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Arthritis Flashcards

1
Q

Definition

A

Inflammation of > 1 joints

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2
Q

Types

A
  1. Osteoarthritis (OA)- most common also known as degenerative jt dz
  2. Rheumatoid arthritis (RA)- autoimmune disease
  3. Psoriatic arthritis- autoimmune disease
  4. Septic arthritis- infectious process
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3
Q

Pathophysiology of OA

A

Joint cartilage deteriorates w/ aging (loss of articular cartilage)

Progressive loss of cartilage and bony overgrowth (osteophytes)

Bone cysts may form

Inflammation around articular surface of joint (decrease amount of hyaluronic acid in joint)

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4
Q

Risk factors for OA

A

Age - #1 risk factor

F>M
increase BMI
Joint injury/trauma
Contact sports 
Certain occupations
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5
Q

2 common Signs and Sxs of OA

A
  1. Joint Pain
    Worsens with activity or weight bearing (WB)
    Relieved with rest
  2. Joint Stiffness
    Morning joint stiffness < 30 minutes, becomes less stiff w/ movement
    (RA stiffness greater than 30 mins)
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6
Q

other signs of OA

A

Joint crepitus
↓ ROM
Usually onset is insidious
Commonly affects wrist, hand, hip, knee, back

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7
Q

Herberden’s Nodes

A

OA

DIP joint swelling

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8
Q

Bouchard’s nodes

A

OA
PIP joint swelling

Bouchard is a PImP

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9
Q

OA diagnostics

A

WEIGHT BEARING X-ray while standing (AP/Lateral/Merchant)

  1. Asymmetrical joint space narrowing
  2. Subchondral sclerosis (Shows up as white)
    increase bone formation (density) of articular bone
  3. Bone cysts
  4. Bone spurs (osteophytes)
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10
Q

Lab findings for OA

A

Synovial fluid is NON-inflammatory

Color: clear to straw-colored
Clarity: transparent
<25%
Culture of fluid- negative

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11
Q

OA treatment

A
  1. Weight loss
  2. Low impact physical activity
  3. Pain control
    Acetaminophen - first line
    NSAIDs (Aleve, naproxen BID), intra-articular cortisone (steroid) injection into joint
  4. Physical Therapy
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12
Q

RA

A

Chronic symmetric, inflammatory, peripheral polyarthritis of unknown etiology (autoimmune dz that 1st targets synovium)

Major manifestation- synovitis of multiple joints

Systemic extra-articular involvement (late in disease)- skin, eyes, vascular systems

Juvenile form (JRA) <16 yrs age

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13
Q

Signs and Sxs of RA

A
  1. Morning stiffness >30 minutes (greater than 30 mins)
    Very stiff and lasts > 1 hr after waking
    Pain and stiffness gets better w/ mobility and as day progresses (gets better w/ movement)
  2. Symmetrical polyarthritis, most commonly affecting small joints hands & feet
    Wrists and MCP jts commonly involved
    DIP is spared
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14
Q

systemic manifestations of RA

A
  1. subcutaneous nodules over bony prominences
  2. ocular sxs - dry eyes, scleritis (inflammation of whites of eyes)
  3. vasculitis, pulmonary fibrosis
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15
Q

deformities common w/ progression of RA

A
  1. Boutonniere deformity – flexion of PIP and extension of DIP
  2. Swan neck deformity – flexion of DIP and extension of PIP
  3. ulnar deviated fingers
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16
Q

RA diagnostics Labs general

A
  1. CBC w/diff
  2. Erythrocyte sedimentation rate (ESR)
    Most of time will be elevated
  3. C-reactive protein (CRP)
    Most of time will be elevated
  4. Antinuclear antibody (ANA)
    Auto antibodies body produces
    can be elevated in up to 1/3 of RA pts
    Not diagnostic , also elevated in Lupus, normal healthy people can have elevated ANA 5% of time and it wont mean anything
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17
Q

what 2 labs are specific for RA

A
  1. Rheumatoid factor (RF )
  2. Anti-cyclic citrullinated peptide antibodies (anti-CCP)
    Positive in 70-80% pts w/ RA
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18
Q

