Arthrite inflammatoire Flashcards
T-Slides
1
Q
What are the main categories of inflammatory arthritis?
A
- Rheumatoid arthritis
- Seronegative arthritis/Spondyloarthritis
2
Q
What types of infectious arthritis are mentioned?
A
- Septic
- Gonococcal
- Lyme arthritis
3
Q
List the types of crystal arthritis.
A
- Gout
- Pseudogout
4
Q
What connective tissue diseases are covered?
A
- SLE
- Sjogren’s Syndrome
- Systemic Sclerosis
- Myositis
5
Q
What are the types of vasculitis described?
A
- Large vessel
- Medium vessel
- Small vessel
6
Q
Identify the non-inflammatory/regional pain conditions.
A
- Osteoarthritis
- Fibromyalgia
7
Q
What are the cardinal features of inflammation in arthritis?
A
- Morning stiffness (typically >60min)
- Worse with rest, better with activity
- Night pain (especially latter half of night)
- Swelling
8
Q
Define the types of arthritis based on the number of joints involved.
A
- Mono-arthritis: 1 joint
- Oligo-arthritis: 2-4 joints
- Poly-arthritis: 5 or more joints
9
Q
Differentiate between acute and chronic arthritis based on duration.
A
- Acute: < 6 weeks duration
- Chronic: > 6 weeks duration
10
Q
What are the characteristics of synovial fluid in non-inflammatory arthritis?
A
- Appearance: Clear
- WBC Count: ≦ 2000
- % PMNs: 50%
- Crystals: No
11
Q
What findings indicate septic arthritis in synovial fluid analysis?
A
- Appearance: Cloudy/pus
- WBC Count: >50,000
- % PMNs: >75% indicative of bacterial infection
12
Q
What conditions can cause monoarthritis in acute cases?
A
- Infection
- Crystal
- Trauma
- Hemarthrosis
- New IA
13
Q
What conditions can cause chronic polyarthritis?
A
- Inflammatory
- Crystal
- Reactive
- Paraneoplastic
14
Q
What is the ACR/EULAR classification score for definite rheumatoid arthritis?
A
Score ≥ 6 is Definite RA
15
Q
What joint involvement scores are part of the ACR/EULAR classification for RA?
A
- 0 = 1 large joint
- 1 = 2-10 large joints
- 2 = 1-3 small joints
- 3 = 4-10 small joints
- 5 = >10 joints, at least 1 small
16
Q
List some extra-articular manifestations of rheumatoid arthritis.
A
- Cardiac issues (e.g., pericarditis, CAD, myocardite)
- Lung conditions (e.g., interstitial lung disease NSIP et IUP, pleural effusion, nodule pulmonaire, bronchiolite obliterans, caplan’s syndrome )
- Hematologic issues (e.g., anemia, Felty’s syndrome, Mx lymphoproliferative )
- Neurologic issues (e.g., carpal tunnel syndrome, C1 et C2 instability )
- Other (e.g., rheumatoid nodules, vasculitis, sclérite, sicca, Raunaud, Neutrophilic dermatose )
17
Q
XR findings of RA
A
periarticular osteopenia
narrowing joint space
marginal erosions
18
Q
What are the contraindications for using Methotrexate (MTX)?
A
- Pregnancy/breastfeeding/childbearing potential (without contraception)
- Known ILD
- Known advanced liver disease
- Pre-existing bone marrow failure/severe cytopenias
- Active severe infection
19
Q
What are the types of DMARDs used in RA management?
A
- Conventional synthetic DMARDs (csDMARD)
- Biologic DMARDs (bDMARD)
- Small molecules/targeted synthetic DMARDs (tsDMARD)
20
Q
Fill in the blank: The ‘Treat to Target’ strategy aims to treat until patients reach a _______.
A
[low disease activity state or remission]
21
Q
What are the side effects of Methotrexate (MTX)?
A
- Hepatotoxicity
- Nausea
- Pancytopenia
- Pulmonary complications
- Oral ulcers
- Alopecia
- Teratogenic
22
Q
What monitoring is required for patients on Methotrexate (MTX)?
