Rheumatology Flashcards
(22 cards)
Vasculitis:
- Definition
- Symptoms (9)
- What examinations (6)
- Name types
- Investigations
- Management
Vasculitis:
- Definition: inflammation of bv due to thrombosis, ischaemia, bleeding, aneurysms
- Symptoms (9): abdo pain, headaches, vision changes, haematuria, arthralgia, raynauds, haemoptysis, pericarditis
- What examinations (6): bp, skin, cranial nerve, ocular, cardio, resp, abdo
- Name types: small (cANCA granulmatosis w polyangitis, pANCA esosinophilic gran with polyang), med (kawasaki), large (temporal arteritis, takayasu)
- Investigations: urine dip, fbc (normo anaemia), crp/esr/pv, u+es, lfts, ana, ANCA+, c3/4, hepb/c, hiv, cxr
- Management: treat cause, steroids, cyclophosphamide
Systemic sclerosis:
- Definition
- Types + symptoms
- Investigations
- Management
Systemic sclerosis:
- Definition: autoimmune disorder where hyperplasia of fibroblast activity leading to vascular damage and fibrosis causing scleroderma
- Types + symptoms:
Limited: Calcinosis cutis, Raynauds, Esophageal dysmotility, Sclerodactylyl, Telangiectasia - scleroderma on face + distal limbs
Diffuse: pulmonary fibrosis + htn, htn, glomerulonephritis - scleroderma on trunk + proximal limbs
- Investigations: ANA, anti centromere (limited), scl70 (diffuse), xray (calcinosis), ecg + echo, cxr + hrct
- Management:
smoking, physio, skin stretching
ccb/sildenafil, acei, pred for flares, ppi, methrotrexate/ mycophenolae mofetil
Sjögren’s syndrome:
- Definition
- Symptoms
- Investigations
- Management
- Complications (7)
Sjögren’s syndrome:
- Definition: autoimmune disorder of exocrine glands where decrease in lacrimal and salivary ducts. Is a type 4 hypersens reaction. Associated with RA + SLE
- Symptoms: Myalgia, Arthralgia, Dry eyes (xerophthalmia), Fatigue, Raynauds, Enlarged parotids, Dry mouth (xerostomia)
- Investigations: anti Ro + La, ANA + RF +, schirmers test tear volume <10mm, salivary gland biopsy shows local lymphocyte infiltration
- Management: artificial tears, lubricants, skin emollients, pilocarpine stimulates saliva production
- Complications (7): conjunctivitis, candidiasis, dental problems, pneumonia, vasculitis, renal impairment, NHL
Hypermobility spectrum disorder:
- Definition
- Symptoms (8)
- Management
Marfans:
- definition
- symptoms
Hypermobility spectrum disorder:
- Definition: joints moving beyond normal limits due to inc laxity of ligaments, capsules, tendons
- Symptoms (8): pain joint worse with usage, archnodactyl, marfoid habitus, epichondylitis, fatigue, myopia, hernias, thin scars, high beighton score
- Management: strengthening exercises, splint, paracetamol
Marfans:
- def: auto dom fbn1 gene which codes for fibrillin. 40-50 yrs life expectancy
- symptoms: tall, high arched palate, arachnodactyl, scolioisis, aortic aneurysm/dilatation, blue sclera
- mx: regular echo, b blocker, acei
Ehlers Danlos:
- definition: auto dom affecting type 3 collagen means inc elasticity
- symptoms: fragile skin, recurrent joint dislocation, easy bruising, aortic regurg, subarach haem, retinal streaks
Polymyalgia rheumatica:
- Definition
- Symptoms (5)
- Risk factors (3)
- Examination findings (3)
- Investigations
- DD
- Management
- definition: proximal muscle pain clinical syndrome
- symptoms: rapid onset, bilat shoulder, hip girdle and neck pain, early morning stiffness, dec rom, night time pain, fever, dec weight, depression
- risk factors: Caucasian, >70, fem, gca
- ex findings: dec rom, normal muscle strength but tender
- ix: inflamm markers inc (crp, esr, pv), ck/emg normal
- mx: 15mg pred and response should be rapid (if don’t respond think cancer)
Giant cell arteritis / temporal arteritis:
- Definition
- Risk factors (5)
- Symptoms (4)
- Complications (3)
- Investigations
- Management
Giant cell arteritis:
- Definition: aka temporal arteritis is vasculitis of temporal artery which supplies the muscles of mastication
- Risk factors (5): PMR, >60, caucasion, F, HLADR4
