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Yr3 - General Medicine > Rheumatology > Flashcards

Rheumatology Flashcards

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1
Q

ANA

A

Anti-Nuclear Antibodies

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2
Q

ANCA

A

Anti-Neutrophilic Cytoplasmic Antibodies

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3
Q

Anti-CCP

A

Anti-Cyclic Citrullinated Peptide

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4
Q

CTS

A

Carpal Tunnel Syndrome

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5
Q

DXA

A

Dual Energy X-Ray Absorptiometry

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6
Q

GPA

A

Granulomatosis with PolyAngiitis

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7
Q

PV

A

Plasma Viscosity

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8
Q

RF

A

Rheumatoid Factor

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9
Q

Causes of acute monoarthritis

A 
Septic arthritis until proven otherwise
- streptococcal most common
Crystal-induced
- gout - often men
- pseudogout - often elderly women with severe OA
Trauma
- haemarthrosis
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10
Q

Causes of chronic monoarthritis

A 
Infections
- TB
Inflammatory
- Psoriatic arthritis
- Reactive arthritis
- Foreign body
Non-inflammatory
- OA
- Traumatic - meniscal tear
- Osteonecrosis - a/w prednisolone use
- Neuropathic - Charcot's joint
Tumours - rare
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11
Q

Causes of acute polyarthritis

A 
Inflammatory arthritis
- RA
- PsA
- Reactive arthritis
Autoimmune arthritis
- SLE
- vaculitis
Viral infection
- HIV
- Chikungunya
- Parovirus
Crystal arthritis
- Uncontrolled gout
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12
Q

Caues of chronic polyarthritis

A 
Inflammatory arthritis
- RA
- PsA
- Reactive arthrits
Autoimmune arthritis
- SLE
- vasculitis
Crystal arthritis
- Uncontrolled gout
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13
Q

Causes of arthritis of DIPJs

A

PsA
- nail dystrophy on affected digit
OA - common
- Heberden’s nodes

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14
Q

Features to ask for rheumatology history

A 
Pain
- location, duration, pattern, relief/exacerbation
Stiffness
Joint swelling and deformity
Fatigue
Weakness
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15
Q

Features of inflammatory disease

A 
Morning stiffness - > 1 hour
Better on activity
Worse on resting
Significant fatigue
Systemic involvement
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16
Q

Features of mechanical disease

A 
Morning stiffness < 30 mins
Worse on activity
Better on rest
Minimal fatigue
Non systemic involvement
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17
Q

Features of GALS assessment

A

Gait, Arms, Legs, Spine

- quick screening assessment for MSK disorders

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18
Q

Stages of Arms of GALS assessment

A

Inspect hands - palmar and dorsal
Assess pincer-grip and power-grip
Squeezes across 2nd-5th MCPJs - tenderness
Assess active elbow flexion/extension and pronation/supination
Assess active shoulder external rotation

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19
Q

Stages of Legs of GALS assessment

A

Inspects the legs - deformities, leg length, inequality, swellings or muscle wasting
Knee joint effusion
Passive knee flexion and extension
Hip flexion and internal rotation
Inspects feet for deformities and callosites
MTPJ squeeze - tenderness

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20
Q

Stages of Spine of GALS assessment

A

Inspect spine from behind and sides
Palpates supraspinatus
Tests cervical spine lateral flexion
Tests hip and lumbar spine flexion

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21
Q

Features of antalgic gait

A

Pain causes patient to reduce time spent on the affected side

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22
Q

Features of Trendelenberg gait

A

Due to poor hip abduction (weak gluteus medialis)

- pelvis drops to opposite side when standing on affected leg

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23
Q

Features of sensory ataxia gait

A

Wide-based stamping

  • stamping attempt to compensate for lack of sensory input
  • worse when eyes shut
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24
Q

