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1. Rheum RC > Infectious Arthritides - Septic, Lyme, TB, Viral, HIV, Whipple's, ARF > Flashcards

Infectious Arthritides - Septic, Lyme, TB, Viral, HIV, Whipple's, ARF Flashcards

1
Q

Diff between gonococcal and nongonococcal septic arthritis

A

Gonococcal:
–Healthy young (vs children/elderly/ immunocompromised)
–Migratory arthritis (vs monoarthritis)
–Common Rash and Tenosynovitis (vs rare)
–Rare + blood/joint Cx (vs common)
–Good outcome (vs bad)

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2
Q

Septic arthritis RF

A

-Impaired host defense, old (>80), young (<5)
– Neoplastic disease
– Chronic illness (EtOH, DM, cirrhosis, CKD, HIV, IVDU, hyposplenia from Sickle cell)
– Immunodef: hypogammaglobulinemia, complement def
– Skin infxn
– Drugs: GC, chemo, biologic
– Iatrogenic: prosthetic joint, IA GC
– Chronic arthritis (i.e., RA, hemarthrosis, osteoarthritis)

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3
Q

**MTP involvement DDX **

A

Septic, osteomyelitis, cellulitis,
-Diabetic osteolysis/Charcot,
-Intertarsal bursitis,
-Freiberg infarction (infarct of the MT head, often the 2nd),
-Sesamoiditis,
-CRPS,
-Stress fracture

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4
Q

** Septic arthritis likely organisms in DM**

A

In order of freq:
-Staph Aureus
-Streptococci
-Gram negative bacilli
-Polymicrobial
-Coagulase (-) Staph
-Culture negative

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5
Q

When is surgical drainage absolutely indicated for a septic joint?

A

-* Infected hip/ shoulder joints.
-* Vertebral OM with cord compression.
-* Anatomically difficult-to-drain (eg SC), loculated
-* Too thick to aspirate
-* Ongoing sx despite needle drainage
-* Prosthetic joints or foreign body
-* OM requiring surgical drainage.
-* Delayed onset of therapy (>7d)

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6
Q

Poor prognostic factors nongonococcal septic arthritis

A

-Old
-Late diagnosis
-On Immunosuppression
-Transplant, IHD, cirrhosis
-RA
-Multiple joints involved
-Bacteremia
-Gram negative

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7
Q

IVDU septic arthritis presentation

A

More gram neg, but S Aureus still MC
-More insidious w/ LONGER duration fo sx
-More AXIAL (L spine, SI joint, SC, symphysis pubis)

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8
Q

PJI RF

A

Distant site of infection,
-Impaired host defense
-RA, diabetes mellitus,
-Revision arthroplasty (5–10 times increased risk),
-Prolonged operative time
-Superficial joint replacements (i.e., knee, elbow, ankle)

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9
Q

Pseudoseptic arthritis causes

A

-RA
-Crystal
-Seroneg, Behcet’s
-SLE
-HA injection
-Prosthetic joints
-Renal transplant

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10
Q

RF for disseminated gonococcal infxn

A

Women, menstruation, preg, postpartum (cervical pH)
-Non-white, Urban residence, Low SES and educational status,
-High risk sex (multiple partner, prostitute)

-Previous gonococcal infection

-Complement deficiency
-Asplenia (SLE, Sickle cell)

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11
Q

** DGI Sx **

A

Papular/pustular skin rash
-Tenosynovitis (dorsum wrists, fingers, toes, ankles)
-Arthralgia
-
-GU symptoms eg PID

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12
Q

** DGI Tx **

A

Local cervicitis:CTX 250mg IM x1 + Azithro 1g x1
-DGI: CTX 1g IV daily x7d + azithro 1g PO x1

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13
Q

** DGI workup **

A
  • Synovial cell count/culture/crystal/gram stain
    – Blood culture
    – urine NAAT testing for gonorrhea
    – urethral/endocervical NAAT testing for gonorrhea
    -
    -**Test for syphilis and HIV
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14
Q

** DGI List 4 sites you want to culture?
-Give % positive synovial fluid culture?
-**

A

Genitourinary 80%
-Synovial fluid 50%
-Rectum 20%
-Pharynx 10%
-Blood <30%
-Skin Rare

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15
Q

** 40 year old man who 2 years ago had bilateral ankle synovitis treated with intraarticular steroids – complete remission. Comes back with monoarthritis, mouth and genital ulcers.
-Ask 4 other pertinent questions on history?**

A

Infectious history and exposures including sexual history
-Ocular symptoms (photophobia, red eye, pain)
-GI symptoms (diarrhea, weight loss)
-Other rashes?

