RHEUM Flashcards
(193 cards)
1
Q
Blood results consistent with polymyalgia rheumatica?
A
CRP + ESR = high
CK + anti-CCP = normal
2
Q
Antibodies associated with limited cutaneous systemic sclerosis?
A
anti-centromere
3
Q
Antibodies associated with diffuse cutaneous systemic sclerosis?
A
Anti-Scl-70
4
Q
Antibodies associated with drug induced lupus?
A
Anti-histone antibodies
5
Q
What happens to APTT in antiphospholipid syndrome?
A
Prolonged APTT
6
Q
Spinal XR findings in ankylosing spondylitis?
A
Squaring of lumbar vertebrae
Subchondral erosions
Sclerosis
7
Q
Management of acute flares of rheumatoid arthritis?
A
PO prednisolone OR IM methylprednisolone
8
Q
Early XR findings in rheumatoid arthritis?
A
Loss of joint space
Juxta-articular osteoporosis
Soft tissue swellings
9
Q
Late XR findings in rheumatoid arthritis?
A
Periarticular erosions
Subluxation
10
Q
What is the only non-inflammatory arthritis?
A
OA.
11
Q
List 3 seropositive causes of arthritis.
A
RA SLE Scleroderma Vasculitis' Sjogren's syndrome
12
Q
List 3 seronegative causes of arthritis.
A
Psoriatic arthritis
Reactive arthritis
Enteric arthritis
Ankylosing spondylitis.
13
Q
List the main cause of infective arthritis.
A
Septic arthritis.
14
Q
List the 2 types of crystal induced arthritis.
A
Gout
Pseudogout
15
Q
What is meant by the term ‘spondyloarthropathies’?
A
A group of related chronic inflammatory conditions that tend to affect the axial skeleton and have certain shared clinical features.
16
Q
Name 3 of the spondyloarthropathies.
A
Ankylosing spondylitis
Psoriatic arthritis
Enteric arthritis
Reactive arthritis
17
Q
Name 3 features that spondyloarthropathies tend to have in common.
A
1) Seronegative
2) HLA27 positive
3) Axial arthritis (spine + sacroiliac joints)
4) Enthesitis (inflammation at tendon/ ligament insertion sites.
5) Dactylitis (inflammation of an entire digit)
18
Q
List 3 of the extra-articular joint manifestations which can be associated with spondyloarthropathies.
A
Iritis Oral ulcers Psoriaform rashes IBD Aortic valce incompetence
19
Q
In which patients are extra-articular manifestations of rheumatoid arthritis more likely?
A
In those with high titres of RF and anti-CCP as these create abnormal IgG, citrullinated type 2 collagen + vimentin.
20
Q
Lung manifestations of RA?
A
Pulmonary fibrosis/ bronchiolitis obliterans
21
Q
Skin manifestations of RA?
A
Rheumatoid nodules
22
Q
Cardiac manifestations of RA?
A
CVD
IHD
Pericarditis
Pericardial effusion
23
Q
Eye manifestations of RA?
A
Scleritis
Episcleritis
Cataracts 2o to steroid treatment
24
Q
MSK manifestations of RA?
A
Carpal tunnel syndrome
Tendon ruptures
Frozen shoulder
De Quervain’s tenosynovitis
25
What is Felty's syndrome?
RA + neutropenia + splenomegaly.
26
What is Sicca syndrome?
secondary sjogren's syndrome.
27
What is Caplan's syndrome?
RA + pulmonary fibrosis + pulmonary nodules.
28
What is anti-phospholipid syndrome?
A disorder associated with anti-phospholipid antibodies where the blood becomes prone to clotting, causing a hypercoaguable state.
29
Anticardiolipin antibodies?
Antiphospholipid syndrome.
30
Anti-beta-2 glycoprotein I antibodies?
Antiphospholipid syndrome
31
What is systemic sclerosis?
An autoimmune inflammatory and fibrotic connective tissue disorder.
32
What are the 2 types of systemic sclerosis?
Limited cutaneous
| Diffuse cutaneous
33
Features of limited cutaneous systemic sclerosis?
