Arthritities--Pokorny

Question 1

What is a common non-inflammatory arthritis?

Answer 1

osteoarthritis

Question 2

Name the five common inflammatory arthitis conditions

Answer 2

RA

Juvenile idiopathic arthritis

SLE

crystal induced arthritis (gout/pseudogout)

spondyloarthropathies

Question 3

A patient arrives demonstrating limited range of motion, crepitus, osteophytes, pain at the joint line. Symptomes are worse in the morning, but get better with exercise.

What’s your diagnosis?

What test would you order?

Answer 3

Osteoarthritis

common, age related, progressive loss of articular cartilage

Radiography: sclerosis and osteophytes of the joint

Question 4

What is a good indicator of non-inflammatory arthritis?

Answer 4

osteoarthritis

Morning stiffness that goes away after 30mins

specifically DIP joint inflammation is indicitive

Question 5

Rheumatoid arthritis

Answer 5

A form of symmetric inflammatory arthritis that is systemic (fatigue, fever, weight loss) and progressive

Morning stiffness lasts longer than 1 hour is indicative

Look for **MCP subluxation, **and ulnar deviation

Look for positive anti CCP antibody and Rheumatoid factor

Question 6

What is a common autoimmune disease associated with a positive ANA test?

Answer 6

ANA = antinuclear antibodies

95% specific for SLE

Systemic Lupus Erythematosus

To help rule in SLE look for butterfly or malar rash

Be aware that many other diseases are associated with a postive ANA…

scleroderma, Sjögren’s syndrome, polymyositis/ dermatomyositis, mixed connective tissue disease, drug-induced lupus, and autoimmune hepatitis. A positive ANA can also be seen in juvenile arthritis.

Question 7

What are three conditions linked with an anti-Ro/SSA antibody?

Answer 7

anti-Ro/SSA antibodies (with or without anti-La/SSB antibodies) identify pregnant women who are at increased risk of having a child with neonatal lupus syndrome–congenital heart block

rheumatoid arthritis (RA)

systemic lupus erythematosus (SLE)

[Sjögren’s syndrome]

–incomplete list–

Question 8

Gout

biochemistry…

Answer 8

caused by deposition of monosodium urate due to hyperuricemia

90% caused by underexcretion; 10% by overproduction

can be caused by;

Lesch-Nyhan syndrome (HGPRT deficiency),

PRPP excess (due to deficiency in PRPP synthetase),

and increased excretion of uric acid (e.g., thiazide diuretics), T cell turnover, or von Gierke’s disease.

Question 9

How do you diagnose gout?

Answer 9

check uric acid levels (low PPV value)

Gold standard** = check synovial fluid for needle-shaped crystals (yellow under polarized light)

Question 10

In the classification of synovial joint fluid, what markers distinguishes non-inflammatory from inflammatory? Septic? Normal?

Answer 10

2000 Leukocytes/mm3 is the magic number!

Non-inflammatory: clear, yellow, viscous (Leukocytes/mm3 = 200-2000)

Inflammatory: cloudy, yellow, decreased viscosity (2000-100,000)

Septic: Purulent, markedly decreased viscosity (>50,000)

Normal: clear, colorless, viscous (<200)

Question 11

What should you remember about the initial therapy of gout?

Answer 11

Acute: Allopurinol is NOT appropriate during an acute attack of gout

NSAIDs, colchicine, prednisone, and other antinflammatory is OK! [NSAIDs (e.g., indomethacin), glucocorticoicls]

Goal: keep uric acid level <6

Chronic: xanthine oxidase inhibitors (remember? draw it out) (e.g., allopurinol, febuxostat).

Question 12

Pseudogout

Answer 12

Calcium pyrophosphate dehydrate (CPPD) disease.

Age (older female) is common.

Forms basophilic, rhomboid crystals that are weakly positively birefringent.

X-rays: chondrocalcinosis (calcinization (sp.) of cartilage (eg. meniscus) in knees, wrists, elbows.

Diagnose with crystal (less sharp, rhomboid shaped). No tophi. No marker.

Question 13

Basophilic material would stain how in an H and E stain?

Answer 13

Dark purple!

Hematoxylin would be the stain

similar to nucleus of cells

Question 14

A 40 year old male arrives at your office. If your split-second diagnosis came between gout and pseudogout/CPPD, what would you choose and why?

Answer 14

Gout—associated with younger males (30-60 year olds). Pseudogout is mostly seen older (>50) individuals and there is no gender difference.

Question 15

inflammatory back pain

Answer 15

Aka: ankylosing spondylitis

Morning stiffness

Gradual onset with a duration of >3 months, decreases with exercise.

Associated with HLA 27 gene mutation

X-ray shows opaque (calcifying) intervertebral disk.

Question 16

clinical features of the spondyloarthropathies

Answer 16

Multisystem inflammatory disorder

Affects spine (kyphosis), peripheral joints, periarticular structures

Seronegative (Rh factor and CCP antibody are negative)

Positive HLA B 27 (costly genetic test that is associated)

e.g. = psoriatic arthritis

Question 17

clinical features of psoriatic arthritis

Answer 17

a spondyloarthropathy

Associated with psoriasis… duh!

Nail pitting (bad looking nails)

Psoriatic rash

DIP joint arthritis (and others) + sausage fingers

Question 18

Reiter’s Syndrome

Answer 18

Reactive arthritis (previously Reiter syndrome) is an asymmetric polyarthritis mainly affecting the lower extremities.

A spondyloarthropathy

Question 19

ankylosing spondylitis

Answer 19

Associated with HLA B27 (>90%)

Ankylosing spondylitis is a chronic systemic inflammatory disease that affects primarily the sacroiliac joints and spine, resulting in chronic back pain

The condition is classified as a seronegative spondyloarthropathy along with reactive arthritis , psoriatic arthritis , and inflammatory bowel disease–associated spondyloarthritis or enteropathic arthritis