A
- Initial CBC, LFTs, Cr q2-4 weeks
- Then q12 weeks after 3 months
- ESR and CRP for disease monitoring
23
Q
True or False: Anti-CCP has 95% specificity and can predict more erosive disease in RA.
A
True
24
Q
What is the risk associated with JAK inhibitors like Tofacitinib?
A
- Increased risk of all-cause mortality
- MACE
- VTE
- Cancer
25
What is the recommended therapy for patients with moderate to severe RA and a lymphoproliferative disorder?
* Use rituximab first line
26
What should be done if a patient with Hepatitis B is starting a biologic DMARD?
* Prophylactic antiviral therapy if core Ab +
27
What are the common side effects of Hydroxychloroquine?
Retinal toxicity, rash, photosensitivity, myotoxicity (rare), cardiotoxicity (rare)
## Footnote
Hydroxychloroquine is used in the treatment of rheumatoid arthritis and other autoimmune diseases.
28
List the side effects associated with Leflunomide.
* GI (nausea, GI pain, dyspepsia, diarrhea)
* Hepatotoxicity
* HTN
* Myelosuppression (rare)
* Peripheral neuropathy
* Teratogenic
## Footnote
Leflunomide is an immunosuppressive agent used in rheumatoid arthritis.
29
What is the contraindication for Sulfasalazine?
Contraindicated if sulfa allergy
## Footnote
Sulfasalazine is often used to treat inflammatory bowel disease and rheumatoid arthritis.
30
What are the initial monitoring requirements for patients on Methotrexate?
Baseline CBC, LFTs, Cr, HBV, HCV
## Footnote
Regular monitoring is essential for early detection of potential toxicity.
31
How often should CBC, LFTs, and Cr be monitored after starting Methotrexate?
Initial CBC, LFTs, Cr q2-4 weeks, then q12 weeks after 3 months
## Footnote
Monitoring helps to manage potential side effects from Methotrexate.
32
What should be done for nausea management in low-dose Methotrexate toxicity?
* Increase folic acid to 5mg daily
* Trial H2 blocker or PPI
* Add leucovorin post MTX dose
## Footnote
These interventions help mitigate gastrointestinal side effects.
33
What should be done in case of hepatotoxicity from Methotrexate?
* Mildly elevated LFTs= reduce MTX dose
* Elevated LFTs > 2x ULN = hold MTX dose then resume at lower dose 1-2 weeks after normalization
## Footnote
Monitoring liver function tests is critical.
34
What risks are associated with biologic therapies?
* Infection (new or reactivation)
* Drug-induced SLE/antibodies
* Local skin reactions
* Malignancy risk
## Footnote
Biologics are often used in the treatment of autoimmune diseases but require careful monitoring.
35
What baseline testing is required before starting a biologic?
* Hepatitis B surface Ag, Surface Ab, Core Ab
* Hepatitis C serology
* TB skin test, IGRA, and/or CXR as appropriate
## Footnote
These tests help assess the risk of serious infections.
36
What is the management approach for patients with prior solid organ malignancy before starting biologics?
Consult Oncologist prior to starting
## Footnote
Oncology consultation is crucial due to the increased risk of malignancy.
37
What are the vaccination recommendations for patients with rheumatic diseases on immunosuppressants?
* Yearly Influenza
* Pneumococcal for patients <65 on immunosuppressants
* Tetanus toxoid as per general recommendations
* Hepatitis A and B for high-risk patients
* Herpes Zoster recommended for patients >18 on immunosuppressants
* HPV recommended for patients aged 26-45
* COVID-19 regular vaccines/boosters as per timelines
## Footnote
Vaccinations should be planned around immunosuppressive therapy.
38
Fill in the blank: Patients on Methotrexate should hold the drug for _______ after receiving a non-live vaccine.
2 weeks
## Footnote
This helps ensure the vaccine is effective and minimizes the risk of adverse effects.
39
What should be done for patients on leflunomide who are planning to conceive?
Measure leflunomide levels and treat with cholestyramine washout if detectable
## Footnote
This is important to minimize teratogenic effects.
40
What is the clinical presentation of EORA?
Elderly onset RA (65y+), M=F, usually more drastic initial presentation, may have PMR-like presentation
## Footnote
Elderly onset rheumatoid arthritis can mimic other conditions.
