ABIM 2015 - Rheum Flashcards
What type of JOINT pain are Cytokines (Interleukins, TNF) associated with ?
INFLAMMATORY
Redness, Heat, Swelling imply what type of JOINT pain?
INFLAMMATORY
Morning stiffness >60 minutes, fatigue, fever, malaise, joint erythema area all due to this type of JOINT condition?
INFLAMMATORY
If a joint is palpated directly and pain is elicited, what causes for the pain does that indicate?
JOINT arthritis vs injury (meniscal tear)
If the area SURROUNDING a joint is palpated and pain is elicited, what causes for the pain does that indicate?
Bursitis, Ligament strain, Tendinitis
What does PASSIVE motion of a joint mean?
Moving that joint by examiner WITHOUT ANY effort by patient
PAIN elicited on PASSIVE motion of a joint (moving that joint by examiner WITHOUT ANY effort by patient) suggests what etiology?
Arthritis
PAIN elicited on ACTIVE motion of a joint AGAINST resistance (by examiner) suggests what etiology?
Tendon pathology (overuse/excessive strain)
If an imaging study demonstrates SYMMETRIC joint-space narrowing, PERIARTICULAR osteopenia and erosions, this suggests what type of joint pathology?
Arthritis
If synovial fluid is sampled from a PAINFUL joint and demonstrates LEUKOCYTES (WBC’s) >2000/µL (mostly NEUTROPHILS), this indicates what type of JOINT pathology?
INFLAMMATORY
If an imaging study of a PAINFUL joint demonstrates ASYMMETRIC joint-space narrowing, OSTEOPHYTES and SUBCHONDRAL sclerosis, this suggests what type of joint pathology?
NON-INFLAMMATORY
Traumatic hemarthrosis or internal derangement of a joint (non-inflammatory), crystalline or septic arthritis (inflammatory) are what type of JOINT pathologies?
ACUTE MONOARTICULAR (single joint)
What must be done for ALL ACUTE MONOARTICULAR arthritis?
JOINT ASPIRATION to evaluate for INFECTION + serology ± synovial biopsy
What INFECTION sources can affect JOINTS?
Hematogenous and LOCAL skin breaks
What constitutes CHRONIC arthritis?
> 26 weeks
Mycobacteria (tuberculosis), Fungi or Borrelia burgdorferi (LYME) INFECTIONS can cause what type of arthritis?
CHRONIC MONOARTICULAR Inflammatory arthritis
What causes CHRONIC NON-INFLAMMATORY MONOARTICULAR or OLIGO-arthritis?
OSTEOARTHRITIS
Gonorrhea or Rheumatic Fever can cause what type of JOINT pathology?
ACUTE INFLAMMATORY OLIGOARTHRITIS (2-4 joints)
SPONDYLOarthritis (inflammatory rheumatic diseases) or Connective Tissue diseases can cause what type of arthritis?
CHRONIC INFLAMMATORY OLIGOARTHRITIS
When arthritis involves >4 JOINTS it may be an early manifestation of an inflammatory POLYARTHRITIS and can be caused by these infectious and autoimmune diseases?
Infections: Parvovirus B19, HIV, Hep B, Rubella
Autoimmune: RA, SLE, SPONDYLOarthritis
What do most SYSTEMIC INFLAMMATORY (RA, SLE) conditions share as a common symptom?
Fever
What do the two ARTHRITIC conditions STILL disease and Familial Mediterranean Fever share as a common symptom?
Fever
In Juvenile Inflammatory Arthritis with positive ANA, JOINTS are minimally involved, what is involved mostly?
IRITIS (iris), UVEITIS (choroid layer - posterior eye; ciliary body and iris - anterior eye)
What tests should be done in a patient who presents with otherwise ASYMPTOMATIC IRITIS (inflammation of the iris, which is part of the anterior UVEA of the eye)?
Look for SYSTEMIC inflammatory disease! CXR (r/o sarcoidosis), HLA-B27 for possible spondyloarthritis and ANCA (for granulomatosis with polyangiitis - Wegener Granulomatosis)
How many patients with RA have eye (any structure) involvement?
25% (usually keratoconjunctivitis sicca - dry eye)
Dry eyes (not keratoconjunctivitis sicca) caused by the inflammation of the LACRIMAL and other exocrine glands is seen with what SYSTEMIC inflammatory condition?
Sjögren syndrome
Rotator Cuff Tendinitis, Biceps Tendinitis, Lateral Epicondylitis, de Quervain Tenosynovitis, Carpal Tunnel Syndrome, Trigger Finger, Ischial Bursitis, Piriformis Syndrome, Trochanteric Bursitis, Pes Anserine Bursitis, Plantar Fasciitis are ALL what type of GENERAL conditions?
OVERUSE Syndromes
Tendon? Ligament?
Tendon - attachment of a muscle to bone
Ligament - attachment of bone to bone
Pain in the anterior SHOULDER when lifting heavy objects?
Biceps Tendinitis
ELBOW pain when carrying a purse/briefcase or gripping a steering wheel?
Lateral Epicondylitis
Pain in the UPPER, OUTER ARM with overhead activities or when reaching behind the back, ABDucting the arm between 30º - 150º but with less pain on PASSIVE motion of the shoulder?
