Arthritis Flashcards
In a UK National Morbidity Survey, rheumatic
disease composed just over_______ of all morbidity
presenting to the family doctor
7%
The commonest cause of arthritis was________
which affects 5–10% of the population
osteoarthritis (OA),
The population incidence of rheumatoid arthritis
(RA) is _____
1–2%.
There should be no systemic manifestations with ______
OA.
The pain of inflammatory disease is ______ at rest
(e.g. on waking in the morning) and improved by
_____
worse
activity
Causes of _______ include crystal deposition
disease, sepsis, osteoarthritis, trauma and
spondyloarthritis
monoarthritis
______ is almost exclusive to males: in
women, it is usually seen only in those who are
postmenopausal or taking ________
Acute gout
thiazide diuretics
The probability diagnoses for the patient presenting
with arthritis are:
- ______ (mono- or polyarthritis)
- ______ (if acute and polyarthritis
osteoarthritis
viral arthritis
OA is very common in general practice. It may be
primary, which is usually ________, and can affect
many joints
symmetrical
secondary OA follows _______
injury and other wearand-
tear causes
Viral polyarthritis is more common than realised.
It presents usually within ______days of the infection,
and is usually mild
10
Serious disorders not to be missed
It is important to be forever watchful for_________. It presents typically as a migratory
polyarthritis involving large joints sequentially, one
becoming hot, red, swollen and very painful as the
other subsides. It rarely lasts more than 5 days in any
one joint
rheumatic fever (RF)
Serious disorders not to be missed
_______may present
in a single joint or as flitting polyarthritis, often
accompanied by a rash
Gonococcal infection
______can cause arthritis and sacroiliitis and can be confused with the spondyloarthropathies
Brucellosis
________ is becoming a great mimicker. It
can present as a chronic oligoarticular asymmetrical
arthritis. 3 It can also present as a rash very similar to
psoriasis
HIV infection
With the large influx of migrants from South-
East Asia the possibility of ______ presenting as
arthritis should be kept in mind.
tuberculosis
In respect to malignant disease, arthralgia is associated with 1 2 3
acute leukaemia, lymphoma and
neuroblastoma in children
bronchial carcinoma may cause __________ especially of the wrist and ankle (not a true arthritis but simulates it).
hypertrophic
osteoarthropathy,
Monoarticular metastatic disease may
involve the knee ______
(usually from lung or breast).
What are the red flags for polyarthritis
- Fever
- Weight loss
- Profuse rash
- Lymphadenopathy
- Cardiac murmur
- Severe pain and disability
- Malaise and fatigue
- Vasculitic signs
- Two or more systems involved
There are several pitfalls, most of which are rare.
A common pitfall is gout. This applies particularly to
older women taking diuretics, whose osteoarthritic
joints, especially of the hand, can be affected. The
condition is often referred to as ______ and
does not usually present as acute arthritis.
nodular gout
Pitfalls
it can mimic the connective tissue
disorders in its early presentation—typically a
woman in the third or fourth decade
Fibromyalgia syndrome
Another ‘trap’ is __________ in a patient with a
bleeding disorder
haemarthrosis
Infective causes that may be overlooked are
______, especially in travellers returning from a
tropical or subtropical area, and _______ which
is now surfacing in many countries, especially where
ticks are found
dengue fever
Lyme disease,
Sarcoidosis causes two forms: an acute benign
form, usually in the ________, and a chronic
form with long-standing sarcoidosis that involves
_________ disease.
ankles and knees
joints (large or small) adjacent to underlying bone
Haemochromatosis can present with a degenerative
arthropathy that characteristically affects the ________
second
or third metacarpophalangeal joints
Drug-induced arthritis usually affects the hands
and is generally_____
symmetrical
Those that include a lupus syndrome include the 1 2 3
anti-epileptics,
chlorpromazine and some
cardiac drugs
_________may be associated with
septic arthritis, hepatitis B and C, HIV-associated
arthropathy, SBE with arthritis and serum sickness
reactions.
