Arthritis Part 2 Flashcards
chronic arthritis in +1 joints for at least 6 wks
Juvenile Idiopathic Arthritis (JIA)
4 main subtypes of JIA?
which is MC?
- oligoarticular (MC)
- polyarticular
- systemic
- enthesitis-associated
what is the enthesis?
the site of insertion of a tendon, ligament, fascia, or articular capsule into bone
- arthritis of < 4 joints
- medium to large joints
- asymmetrical → leg-length discrepancy - involved leg grows longer d/t inc blood flow and growth factors
- synovitis - mild, painless
- systemic sx uncommon except for inflammation in eye
which type of JIA?
oligoarticular JIA
- arthritis >5 joints
- Both large and small joints are involved - symmetrical pattern
- low-grade fever, fatigue, rheumatoid nodules, and anemia possible
- Further divided into rheumatoid factor (RF)–positive and RF–negative disease
which type of JIA?
polyarticular
difference between presentations of RF+ vs RF-
polyarticular JIA
RF+ disease resembles adult RA w/ more chronic, destructive arthritis
- More rare
- can involve any number of joints and affects both large and small joints
- high F (39–40°C) 1-2x per day - nml temp in between fevers
- evanescent, salmon-pink macular rash MC on pressure areas when fever is present
- systemic: HSM, LAD, leukocytosis, and serositis
which type of JIA?
systemic
- MC males, >10 y/o, MC LE, large joint arthritis
- inflammation of tendinous insertions (enthesopathy), such as the tibial tubercle or the heel
- Low back pain and sacroiliitis
which type of JIA
Enthesitis-associated
w/u for JIA
no diagnostic test
- Inc ESR CRP, WBCs, platelets
- RF (+): MC polyarticular if onset >8 y/o
- Anti–CCP ab: MC RA, and may be detectable prior to RF
- ANA (+): MC late-onset RF (+)
- HLA B27 antigen: enthesitis-associated
- joint fluid analysis: inflammation
- XR; MRI
- RBC > WBC; < 2,000 WBC
- Glu nml
this joint fluid analysis is indicative of what disorder?
trauma
- 3,000–10,000 WBC, mostly mononuclear cells
- Glu nml
this joint fluid analysis is indicative of what disorder?
Reactive arthritis
- 5,000–60,000 WBC, mostly NEUT
- Usually normal or slightly low glucose
this joint fluid analysis is indicative of what disorder?
Juvenile idiopathic arthritis and other inflammatory arthritides
- > 60,000 WBC, > 90% NEUT
- Low to normal glucose
this joint fluid analysis is indicative of what disorder?
Septic arthritis
how may a later course of JIA with +RF present on XR?
joint space narrowing due to cartilage thinning and erosive changes of the bone related to chronic inflammation
tx for JIA
- NSAIDs (1st line)
- DMARDs: MTX (2nd)
- TNF inhibitors: etanercept (Enbrel), infliximab (Remicade)
- CS - severe, systemic
- injections - TAC
- Topicals - uveitis; MTX, cyclosporine for failed topicals - rehab
which type of JIA has the highest rate of remission?
oligoarticular
which type of JIA has the highest risk for chronic, erosive arthritis that may continue into adulthood
RF positive disease
A group of diseases involving theaxial skeleton
spondyloarthritis
what makes seronegative spondyloarthritis diffrent from RA?
negative forrheumatoid factor
different pathophys than what is commonly seen in RA
- Male, onset < 40 y/o
- inflammatory arthritis of spine and SI joints
- Asymmetric oligoarthritis of large peripheral joints
- Enthesopathy
- Major association with the HLA-B27 gene
Seronegative Spondyloarthritis
- infection plays a key role in which spondyloarthropathy MC?
