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Finals > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

Risk factors for septic arthritis

A
  • Recent joint surgery/replacement
  • Pre-existing joint disease = RA
  • Diabetes mellitus
  • Immunosuppression = HIV
  • CKD
  • IV drug abuse
  • Recent intra-articular steroid injection
  • Direct/penetrating trauma
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2
Q

Bacterial causes of septic arthritis

A
  • Staphylococcus aureus
  • Group A Streptococci (strep. Pyogenes)
  • Neisseria gonorrhoea = sexually active young adults
  • Haemophilus influenzae = children
  • E.coli
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3
Q

Most common sites for septic arthritis

A

knee>hip>shoulder

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4
Q

Presentation of septic arthritis

A
  • Agonisingly painful, red, hot, swollen joint
  • Stiffness and reduced range of motion
  • Systemic: Fever, lethargy, sepsis
  • In elderly and immunosuppressed and RA = Articular signs may be muted
  • In children = limping or protecting joint
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5
Q

Gold standard investigation for septic arthritis

A
  • Urgent joint aspiration and synovial fluid sampling
    o Always aspirate before antibiotics given
    o Send fluid for urgent gram-staining, culture, Abx sensitivities
    o Fluid will be purulent/opaque/thick/pussy due to high WCC (Normal fluid is clear yellow and thin)
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6
Q

Kocher criteria for septic arthritis

A
  • Fever
  • Non-weight bearing
  • Raised ESR
  • Raised WCC
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7
Q

Management of septic arthritis

A
  • Empirical IV Abx until sensitivities known (switch to oral after 2 wks, continue 4-6 weeks)
    1. Flucloxacillin
    2. Clindamycin (penicillin allergy)
    3. Vancomycin + rifampicin = penicillin allergy, MRSA, prosthetic joint
  • Stop immunosuppression temporarily
  • Joint should be immobilised early = followed by early physiotherapy to prevent stiffness and muscle wasting
  • Needle aspiration joint drainage repeatedly until no recurrent effusion can help relieve pain = Surgical washout is more pleasant
  • NSAIDs = ibuprofen for pain
  • Arthoscopic lavage may be required
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8
Q

What is osteomyelitis

A

Infection of bone and bone marrow (usually long bones)

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9
Q

Risk factors for osteomyelitis

A
  • Open bone fracture
  • Orthopaedic surgery
  • Immunocompromised = HIV, TB, sickle cell anaemia
  • Diabetes mellitus
  • Peripheral vascular disease
  • Malnutrition
  • Inflammatory arthritis
  • Prosthetic material
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10
Q

Causes of osteomyelitis

A
  • Staphylococcus aureus (90%)
  • Salmonella = complication of sickle cell anaemia
  • Pseudomonas aeruginosa and Serratia and marcesans in IVDU
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11
Q

Presentation of osteomyelitis

A
  • Onset over several days
  • Dull pain worse on movement
  • Fever, sweats, rigors and malaise
  • Tenderness, warmth, erythema and swelling
  • Draining sinus tract = associated with deep/large ulcers that fail to heal despite treatment
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12
Q

Investigations of osteomyelitis

A
  • Plain X-ray may show osteopenia
  • MRI = marrow oedema from 3-5 days (done after x-ray)
  • Blood culture to determine cause
  • Raised ESR/CRP and WCC
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13
Q

Management of osteomyelitis

A
  • Immobilisation
  • Prolonged antibiotic therapy = IV flucloxacillin
  • Drainage and Debridement
  • IV Teicoplanin
  • Oral fusidic acid
  • Stop treatment guided by ESR/CRP monitoring
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14
Q

What is pseudogout

A

Microcrystal synovitis caused by calcium pyrophosphate dihydrate crystals deposited in joint

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15
Q

Risk factors for pseudogout

A
  • Diabetes
  • Osteoarthritis
  • Joint trauma/injury
  • Metabolic disease = Hyperparathyroidism, Haemochromatosis
  • Intercurrent illness
  • Surgery = parathyroidectomy
  • Blood transfusion, IV fluid
  • T4 replacement
  • Joint lavage = going into joint and shaking around crystals
  • Acromegaly
  • Wilson’s disease
  • Low magnesium, low phosphate
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16
Q

