Rheumatology Flashcards
(99 cards)
1
Q
Name the type of vasculitis’s there are:
A
Large:
- Temporal/ Giant
- Takayasu arteritis
Medium:
- Kawasaki
- Polyarteritis nodosa
- Buerger’s disease
Small:
- Henock Scholien
- Granulomatosis with polyangiitis
- Eosinophilic Granulomatosis with polyangiitis (Chaurg Straus)
- Microscopic polyangiitis
- Cryoglobulinemia
2
Q
What should make one think this may be vasculitis?
A
When there is multisystem involvement
Rashes
Raised inflammatory markers - especially ESR
Abnormal urinalysis
3
Q
What are the symptoms of Kawaski disease?
A
CRASH - Conjunctivitis - Rash - Adenopathy (lymphadenopathy) - Strawberry tongue - Hand/ feet rash - on palsm \+ - Fever
4
Q
How can Henock - Scholein be differentiated from other syndromes that cause purpuric rashes such as ITP and TTP?
A
The platelet count will remain normal to high in Henock, where as the others cause thrombocytopenia
5
Q
What is Felty’s syndrome?
A
Where in RA there is splenomegaly and Neutropenia
6
Q
What investigations should be done in suspected vasculitis?
A
^ESR/ CRP
ANCA test - immunofluorescence followed by ELISA
Renal Status - creatinine, urea
Urine analysis - RBC casts, proteinuria
Angiography
Biopsy
7
Q
Which vessels do giant cell vasculitis tend to affect?
A
Temporal
Ophthalmic
External carotid
8
Q
What vasculitis is hepatitis associated with?
A
Polyarteritis nodosa
- associated with Hep B* major risk factor
9
Q
How is polyarteritis nodosa diagnosed?
A
Angiography
and
Biopsy
Angiography will show the Rosary sign
- skipping of lesions causing a bead like appearance
10
Q
At diagnosis of Kawasaki disease, what must be done?
A
Echocardiogram to assess for any damage to the heart
11
Q
What is needed to diagnose granulomatosis polyangiitis?
A
c- ANCA levels
+
Biopsy from affected site
12
Q
Which vasculitis are typically treated with steroids?
A
Giant cell
Takayasu
polyarteritis nodosa
13
Q
What is the treatment of ANCA+ and Cryoglobulinemic type vasculitis?
A
Immunosuppressive medication (such as cyclophosphamide)
+
Steroids
14
Q
How should Kawasaki vasculitis be treated?
A
IV immunoglobulins
- within the 1st 10 days
+
Aspirin
- prevent clots
15
Q
What type of vasculitis is p-ANCA positive? and what are some symptoms of it?
A
Eosinophilic granulomatosis with polyangiitis
- chronic sinusitis
- asthma
- blood eosinophilia
16
Q
What is a highly suggestive feature of Lupus?
A
Multisystem involvement with increased ESR but normal CRP
17
Q
What disease is associated with Anti- centromere antibodies?
A
Systemic Sclerosis - limited (CREST) type
18
Q
What are the symptoms of CREST?
A
Calcinosis Raynaud's Oespahgeal dysmotility Sclerodactyly Telectangasia
19
Q
What is a distinguishing feature of polymyalgia rheumatica that helps distinguish it form other muscle diseases?
A
Normal Creatine kinase
20
Q
Which drugs can be taken for RA during pregnancy?
A
Sulfasalazine
Hydroxychloroquine
21
Q
What is the different areas of diagnostic criteria for RA?
A
Number of joints affected
Serology markers
Duration of symptoms
Acute reactant proteins. ESR. CRP
Scores of >6 are diagnostic
22
Q
What are the symptoms of polymyalgia rheumatica?
A
Subacute <2 weeks pain onset
- bilateral
- should pain
- limb girdle pain
- fatigue
- weight loss
- depression
- Carpel tunnel syndrome
- temporal arteritis
23
Q
How is the diagnosis of polymyalgia rheumatica made?
A
Clinical symptoms \+ Response to steroids \+ Ruling out other conditions \+ Rapid onset <2 weeks
- ESR >40
24
Q
What advice/ additional interventions should be given to anyone on steroids?
A
STOP
- sick day rules - double
- Ticket - to say steroid dependent
- Osteoporosis treatment
- PPIs
25
What autoimmune antibodies are associated with Dermatomyositis?
