Rheumatology Flashcards

Question

Management - Paget's Disease

Answer 1

• Bisphosphonates - interfere with osteoclast activity & return normal bone metabolism, improve sx • Vit D & Calcium supplementation • NSAIDs for bone pain Monitor ALP & symptoms

Answer 2

Two key complications are osteosarcoma (at increased risk) & spinal stenosis/spinal cord compression

Answer 3

Gout - deposition of urate crystals in joints | Pseudogout - calcium pyrophosphate crystals

Answer 4

``` High purine diet - meat, seafood Alcohol Diuretics Existing CVD or renal dysfunction Family hx Male ```

Answer 5

Red hot swollen painful joint Gouty tophi on hands, elbows & ears ``` typical joints: base of the big toe (metatarsophalangeal joint) Wrists Base of thumb (carpometacarpal joints) Also knee and ankle ```

Answer 6

SEPTIC ARTHRITIS Gout Pseudogout Bleeding into joint

Answer 7

Bedside • Observations - considering if systemically unwell • Joint examination - red, hot, swollen, ROM ``` Bloods • FBC - Hb, WBC • U&Es • LFTs • ESR/CRP - ESR may be high • Cultures - exclude sepsis ``` Imaging • X-ray - assessing for joint damage, signs of OA etc Specialist • Joint aspiration & microscopy/culture - gold standard for diagnosis of crystal arthropathies ○ Gout - negatively birefringent needles Pseudogout - positive birefringence, rhomboid/brick shaped crystals • Cell count > 50,000 cell/cm3 - think septic arthritis!

Answer 8

• Acute attacks - NSAIDs (1st line) --> colchicine (2nd or if CA) --> intraarticular corticosteroids (3rd line) • Prophylaxis - allopurinol (xanthine oxidase inhibitor), lifestyle changes Start allopurinol after acute attack has settled

Answer 9

``` Diabetes Advancing age Prothesis Immunodeficiency/suppression IVDU ```

Answer 10

``` Symptoms • Pain • Swelling • Fevers Inability to weight bear ``` ``` Signs • Pain on active and passive movement • Reduced ROM (range of motion) • Erythema • Warmth • Joint effusion ```

Answer 11

Antibiotics - typically at least 6 week course (flucloxacillin 200-500mg 4x times a day, 2week IV then 6 week oral), liase w/ microbiology Joint aspirate/washout

Answer 12

Definition: Synovitis occurs in joints as a reaction to recent infective trigger (one of the spondyloarthropathies) Typically causes acute monoarthritis, affecting a single joint in the lower limb (most often the knee) presenting with a warm, swollen and painful joint.

Answer 13

The most common infections that trigger reactive arthritis are gastroenteritis or sexually transmitted infection. Chlamydia is the most common sexually transmitted cause of reactive arthritis. Gonorrhoea commonly causes a gonococcal septic arthritis.

Answer 14

Management of reactive arthritis when septic arthritis is excluded: • NSAIDs • Steroid injections into the affected joints Systemic steroids may be required, particularly where multiple joints are affected

Answer 15

Chronic multi-system inflammatory disorder characterised by inflammation of the sacroiliac joints & axial skeleton. Part of the SpA group & a/w HLA-B27 - tends to present in young men as chronic back pain, morning stiffness & eventually spinal deformity • Back pain - worse w/ rest, better w/ exercis • Neck pain • Alternating buttock pain • Morning stiffness • Fatigue • Arthritis • Enthesitis (inflammation at the insertion of tendons and ligaments) • Positive Schöber test (assesses decrease in lumbar spine flexion) Spinal deformity (seen in advanced disease)

Answer 16

○ Aortitis - can lead to aortic regurgitation ○ Anterior uveitis - unilateral red eye, pain & photophobia ○ AV block ○ Apical lung fibrosis ○ Amyloidosis IgA nephropathy

Answer 17

Modified New York criteria - clinical & radiological criteria Bloods - FBC, U&Es, LFTs,CRP & ESR, HLA-B27 Imaging - Plain SIJ XR OR MRI SIJ & whole spine if XR normal ``` Management - Non-pharmacological Treatments • Patient Education • Smoking Cessation • Input from PT & Ots • Psychological support Pharmacological • NSAIDs - naproxen, ibuprofen, celecoxib ○ Along w/ PPI ○ Relieve symptoms & help w/ physio DMARDs - tend to be ineffective ```

Answer 18

• Thickening of skin in 2 distinct subtypes: ○ Limited (distal elbows, knees & neck) or diffuse • Raynaud's phenomenom • Digital ulceration • ILD • Renal disease - accelerated HTN & proteinuria • Pulmonary hypertension Investigations & Diagnosis: Auto-antibodies • ANA, Scl-70, anticentromere, anti-RNA polymerase Others - investigations for complications • Lung (pulmonary fibrosis) - CXR, pulmonary function tests, high resolution CT scan Heart (pericariditis) - ECG, echo

Answer 19

