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Fifth Year Medicine > Rheum > Flashcards

Flashcards in Rheum Deck (80):
1

Causes of anterior uveitis?

(Multiple)

Ankylosing spondylitis (hla-b27)
Sarcoid/TB
Inflammatory bowel disease

Rheumatoid arthritis (tend to be scleritis moreso)
Reiter's
Herpes simplex / Herpes zoster (choroiditis) /STIs
MS

2

Characteristic xray features of osteoarthritis, rheumatoid arthritis and gout?

Osteoarthritis (LOSS)- loss of joint space, osteophytes, subarticular sclerosis, subchondral cysts

RA (SOLE)- soft tissue swelling, osteopenia, loss of joint space, erosions,

Gout- normal joint space, periarticular erosions, soft tissue swelling

3

Blood test IHx for back pain?

FBC, ESR, CRP (infection, myeloma, tumour)
ALP (Paget's)
Serum/urine electrophoresis (myeloma)
PSA (prostate mets)

MRI if red flag symptoms

4

How do you do the straight leg test and femoral stretch test, what are they looking for?

Staight leg: pain below knee on lifting a straight leg, especially if foot is dorsiflexed

Femoral: lay on front, knee bent and lift (extend) hip = pain on anterior thigh

Sciatic nerve stretch, can be lumbar disc prolapse

5

Which joints are affected in osteoarthritis compared to rheumatoid arthritis?

OA: DIP (Hebedon's nodes)
PIP (Bouchard's)
carpo-metocarpal joints + knees

RA: MCP + MTP
PIP
Wrist
~monoarthritis of large joints

6

Hand signs of rheumatoid arthritis?

Early: swollen MCP, PIP joints + tenosynovitis

Later: swan-necking, Boutonniére's
ulnar deviation, Z-deformity of thumbs
wrist subluxation

Nodules of elbows , Raynaud's, carpal tunnel

7

Specific antibody found in rheumatoid arthritis?

Anticyclic citrullinated peptide Abs
= ACPA / anti-CCP

8

What is a high titre of rheumatoid factor in rheumatoid arthritis associated with?

Severe disease
Erosions
Extra-articular disease

9

How is disease activity measured in rheumatoid arthritis?

DAS28 score- tenderness and swelling at 28 joints

MCPs, PIPs, wrists, elbows, shoulders, knees
+ ESR + patient's reported symptom severity

10

Name some disease modifying drugs (DMARDS)

Common: Methoxtrexate, sulfasalazine, hydroxychloroquine

Rarely: IM gold, leflunomide
penicilamine, azathioprine, ciclosporin

11

SE of DMARDs
Particularly methotrexate, sulfasalazine and hydroxychloroquine

Immunosuppression- pancytopenia, neutropenic sepsis

Methotrexate- pneumonitis, oral ulcers, hepatotoxicity
Sulfasalazine, low sperm count, rash, oral ulcers
Hydrochloroquine- irreversible retinopathy

12

When do you consider using biological agents in rheumatoid arthritis?

When there is a failure to respond to DMARDs after 6 months
AND
Patient has a DAS28 score of >5.1

13

For rheumatoid arthritis what is the biological agent ladder? Ie mechanism of different antibodies to be tried

Often taken with methotrexate:
1. TNF inhibitors (infliximab)
2. B cell depletion (rituximab)
3. IL-1 and IL-6 inhibition (toclizumab)
4. Disrupt T cell function (abatacept)

14

SEs of biological agents?

Infection- hepatitis B + TB reactivation (SCREEN)
Hypersensitivity
Neutrilizing antibodies
Reversible SLE-type illness

Worsened heart failure

15

What are the four diagnostic categories used in diagnosing rheumatoid arthritis?

Joint involvement (number of large and small)
Serology (RF and anti-CCP)
Acute phase reactants (CRP or ESR)
Duration of symptoms (6 weeks +)

Score 6/10 is diagnostic

16

Causes of monoarthritis?

Septic arthritis
Crystal arthritis (gout + pseudogout)
Osteoarthritis
Trauma- haemoarthritis

17

Causes of oligoarthritis (under 5 joints)

Crystal arthritis (gout, pseudogout)
Psoriatic arthritis
Reactive arthritis (yersinia, salmonella, campylobacter)
Ankylosing spondylitis
Osteoarthritis

18

Causes of symmetrical polyarthritis (5 + joints involved)

Rheumatoid arthritis
Osteoarthritis
Viruses- hepatitis A, B + C, mumps

Connective tissue disease, Behcet's,
leukaemia, sickle cell, Familial mediterranean fever
endocarditis, sarcoid,
haemochromatosis,

19

What is Familial Mediterranean fever?
Rx?