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16
Q

** 40 year old man who 2 years ago had bilateral ankle synovitis treated with intraarticular steroids – complete remission. Comes back with monoarthritis, mouth and genital ulcers.
-Name 3 possible diagnoses?**

A

Behcet
-IBD with associated aphthous ulcers and peripheral arthritis
-HIV
-HSV
-?sarcoid
-?SLE
-gonococcal

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17
Q

** 40 year old man who 2 years ago had bilateral ankle synovitis treated with intraarticular steroids – complete remission. Comes back with monoarthritis, mouth and genital ulcers.
-Name 4 investigations?**

A

CBC
-Arthrocentesis (cell count, culture, microscopy)
-Swab of ulcer
-CXR (screen for PA aneurysms in Behcet)
-General STI testing including HIV testing, chlamydia
-?Pathergy testing

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18
Q

** 40 year old man who 2 years ago had bilateral ankle synovitis treated with intraarticular steroids – complete remission. Comes back with monoarthritis, mouth and genital ulcers.
-Name 3 therapies of most likely diagnosis? **

A

Topical corticosteroids (for ulcers)
-Colchicine titrate up to 0.6 TID
-Prednisone
-AZAthiorpine (for refractory ulcers, arthritis)

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19
Q

Syphilis presentation

A

-Fever, H/A, LN
-Mucosal ulcers, Sore throat
-Polyarthritis
-Maculopapular rash(palms and soles)
-Condyloma lata.

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20
Q

Lyme pathophys

A

Host’s inflammatory response to the spirochete (B. burgdorferi)

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21
Q

Lyme 1st stage manifestations

A

Early localized ECM
–Erythema migrans - annular lesion w/ central clearing
–Flu-like symptoms (H/A, arthralgia, fever, Regional LN)

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22
Q

** Lyme 2nd stage manifestations **

A

Disseminated infection:
–Neuro: CN palsy, meningitis, radiculoneuritis, sensorineural hearing loss
–iritis/keratitis
–Cardiac: AV block, myo/pancarditis, NO VALVE involvement
–Skin - satellite lesion
–MSK: migratory arthralgia,
–Other: LN, splenomegaly, hepatitis,

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23
Q

**Lyme 3rd stage manifestations **

A

Persistent infection (late disease):
–MSK: asymmetric oligoarthritis large joints (knees) w/ inflammatory fluid
–Neuro: encephalomyelitis, stroke like presentation, encephalopathy, polyneuropathy

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24
Q

** Name 5 non-MSK features in early disseminated Lyme disease **

A

Carditis
-Heart block
-Erythema migrans
-Cranial palsy, radiculoapthy, encephalopathy
-Keratitis
-SNHL
-Hepatitis, HSM

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25
Q

Lyme Diagnosis

A

1) Enzyme immunoassay (EIA) OR Immunofluorescence (IFA)
– Negative = consider alternate dx OR too early (<30d) → get Western Blog (WB)
– Positive/Equivocal = get IgG Western blot (IgM too if <30d)
-
-*if IgM + but NOT IgG likely false+ IgM

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26
Q

** Reasons for Lyme False + **

A
  • Previously treated
    – Subclinical past infxn bc in endemic area
    – AB against other spirochetes, syphilis, leptospirosis (eg >1mo sx w/ +IgM ELISA and -IgG ELISA)
    – Cross-reactivity with other diseases: IE, SLE, RA, MS, HPylori, EBV, CMV, malaria, non lyme spirochetes,
    – Interpretation error of faint band
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27
Q

** Lyme Tx **

A

Early/Disseminated/Late:
-Doxycycline 100mg po BID x 14d
-
-*if CNS: CTX 2g daily

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28
Q

** Antibiotic-refractory Lyme arthritis pathophys and Tx **

A

HLADR4 and DR2 alleles bind B Burgdorferi and cross react w/ human protein → autoimmune inflamm

