Rheum Flashcards

Question

What is the aetiology of SLE and what are commonly associated diseases

Answer 1

B cell secretion of autoantibodies to variety of antigens creating immune complexes that deposit in a range of sites associated with sjogrens, autoimmune thyroid disease, antiphospholipid syndrome (- anticardiolipid and lupus anticoagulant antibodies cause clots. Coagulation defect, livedo reticularis, recurrent miscarriages, thrombocytopenia)

Answer 2

General – malaise, weight loss, fever - MSK – arthralgia/arthritis, myalgia/myositis - Derm – rash, alopecia, oral and nasal ulcers - Neuro – delirium, dementia, convulsions, loss of vision, stroke, headache, MS symptoms, anxiety, depression - Renal – haematuria, oedema, high BP - Resp – dyspnea and pleuritic chest pain - Cardio – pericarditis, myocarditis, murmers, angina (premature coronary artery disease) - Haem – lymphadenopathy, anaemia, thrombophlebitis - GI – nausea, vomiting, pseudo obstruction - Antiphospholipid – recurrent miscarriage, DVT/PE - Sjogrens symptoms – dry eyes, mouth, enlarged parotid Drug History - procainamide, hydrasalazine, minocycline can induce

Answer 3

Bloods - anaemia : chronic disease or may be haemolytic (high retics and bili, low haptoglobins, coombs + and high LDH if immune - high ESR, normal CRP - platelets, white cells low - prolonged APTT not corrected by addition of normal plasma Immunological - ANA (sens/not spec) - AntidsDNA and Anti-SM -low C3 and C4 Other renal biopsy - glomerulonephritis

Answer 4

Acute flare - prednisone - IV cyclophosphamide (life threatening flare) Maintenance - NSAIDS + hydroxychloroquine for joint and skin - steroids for lungs, CNS, heart and haem involvement - tapering of steroids with other DMARDS - MTX, mycophenolate or azathioprine - warfarin for hypercoagulability if previous DVT/PE - Belimumab or Rituxamab for severe Treatment of lupus nephritis - steroids + cyclophosphamide, mycophenolate and rituxamab for glomerulonephritis (needs renal r/v) - Control BP with ACEi or CCB Cutaneous symptoms - topical steroids - sunscreen/ avoiding sun Treatment of APS - aspirin or warfarin

Answer 5

RISK FACTORS/TRIGGERS - Recent strep infection - Stress - Skin trauma - Drugs (lithium, NSAIDS, B blockers) - Alcohol, smoking - Obesity - Family history (HLA associations) ASsociated with - Inflammatory arthritis (30% of psoriasis patients develop psoriatic arthritis) - Inflammatory bowel disease - Uveitis - Coeliac Disease - Metabolic Syndrome

Answer 6

Non-Pharmacological - Education – control not cure is the aim - Encourage a support group - Remove triggers Pharmacological - Mild o Daivobet Cream (Vit D analogue calcipotriol + betamethasone) o Emollients o Tar preparations o Salicylic Acid - Moderate/Severe o Warrants treatment with systemic agent and/or phototherapy o Methotrexate, ciclosporin, acitretin o Narrowband UVB, broadband UVB, photochemotherapy (PUVA) o Consider biologic drugs e.g. etanercept if no improvement with non-biologics + PUVA - Psoriatic Arthropathy o Etanercept, infliximab or methotrexate

Answer 7

scleroderma: autoimmune skin fibrosis from over production of collagen Systemic sclerosis = scleroderma + vascular disease - can be limited cutaneous (to face and extremities) or diffuse cutaneous (also affect whole organs CREST - calcinosis, raynauds phenomena, oesophageal dysmotility, sclerodactyly

Answer 8

Risk factors - fam hx, silica dust exposure Hand Exam Skin - bilateral skin thickening extending to MCP joints, - symmetrical thickening of fingers, puffy, sclerodactyly - prayer signs -pigmentation finger tip ulcers, pitting scars telangectasia abn nailfold capillaries - carpal tunnel secondary to flexion contracture - calcinosis on extensor surface - raynauds Other - GORD - interstitial lung disease - pul htn

Answer 9

Bloods - FBC o Anaemia o Reactive thrombocytosis o Hemolysis - Renal function (Cr) - ANA/ENA o ANA+ (nucleolar pattern) o RF+ (30%) o Anti-centromere Ab (75%) - LcSSc o Anti-topoisomerase (scl70) + (40%) – DcSSc o Anti-RNA poly+ (20%) – dcSSc o Anti-Ro +/- o ESR N/raised Echo - PA pressure and RH enlarged Lung FTs - Initial evaluation. Low lung diffusion capacity suggests PAH, decr FVC precede ILD Monitoring - FBC, Renal function, ECHO, PFTs

Answer 10

Lifestyle - Smoking cessation, reg exercise/PT - splints decr ROM and CTS Immunosuppression - MTX/ hydroxychloroquine (arthritis/myositis) - Mycophenolate (lung involvement) - cyclophosphamide Digital ischaemia - iloprost or sildenafil Analgesia - paracetamol, nsaids Raynaud - analgesia - nifedipine, amlodipine fluoxetine topical nitrate sildenafil Dysphagia - supportive, dilitation, PPI if GORD Calcinosis - NSAIDS, excision Inflam arthritis - hydroxychloroquine, mtx, - prednisone <5mg daily otherwise renal crisis in pt with diffuse scleroderma rnp 3. Acute renal crisis ( new onset hypertension, raised Cr, intravascular haemolysis).

