rheum

Question 1

rheumatoid arthritis, splenomegaly and low WCC

Answer 1

felty’s syndrome

Question 2

test when starting on azathioprine

Answer 2

Thiopurine methyltransferase (TPMT) deficiency is present in about 1 in 200 people and predisposes to azathioprine related pancytopaenia

nausea/vomiting
pancreatitis
increased risk of non-melanoma skin cancer

A significant interaction may occur with allopurinol and hence lower doses of azathioprine should be used.

Question 3

causes of dactylitis

Answer 3

spondyloarthritis: e.g. Psoriatic and reactive arthritis
sickle-cell disease
other rare causes include tuberculosis, sarcoidosis and syphilis

Question 4

DAS 28

Answer 4

disease activity score in 28 joints fo rRA

Question 5

meds to avoid with methotrexate

Answer 5

Trimethoprim and co-trimoxazole, anti-folate antibiotics

Question 6

mx of gout

Answer 6

acute: nsaids and colchicine +- PPI

long term: allopurinol 2nd line febuxostat

Question 7

ix for osteomalacia

Answer 7

low 25(OH) vitamin D (in 100% of patients, by definition)
raised alkaline phosphatase (in 95-100% of patients)
low calcium, phosphate (in around 30%)
x-ray: children - cupped, ragged metaphyseal surfaces; adults - translucent bands (Looser's zones or pseudofractures)

Question 8

mx of ankspond

Answer 8

encourage regular exercise such as swimming
NSAIDs are the first-line treatment
physiotherapy
the disease-modifying drugs which are used to treat rheumatoid arthritis (such as sulphasalazine) are only really useful if there is peripheral joint involvement
the 2010 EULAR guidelines suggest: ‘Anti-TNF therapy should be given to patients with persistently high disease activity despite conventional treatments’ (2 NSAIDS)
research is ongoing to see whether anti-TNF therapies such as etanercept and adalimumab should be used earlier in the course of the disease

Question 9

drugs and antibodies in drug induced lupus

Answer 9

procainamide
hydralazine

Less common causes
isoniazid
minocycline
phenytoin

antihistone antibodies

Question 10

causes of positive anca

Answer 10

cANCA - granulomatosis with polyangiitis (Wegener’s granulomatosis)
pANCA - Churg-Strauss syndrome + others (see below)

Other causes of positive ANCA (usually pANCA)
inflammatory bowel disease (UC > Crohn’s)
connective tissue disorders: RA, SLE, Sjogren’s
autoimmune hepatitis

Question 11

marfans abnormalirty

Answer 11

chromosome 15 that codes for the protein fibrillin-1

Question 12

acromegaly pts can get

Answer 12

pseudogout

Question 13

antibodies is most specific for limited cutaneous systemic sclerosis?

Answer 13

anticentromere

Question 14

comlication of chemotherapy

Answer 14

Chemotherapy patients are at increased risk of gout from increased urate production

Question 15

dermatomyositis associated with

Answer 15

breast, ovarian and lung ca

Question 16

dermatomyositis antibodies

Answer 16

antibodies against histidine-tRNA ligase (also called Jo-1)
antibodies to signal recognition particle (SRP)
anti-Mi-2 antibodies

Question 17

t score for bisphosphonates if on steroids

Answer 17

t -1.5

more than 7.5mg pred for 3 months

Question 18

mx of reactive arthritis

Answer 18

symptomatic: analgesia, NSAIDS, intra-articular steroids
sulfasalazine and methotrexate are sometimes used for persistent disease
symptoms rarely last more than 12 months

Question 19

mx of OA

Answer 19

• weight loss advice
• paracetamol +-topical NSAIDS
• 2lin: oral NSAIDs
• supports, shock absorbers
• joint replacement

Question 20

features of antiphospholipid syndrome

Answer 20

venous/arterial thrombosis
recurrent fetal loss
livedo reticularis
thrombocytopenia
prolonged APTT
other features: pre-eclampsia, pulmonary hypertension

Question 21

ehlers danlos

Answer 21

type 3 collagen
elastic, fragile skin
joint hypermobility: recurrent joint dislocation
easy bruising
aortic regurgitation, mitral valve prolapse and aortic dissection
subarachnoid haemorrhage
angioid retinal streaks

Question 22

(paradoxically) prolonged APTT + low platelets

Answer 22

antiphospholipid syndrome

Question 23

s/e of hydroxychloroquine

Answer 23

bull’s eye retinopathy - may result in severe and permanent visual loss
recent data suggest that retinopathy caused by hydroxychloroquine is more common than previously thought and the most recent RCOphth guidelines (March 2018) suggest colour retinal photography and spectral domain optical coherence tomography scanning of the macula
baseline ophthalmological examination and annual screening is generally recommened

A contrast to many drugs used in rheumatology, hydroxychloroquine may be used if needed in pregnant women.

