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Rheum Flashcards

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1
Q

What movements are affected in adhesive capsulitis?

A

External rotation mostly
Internal rotation
Abduction

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2
Q

What renal signs are associated with ANCA vasculitis?

A

Immune complex glomerulonephritis
Raised creatinine
Haematuria
Proteinuria

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3
Q

ANCA vasculitis CXR findings

A

Nodular/fibrotic/infiltrative lesions

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4
Q

cANCA target and conditions

A

Serine proteinase 3 SP3
Granulomatosis with polyangiitis (wegners)

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5
Q

pANCA target and conditions

A

Myeloperoxidase MPO
Eosinophilic granulomatous with polyangiitis (churg Strauss)
Ulcerative colitis
PSC
Anti GBM
Crohn’s

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6
Q

Can you use ANCA levels for monitoring?

A

cANCA has some correlation with disease activity
pANCA can’t be used to monitor disease

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7
Q

Ank spond features other than back signs

A

Atypical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
AV node block
Amyloidosis
Cauda equina, peripheral arthritis

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8
Q

When are DMARDs indicated in ank spond?

A

Peripheral joint involvement

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9
Q

APTT in antiphospholipid syndrome

A

Paradoxically rises
Due to lupus anticoagulant antibodies reacting with phospholipids in coag cascade

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10
Q

What is associated with antiphospholipid syndrome?

A

SLE
Other autoimmune conditions
Lymphoproliferative disorders
Phenothiazines

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11
Q

Investigating antiphospholipid syndrome

A

Anticardiolipin antibodies
Anti beta 2 glycoprotein I antibodies
Lupus anticoagulant
Thrombocytopenia
Prolonged APTT

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12
Q

Secondary thromboembolism prophylaxis

A

VTE:
Lifelong warfarin INR 2-3
INR 3-4 if recurrent VTE
Add aspirin if VTE occurred while on warfarin

Arterial:
Lifelong warfarin INR 2-3

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13
Q

Causes of avascular necrosis and how to investigate?

A

Long term steroids
Chemo
Alcohol XS
Trauma

MRI

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14
Q

How to test for azathioprine toxicity?

A

TMPT test

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15
Q

How does azathioprine work?

A

Metabolised to mercaptopurine
Inhibits purine synthesis

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16
Q

Oral ulcers
Genital ulcers
Anterior uveitis
HLA B51

A

Behcets

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17
Q

How to diagnose behcets?

A

Clinical findings
Pathergy test: needle prick puncture develops small pustule

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18
Q

How do bisphosphonates work?

A

Pyrophosphate analogue
Inhibits osteoclasts
Decreases demineralisation in bone

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19
Q

Bisphosphonates side effects

A

Oesophagitis, oesophageal ulcers
Osteonecrosis of jaw
Atypical stress fractures
Acute phase response (fever, arthralgia, myalgia)
Hypocalcemia