Intravenous drug abuse
_________ can uncommonly cause
acropathy (clubbing and swelling of the fingers) and
may present as pseudogout
Hyperthyroidism
_________ can present with an arthropathy or cause proximal muscle pain, stiffness and weakness.
hypothyroidism
________ may cause an arthropathy that can be painless or mild to moderately painful.
Diabetes mellitus
The spondyloarthropathies may be a causative
factor. They often present with an acute monoarthritis,
particularly in teenagers some time before causing
_____ and ______
sacroiliitis and spondylitis
So-called _______ of the lower limb are
common in children, and the physical examination
and investigations are norm
‘growing pains’
Clinical approach to dx:
A priority is to determine whether or not the arthritis
is caused by:
a primary rheumatic disorder or whether
it is part of an underlying systemic disorder
A family history is important because a positive
family history is associated with conditions such as
RA (rarely), ankylosing spondylitis, connective tissue
disorders (rarely), psoriasis, gout, pseudogout and
haemophilia
A very hot, red, swollen joint suggests either
______
infection or crystal arthritis.
Joint swelling: • acute (1–4 hours) with intense pain = \_\_\_\_\_ • subacute (1–2 days) and soft = \_\_\_\_\_\_ • chronic and bony = \_\_\_\_\_ • chronic and soft/boggy = \_\_\_\_\_\_
blood infection or crystals (e.g. gout)
fluid (synovial effusion)
osteoarthritis
synovial proliferation
A coarse crepitus suggests ______
OA
Inspection should note
the presence of lumps or bumps such as ________on the osteoarthritic DIP joints of the hands,
Heberden
nodes
_________on the osteoarthritic PIP joints of
the hands, and rheumatoid nodules, which are the
only pathognomonic finding of RA and gouty tophi
Bouchard nodes
Important to do serological testing for the AUS epidemics:
polyarthritis, Lyme disease, rubella, Brucella, hepatitis
B, gonococcus, mycoplasma, HIV tests, parvovirus
and Barmah Forest virus.
______ or at least a fourfold rise on paired
sera confirms recent infection
Seroconversion
________ has limited value in the
diagnosis of polyarthritis but is very useful for specific
joints such as the shoulder and the knee
Arthrography
____ for joints such as the shoulder and the
hip can be very useful
Ultrasound
examination
______ should not be used for arthritis
screening. It has a high sensitivity for ankylosing
spondylitis, but low specificity, and should rarely be
ordered
HLA-B 27
Immno tests to rule out CTD
rheumatoid factor and anti-CCP
• antinuclear antibodies
• dsDNA antibodies
____ is very common in children.
viral arthritis
FBE in pts with viral arthritis
lymphopaenia, lymphocytosis or atypical lymphocytes.
It is worth noting that underlying____ can be present as joint pain if the tumour is adjacent to the joint
bone tumours
Acute-onset monoarticular arthritis
associated with fever is _____until proven otherwise
septic
defined as
a chronic arthritis persisting for a minimum of 6
weeks (some criteria suggest 3 months) in one or
more joints in a child younger than 16 years of age
JIA, also known as juvenile chronic arthritis and
juvenile rheumatoid arthritis (US)
The commonest types of JIA are _________ arthritis, affecting four or fewer
joints (about 50%), and ________
affecting five or more joints (about 40%).
oligoarticularc (pauciarticular)
polyarticular arthritis,
Systemic onset arthritis, previously known as _______
accounts for about 10% of cases.
Still syndrome,
SSx of JIA
The children can present with a high
remittent fever and coppery red rash, plus other
features, including lymphadenopathy, splenomegaly
and pericarditis
T or F
In JIA
Arthritis is not an initial feature but develops ultimately, usually involving the small joints of the hands, wrists, knees, ankles and metatarsophalangeal joints
T
Other subtypes of JIA
- Oligo (pauci) articular
- Seropositive polyarticular (juvenile RA)
- Seronegative polyarticular
- Systemic onset arthritis (Still disease)
- Enthesitis related arthritis
- Psoriatic juvenile arthritis
Other musculoskeletal conditions that become more prevalent with increasing age are
- polymyalgia rheumatica
- Paget disease of bone
- avascular necrosis
- gout
- pseudogout (pyrophosphate arthropathy)
- malignancy (e.g. bronchial carcinoma)
This crystal deposition arthropathy (chondrocalcinosis) is
noted by its occurrence in people over 60 years. It usually
affects the knee joint but can involve other joints
Pseudogout
Although it usually begins between the ages of
30 and 40 it can occur in elderly patients, when it
occasionally begins suddenly and dramatically
RA
In RA,it tends to respond to small doses of______and has a good prognosis.
prednisolone
RF is an inflammatory disorder that typically occurs
in children and young adults following a ____
group
A Streptococcus pyogenes infection
T or F
RF is uncommon
in developing countries and among Indigenous
Australians
F
common
Dx of RF
Based on clinical criteria:
_____ or _______
in the presence of supporting evidence of preceding
Group A streptococcal infection.
