Inflammatory Arthritis Flashcards
1
Q
Type 0 synovial fluid
A
Normal
Transparent, viscous
WBC <200, mainly monos
2
Q
Type 1 synovial fluid
A
Non-inflammatory
Yellow, translucent
Viscous
WBC <200, mainly monos
3
Q
Type 2 synovial fluid
A
Inflammatory
Yellow, cloudy
Thin/watery
2000-100 000 WBCs, mainly polys
4
Q
Type 3 synovial fluid
A
Septic Opaque, cloudy Thin/watery or thick pus >100 000 WBCs, mainly polys Often +ve culture
5
Q
Type 4 synovial fluid
A
Hemorrhagic
Bloody, non-clotted blood
RBCs
6
Q
Viruses/parasitic disease that commonly cause arthritis
A
Rubella Hep B in prodrome Parvovirus B19 HIV Chikungunya Tick borne arthritis Lyme disease
7
Q
RA is a/symmetric poly/oligo/monoarthritis
A
Symmetric poly arthritis
8
Q
3 Ds to rmb in RA history
A
Diurnal variation (nights vs mornings) Distribution of joints involves (NO DIPS) Duration (acute vs chronic)
9
Q
Seropositive RA means they have…
A
Rheumatoid factor and/or anti-CCP
10
Q
Distribution of RA
A
PIPs, MCP, wrist, elbow, shoulders, hips, knees, ankles, feet (MTPs)
11
Q
Potential articular consequences of RA
A
Ulnar deviation
Z-deformity of thumb
Swan neck of finger
Boutonnier of pink finger
12
Q
X-ray of RA
A
Juxta-articular osteopenia
Erosions
Concentric joint sp loss
13
Q
Chronic back pain: # months
A
> 3 months
14
Q
4 types of spondylarthropathy
A
Psoriatic arthritis
Enteric arthritis
Axial spondyloarthritis
Reactive arthritis
15
Q
Dx of axial spondyloarthritis
A
Sacoilitis on imaging plus >/= 1 SpA feature
OR 2. HLA-B27 plus >/= 2 SpA features
16
Q
SpA features
A
- Inflammatory back pain
- Arthritis
- Enthesitis
- Uvelitis
- Dactylitis
- Psoriasis
- Crohn’s/colitis
- Good response to NSAIDs
- Fam hx for SpA
- HLA-B27
- Elevated CRP
17
Q
SpA strong clinical features
A
IBD, psoriasis, uveitis, peripheral arthritis
18
Q
SpA soft clinical features
A
Enthesitis, inflammatory back pain hx, response to NSAIDs
19
Q
Imaging used to detect sacroilitis
A
STIR MRI (fat suppression technique that looks for bone marrow edema)
20
Q
X-ray evidenced axial spondylitis
A
Ankylosing spondylitis
21
Q
MRI evidenced axial spondylitis
A
Non-radiographic axial spondylarthropathy
22
Q
HLA-B27+ and strong clinical suspicion of axial spondylitis
A
Non-radiographic axial spondylarthopathy
23
Q
Axial spondylarthoparthy typical pt
A
M:F = 3:1
20-40y.o.
Most common in Haida natives
24
Q
Inflammatory back pain
A
Need 4 out of 5:
- Onset of symptoms <40y. for >3mo
- Insidious onset
- Improves with exercise
- Does not improve with rest
- Pain at night and improves upon getting up
Other variables: prolonged AM stiffness, alternating buttock pain, good NSAID response
25
HLA-B27: what is it and what is the rate of occurrence?
