Rheumatology medicine block Flashcards
What is the pathogenesis of rheumatoid arthritis?
- Ab to RF and anti CCP
- Activate macrophages = TNFa which stimulates inflam cascade
- Proliferation of synoviocytes = on cartilage, restrict nutrients and cause damage
- Increased osteoclast differentiation so more bone damage
Describe the typical history of RA
- Female, 30-50
- Progressive, peripheral, symmetrical arthritis
- > 6 weeks morning stiffness more than 30 mins
- Also malaise and fatigue
What joints are affected in RA?
Any joint can be affected but usually PIPs, MCPs and MTPs w DIPs usually spared
What are the findings on examination of someone with RA?
- Soft tissue swelling and tenderness
- Swan neck and Boutonniere’s deformity
- Rheumatoid nodules, most commonly on elbow - aggressive disease, +ve RF Ab
- Z thumb
- PIPJ synovitis
Draw the difference between swan neck and Boutonniere’s deformity
Answers on ipad
What are the Ix in RA?
- RF and anti CCP Ab (this is more specific than RF)
- FBC = normocytic anaemia due to ACD
- Increased inflam markers
- XR changes in established disease
- PFTs if pulm fibrosis
What is the treatment of RA?
- DMARD therapy, start w methotrexate
- In severe disease use combination DMARD eg. + sulfasalazine or hydrochloroquine
- NSAIDs for sx control w PPI cover
- If DMARD combination not working try biologicals eg. anti TNFs
What are the extra articular manifestations of RA?
- 3Cs - CVD, CTS, cord compression
- 3Ps - pleural disease, pulm disease, pericarditis
- 3As - anaemia, amylordosis, arteritis
- 3Ss - Sjogren’s, scleritis, splenomegaly
What is Felty’s syndrome?
Splenomegaly + neutropenia + RA
What are the XR features of RA?
Loss of joint space
Erosions
Soft tissue swelling
Subluxation
What is giant cell arteritis?
Chronic vasculitis of med and large vessels originating off the arch of the aorta.
Age is the biggest RF, pt almost always >50.
What are the arteries that originate from the arch of the aorta?
- Brachiocephalic artery = R common carotid and R subclavian
- L common carotid
- L subclavian
Go to supply the head and arms.
What are the symptoms of GCA?
- Headache = localised, over temples, unilateral
- Jaw and tongue claudication, pain eating and talking
- Visual disturb = amourosis fugax, diplopia, blind due to occlusion of artery = AION
- Scalp tenderness over temporal artery
What is AION?
Ant ischaemic optic neuropathy
What is the diagnostic criteria for GCA?
> 50 yo pt w 2 or more of the following:
- Raised inflam markers
- Tenderness/reduced pulsation in temporal artery
- New onset headache or visual symptoms
- Biopsy shows necrotising arteritis
How do you treat GCA?
- Prednisolone 60-100mg OD for 2 weeks and then consider reducing
- IV methyprednisolone for 1-3 days for acute visual sx
- Baby aspirin to avoid thrombotic events
What is polymyalgia rheumatica?
Pain and stiffness in the shoulder, hip and neck in the elderly, presentation normally at 70-80yo.
Is associated w morning stiffness, raised inflam markers and GCA.
How do you diagnose polymyalgia rheumatica?
- Typical hx and exam + raised inflam markers
- Can do a temporal artery biopsy if sx of GCA
What is the typical hx of a pt w polymyalgia rheumatica?
- Sudden onset proximal joint pain and stiffness
- Difficulty rising from a chair and brushing hair
- Night time pain
- 25% of pt have systemic sx
What can you find on examination in polymyalgia rheumatica?
- Reduced ROM in shoulders, neck and hips
- Normal muscle strength but tenderness
How do you treat polymyalgia rheumatica?
Has a dramatic response within 5 days to prednisolone, 15 mg OD.
Then taper it down slowly, too quick = relapse.
Can use methotrexate for steroid sparing in a relapsing pt.
What are spondyloarthropathies?
Conditions that affect the spine and peripheral joints w an association w HLA-B27.
- Psoriatic arthritis
- Ankylosing spondylitis
- Reactive arthritis
- Enteropathic arthritis
What are the common clinical features of all spondyloarthropathies?
