9) Rheumatology (Part 1) Flashcards
1
Q
Osteoarthritis characteristics
A
- Structural and functional failure of synovial joints
- AKA DJD - Any joint
- Most common form of arthritis
- Knee is most common joint
- DIP, PIP, wrist, hip, cervical and lumbar spine
- Pain after activity, Slowly progressive
2
Q
Bony changes seen in OA
A
- Bony enlargement, crepitus, decreased range of motion,
- Hand deformities (Heberden’s nodes are Hard painless on DIPs,
Bouchard’s nodules are on PIP) - X-ray is gold standard, showing osteophytes, joint space narrowing, subchondral sclerosis, and cysts
3
Q
OA management
A
- Weight loss, Physical Therapy, muscle strengthening
- Ice for a warm joint, heat for a stiff joint
- Assistive devices like canes, walkers
- Acetaminophen is analgesic of choice
NSAIDs - Surgical
4
Q
Surgical management of OA
A
- Arthroscopic debridement and lavage
- Arthroplasty
- Total joint replacement for night pain unresponsive to medication or difficulty with ADLs
5
Q
Fibromyalgia
A
- 3rd most common rheumatologic disorder OA, RA
- Middle aged women with pain in AM
- Diffuse pain, fatigue, sleep disturbance, trigger points
6
Q
Fibromyalgia Tx
A
- SSRIs
- Tricyclics for sleep
- Stretching, swimming, PT
- Stress control
7
Q
Inflammatory disorders
A
- Infectious (GC, TB)
- Crystal-induced (gout, pseudogout)
- Immune-related (RA, SLE)
- Reactive (Reiter’s syndrome)
- Idiopathic
8
Q
Noninflammatory disorders
A
- Trauma (rotator cuff tear)
- Ineffective repair (osteoarthritis)
- Cellular overgrowth (pigmented villonodular synovitis)
- Pain amplification (fibromyalgia)
9
Q
Gout
A
- Urate crystal deposition (usually in small) joints
- Men >30 with Hx food, etoh excess on diuretics with sudden onset asymmetric nocturnal severe pain in MTP joint (podagra)
- Joint fluid - negatively birefringent crystals (double refraction)
- Elevated serum uric acid, tophi skin lesions
10
Q
Acute gouty attack Tx options
A
- NSAIDs
- Colchicine
- Corticosteroids
- Interleukin-1 inhibitors
11
Q
NSAIDs for gout
A
- Full dose (eg, naproxen 500 mg twice daily or indomethacin 25–50 mg every 8 hours) until the symptoms have resolved (usually 5–10 days)
- Contraindications include active peptic ulcer disease, impaired kidney function, and a history of allergic reaction to NSAID
12
Q
Colchicine for gout
A
- If the attack is less than 36 hours
- A loading dose of 1.2 mg followed by a dose of 0.6 mg 1 hour later and then dosing for prophylaxis (0.6 mg once or twice daily) beginning 12 hours later
- Patients who are already taking prophylactic doses of colchicine and have an acute flare of gout may receive the full loading dose (1.2 mg) followed by 0.6 mg 1 hour later (before resuming the usual 0.6 mg once or twice daily) provided they have not received this regimen within the preceding 14 days (in which case, NSAIDs or corticosteroids should be used)
13
Q
Corticosteroids for gout
A
- Often give dramatic symptomatic relief in acute episodes of gout and will control most attacks
- Most useful in patients with contraindications to the use of NSAIDs
- May be given IV (eg, methylprednisolone, 40 mg/day) or orally (eg, prednisone, 40–60 mg/day)
- These corticosteroids can be given at the suggested dose for 5–10 days and then simply discontinued or given at the suggested initial dose for 2–5 days and then tapered over 7–10 days
- If the patient’s gout is monarticular or oligoarticular, intra-articular administration of the corticosteroid (eg, triamcinolone, 10–40 mg depending on the size of the joint) is very effective
- Because gouty and septic arthritis can coexist, albeit rarely, joint aspiration and Gram stain with culture of synovial fluid should be performed when intra-articular corticosteroids are given
14
Q
Interleukin-1 inhibitors for gout
A
- Anakinra (an interleukin-1 receptor antagonist), canakinumab (a monoclonal antibody against interleukin-1 beta), and rilonacept (a chimera composed of IgG constant domains and the extracellular components of the interleukin-1 receptor) have efficacy for the management of acute gout, but these drugs have not been approved by the US Food and Drug Administration (FDA) for this indication
15
Q
Gout prevention
A
- Diet: avoid excessive alcohol (particularly beer), organ meets and beverages sweetened with high fructose corn syrup
- Avoid hyperuricemic medications (Thiazides, loop diuretics, and niacin)
- Urate lowering medications to maintain serum uric acid <5-6mg/dL
