MS Flashcards
Amyloidosis H and P ?
Periorbital purpura
Fatigue Involuntary weight loss Macroglossia (uncommon) Kidney and liver edema CHF crackles JVD Carpal tunnel syndrome - cause of the swelling
Amyloidosis screening ?
Serum or urine Immunohistochemical analysis
AL– detectable immunoglobulin light-chain protein Not diagnostic ( but it gives you a clue)
AA– detect precursor protein from which AA amyloid fibrils derive
AA type then we can detect the protein
Amyloidosis Disgnosis lab ?
Congo red stain - apple-green birefringence when viewed under polarized light (cotton-wool dye)
Tissue biopsy
Bone marrow biopsy - AL– monoclonal population of plasma cells
Amyloidosis Tx: AL ?
Corticosteroids
Melphalan
Autologous stem cell transplant
Amyloidosis Tx: AA ?
Corticosteroids
TNFs - biologics
humera etc.
Chlorambucil
Autologous stem cell transplant
high tx ass. mortality
Behcet’s syndrome
Recurrent, painful aphthous ulcers
mouth and genitals
Lesions
tender, erythematous, papular
resemble erythema nodosum, but will ulcerate
EN does not ulcerate
Pathergy phenomenon– formation of a sterile pustule at the site of a needle stick
couple days later it is going to result in a sterile pustule
Uveitis (anterior or posterior)
Nonerosive arthritis
Neurologic
cranial nerve palsies, seizures, encephalitis, mental disturbances, and spinal cord lesions
sxs. if neurologic involvement
Behcets tx ?
Corticosteroids
Topical -for oral aphthous ulcers
Systemic -for vision-threatening uveitis
Biologics
Mainstay, with steroids
Colchicine
0.6 mg once to three times daily orally
Corticosteroids
1 mg/kg/d of oral prednisone
are a mainstay of initial therapy for severe disease manifestations
Infliximab or cyclophosphamide is indicated for severe ocular and central nervous system complications
Behcet’s syndrome patho ?
Systemic perivasculitis
all through the body there is inflammation of blood vessels
Endothelial swelling
Polymyalgia rheumatica H and P ?
Proximal joint pain and stiffness Neck, shoulder, and pelvic Bilateral and symmetrical osteoarthritis is not always symmetrical ( RA is?) Worst in the morning and after rest
Fatigue
Fever
Weight loss
Depression
jaw claudication - hurts to chew and causes pain in the master muscle with chewing - sxs. of GCA
Polymyalgia rheumatica labs ?
ESR is markedly elevated ( +40 mm/ hr)
not really helpful
Temporal arteritis is confirmed by biopsy
GCA - painful temple - worry about blindness
Polymyalgia rheumatica tx ?
Low dose corticosteroids 20 mg/day
If temporal arteritis ( then bump up dose cause we need to get the inflammation down)
High dose corticosteroids 40-60 mg/day
Polymyositis H and P ?
Symmetric proximal muscle weakness
insidious, painless
muscle atrophy - more concavity to the fossa
Dysphagia
Polyarthralgias
Dermatomyositis
Gottron’s papules
Rash (malar or heliotrope)
Polymyositis labs ?
Step 1
CK
Aldolase - blood test to check for algalsae levels and it is found it high amount in muscle tissue
ANA - anti nuclear ABS - this is for LUPUS
Step 2 Antibody testing anti-Jo-1 antibody anti-Mi-2 anti-SRP anti-155/140
Step 3
Muscle biopsy
Polymyositis Tx ?
High-dose steroids 1-2 mg/kg/day (this is a lot of prednisone)
control the inflammation
Methotrexate - not a lot of studies proving it work
Consider other DMARDs
Muscle strengthening
Pain control
Rheumatoid arthritis H and P ?
Arthralgia, fatigue, fever
Joint destruction
Bilateral
MCP and PIP joints
MTP and PIP joints
Valgus deformity
Swan neck deformity
Boutonniere deformity
Rheumatoid nodules - along the extensor surface of the arm - firm, 1 cm big and contender and they occur at pressure points ( may go away with tx)
Rheumatoid arthritis labs ?
