Kinder CIS part 3 Flashcards

Question

Ankylosing Spondylitis labs

Answer 1

ESR and CRP elevated in 50% of patients and more associated with peripheral disease RF negative ANA negative Serum complement levels normal

Answer 2

Sacroiliac Joints - Bilateral - Early radiographic changes - --- Sclerosis on the iliac side of the SI joint margins - Erosions with pseudo widening of the SI joints - Eventual fusion - MRI is more sensitive for detecting early disease when the plain radiograph may still be normal Spine - “shiny corners” or Romanus lesions - syndesmophytes

Answer 3

Modified New York Diagnostic Criteria Clinical - Low back pain and stiffness for more than 3 months that improves with exercise but is not relieved with rest - Limitation of motion of the lumbar spine in the sagittal and frontal planes - Limitation of chest expansion to 2.5 cm or less, measured at the level of the 4th intercostal space Radiographic - Sacroiliitis Assessment of Spondyloarthritis International Society Classification for Axial Spondyloarthritis in patients with back pain for ≥ 3 months and age at onset of < 45 years Sacroiliitis on imaging + ≥ 1 Spondyloarthritis features OR HLA-B27 + ≥ 2 Spondyloarthritis features

Answer 4

Physical Therapy - Maintain an erect spine - Promote chest expansion - Swimming is an excellent exercise NSAID - If first drug not effective, should trial a second Anti-TNF agents - Active Disease - Not responsive to two NSAIDs Prognosis - Excellent

Answer 5

20% of patients with Crohn disease and Ulcerative Colitis Most commonly presents with peripheral arthritis that correlates with bowel diseases activity Can present with spondylitis that progresses in the absence of active bowel disease – less common Peripheral Arthritis is migratory and rarely erosive Spondylitis usually more benign than ankylosing spondylitis May present with sacroiliitis without spondylitis Cutaneous Manifestations - Erythema nodosum and pyoderma gangrenosa No male predominance

Answer 6

Treatment of the underlying IBD - Sulfasalazine NSAID – avoided - May exacerbate IBD Anti-TNF agents - If sulfasalazine has failed

Answer 7

Inflammatory arthritis triggered by antecedent gastrointestinal or genitourinary infections Asymmetric oligoarthritis most commonly affecting the lower extremities Enthesitis and dactylitis Extra-articular manifestations: - Conjunctivitis, anterior uveitis, urethritis, circinate balanitis, oral ulcers, and keratoderma blennorrhagicum ``` Adults between 20-40 years of age Post GI infection affects men and women equally Post GU subtype affects men 9:1 Reiter Syndrome - Peripheral arthritis - Conjunctivitis - Urethritis/Cervicitis ```

Answer 8

``` Develops 1-4 weeks after gastroenteritis or sexually transmitted disease Shigella Salmonella Campylobacter Yersinia Chlamydia HIV – occasionally 25% of patients have no symptoms of infection 30-50% HLA-B27 ```

Answer 9

Articular - Asymmetric oligoarthritis of peripheral joints Knees, ankles, and feet - Inflammatory low back pain in 50% - Unilateral sacroiliitis in 25% of patients Enthesitis - Achilles tendon - Plantar Fascia - Pelvic Bones Dactylitis - Sausage digit, toes more common than fingers - Reactive arthritis and Psoriatic Arthritis Mucocutaneous Lesions - Circinate balanitis - Keratoderma blennorrhagicum - Urethritis/Cervicitis - Aphthous ulcers - Onchodystrophy Ocular Inflammation - Conjunctivitis, iritis, scleritis, episcleritis, and keratitis - 25% of cases - Intermittent eye pain and visual changes Heart – rare - Aortitis - Valvular heart disease – Aortic regurgitation - Complete Heart Block Synovial Fluid Analysis - 5000-50,000 cells/mcL - Sterile

Answer 10

NSAIDs treatment of choice for articular manifestations Treat active infection with antibiotics Sulfasalazine Methotrexate

Answer 11

Chronic inflammatory arthritis associated with skin and nail psoriasis Symmetric polyarthritis or asymmetric oligoarthritis of peripheral joints - Frequent DIP involvement Spondylitis and enthesitis may occur History of psoriasis or family history of psoriasis Dactylitis and nail dystrophy RF negative Erosion and osteolytic destruction of interphalangeal joints and juxta-articular new bone formation

Answer 12

Mean age of onset 30-55 years old Men and women equally affected 20-30% of adults with psoriasis Group A streptococcal infections implicated in guttate psoriasis HIV associated with psoriasis and psoriatic psoriasis Physical trauma implicated Arthritis can proceed psoriasis in 15-20% of cases

Answer 13

Symmetric polyarthritis Asymmetric oligoarthritis of the hands and feet DIP joints in asymmetric fashion Other joints - Knees, hips, and sternoclavicular joints Joint deformities, juxta-articular erosions, joint space narrowing, and bone ankylosis Arthritis mutilans - Complete subluxation and telescoping

Answer 14

Dactylitis - Sausage digit - 30-50% of psoriatic arthritis patients - Toes more often than fingers Enthesitis - Inflammation occurring at the site of tendon insertions into bone - Achilles tendon - Plantar Fascia - Pelvic bones

Answer 15

Skin and Nail Changes - Psoriasis lesions Can be subtle and degree does not correlate with arthritis Hairline, scalp, external auditory canal, periumbilical area, and gluteal cleft - Nails Ridging, pitting, onycholysis, and hyperkeratosis Nail of DIP joint affected Spondylarthopathy - Less common than peripheral - Unilateral sacroiliac involvement - Cervical spine common - -- Atlaontoaxial instability - Affects vertebra in a noncontiguous fashion

Answer 16

20% with hyperuricemia

Answer 17

