Neuromuscular Flashcards
The percentage of multiple sclerosis patients that are women:
70%
MC locations for MS lesions:
optic nerves, periventricular white matter, cerebral cortex, brain stem, cerebellum, spinal cord
Which cells are mainly responsible for the demyelination reaction in multiple sclerosis?
CD4+ Th1 cells
Three main cytokines responsible for the inflammatory reaction in MS
TNF-alpha, IFN-gamma, IL-2
In MS, a patient who experiences one flare up followed by complete remission and then another flare up followed by a progressive increase in disability has which MS classification?
Secondary progressive
In MS, a patient who experiences a steady increase in disability over time with occasional flare ups has which MS classification?
Progressive-relapsing
The natural history of MS tends to go from relapsing-remitting classification at the time of diagnosis to which classification 11-15 years down the road?
Secondary-progressive
An MS patient according to the Expanded Disability Status Scale is given a score of 6.0-6.5 based on what degree of disability? (What are they having trouble doing?)
Patient now needs walking assistance
About how much time does it take for an MS patient to reach an EDSS score of 6?
About 15 years on average
Top three MC presenting symptoms with MS:
Sensory symptoms in arms and legs, unilateral vision loss, and multiple symptoms at onset
Name an infection, and inflammatory syndrome, and one other condition that could mimic MS
Infections: Lyme, neurosyphilis, PML/HIV/HTLV-1
Inflammatory: SLE, Sjogren’s, CNS vasculitis, sarcoidosis, Behcet’s disease
Other: B12 or E deficiency, CADASIL, CNS lymphoma, cervical spondylosis, motor neuron disease, myasthenia gravis
The following antibiotics would be suitable for which general type of bacterial infection? Vancomycin, daptomycin, linezolid, clindamycin, B-lactams, fluoroquinolones, sulfa drugs, and glycylcycline.
Gram positive organisms.
The following antibiotics would be suitable for which general type of bacterial infection? B-lactams, fluoroquinolones, gentamicin, polymyxins, tigecycline
Gram negative organisms
The following antibiotics would be suitable for which general type of bacterial infection? Clindamycin, metronidazole, penicillins, fluoroquinolones, glycylcycline.
Anaerobic organisms.
Which three antibiotics are the only ones indicated for MRSA?
Vancomycin, daptomycin, and Synercid
Bacteremia with this multi-drug resistant gram negative rod usually occurs in patients with co-morbidities and who have been in hospital settings. It has a mortality of 39%.
Pseudomonas aeruginosa.
Studies have shown that nonmotor features such as sleep disturbances and constipation can predate which disease by years?
Parkinson disease
What are some autonomic effects seen with Parkinson disease?
Drenching sweats, dyspnea, orthostatic hypotension, sexual dysfunction, seborrhea, constipation
What are some cognitive or psychiatric effects seen with Parkinson disease?
Anxiety, depression, fatigue, slow thinking, hallucinations, sleep dysfunction (apnea, REM behavior disorder)
What are some sensory or nociceptive effects seen with Parkinson disease?
Tingling sensations, akasthisia, olfactory deficit, diffuse pain
In parkinson Disease, is it common or uncommon for symptoms to begin unilaterally?
Common
How long is the incubation period for Lyme disease?
3 - 32 days
In stage 1 of Lyme disesase, the infection is:
Localized, erythema migrans (EM)
In stage 2 of Lyme disease, the infection is:
Disseminated and occurs within several days of EM.
Some features of stage 2 Lyme disease are:
Secondary annular lesions, malaise, fatigue, fever, chills, headache, lymphadenopathy, hepatitis, neurologic signs, cardiac signs, migratory arthritis
In stage 3 of Lyme disease, teh infection is:
Persistent, continuing months after illness onset with 60% of patients developing intermittent joint pain and swelling
Medications acceptable for treating early Lyme infection (stage 1 or 2)
Doxycycline
Amoxicillin
Cefuroxime
2 - 4 weeks
Medications acceptable for treating Lyme arthritis:
Doxycycline or amoxicillin,
2 - 4 weeks of ceftriaxone
Medications for treating neurologic Lyme effects (except isolated Bell’s Palsy):
Ceftriaxone 2g IV daily for 2 - 4 wks
Medications for cardiac Lyme disease :
First degree HB- oral regimens
Second degree HB - ceftriaxone
Diagnose ehrlichiosis via what microscopic test? What will you see?
