Flashcards in Rheum Deck (113):
What are the features of lupus?
- Discoid rash
- oral ulcers
- Malar rash
- Immunological features - dsDNA, RhF
- ESR increase
What antibodies are seen in drug induced lupus?
Anti - histone antibodies
What is the effect of recurrent PEs?
V;Q mismatch leading to decreased transfusion factor and pulmonary hypertension leading to cor pulmonale
What is the mechanism of action of Varencilline?
Partial nicotinic receptor agonist
What is the mechanism of action of Buproprion?
Norepinepherine and dopamine reuptake inhibitor and partial nicotinic antagonist
What are the antibodies seen in coeliac disease?
What is seen on XR in a patient with vit D deficiency?
Rickets - growth retardation- knocked knees and bowed legs and deformity at the metaphyseal - epiphyseal junction and large head
Osteomalacia - pathological #
Where are the most common sites for septic arthritis?
Hip, knee and shoulder
What are the main causes of septic arthritis?
What are the risk factors for SA?
What tests should be done in suspected SA?
U&Es and LFTs
Joint aspiration - turbid and yellow in colour, decreased viscosity, larger level of WBCs and neutrophils
What are the symptoms of SA?
fatigue and general malaise
inflammed and tender joint
*all very rapid onset*
What is the treatment for SA?
Always involve orthopaedics and micro
Empirical antibiotics after aspiration
Consider washout and debribement
Staph aureus - flucoxacillin
MRSA - vancomycin
Gonnococcal or gram negative - cefotaxime
What is the pathophysiology seen in RA?
inflammatory condition affecting the synovial membrane which leads to synovial hypertrophy and then break down. Lead by T cells
What are RF for RA?
Family history, smokers, female , 50-60y/o
How does RA present?
Polyarthritis - typically symmetrical hand and feet involvement
relieved by movement
soft tissue swelling
What are the signs of RA on examination?
Boutonneire - flexion of PIP and hyperextension DIP
Swan neck - hyper extension of PIP and flexion of DIP
Tenosynovitis and extensor tendon rupture
Z shaped thumb
Subluxation and ulna deviation of the digits
Soft tissue swelling at the MCP, PIP and wrist.
What are found on blood tests in RA?
Anaemia of chronic disease
Increased ESR or CRP
What are the XR finding in RA?
Loss of joint space
juxta articular osteopenia
soft tissue swelling and subluxation
What is the managment of RA?
NICE recommends MTX and one other DMARD with short course of corticosteriods
DAS28 used to measure disease activity and indicate when to start biological agents
NSAIDs good for pain
Physio and and OT involvement
Surgery - extensor tendon repair and carpal tunnel release
What are sufferers of RA at more risk of?
2-3 fold increased risk of IHD
What are the extra articular manifestations of RA?
intersititial lung disease
carpal tunnel disease
episcleritis and kerratoconjuncitivitis sicca
osteoporosis and amyloidosis
What are the risk factors for OA?
may relate to occupation
increased bone density
What are the signs of OA?
squaring of the thumb
Bouchard and Heberden nodes
Where does OA effect?
What are the signs of OA on XR?
Loss of joint space
What is the management of OA?
Physio and OT invovlement
Heat and cold packs
Walking aids and supports
Pharmacological - start with paracetamol and topical NSAID > weak opioid > NSAID and PPI > intra articular corticosteriods
Surgery - arthroscopy and replacement
What is the pathophysiology of gout?
Uric acid precipitant on articular cartilage, tendons and surrounding tissue due to increased uric acid levels due to impaired renal excretion and over production of uric acid and over consumption of purine rich food.
What are the risk factors for gout?
HTN, CKD, alcohol, thiazide duiretics, trauma, infection and dehydration
What are the signs and symptoms of gout?
often big toe joint
Burning pain that came on over night
low grade fever
may have tophi
What investigations are done in suspected gout?
Cultures - rule out SA
Polarised light microscopy - negative needles
urine analysis and serum urate which may be raised or normal
What are the XR finding in Gout?
Normal joint space
soft tissue swelling
peri articular erosions
What is the management of gout?
high dose NSAID or colchicine
Rest and elevation
Lose weight and stop precipitating factor
Prevention -- allopurinol - started 3 weeks post attack in greater than 1 attack in a year, tophi or renal stones
should be continued in acute attack if already on
What is psuedogout?
Ca pyrophosphate dehydrate depositon in the joints
What are the risk factors for psuedogout?
OA and DM
How does psuedogout present?
Acute monoarthropathy of large joints in the elderly
Wrist, hip and knee
What investigations should be done in suspected pseudogout?
Cultures to rule out SA
Polarised light microscopy - weakly positive rhomboids
What is seen on XR in psuedogout?
What is the management of psuedogout?
