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Rheumatology and Orthopaedics > Rheumatology for Finals > Flashcards

Rheumatology for Finals Flashcards

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1
Q

Which 2 antibodies are key in rheumatoid arthritis?

A

Rheumatoid factor

Anti-CCP antibodies

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2
Q

Which antibodies might be present in limited systemic sclerosis?

A

Anti-centromere antibodies

ANA

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3
Q

Which antibodies might be present in diffuse systemic sclerosis?

A

Anti-topoisomerase antibodies (also called anti-Scl 70)
Anti-RNA polymerase I and II antibodies
ANA

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4
Q

Which condition is associated with anti-dsDNA antibodies?

A

Systemic Lupus Erythromatosis

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5
Q

Give 3 antibodies associated with antiphospholipid syndrome

A

Anti-cardolipin antibody
Anti-beta-2 glycoprotein
Lupus anticoagulant

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6
Q

Which condition is associated with c-ANCA antibodies?

A

Wegener’s (Granulomatosis with polyangiitis)

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7
Q

Give 3 conditions which are associated with p-ANCA antibodies

A

Microscopic polyangiitis
Churg-Strauss syndrome
Primary sclerosing cholangitis

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8
Q

Which antibodies are associated with primary biliary cirrhosis?

A

Anti-mitochondrial antibodies

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9
Q

HLA B27 is associated with which condition(s)?

A

Seronegative arthropathies

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10
Q

HLA B51 is associated with which condition(s)?

A

Behcet’s disease

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11
Q

Which joint is typically affected in acute gout?

A

Metatarsalphalangeal joint of great toe

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12
Q

What would joint fluid microscopy show in gout?

A

Negatively birefringent crystals

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13
Q

Which joint is typically affect in peudogout?

A

Knee joint

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14
Q

What is the treatment of acute gout?

A

NSAIDs e.g. Indomethacin
Colchicine
May be a role for intra-articular steroid injections

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15
Q

What is the treatment of chronic gout?

A

Lifestyle advice

Allopurinol - Start 2 weeks after acute attack has resolved (but after the 2nd attack)

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16
Q

Which joints are particularly involved in rheumatoid arthritis?

A

Small joints of the hands, especially proximal inter-phalangeal joints (NOT distal) and metacarpalphalangeal joints

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17
Q

True / False: Joint involvement in rheumatoid arthritis is usually symmetrical

A

True

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18
Q

Give 4 features of Felty’s syndrome

A

Rheumatoid arthritis
Neutropenia
Splenomegaly
Ulcers

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19
Q

What does a DEXA scan result of 0 to -1 indicate?

A

Normal - No osteoporosis

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20
Q

What does a DEXA scan result of -1 to -2.5 indicate?

A

Osteopenia

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21
Q

What does a DEXA scan result of less than -2.5 indicate?

A

Osteoporosis

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22
Q

How would you advise a patient to take a bisphosphonate tablet?

A

First thing in the morning, before food or drink (except water). Take whilst standing with plenty of water. Do not lie down for 30 minutes after taking. Take weekly, on the same day each week.

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23
Q

What are the main side effects of bisphosphonates?

A

GI ulceration, reflux
Jaw osteonecrosis
Photosensitivity

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24
Q

List 4 seronegative arthropathies

A

Ankylosing spondylitis
Reactive arthritis
Psoriatic arthritis
Enteropathic arthritis