41
What are the clinical features of Seronegative Arthropathies?
* SI joint/Axial involvement
* Peripheral joints
* Asymmetric, large joint involvement
* Enthesitis, inflammatory back pain, response to NSAIDs
## Footnote
These features help differentiate seronegative spondyloarthropathies from other types of arthritis.
42
What is the first-line therapy for Axial Disease in Seronegative Spondyloarthropathies?
NSAIDs
## Footnote
Non-steroidal anti-inflammatory drugs are the mainstay of treatment.
43
What should be avoided in patients with Psoriatic Arthritis during treatment?
Steroids, due to paradoxical worsening of psoriasis with taper
## Footnote
Careful management of psoriasis is necessary to avoid exacerbations.
44
List the drugs classified as TNF-α inhibitors.
* Etanercept
* Infliximab
* Adalimumab
* Certolizumab
* Golimumab
## Footnote
These medications are used to treat various forms of inflammatory arthritis.
45
What is the management strategy for peripheral disease in Seronegative Spondyloarthropathies?
* Non-pharmacologic: PT, OT, smoking cessation, weight loss, exercise
* Pharmacologic: NSAIDs, glucocorticoids, DMARDs, biologics/small molecules
## Footnote
A multifaceted approach is essential for effective management.
46
What are the FDA Black box warnings associated with Tofacitinib and Upadacitinib?
CV disease, VTE, malignancy, death
## Footnote
JAK inhibitors like Tofacitinib and Upadacitinib have serious safety concerns.
47
What is the safety profile of Abatacept in treating PsA?
Favorable safety profile, especially in terms of infection risk
## Footnote
Abatacept is a CTLA-4 inhibitor used in PsA.
48
List the types of inflammatory arthritis.
* Rheumatoid arthritis
* Seronegative arthritis/Spondyloarthritis
## Footnote
This classification helps in understanding various inflammatory joint diseases.
49
What are the types of infectious arthritis?
* Septic
* Gonococcal
* Lyme arthritis
## Footnote
Infectious arthritis can result from bacterial infections in the joints.
50
What conditions fall under crystal arthritis?
* Gout
* Pseudogout
## Footnote
Crystal arthritis involves joint inflammation due to crystal formation.
51
What are the common causes of Reactive Arthritis?
* C. trachomatis
* Yersinia
* Salmonella
* Shigella
* Campylobacter
## Footnote
Reactive arthritis typically follows infections in the gastrointestinal or urogenital tract.
52
What is the typical presentation of Reactive Arthritis?
Asymmetric, mono- or oligoarthritis, lower extremity predominant
## Footnote
It can also lead to inflammatory back pain and sacroiliitis.
53
What is the first-line treatment for Reactive Arthritis?
* NSAIDs
* Intra-articular corticosteroids
## Footnote
DMARDs may be considered for recurrent or chronic cases.
54
What is the most common causative agent in Septic Arthritis?
S. aureus
## Footnote
This bacterium is prevalent in both native and prosthetic joints.
55
What is the empirical treatment for Gram-positive community-acquired infections in septic arthritis?
Cefazolin 1-2g IV q8h
## Footnote
This is recommended for initial management.
56
What are the two common syndromes of Gonococcal Arthritis?
* Triad of tenosynovitis, vesiculopustular skin lesions, migratory polyarthralgias without purulent arthritis
* Purulent arthritis without skin lesions
## Footnote
Each syndrome has distinct clinical features and treatment approaches.
57
What are the key features of Lyme Arthritis?
* Late onset (>6 months post infection)
* Oligoarthritis with synovitis and swelling
* Most commonly affecting the knee
## Footnote
Symptoms can fluctuate and may include swelling without significant pain.
58
What is the gold standard for diagnosing Gout?
Arthrocentesis with synovial fluid demonstrating MSU crystals
## Footnote
Presence of crystals confirms the diagnosis but does not rule out septic arthritis.
59
What is the risk factor for Gout related to diet?
* Beer
* Red meat
* Seafood
## Footnote
Dietary habits significantly influence uric acid levels.
60
What are the characteristics of CPPD crystals in Pseudogout?
