Rhuematology Flashcards
Rheumatoid arthritis diagnostic antibodies?
Anti-CCP
Rheumatoid factor
To revise the mnemonic differentiating OA and RA:
==== OA ====
L loss of joint space
O osteophytes
S subchondral sclerosis
S subchondral cysts
==== RA ====
L loss of joint space
E erosions
S soft tissue swelling
S soft bones (osteopenia)
S Subluxation
What antibodies are associated with limited cutaneous systemic sclerosis
anti-centromere antibodies
What is azathioprine?
metabolised to the active compound mercaptopurine, a purine analogue that inhibits purine synthesis. A thiopurine methyltransferase (TPMT) test may be needed to look for individuals prone to azathioprine toxicity.
First line for osteoporosis?
Bisphosphonates- Alendronate
If can’t tolerate give riseronate or etidrone
What does raloxifen do?
selective oestrogen receptor modulator (SERM)
prevent bone loss and to reduce the risk of vertebral fractures, but has not yet been shown to reduce the risk of non-vertebral fractures
What is Strontium ranelate
‘dual action bone agent’ - increases deposition of new bone by osteoblasts (promotes differentiation of pre-osteoblast to osteoblast) and reduces the resorption of bone by inhibiting osteoclasts
What is denosumab?
human monoclonal antibody that inhibits RANK ligand, which in turn inhibits the maturation of osteoclasts
X-ray findings in psoriatric arthritis?
often have the unusual combination of coexistence of erosive changes and new bone formation
periostitis
‘pencil-in-cup’ appearance
What rheumatoid arthritis factor has the highest specificity?
Anti-cyclic citrullinated peptide antibody
What kind of nodes suggest OA?
Herbeden’s nodes
X ray findings in ankylosing spondylitis?
sacroiliitis: subchondral erosions, sclerosis
squaring of lumbar vertebrae
‘bamboo spine’ (late & uncommon)
syndesmophytes: due to ossification of outer fibers of annulus fibrosus
chest x-ray: apical fibrosis
What is given in temporal arteritis if evolving visual losss?
IV methylprednisolone
Interactions of methotrexate?
avoid prescribing trimethoprim or co-trimoxazole concurrently - increases risk of marrow aplasia
high-dose aspirin increases the risk of methotrexate toxicity secondary to reduced excretion
Poor prognostic features of RA?
rheumatoid factor positive
anti-CCP antibodies
poor functional status at presentation
X-ray: early erosions (e.g. after < 2 years)
extra articular features e.g. nodules
HLA DR4
insidious onset
Mneumonic for SLE?
Serositis: pleurisy or pericarditis
Oral ulcers
Arthritis
Photosensitivity
Blood: anaemia, leukopenia, lymphopenia and thrombocytopenia
Renal disorder: lupus nephritis - minimal mesangial, mesangial proliferative, focal, diffuse, membranous and advanced sclerosis
Antinuclear antibody
Immunology: anti-Smith, anti-ds DNA and antiphospholipid antibody
Neurologic disorder: seizures or psychosis
Malar rash
Discoid rash
Features of Behcet’s?
1) oral ulcers 2) genital ulcers 3) anterior uveitis
Things metnioned in FRAX scoring tool?
history of glucocorticoid use
rheumatoid arthritis
alcohol excess
history of parental hip fracture
low body mass index
current smoking
Most common occular complication in temporal arteritis?
anterior ischemic optic neuropathy
results from occlusion of the posterior ciliary artery
In young adults with septic arthritis, what is the most common organism?
Neisseria gonorrhoea
Highly specific tests for SLE?
Anti dsDNA
Anti-smith
If a patient has diffuse cutaneous systemic sclerosis and renal disease what medication should they be started on?
Ace Inhibitor
What is hydroxychloroquine used in?
Management of rheumatoid arthritis and SLE
Mneumonic for Felty’s syndrome?
SANTA:
- Splenomegaly
- Anaemia
- Neutropenia
- Thrombocytopenia
- Arthritis
First line for acute management of gout?
