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Flashcards in Rheumatology Deck (79)
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1
Q

Name 3 signs of joint damage in rheumatoid arthritis

A
Ulnar deviation of fingers
Dorsal subluxation at the wrist
Boutonnieres deformity
Swan neck deformity of fingers
Z deformity of thumb
Rupture of hand or feet extensor tendons
2
Q

What immunological investigations should be done in suspected rheumatoid arthritis?

A

Rheumatoid factor
ANA
Anti-cyclic citrullinated peptide antibodies

3
Q

What are the early radiological signs of rheumatoid arthritis?

A

Soft tissue swelling

Peri-articular osteopenia

4
Q

Name three extra-articular complications of rheumatoid arthritis

A
Vasculitis
Pleurisy
Pericarditis
Dry eye syndrome
Felty's syndrome
Anaemia
Cervical myelopathy
Infections
5
Q

What are the principals of managing rheumatoid arthritis?

A

Refer to rheumatology early
Analgesia with NSAIDs + PPI
Don’t delay referral
Measure disease activity and screen for comorbidities
Give DMARDs early (methotraxate and another and short term steroids at first)
Biological therapies if 2 DMARDs tried for 6 months and failed
Encourage exercise
COnsider surgery if on maximum therapy but still uncontrolled pain, or significantly restricted function

6
Q

What is the diagnostic criteria for lupus?

A
4 out of:
Arthritis of at least 2 joints (non-erosive)
Renal disorder
ANA
Serositis
Haematological disorder
Photosensitivity
Oral and nasopharyngeal ulcers
Immune disorder with positive ds-DNA and positive anti-phospholipid antbody
Neurological eg seizures or psychosis
Malar rash
Discoid rash
7
Q

Briefly describe the pathophysiology of SLE?

A

Inate susceptibility based on immune regulatory genes, complement levels, HLA type and hormone levels combine with environmental triggers such as drugs, UV exposure and microbial response (Eg to EBV)
This triggers autoimmune proliferation with hyperactive T and B cell activation, increased CD4:CD8, defective clearance of immune complexes and impiared tolerance
THis leads to production of autoantibodies with apoptosis, self-exposure and self-recognition

8
Q

How should lupus activity be monitored?

A
Anti-dsDNA antibody (high)
Complement levels (C3 low)
ESR (high, CRP low)
BP
Urine for protein and casts
FBC
U&E
LFTs
9
Q

What are the features of the discoid rash of lupus?

A

Erthematous papules or pustules on head and neck. Leads to hyperpigmented keratotic papules and then atrophic, depressed scarring and depigmentation

10
Q

What are the features of the malar rash of lupus?

A

Fixed erythematous flat or raised rash over malar eminences, sparing the nasolabial folds

11
Q

What immune markers are positive in lupus?

A

ANA
Anti ds-DNA
ENAs inc Ro and La
Anti-phospholipid antibody

12
Q

What are the features of antiphospholipid syndrome?

A

Seen in SLE. Antibodies cause coagulation defect, livedo reticularis, recurrent miscarrdiages and thrombocytopenia

13
Q

What is the significance of a woman with SLE being Ro positive?

A

Ro can cross the placenta and cause congential heart block

14
Q

What are the principles of managing SLE?

A

Hydroxyquinalone for joints and skin involvement.
DMARD such as methotrexate, azathioprine or ciclosporin, covered by prednisolone
Avoid sunlight and UV exposure
Avoid NSAIDs or use sparingly
Monitor bloods for cytopenias and toxicity of drugs
Monitor for opportunistic infections
Aggressive goals for BP and lipid levels to try and minimise cardiovascular risk

15
Q

What are some causes of raised ANA?

A
Normal variant
rheumatological disease
Malignancy
Hepatic disease
Haematological disorder eg ITP
Drugs eg isoniazid
Pulmonary disease
Chronic infection
Other eg graves disease and T1DM
16
Q

What is the triad of granulomatosis with polyangitis?

A

Renal disease
Lung disease
Upper airway involvement

17
Q

What are some upper airway features of granulomatosis with polyangitis?

A
Tracheal obstruction (med emergency)
Epistaxis
Sinusitis
Saddle nose from septal destruction
Nasal obstruction
18
Q

What are some renal features of granulomatosis with polyangitis?

A

Rapid glomerulonephritis with proteinuria and haematuria

19
Q

What are some pulmonary features of granulomatosis with polyangitis?

A

Cough

Hameoptysis that may be severe in pulmonary haemorrhage

20
Q

Other than the main triad, what are some other features of granulomatosis with polyangitis?

A

Arthritis
Peripheral neuropathy
Scleritis
Purpura

21
Q

What investigations should be done in suspected granulomatosis with polyangitis and what will there abnormalities be?

A
FBC and plasma viscosity (PV raised)
U&Es, LFTs and CRP (CRP raised
ANCA (positive)
Urinalysis - proteinuria and haematuria
CXR - may be signs of pulmonary haemorrhage
Lung function tests
CT of sinuses and orbit
COnsider renal biopsy - granulomata, glomerular necrosis, vasculitis
22
Q

How should granulomatosis with polyangitis be managed?

