RHEUMATOLOGY Flashcards
Define rheumatoid arthritis
An autoimmune disease associated to Fc portion of IgG (RF) and anti-CCP
Describe the pathogenesis of RA in as much detail as you can
1) Citrullination of self antigens. These are recognised by T and B cells. T and B cells produce antibodies aka RF and anti-CCP.
2) Macrophages and fibroblasts get stimulated and release TNFalpha
3) Inflammatory cascade starts - causes proliferation of synoviocytes = these will grow over cartilage and cut off nutrition to it = damages cartilage !
4) Macrophages also stimulate osteoclast = get bone damage
Note: citrullination is just where amino acid arginine is converted to citrulline. This is v important bc citrulline is not one of the 20 amino acids in our DNA code - so leads to modification (here it causes RA!)
What is clinical presentation of RA?
Female gender (3:1). 30-50yrs Symptoms are progressive, peripheral and symmetrical polyarthritis Affects MCPs,PIPs, MTPs - does NOT affect DIPs Affects hips, knees, shoulders, c-spine History over 6 weeks Morning stiffness for over 30 mins. Commonly have fatigue, malaise
What can be found on examination in a pt with RA?
Soft tissue swelling and tenderness.
Ulnar deviation, or palmar subluxation of MCPs
Swan neck or/and Boutonniere deformity to digits
Rheumatoid nodules (usually on elbow)
Median N - carpal tunnel association
Name three investigations (or more!) you would consider for a pt with suspected RA
RF, anti-CCP, FBC, WCC, inflammatory markers, X ray or can do MRI or USS in early disease.
Why is a WCC done in blood test for suspected RA?
Can be elevated due to complication of septic arthritis
Why is FBC carried out as an investigation for RA?
May show normocytic anaemia which is a feature of chronic disease
How is RA initially treated?
DMARD monotherapy - methotrexate
Describe treatment you would discuss with patient recently diagnosed with RA
- DMARD such as methotrexate. Can discuss use of combination
- Steriods to be used acutely both orally or intra-articular
- NSAIDs + PPI to aid with symptom control
- Non drug options - OT/PT, podiatry, psychological
What are the extra-articular features of severe RA?
Remember with mnemonic CAPS: (come in 3s)
C - carpal tunnel, CVD, cord compression
A - anaemia, amyloidosis, arteritis
P - pericarditis, pleural dosease, pulmonary disease
S - Sjögren’s, scleritis, Splenic enlargement
What features are characteristically seen in an XRAY of RA?
LESS Loss of joint space Erosions (periarticular) Soft tissue swelling Subluxation
Define giant cell arteritis
Chronic vasculitis of large and medium sized vessels in individuals over 50yrs.
Why is giant cell arteritis an emergency?
Occlusive arteritis can lead to anterior ischaemic optic neuropaty and acute visual loss. The visual symptoms are an opthalmoc emergency
What are the risk factors for GCA aka Temporal arteritis?
Age
White ethnicity
PMH of polymyalgia rheumatica
Genetic predisposition with HLA-DR4
How does GCA present?
Presentation is acute
Headaches in 70% of presentations
Localised, unilateral, piercing or stabbing over the temple
Tongue and/or jaw claudication upon mastication
Constitutional symptoms
Visual symptoms
Scalp tenderness, especially over temporal artery
How is giant cell arteritis diagnosed?
- Over 50
- The presence of two or more of these symptoms:
Raised ESR, CRP or PV
New onset of localised headache
Tenderness or decreased pulsation of temporal artery
New visual symptoms
Biopsy of necrotizing arteritis
How is GCA treated?
- Prednisolone 60-100mg PO per day for at least 2 weeks then slowly reduce
- if visual symptoms are present - 1g methylprednisolone IV pulse therapy for 1-3 days
- low dose aspirin therapy to reduce thrombotic risks
What is your immediate managment in pt with suspected GCA?
Steroid therapy
How is polymyalgia rheumatica (PMR) characterised?
Pain and stiffness in shoulder, hip girdles and neck.
Who does PMRF usually affect?
The elderly - incidence increases with age. Average age is 70.
