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Finals Bible: Medicine > Rheumatology > Flashcards

Rheumatology Flashcards

(132 cards)

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1
Q

What is rheumatoid arthritis?

A

Chronic systemic inflammatory disorder of unknown cause with characteristic joint involvement

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2
Q

Diagnostic criteria for rheumatoid arthritis?

A

4/7 of:

morning stiffness >1 hour
Arthritis of 3 or more joints
Arthritis of hand joints
Symmetrical arthritis
Rheumatoid nodules
Rheumatoid factor positive
X-ray changes
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3
Q

Clinical features of rheumatoid arthritis - hands?

A

Symmetrical poly arthritis sparing the DIPS

Ulnar deviation and prominent ulnar styloid
Swan neck deformity
Boutonniere deformity
Z-thumb
Subluxation at MCP's and wrist
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4
Q

Clinical features of rheumatoid - not hands?

A

Atlanto-axial instability due to weakening of transverse ligament holding odontoid of C2 against arch of C1
- diagnosed when odontoid > 3mm from anterior arch

Anaemia of chronic disease

Scleritis

Interstitial fibrosis, pulmonary nodules

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5
Q

X-ray changes in rheumatoid?

A

BENJ

Bone cysts
Erosions
Narrowing of joint space
Juxta-articular osteoporosis

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6
Q

What markers should you look for in rheumatoid arthritis?

A

Rheumatoid factor = 70%
- IgM to Fc of IgG

Anti-CCP, much more specific but less sensitive

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7
Q

Management of Rheumatoid arthritis?

A

Conservative = info/counselling, OT.

Medical:
Analgesics and NSAIDs

1st line = Methotrexate 7.5mg PO once weekly + 1 other DMARD e.g. Sulfasalazine

2nd line = biologicals, only if you have tried two DMARDs one being methotrexate, and DAS score >5.1 twice

Steroids used for bridging when starting DMARDs + for systemic flair ups

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8
Q

Examples of DMARDs and their SE’s in rheumatoid arhtirits?

A

Methotrexate = Pulmonary fibrosis, BM suppression

Sulfasalzine = reduced sperm, Heinz body anaemia, BM supression

Leflunomide = HTN and interstitial lung disease

Hydroxychloroquinine = Rash, retinopathy

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9
Q

Examples of biologicals and their SE’s in rheumatoid arthritis?

A

Anti-TNF e.g. Etanercept and infliximab = BM suppression and hair loss

Anti-B cell e.g. Rituximab = Cytokine release syndrome, infusion reaction

Anti-IL6 e.g. tocilizumab = BM suppression and mouth ulcers

CTLA4-Ig fusion e.g. Abatacept = GI and BM suppression

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10
Q

Monitoring in rheumatoid?

A

LFT’s and FBCs every 1-2 months early doors then every 3-4 months once stable

DAS score = disease activity score

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11
Q

What is osteoarthritis?

A

The degenerative loss of articular cartilage

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12
Q

Clinical features of osteoarthritis?

A

Pain on activity and worse at end of day / night

morning stiffness <45 minutes

Functional limitation

Affects weight bearing joints = knees, hips

Hands DIP

Spine lumbar affected most

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13
Q

X-ray changes in OA?

A

Loss of joint spaces
Osteophytes
Subchondral cysts
Sclerosis

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14
Q

Management of osteoarthritis?

A

Conservative = weight control, exercise and appropriate orthotics

Medical = analgesia:
1st line = paracetamol
Then NSAIDs
Then Opioids

Intra-articular steroid injections

Surgery = Replace joints

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15
Q

What is septic arthritis?

A

Inflammation of the joint due to the presence an MO

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16
Q

Common MO’s in septic arthritis?

A

Staph aureus = 60%
S. Pyogenes = 15%
N. Gonnorhoea in sexually active patients

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17
Q

Diagnosis of septic arthritis?

A

Joint aspiration prior to antibiotics:
Gram stain
WCC > 50,000/mm3
+ve culture

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18
Q

Management of septic arthritis?

A

Local guidelines = IV for two weeks or until improvement then four weeks orally

No RF’s for atypical = Vancomycin 1g IV BD for two weeks, then clindamycin

If high risk G-ve in elderly / UTI / recent abdo surgery = Ceftriaxone 2g IV OD for 2 weeks, then cefalexin

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19
Q

What is gout?

