Arthridites and Vasculidities Flashcards
Non-inflammatory symptoms
exacerbated by activity and relieved with rest; stiffness last less than 30 minutes
Osteoarthritis
Leading cause of arthritis in the adult, mainly affecting the elderly; chronic, slowly progressive in weightbearing joints (hands, knees, hip, lower back, neck)
Osteoarthritis clinical features
- Clinical features: A.M stiffness, gel phenomenon, joint pain and tenderness, crepitus (knees), bony swelling, angulation deformities
o Heberden’s node – hard or bony swellings that can develop in the distal interphalangeal joints (DIP)
o Bouchard’s node - hard, bony outgrowths or gelatinous cystson theproximal interphalangeal joints (PIP)
Osteoarthritis lab findings
normal laboratory and synovial fluid because the disease is non-inflammatory
Osteoarthritis radiographic features
joint space narrowing, spur (or osteophyte) formation, does not correlate with symptoms
a. Diffuse idiopathic skeletal hyperostosis: lumbar spine
i. bony hardening (calcification) of ligaments in areas where they attach to your spine.
b. First carpometacarpal joint
i. joint formed by the trapezium bone on the wrist and at the first metacarpal bone of the thumb
c. Spinal stenosis – caused by osteophytes compressing the spinal cord
Osteoarthritis joint effusions
septic usually have > 50,000 leukocytes
Osteoarthritis treatment
weight loss, acupuncture, physical therapy (muscle strength), devices to take pressure off the affected joint (cain), medications (NSAIDs, narcotics), intra-articular corticosteroid injections, joint replacement
Inflammatory symptoms
Prolong stiffness > 1 hr, gets better with activity
Rheumatoid arthritis
inflammatory joint disease (1% prevalence), CD4+ T cell mediated inflammation, associated with HLA-DR4 -> bilateral symmetrical arthritis, lasts at least 6 weeks (think viral infection before)
Rheumatoid arthritis characteristics
- Soft tissue swelling or fluid in at least 3 joint areas simultaneously
i. bilateral symmetrical arthritis affecting small joints, at least one area swollen in a wrist, MCP, or PIP joint - Rheumatoid nodules
- Affects the neck but not lumbar spine (X-ray before surgery)
- In older adults, Sjogren’s syndrome may manifest by ocular (lacrimal) and oral (salivary) dryness
Rheumatoid arthritis clinical findings
a. Tendon rupture
b. Nodules ulnar deviation
c. Swan neck and boutonniere deformity
d. Arthritis mutilans
e. Episcleritis, corneal disease
Rheumatoid arthritis extraarticular manifestations
a. Causes variety of nonspecific symptoms including malaise, myalgias, fever, weight loss, and fatigue
b. Rheumatoid nodules typically over the elbow but can develop at any location
c. Inflammation of the lining of the heart, lung, eye, etc.
d. Nodular cavitary
Rheumatoid arthritis lab findings
a. Rheumatoid factor – 80% of patients
i. Found in other rheumatologic and non-rheumatologic conditions (normal individuals, chronic infection)
b. Anti-cyclic citrullinated antibody (anti-CCP) – more specific (95%), poor prognosis
c. ESR and CRP are useful for differentiating from noninflammatory conditions
d. Anemia of chronic disease
Rheumatoid arthritis radiographic findings
symmetric involvement, marginal erosions (pannus formation -> hyperplastic synovial cells, inflammatory cells, followed by bone and cartilage loss), joint swelling, juxtaarticular osteopenia, joint-space narrowing
Rheumatoid arthritis treatment
a. Non-biologic: methotrexate (1st line)
b. Biologic: anti-TNF alpha
i. Rituximab – most effective, mAb to C20 that depletes B cells
Gout
- Prolonged period of asymptomatic hyperuricemia precedes the initial acute gouty attack o Most people with elevated uric acid levels never develop gout - Caused by monosodium urate crystal deposition in joints o Undersecretion (90%) – idiopathic, renal insufficiency, drugs and toxins o Overproduction (10%) – ethanol, HGPRT or G6PD deficiency, PRPP synthetase overactivity, cytotoxic chemotherapy
Gout stages
a. Acute gouty arthritis
i. Abrupt onset of severe joint inflammation, often with onset in the night
ii. 75% of initial attacks in 1st MTP joint (podagra), usually monarticular, lasts 3-10 days
iii. joint is warm, swollen, erythematous, tender
b. Intercritical stage
c. Chronic tophaceous gout (large crystalline aggregates) in the ear, toes
Gout lab findings
needle shaped urate crystals, negatively birefringent crystals
What causes acute gout attack?
Acute attacks tend to occur after large meal and alcohol consumption (alcohol metabolites (lactic acid) compete for same excretion site in kidney as uric acid)
Gout treatment
o Analgesic: NSAID, colchicine, glucocorticoids
o Prevention medication: DO NOT start during acute gout, goal of
Calcium pyrophosphate dihydrate (CPPD, or pseudogout)
Deposition of calcium pyrophosphate within the joint space
Pseudogout crystals
Crystals are rhomboids, positive birefringent crystals
Pseudogout presentation
- Presentation similar to gout
o Chondrocalcinosis (deposition of calcium in the joint)
♣ Most common in the knee
♣ X-ray shows crystal deposits punctate and linear densities in the articular cartilage
Pseudogout treatment
similar to gout but there is no effective preventive measure -> NSAID, colchicine, steroid
Calcium hydroxyapatite: Milwaukee shoulder
Elderly individuals (mostly women), swollen shoulder - Crystal deposition in the joint causes the release ofcollagenases,serine proteases,elastases, andinterleukin-1. This precipitates acute and rapid decline in joint function and degradation of joint anatomy.