Presentation of pseudogout

A
  • Severe hot, pain, stiffness, swelling joint
  • Fever
  • Typically distributed to knee > wrist > shoulder > ankle > elbow
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17
Q

Investigations of pseudogout

A
  • Joint fluid aspiration and microscopy
    o Small weakly- positively birefringent rhomboidal calcium pyrophosphate crystals
    o Joint fluid looks purulent  sent for culture to exclude septic arthritis
  • X-ray = chondrocalcinosis (linear calcification parallel to articular surfaces)
  • Bloods = Raised WCC
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18
Q

Management of pseudogout

A
  • High dose NSAIDs (ibuprofen)
  • Oral/ IM/ intra-articular corticosteroid = prednisolone
  • Colchicine
  • Physiotherapy
  • Joint washout
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19
Q

What is gout

A

Inflammatory arthritis associated with hyperuricaemia and urate crystals deposited in joint lining

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20
Q

Epidemiology of gout

A
  • Rises in post-menopausal women
  • Chinese, Polynesian, Filipino = uncommon in native country but increased if westernised diet
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21
Q

Risk factors for gout

A
  • High alcohol intake
  • Purine rich foods = red meat, seafood
  • High fructose intake = sugary drinks, cakes, sweets and fruit sugars
  • High saturated fat diet
  • Drugs = low-dose aspirin, diuretics
  • Family history
  • CVD, CKD, Hypertension, DM
  • Obesity
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22
Q

Presentation of gout

A
  • Sudden hot, painful, swelling and redness of usually one joint
  • Typically base of big toe, wrists, base of thumb
  • Precipitated by excess food, alcohol, dehydration or diuretic therapy, cold, trauma or sepsis
  • Smooth white deposits (tophi) in skin and around joints
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23
Q

Gold standard investigation of gout

A
  • Joint fluid aspiration and microscopy
    o Long needle shaped crystals
    o Negatively bifringent under polarised light
    o Monosodium urate crystals
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24
Q

XR findings in gout

A

o Joint effusion (early sign)
o Space between joint is maintained
o Lytic lesions in bone
o Punched out erosions
o Erosions have sclerotic borders with overhanging edges

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25
Q

Bloods tests in gout

A
  • Serum uric acid raised  measure 2 weeks after episode as may be high, normal or low during attack
  • Serum urea and creatinine + estimated glomerular filtration rate
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26
Q

Management of acute flare of gout

A
  1. NSAIDs (ibuprofen)
  2. Colchicine  renal impairment or heart disease
  3. Oral prednisolone
  4. Intra-articular steroid injection
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27
Q

Side effects of colchicine

A

diarrhoea and abdo pain

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28
Q

Long term management of gout

A

o Allopurinol
 Colchine cover considered when starting allopurinol
o Febuxostat

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29
Q

Side effects of allopurinol

A

fever, rash, low WCC

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30
Q

Prophylaxis of gout

A

o Lose weight
o Less alcohol and good fluid intake
o Avoid purine rich food
o Dairy and increased vitamin C can reduce gout
o Stop diuretics and switch to ARB

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31
Q

Complications of gout

A
  • Hypertension
  • Renal disease
  • CVS disease
  • DMT2
  • Osteoarthritic damage to joints
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32
Q

What is osteoarthritis

A

Mechanical degenerative non-inflammatory disease of the joints

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33
Q

Risk factors for osteoarthritis

A
  • Age
  • Joint hypermobility
  • Diabetes
  • Family history
  • Obesity
  • Occupation = manual labour (small joints of hand), farming (hips), football (knees)
  • Local trauma
  • Inflammatory arthritis = RA
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34
Q