``` 1.Asymmetric Oligoarthritis 2. SI 3. Symmetric polyarthritis 4. DIP 5. Opera glass “arthritis mutilans” ``` ** pencil in cup = arthritis mutilans

Answer 18

NSAID DMARD Methotrexate, sulfasalazine, azathioprine, hydroxychloroquine, and cyclosporine Biologics Anti-TNF Glucocorticoids - Intra-articular injections effective for 1-2 joints - Systemic may lead to an exacerbation of severe pustular psoriasis on taper

Answer 19

Acute onset of painful, warm, and swollen joint Usually monoarticular Typically affects large weight-bearing joints Cell count > 50,000 cells/mcL with over 80% neutrophils Positive culture Staphylococcus aureus is the most common etiology in native joints

Answer 20

25-50% rate of permanent joint damage Fatality Rate 11% in monoarticular bacterial arthritis Risk Factors for bacterial arthritis - Chronic arthritis - Prosthetic joints - Parenteral drug use - Extremes of age - Diabetes - Immunocompromised conditions

Answer 21

Pathogenesis - Hematogenous Spread in more than 50% of cases - Direct inoculation - Spread from adjacent bony or soft tissue infections Skin infections are the most common predisposing infections Other infections - Transient bacteremia from respiratory, GI, or GU can also cause infections

Answer 22

Abrupt onset of painful, warm, and swollen joint Signs of Septic Arthritis - Joint effusion - Moderate to severe joint tenderness to palpation - Marked restriction of both passive and active range of motion Monoarticular Arthritis is considered septic arthritis until proven otherwise Polyarticular septic arthritis is more common in patients with rheumatoid arthritis, connective tissue diseases or overwhelming sepsis

Answer 23

mostly knee hip shoulder also wrist, ankle, elbow, small joints (rare) Sternoclavicular Joint 21% of cases associated with IV drug abusers Less common risk factors include diabetes, trauma, infected central lines, and other distant infections

Answer 24

Fever in 60-80% of patients Shaking chills in 20% of those with fever Symptoms of antecedent infection - Cough - GI symptoms - Dysuria 50% of patients will have an identified source of infection - Pneumonia, otitis, bronchitis, pharyngitis, cutaneous, GI, or GU

Answer 25

Laboratory - Elevated white count - ESR and CRP elevated - Bacteremia in 40-50% Synovial Fluid Analysis - Cloudy - White count > 50,000 WBC/mcL in 50-70% of cases - Gram stain positive in 50-75% - Culture positive in 70-90% - Micro Staph aureus in 60-70% of cases

Answer 26

mostly staph auerus some strep (A) Gram neg bacilli rarely anaerobes, staph epidermidis

