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1. Rheum RC > Medical Manifestations: Endo/Heme/Onc > Flashcards

Medical Manifestations: Endo/Heme/Onc Flashcards

1
Q

Endocrine diseases w/ rheum manifestations

A

-DM
-Hyper/Hypo TSH, PTH
-Acromegaly
-Cushings
-Hyperlipoproteinemia

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2
Q

** MSK / Rheum complications in DM **

A
  • Charcot joint, diabetic osteolysis
  • Diabetic stiff hands (cheiroarthropathy) - prayer sign
  • Amyotrophy, Muscle infarction
  • Adhesive capsulitis
  • Calcific shoulder periarthritis
  • CRPS (shoulder hand syndrome)
  • Flexor tenosynovitis (trigger fingers)
  • Dupuytren’s contractures
  • CTS + Thenar atrophy
  • DISH
  • Septic joint / OM
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3
Q

** Diabetic cheiroarthropathy pathogenesis**

A
  • Excessive glycosylation of dermal and periarticular collagen
  • Decreased collagen degradation
  • Increased dermal hydration
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4
Q

** Diabetic cheiroarthropathy risk factors**

A

-DM duration,
-Glucose control
-Renal/retinal microvascular disease

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5
Q

** Charcot MSK manifestations**

A

-Midtarsal collapse → Rocker bottom feet
-Painless, swelling, deformity (tarsometatarsal, ankle, knee, hip, spine)
-Bony prominence skin ulcer, infxn

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6
Q

** Charcot radiographs **

A

5D’s:
- Destruction,
- Debris,
- Density (increased),
- Disorganization,
- Dislocation

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7
Q

** Charcot pathogenesis **

A
  • Sensoral neuropathy + repetitive microtrauma
  • Autonomic neuropathy → MORE blood flow

Both of which cause more inflammation, osteoclastic resorption, osteopenia, and #

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8
Q

** Charcot Tx **

A
  • Protected weight bearing,
  • Soft casts, good shoes,
  • Treat/Prevent skin ulcers
  • Neuropathic meds
  • Amputation as needed
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9
Q

Diabetic osteolysis
– what is it
– pathogen

A

Osteoporosis / Resorption of distal metatarsal bones and proximal phalanges +/- acroosteolysis
-Pathogenesis: unknown, ~to charcot

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10
Q

Diabetic amyotrophy manifestations
+what doesnt it have

A

-Muscle wasting, weakness AND SEVERE pain (proximal muscles: pelvis, thigh, paraspinal, shoulder girdle)
-Distal symmetric neuropathy, autonomic neuropathy

-NO diabetic retinopathy or nephropathy

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11
Q

Diabetic amyotrophy pathogenesis

A

Injury to peripheral nerves, nerve roots, lumbosacral plexus via:
-Ischemia
-Immune mediated microvasculitis
-Inflammation

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12
Q

Diabetic amyotrophy
– nerve bx findings
– muscle bx

A

Nerve: Inflammatory infiltrate of blood vessel
-Muscle: fiber atrophy w/o inflammation

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13
Q

Diabetic muscle infarction
– Manifestations
– Ix

A

Acute onset pain/swelling thigh or calves
-Elevated CPK
-MRI to r/o infxn, malignancy
-Excisional Biopsy

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14
Q

Dequervain’s tenosynovitis pathogenesis

A

-Microvascular disease affecting nerves & blood vessels
- Protein glycosylation
- ECM protein deposition in skin/ & periarticular structures

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15
Q

Dupuytren’s contracture pathogenesis

A

Microvascular ischemia → contractile myofibroblasts producing increased collagen

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16
Q

CTS physical exam tests

A

Tinel’s
-Phalen’s
-Durkan’s

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17
Q

CTS manifestations

A

Nocturnal paresthesias
-Hand pain
-Pain radiating to elbow/shoulder (Valleix phenomenon)
-Thenar atrophy

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18
Q

CTS pathogenesis

A

Neuropathy due to:
-Extrinsic compression
-Microvascular disease ischemia of vasa nervorum

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19
Q

SSc DM complication mimickers

A

Diabetic stiff hand (flexion contracture and indurated digits)
-Distal neuropathy ~ Raynaud’s
-Scleredema diabeticorum (thickened skin upper back/neck)

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20
Q

DM meds causing rheumatic manifestations

A

OP:
- Glitazone
- SGLT2 (-flozin)

