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General Medicine Pt2 > Sero-positive inflammatory arthritis (excluding RA) > Flashcards

Sero-positive inflammatory arthritis (excluding RA) Flashcards

1
Q

Define sero-positive inflammatory arthritis

Give three examples

A

Inflammatory arthropathies that test positive for rheumatoid factor

Includes:

  • Rheumatoid arthritis
  • Systemic lupus erythematosus (SLE)
  • Sjorgren’s syndrome
  • Bacterial and viral infections eg. septic arthritis
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2
Q

What is Systemic lupus erythematosus (SLE)?

A

A multi-systemic autoimmune disease featuring autoantibodies against a variety of autoantigens (ANA).

Insufficient phagocytosis of these ANAs causes secretion of pathogenic autoantibodies, resulting in a tissue damage.

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3
Q

Name three risk factors for SLE

A
  • Female (9:1) - especially pre-menopausal
  • Aged 20-40
  • Afro-Caribbean and Asian ethnicity
  • HLA B8, DR2, DR3 associated
  • FHx in 1o relatives
  • Epstein-Barr virus

Drug-induced lupus

UV light - can trigger flares

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4
Q

Name three causes of drug-induced lupus

How does drug-induced lupus differ from typical SLE?

A
  • Hydralazine: HTN vasodilator
  • Isoniazid
  • Procainamide: Class Ia antiarrhythmic
  • Penicillamine: Wilson’s disease treatment
  • Anti-TNF

Drug-induced lupus is usually mild as it does not affect the kidneys or CNS. 95% positive for anti-histone antibodies

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5
Q

Give five presenting features of systemic lupus erythematosus

A

High variable presentation between patients.

  • Non-specific symptoms of fatigue, malaise, myalgia, fever
  • Symmetrical small joint arthralgia
  • Photosensitive malar/butterfly rash; Discoid rash; alopecia
  • Recurrent pleurisy and pleural effusions, ILD
  • Pericarditis; Libman-Sacks endocarditis
  • Lupus nephritis; end-stage renal disease
  • Depression, psychosis, epilepsy, migraines, cerebellar ataxia, aseptic meningitis, stroke
  • Sjogren’s (15%), retinal vasculitis
  • Mouth ulcers
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6
Q

How is systemic lupus erythematosus diagnosed?

A

4 of 11 of the following: SOAP BRAIN MD

  • Serositis: Pleurisy or pericarditis
  • Oral ulcers
  • Arthritis: Non-erosive, 2+ peripheral joints
  • Photosensitivity
  • Blood disorders: Leukopenia, lymphopenia, thrombocytopenia
  • Renal (lupus nephritis): Proteinuria (>0.5g/d) or cellular casts
  • ANAs (95%)
  • Immune: Anti-dsDNA (70%), anti-Sm, or anti-pl antibodies
  • Neurological: Seizures or psychosis
  • Malar rash
  • Discoid rash
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7
Q

What markers are used to monitor progression of SLE?

A
  • Raised Anti-dsDNA
  • Reduced C3 and C4
  • Raised ESR
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8
Q

Request three investigations for suspected SLE

A
  • FBC: Leukopenia, lymphopenia, thrombocytopenia
  • Normal CRP and raised ESR
  • U+Es; Urinalysis: Proteinuria and cellular casts
  • ANA; Anti-dsDNA; Anti-Sm (most specific)
  • Anti-phospholipid: associated with antiphospholipid syndrome
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9
Q

Outline the management of SLE

A
  • Avoid excessive exposure to sunlight
  • Reduce increased cardiovascular risk
  • Many respond well to NSAIDs, and do not need steroids or immunosuppresive agents
    • Maintenance: NSAIDs, hydroxychloroquine (retinal tests), azathioprine
    • Cutaneous lupus: Topical steroids
    • Severe flares: Urgent IV cyclophosphamide + high-dose prednisolone/single dose IM long-acting steroid
    • Lupus nephritis: ACEi
    • If glomerulonephritis on Bx, high-dose prednisolone + cyclophosphamide/mycophenolate
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10
Q

What is anti-phospholipid syndrome?

A
  • Autoimmune coagulation disorder
  • Thrombosis and/or recurrent miscarriages
  • Persistently positive tests for anti-phospholipid antibodies
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11
Q

Describe the clinical features of anti-phospholipid syndrome

A
  • Coagulation defect eg. DVT; stroke
  • Livedo reticularis: reticular cyanotic discolouration
  • Recurrent miscarriage
  • Thrombocytopenia: increased APTT
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12
Q

How is anti-phospholipid syndrome diagnosed?

A

Both:

  • Hx of thrombosis and/or recurrent miscarriage
  • One positive blood test:
    • Anticardiolipin test
    • Lupus anticoagulant test
    • Anti B2-glycoprotein I test
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13
Q

Describe the management of anti-phospholipid syndrome

A

Treat if patient has had at least one thrombosis

  • Low-dose aspirin or warfarin (Target INR 2-3)
  • If pregnant, give aspirin and LMWH in early gestation
    • Does not prevent pre-eclampsia or poor foetal growth
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14
Q

Define Sjogren’s syndrome

A
  • A chronic inflammatory autoimmune disorder
  • Lymphocytic infiltration and fibrosis of exocrine glands
    • esp. lacrimal and salivary glands
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15
Q

What is primary Sjogren’s syndrome?

A

Syndrome of dry eyes

In the absence of RA or any autoimmune disease

Anti-Ro (90% in primary, 10% in secondary)

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16
Q

Give two risk factors for Sjogren’s syndrome

A
  • Female 9:1
  • Commonest onset 40-50yrs
  • Associated with lymphoma (40x increased risk)
17
Q

Give three presenting features of Sjogren’s syndrome

A
  • Majority only dryness (eyes, mouth, vagina) and fatigue
  • Parotid and salivary gland enlargement may be seen
  • Minority have systemic symptoms such as:
    • Arthralgia
    • Raynaud’s phenomenon
    • Dysphagia and dry cough

Other organ-specific autoimmune disease eg. thyroid disease, myasthenia gravis, PBC, autoimmune pancreatitis

18
Q

How is Sjogren’s syndrome investigated?

A
  • Schirmer tear test
    • <10mm in 5 min suggest defective tear production
  • Rose Bengal staining
  • Immunology:
    • RF positive
    • ANA (80%)
    • Anti-Ro: (60-90% in primary Sjogren’s)
    • Anti-La
19
Q

Outline the management of Sjogren’s syndrome

A

Symptomatic treatment:

  • Dry eyes: artificial tears, avoid smoke filled rooms
  • Dry mouth: good oral hygiene, regular drinks, sugar-free lozenges, artificial saliva
  • Arthralgia: NSAIDs, hydroxychloroquine
20
Q

How does viral arthritis differ from bacterial arthritis?

A
  • Arthritis in viral disease is generally a transient polyarthritis
    • Occuring before, during, or after many viral illnesses
  • Bacterial causes of septic arthritis are a medical emergency

General Medicine Pt2 (15 decks)

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