Presentation of osteoarthritis

A
  • Gradual in onset and progressive
  • Joint pain and stiffness (<30 mins in morning)
  • Worsened by activity and relieved by rest
  • Functional impairment = walking, AoDL
  • Bouchard’s nodes = bone swelling at PIPJs
  • Heberden’s nodes = bone swellings at DIPJs
  • Squaring at base of thumb
  • Limited joint movement/range of motion
  • Weak grip
  • Muscle wasting of surrounding muscle groups
  • Crepitus (grating) = crunching sensation when moving joint due to disruption of normally smooth articulating surfaces of joints
  • Alteration in gait
  • Joint swelling = bony enlargement, effusion, synovitis (inflammatory)
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35
Q

Joints must commonly affected in osteoarthritis

A

o DIPJs and first carpometacarpal joints of hands
o First metatarsophalangeal joint of foot
o Weight-bearing joints = vertebra, hips and knees
o Sacro-iliac joints

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36
Q

XR findings in osteoarthritis

A

Loss of joint space,
Osteophytes forming at joint margins,
Subarticular sclerosis,
Subchondral cysts,
Abnormalities of bone contour

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37
Q

Conservative management of osteoarthritis

A
  • Lifestyle changes  Weight loss, Exercise
  • Physiotherapy = improve strength and support joint
  • Occupational therapy = support activities and function
  • Local heat or ice packs applied to affected joint may help
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38
Q

Medical management of osteoarthritis

A
  • Analgesia
    1. oral paracetamol, topical NSAIDs, topical capsaicin
    2. oral NSAIDs + PPI (omeprazole)
    3. opiates (codeine/morphine)
  • Intra-articular corticosteroid injections = short term improvement
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39
Q

Surgical management of osteoarthritis

A

o Arthroscopy = Scope inserted into joint to assess damage and remove loose bodies  bone or cartilage fragment that cause ‘knee lock’
o Arthroplasty (knee or hip replacement)
o Osteotomy = Cut bone to change shape/length
o Fusion = Usually of ankle and foot to prevent painful grinding of bone

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40
Q

What is rheumatoid arthritis

A

Chronic systemic inflammatory autoimmune disease of the joints characterised by symmetrical, deforming, peripheral polyarthritis

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41
Q

Risk factors for rheumatoid arthritis

A
  • Females = Before menopause women are affected 3x more than men
  • Family history
  • Genetic factors (HLA-DR4 and HLA-DR1) = increased susceptibility and severity
  • Smoking
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42
Q

Presentation of rheumatoid arthritis

A
  • Symmetrical swollen, painful and stiff joints
  • Worse in morning and cold = Morning stiffness lasting >30 mins
  • Pain worse after rest but improves with activity
  • Fatigue, sleep disturbed
  • Slowly progressive
  • Weight loss
  • Flu-like illness
  • Muscle aches and weakness, wasting
  • Symmetrical involvement of small joints of hand, metacarpophalangeal, proximal interphalangeal (not DIP), metatarsophalangeal of feet, (Wrists, elbows, shoulders, knees and ankles)
  • Hand deformities = Ulnar deviation, Swan neck, Z thumb, Boutonniere deformity
  • Joints usually swollen, warm and tender
  • Movement limitation
  • Synovitis and effusions in knees
  • Tenosynovitis = inflammation of tendons
43
Q

Antibodies in rheumatoid arthritis

A
  • Positive rheumatoid factor (70-80%)
  • Positive anti-cyclic citrullinated peptide (30%) = presents early
44
Q

XR findings in rheumatoid arthritis

A

o Early  Loss of joint space, juxta-articular osteoporosis, soft-tissue swelling
o Late  periarticular erosions, subluxation

45
Q

Bloods in rheumatoid arthritis

A

ESR/CRP raised
Raised platelets
Normochromic normocytic anaemia

46
Q

Analgesia in rheumatoid arthritis

A

NSAIDs (+ PPI)

47
Q

Management of rheuamtoid arthritis

A
  • 1st line = DMARD monotherapy (methotrexate) ± short course prednisolone
  • 2nd line = methotrexate + leflunomide/sulfasalazine
  • 3rd line = methotrexate + anti-TNF (infliximab)
  • Intra-articular injection (semicrystalline steroid)
48
Q

