Rheumatology Flashcards
(40 cards)
Rheumatoid Arthritis
What is the diagnostic criteria for rheumatoid arthritis?
> ACR 1987 requires 4 of the following for 6 weeks or more:
- Morning stiffness > 1 hour
- Symmetrical joint involvement
- Involvement of small joints of hands
- Arthritis affecting 3 or more joints
- Positive rheumatoid factor
- Rheumatoid nodules
- Radiographic evidence
Rheumatoid Arthritis
What are the poor prognostic markers in rheumatoid arthritis?
- Positive RF
- Positive Anti-CCP
- Early radiographic evidence of erosive disease
- Impaired functional status
- Persistently active synovitis
Ankylosing Spondylitis
What are the systemic manifestations of ankylosing spondylitis?
> Mnemonic 6A’s:
- Anterior uveitis
- Atlanto-axial subluxation
- Apical lung fibrosis
- Aortic regurgitation, Mitral valve prolapse, Atrioventricular conduction defects
- Amyloidosis (kidneys)
- (Autoimmune bowel disease - UC)
- Achilles tendonitis, Plantar fasciitis
- (Arthritis)
Psoriatic Arthropathy
What are the indications for TNF-a inhibitor therapy in rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, crohn’s disease?
>Rheumatoid Arthritis: -Not responding to Methotrexate & one other DMARD >Psoriatic Arthritis -Not responding to two or more DMARDs >Ankylosing Spondylitis -Not responding to two or more NSAIDs >Crohn's Disease: -Fistulating disease -Refractory to immune modulators
Psoriatic Arthropathy
What are the contraindications to TNF-a inhibitor therapy?
> Contraindications to TNF-a inhibitor therapy:
- Pregnancy, Breast feeding
- Active bacterial infection, Septic arthritis in previous 12 months
- Active tuberculosis (requires 2 months of anti-tuberculous prior to TNF-a inhibitor therapy)
- Latent tuberculosis (give isoniazid for 6 months alongside TNF-a inhibitor therapy)
- Demyelinating disease
- Congestive cardiac failure
Psoriatic Arthropathy
What are the side effects of TNF-a inhibitor therapy?
> Side Effects of TNF-a inhibitor therapy:
- Serious infection e.g. tuberculosis
- Haematological abnormalities (anaemia, leukopaenia, thrombocytopaenia)
- Haematological malignancy
- Worsening heart failure
Marfan’s Syndrome
What are the causes of high-arched palate?
- Marfan’s syndrome
- Turner syndrome
- Friedrich’s ataxia
- Tuberous sclerosis
Marfan’s Syndrome
What are the causes of lens dislocation?
- Marfan’s syndrome (up & out)
- Homocystinuria (down & in)
- Ehler Danlos syndrome
Osteomalacia and Rickets
What is the difference between Osteoporosis and Osteomalacia?
> Osteomalacia:
- Decreased mineralization
- Calcium, Phosphate or Vitamin D deficiency
- Symptoms of proximal myopathy & bone pain
- Can be associated with secondary hyperparathyroidism
- Treated with calcium, phosphate, vitamin D replacement
Vitamin D deficiency causes secondary hyperparathyroidism and exacerbates osteopenia/osteoporosis. Raised PTH levels induce phosphaturia/hypophosphataemia causing defect in mineralisation of osteoid (osteomalacia). Unlike osteoporosis, osteomalacia causes non-specific bone pain, severe proximal myopathy, impaired balance and raised alkaline phosphatase. (ref: Hall)
Osteogenesis Imperfecta
What is the molecular defect in osteogenesis imperfecta?
What are the clinical findings?
- Symptoms of brittle bones, blue sclerae, deafness
- Due to defects in type I collagen synthesis
- Treat with calcium & vitamin D supplementation, bisphosphonates
Polydactyly
What is the classification of Polydactyly?
What are the causes of Polydactyly?
>Classification -Post-axial: ulnar side of hand -Pre-axial: radial side of hand -Central: on middle three fingers >Causes: -Bardet-Biedl syndrome -Holt-Oram syndrome -Carpenter syndrome -Patau syndrome -Familial (AD inheritance) >Assoc. features include cognitive & cardiac deficits
Scleroderma
What is the diagnostic criteria for scleroderma?
