Rheumatology Flashcards
(130 cards)
1
Q
Alendronic acid
A
Bisphosphonate
2
Q
Scleroderma symptoms
A
Shiny skin patches (SCLERO DERMA) from fibrosis
Raynaud’s
Dysphagia
Limited ROM
3
Q
Investigation for scleroderma
A
Serum nuclear antigens (anti nuclear antibodies ANA)
- Anti-SCL 70
- Anti-centromere antibodies (ACA)
4
Q
Ankylosing spondylitis presentation
A
YOUNG, MALE BACK STIFFNESS (inflammatory - improves with exercise) + worse morning/night Weight loss, fever, fatigue Uveitis (red inflamed eyes) FHx arthritis Other autoimmune conditions
5
Q
Non-inflammatory presentation in MSK
A
Does NOT improve with exercise
6
Q
Ankylosing spondylitis investigation
A
X-Ray: BAMBOO SPINE (calcification of ligaments), narrowing of joint spaces, fusion of sacro-iliac joints, squaring of the vertebral bodies,
Bloods: HLA B27 (90%)
7
Q
Reactive arthritis presentation
A
Post-infection e.g. STI (chlamydia)
Can’t see (conjunctivitis)
Can’t pee (urethritis)
Can’t climb a tree (arthritis)
8
Q
SeroNEGATIVE spondyloarthropathy
A
= ABSENCE of RF and anti-CCP
+ strong HLA-B27 association
Psoriatic arthritis
Ankylosing spondylitis
Reactive arthritis
IBD associated
SPINEACHE Sausage digit (dactylitis) Psoriasis Inflammatory back pain NSAIDs: good response Enthesitis (particularly in the heel) Arthritis Crohn’s/Colitis/elevated CRP (can be normal in AS) HLA-B27 Eye (Uveitis)
9
Q
Multiple myeloma investigations
A
Diagnostic: Serum electrophoresis (IgG, IgA, light chain proteins) + CRAB symptoms
Prognostic: Serum LDH (lactate dehydrogenase), CRP, B2-microglobulin, albumin
10
Q
Management of septic arthritis
A
SEPSIS 6 (TAKE 3 + GIVE 3) Joint aspiration (Dx - cultures, Tx - arthrocentesis)
11
Q
Risk factors for septic arthritis
A
immunosuppressants diabetes HIV old age IV drug use
12
Q
Most likely causative organism for septic arthritis
A
Staph aureus
13
Q
Presentation of septic arthritis
A
RED, HOT, SWOLLEN joint (isolated, different to reactive = multiple areas affected)
Fever + systemically unwell
14
Q
Paget’s disease of the bone
A
Abnormal bone turnover: body absorbs OLD bone (osteoclasts) and forms ABNORMAL NEW bone
= structurally disorganised + weaker mosaic bone (woven bones)
15
Q
1st line treatment of Paget’s
A
Bisphosphonates: IV Zoledronate (suppresses osteoclast OR osteoblast overactivity)
- used for ANY bone turn over abnormality
Adjunct: NSAIDs
16
Q
Goodpasture’s syndrome Ix
A
anti glomerular basement membrane (anti-GBM) antibodies
17
Q
Gold standard investigation for RA
A
Anti-CCP (specific)
RF is 70% sensitive
18
Q
key clinical features found in the arms/hands of RA patients
A
ulnar deviation
swan neck deformity
boutonniere deformity
19
Q
RA signs on X-ray
A
LESS:
loss of joint space
EROSION of bones
soft tissue swelling
Soft bones
20
Q
one joint never affected in RA
A
DIPJ
21
Q
marker to monitor progression of RA
A
CRP
ESR takes too long to change so not immediate
22
Q
RA treatment
A
DMARDs
23
Q
Autoimmune cause of miscarriage
A
Antiphospholipid syndrome
- antibodies stop the egg from implanting and inhibit growth of foetal cells
24
Q
Autoimmune cause of increased clotting
A
APL
25
APL treatment
Lifestyle
Anticoagulation:
- Chronic: warfarin
- Pregnancy: heparin + aspirin (warfarin is TERATOGENIC)
26
SLE risk factors
```
female
HLA gene
other autoimmune conditions
FHx
UV radiation
```
27
SLE clinical manifestations
systemic: glomerulonephritis, CNS (psychiatric), glomerulonephritis, joint pain, pericarditis
erythematosus: RED MALAR PHOTOSENSITIVE RASH
28
two gold standard diagnostic markers for SLE