X-ray for RA would show what

A

STS
joint space narrowing
MCP, MTP and or PIP involvement

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19
Q

how would you describe the synovial fluid in RA

A

Inflammatory

Color: straw to milky

> 2000-7500 WBC/mcl

PMNs 50% or more

negative string test

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20
Q

Objectives of RA tx

A

decrease inflammation and pain
prevent disease progression
preserve function/ROM
prevent deformities

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21
Q

First line for RA to prevent disease progression

A

Methotrexate (Rheumatrex)

1st synthetic DMARD
First Line for RA to retard or halt disease process

Folate analog
Inhibits dihydrofolate reductase, therefore inhibits DNA synthesis

In RA, principle moa is inhibiting neutrophils

Tetratogenic

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22
Q

second line synthetic DMARD for RA

A

Sulfasalazine (Azulfidine)- second line for RA

Suppress T-cell or B-cell activation (etiology unknown)

Side effects (n/v/ha/ skin rashes/leukopenia) 
causes about 30% pts to d/c drug

Other DMARDS- azathioprine, cyclosporine, hydroxychloroquine (Plaquenil)

Give if child bearing age, or for IBD

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23
Q

2 common synthetic DMARDS for RA

A

MTX - first line to prevent progression

Sulfasalazine- second line for RA

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24
Q

Biologic DMARDS for RA treatment

A

usually prescribed w/ MTX

Etanercept (Enbrel)- SQ

Adalimumab (Humira)- SQ
Human monoclonal antibody-TNF inhibitor

Infliximab (Remicade)- IV
Monoclonal antibody
Potential SE - development of TB

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25
NSAIDS for RA tx
provides symptomatic relief, but does not alter disease progression used in conjunction w/ DMARDS Indomethacin (inhibits prostaglandin production, COX 1 and COX 2) Celecoxib (selective COX2 inhibitor)
26
Corticosteroids for RA tx
Oral prednisone 5-10 mg daily inhibit prostaglandin synthesis Prolonged use can lead to: Hyperglycemia, osteoporosis, poor wound healing Can be used short-term while other DMARDs take effect
27
Definition of psoriatic arthritis
Inflammatory arthritis w/ skin involvement Psoriasis precedes onset of arthritis 80% of cases (up to 2 yrs)
28
Signs and sxs of psoriatic arthritis
Symmetric polyarthritis (resembles RA) * “Sausage”digits (dactylitis) of fingers & toes (DIPs)* Sacroliitis and spinal involvement common Pitting of nails and onycholysis are common
29
psoriatic arthritis labs
ESR and CRP RF negative HLA-B27 (gene marker associated with rheumatologic diseases, positive is PA, reactive arthritis and alkylosing spondylitis)
30
psoriatic arthritis x-ray
SHARPENED PENCIL | irregular destruction of joint and bone
31
Are DIP joints affected in PA? RA?
RA- DIP are spared | DIP are affected in PA and OA
32
TX for psoriatic arthritis
1. NSAIDS - mild case 2. MTX *drug of choice in pts who do not respond to NSAIDS* improves cutaneous and arthritic manifestations 3. TNF inhibitors (biologic DMARD) added if MTX not effective
33
Septic Arthritis; General
usually single joint involved bacteria spread by blood to joint Most commonly knee, followed by hip, shoulder, ankle, wrist Children less than 3 - hip MC
34
what is the most common pathogen to spread septic arthritis
Staph aureus
35
risk factors for septic arthritis
Previous joint damage IV drug use Immunocompromised pts
36
signs and sxs for septic arthritis
acute swelling of joint (30mins-1hour) fever joint warmth erythema Tenderness (pain w. ROM)
37
fluid analysis for septic arthritis
yellow- green 50,000-100,000 WBC!!!!
38
septic arthritis diagnostic studies
1. X-ray for STS 2. Joint aspiration *diagnostic* Differentiates between inflammation & infection send for C&S
39
TX for septic arthritis
1. drain and start empiric abc *start broad spectrum ABX8 cover staph, step, gram negative 2. Hospitalization always necessary 3. Ortho consult immediately
40
2 types of arthritis that are inflammatory
RA Psoriatic arthritis
41
population of gonococcal arthritis
