Exam 3 - Rheumatology Flashcards
What is fibromyalgia?
Disorder included with rheumatologic conditions - characterized by symptoms of widespread MS pain, fatigue, nonrestorative sleep, depression, HA, GI complaints (e.g. IBS)
- More than 3 months of MSK pain
Fibromyalgia diagnostic considerations
- Must meet report of pain survey in 19 areas as well as severity of symptoms → replaced tender point examination
- More common in females, ages 40-50 years
American College of Rheumatology criteria for diagnosing fibromyalgia
- WPI >7 and SSS score >5 OR WPI of 4-6 and SSS score >9
- Generalized pain (in at least 4-5 regions)
- Symptoms present for longer than 3 months
Fibromyalgia clinical presentation
- Persistent widespread pain
- Chronic fatigue
- Somatic complaints → non restorative sleep, cognitive difficulties, auditory/vestibular/ocular complaints, chronic rhinitis or “allergies”, migraines, palpitations, IBS, subjective sense of joint swelling, mood disorders
Fibromyalgia physical examination findings
- Normal muscle strength
- No evidence of synovitis or soft tissue inflammation
Are labs indicated for the diagnosis of fibromyalgia?
- CBC, chem profile, TSH, ESR, CRP to exclude other disorders
- ANA, rheumatoid factor, anti-citrullinated protein antibody (ACPA) only in setting of synovitis, lupus, or RA
- Sleep study for OSA
Can fibromyalgia be diagnosed back on history and physical examination alone?
Yes, but want to exclude other causes first
- Patient report of widespread pain present in up to 19 + fatigue + disordered sleep for >3 months
Non pharmacological management of fibromyalgia
- CBT
- Exercise (to combat muscle wasting)
- Acupuncture
- Massage
- Chiropractor
Pharmacological management of fibromyalgia
- TCAs (amitriptyline, cyclobenzaprine)
- SNRIs (duloxetine and milnacipran)
- Gabapentin (Neurontin) and pregabalin (Lyrica) for pain
- Tylenol
- Opioids ONLY after all other meds and therapies failed
What are the four stages of a gout attack?
- Asymptomatic hyperuricemia → elevated serum urate but no acute attacks, crystals may deposit in joints and cause asymptomatic damage
- Acute gout attacks → activation of inflammatory response leading to intense pain, swelling, redness, warmth
- Intercritical gout (intervals between acute attacks)
- Chronic tophaceous gout → due to uncontrolled hyperuricemia
- Firm swelling most commonly found on digits of hands and feet, and olecranon bursa
Risk factors for gout
- Use of diuretics or low dose aspirin use
- Obesity
- CKD
- Metabolic syndrome
- Advanced age
- Local trauma
- Binges of alcohol
- Overeating/fasting
- Newly initiated urate-lowering therapy
How does gout appear in men vs women?
- Recurrent episodes of painful monoarthritis in men
- Oligoarticular arthritis (4 or fewer joints) in postmenopausal women and men with subsequent flares
Acute gout clinical presentation
- Rapid onset (pain peak within 2-4 hours) and increasing pain
- First attack at night and patient wakes up from sleep
- Tenderness, warmth, redness, swelling, decreased ROM in affected joint (usually in first MTP)
- Heberden’s nodes
Gout diagnostic studies
Confirmed with needle aspiration → MSU crystals in synovial fluid or tophi aspiration
What are the goals of gout management?
1) treat acute attacks
2) lowering of total body uric acid pool to prevent tissue deposition of MSU crystals
3) anti-inflammatory prophylaxis to prevent further acute attacks
Non pharmacologic management of gout
- Avoid diuretics
- Control weight
- Limit alcohol consumption
- Consume low fat dairy products, cherry juice concentrate
- DASH diet
- Topical ice
Pharmacologic management of acute gout attacks
- NSAIDs and oral corticosteroids for initial treatment (corticosteroids preferred of CrCl <50, on anticoagulant therapy, or hepatic dysfunction)
- Colchicine should be used within 36 hours of onset of acute attack
- NOT used if GFR is <50
Pharmacologic management of chronic gout attacks
- Urate lowering therapy (ULT) should be started 4-8 weeks after attack is resolved
- Xanthine oxidase inhibitors (allopurinol, febuxostat)
- Uricosuric agents (probenecid, lesinurad)
- Recombinant uricase (pegloticase)
What is considered chronic gout?
Patients who have 2+ gout attacks a year
True/false: There is an increase in acute attacks after ULT therapy initiation for gout
True - due to inflammation caused by changes in the chemical and/or physical state of preexisting MSU crystals
What medication should be prescribed to patients prophylactically for patients starting ULT therapy for gout?
- Give prophylactic low dose anti inflammatory treatment when initiating patient on ULT → e.g. colchicine
- Alternative → NSAIDs
What are the three types of treatment for gout?