ANA (anti nuclear antibodies) - VERY SENSITIVE but not very specific
anti-dsDNA (double stranded) - periods of active disease
29
ESR and CRP changes in SLE
high ESR
| normal CRP
30
SLE Tx
1st line: oral corticosteroids (prednisolone)
hydroxychloroquine
methotrexate
31
Gout causes
Thiazides (urea reabsorption)
High purine diet
Tumour lysis syndrome
32
Gout treatment
a) <1 flare up
b) acute + >1 flare up
b) long-term
a) educate on lifestyle changes
b)
1st line - NSAIDs or Colchicine (C for aCute😚)
2nd line - intra-articular steroid injection
c)
1st line - Allopurinol [inhibits xanthine oxidase synthesis] with colchicine
2nd line - febuxostat
33
Gout investigation
1st line: bloods
- confirm hyperuricaemia
Gold standard: BIOPSY
- polarised light microscopy of the synovial fluid: NEEDLE SHAPED NEGATIVELY birefringent crystals
34
Psuedogout investigation
polarised light microscopy of the synovial fluid: RHOMBOID POSITIVELY birefringent
35
Osteoarthritis Px + X-Ray signs
```
LOSS:
Loss of (Narrowed) joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts
```
Joint pain worse with movement
Stiffness on rest
Limited joint movement
Bone swelling in fingers (Heberden, Bouchard)
36
Osteoarthritis:
HD
BP
Heberden - distal
| Bouchard - proximal
37
Red flags for BACK PAIN - TUNA FISH
1st line management: refer to hospital for urgent assessment
38
Osteoporosis DEXA scan results
DEXA: Dual Energy X-Ray Absortiometry
| T score below -2.5 = diagnostic
39
Osteoporosis risk factors
```
Age (post-menopausal women)
Steroid use
Hyperthyroidism
Alcohol and smoking
Low BMI
Alcohol abuse
Female
```
40
Osteoporosis treatment
1st line: Bisphosphonates (alendronate) and AdCal (Vit D + calcium)
2nd line: Denosumab (monoclonal RANK ligand)
41
Side effects of bisphosphonates
```
TMJ osteonecrosis
GI upset (sit upright after taking medication to prevent oesophageal cancer + take first thing in the morning with water)
```
42
Rickets presentation
young
malnourished (Vit D deficiency)
bowed femur + tibia (may present as waddling gait)
Rickets in adults = Osteomalacia
43
Rickets pathophysiology
Inadequate calcium for mineralisation = excessive non-mineralised osteoid build up
44
RANK-L
activates osteoclasts, promoting bone reabsorption
45
Osteomyelitis causative organisms
Staph aureus: most common
Salmonella species: SICKLE CELL
Neisseria gonorrhoea: sexually active
Pseudomonas aeruginosa: diabetes, IVDU, puncture wounds
46
Multiple myeloma
Bone marrow cancer
| Cancerous PLASMA cells (>10%)
47
Multiple myeloma symptoms
```
CRAB:
Calcium (HIGH)
Renal
Anaemia
Bone problems
```
48
Osteoarthritis
LOSS of CARTILAGE + DISORDERED BONE repair
Most common arthritis
F > M
49
Major risk factor for OA
Obesity
50
Joints affected in OA
Large weight bearing joints (knees, hips)
51
Osteoarthritis treatment
Paracetamol (analgesics ladder > NSAIDs etc)
Cortisol intraarticular injections (methylprednisolone)
Joint replacement
Weight loss
Lifestyle
52
RA diagnostic criteria
```
RF RISES
Rheumatoid factor POSITIVE
Fingers/hand/wrist involvement
Rheumatoid nodules present
Involvement of >3 joints
Stiffness in the morning for >1 hour
Erosions seen on X-Ray
Symmetrical involvement
```
More than 6 weeks, More than 4 of the above
53
Rheumatoid arthritis
Autoimmune disease
Symmetrical, deforming, peripheral polyarthris
F X3 > M
54
RA Px
Pain in affected joints
Hand deformities
Morning stiffness >30 minutes
Systemic: scleritis, pleural effusions, pericarditis
55
RA Tx
DMARDs (disease modifying antirheumatic drugs)
- METHOTREXATE (with folate)