Anti - Jo
26
What are the skin lesions typically seen with dermatomyositis?
Photosensitivity
Maculopapular rash
Gottron's papules - on knuckles
Lilac purple rash across eyelids ** very characteristic
27
Dermatomyositis and Myositis may be due to what serious conditions?
Paraneoplastic effects from:
- lung
- ovarian
- pancreatic cancer
28
what investigations should be done into suspected dermatomyositis and how is it treated?
Muscle biopsy - diagnostic
- MRI can help identify areas of abnormal muscle for biopsy
CK levels - useful for measuring disease activity
Anti- Jo
CXR/ Spirometry
* *screening for malignancy
- CT chest/Abdo/ Pelvis
Management:
- exercise programme
- prednisolone
Azathioprine/ methotrexate 2nd line
29
What are the diagnostic tests into Sjogren's syndrome?
Schirmer tear testing
- 5 mins analysis of amount of tear production
Salivary gland biopsy
Auto antibodies
- RF
- ANA
- Anti - Ro
- Anti - La
30
Which antibodies are associated with CREST syndrome?
Anti - Centromere
31
Which antibodies are associated with Diffuse systemic sclerosis?
DNA SCL-70 antibodies
32
What is the treatment for systemic sclerosis?
Non Medical:
- Stop smoking
- skin stretching
- avoidance of cold
- Physiotherapy
Medical
- nifedipine
- Metoclopramide - motility
- PPIs - gastric reflux
- Analgesia - joint pain
Diffuse disease:
- ACE inhibitors (kidney damage can occur)
- IV cyclophosphamide
33
What are the diagnostic tests for Sjogrens syndrome?
Schrimer Test
Biopsy of salivary gland
Anti Ro and Anti La antibodies
34
How does Takayusa present, how is it diagnosed and what is the treatment?
Claudication
Fever
Weight loss
Loss of radial pulses
Angiogram
ESR
treatment:
- High dose steroids
35
What are the symptoms / clinical features of temporal arteritis?
Headache
- temporal headache
- occipital region pain
Scalp tenderness
Jaw Pain
- brought on by chewing
Amaurosis Fugax
Sudden loss of vision
TIAs
36
What investigation should be done into temporal arteritis?
Bloods:
- FBC : anaemia, high platelets, WCC
- ESR
- LFTs - often albumin is low
X-rays:
- Ultrasound of temporal artery
- Angiography
Biopsy of temporal artery
37
What would you see on biopsy of the temporal artery in giant cell arteritis?
Fragmentation of the internal elastic lamina with necrosis of the media
+
Inflammatory infiltrate
38
What are some differentials for temporal arteritis?
PMR
Amyloidosis
Haematological malignancies
Takayasu's arteritis
39
What deformity can occur in granulomatosis polyangiitis?
Saddle nose deformity
40
List some features found clinically on RA:
Sausage shaped fingers
Synovitis
Prominent radius head
Z-shaped deformity of thumb
*then usually stuff remember symmetry
41
What are some side effects of methotrexate:
How often is it given and what should be given with it?
Pancytopenia
Pneumonitis
Liver toxicity - need regular LFTs
Stomastiis
Once weekly.
Folic acid
- sub cut
42
What score is used to monitor disease progress in RA?
Disease Activity Score of 28 joints - DAS28
- joints
- ESR
- General health
<0.6 is poor prognosis
*ultrasound is also usually used
43
What are some features of poor prognosis indicators in RA?
```
Multiple joint involvement
HLA DR4 positive
RF positive
Early -x-ray changes
Extra-articular features
```
44
What investigations do you want to do into Lupus?
Bloods:
- FBC - leukopenia/ thrombocytopenia
- ESR
- U&Es - renal nephritis
- Complement studies - Low C3, C$
- ANA, ds DNA
Orifices:
- Urine analysis
X-rays:
- CXR - pleural effusion
- Joint x-rays - non erosive
ECG
- pericarditis
Special tests:
45
What is it called when lupus affects the kidneys and how is confirmed?
Lupus nephritis
Renal biopsy
46
How can infection and Lupus be differentiated?
CRP levels
47
What are some complications that can occur in birth with lupus?
Miscarriage - PLS
Pre-eclampsia
Worsening of symptoms
Preterm
Neonatal lupus
- transcient discoid rash
48
What is the diagnostic criteria for RA?
