Rheumatology Medicine 🩼✅ Flashcards
AI polyendocrinopathy syndrome 1?? What is this
AIRE mutation. Chronic mucocandidiasis, hypoparathyroidism, Addison’s,
AI polyendocrinopathy syndrome 2… what is it???
HLA DR3/4 associated. Addisons and thyroid AI. And more like pernicious anemia
How to diagnose and manage a Polyendocrinopathy case
Invx with the specific antibody (anti TPO, parietal cell, IF). Manage the specific disease (antifunal, B12) and immunosuppressant
Why could primary adrenal insufficiency patients get hyponatremia
They get high ADH…
addisons is associated with what acid base abnormality
Non AG met acidosis
Initial test for addisons
Morning cortisol
If suspect addisons, and done the morning cortisol test… comes back less than 3… what next
Do morning ACTH (this doesn’t confirm diagnosis)
How to confirm Addison’s disease diagnosis
Synacten test (give ACTH, and see a failure of cortisol to rise). Should measure cortisol before, 30 mins and 60 mins after
A cortisol level of what post synacten is indicative of addisons
Less than 18-20
What is the insulin tolerance test for Addison’s? CI for test?
Give insulin (usually lowers glucose which will increase ACTH and cortisol. Cortisol doesn’t increase in Addisons. CI’d in elderly and seizure patients
What is the overnight metyrapone test for addisons
Give metyrapone (usually inhibits cortisol prod, increasing ACTH, and increasing 11(OH)cortisol. In addisons 11(OH)cortisol doesn’t increase
What imaging is considered in primary adrenal insufficiency
CT/MRI abdomen
Antibody to screen for in addisons (only positive some of the time)
Anti 21(OH) ase
Treatment for addisons (consider three elements)
(Hydrocortisone or prednisolone =highest dose in morning) and (fludrocortisone =mineralcorticoid) and (DHEA =in females only who have depression/low libido)
What is stress dose steroids in addisons
Steroid dose increased in Sx, illness to reduce risk of adrenal crisis
Discuss the invx and dx of adrenal crisis
Based at first on clinical suspicion (and basic labs). Can take random cortisol level (do before admin cortisone). Synacten only once patient stabilised
How to
Manage a patient with addisons crisis (consider 4 elements)
Hydrocortisone (prednisolone 2nd line). Fludrocortisone (got flu = sepsis) only if septic shock, or if patient receiving a non-hydrocortisone GC. 1L of isotonic saline in first hour. IV dextrose.
When do we give fludrocortisone in addinsonian crisis?
Fludrocortisone only if septic shock, or if patient receiving a non-hydrocortisone GC.
HLA for RA
HLA DR4 and DR1
What is the clinical diagnosis criteria (not that strict) for RA
Arthralgia and joint stiffness for 6 or more weeks in 3 or more joints
Initial imaging for for RA
X ray (if both hands and feet). Good to get baseline too!
Why do TFTs in RA patients?
AI thyroiditis is common in RA patients
Most specific AB marker for RA?
Anti CCP
HLA in RA?
HLA DR4 and DR1 (4 propellers 1 camera)
Late vs early findings of RA on X-RAY
Early: soft tissue swelling and osteopenia subchondrallu.
Late: joint space narrows, subchondral cysts, more generalised osteopenia
Use of US in RA Invx
Can detect early changes, likely signs of inflam (synovial hyperemia)
Use of MRI in RA?
Can detect early changes (inflam), and good to check for atlantiaxial subluxation
Acute RA flare Tx
Lowest dose possible GCs (prednisone) for less than 3 months. NSAIDs can also be used instead
Long term therapy for RA (basic idea)
DMARDS are first line (like MTX), but need to bridge with NSAID, since they take time to work
When is hydroxychloroquine given in RA
Can be used as a chronic treatment, for low disease activity patients (not a 1st line)
First line DMARD for RA
methotrexate! In all patients (except preg of course)
When is sulfalazine given in RA
In low activity RA, when MTX is contraindicated
When is leflunomide given in RA?
