Rheumatology

Question 1

Xray changes in OA

Answer 1

Loss of joint space
Osteophytes (bone spurs)
Subarticular sclerosis (Inc density of bone along joint line)
Subchondral cysts (fluid-filles holes in the bone)

Question 2

Hands signs in advanced RA

Answer 2

Z shaped deformity to the thumb
Swan neck deformity (hyperextended PIP and flexed DIP)
Boutonniere deformity (hyperextended DIP and flexed PIP)
Ulnar deviation of the fingers at the MCP joints

Question 3

Investigations for RA

Answer 3

RF (present in 70% pts)
Anti-CCP antibodies (more sensitive and specific than RF)
CRP, ESR
X-rays - hands and feet for bone changes
US or MRI - to detect synovitis

Question 4

Treatment for RA in pregnancy

Answer 4

Hydroxychloroquine
Sulfasalazine (extra folic acid is required)
(Methotrexate is teratogenic)

Question 5

What is the first-line treatment for OA?

Answer 5

Topical NSAIDs for knee osteoarthritis
Oral NSAIDs where required and suitable (co-prescribed with a proton pump inhibitor for gastroprotection)

Intra-articular steroids
Joint replacement

Question 6

What is the most common gene associated with RA?

Answer 6

HLA-DR4

Question 7

List the unique side effects of DMARDs.

Answer 7

Methotrexate: Bone marrow suppression and leukopenia, and highly teratogenic
Sulfasalazine: Orange urine and male infertility (reduces sperm count)
Hydroxychloroquine: Retinal toxicity, blue-grey skin pigmentation and hair bleaching
Anti-TNF medications: Reactivation of tuberculosis
Rituximab: Night sweats and thrombocytopenia

Question 8

How to distinguish between RA and psoriatic arthritis?

Answer 8

Psoriatic arthritis tends to affect the distal interphalangeal (DIP) joints and axial skeleton, whereas rheumatoid arthritis tends not to affect these joints

Question 9

How do you manage an acute, warm, swollen, painful joint?

Answer 9

Treat as septic arthritis: abx, aspirate (gram stain, C&S, crystals)

Question 10

What is ankylosing spondylitis?

Answer 10

Inflammatory condition affecting the axial skeleton (vertebral column, sacroiliac joints)
Part of the seronegative spondyloarthropathy group of conditions, also including psoriatic arthritis and reactive arthritis

Question 11

What are associated conditions with ankylosing spondylitis?

Answer 11

A – Anterior uveitis
A – Aortic regurgitation
A – Atrioventricular block (heart block)
A – Apical lung fibrosis (fibrosis of the upper lobes of the lungs)
A – Anaemia of chronic disease

Question 12

What tests are done to confirm ankylosing spondylitis?

Answer 12

Inflammatory markers
HLA-B27 gene testing
X-ray spine and sacrum
Schober’s test

Question 13

What are the tests for SLE?

Answer 13

ANA
Inflammatory markers
anti-dsDNA (highly specific to SLE)

Question 14

What are the 2 main patterns of disease in systemic sclerosis?

Answer 14

Limited cutaneous systemic sclerosis
Diffuse cutaneous systemic sclerosis

Question 15

List the features of limited cutaneous systemic sclerosis.

Answer 15

C – Calcinosis
R – Raynaud’s phenomenon
E – Esophageal dysmotility
S – Sclerodactyly
T – Telangiectasia

• Calcinosis = calcium deposits under the skin most commonly found in the fingertips
• Raynaud’s phenomenon = First white, due to vasoconstriction
  Then blue, due to cyanosis
  Then red, due to reperfusion and hyperaemia (Raynaud’s disease is where Raynaud’s phenomenon occurs without an associated systemic disease. It is idiopathic and makes up 80-90% of patients with Raynaud’s phenomenon)
• Sclerodactyly = skin changes in the hands. Skin tightening around the joints restricts the range of motion and reduces function. The fat pads on the fingers are lost. The skin can break and ulcerate.
• Scleroderma = hardening of skin

Question 16

List the features of diffuse cutaneous systemic sclerosis.