Joints affected
Serology
- Rh Factor
- Anti - CCP
Duration of symptoms
>6 weeks
Acute phase reactant proteins
- ESR
- CRP
49
What surgical operations may be indicated for RA?
Synovectomy
- finger tendon sheath to reduce contractures
Joint arthroplasty
50
What is psoriatic arthritis associated with?
nail changes
- Pitting nails
- Onycholysis
- Subungual Hyperkeratosis
- Onychauxis
- colour changes
Synovitis
palmo-pustular changes
Metabolic syndrome
51
What are the different types of Psoriatic arthritis and how do they present?
Asymmetrical Oligoarthritis
- synovitis
- enthesitis
- dactylitis
Symmetrical Polyarthritis
- symptoms of RA without extra articular
DIPJ arthritis
- Periarticular swelling
- Nail dystrophy
AS arthritis
- resembles AS
Mutlins
- Telescoping of the digits
- shortening and destruction
- opera glass hand
52
What is the diagnostic criteria and disease monitoring scoring system used for psoriatic arthritis?
Diagnostic criteria: CASPAR
- evidence of psoriasis / family history
- dactylitis / of previously
- Negative Rh
- Radiological keeping
- Nail changes
Disease monitoring: DAPSA-64
- >28 is severe
53
Which bones are most likely to be affected in paget's disease?
Skull, spine, pelvic bone
54
Where does a malar rash spare?
Nasal labia folds
55
What are the specific antibodies towards lupus?
dsDNA
Anti-smith
56
What gene is linked to anti-phospholipid syndrome?
HLA DR7
57
What investigations should be done into lupus?
Bloods:
- FBC - anaemia
- U&Es - kidney involvement
- ESR
- Complement studies - C3, C4 will be low
- Ant- ANA
- Anti - dsDNA
- Anti Smith
Orifices:
- Urine analysis - protein, blood (lupus nephritis)
X-rays:
- Joint's
ECG:
- pericarditis
Special tests:
- Kidney biopsy
58
What is the general management of Lupus and what is the scoring system used?
SELENA SLEDIA - scoring system used
Avoid sun exposure
Mild:
- NSAIDS
- hydroxychloroquine
Moderate:
- Hydroxychloroquine
- Steroids
- Belimumab
Severe:
- Cyclophosphamide
- Plasmapheresis
59
Differentials for Lupus?
RA
Phospholipid syndrome
Systemic Sclerosis
60
What is the medical management of SA?
1st line:
- NSAIDs
- Steroid injection
2nd line:
- Infliximab
- Etanercept
3rd line:
- Secukinumab = IL-17 Inhibitor
Cardiovascular management
61
What are the manifestations of Reactive arthritis?
Asymmetrical arthritis
- usually follows a few weeks after infection
Sterile conjunctivitis or anterior uveitis
Urethritis
Dactylitis
Enthesitis
Skin:
- Keratoderma Blennorrhagica
**usually develops within 4 weeks of the infection
62
What are the risk factors for systemic scleroderma?
Bleomycin
Vinyl chloride
Female - 30 -50 years old
63
What are the features of limited scleroderma?
Calcinosis
Raynaud's
Esophageal dysmotility
Sclerodactyly - intense tight fibrosis tissue around hands
Telectangasia
64
What are the symptoms of diffuse scleroderma?
edematous onset followed by raynaud's.
Extensive skin thickening
- Heart burn
- Malabsorption for G.I track
- Acute hypertensive renal crisis
- Lung fibrosis
- Myocardial fibrosis
65
What are the specific antibodies related to scleroderma?
CREST syndrome: anti- centromere
Diffuse:
Anti - SCL-70
66
What investigations should be done into Scleroderma?
Bloods:
- FBC
- U&Es - kidney involvement
- Antibodies
- Rh factor
Orifices:
- urine microscopy
- Protein: creatinine ratio
X-rays:
- High resolution CT for fibrosis of lung
- Barium swallow
ECG:
- Heart block/ fibrosis
67
What is the classical onset of polymyalgia rheumatica?
```
50 year old woman, sudden onset pain and stiffness in:
- neck
- shoulders
- pelvis
last for >30 mins
```
68
What is Behcet's disease, where is it common, what is the genetic factor and what is diagnostic test?