Gene defect 16p
Recurrent peritonitis + pleurisy
Fevers + Abdo pain + arthritis

Rx: colchicine

20

Causes of asymmetrical polyarthritis (5+ joints involved)

Reactive arthritis (yersinia, salmonella, campylobacter)
Psoriatic arthritis

21

What are the different types of crystal deposited in gout and pseudogout?

Gout- monosodium urate
PSeudogout- calcium pyrophosphate

22

What are the different factors that may contribute to gout or pseudogout?

Gout: dietary purines, alcohol excess,
diuretics, cytotoxics + leukaemia (tumour lysis)

Pseudogout: as it's calcium pyrophosphate
age
hyperparathyroidism
haemochromatosis
hypophosphataemia

23

How do IHx differentiate between gout and pseudogout

Polarized light microscopy of synovial fluid:
Gout- Needle-shaped Negatively birefringent urate crystals
Pseudogout- Positively birefringent rhomboid crystals

Xray: soft tissue swellings
Gout- erosions, joint space intact
Pseudogout- calcium deposits

24

When should you start prophylaxis for gout?
What is it?

>1 attack in a year
Renal stones (urate)
Tophi (deposits in pinna, joints)

Allopurinol until urate id

25

How long after an acute attack of gout should you wait before starting allopurinol prophylaxis (if indicated)?

3 weeks (as can precipitate an another acute attack)
If on allopurinol already and there's an acute attack, don't stop allopurinol

26

Rx for acute attack of gout or pseudogout?

NSAIDs
± colchicine

27

What does seronegative mean in arthritides? Which are included in this category?

Rheumatoid factor -ve

Ank Spond, Enteric arthropathy (IBD), Psoriatic arthritis, Reactive arthritis (after GI or GU problem)

Often HLA-B27 +ve, involving the spine

28

Enthesitis- inflammation of tendon insertion site is often a problem for which tendons in those with ankylosing spondylitis?

Achilles tendonitis
Plantar fasciitis
Tibial + ischial tuberosities
Iliac crests

29

Xray of a spine shows 'bamboo spine', what is this characteristic of?

Ankylosing spondylitis

Calcification of spinal ligaments due to ongoing inflammation of them

30

'Pencil in cup' Xray findings of distal interphalangeal joints is characteristic of...?

Severe psoriatic arthritis

31

Which infections may be implicated in reactive arthritis?

Following urethritis- chlamydia, ureaplasma sp.

Or dysentery- campylobacter, salmonella, shigella, yersinia

32

Urethritis, arthritis + conjunctivitis (with raised ESR + CRP)

What have you got?

Reiter's syndrome

Check for GU infections (STI screen)
Or GI infections (Stool culture, serology)

33

Features of limited systemic sclerosis (CREST)?

Calcinosis (subcutaneous tissue)
Raynauds
oEsophageal + gut dismotility
Sclerodactyly (swollen, tight digits)
Telangiectasia

34

What is the difference between limited and diffuse cutaneous systemic sclerosis?

Limited- skin involvement is hands, feet and face
Anticentromere antibodies in 70-80%

Diffuse- whole body can be sclerosed, early organ sclerosis
Anti-topisomerase1 (Scl70) antibodies in 40%, anti-RNA polymerase in 20%

35

What skin signs may arise in dermatomyositis?

Alongside striated muscle inflammation + symmetrical proximal muscle weakness:

Heliotrope rash- purple rash on eyelids with oedema
Macular rash- shawl sign over back + shoulders
Nailfold erythema
Gottron's papules- roughened red papules over knuckles
Subcutaneous calcifications

36

Patient has roughened red papules over the knuckles and knee's (known as...?) with proximal muscle weakness and a raised creatinine kinase.
Diagnosis?

Dermatomyositis
= Gottron's papules

37

IHx for suspected dermatomyositis?

Definitive: muscle biopsy

Bloods: muscle enzymes in plasma (ALT, AST, CK, LDH)
Anti-Mi2, anti-Jo1 (= aggressive)
Electromyography = fibrillation potentials


38

Anti-double stranded DNA is specific for...?

Anti-dsDNA- SLE

(Don't Say it's SLE or i Do Not Attend, easy)

39

Suspect a patient has drug-induced SLE, what antibody would you look for?
Which common drugs cause it?

Anti-histone Ab

Isoniazid
Hydralazine (vasodilator)
Phenytoin

(HISs at the Dr for starting meds)

40

Which antibody tests may be +ve in Sjögren's syndrome?

