Rheumatology Flashcards
(104 cards)
1
Q
What is the inheritance pattern of Marfan’s syndrome?
A
Autosomal dominant
2
Q
Which autoantibodies would you expect to find in Limited Cutaneous Systemic Sclerosis?
A
ANA (90%) -> anti-centromere Rheumatoid factor (30%)
3
Q
Which autoantibodies would you expect to find in Diffuse Cutaneous Systemic Sclerosis?
A
ANA (90%) -> anti-scl-70 Rheumatoid factor (30%)
4
Q
What is the mechanism of action of methotrexate?
A
Inhibits dihydrofolate reductase, an enzyme essential for the synthesis of purines and pyrimidines.
5
Q
What are the indications for methotrexate?
A
- Inflammatory arthritis, especially rheumatoid arthritis
- psoriasis
- some chemotherapy acute lymphoblastic leukaemia
- UC
6
Q
What are the adverse affects associated with methotrexate?
A
Mucositis Myelosuppression Pneumonitis Pulmonary fibrosis Liver cirrhosis
7
Q
How often is methotrexate taken?
A
Weekly
8
Q
What drugs should be avoided in patients taking methotrexate?
A
Trimethoprim
Cotrimoxazole
9
Q
What autoantibodies would you expect to find in SLE?
A
99% have ANA: - anti-dsDNA (99%) - anti-Smith (99%) (also Ro and La) 20% have RF
Also -low C3 and 4
10
Q
What monitoring is required in SLE?
A
ESR during active disease (CRP is often normal)
Complement levels are low during active disease
Anti-dsDNA can be used to disease monitoring (but not present in everyone)
11
Q
What is osteomalacia?
A
Normal bony tissue, but dec mineral content
12
Q
What are the causes of osteomalacia?
A
Vitamin D deficiency Renal failure Drug-induced - anticonvulsants Vitamin D resistant (inherited) Liver disease
13
Q
What are the features of osteomalacia?
A
Bone pain
Fractures
Muscle tenderness
Proximal myopathy
14
Q
What blood results would you expect in osteomalacia?
A
Low Ca
Low phos
Low Vit D
High ALP
15
Q
What is the treatment for osteomalacia?
A
Calcium with vitamin D
16
Q
What autoantibodies would you expect in drug-induced lupus?
A
ANA - 100%
- anti-histone (85%)
- anti-Ro and -Smith (5%)
dsDNA NEGATIVE (vs SLE where it’s +ve)
17
Q
Give two drugs that can cause drug-induced lupus
A
procainamide
hydralazine
18
Q
What is important to check with patients on hydroxychloroquine?
A
Vision - can cause Bull’s eye retinopathy
19
Q
What is a common side effect of Leflunomide?
A
HTN
20
Q
What are the requirements before allopurinol treatment can be initiated?
A
> = 2 attacks in 12m
21
Q
What autoantibodies would you expect in RA?
A
Anti-CCP
RF
(Around 20% are seronegative)
22
Q
What autoantibodies would you expect in Sjogren syndrome?
A
ANA - Ro and La (La is more specific)
RF
23
Q
What blood results would you expect in anti-phospholipid syndrome?
A
Prolonged APTT
Dec platelets
24
Q
What percentage of patients with psoriasis develop an associated arthropathy?
A
10-20%
25
Give the 6 As that are associated with ankylosing spondylitis
```
Apical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
AV node block
Amyloidosis
```
26
What causes splenomegaly in RA patients?
Felty's syndrome
27
An allergy to which drug may be a contra-indication for the prescription of sulfasalazine?
Aspirin
28
What are the adverse effects of azathioprine?
- bone marrow depression
- N+V
- pancreatitis
29
What is the first-line treatment for fibromyalgia?
CBT
30
What is the first-line treatment for osteoarthritis?
Paracetamol + topical NSAID (if hands or knees)
31
What are the characteristic features of scleroderma?