Antigen presenter to T-cells --> affects production of IL23 and IL17
7-10% of population is B27+, 98% of these ppl will NOT get ankylosing spondylitis
0.2-0.5% of population gets ankylosing spondylitis
1% of population gets axial spondylarthropathy
80% of ankylosing spondylitis pts are B27+
26
Treatment for ankylosing spondyloarthropathy
- Exercise/physiotherapy
- NSAIDs
- Biologics: TNF inhibitors, IL17A inhibitors
No role for steroids or DMARDs*
27
Screening for axial spondylarthritis
Symptom onset <45y and back pain >3mo AND any one of ABCDE: AM stiffness, B27+, colitis (crohn's/UC), derm (psoriasis), eye (uveitis)
28
CASPAR criteria for PsA
Inflammatory articular disease (joint, spine, entheseal) and >/= 3 on:
1. Evidence of psoriasis (current =2, past = 1, fam hx = 1)
2. Psoriatic nail dystrophic (pitting, onycholosis, hyperkeratosis) = 1
3. Negative test results for RF = 1
4. Dactylitis (current or hx = 1)
5. Radiologic evidence of juxta-articular new bone formation = 1
29
PsA epidemiology
M=F
4-30% of PsC patients
3% annual risk of PsC turning to PsA
30
PsA process
70% skin precedes joints
15% joints precede skin
15% together
31
Tx for mild PsA
Mild PsA = <5 joints, CRP-, no erosions, no dactylics
NSAIDs or steroid injections
If no resolution >3mo, start DMARD
32
Tx for moderate PsA
DMARD
33
DMARD
Leflunomide
Methotrexate
Cyclosporide
Sulfasalazine
34
Newer tx for PsA
```
Anti-TNF Inhibitors
IL12/23 inhibitors
IL17A inhibitors
JACK inhibitors
PDE4 inhibitors
IL23 inhibitors
```
35
SOAPBRAIN MD for SLE
```
Serositis
Oral ulcers
Arthritis
Photosensitivity, pulmonary fibrosis
Blood cells
Raynaud's or renal
ANA
Immunologic (anti-Sm, anti-dsDNA, APLAS)
Neuropsych
Malar rash
Discoid rash
```
36
Malar rash
Fixed erythema, flat or raised, over malaria eminence tending to spare nasolabial folds
37
Discoid rash
Erythematous raised patches with adherent keratitis scaling and follicular plugging
```
FEAST:
Follicular plugging
Erythematous
Atrophy
Scarring
Telangiectasia
```
38
Renal disease of SLE
>0.5g/d proteinuria
>/= 3+ dipstick proteinuria
Cellular casts
Lupus nephritis: 4 classes
39
Neuro disease of SLE
Seizures
| Psychosis (without other causes)
40
Hematologic disease of SLE
Hemolytic anemia with reticulocytosis
Leukopenia (<4000/uL on >/=2 occasions)
Lymphopenia (<1500/uL on >/=2 occasions)
Thrombocytopenia (<100 000/uL in absence of offending drugs)
41
Arthritis of SLE
- Nonerosive, transient, symmetrical, affecting small joints, seldom deforming, less severe than RA
- Most common presenting feature of SLE
- Jaccoud's arthropathy: non-erosive, reducible deformities
42
Cardiovascular disease of SLE
Atherosclerosis
Pericarditis
Myocarditis
Libman-Sacks endocarditis (mitral, tricuspid)
43
Respiratory disease of SLE
```
Interstitial lung disease
Pneumonitis
Pleural effusions
Pulmonary hemorrhage
Pulmonary HTN
Shrinking lung syndrome
```
44
GI and hepatic disease of SLE
- Uncommon
- Severe abdo pain indicating mesenteric vasculitis
- Diverticulitis
- Pancreatitis
- Hepatic abnormalities (usually due to tx, not SLE itself)
45
Lupus nephritis class I
normal - minimal mesangial glomerulonephritis, no tx, doesn't lead to renal failure
46
Lupus nephritis class II
mesangial proliferative lupus nephritis, typically responds to tx with corticosteroids, renal failure rare
47
Lupus nephritis class III
focal proliferative nephritis, responds to tx with high dose corticosteroids, renal failure uncommon
48
Lupus nephritis class IV
diffuse proliferative nephritis, mainly treated with corticosteroids and immunosuppressants, renal failure OCMMON
49
Lupus nephritis class V
Membranous nephritis characterized by extreme edema and protein loss, renal failure uncommon
50
Lupus nephritis class VI
glomerular sclerosis
51
Drug-induced lupus
```
Normal complement and no anti-DNA AB
Anti-histone +
Symptoms resolve when stopping drug
M:F equally affected