A

Disorder of purine metabolism, characterised by hyperuricaemia and the deposition of monosodium rate crystals in joints

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20
Q

Precipitating factors for acute gout?

A

Starvation or alcohol excess

Surgery

drugs = Thiazides, furosemide, high dose salicylates

Reduced excretion in renal failure

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21
Q

What does synovial fluid show in gout?

A

-vely birefringent needle shaped crystals

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22
Q

Management of acute gout?

A

NSAIDS e.g.naproxen 500mg PO BD 2 weeks

2nd line = prednisolone

3rd line = colchicine
- useful if contraindication to NSAIDS e.g. GI bleed

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23
Q

Prophylaxis for gout?

A

Conservative = weight loss, dietary modifications and avoid alcohol

Medical prophylaxis if recurrent attacks, tophi and erosive disease

Xanthine oxidase inhibitor = allopurinol 100mg PO OD
- don’t start within 2 weeks of attack

2nd line = Probenecid = increased renal excretion

Refractory = pegolticase

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24
Q

What is pseudogout?

A

Deposition of calcium pyrophosphate crystals in joint

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25
Pseudogout associations?
4 H's Hypoparathyroid Haemochromatosis Hypomagnesaemia Hypophosphatia
26
Synovial fluid findings in pseudogout?
+vely birefringent rhomboid crystals
27
X-ray change in gout vs pseudogout?
Gout = punched out erosions Pseudogout = linear calcium deposition in cartilage
28
Management of pseudogout?
Accessible joints = IA corticosteroids Inaccessible = Colchicine + NSAIDs If refractory = systemic corticosteroids
29
What is a seronegative spondyloarthritis
Any joint disease of the vertebral column that is seronegative i.e. RF -ve
30
Types of seronegative spondyloarthritis?
Anyklosing spondylitis = HLA-B27 Psoriatic arthritis Reactive arthritis Enteropathic arthritis
31
What is ankylosing spondylitis?
Chronic inflammation of the spine, sacra-iliac joint and axial joints Strongly HLA-B27
32
Clinical features of ank spond?
Insidious back pain > 3 months Early morning stiffness, and bad at night Relived by exercise Enthesitis is common = heel and knee
33
Extra articular signs of ank spond?
AAAA Anterior uveitis Aorititis = aortic regurgitation Amylodosis Apical lung fibrosis
34
X-ray findings in ankylosing spondylitis?
Sacra-Iliac fusion Squaring of vertebral bodies Bamboo spine Syndesmophytes = Ossification of annulus fibrosis (the tough circular exterior of the intervertebral disc
35
Management of ankylosing spondylitis?
Conservative = educate and physio Medical = NSAIDs for pain IA injection of intra-articular disease / entheisits Peripheral joint involvement = sulfasalazine If refractory: - continue NSAIDs - TNF alpha inhibitor e.g. Adalimumab or Etanercept
36
What is psoriatic arthritis?
Inflammatory arthritis in association with psoriasis
37
Clinical features of psoriatic arthritis?
Psoriasis generally precedes arthritis Some may have nail dystrophy = pitting and onycholysis Can have multiple patterns, but most common is polyarthritis mimicking RA
38
X-ray changes in psoriatic arthritis?
May see axial changes like in ankylosing spondylitis Pencil cup deformity
39
Management of psoriatic arthritis?
If limited peripheral joint disease = Naproxen 500mg PO BD + physio ± steroid injections Progressive peripheral joint disease: Methotrexate 2nd line = Etanercept or adalimumab
40
What is enteropathic arthritis?
Arthropathy associated with pathology in large / small bowel e.g. IBD, coeliacs
41
Clinical features of enteropathic arthritis?
May only have arthralgia Asymmetrical oligoarticular disease May see associated skin lesions e.g. pyoderma gangrenous and erythema nodosum
42
Management of enteropathic arthritis?
Treat the IBD Symptomatic = NSAIDsand steroids for flares Sulfasalazine as treats the joints and the IBD
43
What is reactive arthritis?