Rheumatoid factor
Anti-nuclear Ab
Anti-Ro
Anti-La

Noclear Rheum to ROw on a LAke of tears (due to dry eye)

41

Antimitochondrial Abs are associated with...?

Primary biliary cirrhosis (95%)
Autoimmune hepatitis (30%)
Idiopathic cirrhosis (30%)

(liver needs lots of energy to do its shiz, needs mitochondria to run SMOOTH muscle Ab)

42

Which autoantibodies are associated with primary biliary cirrhosis, autoimmune hepatitis and idiopathic cirrhosis?

Anti-mitochondrial Ab
Anti-smooth muscle Ab

(liver needs lots of energy to do its shiz, needs mitochondria to run SMOOTH)

43

What autoantibody is associated with pernicious anaemia?
What other condition is it associated with?

Gastric parietal cell Ab 90%
Intrinsic factor 50%

Gastric parietal Abs may cause atrophic gastritis (autoimmune form, can also be caused by H Pylori)

44

Antibodies associated with coeliac disease?

IgA anti-tissue transGLUTaminase antibody

(the one that sounds like GLUTen)

IgA anti-endomysial antibody
a-gliadin Ab

45

Antibodies to check if suspect dermatomyositis or polymyositis?

you JOking MI??

Anti-jo1
Anti-Mi2

46

Autoantibodies associated with diabetes mellitus type 1?

Islet cell Ab
Glutamic acid decarboxylase Ab

(Oh GAD! D for diabetes)

47

Patient has autoantibodies against glomerular basement membrane? What have they got?

Goodpasture's syndrome

48

Which conditions are +ve for c-ANCA vs p-ANCA?

C the GP?

PCP?

C-ANCA:
Granulomatosis with polyangitis (wegeners)
Polyangiitis (microscopic)
Polyarteritis nodosa

P-ANCA:
Polyangiitis (microscopic)
Churg-Strauss
Pulmonary-renal vasculitidies

49

Autoantibody found in myaesthenia gravis?

Acetylcholine receptor Ab (on muscle)

50

Name the syndromes associated with autoantibodies against membrane channels?

Anti-voltage gated K+ channel = Limbic encephalitis

Anti-voltage gated Na+ channel = Lambert Eaton syndrome

Anti-aquaporin 4 = Neuromyelitis optica (Devic's)

51

What is the pathology of SLE?

Polyclonal B-cell secretion of autoantibodies
= tissue damage from

Immune complex formation + deposition
Complement activation

52

Autoantibodies associated with SLE?

Anti-dsDNA (specific)
Antinuclear (homogenous especially) = ANA
Rheumatoid factor
Anti-phospholipid, (cardiolipin or lupus anticoagulant)

Anti-extractable nuclear = ENA: Ro, La, Sm, RNP

(Same as sjogrens, Noclear Rheum to Row on Lake)

53

How can you monitor activity of SLE?

1. Anti-dsDNA titres
2. C3 + C4 drop (complement)
or C3d + C3d rise
3. ESR

54

Multisystem disorder with raised ESR and normal CRP, what should you think of?

Systemic lupus erythematosus

55

What features occur in acute SLE?

Rx?

Where inflammation of such things is very bad:
Pericarditis- heart
Nephritis- renal
Haemolytic anaemia
CNS- seizures, psychosis

Rx- urgent IV cyclophosphamide + prednisolone

56

What does antiphospholipid syndrome cause?

(CLOTs)

Coagulation defects
Livedo reticularis (blue-pink skin mottling in skin)
Obstetric (miscarriage)- Rx aspirin
Thrombocytopenia (low platelets)

57

Diagnostic criteria of SLE

5 Tissue linings (skin, mucosa, pleura)
3 blood
2 organs
1 bone

*Malar rash (flat/raised erythema)
*Discoid rash (raised patches with scales > atrophic scars)
*Photosensitivity
*Oral/nasal ulcers
*Serositis- pleuritis, pericarditis

*Haem- low plts, lymphocytes or Hb from haemolytic anaemia
*Immunology- dsDNA, Sm, phospholipid
*Antinuclear Ab- 95%

*CNS- psychosis, seizures
*Renal- proteinuria alot or RBC/granular cell casts

*Bone- non-erosive arthritis of 2+ joints

58

60 year old lady comes in with 2 weeks of morning stiffness and tenderness of the shoulders and thighs with mild aching of the joints. She has felt fatigued and lost appetite.

Creatinine kinase is normal, CRP is raised
Diagnosis and differential?

Polymyalgia rheumatica

D: myositis or myopathy (but CK is normal)
Recent onset rheumatoid arthritis, osteoarthritis of shoulder
Hypothyroidism, occult malignancy/infection
Spinal stenosis, bilateral tendon impigement

59

Rx of polymyalgia rheumatica?

