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Rheumatology Flashcards

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1
Q

Common antibodies in SLE

A

ANA

Anti-smooth muscle

Anti-double stranded DNA

Antiphospholipid

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2
Q

Common antibodies in RA

A

Rheumatoid factor

Anti CCP

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3
Q

Common antibodies in Sjogren’s

A

Anti Ro

Anti La

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4
Q

Common antibodies in Systemic Sclerosis

A

Limited = Anti Centromere

Diffuse = Anti Scl 70

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5
Q

Polymyositis antibodies

A

Anti Synthetase

Anti-Jo1

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6
Q

Rheumatoid Arthritis

A

FM = 3:1, usually 30-50 years old at onset

Associated with HLA-DR4

Symmetrical, deforming, polyarthropathy
- Small joints mainly (70% have RA in wrist or hands)
- Spares DIPs
Morning stiffness
Slow onset

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7
Q

Outline the American Classification Criteria for RA

A

= 4 components, A to D

A = joint involvement (type and number)

B = Serology (RF and anti CCP)

C = Acute phase reactants (CRP, ESR)

D = duration of symptoms (>6 weeks)

Score >6/10 = suggestive of RA

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8
Q

How would you investigate a patient in whom you suspect RA?

A

Bloods
- Routine FBC (?Felty’s), inflam markers, baseline U&Es
- RF (positive in 70%)
- anti CCP (positive in 70-80%, more specific)

Xrays of affected joints
- Loss of joint space, osteopaenia, subluxation, erosions

CXR –> HRCT if suspicious for fibrosis/nodules

Lung function tests

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9
Q

Poor Prognostic Features for RA

A

RF positive
Anti-CCP antibodies
Poor functional status at presentation
HLA DR4 positive
Early erosions on xrays (<2 years)
Extra-articular features e.g. fibrosis
Insidious onset

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10
Q

Possible Extra-Articular Features of RA

A

Can have multisystem involvement!

NEURO - peripheral neuropathy, mononeuritis multiplex

OCULAR - episcleritis, scleritis, keratoconjunctivitis

CARDIO - IHD, peri/myocarditis

RESP - pulmonary fibrosis (lower), effusions, nodules

HAEMATO - anaemia (secondary to chronic disease/NSAIDs), Felty’s syndrome, bone marrow suppression (secondary to MTX)

SKELETAL - osteoporosis

Increased risk of amyloidosis!

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11
Q

How would you manage a patient with RA?

A

MDT approach - rheumatologists, PT/OT

Exercise programme

Initial Rx = DMARD monotherapy (e.g. MTX) +/- prednisolone
Flares = PO/IV steroids
Biologic therapy e.g. Infliximab
- Indicated if on >2 DMARDs and 2 x DAS28 scores >5.1 at least 2 months apart

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12
Q

How can you monitor response to treatment in RA?

A

CRP &ESR

Disease Activity Score 28

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13
Q

How does MTX toxicity present? What can you give to treat this?

A

Bone Marrow Suppression
= symptoms of anaemia
= increased risk of infections (neutropaenia)
= bleeding/bruising (thrombocytopaenia)

Can also cause hepatitis

Rx = folinic acid

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14
Q

What are the main differences between Psoriatic Arthropathy and RA?

A

Psoriatic Arthropathy =
1) Asymmetrical (typically)

2) Negative RF, negative anti CCP

3) Nail changes e.g. pitting, oncholysis

4) Dactylitis

5) FHx/PMHx of psoriasis

6) F:M = 1:1

7) Skin change e.g. psoriatic plaques, koebner’s phenomenon
- Poor correlation with cutaneous psoriasis

8) Associated with HLA B27

9) More likely to affect DIPs

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15
Q

How would you manage a patient with Psoriatic Arthopathy?

A

MDT approach - rheum, derm, OT/PT

Mild Disease = NSAIDs

Moderate disease/little response to NSAIDs
= DMARDS e.g. MTX or sulfasalazine
= TNF inhibitors

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16
Q

Which DMARD should you avoid using in Psoriatic Arthopathy?

A

Hydroxychloroquinne - can exacerbate psoriatic skin lesions

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17
Q

Differentials for Shortness of Breath in SLE / CTD

A

Multisystem disorders!

CARDIAC - Pericarditis, pericardial effusion, IHD, cardiomyopathy

RESP - Pneumonia (increased risk of infections), pulmonary fibrosis, PE, pleural effusion
- Renal failure –> pulmonary oedema
- ARDS reaction to biologics

NEUROMUSCULAR - Myositis, GBS

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18
Q

Screening Questions for Connective Tissue Disease

A

1) Any rashes? Do they worsen in the sun? (PHOTOSENSITIVITY!)

2) Any hair loss?

3) Have you noticed any changes to your hands?

