7. Inflammatory Arthritis Flashcards
1
Q
What is synovial chondromatosis aka osteochondromatosis, synoviochondrometaplasia?
A
Metaplastic changes in synovium produce cartilaginous bodies.
1 - These cartilaginous bodies may (or may not) calcify or ossify.
2 - they may (or may not) be free within joint capsule
2
Q
What is seen on radiograph with synovial chondromatosis?
A
Multiple round / oval and well-defined osseous or cartilaginous densities within joint capsule
It will not be visualized on plain film if it isn’t calcified or ossified
3
Q
Who gets synovial chondromatosis?
A
20-50 yo
M>F 3:1
4
Q
Where is the MC location for synovial chondromatosis?
A
Knee 70%
Elbow, hip 20%
It can form at any site with synovium
5
Q
What are symptoms of synovial chondromatosis?
A
Mild
Chronic, slow, progressive
6
Q
If there is just one osteochondritis body plus a defect in the host bone, what is DDX instead of synovial chondromatosis?
A
Osteochondritis dissecans
7
Q
What is the prognosis for synovial chondromatosis?
A
Risk of 2˚ DJD
Malignant transformation reported, but extremely rare
8
Q
Tax for synovial chondromatosis?
A
Surgical removal
Though recurrence is not uncommon
9
Q
What are the 3 inflammatory arthropathies?
A
RA
Juvenile Idiopathic Arthritis
Seronegative spondyloarthropathies
10
Q
What is the MC inflammatory arthritis?
A
Rheumatoid Arthritis (RA)
11
Q
What is RA?
A
Multisystem AI that targets synovial tissues and joints. Progressive, bilateral symmetry.
12
Q
Locations of RA?
A
Wrist and hands
Feet
Shoulder, hip, knee
Cervical spine
13
Q
What is the pathologic process of RA?
A
Antigen-antibody complex deposited in synovium with resulting inflammatory cascade
A synovial proliferation = pan USA
14
Q
What does pannus do and what is it associated with?
A
Erodes bone and articular cartilage
RA
15
Q
How do you diagnose RA?
A
Lab tests
Radiographic changes
16
Q
What do you expect to see for RA lab test?
A
RF (+)ve in 70% (2-3% are (+)ve w/o RA)
Anti-CCP in addition to RF increases sen + spec
In acute cases:
- increased ESR
- increased CRP
Anemia (normocytic normochromic)
Synovial fluid eval + biopsy
17
Q
Know the ACR - EULAR classification criteria?
A
[see notepacket slide 17)
18
Q
Age of onset of RA?
A
20-60 yo
19
Q
Sex of RA?
A
F:M 3:1 until age 60
1:1 after 60 yo
20
Q
What joints are MC for RA to start?
A
MCP
PIP
Wrist
Larger joints and spine later
21
Q
What systemic sx show up in RA?
A
Fatigue
Malaise
Generalized weakness
Fever
22
Q
PE for RA?
A
Morning stiffness >1 hour
Pain with motion or tenderness
Soft tissue swelling or joint effusion but NO REDNESS
Bilateral symmetrical joint swelling (except DIP)
Sometimes nodules
23
Q
Where are boutonnière deformities located?
A
DIP extension
PIP flexion
24
Q
Where are swan neck deformities located?
A
DIP flexion
PIP extension
25
Where are hitchhiker thumb deformities located?
MCP flexion
| IP extension
26
In RA, what is the earliest change and where is it located?
| What are other changes in the same area?
Tendinopathy around the wrist
Ulnar and radial styloid erosion
27
What sign is visible in RA wrist?
“Spotty carpal” sign
28
Cervical spine involvement happens in ___% of RA patients
50-80%
29
Foot is the initial site of involvement in ___% of RA patients
15%
30
Canal stenosis possible due to “______” kyphotic changes in RA spine
Stepladder
31
What is visualized in RA chest?
```
Pericarditis
Pulmonary nodules
Diffuse interstitial fibrosis
Pleural effusions
Rib erosions
```
32
TX for RA?
```
Refer to rheumatologist
DMARDS to slow/stop inflamm
Protect from deformity and disability
Lifestyle mods
Psychological support
```
33
DMARDs stands for?
Disease Modifying Antirheumatic Drugs
34
Prognosis of RA?
Variable: periods of exacerbation/remission and gradual progression
35
What findings suggests poorer prognosis for RA patient?
```
Earlier onset
Nodules
High levels RF
Sustained activity
Extraarticular manifestations
```
36
What is JIA?
Juvenile Idiopathic Arthritis
- One of several forms of juvenile chronic polyarthritis
- Similar to adult onset RA
- Onset before 16 yo
37
What is the worst kind of JIA? And what are the %
1. Systemic arthritis
2. Oligoarthritis
3. Polyarthritis, RF neg
4. Polyarthritis, RF pos
Systemic arthritis is the worst kind, destructive
1. Systemic arthritis - 5%
2. Oligoarthritis - 30%
3. Polyarthritis, RF neg - 20%
4. Polyarthritis, RF pos - 5%
38
Systemic Arthritis is a type of JIA also called __?
