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Fifth Year Medicine > Rheum > Flashcards

Rheum Flashcards

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1
Q

Causes of anterior uveitis?

Multiple

A

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

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2
Q

Characteristic xray features of osteoarthritis, rheumatoid arthritis and gout?

A

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

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3
Q

Blood test IHx for back pain?

A

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

MRI if red flag symptoms

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4
Q

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

A

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

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5
Q

Which joints are affected in osteoarthritis compared to rheumatoid arthritis?

A

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

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

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6
Q

Hand signs of rheumatoid arthritis?

A

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

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7
Q

Specific antibody found in rheumatoid arthritis?

A

Anticyclic citrullinated peptide Abs

= ACPA / anti-CCP

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8
Q

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

A

Severe disease
Erosions
Extra-articular disease

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9
Q

How is disease activity measured in rheumatoid arthritis?

A

DAS28 score- tenderness and swelling at 28 joints

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

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10
Q

Name some disease modifying drugs (DMARDS)

A

Common: Methoxtrexate, sulfasalazine, hydroxychloroquine

Rarely: IM gold, leflunomide
penicilamine, azathioprine, ciclosporin

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11
Q

SE of DMARDs

Particularly methotrexate, sulfasalazine and hydroxychloroquine

A

Immunosuppression- pancytopenia, neutropenic sepsis

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

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12
Q

When do you consider using biological agents in rheumatoid arthritis?

A

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

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13
Q

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

A

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)
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14
Q

SEs of biological agents?

A

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

Worsened heart failure

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15
Q

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

A

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

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16
Q

Causes of monoarthritis?

A

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

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17
Q

Causes of oligoarthritis (under 5 joints)

A 
Crystal arthritis (gout, pseudogout)
Psoriatic arthritis
Reactive arthritis (yersinia, salmonella, campylobacter)
Ankylosing spondylitis
Osteoarthritis
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18
Q

Causes of symmetrical polyarthritis (5 + joints involved)

A

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

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

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19
Q

What is Familial Mediterranean fever?

Rx?

A

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

Rx: colchicine

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20
Q

Causes of asymmetrical polyarthritis (5+ joints involved)

A 
Reactive arthritis (yersinia, salmonella, campylobacter)
Psoriatic arthritis
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21
Q

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

A

Gout- monosodium urate

PSeudogout- calcium pyrophosphate

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22
Q

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

A

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

Pseudogout: as it's calcium pyrophosphate
age
hyperparathyroidism
haemochromatosis
hypophosphataemia
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23
Q

How do IHx differentiate between gout and pseudogout

A

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

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24
Q

When should you start prophylaxis for gout?

What is it?

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

Allopurinol until urate id

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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

Fifth Year Medicine (32 decks)

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