Sterile inflammation of joint, initiated by infection e.g. Salmonella / shigella / yersinia
44
Classic triad of reactive arthritis?
Arthritis Conjuctivitis Urethritis
45
Clinical features of reactive arthritis?
Arthritis weeks after urethritis / dysentry Often self limiting Associated: - Conjunctivitis - Uveitis - Oral ulcers - Keratoderma blennorhagica
46
Management of reactive arthritis?
NSAIDs and steroids acutely Ongoing = sulfasalazine
47
What is osteoporosis?
Predisposition to fractures due to low bone mass and micro-architectural deterioration of bone tissue
48
What is the bone mineral density of osteoporosis and osteopenia?
Osteoporosis is
49
RF's for osteoporosis?
``` Post-menopause Previous # Steroids Low BMI Malabsorption Alcoholic / smoker ```
50
Pathology of osteoporosis?
Increased osteoclast activity = reduced density
51
Investigations for osteoporosis?
FRAX tool for 10 year fracture risk - used in all women >65, men >75 Younger if RF's Bloods NORMAL DEXA scan
52
How does FRAX score affect management?
Low risk = conservative Intermediate = DEXA High risk = Medical therapy
53
Management of osteoporosis?
Conservative = manage RF's, dietary advice, exercise, falls prevention with OT and physio. Medical = Calcium and vitamin D Anti-resorptive agents = bisphosphonates e.g. alendronate 10mg PO OD OR RANK-L antibodies = Denosumab 60mg SC twice yearly
54
What is osteomalacia?
Inadequate bone mineralisation due to vitamin D deficiency. Can be due to poor absorption or poor metabolism
55
Biochem of osteomalacia? X-ray signs?
Low vitamin D Low calcium and phosphate = PTH raised = secondary hyperPTH High alkaline phosphatase Loosers zones
56
Management of osteomalacia?
Vitamin D supplementation
57
Anti-Scl 70?
Systemic sclerosis
58
Anti-centromere?
CREST
59
Anti-jo 1?
Polymyositis
60
C-ANCA?
GPA / Wegeners
61
P-ANCA?
Microscopic polyangitis and EGPA/Churg Strauss
62
Anti-ro/la?
Sjogrens
63
Anti-CCP?
RA
64
Anti dsDNA or Anti-Sm?
SLE
65
Clinical features of SLE?
``` Skin features: MALAR (rash) Mouth ulcers Alopecia Livedo reticularis Abnormal sensitivity to light Raynauds ``` Arthritis Pericarditis, pneumonitis, nephritis Blood disorders e.g. anaemia, leucopenia, thrombocytopaenia
66
Diagnostic criteria for SLE?
4 of: BD PANORAMAS.... Blood disorder Discoid rash ``` Photosensitive Arthritis Neuro disease Oral ulcers Renal disease ANA = 99% +ve Malar rash Autoantibodies to dsDNA or Sm = very specific but not that sensitive Serositis ```
67
Management of SLE?
Conservative = avoid sun, stop smoking, healthy Medical: Mucocutaneous = eye drops and sunscreen Joints = Naproxen 500mg BD + hydroxychloroquinine if severe Steroids if refractory and severe If nephritis may need immunosuppressants e.g. cyclophosphamide
68
What is drug induced lupus? Clinical signs?
Variant on SLE that resolves within days to months on drug withdrawal Mostly skin and lung signs
69
Most common drugs causing drug induced lupus?
Anti-hypertensives = Hydralazine Anti-arrhythmic = Procainamide Antibiotics = Minocycline and isoniazid
70
What are the antibodies for drug induced lupus?
ANA+ve 100%, anti-histone 95%
71
what is anti-phospholipid syndrome?
Due to anti-phospholipid antibodies against anti-cardiolipin and lupus anticoagulant. mainly primary, but can be secondary due to SLE
72
Diagnostic criteria for antiphospholipid syndrome?
Vascular thrombosis in any organ OR a pregnancy event + Persistently positive for antibodies
73
Clinical features of antiphospholipid syndrome?
Clotting Miscarriage Livedo reticularis Cardiac valve lesions If due to lupus anticoagulant = prolonged APTT
74
Management of antiphospholipid syndrome?
Initially LMWH e.g. Dalteparin Then lifelong warfarin INR 2-3 If pregnant LMWH only
75
What is systemic sclerosis?
Disease of unknown aetiology characterised by fibrosis of skin, vessels and internal organs
76
Classification of systemic sclerosis?
Diffuse = 30% = early and severe organ involvement Limited = 70% = CREST, skin limited to face, hands and feet.
77
Clinical features of limited vs diffuse sclerosis?
