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Medicine > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

What type of drug is infliximab?

A

A TNF alpha inhibitor

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2
Q

How can Reynaud’s be managed?

A

Conservative: gloves, hand warmers
Medical: CCBs eg nifedipine

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3
Q

How does rheumatoid arthritis typically present?

A

Typically of small joints, symmetrical, swelling, morning stiffness >30mins, pain

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4
Q

What is the DAS28 score?

A

Measure disease activity for rheumatoid arthritis
Diagnosed if >6
Based on joint involvement, serology, acute phase reactants and symptom duration

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5
Q

What signs could be present on a px with rheumatoid arthritis?

A 
Swelling
Positive squeeze test
Rheumatoid nodules on elbows
Swan neck deformity
Boutonnière deformities
Ulnar deviation of fingers
Claw toes
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6
Q

What can be raised in the blood for RA?

A 
Rheumatoid factor
Anti-CCP
CRP
ESR
Often also anaemia of chronic disease
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7
Q

What can caused Raised rheumatoid factor?

A 
Sjögren’s syndrome
RA
SLE
Felty’s syndrome
Systemic sclerosis
Infective endocarditis
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8
Q

What radiographic changes can be seen in rheumatoid arthritis?

A 
LESS
=
Loss of joint space
Erosions of bone
Soft tissue swelling
Subluxation

(No sclerosis of osteophytes!)

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9
Q

What should a px with newly diagnosed RA be prescribed?

A

Methotrexate + one other DMARD + course of glucocorticoid (“bridge the gap” while DMARDs start to work)

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10
Q

What conservative management can be recommended for DA?

A

Smoking cessation
Occupational therapy
Exercise

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11
Q

How long do DMARDs take to work for symptomatic relief?

A

6-12 weeks

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12
Q

What is the gold standard drug for RA?

A

Methotrexate

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13
Q

How is methotrexate taken?

A

WEEKLY
Alongside folic acid
Can be P.O./ IM/ SC

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14
Q

What are some side effects of methotrexate?

A 
Immunosuppression (risk of pancytopenia = low platelets, low RBCs, low WBCs)
Nausea if PO
Pneumonitis
Hepatotoxic
Teratogenic
Oral ulcer
Hair thinning
Insomnia
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15
Q

What monitoring must be done before prescribing and whilst taking methotrexate?

A

CXR before as CI if lung disease due to risk of pneumonitis
LFTs and FBC due to risk of hepatotoxicity and pancytopenia
U&Es as it is renally excreted (so could lead to toxicity if Renal compromise)

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16
Q

What would you advise a px taking MTX who wants to try for a baby?

A

Stop MTX at least 3/12 before trying for baby

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17
Q

Which Abx cannot be taken for a px also taking MTX?

A

Trimethoprim

As both inhibit folate

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18
Q

Other than methotrexate, which other DMARDs are used for rheumatoid arthritis?

A

Sulfasalazine

Hydroxychloroquine

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19
Q

When are biological agents indicated in the management of rheumatoid arthritis?

A

After failure to respond to 2 DMARDs inc MTX (and DAS28 >5.1)

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20
Q

What is a risk of biological agents?

A

Can reactive TB

Must do pre biological screening

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21
Q

What are some side effects of sulfasalazine?

A 
Hepatotoxicity 
Rash
Low sperm count
Oral ulcers 
Diarrhoea and vomiting
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22
Q

What side effect can hydroxychloroquine cause?

A

Ocular toxicity so requires annual ophthalmology review

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23
Q

What are spondylarthropathies?

A

Rheumatoid factor -ve
HLA-B27 gene linked

= ankylosing spondylitis + reactive arthritis + psoriatic arthritis

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24
Q

How will gout present?

A

Acute episodes of severe pain, erythema and swelling in affected joint
>50% in MTP joint of big toe

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25
Q

What are tophi?

A

Long term urate deposits on a joint, can be seen in gout

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26
Q

What causes gout?

A

Hyperuricaemia

Precipated by less excretion eg due to diuretics, CKD, or increased production eg due to diet, severe psoriasis

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27
Q

When a joint affect by gout is aspirated, what will be seen?

A

Negatively biofringent needle shaped urate crystals

28
Q

How is an acute attack of gout managed?

A

1st line: NSAIDs and colchicine
If CI: oral steroids or intra articulate joint injection
Continue allopurinol if already taking!

29
Q

When is colchicine used?

A

1st line for acute attack of gout alongside NSAIDs

30
Q

What is a common side effect of colchicine?

A

Severe diarrhoea

31
Q

How is gout managed prophylactically?

A

Lifestyle:
Less alcohol, weight loss, avoid foods high in purine

1st line: allopurinol
Dose must be titrated according to plasma urate levels
Wait until 3 weeks after an acute attack to start as it could cause another attack

2nd line: febuxostat

32
Q

When is gout prophylaxis indicated?

A 
>2 attacks in 12month
Tophi
Renal Disease
Uris acid renal stones 
Prophylaxis if on diuretics
33
Q

What is deposited in psuedogout?

A

Calcium pyrophosphate crystals

34
Q

How do gout crystals differ to pseudogout crystals?

A

Gout: -ve biofringent needle shaped urate crystals
Pseudogout: +ve biofringent rhomboid shaped calcium pyrophosphate crystals (usually affects larger joints)

35
Q

What are some risk factors for pseudogout?

