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Flashcards in RHEUMATOLOGY Deck (73)
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1
Q

What is rheumatoid arthritis?

A
An autoimmune 
systemic inflammatory disorder 
affecting mainly the joints of the hand 
but also associated with extra-articular features. 
Symmetrical deforming polyarthritis
2
Q

What are the HLA associations of Rh A?

A

HLA DR1

HLA DR4

3
Q

What is the epidemiology of Rh A?

A

Females

30-50yo

4
Q

What is the PC of RhA?

A

Gradual joint pain, swelling
Worst in the mornings
Impairs function and movement

+ systemic symptoms: weight loss, fever, fatigue.

5
Q

Early signs on OE for RhA

A

SYMMETRICAL swelling of joints
Warm + Tender joints
MCP, PIP commonly affected
Decrease in range of movement

6
Q

Late signs on OE for RhA

A
SYMMETRICAL deformed arhtopathy
Ulnar deviation of finger
Radial deviation of wrist
"swan neck"
"boutoinnere"
"z" of thumb
Rheumatoid nodules - hard, firm SC nodules found commonly on elbows and palms (associated with RhF)
7
Q

What investigations do you carry out for RhA?

A
RhF + 
Anti-CCP + (500 SBA book says this is the most sensitive specific investigation for RhA)
ANA +
Bloods: low HB, high Plt
High ESR + CRP

Joint aspiration to exclude septic arthritis.

8
Q

What do you expect to see on Xray for RhA

A

“DONS”

Deformity
Osteopenia
Narrowing of joint space
Swelling of soft tissues

9
Q

Which joints are usually spared on new onset RhA?

A

DIP

500 SBA

10
Q

Define psoriasis

A

• A chronic inflammatory skin disease, which has characteristic lesions and may be complicated by arthritis

11
Q

Recognise ALL the signs/symptoms of psoriasis

A
  • Itching and occasionally tender skin
  • Pinpoint bleeding with removing scales (Auspitz phenomenon)
  • Skin lesions may develop at sites of trauma/scars (Koebner phenomenon)
  • Discoid/Nummular psoriasis - symmetrical, well-demarcated erythematous plaques with silvery scales over extensor surfaces (knee, elbows, scalp, sacrum)
  • Flexural psoriasis - less scaly plaques in axilla, groins, perianal and genital skin
  • Guttate psoriasis - small drop-like lesions over trunk and limbs
  • Palmoplantar psoriasis - erythematous plaques with pustules on palms and soles
  • Generalised pustular psoriasis - pustules distributed over limbs and torso

Nail signs:
o Pitting
o Onycholysis
o Subungual hyperkeratosis

12
Q

Signs of psoriatic arthritis

A
o  Asymmetrical oligoarthritis  
o  Symmetrical polyarthritis  
o  Distal interphalangeal joint predominance  
o  Arthritis mutilans  
o  Psoriatic spondylitis 

Mostly affects DIP and is assymetrical (5% of psoriasis pts will develop psoriatic arthritis) - from 500 SBA

13
Q

Define osteoarthritis

A

• Age-related degenerative joint disease when cartilage destruction exceeds repair, causing pain and disability

14
Q

Recognise the presenting symptoms of osteoarthritis

A
  • Joint pain and discomfort - Use-related *
  • Stiffness or gelling after inactivity
  • Difficulty with certain movements *
  • Feelings of instability
  • Restriction walking, climbing stairs and doing manual tasks

• Systemic features are usually absent

15
Q

Recognise the signs of osteoarthritis on physical examination

A

• Local joint tenderness
• Bony swellings along joint margins
o Heberden’s Nodes - DISTAL interphalangeal joint
o Bouchard’s Nodes - PROXIMAL interphalangeal joint
• Crepitus and pain during joint movement
• Joint effusion
• Restriction of range of joint movement

16
Q

What are the classic OA signs on joint xray?