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25
Give the typical features of ankylosing spondylitis
``` Young male patient Back pain, worse at night Early morning stiffness Relieved by exercise Localised tenderness over sacroiliac joints, may radiate to hips and buttocks Progressive loss of spinal movements ```
26
What is the typical x-ray appearance of psoriatic arthritis?
'Pencil-in-cup' deformity
27
What are the features of Takayasu's arteritis?
``` Middle age, female, Asian patients Unequal BP in each arm - Hypertension Intermittent claudication Absent peripheral pulses Carotid bruit Aortic regurgitation Malaise Headache Associated with renal artery stenosis ```
28
What is Takayasu's arteritis?
Rare, large vessel arteritis affecting the aortic arch and it's branches
29
How might you treat Takayasu's arteritis?
Steroids
30
Which antibodies are associated with systemic lupus erythromatosis?
``` Anti-dsDNA ANA Anti-Smith Anti-Ro Anti-La ```
31
Which antibodies are associated with drug induced lupus?
Anti-histone antibodies
32
Which drugs cause drug-induced lupus?
``` Hydralazine Procainamide Minocycline Phenytoin Isoniazid ```
33
Are complement levels low or high in SLE?
Low - There is consumption of complement so C3 and C4 are low, but their degradation products are high
34
Give some features of systemic lupus erythromatosis
Fatigue, fever, myalgia, lymphadenopathy Skin involvement: Malar rash, discoid rash, photosensitivity at exposed areas, levido reticularis, non-scarring alopecia Raynaud's phenomenon Non erosive arthritis Arthralgia Serositis: Pleurisy, pericarditis Mouth ulcers Renal involvement: Proteinuria, glomerulonephritis Neurological symptoms: Depression, anxiety, seizures, psychosis Haematological involvement: Haemolytic anaemia, leukopenia, lymphopenia, thrombocytopenia
35
What is the treatment for SLE?
- Severe flair ups may require IV cyclophosphamide and high-dose prednisolone - Skin symptoms: Topical steroids - Maintenance: NSAIDs, hydroxychloroquine, steroids, azathioprine, methotrexate, mycophenolate
36
What type of crystals are present in gout?
Monosodium urate
37
What type of crystals are present in pseudogout?
Calcium pyrophosphate dehydrate
38
What does joint microscopy commonly show in pseudogout?
Positively birefringent rhomboid shaped crystals
39
What might be the appearance of pseudogout on x-ray?
Chondrocalcinosis i.e. calcification of cartilage
40
What is the most common side effect of colchicine?
Diarrhoea
41
What is the role of allopurinol in acute management of gout?
Allopurinol should not be started during an acute attack of gout as it can worsen the attack. However if the patient is already on allopurinol, it should be continued. Start allopurinol 2 weeks after an attack.
42
Give some drug causes of gout
Thiazide diuretics Furosemide Pyrazinamide Cytotoxics
43
What is the diagnosis in an isolated raised ALP?
Paget's disease
44
What abnormalities of blood results are you likely to see in osteoporosis?
No abnormality - All likely to be normal
45
How are patients risk assessed for osteoporosis?
FRAX score predicts the patient's 10 year risk of fracture - Low risk = Reassure - Intermediate risk = Do a DEXA scan - High risk = Start bisphosphonates
46
What is the management of osteoporosis?
Lifestyle modification: Stop smoking, reduce alcohol, lose weight, OT assessment for falls risk Bisphosphonates
47
What are the features of osteoarthritis on x-ray?
Loss of joint space Osteophytes Subchondral sclerosis Subchondral cysts
48
What are the features of rheumatoid arthritis on x-ray?
Loss of joint space Erosions Subluxation Soft tissue swelling
49
What is the management of osteoarthritis?
``` Conservative: Weight loss Physiotherapy - Increase muscle strength Analgesia: - Topical - Oral NSAIDs, paracetamol Intra-articular steroid injection Joint replacement ```
50
Give some extra-articular features of ankylosing spondylitis
``` Anterior uveitis Aortic regurgitation, AV node blockade Plantar fasciitis Achilles tendonitis Apical lung fibrosis Amyloidosis ```
51
What test can be done to evaluate spinal movement in ankylosing spondylitis?
Shober's test
52
