Arthridides Flashcards
What is the 1 non-inflammatory arthritis we talked about?
osteoarthritis
What are the 5 inflammatory arthritides we talked about?
rheumatoid arthritis
juvenile idiopathic arthritis
systemic lupus erythematosis
crystal induced arthritis (gout and pseudogout0
spondyloarthropathies
Whihc is the most common form of arthritis?
osteoarthritis
What joints does osteoarthritis prefer?
the small joints of the hands - MCPs, PIPs, and DIPs
especially the base of the thumb and the great toe
knees
hips
C-spine and L-spine
WHat is the basis of osteoarthritis?
age-related progressive loss of articular cartilage
Describe the clinical presentation of OA?
it’s a gradual onset of intermittent pain initially
it’s use-related pain in the knees, hips, and hands which is worse with overuse and relieved by rest
morning stiffness less than 30 minutes
What will you see on physical exam in OA?
localized pain to palpation of joint line
limited ROM
bony enlargement - will be hard when pressed (osteophytes)
soft tissue swelling
crepitus
instability/deformity
What are the bumps that develop at the joints in OA called?
Bouchards nodes
What wil you see on x-ray in OA?
sclerosis with new bone formation int he subchondral traveculae
osteophytes (bone spurs at the joint margins)
loss of cartilage (loss of joint space)
What are some non-pharmacologic treatments for OA?
weight reduction for knees
exercise with PT
assistive devices with cane or walker
joint replacement
What are some pharmacological treatments for OA?
acetaminophen and NSAIDS for pain relief
topical agents like capsaicin and methylsalicylate
intra-articular steroid injections
hyaluronic acid derivatives
Will any lab tests show OA?
No lab tests
ESR will be normal, there will be no positive RF, and the synovial fluid will be noninflammatory
What is the age of onset for rheumatoid arthritis? In what gender?
Age of onset from 30 to 50 years old (so younger than OA)
usually women
Describe rheumatoid arthritis.
it’s an insidious onset of inflammatory arthritis which is usually symmetric.
It’s a chronic, progressive, disabling and erosive disease
What joints does RA like?
the wrists, MCPs, PIPs NOT the DIPs!!!
shoulders
knees
what are the two blood markers for rheumatoid arthritis? Can they be false negative?
Rheumatoid factor
anti CCP antibody
they can be negative in RA
What are some extra-articular manifestions of RA?
subcutaneous nodules
pericarditis
pulmonary nodules or fibrosis
inflammatory eye disease
vasculitis
What will you see on an exam of an RA hand/
redness and swelling of the joitns
they’ll be soft, warm, and painful to touch
skin will be shiny due to swelling
relative sparing of the DIP joints
in progressing RA you get MCP joint subluxation with ulnar deviation of the fingers
also development of rheumatoid nodules
extremely severe cases will result in rheumatoid mutans
What will you see on x-ray in RA?
erosion of the bone
misalignment of the mionts
no cartilage (lack of joint space)
Why might someone with RA not be able to move their fingers?
RA causes inflammation of the tendons and this can lead to tendon rupture
What are some meds you can give for RA?
NSAIDs and steroids to reduce the inflammation and help with pain
DMARDs and Biologics to actually slow the progression
How young does a patient have to be to get a diagnosis of juvenile idiopathic arthritis? What gender usualy gets it?
less than 16 years
girls
What are the 3 subtypes of JIA?
systemic onset
polyarticular onset
pauciarticular onset
Describe systemic onset JIA
equal across gender
peak onset 1-6 years
this is a systemic disease with daily spikin gfevers and an evanescent rash. you get lymphadenopathy, hepatosplenomegaly, pericardial effusion, fatigue, weight loss, anemia
RF and ANA are generally negative in this one
about half will end up haing severe chronic athritis
Describe polyarticular JIA
it’s arthritis in 5 or more joints
more in girls
malaise, weight loss, fever, lymphadenopathy, anemia
you can have positive RF in this one, but not always
if they are RF+ they will have a poor progrnosis
Describe oligoarticular/pauciarticular JIA
this one is the most common of the JIAs
you get arthritis affecting 4 or fewer joints
early onset at 1-5 years old, more in girls
affects knees, ankles, wrists, and elbows
POSITIVE ANA - so you need to check their eyes for iridocyclitis because it can cause blindness!!!!!!