- develops 1–4 wks after bacterial dysentery or nongonococcal STI
reactive arthritis
RF for reactive arthritis
- 0.2% in the general population
- 2% in HLA-B27 individuals
- 20% in pts with HLA-B27 infected w/ Salmonella, Shigella, or enteric organisms
- A chronic inflammatory disease of the joints of the axial skeleton
- onset late teens or early 20s
Ankylosing Spondylitis
- onset gradual
- intermittent periods of back pain that may radiate to butt
- Back pain worse AM w/ stiffness that lasts hours - improve w/ activity
- Severe: progressive sx in cephalad direction, entire spine becomes fused, allowing no motion in any direction
- Lumbar curve flattens, thoracic curvature exaggerates
- SOB
- Absent Constitutional sx
Ankylosing Spondylitis
associated findings of Ankylosing Spondylitis
- acute arthritis of peripheral joints
- Enthesopathy - Achilles tendon, plantar fasciitis, or “sausage” swelling of a finger or toe
- Anterior uveitis
- Spondylotic heart disease - AV conduction defects and aortic regurg (severe)
- Pulmonary fibrosis (late disease)
- Cauda equina fibrosis (late)
w/u for Ankylosing Spondylitis
- Elevated ESR
- (-) RF and anti-CCP
- CBC - Anemia
- HLA-B27 MC in white pts; not diagnostic
- XR, MRI - SI joints, later, erosion and sclerosis of SI joints (BL and symmetric); Fusion of posterior facet joints of spine
imaging shows:
“The shiny corner sign”
“Bamboo spine”
dx?
Ankylosing Spondylitis
tx Ankylosing Spondylitis
- NSAIDs (1st line)
- TNF inhibitors (2nd)
- PT
- CS ineffective!! Can worsen osteopenia
what worsens the prognosis of Ankylosing Spondylitis
Developing hip disease < 2 yrs of onset
what comes first in Psoriatic Arthritis, psoriasis or arthritis?
MC psoriasis
arthritis can precedes/occur simultaneously - arthritis can occur up to 2 years before skin disease
- Symmetric polyarthritis that resembles RA but fewer joints
- Oligoarticular form
- MC DIP joints - asymmetric early; nail pitting, and onycholysis; “sausage” swelling
- Arthritis mutilans
- Spondylotic form - MC sacroiliitis and spine
- HLA-B27-positive
Psoriatic Arthritis
Arthritis is at least ? times MC in pts with severe skin disease than in those with only mild skin findings
Psoriatic Arthritis
5x
w/u for Psoriatic Arthritis
- Inc ESR
- RF (-)
- possible inc Uric acid levels
- possible reduce iron stores
- XR
T/F: increased uric acid levels can cause gouty attacks in psoriasis arthritis
F
XR findings of psoriasis arthritis
- marginal erosions and irregular destruction of joint and bone - “sharpened pencil”
- Fluffy periosteal new bone, esp at insertion of muscles and ligaments into bone
- Psoriatic spondylitis = asymmetric sacroiliitis and syndesmophytes - coarser than ankylosing spondylitis
tx for psoriasis arthritis
- NSAIDs (1st line)
- MTX (2nd) - Can improve both cutaneous and arthritic manifestations
- TNF inhibitors - if refractory to MTX; effective for both arthritis and psoriasis
- CS - less effective; may precipitate pustular psoriasis during tapers
what medication to avoid in psoriasis arthritis as it may exacerbate the psoriasis
antimalarial
- Precipitated by GI and GU infections
- Asymmetric sterile oligoarthritis, MC LE
- MC associated with enthesitis.
- Extra-articular sx common - urethritis, conjunctivitis, uveitis, and mucocutaneous lesions.
- Triad: arthritis, conjunctivitis/Uveitis, and urethritis
- MC young men
- Associated with HLA-B27
Reactive Arthritis
- Develop within 1–4 weeks after either: GI infection or STI
- Synovial fluid from affected joints is culture-negative
- Asymmetric arthritis, MC large weight-bearing joints (knee and ankle)
- Sacroiliitis or ankylosing spondylitis if frequent recurrences
- Fever and wt loss at onset
Reactive Arthritis
extraarticular manifestations of Reactive Arthritis
- Ocular - conjunctivitis, anterior uveitis episcleritis, and keratitis; chlamydia
- GU - dysuria, pelvic pain, urethritis, cervicitis, prostatitis, salpingo-oophoritis, or cystitis. Urethritis can occur even when arthritis is induced by enterobacteriaceae
- GI - diarrhea.