15mg Prednisolone

60

What should be excluded in patients with fatigue or chronic pain before diagnosing fibromyalgia?

Rheumatoid arthritis, polymyalgia rheumatica (CRP up)
Vasculitis (ESR up)
Hypothyroidism, multiple myeloma (Ca, T3, TSH, ALk Phos)

61

What analgesia do you offer for fibromyalgia?

Low dose tricyclic antidepressants (amitriptyline, pregabalin)

Shouldn't respond to NSAIDs (if it does, then reconsider diagnosis)

62

Rheum causes of anterior uveitis, conjunctivitis, episcleritis scleritis

Ant uveitis: Ank spond + Reiter's
Conjunctivitis: Reiters (urethritis, conjunctivitis, arthritis)
Episcleritis: SLE, PAN, rheumatic fever, RA
Scleritis: vasculitis, RA

63

Conditions associated with keratoconjunctivitis sicca?

Sjögrens (duh)
Rheumatoid arthritis
SLE
Sarcoid

64

What are the symptoms and signs of accelerated (malignant) hypertension?

Symptoms: headache ± visual disturbance
BP >200 systolic or >130 diastolic

Eye: hard exudates + macular oedema (from leaks from arterioles)
FLAME HAEMORRHAGES
Papilloedema

65

Associations of erythema nodosum (painful blue red raised lesions on shins)

Common:
I Strepped Sar and AwIDE- now I have shin splints- Dapsome Pill on it?

Strep, Sarcoid, Sulfonamides, Dapsone, The Pill

Yessir, I Lept, Myback Cgrohns
(Yersinia, leptospirosis, Mycobacterium, Crohns/UC)

66

40 year old woman has pain on moving the thumb and tenderness over the 1st extensor compartment. What test could confirm the most likely diagnosis?

Finkelstein's: grip thumb in palm

De Quervain's tenosynovitis

67

What is the mechanism by which allopurinol and azathioprine interact?

Azathioprine becomes mercaptopurine,
which is metabolised by thiopurine methyltransferase (some patients are deficient)

Or xanthine oxidase (inhibited by allopurinol)

68

Worst SEs of DMARDs given in RA?

Methotrexate: pancytopenia (FBC), pneumonitis, hepatotoxicity
Sulfasalazine: rash
Hydroxychloroquine: irreversible retinopathy (ophthal review)

69

When can biological agents be initiated for RA?

After 6 months of 2 DMARDs and a Das28 score > 5.1

70

SE of biological immune agents?

Reactivation of TB and Hepatitis B
Hypersensitivity
Heart failure worsening
SLE-like illness (reversible)

71

Most sensitive imaging to look for ankylosing spondylosis?

Clinical diagnosis but
MRI-
sacroilitis, irregularities, erosions, sclerosis, vertebral syndesmophytes

72

Which disease do 'pencil in cup' changes occur on xray?

Psoriatic arthritis

73

What valve abnormality is associated with spondyloarthropathies (ank spond, reactive arthritis etc)

Aortic valve incompetence

All tend to be RF -ve, HLA B27, spinal etc

74

What respiratory complication should be checked for in limited cutaneous systemic sclerosis?

Pulmonary hypertension- can become life threatening

In diffuse cutaneous systemic sclerosis, lung fibrosis is the problem

75

Rx for acute SLE flare?

IV cyclophosphamide
High dose prednisolone

(I'm so pred up with all this cycles- I want to SLEep)

76

What are the features of an acute SLE attack?

Lungs- severe pericarditis
Kidneys- nephritis
Blood- haemolytic anaemia
CNS disease- seizures or psychosis

Rx: high dose pred + cyclophosphamide (i'm so pred up with these cycles, I want to SLEep)

77

SLE Rx for:
Joint and skin disease
Kidney disease?

Joint + skin: NSAIDs + hydroxychloroquine ± low dose steroids

Nephritis: Steroids + cyclophosphamide

78

How does the size of the blood vessel affected in vasculitis determine the Rx?

Large vessel (Takayasu's, GCA)- steroids
Medium (PAN + kawasaki) or small (Wegener's, Henoch Schonlein etc) - steroids + IV cyclophosphamide

79

Medical therapies that can be tried in fibromyalgia?

11/18 tender pain points ± fatigue, morning stiffness

CBT, graded exercise
Low dose TCAs (amitriptyline) ± tramadol

80

Which type of cancer is associated with thrombophlebitis migrans?

Pancreatic cancer- crops of tender nodules along blood vessels throughout the body