CREST syndrome:
```
Calcinosis
Raynaud's phenomenon
Oesophageal dysmotility
Sclerodactyly
Telangiectasia
```
34
Features of diffuse cutaneous systemic sclerosis?
Features of CREST syndrome PLUS effects on internal organs:
```
HTN
CAD
Pulmonary HTN
Pulmonary fibrosis
Glomerulonephritis
```
35
What is Sjogren's syndrome?
An autoimmune condition affecting exocrine glands + leading to symptoms of dry mucous membranes (eyes, mouth, vagina).
36
What is primary Sjogren's syndrome?
Occurs in isolation.
37
What is secondary Sjogren's syndrome?
Occurs secondary to another disease (SLE or RA).
38
Anti-Ro + Anti-La antibodies?
Sjogren's syndrome.
39
Special test for Sjogren's syndrome?
Schirmer test (if <10mm = significant).
40
What is polymyositis?
Chronic inflammation of the muscles.
41
What is dermatomyositis?
Chronic inflammation of the skin + muscles.
42
Diagnostic investigation for polymyositis/ dermatomyositis?
CK (often >1000).
43
Anti-Jo-1 antibodies?
Polymyositis (sometimes dermatomyositis).
44
Anti-Mi-2 antibodies?
Dermatomyositis
45
Dermatomyositis antibodies?
Anti-Mi-2
| ANA
46
What is vasculitis?
Inflammatory disorders for the blood vessels characterised based upon the size of the blood vessels that they affect.
47
List 3 small vessel vasculitis'.
Henoch-Schonlein Purpura
Eosinophilic granulomatosis with polyangiitis
Microscopic polyangiitis
Granulomatosis with polyangiitis
48
List 3 medium vessel vasculitis'.
Polyarteritis nodosa.
Eosinophilic granulomatosis with polyangiitis.
Kawasaki disease.
49
List 2 large vessel vasculitis'.
GCA
| Takayasu's arteritis.
50
ESR + CRP in vasculitis.
Elevated.
51
pANCA associated vasculitis'?
Microscopic polyangiitis.
| Eosinophilic polyangiitis with granulomatosis.
52
cANCA associated vasculitis'?
Granulomatosis with polyangiitis.
53
What is Marfan's syndrome?
Autosomal dominant connective tissue disorder.
54
Where is the defect in Marfan's syndrome?
On the gene coding for fibrillar 1.
55
Renal failure ± SOB ± haemoptysis?
Microscopic polyangiitis.
56
Enteric arthritis is associated with what conditions?
IBD
GI bypass surgery
Coeliac disease.
57
When does enteric arthritis usually improve?
Upon treatment of the underlying bowel disease.
58
What can be used for resistant cases of enteric arthritis?
DMARDs.
59
Define osteoarthritis.
Non-inflammatory arthritis described as 'wear and tear' within synovial joints.
60
Most common aetiology of OA.
Genetic factors + overuse + injury.
61
3 causes of secondary OA.
```
Joint disease
Obesity
Occupation
Injury
Haemochromatosis
```
62
5 risk factors for development of OA.
```
Increasing age
Obesity
Female sex
Certain occupations
Trauma/ injury
Exercise stresses
Joint misalignment
Joint laxity
```
63
Joints most common affected by OA.
Hips, knees, small joints of hands.
64
5 general features of OA?
1) Joint pain + stiffness worsened by activity.
2) Deformity, swelling + reduced function/ ROM.
3) Asymmetrical distribution across joints.
4) Gelling of joints after rest.
5) Background ache in joint at rest.
6) Instability.
7) Warmth + tenderness if synovitis.
8) Pain ± crepitus on movement.
65
Which parts of the hands are commonly affected by OA?
Carpals
DIPJs
PIPJs
Thumb MCP joint
**NOTE: other MCPs are not involved.
66
Signs of OA on the hands?
1) Squaring at base of thumb.
2) Bouchard's nodes at PIPJs.
3) Heberden's nodes at DIPJs.
4) Mucoid cysts adjacent to joint on dorsal surface (can cause nail ridging).
**Potential wasting of thenar muscles.
67
How is OA pain in the hands typically exacerbated?
Pinching/ strong grip actions.
68
Where will the pain be in OA of the hip?