Arthralgia/myalgia:
- DPP4i (-gliptins)

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21
Q

Hypothyroidism MSK manifestations

A

-Myxedematous arthropathy (noninflammatory; ++viscous 2/2 hyalronic acid)
-Reversible bone marrow edema (~AVN)
-CPPD

TRAP
-Tunnel (CTS)
-Raynauds
-Aching myalgia
-Proximal muscle weakness/stiffness with high CK

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22
Q

HYPERthyroid rheum syndromes

A

-OP
-Myopathy (painless prox muscle weakness)
-Thyroid acropachy
-Adhesive capsulitis (controversial)

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23
Q

Thyroid acropachy manifestations

A

Soft tissue hand swelling
-Metacarpal and Phalangeal: clubbing & PERIOSTITIS

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24
Q

Thyroid acropachy associated withwhich thyroid disease

A

Graves

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25
Q

IIM vs Hypo/HyperThyroid
-CK, Weakness, Biopsy

A

IIM: CK up, Mild/severe, inflammation
-Hypothyroid: CK up, mild, N
-Hyperthyroid: CK N, mild, N

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26
Q

Thyroid meds causing rheum manifestations

A

PTU → sysetmic vasculitis or drug induced lupus
-Methimazole → lupus like syndrome

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27
Q

Primary hyperPTH rheum syndromes

A

-Myopathy w/ NORMAL CK
-Osteoporosis
-CPPD
-Soft tissue calcifications
-Tendon ruptures
-Osteogenic synovitis from subchondral collapse → OA and reactive synovitis
-Osteitis fibrosa cystica

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28
Q

** 5 peripheral radiographic signs of hyperparathyroid or Osteitis fibrosa cystica
2 axial and skull findings**

A

Peripheral
- Chondrocalcinosis
- Soft tissue calcification
- Osteopenia, osteoporosis
- Brown tumors (lytic lesions in hands)
- Acro-osteolysis
- Subperiosteal resorption and blurred cortical margins

Axial
- Sacroilliitis
- Osteoid deposition at vertebral endplate → sclerotic bands (rugger jersey spine)
- Compression fracture

Skull
- Salt and pepper sign - lucencies caused by trabecular resorption

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29
Q

Knuckle knucle dimple knuckle sign
-What disease

A

Pseudohypoparathyroidism (PTH resistance) w/ skeleta deformity with a short 4th metacarpal

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30
Q

Acromegaly Rheum manifesetations

A

MSK:
-OA (knees, shoulders, hips, hands, C/L/S spine), crepitus
-Vertebral fracture
-Prox muscle weakness (normal EMG/CK)

-CTS
-Raynaud’s
-Rare chondrocal

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31
Q

Acromegaly pathogenesis

A

Excess GH (tumor, central) causes elevation of IGF1 that affect osteocytes, chondrocytes, and fibroblasts

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32
Q

** Acromegaly radiographic findings **

A

-Soft tissue thickening
-Spade phalanx
-Skull thickening, enlarged sella turcica
-Increased joint/disk space
-Chondrocalcinosis
-Periosteal apposition (diameter thickening) of tubular bones

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33
Q

Excessive GC rheum syndromes

A

-OP
-AVN
-Prox muscle weakness (normal EMG, CK, biopsy shows t2b muscle fiber atrophy)
-Steroid withdrawal

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34
Q

Steroid withdrawal syndrome manifestations

A

Aka slocumb’s syndrome
-Myalgias, Arthralgias
-Noninflammatory joint effusion
-Lethargy
-Low grade fever

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35
Q

Familial hyperlipoproteinemia types & associated MSK disorders

A

Type 1, 4, 5: gout

-Type 2, 3: tendinous xanthomas on digital extensor tendon & achilles tendon → tendinitis; tuberous xanthoma over extensors ~RA nodules or tophi

-Type 2: migratory inflamm arthritis ~rheumatic fever (no cholesterol crystals)

-Type 3: osseous xanthomas in long bones → #

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36
Q

Bloody synovial fluid: hemarthrosis vs traumatic tap
-How to use Hct

A

Hct ~ peripheral blood = Traumatic
-Hct < peripheral blood = Hemarthrosis

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37
Q

** Hemarthrosis causes**

A

-Vascular: ateriovenous fistula, ruptured aneurysm

-Heme: Hemophilia, VwD, Sickle Cell, Thrombocytopenia, myeloproliferative dz , hemoglobinopathy