Rhomboid shaped, positively birefringent
## Footnote
These crystals can be identified in synovial fluid to confirm CPPD.
61
What is the treatment for acute Gout?
* NSAIDs
* Colchicine
* Glucocorticoids (IA / PO)
## Footnote
Treatment options are based on the severity and individual patient factors.
62
What is the first-line therapy for chronic Gout?
Allopurinol
## Footnote
It is used to lower uric acid levels and prevent future attacks.
63
What is the significance of Anti-dsDNA in SLE?
Specific (97-98%) for SLE, associated with lupus nephritis
## Footnote
It can be used for monitoring disease activity.
64
What is the entry criterion for SLE classification?
ANA titre ≧ 1:80
## Footnote
This criterion is essential for the diagnosis of SLE.
65
What differentiates Malar Rash from Rosacea?
Malar rash lasts a few days to weeks, spares nasolabial folds, and is precipitated by sun exposure
## Footnote
Rosacea involves flushing, telangiectasias, and can cross nasolabial folds.
66
What is associated with lupus nephritis?
Monitoring disease activity along with serum complements (C3, C4) in concordant individuals
## Footnote
Concordance occurs when there is a flare, high anti-dsDNA, and low complements.
67
Define concordance in the context of lupus nephritis.
When flare, high anti-dsDNA, low complements
68
Define discordance in the context of lupus nephritis.
When flare, above pattern doesn’t apply
69
What does Anti-Sm indicate in lupus labs?
Specific but not sensitive (30-40%)
70
What does Anti-histone indicate in lupus labs?
Drug-induced lupus; SLE (50-70%)
71
What is required for the diagnosis of MCTD?
Anti-RNP
72
What are the risks associated with Anti-Ro (SSA) and Anti-La (SSB)?
Sjogren’s syndrome; risk of congenital heart block and neonatal cutaneous lupus
73
What is the recommended background therapy for all SLE patients?
HCQ (hydroxychloroquine)
74
What are the benefits of using HCQ in SLE management?
Increases survival and decreases risk of renal flare
75
What should be considered for patients with UPCR >500mg/d or hypertension?
ACEi or ARB
76
List general non-pharmacologic measures for SLE management.
* Sun protection
* Regular CV risk assessment
* Smoking cessation
* Bone protection
* UTD vaccinations
* Preventative health care
77
What are the classifications of lupus nephritis?
* Class I: Minimal Mesangial LN
* Class II: Mesangial Proliferative LN
* Class III: Focal LN
* Class IV: Diffuse LN
* Class V: Membranous LN
* Class VI: Advanced sclerotic LN
78
What are the treatment recommendations for lupus nephritis?
Biopsy all SLE patients with glomerular hematuria, proteinuria >0.5g/24h, or unexplained decrease in GFR
79
What is the induction treatment for Class III/Class IV lupus nephritis?
High dose glucocorticoids + another agent (MMF, BEL, CNI, CYC)
80
Identify the preferred treatment for patients with future fertility considerations in lupus nephritis.
MMF (2-3g/day x 6 months)
81
What are the risks associated with Cyclophosphamide in lupus nephritis treatment?
* Infertility
* Infection
* Malignancies
* Cytopenias
82
What are the criteria for Anti-Phospholipid Syndrome (APS)?
Persistent antiphospholipid antibodies with thrombotic events or pregnancy morbidity
83
What is the management for thrombotic APS?
Vitamin K antagonist therapy for life (warfarin)
84
What is recommended for patients with high risk APS profile without prior thrombosis?
ASA 81 mg for life
85
What are the considerations for lupus and pregnancy?
Avoid pregnancy until disease is well controlled; continue HCQ during pregnancy
86
What is the significance of drug-induced lupus?
Common drugs include hydralazine, procainamide, and quinidine
87
What is the clinical manifestation of Livedo racemosa?
Violaceous net-like blotching of skin
88
What is Libman Sacks Endocarditis?
Non-infectious endocarditis associated with APLAS
89
What is the treatment for Libman Sacks Endocarditis?
Steroids and anticoagulation
90
What is the treatment for embolic phenomena?
Steroids and anticoagulation
91
What are the clinical manifestations of Sjogren’s Syndrome?