In general, what is systemic lupus erythematosus?
an autoimmune disease with producion of antibodies against components of the cell nucleus
these are the antinuclear antibodies = ANA
95% will be ANA positive
What is the age of onset and usual gender for SLE?
peak incidence between ages 15 and 40 with way more females than males.
What are some symptoms to look for in a PE if you’re worried about SLE?
buttery fly rash, discoid rash, photosensitivity, oral ulcers arthrtitis, serositis, renal dysfunction, neurologic symtoms, anemia, epiepsy
In a patient with SLE, if they have a high titer dsDNA antibody, what should you check?
check their kidney unction because it’s associated with glomerulonephritis
If a patient with SLE is pregnant and she’s positive for antibodies to Ro (SSA), what do you need to check for?
Neonatal lupus in the fetus with congenital heart block
How can you differentiate a malar rash from a seborrheic dermatitis or sunburn?
there will be sparing of the nasal labia
Why should you avoid the TNF biologic meds in SLE?
because they’ve been found to cause drug-induced lupus
How can you differentiate drug-induced lupus from SLE?
drug induced will be less severe and in an older person
CNA and renal involvment are rare in drug induced
they’ll have antihistone antibodies, but not ANA
therapy is to just stop the medication
What are the two types of crystal-induced arthritis we talked about?
gout and pseudogout
Gout is depositition of ____ with high blood levels of _____
monosodium urate wit high levels of uric acid
What are the symptosm of gout?
acute inflammatory arthritis in a joint (usually big toe but not always)
in the skin you get accumulation of crystals - look slike white bumps called tophi
in th ekidneys you get uric acid urolithiasis and nephropathy
What are the 3 stages of gout?
asymptomatic hyperuricemia
acute intermittent gout
chronic tophaceous gout
Is hyperuricemia more often caused by uric acid overproduction or uric acid underexcretion?
90% is underxcretion
can be from renal failure, hypertension, obesity, low dose aspirin, DIURETICS, dehydration, starvation
At what age and in what gender does an acute first attack of gout occur?
in 40s - 60s
males much more common
women that do get is have a later onset - usually after menopause with diuretic use, hypertension, or renal insufficiency
Describe an acute episode of gouty arthritis
it’s an abrupt onset of inflammation in a joint, often occurring at night
the pain will escalate over the following 8 hours
may subside within 3 to 10 days on its own
in severe cares you can get fever, chills, and malaise
as there can also be involvment with periarticular structures it is hard to distinguish on sight from cellulitis, bursitis or tendonitis
Acute gout is usually in the ___ extremities, but not always.
lower extremities initially
podagra = first MTP
other MTPs, mid foot, ankles, heels, knees, wrists, fingers, elbows
How do you definitively diagnose gout?
You have to tap the joint and view the fluid under a microscope, looking for crystals
a uric acid level may be normal even if gout is present
How are uric acid levels used in gout?
Since they’re not great in diagnosis, they make better markers for management. The typical target in therapy is to keep it under 6.
What are some triggering factors for gout?
alcohol ingestion
trauma - stubbing the toe
severe illness
IV hydration
thiazide diuretics, low dose aspirin, cyclosporine
high purine foods in diet
contrast dye
Describe advanced gout
this is uncontrolled hyperuricemia with chonic arthritis leading to constant pain in joints
flares will be more intense and will last longer
it’s a destructive arthritis that will be polyarticular at this point, affecting both upper and lower extremities
they often develop solid uric acid deposits called tophi that can drain and become infected
Where are common locations of tophi?
helix of the ear
periarticular regions fo the fingers (heberden’s nodes0, wrists and olecranon bursa
Why shouldn’t you start a patient on allopurinol during their furst acute attack of gout?
