Ortho/Rheum -- 12% of EOR Flashcards
How is fibromyalgia diagnosed?
Clinical diagnosis
- Labs will be normal
- Chronic pain 3+ months
- Tenderness in 11+ of 18 trigger points (must be bilateral, above and below waist)
- Sleep studies will show no REM cycle
How is fibromyalgia treated?
Conservative measures:
- Patient education
- Sleep hygiene
- Low impact aerobic exercise
Medical treatment:
- TCAs (amitryptilline) = 1st line
- SSNRI (duloxetine)
- Pregabalin, esp useful for sleep symptoms
How do the presentations (not diagnostic findings) of gout and pseudogout differ?
- Pseudogout usually in patients 60+ YO
- Gout is usually found in a younger population than pseudogout
- Pseudogout more likely to be found incidentally (asymptomatic) than gout – but clinically indistinguishable when symptomatic
Describe the color, polarity, and morphology of the findings on arthrocentesis in gout
- Yellow (when parallel to polarizer)
- Negatively bifrigent
- Needle-shaped
Describe the color, polarity, and morphology of the findings on arthrocentesis in pseudogout
- Blue (when parallel to polarizer)
- Positively bifrigent
- Rhomboid-shaped
What are the crystal compositions in gout and in pseudogout?
Gout: monosodium urate
Pseudogout: Ca pyrophosphae dehydrate
Punched out lesions and tophi are XR findings in what rheumatological condition?
Punched-out “rat-bite” lesions and tophi are associated with gout
What XR findings might be found in pseudogout?
Fine, linear calcifications of the cartilage
What kind of anti-hypertensive medication must be avoided in patients with gout?
Thiazide diuretics
What is the treatment for an acute gout attack?
- NSAIDs – indomethacin TID is first line
- Steroids if refractory or if renal dz precludes NSAID use
- Colchicine can be used but has bad GI AEs
What is the treatment for chronic gout prophylaxis?
- LSMs
- Allopurinol – do NOT start during acute attack
- Colchicine
- Uricosuric drugs - probenecid, suulfinpyrazone – these are CIx w/renal dz
What is the very general pathophys of gout?
Uric acid accumulation and deposition in synovial fluid, 2/2 to:
- Underexcretion from kidneys (renal dz, thiazides, ASA)
- Overproduction due to increased cell turnover (chemo, cancer, hemolysis)
What is the tx for pseudogout?
- Colchicine
- NSAIDs are 1st line if 2+ joints involved
- Steroids:
- intraarticular if 1-2 joints
- PO if 3+ joints
What is used for prophylaxis of pseudogout, when is it initiated, and what is the MOA?
Colchicine used for prophylaxis in pts with 3+ attacks per year
Colchicine inhibits microtubule assembly
What are some AEs associated with cochicine use?
Diarrhea and bone marrow suppression –> neutropenia
What drugs can cause/exacerbate gout?
- ACEi’s
- ARBs except losartan
- ASA
- Thiazide diuretics
- Loop diuretics
- Pyrazinamide
- Ethambutol
What body systems are involved in polyarteritis nodosa? What body system is characteristically spared?
Renal GI CNS Dermatologic \+ constitutional symptoms
Pulmonary vessels are generally not involved
50 YO male with hx of HTN, chronic Hep B, and Raynaud’s presents with vague symptoms of malaise and arthralgia, some fevers, neuropathy, and worsening pain after meals. What is this suspicious for and how is it treated?
Polyarteritis nodosa, treated with steroids +/- cyclophophamide if severe/refractory
In patients with Hep B, antiviral tx of hepatitis and possibly plasmapheresis
What viral illness is associated with polyarteritis nodosa?
Hep B and Hep C
What lab findings might be expected in a patient with polyarteritis nodosa?
Elevated ESR
Proteinurea
ANCA (-)
How is polyarteritis nodosa diagnosed?
Definitive diagnosis via biopsy - will show necrotizing medium vessel vasculitis without granulomas
Renal and/or mesenteric angiography will show microaneurysms with abrupt cut off of small arteries (“beading”)
What vessels are affected in polyarteritis nodosa?
