auto-immune

Question 1

Hashimotos thyroiditis type + abs

Answer 1

2 + 4

anti-TG + ANTI-TPO

Question 2

T1DM

Answer 2

anti glutamic acid decarboxylase
anti islet antigen 2
type 4

Question 3

Myaesthenia Gravis

Answer 3

fluctuating weakness
extra occluar weakness or ptosis
EMG (electromyography) studies abnormal
tensilon test +ve

Question 4

tensilon test +ve meaning

Answer 4

inject edrophonium

Question 5

Goodpastures biopsy

Answer 5

crescentric nephritis

Question 6

gum infection making RA worse

Answer 6

Porphyromonas gingivalis gum infection

Question 7

RA antibodies

Answer 7

Anti cylic citrullinated peptide (arginine to citrulline by peptidylarginine deaminase )

Question 8

speckled abS meaning

Answer 8

Extractable antinuclear antigens e.g. ribonucleoproteins (La, Ro, Sm, U1RNP) - other extractables = centromere, SCL70

Question 9

sjogren’s synd

Answer 9

anti-ro anti-la

Question 10

3 types of vasculitis (type 2 hypersensitivity)

Answer 10

Granulomatosis with polyangitis
Eosinophilic granulomatosis with polyangitis (Churg-Strauss)
Microscopic polyangitis

Question 11

ANCAs hit me

Answer 11

anti-neutrophil cytoplasmic antibodies
cytoplasmic + perinuclear
proteinase 3 + myeloperixidase

Question 12

Diffuse cutaneous systemic sclerosis

Answer 12

scleroderma affects trunk and proximal limbs (progresses beyond forearms)
anti scl-70 (topoisomerase) antibodies (also fibrallin, RNA polymerase) - NUCLEOLAR PATTERN ON ANA STAIN (ltd wont be)
CREST + more exrensive GI disease, interstial pul disease - primary pul htn, scleroderma kidney/renal crisis

Question 13

Limited cutaneous systemic sclerosis

Answer 13

Raynaud’s may be first sign
scleroderma affects face (peri-oral) and distal limbs predominately (Not proxiamal to forearms)
anti-centromere antibodies
a subtype of limited systemic sclerosis is CREST syndrome: Calcinosis, Raynaud’s phenomenon, oEsophageal dysmotility, Sclerodactyly, Telangiectasia
Can have pul htn

Question 14

idiopathic inflammatory myopathy - dermatomyositis

Answer 14

type 3 HS (immune complex mediated vasculaitis) , perivascular CD4 t-cells + B-cells within muscles
the majority of patients are ANA positive, with around 25% anti-Mi-2 positive (more a feature in d>p)
also amino-acyl transfer RNA synthetase antibody e.g. Jo-1

Question 15

anti-phospholipid antibodies

Answer 15

lupus anticoagulant (prolonged phopholipid dependant coagualtion tests - cant be assessed if on anticoag tx) 
anti-cardiopolin antibody (Ig against phospholipids, b2 glycoprotein 1)

Question 16

systemic sclerosis pathogenesis

Answer 16

th17 + th2 inflammation –> fibroblasts/fibrosis
polymorphisms type 1 collagen alpha 2 chains + fibrillin 1 , tgf-b, microvascular disease as activated endothelial cells
Loss of b cell tolerance to nuclear antigens

Question 17

polymyositis

Answer 17

type 4 HS CD8 kill myofibrols via perforin and granzymes

ANTI-SIGNAL RECOGNITION PEPTIDE ANTIBODY (Anti-SRP) - nulcear and cytoplasmic

Question 18

cytoplasmic antibody

Answer 18

aminoacylt transfer RNA synthetase (Jo-1) - dm

anti-signal recognition peptide antibody (polymyositis)

Question 19

rouloux indicates

Answer 19

MM
Anaemia, high ESR, high calcium
Igs and electrophoretic strip, Urinary BJP, skeletal survey
Refer to haematologist for specialist management

Question 20

Rheumatoid arthritis – genetic predisposition

Answer 20

Peptidylarginine deiminase polymorphisms increase citrullination of proteins
PTPN 22 - Protein tyrosine phosphatase non-receptor 22 is a lymphocyte specific tyrosine phosphatase which suppresses T cell activation. 1858T allele increases susceptibility to rheumatoid arthritis, SLE, type 1 diabetes

Question 21

ra TX

Answer 21

methotrexate, Sulphasalazine, hydroxychloroquine, leflunomide
Further treatment; - TNFalpha antagonist. Inhibits downstream events in inflammation.
Rituximab. Antibody specific for CD20. Depletes B cells (not plasma cells).
Abatacept. CTLA-4 – Ig fusion protein. Binds to ligands of CD28 (CD80 and CD86) and thereby inhibits T cell activation.
Tocilizumab. Antibody specific for IL-6 receptor – widespread effects

Question 22

Before starting RA drugs

Answer 22

Screen for exposure to TB using CXR and TB ELISPOT
Anti TNF treatments can cause reactivation of TB (has been found to do this in a proportion of patients on it)
Screen for exposure to Hepatitis B
Screen for exposure to Hepatitis C
Consider possibility of HIV infection
Prior history of septic arthritis/infected joint prosthesis
Educate patient to stop drug and seek advice if acute infection
Consider need for vaccinations
Consider risk of malignancy
- Prior history of malignancy
- Advise re sun exposure/skin protection