Arthritis - Part 2 - Exam 2 Flashcards
What is juvenile idiopathic arthritis characterized by? What is the underlying cause?
Characterized by chronic arthritis in one or more joints for at least 6 weeks
autoimmune process with genetic susceptibility factors
What are the 4 main types of juvenile idiopathic arthritis?
oligoarticular
polyarticular
systemic
enthesitis-associated
What is an enthesis?
The enthesis (plural entheses) is the connective tissue between tendon or ligament and bone.
What is oligoarticular JIA characterized by? What type of joints? Is it symmetrical or asymmetrical? Describe the synovitis?
characterized by arthritis of four or fewer joints
affects medium to large joints
often ASymmetrical
synovitis is usually mild and may be painless
What is the common systemic feature of oligoarticular JIA?
inflammation in the eye
asymptomatic uveitis, which may cause blindness if untreated
What is the MC type of JIA?
Oligoarticular
What is polyarticular JIA characterized by? What type of joints? What is the patten?
arthritis involving five or more joints
Both large and small joints are involved
typically in a symmetrical pattern
What are two subtypes of polyarticular JIA? Which one is worse? How common is it?
rheumatoid factor (RF) positive and RF negative
RF positive disease resembles adult rheumatoid arthritis with more chronic, destructive arthritis
What type of JIA?
high fever
a characteristic evanescent, salmon-pink macular rash
hepatosplenomegaly
lymphadenopathy
leukocytosis
serositis
When is the rash usually present?
systemic
90% of patients have a characteristic evanescent, salmon-pink macular rash that is most prominent on pressure areas and when fever is present. Fever usually only spikes 1-2 times per day
How common is systemic JIA?
comprises only 5 - 10% of all patients with JIA
Where are the common locations for Enthesitis-associated JIA? What is the MC pt type? What is the hallmark?
typically associated with lower extremity, large joint arthritis
most common in males, older than 10 years of age
inflammation of tendinous insertions (enthesopathy) usually on tibial tubercle or heel
_____ and _____ are also commonly seen in this form of _____ JIA
Low back pain
sacroiliitis
Enthesitis-associated
What is the diagnostic test for JIA?
not one specific!
but want to check elevated markers of inflammation ESR CRP, WBCs and platelets
____ is positive in about 5% of patients, usually when the onset of polyarticular disease occurs after age ____
RF is positive in about 5% of patients, usually when the onset of polyarticular disease occurs after age 8 years.
_____ has a very high specificity for rheumatoid arthritis and may be detectable prior to the RF
Anti–CCP antibody
A positive _____ is also common in patients with the late-onset RF positive form of the disease.
ANA test
Carriage of ____ antigen is associated with an increased risk of developing enthesitis-associated arthritis
HLA B27
What is the main indication for joint aspiration and synovial fluid analysis? But it will show _____
to rule out infection
but it will show inflammation
What are the joint fluid analysis results consistent with JIA?
What will xrays of RF positive dz late in the disease course show?
plain films may demonstrate joint space narrowing due to cartilage thinning and erosive changes of the bone related to chronic inflammation
What are the objectives of tx for JIA?
to restore function
relieve pain
maintain joint motion
prevent damage to cartilage and bone
_____ are first line therapy agents in JIA. How long does it take to see an improvement?
NSAIDs
The average time to symptomatic improvement is 1 month, but in some patients a response is not seen for 8–12 weeks.
_____ are second line therapy for JIA in pts who fail to respond to NSAIDs. When do they start to see an improvement? What is the next step?
Methotrexate
Symptomatic response usually begins within 3–4 weeks
still no response with methotrexate, then TNF inhibitors
_____ are reserved for children with severe involvement, primarily patients with systemic disease. Can use _____ in pts who have arthritis in 1 or few joints
Steroids
Local steroid joint injections
_____ is a super common SE in JIA and needs to follow with ______
Uveitis
ophthalmologist
What are some non-pharm tx options in JIA?
PT, OT
focusing on range of motion, stretching, and strengthening.
as heat, water therapy, and ultrasound, get the kiddos moving!!
What type of JIA has the highest rate of clinical remission? What type has the highest risk for chronic, erosive arthritis that may continue into adulthood?
Oligoarticular
RF positive disease
What is a worse dz prognosis in JIA?
The prognosis is worse in patients with persistent systemic disease after 6 months
What are Spondyloarthropathies? What does Seronegative mean in this context?
