RHEUMATOLOGY Flashcards
(114 cards)
1
Q
What are the risk factors for osteoarthritis?
A
Female Age Overuse Trauma Family history
2
Q
What is the pathophysiology of OA?
A
Imbalance between the cartilage being worn down and the chondrocytes repairing it.
3
Q
Which joints are commonly affected in OA?
A
Knees
Hip
DIP
Sacroiliac
4
Q
What are the findings on XR in OA?
A
L - loss of joint space
O - osteophyte formation
S - subchondral sclerosis
S - subchondral cysts
5
Q
What signs can be seen in the hands in OA?
A
Heberden’s nodes (DIP)
Bouchard’s nodes (PIP)
Squaring of the base of the thumb (carpo-metacarpal joint)
6
Q
How is OA diagnosed?
A
Can be diagnosed clinically without investigation if:
45 years old
No morning stiffness (<30 mins)
Activity related pain
7
Q
What is first-line management for OA?
A
Weight loss
OT, physio and orthotics can also help.
8
Q
Which joints are most commonly replaced in OA?
A
Knees
Hips
9
Q
What are the risk factors for RA?
A
Female (3x more common)
Family hx
10
Q
What is the pathophysiology of RA?
A
Autoimmune condition that causes chronic inflammation of the synovial lining of the joints, tendon sheaths and bursa.
11
Q
Which joints are commonly affected in RA?
A
PIP and MCP Wrists Ankles Cervical spine Knees and shoulders
12
Q
What age do patients present with RA?
A
Middle age (but can be any)
13
Q
What are the genetic associations of RA?
A
HLA-D4 (RF positive patients)
HLA-D1 (less common)
14
Q
What is the key antibody involved in RA?
A
Rheumatoid-factor
15
Q
What does RF target?
A
Fc portion of IgG
16
Q
Which antibody is most specific for RA?
A
Anti-CCP (cyclic citrullinated peptide antibodies)
17
Q
How does RA present?
A
Joint pain
Stiffness
Swelling
Systemic symptoms: flu-like, myalgia, weight loss, fatigue
18
Q
What is palindromic rheumatism? How long does it last?
A
Flare of RA
48 hours
19
Q
What is atlantoaxial subluxation?
A
Local synovitis that can lead to spinal cord compression in RA
20
Q
Name 4 key changes in the hands in RA.
A
Swan-neck deformity OR Boutonniere’s deformity
Z-shaped deformity of the thumb
Ulnar deviation
21
Q
Name some extra-articular manifestations of RA?
A
Pulmonary fibrosis Bronchiolitis obliterans Felty's syndrome Anaemia of chronic disease Episcleritis Amyloidosis
22
Q
What is Caplan’s syndrome?
A
Pulmonary fibrosis in RA
23
Q
What is Felty’s syndrome?
A
RA
Neutropenia
Splenomegaly
24
Q
What are the findings on XR in RA?
A
Joint destruction and deformity
Soft tissue swelling
Periarticular osteopenia
Bony erosions
25
Which four factors are used to diagnose RA?
1. Small/symmetrical joint distribution
2. Serology
3. Inflammatory markers
4. Duration of symptoms
Score equal or greater than 6 = RA
26
What investigation might be needed for patients with RA requiring a GA?
Cervical MRI
27
Which blood tests are done in RA?
RF
Anti-CCP
ESR/CRP
FBC - anaemia
28
What is HAQ?
| What is it used for?
Health Assessment Questionnaire - measures functional ability in RA
29
What is the DAS28 score?
Looks at severity of RA
30
What factors indicate worse prognosis in RA?
```
Male
Early onset
More joints affected
Presence of RF/anti-CCP
Erosions on XR
```
31
When should you refer to rheumatology? When should the referral be urgent?
Any adult with persistent synovitis.
| Urgent = if involving the small joints of the hands/feet.
32
What does DMARDs stand for? Name 4 different types of DMARD.
Disease modifying anti-rheumatic drugs.
Methotrexate
Sulfasalazine
Leflunomide
Hydroxychloroquine
33
What are the treatment steps in medical management of RA?
1. Methotrexate monotherapy
2. Combined DMARD
3. Methotrexate + biological therapy
4. Methotrexate + rituximab
34
Name 4 different types of biological therapy used in RA.
Anti-TNF: Infliximab
Anti-CD20: rituximab
Anti-IL6
JAK inhibitors
35
What is the most important side effect of biological therapies?
Immunosuppression
36
Name a notable side effect of methotrexate?
Pulmonary fibrosis
37
Name a side effect of Rituximab.
Night sweats
| Thrombocytopenia
38
Name a side effect of sulfasalazine.
Male infertility
39
Name a side effect of hydroxychloroquine.
Nightmares and reduced visual acuity.
40
Name a side effect of anti-TNF medications.
Reactivation of TB/hepatitis B
41
What are the red flags for lower back pain?
```
Age <20 or >50
History of previous malignancy
Night pain
History of trauma
Systemically unwell
```
42
What is scleroderma?
autoimmune inflammatory and fibrotic connective tissue disease.
43
What are the two patterns of disease seen in scleroderma?