Deep pain in anterior groin on walking/ climbing stairs.
69
Where is pain referred to in OA of the hip?
Lateral thigh + buttock
| Anterior thigh + knee.
70
Movement most affected by OA of the hip?
Internal rotation with hip flexion.
71
Features of advanced OA in the hip?
Trendelenberg gait.
| Fixed flexion external rotation deformity.
72
What would suggest patellofemoral involvement in OA of the knee?
Pain worse on walking upstairs and even more so on walking downstairs.
73
When can diagnosis of OA be clinical?
If patient is >45, has typical activity related pain + no morning stiffness is present.
74
Bedside investigations for OA?
History
Examination
Weight + BMI
75
Blood investigations for OA?
CRP can be slightly elevated.
76
Imaging investigations for OA?
Plain XR if diagnostic uncertainty/ to exclude other diagnoses.
77
Signs of OA seen on XR?
```
Loss of joint space
Osteophyte formation
Subarticular sclerosis (increased density of bone along joint line)
Subchondral cysts (fluid filled holes in bone)
```
78
Conservative management of OA?
```
Education
Weight loss
Physiotherapy to improve surrounding muscle strength
Local heat/ cold packs
Occupational therapy
Orthotics
```
79
Medical management of OA?
1st = regular paracetamol + topical NSAID/ topical capsaicin.
2nd = regular paracetamol + oral NSAID (+PPI)
3rd = weak opioid adjunct
4th = intra-articular steroid injection.
80
Surgical management of OA?
Joint replacement in severe cases
OR
Arthroscopic lavage + debridement if history of locking.
81
Define rheumatoid arthritis.
Autoimmune condition causing a chronic systemic inflammatory disease characterised by a symmetrical, deforming + peripheral polyarthritis.
82
Peak onset of rheumatoid arthritis?
Age 30-50
83
Who is RA more common in?
3x more common in women.
84
Aetiology of RA?
Autoimmune process caused by the presence of a predisposing gene + environmental trigger (smoking/ specific pathogen).
85
Predisposing gene present in RA?
HLADR4 and/or HLADR1
86
Typical clinical picture of patients with RA?
A distal, symmetrical poly arthritis ± inflammation of tendons and bursa.
87
Joints affected by RA?
Wrists, ankles, MCP + PIP joints are main ones
**Can affect any synovial joint though.
88
Onset of RA?
Rapid + overnight
OR
Over months to years
OR palindromic
89
3 typical symptoms of RA?
Pain, swelling + stiffness in small joints of hands + feet.
90
When is pain worse in RA?
Worse at rest + during periods of inactivity.
91
Description of the feeling of joints in RA?
Swelling causes a boggy sensation around joints.
92
Describe the pattern of joint stiffness in patients with RA?
Early morning stiffness lasting <1 hour.
93
Associated symptoms of rheumatoid arthritis?
Fatigue
Weight loss
Flu-like symptoms
Muscle aches + weakness
94
5 signs seen on examination of a patient with rheumatoid arthritis in the hands?
1) Positive MCP/MTP joint squeeze test.
2) Ulnar deviation of wrists + fingers.
3) Volar subluxation of wrists + fingers.
4) Z-deformity of thumb.
5) Boutonnière deformity
6) Swan neck deformity
95
Risk factors for RA?
```
Increasing age
Smoking
HLADR4/1 genes
FHx
Female sex
```
96
Blood investigations in RA?
```
FBC
U&Es
LFTs
RF
Anti-CCP
CRP + ESR
```
97
Imaging investigations in RA?
Plain XR of hands + feet - to determine disease severity.
USS/MRI to confirm and evaluate synovitis (have a greater sensitivity for detecting bony erosions).
98
XR findings in patients with RA?
Soft tissue swelling
Juxta-articular osteopenia
Decreased joint space
Erosion of bone/ subluxation
99
How is RA diagnosis made?
Clinical diagnosis based upon American college of rheumatology criteria.
100
Criteria for RA diagnosis according to American college of rheumatology?
1) Joints involved (more points for higher numbers and smaller joints involved)
2) Serology (RF + anti-CCP)
3) Inflammatory markers (ESR+CRP)
4) Duration of symptoms (>/< 6 weeks)
**A score of 6 or more indicates RA.
101
Why is it important to start treatment for RA ASAP?
