Rheumatology Revision Flashcards
chronic pain in specific areas or pain all over
- worse when stress, with activity or in cold weather
- associated with morning stiffness
lethargy, cognitive impairment,
sleep disturbance, headaches, dizziness
women in 30-50yrs
fibromyalgia
Ix and dx of fibromyalgia?
typically clinical diagnosis
blood tests to r/o other ddx = TFTs, ESR/CRP, RF and CCP
11/18 trigger points
Management of fibromyalgia?
non-pharm = educate, exercise and CBT
first line pharm tx = amitriptyline
sudden onset pain (can last 1-2wks) spontaneous but can also be triggered big toe affected joint - warm, shiny, swollen and red very painful - cannot touch bedsheets
gout
what causes gout?
uric crystal deposition into joint space
can be mono or oligoarthritis
Ix in gout?
GOLD standard = joint aspiration and crystal analysis
= -ve birefringent crystals
serum uric conc may drop in acute attack
- often checkes around 2/52 after attack
leucocytosis, raised ESR/CRP
XR = effusion, punched out erosions, eccentric erosions and soft tissue trophi
Acute management of gout?
NSAIDs + colchicine 500mg BD
can give prednisolone
resolves within 2wks
need to exclude septic joint, RICE protocol
Prophylactic management of gout?
allopurinol - OD to prevent frequent attacks
- main S/E is diarrhoea
- can continue use if already on during acute attack, but cannot be initiated in acute attack
- indicated if 2+ attacks in 1 yr, renal disseas/uric stones and on diuretics
- lower dose in reduced eGFR
second-line = febuxostat
commonly knee affected
painful, swollen , warm , erythematous
acute onset
pseudogout
Ix for pseudogout?
aspirate joint & crystal analysis
- +vely birefringent crystals
XR = chondrocalcinosis - linear calcifications
management of pseudogout?
IA steroids
NSAIDs for pain mx
older pt (>60) for the past month has been having…
morning stiffness, achy pain in the shoulders and hips
- can affect proximal limbs
lethargy
depression
low grade fevers, night sweats and anorexia
polymyalgia rheumatica
What is PMR associated with?
temporal arteritis and GCA
often seen in older pts, and mainly females
Investigations and diagnosis of PMR?
raised inflammatory markers - ESR>40
CK normal
EMG normal
Management of polymyalgia rheumatica?
prednisolone 15mg OD
usually rapid response to steroids, if any failure to effectively respond - consider alternative dx
stiffness in peripheral joints
hands and fingers commonly affected - joints may be swollen
multiple joints are affected
symmetrical
may have ulnar deviation, swan neck deformity, hyperextended PIP and flexed DIP (Boutonniere) , thumb deformity
hyperextension of interphalangeal joint
Rheumatoid arthritis
How is Rheumatoid arthritis investigated?
bloods - FBC, ESR/CRP, anti-CCP, RF, ANA
XR = bone erosions
Which blood test is the most specific for Rheumatoid arthritis?
anti-CCP
What criterion used for diagnosis of rheumatoid arthritis? What score is needed for a diagnosis?
American college of rheumatology criterion
6/10 = diagnosis
Management of Rheumatoid Arthritis?
usually initiated in 2° care
- DMARD = methotrexate (or sulfasalazine)
- short term bridging steroids on initiation of tx
what is methotrexate regime? What is monitored? How is monitoring assessed?
methotrexate is given on a weekly basis
- co-prescribed with folic acid which is given 24hrs after methotrexate dose
monitor LFTs (hepatoxic drug), monitor FBC (WCC), monitor ESR/CRP
monitoring based on DAS28 score
methotrexate - side effects?
mucositis = inflamed mouth and gut pulmonary fibrosis liver cirrhosis myelosuppression pneumonitis
Methotrexate - contraindications? things to avoid?
contras = pregnancy (tetragenic)
avoid prescribing alongside trimethoprim and co- trimaxazole
avoid prescribing with aspirin
mono/oligoarthritis non-symterical joints common affecting knee and DIPs dactylitis - swollen digit enthesitis = swollen tendon pitting nails
known to have psoriasis
Reactive arthritis
What are the investigations for psoriatic arthritis?
