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rheumatology Flashcards

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1
Q

arthropathy definition

A

disease of a joint

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2
Q

arthritis definition

A

inflammation of a joint

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3
Q

arthralgia definition

A

pain in a joint

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4
Q

seropositive condition

A

auto-antibodies present in serum

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5
Q

anti-CCP antibody

A

rheumatoid arthritis

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6
Q

anti-nuclear antibody

A

SLE, Sjorgen’s syndrome, systemic sclerosis, mixed connective tissue disease, autoimmune liver disease

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7
Q

anti-double stranded DNA antibody

A

SLE

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8
Q

anti-Sm

A

SLE

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9
Q

anti-Ro

A

SLE, Sjorgen’s syndrome

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10
Q

anti-La

A

Sjorgen’s syndrome

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11
Q

anti-centromere antibody

A

systemic sclerosis (limited)

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12
Q

anti-Scl-70 antibody

A

systemic sclerosis (diffuse)

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13
Q

anti-RNP antibody

A

SLE, MCTD, myositis

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14
Q

anti-cardiolopin antibody and lupus anti-coagulant

A

anti-phospholipid syndrome

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15
Q

anti-neutrophil cytoplasmic antibody (ANCA)

A

small vessel vasculitis (GPA, EGPA, MPA)

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16
Q

osteoarthritis X-ray signs (LOSS)

A

loss of joint space osteophytes sclerosis subchondral cysts

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17
Q

the four groups of inflammatory arthropathies

A

seropositive, seronegative, infectious and crystal deposition arthropathies

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18
Q
A

osteoarthritis

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19
Q
A

inflammatory spondylitis

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20
Q
A

psoriatic arthritis

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21
Q
A

rheumatoid arthritis

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22
Q

is RA more common in men or women?

A

women

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23
Q

joints most commonly affected by RA

A

small joints of the hands and feet

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24
Q

what role does the pannus play in the pathogenesis of RA?

A

an inflammatory pannus forms and then attacks and denudes the articular cartilage leading to joint destruction