Still Disease
39
MC age group for Systemic presentation JIA AKA Still Disease?
<5 yo
40
What JIA is typically found in teenage girls?
A. Systemic arthritis AKA Still Disease
B. Oligoarthritis
C. Polyarthritis, RF neg
D. Polyarthritis, RF pos
D. Polyarthritis, RF pos
41
Which JIA has fever, rash, hepatosplenomegaly?
A. Systemic arthritis AKA Still Disease
B. Oligoarthritis
C. Polyarthritis, RF neg
D. Polyarthritis, RF pos
A. Systemic arthritis AKA Still Disease
42
Which JIA is the most common and does not carry into adulthood?
A. Systemic arthritis AKA Still Disease
B. Oligoarthritis
C. Polyarthritis, RF neg
D. Polyarthritis, RF pos
B. Oligoarthritis
43
What are the 4 seronegative spondyloarthropathies?
And which one is MC?
Ankylosis spondylitis - MC
Reactive arthritis (Reiter)
Psoriatic arthritis
Enteropathic arthropathy
44
Who gets AS?
Young males
It’s a chronic inflamm process of unknown etiology. Axial skeleton predominance.
Bony ankylosis, ligament ossification, enthesopathy.
Ankylosis Spondylitis AKA Marie-Strumpell or Becchterew disease
45
What are the clinical features of AS?
- age
- gender
- symptoms
- systems involved
- lab results
```
Onset 15-35 yo
M:F
Low back aching, stiffness esp early AM
Pain, tenderness at enthesopathies
Involves eyes, heart, great vessels, lungs, GI, GU
Increased ESR, positive HLA-B27
```
46
Is AS bilateral/unilateral?
| Symmetric/asymmetric?
Bilateral
| Symmetric
47
Classic finding in AS?
SI joints
| Bilateral, symmetric involvement
48
Romanus lesion
Shiny corner sign
Syndesmophyte formation
Late stage NP calcification; “balloooning” of disc space.
What is it?
AS
49
Dagger sign
Railroad track
Trolley track
What is it?
AS
50
TX for AS?
Pain control
Maint mobility/prevent deformity
Anti-inflamm
51
“Carrot sick” or “chalk-stick” fractures is a possible complication of ?
AS
52
1-2% of ____ patients may get interstitial lung disease
AS
53
What are enteropathic arthritis diseases?
UC and Crohn disease
Also: Whipple disease, Salmonella, Shigella, Yersinia
54
15% of psoriasis patients may get ___?
Psoriatic arthritis
55
Onset of Psoriatic arthritis
20-50 yo
DDX from reactive arthritis is difficult
56
Sausage digit
Psoriatic arthritis
57
Lab changes in psoriatic arthritis?
Increased ESR (acute)
Negative RF
Occasional hyperdrive is
75% HLA-B27
58
MC locations of psoriatic arthritis?
DIPs
SI joints
Spine
59
Hallmark combo of psoriatic arthritis?
Erosion + periostitis
60
Involvement of all 3 joints in single digit is called what?
What condition?
‘ray pattern’
| Psoriatic
61
Pencil-in- cup deformity
Psoriatic
62
‘Opera glass’ hand
Psoriatic
63
Is psoriatic symmetric /asymmetric?
Non-marginal or marginal syndesmophytes?
Asymmetric, non-marginal syndesmophytes
| Opposite of AS, which has symmetric, marginal syndesmophytes
64
Treatment for psoriatic?
Early PT/ rehab
| NSAIDs, DMARDS to reduce inflamm
65
What is reactive arthritis?
- AKA
- body system involvement
- onset age
- gender
- triad
AI reaction to distal infection
AKA reiter syndrome
associated with GI or GU infection
- onset 15-35 yo
- M>F
- urethritis, conjunctivitis, polyarthritis
66
“Lover’s heel”
Reactive arthritis
- painful plantar or achilles enthesopathy
67
Lab results for Reactive arthritis ?
Increased ESR
Anemia
Leukocytosis
75% HLA-B27, negative RF
68
Which sacroilitis are symmetrical?
Asymmetrical?
Symmetrical
- AS
- enteropathic spondyloarthropathy
Asymmetrical
- psoriatic
- reactive
69
What is an AI CT disorder with multiple system involvement? Chronic disease with periods of exacerbation and remission?
systemic lupus erythematosus (SLE)
70
Clinical features of systemic lupus erythematosus (SLE)?
- onset
- gender
- lab results
- symptoms
onset 10-40 yo
Female
(+) ANA
Fever, joint pain, rash
71
Is systemic lupus erythematosus (SLE) bilateral/unilateral?
| Symmetric/asymmetric?