Features of cerebellar ataxia gait

A

Wide-based staggering

- arms often flung out to try to improve balance

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25
Features of hemiplegic gait
Narrow-based - leg swung forwards - toes scrap ground
26
Features of festinant of projectile gait
Difficulty initiating walking - shuffling run - reduced arm swing
27
Features of waddling gait
Duck-like | - due to bilateral hip muscle weakness
28
Features of psychogenic gait
Variable | - worse under observation
29
Define varus
Bow-legged
30
Define valgus
Knock-kneed
31
Sensory nerve supply to hand of median nerve
Skin over thenar eminence Lateral 2/3 palm of hand Palmar aspect of lateral 3.5 fingers Dorsal fingertips of lateral 3.5 fingers
32
Motor supply of median nerve to hand
``` All muscles of anterior compartment except - flexor carpi ulnaris - medical parts of flexor digitorum profundus Intrinsic mucles of hand - LOAF - lateral two lumbricals - opponens pollicis - abductor pollicis brevis - flexor pollicis brevis ```
33
Features of median nerve palsy
Numbness of hand in median nerve distribution - sparing of palm due to intact palmar cuaneous branch Weakness of thumb opposition and abduction Thenar eminance wasting
34
Sensory supply of ulnar nerve to hand
``` Skin over hypothenar eminence Medial 1/3 palm of hand Palmar aspect of lateral 1.5 fingers Medial 1/3 dorsum of hand Dorsal aspect of medial 1.5 fingers ```
35
Motor nerve supply of ulnar nerve to hand
Two muscles of forearm - flexor carpi ulnaris - flex ring and little fingers at DIPJs Most intrinsic muscles of hand
36
Clinical features of ulnar nerve palsy
Numbness over hypothenar eminence and in ulnar nerve distribution of hand Paralysis of flexor carpi ulnaris - weak wrist flexion and adduction Paralysis of medial two parts of flexor digitorum profundus - weakness of flexion of ring and little finger DIPJs Paralysis of most intrinsic mucles of hand - weak MCPJ flexion and IPJ extension of ring and litter finger, loss of finger abduction and adduction, loss of opposition of little finger Claw hand deformity - fixed flexion of IPJs and hyperextension of MCPJs of ring and little fingers due to unopposed median nerve function
37
Interpreting blood tests in rheumatic disease
``` Hb - anaemia of chronic disease - RA - NSAIDs Platelets - rise in inflammation or bleeding - fall in SLE Neutrophils - rise in inflammation, sepsis and prednisolone usage - fall in SLE or with DMARD toxicity Lymphocytes - fall in SLE or DMARD incuded U&E - rise in NSAIDs, renal disease in lupus/vasculitis or gout Uric acid - elevated in gout - falls in inflammation LFTs - hepatic rise due to DMARD toxicity CK, ALT, LDH - rise in myositis ```
38
What does ESR test reflect the presence of?
Fibrinogen | Immunoglobulins
39
Advantages of ESR test
Widely understood | Well established in diagnosis and monitoring of GCA
40
Disadvantages of ESR test
No technique for calibration to test for accuracy Poor reproducibility Test takes 1 hour Must be carried out within 4 hours of blood sampling
41
What does PV test reflect the presence of
Fibrinogen | Immunoglobulins
42
Advantages of PV test
Automatable Sensitive No affected by haemocrit Measurement can be made on stored blood samples
43
Disadvantages of PV test
Not widely used - lack of familiarity with interpretation
44
What does CRP test reflect the presence of
C-Reactive Protein
45
Advantages of CRP test
Automatable Very sensitive Not affected by haematocrit Measurement can be made on stored blood samples
46
Disadvantages of CRP test
Short lived indicator | Good at monitoring sepsis as rises and falls quickly
47
Autoantibodies in RA
Rheumatoid factor (RF) - antibody directed against Fc fragment in human immunoglobulin G - seropositive patients tend to have more severe disease Anti-cyclic citrullinated peptide antibody (ACPA) - more specific for RA for RF Neither rise in disease flares
48
Antinuclear antibodies (ANA) and their disease associations