- Medications to control attacks of joint pain (NSAIDs, colchicine, corticosteroids)
- Prophylaxis (colchicine, NSAIDs)
- Medications to lower uric acid levels (allopurinol, febuxostat)
OA risk factors
- Female (middle age and older)
- Obesity
- Prior trauma
- Genetics
- Repetitive activities
- Metabolic disorders
- Neurologic disease
- Hematologic conditions
OA vs RA
OA clinical presentation (history)
- Insidious, progressive pain/stiffness of one or more joints
- Symptoms common after waking up (duration <1 hour)
- Pain with weight bearing activities
- Crepitus, swelling, joint deformity, gradual loss of motion
OA physical examination findings
- If cervical or lumbar spine spine is involved, neuropathy and radiculopathy → groin/butt pain causes patient to “favor” the hip → Trendelenburg gait
- Heberden nodes (distal) and Bouchard nodes (proximal)
OA diagnostic studies
X-ray (will see radiographic changes as disease progresses)
Pharmacological management of OA
- Pills
- Acetaminophen → first line
- Tramadol for moderate to severe pain
- NSAIDs (may be given with H2 blockers or PPIs to reduce GI intolerance)
Pharmacological management for OA
- Injectables
- Hyaluronan injections for mild to moderate OA (improves fluid viscosity)
- Intra articular corticosteroid injections → not recommended more often than every 3-4 months
Non pharmacological management of OA
- Exercise
- Locally applied heat, ice
- Warm baths
- Custom orthotics
- Weight reduction
What is poly myalgia rheumatica (PMR)?
Treatable, chronic systemic inflammatory condition of unknown cause most often in older adults
- Does not occur in adults younger than 50 years
PMR clinical manifestations
- Stiffness/aching of shoulder girdle, pelvic girdle, neck
- Pain worse at night and can radiate to elbows and knees (can have morning stiffness >1 hour)
- Low grade fever, depression, fatigue, malaise, weight loss
How is PMR different from RA?
Inflammatory arthritis of knees and wrists
- Asymmetric, self limiting, responsive to systemic corticosteroids
PMR physical examination findings
- Painful active ROM of shoulder and hips
- No signs of synovitis
American College of Rheumatology diagnostic criteria for PMR
- Patient 50+ years with new onset bilateral shoulder pain
- Elevated ESR and/or CRP
- Negative RF and anti-CCP
- Morning stiffness >45 minutes
- New hip pain in the absence of peripheral synovitis
PMR lab studies to rule out other inflammatory diseases
- CBC, ESR, CRP, CMP, LFTs, serum protein electrophoresis, RF and anti-CCP, UA, TSH
- Chest x-ray
PMR management/treatment
- Referral to rheumatologist
- Referral to ophthalmologist or plastic surgeon with any sign of temporal arteritis
- Systemic corticosteroids (low dose prednisone)
- Consider bone protective measures for patients with chronic PMR and require lifelong corticosteroids
What is the most significant complication of PMR?
Giant cell arteritis → report any new headache, change in vision, scalp tenderness, pain on chewing
Giant cell arteritis clinical manifestations
- Involvement of CNs → severe headache (temporal region), jaw claudication, visual impairment, scalp tenderness, prominent or tender temporal artery, tongue infarction, stokes, neuropsychiatric symptoms
Giant cell arteritis diagnostic studies
- Color doppler ultrasound of temporal arteries → halo sign
- Gold standard → unilateral temporal artery biopsy
Giant cell arteritis management/treatment
- Prednisone
- Pulse IV methylprednisolone for visual impairment
- Adjunctive therapy with steroid sparing agents (e.g. methotrexate)
- Low dose aspirin
What is rheumatoid arthritis?
