Adult Patient with Arthritis Flashcards
What is the first line medical treatment for Rheumatoid Arthritis?
Methotrexate (synthetic DMARD)
What is the gold standard diagnostic test to differentiate Gout from Pseudo-gout, and what will you see?
Synovial Fluid
Gout: needle shaped monosodium urate crystals negatively birefringent
Psuedogout: Rhomboid shaped CCPD crystals, positively birefringent
Methotrexate is a teratogen, what is the alternative treatment for RA if your patient becomes pregnant?
hydroxychloroquine
RA articular manifestations
ulnar deviation
boutonniere deformity
swan neck deformity
What are common extra-articular manifestations of RA?
Derm: Rheumatoid nodules Mucosal: Sicca symptoms, Sjogren syndrome Ocular: scleritis Pulmonary: Interstitial fibrosis Cardiac: pericarditis, pleural effusion Lymph: lymphedema
What are major differences between RA and OA?
RA: rapid onset, typically in 20s - 40s. symmetrical joint involvement, polyarticular. joint pain may improve with usage of joint. systemic symptoms include fatigue and malaise.
OA: slow onset, typically in older age. often begins unilaterally and limited to one set of joints. joint pain worsens with usage of joint. no systemic symptoms.
What are the four seronegative spondyloarthropathies?
P: psoriatic arthritis
A: ankylosing spondylitis
I: IBD associated arthritis
R: reactive arthritis
In a synovial fluid analysis you see crystals that are rhomboid shaped and positively birefringent. What is the most likely diagnosis?
Pseudogout
What joint in the hands is typically spared in RA, compared to OA?
DIP
What is the typical presentation of end stage psoriatic arthritis?
Arthritis Mutilans
What joints are commonly affected by Rheumatoid Arthritis?
Symmetric small joints—MCP, PIP, and MTP (spares DIP) joints
What is the common age of onset for RA vs OA?
20’s to 40’s
How does septic arthritis occur?
- hematogenous spread (>50%)
- direct inoculation
- spread from adjacent tissue infection
What are possible complications of septic arthritis?
- osteomyelitis
- persistent/recurrent infection
- decreased joint mobility
- ankylosis
- persistent pain
What are the early treatments for septic arthritis (caused by gram-positive cocci) in prosthetic joints?
Salvage prosthesis; debride + antibiotics ( IV vancomycin)
Are males or females more likely to develop reactive arthritis post-GU?
Males > females
Which lab test is more sensitive for RA, rheumatoid factor or anti-CCP?
anti-CCP
True or false: When performing a synovial fluid analysis, you should attempt to guide the needle into the most infected area to obtain the most accurate cell counts?
False
What is the most common cause of reactive arthritis?
Leukemia
Crepitus is most commonly noticed with which arthritis? (OA or RA)
OA
What will you see on x-ray of someone who has ankylosing spondylitis?
Bamboo spine
True or false: passive range of motion is painless in someone with septic arthritis.
False. PROM is extremely painful in those with septic arthritis
First-line treatment for ankylosing spondylosis?
NASIDs- for pain and stiffness
Physical exercise and PT- help delay progression and prevent spinal deformity
Then can move on to: DMARDs or Anti-TNF, surgery
Common presentations of psoriatic arthritis?
Spondyloarthropathy, dactylitis (sausage fingers/toes), enthesitis (inflammation of tendon insertions), skin plaques, onycholysis
For a patient with osteoarthritis, is Acetaminophen or Ibuprofen a better first line treatment and why?
Acetaminophen because it has a safer toxicity profile than NSAIDs
What is the term for when an individual has gout in the 1st MTP?
Podagra
What is the first line treatment for reactive arthritis?
NSAIDs (Ibuprofen 600-800 mg PO every 6-8 hours prn)
What are the clinical findings of fibromyalgia?
Pain (allodynia & hyperalgesia), fatigue, non-restorative sleep, depression & anxiety, impaired cognition, morning stiffness, others (GI upset, incontinence, pelvic pain, dysmenorrhea, neuro complaints)
What is the treatment for gout?