2 or more major criteria
or
1 major + 2 or more minor criteria
Major criteria for RF
Carditis • Polyarthritis • Chorea (involuntary abnormal movements) • Subcutaneous nodules • Erythema marginatum
Minor criteria for RF
- Fever ( ≥ 38 ° C)
- Previous RF or rheumatic heart disease
- Arthralgia
- Raised ESR >30 mm/hr or CRP >30 mg/L
- ECG—prolonged PR interval
Other dxtics for RF
- streptococcal _____
- ________ (repeat in 10–14 days)
- C-reactive protein
- plus ECG and echocardiogram (if ↑ PR) and CXR
ASOT
streptococcal anti-DNase B
Tx of RF in children
What abx to give?
Benzathine penicillin 900 mg IM (450 mg in child
<20 kg) statim or phenoxymethylpenicillin
500 mg (o) bd, 10 days
Tx of RF in children
What apin reliever to give?
• Paracetamol 15 mg/kg (o) 4 hourly (max. 60 mg/
kg/day); aspirin or naproxen for arthritis
T or F
Septic arthritis
evolves over hours or days and can rapidly destroy
a joint structure
T
Organisms associated with Septic arthritis
The commonest
organisms are S.aureus and N. gonorrhoea.
__________ is the most common type of arthritis, occurring in about 10% of the adult population and in 50% of those aged over 60
OA
___________is usually symmetrical and can affect
many joints. Unlike other inflammatory disease the
pain is worse on initiating movement and loading the
joint, and eased by rest.
Primary OA
OA is usually associated with
_________, especially after activity, in contrast to RA
stiffness
In primary OA all the synovial joints may be involved,
but the main ones are:
1
2
3
• first carpometacarpal (CMC) joint of thumb
• first metatarsophalangeal (MTP) joint of
great toe
• distal interphalangeal (DIP) joints of hands
_______ can complicate OA, especially
in the fingers of people taking diuretics (e.g. nodular
gout).
Crystal arthropathy
OA does not exhibit the typical inflammatory pattern.
The clinical diagnosis is based on:
• gradual onset of pain after\_\_\_\_ • the pattern of joint involvement • the lack of \_\_\_\_\_\_\_\_\_ • the transient nature of the \_\_\_\_\_\_ • takes <30 minutes to settle after rest while inflammatory arthritis takes at least 30 minutes
activity (worse
towards the end of the day)
soft tissue swelling
joint stiffness or
gelling
Xray findings of OA
• Joint space narrowing with\_\_\_\_\_ • Formation of osteophytes on the joint margins or in ligamentous attachments • \_\_\_\_\_\_in the subchondral bone • Altered shape of bone ends
sclerosis of subchondral bone
Cystic areas
Pain meds for OA
Simple analgesics (regularly for pain). Use
_________ (avoid codeine or
dextroproproxyphene preparations, and aspirin if
recent history of dyspepsia or peptic ulceration).
paracetamol/acetaminophen
As a rule
________ are not recommended
but occasionally can be very effective for an
inflammatory episode of distressing pain and
disability on a background of tolerant pain (
IA corticosteroids
Viscosupplementation. ________,
especially for OA of knee. Supported by level I
evidence
Intra-articular hylans
__________, a natural
amine sugar, derived from chitin in shellfish
shell, has had anecdotal claims of efficacy for the
treatment of OA
Glucosamine
C ontraindicated drugs. For OA these include the
________
immunosuppressive and disease-modifying drugs
such as oral corticosteroids, gold, anti-malarials
and cytotoxic agents
_____ which is an autoimmune disease of unknown
aetiology, is the commonest chronic inflammatory
polyarthritis and affects about 1–2% of the
population
RA,
Genetic factors may represent a risk of ______ of
developing RA.
