Intro to Rheumatology and Crystalline Arthritis Flashcards
What qualities of a joint make you think inflammatory arthritis?
morning stiffness >30min, waking early with pain
pain that improves with activity
swelling and warmth
What is the first concern with a mono arthritic joint and what tests would you send for?
mono arthritis is infection until proven otherwise, send synovial aspirate for cell count, crystal exam and culture**
Name common causes of non-inflammatory, inflammatory, septic and hemorrhagic joints.
non-inflammatory: osteoarthritis, mechanical, neuropathic joint
inflammatory: RA, spondyloarthritis, crystalline, viral/fungal
septic: bacterial infection
hemorrhagic: trauma, coagulopathy
Name risk factors for the development of gout.
obesity, high protein diet, alcohol, hyperuricemia, renal failure, tumor lysis, meds (cyclosporine, HCTZ, diuretics)
commonly 1st MTP (Podagra) also in the midst, ankle, knee, wrist, finger and elbow
occurring most commonly in men >40yo or postmenopausal women
What are the clinical features of gout
fever, grossly swollen, warm and red joint
over saturation of urate, causing crystallization (large needles that are negatively birefringent and yellow when parallel with filter), tophi
triggered by surgery, trauma, illness, acute alcohol consumption or diet change
improves with or without treatment in 7d
What are the goals and medications of gout treatment?
decrease rate production: xanthine oxidase
control inflammation: NSAIDs, colchicine, corticosteroids
increase renal elimination of urate: probenecid
Describe the mechanism and risks of colchicine.
must be used within 48h of onset, it is an anti-microtubule that surprises cell proliferation, chemotaxis and activation of inflammatory cells
toxicities inclue: GI upset, diarrhea, marrow suppression and myopathy (not used in low GFR)
Which patients would you use corticosteroids instead of NSAIDs?
if renal impairment present, use corticosteroids, NSAIDS can also cause GI ulcers
Under what conditions would you consider chronic gout treatment?
3 episodes/yr 5 episodes/lifetime hyperuricemia complications including top, joint destruction, nephropathy prophylaxis due to cytolitic chemo tx
What are the med(s) of choice for chronic gout treatment and what are their mechnisms and risks?
1) allopurinol (xanthine oxidase inhibitor) oral daily slowly titrated upward
risks include cytopenias, rash, drug fever, hypersensitivity (Steven Johnson)
**pair with colchicine for 1st 6mo to prevent flares
2) probenecid: increases excretion of uric acid (requires good kidneys and low baseline excretion- monitoring required)
3) Febuxostat: new XO inhibitor; expensive but used if allopurinol hypersensitivity
Describe the clinical presentation of calcium pyrophosphate arthritis (pseudo gout)
affects commonly the knee, wrist and hand (also ankle, and hip, NOT 1st MTP)
suspicion should be high with non weight bearing joints or tricomparment DJD
may present as acute or chronic
crystal exam will show very small rhomboid crystals that are positively birefringent and blue when parallel with filter
radiography may show hazy calcification between joints
Who most commonly gets calcium pyrophosphate arthritis and how would you confirm the diagnosis?
most cases in adults over 84yo, increases with age
important to evaluate Ca++, Mg++, Phosphate, PTH, TSH and Iron saturation (HH)–> anything that effects calcium balance
How do you treat acute cases of calcium pyrophosphate arthritis?
NSAIDS, steroids and colchicine (prevention is unknown at this time)
