Vasculitis

Question 1

What is Gout

Answer 1

• crystal arthropathy associated with chronically high blood uric acid levels.
• Urate crystal deposited in the joints
• Monoarthopathy

Question 2

What is the common presentation of gout

Answer 2

• Unilateral, hot swollen, painful joint

- RULE OUT septic arthritis

Question 3

Which joint is most affected by gout

Answer 3

Base of big toe (metatarso-phalangeal joint)
Wrists
Base of thumb
( knee and ankle)

Question 4

What are the risk factors for gout

Answer 4

Male
Obesity
High purine diet (e.g. meat and seafood)
Alcohol
Diuretics
Existing cardiovascular or kidney disease
Family history

Question 5

What will aspiration of gout show

Answer 5

No bacterial growth
Needle shaped crystals
Negative birefringent of polarised light
Monosodium urate crystals

Question 6

What might you see on xray of a joint with gout

Answer 6

Typically the space between the joint is maintained
Lytic lesions in the bone
Punched out erosions
Erosions can have sclerotic boarders with overhanding edges

Question 7

What is the management of an acute flare of gout

Answer 7

NSAIDs (e.g. ibuprofen) are first line
Colchicine second line (can’t have NSAIDs (renal))
Steroids can be considered third line

Question 8

How can you prevent further episodes of gout

Answer 8

• Allopurinol

Question 9

What is allopurinol

Answer 9

• xanthine oxidate inhibitor use for the prophylaxis of gout. It reduces uric acid level.
• Do NOT initiate during an acute flare
• Once initiated can be continued during another flare

Question 10

What lifestyle changes can reduce the risk of recurrent gout

Answer 10

• Weight loss
• staying hydrated
• Reduce alcohol
• reduce purine-based food (such as meat and seafood).

Question 11

What is pseudogout

Answer 11

• crystal arthropathy caused by calcium pyrophosphate crystals
• Calcium pyrophosphate crystals are deposited in the joint causing joint problems
• AKA. chondrocalcinosis.

Question 12

What is the presentation of pseudogout

Answer 12

• older adult with a hot, swollen, stiff, painful knee

- Can affect shoulders, wrists and hips

Question 13

What will fluid aspiration of pseudogout show

Answer 13

No bacterial growth
Calcium pyrophosphate crystals
Rhomboid shaped crystals
Positive birefringent of polarised light

Question 14

What Xray findings may you see in a patient with pseudogout

Answer 14

L – Loss of joint space
O – Osteophytes
S – Subarticular sclerosis
S – Subchondral cysts
- Chondrocalcinosis

Question 15

What is the management of pseudogout

Answer 15

• Symptoms usually resolve spontaneously over several weeks.
• NSAIDs
• Colchicine
• Joint aspiration
• Steroid injections
• Oral steroids

Question 16

What is polymyalgia Rheumatica

Answer 16

PMR, is a relatively common condition that causes stiffness and pain in muscles. The word ‘poly’ means many and the word ‘myalgia’ means muscle pain.

Question 17

What is Polymyalgia Rheumatica associated with?

Answer 17

• temporal arteritis
• histology shows vasculitis with giant cells, skip lesions
• muscle bed arteries affected most in polymyalgia rheumatica

Question 18

Features of polymyalgia rheumatica

Answer 18

• typically > 60 years old
• rapid onset (e.g. < 1 month)
• aching
• morning stiffness in proximal limb muscles
• NO WEAKNESS
• mild polyarthralgia, lethargy, depression, low-grade fever, anorexia, night sweats

Question 19

What investigations should be done if suspected polymyalgia rheumatica

Answer 19

• ESR > 40 mm/hr
• Creatine kinase normal
• EMG normal

Question 20

What is the treatment of polymyalgia rheumatica

Answer 20

prednisolone e.g. 15mg/od - dramatic response

Question 21

Side effects of methotrexate

Answer 21

mucositis
myelosuppression
pneumonitis
pulmonary fibrosis
liver fibrosis

Question 22

How long should contraception be used following methotrexate

Answer 22

6 months after cessation of drugs

Question 23

Key advise for methorexate

Answer 23

• avoid pregnancy for 6 months
• taken weekly
• monitoring
• Folate acid 5mg weekly on a diff. day to methotrexate

Question 24

What monitoring should be undertaken when starting methotrexate

Answer 24

• FBCs, LFTs & U&Es
• Weekly until stabilised
• every 2-3 months

Question 25

Key interactions with methotrexate

Answer 25

• Trimethoprim
• co-trimoxazole
• high dose aspirin

Question 26

Can sulfasalazine be used in pregnancy and breast feeding

Answer 26

yes

Question 27

What are the side effects of sulfasalazine

Answer 27

mucositis
myelosuppression
pneumonitis
pulmonary fibrosis
liver fibrosis

Question 28

Who should not be prescribed sulfasalazine

Answer 28

• G6PD deficiency
• ## allergy to aspirin or sulphonamides (cross-sensitivity)