-Tx: No more abx
–NSAID
–IA GC
–HCQ
–Arthroscopic synovectomy

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29
Q

Post treatment Lyme disease syndrome (PTLDS) presentation

A

> 6mo of Fibro/ fatigue symptoms
-Cog dysfunction
-Widespread pain
-Sleep disturbance
-Faituge

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30
Q

Post treatment Lyme disease syndrome (PTLDS) Tx

A

Treat as Fibro

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31
Q

When to give Lyme PPX

A

OLDER than 8yo (ppx not effective)
-Endemic area
-Confirmed adult or nymph Ixodes tick
Attached for at least 36 hours
PPX can be given within 72 hours of tick removal

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32
Q

** Other bugs transmitted by ticks and their sx**

A

B miyamotoi: similar as lyme but NO RASH
-Babesiosis: thrombocytopenia, hemolysis, liver enzymes, intraerythrocytic org on smear
-Human granulocytic anaplasmosis - leukoepenia, thrombocytopenia

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33
Q

RF for osteoarticular TB

A

Female sex
-Old > 65yo
-Endemic country immigrant
-Immunosuppressed eg biologics, EtOH, IVDU, HIV

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34
Q

Osteoarticular TB MSK involvement

A

Spine (pott’s): disk narrowing, vertebral collapse, kyphosis, abscess ,neuro compromise
-Hip, SI joint, knee, ankle, hand/wrist
-OM (lytic lesion w/o periosteal rxn)
-Dactylitis
-Tenosynovitis
-Bursitis

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35
Q

What is Poncet’s disease

A

Culture negative polyarthritis (reactive/immune mediated) in TB of LN or pulmonary
-Tx w/ antiTB meds

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36
Q

** Osteoarticular TB Ix **

A

Synovial fluid smear, culture or adenosine deaminase
-Synovial biopsy: caseating granuloma
-Nucleic acid amplification tests (NAAT)
-CXR
-Bone biopsy
-Blood Cx

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37
Q

** Osteoarticular TB XR findings **

A
  • Lytic lesions with little periosteal reaction
    – Juxtaarticular osteoporosis
    – Osteomyelitis
    – Joint space narrowing
    – Vertebral scalloping and collapse
    – Paravertebral abscess
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38
Q

Osteoarticular TB Tx

A

RIPE x 6-9mo
-DC pyrazinamide after 2 mo
-DC ethambutol once TB confirmed sensitive to isoniazid

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39
Q

NTM risk factors

A
  • Prior surgery/trauma.
    -* Direct inoculation / environmental exposure (soil, water).
    -* IA GC
    -* Preexisting joint disease.
    -* Open wounds
    -* Immunosuppression: eg biologic
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40
Q

Positive TBST

A

PPD>5mm at 48h
-If negative, do IGRA (immunosuppressants can cause false negative)

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41
Q

Biologics highest risk for NTM/ TB

A

TNFi (especially Infliximab )

42
Q

Biologics lowest risk for NTM/ TB

A

Abatacept , Ritux

-*ritux highest risk of hepatitis B reactivation

43
Q

What to do w/ biologic start if latent MTB and normal CXR

A

1 month of latent TB Tx before biologic start
-Complete 9mo of isoniazid

44
Q

What to do w/ biologic start if active TB

A

Complete TB tx before starting biologic

45
Q

What to do w/ biologic start if previously treated NTM

A

Consult ID
-Can consider Ritux or Abatacept
-Avoid TNFi

46
Q

Leprosy symptoms

A

Erythema nodosum 2/2 ReA
-Subcutaneous nodules
-Necrotizing vasculitis
-
-Symmetric small joint polyarthritis (can be RF+)
-Neuropathic acroosteolysis: Charcot, resorption distal metatarsals, aseptic necrosis, “claw” hands
-
-Infection of bone (distal phalanges)

47
Q

Viral arthritis characteristics

A

Acute self-limited (weeks/months)
-Nonerosive,
-Inflammatory arthritis
-Can be RF and ANA+