Monitoring requirements for rheumatoid arthritis

A

DMARDs = monitor FBC and LFT
Disease monitoring = CRP and disease activity

49
Q

Side effects of DMARDs

A

myelosuppression, liver cirrhosis, pneumonitis

50
Q

Flares of RA

A

oral or IM corticosteroids

51
Q

Surgery in RA

A

relief pain, improve function and prevent deformity

52
Q

Complications of rheumatoid arthritis

A
  • Lungs = Pleural effusions, Fibrosing alveolitis, Pneumoconiosis, Interstitial lung disease, Bronchiectasis
  • Heart (rare) = Pericarditis, Pericardial rub, Raynaud’s, Pericardial effusion
  • Eyes = Dry eyes, Episcleritis (non-severe mild redness of eyes), Scleritis (severe pain, can’t look at bright lights)
  • Neurological = Peripheral sensory neuropathies
    o Compression/entrapment neuropathies = carpal tunnel
    o Cord compression = sensory loss, weakness and disturbed bladder function
  • Kidneys = Amyloidosis, Nephrotic syndrome, CKD
  • Skin = Subcutaneous nodules
53
Q

Side effects of corticosteroids

A

Osteoporosis

54
Q

Side effects of methotrexate

A

Nausea
Mouth ulcers
Diarrhoea
Neutropenia
Thrombocytopenia
Renal impairment
Liver fibrosis
Pulmonary fibrosis

55
Q

Contraindications of methotrexate

A

Pregnancy – avoid for at least 6m after Tx stopped

56
Q

What is ankylosing spondylitis

A

Chronic inflammatory disorder of spine, ribs and sacroiliac joints

57
Q

Epidemiology of ankylosing spondylitis

A
  • Males aged 20-30
  • High incidence in Native North Americans
58
Q

Risk factors for ankylosing spondylitis

A
  • HLA-B27 (88%)
  • Family history
59
Q

Presentation of ankylosing spondylitis

A
  • Gradual onset of lower back pain
    o Pain radiates from sacroiliac joints to hip/buttocks
    o Worse at night with spinal morning stiffness
    o Usually improves towards end of day
    o Pain worse with rest and improves with movement
  • Asymmetrical joint pain = normally oligoarthritis (1/2 joints)
  • Progressive loss of spinal movement resulting in reduced thoracic expansion
  • Loss of lumbar lordosis (normal inward curve of spine)
  • Increased kyphosis = curvature of spine that causes top of back to appear more rounded than normal
  • Schober test = Reduced spinal flexion <5cm
60
Q

Associations of ankylosing spondylitis

A
  • Apical pulmonary fibrosis
  • Anterior uveitis = inflammation of middle layer of eye
  • Aortic regurgitation/aortitis
  • Achilles tendonitis
  • AV node block
  • Amyloidosis
  • Anaemia
  • Cauda equina syndrome
  • Peripheral arthritis
  • Weight loss and fatigue
  • Chest pain = costovertebral/costosternal joints
  • Dactylitis = inflammation of finger/toe
  • Enthesitis
  • Restrictive lung disease = restricted chest wall movement
  • Inflammatory bowel disease
61
Q

XR findings in ankylosing spondylitis

A

o Squaring of vertebral bodies
o Sacroiliitis: Subchondral sclerosis and erosions
o Syndesmophytes = areas of bone growth where ligaments insert into bone
o Bamboo spine (late and uncommon)
o Dagger sign  radiodense line related to ossification of supraspinous and interspinous ligaments
o Ossification of ligaments, discs and joints
o Fusion of facet, sacroiliac and costovertebral joints

62
Q

Respiratory investigations in ankloysing spondilitis

A
  • CXR  apical fibrosis
  • Spirometry  restrictive (pulmonary fibrosis, kyphosis, ankylosis of costovertebral joints
63
Q

