AMC Flashcards > Rheumatology > Flashcards

Rheumatology Flashcards

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1
Q

Contraindication NSAIDS

A
  • chronic kidney disease
  • hepatic disease
  • peptic ulcer
  • adverse drug reaction
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2
Q

Auto Antibody - Rheumatoid Arthritis

A
  • RF intial test ( 70%)
  • Anti CCP- conformation (more sensitive and specific )
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3
Q

Auto Antibody - SLE

A

Ana - intial
Anti Ds DNA - confirming
Anti Smith - confirming

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4
Q

Synovial Fluid Analysis

A
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5
Q

Rheumatoid Arthritis S/S

A
  • Pain ( decrease during the day)
  • Morning stiffness ( >1h)
  • Swelling
  • Systemic: Fatiquw, weigth loss, Flu like symptomes, Musscle ache weakness
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6
Q

RA - Diagnostic criteria

A
  • Family history of inflammatory arthritis
  • Symptoms duration of over six weeks
  • Early morning stiffness over an hour
  • Arthritis in more than three regions
  • Swelling in five or more joins
  • Symmetry
  • presence of Rheumatoid nodules
  • Rheumatoid factor positive
  • Raised inflammatory markers in absence of infection
  • Anti-CCP positive
  • Bony erosions on radiographs of hands and feet uncommon for early diseases
  • Strong cardiovascular risk factor
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7
Q
A
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8
Q

RA- most affected joints

A
  • Metacarpophalangeal (MCP) joints
  • Proximal interphalangeal (PIP) joints
  • Wrist
  • Metatarsophalangeal (MTP) joints (in the foot)
  • ankle, knee(mc), shoulder, hip, cervical spine

Symmetrical
Joints : tenderness synovial thickening m

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9
Q

RA - extra articular manifestation

A
  • aggressive treatment
  • 40%
  • Pulmonary fibrosis
  • Felty’s syndrome (a triad of rheumatoid arthritis, neutropenia and splenomegaly)
  • Sjögren’s syndrome (with dry eyes and dry mouth)
  • Anaemia of chronic disease
  • Cardiovascular disease (Pericarditis, Myocarditis, Endocarditis, congestive heart failure)
  • Eye manifestations ( keratoconjunctivitis, Scleritis, Ulcerative keratitis)
  • Rheumatoid nodules (firm, painless lumps under the skin, typically on the elbows and fingers)
  • Lymphadenopathy
  • Carpel tunnel syndrome, osteopenia, Osteoporosis
  • Renal (Amyloidosis, Glomerolunephritis)
  • Bronchiolitis obliterans (small airway destruction and airflow obstruction in the lungs)
  • Caplan syndrome (pulmonary nodules in patients with rheumatoid arthritis exposed to coal, silica or asbestos dust)

MC CAUSE OF DEATH : cardiovasular disease

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10
Q

RA - Handsigns

A
  • Z-shaped deformity to the thumb
  • Swan neck deformity (hyperextended PIP and flexed DIP)
  • Boutonniere deformity (hyperextended DIP and flexed PIP)
  • Ulnar deviation of the fingers at the MCP joints

MCP not affected in OA

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11
Q

RA - Atlantoaxial Subluxation

A
  • can cause spinal cord compression
  • check pre operative
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12
Q

RA - Dx

A
  • Rheumatoid factor
  • Anti-CCP antibodies
  • Inflammatory markers, such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR)
  • X-rays of the hands and feet for bone changes
  • Ultrasound or MRI can be used to detect synovitis (useful when clinical findings are unclear)
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13
Q

RA - Xray changes

A
  • Periarticular osteopenia
  • Boney erosions
  • Soft tissue swelling
  • Joint destruction and deformity (in more advanced disease)
  • subluxation
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14
Q

RA - Treatment

A
  1. Monotherapy with methotrexate, leflunomide or sulfasalazine
  2. Combination treatment with multiple cDMARDs
  3. Biologic therapies (usually alongside methotrexate)
  4. Lifstyle ( exercise, smoking cessation)
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15
Q

DMARDS

A
  • Hydroxychloroquine may be used in mild disease and palindromic rheumatism. “mildest” DMARD.
  • Other cDMARDs : azathioprine, ciclosporin, cyclophosphamide and mycophenolate.
  • NSAIDs are helpful for pain relief but have associated risks and side effects. ( no paracetamol)
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16
Q