``` Anti-dsDNA = SLE - rises with disease activity Anti-RO and anti-LA = SLE, Sjogren's Anti-centromere and anti-Scl70 = Systemic Sclerosis Anti-Jo-1 = Polymyositis ```
49
What are anti-neutrophil cytoplasmic antibodies directed against?
Directed against enzymes present in neutrophils
50
Anti-neutrophil cytoplasmic antibodies and their disease associations
C ANCA = GPA, infection, neoplasia - antibody to proteinase-3 P ANAC = microscopic polyangiitis, infection, neoplasia - antibody to myelopreoxidase
51
Features of Human Leukocyte Antigen B27 (HLA-B27)
``` Class 1 surface antigen - found in 10% of white people - present in 90% of white people with AS Strongly associated with - ankylosing spondylitis - iritis - juvenile arthritis ```
52
Features of synovial fluid analysis
Gram stain and culture - septic arthritis Polarized light microscopy - negatively birefringent needle shaped crystals = gout - positively birefringenet rhomboid shaped crystals = pseudogout
53
Uses of biopsies in rheumatoid diseases
Temporal artery - vasculitis in GCA Muscle - polymyositis or dermatomyositis Skin - vasculitis, dermatomyositis and SLE Lip/salivary gland - Sjogren's Lymph node - rule out lymphoma or TB in SLE Synovial - rare tumours or infection Sural nerve - vasculitis with monoeuritis multiplex / peripheral neuropathy Renal - vasculitis, SLE
54
Use of NSAIDs
Initial therapy | Provide symptomatic relief
55
Side effects of NSAIDs
GI problems Renal impairment Caution in patients with cardiovascular risk and asthma
56
Uses of corticosteroids
For inflammatory arthritis - used initially for a few weeks till DMARDs kick in PO, IV, IM or directly into joint or soft tissue Mainstay of treatment for PMR and GCA
57
Uses of non-biological DMARDs
RA, PsA, SLE and vasculitis Started asap Life-long
58
Most common non-biological DMARDs for inflammatory arthritis
Methotrexate Hydroxychoroquine Sulfasalazine
59
Effects of non-biological DMARDs
Sustained reductions in pain, stiffness and fatigue and improvements in physical function Make take up to 3 months
60
Uses of biological DMARDs
RA, PsA and AS | Psoriasis and IBD
61
Biological DMARDs used in RA
Rituximab - CD-20 inhibitor Tocilizumab - IL-6 inhibitor Adalimumab (Humira) - TNF-alpha inhibitors JAK inhibitors
62
Biological DMARDs used in AS and PsA
IL-17 antagonists
63
Biological DMARDs used in Crohn's disease and its enteropathic arthritis
IL-12/23 blocker
64
Long term effects of DMARDs
Increased infection risk - immunosuppressive Malignancy Ractivation of hepatitis B and TB Regular flu and pneumococcal vaccination - no live vaccinations
65
Drug treatment for osteoporosis
Calcium and vitamin D | Oral bisphosphonates
66
How to take oral bisphosphonates
Taken on empty stomach Avoid food, water or other drugs for 30 mins post - maximise gut absorption Swallow whole with water and avoid bending for 30 mins - reduce chance of ingestion
67
Drugs for acute attacks for crystal arthritis
NSAIDs Colchicine - avoid in renal failure Intra-articular steroid injections
68
Drugs for prophylaxis for crystal arthritis
Allopurinol - urate-lowering - flares common in first 6th months so cover with NSAIDs, colchicine or prednisolone - avoid in renal failure Feboxostat - used if allopurinol not tolerated
69
Side effects of Methotrexate
``` Nausea Oral ulcers Hair thinning Hepatitis, cirrhosis Pneumonitis Bone marrow suppression ```
70
Side effects of Hydroxycholorquine
GI disturbance Retinal pigmentation and loss of vision - annual eye tests No blood tests needed
71
Side effects of Sulfasalazine
GI upset Rash Hepatitis Bone marrow suppression
72
Side effects of Azathioprine
GI upset | Bone marrow suppression
73
Side effects of Cyclophosphamide
Bone marrow suppression Infertility Increased cancer risk
74
Side effects of Ciclosporin
Renal impairment | Hypertension
75
Side effects of Leflunomide
GI upset Hypertension Bone marrow suppression Hepatitis
76
What is dermatomyositis and polymyositis
