Seropositive Arthropathies

Question 1

list all the seropositive arthropathies

Answer 1

rheumatoid arthritis 
SLE
systemic sclerosis 
sjogrens 
vasculitis

Question 2

what do seropositive arthropathies have in common

Answer 2

all diagnosed through blood tests as have certain auto-antibodies present in disease

Question 3

what is the most common seropositive arthropathy

Answer 3

rheumatoid arthritis

Question 4

what is the aetiology for RA

Answer 4

females > males
peak incidence between 35-50 years
certain HLA subtypes and environmental factors such as smoking increase risk

Question 5

describe the pathogenesis of RA

Answer 5

immune response against synovium, immune cells attack which destroys articular cartilage
lining of the joint thickens producing excess fluid and wears away bone underneath

Question 6

which joints are affected in RA

Answer 6

small joints, PIPs, MCP, MTP, wrists but not DIPs

Question 7

describe the presentation of RA

Answer 7

morning stiffness >30 mins
pain improves on movement
joints symmetrically affected
visible synovitis - hands appear boggy and soft

Question 8

RA increases risk of spinal cord compression true/false

Answer 8

true - atlanto-axial subluxation is later complication

Question 9

describe a swan neck deformity

Answer 9

hyperextension at PIP, flexion at DIP

Question 10

describe a boutonniere deformity

Answer 10

flexion at PIP, hyperextension at DIP

Question 11

list some of the extra-articular manifestations of RA

Answer 11

rheumatoid nodules - found on extensor surfaces
increased cardiovascular morbidity
interstitial lung disease
ocular involvement

Question 12

list the ocular symptoms of RA

Answer 12

uveitis, scleritis

Question 13

which auto-antibodies are present in RA

Answer 13

rheumatoid factor

anti-CCP

Question 14

describe the x-ray findings of early and late RA

Answer 14

early - normal x-ray possibly with swelling

late - erosions of bone and subluxations

Question 15

what factors must be present to diagnose RA

Answer 15

involvement of several joints, positive serology, acute phase reactants positive eg CRP and duration longer than 6 weeks

Question 16

what is the first line treatment for RA

Answer 16

DMARDs - specifically methotrexate unless contraindicated

Question 17

what is the window of time DMARDs must be commenced from start of disease

Answer 17

3 months

Question 18

what must initially be added to methotrexate and why

Answer 18

corticosteroid as lag time - acts as short term pain relief

Question 19

list some other examples of DMARDs and their side effects

Answer 19

leflunomide, sulfalazine and hydroxychloroquine

methotrexate and leflunomide are teratogenic, all increase risk of infection and bone marrow suppression

Question 20

if RA doesnt respond to DMARDs what is the next line of treatment and give examples

Answer 20

biologics
TNFalpha inhibitors - infliximab and adalinumab
B cell depletion - rituximab

Question 21

what calculator is used to assess severity of RA

Answer 21

DAS28

Question 22

DAS28 score of what indicates remission of RA

Answer 22

<2.6

Question 23

DAS28 score of what indicates severe disease requiring biologics

Answer 23

> 5.1

Question 24

describe the pathogenesis of SLE

Answer 24

defect in apoptosis causing increased cell death - allows inadequate clearance of antigens and deposition of immune complexes - type 3 hypersensitivity

Question 25

who is lupus most likely to present in

Answer 25

women of child bearing age, more common in black women

Question 26

describe the skin and mucocutaneous presentation of lupus

Answer 26

skin - butterfly malar rash with sparing of nasolabial fold, discoid dermatitis too muco-cutaneous - oral ulceration and Raynauds phenomenon

Question 27

describe the other organ involvement of lupus

Answer 27

``` renal - lupus nephritis resp - interstitial lung disease and pleurisy neuro - seizures and psychosis cardiac - pericarditis and ischaemia MSK - myalgia and inflammatory arthritis ```

Question 28

there is one specific diagnostic test for lupus true/false

Answer 28

false

Question 29

list some of the investigation findings of lupus

Answer 29

FBC showing thrombocytopenia and leucopenia | Anti-dsDNA positive, ANA positive, Anti-sm (low sensitivity)

Question 30

what happens to C3/4 levels in active lupus disease

Answer 30

lowered

Question 31

which test is used in lupus to assess for renal involvement

Answer 31

urinalysis

Question 32

what is the treatment for lupus

Answer 32

depends on manifestations, skin disease and arthralgia give hydroxychloroquine and NSAIDs, arthritis or organ involvement requires immunosuppression if unresponsive may require IV immunoglobulin

Question 33

what is Sjogrens syndrome

Answer 33

autoimmune condition characterised by lymphatic infiltrates in exocrine glands - causes dryness, arthralgia and fatigue

Question 34

list the clinical features of Sjogrens

Answer 34

reduced salivary and lacrimal gland production vaginal dryness polyarthritis peripheral neuropathy and interstitial lung disease

Question 35

which connective tissue disease has an increased risk of lymphoma

Answer 35

Sjogrens

Question 36

which test is used to assess ocular dryness in Sjogrens

Answer 36

Schrimers test

Question 37

other than Schrimers test, list investigations for Sjogrens

Answer 37

lip gland biopsy for dryness | positive anti-Ro and anti-La antibodies

Question 38

what is the management of systemic sclerosis

Answer 38

symptom management as no cure lubricating eye drops, saliva replavements, hydroxychloroquine for joint pain, immunosuppressant if extreme organ involvement

Question 39

what is systemic sclerosis

Answer 39

connective tissue disease causing vasculopathy and autoimmunity due to excessive collagen deposition

Question 40

describe the difference between limited and diffuse systemic sclerosis

Answer 40

limited - confined to hands, feet and forearms | diffuse - spread all across limbs and trunk

Question 41

what is usually the first manifestation of systemic sclerosis

Answer 41

Raynauds phenomenon - blanching, acrocyanosis and reactive hyperaemia

Question 42

what is the treatment for raynauds

Answer 42

calcium channel blockers, ARBs and nitrates

Question 43

what is the pneumonic for limited systemic sclerosis

Answer 43

CREST - calcinosis, raynauds, oesophageal dysmotility, sclerodactyly and telangiectasia

Question 44

list some symptoms of systemic sclerosis

Answer 44

dysphagia telangiectasia skin tightening - beaking of the nose calcinosis - deposition of calcium in the digits

Question 45

state the antibodies present in systemic sclerosis

Answer 45

limited - anti-centromere | diffuse - anti-scl-70

Question 46

how is systemic sclerosis managed

Answer 46

no curative treatment, manage underlying organ damage | immunosuppressant for lung disease, PPI for GI symptoms

Question 47

how does anti-phospholipid syndrome present

Answer 47

migraines increased risk of stroke, MI esp in younger patients recurrent loss of pregnancy typically in second and third trimester recurrent pulmonary emboli

Question 48

what type of rash presents with anti-phospholipid syndrome

Answer 48

livedo reticularis - mottled vascular rash with lace like purple discolouration

Question 49

what investigations are carried out for anti-phospholipid syndrome

Answer 49

bloods - thrombocytopenia | lupus anticoagulant and anti-beta 2 glycoprotein positive

Question 50

what is the management of anti-phospholipid syndrome

Answer 50

if one episode of thrombosis - lifelong anticoagulation eg warfarin, if pregnant give LMWH instead