Rheumatology: From ABCs to SLE Flashcards
Patient presents with joint pain and stiffness. They state it occurs in the knuckle and its closest finger joint of their right index and left ring finger. The stiffness is worst in the morning but improves over the course of the day.
1) What is the suspected diagnosis?
2) What investigations should be done?
3) What scoring systems aid diagnosis?
Rheumatoid arthritis: Symmetrical, multiple joint pain and stiffness that improves throughout the day. May also experience systemic upset.
XR for bone status
Antibodies:
- Anti-Rf
- Anti-CCP
3) DAS28 >2.6
ELAR >=6
In rheumatoid arthritis, what is the…
1) X ray findings
2) Treatment algorithm
1) Periarticular erosions, loss of joint space, evidence of osteoporosis
2) Steroid to reduce flare then…
1. HCQ (mild)/MTX/LFM/SFZ
2. Combo of 2 above
3. MTX + TNFi
4. MTX + rituximab
Which of the following DMARDs are NOT teratogenic?
Methotrexate
Hydroxychloroquine
Sulfasalzine
Leflunomide
Sulfasalzine and HCQ safe in pregnancy
Which DMARDs causes …
Bone marrow suppression
leukopenia
teratogenicity
Methotrexate
Which DMARDs causes …
Hypertension and peripheral neuropathy
Leflunomide
Which DMARD causes…
Male infertility (reduces sperm count)
Sulfasalazine
Which DMARD causes
Nightmares
Reduced visual acuity
Hydroxychloroquine
Which DMARD causes
Reactivation of TB/Hep B
Anti-TNFs (adalimumab, infliximab, etanercept)
What unique side effects does rituximab have?
Night sweats
Low platelet count
Why does a little old lady with Rheumatoid arthritis haunt anaesthetists’ dreams? How does the valiant anaesthetist predict this threat?
Potential for slipping of C1 and C2
Can result in spinal cord compression
Pre-op MRI scans
Patient reports a 6 month history of joint pain occuring in the DIPs of both index fingers as well as the ankles with a 4 week history of itchy eyes. There is a a 15 year history of psoriasis.
1) What is the likely diagnosis?
2) How does the diagnosis differ between sexes?
3) How do you confirm the diagnosis?
4) How is this treated?
1) Psoriatic arthritis: Joint pain that is symmetrical in many joints/assymetrical in few joints/affects the back, A-A joint and sarcum. Long history of psoriasis typically found.
2) Back (spondolytic) pattern more common in males, symmetrical polyarthritis more common in woemn
3) PEST tool to score symptoms
X-ray imaging of choice: ‘Pencil in cup’ deformity
4) NSAIDs for pain
DMARDS –> Anti-TNF –> Ustekinumab
Patient presents with acute joint swelling. The joint is warm, swollen and painful. They also report sore eyes and confess the tip of their penis has also been sore the past 2 days. The patient has been on the ward with a severe bout of gastroenteritis.
1) What is the likely diagnosis?
2) How do you manage this scenario?
3) How can you whittle the differentials using the infective cause?
1) Reactive arthritis: Acute arthritis of a single joint. Triad of ‘can’t see (eye issues), pee (balanthitis) or climb a tree (arthritis)”.Associated with gastroenteritis and chlamydia (among other STIs)
2) Follow ‘hot joint policy’ of antibiotics and joint aspiration until septic arthritis excluded.
Aspirate should be negative for gram stain, culture and sensitivity, as well as no crystals
Manage with NSAIDs, steroids (IA single, systemic multiple)
3) Chlamydia seen in reactive, gonorrhea in septic athritis
Patient presents with lower back pain. They report a 3 month history pain and stiffness, particularly overnight but state that it improves throughout the day. The patient also reports some eye and ankle pains. Their dad has told them to get it seen as he has had similar problems for a while.
1) What is the likely differential?
2) What tests and investigations can be done?
3) What treatment options are there including biologics
1) Ankylosing spondylitis: Lower back pain and stiffness worse at rest and improves with activity. More likely to occur if first-degree relative has it. Associated with HLA-B27.
2)
Measure 10cm above, 5 cm below L5 then bend. Will be <20cm total (Schober’s test)
X-ray shows ‘bamboo spine’ outgrowth at tendon inserts (syndesmophytes) and erosions
3) Typical seronegative malarkey –> Secukinumab
Regarding connective tisssue diseases, which conditions are most associated with the following?
1) Anti-dsDNA
2) Anti-sm
3) Anti-histone
4) Anti-Ro
5) Anti-La
6) Anti-scl70
7) Anti-centromere
8) Anti-RNP
1-2) SLE (dsDNA more specific)
3) Drug induced lupus (will be dsDNA -ve)
4-5) Sjogren’s (Ro 70%, la 30%)
6) Diffuse systemic sclerosis
7) Limited systemic sclerosis
8) Mixed connective tissue disease
Patient presents feeling “poorly”. They have a 6 month history of bouts of fatigue, joint pain and a sore mouth. They also state that the feel more sensitive to the sun. On examination you find a rash across the cheeks and nose bridge and enlarged lymph nodes in the groin. She is of Afro-caribbean and east asian descent.
