Ortho/Rheum Flashcards
Fibromyalgia definition, sx, dx, tx
Characterized by abnormal pain perception of unknown etiology
MC in women 20-55yrs
sx
Chronic, widespread MSK pain, extreme fatigue, stiffness
Sleep/cognitive disturbances (fibro fog), HA, neuro sxs (numbness)
dx
Clinical – normal lab tests
Tenderness in 11/18 trigger points + chronic pain >3mo
Sleep studies show no REM cycle
tx
Conservative: pt education, sleep hygiene, low-impact aerobic exercise (swimming/water aerobics)
Medical: TCAs (amitriptyline) first line
Pregabalin – helpful for sleep sxs
Gout definition, triggers, sx, dx, tx
Uric acid deposition in the soft tissues, joints, & bones
90% occur in men
Triggers:
*attacks associated w/ purine-rich foods (ETOH, liver, seafood, yeasts) causing rapid changes in uric acid concentrations
*meds: thiazide/loop diuretics, ACEI, pyrazinamide, ethambutol, aspirin, ARBs (exception: losartan – ↓ UA levels)
sx
Acute gouty arthritis: first MTP joint of the great toe MC (podagra) & LE
Severe joint pain, erythema, warmth, swelling & tenderness, fever
dx
Arthrocentesis (dx test of choice) – negatively birefringent, needle-shaped crystals
*↑ WBC (<50,000), predominantly neutrophils
x-ray: mouse or rat bite lesions (punched out erosions w/ sclerotic & overhanging margins); tophi may be seen in longstanding disease
↑ ESR & WBC
tx
Acute Attacks:
- NSAIDs initial; AVOID ASPIRIN
- corticosteroids: refractory to NSAIDs or NSAIDs CI (renal disease) – can be injected or PO
- colchicine: unable to use NSAIDs/corticosteroids
Chronic:
- lifestyle: ↓ ETOH (esp. beer), weight loss, ↓ high purine intake
- allopurinol (first line); febuxostat – xanthine oxidase inhibitors (↓ UA production)
- uricosuric drugs: probenecid, sulfinpyrazone
- colchicine
Pseudogout definition, sx, dx, tx
Calcium pyrophosphate dihydrate deposition in the joints & soft tissue, leading to inflammation & bone destruction
MC in females, elderly
Risk Factors: hemochromatosis, hyperparathyroidism, hypomagnesemia
sx
Joints involved: knee MC, elbow, wrist, MCP joint
Severe joint pain, erythema, warmth, swelling, tenderness
dx
Arthrocentesis (dx test of choice) – positively birefringent, rhomboid-shaped calcium pyrophosphate crystals
*↑ WBC 2,000-50,0000, primarily neutrophils
x-ray: linear calcification (chondrocalcinosis)
tx
Acute Attacks:
- intraarticular steroids if 1 or 2 joints
- NSAIDs: if >2 joints
- colchicine
Chronic: NSAIDs
NSAIDs MOA: naproxen indomethacin
Anti-inflammatory (superior to colchicine)
Initial management of choice for acute gout esp. in pts <60yrs w/o significant CV, renal, or active GI disease
Colchicine MOA
Anti-inflammatory
Pts who cannot use either NSAIDs or glucocorticoids; safe in mild renal injury
Allopurinol MOA
Xanthine oxidase inhibition 🡪 decreased uric acid production
*first line prophylaxis for gout (not used for acute attacks)
*prevent urate nephropathy from tumor lysis syndrome
*SAFE IN PTS W/ RENAL INSUFFICIENCY
Uricosuric drugs MOA
- probenecid
- sulfinpyrazone
MOA: Increase urinary uric acid excretion
Prophylaxis for gout
Used in uric acid underexcreters
Polyarteritis Nodosa (PAN) definition, sx, dx, tx
*systemic vasculitis primarily of medium-sized vessels
*MC affects renal, CNS, & GI vessels
PATHO: type III hypersensitivity reaction leads to ischemia & microaneurysms of the affected vessels
*MC in men 40-60yrs
*increased association w/ chronic hep B/C
sx
Renal: HTN (renal artery stenosis), renal ischemia
GI: abdominal pain worse w/ eating, N/V
Constitutional: fever, arthralgia, myalgias
CNS: neuropathy, stroke, mononeuritis multiplex
Dermatologic: ulcers, livedo reticularis (mottled, lace-like purple discoloration), purpura
dx
*increased ESR, proteinuria
*ANCA (-)
Renal or mesenteric angiography
*microaneurysms w/ abrupt cut-off of small arteries (beading)
Bx – definitive 🡪 necrotizing medium vessel vasculitis & no granulomas
tx: glucocorticoids
Polymyalgia Rheumatica definition, sx, dx, tx
*idiopathic inflammation of the joints, bursae, & tendons
*closely associated w/ giant cell arteritis
*MC >50yrs, women
sx