ESR– elevated
CRP– Elevated
CBC – anemia of chronic disease
1 point
Rheumatoid factor
Nonspecific
Positive 80%
even if they gave RA doesn’t mean they will have this factor
Anti-cyclic citrullinated peptide (ACPA) antibodies
Nonspecific
Positive 95%, better test for RA
can be positive years before sxs.
XR joints Soft- tissue swelling - cause synovial proliferation Juxtarticular erosions Joint space narrowing bone out of alignment
Synovial fluid– to exclude gout and septic arthritis
3,000-50,000 WBC
Rheumatoid arthritis Tx ?
1. Synthetic DMARDs
Methotrexate
Hydroxychloroquine
Sulfasalazine
Leflunomide
Minocycline
- Biologic DMARDs
Injection or IV infusion ( once a week or once every 2 weeks)
these are really expensive - Low-dose corticosteroids
possible adverse reactions
If severe joint destruction
Reconstructive/replacement surgery
Rheumatoid arthritis addition H and P ?
Morning stiffness may last for hours ( osteoarthritis it only takes a coupe min to get loosened up)
Stiffness better with activity, worse after rest
Cervical spine may be affected, but rarely involves thoracic or lumbar spine
Synovial proliferation (pannus) around the wrist can compress median nerve and cause carpal tunnel syndrome
Juvenile Idiopathic Arthritis H and P: Systemic ( Still disease) ?
Systemic ( Still disease)
Spiking fevers ( 39° to 40° C; 102.2° to 104° F) - rabbit ear pattern of fever spiking coinciding with this rash below
Salmon- pink maculopapular rash
appearing in the evening and with the fever
Myalgias
Polyarthralgias
Minimal articular findings
Hepatosplenomegaly
Pericardial effusion
Juvenile Idiopathic Arthritis Tx ?
Stop joint inflammation, restore normal function
referrals to PT/ OT to get them moving
NSAIDs and glucocorticoids (PO or intraarticular) are mainstay
DMARD - Methotrexate first, then biologics
Refer to pediatric rheumatologist - cause they need to be monitored very closely
Juvenile Idiopathic Arthritis types ?
Systemic (Still disease) (10-20%)
Oligoarticular (40%) - few
Four or fewer joints
Polyarticular (35%)
Five or more joints
Psoriatic (<10%)
Enthesitis-Related (<10%)
Undifferentiated
Juvenile Idiopathic Arthritis H and P: Polyarticular - Seropositive ?
Resembles adult RA
symmetric involvement in the hands and feet first progressing symmetrically along the body
Symmetric involvement, often hands and feet
Low- grade fever
Fatigue
Rheumatoid nodules - not in everyone
More often an aggressive form in kids then in adults
Juvenile Idiopathic Arthritis H and P: Oligoarticular ?
Morning stiffness
Asymmetric pattern
Knees common, large and swollen - not as painful as what it looks like it should be
Risk of iritis, asymptomatic – can lead to blindness
Juvenile Idiopathic Arthritis H and P: Polyarticular - Seronegative ?
Younger children
Girls > boys
Large joints – knees, ankles, wrists
Can have active arthritis for years without erosive changes - this is a good sign , it is not causing damage for a long long time and sometimes these kids can convert to seropositive
Can convert to seropositive
Juvenile Idiopathic Arthritis H and P: Psoriatic Arthritis ?
Psoriatic rash or family hx of psoriasis
Arthritis, sacroiliitis, sausage digits ( swollen or puffy), nail pitting (yellow on nails like psoriasis)
Anterior uveitis
Variable prognosis
Remissions and exacerbations
Juvenile Idiopathic Arthritis H and P: Enthesitis - Related ?
Inflammation at the site of attachment of tendon/ligament to bone
INFLAMMATION AT THE SITE NOT AT THE BONE
Pain even without true arthritis
Mainly lower extremities
Mainly boys 8-12 yo
+/- associated with IBD
BLOOD diarrhea
Juvenile Idiopathic Arthritis: Chronic synovitis ?