1) What is the likely differential?
2) What tests aid diagnosis?
3) What is the treatment pathway?
1) SLE: Notoriously ‘systemic’ symptoms of joint pain, fatigue and fever. Classic malar (“butterfly”) rash and photosensitivity. More common in Afro-Caribbean women.
2) 1st line: ANA blood test
GS: Anti-dsDNA, Anti-Smith
Can use SLICC or ACR crtieria to diagnose overall picture
3)
Symptom/flare control: NSAIDs, Steroids, Suncream
Mild maintenance: HCQ
Severe: Immunosuppressants (Methotrexate/Azathioprine/Leflunomide)
Treatment resistant: Rituximab or belimumab
How does discoid lupus differ from systemic?
Discoid only has derm manifestations
Patches of inflamed, dry lesions on face, scalp and ears
Photosensitivity
Can lead scarring alopecia that is hypo/hyperpigmented scars
Patient presents with skin changes. They state their hands have become progressively “tight and shiny” and their fingers have white bumps under the skin. They have a pasy medical history of raynauds and reflux.
1) What is the diagnosis?
2) What tests do you want to do?
3) What is the lifestyle advice you would offer?
4) What medical options are there for treatment?
1) Systemic Sclerosis: Presence of Calcinosis (bumps under skin), Raynaud’s, Esophageal problems (reflux, dysphagia), Sclerodactyly (tight skin), Telangectasia (red threads under skin).
2) Antibodies: Anti-ANA, Anti-centromere
Abnormal capillaries and microhaemorrhages in nailfold capillaroscopy
3) Avoid Smoking
Stretch gently + exercise joints to maintain mobility
4) Symptom specific
Analgesia
Antacids
Nifedipine for Raynaud’s
How does limited differ from diffuse systemic sclerosis? How does this alter management?
Limited: CREST
Diffuse: CREST + Lung (HTN, PF), Cardio (HTN, CAD), Kidney (Glomerulonephritis, sclerodermal renal crisis)
Steroids + Immunosuppresants to slow the disease
ACE inhibitors for hypertension
Supportive management for pulmonary fibrosis
Patient presents with joint pain and stiffness for the past 3 weeks. The pain is present in their shoulders down their elbows, as well as groin pain, and is worse on movement.. They also note stiffness that lasts an hour in the mornings. They have tried to manage it alone but are presenting as it has begun to impact their sleep. The patient is 70 years old.
1) Whats the intentional diagnosis?
2) What tests should you run?
3) What is the management protocol
Polymyalgia rheumatica: Bilateral hip and shoulder pain that is worse on movement. Also have morning joint stiffness that lasts >45 minutes. Symptoms also disrupt sleep. Features need to be present for >2 weeks for a diagnosis following exclusion of other causes.
2) See NICE guidelines for exclusion list
Raised inflammatory markers
CK-EMG is normal
Should respond to steroids to confirm diagnosis (good response after 1 week, ~70% response in symptoms + normal inflammatory markers by a month)
Steroids: 15mg until controlled
Reduce by 2.5 every 3 weeks
Reduce by 1mg every 1-2 months
What is the rule of thumb for patients on long term steroids?
DON’T STOP
DON’T: Ensure that they know they are steroid dependent after 3 weeks so DONT stop suddenly in case adrenal crisis occurs
Sick day rules: Discuss increasing dose when sick
Treatment card: So others know they are steroid dependent
Osteoporosis prevention: Give bisphosphonates, calcium and vitamin D supplements
Proton pump inhibitors: For gastric protection
Patient phones a GP with a headache. They state they have had an extremely sore left side of the head that is made worse when they hold their head. They also report feeling hot and during the phone call have said their vision is blurry. They are 60 years old and white.
1) What is the suspected diagnosis?
2) How do you confirm the diagnosis
3) Who do you refer to?
4) How is it managed?
5) What complications are you worried about?
1) Giant cell arteritis: Severe unilateral headache exacerbated by touching the scalp. Associated with systemic symptoms of fever, muscle aches, weight loss. Can cause rapid, irreversible loss of vision. More common in Over 50s and white populations.
2) Clinical presentation
ESR >50mm/hour
Multinucleated giant cells found on temporal artery biopsy
3) Immediate ophtho if visual symptoms present
Rheumatology and vascular for diagnosis and mangagement
4) Immediate long term steroids
Aspirin 75mg
PPI
5) Blindness, Stroke, Aortic aneurysm/dissection
Patient presents with joint pain for the past 6 weeks. The pain is present in their shoulders, as well as hip pain, and is worse on movement.. They state that they feel quite tired and weak. They have also noticed a scaly rash on their flexor surfaces. The patient is 70 years old.
