CRP in lupus?

A

have a low index of suspicion for infection

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26
Q

What are the 2 types of antibodies found in the bloods of RA patients?

A
  • rheumatoid factor

- cyclic citrullinated peptides

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27
Q

What is rheumatoid factor?

A

Antibodies that recognize the Fc portion of IgG as their target antigen typically IgM antibodies i.e. IgM anti-IgG antibody

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28
Q

How common is rheumatoid factor?

A
  • positive in 70% at disease onset

- further 10-15% become positive over the first 2 years of diagnosis

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29
Q

What are cyclic citrullinated peptides?

A
  • more specific than RF

- associated with a worse prognosis

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30
Q

What are anti-nuclear antibodies?

A

antibodies directed at the nuclear component of the cell

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31
Q

What is known about non-specific anti-nuclear antibodies?

A
  • Relatively common in general healthy population at low titre (level)
  • Prevalence of ANA increases with age
  • Sometimes transiently positive following infection
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32
Q

What is the use of anti-nuclear antibodies in rheumatology?

A

high titre ANA with correct clinical features can indicate an autoimmune connective tissue disease

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33
Q

What can a high ANA level with clinical features suggest?

A
  • SLE
  • scleroderma
  • Sjogern’s syndrome
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34
Q

What are the clinical features of SLE?

A
  • Arthritis
  • Skin rash
  • Mouth ulcers
  • Kidney disease
  • Haematological
  • Pleural effusion
  • Pericardial effusion
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35
Q

What are the clinical features of Scleroderma?

A
  • Vasculopathy (esp. Raynaud’s phenomenon)
  • Skin thickening
  • Organ fibrosis
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36
Q

What are the clinical features of Polymyositis?

A
  • Muscle inflammation
  • Weakness
  • High CK
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37
Q

What are the clinical features of Sjorgen’s syndrome?

A
  • Dry eyes
  • Dry mouth
  • Extra-articular features
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38
Q

How is ANA reported?

A

as a maximal dilution at which it is still detectable

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39
Q

What does a negative ANA test exclude?

A

SLE

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40
Q

What does a positive ANA test suggest?

A

suggestive of SLE if clinical and lab features support

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41
Q

What other tests should be ordered if ANA is positive?

A
  • ENA (extractable nuclear antigens)
  • double stranded (dsDNA) antibodies
  • complement levels C3 and C4
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42
Q

What is tested for in an ENA panel?

A
  • Ro
  • La
  • RNP
  • Smith
  • Jo-1
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43
Q

What does a positive Ro antibody test suggest?

A

Lupus or Sjogrens syndrome

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44
Q

What does a positive La antibody test suggest?

A

Lupus or Sjogrens syndrome

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45
Q

What does a positive RNP antibody test suggest?

A

Lupus or mixed connective tissue disease

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46
Q

What does a positive Smith antibody test suggest?

A

Lupus

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47
Q

What does a positive Jo-1 antibody test suggest?

A

Polymyositis

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48
Q

What does a positive dsDNA antibody test suggest?

A
  • highly specific for lupus
  • associated with renal involvement
  • useful for tracking lupus activity over time
49
Q

What does reduced complement levels of C3 and C4 suggest?

A

active lupus

50
Q

How do you do a synovial fluid analysis?

A

obtained by aspirating fluid from a joint

51
Q

What are the indications for joint aspiration?

A
  • Diagnostic: to obtain synovial fluid for analysis

- Therapeutic: to relieve symptoms (+/- concurrent steroid injection)

52
Q

What are the 2 main diagnostic uses of aspiration?

A
  • suspected arthritis
    (send for MC+S, identification of causing organism, sensitivities for ABx)
  • diagnosing crystal arthritis
53
Q

What is the gold standard tests to diagnose suspected septic arthritis?

A

aspiration for a synovial fluid analysis

54
Q

How does a diagnosis of crystal arthritis occur?

A
  • aspirating fluid from the affected joint

- examination under a microscope using a polarised light

55
Q

How does gout present in a synovial fluid arthritis?

A

needle shaped crystals with negative birefringence

56
Q

How does pseudogout present in a synovial fluid arthritis?

A

rhomboid shaped crystals with positive birefringence

57
Q

How does a synovial fluid culture present in septic arthritis?

A

positive

58
Q

How does a synovial fluid culture present in reactive arthritis?

A

sterile

59
Q

Is ABx therapy recommended in septic arthritis?