Answer 11

- Fatigue, sleep disturbance - Keratoconjunctivitis sicca >3m - Xerostoma, (altered swallow/taste) - Vasculitis (skin rash) - Dental carries, incr oral infections - arthralgia, myalgia - Interstitial kidney disease (RTA) - corneal ulceration, no saliva pool - trigeminal neuralgia - peripheral neuropathy (sensory) - VTE Hx (incr risk)

Answer 12

Dry Eyes – optometry review - Meds o artificial tears o ciclosporin ophthalmic drops BD o Cholinergic pilocarpine 5mg TDS  CI: resp disease, HTN - spectacle eye shield, humidifiers - Punctal plugging Dry Mouth – dental review - gels, lozenges, gum, mouthwash - Pilocarpine - Lip balm MSK Sx - Paracetamol, NSAIDs - Prednisone 15mg daily for 2/52 - Hydroxychloroquine, methotrexate Vasculitis - prednisone 1mg/kg OD or - IV Ig 0/4mg/kg/day IV 5days RTA - Kt repletion, alkali

Answer 13

Schirmer’s test - <5mm wet in 5mins Bloods - RF+ close to 100% - ANA+ (70%) - anti-RO (SSA), anti-La (SSB) Urine - deranged P, K, Ca, Salometery - decrd /Salivary gland Bx Lisamine green test, fluorescein Criteria for diagnosis - Clinical diagnosis – no clear criteria - Objective findings of ocular or oral dryness or of glandular parenchymal damage - Serologic or histopathologic evidence of autoimmunity

Answer 14

Proximal muscle weakness - Gottren’s papules (pathognomic); Violaceous fat-topped plaques on dorsal knuckles/wrists/knees/elbows/malleoli - Heliotrope rash: dusky-red rash periorbital, symmetrical - Macular violaceous rash: o Gottren’s sign o Shawl sign: neck, shoulders o V sign: neck, chest o Holsters sign: lateral thigh o Linear extensor erythemas o Facial rash, perioral sparing o Scalp rash - Finger tips: periungal erythema, nailfold capil dilatation, cuticle overgrowth - mechanic’s hands – hyperkeratosis - sub cute proximal symmetrical weakness - photosensitive, pruritis - poikiloderma vascular atrophicans - fatigue, malaise, minor weight loss - Sob (2 to weakness)

Answer 15

INVESTIGATIONS Bloods - raised serum CK (more with polymyositis), LDH, aldolase - ANA+, anti-Jo+, anti-Mi2 (ILD, acute) EMG - abnormal spontaneous activity, abnormal voluntary movements Muscle Bx - perivascular or interfascicular inflam, endo hyperplasia Imaging - MRI: muscle oedema, fibrosis, calcification - CXR: interstitial changes - echo/ECG: arrhythmias, conduction defects

Answer 16

May need to screen for malignancy Severe/acute flare - IV prednisone 1g OD - IV Ig Derm manifestations - Conservative o moisturiser o sunscreen o exercise – PT o healthy diet - Meds o topical Urea o topical doxepin o topical tacrolimus o oral prednisone o DMARDs

Answer 17

COMPLICATIONS Steroid toxicity Respiratory infection, ILD Cardiac disease dysphagia MONITORING - Specialist r/v of muscle strength and markers of severity - regular assessment for development for pulmonary and cardiac involvement

Answer 18

Presentation - rapid onset severe pain (w/I 1hr) - morning stiffness - monoarticular or oligo - 50% 1st MTP (podagra) - red, hot, swollen, tender - tophi: elbows, knees, Achilles Ix Arthrocentesis - raised WBC - negative bifringent needle crystals Bloods - raised WBC, +/- raised serum Urate Xray - periarticular erosions, Normal joint space, ST swelling Dx Monosodium urate crystals in joint fluid/tophus - Plus >6 of; o >1 attack acute arthritis o developed w/I day o monoarthritis, redness observed o 1st MTP painful/swollen o tophus o hyperuricaemia o unilateral 1st MTP or tarsal joint o abnormal swelling on x-ray o subcortical cyst w/o erosion

Answer 19

Acute Attack - Naproxen 500mg PO BD 10-14d or Celecoxib 100-200mg PO BD or prednisone 1mg/kg stat (*renal) or colchicine 1.2 PO, then 0.6mg (*GI bleed) - Steroid injection of affected joint can be very effective. Prophylaxis - Allopurinol starting dose 1.5mg x eGFR, max 100mg o SE: decr WBC, rash, fever o Don’t stop during flare o May trigger attack initially, cover w NSAID or colchicine - Probenecid - Febuxostat Lifestyle - Lose weight, if overweight/ avoid fasting/alcohol excess/ /low dose aspirin.