NSAIDs or colchicine are first-line
If have a duodenal ulcer give colchicine
What is keratoderma blenorrhagica?
waxy yellow/brown papules on palms and soles
Investigations of polymyalgia rheumatica?
raised inflammatory markers e.g. ESR > 40 mm/hr
note creatine kinase and EMG normal
Hyperparathyroidism effects on calcium and phsophate
calcium is high as PTH works to increase free calcium by increasing renal reabsorption, reducing phosphate reabsorption (hence phosphate is low) and increasing calcium reabsorption from the bones (hence ALP is raised
What antiboies are associated with diffuse cutaneous systemic sclerosis?
anti-scl-70
What antiboies are associated with limited cutaneous systemic sclerosis
anti-centromere antibodies
Most useful tool to assess hypermobility?
Beighton score
Adverse effect of hydroxycholoroquine?
bull’s eye retinopathy - may result in severe and permanent visual loss
First line for polymyalgia rheumatica?
Oral predinsolone
X ray findings in pseudogout?
chondrocalcinosis
in the knee this can be seen as linear calcifications of the meniscus and articular cartilage
Adverse effects of interferon-alpha?
flu-like symptoms and depression
Ankylosing spondylitis features - the ‘A’s
Apical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
AV node block
Amyloidosis
What is CREST sundroke?
calcinosis, Raynaud’s phenomenon, oesophageal dysmotility, sclerodactyly, telangiectasia
Features of polymyositits?
proximal muscle weakness +/- tenderness
Raynaud’s
respiratory muscle weakness
interstitial lung disease
e.g. fibrosing alveolitis or organising pneumonia
seen in around 20% of patients and indicates a poor prognosis
dysphagia, dysphonia
around 30% of dermatomyosis patients have antibodies to aminoacyl-tRNA synthetases (anti-synthetase antibodies), including:
antibodies against histidine-tRNA ligase (also called Jo-1)
antibodies to signal recognition particle (SRP)
anti-Mi-2 antibodies
Next step in ankylosing spondylitis after oral NSAIDS?
TNF-alpha blockers
What needs to be checked when starting on azathioprine?
thiopurine methyltransferase (TPMT) test may be needed to look for individuals prone to azathioprine toxicity.
Pharmacologial treatment for Raynauds?
Nifedipine
Cautions of using sulfasalazine?
G6PD deficiency
allergy to aspirin or sulphonamides (cross-sensitivity)
Joint aspiration in pseudogout?
weakly-positively birefringent rhomboid-shaped crystals
Why prescribe folate once a week in patients on methotrexate?
Reduce risk of bone marrow suppression
Management of flares of RA>
Oral or IM corticosteroids
If eGFR less than 30 what can be used to prevent pathological fractures in bony metastases?
Denosumab
What are Gottron’s papules?
roughened red papules over extensor surfaces of fingers
Features of osteomalacia?
bone pain
bone/muscle tenderness
fractures: especially femoral neck
proximal myopathy: may lead to a waddling gait
Who to start oral bisphosphaonates in without doing a DEXA scan?
- Anyone with a BMD <-2.5 on DEXA
- Anyone 75 or Over with a Fragility Fracture
- Anyone on High Dose Corticosteroids (>7.5mg for >3months)
Type IV hypersensitvitiy reaction?
Delayed
T cell mediated ones
Risk factors for pseudogout?
haemochromatosis
hyperparathyroidism
low magnesium, low phosphate
acromegaly, Wilson’s disease
Monitoring SLE?
inflammatory markers- ESR is generally used. during active disease the CRP may be normal - a raised CRP may indicate underlying infection
complement levels (C3, C4) are low during active disease (formation of complexes leads to consumption of complement)
anti-dsDNA titres can be used for disease monitoring (but note not present in all patients)
When to start TNF-Inhibitors in RA?
inadequate response to at least two DMARDs including methotrexate
What is osteomalacia caused by?
Softening of the bones due to severe vitamin D deficiency and can present with bone pain, muscle weakness or bone deformities.
Lab values in osteomalacia?
Calcium decrease
Phosphate decreased
ALP increased
PTH increased
What must be done prior to starting a biologic?
chest X-ray to look for TB prior to starting biologics for rheumatoid arthritis as they can cause reactivation
What is dactylitis?
inflammation of a digit (finger or toe).
Causes of dactylitis?
spondyloarthritis: e.g. Psoriatic and reactive arthritis
sickle-cell disease
other rare causes include tuberculosis, sarcoidosis and syphilis
Antibodies in SLE?
Antibodies in systemic sclerosis?
Anti SCL 70
Anti centreomere
Antibodies in Sjorgren syndrome?
Antibodies in poltmosititis and dermatomyoisitits?