Peripheral blood smear. Morulae (intracytoplasmic inclusion bodies) can be seen with H&E.
What transmits babesia microti?
Ixodes scapularis
What is seen in a peripheral smear with babesiosis?
Maltese cross: tetrads of merozoites
Babesiosis is not covered by which antibiotic used to treat Lyme?
Doxycycline
Treatment options for babesiosis?
Clindamycin and quinine
Azithromycin and atovaquone
7 - 10 days
Rocky Mountain Spotted Fever is transmitted by the
American dog tick
Difference between relapsing fever and other tick-borne illnesses can include symptoms such as:
conjunctival suffusion, diffuse abdominal tenderness
What is the mechanism behind the relapsing fever?
Antigentic variants elicit a whole new but decreased response from the body’s immune system.
Two types of tularemia, go!
Ulceroglandular tularemia and typhoidal tularemia
Transmission of Tularemia via:
Rabbits, hares, ticks
Ulceroglandular tularemia presents with:
Enlarged and tender lymphadenopathy, then necrosis
Typhoidal tularemia presents with:
Fever, chills, headache, myalgias, sore throat, anorexia, nausea, vomiting, diarrhea, abdominal pain, cough. Not associated with prominent lymphadenopathy.
Colorado tick fever is diagnosed by the fact that it is:
A virus and not a bacterium
Manifests as symmetric weakness of the lower extremeities and progresses to an ascending flaccid paralysis over several hours or days. A tick is discovered. This is?
Tick paralysis
STARI presents with a similar skin rash to Lyme:
erythema migrans
What consequence of osteoporosis increases mortality the most?
Hip fractures
What are the genetic risk factors for osteoporotic fractures?
Age Being female Being white or asian Previous fragility fracture Family history of hip fracture or osteoporosis Small frame
What are some modifiable risk factors for osteoporotic fractures?
Menopause estrogen deficiency, Low body weight, Calcium and Vitamin D deficiency, Inadequate physical activity, Excessive alcohol intake, Cigarette smoking, Long-term glucocorticoids
An online tool to calculate risk for fracture:
FRAX
What is the most important factor in determining fracture risk?
Bone density
What bone mineral density T-score for a healthy young woman would qualify as osteoporosis?
-2.5 or less
What is one of the leading cause of falls that Dr. Adelizzi mentioned?
Polypharmacy
Main indications for treatment of osteoporosis:
Postmenopausal women and men age 50+ with the following:
- previous hip or vertebral fracture
- T-score of -2.5 or lower at femoral neck or spine
- T-score btw -1.0 and -2.5 plus a 10-year probability of hip fracture of 3% or greater (or just a 10 year probability of major fracture of 20% or greater based on FRAX)
SERMs are best for helping to prevent what possible consequence of osteoporosis?
Spine fractures
Drug used in osteoporosis that has been very effective:
Bisphosphonates
Bisphosphonates work by:
Causing apoptosis of osteoclasts, preventing bone decomposition
How often should treatments for osteoporosis be administered?
Many are weekly or monthly
What drug for osteoporosis is given intravenously? How often?
Reclast (a bisphosphonate), once a year
What is a contraindication for treatment with bisphosphonate?
Low calcium levels
A chronic inflammation of striated muscle and skin that involves painless and symmetrical proximal muscle weakness and presents with elevated serum muscle enzyme levels.
Dermatomyositis
Systemic symptoms seen with dermatomyositis:
fever, weight loss, arthralgias
GI symptoms seen with dermatomyositis:
dysphagia
Cardiac symptoms seen with myositis:
AV conduction defects, tachyarrhythmias, dilated cardiomyopathy, CHF
Pulmonary symptoms seen with dermatomyositis:
Respiratory muscle weakness, interstitial lung disease
Skin symptoms seen with dermatomyositis:
Heliotrope rash (upper eyelids), Gottron’s papules (over PIP and MCP joints), erythematous rash, Raynaud’s phenomenon
For which malignancies is there increased risk wiith dermatomyositis?
Ovarian, breast, colon, non-Hodgkin’s, melanoma. Nasopharyngeal cancer in Asians.
What distinguishes dermatomyositis from polymyositis?
