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Clin Med III: MSK > Arthritis Part 2 > Flashcards

Arthritis Part 2 Flashcards

1
Q

chronic arthritis in +1 joints for at least 6 wks

A

Juvenile Idiopathic Arthritis (JIA)

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2
Q

4 main subtypes of JIA?
which is MC?

A
  1. oligoarticular (MC)
  2. polyarticular
  3. systemic
  4. enthesitis-associated
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3
Q

what is the enthesis?

A

the site of insertion of a tendon, ligament, fascia, or articular capsule into bone

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4
Q
  • 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?

A

oligoarticular JIA

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5
Q
  • 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?

A

polyarticular

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6
Q

difference between presentations of RF+ vs RF-

polyarticular JIA

A

RF+ disease resembles adult RA w/ more chronic, destructive arthritis

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7
Q
  • 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?

A

systemic

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8
Q
  • 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

A

Enthesitis-associated

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9
Q

w/u for JIA

A

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
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10
Q
  • RBC > WBC; < 2,000 WBC
  • Glu nml

this joint fluid analysis is indicative of what disorder?

A

trauma

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11
Q
  • 3,000–10,000 WBC, mostly mononuclear cells
  • Glu nml

this joint fluid analysis is indicative of what disorder?

A

Reactive arthritis

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12
Q
  • 5,000–60,000 WBC, mostly NEUT
  • Usually normal or slightly low glucose

this joint fluid analysis is indicative of what disorder?

A

Juvenile idiopathic arthritis and other inflammatory arthritides

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13
Q
  • > 60,000 WBC, > 90% NEUT
  • Low to normal glucose

this joint fluid analysis is indicative of what disorder?

A

Septic arthritis

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14
Q

how may a later course of JIA with +RF present on XR?

A

joint space narrowing due to cartilage thinning and erosive changes of the bone related to chronic inflammation

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15
Q

tx for JIA

A
  1. NSAIDs (1st line)
  2. DMARDs: MTX (2nd)
  3. TNF inhibitors: etanercept (Enbrel), infliximab (Remicade)
  4. CS - severe, systemic
    - injections - TAC
    - Topicals - uveitis; MTX, cyclosporine for failed topicals
  5. rehab
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16
Q

which type of JIA has the highest rate of remission?

A

oligoarticular

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17
Q

which type of JIA has the highest risk for chronic, erosive arthritis that may continue into adulthood

A

RF positive disease

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18
Q

A group of diseases involving theaxial skeleton

A

spondyloarthritis

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19
Q

what makes seronegative spondyloarthritis diffrent from RA?

A

negative forrheumatoid factor
different pathophys than what is commonly seen in RA

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20
Q
  • 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
A

Seronegative Spondyloarthritis

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20
Q
  • infection plays a key role in which spondyloarthropathy MC?
  • develops 1–4 wks after bacterial dysentery or nongonococcal STI
A

reactive arthritis

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21
Q

RF for reactive arthritis

A
  • 0.2% in the general population
  • 2% in HLA-B27 individuals
  • 20% in pts with HLA-B27 infected w/ Salmonella, Shigella, or enteric organisms
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22
Q
  • A chronic inflammatory disease of the joints of the axial skeleton
  • onset late teens or early 20s
A

Ankylosing Spondylitis

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23
Q
  • 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
A

Ankylosing Spondylitis

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24
Q

associated findings of Ankylosing Spondylitis

A
  • 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)
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25
Q

w/u for Ankylosing Spondylitis

A
  • 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
26
Q

imaging shows:
“The shiny corner sign”
“Bamboo spine”

dx?

A

Ankylosing Spondylitis

27
Q

tx Ankylosing Spondylitis

A
  1. NSAIDs (1st line)
  2. TNF inhibitors (2nd)
  3. PT
  4. CS ineffective!! Can worsen osteopenia
28
Q

what worsens the prognosis of Ankylosing Spondylitis

A

Developing hip disease < 2 yrs of onset

29
Q

what comes first in Psoriatic Arthritis, psoriasis or arthritis?

A

MC psoriasis
arthritis can precedes/occur simultaneously - arthritis can occur up to 2 years before skin disease

30
Q
  1. Symmetric polyarthritis that resembles RA but fewer joints
  2. Oligoarticular form
  3. MC DIP joints - asymmetric early; nail pitting, and onycholysis; “sausage” swelling
  4. Arthritis mutilans
  5. Spondylotic form - MC sacroiliitis and spine
    - HLA-B27-positive
A

Psoriatic Arthritis

31
Q

Arthritis is at least ? times MC in pts with severe skin disease than in those with only mild skin findings

Psoriatic Arthritis

A

5x

32
Q

w/u for Psoriatic Arthritis

A
  • Inc ESR
  • RF (-)
  • possible inc Uric acid levels
  • possible reduce iron stores
  • XR
33
Q

