Johnston Flashcards
ESR rises with age and are higher in women and can be used to monitor disease activity, especially in what diseases
- polymyalgia rheumatic
- giant cell arteritis
what marker of inflammation is used for assessment of disease activity, synthesized in liver, increased by proinflammatory cytokines and can activate complement and promote phagocytosis
CRP
what level of CR is inflammatory
greater than 8
this is an autoantibody that targets the Fc portion of IgG?
What type of antibody is it most commonly
- RF
- IgM
Rheumatoid factor and RA
- 70-80% of patients
- 100% with “nodular” RA
- RF is found in many other diseases
Anti CCP plus + RF
99.5% specificity for RA
Homogenous pattern immunofluorescense for ANA? Rim pattern? Anti Sm antibodies? Speckled anti SSA/B? Anticentromere?
- Drug induced (procainamide, hydralazine Dilantin)
- Anti DS DNA
- SLE
- Sjogren
- Scleroderma
the malar rash in SLE spares what
nasolabial folds
arthritis in SLE
-2 or more peripheral joints
hematologic finding in SLE
basically every down except reticulocytes are up
what can give a false positibe RPR (test for syphilis)
SLE
what is the Jones Criteria for Rheumatic Fever?
- Carditis
- Joint involvement (arthritis)
- Chorea
- Erythema Marginatum
- Subcutaneous nodules
- Evidence of preceding Strep infection
what level of uric acid is hyperuricemia?
> 6.8 mg/dl
what are tophi
nodular deposits of monosodium urate crystals in the skin from gout
what is podagra
acute onset, monoarticular, often 1st MTP joint affected by gout
Treatment of acute Gout
- NSAIDs
- Colchicine
- Steroids
chronic management of gout
- Xanthine oxidase inhibitor (uricouric drug)
- Probenecid: block tubular resorption of urate and increased uric acid excretion
what imaging is sensitive for soft tissue abnormalities (synovitis, tendonitis, bursitis) and erosions
US
what imaging for RA symmetrical involvement of MCP, periarticular osteopenia erosions
Radiography
MRI is good for what?
downfalls?
- spine, SI, synovitis, tenosynovitis, erosions
- Gadolinium contrast taken up in inflamed synovium (thickened pannus) . . IV gadolinium can cause nephrogenic systemic fibrosis in patient with kidney disease
what is Enthesopathy
-inflammation of ligaments and tendons where they insert into bony attachments . .hallmark for reactive arthritis
- 1 joint involved?
- 3 or less?
- 5 or less
- 6 or more?
- arthritis
- Oligoarthritis
- Pauciarthritis
- Polyarthritis
what hand joints are spared in RA
DIPs
DIPs involved in OA . .what nodes
Herbedens
systemic features of RA
- Fatigue, fever, anemia
- Elevated Acute phase reactants (ESR, CRP)
- Constitutional symptoms: malaise, myalgia, depression
what is rheumatoid factor produced by
B cell in RA synovium
what is more sensitive to detecting erosions than X ray
CT
what do you need to monitor when giving methotrexate for RA
blood counts and liver and renal function
what disorder improves during pregnancy
RA
pts with RA have significantly increased mortality due to what
- CAD
- HF due to endothelial damage from chronic inflammation
- also increase in infection, renal disease, GI, and malignancy
what score on classification of RA is definite RA
6/10
what part of axial spine is affected by RA?
- C1-C2
- be careful when intubating for anesthesia
if rheumatoid nodules present then what will always be + on serology
RF
Extra-Articular manifestations of RA?
