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Rheumatology Conditions Flashcards

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1
Q

What are the shared clinical features of the seronegative spondyloarthropathies?

A
  • Rheumatoid factor negative
  • ‘Axial arthritis’ i.e. inflammation affects the spine and sacroiliac joints
  • HLA-B27 association
  • Enthesitis i.e. inflammation at the enthesis, where tendons and ligaments insert into bone
  • Asymmetrical peripheral arthritis
  • Extra articular manifestations
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2
Q

What is the typical presentation of a patient with ankylosing spondylitis?

A

Young male (late teens, early 20s), gradually worsening low back pain, worse at night, relieved by exercise, also suffering with early morning stiffness. There is also progressive loss of spinal movement, and radiation from sacroiliac joints to hips / buttocks

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3
Q

What is Schober’s Test?

A

Assesses spine flexion: While patient in erect position, make a mark at the 5th lumbar spinous process and another 10cm above it. Ask the patient to bend forward. In normal patients this mark will increase to >15cm, whilst it will not do this in ankylosing spondylitis patients.

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4
Q

What is Schober’s Test?

A

Assesses spine flexion: While patient in erect position, find the posterior iliac spine, and make a mark 10cm above and 5cm below. Ask the patient to bend forward. In normal individuals, the gap between the marks should increase from 15cm to >22cm. Reduced lumbar flexion in ankylosing spondylitis.

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5
Q

What is the treatment for ankylosing spondylitis?

A
  • Intensive exercise regime (physiotherapy, hydrotherapy) to relieve symptoms and maintain posture and mobility
  • NSAIDs improve symptoms and may slow progression
  • DMARDs including methotrexate for peripheral arthritis (has no effect on spinal disease)
  • Anti TNF-alpha drugs
  • Localised treatment based on symptoms including surgery e.g. hip replacement
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6
Q

What may be seen on radiography in a patient with psoriatic arthritis?

A

‘Pencil-in-cup’ deformity i.e. bone erosion causing one bone to be pointed and to articulate with a concave bone adjacent to it

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7
Q

Which organisms are involved in causing reactive arthritis?

A

Gastrointestinal (dysenteric): Shigella, Salmonella, Campylobacter, Yersinia
Sexually Acquired: Chlamydia, Ureaplasma

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8
Q

What is Reiter’s Syndrome?

A

A triad of urethritis, arthritis and conjunctivitis

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9
Q

What are the types of crystals which are responsible for gout and psuedogout?

A 
Gout = Monosodium urate
Pseudogout = Calcium pyrophosphate dihydrate
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10
Q

What are the features of limited cutaneous systemic sclerosis?

A

CREST:

Calcinosis (subcutaneous tissues)
Raynaud's
oEsophageal and gut dysmotility
Sclerodactyly
Telangiectasia
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11
Q

Why is limited cutaneous systemic sclerosis called ‘limited’?

A

Skin involvement is ‘limited’ to the face, hands and feet

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12
Q

What is vasculitis?

A

Inflammation of the blood vessel wall

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13
Q

What features on blood results are common to all types of vasculitis (except giant cell)?

A

Anaemia

Raised ESR

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14
Q

Give 2x primary vasculitis causes and 4x secondary causes of vasculitis which affects large vessels i.e. the aorta and it’s main branches

A

Primary: Giant cell arteritis, Takayasu’s arteritis
Secondary: Rheumatoid arthritis (aortitis), ankylosing spondylitis, Behcet’s syndrome, syphillis infection

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15
Q

Give 2x primary vasculitis causes and 2x secondary (infectious) causes of vasculitis which affects medium sized vessels i.e. the main visceral arteries

A

Primary: Polyarteritis nodosa, Kawasaki disease

Secondary (infectious): Hepatitis B and C

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16
Q

Which drugs may cause vasculitis of the small arteries?

A

Sulphonamides, penicillins, thiazides

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17
Q

List some ANCA positive causes of small vessel vasculitis

A

Wegener’s granulomatosis
Churg-Strauss syndrome
Microscopic polyangiitis

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18
Q

List some ANCA negative causes of small vessel vasculitis

A

Henoch-Schonlein purpura
Cutaneous leukocytoclastic vasculitis
Essential cryoglobulinaemia

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19
Q

Give some systemic autoimmune conditions which may cause small vessel vasculitis

A

Rheumatoid arthritis
SLE
Sjogren’s

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20
Q

Which HLA is associated with Behcet’s syndrome?

