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Rheum Flashcards

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1
Q

What is monoarthritis

A

1 joint involved

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2
Q

What is oligoarthritis

A

<= 5 joints affected

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3
Q

What is polyarthritis

A

> 5 joints affected

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4
Q

Give examples of monoarthritis

A

gout
septic
osteo

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5
Q

Give examples of oligoarthritis

A 
reactive
psoriatic
gout
osteo
ankylosing spondylitis
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6
Q

Give examples of polyarthritis

A

symmetrical:
RA
osteo

asymmetrical
reactive
psoriatic

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7
Q

What conditions is Raynaud’s present in

A

SLE
polumyositis
dermatomyositis

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8
Q

State some signs in the hands that are typical of RA

A 
Z deformity of thumb
ulnar deviation
swan neck deformity
boutonniere deformity
nail pitting
nail fold vasculitis
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9
Q

What is Z deformity of the thumb

A

MCP flexion

IP hyperextension

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10
Q

What is swan neck deformity

A

PIP hyperextension

DIP flexion

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11
Q

What is Boutonniere deformity

A

PIP flexion

DIP extension

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12
Q

What are the key investigations in suspected RA?

A

Bloods: FBC, CRP, ESR, U+E, LFT, RF, ANA, anti-cyclic citrullinated peptide antibodies
Imaging: XR hands and feet, CXR, US/MRI joints

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13
Q

What can happen to CRP and ESR in RA?

A

inflammatory markers, so raised

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14
Q

Does a raised RF diagnose RA?

A

no!

can be raised in other infam diseases and in healthy!

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15
Q

What can a raised ANA (antinuclear antibodies) suggest?

A

SLE
RA
healthy!

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16
Q

What are the systemc problems causes in RA

A

lympadenopathy
pulmonary fibrosis
peripheral nerve entrapment

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17
Q

What vaccines need to be given to those taking DMARDs?

A

influenza - annual
pneumococcal - 10y
live vaccines contraindicated

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18
Q

Does RF or anti-CCP antibodies have a greater specificity for RA?

A

anti-CCP antibodies

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19
Q

What factors indicate a poor prognosis for RA?

A 
rheumatoid factor positive
poor functional status at presentation
HLA DR4
X-ray: early erosions (e.g. after < 2 years)
extra articular features e.g. nodules
insidious onset
anti-CCP antibodies
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20
Q

What complications can methotrexate cause?

A

liver cirrhosis
pneumonitis
myelosupression

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21
Q

What complications can prednisolone cause?

A 
Cushingoid features
Osteoporosis
Impaired glucose tolerance
Hypertension
Cataracts
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22
Q

What monitoring needs to happen in methotrexate treatment

A

Monitoring of FBC & LFTs is essential due to the risk of myelosuppression and liver cirrhosis

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23
Q

How long does is take for DMARDs to produce a full response

A

2-6m

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24
Q

Why are DMARDs the best treatment for inflammatory arthritis

A

suppress disease progress
control the signs and symptoms
limit joint damage.