-Infxn: lyme, septic arthritis

-Trauma: injury, fracture, post-surgical

-Autoimmune: Ehlers Danlos syndrome, Pseudoxanthoma elasticum,

-Metabolic: Scurvy, Charcot joint, Post dialysis, Gaucher’s disease

-Meds: Excessive anticoagulation or thrombolytics

-Inflammatory: Crystal disease (hydroxyapatite), Amyloid

-Neoplasm: pigmented villonodular synovitis, tumor mets to joints, 2ndary tumor of synovium, hemangioma

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38
Q

Synovial fluid findings in fracture

A
  • Fat globulesor cholesterol emboli
  • Direct visualization or
  • Oil red O staining
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39
Q

INR cutoff for joint aspiration

A

4.5

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40
Q

Hemarthrosis Tx

A

-Therapeutic Tap+/- IA GC
-Ice, compression
-Analgesia
-Reversal of supratherapeutic INR

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41
Q

Hemophilia Rheum problems

A

Acute hemarthrosis
-Subacute → Chronic → end stage arthropathy
-Intramusculaar or soft tissue hemorrahge
-Subperiosteal hemorrhage → Pseudotumor
-Septic arthritis

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42
Q

Hemarthrosis Tx in Hemophilia

A

Replace deficient factor to >30% (2% increase per unit/kg body weight)
-Rest, Ice, Analgesia, Compression
-IA GC
-PTto prevent muscle atrophy and contracture

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43
Q

Risk factors for septic arthritis coexisting w/ hemarthrosis

A

-Focus for seeding: Arthroplasty, joint damage

-Portal of entry: previous arthrocentesis, IVDU

-Infection RF: Fever, leukocytosis, HIV

-Persistent activity/pain despite factor replacement

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44
Q

Hemophilia acute radiographic findings

A

Soft tissue swelling,
-Effusion,
-Increased synovial density (iron deposition)

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45
Q

Hemophilia chronic radiographic findings

A

-Erosions
-OA (cysts, osteophytes and sclerosis)
-Wide intercondylar notch (femur/humerus)
-Inferior patella flattening
-Talar flattening

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46
Q

Chronic hemophilic arthropathy Tx

A

Prevention:
- Prophylactic factor 8 infusion (factor goal >5%)

-Nonweightbearing periods for synovitis to regress
-PT for joint stability and muscle strength

-IA GC
-NSAIDs (Cox2 specifici eg celecoxib)

-Chemical synoviorthesis with rifampicin
-Synovectomy (arthroscopic if chronic synovitis or radioisotope if factor inhibitor)
-THA

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47
Q

Sickle Cell disease Rheum manifesetations

A

-Muscle infarct and focal necrosis, rhabdomyolysis

-Bone infarct (dactylitis, AVN) - can cause transudative noninflamm effusion
-Hemarthrosis
-Chronic synovitis
-Hyperuricemia and gout

-Septic arthritis, OM (Salmonella, S Aureus)

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48
Q

RF infection in sickle cell patient

A

-Functional asplenia (decreased bacterial clearance)
-Neutrophil dysfunction at lower O2 tension
-Decreased opsonization and IFNg production

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49
Q

SCD spine XR findings and pathogenesis

A

-Codfish vertebrae (central cup like indentation) from osteoporotic vertebrae weakness from marrow expansion

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50
Q

AVN femoral head Tx

A

Nonweightbearing to prevent collapse and allow revascularization
-Ortho consult: core decompression of femoral head
-Joint replacement

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51
Q

Hydroxyurea rheumatic mimics

A

-Hand foot syndrome (Palmar plantar erythrodysethesia +/- blisters) mimics systemic vasculitis
-Alopecia
-DM like or SSc like sydromes
-DM like rash

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52
Q

MDS autoimmune syndromes

A
  • Vasculitis: PAN, LCV, GCA, uveitis, GN, pleuropericarditis
    -CTD: RP, SLE, Myositis
    -Inflamm polyarthritis: PMR,
    RA, Sjogrens, R3SPE
  • Positive antibodies (ANA, ANCA, RF, APLA, Cryo)