A

HLA-B51

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21
Q

Which country is Behcet’s disease commonest?

A

Turkey. It is historically commonest along the old Silk Road - stretching from eastern Asia to the Mediterranean.

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22
Q

What are the clinical features of Behcet’s Disease?

A
  • Oral ulcers: Recurrent, painful mouth ulcers which may limit eating
  • Genital ulcers
  • Skin lesions: Papulopustular lesions, erythema nodosum
  • Eye lesions: Uveitis
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23
Q

What is the ‘pathergy test’?

A

Indicates Behcet’s disease: A needle pricks an area of skin and a pustule forms at the area of insult due to the defective systemic response to inflammation

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24
Q

What is the treatment for Behcet’s Disease?

A

Immunosuppression - cyclophosphamide, azathioprine

Colchicine for orogenital ulceration

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25
What are the 2 types of systemic sclerosis?
Limited cutaneous scleroderma | Diffuse cutaneous systemic sclerosis
26
True / False: Systemic sclerosis affects men more than women
False. Women > Men (3:1)
27
True / False: Systemic Lupus Erythematosus (SLE) affects women more than males
True - Ratio is about 9:1
28
What is SLE?
Systemic Lupus Erythematosus: A multi-system autoimmune condition characterised by the presence of antibodies to nuclear components which cause inflammation in many systems of the body.
29
Which HLA subtypes are associated with SLE?
HLA-DR3, -B8, -A1
30
Which two types of rashes may be seen in SLE?
Malar rash | Discoid rash
31
What are the key features which, if 4 or more are present, may lead to a diagnosis of SLE?
My Dad Put On Nine Stone, Rather Chunky He Is Anyway: - Malar rash - Discoid rash - Photosensitivity - Oral ulcers - Non-erosive arthritis - Serositis - Renal disorder - CNS disorder - Haematological disoder - Immunological disorder - ANA antibody
32
What is Raynaud's Phenomenon? What are the clinical features?
Intermittent spasming of the peripheral vessels supplying the digits will cause ischaemia in the fingers and toes. Characterised by change in colour from red to white, often associated with pain. There is usually a stimulus - cold or emotion etc.
33
Give two underlying causes of secondary Raynaud's
Systemic sclerosis | Beta blockers
34
List some treatments (medical and non-medical) for Raynaud's
``` Treat underlying cause if secondary e.g. stop beta-blockers Stop smoking Keep hands and feet warm Nifedipine Sildenafil Prostacyclin infusion if severe Sympathectomy ```
35
What is osteoporosis?
Reduced bone density
36
List some risk factors for osteoporosis
Age Female BMI 7.5mg for longer than 3 months
37
What is a DEXA Scan?
Dual energy x-ray absoptiometry Measures the bone density of a patient compared to a healthy young individual. The T score is the number of standard deviations away from the young average that the patient's bone density lies. A decrease of 1 S.D corresponds to a 2.6x increased risk of hip fracture. The femur and spine scores are measured.
38
What are the scores of a DEXA scan and what do they correspond to?
>0 = Patient better than reference 0 to -1 = Patient in top 84% of reference ranges, no osteoporosis -1 to -2.5 = Osteopenia (associated with increased risk of future fragility fracture). Offer lifestyle advice. -2.5 or worse = Osteoporosis. Lifestyle advice and treatment.
39
What is the management for osteoporosis?
Lifestyle management: Stop smoking, reduce alcohol, advise on exercise and mobility, increase dietary calcium and Vit D intake Medical management: Bisphosphonates (Alendronate 70mg weekly), calcium and Vit D supplementation if deficiency, HRT for prevention in post-menopausal women, Teriparatide (recombinant PTH)
40
How would you advise a patient to take bisphosphonates?
Alendronate 70mg tablet weekly Large tablet Take with plenty of water before food (first thing in the morning) Remain upright and don't lie down for at least 30 minutes after taking
41
List some side effects of bisphosphonates
Photosensitivity GI upset Oesophageal ulcers Jaw osteonecrosis
42
What is osteomalacia?
Defective bone mineralisation, despite normal amounts of bone.
43
How may a patient with osteomalacia present?
Bone bain Vit D deficiency Proximal myopathy - 'waddling' gait Fractures
44