What is the management for ankylosing spondylitis?
Physiotherapy, especially hydrotherapy NSAIDs TNF-alpha blockers if unresponsive to NSAIDs Methotrexate only if there is peripheral arthritis
53
Is joint involvement in psoriatic arthropathy symmetrical or asymmetrical?
Asymmetrical
54
What are the 5 types of psoriatic arthritis?
``` Rheumatoid-like polyarthritis Asymmetrical oligoarthritis Sacroiliitis DIPJ joint disease Arthritis mutilans ```
55
How is psoriatic arthritis treated?
As for rheumatoid arthritis
56
List some organisms associated with reactive arthritis
Shigella Salmonela Campylobacter Chlamydia trachomatis
57
How long after an infection does reactive arthritis usually occur?
1-4 weeks
58
What is Reiter's syndrome?
Triad of urethritis, arthritis and conjunctivitis
59
Which vasculitis does polymyalgia rheumatica have a strong association with?
Giant cell arteritis
60
What are the features of polymyalgia rheumatica?
Age over 50 Subacute onset - within 1 month Bilateral aching and morning stiffness affecting shoulders and proximal limb muscles NO weakness Low-grade fever, weight loss, anorexia, night sweats ESR raised Normal CK, normal EMG
61
What is the treatment for polymyalgia?
Steroids 15mg daily - Expect a dramatic response within 1 week
62
Give 3 examples of inflammatory myopathies
Polymyositis Dermatomyositis Inclusion body myositis
63
Give a key difference between polymyalgia rheumatica and polymyositis/dermatomyositis
There is weakness in polymyositis and dermatomyositis but NO (objective) weakness in polymyalgia rheumatica
64
What is the key diagnostic investigation in polymyositis and dermatomyositis? What does it show?
Muscle biopsy for histology shows inflammatory cell infiltration and muscle cell necrosis... Polymyositis: Lymphocyte infiltration of non-necrotic muscle fibres Dermatomyositis: Peri-fascicular atrophy i.e. layers of atrophic muscle fibres at the periphery of fascicles
65
List some investigations in polymyositis and dermatomyositis
Bloods: Raised CK, ANA antibodies in 80% EMG shows fibrillations, increased spontaneous activity Muscle biopsy is definitive diagnostic investigation
66
List some symptoms of polymyositis
Presentation will vary depending on which muscle groups affected: - Axial e.g. shoulder / pelvic girdle: Difficulty squatting, going upstairs, raising arms above head e.g. to comb hair - Pharyngeal / laryngeal: Dysphagia, dysphonea - Respiratory muscle involvement can cause respiratory failure Also Raynaud's, fever, weight loss
67
List some symptoms of dermatomyositis
Any of the features of polymyositis plus skin involvement: - Gottron's papules - Shawl sign - Heliotrope rash - 'V' sign over neck and chest - Mechanics hands - Calcifications - Dilated nail bed capillary loops
68
Which is more associated with malignancy...polymyositis or dermatomyositis
Dermatomyositis
69
What is the treatment for polymyositis and dermatomyositis?
Steroids Immunosuppression (DMARDs) in resistant disease Screen for cancers!
70
What is rheumatoid arthritis?
A symmetrical autoimmune polyarthritis commonly affecting the peripheral joints. It is a chronic, severe inflammatory disorder which can affect men and women of any age.
71
True / False: Rheumatoid factor is common to all patients with rheumatoid arthritis
False - Rheumatoid factor is present in about 80%
72
List some ocular manifestations of rheumatoid arthritis
Episcleritis Scleritis Keratoconjunctivitis sicca Corneal ulceration
73
List some pulmonary manifestations of rheumatoid arthritis
Pulmonary nodules Pulmonary fibrosis (lower lobe) - Due to disease and drugs e.g. methotrexate Pleural effusions Bronchiolitis obliterans
74
What is the management of rheumatoid arthritis?
- MDT approach - Smoking cessation - Analgesia: Paracetamol, NSAIDs - Steroids suppress disease activity: Oral, intra-articular injections, IM methylprednisolone in flare-ups - DMARDs: Methotrexate, sulfasalazine, leflunomide - TNF-alpha blockers: Infliximab, etanercept, adalimumab
75
What does DMARD mean?
Disease Modifying Anti-Rheumatic Drugs
76
What is the first-line treatment regime for rheumatoid arthritis?
Steroids + methotrexate + one other DMARD
77