Rare idiopathic muscle diseases | Characterised by inflammation of striated muscles
77
Epidemiology of dermatomyositis and polymyositis
M:F = 1:1 | Peak onset 40-50 years
78
Symptoms and signs of dermatomyositis and polymyositis
Insidious onset of muscle proximal weakness - often painless SOB Rash Raynaud's syndrome common
79
Diagnostic criteria of dermatomyositis and polymyositis
Symmetricial proximal muscle weakness Raised serum muscle enzyme levels Typical electromyographic changes Biopsy evidence of myositis PM if >3 DM if rash and >2
80
Investigations of dermatomyositis and polymyositis
Raised inflammatory markers Raised ALT (from muscle) with liver enzymes normal 80% antinuclear antibody positive - specific auto-antibodies include anti-Jo-1 and anti-Mi2 Myositis on MRI
81
Treatment for dermatomyositis and polymyositis
High dose corticosteriods - mainstay for first few weeks Inflammatory markers and CK used to monitor disease EMG studies/MRI Long term control - MTX or AZA - IV immunoglobulin - Rituximab In DM sun-protection and HCQ may reduce rash
82
Complications of dermatomyositis and polymyositis
Aspiration pneumonia - upper oesophagus is striated muscle Respiratory failure - diaphragmatic involvement Inflammatory lung disease Increased malignancy risk (DM)
83
Features of dermatomyositis rash
Photosensitive Post inflammatory hyper or hypo pigmentation Appears in light exposed areas such as scalp, face and neck Linear plaques on dorsal aspects of hands - Gottron's papules Dilated nail-fold capillaries, dry cracked palms and fingers Periorbital oedema Violet rash to eyelids
84
What is fibromyalgia
Central pain processing characterised by chronic widespread pain in all 4 quadrants of the body Allodynia is heightened and painful response to innocuous stimuli
85
Pathogenesis of fibromyalgia
Can be induced by deliberate sleep deprivation Sleep disturbance likely trigger in most patients - EEG studies show reduced REM sleep and delta sleep wave Causes hyper-activation in response to noxious stimulation, and neural activation in brain regions associated with pain perception in response to non-painful stimuli
86
Symptoms and signs of fibromyalgia
``` Pain Joint/muscle stiffness Profound fatigue Unrefreshed sleep Numbness Headaches Irritable bowel/bladder syndrome Depression and anxiety Poor concentration and memory "fibrofog" ```
87
Risk factors for fibromyalgia
Affects 5% of population F:M = 9:1 Peak age onset 40-50 Onset may have an obvious trigger - emotional or physical
88
Treatment for fibromyalgia
``` Education CBT Physical - sleep improvement Drugs - pregabalin - amitriptyline ```
89
What is Giant Cell Arteritis
Chronic vasculitis of large and medium sized vessels that occurs among individuals over 50 years of age Most commonly causes inflammation of arteries originating from the arch of the aorta
90
Risk factors for giant cell arteritis
Age is greates risk Increased prevalence in individuals in northern latitude 2-4 times for common than women Strong association with polymyalgia rheumatica Genetic predisposition: HLA-DR4
91
Symptoms of giant cell arteritis
``` Headache - localised, unilateral, boring or lancinating in quality over the temple Tongue or jaw claudication upon mastication Constitutional symptoms Visual findings - weeks to months - amaruosis fugax - blindness - diplopia - blurring Scalp tenderness ```
92
How is diagnosis made of giant cell arteritis
Presence of two or more of the following in patients over 50 - raised ESR, CRP or PV - new onset of localised headache - tenderness or decreased pulsation of temporal artery - new visual symptoms - biopsy revealing necrotising arteritis
93
Treatment of giant cell arteritis
Prednisolone 60-100mg PO per day for at least 2 weeks before tapering down slowly For acute onset visual symptoms consider - 1g methylprednisolone IV pulse therapy 1-3 days Low dose aspirin therapy to reduce thrombotic risks
94
What is gout?
