Rheumatology
Ankylosing spondylitis
➢ An HLA-B27 associated spondyloarthropathy which primarily involves the axial skeleton (i.e. sacroiliitis and
spondylitis)
➢ It’s classified as a seronegative spondyloarthropathy, a group of diseases that are negative for rheumatoid
factor
➢ Common in patients with IBD
Features
• Young man (<30 years old) presenting with lower back
pain and stiffness
• Stiffness which is worse in the morning and improves
with exercise
• A strong association with HLA-B27
• There is often tenderness of the sacroiliac joints or a
limited range of spinal motion
Examination
• Schober's test
- A line is drawn 10 cm above and another line 5 cm
below the back dimples (dimples of Venus)
- The distance between the two lines should increase by more than 5 cm when the patient bends as far
forward as possible
Other important features
- Anterior uveitis (20-30%) → presents with an acutely painful red eye
and severe photophobia
- Aortic regurgitation
Investigations
• Plain x-ray of the sacroiliac joints → This is the most useful
investigation
- It would show evidence of sacroiliitis which is the earliest finding
- Later findings once there is significant chronic spine inflammation
include a “bamboo spine” and squaring of the vertebral bodies
• MRI → more sensitive in demonstrating sacroiliitis
• DO NOT use HLA-B27 to make the diagnosis as it is also positive in 10%
of normal patients
• Elevated ESR and CRP
• FBC → normochromic normocytic anemia
Management
- First line → NSAIDS
- Second line → Anti-TNF therapy
PEPSI
P → Pain lower back
E → Eye symptoms (anterior uveitis)
P → Progressive loss of special movements
S → Stiffness
I → IBD
PLABverse - 1
, Rheumatology
Gout
➢ A disease that affects middle-aged men and presents most commonly with acute Monoarthritis
➢ The metatarsophalangeal joint of the first toe is commonly affected (podagra), but other joints like the knee,
ankle, PIPs, or DIPs may be initially involved
➢ The first episode commonly occurs at night with severe joint pain waking the patient from sleep
➢ The joint rapidly becomes warm, red, and tender (it looks exactly like cellulitis). Without treatment the joint
pain goes away spontaneously in 2 weeks
➢ Certain events that precipitate gout sometimes precede the attack → a person has consumed excessive
amounts of alcohol or started taking diuretics such as thiazide diuretics (xipamide, metolazone, indapamide)
or furosemide → could be indirectly stated by mentioning a cardiac patient
➢ Gout can be associated with: PRV, CML, TL$, Psoriasis
Diagnosis
• Diagnosis is made by → Joint aspirate for microscopy → MSU crystals
• MSU crystals deposit → Tophi
• The serum uric acid during the acute attack may be normal or low and shouldn’t be measured until 4 weeks
after an acute attack → no value in the diagnosis of acute urate arthropathy
Treatment
• Acute management
- NSAIDs (naproxen) → 1st line unless the patient has asthma or renal insufficiency, often prescribed with
PPIs for gastric protection and in elderly
- Colchicine (SE → diarrhea and nausea), should be avoided in renal insufficiency as well
- Intra-articular steroid injection, could be given as tablets or IM, prescribed if asthma or renal insufficiency
• Chronic hypouricemic therapy
- Allopurinol should not be started until 2 weeks after an acute attack has settled as it may precipitate a
further attack if started too early, used to prevent recurrence not to treat
- NSAID or colchicine cover should be used when starting allopurinol
Drugs that precipitate gout [FACT] + Niacin
F → Furosemide
A → Alcohol
C → Cytotoxic drugs/cyclosporine
T → Thiazide
Pseudogout
➢ Usually involves larger joints (knees and ankles)
➢ There should be a history of hemochromatosis or hyperparathyroidism
Diagnosis
• Joint aspirate → calcium pyrophosphate (rhomboid crystals), +ve birefringence
Rheumatoid arthritis
Management
• Acute → NSAIDs (ibuprofen, naproxen), PPIs are used to prevent GI bleed
• Long-term → DMARDs (methotrexate, hydroxychloroquine, sulfasalazine)
PLABverse - 2