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20
Q

Bisphosphonates duration of treatment

A

Stop at 5y if
> 75y
Femoral neck T score > - 2.5
Low FRAX/NOGG score

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21
Q

Osteoporosis blood results

A

Calcium, phosphate, ALP, PTH normal

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22
Q

Osteomalacia blood results

A

Decreased calcium and phosphate
Increased ALP and PTH

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23
Q

Primary hyperparathyroidism, osteitis fibrosis cystica blood results

A

Calcium increased
Phosphate decreased
Increased ALP, PTH

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24
Q

CKD, secondary hyperparathyroidism blood results

A

Calcium decreased
Phosphate increased
ALP increased
PTH increased

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25
Paget's disease blood results
Calcium, phosphate, PTH normal ALP increased
26
Osteoma is associated with what condition
Gardner's (FAP)
27
What is the commonest benign bone tumour?
Osteochondroma
28
Giant cell bone tumour
Benign Multinucleated giant cells in fibrous stroma 20-40y Epiphyses of long bones
29
XR findings of soap/double bubble
Giant cell bone tumour
30
Locations of osteosarcomas
Mataphyses of long bones before closure Femur, tibia, humerus
31
XR sign of codman triangle and sunburst pattern
Osteosarcoma
32
Mutation associated with osteosarcoma
Rb gene
33
Osteosarcoma predisposing factors
Rb gene mutations Paget's disease Radiotherapy
34
Small round blue cell tumour
Ewing's sarcoma
35
Malignant bone tumour occuring in pelvis and long bones causing severe pain
Ewing's sarcoma
36
Ewing's sarcoma genetice
T(11:22) translocation EWS FLI1
37
Onion skin on XR
Ewing's sarcoma
38
Chondrosarcoma affects what areas
Axial skeleton
39
Physiology of carpal tunnel
Prolongation of action potential for motor and sensory
40
How does denosumab work?
Monoclonal antibody Prevents development of osteoclasts Inhibits RANKL
41
Denosumab uses
60mg injection every 6/12 for osteoporosis 120mg every 4/52 to prevent pathological fractures in PT with bone mets from solid tumours
42
Denosumab side effects
SOB Diarrhoea Hypocalcemia URTI Atypical femoral fractures
43
Dermatomyositis non skin features
Prox muscle weakness/tenderness Raynaud's Resp muscle weakness Interstitial lung disease Dysphagia Dysphonia
44
Investigating dermatomyositis
ANA 80% tRNA synthetase antibodies (anti jo-1, anti SRP, anti Mi2) Elevated CK EMG Muscle biopsy
45
What antibodies are specific to dermatomyositis?
Anti Mi 2
46
Anti Jo
Mostly polymyositis Also dermatomyositis with lung involvement, rynauds, fever
47
Features of drug induced lupus
Arthralgia, myalgia Macular rash Pleurisy ANA dsDNA negative Anti histone antibodies
48
Causes of drug induced luoue
Procainamide Hydralazine Isoniazid Minocycline Phenytoin
49
Ehlers danlos features
Elastic fragile skin Hypermobility and dislocation Bruising Aortic regurgitation Mitral prolapse Aortic dissection SAH Angioid retinal streaks
50
What nerves may be involved in medical epicondylitis?
Ulnar
51
Radial tunnel syndrome presentation
Similar to lateral epicondylitis Pain 4-5 cm distal to lateral epicondyle Symptoms worsened by extending elbow and pronating
52
What are extractable nuclear antigens associated with?
ANA positive
53
Anti Ro associations
Sjogrens SLE Congenital heart block
54
Anti La associations
Sjogrens syndrome
55
Anti Jo 1 associations
Polymyositis
56
Anti Scl associations
Diffuse cutaneous systemic sclerosis
57
Anti centromere associations
Limited cutaneous systemic sclerosis
58
Familial Mediterranean fever inheritance
Autosomal recessive