Bilateral
| Symmetric
72
What is a generalized, systemic, inflammatory CT disease associated with CREST syndrome?
Scleroderma AKA systemic sclerosis
73
Clinical picture of scleroderma?
- onset
- gender
- symptoms
- radiographic findings
Onset 30-50 yo
Female
Edema, induration (hardened), atrophy of skin
Acro-osteolytic (unguarded tuft resorption) and soft tissue calcifications
74
What condition is predominantly in women of childbearing age, asymptomatic (though sometimes chronic LBP and stiffness), SI motion may be altered and CMT may increase sx and then they’ll decrease
Osteitis Condensans Ilii (OCI)
75
Bilateral, symmetric triangle shaped area of sclerosis on iliac side of lower SIJ
Radiographic findings of Osteitis Condensans Ilii (OCI)
76
Severely painful pubic bone area
Osteitis Pubis
- usually subsides over 1-2 years
- bone inflammation and resorption w/ spontaneous re-ossification (eventually)
77
What is the latent period of osteitis pubis?
1-3 week following onset of Sx
78
Radiographic findings of osteitis pubis?
Bilateral, symmetric involvement of both sides of symphysis
- irrectular joint margin
- reactive scerosis
- widened joint space
79
This condition is 2˚ to major visceral disorder, esp intrathoracic
Hypertrophic Osteoarthropathy
80
What condition is MC 2˚ to bronchogenic carcinoma?
Hypertrophic Osteoarthropathy
81
What is the triad of clinical and radiographic findings for Hypertrophic Osteoarthropathy?
Digital clubbing
Symmetric arthritis
Periosteal reaction
82
What is the periosteal reaction for Hypertrophic Osteoarthropathy?
- bi/unilateral?
- symmetric/asymmetric?
- single/solid layer?
Bilateral
Symmetric
Solid OR single layer
83
What are the 4 metabolic disorders?
Gout
CPPD
HADD
Ochronosis
84
What condition is hyperuricemia plus recurrent, acute, inflammatory, arthritis, tophus formation?
Gout
85
What are the 5 stages of gout?
AAICG
“Ah Ah! I Conceived Gout!”
1 - Asymptomatic
2 - Acute: red, hot, swollen, monoarticular. Early AM, resolves in 7-10 days, recurrence common.
3 - Intercritical: time (months) between flares.
4 - Chronic tophaceous gout. Chronic, uncontrolled hyperuricemia.
5 - Gouty neuropathy
86
Joint space preserved in Gout?
Yes, until late in the process. Then uniform loss.
87
Overhanging margin sign
Erosion changes seen in Gout.
88
Chondrocalcinosis w/ or w/o secondary DJD
Calcium Pyrophosphate Dihydrate (CPPD) crystal deposition disease
89
Onset and peak age of Calcium Pyrophosphate Dihydrate (CPPD) crystal deposition disease
After 30 yo
| Peak 60 yo
90
How to definitively dx Calcium Pyrophosphate Dihydrate (CPPD) crystal deposition disease?
Aspiration synovial fluid to demonstrate crystals
91
Radiographic features for hyaline cartilage in CPPD?
Parallel to cortex, thin, linear
92
Radiographic features for fibrous cartilage in CPPD?
Thick, irregular, poorly defined, menisci, triangular cartilage, pubic symphysis, annulus fibrosis
93
What condition is 2˚ to DJD and may mimic neuropathic?
Pyrophosphate Arthropathy
DDX 1˚ DJD
- unusual joint or joint compartment involvement
- prominent cysts
- severe changes
- variable osteophyte formation
94
SLAC wrist
- what does it stand for?
- what condition?
SLAC - ScaphoLunate Advanced Collapse
Pyrophosphate Arthropathy
95
MC site for radiographic and clinical findings for Pyrophosphate Arthropathy?
Second location?
Knee
| Wrist
96
Calcification tendinitis that is common at shoulder at hip, MC 40-70 yo. Single site of involvement.
Hydroxyapatite Deposition Disease (HADD)
97
What is the more sensitive lab finding for catching early calcification in Hydroxyapatite Deposition Disease (HADD)?
US
98
What is seen on radiograph in Hydroxyapatite Deposition Disease (HADD)?
Calcification near tendon insertion
| Linear, round, oval, globular
99
4 phases of HADD
- which phase is asymptomatic
- which phase is most symptomatic/painful
1. Pre-calcific ** asymptomatic
2. Calcification/formative
3. Resorptive ** PAINFUL! ** crystals extravasate into adjacent tissues
4. Post-calcific
100
MC tendons involved in shoulder HADD?
Supraspinatus 80%
Infraspinatus 15%
MC at “critical zone” of rotator cuff
101
Where can HADD be seen in spine?
| - name the muscle
Longus colli
| Anterior to C2-C3 bodies and inferior to anterior tubercle of C1