Mild: Xerostomia, keratoconjunctivitis; Severe: florid salivary gland enlargement, adenopathy, extra-glandular symptoms
92
What are the non-glandular involvements associated with Sjogren’s Syndrome?
* Arthritis
* Vasculitis
* Demyelinating neuropathy
* Glomerulonephritis
* Tubulointerstitial nephritis causing renal tubular acidosis
93
What serological tests are associated with Sjogren’s Syndrome?
* ANA
* Anti-Ro
* Anti-La
* RF
94
What is the increased risk associated with Sjogren’s Syndrome?
>40X increased risk of B-cell lymphoma
95
What diagnostic tests are used for Sjogren’s Syndrome?
* Schirmer’s test (<5mm in 5 minutes)
* Unstimulated salivary flow (<0.1mL/min over 5 minutes)
* Minor salivary gland biopsy (lip biopsy) showing focal lymphocytic sialadenitis
96
What are the differential diagnoses for bilateral parotid gland enlargement?
* Sjogren’s
* Infectious (Mumps, TB, bacterial, Hep C, HIV)
* Sarcoidosis
* Lymphoma
* Alcoholism, Anorexia/bulimia
* IgG4 related disease
97
What is the significance of lacrimal gland enlargement in the context of Sjogren's syndrome?
Raises concern for lymphoma
98
What are the serological markers for Systemic Sclerosis (Scleroderma)?
* Anti-centromere (Limited: CREST 60%, Diffuse 15%)
* Anti Scl-70/topo I (~40% of scleroderma patients, mostly diffuse disease)
99
What are the main manifestations of Systemic Sclerosis?
* Skin
* Raynaud’s +/- ulcers
* Lung (ILD, PH)
* GI
* Kidney (SRC)
100
What is Scleroderma Renal Crisis (SRC)?
* Acute/progressive renal failure
* Hypertension
* Usually bland UA
* Increased risk with prednisone, RNAP3 autoantibodies, and early disease
101
What is the treatment for Scleroderma Renal Crisis?
ACE inhibitor (Captopril)
102
What are the clinical features of Raynaud’s Phenomenon?
Triphasic discoloration of the digits: Pallor, Cyanosis, Erythema
103
What distinguishes primary from secondary Raynaud’s Phenomenon?
Primary: Symmetric, predictable onset (cold); Secondary: Asymmetric, can be progressive
104
What are the first-line treatments for Raynaud’s Phenomenon?
* Calcium channel blockers
* Topical nitrates
* PDE5 inhibitors
105
What are the characteristics of Myositis?
Acute, symmetric progressive weakness of proximal muscle groups
106
What are common antibodies associated with Myositis-specific Syndromes?
* Anti-synthetase Syndrome = Anti-Jo1 Antibody
* Anti-MDA5
* Anti-NXP2
* Anti-TIF1-ɣ
107
What is the gold standard for diagnosing Dermatomyositis/Polymyositis?
Muscle biopsy
108
What are the first-line management options for Dermatomyositis/Polymyositis?
* Exercise
* High dose steroids (0.5-1mg/kg)
* DMARDs (MTX, AZA, etc.)
109
What should be monitored in patients with Systemic Sclerosis for early detection of ILD?
PFTs and HRCT
110
What are the common patterns of ILD seen in Systemic Sclerosis?
* NSIP
* UIP
111
What is the significance of anti-HMG CoA reductase antibody in statin-related muscle events?
Up to 50% are actually statin naïve
112
What are the clinical features of Inclusion Body Myositis?
* Older age
* M > F
* Insidious onset
* Distal > proximal muscle weakness
113
What is the treatment for rapidly progressive ILD in myositis?
Triple therapy (IV steroids + 2 immunosuppressive options)
114
What is the screening recommendation for ILD in patients with rheumatic disease?
Screen with PFT that includes DLCO + TLC and/or HRCT
115
What is the next best treatment for a patient with SLE presenting with fatigue, bruising, and confusion?
High dose glucocorticoids and plasmapheresis
116
What are the symptoms presented by the patient with suspected hemolytic anemia?