A

Induce remission with high dose steroids and either ciclophosphamide or methotrexate
Maintain remission with low dose steroids and either methotrexate or azathioprine

23
Q

What are the main features of polymyalgia rheumatica?

A

Pain, aching, tenderness and stiffness of pelvic and shoulder girdle, proximal muscle and neck (symmetrical and bilateral)
Fatigue, anorexia, malaise
Depression
Rapid response to steroids

24
Q

How should polymyalgia rheumatica be managed?

A

15mg oral prednisolone slowly weaned over two years (+bisphosphonates, vit D, calcium and PPI)

25
Q

What are the main features of giant cell arteritis?

A
New onset headache that's usually temporal
Temporal artery and scalp tenderness
Jaw claudication
Amaurosis fugax
\+/- signs of polymyalgia rheumatica
26
Q

How should giant cell arteritis be managed?

A

40-60mg prednisolone asap, weaned for around 2 years. SHould be response within a week

27
Q

How is suspected giant cell arteritis investigated?

A

ESR (Raised)

Temporal artery biopsy - giant cell granulomas

28
Q

What is the pattern of colour change found in Raynaud’s phenomenon?

A

White from ischaemia
Blue from stasis of blood
Red from reactive hyperaemia

29
Q

Name 3 causes of secondary Raynaud’s

A
SLE
Systemic sclerosis
Rheumatoid arthritis
Polymyositis
Vibration injury
Atheroma obstruction
THrombocytosis Polycythaemia vera
Beta blockers
Hypothyroidism
30
Q

How is Raynaud’s managed?

A

Stop smoking
Hand warmers and warm socks
Vasodilators eg nifedipine
Surgical sympathectomy if severe

31
Q

What is the pathology behind sjogren’s syndrome?

A

Autoimmune lymphocytic infiltration of exocrine glands, especially salivary and lacrimal. Polyclonal B lymphocytes are hyperreactive causing immune complexes and autoantibody formation

32
Q

What antibodies are associated with sjogren’s syndrome?

A

Ro and La (predict systemic involvement

Rheumatoid factor

33
Q

What is schirmer’s test?

A

USed to investigate possible sjogrens and assesses conjunctival dryness. Piece of filter paper placed under the lower lid and the distance that tears travel is measured. If less than 5mm in 5 minutes, test is positive

34
Q

What is the typical feature of polymyositis?

A

Insidious, progressive, symmetrical and proximal muscle weakness

35
Q

Apart from muscle weakness, name 3 features of polymyositis

A

Dysphonia
Dysphagia
Shortness of breath

36
Q

What autoantibodies are involved in polymyositis?

A

ANA positive

Anti jo 1

37
Q

How should polymyositis be managed?

A
Screen for malignancy
COrticosteroids 
Bisphosphonates
Immunosuppression eg with methotrexate
Hydroxychloroquine for rash
38
Q

Describe the pathophysiology of systemic sclerosis

A

Endothelial cell injury and vascular dysfunction of small and medium vessels
Immunologic derangement with perivascular infiltration of T cells
FIbroblast activation with excess production and deposition of collagen causing progressive tissue fibrosis and occlusion of microvasculature

39
Q

What are the features of limited systemic sclerosis?

A
Calcinosis
Raynauds
Oesophageal and gut dysmotility
Sclerodactyly
Telangiectasia
Microstomia
Abnormal nail fold capillaries
Pulmonary hypertension
40
Q

What antibodies are associated with systemic sclerosis?

A

ANA
Anti-centromere antibodies
Anti-topoisomerase in diffuse

41
Q

What is the pathology of gout?

A

Occurs due to a disorder in the metabolism of purines (into urate) either by reduced renal excretion or increased production
Increased levels of urate in the blood
Urate crystals are deposited at joints, connective tissue and urinary tract

42
Q

Name 3 causes of gout

A
High dietary purine content
Hereditary
Diuretics
Leukaemia
Excess alcohol intake
Cytotoxic agents and tumour lysis
Renal impairment
43
Q

How is gout diagnosed on microscopy?

A

Polarised light microscopy shows urate cystals (needle shaped) that are negatively birefringent

44
Q

How is gout differentiated from psuedogout on microscopy?

A

Pseudogout involves rhomboid shaped crystals that are positively birefringent

45
Q

What are the features of gout on x ray?

A

Soft tissue swelling initially
Chondrocalcinosis
Punched out erosions of peri-articular bone

46
Q

How should an acute attack of gout be managed?

A
Rule out septic arthritis
Self care if mild
Strong NSAID eg diclofenac +PPI. Or Colchicine.
Steroids if Renal impairment
Paracetamol +/- codeine
Measure urate after 4-6 weeks
47
Q

How can recurrences of gout be prevented?

A

Lifestyle advice
Allopurinol if recurrent attacks or tophi/renal impiarment/renal stones
NSAID for at least 1 month to cover period of increased risk of attack

48
Q

What are the 4 seronegative spondyloarthropathies?