- Symptoms (4): unilat headache over temporal, scalp tenderness, jaw claudication, muscle weakness, fever, amaurosis fungax, diplopia, ant ischaemic optic neuropathy (occlusion of post ciliary artery causes isch of ant optic head so pale swollen optic disc + blurred margins on fundoscopy)
- Complications (3): vision loss, stroke, aortitis
- Investigations: inc esr/crp/pv/fbc (normocytic anaemia)/lfts, duplex uss temp art (hypoechoic halo), temp art biopsy (necrotising arteritis - if biopsy neg repeat bc skip lesions)
- Management: immediate pred 60-100mg - if vision involved then iv methylpred, aspirin low dose, same day ophthal review
Spondyloarthropathies:
- Definition + features
- Types
Enteropathic:
- Definition
- Management
Seroneg Spondyloarthropathies:
- Definition: hlab27 disorders causing peripheral arthritis, sacroilitis, enthesitis, and extraarticular manifestations. Is RF -
- Types: enteropathic, psoriatic, reactive, ank spond
Enteropathic:
- Definition: due to ibd. 1/3 are axial. 2/3 are peripheral associated with flares
- Management: dmards, tnfinhib
Ankylosing spondylitis:
- Symptoms
- Signs
- Investigations
- Management
Ankylosing spondylitis:
- Symptoms: stiffness, bilateral butt pain better with using and wakes up at night, ant uveitis, aortic regurg, av block, apical lung fibrosis, amyloidosis, achilles tendonitis
- Signs: schobers test + (reduced forward flexion), reduced chest expansion, exaggerated thoracic kyphosis, loss lumbar lordosis, reduced lateral flexion
- Investigations: hlab27, crp normal or inc, xray (sacroilitis most common, squaring lumbar vertebral bodies, syndesmophytes, subchondral erosions, bamboo spine fusion of vertebral bodies is a late sign), mri spine if uncertain (bm oedema) spirometry shows restrictive pattern
- Management: exercise, physio, nsaids, tnf inhib
Rheumatoid arthritis:
- Definition
- Symptoms
- Signs
- extraarticular manifestations
- Investigations
- Management
- Complications
- Poor prognostic features
- definition: autoimmune condition where autoab IgM RF to fc portion of igG causes mO + fibroblasts to release tufa to cause proliferation of synoviocytes + osteoclast activity
- symptoms: morning stiffness >30 mins, pain better with usage, 30-50 years, fever, fatigue, symmetrical polyarth mcps/pipjs/mtps/wrist/ankle) - dipjs spared
- signs: ulnar deviation, Swan neck (FLEX, EXTEND FLEX), boutonneries deformity (EXTEND, FLEX, EXTEND), nodules, carpal tunnel, swelling, z thumb, + squeeze test
- extraarticular manifestations:
1. cs: carpal tunnel, cvs disease, cord compression Atlanto axial subluxation
2. as: anaemia, amyloidosis, arteritis
3. ps: pericarditis, pleural disease, pulmonary disease
4. ss: sjogrens, scleritis, splenic enlargement - ix: rf, anti ccp more specific, fbc, crp, esr, xray (LESS loss joint space, erosions of bone, soft tissue swelling, see through bones), das28 used to monitor treatment
- mx: dmard methotrexate weekly, can combine with hydroxychloroquine, sulfalazine, nsaids, steroids if flare, anticd20 rituximab
- Complications: pul fibrosis, episcleritis/scleritis, osteoporosis, isch hd, inc risk infections, feltys (ra + splenomeg + dec wcc)
- poor features: rf+, anti ccp +, poor functional status when presenting, early erosions, hladr4, sudden onset
Gout:
- Definition + pathophysiology
- Symptoms
- Risk factors
- Triggers
- Investigations
- Management
- Complications (3)
Pseudogout:
- symptoms
- risk factors
- ix
- mx
Gout:
- Definition + pathophysiology: inflammatory arthritis due to hyperuriceaemia which deposit in synovial of joints
- Symptoms: most commonly 1st metatarsalphalangeal joint, hands, wrist, elbows, dipjs which go red hot swollen tender
- Risk factors: male, >40, high meat, smoking, alcohol, obese, thiazides, high fructose
- Triggers: diuretics, ckd, myeloproliferative disorder
- Investigations: serum uric acid (>360, repeat in 2 weeks if low), joint aspiration mc+s (monosodium urate crystals - biofringement thin needle shaped under polarised light), xray (joint effusion, punched out lytic lesions)
- Management:
diet/exercise/weight/alcohol
nsaids until 1-2 days post settling, colchicine 6 months max if flare (not if egfr <10), pred if not