NSAIDs first line, corticosteroids if can’t take NSAIDs
What are the preventative treatments for gout?
Diet modifications, allopurinol, Prophylactic colchicine
What is septic arthritis until proven otherwise?
acute, monoarticular arthritis
What is the most common pathogen responsible for reactive arthritis?
Chlamydia
What medications can trigger a gout exacerbation?
diuretics (loops, thiazides)**
salicylates
contrast
What radiographic findings suggest OA?
irregular joint space narrowing**
osteophytes (bone spurs)**
subchondral sclerosis
What is the Schober’s test?
It is used in the physical exam evaluation of what joint condition?
tests lumbar spine flexion
ankylosing spondylitis (will be decreased, <5cm)
What are the common causes of excess urate contributing to gout?
Alcohol Anchovies Organ meat Asparagus Cocoa Mushrooms Spinach Trauma
What is the most common joint disease affecting adults worldwide?
Osteoarthritis
What are some risk factors for septic arthritis?
Extremes age, IV drug use, diabetes, autoimmune disease/immunocompromised, prosthetic joint
Thick and dystrophic nails commonly referred to as Reiter’s nail can be a clinical presentation for which type of arthritis?
Reactive arthritis
What do OA and RA have in common?
PIP Joints Affected
Morning Stiffness
What does HLA stand for?
Human Leukocyte Antigen
What are some common extra-articular manifestations of reactive arthritis?
Conjunctivitis, anterior uveitis, urethritis, circinate balanitis, oral ulcers, keratoderma blennorrhagicum
Reiter Syndrome in reactive arthritis is associated with what 3 manifestations?
Reiter Syndrome = peripheral arthritis + conjunctivitis +urethritis/cervicitis
Things that reactive arthritis, enteropathic arthritis, ankylosing spondylitis, and reactive arthritis have in common (lab wise)
Negative RF and ANA.
Positive HLA-B27
Anklyosing spondylitis common XR finding
Bamboo spine
Main cause of reactive arthritis
post GI or GU infection 1-4 weeks after it.
What are the potential complications of osteoarthritis?
Gout, Pseudogout, osteonecrosis, Baker’s Cyst, Buritis, Meniscal Tear
What radiological deformity is common with Psoriatic Arthritis?
Pencil in a cup deformity
Screening Images to look for in CPPD (Psuedogout)
AP View of Pelvis, Knees, hands
Xray finding in CPPD (Psuedogout)
Chrondrocalcinosis (Linear densities in hyaline articular cartilage)
What are some pieces of information you want to know/ test on a patient before prescribing a DMARD?
if they have history of TB or hepatitis because DMARDs cause immunosuppression and can increase the reactivity of these diseases.
what is the treatment for IBD associated arthritis?
treat IBD and get bowel disease under control
What must be ruled out first when you suspect IBD associated arthritis?
Septic arthritis
What is a complication at end stage Psoriatic arthritis that presents with subluxation and mutilating of the joint?
Arthritis Mutilans
Your pt has RA and is taking Methotrexate. What should you prescribe to reduce its side effects?
Folic Acid
What are the four different types of Pseudogout (CPPD)?
Classic CPPD
Pseudo-OA CPPD
Mimic RA
Meningitis Mimic
What is the epidemiology of Gout?
25% of the time hyperuricemia progresses to gout
Men at 45
Women at 65
What is the leading cause of disability?
Osteoarthritis
What conditions are included with the acronym, PAIR?
Psoriatic arthritis
Ankylosing spondylitis
Inflammatory bowel disease
Reactive arthritis
Which diseases are associated with an increased level of HLA-B27?
PAIR
True or false: Prosthetic joints in septic arthritis that have a late presentation usually develops more than four weeks after implantation
True
What is the most common pathogen that causes septic arthritis?
Staph aureus
Describe the boutonniere deformity sometimes seen in late RA…
flexion at PIP, Hyperextension at DIP
What are some of the diseases commonly associated with a positive RF?