When all other DMARDS not able to be used
If patient with with RA has persistent moderate to severe symptoms, despite 3 months of DMARDs… give what?
Biologicals
How to investigate RA of the cervices spine?
Extension and flexion X-rays of the cervical spine. Or MRI
Before a RA patient undergoes general anaesthesia… need to check what?
Check for atlantoaxial subluxation (with X-RAY)
When do you do surgery in Atlanto axial subluxation
If there is instability or myelopathy
Felty is associated with which cancer?
NHL
Which markers are elevated in RA arthritis patients
RF, Anti CCP (since it comes from RA)
First line and second line Tx for Felty syndrome
Methotrexate (cyclophosphamide 2nd)
If patient with Felty has severe granulocytopenia, can give what?
GCSF
Most common septic arthritis bacteria in < 2 year olds
Kingella Kingae
Most common septic arthritis bacteria in > 2 year olds
Staphylococcus aureus
If patient has prosthetic joint infx (septic arthritis) within 3 months of placement… what is the likely organism
Staphylococcus aureus
If patient has prosthetic joint infx (septic arthritis) between 3-12 months of placement… what is the likely organism
Staphylococcus epidermidis
If patient has prosthetic joint infx (septic arthritis) over 12 months from time of placement… what is the likely organism
Staphylococcus aureus
Gold standArd to diagnose septic arthritis
Arthrocentesis and culture
Can you do an arthrocentesis on a patient with skin/subq infx
No. Big CI
Do you do blood cultures in septic arthritis patients…
Well… if there is acute onset and fever… which is most patients
Preferred initial imaging for septic arthritis patients?
X-ray
Treatment overview for septic arthritis
Arthrocentesis (drainage to dryness). Empiric Abx
Septic arthritis in prosthetic joint usually requires what surgery?
A surgery to remove pus from joint
Empiric Abx for septic arthritis (gram +)
Vancomycin
Empiric Abx for septic arthritis (gram - cocci)
Ceftriaxone (ceftriacocci)
Empiric Abx for septic arthritis (gram - bacilli)
Cefepime (Pime = bacilli)
Targeted Abx for septic arthritis MRSA and MSSA
MRSA: vancomycin
MSSA: naficillin
Targeted Abx for septic arthritis (neisseria G)
Ceftriaxone
Osteoarthritis or RA… which has symmetrical involvement
RA
Radiological findings for OA
Joint space narrowing, subchondral sclerosis and cysts, osteophytes
First line treatment for OA
Exercise and weight loss
Before oral NSAID, how else can we admin NSAIDs in OA
Topical NSAID patch
Role of paracetamol/or intraarticular GC injections (in OA i think)
For short term relief when other medications are unsuitable
When to refer OA patient for joint replacement
If QoL is severely impacted, or other options are ineffective/unsuitable
First line for Juvenile idiopathic arthritis
NSAID
Some 2° causes of Pseudogout
Hyper parathyroidism, Hemochromatosis, chondrocalcinosis, joint damage
Treatment for pseudo gout
NSAID, consider injection of cortisone. GCs oral, if no other option
When do we give colchicine in pseudogout patients
As prophylaxis If patient had many flares! Can help prevent flares. Low dose only
Can a gout attack occur if uric acid levels are normal
Yes
When is a gout attack most likely to occur?
At night
When is an Arthrocentesis done in the diagnostic workup for Gout (note: it’s not often done!)
If there is diagnostic uncertainty, or a higher probability of septic arthritis
Lifestyle advise to a gout patient
No diet proven to help, but Limit alcohol, lose weight and avoid eating high fish and meat meals
Within 24 hours of acute gout flare, Tx options
Oral prednisone or high dose naproxen or Colchicine (intraarticular injection if none above work, IL1 inhib last line/refer to Rheuma first)
Chronic gout management (1st to 3rd line)
1st - allopurinol or febuxostat
2nd - probenecid
3rd - pegloticase
Chronic gout treatment should be for who?