Multisystem inflammatory condition characterised by:
- Oral ulcers
- genital ulcers
* also affects many other organs:
- Iran
- Japan
- Turkey
HLA B51
Pathergy test.
69
What would you see on a FBC of someone with phospholipid syndrome?
Thrombocytosis
70
What is the recommended treatment for fibromyalgia?
CBT
71
What are some common drugs that cause lupus?
Procainamide
hydralazine
Isoniazid
72
What will the optic disc look like in temporal arteritis?
Pale and oedematous
73
What antibodies are associated with drug induced lupus?
Anti-histone body
74
What are the risk factors for lupus?
Family history
Genetics
- HLA DR3
Sex hormone status
Drugs
- hydralazine
- Isoniazid
- Procainamide
- Penicillamine
75
What are some skin manifestations of lupus?
Malar rash
Discoid rash
Livedo Reticularis
Alopecia
76
What defects can occur in the heart due to lupus?
Pericarditis
Aortic valve lesions
Non - infective endocarditis
77
What will the FBC results of lupus show?
Anaemia - anemia of chronic disease + Haemolytic anaemia
Leukopenia
Lymphopenia
Thrombocytopenia
Type II hypersensitivity reaction can destroy the blood cells
78
What is another name for Scl - 70?
Topoisomerase - 1
79
Name two tests to look for antiphospholipid syndrome:
Anticardiolipin test
- detects IgG that bind to negatively charged phospholipids
Lupus anticoagulant test
- despite being called lupus it is for APL
80
What is the core triad of lupus?
Fever
Arthralgia
Rash
81
What is the key radiological featured needed on x-ray to confirm a diagnosis of AS?
Sacroiliitis
82
Patient is on warfarin and develops gout, what is 1st line medication?
Colchicine
**NSAIDS contraindicated with warfarin
83
What is the histological changes seen in RA?
Increased villous hyperplasia
Synovial thickness
Lymphocyte and plasma cell infiltration
84
Name two creams used in psoriasis which have vitamin D analogues in them:
Dovobet
Enstilar
85
How is Psoriatic arthritis differentiated from RA?
Absence of Anti - CCP
Dactylitis
86
What are the radiological findings of psoriatic arthritis?
Pencil in Cup deformity
Dactylitis
Fluffy periostitis
Distal joint erosion
87
What is the treatment for psoriatic arthritis?
1st line:
NSAIDs
Physiotherapy
2nd Line:
- DMARDS
3rd:
- Biologics
- Infliximab
- Apremilast
88
What findings may be present in psoriatic arthritis?
```
Dactylitis
Reduced ROM
Painful
Deformity
Sacroiliac involvement
Psoriasis
Nail changes
Predominantly distal involvement
```
89
What x-ray features are seen with psoriatic arthritis?
Fluffy periostitis
Dactylitis
Distal phalangeal erosion
Pencil in cup deformity
90
What are the symptoms of AS?
Sacroiliac pain
Morning stiffness
Breathlessness
- apical pulmonary fibrosis
Reduced exercise capacity
- aortic regurgitation
Blurring of vision
- anterior uveitis
Plantar fasciitis
Weight loss
Fever
91
What are some clinical findings of AS?
Schober's test positive
- reduced lumbar movement when bending forward
Enthesitis
Diastolic murmur heard left sternal edge
- aortic regurgitation
Hyperextension of the neck
- compensatory mechanism
Loss of lumbar lordosis
Kyphosis
92
What is the diagnostic criteria for AS?
<50 years
Worse on rest
Improvement with movement
Insidious onset
93
What is a common bursitis found with polymyalgia rheumatica?
Trochanteric Bursitis
| - diagnosed via US
94
What are the differentials for polymyalgia rheumatica?
Polymyositis
SLE
Fibromyalgia
Hypothyroidism
RA
95
How is polymyalgia monitored?
ESR and CRP levels
96
In the treatment of Polymyalgia, what occurs at 4 weeks?
Reassessment
| - and started on reducing regime
97
What investigations are wanted into giant cell arteritis?
```
FBC
ESR
CRP
CK level
Rh factors
```
Ultrasound of temporal with biopsy
Fundoscopy
98
What is an adverse effect of hydroxychloroquine?
Retinopathy
99
Which drug is sulfasalazine similar to and as such if there is a allergic reaction should also be avoided?
Aspirin
Mesalazine
Both are salicylic acid based