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25
features of inflammatory arthritis
joint pain with associated swelling morning stiffness improvement of symtpoms with exercise synovitis on examination raised imflammatory markers extra-articular symptoms
26
clinical features of RA
symmetrical synovitis, pain, morning stiffness, early involvement of hands and feet
27
why is the DIP joint not commonly affected in RA?
because RA only affects synovial joints, and the DIP is so small that there is hardly any synovium in it
28
why can RA result in cervical cord compression?
the atlanto-axial joint can be affected, which can lead to subluxation and eventually cervical cord compression
29
30
extra articular manifesations of RA
rheumatoid nodules on extensor surfaces of sites of frefquent mechanical irritation preural effusions, interstitial fibrosis and pulmonary nodules keratoconjunctivitis sicca, episcleritis, uveitis and nodulr scleritis
31
RA investigations
rheumatoid factor, anti-CCP antibody CRP, ESR and PV are usually raised xrays often show no abnormality peri-articular osteopenia and soft tissue swelling
32
RA treatment
DMARDs (methotrexate, sulphasalazine, hydroxychlorquine, leflunomide) simple analgesia NSAIDs steroids anti-TNFa injections
33
disease activity in RA is measured using
DAS28
34
DAS 28 2.7-3.2
low disease activity
35
DAS 28 3.3-5.1
moderate disease activity
36
DAS 28 \>5.1
high disease activity
37
DAS 28 \<2.6
remission
38
patients must have a score of ____ to be eligible for biologic therapy
\>5.1 (high disease activity)
39
operative management of RA
synovectomy, joint replacement, joint excision, tendon transfers, anrthrodesis, cervical spine stabilisation
40
seronegative arthropathies include
ankylosing spondylitis, psoriatic arthritis, enteropathic arthritis and reactive arthritis
41
characteristics of seronegative arthropathy
inflammation/arthritic disease of the spine (spondyloarthropathy) asymmetric oligoarthritis sacroiliitis uveitis dactylitis enthesopathies
42
laboratory signs of seronegative arthropathy
HLA-B27 positive elevated CRP and ESR
43
who is most commonly affected by ankylosing spondylitis?
males aged 20-40
44
which joints are affected by AS
spine and sacroiliac joints
45
AS symptoms
spinal pain and stiffness knee or hip arthritis morning spinal stiffness that improves with exercise gradual loss of spinal movement development of 'question mark' spine (loss of lumbar lordosis and increased thoracic kyphosis)
46
how do you measure lumbar spine flexion?
Schober's test
47
AS associated conditions
anterior uveitis, aortitis, pulmonary fibrosis, amyloidosis
48
xray signs of AS
sclerosis and fusion of SI joints bony spurs from the vertebral bodies (syndesmophytes) producing a 'bamboo' spine common for xrays to be normal at time of presentation
49
MRI features of AS
bone marrow oedema entheitis of the spinal ligaments
50
laboratory signs of AS
90% of sufferers are HLA-B27 positive
51
AS treatment
physiotherapy and exercise NSAIDs anti-TNF inhibitors for more aggressive disease DMARDs if peripheral joint inflammation
52
psoriatic arthritis presentation
asymmetrical oligoarthritis spondylitis dactylitis enthesitis nail pitting and onycholysis (splitting of nail from nail bed)
53
psoriatic arthritis treatment
DMARDs (methotrexate) anti-TNFa therapy for those who don't repsond to standard therapy joint replacement in severely affected large joints DIP fusion
54
enteropathic arthritis definition
inflammatory arthritis involving the peripheral joints and sometimes spine, in patients with IBD
55
enteropathic arthritis presentation
large joint asymmetrical oligoarthritis
56
treatment of enteropathic arthritis
finding medication to manage the underlying condition and the arthritis
57
reactive arthritis definition
occurs in response to an infection in another part of the body, most commonly GU infection (chlamydia, neisseria) or GI infections (salmonella, campylobacter)
58
reactive arthritis presentation
large joints become inflamed 1-3 weeks after the infection (infection triggers autoimmune arthropathy)
59
Reiter's syndrome
urethritis, uveitis or conjunctivits and arthritis
60
SLE mainly involves...
skin, joints, kidneys, blood cells, and nervous system
61
clinical criteria of SLE
- acute cutaneous lupus chronic cutaneous lupus oral or nasa lulcers non-scarring alopecia arthritis serositis renal neurologic haemolyitc anaemia leukopaenia thrombocytopaenia
62
immunologic criteria SLE
ANA anti-DNA anti-Sm antiphospholipid Ab low complement direct Coombs' test
63
what type of hypersensitivity reaction is SLE
type 3 - immune complex mediated
64
SLE general symptoms
fever fatigue weight loss
65
SLE MSK symptoms
arthralgia myalgia inflammatory arthritis increased prevalence of AVN, usually of the femoral head
66
SLE muco-cutaneous symptoms
malar rash photosensitivity discoid lupus subacute cutaneous lupus oral/nasal ulceration raynaud's phenomenon alopecia
67
SLE renal symptoms
lupus nephritis
68
SLE respiratory symptoms
pleurisy pleural effusion pneumonitis pulmonary embolism pulmonary hypertension intersitial lung disease
69
SLE haematological symptoms
leukopaenia lymphopaenia anaemia thrombocytopaenia
70
SLE neuropsychiatric symptoms
seizures psychosis headache aseptic meningitis
71
SLE cardiac symptoms