A
FOUR classic features: 
o  Loss of joint space (narrowing)  
o  Osteophytes  
o  Subchondral cysts  
o  Subchondral sclerosis
17
Q

Explain the aetiology/risk factors of infective arthritis

A
  • May be idiopathic
  • In most cases there is RECENT systemic infection ** allowing for haematogenous spread
•  Risk Factors 
o  Recent orthopaedic procedures   
o  Osteomyelitis 
o  Diabetes  
o  Immunosuppression 
o  Alcoholism
18
Q

Common causative organisms of septic arthritis

A

Neisseria gonorrhoeae

o  Viruses 
•  Rubella  
•  Mumps  
•  Hepatitis B 
•  Parvovirus B19 

o Fungi
• Candida

19
Q

Recognise the presenting symptoms of infective arthritis

A

• Fever
• Excruciating joint pain
• Joint redness, swelling and loss of joint function
• Usually a monoarthropathy (usually affecting one large joint)
o NOTE: it may cause a polyarthropathy in the immunosuppressed

• Tuberculous arthritis develops more slowly and is more chronic

20
Q

Recognise the signs of infective arthritis on physical examination

A
  • Painful, hot, swollen
  • Immobile joint
  • Erythema
  • Severe pain prevents passive movement
  • Pyrexia
  • Look for signs of aetiology
21
Q

Identify appropriate investigations for septic arthritis

A

• Joint Aspiration (IMPORTANT)
o In infective arthritis, the aspirate will be grossly purulent **
o Send synovial fluid for MC&S

• Microscopy - rule out crystal arthritis
o PCR may be used if a viral cause is suspected

•  Bloods 
o  FBC - high WCC, high neutrophils  
o  High CRP and ESR  
o  Blood cultures M MC&S 
o  Viral serology may be useful  

• Plain Joint Radiographs
o Affected joint may look normal initially
o Can show signs of damage following the infection

• MRI Scan
o Useful for detecting osteomyelitis

22
Q

Define reactive arthritis

A

• Characterised by a sterile arthritis occurring after an extra-articular infection (commonly GI or urogenital).

23
Q

What is Reiter’s syndrome

A

Reiter’s Syndrome is defined as a TRIAD of:
o Reactive arthritis
o Urethritis
o Conjunctivitis

24
Q

Explain the aetiology/risk factors for reactive arthritis

A
•  Associated with infections:  
o  GI 
•  Salmonella 
•  Shigella  
•  Yersinia 
•  Campylobacter 

o Urogenital
• Chlamydia trachomatis (60%)*

• It is thought that initial activation of the immune system by a microbial antigen is followed by an autoimmune reaction that involves the skin, eyes and joints

25
Q

Which HLA is associated with Reactive arthritis

A

• HLA-B27 allele is identified in 70-80% of patients

26
Q

Recognise the presenting symptoms of reactive arthritis

A
  • Symptoms can develop 3-30 days after infection
  • Burning or stinging when passing urine (due to urethritis)
  • Arthritis
  • Low back pain (due to sacroiliitis)
  • Painful heels (due to enthesitis and plantar fasciitis)
  • Conjunctivitis
27
Q

Recognise the signs of reactive arthritis on physical examination

A

• Signs of Arthritis
o Asymmetrical oligoarthritis
o Often affects the lower extremities
o SausageMshaped digits

• Signs of Conjunctivitis
o Anterior uveitis M painful red eye

• Oral Ulceration

• Circinate Balanitis
o Scaling red patches on the glans

•  Keratoderma Blenorrhagica 
o  BrownishMred macules  
o  Vesicopustules  
o  Yellowish-brown scales  
o  Found on the SOLES and PALMS 

• Others
o Nail dystrophy
o Hyperkeratosis
o Onycholysis

28
Q

Identify appropriate investigations for reactive arthritis

A

• Bloods
o FBC
o High ESR and CRP
o HLA-B27 testing

• Stool or Urethral Swabs and Cultures
o May be negative by the time the arthritis develops (because the arthritis occurs post-infection)

• Urine
o Screen for Chlamydia trachomatis

• Plain X-Rays
o Useful in chronic cases
o Erosions seen at the entheses (insertion of tendons into bone)

• Joint Aspiration
o To exclude septic or crystal arthritis

29
Q

Which crystals deposit in the joints in pseudogout?