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25
What treatment should be initiated in newly diagnosed active rheumatoid arthritis,
combination of DMARDs (including methotrexate and at least one other DMARD) a short-term corticosteroid, within 3 months of the onset of persistent symptoms.
26
When should you consider changing DMARD for a patient?
If a disease-modifying anti-rheumatic drug does not lead to an objective benefit within 6 months, it should be replaced by a different one.
27
When can a TNF inhibitor be prescribed in RA
an inadequate response to at least two DMARDs including methotrexate
28
What type of hypersensitivity reaction is SLE?
type III
29
What are someof the risk factors for SLE?
afro-caribbean exposure to sunlight drugs: EBV
30
What are the key initial features of SLE?
``` fever rash mouth ulcers joint pain lympadenopathy ```
31
What are key immunological findings in SLE?
``` antinuclear antibody (ANA) ds-DNA antibody RF anti-Smith: anti-U1 RNP, SS-A (anti-Ro) and SS-B (anti-La) ```
32
Which immunological finding is most sensitive for SLE?
ANA (95%) ds-DNA (70%) anti-Smith 30%
33
Which immunological finding is most specific for SLE?
ds-DNA (90%) anti-Smith (90%) ANA
34
What systems are affected with symptoms of SLE?
``` skin serosa mucosa joints kidneys brain blood immune! ```
35
How does SLE affect the skin
malar rash - butterfly, does not affect nasolabial folds discoid rash photosensitivity
36
How does SLE affect the mucosa
ulcers in mouth, nose, vagina
37
Describe the discoid rash in SLE
in sun exposed areas scaly, erythematous, well demarcated rash Lesions may progress to become pigmented and hyperkeratotic before becoming atrophic
38
How does SLE affect the serosa
serositis! eg. pleuritis pericarditis
39
How does SLE affect the joints
arthralgia | non-erosive arthritis - >=2 peripheral joints
40
How does SLE affect the kidneys
proteinuria | glomeulonephritis
41
How does SLE affect the blood
anaemia (haemolytic) thrombocytopenia leukopaenia
42
How does SLE affect the brain
seizures psychosis anxiety and depression
43
How does SLE affect the immune system
ANA anti ds-DNA anti-Smith anti-phospholipid
44
What are the diagnostic criteria of SLE?
4 of the following present: ``` malar rash dicoid rash photosensitivity oral ulcers serositis proteinuria/glomerulonephritis joint problems CNS problems haematological problems immuniological probs (anti ds-DNA, anti-Smith) ANA ```
45
What tests can be used in monitoring SLE?
anti ds-DNA - complement levels - low C3/C4 in active disease due to formation of immune complexes ESR raised in flare up
46
Which drugs can cause SLE?
chlorpromazine, methyldopa, hydralazine, isoniazid, d-penicillamine
47
Describe the treatment of SLE if there is no major organ involvement
anitmalarials - hydroxychloroquine low dose steroids azathioprine/methotrexate
48
Describe the treatment of SLE if there is major organ involvement
cyclophosphamide mycophenylate mofetil calcineurin inhibitors eg. ciclosporin/tacrolimus
49
What diseases is there an increased risk of in SLE?
cardiovascular disease | osteoporosis
50
What is antiphospholipid syndrome?
antibodies affect coagulation leading to pro-thrombotic state
51
What problems are caused by antiphospholipid syndrome
CLOTS Coagulation defect Livedo reticularis Obstetric - miscarriage Thrombocytopenia
52
What is livedo reticularis
mottled reticulated vascular pattern that appears as a lace-like purplish discoloration of the skin. The discoloration is caused by swelling of the venules owing to obstruction of capillaries by small blood clots.
53
What joints does ankylosing spondylitis most commonly affect?
sacroiliac | spine
54
Which HLA is most commonly associated with ank spond?
HLA B27
55
Is ankylpsing spondylitis sero negative or positive?
sero negative
56
What is the typical presentation of ankylosing spondylitis
20/30y male gradual onset back pain and stiffness worse at night, improves with movement pain radiates to thighs and buttocks
57
Why is there a progressive loss of spinal movement in ank spond?
spinal fusion!
58
What are some features of ank spond on spinal examination?
``` reduced lateral flexion of lumbar spine reduced forward flexion Schober's test <5cm decreased thoracic expansion sacroilitis ``` neck hyperextension thoracic kyphosis question mark posture
59
What are some systemic symptoms of ank spond?
``` apical lung fibrosis, Acute iritis Aortic regurgitation Achilles tendonitis AV node block Amyloidosis and cauda equina syndrome onycholysis, fatigue, ```
60
What is Schober's test? What disease is it used to test in?
line is drawn 10 cm above and 5 cm below L5/the back dimples (dimples of Venus). The distance between the two lines should increase by more than 5 cm when the patient bends as far forward as possible Ankylosing spondylitis
61
What is the first feature of ankylosing spondylitis on xray?