Biological Therapies

A
  • Tumour necrosis factor (TNF) inhibitors (e.g., adalimumab, infliximab, etanercept, golimumab and certolizumab)
  • Anti-CD20 on B cells (e.g., rituximab)
  • Anti-interleukin-6 inhibitors (e.g., sarilumab and tocilizumab)
  • JAK inhibitors (e.g., upadacitinib, tofacitinib and baricitinib)
  • T-cell co-stimulation inhibitors (e.g., abatacept)
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17
Q

RA and Pregancy

A
  • sympt can improve or flare
  • Hydroxychlorochine or sulfosalazine( plus folic acid) safest
  • Tetratogenic Methotrexate and leflunamid
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18
Q

Metotrexat

A
  • Mouth ulcer
  • liver toxidity
  • bone marrow supression and leukopenia
  • Tetratogenic
  • interferes with folat metabolism( folic acid 5mg/week)
  • Immunsuppresion
  • bone marrow suppression ( Macrocystic anaemia)
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19
Q

Sulfosalazine

A
  • Orange urine
  • reversible male infertility ( stop before family planing)
  • bone marrow supression
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20
Q

Hydroxychloroquin

A
  • Retinal toxicity (reduced visual acuity (macular toxicity)
  • Blue-grey skin pigmentation
  • Hair lightening (bleaching)
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21
Q

Azathioprim

A
  • thioprin methyltransferase test before medication
  • more likely to get bone marrow supression
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22
Q

Feltys syndrom

A
  • complication of longstanding RA
  • 3 condtions
    1. RA
    2. splenomegaly
    3. abnormal white blood cell count
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23
Q

Felty sydrom - featutres

A
  • fatigue
  • serious infection
  • fever
  • weight loss
  • discoloured patches of the skin