- Skin: subcutaneous nodules; extensor surface of forearm
- Pyroderma Grangrenosum: tender reddish purple papule; leads to necrotic, non healing ulcer
- Rheumatoid Vasculitis: purpura, petechial, splinter hemorrhages, digital infarct
- Heart: HF, pericarditis, CAD due to chronic endothelial inflammation
- Lung: pleuritis most common, nodules, interstitial lung disease, Caplan syndrome (nodular densities after exposure to coal or silica dust, pulmonary fibrosis
- Keratoconjunctivitis Sicca: secondary Sjogrens from RA
Tests for Sjogren
- Ro/SS-a, La/SS-B (both associated with solivary gland involvement
- Schrimers test (filter paper under eyelids)
- slit lamp exam
- RA
- Splenomegaly
- Neutropenia (<2000)
- Fever
- Anemia
- thrombocytopenia
- RF and anti-CCP +
Feltys syndrome
treatment of RA
- NSAID: pain relief, doesn’t halt disease progression
- Corticosteroids: low dose, Bridge or flare therapy
- analgesics for pain controld
- DMARDS: takes 2-6 months for max effect, methotrexate first line, don’t give with pregnancy,
what antimalarial is useful in RA and can be used in pregnant patient
hydroxychloroquine
what are the anti-TNF biologic agents used in RA
- Etanercept
- Infliximab
- Adalimumab
- Rituximab
what are the different spondyloarthropathies
- Ankylosing spondylitis
- Reactive Arthritis
- Psoriatic Arthritis
- enteropathic arthritis
HLA for spondyloarthropathies
B27
describe the joint involvement in spondyloarthropathies
Asymmetric peripheral arthritis
Term: swelling of a finger or toe
Dactylitis
Term: enthesis
Site of ligamentous attachment to bone
Term: Enthesitis
inflammatory changes of the ligament, tendinous insertion into bone, or joint capsule
Term: inflammation of vertebrae
spondylitis
Term: anterior displacement of a vertebral body relative to the adjacent vertebral body below
Spondylolisthesis
Term: defect of the portion of bone b/t the inferior and superior articular process of vertebrae (pars interarticularis)
Spondylolysis
HLA for RA
DR4
RA M:F ratio
what about reactive spondyloarthropathies
- 1:3
- Ankylosing spondylitis is 3;1
- Reactive: 10:1
Reactive arthritis was formerly known as what
Reiter’s syndome
clinical manifestations of ankylosing spondylitis
- Low back pain > 3 months
- morning stiffness, improved with exercise, worse with rest
- Fatigue, weight loss, and fever
- Symmetrical SI joint pain (sacroiliitis); loss of mobility/flexibility; arthritis of hips
- Tendonitis, planar fasciitis (Achilles-heel pain)/Enthesitis
Extra articular manifestation of ankylosing spondylitis
- Eye: IRITIS (not seen in RA)
- photophobis, eye pain, blurred vision
- Aortic insufficiency, aortic aneurysm
- pulmonary fibrosis
- IBD
- Psoriasis
pts with ankylosing spondylitis have problems flexing forward . . what is the test for this called?
What is the text for decreased chest expansion?
- Schober test
- Fabere test
what are syndesmophytes
- found in ankylosing spondylitis
- bridging of vertebrae (boney bridges cause ankyloses)
what are late complications of ankylosing spondylitis
- restrictive lung disease
- compression fractures
- cauda equine syndrome
age for Ankylosing spondylitis
below 40
Clinical manifestations of reactive arthritis
- young men
- asymmetrical oligo-arthritis, lower extremeties (ankles, knees)
- Enthesitis - Achilles tendon/plantar fasciitis
- Dactylitis: sausage digit; finger or toe
- SI pain, asymmetrical
- urethritis, arthritis, conjunctivitis, mucocutaneous lesions (oral ulcers)
- Skin: circunate balanitis (vesicles, ulcers on glans penis)
- Keratoderma blennorrhagicum: painless eruption on palms/soles
how will joint manifestations of granulomatosis with polyangiitis differ from RA
usually involves large joints (hips, ankles, wrists) and usually spares the small joints of the hand
-also C-anca
manifestations and labs of polymyalgia rheumatica
- stiffness and pain in shoulders, hips, and lower back
- trouble combing hair, putting on coat, and rising from chair
- markedly elevated ESRs
