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MSK Week 6 > 2.6.4. Systemic Arthritis Cases > Flashcards

2.6.4. Systemic Arthritis Cases Flashcards

1
Q

How many joints must be involved for a condition to be polyarthritis?

A

More than 3 joints

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2
Q

Generally describe osteoarthritis

A

a disease in which all structures of the joint have undergone pathologic change

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3
Q

What are the clinical features of osteoarthritis?

A

Pain, Morning stiffness, Pain worse with activity, Stiffness after inactivity (gelling), Joint enlargement/instability, Periarticular muscle atrophy, Crepitus DIPs, PIPs, CMC (squaring), Cervical/lumbar spine, Hips, Knees, 1st MTP Joints that are not involved: wrists, elbows, ankles, MCPs, 2nd-5th MTPs

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4
Q

Osteoarthritis is associated with what considering age and gender?

A

Associated with increased age (women > men)

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5
Q

What is the pathology of osteoarthritis?

A

Early: swelling of articular, loosening of collagen framework, increased water content, increased PG synthesis and degradative enzymes Later: decreased PG content, thinning and softening of cartilage, fissuring and cracking of cartilage, exposure of underlying bone

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6
Q

What lab findings do we expect to see with osteoarthritis?

A

Rheumatoid factor (-), CBC (normal), ANA (-), ESR (Normal)

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7
Q

What should we see on radiographs of osteoarthritis?

A

A- no ankylosis; B- bony subchondral sclerosis and cysts; C- cartilage space narrowing; D- deformities common; E- erosion absent; S- soft tissue swelling

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8
Q

What treatments do we have for osteoarthritis?

A

Medications Acetaminophen, NSAIDS, Opioid analgesics Injections Corticosteroids and Viscosupplementation

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9
Q

What is Calcium Pyrophosphate Deposition? (CPPD)

A

CPPD is a syndrome caused by deposition of calcium pyrophosphate dihydrate in cartilage (called chondrocalcinosis on radiographs and pseudogout when it is present acutely like gout)

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10
Q

What are the risk factors for CPPD?

A

Previous joint surgery, epiphyseal dysplasias, hereditary Disease associated Hyperparathyroidism, Hemochromatosis, Hypophosphatasia, Hypomagnesemia, and Post-meniscectomy

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11
Q

What are some risk factors for osteoarthritis?

A

Risk factors: Age, Mechanical trauma, weight-bearing, occupational use, previous inflammatory arthritis, avascular necrosis, metabolic disorders, genetic predisposition, race/ethnicity

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12
Q

CPPD is most commonly associated with what?

A

Most commonly associated with aging and most patients are asymptomatic

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13
Q

What are the clinical features of CPPD?

A

Clinical features Asymptomatic Lanthanic Acute Pseudogout Subacute or Chronic Pseudo- rheumatoid arthritis Pseudo-osteoarthritis Pseudo-neuropathic Pseudo-spondylitic

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14
Q

What joints are involved in CPPD?

A

Joint Involvement (larger > smaller joints) Knee, wrist, MCPs, Hip, Shoulder, Spine, Elbow Gout involves smaller joints like MTP, metatarsophalangeal, etc.

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15
Q

What lab findings shoudl we see in CPPD?

A

Radiographs demonstrating punctate or linear calcifications Finding rhomboid, square, or rod-like crystals is the only way to make a definitive diagnosis Weakly positively birefringent Synovial fluid is typically inflammatory (2,000-50,000 WBCs)

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16
Q

Compare Gout vs. Pseudogout (CPPD)

A
  1. Crystal
    1. Gout: Urate
    2. Pseudogout: CPPD
  2. Shape
    1. Gout: Needle
    2. Pseudogout: Rhomboid/rectangular
  3. Birefringence
    1. Gout: Negative
    2. Pseudogout: Positive
  4. Color of crystals
    1. Gout: Yellow
    2. Pseudogout: Blue
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17
Q

What should we see on radiographs of CPPD?

A

A-ankylosis uncommon; B-bone mineralization decreased; C-calcifications; D-deformities common; E-erosions common; S-soft tissue swelling usually present

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18
Q

What is the treatment for CPPD?

A
  1. Treatment
    1. Joint aspiration
    2. NSAIDs, corticosteroids (oral or injection), ACTH, Colchicine
19
Q

How does arthritis present in time with psoriatic arthritis when compared with the skin symptoms?

A

Skin precedes joint disease (60-70%), they appear within one year of each other (15-20%)

20
Q

In Psoriatic Arthritis (PA), what joint involvment do we see?

A

DIP only (15%), Asymmetric oligoarthritis (30%), symmetric polyarthritis (40%), axial involvement (5%), arthritis mutilans (5%)

Nail changes (90%), dactylitis (>30%), enthesitis (increased, underappreciated on examination), conjunctivitis (20%), iritis (7%)

21
Q

Compare Rheumatoid Arthritis (RA) to PA.

A
22
Q

What lab work should we see with PA?

A

Rheumatoid factor (-), CBC (normal), Chemistry (uric acid may be elevated), ANA (-), CRP and ESR (may be elevated), synovial fluid (WBC count <1000-2000/mm3)

23
Q

What should we see on radiology of PA?

