Rheumatology Passmed Flashcards
What blood results are seen in osteomalacia?
Low serum calcium
Low serum phosphate
Raised ALP
Raised PTH
what is osteomalacia?
Softening of the bones caused by severe vitamin D deficiency
Presents with:
Bone pain
Muscle weakness
Bone deformities
What are the blood results in osteoporosis?
ALL normal (PTH, ALP, Calcium, Phosphate)
What are the blood results in hyperparathyroidism?
High ALP
High PTH
High Calcium
Low phosphate
What is the first line treatment for ankylosing spondylitis?
Regular Exercise
Physiotherapy
NSAIDs
Which drugs should never be prescribed with methotrexate?
Trimethoprim (including co-trimoxasole) - causes bone marrow suppression and severe or fatal pancytopenia
High dose aspirin
What type of hypersensitivity reaction is allergic contact dermatitis?
Type IV (T cell-mediated)
what are the common features of psoriatic arthritis?
Pencil in cup X ray appearance
More likely to be asymmetrical
Dactylitis
When should patients be offered allopurinol?
After the first attack
What should be co-prescribed when starting allopurinol?
Colchicine
OR
NSAIDs
What type of hypersensitivity is SLE?
Type 3 (immune complex - free antigen and antibody combine)
What is the main difference in blood tests between PMR and polymyositis?
Polymyositis causes an increase in creatinine kinase, PMR is NOT associated with an increase in CK.
what are the ‘A’s in ankylosing spondylitis?
Apical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
AV node block
Amyloidosis
Any caudal equine syndrome
Peripheral arthritis
What complication can be seen in temporal arteritis?
Anterior ischaemic optic neuropathy (occlusion in a branch of the ophthalmic artery)
Fundoscopy - swollen pale disc and blurred margins
What are the signs and symptoms of temporal arteritis?
50% have PMR
Raised ESR
Sometimes raised CRP
CK and EMG NORMAL
What is the urgent treatment given in temporal arteritis?
No visual loss:
- High dose prednisolone
Visual loss:
- IV methylprednisolone given first before red
Urgent opththalmology review
What is Ewings sarcoma?
A malignant bone tumour affecting children.
Occurs mostly in pelvis and long bones - causes severe pain.
Onion skin appearance on X-ray.
what is an osteosarcoma?
MOST common primary malignant bone tumour
Seen mostly in children
Occurs mostly in the metaphysics of long bones prior to epiphyseal closure
Sunburst pattern on X-ray
what are the blood results in antiphospholipid syndrme?
Rise in APTT
Thrombocytopenia (low platelets)
What are the features of antiphospholipid syndrome?
Predisposition to VTE and arterial thrombosis
Recurrent foetal loss
Thrombocytopenia
Lived reticular
ASSOCIATED WITH SLE
Anticardiolipin antibodies
What are the features of antiphospholipid syndrome?
Predisposition to VTE and arterial thrombosis
Recurrent foetal loss
Thrombocytopenia
Lived reticular
ASSOCIATED WITH SLE
Anticardiolipin antibodies
what is the primary prophylaxis of antiphospholipid syndrome?
Low dose aspirin
What is the secondary prophylaxis of
Lifelong warfarin INR 2-3
what type of reaction is anaphylaxis?
Type I
Antigen reacts with IgE bound to mast cells
what crystals are seen in pseudogout
calcium pyrophosphate dehydrate crystals
Joint aspiration: Weakly-positive bifringent rhomboid shaped crystals
What is limited cutaneous systemic sclerosis?
Scleroderma which mainly affects the face, distal limbs
Anti-Centromere antibodies
CREST syndrome is a subtype
What is diffuse cutaneous systemic sclerosis?
scleroderma which affects the trunk and proximal limbs
Anti scl-70 antibodies
Organ involvement: Interstitial lung disease, renal disease, hypertension
What is scleroderma
Tightening and fibrosis of the skinWITHOUT organ involvement
what are the components of CREST syndrome?
Calcinosis
Raynauds
Oesophageal dysmotilit
Sclerodactyly
Tenalgiectasia
What are the seronegative spondyloarthropathies?
Positive HLA-B27
Rheumatoid factor negative
Ankylosing spondylitis
Psoriatic arthritis
Reactive arthritis
Enteropathic arthritis
What are the X-ray changes of osteoarthritis?
LOSS
- Loss of joint space
- Osteophytes forming at joint margins
- Subchondral sclrosis
- Subchondral cysts
what are the signs and symptoms of SLE?
Malar rash
Photosensitivity
Raynaids
Lived reticular
Non scarring alopecia
Arthralgia
Non-erosive arthritis
Pericarditis
Myocarditis
Pleurisy
Fibrosing alveoliitis
Proteinuria
Llomerulonephritis
Anxiety and depression
Psychosis
Seizures
What condition can patients undergoing chemotherapy be at a higher risk of?
Gout (due to increased rate levels)
Which antibodies are positive in SLE?
99% Positive:
Antinuclear antibody ANA
Highly specific but not sensitive:
Anti dsDNA (usually the answer in SBA)
Anti smith
Anti - U1 RNP, Anti ro, Anti la
What is the most common organism causing septic arthritis OVERALL?
staphylococcus aureus
What is the most common organism causing septic arthritis in sexually active people?
Neisseria gonorrhoea
what are the signs of septic arthritis
haematogenous spread
acute swollen joint
tarm to touch
fever
restricted movement
What are the investigations that should be done in septic arthritis?