Ankylosing spondylitis
➢ An HLA-B27 associated spondyloarthropathy which primarily involves the axial skeleton (i.e. sacroiliitis and
spondylitis)
➢ It’s classified as a seronegative spondyloarthropathy, a group of diseases that are negative for rheumatoid
factor
➢ Common in patients with IBD
Features
• Young man (<30 years old) presenting with lower back
pain and stiffness
• Stiffness which is worse in the morning and improves
with exercise
• A strong association with HLA-B27
• There is often tenderness of the sacroiliac joints or a
limited range of spinal motion
Examination
• Schober's test
- A line is drawn 10 cm above and another line 5 cm
below the back dimples (dimples of Venus)
- The distance between the two lines should increase by more than 5 cm when the patient bends as far
forward as possible
Other important features
- Anterior uveitis (20-30%) → presents with an acutely painful red eye
and severe photophobia
- Aortic regurgitation
Investigations
• Plain x-ray of the sacroiliac joints → This is the most useful
investigation
- It would show evidence of sacroiliitis which is the earliest finding
- Later findings once there is significant chronic spine inflammation
include a “bamboo spine” and squaring of the vertebral bodies
• MRI → more sensitive in demonstrating sacroiliitis
• DO NOT use HLA-B27 to make the diagnosis as it is also positive in 10%
of normal patients
• Elevated ESR and CRP
• FBC → normochromic normocytic anemia
Management
- First line → NSAIDS
- Second line → Anti-TNF therapy
PEPSI
P → Pain lower back
E → Eye symptoms (anterior uveitis)
P → Progressive loss of special movements
S → Stiffness
I → IBD
PLABverse - 1
, Rheumatology
Gout
➢ A disease that affects middle-aged men and presents most commonly with acute Monoarthritis
➢ The metatarsophalangeal joint of the first toe is commonly affected (podagra), but other joints like the knee,
ankle, PIPs, or DIPs may be initially involved
➢ The first episode commonly occurs at night with severe joint pain waking the patient from sleep
➢ The joint rapidly becomes warm, red, and tender (it looks exactly like cellulitis). Without treatment the joint
pain goes away spontaneously in 2 weeks
➢ Certain events that precipitate gout sometimes precede the attack → a person has consumed excessive
amounts of alcohol or started taking diuretics such as thiazide diuretics (xipamide, metolazone, indapamide)
or furosemide → could be indirectly stated by mentioning a cardiac patient
➢ Gout can be associated with: PRV, CML, TL$, Psoriasis
Diagnosis
• Diagnosis is made by → Joint aspirate for microscopy → MSU crystals
• MSU crystals deposit → Tophi
• The serum uric acid during the acute attack may be normal or low and shouldn’t be measured until 4 weeks
after an acute attack → no value in the diagnosis of acute urate arthropathy
Treatment
• Acute management
- NSAIDs (naproxen) → 1st line unless the patient has asthma or renal insufficiency, often prescribed with
PPIs for gastric protection and in elderly
- Colchicine (SE → diarrhea and nausea), should be avoided in renal insufficiency as well
- Intra-articular steroid injection, could be given as tablets or IM, prescribed if asthma or renal insufficiency
• Chronic hypouricemic therapy
- Allopurinol should not be started until 2 weeks after an acute attack has settled as it may precipitate a
further attack if started too early, used to prevent recurrence not to treat
- NSAID or colchicine cover should be used when starting allopurinol
Drugs that precipitate gout [FACT] + Niacin
F → Furosemide
A → Alcohol
C → Cytotoxic drugs/cyclosporine
T → Thiazide
Pseudogout
➢ Usually involves larger joints (knees and ankles)
➢ There should be a history of hemochromatosis or hyperparathyroidism
Diagnosis
• Joint aspirate → calcium pyrophosphate (rhomboid crystals), +ve birefringence
Rheumatoid arthritis
Management
• Acute → NSAIDs (ibuprofen, naproxen), PPIs are used to prevent GI bleed
• Long-term → DMARDs (methotrexate, hydroxychloroquine, sulfasalazine)
PLABverse - 2