A

A-ankylosis may be seen; B-bone mineralization decreased, C-cartilage space narrowing; D-deformities common; E-erosion common; S-soft tissue swelling usually present

24
Q

What is the treatment for PA?

A
  1. Coordinate therapy for skin and joint disease
  2. Immunosuppressive agents
    1. Methotrexate, Sulfasalazine, Cyclosporine, Antimalarials
  3. Anti- TNF alpha therapy
    1. Etanercept, Infliximab, Adalimumab
25
Q

What are the six key features to look for of appendicular arthritis?

A

Articular vs. non-articular

Acute (<6 weeks) vs. chronic (>6 weeks)

Inflammatory vs. non-inflammatory

Distribution

Pattern

Symmetry

26
Q

What do we mean by articular or non-articular with appendicular arthritis?

A

Articular = painful with limited active/passive ROM

Peri- or non-articular = painful w/ active ROM only

27
Q

What can cause non-articular pain?

A

Non-articular pain can be caused by trauma/fracture, fibromyalgia (nerve system responding to normal stimuli as if it were painful), bursitis, tendinitis, and polymyalgia rheumatica (whole body bursitis)

28
Q

What questions should we ask to characterize a chronic symptom?

A

Is there prolonged morning stiffness; is there soft tissue swelling; are there systemic symptoms; is the ESR or CRP elevated

29
Q

What are systemic symptoms we look for?

A

Systemic symptoms = fevers, weight loss, rashes, nodules, mucosal sores, weakness

30
Q

What are some conditions that involve inflammatory connective tissue?

A

Rheumatoid, psoriatic, and reactive arthritis

SLE (picture of girl below), Scleroderma, Polymyositis

31
Q

What might be some actue conditions?

A

Septic arthritis, Gout (picture of ear below), Pseudogout, Reactive arthritis, Initial presentation of chronic arthritis

32
Q

What are some common differences between inflammatory and non-inflammatory complaints?

A

Inflammatory: stiffness > 1hr, R/C/D/T, pain at rest, improves with exercise, constitutional complaints

Non-inflammatory: stiffness < 30 min, no signs of inflammation, better with rest, worse with exercise, no constitutional complaints

33
Q

What are the different kinds of distribution we may see?

A

Monoarthritis (ANA and RF are not helpful)

Polyarthritis

Oligoarthritis (seen below)

34
Q

What are the three patterns we may see?

A

Additive (most common, least specific)

Migratory

Intermittent

35
Q

What are some examples of additive conditions?

A

Examples: RA, Connective Tissue disease (SLE, systemic sclerosis, idiopathic inflammatory myopathies), Spondyloarthritis (psoriatic and reactive)

36
Q

What are some examples of migratory conditions?

A

Gonococcal (neisseria infections), Rheumatic Fever, Lyme, Childhood Leukemia

37
Q

What are some examples of intermittent disorders?

A

Crystalline

Gout and Pseudogout

Palindromic rheumatism, periodic fever syndromes

Whipple’s disease

Systemic inflammatory arthritis early in the course of the disease

38
Q

What does symmetry suggest to us in arthritis cases?

A

Symmetry suggests RHEUMATOID ARTHRITIS (or other systemic inflammatory connective tissue disease)

Especially in the Wrist, MCP, and PIP

39
Q

What kind of demographics help us in arthritis cases, and what do we expect to see in each group?

A
  1. Children
    1. JIA, Infection
  2. Young adults
    1. Septic, Gonococcal, Spondyloarthritis, RA, Internal derangement
  3. Older adults
    1. Crystal, OA, AVN, Systemic disease, Internal derangement
  4. Gender
    1. Men
      1. Gout, Spondyloarthritis
    2. Women
      1. RA, SLE
  5. Lifestyle
    1. Bacteria, Gout (alcohol), Endocarditis (IV drugs), Disseminated gonorrhea, Lyme, Avascular necrosis (alcohol)
40
Q

What do we expect if the first joint involved is:

First CMC, or

IP joint of hand

Wrist

First MTP

Knee

Ankle

A
  1. First CMC
    1. OA
  2. IP joint of hand
    1. OA, PSA, RA
  3. Wrist
    1. CPPD, Gonococcal, Early RA (both wrists)
  4. First MTP
    1. Gout, OA
  5. Knee
    1. Bacteria, JIA, OA, Crystal, Internal derangement
  6. Ankle
    1. Sarcoid, Reiter’s
41
Q

What is the single most important test in the evaluation of a monoarthritis?

A

Aspiration of the joint

42
Q

Why do we aspirate the joint?

A

Rule out infection (gram stain/culture)

43
Q

What kind of cell counts should we see in joint aspirate, and what does each number range mean?

A

<200 = normal

200-2,000 = Non-inflammatory

2,000-50,000 = Inflammatory

If you look at the test tube, even before you send it to the labs, and can’t see through it then it is probably >2,000 and you should prepare for lots of additional testing

>80,000 = purulent

MSK Week 6 (19 decks)

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