What is cANCA associated with?
Granulomatosis with polyangitis
What is pANCA associated with?
Is azithroprine safe in pregnancy?
Yes
What is osteogenesis imperfecta?
group of disorders of collagen metabolism resulting in bone fragility and fractures. The most common, and milder, form of osteogenesis imperfecta is type 1
BMD in osteopenia?
-1.0 to -2.5
What is an example of a urate lowering therapy?
Allopurinol
What is Behcet’s syndrome?
complex multisystem disorder associated with presumed autoimmune-mediated inflammation of the arteries and veins
Drugs that cause drug induced lupus?
procainamide
hydralazine
isoniazid
minocycline
phenytoin
Adverse effects of sulfalazine?
oligospermia
Stevens-Johnson syndrome
pneumonitis / lung fibrosis
myelosuppression, Heinz body anaemia, megaloblastic anaemia
may colour tears → stained contact lenses
CXR finding in late stage ankylosing spondylitis?
Apical fibrosis
Complications. ofRA?
respiratory: pulmonary fibrosis, pleural effusion, pulmonary nodules, bronchiolitis obliterans, methotrexate pneumonitis, pleurisy
ocular: keratoconjunctivitis sicca (most common), episcleritis, scleritis, corneal ulceration, keratitis, steroid-induced cataracts, chloroquine retinopathy
osteoporosis
ischaemic heart disease: RA carries a similar risk to type 2 diabetes mellitus
increased risk of infections
depression
in marfans there is a defect in which protein?
Fibrillin-1
If patients with osteoporosis can’t tolerate alendronate what is next line?
Risedronate or etidronate
What is paget’s disease treated with?
Bisphosphonates
What is polyarteritis nodosa
vasculitis affecting medium-sized arteries with necrotizing inflammation leading to aneurysm formation.
What are tyoe 3 immune reactions?
characterized by the recruitment of neutrophils and the stimulation of epithelial antimicrobial defenses at infection sites.
After inital thronboembolic event what should be managment of antiphospholipid syndrome?
lifelong warfarin with a target INR of 2-3
Treatment of choice for methotrexate toxocity?
Folinic acid
Osteomalacia bloods?
Calcium decreased
Phosphate decreased
ALP increased
PTH increased
How to remeber bloods in osteomalacia?
I remember it as weak bone disease due to low calcium and vit D
low Ca
Low phosphate
High PTH (due to low Ca)
High ALP (why? Bcos bone is weak so osteoblast try to reconstruct the bone by secrete more ALP)
How to rember bloods in paget disease?
Classic sudden central bone pain in elderly with normal bone profile except ALP
Normal Calcium
Normal phosphate
Normal PTH
High ALP
Bloods in hypoparathyroidism?
Low PTH -> Low Calcium -> high Phosphate -> normal ALP(no problem with bone)
Low serum calcium.
High serum phosphate.
Low PTH.
Normal alkaline phosphatase.
What do bisphosphonates do?
suppressing elevated bone turnover
Sample of synovial fluid from the knee in reactive arthritis?
Develops after an infection where the organism cannot be recovered from the joint
Features of Behcet’s syndrome?
classically: 1) oral ulcers 2) genital ulcers 3) anterior uveitis
thrombophlebitis and deep vein thrombosis
arthritis
neurological involvement (e.g. aseptic meningitis)
GI: abdo pain, diarrhoea, colitis
erythema nodosum
Why is syndesmophytes seen in ankylosing spondylitis?
Due to ossification of outer fibers of annulus fibrosus
What should be prescribed with NSAIDs in all patients with osteoarthritis?
PPI
What causes gout?
High purine diet.
Cheese and wine!
What causes gout?
Diuretics
Chemotherapy- Tumour lysis syndrome. Get an increased in uric acid
Gout presentation
Pain
Limping
TOPHI- Large visible lumps of urate crystals
Usually in large MTP joint, also in ankle and wrist
Crystals in gout?
Negatively befringed needle shape
Crystals in pseudogout
Positive befringed
Rhomboid shaped
Second line for gout?
Febuxostat
What causes pseudogout?
Calcium deposition
Symptoms of polymyalgia rheumatica?
Mild pain, Aching
Stiff
Quick onset- A month ish
Lethargy
Low grade fever
Investigations for polymyalgia rheumatica?
High ESR
Normal creatine kinase
Electomyography normal
What is polymyalgia rheumatica linked with?