A

Calcium pyrophosphate dihydrate

near the surface of chondrocytes

30
Q

What diseases are RF for gout?

A

Haemochromatosis, Wilson’s, Hyperparathyroidism, Acromegaly, Hypophosphotemia, Hypomagnesemia

(you would expect to find pseudgout in a young patient if they have one of these diseases)

31
Q

In which demographic group is pseudogout mostly found?

A

Elderly females (x2)

32
Q

How does pseudogout present?

A

Acute painful swollen joint knee/wrist (ankle, shoulder)

33
Q

What are the signs OE of pseudogout

A

Red, hot, swollen, tender, resticted range of movement

34
Q

What investigations do you carry out for pseudogout?

A

Bloods: raised WCC, raised ESR, (Mg2+, PTH, Pho)
Blood and joint aspirate culture: to exclude septic arthritis
Joint aspirate -
Xray

35
Q

What would the joint aspirate under polarised light

A

Positive birefringence - rhomboid/brick shaped crystals

36
Q

What is a key feature on Xray for pseudogout?

A

CHONDROCALCINOSIS !!!

It will differentiate it from other things like: gout, OA, septic arhritis as there is some overlap in presentation and signs between them.

37
Q

Define ankylosing spondylitis

A

• Seronegative inflammatory arthropathy affecting preferentially the axial skeletal and large proximal joints

38
Q

Which joints are mainly affected in AS?

A

axial skeletal and large proximal joints

39
Q

What is the HLA associated with AS?

A

HLA-B27

40
Q

What’s the pathophysioogy o

A

o Inflammation starts at the ENTHESES* (where ligaments attach to vertebral bodies)
o Persistent inflammation leads to reactive new bone formation*
o Changes begin in the lumbar vertebrae and progress superiorly
o Vertebral bodies become more square
o Syndesmophytes* (vertical ossifications bridging the
margins between adjacent vertebrae)
o Fusion of syndesmophytes and facet joints
o Calcification of anterior and lateral spinal ligaments

41
Q

What is the classic demographic of an AS pt?

A

Young male

42
Q

Recognise the presenting symptoms of ankylosing spondylitis

A

• Lower back and sacroiliac pain **

• Pain pattern
o Worse in the morning **
o Better with activity **
o Worse when resting **

  • Disturbed sleep
  • Progressive loss of spinal movement
  • Symptoms of asymmetrical peripheral arthritis
  • Pleuritic chest pain (due to costovertebral joint involvement)
  • Heel pain (due to plantar fasciitis)
  • NonMspecific symptoms (e.g. malaise, fatigue)
43
Q

Recognise the signs of ankylosing spondylitis on physical examination

A
  • Reduced range of spinal movement (particularly hip rotation)
  • Reduced lateral spinal flexion
  • Schober’s Test
  • Tenderness over the sacroiliac joints
44
Q

What is Schober’s test

A

o Two fingers are placed on the patients back about 10 cm apart
o The patient is asked to bend over
o The distance between the two fingers should increase by > 5 cm on forward
flexion
o Reduced movement would suggest ankylosing spondylitis - AS is a clinical diagnosis !!!!

45
Q

What are the signs OE for later stages of AS?

A

• LATER STAGES:
o Thoracic kyphosis
o Spinal fusion
o Question mark posture

46
Q

What are the signs of exrta-articular disease of AS?