A group of diseases involving theaxial skeleton
diseases are negative forrheumatoid factor
What are the 5 different types of seronegative spondyloarthropathies?
ankylosing spondylitis
psoriatic arthritis
reactive arthritis
the arthritis associated with inflammatory bowel disease
undifferentiated spondyloarthropathy
What is considered the axial skeleton?
skull, spine, ribs
What is the MC population for Seronegative Spondyloarthropathies? Where are the 2 MC joint involvements? Asymmetric or symmetric? mono or olgio?
male before 40 years old
Causes inflammatory arthritis of the spine and sacroiliac joints
Asymmetric oligoarthritis of large peripheral joints
Seronegative Spondyloarthropathies have a major association with the _____ gene. _______ also appears to play a key role in some of the spondyloarthropathies. Which one in particular?
HLA-B27
infection, especially reactive arthritis
When does reactive arthritis characteristically develop?
characteristically develops 1–4 weeks after bacterial dysentery or a nongonococcal sexually transmitted infection
Who is the MC pt with Ankylosing Spondylitis? What is it?
males: late teens or early 20s
A chronic inflammatory disease of the joints of the axial skeleton
Describe the symptoms and onset for Ankylosing Spondylitis?
The onset is usually gradual, with intermittent periods of back pain that may radiate into the buttocks
The back pain is worse in the morning and usually associated with stiffness that lasts hours
The pain and stiffness IMPROVE with activity
advances towards to head
lumbar curve flattens, and the thoracic curvature exaggerates
What am I?
What happens in severe cases?
What are the highlighted findings?
Ankylosing Spondylitis
In severe cases, the entire spine becomes fused, allowing no motion in any direction
**worse in the morning
**stiffness that lasts for hours
**improve with activity
**lumbar curve flattens and thoracic curve exaggerates
What are some associated findings with Ankylosing Spondylitis? Will they have constitutional symptoms?
Transient acute arthritis of the peripheral joints
dactylitis
anterior uveitits
Spondylotic heart disease
NO! (RA will have constitutional symptoms)
What will the lab tests show in Ankylosing Spondylitis?
Elevated ESR
Serologic tests for RF and anti-CCP antibodies are negative
HLA-B27 is found in 90% of white patients and 50% of black patients
may have mild anemia
**Where are the earliest xray changes in Ankylosing Spondylitis seen? In first 2 years of disease, may only be detectable on ____
**sacroiliac joints
MRI
What is the joint involvement patten in Ankylosing Spondylitis?
bilateral and symmetric
**What are 2 xray findings associated with Ankylosing Spondylitis? What additional finding may be appreciated on xray?
**The shiny corner sign
**Bamboo spine
Fusion of the posterior facet joints of the spine
______ Inflammation where the annulus fibrosus attaches to the vertebral bodies initially causes sclerosis
“The shiny corner sign”
______ describes the late radiographic appearance of the spinal column in which the vertebral bodies are fused vertically
“Bamboo spine”
What am I? What dx?
shiny corner sign
Ankylosing Spondylitis
What is the first line tx option for Ankylosing Spondylitis? ____ are used for resistant dz.
NSAIDs
TNF inhibitors
**______ have minimal impact on the arthritis of ankylosing spondylitis and can worsen osteopenia. Everyone needs to be referred to _____
**Corticosteroids, NO STEROIDS
PT for instruction on postural exercises
Developing _____ within the first 2 years of AK disease onset is a worse prognosis. How long will the symptoms persist?
hip disease
Almost all patients have persistent symptoms over DECADES
What is the normal presentation of psoriatic arthritis?
psoriasis usually precedes the onset of arthritis
20% of the time arthritis comes first though
What is the typical joint pattern involvement in PA? What joint is primarily affected?
Symmetric polyarthritis that resembles RA but FEWER joints are involved
DIP joints are primarily affected
_____ is severe deforming arthritis in PA. May also have ____ form that involves the SI and spine
Arthritis mutilans
Spondylotic form
_____ and ____ are clinical features of PA. How are the arthritis and psoriasis related?
nail pitting
Sausage” swelling of the digits
What 4 lab values should you check in PA? What will each be?
ESR/CRP: high
Rheumatoid factor: negative
uric acid: high
Why are the uric acid levels high in PA?
reflecting the active turnover of skin affected by psoriasis
**_____ is the xray finding associated with PA
sharpened pencil
How can you tell Psoriatic spondylitis vs ankylosing spondylitis apart via xray findings?