48
Q

Acute Hep B serology

A

Positive: HBcAb IgM, HBcAb IgG,HBsAg, HBeAg, HBV DNA

-Negative: Anti HBs, Anti HBe

49
Q

Cleared Hep B serology

A

Positive: HBcAb IgG, Anti HBs, +/-Anti HBe
-Negative: HBcAb IgM, HBsAg, HBeAg, HBV DNA

50
Q

Chronic HBV infection serology

A

Positive: HBcAb IgG, HBsAg, HBeAg, HBV DNA, Anti HBs, +/-Anti HBe

-Negative: HBcAb IgM

-*same as acute with negative HBcAb IgM

51
Q

HBV Vaccine serology

A

Only Anti-HBs

52
Q

RF chronic HBV

A

Male
-Immunocompromised

53
Q

HBV rheum manifestations

A

Symmetric migratory polyarthralgia/itis (~RA) - resolves w/ jaundice onset
-Dermatitis - maculopapular, urticarial, petechial
-Membranous nephropathy
-HBV-associated polyarteritis nodosa

54
Q

HBV PAN Tx

A

Immunosuppression
-PLEX
-Antiviral

55
Q

HBV labs

A

Hep B serologies
-Positive RF
-Hypocomplementemia
-

56
Q

When to give ppx antiviral for HBV with biologics

A

Chronic inactive with TNFi, Ritux, or other biologic
-Past resolved infxn with Ritux

57
Q

** List 5 rheumatologic conditions that can accompany Hepatitis C.**

A

Nonerosive polyarthritis
-Cryo vasculitis
-Autoimmune conditions caused by interferon alpha (no longer used)
-Keratoconjunctivitis sicca
-Fibromyalgia

58
Q

HCV serology

A

ANA, RF, Ro, La (if cryo: low complements and cryo+)
-Celiac
-Anticardiolipin
-Antithyroid, Antismooth, AntiLKM

59
Q

Differentiate HCV arthritis from RA

A

HCV nonerosive and usually CCP negative

60
Q

Differentiate HCV sicca from SS

A

Both hv Ro/La
-MSG biopsy shows CD8+T cells (vs CD4+ T cells in SS)

61
Q

Treating Rheum pt w/ HBV or HCV infection

A

Use HCQ, SSZ, and AZA over MTX/LFN
-TNFi are safe

62
Q

Parvovirus B19 sx & labs

A

Hydrops fetalis in infected mothers
-Erythema infectiosum (fifth disease) in children
-Aplastic crisis in adults
-pseudo rheumatoid inflammatory arthritis
-fever, rash, myalgia, arthritis (adults > children)
-Mimicking lupus: cytopenia, hypocomplementemia, a positive ANA, and transient aPL antibodies

63
Q

Parvo B19 labs

A

Cytopenia,aplastic crisis
-Hypocomplementemia,
-Positive ANA, RF, dsDNA, ENA, APLA

64
Q

Mech of viral arthritis eg Hep, Parvo

A

Immune complex deposition causing nonspecific inflammatory response

65
Q

How to distinguish dengue fever from CHIK infection?

A

Dengue
– Arthralgia WITHOUT synovitis
– Abdo pain
– Leukopenia
– Hemorrhagic manifestations
– Breakbone fever

66
Q

What NOT to give in Zika infection

A

NSAIDs and ASA bc can cause bleeding in patietns with other flaviviridae infections

67
Q

** Rheum Manifestations assoc’d w/ HIV **

A

Arthralgia/Arthritis
-Seroneg: ReA, PsA, undiff SpA bc CD8+
-Myalgia, PM, IBM
-Diffuse infiltrative lymphocytosis syndrome
-Vasculitis (all types: LVV, PAN, AAV, HSP, PVCNS, Behcets, Cryo2/3)
-Fibro

68
Q

** Why test HIV in psoriasis **

A

As CD4 drops, can flare psoriasis

69
Q

** Rheum Manifestations assoc’d w/ ART **

A

CD4 mediated: RA, Sjogren’s, SLE, SCLE, Sarcoid
-ReA
-Gout (hyperuricemia)

-Grave’s
-AVN, OP, osteomalacia
-OM
-Rhabdo, lipodystrophy, mitochondrial myopathy

70
Q

Pathophys of HIV rheum syndromes

A

CD4 depletion = T reg cell depletion (for self tolerance and avoiding autoimmunity)