```
CREST syndrome
Calcinosis
Raynaud's
oEsophageal dysmotility
Sclerodactyly
Telangasia
```
32
What are Type 1 hypersensitivity reactions? Describe the skin changes you might expect
Mast cell degranulation (IgE bound)
| Skin changes include urticaria
33
What are Type 3 hypersensitivity reactions?
Caused by the formation and deposition of antibody-antigen complexes. E.g. post-strep glomerulonephritis, SLE
34
What are Type 4 hypersensitivity reactions? What skin changes may occur?
Cell-mediated
E.g. contact dermatitis, T1DM, Hashimotos, IBD, MS
Skin changes include erythema multiforme (target lesions affecting palms, soles and face)
35
Give 3 side effects of methotrexate
Myelosuppression
Liver cirrhosis
Pneumonitis
36
Give 4 side effects of sulfasalazine
Rashes
Oligospermia
Heinz body anaemia
Interstitial lung disease
37
For 3 side effects of leflunomide
Liver impairment
Interstitial lung disease
HTN
38
Give 2 side effects of hydroxychloroquine
Retinopathy
| Corneal deposits
39
Give 5 side effects of prednisolone
```
Cushingoid features
Osteoporosis
Impaired glucose tolerance
HTN
Cataracts
```
40
Give two side effects of NSAIDs
Bronchospasm in asthmatics
| Dyspepsia/peptic ulceration
41
Describe the XR features in ank spond
sacroilitis: 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
42
Initial therapy for newly diagnosed RA
Combination of DMARDs (incl methotrexate and one other DMARD, plus short-term glucocorticoids)
43
Monitoring required when using methotrexate? Why?
| Any other SEs?
FBC + LFTs
Risk of myelosuppression and liver cirrhosis
Other SEs: pneumonitis
44
Name some DMARDs used in RA
Methotrexate
Sulfasalazine
Leflunomide
Hydroxychloroquine
45
Name some TNF-inhibitors
Etanercept
Infliximab
Adalimumab
46
Indications for TNF-inhibitors in RA
An inadequate response to at least 2 DMARDs incl metho
47
55yo pt with 1m Hx of fever, arthralgia and lethargy. He recently developed haemoptysis and dyspnoea. Investigations show that he has an AKI. ANCA is negative. What is the diagnosis?
Goodpastures syndrome
48
What positive investigation results would you expect in Goodpasture syndrome?
Anti-glomerular BM antibodies
49
Outline the three stages of Churg-Strauss disease
1) Allergy - asthma or allergic rhinitis (may lead to nasal polyps)
2) Eosinophilia
3) Vasculitis - small and medium vessels leading to organ damage
50
What underlying condition must be ruled out before a diagnosis of dermatomyositis can be made?
Malignancy - may be paraneoplastic disease and not dermato
51
Which types of complement are low in SLE?
C3 and C4
52
Describe pseudogout crystals
Positively bifefringent rhomboid shaped crystals
53
Diagnostic marker in carcinoid
Urinary 5HIAA (24hr collection)
54
Investigation to diagnose amyloidosis
Rectal biopsy
55
Cause of reduced vision in temporal arteritis
Anterior ischaemic optic neuropathy
56
Difference between limited and diffuse cutaneous systemic sclerosis
Limited - CREST
| Diffuse - affects trunk and prox limbs. HTN, lung fibrosis, renal involvement
57
Name the main four CT diseases in rheumatology
Scleroderma
Polymyalgia rheumatica
SLE
Polymyositis/dermatomyositis
58
Name the main three bone metabolic diseases in rheum
Osteoporosis
Pagets disease
Osteomalacia/Ricketts
59
Name the seronegative arthropathies
Reactive arthritis
Ankolysing spondylitis
Psoriatic arthritis
Enteropathic arthritis
60
Name the crystal arthropathies
Pseudogout
| Gout
61
Which rheumatological conditions are often monoarticular
Trauma
Septic arthritis
Crystal arthritis
Monoarticular presentation of polyarticular disease
62
Which rheumatological conditions are often oligoarticular (<5)
OA
Crystal arthritis
Seronegative spondyloarthropathies
63
Which rheumatological conditions are often symmetrical and polyarticular
RA
| OA
64