Early treatment is associated with better outcomes.
102
What scoring system + blood test can be used to measure RA disease activity?
DAS28 score + CRP.
103
Which questionnaire measures functional ability in RA?
Health assessment questionnaire (HAQ)
104
What is the general aim of management for RA?
To induce remission and to maintain remission through the minimal effective dose.
105
Medical management of RA?
1st line = methotrexate/ sulfasalazine/ leflunomide.
2nd line = dual therapy with 2 of above.
3rd line = methotrexate + TNF-inhibitor (adalimumab/ infliximab/ enteracept).
4th line = methotrexate + rituximab.
106
Surgical management of RA?
Used for very severe deformities
**Not often needed now due to early initiation of DMARDs.
107
What should be prescribed alongside methotrexate?
5mg Folic acid
108
2 important side effects of methotrexate?
Pulmonary fibrosis
| Teratogenicity in pregnancy
109
Which DMARDs are safe to use in pregnancy?
Sulfasalzaine (+5mg folic acid)
| Hydroxychloroquine
110
Main adverse effect of hydroxychloroquine?
Reduced visual acuity (macular toxicity).
111
List 3 poor prognostic features of rheumatoid arthritis.
1) Younger onset.
2) Male.
3) Greater number of joints/organs affected.
4) Presence of RF and anti-CCP antibodies.
5) Erosions seen on XR.
112
Why do women who are pregnant experience an improvement in RA symptoms?
Due to the higher natural production of steroids.
113
What treatment should be offered in primary care for RA whilst the patient is waiting for a specialist appointment?
NSAIDs (+PPI)
114
When should hydroxychloroquine be considered as mono therapy management in a patient with RA?
If they have very mild or palindromic disease.
115
Define psoriatic arthritis.
A seronegative inflammatory arthritis associated with psoriasis.
116
What percentage of people with psoriasis are affected by psoriatic arthritis?
10-20%.
117
How long after skin psoriasis development does psoriatic arthritis occur?
psoriatic arthritis tends to develop 5-10 years after skin psoriasis.
118
What percentage of people develop psoriatic arthritis but do not develop skin arthritis?
20% of those with psoriatic arthritis do not develop skin psoriasis.
119
3 associations of psoriatic arthritis?
```
Metabolic syndrome
CVD
IBD
Anxiety
Depression
```
120
3 different patterns of psoriatic arthropathy?
Symmetrical poly arthritis
Asymmetrical pauciarthritis
Spondylitic pattern
Arthritis mutilans
121
Which joints in symmetrical psoriatic poly arthritis are affected?
Similar to RA.
Hands, wrists, ankles + DIPJs.
MCPs less commonly affected.
**More common in women
122
Which areas are affected by asymmetrical pauciarthritis?
Mainly digits and feet.
123
How does spondylitic psoriatic arthritis present?
Back stiffness
Sacroiliitis
Atlanto-axial joint involvement
**More common in men
124
What is arthritis mutilans?
Very rare form of arthritis causing complete joint destruction in phalanxes.
125
What sign is seen in arthritis mutilans?
Telescopic finger (complete joint destruction in phalanxes)
126
5 features of psoriatic arthritis?
```
Psoriatic places on skin
Dactylitis
Night-time axial pain
Enthesitis
Acneiform rashes/ palmo-plantar pustulosos
Anterior uveitis
Aortitis
```
127
3 nail changes seen in patients with psoriatic arthritis?
Pitting
Onycholysis
Subungual hyperkeratosis
128
Bedside test used to screen for psoriatic arthritis?
Psoriasis epidemiological screening tool (PEST)
129
Blood results seen in psoriatic arthritis?
RF + CCP commonly negative
| CRP + ESR raised
130
Bony changes seen on plain XRs in patients with psoriatic arthritis?
```
Pencil in cup deformity
Erosive changes (osteolysis)
Ankylosis
Periostitis
Dactylitis
```
131
Management used for psoriatic arthritis?
NSAIDs for pain
DMARDs (methotrexate/ sulfasalazine/ leflunomide)
Anti-TNF biologics
LAST LINE = ustekinumab (targets IL-12 + IL-23).