Recurrent gout attacks, renal insufficiency, tophi
When giving a XOI for gout, give with?
Colchicine to reduce flare risk
Use of peglitcase in gout? How to give it
For severe refractory gout (3rd line in chronic Mx). IV infusion every 2 weeks
Use of rasburicase
Only in tumour lysis syndrome
Diagnostic criteria for ankylosing spondylitis
Lower back pain > 3 months, <45 years old (+)
- sacrolititis on X-ray or MRI
Or/&
- HLA b 27
Best initial Invx for ankylosing spondylitis (to Dx)
Sacroiliac joint PA X-ray
Most sensitive method for early detection of ankylosing spondylitis
MRI
First line treatment for ankylosing spondylitis, and the step up?
NSAID, then TNF alpha inhibitors
Is Reiter syndrome usually oligo or poly arthritis? Migratory?
Oligo and migratory
First line Tx for Reiter syndrome (and consider what else?)
NSAIDs. And treat any underlying infx
Main difference between many of the seronegative arthritis and RA? I’m regards to the location of arthritis
Most seronegatives are asymmetrical. Unlike RA
Tx for Psoriatic arthritis
NSAID (1st), DMARD (2nd)
Fragility fracture most common location
Vertebral
Diagnosis of osteoporosis
DXA (-2.5 means osteoporosis) and (-1means osteopenia)
Calcium, phosphate and PTH in osteoporosis patients
Normal!
When to treat osteoporosis
If had fragility fractures, and or if T score < -2.5
First line for osteoporosis Tx
Bisphosphonates
Aside from bisphosphonates, what are other treatments for osteoporosis
Teriperatide, tamoxifene, denosunab, calcitonin
Calcium, phosphate, ALP and PTH levels in Pagets
Calcium normal , phosphate normal, ALP elevated and PTH levels normal
First line treatment for Pagets
Bisphosphonate
GCA suspect, management
High dose CSs first, then biopsy
Usually diagnose Takayasu how?
Angiogram/arteriography (not biopsy)
Treatment for takayasu
Corticosteroids are first line. Or there immunosuppressive Tx can be given. Bypass Sx or angioplasty given if severe
Buergers disease Dx?
A clinical diagnosis.
Advice and treatment for Buergers disease
Stop smoking. Consider CCB or iloprost
Kawasaki disease treatment
IV immunoglobulin and aspirin
Important invx in Kawasaki disease
Echo/CTA
Treatment of polyarteritis nodosa
CSs, and cyclophosphamide
HLA associated with Behcets
HLA B51
Which two viruses can be seen to cause Behcets
HSV, parvovirus
Treatment for Churg Strauss
GCs
Wegeners treatment
CSs and ( rituximab or cyclophosphamide )
HSP treatment
Supportive care, CSs/or NSAIDs, monitor BUN/Cr
Goodpastures treatment
Plasmaphoresis and immunosuppressant
Parvovirus in adult (arthritis). How to diagnose and treat
Check for anti ParvoV IgM. No need to treat
Antibiotics given for Lymes-arthritis
Doxycycline, amoxicillin, or Ceftriaxone (doxy, foxy, amoxi)
Gonococal septic arthritis. Treatment?
IV ceftriaxone and oral doxy in case chlamydia coinfx
Do you need to biopsy muscles in polymyalgia Rheum?
No! Would be normal
Treatment for polymyalgia rhematica
Low dose oral GCs.
When does neonatal lupus occur
When mum has anti Ro and La crossing placenta to fetus. High in SLE, Sjr patients
Who will have an abnormal strength test…. PMR or polymyositis patients
Polymyositis patients
Main specific AB for poly/dermato myositis
Anti Jo (tRNA synthetase)
Aside from antibody testing, what is the gold standard to Dx poly/dermato myositis
Muscle biopsy
1st line Tx for poly/dermato myositis
GCs. MTX or Azathioprine 2nd
Advice and first line treatment for fibromyalgia
Regular excersize , and TCAs
Is symmetrically, and no ulceration in Raynauds, a sign of 1° or 2° cause
1°
Is asymmetry, and ulceration in Raynauds, a sign of 1° or 2° cause
2°
Medical therapy for raynauds
CCB
CREST syndrome antibody
Anti centromere
Diffuse Systemic sclerosis antibody
Anti scl 70 (topoisomerase I)
Mixed connective tissue disease antibody
Anti U1 RNP
If a patient has anti RNA polymerase III antibodies in diffuse S.S. What does this indicate?
