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Rheumatology Flashcards

(48 cards)

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1
Q

management of raynaud’s

  • 1st line
  • 2nd line
A

1st line: calcium channel blocker eg nifedipine

2nd line: IV prostacyclin (epoprostenol) infusion

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2
Q

what suggests primary raynaud’s (2)

A

<40y old

bilateral symptoms

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3
Q

what suggests secondary raynauds (6)

A
  • unilateral onset
  • rash
  • older - >40
  • autoantibodies
  • fts suggestive of a CTD - arthritis, recurrent miscarriages, calcinosis
  • digital ulcers; chillblains
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4
Q

secondary causes of raynauds (8)

A
  • CTDs: scleroderma (most common), RA, SLE
  • Leukaemia
  • Type 1 cryogloublinaemia, cold agglutinins
  • Use of vibrating tools
  • Drugs: COCP, ergot
  • Cervical rib (extra rib above 1st rib > thoracic outlet syndrome > raynauds)
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5
Q

patterns of psoriatric arthropathy

A
  1. symmetric polyarthritis (most common: 30-40% - like RA)
  2. asymm oligoarthritis - usually hands and feet. 20-30%
  3. sacroilitis
  4. DIP joint disease
  5. arthritis mutilans
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6
Q

Xray of psoriatric arthropathy

A

often have the unusual combination of coexistence of erosive changes and new bone formation
periostitis
‘pencil-in-cup’ appearance

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7
Q

other signs of psoriatric arthritis

A

psoriatic skin lesions

periarticular disease - tenosynovitis and soft tissue inflammation resulting in:

  • enthesitis: inflammation at the site of tendon and ligament insertion e.g. Achilles tendonitis, plantar fascitis
  • tenosynovitis: typically of the flexor tendons of the hands
  • dactylitis: diffuse swelling of a finger or toe

nail changes: pitting, onycholysis

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8
Q

whats the first Ix to do for septic arthritis

A

synovial fluid sampling

- only dont do 1st if septic/unstable

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9
Q

abx for septic arthritis

A

IV fluclox - or clindamycin if pen allergic - for 6-12wks

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10
Q

common bacteria that cause septic arthritis

A
  • staph aureus (most common)
  • n gonorrhoea (young and sexually active)

most common site = knee

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11
Q

reactive arthritis symptoms

A

Triad of symptoms (cant see, pee or climb a tree)

Urethritis

Conjuncitivitis

Arthritis

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12
Q

reactive arthritis causes (bacteria)

A

STI (more common in men): chlamydia trachomatis

Dysentery: shigella flexneri, salmonella typhimurium, salmonella enteritidis, yersinina enterocolitica, campylobacter

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13
Q

reactive arthritis mx

A

Symptomatic: anlagesia, NSAIDs, steroid injections into the joint

Persistent disease: can use sulfasalazine, methotrexate

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14
Q

important

mx of ank spond

A

1st line: exercise + NSAIDs; physio

if persistently high disease activity despite this: anti-TNF therapy

DMARDS for RA only useful if peripheral joints involved (EG sulfasalazine)

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15
Q

XR changes seen in ank spond

A 
Plain XR: most useful Ix in diagonsis 
- Can be normal early on 
LATER
- Sacroilitis (subchrondral erosions, sclerosis) 
- Squaring of lumbar vertebrae 
- Bamboo spine  
- Syndesmophytes (ossification of outer fibres of annulus fibrosus [exterior of intervertebral disc]) 
- Apical fibrosis on CXR

If negative XR but high clinical suspicion > MRI
- Signs of early inflam involving SI joints (bone marrow oedema) confirm dx

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16
Q

paget’s disease: blood levels of calcium/phosphate/other tests

A
  • normal value of calcium, phosphate
  • high ALP

Other markers of bone turnover will be high:

  • procollagen type I N-terminal propeptide (PINP)
  • serum C-telopeptide (CTx)
  • urinary N-telopeptide (NTx)
  • urinary + serum hydroxyproline
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17
Q

paget’s disease: tx and indications for it

A

Indications for tx

  • Bone pain
  • Skull or long bone deformity
  • Fracture
  • Periarticular paget’s