Medium-sized vessels
Pt presents with symmetric, painless muscle weakness in proximal muscles evidenced by difficulty combing hair and rising from chair.
What is this suspicious for?
Polymyositis
Pt presents with symmetric, painless muscle weakness in proximal muscles evidenced by difficulty combing hair and rising from chair.
What lab findings might be expected for the likely diagnosis?
Elevated Cr Kinase Elevated aldolase Elevated ESR, CRP, possible RF Normocytic, normochronic anemia Anti-Jo-1 Anti-signal recognition protein \+ ANA
Pt presents with symmetric, painless muscle weakness in proximal muscles evidenced by difficulty combing hair and rising from chair.
What is the diagnostic test for the most likely diagnosis?
Muscle biopsy showing endomysial inflammation is definitive
Usually first step is electromyography
How is polymyositis treated?
High-dose corticosteroids are first line
Alternatives:
- Methotrexate
- IVIG
- Mycophenolate
- Azathioprine
What is one key characteristic that helps distinguish polymyositis from dermatomyositis?
Polymyositis is not associated with a rash
What are two key characteristics that help distinguish polymyositis from polymyalgia rheumatica?
Polymyositis has loss of muscle strength and is painless
Polymyalgia rheumatica has normal muscle strength and is painful
What are two lab findings that can help distinguish polymyositis from polymyalgia rheumatica?
Polymyositis has loss of strength and for that reason is associated with increased Cr kinase and increased aldolase
These will be normal in polymyalgia rheumatica
What are some extramuscular/extraarticular findings in polymyositis?
Dysphagia
Low grade fever
Weight loss
Fatigue
How do the presentations of polymyositis and polymyalgia rheumatica differ?
Polymyositis is painless and associated with muscle weakness
Polymyalgia rheumatica is painful but with no muscle weakness. It is also worse in the AM. There may be decreased active/passive ROM.
Both can have vague constitutional symptoms and both affect the proximal muscles
What is the treatment for polymyalgia rheumatica?
Low-dose steroids
Methotrexate if refractory or if steroids are CIx’d
What is the condition associated with the phrase “can’t pee, can’t see, can’t climb a tree” and what are the specific findings being described?
Reactive arthritis
Triad:
- Urethritis/cervicitis/blanitis
- Uveitis or conjunctivitis
- Arthritis
What is the work-up for reactive arthritis?
Arthrocentesis and negative cultures to r/o septic arthritis
Labs will show elevated WBCs, ESR
May see a normochromic anemia
Reactive arthritis is a reaction to what, and what is the timeline?
Reaction to infection or inflammation elsewhere in the body
Often occurs 1-4 weeks after chlamydia or GI infection (salmonella, shigella, campy, or yersinia)
What is the treatment for reactive arthritis?
NSAIDs are first line
Can use methotrexate or sulfasalazine 2nd line
Intraarticular steroids can be used
Antibiotics may be needed to clear the causative infection (not of the joint)
What the the gene associated with reactive arthritis antibodies?
HLA-B27
What are the genes associated with RA antibodies?
HLA-DRB 1 and 4
What joints are characteristically affected and which are spared in RA?
Small joints are affected:
- MCP
- PIP
- Wrist
- MTP
- Ankle
Spares the DIP joints!
What kind of deformities may be seen in RA?
- Ulnar deviation of the hand
- Swan neck deformities
- Boutonniere deformities
- Rheumatoid nodules over bony prominences
What is Felty syndrome?
RA +
Splenomegaly +
Neutropenia
What is Caplan syndrome?
RA +
Pneumococoniosis +
Pulmonary nodules
What joints of the spine might be affected in RA?
Cervical spine; may see C1-C2 subluxation
What antibody may be positive in RA?
Anti-CCP is most specific
RF+ likely (sensitive, non-specific)
What are characteristic XR findings associated with RA?