Rotator Cuff Tendinitis
Pain along the RADIAL aspect of the wrist when grabbing the thumb (inside a closed fist) and stretching it with the wrist (not flexing)?
de Quervain Tenosynovitis
LOCKING of a finger on FLEXION with pain and crepitus on palpation of the tendon sheath with a flexor tendon NODULE on the PALMAR aspect of the metacarpophalangeal joint?
Trigger Finger
Pain in the buttocks worsens when sitting? With SCIATICA symptoms?
Ischial Bursitis; Piriformis Syndrome
Pain in the LATERAL HIP that worsens when lying on that side?
Trochanteric Bursitis
Pain just BELOW KNEE, anteromedially, when exercising or climbing stairs?
Pes Anserine Bursitis
Pain on the BOTTOM of the HEEL when walking?
Plantar Fasciitis
SYMMETRIC JOINT involvement, (MCP, PIP), also wrist, hips, knees, elbows, shoulders, cervical spine, dry eyes/mouth, lung disease and EROSIVE joint changes on X-ray?
RA
SYMMETRIC JOINT involvement, fever, rashes, kidney disease and neurological involvement, NO joint erosions on x-ray, POSITIVE ANA?
SLE
Ankylosing Spondylitis, Psoriatic Arthritis, Reactive Arthritis (Reiter syndrome), IBD-arthritis are ALL what type of arthritis?
HLA-B27 associated SPONDYLOarthritis
Sacroiliac and SPINAL involvement, SYMMETRIC shoulders and hips affected, SPINAL LIGAMENT CALCIFICATION on radiology, UVEITIS?
Akylosing Spondylitis (HLA-B27 positive)
ASYMMETRIC JOINT involvement, DIP joints mainly affected, sausage digits (dactylitis), EROSIONS and OSTEOPHYTES on x-rays of joints, PENCIL-in-CUP deformities, oil drop deformity in nails and nail pitting?
Psoriatic Arthritis (HLA-B27 positive)
ASYMMETRIC JOINT involvement, KNEE and ANKLES, ACHILLES Tendinitis, PLANTAR Fasciitis, SACROILIITIS, UVEITIS, KERATODERMA BLENNORRHAGICUM, CHLAMYDIA and ENTEROPATHIC infections?
Reactive Arthritis (HLA-B27 positive) - “Reiter Syndrome” - can’t see (uveitis), can’t pee (Chlamydia), can’t climb a tree (knees, ankles, sacroiliitis, plantar fasciitis, achilles tendinitis)
PAINLESS oral ulcerations (tongue and hard palate) with alopecia and painful indurated subcutaneous swelling with overlying erythema of the skin can be seen in?
SLE
Skin THICKENING involving FACE, HANDS, FEET?
Systemic Sclerosis (SCLERODERMA)
PURPURIC lesions, Cutaneous nodules, Ulcers?
Vasculitis
Oral and Genital Ulcers, Erythema Nodosum?
Beçhet disease
When you see a psoriatic-like rash on the penis “circinate balanitis,” what is it associated with?
REACTIVE Arthritis (Reiter Syndrome)
High FEVER, JOINT PAIN and a Salmon-Colored Rash on trunk and PROXIMAL extremities?
Adult-onset STILL Disease
Lots of LARGE, target/bull’s-eye lesions in association with STREPTOCOCCAL infection?
Rheumatic Fever (erythema marginatum)
What is the rash of LYME disease called?
Erythema Chronicum Migrans (or just Erythema Migrans)
Pneumonitis (bronchiolitis obliterans with organising pneumonia or interstitial lung disease) with NODULES in the lungs and pleural EFFUSIONS can be seen in this SYSTEMIC Inflammatory disease?
RA
Systemic Sclerosis (scleroderma), CREST syndrome, Lupus, granulomatosis with polyangiitis and Churg-Strauss syndrome are all systemic inflammatory diseases that can ALL affect what organ?
LUNGS
Cavitary lung NODULES with consolidation and WEDGE infarcts, hematuria with red cell casts, bloody, purulent nasal discharge are all seen in this SYSTEMIC inflammatory disease?
Granulomatosis with Polyangiitis (Wegener Granulomatosis)
Eosinophilic Pneumonitis is seen in this ASTHMA-related autoimmune vasculitis?
Churg-Strauss Syndrome
Pulmonary Artery HTN in the ABSENCE of pulmonary parenchymal disease, associated with calcinosis (calcium deposits in soft tissues), Raynaud phenomenon, esophageal dysmotility, sclerodactyly and telangiectasia is seen in?
CREST Syndrome
Diarrhea after an enteric infection (salmonella, shigella, campylobacter, yersinia, clostridium) followed by JOINT pain, uveitis is seen in?
Reactive Arthritis (Reiter Syndrome)
What two SYSTEMIC diseases is Carpal Tunnel Syndrome associated with?
DM & Hypothyroidism (but also just overuse)
Adhesive Capsulitis of the SHOULDER and Dupuytren Contracture are associated with this SYSTEMIC disease?
DM
Arthralgia and Myopathy (with elevated CK) can be seen in this thyroid condition?
HYPOthyroidism
Myopathy (with elevated CK) and Osteoporosis can be seen in this thyroid condition?
HYPERthyroidism
Calcium Pyrophosphate Deposition disease (CPPD), Hypercalcemia with Constipation and Osteoporosis can be seen in this glandular disease?
