UKMLA: Rheumatology

AS: What is the epidemiology?

• There is a peak in onset between the ages of 20 to 30 years

• It is twice as common in men than women (with higher rates of HLA-B27 positivity in men)

• It is strongly heritable

AS: What are the symptoms?

• Lower back and buttock pain

• Pain elsewhere in the spine may also occur

• Stiffness that is worse in the morning and with rest, and improves with activity

• Patients may wake in the second half of the night with pain

• Pain and stiffness respond to NSAIDs

AS: What is schober’s test?

• Mark two points on the back (one at the level of the L5 spinous process and one 10 cm above this)

• On forward flexion, the distance between the two points should increase by 5cm or more

• If the increase in distance is <5 cm, this indicates restricted forward flexion

AS: What is the typical x-ray finding?

Pelvic x-ray→ sacroiliitis

‘Bamboo’ spine appearance

AS: What is the management?

1. NSAIDS with PPI to prevent peptic ulcers

2. Paracetamol ± codeine

3. -mab biologics

4. Surgery

Gout: What is it?

Gout is a form of arthritis that occurs when monosodium urate crystals deposit in joints

Gout: What are the different types?

• Acute→ within 24 hours and very painful

• Tophaceous→ chronic but painless

Gout: What is the gold standard investigation?

Joint aspiration→ needle shaped monosodium urate crystals with negative birefringence

Gout: What are some additional investigations?

• Urate levels→ over 360

• Repeat urate levels within 2-4 weeks of flare

• HLA-B5801 screening for East Asians before starting allopurinol

Gout: What is the management?

1. NSAIDS at maximum dose

2. Colchicine

3. Prednisolone

Gout: Which drugs are used for prevention via urate-lowering therapy?

ULT:

1. Allopurinol (check HLA-B5801 in East Asians first before starting!!)

2. Uricosuric drugs

OA: What is the epidemiology?

• More women than men are affected

• Average age of onset is 55

• The commonest joint affected is the knee, followed by the hip then the hand

OA: What are the symptoms?

• Pain in the affected joint exacerbated by use

• Crepitus→ friction between bone and cartilage

• Limping/antalgic giant

• Herberdens nodes on DIP

• Bouchards nodes on PIP

OA: What are the typical findings on x-ray?

Typical findings can be remembered with the mnemonic "LOSS":

• Loss or narrowing of joint space due to thinning of cartilage

• Osteophytes i.e. formation of new bony spurs at the joint margins

• Subchondral sclerosis i.e. increased bone density beneath the cartilage

• Subchondral cysts which are fluid-filled sacs in the subchondral bone

OA: What is the management?

• Conservative

• Topical NSAIDS and analgesia

• Topical capsaicin for knee OA

• Steroid injections

• Arthroplasty surgery (joint replacement)

RA: What is the epidemiology?

• The majority of patients are female (3:1 ratio)

• Onset peaks between 30-50 years old

• Smoking is a risk factor and worsens the symptoms

RA: What are the symptoms and signs?

• Ulnar deviation

• Swan neck deformity

• Pain which improves with movement

• Prolonged early morning stiffness (over an hour)

RA: What are the investigations?

• Rheumatoid factor positive

• Anti-CCP antibodies positive

• Joint aspiration with synovial fluid analysis to rule out septic arthritis

RA: What is the management?

Conservative:

• Urgent referral to rheumatology

• Education and self-management

• Regular monitoring using DAS28 score

Medical:

• Analgesia: paracetamol, NSAIDs

• cDMARDs (e.g. methotrexate) as first-line treatment

• Escalate dose or add another DMARD if needed

• Disease-modifying antirheumatic drugs (DMARDs) are first-line → METHOTREXATE

SLE: What is it?

A complex autoimmune disease that may affect a wide variety of organs

SLE: What is the epidemiology?

• SLE is nine times more common in women than men

• It is most common in people of Afro-Caribbean and South Asian descent

• Mean age at diagnosis is 49 years

SLE: What are the risk factors?

• Smoking

• Ultraviolet light

• Silica exposure

• Epstein-Barr virus

• COCP

• Infection

• Stress

SLE: What are the general symptoms?

• Systemic - fevers, fatigue, weight loss, myalgia, malaise, mouth ulcers

• Dermatological - photosensitivity, malar rash, discoid rash, livedo reticularis, alopecia, Raynaud's phenomenon, cutaneous vasculitis

Rash is usually photosensitive aka gets worse in sunlight

SLE: What are the systemic symptoms?

SLE: Which antibodies are specific markers for SLE diagnosis?

Anti-double stranded DNA (anti-dsDNA)

SLE: Why is urinanalysis so important?

To look for proteinuria→ evidence of lupus induced glomerulonephritis

SLE: What is the management?

• Hydroxychloroquine for all patients

• Steroids (oral prednisolone, IV methylprednisolone for acute cases)

• Steroid-sparing agents → cyclophosphamide (methotrexate, azathioprine)

• Biologics (belimumab, rituximab) for severe/refractory cases

SLE: What is the management of neuropsychiatric symptoms e.g. headaches and psychosis due to SLE?

High-dose steroids and cyclophosphamide

SLE: How can you differentiate between SLE and drug-induced lupus?

Drug-induced lupus:

• Black people

• Butterfly rash is not so common

• Positive anti-histone antibodies

• Typically induced by use of hydralazine or isoniazid (first line TB treatment which taken for 6 months)

SLE:

• Black people

• Butterfly rash is more common

• Positive anti-dsDNA and anti-smith antibodies

SLE: Use of which drug can cause neutrophilia?

Steroids!!

SLE: What is the complication of SLE in pregnant women?

May cause congenital heart block leading to foetal bradycardia during second trimester

SLE: What are the expected blood findings?

• Low C3 + C4

• High ESR

• Anti-dsDNA antibody positive

• High creatinine

SLE: How do you differentiate between Sjrogen syndrome, dermatomyositis and SLE?

• Sjrogen syndrome→ Anti-ro antibodies

• Dermatomyositis→ anti-jo antibodies + non-photosensitive facial rash