Rest, cold packs, aspiration and intra articular steriods
NSAIDs and colchine may help
Chronic - MTX and hydrochloroquinine
What are the common features of the spondyloarthropathies?
affect the axial skeleton
seronegative - no RhF
HLA B27 positive
Asymmetrical large joint oligo or monoarthritis
Extra articular manifestations - anterior uveitis, oral ulcers, valve incompetance , dactylitis and enthelitis
What is AS?
Inflammation of the SI joints followed by involvement of the surounding tissue leading to
- subchondral granulation tissue
- calcification of annular fibrosis
Explain the presentation of AS?
Gradula onset back pain, worse at night
spinal morning stiffness that eases with movement
Pain radiates into the hip and buttock
What are the signs of AS?
Neck hyper extension leading to ? posture
Reduced schober <5cm
Reduced chest expansion
Positive Sacroiliac stretch
What is found on investigation of AS
CXR may show fibrosis in the apex
Osteoporosis on DEXA
What is found on XR of AS?
Early - bony erosions, widening of SI joints and vertebral bodies appear square with shiny corners
Late - ossification of longitudinal ligements of spine and bamboo appearance
What is the management of AS?
Exercise and intense physio
NSAIDs to reduce pain
Anti TNF blockers in severe disease
Local steriod injections
What are the associated As in AS?
Aortic valve incompetance
Apical lung fibrosis
What are some indications of poor prognosis in AS?
Early hip invovlement
poor response to NSAIDs
What is enteropathic arthritis?
Arthritis associated with bowel pathology
IBD, GI bypass, whipples disease and coeliac
How does enteropathic arthritis present?
Asymmtrical large joint oligoarhritis mainly affecting the lower limbs
How is enteropathic arthritis managed?
NSAIDs or intra articular steriods for arthritis
*NSAIDs may worsen crohns*
What is psoartic arthritis?
Pathophysiology involves the release of T cells and chemo/cytokines
Affects 10-40% with skin changes
can present before skin changes
How can Psoaratic arthritis present?
-Asymetrical oligo or polyarthritis
What are the best predictor that a patient may develop psoaratic arthritis in those with skin disease?
Nail changes - pitting, onchylolysis and hyperkeratosis
What is the management of psoatic arthritis?
CASPAR scoring tool
Intra articular steriods
In progressive peripheral joint disease MTX first line
What is seen on XR in Psoriatic arthritis?
Erosive changes with pencil cupping
What is reactive arthritis?
Sterile arthritis following a GI or GU infection.
Causes include Camplylobacter, salmonella, shingella, ureaplasma and chlamydia
Where is mainly affected in reactive arthritis?
What are the extra articular manifestations of reactive arthritis?
Keratoderma blenoorhagia- brown raised plaques on sole and palms
Circinate Balanitis- painless penile ulceration secondary to chalmydia
What is the management for Reactive arthritis?
No specific management - splint acutely
NSAIDs or local steriod injections
Sulfasalazine or MTX if last >6 months
What is systemic sclerosis?
Caused by over production of collagen due to T cell cytokine release
What are the features of limited systemic sclerosis?
What may been seen on examination of a patients face with limited system sclerosis?
Beak nose and microstomia
What investigations should be done with someone with limited systemic sclerosis?
What is the management of a patient with limited systemic sclerosis?
Treat raynaurds as protocol
PPI and prokinetics such as metaclopramide
What may be a life threatening complication of limited systemic sclerosis and how is it managed?
Pulmonary hypertension- treated with sidenafil and bosentan
What is systemic diffuse sclerosis?
Affects the whole body
Lungs - fibrosis
Heart - arrhythymias and conduction disorder
Renal - acute hypertensive crisis
What are the antibodies in systemic diffuse sclerosis?
SCL -70 antibodies
Anti - RNA polymerase antibodies
What other investigations are done in systemic diffuse sclerosis apart from antibodies?
CXR - bibasal fibrosis and cardiomegaly
ECG and ECHO- signs of pulmonary hypertension
Urine dip - protein and haematuria
What is the management of systemic diffuse sclerosis?
BP control with ACEi
NO CURE - immunosuppression - consider cyclophosphamide
What is SLE?
Relapsing and remitting type 3 autoimmuine connective tissue affecting the entirety of the body
Who does SLE present in?
Women of child bearing age
What are the investigations and blood tests done in SLE?
Decreased WCC and platelets
Arthralgia - non erosive peripheral joints and Jaccoud's - reducible deforming arthropathy
What is the management of SLE?
Acute flares - pred and IV cyclophosphamide
Cutaneous symptoms - topical steriods and sun cream
Maintainence - NSAIDs, hydroxychloroquinine and low dose steriods
What can be monitored during a flare to check response to treatment?
Anti dsDNA and ESR
What do patients with SLE have an increased risk of developing?
Permenant neurological damage
What are the features of antiphospholipid syndrome?
