Rheumatology Flashcards
(97 cards)
1
Q
What medications are effective for osteoarthritis?
A
NSAIDs
Duloxetine (SNRI)
Intra-articular glucocorticoids
2
Q
What is fibromyalgia and its clinical features?
A
Central nociplastic pain disorder
Chronic widespread pain
Allodynia
Fatigue
Fibrofog
Sleep disturbance
Mood disturbance
Sensory sensitivity
Medication intolerance
Altered interoception
3
Q
How is fibromyalgia managed non-pharmacologically?
A
Movement practice (exercise)
Attention to sleep
Cognitive therapy
4
Q
What medications can be used in the management of fibromyalgia?
A
TCAs
Gabapentinoids
SNRIs
Tramadol
5
Q
How is rotator cuff disease diagnosed?
A
Clinically, no role for imaging
6
Q
How is rotator cuff disease managed?
A
Non-invasively with time, PT and NSAIDs
7
Q
How is greater tronchateric pain diagnosed?
A
Clinically, features of maximal tenderness over greater trochanter, positive Trendelenberg test
8
Q
How is greater trochanter pain managed?
A
PT and analgesia
No evidence to support gluco-corticoid injection
9
Q
What conditions are associated with yellow nail syndrome? How is it managed?
A
Chronic resp illness, lymphoedema, rarely RA, malignancy, immunodeficiency
Treatment includes Vit E, zinc, itraconazole (speeds up nail growth not antifungal activity)
10
Q
What is the classical appearance of mycosis fungiodes?
A
Poikilodermatous patches= (hypopigmentation, hyperpigmentation, telangiectasias and atrophy) in bathing suit distribution
11
Q
What HLA types are associated with DRESS to anti-retrovirals?
A
HLA-B5701 and abacavir
HLA-B3505 and nevirapine
12
Q
How is lipoatrophy associated with anti-retrovirals for HIV treated?
A
Switching to non-thymidine agents (didanosine, lamivudine, zalcitabine)
Pravastatin
13
Q
What medications are commonly associated with SJS and TENS?
A
Allopurinol, NSAIDs, antibiotics, anti convulsants
14
Q
What HLA type is associated with SJS/TEN and carbamazepine?
A
HLA-B*1502, Han Chinese esp in Taiwan
15
Q
What immunological tests are associated with dermatomyositis?
A
ANA, anti-Jo1, anti-p55/140 (cancer), anti-Mi2
16
Q
What are the two types of axial apodyloarthritides?
A
- Axial spondyloarthritis: involves spin and sacroiliac joints
- Peripheral spondyloarthritis: involve peripheral joints or entheses or dactylitis
17
Q
How is axial spondyloarthrtitis classified?
A
3 months of inflammatory back pain and age of onset < 45
AND
Sacroilitis on imaging + 1 feature of axial spondyloarthrtitis
OR
HLA-B27 positive and 2 other features of axial spondyloarthrtitis
18
Q
What are clinical features of axial spondyloarthrtitis?
A
-inflammatory back pain
- arhtritis
- enthesitis
- uveitis
- dactylitis
- psoriasis
- crohn’s/colitis
- good response to NSAIDs
- family history of SpA
- HLA-B27
- raised CRP
19
Q
What is the diagnostic criteria for peripheral spondyloarthritis?
A
Peripheral arthritis and/or enthesitis and/or dactylitis
AND
1 non-joint SpA feature
OR 2 other joint SpA features
20
Q
What is inflammatory back pain?
A
- age onset < 40
- insidious onset
- improves with exercise
- no improvement with rest
- pain at night (2nd half of night)
21
Q
What are key features in the pathophysiology of axial spondyloarthrtitis?
A
- genetic susceptibility (HLA-B27)
- IL-23 binding to T-cells resulting in IL-17 production
- IL-17 can also result from chronic gut or skin inflammation
- IL-17 acts on epithelial, endothelial and fibroblasts resulting in synovitis
- IL-7 can act on osteoclasts resulting in bone erosion
- new bone forms at sties of mechanical stress (SIJ, vertebrae)
22
Q
What is the treatment for axial spondyloarthrtitis?
A
1st line:
- NSAIDs
- PT
- if has primarily peripheral disease can consider DMARDs (sulfasalazine, methotrexate) or local steroids (DMARDs have no effect for axial disease)
2nd line: failed 12/52 of therapy
- TNFa blocker: adalimumab, certolizumab pegol, etanercept, golimumab, infliximab
- IL-17 blocker: secukinumab
- JAK inhibitor: tofacitinib, upadacitinib
23
Q
What biologics for axial spondyloarthrtitis should be avoided in IBD?
A
- secukinumab
- etanercept
24
Q
What biologic should be used for axial spondyloarthrtitis if IBD or uveitis present?