A

Psoriatic arthritis
Ankylosing spondylitis
Enteropathic spondylitis
Reiter’s syndrome

49
Q

Give 5 shared features of the seronegative spondyloarthropathies

A
Axial arthritis
Rheumatoid factor negative
Asymmetrical large joint oligo- or monoarthritis
Enthesitis
Dactylitis
Extra-articular features
50
Q

Which joints are predominantly affected in psoriatic arthritis?

A

Distal interphalangeal joints

51
Q

What is arthritis mutilans?

A

Resoprtion of the distal phalynx

52
Q

What changes are found on x ray in psoriatic arthritis?

A

Erosive changes
Osteolyis
Periosteal reaction

53
Q

How is psoriatic arthritis managed?

A

NSAIDs
Corticosteroid injections
DMARDs, especially sulfasalazine and methotrexate

54
Q

What is reiter’s syndrome?

A

A triad of conjunctivitis, arthropathy and urethritis

55
Q

Name two organisms that commonly cause reactive arthritis?

A

Chlamydia trachomatis
Shigella
Campylobacter
Salmonella

56
Q

How is reactive arthritis managed?

A

NSAIDs
Antibiotics if organism can be isolated or steroid injections
DMARD if no response in 6 months

57
Q

What are the main features of the pain of ankylosing spondyloarthritis?

A
Lower back, radiating to the hips and buttocks
Worse at night and on waking
Improved by activity
Gradual onset
May wake them up at night
58
Q

What features are found on x ray in ankylosing spondylitis?

A

Sacroiliitis - sclerosis and erosions
Syndesmophytes of the vertebra
Ligamentous calcification of the spine

59
Q

What is the pharmacological management of ankylosing spondylitis?

A

NSAID
anti-TNF
?steroid injection
?DMARD

60
Q

Give three features that should raise your suspicion of ankylosing spondylitis in a person with chronic lower back pain

A
Under 45
Present for >3 months
Family history of spondyloarthropathy
Inflammatory stiffness
Buttock pain
Costochondritis
Enthesitis
Asymmetric lower limb arthritis
Anterior uveitis
Symptoms wake them at night
Rapid response to NSAIDs
61
Q

Give three risk factors for the development of fibromyalgia?

A

Female
Divorced
Low household income
Low educational status

62
Q

What is the diagnostic criteria for fibromyalgia?

A

Chronic (>3 months), widespread pain associated with unrefreshing sleep and fatigue in the absence of inflammation and with at least 11 tender points on palpation

63
Q

What are the x ray features of osteoarthritis?

A

Loss of joint space
Osteophyte formation
Subchondral sclerosis
Subchondral cyst formation

64
Q

What are the x ray features of rheumatoid arthritis?

A

Loss of joint space
Periarticular erosions
Subluxation
Juxta-articular osteoporosis

65
Q

What are the x ray features of gout?

A

Soft tissue tophi
Punched out juxta-articular erosions with sclerotic edges
Eccentric erosions
Joint effusion

66
Q

What are the x ray features of psoriatic arthritis?

A
Pencil in cup deformity
Juxtaarticular periostitis
Subluxation
Enthesitis
Marginal bone erosions
Bone proliferation
67
Q

What is the joint distribution of osteoarthritis of the hands?

A

Carpometacarpal
PIP
DIP

68
Q

What is the joint distribution of rheumatoid arthritis of the hands?

A

MCP

PIP

69
Q

What is the joint distribution of psoriatic arthritis of the hands?

A

DIP

70
Q

Give 3 risk factors for the development of pseudogout

A
Increasing age
Hypothyroidism
Hyperparathyroidism
Diabetes mellitus
Haemochromatosis
Wilson's disease
Acromegaly
Low magnesium
Low phosphate
71
Q

How is pseudogout differentiated from gout?

A

Pseudogout usually occurs in large joints, whereas gout is usually in smaller joints
On microscopy, gout shows negatively birefringent needle shaped urate crystals and pseudo-gout shows positively birefringent rhomboid CPPD crystals

72
Q

What x ray changes are seen in pseudogout?

A

Chondrocalcinosis

73
Q

How is psuedogout managed?

A

Similarly to gout
NSAIDs and analgesia
Steroids if necessary

74
Q

What monitoring is required for methorexate?

A

Baseline and regular fbc, U&Es and LFTs

75
Q

How should methotrexate be prescribed?

A

Weekly doses titrated to effect with folic acid co-prescribed

76
Q

What monitoring is required for sulfasalazine?

A

Baseline FBC and LFTs and regularly monitor for the first 6 months of treatment

77
Q

What is the mechanism of action of azathioprine?

A

COnverted to 6-mercaptopurine analogue which inhibits the synthesis of DNA and RNA

78
Q

What monitoring should be done for azathioprine?

A

Baseline TPMT status, LFTs, FBC and U&Es

Regular monitoring of FBC and LFTs

79
Q

What is the most important side effect of hydroxychloroquine use?

A

Retinopathy