15–70%
RA generally presents with the _______ onset of
pain and stiffness of the small joints of the hands
and feet
insidious
Joints involved in RA
• Hands: \_\_\_, \_\_\_\_\_\_\_, \_\_\_\_\_joints (30%) • Wrist and elbows • Feet: MTP joints, tarsal joints (not IP joints), ankle • Knees (common) and hip (delayed—up to 50%) • Shoulder (\_\_\_\_\_\_\_) joints • Temporomandibular joints • Cervical spine (not \_\_\_\_\_\_\_)
MCP and PIP joints, DIP
glenohumeral
lumbar spine
Clinical features of RA
• Insidious onset but can begin acutely ____
• Any age 10–75 years: peak _____years but
bimodal 25–50 (peak age) and 65–75
• Female to male ratio = _____
(explosive RA)
30–50
3:1
Later stages of RA associated with
deformity, subluxation, instability
or ankylosing
Later stages of RA associated with
deformity, subluxation, instability
or ankylosing
Deformities associated with RA
swan necking, boutonnière and z
deformities, ulnar deviation
Dxtics for RA
• ______ usually raised according to activity of
disease
• Anaemia (_____ and _______ may
be present
ESR/CRP
normochromic and normocytic)
\_\_\_\_\_\_\_ — positive in about 70–80% (less frequent in early disease) — 15–25% of RA patients will remain negative
Rheumatoid factor
______: more specific for RA (96% specificity)
Anti-cyclic citrullinated peptide (anti-CCP)
antibodies
Xray findings associated with RA
— erosion of joint margin:\_\_\_\_\_\_\_ appearance — loss of joint space (may be destruction — \_\_\_\_\_\_\_ — cysts — advanced: \_\_\_\_\_\_\_\_\_
‘mouse-bitten’
juxta-articular osteoporosis
subluxation or ankylosing
Revised criteria for the diagnosis of
rheumatoid arthritis
- Symptom duration of______weeks
- Early morning stiffness of ______
- Arthritis in _______
- Bilateral compression tenderness of the ________
- Symmetry of the areas affected
- ______ positivity
- _______ positivity
- Bony erosions evident on radiographs of the hands or
feet, although these are uncommon in early disease
> 6
> 1 hour
three or more regions
metatarsophalangeal joints
Rheumatoid factor
Anti-cyclic citrullinated peptide antibody
Since many studies show disease progression in
the first 2 years, relative aggressive treatment
with ______ from the outset is advisable, rather
than to start stepwise with analgesics and
NSAIDs only
disease-modifying antirheumatic drugs
DMARDs
RA Tx
________ in doses to deliver 4 g of omega-3 long-chain
polyunsaturated fatty acids daily (typically 0.2 g/kg)
has been shown to reduce symptoms and the need for
NSAIDS through its anti-inflammatory activity
Fish oil
Oral use should be considered in patients with severe
disease as a temporary adjunct to DMARD therapy
and where other treatments have failed or are
contraindicated
Glucocorticoids
The dose of prednisolone for RA is _______.
Avoid doses higher than 15 mg daily if possible
5–10 mg (o) daily.
These agents target synovial inflammation and
prevent joint damage. The choice depends on several
factors, but is best left to the specialist coordinating
care.
Disease-modifying antirheumatic drugs
DMARDs
In most patients with recently diagnosed RA,
_______is the cornerstone of management and
should be commenced as early as possible
methotrexate
_______ are the newer
agents which should be considered if remission
is not achieved with appropriate methotrexate
monotherapy, ‘triple therapy’ or other combinations
Biological DMARDs (bDMARDs)
Standard initial drug therapy
_________ (or occasionally another DMARD) is standard. Less than 20% will reach disease remission and, if not achieved, increase the dose or consider combination therapy
Monotherapy with methotrexate
Consider standard triple therapy for RA:
methotrexate + sulfasalazine + hydroxychloroquine.
Arthritis is the commonest clinical feature of
________(over 90%). It is a symmetrical polyarthritis
involving mainly small and medium joints, especially
the proximal interphalangeal and carpal joints of the
hand
SLE
________can present as a polyarthritis
affecting the fingers of the hand in 25% of patients,
especially in the early stages. Soft tissue swelling
produces a ‘sausage finger’ pattern
Scleroderma
Arthralgia and arthritis occur in about 50% of
patients with _________ and may
be the presenting feature before the major feature
of muscle weakness and wasting of the proximal
muscles of the shoulder and pelvic girdles appear
polymyositis/dermatomyositis
Arthritis, which can be acute, chronic or asymptomatic,
is caused by a variety of _______
crystal deposits in joints
The three main types of crystal arthritis are
1
2
3
- monosodium urate (gout),
- calcium pyrophosphate dihydrate (CPPD)
- calcium phosphate (usually hydroxyapatite).
