Monoarticular Arthritis and Spondyloarthropathies - Rheumatology

Question 1

What sexually transmitted bacteria is commonly responsible for septic arthritis?

Answer 1

N. Gonorrhea

Question 2

What WBC count would be expected with each of the following?

1. Septic arthritis
2. Crystal-induced monoarthritis
3. RA
4. Spondylarthropathy
5. SLE

Answer 2

All are inflammatory, thus, WBC > 2000mm^3.

Question 3

What WBC count wound be expected for the following?

1. OA
2. Trauma (acute)
3. Avascular Necrosis

Answer 3

All are non-inflammatory, thus, WBC

Question 4

What non-gonnococcal infective agents may cause septic arthritis?

Answer 4

Lyme disease (Borrelia Bergdorferi), mycobacteria (TB, leprosy), Virus (HIV, etc.), Fungi

Question 5

Pt. presents with fever, chills, and a swollen and painful knee. A dermatitis (pustule on erythematous base) was present just before the onset of pain in the knee. The Pt. does note that he had recent sexual contact with a prostitute, but denies the presence of genital/urinary symptoms. Arthrocentesis reveals gram negative cocci and blood culture does as well. What bacteria do you have a high index of suspicion for causing this presentation?

Answer 5

Neisseria Gonorrhea

Question 6

What are some common risk factors for non-gonococcal arthritis?

Answer 6

Elderly> 80
DM
RA
Prosthesis
Immunocompromised
Skin infection

Question 7

Pt. presents with pain in his back and knee. He states these episodes have occurred before without back pain, but subsided on their own. Studies reveal a calculus in the urinary tract and nephropathy as well as hyperuricemia (>7.0mg/dL). Aspiration of the knee joint reveals needle shaped, negatively bifringent (yellow when parallel to red compesator axis) monosodium urate crystals. What is his diagnosis?

Answer 7

Uric acid calculus w/ gouty arthritis

Question 8

What is the cause of uric acid buildup in hyperuricemia?

Answer 8

Cell breakdown produces purines and uric acid overproduction or under excretion leading to hyperuricemia.

Question 9

Gout Definition

Answer 9

Acute and or chronic arthritis w/ recurrent episodes of explosive joint inflammation associated w/ crystals of monosodium urate - if untreated, can lead to crystal deposition in the form of tophi in bursa, tendons, etc. that can be disfiguring.

Question 10

Incidence of gout doubles when serum uric acid levels increase to what level?

Answer 10

9.0mg/dL or more

Question 11

What is the definitive diagnosis of gout?

Answer 11

Joint aspiration and observation of crystals.

Question 12

What population is predominantly affected by gout?

Answer 12

Middle aged men or postmenopausal women

Question 13

What are the three names for deposition of calcium pyrophosphate in a joint?

Answer 13

• Pseudogout
• Calcium pyrophosphate deposition disease
• Chondrocalcinosis

Question 14

What qualities of pseudogout crystals differ from gout?

Answer 14

Crystals are weakly positive birefringent and rhomboid shaped, rather than negative birefringent and needle shaped.

Question 15

Why is pseudogout called chondrocalcinosis?

Answer 15

Cartilage calcifications are common, hence, chondro - calcinosis.

Question 16

What disease processes is chondrocalcinosis commonly associated with?

Answer 16

General: Aging, renal failure
Metabolic: Hypothyroid, hyperparathyroid, hemachromatosis (iron salt deposition in tissues), hypophosphatemia (may be due to hyperPTH as PTH increases phosphate elimination in the urine)
Joint diseases: OA

Question 17

Seronegative spondyloarthropathies such as ankylosing spondylitis, reactive arthritis (including Reiter’s syndrome), and psoriatic arthritis are commonly associated with what two bowel diseases?

Answer 17

Crohn’s disease and ulcerative colitis (especially)

Question 18

The absence of what factor in the serum would differentiate seropositive from seronegative spondlyoarthropathies like ankylosing spondyloarthritis, reactive arthritis (Reiter’s), and psoriatic arthritis?

Answer 18

RF factor (Rheumatoid factor)

Question 19

What joints are commonly affected in spondyloarthropathies?

Answer 19

SI and spinal joints

Question 20

A patient arrives with uveitis, aortic regurgitation, and some ulcers in the mouth. Your assessment reveals SI and spinal joint pain as well as pain at the tendon and ligament attachment points (enthesitis). Peripheral arthritis is present also. Labs reveal the absence of RF factor, but an increased HLA-B27 level in the blood. What three diagnosis are in your differential?

Answer 20

Ankylosing spondyloarthritis, reactive arthritis (Reiter’s), and psoriatic arthritis - seronegative spondyloarthopathies

Question 21

A young adult male has Hx. of somatic complaints at the SI joint and in his back. Labs are seronegative for rheumatoid factor with elevated HLA-B27.
X-rays show calcification of longitudinal ligament of spine and characteristic bamboo spine. He has visual problems due to acute anterior uveitis. No skin lesions are present. He does have complaints of difficulty urinating due to prostatitis. What is the likely diagnosis?

Answer 21

Ankylosing spondylitis

Question 22

Young adult male arrives w/ somatic complaints at the SI joint and in his back as well as pain in the heels/soles of his feet. Labs are seronegative for rheumatoid factor with elevated HLA-B27. Evaluation reveals a dermatitis on the glans of the penis (circinate balanitis), urethritis, and crusty lesions on the soles of the feet (keratoderma blennorrhagicum). He has Hx. of acute anterior uveitis and conjunctivitis. Scans reveal periosteal reactions at the plantar fascia insertion and erosion of the achilles tendon at the calcaneous. Some oral lesions are present also. What is the likely diagnosis?

Answer 22

Reactive Arthritis (Reiter’s Syndrome)

Question 23

40 year old male/female arrives w/ somatic complaints at the SI joint and in his/her back. Labs are seronegative for rheumatoid factor and high for HLA-B27. The pt. was referred after uveitis diagnosis years ago (chronic). Characteristic skin plaques are present on the body as well as pits in the nails on the hands and feet. The Pt. identifies several swollen smaller joints (wrist/finger -sausage thumb) and a larger joint (knee/hip/etc.). What is the most likely diagnosis?

Answer 23

Psoriatic Arthritis

Question 24

(Any aged) Pt. arrives w/ somatic complaints at the SI joint and in his back. Labs are seronegative for rheumatoid factor and high for HLA-B27. Assessment reveals small, red, swollen nodules on the shins below the knees. Aspiration of the nodules reveals pyoderma (pus formation). The pt. was referred years ago w/ chronic uveitis, and has struggled with abdominal discomfort and the need to relief the bowels w/ loose stools for years also. What is the likely diagnosis?

Answer 24

IBS assoc. spondyloarthropathy

Question 25

What is the Schober maneuver?

Answer 25

Measurement of ability to flex the back using a measuring tape on the lumbar spine - assesses for restriction in spondyloarthropathies