Limited = CREST + 15% have pulmonary HTN ``` Calcinosis Raynauds oEsophageal dismotility Sclerodactyly Telangiectasia ``` ``` Diffuse: Widespread skin involvement Organ fibrosis: GI = GORD, aspiration and incontinence Lung fibrosis Cardiac = arrhythmias Renal = acute HTN crisis ```
78
Management in systemic sclerosis?
Conservative = exercise, stop smoking, skin emollients Hand warmers for Raynauds Medical = immunosuppressants e.g. methotrexate or mycophenolate then treat symptomatically..... ``` Calcinosis = excision Raynauds = Nifedipine 10mg PO TDS GORD = PPI's ``` Renal crisis = ACEI Captopril 12.5mg PO OD
79
What is Sjogrens?
Autoimmune condition characterised by inflammation and destruction of the exocrine glands
80
Clinical features of sjogrens - glandular?
Dry itchy eyes = Keratoconjunctivitis sick and dry mouth Other glands = dry skin, otitis media, chest infection and pancreatic insufficiency
81
Clinical features of sjogrens - extra glandular?
``` Fatigue and arthralgia Peripheral neuropathy RTA Vasculitis LN's and hepatosplenomegaly ```
82
Serology for sjogrens?
RF+ve ANA speckled +ve Antibodies to ro and la
83
Management of sjogrens?
Dry eyes = artificial tears, ophthalmic ciclosporin Dry mouth = artificial saliva Arthritis = Naproxen 2nd line = hydroxychloroquinine Vascultitis = corticosteroids
84
What is myositis?
Group of disorders with immune mediated muscle injury causing proximal muscle weakness
85
four types of myositis?
Polymyositis Dermatomysositis Inclusion body myositis Necrotising myopathy
86
Women aged 50-70, symmetrical proximal muscle weakness, dysphagia, systemic upset and arthralgia
Myositis
87
What is dermatomyositis?
Myositis + skin signs
88
Dermatomyositis skin signs?
FACE: Heliotrope rash = lilac rash affecting eyelids and nasolabial folds HANDS: Gottrons papules = purple erythematous flat lesions over interphalangeal region of fingers Mechanic hands = cracking and fissuring over skin pads Nailfold abnormalities = periungual erythema, dilated capillary loops BODY: V-sign rash = Confluent erythematous rash over anterior chest and neck Macular rash = shawl like erythematous over shoulders
89
Who does anti-synthetase syndrome affect?
30% of patients with polymyositis and dermatomyositis
90
What are the features of anti-sdnthetase syndrome?
MARIMBA ``` Myositis Acute onset Raynauds Interstitial lung disease Mechanic hands B-symptoms Arthritis ```
91
CK raised, anti-jo1 and EMG characteristic findings
Myositis
92
Management of myositis?
Physio and rehab Medical = immunosuppression High dose steroids for 1 week then taper 2nd line = azathioprine / methotrexate
93
What is polymyalgia rheumatica?
Clinical syndrome of proximal limb girdle pain and stiffness, associated with rapid response to steroids 70 years old female
94
Clinical features of polymyalgia rheumatica?
Acute onset, bilateral proximal muscle pain = Neck, shoulder and hip Early morning stiffness Normal muscle strength but hard to assess due to pain
95
Investigations In polymyalgia rheumatica? Management?
CRP and ESR raised USS for bursitis and effusions = commonly trochanteric Prednisiolone high dose then taper to response Will see rapid response in 48 hours Usually on low dose for prednisolone for a year
96
What is a vasculitis?
Inflammation of the blood vessels with narrowing / occlusion = tissue ischaemia or necrosis
97
What is the Chapel-Hill Classification of vasculitides?
By size: Large = Giant cell arteritis and Takayasu's Medium = Polyarteritis nodosa and Kawasakis Small = GPA, EGPA and microscopic polyangitis HSP
98
What is giant cell arteritis associated with?
Polymyalgia rheumatica
99
Clinical features of GCA?
Commonly affects temporal and ophthalmic = unilateral headache, temporal Scalp tenderness and jaw claudication Visual phenomenon May have proximal weakness due to PMR
100
Investigations for GCA?
Raised CRP | Gold standard = temporal artery biopsy
101
Management of GCA?
Do not delay steroids as blindness risk High dose 60mg PO OD for 4 weeks then taper down IV steroids if impending visual loss Aspirin 75mg + GI and bone protection
102