HYPERparathyroidism
Arthralgia, Bone Pain, Calcium Pyrophosphate Deposition Disease (CPDD) can be seen in this glandular disease?
Acromegaly
What disease are Hemarthroses (bleeding into joints) seen in?
Hemophilia
What does an ELEVATED ESR mean in Pregnancy, DM, Anemia and ESRD?
NOTHING, falsely elevated
What HIGHLY-ELEVATED lab value is seen in patients with Giant Cell Arteritis (temporal arteritis), Multiple Myeloma and Metastatic Cancer?
ESR >100 mm/h
What is CRP and why is it better than ESR?
It is an acute-phase reactant and a DIRECT measure of inflammation that responds more QUICKLY to changes in disease state
COMPLEMENT (C3 & C4) production and consumption increase during inflammation as it serves as a LEUKOCYTE attractant however COMPLEMENT is DECREASED (LOW) in these types of INFLAMMATORY conditions?
IMMUNE-COMPLEX MEDIATED (autoimmune) conditions - consume complement resulting in LOW complement levels (C3 and C4) - (SLE, cryoglobulinemic vasculitis, urticarial vasculitis)
Can a person with a negative ANA have lupus?
NO
Above what level ANA dilution is considered PROBABLE for lupus (IF SUSPECTED) thus warranting further studies?
ANA ≥ 1:160
What rheumatological conditions demonstrate JOINT erosions?
RA, Psoriatic Arthritis, GOUT
Positive ANA (≥1:160), Anti-ds-DNA Ab, Anti-Smith Ab are seen in what SYSTEMIC autoimmune disease?
SLE
What is the MOST SPECIFIC (rules-in disease) lab test for SLE?
Anti-Smith Ab
If positive ANA (≥1:160) and positive Anti-Smith Ab?
Almost assured to have SLE
A POSITIVE Anti-U1-RNP Ab (≥1:10,000) is seen in?
Mixed Connective Tissue Disease (MCTD)
POSITIVE Anti-Ro/SSA; Anti-La/SSB (SS stands for Sjögren Syndrome) Ab’s are seen in?
Sjögren Syndrome
POSITIVE Anti-Scl-70 and Anticentromere Ab’s are seen in what condition?
Progressive Systemic Sclerosis (scleroderma)
A POSITIVE c-ANCA is seen in what disease?
Granulomatosis with Polyangiitis (Wegener Granulomatosis)
A POSITIVE p-ANCA is seen in what disease?
Churg-Strauss Syndrome (IBD and microscopic polyangiitis)
A POSITIVE Anti-Jo-1 Ab is seen in what disease?
Myositis
What is the MOST SENSITIVE (rules-out disease) lab test for RA?
Anti-cyclic citrullinated peptide (NO, definitely NOT RF)
Antihistone Ab’s are seen in what condition?
DRUG-induced SLE
What diseases are CRYOGLOBULINS seen in?
HEP C, also in Vasculitis and Multiple Myeloma
What is the use of plain radiographs in monitoring OSTEOARTHRITIS?
Evaluating the severity of Joint Space Loss
When evaluating the EROSIVE lesions of JOINTS in diseases such as RA, Psoriatic Arthritis or GOUT, what imaging is REQUIRED?
TWO (2) VIEW Plain Radiographs
What is the BEST imaging modality for BONE if plain radiographs are not sufficient?
CT
What is the BEST imaging modality for SOFT TISSUES (cartilage, synovium, tendons, ligaments)?
MRI
What test is used to differentiate between INFLAMMATORY and NON-inflammatory JOINT effusions, ESPECIALLY when distinguishing between infectious arthritis and acute crystalline arthropathy?
JOINT Aspiration (Cell count, Gram stain w/culture, Crystal analysis)
Fever, Leukocytosis (elevated WBC’s), elevated INFLAMMATORY markers are POSITIVE in both Infectious Arthritis and Gout, how can you distinguish between the two?
JOINT Aspiration (Cell count, Gram stain w/culture, Crystal analysis)
A JOINT Aspirate with ≥50,000/µL leukocytes (mostly PMN’s) is suspicious for what?
INFECTIOUS Arthritis
A JOINT Aspirate with ≤2,000/µL leukocytes NOT associated with what?
NOT associated with an INFLAMMATORY condition
Does the presence of CRYSTALS in a JOINT aspirate rule out INFECTION?
NO (not if suspicion is high)
NEEDLE shaped, NEGATIVELY-birefringent, yellow/blue crystals in JOINT aspirate indicate what?
GOUT (urate crystals)
RHOMBOID shaped, POSITIVELY-birefringent, yellow/blue crystals in JOINT aspirate indicate what?
Calcium Pyrophosphate Crystals (CPPD) - PSEUDOgout
Bony EROSIONS, Joint Subluxations, MCP and PIP HAND joint involvement are seen in?
RA
Bony EROSIONS and OSTEOPHYTES, DIP involvement, PENCIL-in-CUP deformities, oil-drop nails and nail-pitting are seen in?
Psoriatic Arthritis
ASYMMETRIC JOINT-SPACE Narrowing, Osteophytes, CYSTIC changes, collapse of spinal disks, DIP (Heberden nodes) and PIP (Bouchard nodes) involvement, kyphosis are seen in?