- Coagulation defects
- Livedo reticularis - pink/blue mottling of the skin caused by capillary dilation and stasis in the venules
What is found on investigation in patients with antiphospholipid syndrome?
Anti-cardolipin and lupus anticoagulant antibodies
What is the management of anti-phospholipid antibodies?
Anticoagulation - low dose warfarin or aspirin
What drugs may lead to drug induced lupus?
Isoniazid, hydralazine, procainamide, phenytoin
What is polymyositis?
Lymphocytic inflammation - mainly cytotoxic T8 lymphocytes
How does polymyositis present?
Progressive proximal muscle wasting and weakness of striated muscle due to inflammation
May also have dysphagia, dysphonia, respiratory weakness
What investigations should be done in patients with patients polymyositis?
Anti Mi2 and anti Jo1
Muscle enzymes will also be increased in serum - ALT, AST LDH and CK
How is polymyositis managed?
immunosuppressant and cytotoxic drugs in resistant cases
What should be done in a patient with polymyositis?
Screen for underlying malignancy
Tumour markers, CXR, mammogram, pelvis/abdo US and CT
What are the differentials for polymyositis?
drug induced myopathy - statins
Mixed connective tissue disease
hereditary neuromuscular disorder
What is dermamyositis?
Polymyositis with dermatological signs
- Macular rash - over back and shoulders in shawl sign
- Heliotropic rash - liliac purple rash on eye lids with oedema
- nail fold erythema- dilated capilary loops
- Gottrons papules - roughened red papules over knuckles
What is relapsing polychondritis?
Inflammation of elastic cartilage leading to destruction
What are the signs of relapsing polychondritis?
Recurrent chest infections
How is diagnosis made and what is the management of relapsing polychonritis?
Diagnosis is clincial
Management - steriod and DMARDs
consider CPAP for those with resp invovlement
What is sjrogens?
Autoimmune destruction of exocrine glands
primary -females and more common in 40-50 y/o
secondary - to RA, SLE and SS
What are the signs and symptoms of sjrogens?
Dry eyes - keratoconjunctivitis sicca
Bilateral parotid gland swelling
What is the management of sjrogen'?
NSAIDs and hydroxychloroquinine for arthralgia
pilocarpine may help with saliva production
Immunosuppresion for systemic disease
Who is behcets disease associated with?
Turkish, mediterreans and japanease men
What are the clinical features of Behcets disease?
1) recurrent genital and oral ulceration
erythema nodosum, vasculitis, non erosive large joint arthropathy
What is the management of Behcets?
What is the management of raynaurds?
CCB - nifedipine or sidenafil
What is polymyalgia rheumatica?
inflammatory condition that results in muscle pain - usually occuring in females over 65
What are the clinical features of polymyalgia rheumatica?
bilateral shoulder and thigh muscle pain lasting greater than 1 month
morning stiffness greater than 1 hour
systemic feature - WL and fever
*always screen for GCA*
What is the management of polymyalgia rheumatica?
Corticosteriod - will have prompt response- consider bone and stomach protection
Myeloma and thyroid screen
What is fibromyalgia?
Chronic pain and presence of hyperalgesic points and allodynia
How does fibromyalgia present?
Associated with stress, anxiety and PTSD
- Insomnia/ IBS/ Irrritable bladder
- Blues - anxiety and depression
- Rigidity - muscle and joint morning stiffness
-Ow - Pain
Need 11/18 points based on digital palpation
What is the management of fibromyalgia?
2) heat treatment, exercise programme and CBT
3) tramadol, moderate pain relief and antidepressants
What are the signs and symptoms of anterior uveitis?
Symptoms - occular eye pain, photophobia and blurry visision
Signs - red eye adjacent to iris
need slit lamp to see WBC and protein precipitates
What is the treatment of anterior uveitis?
Steriods in non infective causes
What is osteoporosis?
What are the risk factors for osteoporosis?
Steriod and smoking
Hypothyroid and hyperparathyroid
Alcohol and AGe >50
Thin and decreased testosterone
Renal or liver failure
Deficiency of Ca or vit D
What should be done in the management of oestoporosis?
Full bone profile and DEXA scan - use FRAX tool
- Denosumab - monoclonal antibody against RANK -L
- Stronuim renelate
- Teriparatide (PTH analogue)
Raloxefine, HRT and calcitonin
Where does paget's disease most commonly affect?
Pelvis, spine, skull, fibula and tibia
What are the phases of pagets disease?
Lytic > mixed > sclerotic
How does pagets present?
Usually asymptomatic - >55y/o males with increased isolated ALP
Increased temp over area, secondary OA, cranial nerve pathologies from compression
What is seen on XR in patients with pagets?
Localised enlargement, patchy cortical thinning with sclerosis, osteolysis and deformitity, advanced lytic lesions in long bones