Affects patients with GCA (there’s evidence that PMR and GCA are associated to one another)
How does PMR present (just from a history)?
Sudden onset of pain in proximal limbs - so the neck, shoulders and hips.
Difficulty getting up from chair (hip pain), and combing hair (shoulder pain).
Pain at night time
Systemic symptoms - fatigue, weight loss, low grade fever
From Z2F:
Presence of symptoms for at least 2 weeks
Bilateral shoulder pain that radiates to the elbow
Bilateral pelvic girdle pain
Worse with movement
Interferes with sleep
Stiffness for at least 45 minutes in the morning
May also have systemic symptoms - weight loss, fatigue, low grade fever, low mood Upper arm tenderness Carpal tunnel syndrome Pitting oedema 
Patterns of Joint / Muscle involvement:
If joint involvement was symmetrical it would suggest ____(1)____
Whereas, asymmetrical joint involvement would suggest ___(2)_____ or ____(3)_____
(1) RA
(2) Gout
(3) Psoriatic Arthritis
What investigations may you consider for pt with suspected PMR?
Bloods - ESR, CRP, polycythemia vera
Temporal artery biopsy if symptoms of GCA
Patterns of Joint / Muscle involvement:
Small joint only would suggest___(1)_____
Large joints only would suggest ___(2)____
Large and small joints would suggest ____(3)______
(1) Early stages of RA
(2) OA
(3) Late stages of RA
Give the medical term for describing the number of joints involved for the below:
(1) 1 joint
(2) 2-4 joints
(3) >4 joints
(1) monoarticular
(2) Oligoarticular / pauciarticular
(3) Polyarticular
List some causes of acute polyarthritis. Use categories below to give specific conditions
- Inflammatory arthritis
- Autoimmune arthritis
- Viral infection
- Crystal arthritis
- Inflammatory arthritis
- RA
- PsA
- Reactive arthritis - Autoimmune arthritis
- SLE
- Vasculitis - Viral infection
- HIV
- Parovirus
Chikungunya - Crystal arthritis
- UNcontrolled Gout
What are the causes of chronic monoarthritis? Use categories below to think of specific conditions
- Infections
- Inflammatory
- Non- inflammatory
- Tumours
- Infections
- TB - Inflammatory
- Psoriatic arthritis
- Reactive arthritis
- Foreign body - Non- inflammatory
- OA
- Trauma (meniscal tear)
- Osteonecrosis (prednisolone use)
- Neuropathic ( Charcots arthropathy ) - Tumours
- he says v rare!
What 2 conditions __(1)____ and ____(2)______can cause arthritis of the DIPJs?
In ___(1)___ changes will also be seen on the nail of the digit.
___(2)___ is the most common disease affecting this joint. ____(3)____ nodes can be seen on the DIPJ in this disorder.
(1) PsA
(2) OA
(3) Heberden’s Nodes affecting the DIPJ in OA
What investigations may you consider for pt with suspected PMR?
Bloods - ESR, CRP, polycythemia vera
Temporal artery biopsyy if symptoms of GCA
History taking - DRUG HISTORY of a rheum patient
____(1)____ causes cutaneous hypersensitivity vasculitis
____(2)___ cause Lupus skin rashes
____(3)___ worsen Raynaud’s symptoms
____(4)____ reduce uric acid excretion and can lead to gout.
HINTS (1) AB, (2) DMARD (3) HEART (4) WATER
__Penicillin____ causes cutaneous hypersensitivity vasculitis
___Sulfasalazine___ cause Lupus skin rashes
____ Beta Blockers___ worsen Raynaud’s symptoms
____Diuretics_(thiazides)___ reduce uric acid excretion and can lead to gout.
History taking - PMHS HISTORY of a rheum patient
Seronegative Spondyloarthropathy is associated with which 3 conditions?
A history of STI / diarrhoea could indicate what 2 types of arthiris
Seronegative Spondyloarthropathy is associated with:
- Anterior uveitis
- Psoriasis
- IBD
Hx of STI / Diarrhoea could indicate:
- reactive arthritis
- gonococcal arthritis
History taking - Social HISTORY of a rheum patient
SMOKING:
Smoking is implicated in causing and making ___(1)____more severe
Patients with ____(2)____ symptoms in the hands should be advised to stop smoking
Smoking is implicated in causing and making ___RA____more severe
Patients with ____Raynaud’s ____ symptoms in the hands should be advised to stop smoking
Compare and Contrast the features of Inflammatory vs Mechanical disease.