71
Q

HIV autoimmune serologies

A

RF, ANA, Anticardiolipin, Cryo, ANCAs

72
Q

HIV assoc’d arthritis manifestations and Tx

A

Seroneg oligoarticular knees/ankles
-Noninflammatory, culture neg, synovial fluid
-Normal XR
-Tx: NSAID, steroid, PT
-
-Prolonged:
– RA like erosions and joint space narrowing
–Jaccoud’s
-Tx: NSAIDs, HCQ, SSZ

73
Q

Diff between HIV assoc’d arthritis and painful articular syndrome

A

Painful articular syndrome lasts <24h
– Occurs late in HIV
– Due to transient bone ischemia (no synovitis)
– Tx = narcotics

74
Q

When to give DMARDs in pt w/ HIV

A

Adherence to ART
-Viral load is low
-CD4 T cell count >200/uL

75
Q

HIV related wasting syndrome - sx and bx

A

Noninflamm necrotizing myopathy
-Bx: atrophy and necrosis WITHOUT inflamm

76
Q

HIV associated PM vs PM

A

HIV assciated PM:
– Lower CK (can be normal)
– NO autoantibodies
-Otherwise, EMG, MRI, biopsy is the same
-
-Tx: Steroids+ART (2nd line = MTX)

77
Q

AZT induced myopathy vs PM

A

AZT induced myopathy
– Biopsy shows AZT induced toxic mitochondrial myopathy with RAGGED RED FIBERS
-
-Tx: Hold AZT x4wks and monitor

78
Q

** Diffuse infiltrative lymphocytosis syndrome vs Sjogren’s **

A

DILS:
– CD8+ predominant lymphocytic infiltration of salivary/lacrimal gland (vs CD4 in sjogrens)
– COMMON parotid swelling and extraglandular mx (less common in SS)
– RARE AB (RF, ANA, Ro/LA)
– Steroids help glandular (less helpful in SS)
-

79
Q

** Name the rheumatic diseases that may improve in association with AIDS **

A

SLE and RA are CD4 driven, thus IMPROVE with AIDS
-Can worsen with ART

80
Q

MoA of IRIS

A

Increasing CD4 counts w/ Tx exacerbates preexisting RA, SLE, Sarcoid
-CD4 and cytokines can cause new RA, SLE, Sarcoid, PM, ReA, SCLE, GBS, autoimmune thyroid

81
Q

IRIS Tx

A

Self limited, continue ART unless ocular or CNS symptoms → then DC and give GC

82
Q

When should screening for HIV be considered by the rheumatologist?

A

1) Diagnosis of ReA with sexual or unknown mode of acquisition,
-2) IVDU
-3) Septic arhtiris/pyomositis
-4) PsA w/ refractory or atypical rash
-5) atypical SLE or unexplained autoantibody
-6) Sicca without Ro/La
-7) Autoimmune dz refractory to usual tx

83
Q

HTLV1 (human T lymphotropic virus type 1) disease association

A

-T cell leukemia and NHL - hyperCa, skin involvement
-Chronic inflamm syndrome - seroneg oligo/polyarthritis w/ tenosynovitis and nodules w/ fibrinoid necrosis

84
Q

HTLV1 smear cells

A

Flower cells

85
Q

** Whipple’s pathogen**

A

Tropheryma whipplei

86
Q

** Whipple’s symptoms**

A

-Wasting/weight loss, abdo pain, Steatorrhea, diarrhea, malabsorption
-Arthritis (seroneg palindromic rheumatism of knees, ankles, wrists, SI joints, spine)
-Eye inflammation (Panuveitis, keratitis, retinitis, optic neuritis, orbital pseudotumor) , Supranuclear ophthalmoplegia
-Hyperpigmentation of skin, skin lesions
- Encephalopathy, Psychiatric symptoms
-Interstitial nephritis

-Pancytopenia, Lymphadenopathy
-Endocarditis (cultre negative)

87
Q

Whipple’s CNS sx

A

Dementia
-Psych
-Myoclonus
-Oculomasticatory or oculofacial-skeletal myorhythmia (pathognomonic)