Answer 16

Diffuse cutaneous systemic sclerosis includes the CREST features and also affects internal organs, causing:

Cardiovascular problems (e.g., hypertension and coronary artery disease)
Lung problems (e.g., pulmonary hypertension and pulmonary fibrosis)
Kidney problems (e.g., glomerulonephritis and scleroderma renal crisis)

Question 17

What is the treatment for Raynaud’s?

Answer 17

Keeping the hands warm (e.g., gloves and hand warmers)
Calcium channel blockers (e.g., nifedipine)
Other specialist drugs include losartan, ACE inhibitors, sildenafil and fluoxetine

• Beta blockers can worsen the symptoms of Raynaud’s.

Question 18

What is the non-medical management of systemic sclerosis?

Answer 18

Avoiding smoking
Gentle skin stretching to maintain the range of motion
Regular emollients
Avoiding cold triggers for Raynaud’s
Physiotherapy to help maintain healthy joints
Occupational therapy for adaptations to daily living to cope with limitations

Question 19

Name the antibodies that are positive in systemic sclerosis.

Answer 19

ANA
anti-centromere antibodies (limited cutaneous systemic sclerosis)
anti-Scl-70 (diffuse cutaneous systemic sclerosis)

Question 20

What is the most common joint affected in reactive arthritis?

Answer 20

Knee

Question 21

What are the most common triggers for reactive arthritis?

Answer 21

Gastroenteritis
Chlamydia

• Gonorrhea typically causes septic arthritis

Question 22

What is the classic triad with reactive arthritis?

Answer 22

Can’t see (conjunctivitis/ anterior uveitis)
Can’t pee (urethritis)
Can’t climb a tree (arthritis)

Question 23

Which group of conditions are part of seronegative spondyloarthropathy?

Answer 23

Psoriatic arthritis
Reactive arthritis
Ankylosing spondylitis

Question 24

Which antibody is highly specific to SLE but not very sensitive?

Answer 24

Anti-Sm

Anti-dsDNA (also highly specific)

Also check ANA

Question 25

What is the key complication of giant cell arteritis?

Answer 25

Vision loss

Question 26

Which antibodies are associated with polymyositis?

Answer 26

Anti-Jo-1 antibodies

Question 27

Antiphospholipid syndrome is associated with which autoimmune condition?

Answer 27

SLE

Question 28

What is Sjögren’s syndrome?

Answer 28

An autoimmune condition affecting the exocrine glands (lacrimal, salivary glands)

Question 29

Which antibodies are associated with Sjögren’s syndrome?

Answer 29

Anti-Ro Anti-La

Question 30

Test for Sjögren’s syndrome?

Answer 30

Schirmer test

Question 31

Explain the mechanism of action of pilocarpine.

Answer 31

Pilocarpine stimulates muscarinic receptors, stimulating the parasympathetic nerves and promoting salivary and lacrimal gland secretion

Question 32

When is gout prophylaxis initiated?

Answer 32

Prophylaxis is not started until weeks after the acute attack has resolved. NSAIDs or colchicine may be given to prevent a gout attack during the initial period. Once allopurinol or febuxostat is initiated, it is continued during an acute attack.

Question 33

Who should be assessed for osteoporosis?

Answer 33

Individuals over age 50 who have experienced a fragility fracture

Question 34

How is osteoporosis defined?

Answer 34

Bone mineral density of 2.5 or more standard deviations below the peak bone mass for young adults (i.e., T-score ≤ –2.5)

Question 35

What does the FRAX measure?

Answer 35

The 10-year risk of a major osteoporotic fracture and a hip fracture

Question 36

What is Paget's disease?

Answer 36

Excessive bone turnover (reabsorption and formation) due to increased osteoclast and osteoblast activity. The excessive turnover is not coordinated, leading to patchy areas of high density (sclerosis) and low density (lysis)

Question 37

What blood test are associated with Paget's disease?

Answer 37

Raised ALP Normal calcium Normal phosphate

Question 38

Treatment for Paget's disease

Answer 38

Bisphosphonates

Question 39

What is the testing interval for patients with a T score of -2.5 or below?

Answer 39

q1-3 yrs (otherwise 5-10 yrs)