Fatigue, bruising, new onset confusion, scattered ecchymosis, petechiae
## Footnote
The patient also has a temperature of 38.6C, HR 110, BP 170/110mmHg, SpO2 94%
117
What laboratory findings are noted in the patient with suspected hemolytic anemia?
Hb 73, MCV 84, WBC 2.3, Plts 29, INR 1.4, Cr 174, bili 75, low haptoglobin, LDH 600, low complements, dsDNA 10, UA shows +blood and protein
## Footnote
These findings indicate anemia, thrombocytopenia, acute kidney injury, and potential hemolysis.
118
What is the PLASMIC score of the patient, and what does it indicate?
7, which is high risk
## Footnote
A high PLASMIC score indicates a higher likelihood of thrombotic microangiopathy (TMA).
119
What is the next best treatment for the patient with suspected TMA?
High dose GC, PLEX
## Footnote
This treatment is initiated while awaiting additional test results.
120
List the types of inflammatory arthritis.
* Rheumatoid arthritis
* Seronegative arthritis/Spondyloarthritis
## Footnote
This is part of the broader classification of inflammatory arthritis.
121
What are the types of infectious arthritis?
* Septic
* Gonococcal
* Lyme arthritis
## Footnote
These infections can lead to joint inflammation and require specific treatments.
122
Name two types of crystal arthritis.
* Gout
* Pseudogout
## Footnote
These conditions are caused by the deposition of crystals in the joints.
123
What are the connective tissue diseases listed?
* SLE
* Sjogren’s Syndrome
* Systemic Sclerosis
* Myositis
## Footnote
These diseases often involve systemic inflammation and can affect multiple organ systems.
124
What are the classifications of vasculitis based on vessel size?
* Large vessel
* Medium vessel
* Small vessel
## Footnote
This classification helps in understanding the types of vasculitis and their potential complications.
125
What clinical features are associated with Giant Cell Arteritis?
* Headache
* Jaw claudication
* Diplopia
* Scalp tenderness
* Amaurosis Fugax
* Stroke
## Footnote
These symptoms are critical for the diagnosis and management of Giant Cell Arteritis.
126
What is the recommended imaging for suspected Giant Cell Arteritis?
* Ultrasound of temporal arteries
* Temporal artery biopsy
* CTA of neck and large vessels
## Footnote
Ultrasound is particularly useful for identifying the halo sign in the arteries.
127
What is the treatment for Giant Cell Arteritis with visual symptoms?
IV pulse steroids 1g x 3 days then Prednisone 1mg/kg daily + Tocilizumab (TCZ)
## Footnote
This aggressive treatment is crucial to prevent vision loss.
128
What are the absolute criteria for diagnosing Giant Cell Arteritis?
* Age ≥ 50y
* Morning stiffness in shoulders and neck
* Sudden vision loss
* Jaw/tongue claudication
* New temporal headache
* Scalp tenderness
* Abnormal temporal artery
## Footnote
Each criterion has specific points contributing to the overall score for diagnosis.
129
What is the preferred imaging modality for Takayasu’s Arteritis?
MRI
## Footnote
MRA or CTA can be alternatives, but MRI is preferred for its detailed imaging of vascular structures.
130
True or False: Imaging is routinely recommended for follow-up in large vessel vasculitis.
False
## Footnote
Imaging is not routinely recommended; however, it can be used for suspected relapse.
131
Mono chronique cause?
OA
IA
Infection ( Fungal/TB)
AVN
132
Poly acute cause
Infectueuse
New
IA
133
Chronic inflammatory arthritis sero-positive ( 7)
RA
SLE
Sclerodermie
Sjogren
Dermatomyosite
Polymyosite
Mixed connective tissue disease
134
Chronic inflammatory arthritis sero-négative ( 7)
arthrite psoriasique
Enterpathic arthritis
Spodylite ankylosante
Arthrite réactive
arthrite indifferentié
135
A 43-year-old male with longstanding seropositive rheumatoid arthritis. He was started on methotrexate with improvement in his joint symptoms. He presents to his follow up appointment and with concerns for “bumps” on extensor surfaces of the hands and elbows.
What do you recommend at this time?
A. Continue MTX and add leflunomide
B. Continue MTX and plan for anti-TNF start
C. Stop MTX
D. No change to therapy