Psoriatic spondylitis causes asymmetric sacroiliitis and syndesmophytes, which are coarser than those seen in ankylosing spondylitis
What is the first line tx for PA? Then ____ , then ______. _____ are less effective. _____ may also exacerbate psoriasis
NSAIDs
methotrexate
addition of TNF inhibitor
steroids are NOT effective
Antimalarials
______ was formerly referred to as Reiter’s syndrome. What are 2 precipitating factors? What is the MC pt population?
reactive arthritis
preceding GI and GU infections (but more commonly GU infections)
young men with HLA-B27 gene
______ presents as an asymmetric sterile oligoarthritis, typically of the lower extremities. What are some extra-articular manifestations? What is the major one?
reactive arthritis
urethritis major one, conjunctivitis, uveitis, and mucocutaneous lesions.
What is the triad of reactive arthritis?
Arthritis, conjunctivitis/Uveitis, and urethritis
most reactive arthritis cases develop within _____ after ______. What will the synovial fluid culture show?
1-4 weeks
GI infection or STD
culture-negative
What is the joint involvement pattern of reactive arthritis? Will reactive arthritis have systemic symptoms?
asymmetric and involved large weight bearing joints (think knee and ankle)
Systemic symptoms including fever and weight loss are common at the onset of disease
Which type of arthritis has LOTS of other organ involvement?
reactive arthritis
conjunctivits, anterior uveitis
GU symptoms
GI: diarrhea
oral lesions
skin/nail changes
genital lesions
cardiac manifestations
none are SPECIFIC to reactive arthritis though just also commonly seen
Describe the timing for the other organ involvement in reactive arthritis?
Most signs of the disease disappear within days or weeks but the arthritis may persist for several months or become chronic
________ An inflammatory process affecting themucous membranesof the mouth and lips, with or withoutoral ulceration. Associated with what type of arthritis?
Stomatitis
reactive arthritis
________ skin lesions commonly found on thepalmsandsolesbut which may spread to thescrotum,scalpandtrunkalso, and which resemble psoriasis. What type of arthritis?
Keratoderma blennorrhagicum
reactive arthritis
What will the synovial fluid show in reactive arthritis?
demonstrates inflammatory process but no sign of active infection
____ is the tx for reactive arthritis, ______ is good prevention
same as all the other types of arthritis, NSAIDs, methotrexate, sulfasalazine, anti-TNF agents
Prevention may occur by treating STD at the time of, which may reduce risks of developing Reactive arthritis
What is the tx for chronic reactive arthritis associated with chlamydial infection?
combination antibiotics taken for 6 months
_____ of patients withIBD have arthritis. More cases with ____ than ____. What is the general trend?
1/5th
Crohn disease
Ulcerative Colitis
if IBD flares then arthritis will also flare
What are the 2 types of arthritis that occurs with arthritis associated with IBD?
peripheral
spondylitis
_______ usually affects the large joints of the arms and legs, including the elbows, wrists, knees, and ankles. The activity of the joint disease parallels that of the bowel disease. What is the highlighted feature? When does the arthritis usually begin?
Peripheral arthritis of IBD related dz
the activity of the joint disease parallels that of the bowel disease
The arthritis usually begins months to years after the bowel disease
_______ is indistinguishable by symptoms or radiographs from ankylosing spondylitis and follows a course independent of the bowel disease. What is the highlighted factor? What is the associated timing?
Spondylitis of IBD associated arthritis
Follows a course independent of the bowel disease
These symptoms may come on months or even years before the symptoms of IBD appear
What is the tx for arthritis associated with IBD? Are steroids helpful?
Controlling the intestinal inflammation usually eliminates the PERIPHERAL arthritis
NSAIDs improve joint pain but make IBD worse-> use cautiously
ROM exercises
DMARDs
steroids are helpful!
What is the joint involvement pattern of septic arthritis? (also called acute bacterial arthritis) What are the key risk factors?
Acute onset of inflammatory monoarticular arthritis, most often in large weight-bearing joints and wrists
bacteremia
damaged/prosthetic joints
compromised immunity
break in skin integrity
_____ is the MC cause of septic arthritis
Staphylococcus aureus
The onset is usually acute, with pain, swelling, and heat of the affected joint worsening over hours and pain gets worse with movement
What am I?