T/F: increased uric acid levels can cause gouty attacks in psoriasis arthritis

A

F

34
Q

XR findings of psoriasis arthritis

A
  • 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
35
Q

tx for psoriasis arthritis

A
  • 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
36
Q

what medication to avoid in psoriasis arthritis as it may exacerbate the psoriasis

A

antimalarial

37
Q
  1. Precipitated by GI and GU infections
  2. Asymmetric sterile oligoarthritis, MC LE
  3. MC associated with enthesitis.
  4. Extra-articular sx common - urethritis, conjunctivitis, uveitis, and mucocutaneous lesions.
  5. Triad: arthritis, conjunctivitis/Uveitis, and urethritis
  6. MC young men
  7. Associated with HLA-B27
A

Reactive Arthritis

38
Q
  • 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
A

Reactive Arthritis

39
Q

extraarticular manifestations of Reactive Arthritis

A
  • 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

40
Q

hyperkeratotic skin lesions on soles and palms resembling pustular psoriasis

A

keratoderma blennorrhagica

41
Q

painless erythematous lesions with small, shallow ulcers on the glans penis and urethral meatus

A

circinate balanitis

42
Q

An inflammatory process affecting themucous membranesof the mouth and lips, with or withoutoral ulceration

A

stomatitis

43
Q

w/u for reactive arthritis

A
  • Synovial fluid analysis - inflammatory, but no sign of active infection
  • XR - permanent/progressive joint disease in SI as well as peripheral joints
44
Q

tx for reactive arthritis

A
  1. NSAIDs (1st line)
  2. Preventing STD
    - chronic reactive arthritis associated with chlamydial infection: abx x 6 mo
  3. sulfasalazine or MTX (2nd)
  4. Anti-TNF agents if refractory
45
Q

IBD associated Arthritis is MC associated with what other condition?

A

Crohns > ulcerative colitis

46
Q
  • 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
A

Peripheral arthritis

47
Q
  • 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
A

Spondylitis

48
Q

tx for arthritis associated IBD

A
  • Control intestinal inflammation
  • Spondylitis - NSAIDs, may activate bowel disease in a few pts, use cautiously
  • ROM exercises
  • DMARDs
  • Corticosteroids
49
Q

Septic arthritis - Acute onset of inflammatory _____ arthritis, most often in large weight-bearing joints and wrists.

A

monoarticular

50
Q

RF of septic arthritis

A
  • 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
51
Q

MCC of septic arthritis

A
  1. Staph
  2. MRSA and group B strep are also common
  3. G- bacteria: E.coli and pseudomonas, are MC in IVDU
52
Q
  • 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 -
A

septic arthritis

53
Q

What RF causes septic arthritis to manifest in uncommon sites such as the sternoclavicular and SI joint?

A

IV drug users

54
Q

pathogens that cause >1 joint involved in septic arthritis?

A

Patients with rheumatoid arthritis, associated endocarditis, and infection with group B streptococci.

55
Q

w/u for septic arthritis

A
  • Synovial fluid analysis
  • Blood cx
  • CBC
  • XR; MRI/CT
56
Q

synovial fluid findings indicative of septic arthritis?

A
  • WBC >50,000; MC >100,000
  • > 90% PMN cells
  • Gram stain and cx are positive
57
Q

possible imaging findings of septic arthritis

A
  • 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
58
Q

tx for septic arthritis

A
  • Emmpiric - ceftriaxone / cefotaxime/ ceftazidime
  • Vanc if suspected MRSA
  • Urgent ortho surgery consult for drainage if needed
59
Q

indications for open surgical drainage in septic arthritis

A
  • if conservative tx fails
  • concomitant osteomyelitis requiring debridement
  • involved joint (eg, hip, shoulder, sacroiliac joint) cannot be drained by more conservative means.
60
Q

Gonococcal arthritis MC affects what pt demographic?

A
  • healthy
  • female
  • during menses and pregnancy
  • < 40 y/o
61
Q
  1. 1-4 d of migratory polyarthralgias involving wrist, knee, ankle, or elbow
  2. diverges into 2 different patterns
    - first (MC): tenosynovitis MC wrists, fingers, ankles, or toes.
    - second: purulent monoarthritis MC knee, wrist, ankle, or elbow
  3. fever
  4. GU sx
  5. asx small necrotic pustules distributed over extremities, especially the palms and soles

dx?
w/u?
tx?

A
  • Gonococcal arthritis
  • CBC, blood cx, synovial fluid, mucosal cx, XR
  • Admit, azithromycin + rocephin/ceftizoxime/cefotaxime

responds fast, MC drainage not needed

62
Q

presentation and mgmt of nongonococcal arthritis?

A
  1. newborn or nonsexually active elderly, immunocomp, rheumatoid or other arthritis
  2. single hot, swollen, painful joint; MC knee
  3. bacteria - 90% in synovial fluid, 50-70% in blood
  4. longer abx tx, need joint drainage; poorer prognosis

Clin Med III: MSK (14 decks)

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