> ARA Diagnostic Criteria requires 1 Major or 2 Minor criteria:
- Major criteria include sclerosis of skin affecting arms, face, neck
- Minor criteria include sclerodactyly, finger pulp atrophy, bilateral pulmonary fibrosis.
Systemic Lupus Erythematosus
What is the diagnostic criteria?
> ACR 1997: 4 of 11 = lupus (or Nephritis+ANA/dsDNA)
- “DUMP CARS HIA”
- Discoid rash
- Ulcers, Oral ulcers
- Malar rash
- Photosensitivity
- CNS, Neurologic disease a. Seizures OR b. Psychosis
- Arthritis - symmetrical, polyarticular; unlike RA - non-erosive; reducible; sometimes asymm.; and pain is out of proportion to swelling
- Renal, Kidney disease a. > 0.5g/day protein OR b. ≥ 3+ dipstick protein OR c. Cellular casts
- Serositis
- Haematological disorders a. Haemolytic anaemia OR b. Leukopenia OR c. Lymphopenia OR d. Thrombocytopenia
- Immunologic abnormalities (a) Anti-‐dsDNA (b) Anti-‐Sm (c) Antiphospholipid
- ANA is positive
Systemic Lupus Erythematosus
What are the causes of drug-induced lupus?
How can you differentiate drug-induced lupus from SLE?
> Causes of Drug-Induced Lupus:
-Procainamide (most common), Hydralazine, Isoniazid, Methyldopa, Quinidine, Phenytoin, Chlorpromazine, Carbamazepine, Sulphonamides, Tetracycline.
> Differentiating Drug-inducted Lupus from SLE:
-Drug-Induced Lupus has M:F ratio of 1:1, Less Renal/CNS involvement & More Lung involvement, Anti-histone antibodies, Resolution within days-weeks of drug discontinuation
Systemic Lupus Erythematosus
What is the WHO classification of lupus nephritis?
> Mnemonic: No Man Feared Diabetes Mellitus
- Class I: Normal
- Class II: Mesangial
- Class III: Focal Proliferative
- Class IV: Diffuse Proliferative
- Class V: Membranous
- Class VI: Sclerosing
What are side effects of methotrexate?
- hepatic toxicity
- pulmonary fibrosis
- haematological: low WCC, thrombocytopenia
Side effects of cyclosporin?
- renal impairment
- HTN
What are side effects and precautions when using Biologics?
- infection
- TB reactivation
- Allergic reaction
- no live vaccines
- CI in active HepB and C
- increase skin cancer
- not good in pregnancy
What is the differential for deforming symmetrical arthropathy?
- RA
- psoriatic arthritis
- SLE (jaccoud arthropathy)
- tophaceous gout
- other seronegative arthropathy
- very severe OA
What are the XR changes of RA?
- soft tissue swelling
- symmetrical joint space narrowing
- marginal joint erosions
- juxta-articular joint osteoporosis
Investigations for RA?
- RF, anti-CCP
- ESR/CRP
- Hb re: anaemia chronic disease
- XR
Management of RA?
Non pharm: Physio, splints, OT Pharm: - NSAID - DMARD: MTX, leflunomide, hydroxychloroquine, cyclo, azathio - Biologics: TNF, non TNF Surgical: joint replacement
What is on the SLE criteria list?
MD SOAP BRAIN Malar rash Discoid rash Serositis Oral ulcers Arthritis Photosensitive rash Blood abnormal: haemolytic anaem, leukopenia Renal disorder: proteinuria, GN ANA Immunologic disorder: dsDNA, anti-Sm, antiphospholipid Neuro disorder: psychosis or seizure 4 or more = dx of SLE
What are the investigations for SLE?
- ANA, dsDNA, anti-Sm, anti-ro (congenital CHBlock)
- anti U1RNP if MCTD suspected rather than pure SLE
- ESR, C3/C4, CH50
- FBC: hb, low WCC, low play
- UA: proteinuria, blood
- renal biopsy
- APS: anti cardiolipin, B2 glycoprotein, lupus anticoagulant
- MRI and LP if CNS lupus