A
TNFa mAb: adalimumab, certolizumab pegol, golimumab, infliximab
NOT etanercept in IBD
25
What is the diagnostic criteria for psoriatic arthritis?
Peripheral or axial arthritis or anthesitis + 3 points from:
- Current skin psoriasis (2 pts)
- Prior or FHx of skin psoriasis (1 pt)
- dactylitis (1 pt)
- nail changes (1 pt)
- RF negative (1pt)
- juxta-articular new bone on x-ray (1 pt)
26
What are the five distinct patterns of joint involvement of psoriatic arthritis?
1. Asymmetric oligoarthritis (most common)
2. Symmetric polyarthritis
3. Spondyloarthritis (assymetrical, asymptomatic)
4. DIPJ with nail disease (pitting oncholysis)
5. Arthritis mutilans (shortening of bone)
27
In what disease do you see a pencil in cup deformity?
Psoriatic arthritis (arthritis mutilans)
28
How is psoriatic arthritis treated?
- NSAIDs
- intra-articular steroids (not usually systemic)
- If peripheral: methotrexate, sulfasalazine, leflunomide
- Anti-TNFa: adalimumab, certolizumab pegol, etanercept, golimumab, infliximab
- Anti-IL-17: secukinumab, ixekizumab
- Anti-p40 subunit IL-12/23 = ustekinumab
- Anti-p19 subunit IL-23: guselkumab
- JAKi: tofacitinib, upadacitinib (Axial involvement)
29
What DMARD has activity for all manifestations of psoriatic arthritis?
TNFi
(not etanercept for IBD or uveitis)
30
What are the safety considerations for JAKi?
- VTE
- major CV events
- malignancy (haem, lung)
- shingles risk
31
What are clinical features of reactive arthritis?
Sterile arthritis following a remote infection 1-4/52 prior
Asymmetric, oligoarticular, lower limb
Enthesitis
Dactylitis
Sacro-iliitis
Extra-articular:
- skin: keratoderma blenorrhagica, circinate balanitis, mouth ulcers
- ocular: conjunctivitis, uveitis
- genito-urinary: aseptic urethritis, cervicitis, prostatisit
- constitutional symptoms
Classic triad: arthritis/urethritis/conjunctivitis
32
How is reactive arthritis treated?
- treat underlying infection
- NSAIDs
- IA steroids
- systemic steroids if unwell
- Sulfasalazine for chronic symptoms
33
How should IBD associated apondyloarthritis be treated?
- caution with NSAIDs
- Sulfasalazine, anti-TNF or IL-23 blockade for peripheral joints
- Anti-TNF for axial
(avoid IL-17 blockade and entanercept)
34
What are the 3 pillars of systemic sclerosis?
- autoimmunity
- vasculopathy
- interstitial fibrosis
35
What are clinical features of diffuse cutaneous systemic sclerosis?
- Raynauds (short history)
- Rapid onset skin changes leading to contractures
- skin of trunk and proximal limbs
- tendon friction rubs
- constitutional symptoms
- early onset organ involvement (lung, kidney)
- Scl-70 antibodies (ILD)
- anti-RNA polymerase III antibodies (renal crisis)
- ANA with nucleolar pattern
36
What are clinical features of limited cutaneous systemic sclerosis?
Previously CREST
Calcinosis
Raynauds (years)
Oesophageal dysmotility
Skin changes (upper limb and face)
Telangiectasia
Anticentromere antibodies
37
What therapies are indicated for the treatment of skin thickening in systemic sclerosis?
-Methotrexate (2nd line is mcyophenylate, cyclophosphamide)
- PT
- OT
38
How should ILD be screened for in systemic sclerosis?
- All patients get PFTs and HRCT at baseline
- diffuse get serial PFTs every 3-4 months for 3-5 years the annually
- limited get annual
39
How should ILD be treated in systemic sclerosis?
- mycophenylate (2nd line is cyclophosphamide)
- anti fibrotic = nintedanib
- tocilizumab if systemic inflammation
40
What indicates a role for right heart catheter study to evaluate for pulmonary hypertension in systemic sclerosis?
DLCO <70% predicted + FVC/DLCO > 1.8
OR
proBNP > 210
41
How is Raynaud's treated?
- treat underlying cause (cryoglobulinaemia)
- cold avoidance
- smoking cessation
- caffeine cessation
- hand skin cares
- keeping warm during procedures
- nifedipine (2nd line = ARB, sildenafil)
- severe = IV prostacyclin
42
How should rheumatological digital tip ulcers be treated?
- cold avoidance
- vasodilator therapy (IV iloprost, sildenafil, bosentan)
- analgesia
- wound care
43
How should rheumatological PIP ulcers be treated?
wound care
44
How should calcinosis be managed?
wound care/debridement if ulcerate
45
How should critical digital ischaemia be managed?