Usually occurs in otherwise healthy sexually active young adults, M or F Most common in young women onset of menses
42
signs and sxs of GC Arthritis
1. *Prodromal migratory polyarthralgias involving wrist, knee, ankle or elbow* 2. *Joint pain occurs over 1-4 days (septic is more acute*) Fever Abdominal pain Dysuria
43
two forms of GC arthritis
1. Tenosynovitis (commonly wrists, fingers, ankles, or toes), skin rashes, polyarthralgia syndrome, fever, chills, generalized malaise Skin lesions 2. Purulent monoarthritis w/o skin lesions (frequently knee, wrist, ankle or elbow) Affects one joints, no skin lesions
44
Lab studies for GC arthritis
1. Joint fluid aspirate Cultures Urethral, rectal, throat cultures & BC should be done on all pts suspected of GC arthritis 2. Urinary NAAT for N. gonorrhea 3. x-ray- sts if in joint
45
GC Arthritis treatment
1. Admission to hospital to confirm dx 2. Joint aspiration to drain infected fluid 3. IV Abx x 48-72 hrs, then change to IM Abx x 7-14 day course 3rd generation cephalosporin - Ceftriaxone IV, Cefixime PO
46
Reactive Arthritis
Formerly Reiter’s Syndrome infection in body, body is reacting and get arthritis TRIAD - urethritis (usually first), conjunctivitis, oligoarthritis (last) mouth ulcers GU pathogens- chlamydia GI - shigella
47
signs and sxs for reactive arthritis
1. *Asymmetric sterile oligoarthritis (1-4 joints)* Large WB joints Knee & ankle 2. Dactylitis Painful oral ulcers Penile lesions Ulcers on extremities, palms and soles Plantar heel pain Fever & weight loss common
48
Reactive arthritis diagnostics
increase ESR, CRP, HLA- B27 clinical based on hx, sxs nand triad (back pain, few weeks ago have dysuria and GU sxs, ask about eyes)
49
TX for reactive arthritis
Usually self-limited process (3-12 mos) but symptomatic tx needed NSAIDs- Mainstay of treatment If one joint, cortisone injection if not responding to NSAIDS - sulfasalazine
50
2 forms of crystal induced arthritis
1. gout | 2. pseudogout
51
general info on gout
Metabolic disease marked by uric acid deposits causing painful arthritic joints podagra - gout of big toe Hyperuricemia results from: 1. Under-excretion problem Most common 2. Overproduction problem
52
risk factors for gout
1. M>F 2. Family hx of gout 3. Alcohol Beer 4.Medications Diuretics (loop or thiazide) Chemotherapy – release of uric acid Niacin 5. Diet – high protein, salmon, liver, red meat, 6. Chronic kidney disease – not excreting as much uric acid as they should be 7. Hypothyroidism
53
signs and sxs of gout
1. Sudden onset joint PAIN Frequently nocturnal 2. 1st MTP jt (Podagra) Can affect knee, ankles & other toes also 3. Localized erythema, swelling, warmth Dusky red, tense, warm skin over joint +/- fever Tophi may be found in chronic disease *red, hot, swollen, painful big toe)
54
lab diagnostics for gout
1. serum uric acid > 6 | * 2. monosodium urate crystals, needle-like negatively birefringent crystals*
55
X-ray for gout later in disease will show:
"rat bite" may be seen late in disease Punched out erosions with an overhanging rim of cortical bone
56
acute tx for gout
1. NSAIDS indomethacin, celebrex contraindications: renal disease, allergy to NSAIDS, active PUD 2. colchicine, second line after NSAIDS or if pts can't take NSAIDS
57
pseudogout general
Calcium pyrophosphate dihydrate (CPPD) deposition disease in fibro- and hyaline cartilage Chondrocalcinosis of affected joints Most common: knees and wrists
58
risk factors for pseudogout
age > 60 | OA
59
signs and sxs for pseudogout
painful inflammation of a joint | +/- redness
60
Dx studies for pseudogout
*Calcium pyrophosphate crystals Rhomboid-shaped positively birefringent* calcium pyrophosphate dihydrate (CPPD) joint fluid
61
x-ray of pseudogout
Fine linear calcifications in cartilage -chondrocalcinosis incidental finding on xrays: does not always cause symptoms calcified meniscus
62
treatment of pseudo gout
1. Treat underlying disease, (OA) if present 2. NSAIDs – acute pain Indomethacin / Indocin Naproxen / Naprosyn Celebrex 3. Intra-articular steroid injection when NSAIDs contraindicated

Ortho (5 decks)

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