DM has the typical rash presentation
Individual criteria for Bohan and Peter diagnosis of PM and DM involve:
Muscle biopsy, presence of increased serum skeletal muscle enzymes, EMG pattern, symmetric proximal muscle weakness, DM rash
Ezymes leaked from injured skeletal muscle that can be used in meeting criteria for PM diagnosis:
CK, Aldolase, AST/ALT, myoglobin
Major inflammatory causes of myopathy:
PM, DM, inclusion body myositis, juvenile DM, vasculitis, overlap syndromes (lupus, scleroderma, RA, sjogren’s)
Major endocrine causes of myopathy:
Hypothyroidism, Cushing’s syndrome
Major electrolyte disorders causing myopathy:
Hypokalemia, hypophosphatemia, hypocalcemia, hypernatremia, hyponatremia
Myopathies can be caused by metabolic disorders such as:
disorders of carbohydrate, lipid, or purine metabolism
Myopathies can be caused by drugs and toxins such as:
Cocaine, heroin, alcohol, corticosteroids, colchicine, antimalarials, HMG-CoA reductase inhibitors, penicillamine, zidovudine
Myopathies can be caused by infections such as:
Influenza, parainfluenza, Coxsackie, HIV, CMV, echovirus, adenovirus, EBV
Pyomyositis, lyme, fungal, parasitic (trichinosis, toxoplasmosis)
Myopathies can be caused by rhabdomyolysis:
Crush trauma, seizures, alcohol abuse, exertion, vascular surgery, malignant hyperthermia
An autoimmune disorder that presents with fever, mechanic’s hand, Raynaud’s, inflammatory arthritis, ILD, myositis, and Anti-Jo-1 antibodies is:
Antisynthetase syndrome
EMG for DM and PM classic triad consists of:
- increased insertional activity, spontaneous fibrillations
- abnormal myopathic low amplitude, short-duration polyphasic motor potentials
- complex repetitive discharges
Immunopathogenesis for DM:
B cells and CD4+ cells, MAC, infiltrates around BVs, micro-infarct muscle fiber damage
JDM associated with increase in which antibodies?
Coxsackie-B
JPM associated with which virus and agammaglobulinemia?
Echovirus
ADM associated with which sex and is 63% positive for which antibody? How does it present?
Females, ANA. 2 year history of DM rash, but normal muscle strength, muscle enzymes, and EMG.
Treatment for PM and DM involves:
Prednisone and possibly methylprednisone for 4 weeks with slow taper over the course of a year afterwards.
Some other measure that can be taken in treatment of DM and PM:
Exercise, monitor FVC if very ill, aspiration risk assessment, caution wrt opportunistic infections, avoid sunlight, meds that are safe if pregnant
What are poor prognostic factors for DM and PM?
Older age at diagnosis, ethnicity, bulbar involveent, delayed treatment, cardiac and pulmonary involvement
A systemic autoimmune disease whose characteristics are xerophthalmia, xerostomia, pneumonitis, interstitial nephritis, neurological, and lymphoproliferative features.
Primary Sjogren’s
A systemic autoimmune disease presenting with xerophthalmia, xerostomia accompanying another primary autoimmune disease
Secondary Sjogren’s
Sjogren’s predominately affects:
Women, 30 - 50 years
What is the genetic factor associated with risk for developing Sjogren’s?
HLA-DR, correlates closely with ANA and anit-SS-A
A test for Sjogren’s that measures whether or not the eye has enough tears to keep moist is:
Schirmer’s test
ANA testing is: (sensitive/specific)
Sensitive
What is the gold standard for diagnosis of Sjogren’s?
Lip biopsy
Medications used in treatment of Sjogren’s:
Hydroxychloroquine, corticosteroids, methotrexate, cyclophosphamide (for vasculitis)
MC direction of hip dislocation?
Posteriorly
Which artery is at risk of laceration with femoral neck hip fracture?
Medial femoral circumflex artery
Letournel classifies pelvic injury in what manner?
Anatomical
Tile classification of pelvic injury has three types:
Type A: stable pelvic ring
Type B: rotationally unstable, vertically stable
Type C: rotationally and vertically unstable
Young-Burgess classification of pelvic injury is based on:
direction of force causing injury.
Lateral compression, AP compression, vertical shear, combined
Which spinal cord injury would produce the following:
Injury to lumbosacral nerve roots, flaccid paralysis of LL, LMN lesion, sensory loss, areflexic bowel and bladder, absent bulbocavernous reflex, impotence.
Cauda Equina syndrome
Which spinal cord injury would produce the following:
Injury of sacral cord and lumbar nerve roots, areflexic bladder and bowel, normal motor fxn in legs, areflexic legs, saddle sensory loss
Conus Medullaris syndrome