- Colchicine prophylaxis: 0.6mg once or twice a day
16
Q
Urate lowering medications to maintain serum uric acid (gout prevention)
A
- First line: Xanthine oxidase inhibitors (allopurinol or febuxostat)
- Uricosuric agents (probenecid)
- Uricase (pegloticase)
17
Q
Pseudogout
A
- Calcium pyrophosphate dihydrate (CPPD) crystal deposition (usually in larger) joints
- Serum urate is Normal
- Joint fluid: positively birefringent crystals
18
Q
Causes of Pseudogout (metabolic disorders)
A
- Hyperparathyroid
- Hyperthyroid
- Wilson’s disease
- DM
- Gout
19
Q
Acute Pseudogout attack Tx
A
- NSAIDs (eg, naproxen 500 mg twice daily or indomethacin 25–50 mg every 8 hours) x 5 – 10 days are helpful in the treatment of acute episodes
- Aspiration of the inflamed joint and intra-articular injection of triamcinolone, 10–40 mg is also effective
20
Q
Pseudogout prevention
A
- Colchicine, 0.6 mg orally once or twice daily, is more effective for prophylaxis than for acute attacks
21
Q
Juvenile arthritis (juvenile idiopathic arthritis)
A
- Causes joint inflammation for at least 6 weeks in children 16 years or younger
- Most common type of childhood arthritis
22
Q
Juvenile arthritis (juvenile idiopathic arthritis) symptom occurrence
A
- Fever – 98 percent (daily but intermittent nature of the fever)
- Arthritis – 88 percent (8 percent with monoarthritis, 45 percent with oligoarthritis, and 47 percent with polyarthritis)
- Rash – 81 percent
- Lymphadenopathy – 31 percent
23
Q
Juvenile arthritis (juvenile idiopathic arthritis) diagnostic tests
A
- No specific diagnostic tests
- Labs may show elevated ESR, CRP, and positive ANA
24
Q
Juvenile arthritis (juvenile idiopathic arthritis) characteristics
A
- Like adult RA with variable outcomes
- Disease control prevents joint damage
- NSAIDS, celebrex, DMARDS (disease modifying antirheumatic drugs), TNF blockers
- Complications include growth retardation, and osteoporosis
25
Q
*Macrophage activation syndrome(MAS) of JIA can be life-threatening, should be treated with corticosteroids
A
- Fever
- Splenomegaly
- Cytopenia
- High triglycerides
- High Ferritin
- Low platelets
- High AST
- Low WBCs
- CNS dysfunction
- Hemorrhage
- Hepatomegaly
26
Q
Polyarteritis nodosa
A
- Autoimmune vasculitis of medium arteries (skin, joints, nerves, kidneys)
- Middle-aged men with fever, malaise, weight loss, peripheral neuropathy and/or proteinuria
27
Q
Polyarteritis nodosa signs and symptoms
A
- PE Palpable purpura, nondeforming arthritis
- Lungs are spared
28
Q
Polyarteritis nodosa lab findings
A
- Elevated ESR
- Leukocytosis
- Anemia, thrombosis
- Proteinuria or hematuria
- ANCA negative
29
Q
Polyarteritis nodosa diagosis
A
- Tissue biopsy
30
Q
Polyarteritis nodosa Tx
A
- Steroids and immunosuppressants
31
Q
Polyarteritis nodosa ACR criteria: vasculitis and 3 of…
A
- Weight loss
- Livedo reticularis rash
- Testicle, muscle pain or tenderness
- Nerve disease
- Elevated BUN/creatinine
- HTN (diastolic)
- Hepatitis B
- Aneurysms on angiogram
- Arteritis on biopsy
32
Q
Idiopathic inflammatory myopathies
A
- Polymyositis
- Dermatomyositis is Polymyositis with skin lesions
- Overlap myositis occurs with other connective tissue disorders like scleroderma, SLE, RA, Sjogren’s
33
Q
Polymyositis
A
- Inflammation of muscles, no official criteria
- Middle-age women> men
34
Q
Polymyositis signs and symptoms
A
- Symmetric proximal muscle weakness so they “have difficulty rising from chair”
- Fatigue
- Arthralgias
- Weight loss
- Muscle pain
35
Q
Polymyositis lab findings
A
- Elevated serum muscle enzymes: CK, LDH, AST, ALT
- ANA is + in 80% of pts
- Autoanibodies specific to PM are Anti-Jo-1, Anti-SRP, Anti-Mi-2
- Electromyography shows muscle irritability
36
Q
Polymyositis diagnosis
A
- Open Muscle Biopsy is definitive for PM showing inflammation with varying degrees of degeneration, regeneration, and necrosis of fibers
37
Q
Polymyositis Tx
A
- 1st Glucocorticoids- prednisone tapering over a year
- 2nd “glucocorticoid-sparing agents” azathioprine or methotrexate
38
Q
Dermatomyositis skin lesions
A
- Heliotrope rash
- Gottron’s sign
- Shawl sign
- Erythroderma
- Nail changes
- Mechanic’s hands
39
Q
Heliotrope rash (Dermatomyositis)
A
- Violet color around eyes
40
Q
Gottron’s sign (Dermatomyositis)
A
- Erythematous scale over finger joints
41
Q
Shawl sign (Dermatomyositis)
A
- Flat erythema in a V over chest and shoulders
42
Q
Mechanic’s hands (Dermatomyositis)
A
- Roughened cracking hand skin