A

yes

60
Q

Is ABx therapy recommended in reactive arthritis?

A

no

61
Q

Is joint lavage recommended in septic arthritis?

A

yes - in large joints

62
Q

Is joint lavage recommended in reactive arthritis?

A

no

63
Q

What is the first line imaging in rheumatology?

A

x-rays

64
Q

Why are MRIs used in rheumatology?

A
  • Best visualization of soft tissue structures like tendons and ligaments
  • Best for spinal imaging: can see spinal cord and exiting nerve roots
  • but, Expensive and time-consuming
65
Q

Why are US used in rheumatology?

A
  • can visualize soft tissue structures.

- Good for smaller joints, less good for deep/large joints like knee or hip

66
Q

What are the XR features of osteoarthritis?

A
  • joint space narrowing
  • subchondral bony sclerosis
  • osteophytes
  • subchondral cysts
67
Q

What causes the joint space narrowing on a XR of osteoarthritis?

A

loss of articular cartilage leading to bone to bone contact

68
Q

What are osteophytes?

A

bone spurs

69
Q

What features of rheumatoid arthritis can be seen on a XR?

A
  • soft tissue swelling
  • peri-articular osteopenia
  • bony erosions
  • joint space narrowing
70
Q

When do bony erosions occur?

A
  • only in established disease

- aim is to treat before formation

71
Q

Why can US be better than XR in rheumatoid arthritis?

A

better to detect synovitis

72
Q

What features of rheumatoid arthritis can be seen on a US?

A
  • Synovial hypertrophy (thickening)
  • Increased blood flow (seen as doppler signal)
  • May detect erosions not seen on plain X-ray
73
Q

When does joint space narrowing occur in oestoarthritis?

A

primary abnormality

74
Q

When does joint space narrowing occur in rheumatoid arthritis?

A

secondary damage due to synovitis

75
Q

What are Heberden’s nodes?

A

osteophytes at the distal inter-phalangeal joints

76
Q

What are Bouchard’s nodes?

A

osteophytes at the proximal inter-phalangeal joints

77
Q

What is a common early radioactive sign of inflammatory arthritis?

A

juxta-articular osteopenia

78
Q

Where do bony erosions tend to occur?

A

the margins of the joint where the synovium is in direct contact with bone

79
Q

What are the radiographic features of gout?

A

juxta-articular ‘rat bite’ erosions at the metaphalangeal joint of the big toe

80
Q

What are the radiographic features of psoriatic arthritis?

A
  • asymmetrical pattern of joint involvement
  • erosions of interphalangeal joints
  • MCPJs not affected
81
Q

What investigations should be done for suspected SLE?

A
  • ESR, CRP
  • haematology
  • renal function tests
  • antibodies and complement
  • clotting
82
Q

What would be seen on a haematology screen for SLE?

A
  • haemolytic anaemia
  • lymphopenia
  • thrombocytopenia
83
Q

What renal function tests should be done in SLE?

A
  • uP:CR

- albumin

84
Q

What would be included immunological screen for SLE?

A
  • anti-nuclear antibodies
  • anti-double-stranded DNA antibodies
  • complement consumption
85
Q

What would be seen on a clotting screen for SLE?

A
  • anti-phospholipid antibodies
  • lupus anticoagulant
  • anti-cardiolipin antibodies
86
Q

What would be seen immunological screen for SLE?

A
  • low complement C3 and C4

- high levels of anti-ds-DNA antibodies

87
Q

What are the aims when treating SLE?

A

remission or low disease activity and flare prevention

88
Q

What medication is recommended in all patients with lupus?

A

hydroxychloroquine

89
Q

What treatment should be minimised/withdrawn for SLE?

A

maintenance treatment glucocorticoids

90
Q

What can help reduce the usage of maintenance treatment glucocorticoids?

A

the appropriate initiation of immunomodulatory agents (methotrexate, azathioprine, mycophenolate)

91
Q

What treatment is used in persistently active or severe SLE?

A
  • cyclophosphamide

- B cell targeted therapies (rituximab and belimumab)

92
Q

What should patients with SLE be assessed for?

A
  • anti-phospholipid antibody status

- infectious and CVD risk profile

93
Q

What is Sjögren’s syndrome?

A

autoimmune exocrinopathy:

- lymphocytic infiltration of exocrine glands and occasionally other organs (extra-glandular involvement)

94
Q

How does Sjögren’s syndrome present?