- Oral - painless mucosal ulcers
- Cutaneous eruptions and other skin changes - keratoderma blennorrhagica, erythema nodosum
- Nail changes - similar w/ psoriasis
- Genital lesions - circinate balanitis
- CV - valve disease, aortic insufficiency, w/ greater chronicity of illness. Pericarditis very rarely
Mucocutaneous or other manifestations are not specific for reactive arthritis
hyperkeratotic skin lesions on soles and palms resembling pustular psoriasis
keratoderma blennorrhagica
painless erythematous lesions with small, shallow ulcers on the glans penis and urethral meatus
circinate balanitis
An inflammatory process affecting themucous membranesof the mouth and lips, with or withoutoral ulceration
stomatitis
w/u for reactive arthritis
- Synovial fluid analysis - inflammatory, but no sign of active infection
- XR - permanent/progressive joint disease in SI as well as peripheral joints
tx for reactive arthritis
- NSAIDs (1st line)
- Preventing STD
- chronic reactive arthritis associated with chlamydial infection: abx x 6 mo - sulfasalazine or MTX (2nd)
- Anti-TNF agents if refractory
IBD associated Arthritis is MC associated with what other condition?
Crohns > ulcerative colitis
- MC large joints of the arms and legs, including the elbows, wrists, knees, and ankles
- joint disease parallels that of the bowel disease
- The arthritis usually begins months to years after the bowel disease
Peripheral arthritis
- indistinguishable by sx or XR from ankylosing spondylitis
- Follows a course independent of the bowel disease.
- 50% of pts are HLA-B27-positive.
- These sx may come on months or even years before the symptoms of IBD appear
Spondylitis
tx for arthritis associated IBD
- Control intestinal inflammation
- Spondylitis - NSAIDs, may activate bowel disease in a few pts, use cautiously
- ROM exercises
- DMARDs
- Corticosteroids
Septic arthritis - Acute onset of inflammatory _____ arthritis, most often in large weight-bearing joints and wrists.
monoarticular
RF of septic arthritis
- Bacteremia - IVDU, endocarditis, infection at other sites
- Damaged or prosthetic joints - rheumatoid arthritis
- Compromised immunity - DM, advanced CKD, alcoholism, cirrhosis, and immunosuppressive therapy
- Loss of skin integrity – trauma, cutaneous ulcer or psoriasis
MCC of septic arthritis
- Staph
- MRSA and group B strep are also common
- G- bacteria: E.coli and pseudomonas, are MC in IVDU
- acute, with pain, swelling, and heat of affected joint worsening over hours.
- Pain aggravated by motion
- MC knee; hip, wrist, shoulder, and ankle.
- Chills and fever
- Rarely More than one joint is involved -
septic arthritis
What RF causes septic arthritis to manifest in uncommon sites such as the sternoclavicular and SI joint?
IV drug users
pathogens that cause >1 joint involved in septic arthritis?
Patients with rheumatoid arthritis, associated endocarditis, and infection with group B streptococci.
w/u for septic arthritis
- Synovial fluid analysis
- Blood cx
- CBC
- XR; MRI/CT
synovial fluid findings indicative of septic arthritis?
- WBC >50,000; MC >100,000
- > 90% PMN cells
- Gram stain and cx are positive
possible imaging findings of septic arthritis
- Demineralization may not develop for several days.
- MRI/CT - more sensitive in detecting fluid in joints not accessible to PE (eg, the hip).
- Bony erosions and narrowing of joint space followed by osteomyelitis and periostitis within 2 weeks possible
tx for septic arthritis
- Emmpiric - ceftriaxone / cefotaxime/ ceftazidime
- Vanc if suspected MRSA
- Urgent ortho surgery consult for drainage if needed
indications for open surgical drainage in septic arthritis
- if conservative tx fails
- concomitant osteomyelitis requiring debridement
- involved joint (eg, hip, shoulder, sacroiliac joint) cannot be drained by more conservative means.
Gonococcal arthritis MC affects what pt demographic?
- healthy
- female
- during menses and pregnancy
- < 40 y/o
- 1-4 d of migratory polyarthralgias involving wrist, knee, ankle, or elbow
- diverges into 2 different patterns
- first (MC): tenosynovitis MC wrists, fingers, ankles, or toes.
- second: purulent monoarthritis MC knee, wrist, ankle, or elbow - fever
- GU sx
- asx small necrotic pustules distributed over extremities, especially the palms and soles
dx?
w/u?
tx?
- Gonococcal arthritis
- CBC, blood cx, synovial fluid, mucosal cx, XR
- Admit, azithromycin + rocephin/ceftizoxime/cefotaxime
responds fast, MC drainage not needed
presentation and mgmt of nongonococcal arthritis?
- newborn or nonsexually active elderly, immunocomp, rheumatoid or other arthritis
- single hot, swollen, painful joint; MC knee
- bacteria - 90% in synovial fluid, 50-70% in blood
- longer abx tx, need joint drainage; poorer prognosis