``` Fatigue Weight loss Arthralgia (joint pain) and non-erosive arthritis Myalgia (muscle pain) Fever Photosensitive malar rash. This is a “butterfly” shaped rash across the nose and cheek bones that gets worse with sunlight. Lymphadenopathy and splenomegaly Shortness of breath Pleuritic chest pain Mouth ulcers Hair loss Raynaud’s phenomenon ```

Answer 20

Definition: Large vessel vasculitis which is sight-threatening Inflammation of medium & large sized arteries - preferential involvement of branches of carotid (Temporal, ophthalmic & occipital) Presentation/Clinical Features: • Unilateral headache - usually temporal • Scalp pain • Jaw/tongue claudication • Visual symptoms - blurring, amaurosis fugax (temporary monocular blindness), diplopia • Constitutional symptoms: fever, weight loss, fatigue Investigations & Diagnosis: Suspected GCA should be assessed immediately w/ urgent referrals to rheumatology & ophthalmology team Bloods • FBC • U&E • LFT • ESR/CRP: typically elevated but may be normal at presentation (<5%). Keep a high index of suspicion Temporal artery biopsy Sampling of a small piece of tissue from the temporal artery. Due to the presence skip lesions, a negative biopsy does not exclude GCA Management: Immediate management • Start steroids immediately - do not wait for investigations ○ 40mg OD if no visual sx or jaw/tongue claudication ○ 60mg OD if those sx are present ○ Consider IV steroids if signs of cerebral ischaemia or visual loss Ongoing management • Regular monitoring - ESR & CRP • Steroid reducing plans ○ + protection i.e. bone, PPI cover

Answer 21

o Granulomatosis w/ polyangiitis – small vessel vasculitis which affects respiratory tract & kidneys, a/w cANCA  Epistaxis, crusty nasal secretions, hearing loss & sinusitis  Cough, wheeze, haemoptysis, ILD  Glomerulonephritis  Rashes o Eosinophilic granulomatosis with polyangiitis – small & medium vessel vasculitis, a/w pANCA  Lung & skin manifestations but can affect other organs inc kidneys  Often presents w/ severe asthma in late teenage years or adulthood  Elevated eosinophil levels on FBC o

Answer 22

o Autoimmune disease which attacks exocrine glands, resulting in  Dry eyes, dry mouth, dry vagina & dry skin o Extra-glandular features: dysphagia, ILD, sensory neuropathy, arthralgia, CNS complications o Can also cause gland swelling – but if persists think about lymphoma Substitute lubricants for dry eyes & mouth, steroids & immunosuppressants can be used for systemic disease

Answer 23

Polymyositis & dermatomyositis are autoimmune disorders where there is inflammation in the muscles (myositis) ® Polymyositis – chronic inflammation of muscles ® Dermatomyositis – is a CTD where there is chronic inflammation of the skin and muscles • Clinical Features: muscle pain, fatigue, weakness ○ Occurs bilaterally & typically affects proximal muscles ○ Mostly affects shoulder & pelvic girdle Develops over weeks Can be a paraneoplastic syndrome for ovarian, lung, breast & gastric cancers • Corticosteroids are the first line treatment of both conditions. • Other medical options where the response to steroids is inadequate: • Immunosuppressants (such as azathioprine) • IV immunoglobulins Biological therapy (such as infliximab or etanercept)

Rheumatology Flashcards

(47 cards)