Allopurinol after 1st attack when symptoms have resolved indefinitely (xanthine oxidase inhibitor)
- Complications (3): tophi, kidney stones causing ckd, oa
Pseudogout:
- symptoms: knees, wrists, back
- risk f: age, hyperparathyroidism, haemochromatosis, low mg/pi
- ix: weakly + biofringent rhomboid shaped calcium pryophosphate crystals under polarised light, xray shows chonedrocalcinosis (linear calcification)
- mx: same as gout but no uric acid lowering meds
Polymyositis:
- Definition
- Symptoms
- Investigations
- Management
Polymyositis:
- Definition: inflammatory disorder where T cells against striated muscle fibres, associated with malignancy (lung, breast, ovarian, gastric)
- Symptoms: symmetrical proximal muscle weakness, raynauds, resp muscle weakness, ILD, dysphagia (risk aspir pneumonia), dysphonia
- Signs: tender
- Investigations: inc CK, LDH/AST/ALT inc, anti jo + mi2, emg, muscle biopsy
- Management: high dose steroids, azathioprine
Raynauds phenomenon:
- Definition
- Raynauds syndrome definition
- Factors suggesting underlying disease
- Other conditions it is associated with (4)
- Causes
- Investigation
- Management
- Complications (3)
Raynauds phenomenon:
- Definition: vasospasm of vessels supplying digits
- Raynauds syndrome definition: when idiopathic
- Factors suggesting underlying disease: >40yrs, unilat symptoms, rashes, autoab
- Other conditions it is associated with (4): SLE, sclerosis, derm/polymyo
- Causes: b blockers, vibrating tools, inc blood viscosity (leuk, cocp)
- Investigation: nail fold capillaroscopy
- Management: stop smoking, ccb nifedipine, phosphodiesterase inhib, refer if secondary cause suspected
- Complications (3): ulcers, ischaemia, infection
Systemic lupus erythematosus:
- Definition
- Triggers of drug induced
- Risk factors
- Symptoms
- Investigations
- Management
- Complications (6)
Systemic lupus erythematosus:
- Definition: autoimmune disorder where t cell lymphocytes are decreased and there is increased b cell leading to type 3 hypersensitivity reaction where immune complexes deposit in organs. HLAB8
- Triggers: hydralazine, procainamide isoniazid, minocycline, phenytoin (anti histone ab)
Risk f: afro carribean
- Symptoms: Serositis, Oral ulcers, Arthritis small joints, Photosensitivity (discoid rash well demarc rash in sun exp areas - needs topical steroids, malar rash spares nasolabial folds, Blood (dec WCC, thrombocytopenia), Renal proteinuria/glomerulonephritis, Autoimmune ab, Immunologic complements dec, Neurological seizures
SLE inc risk CVS hence percarditis, myocarditis
- Investigations: esr/pv inc, crp dec or normal, c3/4 dec, ANA+, antidsdna inc during disease activity, urinalysis alb: creat, skin + renal biopsy diagnostic
- Management: sun protection, nsaids, pred, hydroxychloroquine, mycophenolate mofetil
- Complications (6): lupus nephritis, pericarditis, ILD
Fibromyalgia:
- Definition + pathogenesis
- Symptoms (8)
- Investigations
- Management
- definition: chronic widespread pain in 4 quadrants of the body + allodynia induced by sleep deprivation which hyperactivates to noxious stimuli + neural activation in pain perception regions of brain
- symptoms: fatigue, joint pain, unrefreshed sleep, numb, headaches, ibs, anxiety/dep, poor conc, tender if >11/18 points of body
- ix: all normal but to rule out: fbc, esr, crp, u+es, lfts, ca, ck, tfts
- mx: education, aerobic exercise, cbt, amitriptyline, pregabalin
Osteoporosis:
- Definition
- Definition of a fragility fracture + common bones
- Causes inc secondary causes
- When to assess risk
- Investigations
- When to skip dexa
- Management
Osteoporosis:
- Definition: decreased bone mineral density decreasing bone strength hence increasing risk of fractures
- Risk factors - modifiable and non: age, previous, steroids/ssris/ppis, post menopausal, smoking, female, alcohol, decreased vitamin d/calcium, ED, coeliac, hyperparathyroidism, hyperthyroidism
- Investigations:
first find out 10 year fracture risk by FRAX tool. Esp if >75M/65F, previous fracture, reduced bmi, steroids, falls
FBC, crp/esr, u+es (alb, creatinine), lfts, tfts, bone profile (serum ca)