Limited cutaneous systemic sclerosis
| Diffuse cutaneous systemic sclerosis
44
What is another name for limited cutaneous systemic sclerosis?
CREST syndrome
45
What are the features of limited cutaneous systemic sclerosis?
```
Calcinosis
Raynauds phenomenon
Esophageal dysmotility
Sclerodactyly
Telangiectasia
```
46
What is the appearance of the skin in scleroderma? Where is it most noticeable?
Skin, hard skin - can lead to breaking and ulceration
| Hands and face
47
What is telangiectasia?
Small dilated veins
48
How does SS affect the lungs?
Pulmonary fibrosis
| Pulmonary hypertension
49
How does SS affect the kidneys?
Scleroderma renal crisis: renal failure and hypertension
50
What is the difference between primary and secondary Raynaud's?
Primary - just Raynaud's
| Secondary - Raynaud's with systemic disease
51
Which three autoantibodies are positive in patients who have SS?
```
Antinuclear antibodies (ANA) - non-specific
Anti-centromere antibodies = limited
Anti-Scl-70 antibodies = diffuse
```
52
Which antibodies are most associated with limited cutaneous systemic sclerosis?
Anti-centromere antibodies
53
Which antibodies are most associated with diffuse cutaneous systemic sclerosis?
Anti-Scl-70 antibodies (associated with most severe disease)
54
Anti-ANA antibody is positive in which other autoimmune conditions?
SLE
| Autoimmune hepatitis
55
What is nail fold capillaroscopy? What are the findings in SS?
This is a technique where the area where the skin meets the fingernails at the base of the fingernail (the nailfold) is magnified and examined. This allows us to examine the health of the peripheral capillaries.
Abnormal capillaries, avascular areas and micro-haemorrhages indicate systemic sclerosis.
56
Medical management of scleroderma?
```
• Nifedipine --> Raynaud's
• PPI --> oesophageal dysmotility
• Analgesia --> joint pain
• Abx ---> skin infection
Antihypertensives ---> HTN
```
57
What is seen on temporal arteritis histology?
'skips' certain sections of the affected artery whilst damaging others.
58
What are the features of GCA?
```
> 60 years old
rapid onset (e.g. < 1 month)
headache (85%)
jaw claudication (65%)
visual disturbances
tender temporal artery
```
59
Which blood tests should be done in GCA?
ESR >50
| CRP^
60
What is the management of GCA?
Immediate high dose glucocorticoids = PO prednisolone
Urgent opthalmology review
Bone protection (due to steroid treatment)
61
What is the management of GCA with evolving visual loss?
IV methylprednisolone
62
Which feature seen on XR distinguishes RA from OA?
Osteophyte formation
63
Which features of ankylosing spondylitis are seen on XR?
- sacroiliitis: subchondral erosions, sclerosis
- squaring of lumbar vertebrae
- 'bamboo spine' (late & uncommon)
- syndesmophytes: due to ossification of outer fibers of annulus fibrosus
- chest x-ray: apical fibrosis
64
If there is a high suspicion of AS but XR is negative, what is the next step?
MRI
65
What will spirometry show in AS?
Restrictive pattern: PF, kyphosis and analysis of the costovertebral joints
66
What is the management of AS?
Excerise (swimming)
NSAIDs
Physio
67
When should you use DMARDs and Anti-TNF therapies in AS?
DMARDs (Sulphasalazine) - peripheral involvement
Anti-TNF (Etanercept) - persistent disease despite treatment
68
What is shown on joint aspirate in RA?
^WBC (neutrophils)
Yellow/cloudy
No crystals
69
How many types of hypersensitivity reaction are there?
5
70
What are the 5 types of hypersensitivity reaction?
```
1 = Anaphylactic (asthma)
2 = cell bound (ITP)
3 = immune complex (SLE)
4 = T cell mediated (MS/TB)
5 = antibodies (Graves/MG)
```
71
How can you remember the hypersensitivity reactions?
```
ABCD
I: Anaphylactic
II: Binding antibodies
III: Complex-mediated
IV: Delayed
```
72
What is gout?
deposition of monosodium urate monohydrate in the synovium
| It is caused by chronic hyperuricaemia (uric acid > 450 µmol/l)
73
What is the first-line management in gout?
NSAIDs/colchicine
Max dose of NSAIDs prescribed until 1-2 days after symptoms resolution
74
What is the main side-effect of colchicine?
Diarrhoea
75
What are the indications for urate lowering therapy?
all patients after first attack of gout
76
What is first-line for urate lowering therapy?
Allopurinol
aim for uric acid <300
77
What lifestyle advice should be given to a patient with gout?
1. reduce alcohol intake and avoid during an acute attack
2. lose weight if obese
3. avoid food high in purines e.g. Liver, kidneys, seafood, oily fish (mackerel, sardines) and yeast products
78
Which drugs should be stopped in gout?
Thiazides
Losartan
(increase vitamin C intake)
79
Which risk factors are used in the FRAX score? (6)
1. history of glucocorticoid use
2. rheumatoid arthritis
3. alcohol excess
4. history of parental hip fracture
5. low body mass index
6. current smoking
80
What is Behcet's syndrome?
multisystem disorder associated with presumed autoimmune-mediated inflammation of the arteries and veins.