Complications of ankylosing spondilitis

A

Vertebral fractures

64
Q

Management of ankylosing spondilitis

A
  • Physiotherapy
  • Exercise and mobilisation
  • Avoid smoking
  • NSAIDs
  • Steroids during flares
  • Anti-TNF (etanercept) or monoclonal antibody against TNF (infliximab)
  • Secukinumab (monoclonal antibody against interleukin-17)
  • Bisphosphonates = osteoporosis
  • Surgery = hip replacement to improve pain and mobility
65
Q

Presentation of psoriatic arthritis

A
  • Stiffening and soreness of joint
  • Symmetrical polyarthritis (F>M)  Hands, wrists, ankles, DIP joints
  • Asymmetrical oligoarthritis  Fingers and toes and feet
  • Spondylitic pattern (M>F)
    o Back stiffness
    o Sarcoiliitis
    o Atlanto-axial joint involvement
  • Arthritis Mutilans (severe)
    o Progressive shortening of digit due to osteolysis
    o Skin folds as digit shortens = telescopic finger
  • Plaques of psoriasis on skin
  • Pitting of nails
  • Onycholysis = separation of nail from nail bed
  • Dactylitis = inflammation of full finger
  • Enthesitis = inflammation at points of tendon insertion
  • Tenosynovitis
66
Q

Screening for psoriatic arthritis

A

Psoriasis Epidemiological Screening Tool (PEST)

67
Q

XR findings in psoriatic arthritis

A

o Periostitis = thickened irregular outline of bone
o Ankylosis = bones joining together cause joint stiffening
o Osteolysis = destruction of bone
o Dactylitis = soft tissue swelling
o Pencil-in-cup appearance = central erosions of bone beside joints

68
Q

Management of psoriatic arthritis

A
  • Managed by rheumatologist
  • NSAIDs (mild)
  • DMARDs (methotrexate)  mod/severe
  • Anti-TNF medications (etanercept, infliximab, adalimumab)
  • Intra-articular corticosteroid injections
  • Psoriasis treatment
69
Q

Risk factors for reactive arthritis

A
  • Male (post-STI)
  • HLA B27
70
Q

Causes of reactive arthritis

A
  • Gastroenteritis = salmonella, shigella, campylobacter
  • STI = chlamydia, gonorrhoea
71
Q

Presentation of reactive arthritis

A
  • “Can’t see, can’t wee, can’t bend my knee”
  • Typically develops with 4 wks of initial infection
  • Acute monoarthritis usually of knee  Warm, swollen and painful joint
  • Bilateral conjunctivitis, Anterior uveitis
  • Circinate balanitis = dermatitis of head of penis
  • Keratoderma blennorrhagica = raised waxy yellow/brown plaques and pustules on palms and soles
  • Nail dystrophy
72
Q

Investigations for reactive arthritis

A
  • ESR/CRP raised
  • Sexual health review
  • Aspirate joint = gram staining, culture, sensitivity
    o Exclude gout/pseudogout with crystal examination
  • Urethral swab
  • Stool culture
  • X-ray = enthestitis
73
Q

Management of reactive arthritis

A
  • NSAIDs and analgesia
  • Steroid injections into affected joints
  • Systemic steroids and Abx
  • Recurrence = DMARDs (methotrexate) and anti-TNF
  • Screen sexual partners
74
Q

What is SLE

A

Inflammatory autoimmune connective tissue disease affecting multiple systems

75
Q

Risk factors for SLE

A
  • Family history
  • Pre-menopausal women
  • Genetics = HLA genes linked with SLE
  • Drugs = Hydralazine, isoniazid, procainamide and penicillamine
  • UV light = trigger flares
  • Epstein-Barr virus = potential trigger
  • Commoner in African-Caribbeans and Asians
76
Q

Presentation of SLE

A
  • Fatigue
  • Weight loss
  • Joint pain and non-erosive arthritis
  • Muscle pain
  • Fever
  • Shortness of breath
  • Pleuritic chest pain
  • Photosensitive malar rash (butterfly rash), spares nasolabial folds
  • Discoid rash  scaly, erythematous, well demarctated rash in sun exposed areas
  • Lymphadenopathy
  • Splenomegaly
  • Mouth ulcers
  • Hair loss (non-scarring alopecia)
  • Livedo reticularis
  • Raynaud’s phenomenon
77
Q