-Neutrophilic disease: Sweet’s, pyoderma gangrenosum
-Other: AIHA

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53
Q

MDS autoimmune syndrome pathogenesis

A

Accelerated apoptosis of maturing hematopoeitc cells increasing cytokine production (IL6, TNFa, IFNg)

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54
Q

MDS autoimmune syndrome tx

A

GC
-DMARD (HCQ, MTX)
-Biologics

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55
Q

Mechanisms of malignancy causing MSK sx

A

-Tumor invasion
-Paraneoplastic
-Treatment related
-Malignancy 2/2 dz activity or immunosuppression

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56
Q

MC cancer causing bone mets

A

KTL PB
-Kidney
-Thyroid
-Lung
-Prostate
-Breast

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57
Q

MSK features of leukemia and lymphoma

A

Polyarthralgia/arthritis
-Bone pain (subperiosteal infiltration)
-Hemarthrosis
-Gout from chemothearpy
-Septic arthritis

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58
Q

XR findings leukemia/lymphoma

A
  • Metaphyseal radiolucent band
  • Osteolytic lesions
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59
Q

Paraneoplastic syndromes assoc’d w/ malignancy

A

Myopathy
-Arthropathy
-Vascular
-Cutaneous
-Miscellaneous

60
Q

Paraneoplastic myopathies assoc’d w/ malignancy:

A

DM, PM, Lambert Eaton

61
Q

Paraneoplastic arthropathies assoc’d w/ malignancy:

A

-HPOA,
-Amyloid,
-2ndary gout,
-Carcinomatous polyarthritis,
-Atypical PMR
-RS3PE

62
Q

Paraneoplastic vascular manifestations assoc’d w/ malignancy:

A

-PAN,
-LCV, HSP,Cryo
-Granulomatous vasculitis,
-Digital necrosis,
-Strokes

63
Q

DERM manifestations assoc’d w/ malignancy

A

-Sweet’s,
-Palmar fasciitis,
-Scleroderma,
-Paniculitis,
-Erythromelalgia,
-Multicentric reticulocytosis

64
Q

Paraneoplastic miscellaneous manifestations assoc’d w/ malignancy

A

Septic arthritis,
SLE-like syndrome APLA,
Oncogenic osteomalacia,
Sarcoid,
Lymphomatoid granulomatosis

65
Q

Atypical PMR features

A

-Poor steroid response
-Asymmetric
-ESR normal or VERY high
-Adenopathy

66
Q

RF Cancer in DM/PM

A

Older age DM/PM onset
-Treatment resistant myositis
-Pharyngeal / Diaphragmatic involvement
-LCV
-Amyopathic DM
-DM with cutaneous necrosis
-TIF1 or NXP2

67
Q

**HPOA syndrome **

A

Clubbing fingers/toes
-Periostitis of tubular bones
-Arthritis (noninflamm synovial fluid)
-
-Localized form: hemiplegia, aneurysm, infective arteritis, patent ductus arteriosus

68
Q

HPOA causes

A

Primary (genetic)
-Cancer (GI, hepatic)
-Chronic infections (lung, subacute IE, HIV)
-Cystic fibrosis
-Congenital cyanotic heart disease
-IBD
-Cirrhosis
-Graves
-Voriconazole

69
Q

HPOA pathogenesis

A

Hypoxemia increases circulating growth factors, platelet-derived growth factor (PDGF), VEGF, PGE2 causing:
- Smooth muscle proliferation, - Angiogenesis
- Collagen deposition.
- Effect on osteoblasts and osteoclasts

70
Q

HPOA Tx

A

Zoledronic acid

71
Q

Carcinomatous polyarthritis features

A
  • Explosive onset
    – Asymmetric oligo/poly
    – Late age of onset
    – Lower extremity predominant
    – Spares wrist and small hand joints
    – NO erosions, nodules, RF
    – NORMAL XR
72
Q

Sweet’s syndrome features

A

–Abrupt onset raised/painful papules/plaques of face, neck, trunk, dorsum of hands
– Fever
– Peripheral neutrophylic leukocytosis
– Dense dermal neutrophilic infiltrates w/o vasculitis on biopsy

73
Q

Sweet syndrome causes

A

-Infxn: GI/GU, HIV, TB, Viral Hep, Chamydia
-Cancer: Heme> solid
-Autoimmune: IBD, SLE, RA, RP, Sarcoid, Thyroid
-Autoinflmmatory: VEXAS