88
Q

Whiples triad

A

Dementia,
-Supranuclear ophthalmoplegia
-Myoclonus

89
Q

Whipples Dx

A

Biopsy showing organism in one involved tissue by 2 methods (PAS stain, PCR, immunohistochemical stain OR
-PCR testing in 2 involved sites (eg synovial fluid and CSF)
-*always test CNS regardless of neuro symptoms

90
Q

** Whipple’s Tx **

A

CTX 2g x14d (up to 28d for neuro or IE) then longer term Septra DS BID fora year
-*can cause IRIS (esp if CNS involved or previous immunosuppression)

91
Q

** Rxn when taking abx for Whipple **

A

Jarisch-Herxheimer reaction within 24h (in pt w/ spirochete infxn): fever, chills, headache, hypotension, severe abdominal or pleuritic chest pain.
-IRIS- Immune reconstitution syndrome within weeks: disease symptoms and high fever

92
Q

Rheumatic fever symptoms

A

J—joints (migratory NONEROSIVE arthritis)
-♥—carditis (peri/myocardium, valves - MV, AoV, CHF, heart block)
-N—nodules (subcutaneous)
-E—erythema marginatum (irreg serpignous nonpruritic rash sparing face)
-S—Sydenham’s chorea (asymmetric movement face/hands/feet)

-Fever

93
Q

Rheumatic fever Jones criteria

A

Initial ARF = 2 major or 1 major + 2 minor
-Recurrent ARF = 2 majr or 1 maj + 2 minor or 3 minor

-Major
Carditis
-Arthritis
Chorea
-EM
-Subcutaneous nodule

-Minor
-Arthralgia
-Fever
-ESR >60, CRP >3
-Prolonged PR (unless carditis is present already)

94
Q

Situations in which a diagnosis of ARF might be made without strict adherence to the Jones criteria

A
  1. Isolated chorea months after initial strept infxn & negative serology
  2. Indolent carditis and/or typical mitral/aortic valve lesion as only manifestation
  3. Previous rheumatic heart disease
95
Q

GAS Lab tests

A

Throat cx for GAS
-Rapid Strep Ag test
-*neither tell you if carrier vs active infxn and can be negative if in latent period
-
-Preferred:
-Antistreptolysin test or antideoxyribnuclease B test

96
Q

How does GAS cause ARF

A

Molecular mimicry
– Ig against GAS peptidoglycans cross react w/ cardiac myosin
-
-GAS protein can also bind collagens to create immune rxn

97
Q

ARF exam test

A

Milkmaid grip = involuntary grasp/release when trying to hold constant grip (pathognomonic)
-Jaccoud’s if recurrent ARF

98
Q

ARF prevention

A

-ABX PPX 5y (or 10Y if mild cardiac sx) from last attack or until age 21
-Severe carditis w damage = PPX for 10 years or until age 40 (can consider lifelong ppx
-Abx PPX for ARF pt if frequent exposure to children until exposure ends

99
Q

Complications of Strep infxn

A

ARF
-PANDAS (pediatric autoimmune neuropsych d/o assoc’d w/ strep) eg OCD, Tic

100
Q

ARF Tx

A

Azithro, Clinda
-Penicillin G or V or Amox if carditis/neuro
-Arthritis: ASA or Naproxen

101
Q

List the main type/pattern of arthritis and 1 skin manifestation for each of the following infections
-Lyme
-Gonorrhea
-Parvo
-Mycobacterium
-

A

Lyme: early migratory arthralgia, late mono>oligoarhtritis
– erythema migrans
-
-Gonorrhea: tenosynovitis and migratory polyarthralgia
– pustular dermatitis
-
-Parvo: symmetric polyarthalgia/arthritis
– facial erythema (slapped cheek)
-
-Mycobacterium: Tenosynovitis, OM, dactylitis, septic arthritis
– Subcutaneous nodules

102
Q

** How does HIV, syphilis, and lyme arthritis present with **

A

HIV: Seronegative, oligoarticular, non-destructive, lower extremity predominant arthritis

-Syphilis: symmetric polyarthritis involving knees/ankles > small joints of hands

-Lyme: migratory arthralgia → late asymmetric oligoarticular arthritis of large joints (knees)

1. Rheum RC (23 decks)

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