Internal Medicine: Clinical Immunology - Rheumatology

Data

Official data in SubjectManager for the following academic year: 2023-2024

Topic

The goal of the course is to learn the basic knowledge of clinical immunology and rheumatology, to practice the examination of patients with musculoskeletal and joint complaints, to learn the basics of clinical immunological problems.

Lectures

• 1. Introduction. General characteristics of systemic autoimmune diseases. Non differentiated collagenosis. Overlap syndromes, mixed connective tissue disease. - Dr. Kumánovics Gábor
• 2. Differential diagnostics of arthritis. Early arthritis. Rheumatoid arthritis - diagnostics. - Dr. Kurucz Grácia Katalin
• 3. Rheumatoid arthritis. Therapy, methods of monitoring the patients. - Dr. Czirják László István
• 4. Systemic sclerosis. - Dr. Czirják László István
• 5. Systemic lupus erythematosus. - Dr. Czirják László István
• 6. Sjögren's syndrome. Inflammatory myopathies. - Dr. Gulyás Katinka
• 7. Systemic vasculitis. Secondary immunodeficiencies. - Dr. Minier Tünde
• 8. Spondylarthropathies. Juvenile idiopathic arthritis. - Dr. Horváth Gábor I
• 9. Differential diagnostics of low back pain. Treatment. Algodystrophy. Pain relief in rheumatology. - Undiné Dr. Tamaskó Mónika
• 10. Cervical pain, brachialgia - diagnostics and therapy. Tunnel syndromes. Soft tissue rheumatism. - Dr. Tuba Éva
• 11. Osteoporosis, osteoarthritis. Osteonecrosis. - Dr. Sarlós Gézáné (Dr. Varjú Cecilia)
• 12. Diagnostic tools, therapeutical options and follow up of patients in rheumatology. - Dr. Sarlós Gézáné (Dr. Varjú Cecilia)
• 13. Diagnosis and treatment of gout and crystal induced arthropathies. Rheumatical consequences of metabolic and internal diseases. - Dr. Szendelbacherné Dr. T. Kovács Katalin
• 14. Fibromyalgia. Physiotherapy of rheumatic disorders. Rehabilitation in rheumatology. - Dr. Birkás Gyöngyvér

Practices

• 1. Learn and practice the examination of patients with musculoskeletal complaints. GALS assessment. General characteristics of systemic autoimmune illnesses.
• 2. Learn and practice the examination of patients with musculoskeletal complaints. GALS assessment. General characteristics of systemic autoimmune illnesses.
• 3. Physical examination of patients with musculosceletal complaints. Differentiation between pain in degenerative disorders and inflammatory conditions. Demonstration of characteristic features of osteoarthritis, inflammatory arthritis. Recognition of early and late manifestations.
• 4. Physical examination of patients with musculosceletal complaints. Differentiation between pain in degenerative disorders and inflammatory conditions. Demonstration of characteristic features of osteoarthritis, inflammatory arthritis. Recognition of early and late manifestations.
• 5. Rheumatological imaging procedures (X-ray, CT, MR. Joint ultrasonography. Articular aspirations.
• 6. Rheumatological imaging procedures (X-ray, CT, MR. Joint ultrasonography. Articular aspirations.
• 7. Nail fold capillaroscopy. Differential diagnosis of Raynaud’s syndrome. Differential diagnosis of hand and elbow pain.
• 8. Nail fold capillaroscopy. Differential diagnosis of Raynaud’s syndrome. Differential diagnosis of hand and elbow pain.
• 9. Examination of patients with inflammatory rheumatological conditions (SPA, gout). Differential diagnosis of back pain and limb muscle weakness.
• 10. Examination of patients with inflammatory rheumatological conditions (SPA, gout). Differential diagnosis of back pain and limb muscle weakness.
• 11. Rheumatological examination (osteoporosis, osteoarthritis). Differential diagnosis of neck and shoulder pain.
• 12. Rheumatological examination (osteoporosis, osteoarthritis). Differential diagnosis of neck and shoulder pain.
• 13. Rheumatological examination (most important steps during examination, differential diagnosis of arthritis). Rehabilitation. Physiotherapy. Exercise. Orthesis.
• 14. Rheumatological examination (most important steps during examination, differential diagnosis of arthritis). Rehabilitation. Physiotherapy. Exercise. Orthesis.

