8 Rheum Flashcards
Arthrocentesis for joint pain:
what are 4 possibilities?
appearance, WBC, polys
- Normal: clear, WBC <2, Polys <25%
- non inflamm: clear, <2, >25%
- inflamm: yellow/white, 2-50, >50%
- septic: cloudy, >50, >75%.
normal
OA
everything else (look for crystals)
septic joint
Antibodies to memorize
ANA Anti-histone Anti dsDNA Anti Smooth muscle Mitochondrial Ab anti-centromere topoisomerase Anti Ro+La Anti CCP Anti RF Anti Jo
ANA–Lupus, sensitive
Anti-histone–drug induced lupus
Anti dsDNA–lupus, specific+renal involvement
Anti Smooth muscle–Autoimmune hepatitis
Mitochondrial Ab–PBC
anti-centromere–CREST/Scleroderma (C for CREST and Centromere)
topoisomerase Ab (aka Anti Scl-70)–Scleroderma, systemic
Anti Ro+La–Sjogrens
Anti CCP–RA
Anti RF–RA
Anti Jo–Polymyositis
What ab?
Lupus, sensitive drug induced lupus lupus, specific+renal involvement Autoimmune hepatitis PBC CREST/Scleroderma Scleroderma, systemic Sjogrens RA RA Polymyositis
ANA–Lupus, sensitive
Anti-histone–drug induced lupus
Anti dsDNA–lupus, specific+renal involvement
Anti Smooth muscle–Autoimmune hepatitis
Mitochondrial Ab–PBC
anti-centromere–CREST/Scleroderma (C for Centromere and CREST)
topoisomerase Ab (aka Anti Scl-70)–Scleroderma, systemic
Anti Ro+La–Sjogrens
Anti CCP–RA
Anti RF–RA
Anti Jo–Polymyositis
Lupus criteria
what other 2 things not on criteria to remember:
4 of 11: SOAP BRAIN MD
Serositis
Oral ulcers
Arthritis
Photosensitivity
Blood--hemolytic anemia, antiphospholipid, etc Renal ANA+ Immune labs (anti histone, anti dsDNA) Neuro
Malar Rash
Discoid Rash
- libman-sacks endocarditis
- alopecia
Lupus miscarriages: what trimester?
2nd trimester losses
Diagnostic tests of SLE:
- screen, confirm, track
- renal involvement screen, confirm
- flare
1st: ANA to screen
confirm: Anti-dsDNA (most spec), anti-Smith, anti-histone (drug)
Track: ESR, CRP
Renal involvement:
Screen: UA
confirm: Kidney bx
Flare: complement levels (low C3, C4)
SLE, drug induced
- which drugs
- how present differently than regular SLE
SHIPP
sulfa hydralazine INH procainamide phenytoin
-spares CNS and Renal sxs. (reminds of FAT RN) Usu skin and joint presentation
SLE treatment approach, what to know
Know 3 tx in SLE:
- arthalgias, serositis: NSAIDs, then Hydroxychloroquine, MTX 2nd line.
- Flares: Steroids
- Nephritis, cerebritis, severe flare: Cyclophosphamide, MMF 2nd line
RA + splenomegaly, think what
think neutropenia. This is Felty’s syndrome
RA, Splenomegaly, Neutropenia
Pt going for surgery. Pt has RA, think what and why
Get cervical film. Spine involvement C1,C2.
Morning stiffness + spine, think what
C1,C2 then RA
lower back, then Ank Spond.
RA: what joints
MCP and PIP.
If DIP, then NOT RA! never affects DIPS
RA tests
Rh factor: sens
Anti-CCP: spec
RA dx criteria
“Nobody Should Have Rhematoid Symptoms 3X”
Nodes Symmetric Hand RF or CCP Stiffness, AM 3+ joints, spares DIPs X-ray findings of erosions
However, IRL can have RA with Rh-, CCP-; or no RA with Rh+ and CCP+
RA Treatments, how to approach
4 categories to know:
Start MTX (or other DMARD) even at first presentationt! can slow progression
- DMARD–everyone gets. MTX, Hydroxy 2nd line
- Anti-TNF–severe.
- Steroids–flares
- NSAIDs–symptomatic
RA refractory to MTX and hydroxychloroquine.
What to do next?
Start Anti-TNFs because failure of DMARDs.
Always get TB screen and vaccinate first!
CREST vs systemic scleroderma
CREST: Think: SKIN AND GI, SPARES HEART AND KIDNEYS
CREST: Calcinosis, Raynauds, Esophageal dysmotility, Sclerosis, Telangiectasia
Scleroderma, systemic: CREST +
heart (pericarditis, restrictive)
kidneys (renovascular HTN)
Myopathy DDx (5)
- sxs differences? Pain vs weakness
- lab results for each?
“SPISH”
- steroid induced–PAINLESS, prox weakness
- polymyalgia rh–pain and morning stiffness esp shoulders, NO WEAKNESS
- inflamm myopathy–pain, prox weakness
- statin-induced–pain, possible weakness
- hypothyroid–pain and prox weakness
ESR, CK
- nl, nl
- high, nl
- high, high
- nl, high
- nl , high
Gonorrhea, disseminated sxs
Triad:
- tenosynovitis–asymmetric, wrists, hands, finges
- arthritis–migratory
- dermatitis–macular; spares face, palms, soles
Septic joint tx? non-gonococcal
Test: Naf, wait for cx/sens
IRL: Vanc
You suspect septic joint, tap shows nothing on gram stain. Think what?
Gonorrhea is intracellular, may not show on G strain. Still do empiric double coverage (Ceftriaxone and Vanc)
Dx with NAAT. tx while testing
Gout from Tumor lysis syndrome. What tx for ppx? If ppx didn’t work, use what?
Allopurinol
Rasburicase
You dx Septic joint and tx. What else to think about?
Source?
- direct inoculation–trauma
- hematogenous (think endocarditis, IVDA, intra-abd abscess)
Seronegative arthropathies
-name them
PAIR
Psoriatic arthritis
Ank Spond
IBD
Reiter’s reactive arthritis–can’t see, pee, climb tree
psoriatic arthritis
- which joints
- what to be careful in tx
symmetric DIP, PIP (like OA)
-NO ORAL STEROIDS, topical good
Reactive arthritis
- dx–how do you know urethritis and arthritis is not gonococcal septic joint?
- tx
Can’t see/pee/climb tree
-symmetric arthritis, as opposed to unilateral in gonorrhea
-Doxy for chlamydia, and NSAIDs
Wegener’s sxs
“weCeber’s triad:”
- nasopharynx
- lungs–hemoptysis
- kidneys–hematuria
Vasculitis–list them by categories
large vessel: Temporal arteritis, Takayasu’s
med: PAN (Hep B), kawasaki’s
small: Wegener’s (triad), microscopic polyangiitis (wegener’s -nasopharynx), churg-strauss (asthma), HSP
Kawasaki’s sxs
CRASH and burn
Conjunctivitis Rash--truncal and hands Adenopathy Strawberry tongue Hands (rash)
Fever 5+days
Scleroderma renal crisis/sxs, think what?
Ace-i as treatment, always.
Tx the renovascular HTN
Ank Spond.
tx?
NSAIDs first line, esp if only axial involvement
Etanercept if NSAIDs fail. works for axial and peripheral skeleton
Nonbiologic DMARDs (eg MTX, hydroxy) can be used only for peripheral arthropathy. Etanercept always tried first, these can be added on.