Osteoarthritis
Sacroiliitis with SQUARING of the vertebral bodies are seen in?
Ankylosing Spondylitis
Calcification of a spinal ligament (anterior longitudinal ligament) is seen in?
Diffuse Idiopathic Skeletal Hyperostosis (DISH)
Chondrocalcinosis of the KNEES, SHOULDERS, WRISTS and PUBIC SYMPHYSIS is seen in?
Calcium Pyrophosphate Deposition disease (CPPD) - PSEUDOgout - yellow/blue, RHOMBOID, positively-birefringent crystals
What are the Disease Activity Score (DAS) and the Health Assessment Questionnaire?
Instruments used to measure Rheumatic disease activity and progression as well as overall patient function and wellness
These agents inhibit cyclooxygenase (COX) enzymes and block prostaglandin E2 generation?
NSAIDS (reducing prostaglandin E2 provides most of the anti-inflammatory and analgesic effects of NSAIDS however prostaglandin E2 maintains the gastric lining and kidney blood flow
These NSAIDS cause LESS GI adverse effects and less asthma effects but do not alter renal toxicity or HTN?
COX-2 (selective) inhibitors - CELECOXIB
Which is the ONLY NSAID that DOESN’T cause cardiovascular risk?
Naproxen
What are two good analgesic-only medications that are not anti-inflammatory and not addicting?
Acetaminophen and Tramadol
The drug is used in the treatment of GOUT, PSEUDOgout and Familial Mediterranean Fever?
Colchicine
What should be given to all patients on chronic corticosteroid therapy?
Calcium + Vitamin D and bisphopshonates (to avoid osteoporosis)
What are DMARDS (Disease Modifying Anti-Rheumatic Drugs)?
IMMUNOSUPPRESSIVE agents
What is the GOLD-standard DMARD for RA?
Methotrexate (also used for Psoriatic Arthritis, Systemic Vasculitis, Polymyositis)
LIVER toxicity and macrocytic ANEMIA (interferes with liver hematopoiesis) are two adverse effects of this DMARD used for RA requiring routine surveillance blood work and PROHIBITING ALCOHOL use during treatment?
Methotrexate (folic acid antagonist) - EXTREMELY TERATOGENIC
What DMARD used for the treatment of RA can CAUSE multiple RA nodules (NODULOSIS) and pneumonitis?
Methotrexate (folic acid antagonist) - EXTREMELY TERATOGENIC
What can be added to METHOTREXATE to reduce its toxicity but not affect its therapeutic effects?
Folic Acid
Because METHOTREXATE is a HIGHLY TERATOGENIC drug, WHEN must it be discontinued prior to pregnancy?
AT LEAST 3 MONTHS PRIOR to CONCEPTION!!!
This DMARD is used frequently in the treatment of LUPUS to prevent flares and reduce morbidity and mortality?
Hydroxychloroquine (pregnancy SAFE)
What DMARD can cause visual loss due to RETINAL PIGMENT deposition requiring routine eye exams?
Hydroxychloroquine (pregnancy SAFE)
This DMARD is used mainly for the treatment of IBD however it does have moderate effect in RA and can cause agranulocytosis, hepatitis and reversible oligospermia?
Sulfasalazine (pregnancy SAFE)
This DMARD is as good as METHOTREXATE (gold-standard for RA treatment) with adverse effects of interstitial ling disease (like methotrexate) and like methotrexate, it is EXTREMELY teratogenic?
Leflunomide (EXTREMELY TERATOGENIC)
What must be done which is UNIQUE to this DMARD when planning pregnancy due to its EXTREMELY TERATOGENIC effects and EXTREMELY LONG half-life (MONTHS)?
Leflunomide (EXTREMELY TERATOGENIC) - MUST take cholestyramine TID x 8 days to remove from system and recheck levels TWICE prior to conception
This DMARD is a corticosteroid-SPARING agent and also used in maintenance of LUPUS, IBD, Vasculitis and Polymyositis?
Azathioprine (TPMT) - pregnancy SAFE
This DMARD, a potent ALKYLATING agent is used to treat life-threatening LUPUS and systemic VASCULITIS however can cause BLADDER Cancer, LYMPHOMA and Hemorrhagic Cystitis requiring close blood work monitoring?
Cyclophosphamide (NOT safe for pregnancy - D)
When is the ONLY time pregnancy class D DMARD Cyclophosphamide should be used in a pregnant patient?
When the LIFE is in DANGER
This Anti-REJECTION DMARD inhibits BOTH B-lymphocytes and T-lymphocytes and is used to treat LUPUS NEPHRITIS and is used as a corticosteroid-SPARING agent for systemic Vasculitis and Polymyositis while having fewer side effects than Cyclophosphamide?
Mycophenolate Mofetil (TERATOGENIC)
This DMARD specifically targets T-lymphocytes and is used in MANY rheumatic and autoimmune disease with side effects such as HIRSUTISM, NEPHROTOXICITY and TREMOR) therefore used only as a THIRD-line agent?
Cyclosporine (pregnancy SAFE)
These class of DMARDS have a much greater SPECIFICITY for targeted immune suppression with fewer side effects?
BIOLOGIC AGENTS (TNF-α, Anti-IL, anti-CD20, etc.)
What is necessary prior to use of ALL biologic agents?