-Primary immunodeficiency
-Pregnancy

-Drugs: GCSF, antibiotics, AEDs, NSAIDs, Imuran, Diclofenac, hydralazine, antiHIV, clozapine, PTU, Lasix,

74
Q

Ovarian carcinoma rheum syndromes

A

-SLE -like syndrome, +ANA
-DM/PM
-Sweet’s

-Palmar fasciitis
-Adhesive capsulitis
-CTS

-Fibro, CRPS

75
Q

Palmar fasciitis syndrome features

A

-Painful symmetric digital contractures
-Palmar fascia fibrosis (woody)

-CRPS
-Polyarthritis

76
Q

Palmar fasciitis histology

A

-Fibrosis with increased fibroblast and mononuclear cells
**-NO collagen deposition
**
-IgG deposit in palmar fascia

77
Q

Palmar fasciitis Tx

A

Treat underlying tumor
-Poor response to chemo, NSAID, GC

78
Q

Shoulder hand syndrome sx

A

Shoulder pain with decreased ROM
-Hand puffiness and stiffness with vasomotor instability

79
Q

CTD’s assoc’d with cancer (and risk factors)

A

-RA (dz duration/activity, Felty’s, immunosuppresion)
-Sjogren (extraglandular: pupura, ulcers, adenopathy, splenomegaly, cryo)

-SLE (adenopathy, splenomegaly)
-Discoid SLE (plaques >20y)
-DM/PM (older, skin ulcers, NXP2)

-SSc (RNApol3, pulm fibrosis, barett’s metaplasia)
-Eosinophilic fasciitis (thrombocytopenia, aplastic anemia)

-AAV (cyclo)

-Paget’s

80
Q

Nonbiologic DMARDs (and assoc’d cancer)

A

MTX (lymphoma)
-Aza (NHL)
-Cyclosporine (lymphoma, skin)
-MMF (CNS lymphoma, skin)
-Cyclo (lymphoma, bladder ca)

81
Q

What rheum manifestations
- Bleomycin
- Gemcitabine

A

Bleomycin: Raynaud’s, SSc

Gemcitabine: SSc like illness w/ critical digital ischemia

82
Q

Taxanes → what rheum manifestations

A

Arthralgias
-Myalgias
-Subacute cutaneous lupus

83
Q

Interferon alpha → what rheum manifestations

A

Arthralgias
-SLE like syndrome
-Positive autoantibodies
-Autoimmune thyroid dz

84
Q

Immunotherapy mech of rheum symptoms

A

-ICI block CTLA4, PD1 PDL1,
(negative signals on activated T cells) = increased autoreactive T cells and inflammatory cytokines (TNFa, IL-6/17)

85
Q

5 grades of ICIs

A

1= asymptomatic or mild
-2= limit iADL
-3= limit ADL
-4 = life threatening
-5 = death

86
Q

ICI Tx

A

Steroids
-DMARDs: MTX, HCQ, SSZ
-Anti TNF
-Anti-IL6

87
Q

IRAE manifestations

A

PsA
-Vasculitis
-PMR
-Sjogrens
-Myositis
-GN
-Sarcoid
-Uveitis / Scleritis / Retinitis
-Optic neuritis
-DRESS
-Myocarditis / Pericarditis
-Transverse myelitis

88
Q

Rheum cause of Corneal melt**

A

RA (most common)
Vasculitis
ANCA vasculitis (GPA most common)
PAN
Relapsing polychondritis
SLE
Sjogren’s
SSc (rare)
GCA (very rare)
IBD
Sarcoidosis

89
Q

Rheum cause of lens dislocation**

A

Marfan

90
Q

Rheum cause of scleritis**

A

RA
GPA
RPC
SLE, UCTD
IBD, Seroneg, Poderma gangrenosum
Sarcoid
Behcet, Cogan
TAK, GCA, PMR
HUVS, Hep C related vasculiti

91
Q

Rheum cause of sterile conjunctivitis**

A

-SS,
-KD,
-ReA
-Vasculitis
- RA
- SLE

92
Q

Rheum cause of anterior uveitis**

A

-Seronegative (PEAR)
-Behcet
-Sarcoid
-KD
-JIA, Kawasaki, TINU (tubulointerstitial nephritis & uveitis)
- HUVUS
- Cryo