Steroids
Biologics (TNF-a blockers, Infliximab, B-cell inhibitors (Rituximab))
NSAIDs, Opioids for pain management
56
Feltys syndrome/triad
Presence of 3 conditions:
SPLENOMEGALY
RA
GRANULOCYTOPENIA (neutropenia)
57
Osteoporosis
DECREASE in bone density and micro-architectural deterioration
>> INCREASE in bone fragility and susceptibility in fracture
58
Causes of osteoporosis
Endocrine (Cushing’s, PTH)
Haematology (Myeloma)
GI (malabsorption)
Iatrogenic (steroids)
59
Osteoporosis Px
Not clinically apparent until a fracture occurs
60
Risk assessment for osteoporosis
FRAX
| Qfracture
61
Systemic lupus erythematosus
Inflammatory, multisystem autoimmune disorder with arthralgia and rashes
Female 9X > Males
Peak 20-40 yo
TYPE 3 Hypersensitivity
62
Antiphospholipid syndrome
Antibody-mediated thrombophilia characterised by thrombosis (arterial or venous) and/or recurrent miscarriages
Associated with SLE in 20-30%
63
APL syndrome Px
Coagulation defects
Pregnancy issues
Thrombocytopenia
Livedo reticularis (below)
64
APL diagnostic criteria
At least 1 clinical and 1 lab
Clinical:
- vascular thrombosis
- pregnancy morbidity
Lab:
- anticardiolipin antibody
- lupus anticoagulant
- anti B2 glycoprotein 1 antibody
65
APL arterial thrombosis
More common in males
MI, stroke
Libman-Sacks endocarditis
66
APL venous thrombosis
More common in females
| PE, DVT
67
Sjogrens definition
Chronic inflammatory autoimmune disorder
destruction of EPITHELIAL EXOCRINE glands (especially the LACRIMAL and SALIVARY glands)
typically occurs in women
68
Sjogrens Px
Dry eyes, mouth, parotid gland enlargement
Joint pain
Raynauds
Systemic features
Associated with RA, SLE, PBC, scleroderma
69
Sjogrens Ix
Rose Bengal staining and slit lamp eye exam
Rheumatoid factor, ANA, Anti-Ro (SSA), Anti-La (SSB)
70
Sjogrens Tx
Lifestyle: humidifier, eye drops, mouth wash
Medications: NSAIDs, hydroxychloroquine, pilocarpine (M3 agonist - increase exocrine secretions)
71
Raynaud’s phenomenon
Intermittent spasm in the arteries supplying the fingers and toes usually precipitated by cold and relieved by heat
Associated with: SLE, scleroderma, RA, dermatomyositis
Tx: CCB
72
Exocrine vs endocrine gland
Exocrine: ductal system
Endocrine: directly into bloodstream
73
Systemic sclerosis patho
Multisystem autoimmune disease
Increased fibroblast activity (causing increased COLLAGEN deposition) = abnormal growth of connective tissue
Highest mortality of autoimmune rheumatic diseases
74
CREST
Calcinosis - calcium deposits in subcutaneous tissue
Raynaud’s
Eosophageal dysmotility or strictures
Sclerodactylyl (local thickening on fingers/toes)
Telenagiectasia (spider veins)
75
Scleroderma Px
Limited (CREST): hands, face, feet, forearms; ‘beak’ like nose and small mouth (microstomia)
Diffuse: widespread skin changes, organ damage occurs earlier (GI e.g. GORD, renal, lung)
76
Scleroderma Tx
Immunosuppressants
```
Symptom relief:
PPIs (GI)
ACEi (renal)
Cyclophosphamide (pulmonary fibrosis)
CCB (Raynaud’s)
```
77
Polymyositis/dermatomyositis
RARE MUSCLE DISORDER
Unknown aetiology
Inflammation and necrosis of skeletal muscle fibres
Dermatomyositis = poly + skin involvement
78
Polymyositis Px
Symmetrical progressive muscle weakness and wasting of the proximal muscles of the shoulder and pelvic girdle
79
Dermatomyositis Px
Heliotrope (purple) discolouration of eyelids
| Scaly erythematous plaques over the knuckles
80
Polymyositis Ix
Muscle biopsy
Bloods: INCREASED creatine kinase, aminotransfersases, LDH, aldolase
Immunology: ANA
81
Polymyositis Tx
1. ORAL PREDNISOLONE