______ is an abnormality of uric acid metabolism
resulting in hyperuricaemia and urate crystal
deposition.
Gout
Urate crystals deposit in:
- joints—_________
- soft tissue—______
- urinary tract—________
acute gouty arthritis
tophi and tenosynovitis
urate stones
Four typical stages of gout are recognised:
• Stage 1 —\_\_\_\_\_\_\_ • Stage 2 —\_\_\_\_\_\_\_ • Stage 3 —\_\_\_\_\_\_\_ (intervals between attacks) • Stage 4 —\_\_\_\_\_\_\_
asymptomatic hyperuricaemia
acute gouty arthritis
intercritical gout
chronic tophaceous gout and chronic
gouty arthritis
What crystal is deposited?
Acute gout
Tophaceous gout
Asymptomatic
Chronic gouty arthritis
Monosodium
urate
What crystal is deposited?
Acute pseudogout Destructive arthropathy (like RA) Asymptomatic (most common
Calcium
pyrophosphate
dihydrate
(CPPD)
What crystal is deposited?
Acute calcific periarthritis
Destructive arthropathy
Acute arthritis
Basic calcium phosphate
Where are crystals deposited?
Basic calcium phosphate
Calcium pyrophosphate dihydrate (CPPD)
Monosodium urate
Shoulder (supraspinatus)
Knee, wrist
Metatarsophalangeal joint of big toe
Develops in postmenopausal women with kidney
impairment taking diuretic therapy who develop
pain and tophaceous deposits around osteoarthritic
interphalangeal (especially DIP) joints of fingers
Nodular gout
Dx of nodular gout
_________ → typical uric acid
crystals using compensated polarised
microscopy; this should be tried first (if possible)
as it is the only real diagnostic feature
Synovial fluid aspirate
Dx of nodular gout
• _______ (up to 30% can be
within normal limits with a true acute attack) 19
• __________ punched out erosions at joint margins
Elevated serum uric acid
X-ray:
The acute attack of nodular gout
_______ in full dosage, are first-line and effective.
_______ Avoid if kidney impairment, with macrolide antibiotics, long-term use
_______intra-articular following aspiration and culture (gout and sepsis can occur together); a digital anaesthetic block is advisable
NSAIDs,
Colchicine:
The acute attack of nodular gout
- Avoid _______
- Monitor______
aspirin and urate pool lowering drugs (probenecid, allopurinol, sulphinpyrazone)
kidney function and electrolytes
Prevention of gout
________(a xanthine oxidase inhibitor) is the drug
of choice: dose 100–300 mg daily.
Allopurinol
Indications of Allopurinol
1
2
3
4
- frequent acute attacks
- tophi or chronic gouty arthritis
- kidney stones or uric acid nephropathy
- hyperuricaemia
ADR of Allopurinol
1
2
- rash (2%)
* severe allergic reaction (rare)85775
treatment of intercritical and chronic gout
Allupurinol
• Commence_____ after last acute attack.
• Start with 50 mg daily for the first week and
increase by 50 mg weekly to maximum ____
6–8 weeks
300 mg.
treatment of intercritical and chronic gout
Allupurinol
• Check uric acid level ______ aim for level
<0.38 mmol/L.
• Add ______ 0.5 mg bd for 6 months (to avoid
precipitation of gout) or______ 25 mg bd
or other NSAIDs
after 4 weeks:
colchicine
indomethacin
Good for hyperexcretion of uric acid by blocking renal
tubular reabsorption.