Question 24

ank spond dx criteria

Answer 24

Sacroilitis on imaging* plus 1 or more spondyloarthritis features†
or
HLA-B27 plus 2 or more other spondyloarthritis feature

Question 25

polyarteritis nodosa fx

Answer 25

fever, malaise, arthralgia weight loss hypertension mononeuritis multiplex, sensorimotor polyneuropathy testicular pain livedo reticularis haematuria, renal failure perinuclear-antineutrophil cytoplasmic antibodies (ANCA) are found in around 20% of patients with 'classic' PAN hepatitis B serology positive in 30% of patients

Question 26

behcets features

Answer 26

classically: 1) oral ulcers 2) genital ulcers 3) anterior uveitis thrombophlebitis and deep vein thrombosis arthritis neurological involvement (e.g. aseptic meningitis) GI: abdo pain, diarrhoea, colitis erythema nodosum

Question 27

different spondyloarthropathies

Answer 27

ankylosing spondylitis psoriatic arthritis Reiter's syndrome (including reactive arthritis) enteropathic arthritis (associated with IBD

Question 28

mx RA

Answer 28

DMARD monotherapy +/- a short-course of bridging prednisolone. In the past dual DMARD therapy was advocated as the initial step. poor response to 2 DMARDS- tnf inhibitors measure with DAS28 and CRP

Question 29

pencil and cup dips and pips | plantar spur

Answer 29

psoriatic arthritis

Question 30

Antisynthetase syndrome fx

Answer 30

autoantibodies against aminoacyl-tRNA synthetase e.g. anti-Jo1. ``` It is characterised by myositis interstitial lung disease thickened and cracked skin of the hands (mechanic's hands) Raynaud's phenomenon ```

Question 31

how to test if hip pain is referred from back

Answer 31

femoral nerve stress test

Question 32

complication of RA in surgery

Answer 32

atlantoaxial subluxation, screen with 2 view c spine x rays

Question 33

complication of penicillamine (chelating agent for wilsons)

Answer 33

membranous glomerulonephritis (nephrotic syndrome)

Question 34

bisphonsphonate holidays not allowed if

Answer 34

``` ge >75 Glucocorticoid therapy Previous hip/vertebral fractures Further fractures on treatment High risk on FRAX scoring T score ```

Question 35

ank spond associations

Answer 35

``` Apical fibrosis Anterior uveitis Aortic regurgitation Achilles tendonitis AV node block Amyloidosis ```

Question 36

RA XRAY

Answer 36

Early x-ray findings loss of joint space juxta-articular osteoporosis soft-tissue swelling Late x-ray findings periarticular erosions subluxation

Question 37

score to assess hypermobility

Answer 37

beighton score

Question 38

patients who are allergic to x may also react to sulfasalazine

Answer 38

aspirin

Question 39

reactive artritis aspirate appearance

Answer 39

cloudy yellow, culture negative, no crystals, WCC 20,000/mm3

Question 40

interferon features and uses

Answer 40

Interferon-alpha produced by leucocytes antiviral action useful in hepatitis B & C, Kaposi's sarcoma, metastatic renal cell cancer, hairy cell leukaemia adverse effects include flu-like symptoms and depression Interferon-beta produced by fibroblasts antiviral action reduces the frequency of exacerbations in patients with relapsing-remitting MS Interferon-gamma predominately natural killer cells. Also by T helper cells weaker antiviral action, more of a role in immunomodulation particularly macrophage activation may be useful in chronic granulomatous disease and osteopetrosis

Question 41

osteogenesis imperfecta

Answer 41

Overview autosomal dominant abnormality in type 1 collagen due to decreased synthesis of pro-alpha 1 or pro-alpha 2 collagen polypeptides ``` Features presents in childhood fractures following minor trauma blue sclera deafness secondary to otosclerosis dental imperfections are common ```