Antibodies in SLE

A
  • ANA positive = most sensitive
  • Anti-double stranded DNA (anti-dsDNA) positive = most specific to SLE
  • Anti-RO, Anti-Smith, anti-a, Rheumatoid factor
78
Q

Bloods in SLE

A
  • ESR raised and normal CRP
    o Raised CRP may indicate underlying infection
  • FBC = normocytic anaemia of chronic disease
  • Leucopenia, lymphopenia and thrombocytopenia
  • Complement levels (C3 and C4) decreased during active disease
  • Immunoglobulins raised
79
Q

Other investigations in SLE

A
  • Urine protein: creatinine ratio = proteinuria in lupus nephritis
  • Renal biopsy in lupus nephritis
80
Q

Management of SLE

A
  • NSAIDs
  • Hydroxychloroquine (anti-malarial)
    o Baseline opthalmological examination and annual screening
  • Steroids (prednisolone) if internal organ involvement
  • Sun cream and sun avoidance
  • Other immunosuppressants = Methotrexate, Mycophenolate mofetil, Azathioprine, Tacrolimus, Leflunomide, Ciclosporin
  • Biological therapies = Rituximab, Belimumab
  • Reduce CVD risk factors = Smoking cessation, Weight loss, Treat blood pressure and give statins
81
Q

Side effects of hydroxychloroquine

A

Bull’s eye retinopathy

82
Q

Complications of SLE

A
  • Lung  Recurrent pleural effusions, pneumonitis and atelectasis, Pulmonary embolism, Interstitial lung disease  pulmonary fibrosis
  • Heart  Pericarditis and pericardial effusions, Arrhythmias, Arterial and venous thromboses, Increased frequency of IHD and stroke, Abnormal clotting, myocarditis
  • Kidneys  Glomerulonephritis with persistent proteinuria, Renal failure = lupus nephritis
  • CNS  Seizures, Psychosis, Depression, Epilepsy, Migraines, Cerebellar ataxia
  • Eyes  Retinal vasculitis, Episcleritis, Conjunctivitis
  • Sjogren’s (15%)
  • Obstetrics  Recurrent miscarriage, intrauterine growth restriction, pre-eclampsia and pre-term labour
83
Q

What is sjogren’s syndrome

A

Autoimmune disorder affecting exocrine glands resulting in dry mucosal surfaces

84
Q

Presentation of sjorgren’s syndrome

A
  • Dry eyes  keratoconjunctivitis sicca
  • Dry mouth
  • Vaginal dryness
  • Arthralgia
  • Raynaud’s, myalgia
  • Sensory polyneuropathy
  • Recurrent episodes of parotitis
  • Renal tubular acidosis
  • Positive Schirmer’s test
85
Q

Antibodies in sjogren’s syndrome

A
  • Rheumatoid factor positive (50%)
  • ANA positive (70%)
  • Anti-Ro (SSA) antibodies (70% with PSS)
  • Anti-La (SSB) antibodies (30% with PSS)
86
Q

Other investigations in sjogren’s syndrome

A
  • Schirmer’s test  filter paper near conjunctival sac to measure tear formation
  • Histology  focal lymphocystic infiltration
  • Hypergammaglobulinaemia
  • Low C4
87
Q

Management of sjogren’s syndrome

A
  • Artificial saliva and tears
  • Pilocarpine  may stimulate saliva production
88
Q

Complications of sjogren’s syndrome

A

Lymphoma

89
Q

What is fibromyalgia

A

Widespread MSK pain after other diseases have been excluded

90
Q

Risk factors for fibromyalgia

A
  • Low household income
  • Divorced
  • Low educational status
91
Q

Associations of fibromyalgia

A
  • Depression
  • Chronic headache
  • IBS
  • Chronic fatigue syndrome
  • Myofascial pain syndrome
  • Rheumatoid arthritis
92
Q

