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Flashcards in Rheumatology Deck (79):
1

Name 3 signs of joint damage in rheumatoid arthritis

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

What immunological investigations should be done in suspected rheumatoid arthritis?

Rheumatoid factor
ANA
Anti-cyclic citrullinated peptide antibodies

3

What are the early radiological signs of rheumatoid arthritis?

Soft tissue swelling
Peri-articular osteopenia

4

Name three extra-articular complications of rheumatoid arthritis

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

5

What are the principals of managing rheumatoid arthritis?

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

What is the diagnostic criteria for lupus?

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

Briefly describe the pathophysiology of SLE?

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

How should lupus activity be monitored?

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

9

What are the features of the discoid rash of lupus?

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

10

What are the features of the malar rash of lupus?

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

11

What immune markers are positive in lupus?

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

12

What are the features of antiphospholipid syndrome?

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

13

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

Ro can cross the placenta and cause congential heart block

14

What are the principles of managing SLE?

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

What are some causes of raised ANA?

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

What is the triad of granulomatosis with polyangitis?

Renal disease
Lung disease
Upper airway involvement

17

What are some upper airway features of granulomatosis with polyangitis?

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

18

What are some renal features of granulomatosis with polyangitis?

Rapid glomerulonephritis with proteinuria and haematuria

19

What are some pulmonary features of granulomatosis with polyangitis?

Cough
Hameoptysis that may be severe in pulmonary haemorrhage

20

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

Arthritis
Peripheral neuropathy
Scleritis
Purpura

21

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

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

How should granulomatosis with polyangitis be managed?

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

23

What are the main features of polymyalgia rheumatica?

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

How should polymyalgia rheumatica be managed?

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

25

What are the main features of giant cell arteritis?

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

26

How should giant cell arteritis be managed?

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

27

How is suspected giant cell arteritis investigated?

ESR (Raised)
Temporal artery biopsy - giant cell granulomas

28

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

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

29

Name 3 causes of secondary Raynaud's

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

30

How is Raynaud's managed?

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

31

What is the pathology behind sjogren's syndrome?

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

32

What antibodies are associated with sjogren's syndrome?

Ro and La (predict systemic involvement
Rheumatoid factor

33

What is schirmer's test?

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

What is the typical feature of polymyositis?

Insidious, progressive, symmetrical and proximal muscle weakness

35

Apart from muscle weakness, name 3 features of polymyositis

Dysphonia
Dysphagia
Shortness of breath

36

What autoantibodies are involved in polymyositis?

ANA positive
Anti jo 1

37

How should polymyositis be managed?

Screen for malignancy
COrticosteroids
Bisphosphonates
Immunosuppression eg with methotrexate
Hydroxychloroquine for rash

38

Describe the pathophysiology of systemic sclerosis

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

What are the features of limited systemic sclerosis?

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

40

What antibodies are associated with systemic sclerosis?

ANA
Anti-centromere antibodies
Anti-topoisomerase in diffuse

41

What is the pathology of gout?

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

Name 3 causes of gout

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

43

How is gout diagnosed on microscopy?

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

44

How is gout differentiated from psuedogout on microscopy?

Pseudogout involves rhomboid shaped crystals that are positively birefringent

45

What are the features of gout on x ray?

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

46

How should an acute attack of gout be managed?

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

How can recurrences of gout be prevented?

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

What are the 4 seronegative spondyloarthropathies?

Psoriatic arthritis
Ankylosing spondylitis
Enteropathic spondylitis
Reiter's syndrome

49

Give 5 shared features of the seronegative spondyloarthropathies

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

50

Which joints are predominantly affected in psoriatic arthritis?

Distal interphalangeal joints

51

What is arthritis mutilans?

Resoprtion of the distal phalynx

52

What changes are found on x ray in psoriatic arthritis?

Erosive changes
Osteolyis
Periosteal reaction

53

How is psoriatic arthritis managed?

NSAIDs
Corticosteroid injections
DMARDs, especially sulfasalazine and methotrexate

54

What is reiter's syndrome?

A triad of conjunctivitis, arthropathy and urethritis

55

Name two organisms that commonly cause reactive arthritis?

Chlamydia trachomatis
Shigella
Campylobacter
Salmonella

56

How is reactive arthritis managed?

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

57

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

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

What features are found on x ray in ankylosing spondylitis?

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

59

What is the pharmacological management of ankylosing spondylitis?

NSAID
anti-TNF
?steroid injection
?DMARD

60

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

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

Give three risk factors for the development of fibromyalgia?

Female
Divorced
Low household income
Low educational status

62

What is the diagnostic criteria for fibromyalgia?

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

What are the x ray features of osteoarthritis?

Loss of joint space
Osteophyte formation
Subchondral sclerosis
Subchondral cyst formation

64

What are the x ray features of rheumatoid arthritis?

Loss of joint space
Periarticular erosions
Subluxation
Juxta-articular osteoporosis

65

What are the x ray features of gout?

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

66

What are the x ray features of psoriatic arthritis?

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

67

What is the joint distribution of osteoarthritis of the hands?

Carpometacarpal
PIP
DIP

68

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

MCP
PIP

69

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

DIP

70

Give 3 risk factors for the development of pseudogout

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

71

How is pseudogout differentiated from gout?

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

What x ray changes are seen in pseudogout?

Chondrocalcinosis

73

How is psuedogout managed?

Similarly to gout
NSAIDs and analgesia
Steroids if necessary

74

What monitoring is required for methorexate?

Baseline and regular fbc, U&Es and LFTs

75

How should methotrexate be prescribed?

Weekly doses titrated to effect with folic acid co-prescribed

76

What monitoring is required for sulfasalazine?

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

77

What is the mechanism of action of azathioprine?

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

78

What monitoring should be done for azathioprine?

Baseline TPMT status, LFTs, FBC and U&Es
Regular monitoring of FBC and LFTs

79

What is the most important side effect of hydroxychloroquine use?

Retinopathy