Then if high risk give DEXA dual energy xray absorptiometry of lumbar + hip - if T <-2.5 then porosis, if -1–2.5 then penia, if >-1 then normal. (t score is compared to young health adult but Z is adjusted for age/gender/ethic)
If <65 + steroids offer scan. If 0–1.5 repeat in 3 years. If <-1.5 start bone protection
- When to skip dexa: If on long term steroids + >65 w previous fragility fracture/ vertebral fracture / >75 and fragility fracture don’t need dexa to start treatment
- Management:
for penia weight bearing ex, vit d/ca, dec smoking + alc
for porosis vit d/ca (ca only if low levels), alendronic acid once week (or iv zoledronate if hip fracture) (oral bisphosphonate inhibits osteoclast activity - oesophagitis, ulcers, hypocalcaemia, osteonecrosis jaw, atypical stress fractures- take on empty stomach 30 mins before/ sit upright 30 mins/ big glass of water) for at least 5 years, denosumab if renal impairment (monoclonal ab inhibits osteoclast maturation, sc every 6 months, SE: dyspnoea, diarrhoea)
Stills disease
- symptoms
- ix
- mx
Stills disease
- symptoms: arthralgia, salmon pink maculopapular rash, pyrexia worse in afternoon, lymphadenpathy
- ix: inc ferritin, yamaguchi criteria
- mx: nsaids at least 1 week, steroids, methotrexate
Psoriatic:
- Symptoms
- Investigations
- Management
Psoriatic:
- Symptoms: symmetrical polyarthritis especially hands (DIPJS) /feet, dactylitis, enthesitis, sarcoilitis, psoriasis plaques, nail pitting (reiter syndrome)/onchylosis, arthritis mutilans (telescoping and deformity of fingers)
- Investigations: crp inc, xray (periarticular erosions and bone resorption- late sign is pencil cup central joint erosions)
- Management: nsaids if mild, methotrexate, tnf inhib
Reactive:
- Definition
- Causes
- Symptoms
- Investigations
- Management
- definition: reiters syndrome, a spondyloarthropathy where synovitis develops after an infection due to ab made inflaming the joints
- Causes: salmonella, shigella, campylobacter, chlamydia
- symptoms: 4 weeks after infection: can’t see (conjunct, ant uveitis), can’t wee (urethritis), can’t climb up a tree (lower limb arthritis), keratoderma blennorrhagica (yellow waxy rash)
- ix: aspirate for serology + microscopy, inc crp, hlab27
- mx: treat infect, nsaids, 2 years if not dmards
Pagets disease:
- definition
- risk facotrs
- symptoms
- ix
- mx
- complications
Pagets disease:
- definition: inc but uncontrolled bone turnover due to excessive clast and blast activity affecting mostly skull, spine, pelvis, long bones
- risk factors: age, male, northern, fx
- symptoms: old man with bone pain, bowing of tibia, bossing of skull
- ix: bone profile (alp inc), u+es, xrays (osteolysis, lytic lesions, thickened skull), inc uptake in bone scintigraphy
- mx: treat if pain/deformity/fracture - bisphosphonates
- complications: deaf via cranial nerve entrapment, bone sarcoma, fracture, skull thickening, high CO
Osteomalacia:
- definition
- causes
- symptoms
- ix
- mx
Osteomalacia:
- definition: softening of bones due to vit d levels (rickets in children)
- causes: vit d deficiency, ckd, anticonvulsants, cirrhosis liver, coeliac
- symptoms: bone pain, bone tenderness, fractures, proximal myopathy/waddling gait
- ix: low ca/pi, inc pth, low vit d, lfts (inc alp), xray (translucent bands)
- mx: vit d + loading dose, ca
Osteogenesis imperfecta:
- definition
- symptoms
- ix
Osteogenesis imperfecta:
- definition: auto dom, results in abnormal type 1 collagen resulting in bone fragility and fractures
- symptoms: fractures, blue sclera, deafness (otosclerosis), dental issues
- ix: bone profile normal
Dermatomyositis:
- definition
- symptoms
- ix
Dermatomyositis:
- definition: inflammatory disorder involving muscle and skin
- symptoms
Skin: photosensitivity, macular rash over back/shoulder, heliotrope rash in periorbital region, grottens papules on extensor surfaces of fingers, dry + scale hands with cracks
Others: proximal muscle weakness, tender, raynauds, resp muscle weakness, ILD, dysphagia, dysphona
- ix: ANA+, anti Jo1 + anti Mi2, inc CK, inc CRP