1) What is the suspected diagnosis
2) How is the condition diagnosed
3) How to treat
1) Polymyositis/dermatomyositis: Muscle pain, fatigue and weakness that occurs bilaterally and usually the shoulders or hips. Skin changes include scaly flexures (Gottron’s lesions), dorsal or facial rashes. Eye swelling and bumps under the skin can also occur.
2) Clinical presentation with
ELEVATED CK (Contrast with normal in PMR)
Reduced EMG readings
Anti-jo1 (both), Mi-2, ANA (derm)
Defiinitive is muscle biopsy showing immune cell infiltration
3) Steroids are first line
Immunosuppresants/IGs/Biologics if that doesnt work
27 year old Patient presents to A+E with a suspected stroke. From glancing at her ECS you note that they have had 2 miscarriages in the past. They were diagnosed with lupus nearly 3 years ago.
1) What is the likely underlying cause of the stroke?
2) How do you investigate the suspected cause?
3) How do you manage the condition?
1) Anti-phospholipid syndrome: Recurrent miscarriage and/or thrombosis due presence of anti-phosholipid antibiodies inducing a hypercoagulable state.
2) Reucurrent thrombosis or miscarriage along with
Lupus anticoagulant
Anticardiolipin
Anti-B-GP1 antibodies
3) Warfarin with range 2-3 (3-4 with thrombosis)
If pregnant: LMWH + aspirin
Patient with lupus reports a 2 month history of dry eyes, mouth and vagina. What
1) Is the likely diagnosis?
2) Is the clinical and antibody testing you want to do?
3) How do you manage the condition?
1) Sjogren’s Syndrome: Dry mucous membranes that is either primary or secondary to SLE.
2) Schirmer’s test: Place filter paper under lower eyelid for 5 mins, <10mm is significant for Schirmer’s
3) Aritficial saliva, tears, lubricants, HCQ
Name the vasculitis associated with the following…
purple spots, joint and abdo pain, renal problems, p-ANCA
severe asthma, elevated eosinophils, p-ANCA
renal failure +/- breathlessness, haemoptysis
Saddle nose, cough, wheeze, glomerulonephritis, c-ANCA
Purplish rash in Hep B,C or HIV patient
Persitent fever, peeling skin, Strawberry tongue, children
Fever, aches, aneurysms in over 40s
Henoch-Schonlein purpura: purple spots, joint and abdo pain, renal problems, p-ANCA
Eosinophilic Granulomatosis with polyangiitis: severe asthma, elevated eosinophils, p-ANCA
Microscopic polyangitis: renal failure +/- breathlessness, haemoptysis
Granulomatosis with polyangiitis: Saddle nose, cough, wheeze, glomerulonephritis, c-ANCA
Polyarteritis Nodosa: Purplish rash in Hep B,C or HIV patient
Kawasaki disease: Persitent fever, peeling skin, Strawberry tongue, children
Takayasu’s arteritis: Fever, aches, aneurysms in over 40s
Patient presents with sore joints. They state that they have pain in their fingers and elbows over the past 2 months. In the same time frame, they report a sore mouth, genitals and eyes. They also have large red patches on their shins. They are from Turkey originally
1) What is the likely diagnosis?
2) How do you test for it?
3) How is it treated?
Behcet’s syndrome: Classic symptoms of Oral ulcers, genital ulcers and anterior uveitis. Joint pain, GI, neuro symptoms and erythema nodosum are associated with the condition.
2) Typically clinical
Positive pathergy test: pricking forearm with sterile needle creates >5mm weal.
3) Topical + Systemic steroids
Colchicine
Immunosuppressants and biologics
How does gout differ from pseudogout?
Chondrocalcinosis: white line through joint space is pathogmonic
Aspirate: Calcium pyrophosphate crystals, Rhomboid, +ve birerefringence
Osteoarthritic changes
Regarding osteomalacia…
1) Which patient groups are more likely to get it?
2) What is the value difference for vit D insufficiency and deficiency
3) What are the 3 vitamin D treatment regimes?
4) What is the maintenance dose following the treatment doses?
1) Darker skin, colder climates, stay inside more
2) <75 insufficiency, <50 deficiency
3) 50,000 IU once weekly over 6 weeks
20,000 IU twice weekly over 7 weeks
4000IU daily over 10 weeks
4) Maintenance dose 800IU day
65 year old patient presents with joint pain. They report a 3 month history of deep pain in their upper and lower back. They also report finding it harder to hear. You decide to do an X-ray. What…
1) Is the potential diagnosis from the history?
2) What would you find on X-ray
3) What blood results would you expect?
4) How do you manage the condition
5) What are the two main concerns for the long term?
1) Paget’s disease: Bone pain in the axial skeleton, deformity of long bones and hearing loss.
2) Osteolytic lesions that are well circumscribed, can be v shaped in long bones
Skull has light patchy areas
3) Raised ALP with normal calcium and phosphate
4) Bisphosphonates are mainstay +/- Calcium, vit D
NSAIDs for pain
5) Osteoscarcoma, spinal stenosis/cord compression