59
Familial Mediterranean fever features
Pyrexia Abdo pain (peritonitis) Pleurisy Pericarditis Arthritis Erysipeloid rash lower limbs Attacks 1-3 days
60
Managing familial Mediterranean fever
Colchicine
61
What counts as uricaemia?
> 0.45 mmol/L
62
Drugs causing gout
Thiazides, furosemide Ciclosporin Alcohol Cytotoxics Pyrazinamide Aspirin
63
Gout- when should you check uric acid levels?
Once acute episode has settled (2/52)
64
How does colchicine work?
Binds to tubulin and interferes with mitosis Inhibits microtubule polymerization So inhibits neutrophil activity and motility
65
Colchicine and renal impairment
Reduce dose if eGFR 10-50 Avoid if eGFR < 10
66
What can you give for gout if NSAIDs and colchicine are contraindicated?
15mg prednisolone OD Intra articular steroid injection
67
Urate lowering therapy is especially recommended for who?
2 or more gout attacks in 1y Tophi Renal disease Uric acid renal stones On cytotoxics or diuretics (prophylaxis)
68
Uric acid level targets
< 0.36 mmol/l < 0.3 if tophi/chronic gouty arthritis or flares ongoing despite urate <0.36
69
Urate lowering therapy
Colchicine first line Febuxostat second line Uricase Pegloticase infusion
70
How does febuxostat work?
Xanthine oxidase inhibitor Reduces urate levels
71
Gout predisposing factors
Decreased urate excretion (diuretics, CKD, lead) Increased urate production (myelo or lymphoproliferative, cytotoxics, psoriasis) Lesch Nyhan
72
Lesh Nyhan syndrome
HGPRTase deficiency X linked recessive Results in gout, renal failure, neuro deficits, LDS, self mutilation
73
Transient synovitis of hip
2-10y Associated with viral infection
74
Perthes
Avascular necrosis of femoral head 4-8y Progressive pain Limo
75
Hip XR: Widened joint space, decreased femoral head size/flattened femoral head
Perthes
76
SUFE
10-15y Obese Femoral head epiphysis displaces posterio inferiorly No internal rotation of leg in flexion
77
Hydroxychloroquine side effects
Bulls eye retinopathy
78
Secondary causes of iliopsoas abscess
Crohn's Diverticulitis, colorectal cancer UTI GU cancer Vertebral osteomyelitis Femoral catheter, lithotripsy Endocarditis IVDU
79
Diagnosing iliopsoas abscess
Supine, flex knee, externally rotate hip Ask PT to lift ipsilateral thigh CT abdo
80
Osteochondritis dissecans
Pain after exercise Intermittent swelling and locking
81
Patellar subluxation
Medial knee pain Lateral subluxation
82
Langerhans cell histiocytosis features
Bone pain (skull, femur) Cutaneous nodules Recurrent otitis media/mastoiditis
83
Tennis racket birbeck granules on electromicroscopy
Langerhans cell histiocytosis
84
Geographic skull on XR
Punched out scalloped edged lesions Bevelled edge Parietal regions Sign of Langerhans histiocytosis
85
Leflunomide and pregnancy
Must use contraception during leflunomide treatment and 2y after (women) or 3months (men)
86
Leflunomide side effects
Diarrhoea HTN Weight loss, anorexia Peripheral neuropathy Myelosuppression Pneumonitis
87
Leflunomide monitoring
FBC LFT blood pressure
88
Leflunomide contraindications
Pregnancy Caution in liver and lung disease
89
Facet joint pain features
Worse in morning and on standing Worse on extension May be tenderness over facets
90
L3 compression
Anterior thigh sensory loss Weak hip flexion, knee extension, hip adduction Reduced knee reflex Pos femoral stretch test
91
L4 compression
Sensory loss anterior knee, medial malleolus Weak knee extension, hip adduction Reduced knee reflex Positive femoral stretch test
92
L5 compression
Sensory loss dorsum of foot Weak foot and big toe dorsiflexion Reflexes intact Positive sciatic stretch test
93
S1 compression
