Connective Tissue and Joint Disease Flashcards
Scleroderma diagnosis and treatment
Diagnosis: Elevated ANAs highly sensitive
Anti-centromere specific for limited form
Anti-topoismerase I specific for diffuse form
Barium swallow and PFTs for complications
Treatment:
No effective cure
NSAIDs for musculoskeletal pain, H2 blockers or PPIs for esophageal reflux
Raynauds: avoid cold and smoking, keep hands warm, use CCBs if severe
Sjogren’s Syndrome diagnosis and treatment
Diagnosis: ANAs in 95% can also have RF
Ro (SS-A) and La Abs
increased ESR, normocytic normochromic anemia, leukopenia
Schirmer test: filter paper inserted into eye to measure lacrimal output-high sensitivity and specficity
Salivary gland biopsy (lip or parotid) most accurate but not done
Treatment:
Pilocarpine or Cevimeline (enhances oral and ocular secretions)
Artificial tears
Good oral hygeine
NSAIDs, steroids for arthralgias, arthritis
Diagnosis and Treatment of Rheumatoid Arthritis
Diagnosis: High titers of RF (the higher=more severe disease)
Anti-citrullinated peptide/proteins-specific!
elevated ESR, CRP
Normocytic normochromic anemia (anemia of chronic disease)
Radiographs
Loss of juxtaaricular bone mass (periarticular osteoporosis)
narrowing of joint space
Bony erosions
Treatment:
Exercise helps with range of motion and muscle strength
NSAIDs for pain control (corticosteroids if nonresponsive)
Methotrexate (DMARD) takes 6 weeks to take effect
Use with folate
Leflunomide can also be used
Combo with hydroxychloroquine and sulfasalazine higher remission rates
Anti tumor necrosis factor can help as well
Cervical spine radiographs before undergoing surgery
Diagnosis and treatment of Gout
Diagnosis:
Synovial fluid: cloudy yellow, >5000 WBCs, 50-70% PMNs, negatively biferingent Crystals
Radiographs: punched out lesions
Treatment:
Avoid thiazide and loop diuretics, obesity, alcohol, red meat and seafood
Bed rest
NSAIDs for acute gout (indomethacin)
Colcichine if can’t tolerate NSAIDs
Corticosteroids (oral prednisone 7-10 days) if don’t respond to either
Intra articular corticosteroid injections provides dramatic relief
Prophylactic
Must have 2 acute gouty attacks per year
Colcichine and NSAID for 3-6 months
Uricosuric drugs (probenecid, sulfinpyrazone) if 24 hour urine uric acid is less than 800 mg/day
Allopurinol if 24 hr urine uric acid is greater than 800 mg/day
Pseduogout diagnosis and treatment
Diagnosis: monoarticular-knees and wrists
weakly positively birefrigent rod shaped and rhomboidal crystals
Radiographs: chondrocalcinosis
Treatment:
underlying disease-OA, hemochromatosis, hyperparathyroidism, hypothyroidism, and Bartters syndrome
Inclusion body myositis
male more than female
no autoAbs
proximal and distal muscle Involvement-weakness and atrophy of quads, forearm flexoors and tibialis anterior (assymetrical)
Facial weakness and dysphagia
Loss of deep tendon reflex (not involved in dermatomyositis and polymyositis)
relatively low CK
Prognosis is poor
Endomysial inflammation
Dermatomyositis diagnosis and treatment
Diagnosis: CK is significantly elevated
LDH, aldolase, AST, ALT are also elevated
ANA
Antisynthetase Abs (anti-Jo-1)-abrupt onset of fever, cracked hands, Raynauds, interstitial lung disease, arthritis-does not respond well
Antisignal recongition particle-cardiac manifestations, worst prognosis
Anti-Mi-Abs-better prognosis
EMG-abnormal in 90%
Muscle biopsy-perivascular and perimysial inflammation
Treatment: corticosteroids is initial continue until symptoms improve and then taper slowly Immunosuppressive agents (if unresponsive)-methotrexate, cyclophosphamide, chlorambucil Physical therapy
Look for underlying lung, breast, ovary, GI and myeloproliferative cancers
Polymyositis treatment and diagnosis
Diagnosis: CK is significantly elevated
LDH, aldolase, AST, ALT are also elevated
ANA
Antisynthetase Abs (anti-Jo-1)-abrupt onset of fever, cracked hands, Raynauds, interstitial lung disease, arthritis-does not respond well
Antisignal recongition particle-cardiac manifestations, worst prognosis
Anti-Mi-Abs-better prognosis
EMG-abnormal in 90%
Muscle biopsy-endomysial inflammation
Treatment: corticosteroids is initial continue until symptoms improve and then taper slowly Immunosuppressive agents (if unresponsive)-methotrexate, cyclophosphamide, chlorambucil Physical therapy
Diagnosis and treatment of Polymyalgia Rheumatica
Diagnosis: elevated ESR greater than 100
Treatment: corticosteroids
response within 1-7 days begin tapering after 4-6 weeks
Ankylosing Spondylitis diagnosis and treatment
Diagnosis: Imaging studies of lumbar spine and pelvis (plain film, MRI, CT)-sclerotic changes (vertebral columns fuse producing bamboo spine)
Elevated ESR
Worse in morning, improves with exercise and hot shower and worsens with rest or inactivity
Treatment:
NSAIDS (indomethacin) for symptomatic relief
Anti-TNF medications (etanercept, infliximab)
Physical therapy
Severe signs of Back pain and diagnosis requirements
Age >50
history of previous cancer
constitutional symptoms
night time pain-sleep difficulty
pain duration >1 month
no response to previous therapy
neurological symptoms
If positive perform MRI in 24 hours if not severe
if severe emergency MRI plus glucocorticoids then radiation or surgery
NO red flags perform Xray-if positive then MRI, if negative perform bone scan
reactive arthritis, causes diagnosis and treatment
Causes: Salmonella, Shigella, campylobacter, chlamydia, yersinia
Diagnosis: synovial fluid: cloudy yellow, >5000 WBC, 50-70% PMNs
Treatment: NSAIDs
Sulfasalizine or azathioprine if unresponsive
Diagnosis and treatment of giant cell arteritis
Diagnosis: ESR elevated
Biopsy of temporal artery
Treatment: Treat immediately with oral prednisone
if loss vision treat with IV steroids and admit to hospital
Diagnosis confirmed: treat for 4 weeks then taper gradually but maintain for 2-3 years
Takayasus arteritis
Vasculitis of aortic arch leading to stenosis and narrowing
Clinical: constitutional-fever, sweats, malaise, arthralgias, fatigue
Absent carotid, radial or ulnar pulses
Aortic regurgitation may be present
Severe complications: limb ischemia, aortic anuerysms, aortic regurgitation,stroke and HTN due to RAS
Diagnosis: arterogram
Decreased or absent peripheral pulses, discrepancies of BP (arm vs. leg), arterial bruits
Treatment: steroids, surgery or angioplasty to recannulate stenosed vessels
Churg Straus syndrome
Clinical: fever, fatigue, weight loss, prominent respiratory tract findings (asthma, dyspnea) and skin lesions (subcutaneous nodules, palpable purpura)
Diagnosis: skin or lung biopsy-prominence of eosinophils
p-ANCA
Poor prognosis even with steroid treatment