Presentation of fibromyalgia

A
  • Symptoms present for at least 3 months and other causes have been excluded
  • Widespread chronic pain
    o Predominantly neck and back but may be all over
    o Aggravated by stress, cold and activity
    o Associated with generalised morning stiffness
    o Paraesthesiae of hands and feet
  • Extreme fatigue occurring after minimal exertion
  • Non-restorative sleep
    o Frequent waking during night
    o Waking unrefreshed
  • Poor concentration and forgetfulness
  • Low mood, irritable and weepy
  • Pain at 11/18 tender point sites on digital palpation
93
Q

Exclusion investigations in fibromyalgia

A
  • Thyroid function test = exclude hypothyroidism
  • ANAs and DsDNA = exclude SLE
  • ESR and CRP = exclude PMR + inflammatory arthritis
  • Ca2+ and electrolytes = exclude hypercalcemia
  • Vit D = exclude low vit D
94
Q

Management of fibromyalgia

A
  • Educate patient and family = Explain real symptoms but pain doesn’t always mean damage
  • Reset pain thermostat
  • Improve aerobic fitness = tire them to improve sleep
  • Low-dose antidepressants and anticonvulsants  amitriptyline, pregabalin
95
Q

What is polymyalgia rheumatica

A

Common condition in older people characterised by muscle stiffness and raised inflammatory markers

96
Q

Risk factor for PMR

A
  • SLE
  • Polymyositis/ dermatomyositis
97
Q

Presentation of PMR

A
  • Rapid onset <1m
  • Mild polyarthritis of peripheral joints
  • Sudden onset of severe pain and stiffness of shoulders and neck, hips and lumbar spine = limb girdle pattern
  • Symptoms worse in morning, lasting from 30 mins to several hours
  • Fever (low-grade)
  • Weight loss and anorexia
  • Depression
  • Lethargy
  • Night sweats
98
Q

Investigations in PMR

A
  • Both ESR and CRP raised = diagnostic
    o ESR >40mm/hr
  • Serum ALP raised
  • Temporal artery biopsy  Shows giant cell arteritis in 10-30% cases
  • Creatinine kinase and EMG normal
99
Q

Management of PMR

A
  • Prednisolone 15mg OD
    o Produce dramatic reduction of symptoms of PMR within 24-48 hours of starting treatment
    o If improvement doesn’t occur then diagnosis questioned
    o Decrease dose slowly
  • GI and bone protection  lansoprazole and alendronate and Ca2+ and vit D
100
Q

What is polyarteritis nodosa

A
  • Necrotising vasculitis that causes aneurysms ad thrombosis in medium sized arteries
  • Leading to infarction in affected organs
101
Q

Associations of polyarteritis nodosa

A
  • Hep B
  • RA, SLE, scleroderma
102
Q

Presentation of polyarteritis nodosa

A
  • Numbness
  • Tingling
  • Abnormal/lack of sensation
  • Inability to move part of body
  • Abdo pain due to arterial involvement of abdominal viscera
    o Mimicking acute cholecystitis, pancreatitis or appendicitis
  • GI haemorrhage due to mucosal ulceration
  • haematuria and proteinuria
  • Hypertension and acute/chronic kidney disease
  • Coronary arteritis = MI and heart failure
  • Subcutaneous haemorrhage and gangrene occur
  • Fever, malaise, weight loss and myalgia
    o Initial symptoms followed by dramatic acute features (organ infarction)
103
Q

Investigations of polyarteritis nodosa

A
  • Bloods  Anaemia, WCC raised, ECR raised
  • ANCA negative
  • Biopsy of kidney
    o Hypertension and other damage
    o Can be diagnostic
  • Angiography  Demonstrates micro-aneurysms in hepatic, intestinal or renal vessels
104
Q

Management of polyarteritis nodosa

A
  • ACE-inhibitors = Ramipril
  • Corticosteroids = prednisolone
    o In combination with immunosuppressive drugs = azathioprine or cyclophosphamide
  • Hep B  Should be treated with antiviral after initial treatment with steroids

Finals (23 decks)

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