4) Do you suffer from dry eyes / dry mouth / ulcers?

5) Are you SoB?

6) Any difficulty swallowing? Any heartburn?

7) Any diarrhoea / weight loss?

8) Any muscle pain or weakness?

9) Any difficulty getting out of a chair/car?

10) How is this affecting your everyday life?

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19
Q

SLE

A

Multisystem autoimmune disorder

Relapsing-remitting

F:M = 9:1, 20-40 year olds

Features (ACR diagnostic criteria =>4/11 present)
- Malar Rash
- Discoid rash
- Photosensitivity
- Oral ulcers
- Non-erosive arthritis (symmetrical, hands & knees commonly)
- Serositis e.g. pericarditis
- Renal disorder
- CNS disorder e.g. psychosis, seizures, GBS
- Haematological
- ANA +ve

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20
Q

How would you investigate a patient in whom you suspect SLE?

A

Bedside
- BP
- Urine dip, ACR and red cell casts

Bloods
- Routine FBC, U&Es, LFTs
- Inflammatory markers
- ANA (+ve in 99%)
- Anti dsDNA, ENAs, Antiphospholipid
- Complement
- CK (exclude myositis)

CXR

Echocardiogram

?Skin biopsy
?Renal biopsy

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21
Q

How would you manage a patient in whom you suspect SLE?

A

MDT approach as multisystem disorder - rheum/derm/renal/cardio

First line = hydroxychloroquine +/- steroids

If internal organ involvement = IV cyclophosphamide
If lupus nephritis = MMF
If severe flare = ?IVIG

Managing Complications of SLE
- Antihypertensives (ACEIs/ARBs)
- Statins
- Warfarin/LMWH if secondary APS

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22
Q

How can you monitor for disease activity in SLE?

A

Urinary protein + blood
Urinary ACR
Urinary red cell casts

ESR
Anti dsDNA

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23
Q

Sjogren’s Syndrome

A

Autoimmune disorder of exocrine glands

Can be primary or secondary to rheumatoid arthritis/other CTDs

F:M = 9:1

Increased risk of lymphoid malignancy (B-cell) - >40x!

Features
- Dry eyes
- Dry mouth (xerostomia)
- Vaginal dryness
- Arthralgia
- Recurrent parotitis –> bilateral enlarged parotid glands
- Raynaud’s
- Myalgia
- Sensory polyneuropathy

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24
Q

How would you investigate a patient in whom you suspect Sjogren’s?

A

Bedside
- Schrimer’s test (litmus paper on lower eyelid)

Bloods
- Routine FBC, U&Es, LFTs
- RF (positive in 100%)
- Anti Ro (70% of primary SS)
- Anti La (30% of primary SS)

Salivary gland biopsy (definitive test)