Autoimmune disorder characterized by bilateral symmetrical inflammatory polyarthritis and varying degrees of extra-articular involvement
- Insidious onset
Systemic symptoms of RA
- Weakness
- Weight loss
- Malaise
- Fatigue
- Anorexia
- Aching
- Stiffness
Localized symptoms of RA
- Painful, tender, swollen joints
- Morning stiffness for >1 hour
Extra articular symptoms of RA
- Sjogren syndrome (dry eyes and mouth)
- CV disease
RA diagnostic studies
- X-rays
- Labs → CBC, ESR, CRP, creatinine, hepatic panel, UA, RF, anti-CCP
- Normocytic, normochromic anemia common
- Synovial fluid analysis (aspiration)
Non pharmacologic management of RA
- PT, OT, psychological interventions, exercise
- Warm showers in the morning
- Frequent position changes during sleep to alleviate stiffness
- Assess CV risk yearly
Pharmacologic management of RA
DMARDs (methotrexate) + folic acid supplementation, biosimilar medications, NSAIDs, glucocorticoids
Clinical manifestations of ankylosing spondylitis
- Chronic back pain and stiffness (in pelvis and lower back) due to involvement of spine or sacroiliac joints
- Back pain improves with exercise and worsens with inactivity/rest and in the morning
- Buttock pain; hip pain
- Deep ache or nagging discomfort
- Sleep disturbance (wake up to “walk to pain off”)
- Asymmetric joint arthritis (commonly in lower limbs)
Extra articular manifestations of ankylosing spondylitis
- Low grade fever, fatigue, weight loss
- Acute anterior uveitis → unilateral or unilateral alternating
Physical exam findings of ankylosing spondylitis
- Loss of normal lumbar lordosis
- Decreased spine mobility
Ankylosing spondylitis diagnostic studies
- Presence of sacroiliitis on MRI associated with one clinical criterion
- X-ray may not show changes early on in disease process
- “Bamboo” spine appearance
Referrals for ankylosing spondylitis
- Referral to rheumatology
- Referral to orthopedic surgeon (for patients who develop hip arthritis), evaluation by cardiologist
- Periodic ophthalmic monitoring
Non pharmacologic management of ankylosing spondylitis
- Perform exercises tailored for AS (PT)
- Local heat and massage
- Avoid contact sports (can go swimming)
Pharmacologic management of ankylosing spondylitis
- NSAIDs first line therapy
- DMARDs (methotrexate), TNF agents (etanercept, -umab), IL-17 monoclonal antibodies (secukinumab)
- Systemic corticosteroids for short term relief (NOT long term)
- Acetaminophen and muscle relaxants to minimize chance of spine deformity
Psoriatic arthritis clinical manifestations
- Can occur before, with, or after onset of psoriasis
- Nail pitting before rash
- Enthesitis and dactylitis, arthritis mutilans
- Asymmetric sacroiliitis (in AS it is bilateral)
Psoriatic arthritis diagnostic studies
- X-ray of affected joints → subchondral erosions, periostitis, ankylosis
- Late disease will show whittling and “pencil in cup” appearance
Non pharmacologic management of psoriatic arthritis
- Regular exercise (swimming, cycling, walking)
- Referral to rheumatologist and dermatology
Pharmacologic management of psoriatic arthritis
- NSAIDs are first line
- DMARDs are second line (methotrexate)
- Anti-TNF agents → etanercept, infliximab, adalimumab, golimumab, certolizumab)
Clinical manifestations of SLE
- Early symptoms are nonspecific → fatigue, oral ulcers, joint pain, malaise
- Malar (butterfly) rash
- Discoid rash
- Photosensitivity
- Arthritis
- Serositis (pleuritis, pericarditis)
- Persistent proteinuria, cellular casts
- Seizures, psychosis; mood changes, depression, migraines, headaches
- Raynaud phenomenon
SLE diagnostic studies
- Elevated ESR, CRP, serum gamma globulins
- Hemolytic anemia, leukopenia, lymphopenia, thrombocytopenia
- UA, BUN, creatinine, 24 hour urine protein excretion, CrCl
Non pharmacologic management of SLE
- Referral to rheumatology at diagnosis; dermatologist, ophthalmologist, nephrologist, cardiologist, orthopedic surgeon, hematologist, OT, PT, nutritionist
- Visits to gynecologist at shorter intervals (higher risk of HPV and cervical dysplasia)
- Avoid prolonged sun exposure (wear SPF >30)
Pharmacologic management of SLE
- Statins for hyperlipidemia, calcium and vitamin D for osteoporosis
- Antibiotic prophylaxis before dental procedures
- NSAIDs
- PPIs in addition to corticosteroids or aspirin therapy
- Hydroxychloroquine for MSK, mucocutaneous, and serosal manifestations
What is juvenile idiopathic arthritis?
Persistent arthritis for more than six weeks in a child younger than 16 years old
Clinical manifestations (history) of juvenile idiopathic arthritis
- Arthritis → pain (aching), joint stiffness (worse in the morning and after rest), joint effusion and warmth, younger children may be irritable or have behavioral regression
- Nonspecific symptoms → decreased appetite, myalgia, nighttime joint pain, inactivity, FTT
MSK exam findings for juvenile idiopathic arthritis
- Swelling of joint with effusion or thickening of synovial membrane
- Heat over inflamed joint and tenderness along joint line
- Loss of joint ROM and function
- Observe gait abnormalities (may walk with a limp)
- Holds affected joint in flexion
Physical exam findings for juvenile idiopathic arthritis
- Vision screening
- Nail pits or onycholysis
- Ciliary injection
- Fleeting salmon-color rash that is more prominent on the trunk
Juvenile idiopathic arthritis diagnostic studies
- Diagnosis of exclusion
- Watchful waiting since joint pain must be present for >6 weeks
Non pharmacologic management of juvenile idiopathic arthritis
- Referred to pediatric rheumatologist and ophthalmologist
- High risk for uveitis → slit lamp examination every 3-4 months for four years
- Physical therapy mainstay of treatment for chronic childhood arthritis
- Water therapy and using heat or cold to reduce pain and stiffness (e.g. swimming)
Pharmacologic management for juvenile idiopathic arthritis
- Aggressive early pharmacological therapy
- NSAIDs
- DMARDs (managed by pediatric rheumatologist)
- Oral glucocorticoids if there has not yet been a prompt response