Inflammatory arthritis related to a hyperuricemia Acute gout can affect > 1 joint - commonly 1st metatarsalphalangeal joint Associated with high risk of CVD
95
What causes gout?
Deposition of monosodium urate (MSU) crystals that accumulate in joints and soft tissues - acute and chronic arthritis - tophi - soft tissue masses - urate nephropathy - uric acid nephrolithiasis
96
Risk factors for gout
``` Non-modifiable - age > 40 - male Modifiable - increased purine intake - meats and seafood - alcohol intake - high fructose intake - obesity - CCF - coronary artery disease - dyslipidemia - renal disease - organ transplant - hypertension - smoking - DM ```
97
Conservative management of gout
``` Maintain optimal weight Regular exercise Diet modification Reduce alcohol consumption Smoking cessation Maintain fluid intake and avoid dehydration ```
98
Medical management of gout
Acute - NSAIDs - oral/IM steriods - colchicine Chronic - urate lowering therapy - allopurinol and febuxostat - xanthine oxidase inhibitors and reduce urate formation - benzbromarone and sulfinpyrazone - increase renal excretion of uric acid
99
Features of urate crystals
Negatively birefringent needles
100
Cause of pseudogout
Calcium pyrophosphate crystals
101
What is hypermobility
Pain syndrome in people with joints that move beyond normal limits - due to laxity of ligaments, capsules and tendons - thought that pain originates from microtrauma - may affect any number of joints
102
Epidemiology of hypermobility
10% of population - only few symptomatic Often familial More common in women and asian people Usually presents in childhood or young adulthood May feature recurrent subluxations or disclocations
103
Symptoms and signs of hypermobility
``` Pain - around joints - worse after activity Fatigue Soft tissue rheumatism - epicondylitis Abnormal ski - papyraceous scars - hyperextensible - thin striae Marfanoid habitus Arachnodactyly Drooping eyelids Hernias and uterine/rectal prolapse ```
104
Treatment aims for hypermobility
Improve pain and reduce disability
105
Treatment for hypermobility
``` Strengthening exercises to reduce joint subluxation Work on posture and balance Splinting and surgical interventions Advice on pacing and goal setting Specialist pain management Paracetamol mainstay of pain relief ```
106
Features of hypermobility scoring
One point for each feature (left and right) - put hands flat on floor with knees straight - bend elbows backwards - bend knee backwards - bend thumbs back to front of forearm - bend little finger at 90° to back of hand
107
Heritable connective tissue disorders
HSD Marfan syndrome Ehlers Danlos syndrome
108
What is osteoarthritis
Degenerative joint disorder | - progressive loss of articular cartilage accompanied by new bone formation and capsular fibrosis
109
Aetiology of osteoarthritis
Failure of normal cartilage subject to abnormal or incongruous loading for long periods Damaged or defective cartilage failing under normal conditions of loading Break up of cartilage due to defective stiffened subchondral bone passing more load to it
110
Key features of osteoarthritis
Loss of elasticity with a reduced tensile strength | Cellularity and proteoglycan content are reduced
111
Risk factors for osteoarthritis
Increasing age Female Obesity Trauma and joint malalignment through trauma or muscle weakness
112
Symptoms and signs of OA
Hip, knee and spine most commonly affecgted Pain provoked by movement and weight bearing - intermittent at first by later constant Inactivity gelling and feeling of joint giving way
113
X-ray signs of OA
Joint space narrowing Subarticular sclerosis Bone cyts Osteophytes
114
Treatment aims for OA
Improve pain and reduce disability
115
Treatment for OA
``` Non-drug - strengthening and ROM exercises - weight loss - laterally wedged insoles (medial compartment OA) or walking stick Pharmacological - paracetamol - NSAIDs short term - topical NSAIDs and rubefacients and capsaicin - intra-articular corticosteriods Surgery - joint replacement ```
116
Features of nodal OA
