Rheumatology

Question 1

Polymyositis

(Pathophysiology, Difference with Dermatomyositis, Symptoms, Investigations, Associations)

Answer 1

Cytotoxic T cells autoimmunity

Similar to dermatomyositis but no skin signs

Symmetrical proximal muscle weakness
Problems standing up (thighs), walking up stairs (thigh), reaching high cupboards (shoulders)

Raised CK and AST/ALT
Muscle biopsy: Endomysial mononuclear inflammatory infiltrate
EMG studies +ve
ANA/Anti-Jo +ve

Associated with SLE, Raynauds, ILD, Polyarththritis

Question 2

Dermatomyositis

(Pathophysiology, Skin findings, Association)

Answer 2

Autoimmunity of B cells

Skin findings
- Malar rash. “Heliotrope rash”
- Gottron papules over knuckles (Scaly and erythematous)
- V sign over front chest to neck (Increased pigmentation)
- Shawl sign over back/shoulders (Increased pigmentation)
- Holster sign over lateral thigh (Increased pigmentation)
- Periungal erythema over surrounding finger nails

Associated with lung, colon, breast, and ovarian ca

Question 3

Polymyalgia Rheumatica

(Demographic, Symptoms, Investigations, Treatment, Association, Workup prior to starting steroids)

Answer 3

> 50 years old, female, white

Affects neck, shoulder, pelvis

> 2 weeks of symptoms, bilateral shoulder ache, pelvic girdle pain, morning stiffness

Raised CRP and ESR.

Treatment: Steroids
If steroids not improving symptoms after 1 week -> NOT PMR

Associated with GCA

Workup prior to starting steroids (Dx of exclusion)
- Need to rule out RA, Myositis, Myeloma, SLE, Thyroid Disorders, Osteoarthritis, Cervical Spondylosis, Adhesive capsulitis, Fibromyalgia
- Hence Anti-CCP, RF, FBC, U&E, LFT, ANA, Serum electrophoresis, Bence Jones Protein, CK, Ca, TFT, Urine dipstick, CXR.

Question 4

Systemic Lupus Erythematosus (SLE)

(Pathophysiology, Presentation, ESR and CRP trend?, Diagnostic Criteria ‘SOAPBRAINMD)

Answer 4

Sun exposure -> cell breakdown -> apoptosis -> release nucleus bodies -> Raising ANA -> Type 3 hypersensitivity response

Fever & weight loss. Raised ESR but normal CRP.

SOAP BRAIN MD
Serositis (Pericarditis, Myocarditis, Endocarditis, Pleuritis)
Oral ulcers (painless)
ANA +ve
Photosensitivity
Blood disorders (Pancytopenia)
Renal disorders (Proteinuria)
Arthritis
Immunological disorder (anti-dsDNA antibodies, Anti Sm antibodies, Antiphospholipid antibodies)
Neurological Disorder (Seizures, Psychosis)
Malar Rash
Discoid Rash

Question 5

Paget’s Disease

(Osteoblast vs Osteoclast, Presentation, Diagnosis, Phases, Treatment)

Answer 5

OsteoBlast- Build up bone
OsteoClast - Cut down bone

Excessive bone resorption, followed by disorganized
bone formation occurs, producing thickened but weak bone
Affects skull, vertebrae, pelvis and femur

Isolated increase in ALP + bone pain + old man

Diagnosis
- X-Ray: Osteolysis and new bone formation
- Skeletal survey

Lytic phase: Osteoclast activity +
Mixed phase: Osteoclast activity+ but osteoblast activity ++ with weaker bone structures
Sclerotic phase: Osteoclas activity + but osteoblast activity +++

Treatment: Bisphosphonates