Treatment same as RA

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24
Q

Unique SE for Antirheumatica

A
  • Methotrexate: Bone marrow suppression and leukopenia, and highly teratogenic
  • Leflunomide: Hypertension and peripheral neuropathy
  • Sulfasalazine: Orange urine and male infertility (reduces sperm count)
  • Hydroxychloroquine: Retinal toxicity, blue-grey skin pigmentation and hair bleaching
  • Anti-TNF medications: Reactivation of tuberculosis
  • Rituximab: Night sweats and thrombocytopenia
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25
Osteoarthritis - RF
* obesity, age * occupation * trauma * female * family history.
26
Osteoarthritis - commenly affected joints
* Hips * Knees * Distal interphalangeal (DIP) joints in the hands * Carpometacarpal (CMC) joint at the base of the thumb * Lumbar spine * Cervical spine (cervical spondylosis)
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Osteoarthritis - Xray Changes
**L**- loss of joint space **O**- Osteophytes **S**- subarticular sclerosis **S** -subchondral cyst
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Osteoarthrits - Presentation
* Bulky, bony enlargement of the joint * Restricted range of motion * Crepitus on movement * Effusions (fluid) around the joint * symmetrical * Pain ( worse with activity better at rest) * Deformity, Instabiltiy an d reduced function * morning stiffness( <1/2hour)
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Osteoarthritis - Sign in hands
* Heberden’s nodes (DIP) * Bouchard’s nodes (PIP) * Squaring at the base of the thumb (CMC) * Weak grip * Reduced range of motion
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Osteoarthritis - Management
* Nsaids * intraarticular steroids * Joint replacement
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NSAIDS - Adverse Effects
* Gastrointestinal ( gastritis, peptic ulcer) * Renal (AKI, Chronic kidney disease) * cardiovascular ( hypertension, heart failure, MI, Stroke) * excerbating asthma
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SLE Diagnostic
CRP/ESR ANA ( antinuclear) - intial Anti DsDNA - confirming Anti Smith - most specific but not sensitive Antihistone AB - Drug induced lupus Congenital level C3 4 low
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SLE - great pretender
Soap brain MD **S** sclerositis ( pleuritis, pericarditis) **0** oral ulcer **A** Arthritis.(Non deforming -hand feet ) **P** photo sensitivity **B** blood  all low  **R** Renal (proteinuria,glomerulonephritis) **A** Ana **I** immunoglobulin (ds dna)  **N** neurological ( psych seizures) **m** malar rush **d** discoid rash Polyarthritis +fatigue +skinlession Minimal 4 criterias
34
SLE - Treatment
* treat early to avoid unnecessary steroid use **Mild** : Nsaid for atralgia **Moderate** skin, joint, serosa - Hydroxychloroquine * **Severe** kidney involvement - ---- corticosteroids, - immunsupressive drugs(azathioprine, methotrexate- stop progression - Cytotoxic drugs ( cyclophosphamid)
35
SLE - Abnormal findings
* Autoantibodies * Full blood - anaemia of chronic disease, low white cell count and low platelets * CRP and ESR may be raised with active inflammation * C3 and C4 levels may be decreased in active disease * Urinalysis and urine protein:creatinine ratio shows proteinuria in lupus nephritis * Renal biopsy may be used to investigate for lupus nephritis
36
Antiphospholipid syndrom
* secondary to SLE * antiphospolipid antibodies ( anticardiolipin, Antibeta 2 glycoprotein, lupus anticoagulant) * recurrent fetal loss * recurrend thrombotic episodes
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Antiphospholipid Syndrom - Mx
**Thrombosis**: * lifelong anticoagulation ( inr 2.5-3.5) **recurrent fetal loss** * aspirin, heparin +/-Steroids **catastrophic** * high dose steroid * anticoagulant, cyclophosphamid , plasmapheresis
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Secondary Antiphospholipid Syndrome
* **SLE**, other connective tissue diseases, **malignancy**, **drugs** (hydralazine, procainamide, phenytoin, interferon, quinidine), * **infections** (HIV, hepatitis C, TB, infectious mononucleosis)
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Drug induced SLE
* Atralgia * Myalgia * skin * no renal or nervous system effected
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Drug induced SLE - AB
* antihistamin AB * ANA pos * Anti DsDNA **neg** * Anti Ro and Anti smith 5% pos
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Drug induced SLE - Cause
- Phenytoin - Chlorpromazin - Proconamid - Isonazid - hydralazin
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fibromyalgia- Symptoms
– Fatigue and sleep difficulties – Pain in all 4 Quadrants of the body and the axial skeletal on more or less continuous basis for at least three months. – At least 11 out of 18 anatomically specific tender joints. A tender joint hurts at the area where the pressure is applied, and there is no referred pain. – Normal inflammatory markers CRP, ESR etc.
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Congenital Lupus - S/S
* dermatologic * Cardiac ( 65% -congenital complete heart block- 18/20 SSW) * hepatic involvement * splenic abnormalities
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Congenital Lupus - AB
* Anti Ro (most likely detected) * Anti La * U1 ribonukleid protein * C4 down > Transplacental passage
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Skleroderma
* Autoimmun * thickening of skin (accumulation of collagen and injuries of small arteries) * Localised * Systemic (limited cutaneous, diffuse cutaneous)
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Scleroderma Trias
Fingerdiscomfort + atralgia+ GERD +( Skin tightness)
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Localised skleroderma
- does not affect internal organs - Skin, muscle, joint, bones - patches on skin mainly trunk (morphea) - streaks or bands of thick hard skin on arms/legs ( linear scleroderma)
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Systemic Sclerosis
## Footnote - Sausage fingers - tight and shiny skin - Arrythmias, pericarditis - bird like facies
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Limited cutaneous systemic sclerosis - CREST
* **C** calcinosis * **R** raynaud phaenomen * **E** Oesophagus dismobility * **S** Sklerodactyly * **T** Teleangiectasia
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Diffuse Cutaneous Systemic Sclerosis