132
What is the pencil in cup deformity?
Central erosions of the bone adjacent to the joint.
133
Define reactive arthritis.
A condition where synovitis occurs in the joints as a reaction to a recent infective trigger.
134
Causes of reactive arthritis?
Infection.
Normall GI, GU or STIs.
135
Most common cause of reactive arthritis?
Chlamydia.
136
What joint condition does gonorrhoea commonly cause?
A gonococcal septic arthritis.
137
Reactive arthritis is associated with what gene?
HLAB27.
138
Clinical features of reactive arthritis?
Acute monoarthritis affecting single joint in LL (commonly knee).
Joint tends to be warm, swollen + painful.
139
Extra-articular features of reactive arthritis?
Bilateral conjunctivitis
Anterior uveitis
Circinate balantitis
Urethritis
140
Way of remembering symptoms of reactive arthritis?
Can't see
Can't pee
Can't stand on your knee
141
Reactive arthritis differentials?
Gout
Septic arthritis
Pseudogout
142
Bedside investigations for reactive arthritis?
Sexual health review.
143
Blood investigations for reactive arthritis?
ESR + CRP (elevated)
| Infectious serology
144
Imaging investigations for reactive arthritis?
Plain XR may show enthesitis.
145
Special investigations for reactive arthritis?
1) Stool culture if patient has diarrhoea.
| 2) Joint aspiration (gram staining, culture, sensitivity, crystal examination).
146
Initial management of reactive arthritis?
Treat according to 'hot joint' policy:
1) Empirical antibiotics until septic arthritis excluded.
2) Aspirate joint for gram staining, culture, sensitivity + crystal examination.
147
Further management of reactive arthritis?
**After septic arthritis has been excluded.
1) NSAIDs/ local steroid injections
2) Splint affected joints
3) Systemic steroids if multiple joints implicated.
148
Management of reactive arthritis if persisting for >6 months?
1) DMARDs (methotrexate or sulfasalazine)
| 2) Anti-TNF biologics
149
Oral ulcers + genital ulcers + anterior uveitis = ?
Bechet's disease.
150
Define ankylosing spondylitis.
A seronegative inflammatory condition mainly affecting the spine + SI joints, causing progressive stiffness and pain.
151
Risk factors for ankylosing spondylitis?
HLAB27 gene
| First degree family member affected.
152
Typical presentation of ankylosing spondylitis?
Young man with gradual onset lower back pain that is worse during the night, stiff in the morning and relieved by exercise.
153
What does ankylosing spondylitis cause?
Progressive loss of spinal movements in all directions (incl. decreased thoracic expansion).
154
What posture is caused by ankylosing spondylitis?
Question mark posture.
**Kyphosis + neck hyperextension.
155
Systemic symptoms of ankylosing spondylitis?
Weight loss + fatigue.
156
Conditions associated with ankylosing spondylitis?
```
Apical fibrosis
Anterior uveitis
Achilles tendonitis
Aortic regurgitation
AV node block
Amyloidosis
```
157
Why is heart block associated with ankylosing spondylitis?
Due to fibrosis of the heart's conductive system.
158
How is ankylosing spondylitis diagnosed?
Diagnosis is clinical + supported by imaging.
159
What specialist bedside test is used for ankylosing spondylitis?
Schober's test
**distance of <20cm indicates lumbar restriction.
160
Positive blood findings in ankylosing spondylitis?
FBC (normocytic anaemia)
ESR + CRP raised
HLAB27 positive
161
1st line imaging in ankylosing spondylitis?
Plain XR spine + sacrum.
162
XR findings suggesting ankylosing spondylitis?
Squaring of vertebral bodies
Subchondral sclerosis + erosions
Syndesmophytes
163
What would an MRI show in ankylosing spondylitis?
Bone marrow oedema + destructive changes.
164
Why are DEXA scans done in patients with ankylosing spondylitis?
Due to an increased risk of vertebral wedge fractures.
165
Conservative management of ankylosing spondylitis?
Exercise, PT, smoking cessation.
166
Medical management of ankylosing spondylitis?