Seminars

Reading material

Obligatory literature

Literature developed by the Department

Presentations: on NEPTUN Unified Education System

Notes

Recommended literature

Lynn S. Bickley: Bates´ Guide to Physical Examination and History Taking. (The actual version.)
Harrison´s Principles of Internal Medicine Companion Handbook. Short pocket book. (The actual version.)
Philip Seo (with Alan J. Hakim, Gavin P. R. Cluine, Inam Haq): Oxford American Handbook of Rheumatology, Oxford University Press. (The actual version.)

Conditions for acceptance of the semester

Examination of the musculoskeletal system. Passing 5 short written exams during the practices in the semester. Each exam will cover one essential topic which have been previously discussed during the lectures. To be eligible for taking the final exam at the end of the semester, you have to pass at least 3 of the 5 short practical exams.

Mid-term exams

There is no possibility. You must be present at all 7 practices during the semester.

Making up for missed classes

During the practice of another group.

Exam topics/questions

Final exam: the exam will start with a written test of 30 points (23 "single choice" tests for 23 points and 2 essays for 6 points) covering the most important issues. 30 minutes will be provided, 23 correct items will be needed to pass on to the next part, which will be an oral practical exam. This part will comprise of assessing practical skills, including patient's history, physical examination, diagnostic and therapeutical considerations of the patient.

Main topics:
Differential diagnosis, therapy.
1. When do you suspect a systemic autoimmune disease?
2. Necessary procedures if you suspect a systemic autoimmune disease. Basic laboratory tests, autoantibody screening tests, specific autoantibody tests.
3. Primary, secondary Raynaud´s syndrome. Differential diagnosis,therapy. Evaluation of efficacy. Basic investigations in Raynaud´s syndrome. Diagnostic value of nail fold capillary- microscopy.
4. Differentiating between degenerative and inflammatory rheumatoid conditions.
5. Evaluation of activity and damage in rheumatologic diseases.
6. Differential diagnosis of polyarthritides.
7. Characteristics, diagnosis and differential diagnosis of oligoarthritis and monoarthritis.
8. Differential diagnosis of cervical and shoulder pain.
9. Differential diagnosis of elbow and hand pain.
10. Differential diagnosis of low back pain. Differentiation between inflammatory and non-inflammatory back pain.
11. Rehabilitation of patients with rheumatological and musculoskeletal diseases. Physiotherapy of rheumatic disorders. Physical exercise. Orthesis.
12. Pain relief in rheumatology.
13. Effects and side effects of non steroidal antiinflammatory drugs.
14. Glucocorticoid treatment. Effects, side effects, prevention of side effects.
15. Biological therapies. TNF antagonist biological therapy. Other biological treatments in inflammatory rheumatological diseases. (rituximab,tocilizumab, abatacept, secukinumab, ixekizumab). Biosimilars. Janus-kinase inhibotors
16. Infectious side effects of patients with rheumatological disease during systemic treatment (sulphasalazine, methotrexate, leflunomide,azathioprine, corticosteroids, biologicals, Janus-kinase inhibitors).