E.g. Morning stiffness / effect of activity / effect of resting / Fatigue/ systemic involvement
Inflammatory disease: > 1 hour morning stiffness Activity - improves Resting - worsens Fatigue - profound Systemic symptoms - yes
Mechanical Disease < 30 mins morning stiffness Activity - worsens Resting - improves Fatigue - minimal Systemic symptoms - no
History taking - Constitutional symptoms
What are some examples of constitutional symptoms?
What do they indicate? (3)
What are some conditions which may present with constitutional symptoms?
Constitutional symptoms
- Fever
- Weight loss
- Night sweats
- Loss of appetite
What do they indicate?
- Inflammation
- Infection
- Neoplasia
What are some conditions which may present with constitutional symptoms?
Ankylosing spondylitis (all)
GCA
SLE - fever
What are some extra - articular features of SLE?
LOADS IN THE BOOKLET - GUESS A FEW systems based!
Mouth / Eyes
- mouth uclers
Skin
- Digital ulcers
- Malar flush / photosensitivity
- Alopecia
- Raynaud’s
Genito-urinary
- renal failure / hypertension
- Micro -haematuria / proteinuria
Obstetric
-Miscarriage / pre-eclampsia
Neuro
- headache
- seizures
- psychosis
- TIA / CVA
Cardio- Resp
SOB - PE / Pul effusion / Pulmonary HTN / alveolitis/ pleuritic chest pain
What are some extra - articular features of RA?
Mouth / Eyes
- scleritis
- Dry mouth / eyes
Skin
- subcutaneous nodules
Genito-urinary
- renal failure / hypertension
- Micro -haematuria / proteinuria
Neuro
- Compressive - e.g. carpal tunnel syndrome
Cardio- Resp
SOB - alveolitis
What are some extra - articular features of RA?
Mouth / Eyes
- scleritis
- Dry mouth / eyes
Skin
- subcutaneous nodules
Genito-urinary
- renal failure / hypertension
- Micro -haematuria / proteinuria
Neuro
- Compresive - e.g. carpal tunnel syndrome
Cardio- Resp
SOB - alveolitis
What are some extra - articular features of Sjogrens Syndrome?
Mouth / Eyes
- Dry mouth / eyes
Skin
- Raynaud’s
What gene are the Spondyloarthropathies associated with?
HLA - B27
What gene are the Spondyloarthropathies associated with?
HLA - B27
How would a patient with Ankylosing Spondylitis Present?
- Typical pt
- Presenting symptoms
1. Typical pt Young male (teens - mid 30s)
2. Presenting symptoms Gradual development over 3 months Bilateral buttock pain (sacroilliac) lower back pain/ stiffness - wakes pt up in morning- improve with activity Chest wall pain Thoracic pain Often 'flare ups' of symptoms
Examining a pt with Ankylosing Spondylitis
- Early examination vs later on
- What test might you perform and what is normal?
- Early examination - often normal
Later examination
- reduced chest wall expansion
- loss of lumbar lordosis and increased thoracic kyphosis - Schober’s test - to see if decreased lumbar spine range of movement
Mark skin 10cm above and 5cm below the L5 vertebrae. Ask pt to bend forward with straight legs. If distance increases < 20 cm supports diagnosis as restricted movement
Examining a pt with Ankylosing Spondylitis
- Early examination vs later on
- What test might you perform and what is normal?
- Early examination - often normal
Later examination
- reduced chest wall expansion
- loss of lumbar lordosis and increased thoracic kyphosis - Schober’s test - to see if decreased in lumbar spine range of movement
Mark skin 10cm above and 5cm below PSIS. Ask pt to bend forward with straight legs. Distance should increase >20cm = normal test.
What management for a pt with Ankylosing Spondylitis?