Sensory loss posteriolateral leg and lateral foot Weak plantar flexion Reduced ankle reflex Positive sciatic stretch tesr
94
Spinal stenosis pathology
Intervertebral disc loss of proteoglycan and water content Increased stress transfer to posterior facet joints Cartilaginous degeneration, hypertrophy, osteophyte formation Ligamentum flavum thickening and distortion Canal narrows
95
Marfan genetics
Autosomal dominant FBN1 defect Chromosome 15 Codes for fibrillin 1
96
Marfan cardiac associations
Aortic sinus dilatation Aortic aneurysm/dissection/regurgitation Mitral valve prolapse
97
Marfan eye features
Upward lens dislocation Blue sclera Myopia
98
McArdle genetics
Autosomal recessive
99
McArdle disease
Type V glycogen storage disease Myophosphorylase deficiency Decreased muscle glycogenolysis Muscle pain/stiffness after exercise, cramps, myoglobinuria, low lactate after exercise
100
Where does lateral femoral cutaneous nerve come from?
L2/3
101
Where is lateral femoral cutaneous nerve prone to compression?
ASIS and it curves medially and inferiorly
102
How does MTX work?
Antimetabolite inhibits dihydrofolate reductase
103
MTX indications
Inflammatory arthritis Psoriasis ALL
104
MTX side effects
Mucositis Myelosuppression Pneumonitis Pulmonary fibrosis Liver fibrosis
105
MTX monitorint
FBC, U&E, LFT before starting, then weekly, then 2-3 monthly
106
MTX interactions
Trimethoprim and cotrimoxazole- marrow aplasia High dose aspirin- MTX toxicity
107
Mixed connective tissue disease antibodies
Anti U1 ribonucleoprotein antibodies
108
Investigating mixed CTD
Exclude other CTD/vasculitis FBC- anaemia, leucopenia, thrombocytopenia U&e- renal impairment Raised CRP, ESR ANA positive Anti ds DNA and antiscl70 negative
109
Managing mixed CTD
Immunosuppression/DMARD CCB for Raynaud's PPI for reflux Endothelin antagonist/prostacyclin analogue for pHTN
110
CTD prognosis
1/3 remission 1/3 chronic symptoms 1/3 severe systemic involvement and premature death
111
How does mycophenolate mofetil work?
Inhibits inosine monophosphate dehydrogenase Inhibits purine synthesis Reduces proliferation it T and B cells
112
Causes of myopathies
Polymyositis Duchenne, becker, myotonic dystrophy Cushings Thyrotoxicosis Alcohol
113
Osteogenesis imperfecta genetics and pathology
Autosomal dominant Decreased synthesis of pro alpha 1 or 2 collagen peptides --> Type 1 collagen abnormality
114
Osteogenesis imperfecta features
Fractures after minor trauma Blue sclera Osteosclerosis Dental imperfections Normal ca, po4, PTH, ALP
115
Causes of osteomalacia
Vit D deficiency (diet/malabsorption/sunlight) CKD Anticonvulsants Hypophosphatemic tickets (inherited) Liver disease Coeliac
116
Osteomalacia investigations
Low vit d Low Ca, po4 Raised ALP XR: translucent bands
117
Risk factors for haematogenous osteomyelitis
Sickle cell IVDU Immunosuppression Infective endocarditis
118
Osteomyelitis most common organisms
Staph aureus Salmonella most common in sickle cell
119
What conditions predispose to osteoporosis?
Hyperthyroidism, hyperparathyroidism Hypogonadism GH deficiency DM Multiple myeloma, lymphoma IBD, malabsorption, gastrectomy, liver disease CKD Osteogenesis imperfecta Homocysteinuria
120
Meds that may worsen osteoporosis
Glucocorticoids SSRIs Anti epileptics PPI glitazones Heparin Aromatase inhibitors
121
T score
Based on young person bone mass > - 1.0 normal -1.0 - 2.5 osteopenia < - 2.5 osteoporosis
122
Z score
T score but adjusted for age, gender, ethnicity
123
How much prednisolone do you need to take to significantly increase osteoporosis risk?
7.5mg OD for 3 months
124
How to manage patients at risk of corticosteroid osteoporosis?