Main inflammatory rheumatic diseases.
1. Diagnostics of rheumatoid arthritis. New classification criteria in rheumatoid arthritis. Clinical features of the disease. Laboratory and radiological signs.
2. Basic monitoring and therapeutical principals in RA. Assessment of activity and damage.Basic investigations during monitoring of patients.
Activity indexes: DAS28, SDAI, CDAI. What is HAQ index used for? Therapeutical principals in rheumatoid arthritis. Early treatment. Disease modifying therapy. Treat to target (T2T). Strict monitoring of patients.
3. Treatment of RA. Disease modifying drugs in rheumatoid arthritis. Dosage, side effects, monitoring of patients during treatment with sulphasalazine,methotrexate, leflunomide, chloroqube/hydroxychloroquine.
Dosage, side effects, monitoring of patients during treatment with biological therapy, kinase inhibitors. What are the indications for switching disease modifying therapy in rheumatoid arthritis? Assessment of efficacy in the treatment of RA.
4. Diagnosis of SLE. General characteristics, diagnostic steps. Internal manifestations in lupus. Laboratory tests in lupus. Lupus nephritis. Central nervous system manifestations in lupus.
5. Management and treatment of SLE. Monitoring lupus patients. Therapeutical principals in lupus. Assessment of disease activity and monitoring damage.
6. Primary, secondary antiphospholipid syndrome. Laboratory diagnostics,symptoms, treatment.
7. Sjögren’s syndrome - general characteristics. Principals of diagnosis and treatment.
8. Systemic sclerosis. Clinical features, diagnosis. Therapy,assessment of efficacy during treatment.
9. Myositis. Main clinical features of polymyositis and dermatomyositis. Classification. Pharmacological and nonpharmacological treatment of myositis. Assessment of efficacy during treatment.
10. Systemic vasculitis. Classification. Primary, secondary vasculitides. Polymyalgia rheumatica, arteritis temporalis. Clinical features and therapy of ANCA associated vasculitides.
11. General characteristics of spondylarthropathies. Peripheral and axial manifestations. Enthesitis. Extraarticular manifestations.
12. Ankylosing spondylitis. Inflammatory back pain. Axial and peripheral involvement in spondylarthropathies. Clinical features and therapy of ankylosing spondylitis. Pharmacological and nonpharmacological treatment of ankylosing spondylitis. Assessment of efficacy during treatment.
13. Psoriatic arthritis. Spondylarthropathies in inflammatory bowel disease.
14. Autoinflammatory syndromes. Sarcoidosis. Macrophage activation syndrome.

Non inflammatory rheumatic diseases.
1. Osteoporosis, clinical features and diagnosis. Primary osteoporosis. Differential diagnosis of secondary osteoporosis.
2. Prevention and treatment of osteoporosis. Pharmacological therapies. Risk factors. Frax index. Prevention. Calcium, vitamin D substitution, raloxifen, denosumabm teriparatide. Role of physiotherapy in the management of osteoporosis.
3. Crystal induced arthropathies. Diagnosis and management of gout.
4. Rheumatological manifestations of metabolic disorders. Acromegaly. Musculo-skeletal abnormalities in diabetes mellitus (DISH syndrome). Musculo-skeletal signs in thyroid disease.
5. Diagnosis, pharmacological and nonpharmacological treatment of fibromyalgia syndrome.
6. Diagnosis and management of osteoarthritis. Clinical features and therapy of knee osteoarthritis. Clinical features and therapy of hip osteoarthritis. Degenerative disorders of the cervical and thoracic spine.
7. Osteonecrosis.
8. Soft tissue disorders.
9. Compression tunnel syndromes.
10. Algodystrophy.
11. Primary immunodeficiency snydrome: characteristics of CVID. Secondary immunodeficiency disorders. Issue of infectious foci.
12. Bacterial infectious arthritis.
13. Management of anaphylactic shock. List of most common causes.