Nephritis and CNS abnormalities rare
```
```
Caused by CHIMP:
Chlorpromazine
Hydralazine
Isoniazid
Minocycline
Procainamide, propylthiouracil
Other (anti-TNFs)
```
52
Neonatal lupus
- Mom's autoantibodies are passively transferred to fetus: SSA,SSB
- Can cause congenital heart block --> Tx = Dexamethasone
- Test for SSA AB
53
Lab tests for SLE
- Screen with ANA
- Confirmatory tests: anti-dsDNA, anti-smith AB
- Anti-dsDNA = prognostic and monitoring
- If active disease, test q1-3mo
- If inactive disease, test q6-12mo
54
SLE tx
```
NSAIDs
Prednisone
Hydroxychloroquine
Azathioprine (immunosuppressive)
Mycephenolate mofetil (esp good for lupus nephritis)
Cyclosporine (immunosuppressant)
Cyclophosphamide (immunosuppressant)
Rituximab (B-cell deplete)
Belimumab (monoclonal antibody)
Sun avoidance
```
55
3 types of small vessel vasculitis
1. Granulomatosis with polyangiitis (AKA Wegener granulomatosis)
2. Microscopic polyangitis (MPA)
3. Eosinophilic granulomatosis with polyangitis (Churg-Strauss syndrome)
56
Granulomatosis with polyangitis autoantibodies
c-ANCA, PR-3
57
Microscopic polyangitis autoantibodies
p-ANCA, MPO
58
Eosinophilic granulomatosis with polyangitis
p-ANCA,MPO
59
Antiphospholipid syndrome
AI hyper coagulable state caused by antiphospolipid antibodies
60
Antiphospholipid syndrome autoantibodies
Lupus anticoagulant
| Anticardiolipin antibodies: ACL, B2glycoprotein antibodies
61
ENAs
- AB to Smith antigen
- AB to RNP antigen
- AB to SS-A antigen (Ro)
- AB to SS-B antigen (La)
- Jo1-AB
- Scl-70 AB
62
Sjogren syndrome testing
Screen for SS with ANA
| Confirm/prognosis with SS-A (Ro), SS-B (La)
63
Polymyositis/dermatomyositis testing
Screen with ANA
| Confirm PM with Jo-1AB
64
Systemic sclerosis/CREST syndrome
Fibrosis of skin (scleroderma) and vascular disease
```
CREST:
Calcinosis
Raynaud phenomenon
Esophageal dysmotility
Scerlodactyly
Telangiectasia
```
65
CREST syndrome testing
Screen with ANA
| Confirm/prognosis with anticentromere AB, Scl-70AB
66
Mixed CT disease testing
Screen with ANA
| Confirm with RNP antibody
67
Tx of fibromyalgia syndrome
Night time meds (tricyclic antidepressants – ie. amitryptilene or nortryptilene or flexeril 10mg @ 8pm, melatonin, L tryptophan)
Analgesics (plain tylenol, NSAIDs, Tramadol, tramacet)
Others:
• Treat depression: Cymbalta, other anti-depressants
• SNRI: Duloxetine
• Nerve modulating drugs/anticonvulsants: Pregabalin (lyrica), gabapentin (Neurontin)
68
Tx of acute gout attack
Do not tx asymptomatic hyperuricemia
NSAIDs (Indocid): High dose, then taper as symptoms improve
Corticosteroids (if renal, CV, or GI disease and/or if NSAIDs C/I or failed): IA, oral, IM, IV
Ex. Prednisone
Colchicine within first 12h (blocks formation of inflammatory markers ie. IL1)
Have to be careful with colchicine in renal insufficiency
Do NOT use allopurinol for acute attack
69
Tx of chronic gout attack
Conservative:
• Avoid foods with high purine content
• Avoid drugs with hyperuricemic effects (ie. ethambutol, thiazide, alcohol)
Medical:
• Antihyperuricemic drugs (ie. allopurinol): Decrease uric acid production by inhibiting xanthine oxidase
o Use in pt with recurrent attacks (>/=3 attacks)
o Do not start allopurinol until acute attack over
o Start allopurinol with colchicine low dose or NSAID on board
o Do down dose allopurinol in renal insufficiency and monitor Cr
Go low, go slow, esp with tophaceous gout as you can get mobilization gout
If allergic to allopurinol, new drug feboxistat is available
70
Tx of CPPD arthropathy
o Rest, protection
o NSAIDs
o IA or oral steroids to relieve inflammation
71
Tx of giant cell arteritis
Start prednisone (1mg/kg/d) ASAP b/c pt can go blind overnight --> Biopsy temporal artery
72
Tx of dermatomyositis
Tx: Corticosteroids high dose (1-2mg/kg/d) and slow taper
| Can be a perineoplastic syndrome (think it is related to cancer dx) --> Should do reasonable malignancy workup