Answer 20

Presentation - Subacute onset (<2/52) - Bilateral ache, tenderness, morning stiffness (>1hr) - Shoulder girdle (~80%); Pelvic (~60%) - Tenosynovitis, CTS - Low-grade fever, fatigue, anorexia, depress - Response to steroids - Think about rheumatoid arthritis if there is significant peripheral joint involvement. Approx. 10% of RA presents initially like PMR. Investigation Bloods - CRP, ESR >40 (emerging IL-6) - FBC, Serum electrophoresis (r/o myelo) - TSH, CK normal

Answer 21

MANAGEMENT Meds - Prednisone 15mg PO OD (taper to 10mg over 4-6wks, then 1by 1mg/month) - Cholecalciferol 1.25mg monthly Alendronate 70mg PO weekly – if BMD low - Omeprazole 20mg PO OD - Methotrexate – ask advice Advice - Warn pt. of GCA Sx – seek advice MONITORING - monthly for 3m; exam, Hx, ? ESR. If methotrexate do bloods.

Answer 22

PRESENTATION - New Headache - Scalp tenderness - Jaw claudication - visual loss- painless, uni-/bilateral, amaurosis fugax (disc pallor, oedema) - temporal artery thickening/nodule/tender - upper extremity claudication - Other CN abnormalities INVESTIGATIONS Bloods - ESR >50, CRP raised - FBC: o normocytic, normochromic anemia o raised plts o mild WBC raise, ALP rise Biopsy - Temporal artery, w/I 7 days starting steroid (beware skip lesions) Imaging - Thickening of temporal artery

Answer 23

CRITERIA 3/5; age >50, new HA, ESR >50, temporal artery abnormality, abnormal Bx MANAGEMENT - If suspected – do ESR and start o Prednisone 1mg/kg PO OD 4weeks  Taper over 6-12m  w Sx /ESR improvement o IV Prednisolone if visual/neuro Sx  1g 3 days - If confirmed – aspirin 75mg OD - Consider bone protection (vit D, BP) MONITORING - for steroid SE: BP, DM, bones - FBC - incr. risk abdo aneurysms (? USS, echo, CXR)

Answer 24

Fibromyalgia is a condition characterized by chronic widespread pain and fatigue. Commonly associated with depression, anxiety, and PTSD Part of same diffuse group of diseases as chronic fatigue syndrome, however more orientated around the pain. Many doctors consider them to be the same disease. Essentially a functional diagnosis. Investigations are ALL normal. Scoring systems for how many painful joints are present are used for diagnosis. Must be chronic and widespread. Important to rule out other pathological causes of pain. RISK FACTORS FMHx, rheumatological conditions, 20-60y, F

Answer 25

PRESENTATION - Chronic, diffuse pain diffuse tenderness o/e - fatigue unrelieved by rest - sleep & mood disturbance (d, A) - cognitive dysfunction - HA – axial, extend to neck, shoulders - numbness, tingly – variable nature - stiffness, swelling feeling - fluid retention (not observed) - incr sensitivity to sensory stimuli Investigations Clinical - Chronic, widespread pain in muscles & joints - Fatigue, wakening unrefreshed, cognitive sx - >11/18 tender points - lower neck in front. edge of upper breast, below side bone of elbow. inside of knee, hip bone, upper outer buttock. upper inner shoulder, neck and shoulder, base of skull Bloods - ESR, TFT, FBC, RF, anti-CCP, vit D NORMAL - ANA – sometimes positive

Answer 26

MANAGEMENT Education - Thorough explanation about nature of ‘disorder’ – relapsing-remitting (discuss with chronic pain service) - No simple cure - Reassurance no serious pathology, mindful of patient’s perspective of sx Medication - Nortriptyline 10mg nocte - gabapentin 300mg OD then titrate up - Pregabalin 75 PO BD - High dose Venlafaxine Psychology - CBT Lifestyle - Exercise - Good sleep hygiene

Rheum Flashcards

Meds SE, RA, seronegative spondylo - ank spond, reactive, psoriatic,, SLE, psoriasis, systemic sclerosis, sjogrens, PMR, polymyosits/dermatomyositis, GCA, fibromyalgia (50 cards)