- urgent admission
- establish and treat cause
- IV prostaglandin
46
How is faecal incontinence treated in systemic sclerosis?
- exclude overload
- stool firming + laxatives
47
What are indciations for HSCT in systemic scleroderma?
No smokers non responsive to standard treatment:
- diffuse in first 5 years with moderate organ involvement
- limited with progressive visceral involvement
48
What are the 4 types of idiopathic inflammatory myopathies?
- polymyositis
- dermatomyositis
- inclusion body myositis
- immune mediated necrotising myopathy
49
What are the shared features of idiopathic inflammatory myopathies?
Proximal skeletal muscle weakness
Immune mediated muscle inflammation or necrosis
50
What is the pattern of muscle weakness in dermatomyositis and polymyositis?
Symmetrical proximal muscles weakness:
- deltoids, hip flexors, neck flexors
- diaphargmatic and intercostals
- striated muscle of upper 1/3 of oesophagus
51
What rashes can be seen in dermatomyositis?
- gotron's papules (scaling + erythema over hand joints)
- shawl sign (photodistributed poikiloderma)
- helitrope rash
- v sign
- periungal erythema, ragged cuticles
52
What are clinical features of inclusion body myositis?
- insidious onset of asymmetric muscle weakness
- quads often involved
- distal > proximal
- muscle atrophy
- elevated CK
- less responsive to steroids
53
What feature differentiates statin myopathy from immune mediated?
Myopathy persisting despite statin withdrawal suggests immune mechanism
Statins are recognised trigger for immune mediated necrotising myopathy (anti-HMGCR antibodies)
54
Which anti-synthetase antibody is associated with mechanics hands?
Anti-Jo-1
55
What malignancies are associated with dermatomyositis and polymyositis?
DM: cervix, lung, ovaries, pancreas, bladder, CRC, stomach, NHL
PM: lung, bladder, NHL
56
How are dermatomyositis, polymyositis and immune mediated necrotising myositis treated?
- high dose steroids (80 mg/day) tapered over 1 year
- azathioprine
- methotrexate
- rituximab
57
How is inclusion body myositis treated?
Limited response to steroids
IVIg for dysphagia
58
What are clinical features of PMR?
- aching, stiffness around, neck, shoulder and hips
- prolonged morning stiffness (key)
- normal muscle strength but limited by pain
- over 50 y/o
59
How is PMR treated?
- prednisolone 15-25 mg/day for 4 weeks then wean by 2.5 mg every 2 weeks, then by 1 mg/month
- expect response in 48 hours
60
What are the 3 main types of lupus rashes?
Acute (non-scarring):
- malar rash (spares nasolabial folds)
- diffuse erythema of skin
- photosensitivity
Subacute:
- annular, papulosquamous or both
- photosensitivie
Chronic:
- discoid lupus, can scar
61
How is SLE arthritis different to RA arthritis?
SLE typically non erosive and non deforming, synovial effusions uncommon and smaller
62
What is Jaccoud's arthropathy?
Rare part of lupus
Tenosynovitis, RA- like swan-neck deformity and ulnar deviation (no erosion on X-ray) and deformity reducible
63
What is the most common valvular lesion associated with SLE?
Mitral regurgitation
64
How should antiphospholipid syndrome associated with SLE be managed?
- hydroxychloroquine has anti-thrombotic effect
- aspirin as prophylaxis
- lifelong warfarin after first unprovoked venous or any arterial event
(DOACs shown in meta-analysis to be inferior to warfarin)
65
What SLE antibodies are high risk for neuropsychiatric lupus?
antiphospholipid antibodies
Anti-ribosomal p antibodies
Anti neuronal antibodies
66
What CSF features support a diagnosis of neuropsychiatric lupus?
- raised WCC, elevated protein, low glucose
- oligoclonal bands
- anti-dsDNA, anti-neuronal and anti-ribosomal p antibodies
67
What auto-antibodies are associated with neonatal lupus?
anti-Ro
anti-La
(risk of complete heart block 16-26/40)
68
What SLE autoantibodies are associated with renal involvement?
Anti-Sm
Anti-dsDNA
69
What lab measures can be used to measure SLE disease activity?
ESR > CRP
Increased anti-dsDNA
Low C3/C4
(not ANA)
70
What are the benefits of hydroxychloroquine for SLE?
- decrease flares
- decrease organ damage
- improve survival
- improve mycophenylate response in lupus nephritis
- improve cholesterol profile
- anti-thrombotic
Immunomodulatory NOT immunosuppressive
71
What is the major side effect of hydroxychloroquine?
Retinal toxicity
72
When is a renal biopsy indicated in SLE?