A
•  Signs of Extra-Articular Disease: 5 As  
o  Anterior uveitis  
o  Apical lung fibrosis   
o  Achilles tendinitis   
o  Amyloidosis 
o  Aortic regurgitation
47
Q

Identify appropriate investigations for ankylosing spondylitis

A

• Bloods
o FBC - anaemia of chronic disease
o Rheumatoid factor - negative *
o ESR/CRP - high *

• Radiographs
o Anteroposterior and lateral radiographs of the spine
• May show Bamboo spine*

o Anteroposterior radiograph of sacroiliac joints
• Shows symmetrical blurring of joint margins

o LATER STAGES on XRAY:
• Erosions
• Sclerosis
• Sacroiliac joint fusion

o CXR - check for apical lung fibrosis

• Lung Function Tests
o Assess mechanical ventilatory impairment due to kyphosis

48
Q

Generate a management plan for giant cell arteritis

A
  • High dose oral prednisolone IMMEDIATELY to prevent visual loss
  • Reduce the dose of prednisolone gradually
  • Many patients will need to be kept on a maintenance dose of prednisolone for 1-2 yrs
  • Low dose aspirin (with PPIs and gastroprotection) - reduces risk of visual loss, TIAs and stroke
  • Annual CXR for up to 10 yrs to look for thoracic aortic aneurysms
49
Q

What is polymyositis ?

A

Connective tissue disease characterised by inflammation of muscles

50
Q

What causes polymyositis?

A

Autoimmune

Possible viral triggerQ

51
Q

What is the epidemiology of polymyositis?

A

30-60yo Female

52
Q

How does one present with polymyositis

A

Progressive muscle weaknes gradually getting worst over the past few months
(NO RASH)

53
Q

How does a dermatomyositis rash look like?

A

• Blue-purple discolouration of the upper eyelids with periorbital oedema
• Flat red rash involving the face and upper trunk
• Raised purple-red scaly patches over the extensor surfaces of joints and fingers
o Rash may affect knees, shoulders, back and upper arms
o Rash may be exacerbated by sunlight
o Proximal myopathy
o Muscle pain and tenderness in early disease

54
Q

What are the IX for polymyositis

A

CK is raise (50% more)
EMG
Musclebx - defnitive diagnostic test

55
Q

Which auto-ab are related to polymyositis

A

Anti-Jo1

Myosite specific Ab

56
Q

Which auto-ab are related to dermatomyositis

A

Anti-Mi2

ANA

57
Q

Define SLE

A

• Multi-system inflammatory autoimmune disorder

58
Q

What are the American College of Rheumatology criteria

A

• 4/11 of the diagnostic criteria of the American College of Rheumatology provides high sensitivity and specificity for the diagnosis of SLE:
SOAP BRAIN MD

o Serositis
o Oral ulcers
o Arthritis (non-erosive)
o Photosensitivity
o Bloods (haemolytic anaemia/ leukopaenia/ thrombocytopaenia)
o Renal disease (urine casts/proteinuria)
o ANA
o Immunological disorder (anti-dsDNA /anti-Sm /anti-phospholipid)
o Neurological disease (psychosis/seizures)
o Malar rash
o Discoid rash

59
Q

Recognise the presenting symptoms and signs of SLE

A
•  General Symptoms 
o  Fever  
o  Fatigue  
o  Weight loss  
o  Lymphadenopathy  
o  Splenomegaly 
  • Raynaud’s phenomenon
  • Oral ulcers

• Skin Rash
o Malar rash
o Discoid lupus (red scaly patches)
o Atypical rashes (e.g. photosensitivity, vasculitis, urticaria, purpura)

• Systemic Involvement
o Musculoskeletal - arthritis, tendonitis, myopathy
o Heart - pericarditis, myocarditis, arrhythmias, Libman-Sacks endocarditis
o Lung - pleurisy, pleural effusion, basal atelectasis, restrictive lung defects
o Neurological - headache, stroke, cranial nerve palsies, confusion, chorea
o Psychiatric - depression, psychosis
o Renal - glomerulonephritis

60
Q

Identify appropriate investigations for SLE

A
•  Bloods 
o  FBC 
o  U&E 
o  LFT  
o  Raised ESR   *
o  Raised/Normal CRP  *
o  Clotting  
o  Complement  
  • Urine M haematuria, proteinuria, red cell casts
  • Joints M plain radiographs
  • Heart and Lungs M CXR, ECG, echocardiogram, CT
  • Kidneys M renal biopsy (if glomerulonephritis suspected) • CNS M MRI scan, lumbar puncture
61
Q