``` More common in women Affects PIPJs (Bouchard's nodes) and DIPJs (Herberden's nodes) and thumb CMCJ ```
117
What is polymalgia rheumatica (PMR)
Clinical syndrome characterised by pain and stiffness of shoulders, hip girdles and neck Primarily impacts the elderly Associated with morning stiffness and elevated inflammatory markers
118
Epidemiology of PMR
Increasing incidence with age - average onset 70 years Associated with GCA
119
Symptoms of PMR
New sudden onset proximal limb pain and stiffness Difficulty rising from chair of combing hair - proximal muscle involvement Night time pain Systemic symptoms
120
Signs of PMR
Decreased ROM of shoulders, neck and hips Muscle strength normal Muscle tenderness
121
Treatment for PMR
Prednisolone - 15mg then taper down Methotrexate - steriod-sparing in relapsing patients
122
What is Raynaud's phenomenon
Due to vasospasm of the digits Painful Characterised by typical sequence of colour changes in response to cold stimuli Often precipitated by stress
123
Colour change in Raynaud's phenomenon
White - inadequate blood flow Blue - venous stasis Red - re-warming hyperaemia
124
What is Raynaud's syndrome
Idiopathic Raynaud's phenomenon
125
Treatment of Raynaud's syndrome
Measures to keep warm | Avoid smoking
126
Diseases associated with Raynaud's phenomenon
``` Scleroderma SLE Dermatomyositis and polymyositis Sjogren's syndrome Use of heavy vibrating tools Cervial rib Drug induced - beta blockers ```
127
Treament for Raynaud's phenomenon
Keep warm and avoid smoking CCB Phosphodiesterase-5 inhibitors and prostacyclins
128
Complications of Raynaud's phenomenon
Digital ulcers Severe digital ischaemia Infection Gangrene
129
What is rehumatoid arthritis
Autoimmune disease associated with antibodies to Fc portion of IgG (rheumatoid factor) and anti citrullinated cycle peptide (anti-CCP)
130
Pathogenesis of RA
Citrullination of self-antigens which are recognised by T & B cells which can then produce antiboides (RF and anti-CCP) Stimulated macrophages and fibroblasts release TNFalpha Inflammatory cascade leads proliferation of synoviocytes -> grow over cartilage and restrict nutrients and cartilage damaged Activated macrophages stimulate osteoclast differentiation -> bone damage
131
Epidemiology of RA
Female - 3:1 | 30-50 years old
132
Signs of RA
Usually MCPs/PIPs/MTPs - spares DIPs Pain > 6 week history Morning stiffness > 30 mins Commonly fatigue and malaise
133
Symptoms of RA
Soft tissue swelling and tenderness first Ulnar deviation/palmar subluxation of MCPs Swan-neck and Boutonniere deformity Rheumatoid nodules - elbow Check median nerve - carpal tunnel association
134
Investigation for RA
RF and anti-CCP FBC - normocytic anaemia WCC - rule out sepsis X-ray changes in establised disease - USS/MRI more sensitive in early disease
135
Treatment for RA
``` DMARD monotherapy - methotrexate Combintation DMARDs - lefluomide, hydroxychloroquine, sulfasalazine Steriods - acutely Symptom control with NSAIDs + PPI cover Biologics Supportive - OT, PT, podiatry, psychological ```
136
Extra-articular manifestations of RA
``` 3Cs - carpal tunnel syndrome - elevated cardiac risk (CVD) - cord compression - atlanto-axial subluxation 3As - anaemia - amyloidosis -> CKD and nephrotic syndrome - arteritis 3Ps - pericarditis - pleural disease - pulmonary disease 3Ss - Sjogren's - scleritis - splenic enlargement ```
137
X-ray features of RA
Loss of joint space Erosions Soft tissue swelling Subluxation
138
What is Sjogren's syndrome
Chronic autoimmune inflammatory disorder | - characterised by diminished lacrimal and slaivary gland secretion
139
Symptoms of Sjogren's syndrome
``` Myalgia Arthralgia Dry mouth Fatigue Raynaud's phenomenon Enlarged parotids Dry eyes ```
140
Investigations for Sjogren's syndrome
Anti-Ro and anti-La antibodies RF and anti ds-DNA antibodies Schirmer's test - measures tear volume Salivary gland biopsy
141
Treatment for Sjogren's syndrome