* Cardiovascular problems (e.g., hypertension and coronary artery disease) * Lung problems (e.g., pulmonary hypertension and pulmonary fibrosis)-Late, mcc of death * Kidney problems (e.g., scleroderma renal crisis)
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Systemic sclerosis - Dx
* ESR maybe high * Anaemia ( normocystic, normochrome) * ANA ( 90%) * RF ( 30%) * Anticentromere Antibodies - specific ( 90% in crest, 5%in diffuse) * Anti SCL 70 ( Antipoisomerase) - Specific ( just in 20-40% pos) * Skin biopsy( dermal collagen increast)
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Systemic sclerosis - MX
* refer to specialist, pat education * Analgetics and NSAIDs * Avoid vasospasm ( no smoking, bblocker, ergotamine) * Raynaud: CCB( nifedipin) * RR monitoring * D-penicillamine(DMARD) if significant systemic or cutaneous involvement
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Polymyositis/Dermatomyositis
* autoimmun conective tissue disorder * symmetrical * Inflammation of the muscles/skin Weakness+joint and muscle pain + violaceous facial rash = dermatomysositis
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Polymyositis/Dermatomyositis - S/S
* Proximal myopathy ( cant get up from chair/ comb the hair) * Arthralgia * Dysphagia (50%) * Rauynaud * Associated malignancy: lung and ovarys
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Dermatomyositis - Skin changes
* **Gottron lesions** (scaly erythematous patches) on the knuckles, elbows and knees * **Heliotrope rash** (a purple rash on the face and eyelids) * **Periorbital oedema** (swelling around the eyes) * **Photosensitive erythematous** rash on the back, shoulders and neck
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Polymyositis/Dermatomyositis - Diagnosis
* Serum CK and aldolase * Biopsy ( skin and musle) -**best** * Emg * Anti Jo AB ( Polymyosistis)
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Differential - CK
**Dermatomyosytis/polymyositis** CK and ESR high **Polymyalgia Rheumatica** CK normal and ESR high **Drug induced myositis** ( statin, steroids) CK and ESR normal
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Polymyositis/Dermatomyositis - Treatment
* Cortison * Immunsuppressent * cytotoxic * Iv globulin * Biological ( infliximab,etaercept)
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Sjögren
**primary** * dry eyes ( keratoconjunctivitis sicca) * dry mouth **secondary** * dry eyes ( keratoconjunctivitis sicca) * dry mouth * + arthralgia ( RA)
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Sjögren - S/S
* fatigue * Sicca * difficulty swalloing * salivary gland enlargement * Xerotrachea (chronic dry cough, hoarsness) * Dyspareunia * non erosive Arthritis * **can transform in non hodgkin** (44xrisk) *
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Sjögren- Dx
* Autoantibodies - pos ANA, RO, LA * Schirmer test * Sialogram * Biopsy if parotid gland enlargement ( goldstandard)
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Sjögren- Mx
- refer - symptomatic ( eg pilocarpin) - NSAIDs , hydroxychloroquin, steroid for arthritis
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Raynaud - primary
* not associated with other diseases *
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Classification Vasculitis
**Small vessel** *NON-ANCA-ASSOCIATED* * Predominantly cutaneous vasculitis * Henoch-Schönlein purpura * Essential cryoglobulinemic vasculitis *ANCA-ASSOCIATED* * Wegener's granulomatosis *Churg-Strauss vasculitis * Microscopic polyangiitis **Medium-sized vessel** * Polyarteritis nodosa * Kawasaki's disease **Large vessel** * Giant Cell Arteritis (Temporal Arteritis) * Takayasu's
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Major vasculitides
-polyarteritis nodosa (PN), -giant cell arteritis (GCA)& polymyalgia rheumatica -Takayasu arteritis, -Behcet syndrome, -Churg-Strauss vasculitis -Wegener granulomatosis (WG)
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Polyarthritis nodosa
* necrotising vasculitis * young/middle aged man * association - drugabuser, HepB/C, Bcell lymphoma
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Polyarthritis nodosa - S/S
* fever, malaise, myalgia, weight loss * migratory arthralgia/polyarthritis * subcutaneous noduls, skin ulcer * abdominal pain, rectal bleeding * kidney impairment * hypertension * Cardiac disorders: arrythmia, failure infarction
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Polyarthritis nodosa- Dx/Mx
* ESR raised, CRP raised * renal biopsy or affected organ ( best) MX * Corticosteroid, immunsuppressants
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Giant Cell Arthritis
* associated with polymyalgia rheumatica * sudden vision loss with temporal headache, jaw. claudication * ESR high (100) , temporal art biopsy * MX iv Corticosteroid
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Polymyalgia rheumatica
malaise +painful shoulder girdle +morning stiffness( over 50)
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Polymyalgia rheumatica
* pain, stiffness- shoulder/pelvic girdle, cervical spine * symmetrical * 60 -70a * weight loss malaise anorexia
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Polymyalgia rheumatica/temporal arthritis
**non complicated**: Prednisolone **Complicated** ( e.g vision loss) iv methylprednisolone other: Methotrexate, Azathioprin cortison sparing agent
72
Behçet syndrome
* affects all veins and arteries of all size * Mediterran, middle east, east asia * **R** reccurent oran/genital ulcer * **U** uveitis * **S** skin damage * **T** Test Pathergy
73
Behçet syndrome - S/S
- Arthritis (knee) - ulcer - Occular sign ( pain, reduced vision, floaters) -->refer to Ophtalmologist
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Behçet syndrome- Dx
Dx - Pathergy Test - Inflammatory markers - HLAB51 Mx corticosteroid colchicin Immunsuppressive drugs
75
colchecine - Kidney impairment
no or reduced
76
Allopurinol
* If >1 attack in 12 month * not in acute attack ( after 6 week) * Adverse effect: rash, lower in KI * drug interaction amoxicillin, azathioprin * dont touch in flare
77
Chronic use of methotrexate can cause following side effects:
1-Hepatotoxicity 2-Folic acid deficiency 3-Myelosuppression with low platelet and white cell count. 4-Interstitial pneumonitis 5-Fatigue 6-Nausea and vomiting 7-Stomatitis or mouth ulcers.
78
Ankylosing Spondylytis - Treatment
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