Offer bone protection immediately if > 65y or previous fragility # DEXA if < 65y and no fragility # Reassure if t > 0 Repeat DEXA if -1.5 < t < 0 Bone protection if t < -1.5
125
Management of osteoporosis
Alendronate 1st line Second line alternative bisphosphonates 3rd line strontium ranelate or raloxifene
126
How does raloxifene work?
Selective oestrogen receptor modulator Reduces risk of vertebral fractures
127
Raloxifene adverse effects
May worsen menopausal symptoms Increased risk VTE
128
How does strontium ranelate work?
Increases differentiation from pre-osteoblasts to osteoblasts Inhibits osteoclasts
129
Strontium ranelate adverse effects
Cardiovascular events VTE Skin reactions eg sjs
130
How does Teriparatide work?
Recombinant PTH Increases bone density
131
How does Paget's disease present?
95% are asymptomatic Bone pain (pelvis, lumbar, femur) Bowing of tibia, bossing of skull
132
Paget's disease blood results
ALP raised Normal calcium and po4
133
Markers of bone turnover
PINP- pro collagen type 1 n terminal propeptide CTx- serum c telopeptide NTx- urinary N telopeptide Urinary hydroxyproline
134
Complications of pagets
Osteosarcoma Fractures Deafness Skull thickening High output cardiac failure
135
What condition is polyarteritis nodosum associated with?
Hep B
136
Features of polyarteritis nodosa?
Fever, malaise, arthralgia Weight loss HTN Mononeuritis multiplex Sensorimotor polyneuropathy Testicular pain Livedo reticularis Haematuria, renal failure 20% ANCA
137
Polymyalgia rheumatica investigations
ESR > 40 EMG and CK normal
138
Polymyositis is mediated by what type of cells?
T cells
139
Polymyositis is associated with what condition?
Malignancy
140
Polymyositis features
Proximal weakness and tenderness Raynaud's Resp muscle weakness ILD Dysphagia, dysphonia
141
Polymyositis investigations
raised CK, LSH, AST, ALT EMG muscle biopsy Anti Jo seen with lung involvement, Raynaud's, fever
142
Management of polymyositis
Corticosteroids Azathioprine as steroid sparing agent
143
Pseudogout risk factors
> 60y Haemochromatosis Hyperparathyroidism Low mg, po4 Acromegaly Wilsons
144
Pseudogout XR
Chondrocalcinosis
145
Pseudoxanthoma elasticum genetics
Usually autosomal recessive
146
Features of pseudoxanthoma elasticum
Retinal angioid streaks Plucked chicken skin appearance Mitral prolapse Increased risk IHD GI haemorrhage
147
Patterns of psoriatic arthritis
Symmetric polyarthritis Asymmetrical oligoarthritis Sacroiliitis DIP joint disease Arthritis mutilans
148
Psoriatic arthritis treatment
NSAIDS for mild disease MTX ustrkinumab, secukinumab Apremilast PDE4 inhibitor
149
Secondary causes of Raynaud's phenomenon
Scleroderma, RA, SLE Leukaemia Type 1 cryoglobulinemia Cold agglutinins Vibrating tools OCP, ergot Cervical rib
150
Raynaud's treatment
Refer if suspecting secondary Raynaud's Nifedipine IV prostacyclin espoprostenol
151
Organisms that cause reactive arthritis
Shigella flexneri Salmonella typhi/enteridis Yersinia enterocolitia Campylobacter Chlamydia trachomatis
152
Features of relapsing polychondritis
Auricular chondritis, hearing loss, vertigo Nasal chondritis, saddle nose Resp tract, hoarse voice, aphonia, wheeze, inspiratory stridor Episcleritis, scleritis, iritis, keratoconjunctivitis sicca Arthralgia Vascular regurgitation, CN palsies, peripheral neuropathies, renal dysfunction
153
Relapsing polychondritis treatment
Steroids to induce remission Azathioprine MTX Cyclosporine Cyclophosphamide
154
Felty syndrome
Rheumatoid arthritis+ splenomegaly + low WCC
155
Sulfasalazine side effects
Rashes Oligospermia Heinz body anaemia Interstitial lung disease
156
Hydroxychloroquine side effects
Retinopathy Corneal deposits
157
What drug can cause cataracts?