Temporal arteritis
What is rheumatoid arthritis?
Autoimmune condition affecting the joints
Investigations for rhuematoid arthritis?
Inflammatory markers- CRP, ESR
Xray- LESS
RF- Positive in 70-80% (also in 100% of Feltys)
Anti CCP- 70% sensitivity, 95% specific
Signs of rheumatoid arthritis?
Boutiners derformity- finger is flexed at the proximal interphalangeal joint (PIP) and hyperextended at the distal interphalangeal joint (DIP)
Ulnar deviation
Squeeze across MCP joint and will be tender
What is Felty’s syndrome
SANTA
Splenomeglay
Anaemia
Neutropenia
Thrombocytopnia
RA
Management of RA?
NSAIDs
PPI
Referal to rheumatology
DMARDs. If not luck with 2 different DMARDs give TNF alpha inhibitor
Flaires- IM/oral corticosteroids
Extrarticular manifestations of RA?
Eye issues
Rheumatoid nodules- Skin and lung (pulmonary fibrosis)
Small vessel damage and destruction of the lungs
Signs of osteoarthritis?
Herbeden’s nodes and bouchard’s nodes
Squaring of the thumb
SLE common presentation?
Young women
Afro Caribbean origin
Diagnostic criteria in SLE features?
SOAP BRAIN
Serostitis
Oral ulcers
Arthritis
Photosensitivity
Blood
Renal- Portein
ANA
Immunologic- DS DNA
Neurological
Bloods in SLE
ANA- 99% of cases it is positive
Anti-DsDNA- Most useful
What is Sjorgen’s syndrome?
Everything is dry
Autoimmune disorder that destroys the salivary and lacrimal glands
Investigations for sjorgen’s
Anti Ro and Anti La
Management of sjorgens
Lubricants
Artifical tears/saliva
Second line is pilocarpine
Most common cause of reactive arthritis?
Chlamydia
Management of psoriatric arthritis
NSAIDS
Second line is monoclonal antibodies
- First line for spasicity in MS?
o Baclofen and gabapentin
- What are focal seizures?
o previously termed partial seizures
o these start in a specific area, on one side of the brain
o the level of awareness can vary in focal seizures. The terms focal aware (previously termed ‘simple partial’), focal impaired awareness (previously termed ‘complex partial’) and awareness unknown are used to further describe focal seizures
o further to this, focal seizures can be classified as being motor (e.g. Jacksonian march), non-motor (e.g. déjà vu, jamais vu; ) or having other features such as aura
- What is GBS?
o Immune mediated demyelination of the PNS often triggered by infection
- The characteristic features of Guillain-Barre syndrome is what?
o is progressive, symmetrical weakness of all the limbs.
o the weakness is classically ascending i.e. the legs are affected first
o reflexes are reduced or absent
o sensory symptoms tend to be mild (e.g. distal paraesthesia) with very few sensory signs
o “ there may be a history of gastroenteritis
o “ respiratory muscle weakness
o “ cranial nerve involvement
o diplopia
o bilateral facial nerve palsy
o oropharyngeal weakness is common
o “ autonomic involvement
o urinary retention
o diarrhoea
Mnagement for focal seizures
Lamotrigine or levetiracetam
Stroke or TIA driving regulation?
1 month off driving, may not need to inform DVLA if no residual neurological deficit
Features of juvenile myoclonic epilepsy?
- infrequent generalized seizures, often in morning//following sleep deprivation
- daytime absences
- sudden, shock-like myoclonic seizure (these may develop before seizures)
Treatment of juvenile mycolonic epilepsy?
Sodium valproate
- TACs features
- unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
- homonymous hemianopia
- higher cognitive dysfunction e.g. dysphasia
What does TACs involve
Middle and anterior cerebral arteries
Features of PACs
- involves smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery
- Two of three of these
- unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
- homonymous hemianopia
- higher cognitive dysfunction e.g. dysphasia
Features of lacunar infarcts?
- involves perforating arteries around the internal capsule, thalamus and basal ganglia
- presents with 1 of the following:
- unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
- pure sensory stroke.
- ataxic hemiparesis
Features of posterior circulation infarcts?
- involves vertebrobasilar arteries
- presents with 1 of the following:
- cerebellar or brainstem syndromes
- loss of consciousness
- isolated homonymous hemianopia