Which rheumatological conditions are often asymmetrical and polyarticular
OA
| Seronegative spondyloarthopathies
65
Which rheumatological conditions are polyarticular, but can be either symmetrical or asymmetrical
AI CT diseases
| Vasculities
66
Investigations for rheum disorders
Bedside - obs, ECG
Bloods - FBC, UE, LFT, TFT, glucose, CRP/ESR, Autoantibodies, calcium/urate
Micro - joint aspiration, blood cultures
Imaging - XR joint, CT/MRI joint, CXR
67
General management of rheum conditions
Conservative - RICE, physio, braces
Medical - NSAIDs, steroid injections, steroids, DMARDs, biologicals
Surgical - replacement, release
68
What role do DMARDs play in rheum disorders
Control symptoms, delay progression of disease, and improve extra-articular manifestations
69
First and second line DMARDs used in rheum disorders
1st line: methotrexate, sulfasalazine, hydroxychloroquine
| 2nd line: azathioprine, cyclosporin, leflunomide, mycophenolate mofetil
70
Monitoring required for a pt on DMARDs
FBCs, UE, LFT regularly
| Baseline, weekly until stable, every 2-3m
71
When are biological agents indicated in rheum? Give examples
Used to treat mod-severe RA that's not responded well to 1st/2nd line DMARDs
E.g. anti-TNF, rituximab, tocilizumab
72
What is giant cell arteritis?
Large vessel vasculitis
Segmental granulomatous inflammation of ext carotid artery and branches
Associated with polymyalgia rheumatica
Causes irreversible visual loss if not treated
73
3 immediate things to do in GCA
ESR/CRP
High-dose steroids (pred 40-80mg/d PO)
Urgent same day ophthalmology r/v
74
Further management of GCA
Temporal artery biopsy within 1wk of starting steroids (skip lesions)
Cont steroids for 1-2yrs
Taper dose based on ESR and symptoms
PPI + bisphosphonate cover
75
Investigations for gout
```
Bedside - obs
Bloods - FBC, UE, ESR/CRP
Micro - blood cultures
Imaging - XR
Special tests - joint aspiration (send for MC+S)
```
76
Describe the crystals seen in gout
-ve biferingent needle-shaped urate crystals
77
Acute management of gout
Conservative - remove cause, rest, inc fluids, avoid alcohol
Medical - NSAIDs, colchicine (if NSAIDs C/I), steroids (if NSAIDs and colchicine C/I)
Remain on allopurinol if pt is already on it
78
Secondary prevention of gout
Conservative - W/L (if obese), dec alcohol intake, avoid high-purine foods (red meat, liver, oily fish), avoid drug causes (diuretics, cytotoxic drugs)
Medical - allopurinol
79
When should allopurinol be started after the first attack of gout?
Start >2wks after attack under NSAID/colchicine cover
80
Life-threatening drug reaction to watch out for in pts with gout?
Azathioprine + allopurinol!
| Causes neuropenia
81
Features of SLE
```
SOAP BRAIN MD
S erositis (pleuritis, pericarditis)
O ral ulcers
A rthritis
P hotosensitivity
```
```
B lood (anaemia, leukopenia, thrombocytopenia, APS)
R enal (protein, lupus nephritis)
A NA
I mmunologic (dsDNA)
N euro (psych, seizures)
```
M alar rash
D iscoid rash
Others - Raynaud's, alopecia, livedo reticularis
82
Describe the rashes you might see in SLE
Malar - facial erythematous rash sparing nasal folds, photosensitive
Discoid - well-demarcated scaly erythematous rash in sun-exposed areas, photosensitive
83
Blood tests for SLE
1) Autoantibodys:
- ANA (sens)
- Anti-dsDNA (spec)
- Anti-histone (drug-ind)
- Anti-cardiolipin (APS)
2) ESR (inc = disease activity)
3) C3/4 (dec = disease activity)
4) FBC (dec Hb = AIHA, dec WCC, dec plats = APS)
5) UE (lupus nephritis)
6) Clotting (paradox inc APTT in APS)
84
Management of SLE
Conservative - stop drug causes, smoking cess, advice about sun exposure
Medical:
- acute relapse -> high-dose pred, IV cyclophosphamide
- maintenance -> NSAIDs, hydroxychlorquinine ± low-dose pred
- treat complications -> sun cream, ACEi for proteinuria
85
What is antiphospholipid syndrome?