2. Stronger immunosuppressants
Symptomatic treatment of skin disease
82
Paget’s disease of the bone Px
```
Rare under 40 y/o
60-80% are ASYMPTOMATIC
- bone + joint pain
- SKULL CHANGES
- neurological changes
- bowed tibia
```
83
Paget’s disease of the bone Ix
Bloods: marked increase in ALP but NORMAL calcium + phosphate
Urinary hydroxyproline increased
X-ray: osteoarthritis
84
Osteomalacia
DEFECTIVE MINERALISATION of newly formed bone matrix or osteoid in ADULTS
Due to inadequate phosphate or calcium, or due to increased bone resorption (hyperPTH)
85
Rickets
DEFECTIVE MINERALISATION at EPIPHYSEAL GROWTH PLATE (not present in adults)
AKA osteomalacia in CHILDREN
86
Osteomalacia aetiology
Malnutrition (most common) - Vit D, PO4, Ca
Drug induced
Defective 1-alpha hydroxylation
Liver disease
87
Px of osteomalacia in adults
Widespread bone pain and tenderness
Gradual onset and persistent fatigue
Muscle weakness
FRACTURES
88
Px of rickets
```
LEG BOWING and knock knees - WADDLING GAIT
- tender swollen joints
- IMPAIRED GROWTH
- bone and joint pain
Dental deformities
```
89
Osteomalacia Ix
Bloods: U&Es (low calcium), high serum ALP, low Vit D
| X-Rays: defective mineralisation, rachitic rosary
90
Osteomalacia Tx
Lifestyle: nutrition, sunlight
Medications: Vit D replacement
Malabsorption/renal disease: IM calcitrol
91
Alkaline phosphatase (ALP) role
1. Osteoblast activity = increased ALP e.g. Paget’s
| 2. Bone mineralisation (calcium + phosphate deposition into osteoid)
92
why can liver disease cause osteomalacia
LIVER: Inactive vitamin D > 25-OH-Vitamin D
Kidneys: 1-alpha-hydroxylase converts 25-OH-Vit D to CALCITRIOL i.e. active Vitamin D which increases renal reabsorption of calcium + intestinal absorption of calcium + phosphate)
93
Parathyroid hormone
Secreted in response to LOW blood CALCIUM
1. Stimulates resorption of calcium (and a small amount of phosphate) from the bone
2. Boost 1-alpha hydroxylase activity = active Vit D
3. Increases calcium reabsorption and phosphate excretion from the kidneys
94
Most common cause of rickets and osteomalacia
VITAMIN D DEFICIENCY
- intestinal malabsorption (coeliac, crohns)
- lack of UV light exposure (home bound)
- medications e.g. phenytoin (uses hydroxylase enzymes)
- liver + kidney disease
95
PAMPs
Pathogen associated molecular patterns
| Bacterial surface antigens recognised by the innate immune system as FOREIGN
96
Antibiotic management septic arthritis
Staph aureus:
Flucoxacillin
- penicillin-allergy: gentamicin
- MRSA: vancomycin
Gonococcal or Gram -ve (E. Coli)
- cefotaxime
97
Causative organisms of septic arthritis
Most common: staph aureus
Sexually active: neisseria gonorrhoea
Kids: Haemophilus influenza
Gram -ve: E. Coli
98
Gonococcal arthritis
Sexually active adolescents
SPREADS HAEMATOGENOUSLY from initial infection
Affects MULTIPLE JOINTS
Skin lesions + tenosynovitis
99
Food high in purines
```
Red meat
Organ meat e.g. liver
Seafood
Beans
Beer
```
100
Breakdown product of purines
Uric acid
101
Tumour lysis syndrome
Large number of cancer cells die within a short period, releasing their contents into the blood
102
Gout
Uric acid deposits in joint spaces = inflammation (usually of the big toe - podagra)
103
Tophi gout
Uric acid crystals form masses of white growths around the joints and tissues that gout has affected
104
Stages of gout
105
Pseudogout
Px of gout but caused by CALCIUM PYROPHOSPHATE crystals
106
Osteomyelitis
INFECTION of the BONE MARROW causing INFLAMMATION
Myelo = bone marrow
107
Three main ways of organism entry in osteomyelitis