81
What is the triad of symptoms seen in Behcet's syndrome?
oral ulcers, genital ulcers and anterior uveitis
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
82
How is Behcet's diagnosed?
Clinical
HLA B51
83
What are the most common causes of drug-induced lupus?
procainamide
hydralazine
others: isoniazid
minocycline
phenytoin
84
Which antibodies are positive in drug-induced lupus?
Anti-histone antibodies
85
What should be checked in a man who presents with osteoporosis?
testosterone (hypogonadism)
86
Which complement levels might be low in SLE?
C4a and C4b
87
What is seen on blood tests in osteoporosis?
Normal
88
Which immunoglobulins are found in breast milk?
IgA
89
What is the first-line treatment for primary Raynaud's?
Nifedipine
90
How do patients present with osteomalacia?
Bone pain
Proximal myopathy
Waddling gait
91
What is the pathophysiology of osteomalacia?
Vit D def
| Decreased bone mineralisation --> bone softening
92
What is the most common cause of septic arthritis in adults who are sexually active?
Neisseria gonorrhoea
93
Which investigations should be done in septic arthritis?
Synovial fluid sampling
Blood cultures
XR
94
What is the first-line treatment of septic arthritis?
IV flucloxacillin 4-6 weeks
Oral after 2 weeks
needle aspiration can decompress the joint
95
Name 5 skin symptoms seen in dermatomyositis.
```
Gottron lesions (looks like psoriasis)
Photosensitive rash
Heliotrope rash (purple eyelids)
Periorbital oedema
Calcinosis
```
96
Which malignancies are associated with polymyositis/dermatomyositis?
Lung
Breast
Ovarian
Gastric
97
Which antibodies are seen in polymyositis?
Anti-Jo
98
Which antibodies are seen in Dermatomyositis ?
Anti-mi-2
anti-nuclear
anti-jo
99
How do you obtain a definitive diagnosis for dermatomyositis/polymyositis?
Muscle biopsy
100
What is seen on XR in ankylosing spondylitis?
```
4S's:
Squaring of the vertebral bodies
Subchondral sclerosis
Subchondral erosions
Sacroilitis
```
+Bamboo sign (late)
Syndesmophytes are areas of bone growth where the ligaments insert into the bone. They occur related to the ligaments supporting the intervertebral joints.
Ossification of the ligaments, discs and joints. This is where these structures turn to bone.
Fusion of the facet, sacroiliac and costovertebral joints
101
What is the medical management of ankylosing spondylitis?
1. NSAIDs
2. Steroids (oral or injections)
3. Anti-TNF
+physio
+stop smoking
102
Which antibody is positive in ankylosing spondylitis?
HLA-B27
103
Name some extra-articular manifestations of ankylosing spondylitis
Systemic symptoms such as weight loss and fatigue
Chest pain related to costovertebral and costosternal joints
Enthesitis (plantar fasciitis and achilles tendonitis)
Dactylitis is inflammation in a finger or toe.
Anaemia
Anterior uveitis
Aortitis is inflammation of the aorta
Heart block can be caused by fibrosis of the heart’s conductive system
Restrictive lung disease can be caused by restricted chest wall movement
Pulmonary fibrosis (upper lobes)
Inflammatory bowel disease
104
What is SLE?
Systemic Lupus Erythematosus
Autoimmune inflammatory condition that affects multiple systems.
105
Which anti-TNF medication is used in ankylosing spondylitis?
etanercept
106
What is Sjogren's?
an autoimmune condition that affects the exocrine glands. It leads to the symptoms of dry mucous membranes, such as dry mouth, dry eyes and dry vagina
107
What is primary Sjogrens?
Occurs in isolation
108
What is secondary Sjogren's?
Occurs alongside SLE or RA
109
What is the Schirmer test?
The Schirmer test involves inserting a folded piece of filter paper under the lower eyelid with a strip hanging out over the eyelid. This is left in for 5 minutes and the distance along the strip hanging out that becomes moist is measured. The tears should travel 15mm in a healthy young adult. A result of less than 10mm is significant.
110
Which blood test is used to measure vitamin D levels?
Plasma 25(OH)D concentration
111
What level of vitamin D is classified as deficient?
<25nmol/L
112
Who is at increased risk of vitamin D deficiency?
>65 years old
Low exposure to sunlight
African, Afro-Caribbean, South-Asian
113
What signs are associated with vitamin D toxicity?
Hypercalcaemia (main)
```
Confusion
Dehydration
Muscle weakness
Vomiting
Loss of appeptite
```
114
What are the risk factors for osteoporosis?
```
• Older age
• Female
• Reduced mobility and activity
• Low BMI (<18.5 kg/m2)
• Rheumatoid arthritis
• Alcohol and smoking
• Long term corticosteroids. NICE suggest the risk increases significantly with the equivalent of more than 7.5mg of prednisolone per day for more than 3 months)
Other medications such as SSRIs, PPIs, anti-epileptics and anti-oestrogens
```