What is the indication for starting TNF-alpha blockers in rheumatoid arthritis?
Inadequate response following 2 DMARDs including methotrexate
78
Give some side effects of methotrexate
``` Liver fibrosis Lung fibrosis Myelosuppression Mouth ulcers Teratogenicity ```
79
Give some side effects of sulfasalazine
Mouth ulcers Hepatitis Oligospermia Steven Johnsons Syndrome
80
Which drugs might cause reactivation of TB?
TNF-alpha blockers e.g. infliximab
81
What are the features of limited systemic sclerosis?
``` Formerly 'CREST' syndrome: Calcinosis of subcutaneous tissues Raynaud's oEsophageal and gut dysmotility Sclerodactyly i.e. swollen, tight digits Telangiectasia Skin involvement 'limited' to face, hands, feet ```
82
What are the features of diffuse systemic sclerosis?
GI symptoms: Dysphagia, reflux, pseudo-obstruction Renal: Acute renal crisis (causes acute hypertensive crisis), chronic kidney disease Cardiac: Conduction problems due to fibrosis Pulmonary: Fibrosis, pulmonary hypertension
83
Give 2 key complications of systemic sclerosis
``` Pulmonary hypertension (both types) Kidney disease: Acute renal crisis, chronic kidney disease (diffuse) ```
84
What medication should all patients with systemic sclerosis be taking?
ACE-Inhibitors
85
What might be used in the treatment of an acute renal crisis in systemic sclerosis?
Cyclophosphamide
86
Which antibodies are associated with Sjorgren's syndrome?
ANA Anti-Ro Anti-La Rheumatoid factor
87
What is the Schirmer Test?
Assesses lacrimation ability using a strip of filter paper on lower eyelid. Less than 5mm of wetting in 5 minutes is indicative of Sjorgen's Syndrome
88
Which cancer are patients with Sjorgren's at increased risk of?
Lymphoma
89
Give some examples of large vessel vasculitides
Takayasu's arteritis Temporal arteritis (giant cell arteritis) Behcet's disease (not a primary vasculitis)
90
Give some examples of medium vessel vasculitides
Polyarteritis nodosa | Karawaki's disease
91
Give some examples of small vessel vasculitides
``` Wegener's granulomatosis (Granulomatosis with polyangiitis) Churg-Strauss disease Microscopic polyangiitis Henoch-Schonlein Purpura Mixed cryoglobulinaemi ```
92
What is Wegener's also known as?
Granulomatosis with polyangiitis
93
How might small vessel vasculitides be divided up?
ANCA positive Vs. ANCA negative
94
What is the treatment for temporal arteritis?
Prednisolone, typically a 2 year course
95
What investigations might be done in temporal arteritis?
ESR raised | Temporal artery biopsy may show granulomatous lesions...NB skip lesions are common
96
Why is it important to start treatment early in temporal arteritis?
Risk of bilateral visual loss if treatment not started due to anterior ischaemic optic neuropathy
97
What is the Pathergy test?
Used in investigation of Behcet's disease: A needle is used to prick the skin and then 24-48 hours later a pustule will have developed at the site of injury due to poor response to inflammation by the tissues
98
List some features of Behcet's disease
``` Ulcers: Mouth, genitals GI symptoms due to GI ulceration: Pain, diarrhoa Anterior uveitis Arthritis Thrombophebitis Aseptic meningitis ```
99
Which vasculitis has an association with Hepatitis B?
Polyarteritis nodosum
100
List some features of polyarteritis nodosa
``` Levido reticularis Neurological: Mononeuritis multiplex Glomerulonephritis Punched out ulcers Hypertension ```
101
What is polyarteritis nodosa?
A systemic necrotising granulomatous vasculitis which causes aneurysm formation in medium-sized vessels, with thrombosis and infarction
102
Give some features of granulomatosis with polyangiitis
URTI symptoms: Saddle-shaped node, sinusitis, epistaxis Granulomatous formation in lungs Pulmonary haemorrhage Rapidly progressive glomerulonephritis
103
What is the treatment for Wegener's?
Steroids Cyclophosphamide Rituximab
104
What are the features of Churg-Strauss?
Classic triad of: Asthma, eosinophilia, vasculitis | Also: Nasal polyps, diarrhoea, GI bleeding, neuropathy (mononeurotis multiplex)
105
What is the treatment for Churg-Strauss?
Steroids

Rheumatology and Orthopaedics (4 decks)

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