Miscellaneous Flashcards
Characteristics of Spondyloarthropathies
Inflammatory axial spine involvement Asymmetrical peripheral arthritis Enthesitis Inflammatory eye disease Mucocutaneous features Negative RF High frequency of HLA-B27 antibodies Familial aggregation
Define Spondyloarthropathies
Group of inflammatory arthropathies that share distinctive clinical, radiographic, & genetic features
Types of Spondyloarthropathies
Ankylosing spondylitis
Reactive arthritis (Reiter’s syndrome)
Psoriatic arthritis
Enteropathic arthritis (Crohn’s & UC)
Define Ankylosing Spondylitis
Chronic inflammatory disease of the joints of the axial skeleton
Describe Ankylosing Spondylitis
Changes in SI joints & hips
Inflammation around enethesis
Extra-Articular Manifestations of Ankylosing Spondylitis
Anterior uveitis
Aortic valvular disease
Restricted chest expansion
Skin rashes
Diagnostic Features of Ankylosing Spondylitis
Insidious onset low back pain >3 months
Improves with exercise
Morning stiffness >30 minutes
Awakened by pain during 2nd half of the night
Alternating buttock or posterior thigh pain
Sites of enthesitis
Sacroiliitis on x-ray
Radiographic Changes in Ankylosing Spondylitis
Erosion & sclerosis of SI joints
Involvement of apophysial joints of the spine
Ossification of the annulus fibrosus
Calcification of the anterior & lateral spinal ligaments
Squaring & generalized demineralization of the vertebral bodies
“Bamboo spine”
Characteristics of Ankylosing Spondylitis
Male 20-40
Insidious onset
Chronic pain & stiffness of middle spine- referred to one buttock or back of thigh
Morning stiffness that improves with exercise
Criteria for Diagnosing Ankylosing Spondylitis
Limited lumbar motion
Low back pain >3 months
Reduced chest expansion
Bilateral grade 2-4 sacroillitis on x-ray
Unilateral grade 3-4 sacroiliitis on x-ray
Define Reactive Arthritis
Acute inflammation arthritis occurring 1-3 weeks after infectious event
Reactive Arthritis TRIAD
Arthritis
Urethritis (cervicitis)
Conjunctivitis
Complications of Reactive Arthritis
Acute anterior uveitis
Myocarditis
Fasciitis
Signs/Symptoms of Reiter’s Syndrome
Arthritis Enthesitis Dactylitis Dysuria Pelvic pain Conjunctivitis Oral ulcers Rashes Nail changes Genital lesions
Common Pathogens of Reactive Arthritis
Shigella Salmonella Yersinia enterocololitica Campylobacter Chlamydia trachomatis C. pneumoniae Ureaplasma urealyticum
Define Psoriatic Arthritis (PsA)
Chronic inflammatory arthropathy in setting of psoriasis
Nail Changes in Psoriatic Arthritis (PsA)
Pitting
Dystrophy
Onycholysis
Clinical Manifestations of Psoriatic Arthritis (PsA)
Inflammatory arthritis in DIPs Asymmetric arthritis Sausage digits Onycholysis No rheumatoid nodules RF negative Erosive arthritis without osteopenia Sacroiliitis Paravertebral ossification Enthesopathy Pencil & cup deformity
Treatment for Spondyloarthropathies
NSAIDs PT, stretching & exercise Maintain good posture Sulfasalazine Methotrexate TNF inhibitors: Remicade, Humira, Enbrel Prevent eye complications
NSAIDs effective for
Inflammatory back pain
Spinal stiffness
Peripheral arthritis
Enthesopathy
NSAIDs more Effective in Spondyloarthropathies
Penylbutazone
Indomethacine
Diclofenac
Use DMARDs When?