- Sacro iliac/axial disease = back and buttock pain
- Inflam arthopathy of peripheral joints
- Enethesis - inflam of tendon insertions
- Extra articular features
What is the presentation of ankylosing spondylitis?
Younger man, pain in chest wall, thorax and bilateral buttocks
Ankylosing spondylitis:
- Exam
- Ix
- Treatment
Exam - often normal but later on = thoracic kyphosis, reduced chest expansion and Schober’s test
IX - MRI spine and SI joints, raised CRP
Treatments - NSAIDs, physio, TNF inhib, IL-17 inhib
Psoriatic arthritis:
- Exam
- Ix
- Treatment
Exam - oligoarthritis, dactylitis = sausage digits, 10% of psoriasis pt, nail pitting
Ix - raised CRP, central joint erosion on MRI
Treatment - NSAIDs, DMARDs, TNF inhib, IL-17 inhib
What is the clinical hx of a pt w reactive arthritis?
Sterile synovitis following colitis, urethritis, cervicitis. Normally a few days-2 weeks after infection develop acute asymmetrical lower limb arthritis.
Reactive arthritis:
- Exam
- Ix
- Treatment
Exam - keratoderma blenorrhagica
Ix - serology, microbiology, raised CRP, joint aspiration to exclude septic/crystal arthritis
Treatment - treat infection, NSAIDs, joint infection, if doesn’t resolve w/i 2 years = DMARDs
What is the history of enteropathic arthritis and the types?
Hx = 10-20% of pt w IBD get arthropathy.
Type 1 - oligoarthritis, asymmetrical, correlates w IBD flares
Type 2 - polyarthritis, symmetrical, doesn’t correlate w flares
How do you treat enteropathic arthritis?
Don’t use NSAIDs as they cause flares. TNF inhib treat IBD and arthritis, can used DMARDs.
What are the common signs and symptoms of lupus?
A RaSH POINts Medical Dx: Arthritis Renal abnorm Serositis Haem abnorm Photosensitivity Oral ulcers Immunological abnorm Neuro abnorm Malar/discoid rash
What is SLE?
Systemic Lupus Erythematous - autoimmune disease due to inadequate T cell suppressor activity w increased B cell activity. Is a multi system disease w variable presentation. Remission and flares disease.
What are the Ix into SLE?
- ANA +ve = serology
- Raised ESR and plasma viscosity
- FBC = anaemia + leukopenia v common
- Urinanalysis to see if renal disease
- Diagnostic skin and renal biopsy
What is the treatment of SLE?
- Sun protection and advise on healthy lifestyle and reduction of CVS RF
- Hydroxychloroquine for rash and arthritis
- Short course of prednisolone for flares
- Can also add myeophenolate mofetil, azathioprine and rituximab
What does subluxation mean?
Partial dislocation
What is Raynaud’s phenomenon? How does it differ to Raynaud’s syndrome?
Vasospasm of the digits = pain and colour change in response to cold stimulus, often in times of stress:
- White = reduced blood flow
- Blue = venous stasis
- Red = re warming hyperaemia
Syndrome - idiopathic in young women, phenomenon = underlying disease, over 30 yo.
What are the patterns of episodes in Raynaud’s phenomenon and syndrome?
Syndrome - min long, symmetrical, bilateral
Phenomenon - hours long, asymmetrical, affect few digits
What points to a rheumatic cause of RP?
- Abnormal nail fold capillaries
- Puffy fingers
- Photosensitive rash
What are the diseases RP is associated with?
- Scleroderma
- SLE
- Sjogren’s
- Polymyositis, dermomyositis
What are the physical and drug causes of RP?
Physical - cervical rib, cryoglobulinaemia, use of vibration tools
Drug - B blockers
How is RP treated?
- Advise to stop smoking and keep warm
- 1st line = CCB then phosphodiesterase 5 inhib
What are the complications of RP?
- Digital ulcer
- Infection
- Severe digital ischaemia
What is the pathophysiology in vasculitis?
Inflam blood vessel disorder = damange to vessel wall = thrombosis = iscahemia and bleeding +/- aneurysm
What are the glove and sweater questions for taking a hx in vasculitis?