pericarditis pericardial effusion pulmonary hypertension sterile endocarditis accelerated ischaemic heart disease
72
SLE GI symptoms
less common AI hepatitis pancreatitis mesenteric vasculitis
73
SLE investigations
FBC may show anaemia, leukopaenia and thrombocytopaenia ANA - not specific Anti-dsDNA - specific Anti-Sm - specific but low sensitivity Anti-Ro, Anti-La and Anti-RNP - not specific C3/4 levels - low when disease active urinalysis may show signs of glomerulonephritis imaging for organ involvement
74
SLE management
skin disease and arthralgia - hydroxychloroquine, topical steroids, NSAIDs immunosuppression with azothioprine or mycophenolate mofetil severe disease may need IV steroids and cyclophosphamide IV Ig and rituximab may be necessary in unresponsive cases
75
SLE monitoring
anti-dsDNA and complement to monitor disease activity urinalysis for blood or protein BP and cholesterol should be monitored
76
Sjorgen's syndrome symptoms
dryness of eyes and mouth (sicca) arthralgia fatigue vaginal dryness parotid gland swelling
77
Sjorgen's diagnosis
ocular dryness positive anti-Ro positive anti-La lip gland biopsy
78
Sjorgen's management
lubricating eye drops saliva replacement products regular dental care hydroxychloroquine can help with arthralgia and faitgue
79
systemic sclerosis characteristics
vasomotors distrubances (raynauds) fibrosis and subsequent atrophy of the skin and subcutaneous tissue excessive collagen deposition causes skin and internal organ changes
80
cutaneous involvement of SSc has three stages
1 - oedematous 2 - indurative 3 - atrophic
81
major features of SSc
centrally located skin sclerosis that affects the arms, face and/or neck
82
minor features of SSc
sclerodactyly atrophy of the fingertips and bilateral lung fibrosis
83
what are the CREST symptoms in SSc
Calcinosis Raynauds Esophageal dysmotility Sclerodactyly Telangiectasia
84
organ involvement in SSc
pulmonary hypertension, pulmonary fibrosis and accelerated hypertension gut involvement may lead to dysphagia, malabsorption and bacterial overgrowth of the small bowel inflammatory arthritis and myositis
85
limited SSc affects
face, hands, forearms and feet skin changes late organ involvement
86
diffuse SSc affects
skin changes to the trunk early organ involvement
87
limited SSc antibody
anti-centromere
88
diffuse SSc antibody
anti-Scl-70
89
SSc investigations
anti-centromere/anti-Scl-70 antibodies organ screening
90
SSc management
raynauds - calcium channel blockers renal involvement - ACE inhibitors GI involvement - proton pump inhibitors for reflux interstitial lung disease - immunosuppression (cyclophospohamide)
91
mixed connective tissue disease features symptoms seen in other connective tissue diseases, including
raynauds arthralgia/arthritis myositis sclerodactyly pulmonary hypertension interstitial lung disease
92
MCTD antibodies
anti-RNP antibodies
93
MCTD management
calcium channel blockers for raynauds immunosuppression if significant muscle or lung disease
94
antiphospholipid syndrome is a disorder that manifests clinically as...
recurrent venous or arterial thrombosis and/or foetal loss
95
presentation of anti-phospholipid syndrome
recurrent pulmonary emboli or thrombosis late spontaneous foetal loss/recurrent foetal loss migraine livedo reticularis
96
APS investigations
thrombocytopaenia prolongation of APTT lupus anticoagulant, anti-cardiolipin antibodies and anti-beta 2 glycoprotein may be positive
97
APS treatment
anti-coagulation if episodes of thrombosis LMWH in pregnancy if recurrent pregancy loss
98
gout is caused by
urate crystals within a joint
99
hyperuricaemia may be due to...
renal underexcretion or excessive intake of alcohol, red meat and seafood
100
the most common site of gout is
the first metatarsalphalangeal joint (MTP)
101
gout presentation
intensely painful, hot swollen joint
102
how long do gout symptoms normally last
7-10 days
103
what are gouty tophi
painless white accumulations of uric acid in the soft tissues
104
definitive diagnosis of gout
synovial fluid with polarised microscopy
105
what shape are uric acid crystals
needle shaped
106
what type of birefringence do uric acid crystals display
negative (change from yellow to blue when lined across the direction of polarisation)
107
treatment of acute gout
NSAIDs corticosteroids opioid analgesics colchicine if cant tolerate NSAIDs
108
treatment for recurrent gout (or with joint decstruction or tophi) when should they be started
allopurinol or other urate lowering therapies should not be started until an acute attack has settled as they can potentiate a further flare
109
what is pseudogout caused by
pyrophosphate crystals
110
what is chondrocalcinosis
deposition if calcium pyrophosphate in catilage and other soft tissues in the absence of acute inflammation
111
calcium pyrophosphate deposition disease tends to affect
the ankle, knee and wrist
112
calcium pyrophosphate deposition disease can coexist with
hyperparathyroidism hypothyroidism renal osteodystrophy haemochromatosis Wilson's disease
113
treatment of pseudogout
NSAIDs corticosteroids (systemic and IA) colchicine
114
pseudogout prophylaxis?
there is no prophylaxis for pseudogout
115
characteristics of polymyalgia rheumatica
proximal myalgia of the hip and shoulder girdles morning stiffness that lasts over 1 hour symtpoms improve with movement