(+6 weeks)
inflammation of the synoviall lining - decrease ROM, swelling, joint is stiff
Juvenile Idiopathic Arthritis dx labs ?
No specific diagnostic tests
CBC
Rheumatoid factor
ACCP antibody
ESR– normal or elevated
CRP– normal or elevated
ANA– increased often for oligoarticular
Higher likelihood of uveitis
Radiographs
Bone scan
Systemic lupus erythematosus drugs that may induce ?
Procainamide Hydralazine Isoniazid Methyldopa Quinidine Chlorpromazine
Systemic lupus erythematosus H and P ?
Often relapsing and remitting pattern
Fatigue, fever
Malar rash - no scaring
Discoid rash - tends to scar - usually in circles
Photosensitivity
Arthralgias
Oral ulcers (painless)
Lymphadenopathy
Renal symptoms
polyuria, nocturia, foamy urine
Systemic lupus erythematosus dx labs ?
CBC
Anemia
Leukopenia
Thrombocytopenia
BUN– may be elevated
Creatinine– may be elevated
these two only if renal involvement
Urinalysis– possible casts, proteinuria
ESR– elevated usually
ANA– positive 99%, nonspecific
Serum complement ( C3 or C4)– low, can monitor for progression
Antibodies to Smith antigen– elevated, can monitor for progression
Anti-double-stranded DNA– elevated, can monitor for progression
Antihistone antibodies– positive in drug-induced lupus
Systemic lupus erythematosus
Patient Education
Exercise
Sun protection
Pharmacology
NSAIDs - for joint pain
often used for musculoskeletal complaints
Antimalarials ( hydroxychloroquine or quinacrine)
may be used for musculoskeletal complaints and cutaneous manifestations
Corticosteroids (as needed for flares)
Topical or intralesional preparations are often used for cutaneous manifestations
Low- or high- dose oral corticosteroids are used for disease flares and tapered as symptoms resolve.
Methotrexate
used at low doses for arthritis, rashes, serositis, and constitutional symptoms.
Scleroderma H and P ?
Skin
Swelling and tightness in the fingers (sclerodactyly) and hands. May spread to trunk and the face
Raynaud phenomenon
vasospasm of the digital arteries
seen in more than 75% of patients
Musculoskeletal pain
GERD
Limited scleroderma (CREST syndrome)
“Skin Score”
Rate thickness of skin 0-3
17 locations
Helps to monitor progression
High degree of subjectivity
Scleroderma labs ?
ANA– 90% of patients with diffuse type, but nonspecific
Anticentromere antibody—positive with CREST (limited type)
Anti-SCL-70– may be positive with diffuse disease
Indicates poor prognosis
Scleroderma tx ?
No cure
If reflux
PPI
If renal disease
ACEI
If Raynaud
Calcium channel blockers
If pulmonary hypertension
Immunosuppressants
Early and aggressive tx needed
Scleroderma H and P: diffuse ?
Peripheral circulation
Obliterative vasculopathy
Lungs
Fibrosis, Pulm HTN
GI
Constip, GERD, “food stuck”
Renal
Less often, use ACEIs
Cardiac
Ischemia, fibrosis
MSK
Mild to erosive arthritis, joint contractures
Sicca Complex
Dry eyes and mouth
Sjogren syndrome H and P ?
Sicca features
Dry mouth (xerostomia)
food can stick to the mucosa
tooth decay cause no saline
oral infections
Dry eyes (xerophthalmia or keratoconjunctivitis sicca)
more potential for infection
itchy griddy eyes
Parotid glands may be enlarged
Sjogren syndromen labs ?
Initial RF ANA anti- Ro antibodies anti- La antibodies
More diagnostic
Schirmer test - evaluates tear secretions by the lacrimal glands
filter paper placed in the lower eyelid for 5 minutes
Less than 5 mm wetting is positive for decreased secretions
Biopsy of the lower lip mucosa
RF positive in 40 -50% - half the time
ANA positive in 80% - a lot of the time
anti- Ro antibodies positive in 60%
anti- La antibodies positive in 40%
Sjogren syndrome tx ?