Latent TUBERCULOSIS test (PPD or interferon-γ release assay)
What VACCINATION limitations exist for patients using biologic agents?
NO LIVE VACCINES; patients taking either RITUXIMAB or ABATACEPT should get ALL immunizations done PRIOR to use of these agents (live or killed vaccines)
What other DMARD should anti-TNF-α agents be used in COMBINATION with for BEST RA treatment?
METHOTREXATE (folic acid antagonist) or LEFLUNOMIDE - both EXTREMELY TERATOGENIC
What should be done if a patient is taking an anti-TNF-α medication and develops an infection?
anti-TNF-α drug should be stopped and the infection TREATED prior to restarting
Reactivation of TUBERCULOSIS, HISTOPLASMOSIS and COCCIDIOIDOMYCOSIS and He B are all associated with these agents?
anti-TNF-α drugs (pregnancy SAFE)
What should be done when a patient taking anti-TNF-α drugs develops psoriaform skin eruptions, demyelinating syndromes or drug-induced lupus?
STOP the anti-TNF-α drug
What two cancers have been associated with anti-TNF-α drugs and their development requires prompt discontinuation of the drug?
LYMPHOMA and non-melanoma skin cancers
A patient who has moderate or high autoimmune disease activity and POOR PROGNOSIS and has FAILED METHOTREXATE/LEFLUNOMIDE or METHOTREXATE/LEFLUNOMIDE in combination with other DMARDS or FAILED anti-TNF-α drugs can be started on this IMMUNOSUPPRESSIVE medication that can cause LUNG CANCER, COPD exacerbations and LYMPHOMA?
Abatacept (pregnancy SAFE)
What BIOLOGIC agent that antagonizes IL-1ß receptors is used to treat adult-onset STILL disease (HIGH fevers, JOINT pain, Salmon colored rash on trunk and PROXIMAL extremities)?
Anakinra (pregnancy SAFE)
How does RITUXIMAB work and why is it used in many of the LYMPHOMAS and LEUKOCYTIC leukemias?
RAPIDLY depletes anti-CD20 (B-cell) lymphocytes
In patients with RA who have NOT responded well to the COMBINATION of METHOTREXATE/LEFLUNOMIDE + anti-TNF-α drug, what other medication can be used? (this drug has also been shown to be AS EFFECTIVE as Cyclophosphamide in inducing REMISSION in patients with ANCA-associated VASCUITIS)
RITUXIMAB (anti-CD20 “B-cell”) - pregnancy SAFE
Severe INFUSION reactions and RARE reactivation of the JC-virus causing PML have been seen with this drug?
RITUXIMAB (pregnancy SAFE)
In patients with RA who have NOT responded well to an anti-TNF-α drug, what anti-IL-6 receptor antagonist medication can be used that can cause gastric/intestinal RUPTURE and increased SERUM LIPID levels?
Tocilizumab (pregnancy SAFE)
A BIOLOGIC drug used for Crohn disease, Psoriasis, Psoriatic Arthritis and RA that targets TNF-α BEFORE it is formed by antagonizing IL-12 and IL-23 via the p40 subunit is called?
Ustekinumab (pregnancy SAFE)
What BIOLOGIC agent targets B-cell lymphocytes BEFORE they are fully formed and therefore works well specifically for SLE and Sjögren syndrome?
Belimumab (pregnancy SAFE)
What is the MOST EFFECTIVE therapy for RA?
COMBINATION of Methotrexate/Leflunomide + anti-TNF-α inhibitors
A patient who experiences ≥2 gout attacks/YEAR or has gouty urate deposits (TOPHI) requires what?
GOUT treatment
Why is colchicine (NSAID) required when initiating GOUT therapy with a maintenance GOUT agent (allopurinol, febuxostat, probenecid)?
Because initiating a maintenance GOUT medication without the COLCHICINE (NSAID) can trigger GOUT attacks for 3-6 MONTHS
What is the most common side effect of ALLOPURINOL for which it MUST be discontinued?
RASH (can cause Stevens-Johnson syndrome)
Which xanthine oxidase inhibitor is used in patients with mild-to-moderate kidney failure?
FEBUXOSTAT (not a purine analog like allopurinol)
What GOUT drug requires EXCELLENT kidney function and DOES NOT work in patients with KIDNEY DISEASE and can cause KIDNEY STONES which is why ALL patients using this medication must keep VERY WELL HYDRATED?
Probenecid
What medication is used to treat the very high concentration of URIC ACID seen in TUMOR LYSIS SYNDROME, however cannot be used to treat GOUT chronically because it is HIGHLY IMMUNOGENIC?
RASBURICASE
If standard medications fail to control GOUT, what ONE medication can be used, which is a PEG-form of rasburicase?
PEGloticase
White women, between the ages of 30-55 can develop a chronic SYSTEMIC INFLAMMATORY disease with JOINT destruction that increases their prevalence of CAD?
Rheumatoid Arthritis (RA)
A largely inherited condition in which TNF-α induced OSTEOCLAST activation and production of degradative enzymes leads to cartilage damage and bone erosion?
Rheumatoid Arthritis (RA)
How does pregnancy and breast-feeding affect RA?
Risk of RA is reduced in women who have had children and breast-fed for at least 1 year and RA subsides during pregnancy and flares after
The presence of BOTH RF and anti-cyclic citrullinated peptide Ab’s in the blood suggests what?