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25
How would you manage a patient with Sjogren's?
Artificial saliva/tears Long term f/u due to risk of malignancy (B cell lymphoma!!)
26
What is Raynaud's disease?
= exaggerated vasoconstrictive response of digital arteries to cold/stress Can be primary or secondary to underlying CTD (scleroderma, SLE, RA)/leukaemia/drugs e.g. COCP Features - Painful cold hands & extremities - White --> blue --> red - Digital ulcers (if severe)
27
Outline features which are more suggestive of Raynaud's secondary to underling CTD
Onset > 40 Unilateral symptoms Presence of autoantibodies Features of systemic CTD e.g. joint pain, rashes, SoB
28
How would you manage a patient with Raynaud's disease?
Gloves/hand warmers 1st line = CCBs (nifedipine) 2nd line = sildenafil IV prostacyclin infusions if severe e.g. digital ulcers
29
Systemic Sclerosis
Connective tissue disorder, characterised by thickening and fibrosis of the skin +/- systemic involvement F:M = 3:1 3 patterns of disease 1) Scleroderma = localised skin thickening 2) Limited Cutaneous Systemic Sclerosis = distal skin involvement, facial involvement, trunk spared = Anti-Centromere {CREST is a subgroup of this} 3) Diffuse Cutaneous Systemic Sclerosis = Proximal skin involvement (above elbows and knees), trunk involved = Anti Scl 70 abs
30
Features of Systemic Sclerosis
Scleroderma CREST - Calcinosis - Raynaud's - oEsophageal dysmotility - Sclerodactyly - Telangiectasia Microstomia Pulmonary involvement - ILD, pulmonary HTN
31
What medical emergency are patients with Systemic Sclerosis at risk of? What can precipitate it, and what do we use to treat it?
Scleroderma renal crisis = acute HTN and AKI Can lead to pulmonary oedema, encephalopathy and renal failure Common precipitant = steroids! Rx = ACEIs
32
How would you investigate a patient in whom you suspect Systemic Sclerosis?
Bedside - BP - Urine dip - Lung function tests Bloods - Routine FBC, U&Es, inflammatory markers - Autoantibodies -- ANA positive in 90% -- Anticentromere and anti Scl70 -- Anti RNA polymerase III (increased risk of renal crisis) Oesophageal studies/OGD (if features of oesophageal dysmotility) CXR & HRCT (if features of ILD) Echo
33
How would you manage a patient with Systemic Sclerosis?
No curative treatment = symptomatic management mainly Raynauds = CCBs etc Cyclophosphamide has been shown to improve skin thickening, stabilise lung function and improve survival PPIs AVOID steroids!! (can precipitate a renal crisis)
34
Causes of Gout
Main causes = 1) Diuretics 2) Alcohol 3) Trauma 4) CKD Gout is secondary to increased serum urate concentration = either due to 1) Reduced uric acid excretion e.g. CKD, hyperparathyroidism, alcohol 2) Increased uric acid production e.g. MPD, cytotoxic drugs
35
Clinical Features of Gout
Asymmetrical 70% 1st presentation = swollen, hot 1st MTP = Podagra Other common sites = knee/ankle/wrist "Flares" of joint pain and swelling, lasting 3-10 days Often demonstrate diurnal pattern (worst at night!) Tophi! e.g. ears Monosodium urate crystals on joint aspirate (negatively bifringent)
36
How would you manage a patient in whom you suspect gout?
Acute Rx - NSAIDs or colchicine - 2nd line = steroids - Continue allopurinol if already on it - Stop precipitating medications e.g. diuretics Long-term Urate Lowering Therapy - Offer if >2 attacks/year OR presence of erosions/tophi OR renal impairment secondary to calculi - Offer for prophylaxis if on cytotoxics = Allopurinol --> Febuxostat Lifestyle Modifications - Alcohol abstinence - Weight loss - Avoid high purine food e.g. seafood
37
Key Questions for Acute Hot Joint
Onset - acute vs insidious SOCRATES Systemic features Skin lesions Previous history Preceeding trauma Preceeding infection e.g. UTI, STI, gastroenteritis DHx - Anticoagulation - Recent course of steroids (AVN!!!)
37
Pseudogout
Synovitis secondary to calcium pyrophosphate dihydrate crystal deposits Associated with haemochromatosis, hyperparathyroidism, acromegaly Knee most common joint affected Weakly positive bifringent rhomboid crystals on aspirate Rx = NSAIDs or IA/PO steroids
38
How would you investigate a patient with an acutely swollen red hot joint?
Full history Bedside - BP, temp (?fever) - Urine dip Bloods - FBC, U&Es, LFTs, - CRP - Urate, LDH - RF, anti CCP - Blood cultures if suspect septic arthritis Joint Xrays Joint Aspirate - WBC > 50,000 = treat as septic arthritis - MC&S - Cytology for crystals ?MRI of joint
39
Contraindications to a joint aspirate
Prosthetic joint - aspirate in theatre Overlying celluitis Overlying psoriatic plaque (increased risk of septic arthritis) Excess anticoagulation e.g. INR >3 / coagulopathy
40
Ankylosing Spondylitis
HLA B27 associated spondyloarthropathy Axial arthropathy - affects sacroiliac joints & spine Lower back pain and stiffness Worse in morning Improves with exercise Associated with IBD & psoriasis
41
Extra-articular features of Ankylosing Spondylitis
The 8 As Anterior Uveitis Apical fibrosis AV block Aortic regurgitation Amyloidosis Arthritis Achilles tendonitis and cauda equina syndrome
42
Clinical Tests for Ankylosing Spondylitis