Patient Education
Management is mainly symptomatic, with the goal of keeping mucosal surfaces moist
This can be achieved by using artificial tears and saliva, increased oral fluid intake, and ocular and vaginal lubricants
Pharmacology
- Pilocarpine may increase saliva flow
- Cyclosporine drops may improve ocular symptoms
Polyarteritis nodosa H and P ?
Skin lesions
palpable purpura
livedo reticularis
lacy kinda skin
Fever/chills
Anorexia
Weight loss
Abdominal pain- “intestinal
angina”
Peripheral neuropathy
Arthralgias/Arthritis / Myalgias
Hypertension, CP, CHF, MI
Edema
Oliguria
distal ishemica that can lead to gangrene
Livedo reticularis is thought to be due to spasms of the blood vessels or an abnormality of the circulation near the skin surface. It makes the skin, usually on the legs, look mottled and purplish, sort of a net-like pattern with distinct borders
Polyarteritis nodosa labs ?
Step 1
ESR– elevated
CRP– elevated
UA– may have proteinuria, hematuria ( if kidney involvement )
Step 2
ANCA– suggestive, not diagnostic
HBsAg– Hepatitis B may be causative
Diagnosis
Vessel biopsy - might show you necrotizing arteritis
Angiography
Nerve conduction studies
Polyarteritis nodosa tx ?
High doses of corticosteroids
Maybe methotrexate or azathioprine
Consider
- Cytotoxic drugs (cyclophosphamide)
Immunotherapy
Osteomalacia (Rickets) History ?
Delayed growth
Pain in the spine, pelvis and legs
Muscle weakness
Osteomalacia (Rickets) labs ?
Labs
Calcium
Phosphorus
Alkaline phosphatase - maybe be low cause osteoblast activity
Parathyroid hormone - will be high
25-hydroxy vitamin D
1,25-dihydroxyvitamin D
very small HL and not accurate level which is why you want to get the 25 one
Imaging
Skeletal Bowing
Osteomalacia (Rickets) tx ?
Patient Education
Ensure adequate supply of Vit-D or appropriate levels of sunshine in children
Pharmacology (target vit d levels between 20-40 but depend on geographic location)
- 25 hydroxy VD <10 ng/mL [25 nmol/L]
- 25 hydroxy VD levels in the range of 10- 30 ng/mL (25 to 50 nmol/L)
Osteomalacia (Rickets) Physical exam ?
Generalized muscular hypotonia (unknown mechanism)
Craniotabes (areas of thinning and softening of bones of the skull)
Parietal and Frontal Bossing Skeletal bowing (i.e. tibia / fib)
Kyphoscoliosis
Chest skeletal deformities
“Rachitic Rosary”
IN THE PIC expansion of the anterior ribs that for irregularities in the costar junctions
Osteoporosis risk factor ?
History of broken bones
Menopause or hypogonadism
Diet low in calcium and/or vitamin D
Excessive intake of protein, sodium, and caffeine
Inactive lifestyle
Smoking / Alcohol abuse
Certain drugs (e.g., glucocorticoids, anticonvulsants)
Certain disease states (e.g., anorexia nervosa, hyperparathyroidism, hyperthyroidism)
Osteoporosis Hx ?
Acute pain after a fall or minor trauma
Pain is localized to specific, identifiable, vertebral level in the midthoracic to lower thoracic or upper lumbar spine
The pain is described variably as sharp, nagging, or dull; movement may exacerbate pain; in some cases, pain radiates to the abdomen
Pain is often accompanied by paravertebral muscle spasms exacerbated by activity and decreased by lying supine
Patients often remain motionless in bed because of fear of causing an exacerbation of pain
Acute pain usually resolves after 4-6 weeks; in the setting of multiple fractures with severe kyphosis, the pain may become chronic
Osteoporosis dx labs ?
Labs
Usually normal in persons with primary osteoporosis
CBC
LFT
TSH
25-Hydroxyvitamin D level: - decreased
will be most accurate way to measure VD
Serum protein electrophoresis (Multiple myeloma)
RULE OUT MM
24 hour urine calcium/creatinine
Testosterone
Imaging DEXA (Dual-energy x-ray absorptiometry)
Osteoporosis tx ?