*PAIN & STIFFNESS in the proximal joints & muscles
-shoulder, neck, hips, pelvic girdle (worse in
morning) >2wks
-difficulty combing hair & rising from a chair
Constitutional sxs: low grade fever, fatigue, weight loss
PE: normal muscle strength
dx
*increased ESR/CRP
*normocytic normochromic anemia
*normal muscle enzymes (creatinine kinase & aldolase)
tx: low-dose corticosteroids
Polymyositis definition, sx, dx, tx
*idiopathic autoimmune disorder leading to muscle inflammation, primarily involving the proximal limbs, neck, & pharynx; may affect the heart, lungs, & GI tract
*MC in women, 30-50yrs
PATHO: inflammatory myopathy due to CD8+ lymphocyte infiltration of the endomysium
sx
*progressive, symmetric PROXIMAL muscle WEAKNESS (shoulders, hips)
-difficulty combing hair, rising from a chair, climbing stairs, raising arms
*dysphagia, polyarthralgias
*low-grade fever, fatigue, weight loss
PE: DECREASED muscle strength
“Mechanic’s Hands:” hyperkeratotic cracked hands w/ a dirty appearance
dx
*increased muscle enzymes (CK, aldolase)
*(+) anti-Jo-1 antibodies
*(+) anti-SRP (most specific)
*increased ESR/CRP, RF
*normocytic normochromic anemia
Muscle bx 🡪 definitive: endomysial inflammation
tx
*high-dose glucocorticoids
*methotrexate, azathioprine, IVIG
Reactive Arthritis definition, sx, dx, tx
Inflammatory arthritis in response to an infection or inflammation in another part of the body
May be seen 1-4wks after Chlamydia trachomatis or GI infection (salmonella, shigella, campylobacter, yersinia)
HLA-B27 associated w/ increased incidence
sx
Triad: arthritis + ocular (conjunctivitis, uveitis) + genital (urethritis, cervicitis, balanitis)
*ASYMMETRIC
LE joints MC affected (esp. the knees)
Keratoderma blennorrhagicum: hyperkeratotic lesions on the palms/soles
dx
Arthrocentesis to r/o septic arthritis
*↑ WBC (<50,000), primarily neutrophils
*negative cultures
Nonspecific: ↑ ESR & IgG, normochromic anemia
tx
NSAIDs first line
No response to NSAIDs: sulfasalazine, methotrexate, intraarticular steroid injections
Abx may be indicated to treat the underlying cause
Rheumatoid Arthritis defintion, sx, dx, tx
Chronic systemic autoimmune inflammatory disease w/ symmetric polyarthritis, bone erosion, cartilage destruction, & joint structure loss
PATHO: hyperplastic synovial tissue (pannus) leads to joint destruction (T cell mediated)
sx
Systemic sxs: fever, fatigue, weight loss, anorexia
Joint pain/stiffness: *MORNING STIFFNESS >30MIN
*improves later in the day; decreased ROM
MC affects small joints: wrist, MCP, PIP, MTP, ankle – characteristically spares the DIP
Felty syndrome: RA + splenomegaly + neutropenia
Caplan syndrome: RA + pneumoconiosis + pulmonary nodules
PE:
*SYMMETRIC inflamed joints – warm, erythematous, soft “boggy”
*ulnar deviation of the hand
*swan neck & boutonniere deformities
*rheumatoid nodules over bony prominences
dx
Labs: + RF, + anti-CCP Ab (most specific)
*↑ ESR & CRP
x-ray: symmetric joint narrowing, osteopenia, bone & joint erosions *usually normal in first 6mo
*severe associated w/ joint subluxation
C1-C2 subluxation
tx
DMARD + NSAIDs
*DMARD slows disease progression
*NSAIDs for sxs control (steroids second line)
MTX initial DMARD of choice
“Triple Therapy” Regimen: MTX + HCQ + SSZ
DMARD: Methotrexate MOA
MOA: folic antagonist
Indications: initial DMARD in most pts – can be used in combo w/ biologic DMARDs; good for severe disease or high disease activity
DMARD: Indications: Hydroxychloroquine MOA
Indications: can be used in mild disease or if the dx is uncertain; can also be used in combo w/ methotrexate; less effective as monotherapy; safe in pregnancy
Sjogren Syndrome definition, sx, dx, tx
Autoimmune disease primarily affecting the exocrine glands (e.g., salivary, lacrimal)
*MC in females, 40-60yrs
*HLA-DR52
sx
Dry mucous membranes:
*dry mouth (xerostomia) 🡪 dental caries
*dry eyes (keratoconjunctivitis sicca)
*vaginal dryness (dyspareunia)
*bilateral parotid gland enlargement
dx
*(+) antiSS-A (Ro) & antiSS-B (La) antibodies
*(+) Schirmer test (<5mm tears in 5min)
*(+) RF, ANA
Definitive diagnosis 🡪 parotid gland bx