A 
Hyperparathyroidism 
Age
Hypothyroidism
Haemachromotosis
Acromegaly
Low Mg
Low phosphate
36
Q

How is pseudogout managed?

A

Aspirate to exclude septic arthritis
Cool pack
NSAIDs
Steroids (intra articulate or oral or IM)

37
Q

Where does psoriatic arthritis typically present?

A

Asymmetrical oligoarthritis, like RA
DIP joints common
Often nail changes

38
Q

What is dactylitis?

A

Inflammation of a digit aka Sausage finger

Often seen with HLA-B27 linked arthropathies, especially psoriatic arthritis

39
Q

How is psoriatic arthritis managed?

A

As RA is (NSAIDs, MTX, sulfasalazine, anti-TNF agents)

But caution with steroids as they can worsen scenarios

40
Q

What is the triad of reactive arthritis?

A

Urethritis
Conjunctivitis
Arthritis

(Aka Reiters syndrome)

41
Q

What causes reactive arthritis?

A 
Post STI (chlamydia trachomatis)
Post dysentery (Campylobacter, salmonella, shigella)
42
Q

How is reactive arthritis managed?

A

Analgesia
NSAIDs
Intra articulate steroid injections

If persistent disease, MTX and sulfasalazine can be used

Symptoms rarely last for more than 12 months

43
Q

What is ankylosing spondylitis?

A

A HLA-B27 linked, RF-seronegative condition with chronic inflammation of the spine and sacroiliac joints

44
Q

A history of a young pain presenting with gradual onset of lower back pain worse at night, with morning stiffness and pain that improves with exercise is typical of which condition?

A

Ankylosing spondylitis

45
Q

What will investigations show for ankylosing spondylitis?

A

Bloods: CRP and ESR usually Raised, may have normocytic anaemia of chronic disease
MRI and XR can show changes in the spine itself “bamboo spine”
CXR could pulmonary fibrosis

46
Q

How is ankylosing spondylitis managed?

A 
Encourage exercise e.g. swimming
Physio
NSAIDs
Anti-TNF if severe
Surgery for hip replacement
47
Q

Which of the seronegative arthropathies are DMARDs not effective for?

A

Ankylosing spondylitis

48
Q

What is the typical presentation of giant cell arthritis?

A

Common in elderly
Headache and jaw claudication and visual disturbances in affected eye
May have joint pain and stiffness as 50% are ass. with polymyalgia rheumatica

49
Q

Giant cell arteritis is associated with which condition in 50% of patients?

A

Polymyalgia rheumatica

50
Q

How is giant cell arteritis investigated?

A

Biopsy of temporal artery (skip lesions may be present)

Raised inflammatory markers on bloods

51
Q

How is giant cell arteritis managed?

A

2 year course of prednisolone

Also cover with PPI for gastric protection, and bisphosphonates for bone protection

52
Q

What is an example of large vessel vasculitis?

A

Giant cell arteritis

53
Q

What is an example of small vessel vasculitis?

A

Wegenera’s granulomatosis

54
Q

What is Wegener’s granulomatosis?

A

Small vessel vasculitis

Triad of ENT problems, lung problems and kidney disease

55
Q

What is SLE?

A

A multisystem autoimmune disease due to immune complex deposition which can affect any organ

56
Q

What is a discoid rash?

A

A raised, scaly erthymatous rash seen in SLE

57
Q

What is a Malar rash?

A

Butterfly rash

Flat, red rash across the cheeks that spares the nasolabial folds

58
Q

What will bloods and immunology investigations show for SLE?

A
  • 99% are ANA positive
  • anti ds-DNA (99% specific but less sensitive)
  • typically normal CRP, usually Raised ESR
  • Low C3 and C4 (used up)
59
Q

What is the criteria for SLE?

A

Diagnosis requires at least 4 out of 11 on the criteria

  1. Malar rash
  2. Discoid rash
  3. Photosensitivity
  4. Oral ulcers
  5. Arthritis of 2 or more joints
  6. Serositis (pleuritis or pericarditis)
  7. Renal disorder (proteinuria or cellular casts)
  8. CNS disorder (seizures or psychosis)
  9. Haematological disorder
  10. Immunological disorder
  11. +ve ANA
60
Q

How is SLE treated?

A

NSAIDs for joint pain
Topical steroids and sun cream for rash
High dose prednisolone for flares
MTX and azathioprine for systemic involvement

61
Q

Anti phospholipid syndrome is commonly secondary to which condition?

A

SLE

62
Q

Polymyalgia rheumatica is associated with which other rheumatological condition?

A

Temporal arteritis

63
Q

What is a key difference between polymyalgia rheumatica and polymyositis?

A

Both present with stiffness in affected limbs but polymyalgia rheumatica does not have muscle weakness, like polymyositis does
CK will be normal in PMR but will be raised in polymyositis due to increased muscle breakdown

64
Q

What is polymyalgia rheumatica?

A

Pain and stiffness around shoulders, neck and hips
Raised CRP and ESR (unlike DDx fibromyalgia) but normal CK (no muscle weakness unlike polymyositis)
Usually in over 50s
Associate with temporal arteritis

65
Q

How is polymyalgia rheumatica treated?

A

Course of prednisolone

66
Q

What is Sjogren’s?

A

Autoimmune fibrosis of exocrine glands
Primary or secondary to SLE/ RA/ systemic sclerosis
Presents with dry eyes, dry mouth, joint pain

Medicine (7 decks)

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