What are the causes of osteomalacia?
Vit D deficiency caused by decreased intake, absorption, or activation: - Lack of sunlight, poor intake of Vit D - Renal osteodystrophy causing decreased activation of Vit D - Liver disease causing decreased activation of Vit D - Drugs: Anticonvulsants may induce liver enzymes which cause reduction in activation in Vit D - Malabsorption
45
What is Paget's disease?
Disease of increased bone turnover - large numbers of osteoblasts and osteoclasts causes bone remodelling.
46
What are the presenting features of a patient with polymyositis?
Proximal, symmetrical muscle weakness. Symptoms may vary depending on the muscles affected: - Proximal upper limb involvement: Difficulty combing hair - Proximal lower limb involvement: Difficulty going up stairs, rising from chair, squatting - Respiratory muscles: Respiratory depression - Pharyngeal / laryngeal muscles: Dysphagia
47
What are the skin features of a patient with dermatomyositis?
``` Heliotrope rash over eyes Gottron's papules over knuckles Dilated nail bed capillaries 'V' sign rash 'Shawl' sign rash Mechanic's hands ```
48
What is the treatment for myositis and dermatomyositis?
Prednisolone 0.5-1.5mg/kg/day until symptoms improve, then wean off over a number of weeks and months Immunosuppressants and biological agents may be used for resistant conditions
49
What is rheumatoid factor?
Auto-antibody seen in several autoimmune rheumatological conditions. It is an antibody against the Fc portion of IgG.
50
Which condition is associated with anti-Ro and anti-La antibodies?
Sjogren's
51
What is Sjogren's syndrome?
Autoimmune rheumatological condition associated with destruction of exocrine glands, especially the lacrimal and salivary glands. Results in dry eyes, dry mouth, and other features.
52
List some clinical features of antiphospholipid syndrome
Arterial thrombosis e.g. Stroke, TIA, MI Venous thrombosis e.g. DVT, Budd-Chiari syndrome Placenta i.e. recurrent miscarriages
53
Which antibodies are associated with antiphospholipid syndrome?
Anti-cardolipin Anti-beta-2 glycoprotein Lupus anticoagulant
54
Give some characteristic joint changes occurring in osteoarthritis
Destruction of articular cartilage Remodelling of marginal / subchondral bone Thickening of the joint capsule Inflammation of the synovial tissue lining the joint
55
Give some symptoms of osteoarthritis
Pain, worse on movement and with weight bearing Stiffness, mild in the morning and worse after periods of rest ('gelling') Joint crepitus Bone / soft tissue swelling Loss of movement
56
List the abnormalities on x-ray in osteoarthritis
Loss of joint space Osteophytes Subchondral sclerosis Subchondral cysts
57
List some red flag symptoms for back pain (there are 16!)
Age 55, pain at night, pain worse when lying, systemic features (fever, night sweats, weight loss), sudden onset in elderly, constant or progressive pain, abdominal mass, history of malignancy, neurological disturbance, sphincter disturbance, recent or current infection, thoracic spine pain, morning stiffness, immunosuppression, bilateral or alternating leg weakness, exercise-induced weakness or leg claudication
58
What is the triad of clinical features seen in Churg-Strauss syndrome?
Asthma Eosinophilia Vasculitis
59
Which condition is giant cell arteritis closely associated with?
Polymyalgia rheumatica (50% of GCA patients have PMR)
60
What is polyarteritis nodosa?
Necrotising vasculitis associated with aneurysms and thrombosis of medium-sized vessels which causes ischaemia of the associated organs.
61
Which viral infection is associated with polyarteritis nodosa?
Hepatitis B
62
True / False: The lungs are commonly involved in polyarteritis nodosa?
False - Polyarteritis nods affects the kidneys, heart, GI and GU systems as well as the skin. The lungs are rarely involved.
63
List some clinical features of polymyalgia rheumatica
Age over 50 years old Subacute onset (within 2 weeks) Aching and joint tenderness Morning stiffness in shoulders and proximal limbs - gets better after exercise No weakness Features of temporal arteritis e.g. scalp tenderness Systemic features: Fatigue, fever, weight loss
64
What is the treatment of polymyalgia rheumatica?
Steroids (prednisolone 15mg daily) - response should be seen within 1/52 although steroids continued for up to 2 years

Rheumatology and Orthopaedics (4 decks)

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