Haematogenous spread
Open wound/surgery
Contiguously (skin infection e.g. cellulitis > bone)
108
Stages of osteomyelitis
Acute inflammation
Resolution Or progression to Chronic:
Subperiosteal abcess
Sequestrum (necrotic bone within pus)
Involvcrum (new bone surrounding sequestrum)
Cloacae (opening to allow dead bone and bus to come out)
109
Most common causative organism of osteomyelitis
Staphylococcus aureus
- skin > bone
- haematogenous spread
110
High risk individuals for salmonella infections
Sickle cell disease patients
111
Osteomyelitis diagnosis
FBC: CRP, ESR, WCC
X-Ray, MRI
Gold standard: Biopsy + culture
112
Psoriatic arthritis (summary)
Occurs in 10-40% of people with psoriasis (psoriasis = autoimmune destruction of skin cells) - T cells activate osteoblasts + osteoblasts
Painful, swollen, stiff joints
Psoriatic plaques
Dactylitis (sausage fingers)
Telescopic fingers
X-ray: PENCIL IN CUP (thin bone in soft tissue swelling)
113
Osteosarcoma
Primary bone malignancy
Associated with Paget’s disease
Sunburst appearance on X-Ray
114
Osteochondroma
Benign overproduction of bone which deposits on metaphysis
Very common in males <25
Exostosis on X-Ray
115
Secondary bone tumours
```
PB KTL (Lead kettle)
Prostate
Breast
Kidneys
Thyroid
Lungs
```
116
Most common cause of back pain
Mechanical (sprains and strains)
117
Red flags diseases for lower back pain
Cauda equina
Cancer of the spine
Spinal fracture (trauma or osteoporotic collapse)
Spinal infection
Ix: inflammatory markers, FBC, ALP, DEXA scan, MRI (bone pathology)
118
Neuropathic pain relief
TCA
Gabapentin
Pregabalin
119
DMARDs
Non-biologic: methotrexate, leflunomide, sulfasalazine
| Biological: TNF-a inhibitors
120
Ankylosing spondylitis patho
Spondylitis = inflammation of the vertebrae
Autoimmunity against type 1+2 collagen (intervertebral discs + sacroiliac joints) = fibrous deposits + ossification
121
ANCA positive vasculitis
Granulomatosis with polyangiitis
122
Citrullination
Deimination: arginine > citrulline
Immune system attacks citrullinated proteins
Occurs in RA
Anti-citrullinated peptide antibodies (ACPA)
- detected by anti-cyclic citrullinated peptides (anti-CCP) (98% specific for RA diagnosis and can preclude diagnosis)
123
Complications of SLE
Kidney failure
CV: Heart attack, Pericarditis
CNS: Seizures, Stroke
Super infection
124
Lofgrens triad (sarcoidosis)
- Erythema nodosum
- Bilateral hilar lymphadenopathy
- Polyarthralgia (pain in more than one joint)
125
Sarcoidosis Ix
CXR: hilar lymphadenopathy
Serum ACE
FBC: anaemia, leukopenia
Serum Urea:Creatinine (kidney involvement)
Serum CALCIUM (hypercalcaemia): elevated Vitamin D due to macrophages
Spirometry
Histology (non caseating granulomas)
126
Sarcoidosis Tx
```
Corticosteroids
Ventilators support
Oxygen
Lung transplant
Hydroxychloroquine
```
127
Dermatomyositis Ix
```
Creatine kinase
Electromyography
Muscle biopsy
Autoantibodies: Anti-Jo-1 antibodies, Anti-Mi-2 antibodies, Anti-nuclear antibodies
Spirometry
```
128
Dermatomyositis Tx
IV corticosteroids
129
1st line Mx for ankylosing spondylitis
NSAIDs and physiotherapy
130
pain and pins-and-needles in his left hand
worse in the morning than at night, and it usually feels quite numb when he first wakes up until he starts to move it around more
You lightly tap the area just below the palm in the middle of the wrist with your finger and he gets the same sensation of the pins and needles he has been experiencing.
Which nerve is responsible for these symptoms?
Median nerve - CARPAL TUNNEL SYNDROME