Tx

  1. Bisphosphonate (oral risedronate or IV zoledronate)
  2. Calcitonin – less commonly used now
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18
Q

how to tell drug induced lupus and SLE apart

A

drug induced: dont tend to see renal or nervous system involvement.
negative Anti-ds-DNA antibodies. positive anti-histone antibodies

normal SLE: positive for dsDNA. negative for anti histone

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19
Q

dermatomyositis:

  • Abs most specific
  • Abs most common to it
A

most specific: Anti-Mi-2

most common: ANA

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20
Q

dermatomyositis fts

Study These Flashcards
A 
Proximal pain and tenderness 
Heliotrope sign (violaceous rash over eyelids) 
Shawl sign (rash over upper arms, shoulders & upper back)
21
Q

dermatomyostitis tx

22
Q

pseudogout: whats seen in the joint fluid

Study These Flashcards
A

weakly positively birefringent rhomboid-shaped crystals

23
Q

pseudogout RF

Study These Flashcards
A

Haemochromatosis
Hyperparathyroid
Low Mg or low phosphate
Acromegaly, wilsons

24
Q

pseudogout mx

Study These Flashcards
A

Aspiration of joint fluid (to excl septic arthritis)

NSAIDs or steroids (into the joint, IM or oral)

25
prophyria cutanea tarda - mx
Chloroquine Venesection if iron ferritin >600ng/ml
26
prophyria cutanea tarda - causes
Inherited defect in uroprophyrinogen decarboxylase Hepatocyte damage – alcohol, hep C, oestrogen
27
porphyria cutanea tarda presentation
Photosensitive rash w blistering and skin fragility on face + dorsal aspect of hands Oncholysis Hypertrichosis (excessive hair) Hyperpigmentation
28
impetigo - tx
1st line: hydrogen peroxide 1% cream (for systemically well and low risk of complications) Next options - Topical fusidic acid - If resistant to this: topical mupirocin (could be MRSA) Extensive disease: - Oral fluclox - Pen-allergic: oral erythromycin
29
bacteria that cause impetigo
Causes: staph aureus, strep pyogenes
30
uncontrolled psoriasis and psoriatric arthritis - tried NSAIDs and steroids - what now?
etanercept
31
what dose of steroids makes you want to offer osteoporosis prophylaxis
equiv of pred 7.5mg OD for 3 months
32
key XR change in ank spond
syndesmophytes: due to ossification of outer fibers of annulus fibrosus Radiographs may be normal early in disease, later changes include: sacroiliitis: subchondral erosions, sclerosis squaring of lumbar vertebrae 'bamboo spine' (late & uncommon) chest x-ray: apical fibrosis
33
COMPRESSION OF nerve root of - L3 - L4 - L5 - S1
- L3: sensory loss over anterior thigh - L4: sensory loss over anterior knee both L3 & L4: weak quadriceps, reduced knee reflex, positive femoral stretch test - L5: sensory loss of dorsum/top of foot, weak foot and big toe dorsiflexion, positive sciatic nerve stretch test (reflexes intact) - S1: sensory loss to posterolateral leg and lateral foot, weak plantar flexion, reduced ankle reflex, positive SN stretch test
34
osteogenesis imperfecta | whats the problem
type 1 collagen
35
Abs for dermatomyositis: most sens and most spec Abs for polymyositis
dermato: ana most common, anti-mi-2 most specific poly: anti-Jo-1
36
denosumab action?
RANK ligand inhibitor > inhibits maturation of osteoclasts
37
SLE - most sensitive antibody? - most specific? - what Ab do they use for monitoring - what happens to complement?
· Most sensitive = ANA: 99% +ve (high sensitivity = useful rule out test, but low specificity) · Most specific = anti-smith ○ Anti-dsDNA and anti-Smith very specific >99% but less sensitive ○ Anti-dsDNA can be used for monitoring (but not present in all pts) C3 and C4 levels low during active disease (formation of immune complexes > consumption of complement)