RA
What preventable risk factor is STRONGLY associated with RA?
Smoking
Prolonged >60 min MORNING STIFFNESS, SYMMETRIC POLYARTHRITIS of small, medium and large joints involving the MCP’s and PIP’s of the hands, the wrists with deformity and joint dysfunction but SPARING the DIP’s and LUMBAR spine suggest what diagnosis?
Rheumatoid Arthritis (RA)
Anemia of CHRONIC disease, elevated ESR, CRP and ANA (40%), thrombocytosis and HYPOalbuminemia, JOINT aspirates demonstrate elevated leukocyte counts with neutrophil predominance, positive RF(70%) - also seen in MIXED Cryoglobulinemia, Sjögren syndrome and SLE - and positive anti-cyclic citrullinated Ab’s (60%) all suggest what?
Rheumatid Arthritis (RA)
Does the ABSENCE of BOTH RF and anti-cyclic citrullinated Ab’s effectively rule out Rheumatoid Arthritis (RA)?
NO!!
CXR demonstrating periarticular OSTEOPENIA, SYMMETRIC JOINT-SPACE NARROWING and EROSIONS (at the margins of joints) are findings that are often seen in?
Rheumatoid Arthritis (RA)
What imaging modality can detect BONE EROSIONS EARLIER than CXR?
MRI (bone marrow edema and synovial proliferation)
Ulnar deviation of phalanges, Swan neck and Boutonnière deformity, popliteal (Baker) and ganglion cysts are seen in?
Rheumatoid Arthritis (RA)
What is a syndrome of RA where a patient has PANcytopenia, Splenomegaly and LEG ULCERS?
Felty syndrome
CAD, Felty syndrome, vasculitis, nodules, interstitial lung disease, scleritis with scleral ulceration (scleral melt) and secondary amyloidosis are all manifestations seen in what disease?
Rheumatoid Arthritis (RA)
What specific treatment for RA also results in significant reduction of cardiovascular risk?
Methotrexate/Leflunomide + anti-TNF-α inhibitor
What constitutes INSUFFICIENT therapeutic regiment for RA?
Progressive JOINT damage on plain radiographs
LEG ULCERS in RA are part of what RA-syndrome?
Felty syndrome
What is the BEST INITIAL MONOtherapy for a patient with RA of ANY duration or disease activity?
Methotrexate
What patients with RA would be good candidates for initial MONOtherapy with HYDROXYCHLOROQUINE, SULFASALAZINE or MINOCYCLINE?
Those who have had RA for a short time and with a LOW disease activity
What type of therapy can be used for patients with RA that have POOR prognostic features or moderate-to-high disease activity levels?
COMBINATION therapy using METHOTREXATE with HYDROXYCHLOROQUINE or SULFASALAZINE OR any of these with a BIOLOGIC agent
Which of the BIOLOGIC agents used to treat RA tends to provide a better response in patients with POSITIVE Rheumatoid Factor (RF)?
RITUXIMAB
What can be done for a patient with RA that has failed MONOtherapy, COMBINATION therapy with NON-biologic DMARD’s AND COMBINATION therapy with a BIOLOGIC DMARD?
Change the BIOLOGIC DMARD to another (usually after the second change, pt is LESS likely to respond to a third, etc)
What specific RISK in a patient with RA must be checked for in the PRE-OP management as missing this can result in potential CORD COMPRESSION during intubation?
Atlanto-Axial Subluxation (evaluate the cervical spine with BOTH flexion AND extension RADIOGRAPHS
What should be done for a patient with ANEMIA of CHRONIC DISEASE after surgery with significant BLOOD LOSS?
TRANSFUSE
What RA meds should be stopped prior to elective SURGERY?
NSAIDS (to reduce bleeding risk) and anti-TNF-α inhibitors
What two vaccines should be given to ALL patients taking immunosuppressive agents whether diagnosed with RA or any other disease?
INACTIVE Pneumococcal and Influenza Vaccines
Are LIVE-attenuated vaccines safe for use in patients with RA taking BIOLOGIC medications?
NO!!
Can LIVE-attenuated vaccines be used in patients taking NON-BIOLOGIC DMARD’s ± Steroids (prednisone, etc.)?
YES (if low-dose for BOTH)
What should MEN do if they are taking SULFASALAZINE for RA and planing to have a family? Why?
Discontinue it 3 MONTHS before
Because SULFASALAZINE causes OLIGOSPERMIA (reduced sperm-count)
What can NSAIDS cause if taken early during pregnancy?
Interfere with IMPLANTATION
What can NSAIDS cause if taken during the THIRD TRIMESTER?
PREMATURE closure of the DUCTUS ARTERIOSUS
What can CORTICOSTEROIDS cause if taken BEFORE 14 weeks gestation?
CLEFT PALATE (fetus), Gestational Diabetes and HTN (mother)
Are NSAIDS, LOW-dose PREDNISONE or METHOTREXATE safe to use during lactation?
NSAIDS and LOW-dose PREDNISONE - YES
METHOTREXATE - NO!!
What is the MOST COMMON condition affecting 80% of patients ≥55 and 95% of patients ≥65?