93
Q

Rheum and nonrheum cause of intermediate uveitis**

A

Behcet, Sarcoid, Pars Planitis (snowbanks/ snowballs)

Non rheum: Multiple sclerosis, TB, HSV, Whipples,

94
Q

Rheum and nonrheum cause of posterior uveitis**

A

Behcet, Sarcoid, SpA (PsA, IBD), SLE, VKHS (vogt koyanagi harada syndrome)

Nonrheum: toxo, birdshot retinochoroidopathy, cancer related, histoplasmosis, syphilis, HSV, VZV, CMV

95
Q

Rheum and nonrheum cause of panuveitis**

A

Behcet, Sarcoid, Blau syndrome, IBD

Toxo, VKH, TB, HSV, Fungal

96
Q

Rheum cause of retinal vasculitis**

A

Behcet,
Sarcoid
SLE
APS
RA
AAV, GCA, Susac

Nonrheum: CNS lymphoma, leukemia, toxo, TB, lyme, syphilis, HSV, VZV, cat scratch, CMV, HIV, Whipples, Pars planitis, birdshot

97
Q

Rheum cause of orbital inflammation**

A

IgG4,
Sarcoid,
Behcet
GPA,
RA
Thyroid assoc’d

98
Q

** Peripheral nervous system manifestations in CTD**

A

-Length dependent sensory polyneuropathy
-Mononeuritis multiplex
-GBS/CIDP
-Distal axonal polyneuropathy
-Compression neuropathy

99
Q

Anti-Gu disease association

A

GAVE
-SSc
-SLE
-UCTD

100
Q

True/ False
– FMF + AA Amyloid → erosive arthritis
– AL Myloid + MM → HF
– Ank spond + AA amyloid → Proteinuria
– Dialysis pt w/ B2 microglobulin amyloid → periarthritis, CTS, effusive arthropathy, erosive bone lesion

A

-F
-T
-T
-T

101
Q

Which CTD with which ILD?
-UIP

A

UIP = RA >PM/DM, SSc, SS, SLE

102
Q

Which CTD with which ILD?
-LIP

A

SJ > RA

103
Q

Which CTD with which ILD?
-NSIP

A

SSc, DM/PM > SJ, MCTD, SLE, RA

104
Q

Which CTD with which ILD?
-BOOP/ COP

A

DM/PM, RA, SJ, SLE

105
Q

Which CTD with which ILD?
-AIP

A

AIP = SLE, DM/PM

106
Q

** What is a scleroderma mimic associated with diabetes?**

A
  • Diabetic Cheiroarthropathy
  • Scleredema diabeticorum
107
Q

** Longstanding diabetic comes with hand weakness and paresthesia:
-Name 3 possible diagnoses?
-Name 2 investigations?**

A

Three diagnoses:
1. Carpal tunnel syndrome
2. Diabetic neuropathy (length dependent, so must already have symptoms in their feet)
3. Radiculopathy (if unilateral)
4. CRPS

Two investigations:
1. NCS/EMG
2. Cspine imaging, if concerned for radiculopathy

108
Q

** Charcot disease associated processes **

A

Anything that causes peripheral neuropathy
- DM
- EtOH neuropathy
- Infection: Neurosyphylis, Leprosy
- Trauma: Spinal cord injury
- Cerebral palsy

109
Q

** Physical exam maneuver will distinguish between neuropathic joint vs osteomyelitis **

A
  • “Dependent Rubor test” - elevating foot REDUCES erythema in Charcot but NOT in infection
  • Probe to bone points to infection > Charcot
  • Ulcers >2cm more specific for osteomyelitis
  • Sausage Toe seen in OM
  • OM typically affects toes/forefoot (vs midfoot in Charcot)
110
Q

** Imaging technique other than xray/CT/MRI to help make diagnosis between Charcot vs OM**

A
  • WBC scan – negative for Charcot, positive for OM.
  • Bone scan – show uptake in both OM and Charcot.
  • MRI – features of OM and Charcot overlap on MRI. Sens 90%, Sepc 79%.
111
Q