High risk for renal crisis and more skin involvement
Do immunosuppressants have a role in systemic sclerosis
No
How to manage systemic sclerosis. For GI, raynauds, pulm HTN
PPI, CCB, usual pulmonary hypertension meds
Treatment for scleroderma renal crisis
ACEi
HLA associated with Sjogrens
HLA DR52 (Linn Sweden and Turkey)
How to diagnose Sjogrens (is it clinical, AB, or both)
Both, need clinical (evidence of gland dysfunction) and antibodys
What a few ways can prove gland dysfunction in Sjogren syndrome
Schimer test, scintigraphy, sialometry or labial gland biopsy
Antibodies for Sjogrens
Anti Ro and La (RF and ANA usually + too)
Sjogrens treatment (consider multiple elements)
Artificial tears and saliva. Muscarinic agonist, immunosuppressive. NSAID or hydroxychloroquine for arthralgia
HLA associated with APLS
HLA DR7 (7 miscarriages)
Most common cause of 2° anti phospholipid syndrome
SLE. Other causes are: RA, CA, HIV, Infx
Diagnostic criteria for APLS
Sign of A or V thrombosis, recurrent miscarriage Hx, and at least 1 of the following antibodies:
Lupus anticoag
Anti cardiolipin
Anti B2 microglobulin
Low risk APLS patient, Mx?
Low dose aspirin
Long term APLS Mx?
PO Warfarin
If pregnancy (or planning to get pregnant), what treatment should an APLS patient take ?
LMWH and aspirin
HLA. Seen in SLE
HLA DR2 and DR3 (2, 3 SLE)
DILE antibody
Anti histone
Pregnancy advice for SLE
Don’t get pregnant until >= 6 months quiescent
2 Specific antibody’s for SLE
Anti dsDNA and anti smith
First line treatment that all SLE patients should be on
Hydroxychloroquine
Mild to moderate SLE…. Tx?
Hydroxychloroquine plus oral glucocorticoids
Severe SLE induction and maintenance treatment
IV GCs then hydroxychloroquine
Best initial test for sarcoidosis
CXR
Chronic lab markers for sarcoidosis are?
Calcium, ACE. Not inflammatory markers in chronic phase
First line for sarcoidosis treatment
GCs (recall in resp the more complexed treatment plan)
Antibody for primary biliary cholangitis
Anti mitochondrial
HLA seen in graves
DR3 and B8 (Big 🦋)
Best test for Graves suspicion
TSH.
Specific marker for Graves
TSH receptor antibodies
HLA in celiacs
DQ2 and DQ8. CeliaQs
When to do arthroplasty for OA
If severe QoL impairment, and medical therapy not worked/suitable.
Best Imaging for OA
Xray best (MRI can detect sooner)
If suspect Ank spond, and Xray negative…. do what imaging?
MRI (can detect sooner)
Before starting BPS’s, ensure what? (electrolyte wise)
Ca, PO4 are normal
When to treat Osteoporosis patients?
Always. But treat osteopenia if fractures have occured
Acute flare of APLS Tx?
CSs
What is scleroderma renal disease? and how to Tx?
sudden oliguria and HTN. Usually with MAHA. Give ACEi
JIA, and adult onset stills… do they have RF/ACCP?
no, they are seronegative
before starting BPS for osteoporosis… what tests must be done?
Ca and Vit D
Oral or IV antibiotics for osteomyelitis at first?
IV… then consider transition to oral if clinical improvement