Schober's Test = reduced lumbar spine forward flexion - Mark 5cm below line between PSIS, and mark 10cm above - Measure distance when bending forwards - Diagnostic if <5cm increase in distance between 2 points (<20cm distance) On forward flexion, >10cm distance between fingers and floor Occiput to wall distance > 0cm
43
Management of Ankylosing Spondylitis
Conservative - Regular exercise & physio Medical - NSAIDS - DMARDs only useful if peripheral joint involvement = sulphasalazine - Anti TNF therapy e.g. adalimumab, etanercept --- Indicated if axial disease refractory to 2 different NSAIDs with 2 active disease flares 3 months apart --- Symptomatic relief, does not affect progression
44
HLA B27 Associated Arthropathies
Ankylosing Spondylitis Reactive Arthritis Psoriatic Arthritis
45
Reactive Arthritis
HLA B27 associated arthopathy "Post dysenteric" e.g. shigella, salmonella, campylobacter "Post STI" e.g. chlamydia Occurs 2-6 weeks post infection Asymmetrical oligoarthritis (<4 joints) Urethritis Dactylitis Conjunctivitis/anterior uveitis "Can't pee, can't see, can't climb a tree" Management = pain relief, usually resolves within 12 months
46
Kocher Criteria for Septic Arthritis
1) Fever > 38.5 2) Non weight bearing 3) Raised ESR 4) Raised WBC
47
Giant Cell Arteritis
Systemic granulomatous arteritis Large-to-medium vasculitis Usually > 50 years old, F>M Associated with PMR Rapid onset headache (unilateral) -Often localised to temporal region Scalp tenderness Jaw claudication Diplopia --> visual disturbance Painless loss of vision Systemic features e.g. fever
48
How would you investigate and manage a patient in whom you suspect GCA?
Bedside - BP - Fundoscopy Bloods - FBC, U&Es, LFTs - ESR! - Vasculitis screen e.g. ANA ?Temporal artery USS/biopsy - should NOT delay Rx Treatment = high dose steroids to prevent blindness e.g. 60mg pred OD Refer to rheumatology and ophthalmology
49
Paget's Disease
Disease of accelerated bone turnover Typically affects skull, spine, pelvis and long bones of legs Typical presentation = isolated raised ALP in older men with bone pain Spontaenous fractures, bone deformities e.g. bowing of tibia
50
Complications of Paget's Disease
Bone deformities e.g. bowing of tibia, skull thickening CN palsies due to bone thickening e.g. CN VIII compression --> deafness Headaches HTN, IHD, high output heart failure Hypercalcaemia
51
How would you investigate someone in whom you suspect Paget's disease?
Bloods - Routine FBC, U&Es, LFTs - looking for raised ALP - Calcium profile (normal) - C-telopeptide = marker of bone turnover and progression of disease Plain xrays Technetium bone scan (high uptake areas)
52
Management of Paget's
Analgesia Bisphosphonates if - Bony pain - Skull/long bone deformity - Fractures Calcitonin can be used if refractory to bisphosphonates/contraindicated
53
Side Effects of Bisphosphonates
Bone pain Hypocalcaemia Oesophagitis/GI ulcers Fever/flu-like symptoms Osteonecrosis of the jaw!
54
Sarcoidosis
Multisystem granulomatous disorder Non caseating granulomas on biopsy KEY FEATURES - Fever, malaise, weight loss - Erythema nodosum - Lupus pernio - Heerford's syndrome = PUFF -- Parotid enlargement -- Uveitis -- Fever -- Facial nerve palsy - SoB (pulmonary involvement) MULTISYSTEM = neuro to cardiac to lung to renal involvement
55
Poor prognostic features of Sarcoidosis
Insidious onset > 6 months Absence of erythema nodosum Extrapulmonary features CXR stage III-IV Afro-Caribbean Increasing age
56
How would you investigate someone in whom you suspect Sarcoidosis?
Bedside - BP - Urine dip Bloods - FBC, U&Es, LFTs - Calcium profile - ACE CXR - ?hilar lymphadenopathy ?features of fibrosis ?HRCT Biopsy of LNs Spirometry
57
How would you manage a patient with Sarcoidosis?
MDT approach, refer to rheumatology If asymptomatic, no Rx required Analgesia Steroids if: - Progressive CXR/PFT changes - Cardiac or neuro involvement - Hypercalcaemia - Uveitis
58
Ehler Danlos Syndrome
Autosomal dominant CTD, mostly affecting type III collagen = increased elasticity of skin and muscle tissue Features - Elastic, fragile skin - Atrophic scars - Hypermobility and joint dislocation - Easy bruising - Aortic regurg/dissection - MVP - Angioid retinal streaks - Poor wound healing - Prolapses/hernias Increased risk of SAH
59
Polymyositis
Inflammatory myopathy Causes = idiopathic, CTD or malignancy F:M = 3:1 Features - Symmetrical proximal muscle weakness - Raynaud's - Resp muscle weakness - ILD - Dysphagia - Dysphonia/dysarthria Anti-Jo1 antibodies Rx = Steroids
60
Dermatomyositis
Inflammatory myopathy Causes = idiopathic, CTD or malignancy (lung, breast, ovarian) Skin Features (usually precedes myopathy) - Periorbital heliotrope rash - Gottron's papules (red papules on dorsal aspect of fingers) - Photosensitivity rash Features - Symmetrical proximal muscle weakness - Raynaud's - Resp muscle weakness - ILD - Dysphagia - Dysphonia/dysarthria Anti-Mi2 antibodies Rx = Steroids
61
How would you investigate a patient in whom you suspect myositis?
Blood - FBC, U&Es - LFTs - AST and ALT often raised (markers of muscle) - CK - ANA - Anti-Jo1 and Anti Mi-2 EMG Muscle biospy Consider investigating for underlying malignancy e.g. CT TAP, tumour markers

PACES Revision Cards (9 decks)

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