sacroilitis - subchondral erosions, sclerosis
62
What are the later features of ank spond on xray?
squaring of lumbar vertebrae 'bamboo spine' (late & uncommon) syndesmophytes: apical fibrosis on CXR
63
What is the management of ank spond?
Exercise! physio - maintain posture and mobility NSAIDs for pain TNF alpha inhibitors in severe cases which failed to respond to NSAIDs
64
What can spirometry show in ankylosing spondylitis?
a restrictive defect due to a combination of pulmonary fibrosis, kyphosis and ankylosis of the costovertebral joints.
65
What are syndesmophytes?
calcification between corners of vertebrae due to ossification of outer fibers of annulus fibrosus
66
What are the signs of systemic sclerosis in the hands?
Swelling (non-pitting oedema) of fingers and toes Skin becomes hard and thickened - this may limit joint movement or cause joint contractures Swelling and sclerosis reduce hand movements, so patients may be unable to make a fist, or to place the palmar surfaces together - the 'prayer sign'. Fingertips may have pitting, ulcers or loss of bulk from finger pads. Raynaud's phenomenon.
67
What are the key pathophysiological features of systemic sclerosis?
excessive collagen deposition by fibroblasts | damages blood vessels
68
What are the first features of systemic sclerosis
skin thickening and hardening in hands or face Raynaud's oesophageal symptoms
69
What are the three kinds of systemic sclerosis?
limited diffuse scleroderma
70
Describe the features of limited systemic sclerosis
``` affects face, hands and feet CREST slow onset, slow progression affects internal organs anti-centromere antibodies ```
71
What does CREST stand for? What does this mean?
Calcinosis - calcium deposits in skin Raynaud's Esophageal dysmotility Sclerodactyly - tightening of skin in fingers Telangiectasia - dilation of capillaries in skin
72
Describe the features of diffuse systemic sclerosis
affects upper arm, trunk and thighs more rapid onset and progression scl-70 antibodies
73
Describe scleroderma
no multi organ involvement | localised thickening of areas of skin - plaques or linear
74
What are the facial features of systemic sclerosis
``` Tightening of facial skin. Tight lips (microstomia) ```
75
If systemic sclerosis is suspected, which antibodies should be tested for?
scl-70 anti-centromere Anti-RNA polymerase III
76
How is systemic sclerosis managed?
exercise/physio DMARDs: methotrexate, mycophenolate mofetil or cyclophosphamide monitor BP and renal function ACEi if renal failure
77
Which joints does psoriatic arthritis commonly affect
DIP symmetrical polyarthritis sacroilitis
78
What percentage of people with psoriasis develop arthropathy?
10%
79
What changes occur in the hands in psoriatic arthritis>
pitting onycholysis dactylitis - sausage fingers
80
How is psoriatic arthritis managed?
NSAIDs methotrexate or ciclosporin if skin disease alsoproblemaic resistant = anti-TNF local steroid injections to reduce joint inflammation
81
What is Sjogren's syndrome
autoimmune disorder affecting exocrine glands resulting in dry mucosal surfaces.
82
What are the symptoms of sjogren's
dry eyes: keratoconjunctivitis sicca dry mouth vaginal dryness
83
What immunological findings are associated with sjogren's?
RF - 100% ANA - 70% anti-Ro - 70% Anti-La - 30%
84
What is Schirmer's test?
holding filter paper near conjunctival sac to measure tear production
85
What is the pathophysiology of Gout
deposition of monosodium urate crystals in the synovium due to hyperuricaemia
86
What are some factors that increase the risk of gout
increased production - cytotoxic drugs, - psoriasis - eating liver, kidneys, oily fish, yeast decreased exretion - diuretics (thiazide and loop) - CKD
87
what is the differential diagnosis for gout
``` septic arthritis reactive arthritis pseudogout trauma cellulitis ```
88
what are the symptoms of gout
acute severely painful swollen joint (peak at 12hrs, lasts for 6-10d)
89
What can trigger an attack of gout
alcohol stress trauma exercise
90
what are some signs of chronic gout
urate tophi | uric acid renal stones
91
what investigations should be carried out in suspected gout
FBC joint aspiration - MC+S xray joint
92
What are the signs of gout on xray
subcutaenous tissue swelling punched out juxta articular erosions with sclerotic margins preserved joint space no periarticular osteopaenia
93
why do you need to do an FBC in gout?
a myeloproliferative disorder could be the cause - increased cell turnover
94
What is the treatment for an acute episode of gout?
NSAIDs, steroid injection | colchicine
95
What is the treatment for the prophylaxis of gout?
not started until 2 weeks since resolution of flare up | allopurinol
96
What are the indications for prophylaxis of gout
``` two episodes within a year tophi renal disease renal stones prophylaxis if taking cytotoxins or diuretics ```

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