OSTEOARTHRITIS (biomechanical rather than immunological process)
Acute JOINT injury (ligament tear) or repetitive (overuse/obesity) can result in JOINT laxity, cartilage injury, abnormal joint mechanics that can all lead secondarily to what condition?
OSTEOARTHRITIS (biomechanical rather than immunological process)
What is the SINGLE most MODIFIABLE risk factor for OSTEOARTHRITIS of the KNEE?
OBESITY
Morning stiffness
OSTEOARTHRITIS (biomechanical rather than immunological process)
Bouchard (DIP) and Heberden (PIP) nodes as well as bone spurs are seen in this disease?
OSTEOARTHRITIS (biomechanical rather than immunological process)
Involvement of the FIRST CarpoMetaCarpal (CRC) JOINT of the hand (base of thumb) causes “SQUARING” of the wrist in this disease?
OSTEOARTHRITIS (biomechanical rather than immunological process)
ASYMMETRIC JOINT-SPACE narrowing resulting in a VALGUS (lateral joint space - knocked knee - MOST COMMON) or VARUS (medial joint space - bow-legged) deformities are seen in what condition?
OSTEOARTHRITIS (biomechanical rather than immunological process)
Loss of spinal mobility with CANAL STENOSIS due to bone SPURS or DISK DEGENERATION (bulging, fragmentation) leading to NERVE root impingement (cervical radiculopathy, SCIATICA, pseudoclaudication - from lumbar spinal stenosis) or MYELOPATHY (from cervical spinal stenosis) can be seen in?
OSTEOARTHRITIS (biomechanical rather than immunological process)
HAND joints (PIP, DIP, CMC), HIP and KNEE joints are affected in what disease?
OSTEOARTHRITIS (biomechanical rather than immunological process)
When an ATYPICAL JOINT is involved in OSTEOARTHRITIS (typically involved joints: PIP, DIP, CMC, HIP and KNEE), what is suspected to be the cause?
Chondrocalcinosis, Acromegaly or Hemochromatosis OR due to PREVIOUS joint injury due to RA or INFECTION
This erosive disease typically involves ONLY the HAND, it is seen mostly in WOMEN, with FLARES of INFLAMMATION of the DIP and PIP joints with ERYTHEMA, SWELLING, SEVERE PAIN and plain films demonstrating erosions and spurs?
EROSIVE OSTEOARTHRITIS
Calcification of the THORACIC SPINAL LIGAMENTS with little disk narrowing, associated with Achilles or Calcaneal Spurs and calcification of the QUADRICEPS muscle in OBESE MEN ≥40 with symptoms of stiffness and reduced range of motion and elevated levels of INSULIN-like Growth Factor-1 and GROWTH HORMNE?
Diffuse Idiopathic Skeletal Hyperostosis (DISH)
Te demonstration on X-rays of “FLOWING Osteophytes Across FOUR contiguous vertebrae” provides the diagnosis of what?
Diffuse Idiopathic Skeletal Hyperostosis (DISH)
What should be suspected in patients aged ≥40 who have CHRONIC JOINT PAIN WITHOUT significant MORNING STIFFNESS (DIP, PIP, CMC, HIP, KNEE, SPINE)?
OSTEOARTHRITIS (biomechanical rather than immunological process)
Do you see an elevated ESR, CRP or significant Morning Stiffness in a patient with OSTEOARTHRITIS?
NO
A patient presenting with JOINT pain that is described as GROIN pain or BUTTOCK pain worsened by WEIGHT BEARING likely has what?
OSTEOARTHRITIS of the HIP (seen on X-rays as joint space narrowing)
Pain that is WORSENED when STANDING or WALKING suggests osteoarthritis of what?
The KNEE
Pain that is WORSENED when CLIMBING or DESCENDING STAIRS or when SITTING for a PROLONGED period of time in a patient with osteoarthritis likely involves what joint?
The Patello-Femoral joint
BONE CYST formation, JOINT-SPACE narrowing and OSTEOPHYTES can ALL be seen in this condition?
OSTEOARTHRITIS
What are the preferred, NON-PHARMACOLOGIC treatments for patients with OSTEOARTHRITIS?
COMBINATION of WEIGHT LOSS, EXERCISE (physical therapy) and unloading braces (hip and knee)
How is a CANE properly used as an UNLOADING device in a patient with KNEE or HIP OSTEOARTHRITIS?
It is held in the CONTRALATERAL HAND of the affected JOINT and SWUNG forward with the SWINGING of the AFFECTED limb
In addition to NON-PHARMACOLOGIC agents, which PHARMACOLOGIC agent should be used as FIRST-LINE therapy in a patient with OSTEOARTHRITIS?
ACETAMINOPHEN (then NSAID’s)
What medications can be used for maintenance of function and alleviating pain in patients with OSTEOARTHRITIS refractory to combinations of non-pharmacologic therapy with acetaminophen or NSAID’s?
Lidocaine patches (KNEE) or low-dose OPIOIDS
What can be done for patients with OSTEOARTHRITIS who have ONE JOINT that is much more symptomatic with PAIN and loss of function than the rest?
INTRA-ARTICULAR corticosteroid injection (lasts 3 MONTHS)
What are some of the adverse effects seen when patients with OSTEOARTHRITIS receive >3 INTRA-ARTICULAR corticosteroid injections for symptom relief and restoration of function?