Soft tissue swelling Symmetric joint narrowing Osteopenia Bone and joint erosion Joint subluxation
*XR may be normal in early disease
What is the treatment for RA?
DMARDs to slow progression - Methotrexate - Leflunomide NSAIDs for immediate symptom control Steroids are 2nd line for symptom control
What is the MOA of methotrexate?
Folic antagonist
What is the MOA of leflunomide?
T-cell inhibitor
Describe the general pathophys of RA
Hyperplastic synovial tissue causes T-cell mediated joint destruction
Patient presents with multiple dental caries complaining of dyspareunia. Parotid glands appear enlarged on PE. What is this suspicious for?
Sjogren syndrome
- Dry eyes
- Dry mouth ( –> cavities)
- Vaginal dryness
- Parotid gland enlargement
What antibodies are associated with Sjogren syndrome?
antiSS-A (Ro)
antiSS-B (La)
What is a Schirmer test?
Helps measure tear production:
- Filter paper is placed on lower eyelid for 5 minutes
- <5mm of wetting is positive, suggestive of Sjogren’s syndrome
What is Rose Bengal stain used for?
Identifies corneal epithelium changes associated with Sjogren’s syndrome
How is Sjogren’s syndrome treated, and what are some AEs of the treatment?
Cholinergic drugs: pilocarpine or cevimeline to help increase secretions.
AEs are SLUDD problems (salivation, lacrimation, urination, diaphoresis, diarrhea) as well as incontinence, n/v, blurred vision, and bradycardia
Other tx include artificial tears, increased fluid intake, sugar-free gum, artificial saliva, and fluoride
Patients with Sjogren’s syndrome are at heightened risk for what other conditions?
- Non-Hodgkin lymphoma
- Pneumonitis
- Interstitial nephritis
*If exposed to high antibody counts in utero, child has increased risk of congenital heart block
What are the findings associated with limited scleroderma?
- Tight, shiny, thickened skin of face, neck, and extremities distal to elbows/knees. Trunk is spared.
CREST:
- Calcinosis cutis
- Raynaud’s phenomenon
- Esophageal motility disorder
- Sclerodactyly
- Telangiectasias
What are the findings associated with diffuse sclerosis?
Tight, shiny, thickened skin involving distal body parts as well as trunk and proximal extremities.
+ Organ involvement:
- Restrictive lung Dz (/Pulmonary HTN)
- Pulmonary fibrosis
- Myocardial fibrosis
What is the classic triad of findings associated with SLE?
Malar rash
Joint pain
Fever
Aside from the classic triad, what are some findings associated with SLE?
Constitutional: Fevers, chills, fatigue, night sweats CNS: HA, seizures, psychosis Renal: Glomerulonephritis Cardiopulm: Pericarditis, pleuritis Other: Retinitis, oral ulcers, alopecia
What are the antibodies associated with SLE?
ANA
Anti-dsDNA
Anti-Smith
May also see elevated antiphospholipid antibodies
What are some (non-antibody) lab findings associated with SLE?
- Pancytopenia
- Anemia of chronic disease
- Hemolytic anemia
- Thrombocytopenia
How is SLE disease progress monitored?
dsDNA antibodies
What is the treatment protocol for SLE?
Mild disease, affecting skin, joints, and mucosa: Hydroxychloroquine +/- NSAIDs
Moderate disease: Add short-term steroid therapy
Severe (organ-threatening): High dose steroids or intermittent IV pulses of methylprednisolone +/- immunosuppresive agent (cyclophosphamide, mycophenolate, rituximab)
How is scleroderma-associtated pulmonary fibrosis treated?
Cyclophosphamide
What is the most sensitive antibody test for SLE?
Anti-Sm (Anti-dsDNA is ok but less sensitive)
What disease is Anti-U1RNP associated with?
Anti-U1RNP antibody (anti-U1RNP) is generally known to be a serological marker for mixed connective tissue disease (MCTD), but can be detected also in patients with definite SSc or systemic lupus erythematosus (SLE)
With what rheum dz is Hep B associated?
Polyarteritis nodosa