Patient Education
Building bone mass early in life (esp. women)
Nutrition
Exercise
maintaining normal body habitus
Pharmacology
Bisphosphonates, Calcium Metabolism Modifiers :
Alendronate (Fosamax); Ibandronate (Boniva); Zoledronic acid (Reclast)
Parathyroid hormone analogues
Selective Estrogen Receptor Modulators
Monoclonal antibodies
Vitamins (Vit D, and Calcium)
HRT/Estrogen
Paget’s disease (Osteitis deformans) History ?
Most are asymptomatic
Incidental finding of an elevated serum alkaline phosphatase level or characteristic radiographic abnormality may lead to detection of the disease
Most common is bone pain
If skeletal involvement nonspecific headaches, impaired hearing, and tinnitus commonly result from skull involvement.
The patient’s hat size may increase as a result of skull enlargement or deformity.
Paget’s disease (Osteitis deformans) PE ?
Localized pain and tenderness with manual palpation
warmth
chalk stick fx.
Paget’s disease (Osteitis deformans) labs ?
Labs
Serum alkaline phosphatase (elevated due to osteoclastic activity)
Imaging
Plain radiographs and bone scan scintigraphy
Radiolucencies
Radiodensities
Overall bone size enlarged
Coarse trabecular pattern
Advanced “flame shaped” lytic lesions in long bones
Supplemental diagnostics
BONE SCAN- All patients at the time of diagnosis to define involved bones.
Radionuclide bone scan showing the area of increased uptake in the right tibia suggesting active Paget’s disease. The whole body scan is useful for picking up other areas of uptake that may be asymptomatic and otherwise un-diagnosed.
Paget’s disease (Osteitis deformans) tx ?
Patient Education
Importance of proper posture, body mechanics, and avoidance of trauma.
Precautions against falling should be reinforced
PT good idea to increase muscles in areas of pain to reinforce the bone
Pharmacology
Bisphosphonates - consider
Reclast is treatment of choice and is IV form 5 mg dose so give this until alk phos is normalized by 98% with this therapy, the alk phos will NL within 2 years
Vit D and Ca suppléments need to be considered
Surgery or procedures
Fixative for items such as fractures
Gout Risk factors ?
Foods that are rich in purines include anchovies, sardines, sweetbreads, kidney, liver, meat extracts.
Fructose-rich foods / high-fructose corn syrup cause purines to be released Hypertension Diabetes mellitus Renal insufficiency Hypertriglyceridemia Hypercholesterolemia Obesity Anemia
Gout History ?
Spontaneous onset of excruciating pain, edema, and inflammation in the metatarsal-phalangeal joint of the great toe (podagra)
Affected joints are red, hot, and exquisitely tender
Other sites: such as the knee, wrist, elbow, or ankle are possible
Podagra is not synonymous with gout, however: it may also be observed in patients with pseudogout, sarcoidosis, gonococcal arthritis, psoriatic arthritis, and reactive arthritis
Gout PE ?
Erythema over the joint may resemble cellulitis
Skin may desquamate as the attack subsides. The joint capsule becomes quickly swollen, resulting in a loss of range of motion of the involved joint
May be febrile (during acute attack)
Tophi (collections of urate crystals in the soft tissues)- take years to develop after initial attack
Gout dx Labs ?
Labs
Microscopy of joint aspirate
Negatively birefringent monosodium urate crystals
Measurement of serum uric acid is NOT diagnostic of gout
Imaging
Plain radiographs may show findings consistent with gout
Supplemental diagnostics
Arthrocentesis of the affected joint is mandatory for all patients with new-onset acute monoarthritis
Very strongly recommended for those with recurrent attacks whose diagnosis has never been proved by microscopic visualization of crystals
Gout Patient education ?
High-purine foods should be either avoided or consumed only in moderation. Foods very high in purines include organ meats such as sweetbreads (eg, pancreas and thymus), smelt, sardines, and mussels.