Drug:
NSAIDS
TNF inhibitors - e.g. infliximab (Monoclonal AB)
IL-17 inhibitors e.g. Secukinumab (Monoclonal AB) if TNF and NSAIDs don’t work
Non Drug: Physio stop smoking Bisphosphonates if osteoporosis exercise treat complications
How would a pt with Psoriatic Arthritis present?
- Typical patient ?
- Pattern ?
- 10 % pts with hx of psoriasis
- often middle aged.
- Male and females equally affected.
- Nail
- Psoriasis extensor - Different patterns! can be symmetrical like RA. Hands/ wrists / ankles /DIP (not MCP like in RA)
- OFTEN Asymmetrical olgio / arthritis- swollen feet / fingers. “Dactylitis” = swollen fingers
What signs might you see on a pt with Psoriatic Arthritis?
Nail pitting Onycholysis - nail coming away from bed Psoritatic plaques Dactylitis (inflammation of full finger) Enthesitis (inflammation where tendon inserts into bone)
Associated :
EYe - uveitis / conjunctivitis
Aortitis - inflammation of aorta
Amyloidosis
What signs might you see on a pt with Psoriatic Arthritis?
Nail pitting Onycholysis - nail coming away from bed Psoritatic plaques Dactylitis (inflammation of full finger) Enthesitis (inflammation where tendon inserts into bone)
Associated :
EYe - uveitis / conjunctivitis
Aortitis - inflammation of aorta
Amyloidosis
What screening test do patients with Psoriasis complete to see if need to be referred to a rheum?
PEST
Psoriasis Epidemiological Screening tool - asks questions about:
Joint pain
Swelling
Hx of Arthitis
Nail pitting
High score - get you to the rheumatologist.
What is arthritis Mutlians? How related to Psoriatic Arthritis?
most severe form of psoriatic arthritis.
Osteolysis of bones around the joints in the phalanxes.
Causes digit to get shorter and skin to fold over the shortened finger - “telescopic finger”
What is arthritis Mutlians? How related to Psoriatic Arthritis?
most severe form of psoriatic arthritis.
Osteolysis of bones around the joints in the phalanxes.
Causes digit to get shorter and skin to fold over the shortened finger - “telescopic finger”
How do you manage Psoriatic Arthritis?
Rheum and Derm together.
Drugs: NSAID (pain) DMARDS e.g. methotrexate / sulfasalazine Anti-TNF eg.g. infliximab Last line is a IL12/23 Inhibitor Ustekinumab
What is reactive arthritis?
Synovitis in joints post an infective trigger
How does reactive arthritis typically present?
acute monoarthriits (often lower limb asymmetrical)
What are some triggers for reactive arthritis?
Z2F: Most common triggers: gastroenteritis and STI (chlamydia)
Distant infection
Gastroenteritis:
Camplyobacter
Shigella
Salmonella
STI Chlamydia Trachomatis (post urethritis / cervicitis) (Gonorrhoea = gonococcal septic arthritis )
Associated symptoms with reactive Arthritis ?
Eye: Bilateral conjunctivitis / uveitis
Skin: Circinate Balanitis (dermatitis on head of penis) and urethritis
“can’t SEE, can’t PEE, cant CLIMB A TREE” as arthritis, eye prob, balanitis
Investigations for Reactive Arthritis?
Bloods:
Inflammatory markerts - CRP
Rule out:
Septic arthritis- aspirate, gram stain, culture + sensitivities. GIVE AB until excluded
Crystal arthritis - aspirate to check for gout / pseudo gout
Investigations for Reactive Arthritis?
Bloods:
Inflammatory markerts - CRP
Rule out:
Septic / crystal arthritis - aspirate to check for bacteria / crystals
Management for Reactive Arthritis?
Treat infection (may not help arthritis)
NSAIDs
Steroid injection to joint
most resolve within 6 months
If reoccurs DMARDS / Anti-TNFA drugs especially likely if HLA-B27 +ve
What is Enteropathic arthritis?
10-20% of pts with IBD develop
2/3 get peripheral arthritis
1/3 get axial arthritis
With Enteropathic arthritis what are the 2 types of peripheral arthritis and how do they related to IBD flares?