DDX symmetric small joint arthropathy and liver dz

A

Hemochromatosis
Amyloid
Celiac
RA w/ NASH
Hep B/C
PBC, PSC

112
Q

Hemochromatosis: features of the arthropathy, findings on xray

A
  • Symmetric: hands, wrists, knees, hips
  • Lack of warmth/effusion unless CPPD
  • Chondrocalcinosis
  • Hook osteophytes on MCP2/3 >4/5
  • OA: subchondral sclerosis/cysts, flattened metacarpal heads, uniform joint space loss
  • OP
  • Wrist involvement: degeneration between carpal bones and CMC joints, not at radiocarpal joint (as in CPPD)
113
Q

Hemochromatosis: extraarticular manifestations

A
  • Pituitary - infiltration causes hypogonadism
  • Skin: melanin deposition = bronzing
  • Porphyria cutanea tarda,
  • Heart: Cardiomyopathy, CHF
  • Liver: cirrhosis, hepatomegaly, elevated enzymes
  • Pancreas: Diabetes
114
Q

Hemochromatosis: workup

A

CBC, PTH, Ca, PO4, Mg, renal function
Iron studies
Liver enzymes
HFE C282Y if fam hx
MRI/liver biopsy only if iron overload or diagnostic clarity

115
Q

** What is pigmented villonodular synovitis PVNS**

A
  • Benign neoplasm causing hypervascular and proliferative synovial/tendon sheath and erosive monoarthritis
  • MC: hands, wrists, knee, hip, ankle
  • Tx = synovectomy or radiation if refractory
116
Q

** List 5 dermatological lesions that are associated with arthropathy. Outline the features of 1 of these **

A

LCV: RA, SLE, AAV, etc
E nodosum: Behcet, IBD, sarcoid
Pyoderma: RA, Behcet, SLE
Lupus pernio: SLE
Cutaneous SLE: SLE
Psoriasis: PsA
Keratoderma blenorrhagicum: ReA
Dermatitis herpetiformis: Celiac

117
Q

List 5 common causes of Anterior Ischemic Optic Neuropathy (AION)

A

Arteritic AION
- GCA

Non-arteritic AION (sudden, painless vision loss/blurring in one eye, usually upon waking 2/2 lower BP during sleep)
- Anything reducing perfusion or increasing bloodflow resistance to optic nerve
- HTN
- OSA
- Smoking
- Hypercholesterolemia
- Anemia
- Chronic renal failure
- Migraine

118
Q

** CTS DDX**

A

PRAGMATIC.

Pregnancy (20%)
RA (any inflammatory arthritis) Acromegaly
Glucose (diabetes)
Mechanical (overuse, occupational) Amyloid
Thyroid (myxedema)
Infection (tuberculosis, fungal) Crystals (gout, pseudogout)

119
Q

** What are the complications of uveitis?**

A

Blindness/vision loss
Cataracts
Glaucoma
Choroidal neovascularization
Cystoid macular edema
Optic neuropathy
Band Keratopathy (calcium deposition in the corneal epithelium)
Posterior synechiae (adhesion of the iris to the lens which lies posterior to it)

120
Q

** Name three infectious causes of uveitis**

A

HSV, CMV, EBV , VZV
Lyme
TB
Bartonella
Cat scratch

121
Q

** List 3 clinical or laboratory features of uveitis seen in JIA, ankylosing spondylitis, psoriasis, and sarcoidosis **

A

JIA: asymptomatic uveitis, young female, ANA+
Ank spond: HLAB27+, recurrent course, sudden onset, unilateral but can alternate
PsA: HLAB27+, can be bilateral posterior, or anterior
Sarcoid: can be anterior, intermed, posterior, or panuveitis.

122
Q

**What is synechiae? **

A

Adhesions that are formed between adjacent structures within the eye usually as a result of inflammation

Affects aqueous movement causing pressure buildup posteriorly and angle closure glaucoma

123
Q

Basic exam elements for red eye

A

Visual acuity
External structure evaluation: swelling, blepharitis, en/extropion, proptosis, lacrimal gland enlargement
palpebral/bulbar conjunctiva
Ciliary flush (in uveitis, keratitis, acute angle closure glaucoma)
Pupillary size/shape/light response
Fundoscopy for retinal ischemia or vessel abnormality

124
Q

Episcleritis vs scleritis

A

Episcleritis - erythema/discomfort WITHOUT significant pain (good prognosis)
- Brighter red that resolves w/ phenylephrine

Scleritis - severe persistent pain, erythema, photophobia, tearing, decreased visual acuity
-Can hv blue/purple hue
-Avascular areas can suggest scleromalacia perforans