Foods moderately high in purines include anchovies, trout, haddock, scallops, mutton, veal, liver, bacon, salmon, kidneys, and turkey
However, studies show this has only a slight impact on gout
Important
Ask pt about a Hx of peptic ulcer disease, renal disease, or other conditions that may complicate the use of the medications used to treat gout
i.e. may need to use corticosteroids in place of NSAIDS for renal failure patients.
Gout Tx ?
Acute attack:
NSAIDs (most common) Naproxen Indomethacin (Indocin) Corticosteroids Colchicine
Long-term (do not give in acute attack):
Xanthine oxidase inhibitors (allopurinol) or febuxostat (Uloric) or Uricosuric agent (Colchicine, Probenecid)
Gout monitoring ?
Return for a follow-up visit in approximately 1 month to be evaluated for therapy to lower serum uric acid levels
If uric acid–lowering therapy is begun, patients should be seen within 2 weeks to ensure that no toxicity has developed
Then every 1-2 months while medication dosages are adjusted to achieve the target uric acid level of 5-6 mg/dL
Pseudogout aka ?
Aka Calcium Pyrophosphate Deposition (CPPD)
formerly called Pseudogout
Pseudogout patho ?
Many cases are idiopathic, but pseudogout has also been associated with trauma and many different metabolic abnormalities, the most common of which are hyperparathyroidism and hemochromatosis
Pseudogout Hx ?
Same as gout
Spontaneous onset of excruciating pain, edema, and inflammation in the joint (mostly knee)
Affected joints are red, hot, and exquisitely tender
Most common sites: large joints, such as the knee, wrist, elbow, or ankle
Pseudogout PE ?
Similar to gout
Usually involves the knee or the wrist, although almost any joint can be involved, including the first metatarsophalangeal (MTP) joint, as occurs in patients with gout.
Pseudogout dx labs ?
Labs
Positively (but weakly) rhomboid shaped birefringent crystals
Imaging
Plain xray
Supplemental diagnostics
Joint aspirate
Pseudogout tx ?
Patient Education
Same as gout
Pharmacology
Same as gout
Osteoarthritis History ?
Slow, occurring over several years or decades
Pain is usually the initial symptom
Deep, achy joint pain exacerbated by extensive use.
Reduced range of motion and crepitus
Stiffness during rest
Morning joint stiffness usually lasting for less than 30 minutes
Osteoarthritis PE ?
Reduced range of motion
Malalignment with a bony enlargement (possible)
Most cases of osteoarthritis DO NOT involve erythema or warmth
Distal interphalangeal (DIP) joints (but may also involve the proximal interphalangeal (PIP) joints and the joints at the base of the thumb)
Heberden nodes, DIP joints, women > men
Bouchard nodes- PIP
Osteoarthritis dx labs ?
Labs
Not very helpful
Imaging
Plain xray
Supplemental diagnostics
Possibly arthrocentesis to r/o out disorders
Osteoarthritis tx ?
Patient Education
Cardiovascular or resistance exercise
Aquatic exercise
Weight loss, for overweight patients
Pharmacology
Topical capsaicin
Topical nonsteroidal anti-inflammatory drugs (NSAIDs)
Oral NSAIDs (naproxen, ibuprofen, and diclofenac)
Oral opioid (Tramadol)
Intra-articular corticosteroid injections
Nonpharmacologic interventions are cornerstones:
Heat and cold
Weight loss
Exercise
Physical therapy
Occupational therapy
Unloading in certain joints (eg, knee, hip)
Arthroscopy
Fusion
Osteoarthritis risk factors and patho ?
Degeneration of cartilage and hypertrophy of the bone at the articular margins
Heritable metabolic causes (eg, hemochromatosis)
Hemoglobinopathies (eg, sickle cell disease )
Underlying morphologic risk factors (eg, congenital hip dislocation and slipped femoral capital epiphysis)
Disorders of bone (eg, Paget disease and avascular necrosis)
Previous surgical procedures (eg, meniscectomy)
Age / Obesity / Trauma Genetics (significant family history) Reduced levels of sex hormones Muscle weakness Repetitive use (ie, jobs requiring heavy labor) Infection Crystal deposition Acromegaly Previous inflammatory arthritis
Septic Arthritis Risk factors ?
mortality rate depends on organism
N gonorrhoeae septic arthritis mortality is low
S aureus as high as ~50% mortality
S aureus is the most common cause of septic arthritis in all age groups
Septic Arthritis Hx ?
