Rheum - clinical Flashcards by jess thompson

Which joints does RhA most commonly affect?
Which joints does it never affect?
Common presentation in the hands?

MCPs and PIPs
Never affects DIPs (this is osteoarthritis)
Symmetrical, swollen, painful stiff joints

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Extra-articular features of RhA?

rheumatoid nodules
pericaridal/pleural effusion
scleritis
fibrosing alveolitis
vasculitis
carpal tunnel syndrome

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What is Felty’s syndrome?

RhA + splenomegaly + neutropenia

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On examination of RhA hands, what might you find?

What scar patterns on observation might you find?

Early - swollen/synovitis of MCP, PIP, wrist (symmetrical)
Later - ulnar deviation of fingers, dorsal wrist subluxation, Boutonniere, swan-neck deformities of fingers, Z-deformity of thumbs
Scars: palmar surface hand - carpal tunnel release; over MCP joints from joint replacement; Darrachs procedure (removal of ulnar styloid)

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In what conditions might RF be raised?

RhA

Sjogren’s syndrome

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Treatment for new diagnosis of RhA?

Aggressive + early treatment with DMARDs eg methotrexate

COMBINATION OF DMARDS USED AS FIRST LINE

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What antibiotic should be avoided with methotrexate? Why?

Trimethoprim

Both act on folate pathway leading to pancytopenia

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What should patients avoid whilst on anti-TNF therapy?

Live vaccines eg MMR, yellow fever, polio, BCG

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What diagnostic classifications are used for RhA?

ACR and EULAR

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ACR diagnostic criteria?

4 out of 7 of:
morning stiffness (>1 hour lasting >6 weeks)
arthritis of >=3 joints
arthritis of hand joints
symmetrical arthritis
rheumatoid nodules
\+ve rheumatoid factor
radiographic changes

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What does a direct Coombs test test for?

AIHA

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5 hallmarks in the joints of psoriatic arthritis?

1) spondyloarthropathy (joint disease of vertebral column)
2) rheumatoid-like arthropathy
3) large joint monoarthritis
4) oligoarthritis (between 1 and 4 joints)
5) seronegative arthritis

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Extraarticular features of psoriatic arthritis?

Enthesitis (eg palmar fascitis)
Uveitis
Nail change - pitting, onycholysis
dactilytis (“swollen like sausages”) - whole digit swells up

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Who can you assess sacroilitis of spine clinically?

Scherber’s test (10cm above dimples of Venus and 5 cm below, then ask patient to bend forward to touch toes without bending knees - movement of greater than 5cm = normal. less than 5cm = sacroilitis)

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Risk factors for gout?

Ingesting lots of uric acid
Kidney failure
Diuretics (loop and thiazide; interfere with excretion of uric acid in distal tubules)
Chemotherapy (increased purine metabolism from DNA breakdown as lots of cell lysis - often given medication prophylacticly)
Psoriasis - incerased cell turnover

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Crystals appear negatively birefringent under microscopy. What is the disease?

Gout

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Patient presents with hot, red, inflamed big toe. Pain = 10/10, so great is the pain that they don’t want the bedsheets over it. How would you treat initially?

Colchicine or NSAIDs (if no kidney disease)

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Chronic treatment for gout?

allopurinol

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Patient started on sulfasalazine for worsening rheumatoid arthritis. They develop a fever, sore throat and fatigue around a week after they start the drug. Extremely painful ulcers appear in the mouth, lips, genital and anal regions.

What is the problem? Describe the pathophysiology. Give 2 other examples of drugs which might cause a similar reaction?

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Stevens-Johnson Syndrome, a form of toxic epidermal necrolysis (TEN)
Keratinocyte apoptosis mediated by CTL (CD8) causes epidermis to separate from dermis at the epidermal-dermal junction. (Delayed hypersensitivity reaction)
eg anticonvulsants, antibiotics, antifungals, antretrovirals, azathioprine, allopurinol, corticosteroids.
Manage: optimal wound care, nutrition, critical care, pain management

Colour changes seen in hand of Raynaud’s?

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white then blue then red

What diseases are associated with secondary Raynaud’s?

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Connective tissue disease (especially scleroderma: limited cutaneous systemic sclerosis (CREST)/ diffuse cutaneous systemic sclerosis)
Vasculitis
Malignancy
Peripheral vascular disease

Symptoms of limited cutaneous systemic sclerosis?