Prednisolone
158
Gold side effects
Proteinuria
159
Penicillamine side effects
Proteinuria Exacerbation of myasthenia gravis
160
Etanercerpt side effects
Demyelination TB reactication
161
What drugs can cause reactivation of TB?
Etanercerpt Infliximab Adalimumab
162
Rituximab side effects
Infusion reactions
163
How does rheumatoid factor act?
Usually IgM Reacts with Fc portion of IgG
164
How can RF be detected?
Rose Waaler test (sheep red cell agglutination) Latex agglutination (less specific)
165
Conditions associated with positive RF
RA Feltys Sjogrens Infective endocarditis SLE systemic sclerosis
166
RA initial management
DMARD and bridging prednisolone
167
When do you give a TNF inhibitor for RA?
Insufficient response to 2 DMARDs including MTX
168
How does entacerpt work?
Recombinant human protein Acts as decoy receptor for TNFalpha
169
How does infliximab work?
Monoclonal antibody Binds to TNF alpha Prevents it from binding with TNF receptors
170
What route of administration is entacerpt given?
SC
171
What route of administration is infliximab given?
IV
172
What route of administration is adalimumab given?
SC
173
How does rituximab work and how is it given?
CD 20 monoclonal ab B cell depletion Two 1g IV infusions 2 weeks apart
174
How does abtacept work?
Modulates signal required for T cell activation Decreased T cell proliferation and cytokine production
175
What RA drugs are safe in pregnancy?
Sulfasalazine Hydroxychloroquine Low dose steroids NSAIDS up to 32weeks
176
What rotator cuff muscle adducts arm?
Teres minor and subscapularis
177
What rotator cuff muscle rotates arm laterally?
Infraspinatus Teres minor
178
What rotator cuff rotates arm medially?
Subscapularis
179
Sjogrens is associated with an increased risk of what?
Lymphoid malignancy
180
Investigating sjogrens
RF 50% ANA 70% Anti Ro 70% Anti La 30% Schirmers test (tears) Histo (lymphocytic infiltration) Hypergammaglobulinaemia Low C4
181
Features of stills disease
Arthralgia High ferritin Salmon pink maculopapular rash Pyrexia (afternoon/evening) Lymphadenopathy
182
Stills disease RF and ANA
Negative
183
When is sulfasalazine contraindicated?
G6PD deficiency Aspirin/sulfonamide allergy
184
What type of hypersensitivity is involved in SLE?
Type 3
185
SLE is associated with what markers?
HLA B8 HLA DR2 HLA DR3 ANA positive Anti dsDSNA Anti Smith Anti U1, Ro, La
186
Complement levels in SLE active disease
C3, C4 low
187
Neonatal SLE complications
Congenital heart block
188
Anti centromere antibodies
Limited cutaneous systemic sclerosis
189
CREST syndrome
Calcinosis Raynaud's oEsophageal dysmotility Sclerodactyly Telangiectasia
190
Anti Scl 70
Diffuse cutaneous systemic sclerosis
191
What does tumour necrosis factor do?
Activates macrophages and neutrophils Acts as costimulator for t cell activation Mediates response to gram negative septicaemia Anti tumour effect Phospholipase activation
192
TNF binds to what?
P55 and p75 receptors to induce apoptosis
193
Systemic effects of TNF
Pyrexia Increased acute phase proteins Disordered metabolism, cachexia
194
Examples of TNF inhibitors
Infliximab Etanercerpt Adalimumab Golimumab
195
How does rheumatoid factor work?
IgM against Fc of IgG
196
What antibody does pANCA target?
MPO
197
Drug induced lupus antibodies
ANA positive dsDNA negative Antihistone usually positive
198
SLE antibodies associated with congenital heart block
Anti Ro
199
Types of collagen and disorders
1: osteogenesis imperfecta 2: achondroplasia 3: ehlers danlos 4: alports, antiGBM 5: ehlers danlos
200
Dermatomyositis antibodies
80% are ANA positive Anti mi2

Rheumatology (2 decks)

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