Type 1: correlation with IBD flares - oligoarticular and asymmetric arthritis
Type 2 : NO correlation with IBD flares- poly articular symmetrical arthritis
How to treat Enteropathic arthritis? What be mindful of?
NSAIDs can cause IBD flare up.
use DMARDS
TNF inhibitors treat both the bowel disease and arthritis
Mnemonic for extra - articular Ankylosing Spondylitis features - 5 As
Anterior uveitis Aortic incompetence AV block Apical lung fibrosis Amyloidosis
What are features on inflammatory back pain? Mnemonic IPAIN
Insidious onset Pain at night (getting up helps) Age <40 Improves when exercise No improvement with rest
What is Lupus (SLE)?
Inflammatory autoimmune connective tissue disease.
Characterised by inadequate T cell suppressor activity and increased B cell activity.
Anti-nuclear antibodies target proteins in own cell nucleus
Remissions and flares
complex multi organ involvement / varied presentations
What are the common symptoms and signs with SLE?
SOAP BRAIN MD mnemonic
SOAP BRAIN
Serositis -pleurisitis / pericarditis
Oral ulcers - esp palatte, painless
Arthritis - small joint non-erosive
Photosensitivity - malar / discoid rash
Blood disorders - Low WCC, lymphopenia
Renal involvement - glomerulonephritis
Autoantibodies - ANA +ve in 90%
Immunological - low complements e..g C3 C4 low
Neurologic - seizures / psychosis
M - malar rash
D - discoid rash
What investigations for SLE?
Bloods:
Raised ESR / plasma viscosity
FBC - normocytic anaemia of chronic disease / leukopenia
Autoantibodies
ANA +ve (90% are)
Anti dsDNA (specific to SLE) rises with active disease
Antiphospholipid antibodies can occur in SLE - VTE risk
Complement
C3 C4 decreased in active disease
Urinanalysis and protein: creatinine ration for proteinuria in lupus nephritis
Skin biopsy / renal biopsy can be diagnostic
Why is ESR more useful than CRP in SLE?
Often ESR raised (+ plasma viscosity ) in pts where CRP can be normal
Why is FBC particularly useful for SLE?
Simple clue as abnormal in almost all patients
Common complications of SLE?
page 220 of Z2F
CVD- chronic inflammation in vessels - HTV- CAD Anaemia of chronic Disease Pericarditis Plueritis Interstitial lung disease Lupus nephritis Neuro psychiatric SLE Recurrent miscarriage VTE
How to diagnose SLE?
SLICC or ACR criteria
confirm Antinuclear antibodies and establish clinical features suggestive of SLE
Treatment of SLE ?
Drug:
NSADIS
Steroids (prednisolone) short courses for flares
DMARD : hydroxychloroine (rash and arthralgia)
Can move onto Methotrexate / Mycophenolate mofetil / Azathoprine
Biologics for severe disease e.g. Rituximab
Non drug:
Sun avoidance - malar rash
Lifestyle advice - CVD
What is Raynaud’s pnenomenon? What is the typical colour change
Painful vasospasm of digits. Idiopathic, possibly familial, women ++
Colour change in response to cold stimulus:
White = reduced blood flow
Blue = venous stasis
Red = rewarming hyperaemia
What diseases are associated with Raynaud’s?
Scleroderma
SLE
Dermatomyositis and polymyositis
Sjorgen’s syndrome
> 30 yrs when develop think underlying disease
Physical causes of Raynaud’s?
Physical cause:
heavy vibrating tools
sticky blood e..g cryoglobulinaemia
Drug cause of Raynaud’s?
Beta blockers
Treatment for Raynaud’s?
Non drug:
Stay warm
stop smoking
Drug:
Dihydropyridine CCB
Phosphodiesterase-5-inhibitors
Prostacylins
Raynaud’s episodes usually last ___(1)____
The pattern is ___(2)_____ and ____(3)____
___(4)____ is rare
Raynaud’s episodes usually last ___minutes____
The pattern is _bilateral__ and _symmetrical____
___Tissue Necrosis ____ is rare
What are some complications of Raynaud’s?
Digital ulcers
infection
gangrene