Symptomatic - avoid dry or smoky atmospheres - dry eyes = artificial tears - dry mouth = artificial saliva, sugar free gum - skin emolliens - vaginal lubricants
142
Diseases associated with Sjogren's syndrome
``` RA SLE Coeliac disease PBC Auto-immune thyroid disease ```
143
What are spondyloarthropathies?
Group of conditions that affect the spine and peripheral joints and associated with presence of HLA-B27
144
Conditions of spondyloarthopathies
Ankylosing spondylitis Enteropathic arthritis Psoriatic arthritis Reactive arthritis
145
Common clinical features of spondyloarthropathies
Sacroiliac/axial disease - back/buttock pain Inflammatory arthropathy of peripheral joints Enthesitis - inflammation of tendon insertions Extra-articular features - skin, gut, eye
146
Features of ankylosing spondylitis
Long term inflammation of joints of the spine | Usually young men (teens-mid-thirties)
147
Complications of AS
``` Osteoporosis Spinal fractures CVS Pneumonia Kidney disease ```
148
Signs and symptoms of AS
Bilateral buttock pain, chest wall and thoracic pain Exam often normal early Later - loss of lumbar lordosis, exaggerate thoracic kyphosis, reduced chest expansion Raised CRP MRI spine and SI joints - inflammation
149
Treatment for AS
NSAIDs Physio TNF inhibitors IL-17 inhibitors
150
Epidemiology of psoriatic arthritis
10% of patients with psoriasis | M=F
151
Features of psoriatic arthritis
Oligo-arthritis Dactylitis or "sausage" digit Can be symmertrical or monoarthritis
152
Investigations for psoriatic arthritis
CRP often raised Central joint erosions seen early on USS or MRI - pencil in cup x-ray appearance
153
Treatment of psoriatic arthritis
``` NSAIDs DMARDs - TNF inhibitors - IL-17 inhibitors - IL12/23 inhibitors ```
154
What is reactive arthritis
Sterile synovitis developing after a distant infection - post dysentery - Salmonella, Shigella, Campylobacter - urethritis/cervicitis - Chlamydia trachomatis
155
Presentation of reactive arthritis
``` Few days - 2 weeks post infection Acute asymmetrical lower limb arthritis develops Other features incluce - circinate balanits - keratoderma blennorrhagica - conjunctivitis - uveitis - enthesitis ```
156
Investigations for reactive arthritis
Serology/microbiology Inflammatory markers raised Joint aspirate to rule out septic/crystal arthritis
157
Treatment for reactive arthritis
Treat infection NSAIDs and joint injections Most resolve within 2 years - if not may need DMARDs
158
What is enteropathic arthrits
Inflammatory condition affecting the spine and other joints | - associated with IBD
159
Types of peripheral disease of IBD
``` Type 1 - oligoarticular - asymmetric - correlation with IBD flares Type 2 - polyarticular - symmetrical - less correlation with IBD flares ```
160
Treatment of enteropathic arthritis
DMARDs - TNF inhibitors treat both bowel and arthritis NSAIDs can flare IBD
161
Extra-articular manifestations of ankylosing spondylitis
``` Anterior uveitis Aortic incompetence AV block Apical lung fibrosis Amyloidosis ```
162
Features of inflammatory back pain
``` Insidious onset Pain at night - improvement with getting up Age onset < 40 Improvement with exercise No improvement with rest ```
163
What is systemic lupus erythmatosus (SLE)?
Autoimmune disease - inadequate T cell suppressor activity with increased B cell activity - antibodies to certain cell nucleus components Complex multisystem disease charactersied by remissions and flares
164
Common signs and symptoms of SLE
``` Serositis - pleurisy, pericarditis Oral ulcers - painless Arthritis - small joints, non-erosive Photosensitivity - malar/discoid rash Blood disorders - low WCC, lymphopenia, thrombocytopenia, haemolytic anaemia Renal involvement - glomerulonephritis Autoantibodies - ANA positive in 90% Immunologic tests - low complements Neurologic disorder - seizures or psychosis ```
165
Investigations for SLE