116
polymyalgia rheumatica is associated with what type of vasculitis
GCA
117
polymyalgia rhematica investigations
raised CRP and PV/ESR
118
polymyalgia rheumatica response to low dose steroids (diagnostic tool)
symptoms respond very dramatically
119
polymyalgia rheumatica treatment (and time period)
prednisolone dose reduced over 18 months (condition resolved in most individuals)
120
histopathologically, GCA is marked by
transmural inflammation of the intima, media and adventitia of affected arteries patchy infliltration by lymphocytes, macrophages and multinucleated giant cells
121
vessel wall thickening in GCA can result in...
arterial luminal narrowing, resulting in subsequent distal ischaemia
122
GCA presentation
visual disturbances, headache, jaw claudication and scalp tenderness fatigue, malaise, fever
123
new onset headache in patients over 50 years with an elevated ESR, CRP or PV?
consider GCA
124
what type of headache is present in GCA
continuous located in the temporal or occipital areas focal tenderness on direct palpation
125
jaw claudication is a result of ischaemia of the ________ artery
maxillary artery
126
visual symptoms of GCA
unilateral visual blurring or vision loss occasionally diplopia
127
GCA diagnosis
raised inflammatory markers temporal artery biopsy
128
GCA treatment
corticosteroids (prednisolone 40/60 mg depending on visual symptoms) TREATMENT SHOULD NOT BE DELAYED FOR BIOPSY
129
polymyositis causes...
symmetrical proximal muscle weakness
130
dermatomyositis causes
symmetrical proximal muscle weakness skin changes
131
polymyositis is caused by
a T-cell mediated cytotoxic process directed against unidentified muscle antigens
132
myositis antibodies
anti-Jo-1 and anti-SRP
133
polymyositis presentation
symmetrical proximal muscle weakness in the upper and lower extermities insidious onset myalgia
134
a poor prognostic sign in polymyositis
dysphagia secondary to oropharyngeal and oesophageal involvement
135
anti-Jo-1 antibody in polymyositis is associated with
interstitial lung disease
136
polymyositis investigations
raised inflammatory markers serum creatine kinase raised ANA, anti-Jo-1 and anti-SRP muscle biopsy (exclude other casues)
137
polymyositis treatment
prednisolone (40 mg) methotrexate or azathioprine
138
cutaneous features of dermatomyositis
v-shaped rash over chest heliotrope rash (eyelids) purple plaques on bony prominences (Gottron papules on knuckles) poikiloderma (atrophic, red and brown skin)
139
dermatomysotis is associated with an increased risk of
malignancy (breat, ovarian, lung, colon, oesophagus and bladder)
140
fibromyalgia is thought to be a disorder of
central pain processing or a syndrome of central sensitivity
141
fibromyalgia is associated with
RA and SLE
142
fibromyalgia presentation
persistent (\>3/12) widespread pain fatigue disrupted, unrefreshing sleep cognitive difficulties other unexplained symptoms (anxiety, depression, functional impairment of ADLs)
143
fibromyalgia investigations
rule out other differentials hypothyroidism RA SLE PMR
144
fibromyalgia treatment
self-management techniques graded exercise and activty pacing amitriptyline, gabapentin and pregabalin
145
GCA affects what age group
older than 50
146
Takayasu arteritis affects what age group
under 50
147
which arteries does GCA normally affect
temporal arteries
148
early features of large vessel vasculitis
low grade fever malaise night sweats weight loss arthralgia fatigue
149
ANCA associated vasculitis includes
granulomatosis with polangitis microscopic polyangitis renal limited vasculitis Churg-Strauss syndrome
150
GPA is commonly associated with ENT symptoms such as
nose bleeds deafness recurrent sinusitis nasal crusting
151
the most important complication of microscopic polyangitis is
glomerulonephritis
152
investigations for ANCA positive vasculitis
raised ESR, PV and CRP anaemia of chronic disease U+E for renal involvement ANCA CXR (cavitiating lesions in GPA) biospy of affected area
153
management of ANCA associated vasculitis
IV steroids and cyclophosphamide
154
which of the following is not associated with anti-phospholipid syndrome? venous thrombosis livedo reticularis migraine recurrent pregnancy loss thrombocytosis
thrombocytosis
155
a 69 year old woman complains of pain at the base of her thumbs on examination, she has bony swelling of her thumb CMC joints and finger DIP joints postivie ANA and anti-RNP antibody xray shows loss of joint space, subchondral sclerosis, subchondral cysts and osteophytes
osteoarthritis
156
a 32 year old man is diagnosed as having a pulmonary embolus with no clinical risk factors anticardiolipin antibodies are raised what is the most appropriate anticoagulation treatment?
life long warfarin
157
a patient has pain in their lower nack and a positive ANA at a titre of 1:160 is this diagnostic of SLE?
no - a diagnosis of SLE needs a combination of clinical and laboratory findings ANA of this titre is seen in 13% of the normal population
158
in SLE active complement levels rise when disease is active true/false
false - complement is consumed in the response to the formation of immune complexes low levels of complement are a sign of active disease
159
in SLE, patients will likely be on oral steroids long term true/false