Synovial fluid sampling (done prior to abx, can be done under ultrasound guidance)
Blood cultures (haematogenous spread)
Joint imaging
What is the management of septic arthritis?
Flucloxacillin
Clindamycin if penicillin allergic
*4-6 WEEKS of ABX
Patients switched to oral ABX after 2 weeks
needle aspiration to decompress the joint
arthroscopic lavage may be needed
Regarding a DEXA scan, what is the T and Z score?
T score - your bone density compared to a 30 year old
Z score - your bone density adjusted to your age, General and ethicity
What are the DEXA scan results?
> -1.0 = normal
- 1.0- -2.5 = osteopaenia
< -2.5 = osteoporosis
what is the treatment for acute flares of rheumatoid arthritis?
Intramuscular or oral steroids:
methylprednisolone
what is the treatment of Raynaud?
nifedipine
what are the features of osteogenesis imperfect?
AKA - brittle bone disease
Presents in childhood
fractures following minor trauma
blue sclera
deafness secondary to otosclerosis
dental imperfections
ALP, PTH, calcium and phosphate usually NORMAL
what are the blood results in poly myalgia rheumatic?
Raised ESR
raised CRP
Normal anti CCP
Normal CK
what is reactive arthritis
A HLA-B27, seronegative arthritis.
It is an arthritis that develops following an infection where the organisms cannot be recovered from the joint
what are the signs of reactive arthritis
urethritis
conjunctivitis
arthritis
often occurs post STI
caused by chlamydia trachoma’s
what is the treatment for reactive arthritis
analgesia
NSAIDs
intra articular steroids
Sensitive vs specific factors for SLE?
Sensitive - ANA
Specific - Anti dsDNA
what is the complication of hydroxychloroquine
sight loss
what are the adverse effects of methotrexate
mucositis
myelosuppression
pneumonitis
pulmonary fibrosis
liver fibrosis
Interaction with trimethoprim or co-trimoxazole
interaction with aspirin (increases risk of methotrexate toxicity)
toxicity
what is the guidance regarding methotrexate treatment and pregnancy
both women AND men should avoid pregnancy/use effective contraception for 6 months after stopping methotrexate
what is the medication used to treat methotrexate toxicity
folonic acid
what is polymyositis?
an inflammatory disorder causing symmetrical, proximal muscle weakness
it is associated with malignancy
how is marfans syndrome passed on
autosomal dominant
what are the blood results seen in pages disease?
Raised ALP
Normal calcium
Normal phosphate
What is the first and second line imaging for ankylosing spondylitis?
- Plain x-ray of the sacroiliac joints
- MRI (if sacroiliac x-ray is negative but suspicion remains high)
Who should take vitamin D supplementation
- All pregnant women and breastfeeding women
- Children 6 months - 5 years (if not drinking 500ml of formula milk a day)
- Adults >65
- Housebound patients
Which antibody is a good rule out test for SLE?
ANA antibody
Because its positive in 99% of people with SLE
What should be prescribed with methotrexate?
Folate - this reduces the risk of bone marrow suppression
What is sjogrens syndrome?
An autoimmune disorder affecting exocrine glands resulting in dry mucosal surfaces.
Can be primary.
Can be secondary - develops around 10 years after rheumatoid arthritis or SLE.
what are you at increased risk of if you have sjogrens?
Lymphoid malignancy (40-60 fold).
what are the features of sjogrens syndrome?
dry eyes
dry mouth
vaginal dryness
arthralgia
raynauds
myalgia
sensory polyneuropathy
recurrent episodes of parotitis
renal tubular acidosis
what are the tests done for sjogrens disease?
Antibody tests:
- Anti Ro = most associated with primary sjogrens
- anti-La
- ANA
- rheumatoid factor
Schirmers test - strip of paper left under the eyelid for 5 minutes (should travel 15mm). A result of <10mm is significant.
What is the management of sjogrens syndrome?
Artificial tears
Artificial saliva
Vaginal lubricants
Hydroxychloroquine (to halt progression of the disease)
Pilocarpine - many stimulate saliva production
What is dermatomyositis?
an inflammatory disorder causing symmetrical, proximal muscle weakness and characteristics skin lesions
What should be done when someone is diagnosed with dermatomyositis?
A malignancy screen
What is the treatment for osteoarthritis?
- Weight loss, local muscle strengthening exercises and general fitness
- Paracetamol and Topical NSAIDs (topical NSAIDs for knee and hand only)
- Oral NSAIDs, opioids, capsaicin cream and intra-articular corticosteroids.
- joint replacement should be considered if conservation methods fail
what should be prescribed in OA alongside NSAIDs and COX-2 inhibitors?
A PPI
what is the treatment for fibromyalgia
- Aerobic exercise
- CBT
- Medication: Pregabalin, duloxetine, amitriptyline
what blood test can be used to monitor disease activity in SLE?
Complement levels - usually go down in active flare
when can hydroxochloroquine be used?
It CAN be used
What x-ray changes are seen in pseudo gout
chonedrocalcinosis
What is the treatment for raynauds?
Nifedipine
What is the treatment for SLE?
Hydroxychloroquine
what tests should be done if rheumatoid arthritis is suspected
rheumatoid factor
anti CCP (same sensitivity, higher specificity) - can be detected 10 years before RA develops
X-ray of hands and feet
what is the treatment for antiphospholipid syndrome
primary prevention:
daily aspirin
Secondary prevention:
Lifelong warfarin INR target 2-3