``` Raised ESR or plasma viscosity - normal CRP Anaemia and leukopenia common 95% antinuclear antibody positive - anti-Ro and anti-La common - anti-dsDNA rises with disease activity - anti-phospholipid antibodies C3 and C4 fall with disease activity Urinarlysis for renal disease Skin or renal biopsy can be diagnostic ```
166
Treatment for SLE
Sun protection Advice on healthy lifestyle in view of CVS risk Hydroxychloroquine for rash and arthralgia Mycophenolate mofetil, azathioprine and rituximab common used Short course prednisolone for flares
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Epidemiology of SLE
9x more common in women | Peak onset in early adulthood
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What is systemic sclerosis
Multisystem autoimmune disease Increased fibroblast activity resulting in abnormal growth of connective tissue -> vascular damage and fibrosis
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Types of systemic sclerosis (SSc)
Limited | Diffuse
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Features of limited SSc
Calcinosis cutis - calcium deposits in skin Raynaud's phenomenon Oesophageal dysmotility Sclerodactyly - thickening + tightness of skin of fingers/toes -> ulcers Telangiectasia - widened venules -> threadlike red lines on skin
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Features of diffuse SSc
Less common but higher mortality risk | Sudden onset skin involvement - proximal to elbows/knees
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Investigations for SSc
Inflammatory markers normal X-ray hands - calcinosis CXR, HRCT, PFT - pulmonary disease ECG + ECHO - PA hypertension, CCF, myocraditis and arrhythmias
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Antibodies is SSc
``` Positive ANA in 90% patients Limitied SSc - anti-centromere Diffuse SSc - Scl-70 (topisomerase) - anti RNA polymerase III ```
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Treatment for SSc
No cure Psychological support Calcium antagoinst / sildenafil / iloprost for Raynaud's Methotrexate and mycophenolae mofetil reduce skin thickening ACEi prevent hypertensive crisis and reduce mortality from renal failure Short course prednisolone for flares PPI for GI symptomrs
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What is vasculitis
Inflammatory blood vessel disorder
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Features of vasculitis
Constitutional symptoms Raynaud's MSK - arthralgia, myalgia, proximal muscle weakness CNS/PNS - headaches, visual loss, tinnitus, stroke, seizure, encephalopathy Nose bleeds Heart/lung - pericarditis, cough, chest pain, haemoptysis, dyspneoa Abdominal pain Haematuria Neuropahty, digital ulcers/ischaemia
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Signs of vasculitis
Hypertension Palpable purpura, livedo reticularis, nodules, digital ulcers, gangrene, nail bed capillary changes Scleritis, uveitis, episcleritis Crackles, pleural rub, murmurs, arrhythmias Abdominal tenderness and organomegaly
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Types of vasculitis
``` Small-vessel - microscopic polyangiitis (MPA) - granulomatosis with polyangiitis (GPA) - eosinophilc granulomatosis with polyangiitis (EGPA) - IgA vasculitis Medium-vessel - polyarteritis nodosa (PAN) - Kawasaki disease (KD) Large-vessel - Takayasu arteritis (TAK) - giant cell arteritis (GCA) ```
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Causes of vasculitis
``` Primary Secondary - infections - drugs - malignancy - connective tissue diseases ```
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Diagnostic tests for vasculitis
``` ANA, ANCA and RF antibodies Complement levels C3 and C4 Hep screen for B and C and HIV Cryoglobulins Serum and urine protein ```
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Treatment of vasculitis
Rule out infection and stop offending drugs Corticosteriods DMARDs - cyclophosphamide, methotrexate, azathioprine, leflunomide, mycophenolate mofetil, rituximab

Yr3 - General Medicine (9 decks)

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