false - steroids should only be used for short periods to suppress disease activity whilst other agents are introduced long term steroids are associated with an increased risk of CV disease, T2DM and osteoporosis
160
when SLE is more active the level of anti-DNA binding antibody is likely to rise true/false
true
161
in a patient with SLE which of the following is the least likely to be a cause of chest pain pneumothorax pericarditis pulmonary embolus pleurisy MI
pneumothorax
162
which of the following is not a recognised feature of limited systemic sclerosis calcinosis butterfly rash raynauds pulmonary HTN anti-centromere antibody
butterfly rash
163
which best describes the management of CTDs? physio and surgery to stabilise joints immunosuppression to normalise antibody levels high dose steroids on diagnosis treat symptomatically and monitor for major complications
treat symptomatically and monitor for major complications
164
the nail changes associated with psoriatic arthritis are
pitting and onycholysis
165
oligoarthritis, sacroiliitis, spondylitis, dactylitis and enthesitis commonly occur in which type of arthritis
psoriatic arthritis
166
which of the following are included in the spondyloarthopathies ankylosing spondylitis gout psoriatic arthritis reactive arthritis rheumatoid arthritis
AS, psoriatic arthrtitis and reactive arthritis
167
following 2 months of joint pain, a 38 year old lady is diagnosed with RA which of the following treatments is recommended first? azathioprine methotrexate anti-IL6 therapy anti-TNF therapy diclofenac
methotrexate
168
which of the following is an xray finding indicative of gout subchondral cyst formation peri-articular erosion chondrocalcinosis loss of joint space peri-articular osteopaenia
chondrocalcinosis (calcium pyrophosphate in the soft tissue in the absence of inflammation)
169
170
a 24 year olf patient, just diagnosed with RA, is about to commence DMARD therapy, but wants to start a family what treatment is most appropriate leflunomide sulphasalazine methotrexate rituximab cyclophosphamide
sulphasalazine ideally, she should delay her pregnancy until her disease has improved
171
a patient has had successful treatment of acute gout but has had 4 flares this year the most appropriate treatment to prevent further flares is prednisolone colchicine allopurinol sulphasalazine naproxen
allopurinol
172
which of the following is not useful in a patient who presents with symmetrical, small joint swelling on examination there is a nodule on his elow but there are no other skin changes systemic examination reveals features of pulmonary fibrosis hand and feet xrays PV and/or CRP anti-CCP antibody CXR anti-dsDNA antibody
anti-dsDNA antibody | (useful in diagnosis of SLE but not RA)
173
anti-CCP antibody is associated with RA true/false
true
174
bamboo spine is an early radiographic change of AS true/false
false
175
what are the features of Reiter's triad?
reactive arthritis, urethritis and uveitis
176
PMR principally affects patients over the age of 50 true/false
true
177
which of the following is not a common xray finding in osteoarthritis subchondral cyst formation periarticular erosion loss of joint space osteophyte formation subchondral sclerosis
periarticular erosion
178
which of these tests is the initial investigation of choice for detecting renal involvement in vasculitis? urea urinalysis renal ultrasound scan creatinine glomerular filtration rate (GFR)
urinalysis
179
anti-TNF agents are more effective in combination with standard DMARDs true/false
true
180
biological agents are associated with a higher risk of infection than synthetic DMARDs true/false
true
181
all patients with inflammatory arthritis should be given biological agents true/false
false
182
anti-TNF agents are 1.5 times more effective than standard synthetic DMARDs true/false
true
183
biological agents are generally more expensive than synthetic DMARDs true/false
true
184
methotrexate and azathioprine can be used as remission maintaining agents in vasculitis true/false
true
185
patients who are going to be on long term steroids should always be assessed for bone protection true/false
true
186
steroids are the mainstay of treatment in the early stages of vasculitis true/false
true
187
cyclophosphamide is always indicated in vasculitis true/false
false
188
which of the following is not a recognised treatment for OA methotrexate topical analgesics NSAIDs joint replacement physiotherapy
methotrexate
189
in a patient with PMR, the development of a headache should make you consider...
GCA
190
allopurinol should be tritiated until target serum urate is achieved (below 360 micromol/L) true/false
true
191
allopurinol should be stopped during acute gout flares true/false
false
192
steroids can be used to reduce inflammation in acute gout true/false
true
193
in patients with new onset RA, DMARDs should be commeced within 3 months of onset of symptoms true/false
true
194
DMARDs require regular blood monitoring to ensure safety true/false
true
195
DMARDs are slow acting true/false
true - up to 8-12 weeks to take effect
196
DMARDS can reduce the rate of progression of joint damage true/false
true
197
DMARDs can reduce inflammation in joints and reduce pain true/false
false - patients will still need analgesia alongside the DMARD

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