1st line = NSAIDs
2nd line = TNF alpha blockers (adalimumab, intercept)
3rd line = Secukinumab.
**Acute flare Rx = corticosteroids.
**Bisphosphonates after DEXA if required.
167
When might surgery be indicated for patients with ankylosing spondylitis?
If there are deformities of the spine or other joints.
168
3 poor prognostic indicators in patients with ankylosing spondylitis?
ESR >30
Onset <16
Early hip involvement
Poor response to NSAIDs
169
Most common cause of septic arthritis?
Staphylococcus Aureus
170
Risk factors for septic arthritis?
```
Pre-existing joint disease (RA)
DM
Immunosuppression
Chronic renal failure
Recent joint surgery
Prosthetic joints
IVDU
Age >80
```
171
Clinical features of septic arthritis?
```
Suspect in ANY inflamed joint
Single joint affected
Rapid onset of hot, red, swollen + painful joint
Stiffness and reduced ROM
Systemic symptoms
```
172
XR findings in septic arthritis?
NAD
173
Which patients with ?septic arthritis should be referred urgently to orthopaedics?
Patients with suspected septic arthritis in a prosthetic joint.
174
Risk factors for gout?
```
Male sex
Obesity
Hyperuricaemia
High purine diet (meat, seafood)
Alcool
Diuretics
CVD
Kidney disease
```
175
Potential XR findings in gout?
Often normal
Non-specific tissue swelling
Sibchondral cysts
Punched out lesions
176
How is gout diagnosed?
Clinical diagnosis ± joint aspiration findings.
177
Conservative gout management?
```
Rest + limb elevation
Avoidance of trauma
Exposure of joint in cool environment
Ice packs
Bed cage
Lifestyle measures (weight loss, exercise, reduce alcohol intake, increase fluid intake)
```
178
Acute medical management of gout?
1st line = NSAIDs
2nd line = Colcichine (1st line if renal failure or heart disease)
3rd line = corticosteroids/ IM injection of corticosteroids.
179
Prophylactic medical management of gout?
1st line = allopurinol
| 2nd line = Febuxostat
180
Monitoring requirements in patients taking gout prophylaxis?
Serum uric acid level and renal function every 4 weeks at crate lowering therapy initiation.
**Once uric acid is in target range, check annually.
181
Crystals found in gout?
Negatively birefringent
Needle shaped
Monosodium urate crystals
182
Crystals found in pseudo gout?
Positively birefringent
Rhomboid shaped
Calcium pyrophosphate crystals
183
XR findings in patients with pseudo gout?
Chondrocalcinosis is pathognomonic
Other XR changes may be similar to those in OA.
184
Management of pseudo gout?
Cool packs + rest
NSAIDs + PPI ± colcichine/ corticosteroids
Joint aspiration/ washout if severe
185
Define polymyalgia rheumatica.
An inflammatory condition that causes pain + stiffness in the shoulders, pelvic girdle and neck.
186
Clinical features of polymyalgia rheumatica?
Bilateral shoulder pain that can radiate to the elbows.
Bilateral pelvic girdle pain.
Pain worse on movement + interferes with sleep.
Stiffness for at least 45 minutes in the mornings.
**NOTE: weakness is not a feature in polymyalgia rheumatica.
187
Positive investigations in polymyalgia rheumatica?
CRP, ESR + Plasma viscosity normally high.
188
How is polymyalgia rheumatica diagnosed?
Symptoms present for at least 2 weeks.
70% improvement in symptoms after 3-4 weeks steroid treatment.
Inflammatory markers return to normal after 3-4 weeks steroid treatments.
189
Define systemic lupus erythematous.
Inflammatory autoimmune connective tissue disease causing chronic inflammation and subsequent tissue damage.
190
Pathophysiology of SLE?
Anti-nuclear antibodies attack proteins within cell nuclei, generating an immune response.
191
Which antibodies are present in SLE?
ANA (sensitive)
Anti-dsDNA (specific)
Anti-Smith (highly specific)
192
Diagnostic criteria used for SLE?
SLICC/ ACR criteria
**Involve presence of ANA plus presence of a certain number of clinical features.
193
Antibodies present in drug-induced lupus?
Anti-histone antibodies.