A
  • xerophthalmia (dry eyes)
  • xerostomia (dry mouth)
  • parotid gland enlargement
95
Q

What are the most common extra-glandular manifestations in Sjögren’s syndrome?

A
  • non-erosive arthritis

- Raynaud’s phenomena

96
Q

What is meant by secondary Sjögren’s syndrome?

A

if it occurs in the context of another connective tissue disorder

97
Q

What tests can be done if Sjögren’s syndrome is suspected?

A
  • salivary gland biopsy

- Schimer’s test

98
Q

What will a salivary gland biopsy show in Sjögren’s syndrome?

A
  • lymphocytic infiltration
  • predominantly CD4 helper T cells
  • less so: B lymphocytes
99
Q

What will a salivary Schimer’s test show in Sjögren’s syndrome?

A

<5mm after 5 minutes

100
Q

What is Schimer’s test?

A

test to assess tear production

  • filter paper under the lower eyelid
  • extent of wetness measured after 5 minutes
  • abnormal is <5mm after 5 minutes
101
Q

What is inflammatory muscle disease?

A

Proximal muscle weakness due to autoimmune-mediated inflammation either with (dermatomyositis) or without (polymyositis) a rash

102
Q

What are the skin changes seen in dermatomyositis?

A
  • lilac-coloured (heliotrope) rash on eyelids, malar region and naso-labial folds
  • red/purple flat/raised lesions on knuckles (Gottron’s papules)
  • subcutaneous calcinosis
  • fissuring and cracking of the skin (mechanic’s hands)
103
Q

What is associated with inflammatory muscle disease?

A
  • malignancy (10-15%)

- pulmonary fibrosis

104
Q

What is systemic sclerosis?

A
  • thickened skin with raynaud’s phenomenon
  • dermal fibrosis
  • cutaneous calcinosis
  • telangiectasia
105
Q

What are the 2 different types of systemic sclerosis?

A
  • limited

- diffuse

106
Q

What is seen in limited systemic sclerosis?

A
  • fibrotic skin, hands, forearms and face
  • anticentromere antibodies
  • pulmonary hypertension
  • Hx of raynaud’s phenomenon - CREST
107
Q

What dose CREST stand for?

A
  • Calcinosis
  • Raynaud’s phenomenon
  • Esophageal dysmotility
  • `Sclerodactylly
  • Telangiectasia
108
Q

What is seen in diffuse systemic sclerosis?

A
  • Fibrotic skin proximal to elbows or knees (excluding face and neck)
  • Anti-topoisomerase-1 (anti-Scl-70) antibodies
  • Pulmonary fibrosis, renal (thrombotic microangiopathy) involvement
  • Short history of Raynaud’s phenomenon
109
Q

What is overlap syndrome?

A

When features of more than 1 connective tissue disorder are present e.g. SLE and inflammatory muscle disease we can use the term overlap syndrome

110
Q

What tests are done and seen in suspected inflammatory muscle disaster/

A
  • high CPK
  • abnormal electromyography
  • abnormal muscle biopsy
111
Q

What would be seen in abnormal muscle biopsy?

A

polymyositis:
- CD8 T cells
dermatomyositis:
- CD4 T cells in addition to B cells

112
Q

When is the term undifferentiated connective tissue disorder?

A

When incomplete features of a connective tissue disease are present

113
Q

What antibody can be used to identify different connective tissue disorders?

A

Anti-U1-RNP antibody

114
Q

What are the key auto-antibodies in diffuse systemic sclerosis?

A

Anti-Scl-70 antibody

also termed antibodies to topoisomerase-1

115
Q

What are the key auto-antibodies in limited systemic sclerosis?

A

Anti-tRNA transferase antibodies

E.g. histidyl transferase (also termed anti-Jo-1 antibodies)

116
Q

What are the key auto-antibodies in dermato/polymyositis

A

Anti-tRNA transferase antibodies

E.g. histidyl transferase (also termed anti-Jo-1 antibodies)

117
Q

What are the key auto-antibodies in Sjören’s syndrome?

A

-No unique antibodies but typically see:
- Antinuclear antibodies
- Anti-Ro and anti-La antibodies
Rheumatoid factor

118
Q

What are the key auto-antibodies in mixed connective tissue syndrome?

A

Anti-U1-RNP antibodies

BRS YR2 (70 decks)

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