XR = pencil cup deformity - often later stage sign but very characteristic
Elevated CRP & ESR
often CCP neg
Management for psoriatic arthritis
mild cases - treated with NSAIDs
DMARDs - methotrxate = helps skin and joint manifestations
if methotrexate provides an inadequate response = TNFa inhibitors (immunosupressant)
male Hx of GU/GI infection fever joint pain - oligoarthritis/asymmetrical uveitis - red/sore eye urethritis = dysuria
reactive arthritis / reiter’s syndrome
What other features can be seen in reactive arthritis
skin lesions
circinate balantis
keratoderma blennorrhagica
what is Reactive arthritis associated with
HLA-B27
what is reactive arthritis triad?
uveitis
urethritis
arthritis
can’t see, can’t pee and can’t climb a tree
Ix for reactive arthritis?
clinical diagnosis - not need for any Ix
can do tests to rule out other causes
Management for reactive arthritis
NSAIDs
IA steroids for joints
if persistent disease (>6/12) consider DMARD (methotrexate or sulfasalazine)
What is Polyarteritis Nodosa?
rare form of vasculitis affecting medium/small arteries causing aneurysms (microaneurysms)
men, 40-60yrs arthralgia malaise, fevers, weight loss peripheral painful neuropathy ulcers/pupuric rash/mottled skin testicular pain/haematuria
Polyarteritis nodosa
Ix and Dx for Polyarteritis nodosa?
elevated CRP/ESR
FBC = normocytic, normochromic anaemia
renal involvement = raised creatinine
affected skin/tissue = necrotizing inflammation
Management of Polyarteritis nodosa?
steroids
DMARDs if needed
what can increase risk/closely associated with Polyarteritis nodosa ?
Hep B virus infection
proximal muscle weakness
- common complaint = can’t brush my hair
- symmetrical
chronic/subacute onset
dysphagia/phonia
resp muscle weakness/dyspnoea
raynaud’s phenomenon
Polymyositis
What is associated with Polymyositis?
associated with malignancy
Investigations and diagnosis for Polymyositis ?
massively elevated CK
- elevated LDH, adolase, AST/ALT
EMG
antisynthetase/anti-Jo antibodies
Definitive dx = muscle biopsy
Management of Polymyositis?
steroids
Other options include = immunosuppressants, IVIG and biologics
What is scleroderma?
multi-system autoimmune disease via production of autoantibodies
structural & functional abnormalities
- small blood vessels
- fibrosis of skin/internal organs
RFs for scleroderma?
family history
autoimmune disease
sclerodactyly/claw like hand
skin thickening
swelling of hands and feet
severe raynaud’s phenomenon
esophageal dysmotility/dysphagia
telangiectasia
Scleroderma
Ix and Dx of Scleroderma?
Bloods - ANA usually positive, Scl-70 positive and also anti-topoisomerase I
Management of scleroderma?
NSAIDs and steroids
severe dry eyes
severe dry mouth
- associated poor dentition
Fatigue
Pre-exisiting RA or SLE
Sjogren’s syndrome
Ix or dx of Sjogren’s syndrome ?
bloods - +ANA
diagnostic = +SSA/Ro, +SSB/La antibodies
Gold standard = salivary gland biopsy
Management of Sjogren’s syndrome?
symptomatic tx - eye drops, sialogues and punctal plugs
what is the dry eyes and dry mouth also referred to
sicca complex
females, <16yrs 6weeks + hx of.... joint pain and swelling in knee intermittent fever spikes uveitis
family hx of autoimmune conditions
juvenile RA
Investigations and diagnosis for juvenile RA?
elevated ESR/CRP
ANA+
RF +
Management for juvenile RA?
NSAIDs
DMARDs
arthritis raynaud's phenomenon malar rash photosensitivity fatigue weight loss and fevers oral ulcers alopecia/hair loss
Systemic Lupus Erythematous (SLE)
Investiagations and diagnosis for SLE?
ANA+ anti-dsDNA/anti-smith antibodies low complement C3/4 levels raised CRP/ESR immunoglobulins
urine/ACR = protineuria = lupus nephritis
- if found then renal biopsy should be done
What blood test is specific to SLE?
anti-dsDNA and anti-smith
Management of SLE?
hydroxychloroquinolone
NSAIDs and steroids - pred
in severe/resistant SLE = trial other immunosuppressants or biological therapies