It will actually prolong the attack
wait to start them on it after their flare has calmed down
Besides allopurinol (or Febuxostat or probenecid), what can you give/do to treat gout?
NSAIDs, colchicine, pegloticase IV (this gets rid of the tophi), glucocorticoids, analgeics
aspirate the joint
dietary counseling - no alcohol, reduce weight, control hypertension
Which is pseudoogout also known as?
calcium pyrophosphate dihydrate (CPPD) deposition
WHen does pseudogout occur? Gender?
Later in life than gout
men = women
Which joints are most commonly affected in pseudogout
knees ar emost common
wrists
hips
shoulders
ankles
What will X-rays show in pseudogout?
75% of the time, it will show chondrocalcinosis - a thin white line through the joint space
Most pseudogout is idiopathic related to aging, but what are some metabolic diseases that can cause it?
hyperparathyroidism
hemochromatosis
hypothyroidism
How do pseudogout crystals look in comparison to gout crystals?
pseudogout crystals are rhomoboid and blunt at the edges, while gout crystals are long spikes
Is there a lab marker for pseudogout?
nope
What pharmacological treatments are there for pseudogout?
less than for gout
NSAIDs are effective, but colchicine isn’t and ther eis no preventive drug
intra-articular steroid injections will work
What area of the body is affected by the spondyloarthropathies?
the spine, including sacroilliits
In spondyloarthropathis, which will be positive?
HLA B27
RF
CPP antibody
HLA B27 is the gene marker that is present in about 90% of cases
it’s seronegative though, so not RF Or CCP
What are some of the nonvertebral symptoms you can get with the spondyloarthropathies?
platnar fasciitis
inflammatory eye disease
mucocutaneous lesions
asymmetric peripheral arthritis
dactylitis = sausage digits
achilles tenosynovitis
What are the 4 main types of spondyloarthropathies?
ankylosing spondylitis is at the top of the list
psoriatic arthritis
reactive arthritis = Reiter’s syndrome
arthritis associated with IBD/Crohn’s
Describe a presentation of ankylosing spondylitis.
onset before age 40
insidious inflammatory back pain
duration of over 3 months
you get stiffness in the morning and it decreases with exercise (unlike mechanical back pain which is better in the morning and get worse with activity)
axial arthritis and sacroillitis
some peripheral arthritis possible
more often in males
inflammatory eye disease
THEY WILL HAVE A VERY STRAIGHT BACK BECAUSE ITS FUSES - WON’T BE ABLE TO CURVE DOWN TO TOUCH TOES
sometimes cardiac arrhythmias
Why do patients with AS have “bamboo spines”?
because they get ossification on the sides of the spine, making it look like bamboo
won’t be able to bend it
What are some symptoms of psoriatic arthritis?
Associated with psoriasis obvviously, so skin lesions
nail pitting
inflammatory eye disease
peripheral arthritis of the DIP joints
dactylitis = sausage toe
enthesopathy of the achilles tendon
sacroiliitis
arthritis mutilans in bad cases
What will you see on x-rays of the hands in psoriatic arthritis?
A “pencil in a cup” deformity of the finger tips
What does reactive arthritis develop after?
after an infection
usually GI - campylobacter, salmonella, shigella, Yersinia
or genital - chlamydia
those with HLA B27 gene will be predisposed. TYpically in males ages 20-50
Is the reactive arthritis an infection in the joint?
No - it’s inflammation triggered by the bacteria that localizes to a joint
Which joints are usually affected in reactive arthritis? How long after the infection?
usually the knees or ankles
about 1 month after infection
What are some extra-articular manifestations of reactive arthritis?
conjuncitivits
urethritis or cervicitis if chlamydia
genital ulcers
rashes in palms or soles
What is the treatment for spondyloarthrtopathies?
NSAIDs
biologic anti TNF blockers for the axial arthritis
physical therapy and posture education in AS
ABx for Chlamydia