Triad of:
Fever (40-60% of cases)
Fever is usually low-grade (< 102°F)
Pain (75% of cases)
Impaired range of motion - wont be able to move knee at all! but gout they can move it a little bit
Septic Arthritis PE ?
The most commonly involved joint in septic arthritis is the knee (50% of cases)
Hip (20%)
Shoulder (8%) / ankle (7%) / wrists (7%)
Erythema, swelling (90% of cases), warmth
Usually exhibit an obvious effusion
Marked limitation of both active and passive ranges of motion (ROMs)
Septic Arthritis dx labs ?
Labs
Joint aspirate of synovial fluid for crystals via polarizing microscopy and for organisms via gram stain
Always send the aspirate for culture, regardless of the result of the screening evaluation
Imaging
Plain imaging is of limited value but may help r/o other pathology
xray nay show effusion
Septic Arthritis tx ?
Start ABX asap (draw labs first then start ABX)
Ceftriaxone (Rocephin)
GM Neg rods
Drug of choice (DOC) against N gonorrhoeae
Vancomycin (Vancocin)
Against methicillin-sensitive S aureus (MSSA)
Psoriatic arthritis subtype ?
Guttate psoriasis– disseminated lesions developing after streptococcal infection (i.e. strep pharyngitis)
Psoriatic arthritis H and P ?
Psoriasis rash usually preceding
pink silvery scales
leave it alone! dont scratch it or pick at them
Symmetric arthritis (involve the hands and feet) hands and feet
Sausage-finger appearance (dactylitis)
Nails
Pitting, “oil spot”
Onycholysis - separation
Psoriatic arthritis dx labs ?
Rheumatoid factor– negative ESR– elevated CRP– elevated Uric acid– elevated if severe CBC-- normocytic normochromic anemia anti-CCP is negative as well ?
XR affected joint (usually hand)
“Pencil in cup” deformities
middle phalanx withers away while distal stays the same and it can subluxation or dislocatee cause it is loose in there
Psoriatic arthritis Tx ?
Pharmacology
NSAIDs First line for mild Methotrexate Helps skin inflammation and the arthritis Other DMARDs for severe disease Immunomodulators (Etanercept) TNF inhibitors
Surgery or procedures
Surgery for end-stage joint destruction
joint replacement if recurrent dislocations
Reactive arthritis (Reiter syndrome) H and P ?
Preceding infection (GI, GU)
Acute asymmetric arthritis
large joints usually below the waist
Knee and ankle common , also foot
down in feet can cause sausage digits of the toes
Mucocutaneous ulcers(balanitis, stomatitis)
Urethritis/cervicitis
Conjunctivitis
Enthesitis
Reactive arthritis (Reiter syndrome) dx labs ?
Rheumatoid factor– negative
HLA-B27– 30-50% positive
Synovial fluid– culture negative but cloudy and increased WBC’s - causing cloudiness
XR joint– nonspecific degenerative
Culture – dependent on antecedent infection
ESR/CRP - elevated
Reactive arthritis (Reiter syndrome) tx ?
PT
NSAIDs
Steroids
DMARD (sulfasalazine) if refractory to the NSAIDs or steroids
If active infection
Antibiotics
given at the time of infection will reduce the chance of developing reactive arthritis later on
do not alleviate the symptoms
self limited and spontaneously regress but it can take 5 months
can turn into function disability
Fibromyalgia dx ?
Pain for at least 3 months
Pain on both sides of the body
bilateral
Pain above and below waist
Must involve the axial skeleton
Fibromyalgia H and P ?
Nonarticular musculoskeletal aches, pains
Fatigue
Sleep disturbances
Multiple tender “ trigger” points
enough pressure to blanch finger nail and they will experience spots
pain in 11 of the 18 spots then it is dx.