Anti-inflammatory therapy insufficient
Progression of inflammatory axial disease noted
Active persistent polyarthritis
Uncontrolled extra-articular disease
Medications for Uncontrolled Extra-Articular Disease
TNF inhibitors
Sulfasalazine
Methotrexate
Polymyalgia Rheumatica Characterized by
Aching & stiffness in the neck, shoulder & pelvic girdles
Epidemiology of Polymyalgia Rheumatica
Females > Males
Higher incidence at higher latitudes
Etiology of Polymyalgia Rheumatica
Polygenic
Multiple environmental & genetic factors
Possible viruses: adenovirus, RSV, parvovirus, parainfluenza
Possible bacteria: mycoplasma, chlamydia pneumoniae
Clinical Manifestations of Polymyalgia Rheumatica
Persistent pain >1 month
Aching & morning stiffness in neck, shoulders, & pelvis lasting 30 minutes
Bilateral discomfort: interferes with ADLs
Systemic Signs of Polymyalgia Rheumatica
Fever
Malaise/fatigue
Anorexia, weight loss
Distal Manifestations of Polymyalgia Rheumatica
Nonerosive, self-limiting, asymmetric arthritis
Carpal tunnel syndrome
Distal extremity swelling & pitting edema
Labs for Polymyalgia Rheumatica
ESR >40 CRP Modest anemia Mildly abnormal LFTs RF & ANA negative CK & CPK normal
Differential Diagnosis for Polymyalgia Rheumatica
SLE RA Polymyositis Fibromyalgia Late-onset spondyloarthropathy Malignancy Infection
Things to Look for in SLE vs. PMR
Pleuritis Pericarditis Leukopenia Thrombocytopenia Anti-dsDNA antibodies Anti-ENA antibodies
Things to Look for in RA vs. PMR
Small joints of hands/feet
Partially responsive to steroids
Considerable overlap with PMR & seronegative RA
Things to Look for in Polymyositis vs. PMR
Symmetric proximal muscle weakness Pain not prominent Elevated CK, Alk phos. Abnormal EMG Myositis on muscle biopsy
Types of Malignancies That Would Present like EMR
Solid: kidney, ovary, stomach
Heme: myeloma, primary amyloidosis
Infection to Rule out to Diagnose PMR
Bacterial endocarditis
Treatment of Polymyositis Rheumatica
Steroids
Trial of NSAIDs
Course of Polymyositis Rheumatica
Complete/nearly complete resolution of symptoms in a few days
Relapses do occur
Follow ESR or CRP
Treat for 1-2 years
Watch for steroid SE
Methotrexate in refractory cases
Methylprenisolone: similar efficacy, fewer SE
Define Giant Cell Arteritis (GCA)
Chronic vasculitis of medium & large vessels
Pathophysiology of Giant Cell Arteritis (GCA)
Vasculitis of extra-cranial branches of aorta, spares intracranial branches
Transmural inflammation -> intimal hyperplasia -> luminal occlusion
Etiology of Giant Cell Arteritis (GCA)
Influenced by multiple genetic & environmental factors
No evidence of autoantibodies
Cellular immune response
Presentation of Giant Cell Arteritis (GCA)
Generally insidious onset Headache Fever Malaise Weight loss Anorexia
Symptoms of Giant Cell Arteritis (GCA)
Headache Jaw claudication Transient visual symptoms Fixed visual symptoms CNS abnormalities Dysphagia Tongue claudication Limb claudication
Signs of Giant Cell Arteritis (GCA)
Weight loss or anorexia Decreased temporal artery pulsations Fever Artery tenderness Erythematous or swollen scalp arteries Large artery bruits Fundoscopic abnormalities
Complications of Giant Cell Arteritis (GCA)
Blindness
Aortic aneurysms
Stroke
Lab Findings in Giant Cell Arteritis (GCA)
ESR >50
Mild-moderate anemia of chronic disease
Elevated LFTs
Diagnosis of Giant Cell Arteritis (GCA)
Biopsy
MRI/MRA
Other options: arteriography, US, PET
Treatment of Giant Cell Arteritis (GCA)
Glucocorticoids
Vision loss: IV pulse methylprednisolone
Low dose aspirin
Define Fibromyalgia Syndrome (FMS)
Clinical syndrome characterized by widespread muscular pain, fatigue, & muscle tenderness
Cause of Fibromyalgia Syndrome
Abnormal sensory processing in the CNS
Possible genetic role
Triggered by physical, emotional, or environmental stressors
Symptoms of Fibromyalgia Syndrome
Poor sleep Headaches IBS Cognitive & memory problems Numbness & tingling Irritable bladder TMJ disorder Restless leg syndrome Dry eyes & mouth Morning stiffness Anxiety & depression
Who is more likely to develop fibromyalgia?
RA patients SLE patients Ankylosing spondylitis Family history Associations: lyme disease, OSA, sleep deprivation
Diagnosis of Fibromyalgia
4 symptoms
Generalized, chronic pain >3 months affecting the axial, upper & lower segments, & left & right sides of the body
Shared Features of Fibromyalgia & Depression
Strong genetic predisposition Similar co-morbidity Similar sleep disturbances Similar cognitive disturbances Orthostatic features ANS dysfunction Childhood abuse, stress Can be debilitating Imaging studies Neuroendocrine studies
Diagnosis of Fibromyalgia
X-rays: normal Labs: normal Nuclear medicine & CT scans: normal ESR, CRP: normal Distinguish from RA, SLE, PMR & hypothyroidism
Treatment of Fibromyalgia
Medication trial CBT, counseling Physical rehab TCAs: amitriptyline, cyclobenzaprine Anticonvulsants: pregabalin, gabapentin SNRIs: duloxetine, milnacipran Diazepam & clonazepam 2nd line for restless leg syndrome & severe sleep disturbance Therapeutic massage Myofascial release therapy Acupuncture
Patient Self-Management of Fibromyalgia
Schedule time to relax, meditate Establish routine for going to bed and waking up Aerobic exercise on daily basis Self-education Support group CBT
Physical Medicine or Rehabilitation for Fibromyalgia
Avoid inactivity Analgesic advice & non-pharmacologic treatment CV fitness Stretching, strengthening OT Work rehab Ergonomics
Mental Health for Fibromyalgia
Psychopharmacology
Counseling
CBT