What joint is most frequently involved?
septic arthritis
knee is MC
When will you see multiple joints that are septic? Is septic arthritis a medical emergency?
especially in patients with rheumatoid arthritis, associated endocarditis, and infection with group B streptococci
yes! need to be admitted
What are the synovial fluid results for septic arthritis?
The leukocyte count of the synovial fluid usually exceeds 50,000/mcL and often is > 100,000/mcL
90% or more polymorphonuclear cells
What diagnostic imaging should you order in septic arthritis?
imaging are not super helpful in septic arthritis
What is the tx for septic arthritis?
ALWAYS ADMIT THEM
long term abx:
ceftriaxone/cefotaxime/ceftazidime PLUS vanc
then adjust based on C&S, usually for 4-6 weeks
consult orthro to wash out the joint out with abx
______ usually occurs in otherwise healthy individuals and is MC in _____
Gonococcal arthritis
females!!
During what times are Gonococcal arthritis more likely to happen? When is it LESS likely to happen?
during menses and during pregnancy
and is rare after age 40
_______ begins with 1 to 4 days of migratory polyarthralgias involving the wrist, knee, ankle, or elbow, then diverges into 2 different patterns. What are they?
Gonococcal arthritis
tenosynovitis or purulent monoarthritis
What areas of the body do tenosynovitis associated with Gonococcal arthritis happen in? How common is it?
most often affects wrists, fingers, ankles, or toes
60% of gonococcal arthritis patients
What areas of the body do purulent monoarthritis associated with Gonococcal arthritis happen in? How common is it?
most frequently involves the knee, wrist, ankle, or elbow
40% of gonococcal arthritis patients
Most patients with gonococcal arthritis have _____. Describe it. What areas of the body?
Most patients will have asymptomatic but highly characteristic skin lesions
Consist of two to ten small necrotic pustules distributed over the extremities, especially the palms and soles
What am I?
gonococcal arthritis skin lesion
What will the synovial fluid show in gonococcal arthritis?
Synovial fluid analysis may fall into the inflammatory category, as gonorrhea is less virulent
WBC usually ranges from 30,000 to 60,000 cells/mcL.
Gram stain is positive in ¼ of cases and culture in less than half
What also needs to be done after the dx of gonococcal arthritis is made?
Urethral, throat, cervical, and rectal cultures should be done in all patients and are often positive, even in the absence of local symptoms
What is the tx for gonococcal arthritis? Do you need to drain it?
Patients require hospital admission
Abx:
azithro PO with IV Ceftriaxone/cefotaxime/ceftizoxime. Continue IV therapy for 7-10 days
drainage is typically NOT required
______ MOA inhibits pyrimidine synthesis, resulting in antiproliferative and anti-inflammatory effects. When is it used?
Leflunomide (Arava)
Rheumatoid arthritis
_____ MOA binds tumor necrosis factor (TNF) and blocks its interaction with cell surface receptors.What are the 2 major SEs?
Etanercept (Enbrel)
anaphylaxis and demyelinating disorders
What are the important pt education points for bisphosphonates?
need to sit upright for at least 30 minutes after taking medication and no eating immediate after
taking in the AM on an empty stomach
What is Zoledronic acid (Reclast) indicated for?
osteoporosis
What is Teriparatide (Forteo) indicated for?
osteoporosis
What drug class is raloxifene (Evista)? What is the black box warning?
SERM
Increased risk of VTE
How long should you use muscle relaxers for? Which one has the potential of serotonin syndrome?
short term use ONLY (2-3 weeks)
Skelaxin
_____ MOA is a centrally-acting skeletal muscle relaxant pharmacologically related to tricyclic antidepressants; reduces tonic somatic motor activity influencing both alpha and gamma motor neurons
cyclobenzaprine (Flexeril)
____ MOA causes skeletal muscle relaxation by general CNS depression
methocarbamol (Robaxin):
Which muscle relaxer does NOT have sedating effects?
metaxalone (Skelaxin
_____ MOA An alpha2-adrenergic agonist agent which decreases spasticity by increasing presynaptic inhibition; effects are greatest on polysynaptic pathways; overall effect is to reduce facilitation of spinal motor neurons
Tizanidine (Zanaflex):
_____ and ____ are CI to use with Tizanidine (Zanaflex):
ciprofloxacin
fluvoxamine
Denosumab (Prolia) is indicated for what condition?
osteoporosis
An association between _____ and _____ has contributed to investigations of the role of ______ for the treatment of psoriasis
psoriasis (especially guttate psoriasis)
streptococcal infection
tonsillectomy