Dose: 500 mg/day (up to 2 g)
Note: Aspirin antagonises effect
Probenicid
The finding of calcification of articular cartilage
on X-ray examination is usually termed
________
chondrocalcinosis
The crystals in synovial fluid are readily identified
by ______
phase-contrast microscopy
X-rays are helpful in
showing _____
calcification of the articular cartilage
Pseudogout
Management is based on aspiration and
installation of a __________ by
injection into the joint (if joint infection excluded)
plus analgesia
depot glucocorticosteroid
Tx of Pseudogout
Treatment includes:
- ________ 50 mg (o) tds (if tolerated) until symptoms abate and/or
- ______ 0.5 mg (o) tds until attack subsides
and
3.______ 500–1000 mg (o) four times
daily, if necessa
indomethacin
colchicine
paracetamol
The _______ are a group of
related inflammatory arthropathies with
common characteristics affecting the spondyles
(vertebrae) of the spine
spondyloarthropathies
It is appropriate to
regard them as synonymous with the seronegative
spondyloarthropathies in contradistinction to ____, which is seropositive and affects the cervical spine
only
RA
THE SPONDYLOARTHROPATHIES
Apart from back pain this group tends to
present with ______ in younger patients
oligoarthropathy
THE SPONDYLOARTHROPATHIES
The arthritis is characteristically peripheral,
1
2
3
asymmetrical, affects the lower limbs and can exhibit
dactylitis
THE SPONDYLOARTHROPATHIES
• ______with or without spondylitis
• ________, especially plantar fasciitis, Achilles
tendonitis, costochondritis
• Arthritis, especially larger ______
Sacroiliitis
Enthesopathy
lower limb joints
THE SPONDYLOARTHROPATHIES
- Absent _____
- Association with _____
- Familial predisposition
rheumatoid factor
HLA-B 27 antigen
THE SPONDYLOARTHROPATHIES:
Associated DO
iritis/anterior uveitis, mucocutaneous lesions, psoriasiform skin and nail lesions, chronic GIT and GU inflammation)
What are the SPONDYLOARTHROPATHIES:
1 Ankylosing spondylitis 2 Reactive arthritis 3 Inflammatory bowel disease (enteropathic arthritis) 4 Psoriatic arthritis 5 Juvenile onset ankylosing spondylitis 6 Unclassified spondyloarthritis
This usually presents with an insidious onset of
inflammatory back and buttock pain (sacroiliac
joints and spine) and stiffness in young adults (age
<40 years), and 20% present with peripheral joint
involvement before the onset of back painAnkylosing spondylitis
Ankylosing spondylitis
What does Ankylosing spondylitis affect?
It usually affects the girdle joints (hips and shoulders), knees or ankles
Ankylosing spondylitis
• Low back pain persisting for ______months
• Associated morning stiffness >30 minutes
Improvement with ________
• Limitation of lumbar spine motion in______
> 3
exercise and not relieved by rest
sagittal and
frontal planes
_________ is a form of arthropathy in which
non-septic arthritis and often sacroiliitis develop
after an acute urogenital infection
Reactive arthritis
Infectious associated with Reactive arthritis
(usually Chlamydia trachomatis ) or an enteric infection (e.g. Salmonella, Shigella ).
NSU + conjunctivitis ± iritis + arthritis
reactive arthritis
Joints affected in reactive arthritis
the larger peripheral
joints, especially the ankle (talocrural) and knees,
but the fingers and toes can be affected in a patchy
polyarthritic fashion
Inflammatory bowel disease (ulcerative colitis, Crohn
disease and Whipple disease) may rarely be associated
with peripheral arthritis and sacroiliitis
Enteropathic spondyloarthropathy
Like reactive arthritis, this can develop a condition
indistinguishable from ankylosing spondylitis. It is
therefore important to look beyond the skin condition
of psoriasis
Psoriatic arthritis
How many percent of patients with Psoriasis will develop arthritis?
5%
Psoriatic arthritis
1 mainly _______ joints
2 identical RA pattern but RA factor negative
3 identical ankylosing spondylosis pattern with
___ and ____
4 monoarthritis, especially knees
5 severe deformity or ____
DIP
sacroiliitis and spondylitis
‘mutilans’ arthritis
Morning stiffness and pain, improving with
exercis
RA
Flitting polyarthritis and fever =
rheumatic fever;
?endocarditis; ?SLE.
If rheumatoid arthritis involves the neck, beware of
______ and _____
atlantoaxial subluxation and spinal cord compression
If a patient returns from overseas with arthralgia,
think of _______ but
if the pain is intense consider _______
drug reactions, hepatitis, Lyme disease,
dengue fever.
Consider the possibility of _______in people
with a fever, rash and arthritis who have been
exposed to tick bites in rural area
Lyme disease
If a patient presents with Raynaud phenomenon
and arthritis, especially of the hands, consider
foremost ________
RA, SLE and systemic sclerosis