38
mx of RA - 1st line - 2nd line - 3rd line - whats rituximab? - mx of flares?
1st line: DMARD and short course of prednisolone - DMARD options: methotrexate, sulfasalazine, leflunomide, hydroxychloroquine then try another DMARD if not good response to 2: TNF inhibitor (Etanercept, infliximab, adalimumab) Flares: mx w steroids (oral or IM) EXTRA: rituximab (anti-CD20)
38
1st line mx of RA
DMARD and short course of prednisolone
39
antiphospholipid syndrome | - aptt?
causes a paradoxical rise in the APTT. This is due to an ex-vivo reaction of the lupus anticoagulant autoantibodies with phospholipids involved in the coagulation cascade
40
azathioprine - can you use it in preg? - what common drug does it interact with? - SE (4) - how does it work pharmaceutically
Key bits · Safe in pregnancy · Can interact w allopurinol - so use lower doses of azathioprine Notes · SE: BM depression, N&V, pancreatitis, increased risk of non-melanoma skin cancer · Metabolised to mercaptopurine (active: a purine analogue that inhibits purine synthesis) May need to do TPMT (thiopurine methyltransferase test) to look for pts prone toxicity
41
sulfasalazine - if patients are allergic to X or Y they could react to sulfasalazine - caution with what genetic condition? - pharm action - SE - preg?
aspirin, sulphonamides - Caution w G6PD deficiency Notes - Prodrug for 5-ASA - SE: oligospermia, SJS, pneumonitis/fibrosis, myelosuppression, Heinz-body anaemia, megaloblastic anaemia, stained contacts (can colour tears) Details - 5-ASA: decreases neutrophil chemotaxis + suppresses prolif of lymphocytes and pro-inflam cytokines safe in preg and BF
42
drug induced lupus causes - most common 2 - less common (3) is the damage permanent
Most common 1. procainamide (used for cardiac arrhythmias) 2. hydralazine (diuretic: high BP) Less common 3. isoniazid (TB) 4. minocycline (abx) 5. phenytoin (epilepsy) - Don’t get renal or nervous involvement usually Resolves on stopping drug
43
heberden's & bouchard's nodes | what disease are they seen in, where are they, what are they and whats the cause
OA Heberden’s nodes at the DIPJs, Bouchard’s Nodes at the PIPJs. Painless nodes (bony swellings): Due to osteophyte formation
44
RF for osteoporosis
Sig RF: female, older age ``` RF used by major risk assessment tools such as FRAX: • history of glucocorticoid use • RA • alcohol excess • history of parental hip fracture • low BMI • current smoking ``` Other RF • sedentary lifestyle • premature menopause • Caucasians and Asians • endocrine disorders: hyperthyroidism, hypogonadism (e.g. Turner's, testosterone deficiency), GH deficiency, hyperparathyroidism, DM • multiple myeloma, lymphoma • GI: IBD, malabsorption (e.g. Coeliac's), gastrectomy, liver disease • CKD • osteogenesis imperfecta, homocystinuria
45
Medications that may worsen osteoporosis (other than glucocorticoids):
``` • SSRIs • antiepileptics • PPIs • glitazones • long term heparin therapy aromatase inhibitors e.g. anastrozole ```
46
osteoporosis - t score: what is it, values for normal/osteopenia/osteoporosis - z score
Basics T score: based on bone mass of young reference population T score of -1.0 means bone mass of one standard deviation below that of young reference population Z score is adjusted for age, gender and ethnic factors T score > -1.0 = normal -1.0 to -2.5 = osteopaenia < -2.5 = osteoporosis
47
ank spond comps
``` • Apical fibrosis • Anterior uveitis • Aortic regurgitation • Achilles tendonitis • AV node block • Amyloidosis • and cauda equina syndrome peripheral arthritis (25%, more common if female) ```

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