RA, Sjogren syndrome, SLE, etc.
What is the most common mechanism of spread in septic arthritis?
Hematogenous
What is the abnormal cardiac finding associated with ankylosing spondylitis?
1st degree AV block
How do you tx neonates with septic arthritis?
3rd generation cephalosporin
A patient comes in with psoriatic arthritis with increased pain in their knees. You want to do a glucocorticoid injection of both knees; however, there is a plaque over the right knee where you would normally inject. Is it okay to proceed with both knees?
No. Do not inject into a plaque.
What are differentiating characteristics of Join stiffness in RA, OA, and AS?
RA - AM stiffness lasting longer than 30 min
OA - AM stiffness lasting up to 30 min (self limited)
What are the differentiating characteristics of axial spine stiffness noted in AS?
- Low back pain and stiffness > 3mo,
- Better with exercise,
- worse with rest
True or False: IBD associated arthritis is correlated with flares in the bowel?
True
Describe the joint pain seen in IBD-associated arthritis?
Migratory (moves joints), rarely erosive
What is the most common joint affected in septic arthritis?
The knee
True or False: Reiter Syndrome is the same as Reactive arthritis.
False; Reiter syndrome is a type of reactive arthritis
What is the first choice of non-pharmacologic treatment for ankylosing spondylitis?
Physical therapy: avoid spinal deformity and loss of motion through swimming
True or false: On physical exam, a patient with OA will have crepitus, bony enlargement, and tenderness to palpation over the joint.
True.
What is Scleritis and where is it commonly seen?
inflammation deep in the sclera that can lead to eventual blindness.
Associated with RA
What is the LOSS acronym of Osteoarthritis?
L - loss of joint space
O - osteophytes
S - subchondral scleroses
S - subchondral cysts
What dermatologic findings may be seen in enteric arthritis?
Erythema nodosum, pyoderma gangrenosum
What CBC finding is associated with ankylosing spondylitis?
normocytic normochromic anemia of chronic disease
What is the treatment for reactive arthritis?
NSAIDS, Antibiotics, DMARDS
What are common risk factors for nongonococcal acute bacterial (septic) arthritis?
Previous joint damage and IV drug use
criteria to diagnose definite vs probable vs possible CPPD
definite- both positively birefringent crystals and calcification on xrays
probable - either positively birefringent crystals or calcification on xrays
possible - chronic arthritis like osteoarthritis but atypical joint involvement with “attacks”.
name prophylactic medications for gout
allopurinol - inhibits uric acid production
probenecid - increases uric acid excretion in the urine
What are the types of bacteria associated with Reactive Arthritis?
Chlamydia (MC), Campylobacter, Yersinia, Salmonella, HIV, and Shigella
What are the prototypical findings associated with Ankylosing Spondylitis?
a young, adult male, who has chronic low back/buttocks pain which improves with exercise but DOES NOT relieve with rest.
- Decreased ROM in Lumbar Spine (Schober Test)
- Limitation of chest wall expansion
Are men or women more likely to develop Ankylosing Spondylitis? And their age?
Men > women, Young adult.
What are some infectious triggers of psoriatic arthritis?
Strep, HIV
What will distinguish osteoarthritis vs RA on a diagnostic image?
Osteoarthritis will have asymmetric joint narrowing and RA will show symmetric joint narrowing
What is the first line treatment for the rheumatologic d/o that is classic for bamboo spine
NSAID
True or false you treat acute flares or gout and pseudogout the same?
True. Indomethacin (1st line), colchicine, glucocorticoids.
True or false: in psoriatic arthritis the psoriatic rash always precedes the arthritis?
False, the arthritis can occur prior to the rash but is not as common
Treatment for an IVDU w/ septic athritis
IV Vanc + Ceph
Flares of pseudogout are most common after what?
Anesthesia and Surgery (Thyroidectomy)
What medication can precipitate a gout attack?
Loop diuretics, Thiazide diuretics
Risk Factors for Osteoarthritis
Age, Female, prior injuries to the joints, body weight