What is takayasus arteritis?
Granulomatous panarteritis of the aorta and great vessels causing stenosis / occlusion / aneurysm Affects young Asian females
103
Clinical features of takayasus - systemic stage?
Systemic stage = fever, fatigue, weight loss and arthralgia
104
Clinical features of Takayasus - Occlusive stage?
Vascular = claudication, HTN and ABSENT PERIPHERAL PULSES Neuro = Syncope, TIAs Cardiac = Angina and dyspnoea - aortic regurgitation secondary to root dilation
105
Investigations for Takayasus?
Bloods = inflammatory markers raised Non-invasive angiography e.g. MRA CTA
106
Management of Takayasus?
Medical = Steroids, Aspirin and GI and bone protection If cannot tolerate steroids = methotrexate May need surgical intervention if significant limb ischaemia - immunosuppress prior to revascularisation
107
What is polyarteritis nodes (PAN)
Vasculitis of medium sized vessels with aneurysm formation Often middle aged men with Hep B
108
Clinical features of PAN?
Fever and weight loss, arthralgia GI = perforation / haemorrhage Renal = Haematuria, HTN Testes = pain
109
Investigations for PAN?
Angiography, biopsy affected organs
110
Management of PAN?
Non-hepatitis: Poor prognosis = Prednisolone, cyclophosphamide and azathioprine Good prognosis = Prednisolone Hepatitis related: Prednisolone
111
What is Kawasakis?
An acute febrile self limiting vasculitis of medium vessels Asian children
112
Clinical features of Kawasaki's?
Fever > 5 days plus 4 of: - Bilateral conjucntivitis - Cervical lymophadenopathy - Oral mucositis = strawberry tongue - Hand/ feet erythema followed by desquamation - Blotchy red rash 20% will develop coronary vasculitis / aneurysm
113
Management of Kawasakis?
IVIG 2g/kg as single dose The aspiring 80mg/kg / day
114
What is GPA?
Granulomatosis with polyangitis Necrotising granulomatous vasculitis of small vessels
115
Whats the classic triad of GPA?
URT, LRT and glomerulonephritis
116
Clinical features of gPA?
ENT = rhinorrhoea, sinusitis, saddle nose due to nasal ulceration, otitis media LRT = cough and haemoptysis Renal = Glomerulonephritis
117
Investigations forn GPA?
cANCA +ve Urinalysis CXR Biopsy affected tissue = necrotising granulomas
118
Management of GPA?
Organ threatening = Methylprednisolone IV, followed by oral + cyclophosphamide Non-Organ threatening = steroids and methotrexate Maintenance of remission = Steroids and methotrexate
119
What is eGPA?
Also a necrotising granulomatous vasculitis Rare, but prevalent in ASTHMATICS
120
Classic triad of eGPA?
Eosinophilia, granulomatous inflammation and vasculitis
121
Clinical features of eGPA?
Lungs = Asthma, rhinitis or sinusitis Skin = nodules and purpura Neuro = neuropathy
122
Investigations eGPA?
pANCA +ve CXR = infiltrates Biopsy = eosinophilic necrotising granulomas
123
Management of eGPA?
Prednisolone If steroids not sufficient = Methotrexate Severe = Cyclophosphamide and rituximab
124
Clinical features of microscopic polyangitis?
Fever and malaise Lung = pulmonary infiltrates Renal = Glomerulonephritis Neuropathy
125
Investigations for MPA?
pANCA biopsy = necrotising granulomas
126
Management of MPA?
Steroids and methotrexate Cyclophosphamide if more severe
127
What is HSP?
IgA mediated autoimmune hypersensitivity vasculitis Most common vasculitis of childhood. Males
128
Clinical features of HSP?
Hx of URTI Palpable non blanching rash over lower limb extensor surfaces Symmetrical large joint arthralgia / arthritis = Knees and ankles Glomerulonepgirits (IgA nephropathy )
129
Investigations for HSP?
Urinalysis = RBC's, casts and protein Elevated IgA in serum biopsy = Immunofluorescence show IgA and C3
130
Management of HSP?
Steroids If severe add in cyclophosphamide Prognosis excellent, 1 in3 have relapses
131
Pain all over, with multiple trigger points. Normal joints...
Fibromyalgia
132
Management of fibromyalgia?
Information and self care Analgesia = Pregabalin or duloxetine Physio, accupuncture CBT Assess for psychiatric disturbances

Finals Bible: Medicine (6 decks)

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