*gland fibrosis & lymphocytic (mononuclear) infiltration
tx
Lifestyle:
*artificial tears, increase fluid intake
*pilocarpine or cevimeline
*cyclosporine eye drops
Pilocarpine MOA
MOA: cholinergic (muscarinic) drug that increases lacrimation & salivation
Systemic Lupus Erythematous (SLE) definition
*chronic systemic, multi-organ autoimmune disorder of connective tissues
*primarily a type III hypersensitivity reaction (Ag-Ab immune complexes)
Risk Factors:
*young females (onset 20-40s)
*AA, Hispanic, & Native American women
*genetic, environmental
*sun exposure
*infections
*estrogen (OCPs)
SLE sx
Triad:
*joint pain
*fever
*malar “butterfly” rash
Constitutional sxs: fatigue, fever, weight loss
Discoid lupus: annular, erythematous patches on face & scalp *heal w/ scarring
Arthritis & arthralgias:
*migratory, polyarticular, symmetrical
Mucocutaneous involvement:
*malar “butterfly” rash
*oral/nasal ulcers (painless)
Vascular manifestations:
*Raynaud phenomenon
*vasculitis: palpable purpura, petechiae, papulonodular lesions, livedo reticularis, panniculitis, splinter hemorrhages, superficial ulcerations
*thromboembolic disease (antiphospholipid ab)
Kidney involvement:
*lupus nephritis: ranges from asymptomatic hematuria/proteinuria 🡪 nephrotic syndrome 🡪 glomerulonephritis 🡪 loss of kidney function
GI involvement:
*esophagitis, intestinal pseudo-obstruction
*protein-losing enteropathy, lupus hepatitis
*acute pancreatitis, mesenteric vasculitis or ischemia
ulmonary involvement:
*pleuritis (w/ or w/o effusion)
*pneumonitis, interstitial lung disease
*pulmonary HTN, shrinking lung syndrome
*alveolar hemorrhage
Neurologic & neuropsychiatric involvement:
*stroke, seizures, cognitive dysfunction
*delirium, psychosis, peripheral neuropathies
Hematologic abnormalities:
*anemia of chronic disease MC
*leukopenia, neutropenia, thrombocytopenia
*LAD (cervical, axillary, inguinal)
Ophthalmologic involvement:
*keratoconjunctivitis sicca MC manifestation
*due to secondary Sjogren’s syndrome
*retinal vasculopathy: cotton wool spots
Cardiac involvement:
*pericarditis w/ or w/o effusion MC manifestation
SLE dx
*(+) ANA – screening test of choice
*(+) anti-dsDNA, (+) anti-smith
*(+) antiphospholipid antibodies = ↑ risk of arterial & venous thrombosis
Pancytopenia
*anemia of chronic disease (MC)
*hemolytic anemia
*leukopenia, lymphopenia
*thrombocytopenia
*↓ complement levels (C3, C4)
Diagnostic Criteria: 4/11 “SOAP BRAIN MD”
S – serositis (pleuritis, pericarditis, peritonitis)
O – oral ulcers
A – arthritis
P – photosensitivity
B – blood (anemia, leukopenia, thrombocytopenia)
R – renal (glomerulonephritis, proteinuria)
A – ANA
I – immunologic (anti-dsDNA, anti-smith)
N – neurologic (seizures, psychosis)
M – malar rash
D – discoid rash
SLE tx
All patients
*sunscreen
*avoidance of prolonged sun exposure
*smoking cessation
*immunizations
Mild Lupus (skin, joint, mucosal):
*hydroxychloroquine +/- NSAIDs & steroids
Moderate Lupus (significant, non-organ threatening):
*(hydroxychloroquine or chloroquine) + steroids
Severe Lupus (life or organ-threatening):
*high-dose steroids or intermittent IV “pulses” of methylprednisolone + immunosuppressive agents (cyclophosphamide, mycophenolate, rituximab)
Systemic Sclerosis (Scleroderma) definition, sx, dx, tx
Systemic autoimmune connective tissue disorder where collagen deposition leads to fibrosis of the skin & internal organs (lung, heart, kidney, GI tract)
MC in women 30-50yrs
Limited (CREST syndrome): distal extremities
Diffuse (20%): trunk & proximal extremities
sx
Tight, shiny, thickened skin
Limited (CREST syndrome): *spares the trunk
*Calcinosis cutis
*Raynaud’s
*Esophageal motility disorder
*Sclerodactyly (claw hand)
*Telangiectasias
Diffuse (20%): *trunk & proximal extremities
*associated w/ greater internal organ involvement
dx
*(+) anti-centromere antibodies
*CREST specific (limited)
*(+) anti-SCL-70 antibodies
*diffuse
tx
GERD: PPIs
Raynaud: CCBs, prostacyclin
Severe: DMARDs – methotrexate, cyclophosphamide for refractory cases
Pulmonary fibrosis: cyclophosphamide
Pulmonary HTN: bosentan, sildenafil