Acquired AI disorder characterised by production of anti-cardiolipin/lupus anticoagulant autoantibodies, which interact with phospholipids involved in the coagulation cascade causing thrombophilia
86
What are the cardinal features of antiphospholipid syndrome?
```
CLOT
C lotting disorder (thrombosis)
L ivedo reticularis
O bstetric complications (recurrent 1st T miscarriage)
T hrombocytopenia
```
87
6 features of rheumatoid hands
1) Ulnar deviation
2) Boutonniere's deformity (PIP flex, DIP hyperex)
3) Swan neck (PIP ex, DIP hyperflex)
4) Z-thumb (MCP flex, IP hyperex)
5) Loss of knuckle guttering
6) Dorsal subluxation of ulnar styloid process
88
Extra-articular manifestations of RA
- Rheum/MSK - CTS, De Quervain's tenosynovitis, atlantoaxial sublux, Raynaud's, osteoporosis
- Resp - fibrosis, nodules, effusion, bronchiolitis obliterans, drug-related
- Cardiac - IHD, pericarditis
- Ophthalamic - keratoconjunctivitis sicca (Sjogren's), episcleritis/scleritis, drug-related (cararacts)
- Haem - Felty's syndrome, AIHA, amyloidosis
89
What is Felty's syndrome?
RA + splenomegaly + dec WCC
90
Investigations for RA
Bedside - obs, lung function test
Bloods - autoantibodies (RF, Anti-CCP), ESR/CRP, FBC
Imaging - XR, CXR
91
Management of RA
Conservative - OT/PT
Medical:
- early maintenance: combo DMARDs and ST steroids
- further biologicals: TNF-a inhib (infliximab), Rituximab
- symptomatic: NSAIDs, steroids
- cover: PPI, bisphosphonates
92
Specific signs of OA
Herberden's nodes
Bouchard's nodes
Squaring of C-MC joint
Absence of systemic features
93
Specific signs of septic arthritis
Signs of systemic upset
Red hot swollen joint
Tender to palpate, warm to touch, effusion
Marked limitation of movement, inability to weight bear
94
Specific signs of gout
Red hot swollen tender joint
| Joint asp + synovial fluid analysis shows -ve birefrigent needle-shaped crystals
95
Specific signs of psudogout
Acutely tender, red, hot, swollen joint
| Joint asp + synovial fluid analysis shows inc WCC, +ve birefringent rhomboid shaped crystals
96
Specific signs of RA
Early - swollen MCP + PIP joints, with wrist/MTP joint involvement
Late - Boutonniere, swan neck, Z thumb, ulnar dev
97
Specific signs of psoriatic arthritis
```
Dactylitis
Enthesitis (pain, stiffness + tenderness of tendon insertions into bone)
Extra-articular features (plaques, nail changes, uveitis)
```
98
Specific signs of ank spond
Schober's test
| Chest circumference expansion <5cm
99
Specific signs of polymyalgia rheumatica
Normal muscle strength at initial presentation
| Muscle tenderness proximally
100
Specific signs of polymyositis
Proximal muscle weakness and atrophy
Difficulty arising from sitting position
Muscles are tender on palpation
101
Specific signs of dermatomyositis
Gottron's papules and heliotrope rash
| Photosensitivity
102
Specific signs of Sjogren's syndrome
```
Dry eyes
Dry mouth
Parotid swelling
Vaginal dryness and dyspareunia
Dry cough
Dysphagia
```
103
Specific signs of limited scleroderma
```
CREST
Calcinosis
Raynaud's
oEsophageal dysmotility
Sclerodactyly
Telangiectasia
```
104
Specific signs of diffuse scleroderma
CREST + internal organs
- pulmonary HTN/ILD
- RHF, renal impairment