- increased serum Cr without alternate cause
- confirmed proteinuria > 1.0 g/24h
- At least 2 episodes in short time period of : proteinuria > 0.5g/24h AND haematuria OR cellular casts
73
How is lupus nephritis treated?
- Immunosuppression for class III, IV and V (not for I, II or VI) = induction with IV pulsed steroids AND mycophenylate OR cyclophosphamide, maintenance = mycophenylate or azathioprine
- ACEi if proteinuria > 0.5g/day
- Aim BP < 130/80
- statin for LDL > 2.6
- Plasma exchange for thrombotic microangiopathy
74
What are contraindications to pregnancy in SLE?
- severe pulmonary hypertension (>50)
- severe restrictive lung disease (FVC < 1L)
- advanced renal insufficiency
- advanced heart failure
- prior severe pre eclampsia or HELLP
- stroke in last 6/12
- severe disease flare in 6/12
75
How can lupus nephritis be distinguished from pre-eclampsia in pregnancy?
- haematuria/active urinary sediment = SLE
- low complement = SLE
- Anti-dsDNA level raised in SLE
- raised liver enzymes and uric acid = pre-eclampsia
76
Is hydroxychloroquine safe in pregnancy? What immunosupresants are safe?
Yes
Azathioprine
77
What autoantibodies are associated with rheumatoid arthritis?
- RF (anti-IgG Fc) = more severe + extr-articular
- ACPA (anti-citrullinated proteins = post-translational modification) = severe + destructive, associated interstitial and CV
- anti-PAD4
-anti-CarP
78
What is RS3PE syndrome?
Pattern of RA:
- remitting, seronegative, symmetric synovitis with pitting oedema
- hand or foot oedema
- tenosynovitis
- good response to glucocorticoids
- paraneoplastic
79
What is the swan neck deformity of rheumatoid arthritis?
Subluxation of lateral bands of extensor tendons resulting in volar herniation of PIP and and flexion of DIP
80
What is the boutinniere deformity of RA?
Rupture of PIP through extensor tendon due to tenosynovitis resulting in PIP flexion and DIP extension
81
What sort of pleural effusion is associated with rheumatoid arthritis?
Exudate (very low glucose, raised protein : LDH, low complement and low pH)
82
What is felty syndrome?
Extra-articular manifestation of seropositive rheumatoid arthritis:
-splenomegaly
- leukopenia
- lower limb ulcers
- hyperpigmentation
- bone marrow hyperplasia
83
What cancers are associated with RA?
- lung cancer
- lymphoma
84
What are radiographic features of RA?
- periarticular soft tissue swelling
- juxta-articular osteoporosis
- marginal erosions
- joint space narrowing
- symmetric involvement
- deformities
85
What is the most effective DMARD for RA?
Methotrexate
86
Can patients on biologic DMARDs have live vaccines?
No
87
Which patient group with RA should be started on biologics?
- adverse prognostic markers (autoantibodies, high disease activity, radiographic damage)
- failed 2 course with conventional DMARD
(not first line)
88
What biologics are used for the treatment of RA?
TNFi:
- infliximab
- adalimumab
- golimumab
- certolizumab (lacks Fc, safe in pregnancy)
- entancercept (soluble TNF receptor)
Abatacept (CD80 CD86)
Rituximab (anti-CD20)
Tocilizumab (anti-IL-6R)
JAKi:
- tofacitinib
- baricitinib
- upadacitinib
89
When should RA drugs be tapered?
- when in remission for at least 6 months and should maintain therapeutic dose on at least 1 DMARD
- prefer ceasing sulfasalazine over hydroxychloroquine
- prefer ceasing methotrexate over biologic
90
How do gout crystals appear under polarised light microscopy?
intracellular needle-shaped negatively birefringent
91
How is an acute flare of gout managed?
NSAID or Prednisone or colchicine +/- intra-articular steroid
92
What are the two classes of urate lowering therapy?
1. xanthine oxidase inhibitors:
- allopurinol
- febuxostat
2. uricosuric agents = inhibit URAT1 and GLUT9 in proximal tubule
- probenecid
- benzbromarone
93
What is the serum urate target in gout?
< 0.36 (< 0.3 if severe recurrent flares)
94
What are clinical features of allopurinol hypersensitivity syndrome?
- desquamating rash, fever, eosinophilia, end organ damage
- HLAB*5801 (Han Chinese, Thai)
- increased risk with concomitant thiazide use
95
When should an underlying primary metabolic disorder in CPPD be investigated for?
In. patients presenting < 55 years
96
What are features of CPPD in synovial fluid analysis?
- raised WCC, 90% neuts
- rhomboid/rod-shaped crystals
- weak positive bifringence with polarised light
97
How is CPPD managed?
NSAIDs, prednisone, corticosteroid injection