State the autoantibodies associated with SLE

A
•  Autoantibodies 
o  Anti-dsDNA (60%) 
o  Rheumatoid factor (30M50%)  
o  Anti-ENA 
o  Anti-RNP 
o  Anti-SM 
o  Anti-Ro 
o  Anti-La 
o  Anti-histone 
o  Anti-cardiolipin
62
Q

a 55yo female presetns with dry cough and SOB which have been present and have progressed the past few months.
PMH: rheumatoid arthritis
OE: Bilateral fine inspiratory crackles

What is this

A

Pulmonary fibrosis
Is an extra-articular manifestation of RhA
Is also a side effect of methotrexate (a disease-modifying anti rheumatic drug) a drug used in RhA

63
Q

Define anti-phospholipid syndrome

A

• Characterised by the presence of antiphospholipid antibodies (APL) in the plasma, venous and arterial thrombosis, recurrent foetal loss and thrombocytopaenia

64
Q

Explain the aetiology/risk factors of anti-phospholipid syndrome

A
  • Antiphospholipid antibodies (APL) are directed against plasma proteins bound to phospholipids
  • APL may develop in susceptible individuals following exposure to infectious agents
  • Once APL are present, a second event is needed for the syndrome to develop
  • APL has effects on a number of coagulation factors (e.g. protein C, annexin V, platelets, fibrinolysis)
  • Complement activation by APL is critical for the complications
65
Q

Summarise the epidemiology of antiJphospholipid syndrome

A
  • More common in YOUNG WOMEN
  • Accounts for 20% of strokes in < 45 yrs
  • Accounts for 27% of women with > 2 miscarriages
66
Q

Recognise the presenting symptoms of antiJphospholipid syndrome

A
•  RECURRENT MISCARRIAGES   *
•  History of: 
o  Arterial thromboses (stroke) 
o  Venous thromboses (DVT, PE)  * 
•  Headaches (migraine) 
•  Chorea  
•  Epilepsy 

(at a young age)

67
Q

Recognise the signs of antiJphospholipid syndrome on physical examination

A

• Livedo reticularis = A skin finding consisting of a mottled reticulated vascular pattern that appears as a lace-like purplish discolouration of the skin

  • Signs of SLE (e.g. malar rash, discoid lesions)
  • Signs of valvular heart disease
68
Q

Identify appropriate investigations for antiJphospholipid syndrome

A

• FBC - low platelets
• ESR - usually normal
• U&Es - can get APL nephropathy
• Clotting screen - high APTT
• Presence of antiphospholipid antibodies may be demonstrated by:
o ELISA testing for anticardiolipin antibodies
o Lupus anticoagulant assays

69
Q

Which auto-ab are associated with Sjrogens

A

• Autoantibodies
o Rheumatoid factor
o ANA
o AntiMENA (extractable nuclear antigens)

70
Q

What is Sjorgens

A

Characterised by inflammation and destruction of exocrine glands (usually salivary and
lacrimal glands).
o NOTE: when associated with other autoimmune diseases, Sjogren’s syndrome is
termed secondary

71
Q

How does sjogrens present

A
  • Dry eyes (keratoconjunctivitis sicca) - they will be gritty and sore
  • Dry mouth - leads to secondary dysphagia
  • Dry upper airways M leads to a dry cough and recurrent sinusitis
  • Fatigue
  • Fever
  • Weight loss
  • Depression
  • Dry skin or hair
  • Dry vagina - may cause dyspareunia
  • Reduced GI mucus secretions leads to reflux oesophagitis, gastritis and constipation
72
Q

What is Schirmer’s Test

A

o A strip of filter paper is placed under the eyelid

o Positive for Sjogren’s syndrome if < 10 mm of the strip is wet after 5 mins

73
Q

What is Henoch-Schonlein purpura

A

A small vessel vasculitis which usually occurs in children after an upper respiratory tract infection.
purpura, arthritis, gut symptoms, glomerulonephritis, IgA deposition