Mandatory requirements:
1. When do you suspect a systemic autoimmune disease?
2. Autoantibody screening tests, most important specific autoantibody tests.
3. In case of unknown inflammation, what conditions can be considered?
4. Differentiation between pain in degenerative disorders (osteoarthritis) and inflammatory conditions (arthritis.
5. Main causes of monoarthritis.
6. Main causes of polyarthritis.
7. Main causes of Raynaud´s syndrome.
8. Main causes of proximal muscle weakness.
9. Main causes of dryness of the eyes.
10. What diagnostic steps should be made in upper limb complaints?
11. Most common rheumatological reasons of back pain.
12. Most common non - rheumatological reasons of back pain.
13. Lumboischialgia (sciatica), clinical features.
14. Clinical signs of L4 root damage.
15. Clinical signs of L5 root damage.
16. Clinical signs of S1 root damage.
17. Side effects of NSAIDs.
18. Contraindications of NSAID therapy. Necessary precautions.
19. Side effects of glycocorticoids.
20. What kind of supportive treatment is necessary in case of systemic corticosteroid therapy?
21. What is necessary during emergencies in patients on long term corticosteroid therapy? (infections, injuries)
22. Side effects of cytostatic therapies.
23. Meaning of DMARD.
24. Contraindications and side effects of biological therapy.
Main rheumatological illnesses.
25. Most common early clinical signs in SLE.
26. Most common laboratory changes in SLE. What is to be done in SLE?
27. Most common clinical signs in antiphospholipid syndrome.
28. Possible reasons of thrombosis in a young patient.
39. Most common early clinical signs in rheumatoid arthritis.
30. Possible manifestations of RA in late stage
31. Most common laboratory and radiological changes in RA.
32. Most common early clinical signs in ankylosing spondylitis.
33. Most common early clinical signs in psoriatic arthritis.
34. Clinical signs and management in acut arthritis urica.
35. Clinical signs and management in chronic gout.
36. Infectious arthritis, complaints, clinical features, investigations.
37. clinical charecteristics of systemic sclerosis and its manifestations in internal organs
38. clinical characteristics of Sjögren's syndrome and its extraglandulare manifestations
39. clinical characteristics of myositiden and its extramuscular manifestations
40. Interstitial lung disease in systemic autoimmune disorders
41 . Gastrointestinal manifestations in connective tissue diseases
42. Cardiovascular lesions and complications in systemic autoimmune diseases

Non inflammatory rheumatological conditions.
1. Clinical signs of knee osteoarthritis
2. Clinical signs of hip osteoarthritis
3. Investigations in osteoporosis
4. Calculation of FRAX index
5. Main reasons of secondary osteoporosis
6. Medications that cause osteoporosis. Prevention.
7. Compression fracture of the spine.
8. Most common signs of gout.
9. What should be excluded in case of carpal tunnel syndrome?
10. Management of anaphylactic shock.

Practical skills during patient examination.
1. GALS examination.
2. Characteristic cutaneous signs in rheumatology. (Infectious arthritis, gout, livedo, scleroderma, erythema, vasculitis, psoriasis).
3. Physical examination of the hand. (synovitis, arterial pulse, skin signs, characteristic deformities, carpal tunnel syndrome, Heberden-Bouhard nodes etc.).
4. Differentiation between inflammatory and degenerative back pain.

Pharmacological knowledge necessary in practical and theoretical exam.

Immunosupressive agents.
1. Glycocorticoids
1.1. systemic
- prednisolon
- prednison
- metilprednisolon
2. Specific lymphocyte signaling pathway inhibitors
2.1. Calcineurin-inhibitors
- cyclosporin
- tacrolimus
3. Cytotoxic agents
- azathioprine
- cyclophosphamid
- methotrexate
- mycophenolate-mofetil
4. Antibodies
4.1. Monoclonal antibodies
TNF-alfa or receptor antagonits
- infliximab
- certolizumab
- adalimumab
- golimumab
- etanercept
IL-1 or receptor antagonists
- anakinra
- canakinumab
IL-6 or receptor antagonists
- tocilizumab, sartilumab
IL-12/IL-23
- ustekinumab
IL-17
- secukinumab
-ixekizumab
B-cell inhibitors
-CD20 - rituximab
-BAFF - belimumab
CD80/86 (B7) (costimulation)
- abatacept
- belatacept
5. Other immunosupressive agents
- leflunomide
- Janus-kinase inhibitors (tofacitinib, baricitinib, upadacitinib, filgotinib)
6. Antifibrotic drugs
Nintedanib
Pirfenidon

Rheumatoid arthritis therapy
1. symptomatical
1.1. NSAID
1.2. glucocorticoids
1.3 physiotherapy
2. DMARD - disease modifying antirheumatic drugs
- methotrexate (+leucovorin)
- cyclophosphamide
- leflunomide
- chloroquin and hydroxychloroquin
- sulfasalazine
- monoclonal antibodies (TNF-alfa, IL-1R, IL-6R, CD20), co-stimulation inhibitirs and Janus-kinase inhibitors (tofacitinib, baricitinib, upadacitinib, filgotinib)