- Raynaud’s, nose bleed, ulcers
- MSK - arthralgia, myalgia, proximal muscle weak
- CNS - headaches, visual loss, stroke, tinnitus, seizures
- Heart + lung - pericarditis, cough, chest pain, haemopytsis, SOB
- Abdo pain, haematuria, neuropathy, digital ischaemia
What are you looking for on exam in vasculitis?
- General exam - BP, pulsem also look for normal findings on cardio, resp and abdo
- Skin - palpable purpura, livedo reticularis, digital ulcer, nodules, gangrene, nail bed changes
- Neuro - CN exam, sensorimotor exam
- Eyes - ocular fields, scleritis, uvetitis
What is livedo reticularis?
Skin symptom - redish blue web on skin, normally legs, can get worse when cold
What are the primary vasculitides?
- Small vessel = micropolyangitis, MPA
- Med vessel = Kawasaki disease
- Large vessel = giant cell arteritis, GCA
What are the secondary causes of vasculitis?
Secondary causes - drugs, malignancy, infection, connective tissue disorders
What are the ix into vasculitis?
- Bloods - FBC, U&E, LFT, CRP, ESR
- Serology - ANA, RF, cryoglobulins
- Screen Hep B/C, HIV
- CT, CXR, MRI, PET, angiography
What is the treatment of vasculitis?
- Rule out infection and stop secondary cause drugs
- 1st line - corticosteroids
- 2nd line - cytotoxic meds or biologicals
What is systemic sclerosis? What are the 2 different types?
Multi system autoimmune disease, previously known as scleroderma.
Increased fibroblasts = abnormal connective tissue = vascular damage and fibrosis.
1. limited SSc - skin tightness distal to elbow/knee
2. diffuse SSc
What are the signs and symptoms of limited SSc/scleroderma?
CREST:
Calcinosis cutis - Ca2+ deposits in the skin
Raynaud’s phenomenon
Eoseophageal dysmotility
Sclerodactyly - thickening/tight of the skin
Telangiectasia
What are the signs and symptoms of diffuse SSc/scleroderma?
Much less common but a higher risk of mortality = sudden onset skin involvement proximal to the elbow and knees
What are the ix into SSc/scleroderma?
- Normal inflam markers
- XR hands = calcinosis
- CXR + PFT if pulm disease
- +ve ANA
- ECG, ECHO = HTN, HF, arrhythmia
What are the Ab that suggest limited SSc and what are the Ab that suggest diffuse?
Limited - anti centromere Ab
Diffuse - anti RNA polymerase or anti topoisomerase
What is the treatment for SSc/scleroderma?
No cure, have to treat symptoms and psychological support may be needed:
- CCB for Raynaud’s
- Methotrexate/mycophenolate mofetil to reduce skin thickening
- ACEi to prevent HTN crisis and reduce mortality
- Short courses prednisolone for flares
- PPI for GI sx
What are the common signs and sx of Sjogren’s?
MADFRED Myalgia Arthralgia Dry mouth Fatigue Raynaud's phenomenon Enlarged parotids Dry eyes
What are the ix of Sjogren’s?
- Salivary gland biopsy
- Anti Ro and anti La Ab in 90% of people
- Schirmer’s test = measures tear vol
What is the treatment of Sjogren’s?
- Dry eyes = artificial tears - hydromellose
- Dry mouth = artificial saliva, sugar free gym/gummies
- Skin emollient, lube
- Avoid smokey/dry atmospheres
What is hypermobility spectrum disorder?
Pain syndrome that results in joints moving excessively due to lax ligaments, capsules and tendons. Pain usually caused by microtrauma.
Who does hypermobility affect?
- 10% of the population but most are asymptomatic
- Presents in childhood and adulthood
- Subluxation and dislocations recurrent
What are the signs and sx of hypermobility?
- Pain around joints worse after activity, can be generalised
- Soft tissue rheumatism
- Myopia, abnormal skin, drooping eyes
- Rectal prolapse and hernias
- Arachnodactylyl
What is the treatment of hypermobility?
- No evidence for pharmacology except paracetamol for pain
- Strengthening exercises to reduce subluxation
- Posture and balance training
- Specialist pain mangement
- Splinting and surgical intervention
What is the score used in hypermobility?
Beighton’s score
What is fibromyalgia?
Disorder of central pain processing = chronic widespread pain in all 4 quadrants of the body. Most have allodynia.
What is allodynia?
Heightened and painful response to harmless stimuli
What is the underlying pathophysiology of fibromyalgia?
