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60 Cards in this Set

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What is the definitive diagnosis for gout?
Demonstration of monosodium urate (MSU) crystals in aspirated synovial fluid
What is the definitive diagnosis for pseudogout?
Demonstration of calcium pyrophosphate (CPP) in aspirated synovial fluid
Why do men tend to have a higher rate of gout than women?
Oestrogenic hormones have uricosuric effect (increase the excretion of uric acid in the urine)
What is your risk of a 2nd attack of gout after 1, 2 and 10 years?
1 year - 62%
2 years - 78%
10 years - 93%
Do average uric acid levels correlate well with symptoms of gout?
No, acute changes in the levels do
Describe the formation of uric acid
End-stage product of purine metabolism, product of xanthine oxidase catalysed conversion of xanthine and hypoxanthine
How is uric acid excreted?
Renal 70%
Gut 30%
What is the most common cause of gout?
Under-excreted by kidneys (90%), only 10% overproduction or consumption
What initiates an attack of gout?
Loss of normal apoE or apoB coating of crystals, which enables activation of immune cells (macrophages and dendritic cells)
How does an attack of gout end?
Clearance of damaged neutrophils, recoating of urate crystals, production of anti-inflammatory cytokines (IL10, TGF-b)
Is gout usually mono- or poly- arthritic?
Monoarthritic at 90%
What is podagra?
Gout of the big toe (metatarsal-phalangeal joint of great toe); initial joint in 50%, eventually involved in 90%
How does timing of onset differ between gout and pseudogout?
Gout is abrupt, max at 8-12 hours
Pseudogoout is lower, insidious, over several days
Define hyperuricaemia
Males > 0.42 mmol/L
Females > 3.6 mmol/L
What is the cut-off level for urinary uric acid?
> 800mg over 24 hours = over excretor and over producer
Describe gout and psuedogout crystals under polarising microscopy
Gout - strongly negative birefringent needle-shaped crystals
Psuedogout - weakly positive birefringent rhomboidal crystals
What does the synovial fluid look like in gout?
Opaque, creamy-yellow, reduced viscosity, increased cell count
Gram +ve, culture -ve
What are the radiological features suggestive of gout?
Soft tissue swelling, punched out, cookie-cutter borders surrounding erosions, lytic areas with overhanging edges, haziness suggestive of tophi, maintenance of joint space, absence of ostepaenia, location outside the joint capsule
How do you treat an acute attack of gout?
Symptom relief: NSAIDs, colchicine, intra-articular steroid injections
How do you treat gout in the long term?
Prevent attacks - lifestyle and allopurinol to lower stores (xanthine oxidase inhibitor), can use probenecid where allopurinol is not tolerated
What are tophi?
Collections of urate crystals in soft tissue, e.g. helix of ear, fingers, toes
In which joints does osteoarthritis occur?
Synovial joints
Risk factors for OA
Increasing age, obesity, high BMD, women, low oestrogen, trauma, malalignment
Prevalence of OA
What is a protective factor for OA?
Most common joints affected in OA?
Knee and hip, then PIP, DIP, lumbar and cervical spine
Describe the cartilage changes in OA
IL1 + chondrocytes --> MMPs --> degrade cartilage matrix (esp aggrecan) --> increase H20 conc --> swelling, susceptible to injury --> fissures, focal death, decreased thickness
Describe the bony changes in OA
Increased trabecular thickness, cysts development (osteonecrosis due to incrased pressure), osteophyte formation, eburnation (bone on bone glossing), increased joint surface area
Describe the other changes in OA (non cartilage or bone)
Synovium and outer capsule thicken, surrounding muscle may atrophy
What are the radiographic changes in OA?
Osteophytes, joint space narrowing, subchondral sclerosis and cysts
What is the 1st line treatment for OA?
Local analgesia - capsaicin, methylsalicylate, diclofenac sodium
What is giant cell arteritis?
A granulomatous vasculitis of large and medium sized arteries, primarily affects branches of external carotid artery
What is the major complication of GCA?
Optic nerve ischaemia --> blindness
Risk factors for GCA
Age > 50, female, genetics (HLA DRB1), smoking and atherosclerosis
What percentage of GCA has mutlinucleated giant cells?
What are the granulomas composed of in GCA?
T cells and macrophages
Symptoms of GCA
Persistent frontal/temporal headache, tenderness of scalp, PMR symptoms, extremity and jaw claudication, loss of vision (20%)
What will a temporal artery biopsy show in GCA?
Granulomatous inflammation and mulinucleated cells
What will a temporal artery U/S show in GCA?
Wall thickening (halo sign), stenosis or occlusion
Treatment for GCA
Prednisolone (1mg/kg/day PO for 4 wks), aspirin, osteperosis prevention (calcium, vit D, bisphos)
Methotrexate (7.5 mg PO once weekly) if relapsing/recurrent
Pathology of GCA
CD4 T cells enter artery through vasa vasorum and undergo clonal expansion
T cells release cytokines that stimulate macrophages --> inflammation
Damage and thickening/hyperplasia --> occlusion --> ischaemia
Epidemiology of scleroderma
Age 40-50
Prevalence: 10-20/100,000
Females 4x
What does CREST stand for?
Calcinosis, Raynaud's, Esophageal involvement, Sclerodactyly, Telangiectasia
Classification of scleroderma
- Diffuse(30%)
- Limited (70%) = CREST
What cytokines are upregulated in scleroderma?
TGF-b, leukotriene B4, IL-1, IL-4, IL-6
What is Raynaud's syndrome?
At least a 2-phase colour change in fingers and often toes, consisting of pallor, cyanosis or reactive hyperaemia (redness) in response to cold or emotion
What specific lab test are there for scleroderma?
ANA - 90%
Anti-topoisomerase I - diffuse
Anti-cetromere - limited (CREST)
How do you treat a scleroderma renal crisis?
ACEi + antihypertensives
How do you treat cardiac tamponade?
Pericardial window, oral prednisolone and ACEi
How do you treat Raynaud's phenomenon?
Phosphodiesterase-5 inhibitor or endothelin-1 receptor inhibitor
What is Sjogren's syndrome?
An autoimmune disorder that causes dry eyes (keratoconjunctivitis sicca) and dry mouth (xerostomia) from lymphocytic infiltration into lacrimal and salivary glands
Epidemiology of Sjogren's
Female 9x
Prevalence 0.5-1.56%
60% have secondary to RA, SLE or systemic sclerosis
Two age groups: 20-30s and mid-50s
What is the most unifying feature of Sjogren's syndrome?
Ro/La ribonucleoprotein complexes (75-90%)
ANAs (90%)
RF (50%)
Anti-thyroglobulin antibodies (25%)
What is Schirmer's tear test?
A measure of tear production, rose bengal staining and slit lamp examination to show keratitis will confirm ocular abnormality
How do you diagnose Sjogren's syndrome?
Sicca symptoms (xerostomia, rheumatoid arthritis and keratoconjunctivitis sicca), with polyclonal hypergammaglobulinaemia, +ve ANA and antibodies to Ro and La
Epidemiology of SLE
Females 12x
Age 15-45
African > Asian > Caucasian
Genetic factors of SLE
Complement deficiencies (homo C2, hetero C4)
Which antibodies are present in SLE?
ANAs, ds-DNAs, antiphospholipid Abs,
What is the characteristic rash in SLE?
Malar (butterfly) rash
What is hydroxychloroquine?
An antimalarial and DMARD, used in SLE (200-600mg PO daily)