Seronegative spondyloarthropathies names
“PAIR” - psoriatic arthritis, ankylosing spondylitis, inflammatory bowel disease, reactive arthritis
Seronegative spondyloarthropathies common characteristics
- Absence of rheumatoid factor
- Strong association with HLA-B27
- Pathologic changes in ligamentous attachments rather than the synovium
- Involvement of the sacroiliac joints, with or without other joints
Ankylosing spondylitis presentation
Back discomfort before age 40, 70% male; chronic, insidious onset longer than 3 months, morning stiffness > 1 hr, improvement with exercise
Ankylosing spondylitis diagnosis
limited lumbar motion, low back pain not relieved by rest, pain awakens patient at night, sacroiliitis on X-ray, HLA-B27 (90-100%), patient bends over when walking; may develop uveitis (inflammation of the middle layer of the eye and aortic regurgitation
Ankylosing spondylitis radiographic finding
Bamboo finding: vertebral body fusion by marginal syndesmophytes; sacroiliitis
Ankylosing spondylitis treatment
anti-TNF
Reactive arthritis triad
conjunctivitis, urethritis, arthritis
Can’t pee, can’t see, can’t bend my knee”
Reactive arthritis presentation
Starts with urethritis or diarrhea (Shigella, Salmonella, Campylobacter, Yersinia, Chlamydia infections) -> eventually leads to conjunctivitis and arthritis
Reactive arthritis other associations
Often associated with enthesopathy (tendinitis), circinate balanitis (dermatitis of the penis), oral ulceration or keratoderma blennorrhagica (vesico-pustular waxy lesion with a yellow brown color)
Reactive arthritis treatment
anti-TNF
Inflammatory bowel disease types
Crohn’s disease, ulcerative colitisCrohn’s disease, ulcerative colitis
Psoriatic arthritis
10% patients with psoriasis, joint pain and stiffness; asymmetric and patchy involvement
Psoriatic arthritis clinical findings
Dactylitis - “sausage finger”; nail dystrophy and arthritis
Psoriatic arthritis x-ray findings
pencil-in-cup deformity, asymmetric erosive arthritis, arthritis mutilans
Psoriatic arthritis treatment
anti-TNF
Infectious arthritis causes in different age groups
H. influenza (
Infectious arthritis presentation
swollen joint with restricted range of motion, red and painful, systemic effects
Gonococcal arthritis
migratory arthritis with asymmetric pattern
STD = synovitis (knee), tenosynovitis (hand), dermatitis (pustules)
Small vessel vasculitis names
Henoch Schonlein purpura, Cryoglobulinemia, Wegener’s granulomatosis (gramulomatosis with polyangiitis), Churg-Stauss disease (eosinophilic granulomatosis with polyangigiitis)
Henoch Schonlein purpura
a. Acute IgA mediated disorder
b. Most common childhood (2-8 years old) systemic vasculitis
c. Diagnosis: tetrad
i. Purpura (commonly below the waist), abdominal pain, arthritis, hematuria
Cryoglobulinemia
a. Cryoglobulins (Ig that precipitate under cold conditions)
b. 90% of patients have hepatitis C, treat both diseases
c. Manifestation: purpura, gangrene, glomerulonephritis, sensory neuropathy
Wegener’s granulomatosis (granulomatosis with polyangiitis)
a. Triad: focal necrotizing vasculitis, necrotizing granulomas in the lungs and upper airway, necrotizing glomerulonephritis
i. Blood nasal drainage, abnormal chest radiograph, glomerulonephritis
b. Anti neutrophil cytoplasmic antibody (cANCA) is anti-proteinase 3
i. Specific for Wegener’s
c. Treatment: cyclophosphamide, corticosteroids
Churg-Stauss disease (eosinophilic granulomatosis with polyangigiitis)
a. Late onset asthma, purpura, peripheral neuropathy (wrist drop), pulmonary infiltrates (> 10% eosinophils)
b. 60% are positive for p-ANCA (anti-myeloperoxidase)
Medium-vessel vasculitis
Polyarteritis nodosa
Polyarteritis nodosa (PAN)
a. Young adult
b. HBV seropositivity in 30% of patients
c. Fever, weight loss, malaise, headache
d. GI problems, testicular pain, skin, arthritis
e. Hypertension, kidney disease, neuropathy
- Wrist drop is positive
a. PAN – “Pulmonary Arteries Not damaged”
f. Lab findings: innumerable renal microaneurysms and spasms on the angiogram
Large vessel vasculitis
Giant cell (temporal) arteritis, Takayasu arteritis
Giant cell (temporal) arteritis
a. Usually elderly women
b. New headache, jaw claudication (pain with chewing
c. Temporal artery abnormality (tender or decreased pulse), most commonly affects branches of the carotid artery
d. Elevated ESR
e. Abnormal artery biopsy: cell infiltrate, granuloma
f. Treatment: steroids immediately prior to a temporal artery biopsy to prevent irreversible blindness
g. 50% of patients develop polymyalgia rheumatica
i. Presentation: aching and stiffness of the upper or lower extremities
1. Elevated ESR
2. Rapid response to low dose corticosteroids
Takayasu arteritis
a. Usually Asian females 10 mm Hg between arms, fever, night sweats, arthritis, myalgias, skin nodules, ocular disturbance
d. Most commonly affects the aortic arch and proximal great vessels (subclavian)
e. Treatment: corticosteroids