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CREST + scleroderma (tightness of skin) limited to hands
Calcinosis
Raynaud's
oEsophgeal dysmotility
Sclerodactyly
Telangiectasia

What is the most common cause of mortality secondary to scleroderma?

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Pulmonary hypertension

What antibodies are associated with diffuse cutaneous systemic sclerosis?

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Anti-Scl70 antibodies (anti-topoisomerase I) = a form of anti-nuclear antibody (ANA)
[I think there may be more as well…]

What antibodies are associated with limited cutaneous systemic sclerosis?

Anti-centromere antibodies

What might steroids precipitate in a patient with scleroderma?

Renal crisis

What condition is associated with "bamboo spine" on x-ray? | Describe the appearance.

Ankylosing spondylitis Vertebral body fusion by marginal syndesmophytes (calcification or heterotopic ossification inside a spinal ligament or annulus fibrosus) Radiographic appearance thin, curved, radio-opaque spicules that completely bridge adjoining vertebral bodies

What is associated with "dagger spine" appearance on x-ray? What is the cause?

Ankylosing spondylitis | Interspinous ligament calcification

Treatment for ankylosing spondylitis? How would the regimen be changed with peripheral involvement?

Physiotherapy + NSAIDs or anti-TNF therapy. | Add DMARDs - they are useless for spinal changes

How is the severity and progression of ankylosing spondylitis assessed?

Using the BASDAI, subjective measurement by patient

What is the most common gene abnormality in ankylosing spondylitis?

HLA-B27 (around 90% of Caucasians with AS have HLA-B27 abnormality)

Thoracic spine symptoms (pain and stiffness) and elderly age of onset (60/70 year old), what is the most likely diagnosis. What changes are likely to be seen on x-ray?

diffuse idiopathic skeletal hyperostosis (DISH) NOT ANKYLOSING SPONDYLOSIS - usually younger age of onset and affecting lumbar spine. Flowing ossification (florid, flowing ossification along the anterior or right anterolateral aspects of at least 4 contiguous vertebrae)

34 year old man presents with tender, red lumps on his shins with bilateral ankle arthritis Most likely diagnosis? What investigations required?

Sarcoidosis (the skin appearnce is erythema nodosum [panniculitis - inflammation of subcutaneous adipose tissue]) CXR (bilateral hilar lymphadenopathy), lung function, serum ACE (can be used as a treatment marker)

What is lupus pernio?

Cutaneous sarcoid on the face

Antibody for SLE?

anti-dsDNA

When would CRP IN ADDITION TO ESR be raised in someone with lupus?

concurrent infection | In the presence of pleurisy or pericardial involvment

When would complement be most usefully investigated in the management of SLE?

Follow response to treatment and predictor of flair-up

What is Libman-Sacks endocarditis? What causes it?

Inflammatory vegetations on cardiac valves, typically the mitral valve SLE

Difference between Jaccouds arthritis and RhA?

Deforming non-erosive arthropathy characterised by ulnar deviation of the fingers. non-erosive; tendon inflammation and tendon contractures only, no bone involvement

What rashes may be seen in a 40 year old with proximal muscle weakness?

(Dx is dermatomyositis) Gottron's papules - discrete erythematous papules overlying the MCP and PIP joints Heliotrope rash - purple coloured rash over upper eyelids

What antibodies are most strongly associated with dermatomyositis?

Anti-MI-2 antibodies

What antibodies are most strongly associated with polymyositis?

Anti-JO-1 antibodies

What complication should be screened for at presentation and annually for 3 years in a patient diagnosed with dermatomyositis?

Malignancy. Most common are GI and ovarian

What is the difference between myositis, polymyalgia rheumatica and fibromyalgia?

INFLAMMATORY MARKERS, CLINICAL MUSCLE WEAKNESS, PAIN, CREATINE KINASE myositis and PMR are inflammatory conditions with raised inflammatory markers CK rise in myositis - autoimmune destruction of muscle fibres PMR - no actual weakness on examination, pain and stiffness predominate myositis - muscle weakness apparent but often no pain fibromyalgia - pain (neuropathic) and perceived weakness but no raised inflammatory markers

diagnostic criteria for myositis?

2 of 3 from: muscle biopsy (autoimmune destruction of muscle fibres), EMG, MRI (muscle oedema)

Rheum - clinical Flashcards

(45 cards)