125
Q

Scleritis subtypes

A

Diffuse - most benign;

Nodular - tender nodule (dark red)
-Necrotizing - destructive l eg scleromalacia perforans (scleral necrosis/thinning WITHOUT pain/redness)
-Posterior - no redness (hard to dx), and minimal visual change or pain

126
Q

Episcleritis autoimmune diseases

A

RA
IBD
Vasculitis
SLE
Other

127
Q

Scleritis autoimmune diseases

A

RA
GPA
RPC
SLE, UCTD
IBD, Seroneg, Pyoderma gangrenosum
Sarcoid
Behcet, Cogan
TAK, GCA, PMR
HUVS, Hep C

128
Q

Nonrheum cause episcleritis or scleritis

A

HSV
Aspergillus
TB
Lyme
Syphilis
Pseudomonas

Bisphophonates
Trauma
Cancer

129
Q

Episcleritis tx

A

Cold compress and lube
Topical or PO NSAIDs
Topical or PO GCs

130
Q

Scleritis Tx

A

PO NSAIDs - for nonnecrotizing anterior
GC if refractory
MTX, AZA, MMF, CNI, CYC , TNF, Ritux

131
Q

Diff between Anterior vs Intermed vs Posterior uveitis

A

Pain and photophobia in anterior, not in others

Others have blurred vision, floaters,

132
Q

Causes that present with any form of uveitis

A

Behcet
Sarcoid
Lyme
Syphilis
HSV

133
Q

Uveitis presentation in Seroneg

A

Ank Spond and ReA = SUDDEN onset, unilateral

PsA and IBD = insidious bilateral chronic

134
Q

Uveitis presentation JIA

A

ASYMPTOMATIC, NORMAL appearing eye

135
Q

Uveitis rheum causes and their onset / laterality
HLAB27
PsA
JIA
Sarcoid
Behcet

A

HLAB27: SUDDEN, UNIlateral
PsA: insidious, BILATERAL
JIA: insidious, BILATERAL
Sarcoid: SUDDEN, BILATERAL
Behcet: SUDDEN, BILATERAL

136
Q

Uveitis Tx

A

Anterior: topical GC (PO if needed), mydriatic/cycloplegic agents if pain

Uveitis in any segment: periocular/ intravitreal /PO GC, MTX, AZA, MMF, LFN, CNI, CYC, TNF (NOT etanercept), Ritux

137
Q

Retinal vasculitis presentation

A

Bilateral
Painless blurred vision,
Scotomata,
Floaters
Difficulty perceiving colors
Straight lines appear wavy

138
Q

Retinal vasculitis Tx

A

GC for all (even infectious causes + abx)
Aza, CYC, MMF, TNF, Ritux

139
Q

Susac features

A

Triad:
Encephalopathy (involves corpus callosum)
Branch retinal artery occlusion
Sensorineural hearing loss

Irreversible vision/hearing loss

140
Q

Susac Tx

A

Pulse steroids then 1mg/kg for 2-4wks
+/- IVIG, PLEX
MMF, CYC, AZA, CNI, Ritux

141
Q

Orbital inflamm disease rheum causes

A

GPA
Sarcoid
IgG4RD
RA, Sjogren’s
IBD
Behcet
SLE,
AOSD
Amyloid
Histiocytic disorders

Nonrheum: thyroid, cancer, idiopathic

142
Q

Orbital inflamm disease presentation

A

Pain
Orbital swelling
Diplplia
Chemosis
Proptosis

143
Q

Orbital inflamm disease tx

A

Treat underlying

144
Q

Immune mediated inner ear disease (IMIED) presentation vs Idiopathic sudden SNHL vs Menieres

A

IMIED: Rapidly progressive BILATERAL irreversible SNHL with vestibular sx (vertigo, tinnitus, aural fullness)

Idiopathic: unilateral and NOT assoc’d w/ vestibular symptoms. Fails Weberm and humming localizes to good ear

Meniere’s happens over years (vs weeks/months in IMIED)

145
Q

IMIED Tx

A

GC 1mg/kg x2-4wks
Quick taper if no response, slower taper over 2-3mo if response at repeat hearing test

Cochlear implants

146
Q

Conditions can cause acro-osteolysis?

A

SSc
PsA
JIA
Sarcoid
HyperPTH

1. Rheum RC (23 decks)

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