Clinical Approach to RA, Seronegative Arthropathies and Gout (Johnston)

Question 1

What imaging should you use for RA?

Which is more sensitive detecting erosions?

Answer 1

1) X-rays of hands and feet

2) CT (more sensitive detecting erosions)

Question 2

What mortality is highly associated with RA?

Answer 2

1) CAD

2) HF

Question 3

The 2010 RA Classification Criteria has to have a score of what for definite RA?

Answer 3

6/10

Question 4

What is found on labs for RA?

Answer 4

1) RF

2) Anti-CCP

Question 5

What should you not do with RA patient?

Answer 5

Flexion of neck because C1-C2 can sublux

Question 6

Rheumatoid nodules seen in the elbow are always positive for?

Answer 6

RF

Question 7

What physical findings are found in the wrist with RA?

In the knee what can be found?

Answer 7

1) Radial deviation

2) Bakers cyst

Question 8

What is Pyroderma Gangrenosum which can be seen in RA patients?

Answer 8

Tender reddish purple papule that leads to necrotic non-healing ulcer

Question 9

What is Rheumatoid Vasculitis?

Answer 9

Purpura
Petechial splinter hemorrhages
Digital infarct

Question 10

What autoimmune disorder with lacrimal and salivary dysfunction is seen in 35% of RA patients?

What antibody test will be seen?

What else is seen?

Answer 10

Sjogren’s syndrome

Anti Ro and La

Keratoconjunctivitis

Question 11

Seronegative Spondyloarthropathies has immune susceptibility to what HLA?

Answer 11

HLA-B27

Question 12

Seronegative Spondyloarthropathies have a predilection for what areas of the body?

Answer 12

Spine and SI joint

Question 13

Which seronegative spondyloarthropathies has the strongest association with HLA-B27?

Answer 13

Ankylosing Spondylitis

Question 14

Ankylosing Spondylitis is the most common inflammatory disorder of?

Answer 14

Axial skeleton and SI joints

Question 15

What are the clinical manifestations of Ankylosing Spondylitis?

Answer 15

1) Low back pain for more than 3 months
2) Morning stiffness that improves with activity
3) Symmetrical SI joint pain
4) Planter fasciitis

Question 16

What extra-articular manifestation of the eye can occur with Ankylosing Spondylitis?

Answer 16

Anterior uveitis (Iritis)

Question 17

What is found on physical exam for Ankylosing Spondylitis?

Answer 17

Restricted forward flexion (Schober test)

Restricted chest expansion

Question 18

What is found on vertebral imaging for Ankylosing Spondylitis?

Answer 18

1) Squaring (loss of anterior convexity)

2) Shiny corners (sclerosis at edge of vertebral bodies)

Question 19

What is syndesmophytes?

Answer 19

Bridging of vertebrae (boney bridges cause ankylosis)

Question 20

What imaging is more sensitive for erosions?

What imaging detects inflammation before changes seen on other modalities?

Answer 20

1) CT

2) MRI

Question 21

In the differential diagnosis of AS, osteitis condensans ilii, will show what findings on imaging?

What happens in Diffuse idiopathic skeletal hyperosteosis (DISH)?

Answer 21

1) Normal SI joints
2) X-ray shows sclerosis on iliac side of SI joint

3) Normal SI Joint
4) Calcification along 4 contiguous vertebrae bodies

Question 22

The age of onset for AS is?

Answer 22

Below age 40

Question 23

Reactive Arthritis is an autoimmune disease that affects what?

Answer 23

Asymmetric mono-arthritis or oligo-arthritis (large joints) in LE

Question 24

Reactive Arthritis may be associated with infections from what track?

Answer 24

GI/GU (Salmonella, shigella, chlamydia, etc)

Question 25

What HLA is present in 75% of reactive arthritis and IBD associated arthritis?

Answer 25

HLA B27

Question 26

What are the clinical manifestations of reactive arthritis in young men?

Answer 26

1) Arthritis in ankles/knee 2) Achilles inflammation (Enthesitis) 3) Toe/finger inflammation (Dactylitis) 4) Asymmetrical SI Joint 5) Aortic Regurgitation/Insufficiency

Question 27

In regards to reactive arthritis, what is Keratodermia blennorrhagica in a patient with Reiter’s syndrome?

Answer 27

Painless eruptions of the feet

Question 28

Pitting of the nails is associated with?

Answer 28

Psoriatic arthritis

Question 29

Psoriatic arthritis has what classic appearance on imaging?

Answer 29

Pencil in cup

Question 30

Enteropathic Arthritis has what peripheral arthritis symptoms?

Answer 30

1) Parallels activity of IBD 2) Affects large joints of LE 3) Affects small joints of UE

Question 31

What is the characteristic lesion associated with Gout? What appearance does gout have on polarizing microcopy?

Answer 31

1) Tophi, white chalky masses of uric acid | 2) Negative Birefringence, Needle like crystals

Question 32

What are the cutaneous manifestations of Enteropathic Arthritis?

Answer 32

Erythema Nodosum Pyoderma Gangrenosum Uveitis

Question 33

Uric acid is an end product of?

Answer 33

Purine degradation

Question 34

Calcium Pyrophosphate Dehydrate Deposition Disease (CPPD) is also known as?

Answer 34

Pseudogout

Question 35

Pseudogout leads to? It affects what population most commonly?

Answer 35

1) Calcium deposits in articular cartilage of large joints | 2) Older patients

Question 36

The CPPD crystals are described as?

Answer 36

Short blunt rods, rhomboids/cuboids

Question 37

What appearance does pseudogout have on polarizing microcopy?

Answer 37

POSITIVE birefringence

Question 38

What is seen in Felty's syndrome?

Answer 38

RA Splenomegaly RF+Anti CCP