Cartilage atrophy, Fat atrophy and skin Depigmentation
An alternative to INTRA-ARTICULAR corticosteroid injections for symptom control and restoration of function for patients with OSTEOARTHRITIS that lasts 3-6 MONTHS (3 months with corticosteroids), is most efficacious if injected AFTER the joint EFFUSION is drained and there is NO LIMIT to REPEAT injections however is more expensive?
HYALURONIC ACID Injections
In patients with ADVANCED OSTEOARTHRITIS with SIGNIFICANT symptoms of PAIN and LOSS of FUNCTION that affect quality of life and are not responsive to exercise, weight loss and medical therapy, what is the MOST effective SURGICAL treatment?
JOINT REPLACEMENT SURGERY ‘arthroplasty” (HIP, KNEE) with VIGOROUS post-OP REHABILITATION
A CENTRAL pain sensitivity syndrome associated with physical and emotional stressors with WIDE-SPREAD pain and tenderness with ALLODYNIA (pain due to a stimulus that does NOT typically produce pain) and hyperalgesia?
FIBROMYALGIA
First-Degree relatives of patients with this condition are more likely to have MOOD disorders and MIGRAINES?
FIBROMYALGIA
MOOD disorders, FATIGUE, MYALGIA, ARTHRALGIA, PARESTHESIAS, SLEEP DISTURBANCE and COGNITIVE DYSFUNCTION are commonly associated with this disorder?
FIBROMYALGIA
Aside from PAIN, are there any abnormalities noted on physical examination, routine laboratory or imaging tests in patients with FIBROMYALGIA?
NO
WIDE-SPREAD pain, NOT “tenderness” (R & L sides of the body, ABOVE & BELOW the waist, pain in the spine especially LOW BACK PAIN and SHOULDER and BUTTOCK pain) in 11 of 18 SITES elicited on DIGITAL examination is diagnostic for what?
FIBROMYALGIA
Besides treating the underlying issues in a patient with FIBROMYALGIA (sleep, mood disorders, etc.), what is the BEST FIRST-LINE treatment?
NON-PHARMACOLOGIC (REGULAR Aerobic EXERCISE for 30 min/day) with PHYSICAL and COGNITIVE BEHAVIORAL therapy
What are the BEST pharmacologic choices for the treatment of FIBROMYALGIA?
SNRI’s (DULOXETINE or MILNACIPRAN), PREGABALIN or GABAPENTIN and TCA’s (amitriptyline), Cyclobenzaprine
What are the INFLAMMATORY disorders Ankylosing Spondylitis, Psoriatic Arthritis, IBD-Associated Arthritis and Reactive Arthritis (Reiter Syndrome) with inflammation and CALCIFICATION of ENTHESES (the connections between tendons/ligaments and BONE) and NEW BONE formation part of?
SPONDYLOARTHRITIS (HLA-B27 associated)
Family history and HLA-B27 positivity are STRONGLY associated with what disease cluster?
SPONDYLOARTHRITIS
What are the common triggers for REACTIVE Arthritis, a SPONDYLOARTHRITIS?
GI and Urinary infections
What is the trigger commonly seen for PSORIATIC ARTHRITIS, a SPONDYLOARTHRITIS?
Recent TRAUMA/Repeated microTRAUMA (knees and elbows)
What is thought to be the trigger for IBD-associated Arthritis, a SPONDYLOARTHRITIS?
Enteric Bacteria
What should you test for in a patient with PSORIATIC ARTHRITIS or REACTIVE ARTHRITIS who develops a SUDDEN ONSET or SUDDEN INCREASED SEVERITY of their condition?
HIV
In what two (2) SPONDYLOARTHRITIS conditions can you see SAUSAGE-SHAPED digits?
Psoriatic Arthritis and Reactive Arthritis (due to dactylitis)
AXIAL and PERIPHERAL arthritis, Enthesitis, Dactylitis as well as Gastrointestinal, Dermatologic and Ophthalmologic INFLAMMATION is seen in this cluster of disease?
SPONDYLOARTHRITIS
What does the word “SPONDYLO-“ mean?
Affecting the SPINAL vertebra
A MALE patient aged 20-30 presents with c/o PROGRESSIVE INFLAMMATORY BACK PAIN and STIFFNESS of the low back, buttocks, posterior thighs which in time, ASCENDS up the SPINE producing a STOOPED posture with limited mobility of the SPINE and CHEST?
SPONDYLOARTHRITIS
EVEN in a history WITHOUT TRAUMA, back pain in a patient with SPONDYLOARTHRITIS that is NEW, WORSENING or DIFFERENT in character should be examined how and for what?
SPINE Imaging to evaluate for VERTEBRAL fracture, MYELOPATHY and RADICULOPATHY
Progressive ASCENING PAIN and STIFFNESS in the LOWER BACK, BUTTOCKS, POSTERIOR THIGHS and involving the SACROILIAC JOINTS, AORTITIS, RESTRICTIVE LUNG DISEASE, ASYMPTOMATIC INTESTINAL ULCERS and UNILATERAL ANTERIOR UVEITIS is associated with what SPONDYLOARTHRITIS?
Ankylosing Spondylitis
PSORIATIC ARTHRITIS, a SPONDYLOARTHRITIS, is more commonly associated with what OPHTHALOMOLOGIC feature?
CONJUNCTIVITIS