Induced by sleep deprivation = reduced REM sleep and increased D wave.
Neural activation in the pain processing area of the brain in response to non painful stimuli and increase activation in painful stimuli.
What are the signs and symptoms of fibromyalgia?
- Pain and numbness
- Depression and anxiety
- Joint pain and stiffness
- IBD, irritable bladder
- Unrefreshing sleep, fatigue, headaches
- Poor concentration and memory
- No signs on exam but may have ‘tender points’
What are the RF and demographics of fibromyalgia?
- Female:male = 9:1
- Onset ~ 40-50
- 5% of the population affected
- Triggered eg. emotional or physical like painful arthritits
What is the treatment of fibromyalgia?
- Pt improves w an explanation of their sx and measures to improve sleep and activity level
- Low dose amitriptyline or pregabalin
- CBT
What is amitriptyline?
Tricyclic antidepressant used to treat neuropathic pain and depression. Makes pt sleepy so take at night. Blocks reuptake of NA and serotonin.
What are the non modifiable risk factors of osteoporosis?
- Age
- Female
- FH
- Caucasian/SA
- Hx low trauma fractures
What are the modifiable RF of OP?
- Smoking
- Excess alcohol intake
- Low levels of activity
- Ca2+/Vit D deficiency
- Premature menopause
- Low BMI
- Iatrogenic eg. corticosteroids
How do you make a diagnosis of OP?
- DEXA of lumbar spine and hips = gold standards
- T score
What is the treatment of osteopenia?
- Increase weight bearing exercise
- Vit D supplement
- Reduce alcohol and stop smoking
- Increase Ca2+ intake
What is the treatment of OP?
- Vit D +/- Ca2+ supplement
- 1st line = bisphosphonates eg.aldendronic acid = always coprescribe the supplements, take on empty stomach SE - reflux
- 2nd line = denosumab
What is gout and what is the pathophysiology?
- Inflam arthritis related to hyperuricaemia
- Can affect >1 joint but most commonly 1st MTP
- Deposition of MSU crystals which accumulate in joint and soft tissue = arthritis, tophi, urate nephropathy, uric acid nephrolithiasis
- Associated w increased risk CVD
What are the non modifiable and modifiable RF of gout?
Non modifiable = age+men Modifiable: - Drinking beer - Smoking, HTN, DM - Obesity, high fructose, lots of meat and seafood - CHF, CAD, increased lipids - Renal disease - Organ transplant
What is the conservative management of gout?
General prevention - good weight, reg exercise, reduce alcohol, stop smoking avoid dehydration
What is the pharmacological management of gout?
- 1st line = NSAIDs, steroids, colchicine
- Urate lowering therapy eg. allopurinol + febuxostat
- Benxbromarone increased renal excretion of uric acid
What are the drug treatments used in rheumatology?
- NSAIDs
- Corticosteroids
- DMARDs
- Biologicals
- Drugs for OP
- Drugs for crystal arthritis
Describe NSAID usage in rheum
- Initial therapy and sx relief
- SE = GI prob, renal impairment
- Short term but long term w PPI cover
Describe corticosteroid usage in rheum
For inflam arthritis used for few weeks and then reduced when DMARDs kick in. Have SE so used low dose and short as possible.
Mainstay for PMR and GCA.
Describe DMARDs in rheum
- Methotrexate, hydroxychloroquine and sulfasalazine = most common.
- Used in RA, PsA, SLE, vasculitis.
- SE - bone marrow suppression, hepatitis, GI upset, rash.
Describe biologicals in rheum
- Monoclonal Ab
- Used in RA, PsA, AS, psoriasis, IBD
- TNFa inhib
- Rituximab - RA
- IL-17 antagonists - AS, PsA
- JAK kinas inhib - RA, PsA
- SE = increased risk infection, theoretical malignancy risk, reactivation hep B and TB so screen and vaccinate
What DMARD causes anaemia?
Methotrexate - causes folic acid suppression = macrocytic anaemia
What is a common side effect of bisphosphonates?
Dyspepsia
Gout vs pseudogout
Gout - needle shaped negatively birefringent, uric acid or monosodium urate, big toe more commonly
Pseudo gout - rhomboid shaped positively birefringent, calcium pyrophosphate, knee more commonly