Mood changes Cognitive disturbances Anxiety Depression Headaches Irritable bowel syndrome Dysmenorrhea Allodynia in 11 of 18 sites
Fibromyalgia dx labs ?
Diagnosis of exclusion CBC CMP ESR, CRP Thyroid panel
Fibromyalgia tx: patient edu. ?
Patient Education (and friends, family, employer)
Aerobic exercise– improves functioning
Avoid overtraining but keep them moving
Sleep education
Cognitive behavioral therapy - “ i can make it through the day”
Fibromyalgia tx: Pharmacology ?
Tramadol
Pregabalin ( Lyrica) or gabapentin (Neurontin)
FDA- approved
Reported reduced pain and improved sleep
Side effects– fatigue, trouble concentrating, sleepiness, edema
TCA or SSRI– may be used if depression or if additional psychiatric sx
been replaced with SSRIs
Acute rheumatic fever
(Rheumatic heart disease) H and P ?
Arthralgias
Fever
Erythema marginatum
Subcutaneous nodules
Chorea
Acute rheumatic fever
(Rheumatic heart disease) dx labs ?
EKG
PR interval prolonged
CRP or SED rate
elevated
ASO titer
Rising ( ABS increasing)
Rapid strep
Positive
Strep culture
Positive
Echo - look at the valves
Acute rheumatic fever
(Rheumatic heart disease) tx ?
Bed rest until stable
Penicillin IM
(Erythromycin if PCN allergic)
Salicylates - watch for reyes syndrome
Optional
Corticosteroids
Jones criteria: major ? ?
carditis
erythema marginatum and subcutaneous nodules
chorea
polyarthritis
Jones criteria: minor ? ?
fever
polyarthralgias
reversible prolongation of the PR interval
↑ ESR or CRP
Acute rheumatic fever EOD?
5-15 year olds History of strep Jones criteria Valve vegetations, mitral most common Penicillin
Acute rheumatic fever PEARLS ?
Common cause of mitral stenosis
Sarcoidosis patho ?
Multisystem granulomatous disorder
Characterized by noncaseating granulomas
Common areas affected:
Bilateral hilar adenopathy
Pulmonary reticular opacities
Skin, joint, and/or eye
Sarcoidosis Hx ?
Malaise Fever Anorexia Arthralgias Dyspnea on exertion Cough Chest pain
Sarcoidosis PE ?
Lung sounds usually normal
may have crackles
Skin
Erythema nodosum
Lupus pernio
uveitis
Sarcoidosis dx labs ?
Labs
ESR/ CRP– elevated serum angiotensin-converting enzyme (ACE) – usually elevated Liver enzymes– elevated if involvement TB test– negative Serum amyloid A (SAA)– negative Urine calcium– may be elevated Serum calcium– may be elevated
Imaging
CXR
CT (chest)
Supplemental diagnostics
PFT - see how much lung involvement there is
Cardiac Workup
Sarcoidosis tx ?
Course
Supportive
Pharmacology
Corticosteroids (but may increase relapse rate)
Surgery or procedures
Lung transplant for end-stage
parenchyma involvement
Vasculitis: Large vessel ?
Takayasu arteritis - broken heart syndrome
GCA -
Behcet disease
Vasculitis: Medium vessel ?
Polyarteritis nodosa
Buerger disease
Vasculitis: small vessel ?
Immune-complex mediated
Cutaneous leukocytoclastic angiitis (“hypersensitivy vasculitis”)
Henoch-Schonlein purpura
Granulomatosis with polyangiitis ( formerly Wegener granulomatosis)
Vasculitis History ?
Varies – depending on system involved
which vessels
Vasculitis PE ?
palpable purpura
Vasculitis dx labs ?
Biopsy
Gold standard
Vasculitis tx ?
Glucocorticoids
Cytotoxic agents
Cyclophosphamide
Methotrexate
Immunoglobulins
Anaphylaxis tx ?
Airway Epinephrine Stop source Corticosteroids IV fluids
Consider
Antihistamines
Albuterol
Ipratropium
Surgery or procedures
Intubation
Perform early if indicated
Swelling may progress
Cricothyroidotomy if necessary