Answer 27

``` Helpful for joints that are difficult to palpate and aspirate Hip Shoulder Sternoclavicular SI joints ```

Answer 28

Drainage - Initially performed at the time of synovial fluid analysis - Arthroscopic lavage, debridement, and drain insertion - Open surgical debridement may be necessary in some circumstances IV antibiotics - Most treated for 4 week minimum combination of IV and oral - Some more difficult infections treated with 4 weeks IV antbiotics Progressive joint mobilization

Answer 29

Osteomyelitis Persistent or recurrent infection Marked decrease in joint mobility Ankylosis Persistent pain 70-85% of patients with group A Streptococcal infections recover without residual symptoms 50% of patients with Staphylococcal aureus or gram-negative rods have residual joint damage Patients with rheumatoid arthritis and polyarticular infection have a survival rate less than 50%

Answer 30

de quervain's tendonitis

Answer 31

Sexually active young person without prior joint disease Typical Triad - Polyarthritis - Tenosynovitis - Dermatitis Synovial fluid Gram stain and cultures often negative Urethral, cervical, pharyngeal, and rectal testing for Neisseria gonorrhoeae - Positive in up to 90% of cases

Answer 32

Most common cause of acute septic arthritis in young sexually active persons in the United States 1 day to 2 months after sexual contact 25% manifest GU or pharyngeal symptoms Fevers, chills, and migratory polyarthralgias Progresses to monoarthritis or polyarthritis - Knees, ankles, or wrists Tenosynovitis in 2/3 of patients - Dorsum of hand, wrist, ankle, or knee Skin lesions

Answer 33

Blood cultures - Positive in 20-30% Synovial Fluid Analysis - Cell count 30,000-60,000 white blood cells/mcL - Gram stain positive in 25% - Culture positive in 20-50% Urethral, Cervical, pharyngeal and Rectal specimens - Positive in up to 90% of untreated patients

Answer 34

Drainage Antibiotics - IV cephalosporin antibiotic for 2-4 days followed by oral therapy for 7-10 days - Chlamydia should be treated also with Azithromycin or Doxycycline - Sex partners should be treated Prognosis Excellent with treatment

Answer 35

Prosthetic joints are at increased risk for infection ``` Early infection (under 4 weeks) after implantation or infections secondary to hematogenous seeding present with fever, pain, warmth, and swelling - Often can be treated with joint salvage ``` Late infection (>4 weeks) from low virulence organisms introduced at the time of surgery have insidious onset of pain and often don’t have other signs of infection - Often require joint replacement - Coagulase negative staphylococci, Propionibacterium acnes, diphtheroids

Answer 36

Early Prosthetic Joint Infections (< 4 weeks) - Virulent organisms - Classic symptoms - -- Fever, pain, erythema, effusion, and warmth beyond the post-operative period Late Prosthetic Joint Infections (> 4 weeks) - Less virulent organisms - Indolent course - -- Increasing pain, implant loosening, sometimes drainage - -- Usually no fever or leukocytosis

Answer 37

White Count - Elevated in early infection - May be normal in late infection Blood Cultures - May be positive in early infections Synovial Fluid Analysis WBC count > 1700 WBC/mcL Neutrophil Percentage > 65% Gram stain - Positive stain is diagnostic, but negative stain does not rule out infection Culture - More frequently positive in early infection Microbiology - Early – Staphycolococcus aureus, coag-negative staphylococcus - Late – coagulase negative staphylococcus, P acnes, or diphtherioids - Surgical debridement with culture of periprosthetic tissue

Answer 38

Serial x-rays - New subperiosteal bone growth - Transcortical sinus tracts - Radiolucency at the bone-cement interface to suggest joint loosening

Answer 39

Early Infection - Prosthesis Salvage Surgical debridement Antibiotic for 3-6 months --- Oral Ciprofloxacin/Rifampin for 3-6 months in culture proven Staphylococcus aureus infection --- Rifampin penetrates tissues and biofilms ``` Late Infection - Two stage exchange Prosthesis removed, area debrided, and cement spacer inserted Antibiotics for 6 weeks Revision arthroplasty performed ```

Answer 40

Prosthesis failure - Even after successful treatment, these revised joints often require early replacement compared to non-infected joints Recurrent infection