Non steroidal antiinflammatory drugs (NSAID)
1.1. salicilate derivates
- acidum acetilsalicilicum
1.2. Para-aminophenol derivates
- paracetamol (acetaminophen)
1.3. Pirazolon derivates
- phenylbutazon
- oxyphenbutazon
- metamizol-Na (noraminophenazon-Na-mesylat)
1.4. acidum acetylicum derivates
- indometacin
- acemetacin
- diclofenac
- aceclofenac
1.5. Propionic acid derivates
- naproxen
- ibuprofen
- dexibuprofen
- ketoprofen
- dexketoprofen
- flurbiprofen
1.6. Enolic acid derivates
- piroxicam
- meloxicam
- tenoxicam
- lornoxicam
1.7. anthranilic acid derivates
- nifluminsav
- mefenaminsav
- etofenaminsav
1.8. COX-2 specific drugs = coxibs
- parecoxib
- etoricoxib
- valdecoxib

Medications affecting bone metabolism, calcium homeostasis
1. medications affecting the OPG-RANKL-RANK axis
- denosumab (recombinant OPG)
2. Parathormone-analogue
- teriparatid
3. D-vitamins (+Ca)
- colecalciferol
- ergocalciferol
- alfacalcidiol
- calcitriol
4. Calcitonin
- synthetic (salmon) calcitonin (salcatonin)
- synthetic (human) calcitonin (recombinant)
5. Bisphosphonates
- etidronate
- clodronate
- tiludronate
- alendronate
- risedronate
- ibandronate
- pamidronate
- zoledronate
6. others:
- stroncium-ralenate
- tibolon
- raloxifen

 
Gout treatment
1. acute gout treatment
1.1. Colchicin
1.2. NSAIDs
1.3. glucocorticoids
2. Hyperuricaemia treatment
2.1. Uricostatic agents
- allopurinol
- febuxostate
2.2. Uricolytic agents
- rasburicase
- pegloticase
2.3. Uricosuric agents
- probenecid
- sulfinpyrazon
- benzbromaron

Examiners

• Dr. Bakai Rita
• Dr. Birkás Gyöngyvér
• Dr. Czirják László István
• Dr. Deme Marcell István
• Dr. Filipánits Kristóf József
• Dr. Gulyás Katinka
• Dr. Horváth Gábor I
• Dr. Jász Dávid Kurszán
• Dr. Kéringer Patrik
• Dr. Kumánovics Gábor
• Dr. Kurucz Grácia Katalin
• Dr. Minier Tünde
• Dr. Nagy Gabriella
• Dr. Péter Ágnes Eszter
• Dr. Sarlós Gézáné (Dr. Varjú Cecilia)
• Dr. Szendelbacherné Dr. T. Kovács Katalin
• Dr. Tuba Éva
• Dr. Vélin Valentina
• Kremzner Noémi Rita
• Undiné Dr. Tamaskó Mónika

Instructor / tutor of practices and seminars

• Dr. Bakai Rita
• Dr. Bertalan Dalma
• Dr. Birkás Gyöngyvér
• Dr. Czirják László István
• Dr. Deme Marcell István
• Dr. Filipánits Kristóf József
• Dr. Gulyás Katinka
• Dr. Horváth Gábor I
• Dr. Jász Dávid Kurszán
• Dr. Kéringer Patrik
• Dr. Kumánovics Gábor
• Dr. Kurucz Grácia Katalin
• Dr. Minier Tünde
• Dr. Nagy Gabriella
• Dr. Péter Ágnes Eszter
• Dr. Sarlós Gézáné (Dr. Varjú Cecilia)
• Dr. Szendelbacherné Dr. T. Kovács Katalin
• Dr. Tuba Éva
• Dr. Vélin Valentina
• Komjáti Dalma
• Kremzner Noémi Rita
• Palancsa Máté
• Undiné Dr. Tamaskó Mónika