Rheumatology

Question 1

How do osteo and rheumatoid arthritis compare on

Stiffness

Distribution

Finger joints

Systemic upset

Answer 1

Osteoarthritis // rheumatoid

Worse on movement // better on movement

Unilateral, large joints // Bilateral, smaller joints

DIP, PIP // MCP, PIP

No // Yes

Question 2

What is this XR of?

Answer 2

Osteoarthritis

Loss of joint space, osteophytes at joint margin

Question 3

What is this XR showing

Answer 3

Rheumatoid arthritis

Loss oj joint space

Perarticular erosions

Subluxation

Question 4

How do you treat osteoarthritis?

Answer 4

1. Oral paracetamol + topical NSAIDs
2. Oral NSAIDs + PPI
3. Consider weak opiates (eg codeine)

Question 5

What are the investigations and scoring cut offs for rheumatoid arthritis?

Answer 5

XR for bone status + anti-RF (do Anti-CCP if -ve as more specific)

DAS >=2.6 OR ELAR >=6.0

Question 6

What is the treatment ladder for RA?

Answer 6

1. HCQ (mild) / MTX / LFM / SFZ
2. Combo of 2 above
3. MTX + TNFi
4. MTX + rituximab

Question 7

Which DMARDs are safe in pregnancy

Answer 7

SFZ/HCQ

Question 8

Which DMARD causes

Immunosuppression

HTN + neuropathy

Strange visions (nightmares, blurry)

Reactivates TB

Answer 8

Methotrexate

Leflunomide

Hydroxychlorquine

TNFis

Question 9

How can you differentiate psoriatic arthritis from rheumatoid

Answer 9

Can be assymetrical and affect DIPs

Potentially have psoriatic lesions following the joint pain

Question 10

What are the investigations for psoriatic arthritis?

Answer 10

XR: erosion + new bone formation, ‘pencil in cup’

Question 11

What is the treatment for psoriatic arthritis?

Answer 11

NSAIDs for pain

DMARDs –> anti-TNF –> Ustekinumab

Question 12

Since they both occur following infection, how can you separate reactive arthitis and septic arthritis?

Answer 12

Perform a joint aspirate

Reactive will have no crystals or pathogens

Also, reactive arthritis has triad of cant see, pee or climb a tree

Reaactive more assoicated with GI and chlamydia while gonorrhea is more septic arthritis

Question 13

How do you treat septic arthritis

Answer 13

BNF says Fluclox (clindamycin) 4-6 weeks

IVOST after 2 weeks

Question 14

How do you distinguish ankylosing spondylitis from spinal stenosis?

Answer 14

Ank spond // Spinal stenosis

Back pain, anterior uveutis, other things beginning with A// claducation

Reduced flexion (Schober’s <5cm) // relieved on bending forward

Bamboo/question mark spine on XR // XR/MRI for canal narrowing

Question 15

What is the treatment algorithm for ankylosing spondylitis?

Answer 15

1. NSAIDs
2. DMARDs if peripheral joint involvemnet

+ TNFi if resistant

Question 16

Regarding connective tisssue diseases, which conditions are most associated with the following?

1) Anti-dsDNA
2) Anti-sm
3) Anti-histone
4) Anti-Ro
5) Anti-La
6) Anti-scl70
7) Anti-centromere
8) Anti-Jo, SRP
9) Anti-RNP

Answer 16

1-2) SLE (dsDNA more specific)

3) Drug induced lupus (will be dsDNA -ve)

4-5) Sjogren’s (Ro 70%, la 30%)

6) Diffuse systemic sclerosis
7) Limited systemic sclerosis
8) Polymyositis
9) Mixed connective tissue disease

Question 17

Joint pain + fatigue + ulcers + photosensitive rash suggests what?

Answer 17

Lupus

Question 18

For SLE, what do you use for…

Symptoms

Control

Answer 18

NSAIDs, Steroids, suncream

Mild: HCQ

Severe: Immunosuppressants

Resistant: Rituximab, belimumab

Question 19

How can PMR and myositis be distinuished based on

Features

Lab findings

Answer 19

PMR // myositis

STIFFNESS in hips and shoulders // WEAKNESS in hips and shoulders + skin maniefasations if dermatomyositis

normal CK // raised CK, anti-jo, SRP

Question 20

How do you treat polymyalgia rheumatica?

Answer 20

Exercise

5mg prednisilone

Question 21

What is the definitive investigation and treatment steps for myositis?

Answer 21

Muscle biopsy showing immune cell infiltration

40mg prednisilone

Immunosuppressants/IGs/Biologics if that does not work

Question 22

How does systemic sclerosis and polymyositis differ in terms of

Features

Antibodies

Answer 22

polymyositis // Systemic sclerosis

Both have fibrosis and dysmotility

Proximal muscle weakness // CREST

Anti-Jo, anti-synthase // Anti-centromere (central =limited), Anti-scl70 (Scl=Systemic)

Question 23

Following a diagnosis of polymyositis, what do you need to check for?

Answer 23

Malignancy

Question 24

Dry eyes + mucosa + joint pain indicates what?

How do you investigate this?

How do you treat this?

Answer 24

Sjogren’s syndrome

Antibodies: ANA, RF, Ro and La

Schirmer’s to measure tear formation

Artificial tears and pilocarpine for saliva

Question 25

What is a complication of Sjogren’s?

Answer 25

Increase in lymphoid malignancy

Question 26

Differntiate temporal arteritis and takayasu

Answer 26

Temporal // takayasu

>50s, rapid onset of headache and jaw claudication; PMR symptoms // <50s asian women; renal artery stenosis

Question 27

How do you investigate and treat temporal arteritis?

Answer 27

Temporal artery biopsy shows skip lesions

High dose pred OR IV dex if visual loss

Taper steroids down after that

Question 28

As both have sinusitis and breathlessness how do you differentiate eGPA and GPA?

Answer 28

eGPA: Asthma, pANCA, eosinophils

GPA: Nosebleeds, cANCA