Polymyalgia Fibromyalgia HLAB27 Flashcards
Spondyloarthropathies
- definition
- characterized by
- diseases included in this
Definition
-a group of inflammatory arthropathies that share distinctive clinical, radiographic, and genetic features
Characterized by
- inflammatory axial spine involvement
- asymmetrical peripheral arthritis
- enthesitis
- inflammatory eye disease
- mucocutaneous features
- negative rheumatoid factor
- high frequency of HLA B27 antibodies
- familial aggregation
Diseases
- ankylosing spondylitis
- reactive arthritis
- psoriatic arthritis
- enteropathic arthritis (crohns and UC)
Ankylosing Spondylitis
- what is this
- high incidence where
- MC in who
- diagnostic features
- first sx
What
- chronic inflammatory disease of the joints of the axial skeleton
- changes are seen in sacroiliac joints and hips, inflammation around enthesis (where tendons and ligaments attach to bones), and extra-articular manifestations (anterior uveitis, aortic valvular disease, restricted chest expansion)
Higher incidence at higher latitudes, scandinavian countries
MC in men aged 20-40
Diagnostic features
- insidious onset low back pain for greater than 3 months
- improves with EXERCISE (not rest)***
- morning stiffness more than 30 min
- awakened by pain during the 2nd half of the night
- alternating buttock or posterior thigh pain
- sites of enthesitis
- sacroiliitis on xray
First sx are typically chronic pain and stiffness in the middle spine associated with referred to one or the other buttock or the back of the thigh
Ankylosing spondylitis
- extra-articular manifestations
- imaging and what is seen
- Dx criteria
Extra-articular manifestations
- skin rashes
- eye inflammation- especially uveitis
- lung involvement
- cardiac involvement- with aortic valve disease
Imaging
- radiographs are the single most important imaging technique for dx and follow up
- early changes at the sacroiliac joints: erosion and sclerosis
- involvement of the apophysial joints of the spine
- ossification of the annulus fibrosus
- clacification of the anterior and lateral spinal ligaments
- squaring and generalized demineralization of the vertebral bodies (bamboo spine)
Dx criteria
- definite if: criteria 4 or 5, plus 1, 2, or 3
1. limited lumbar motion
2. low back pain for more than 3 months- improved with exercise, not relieved by rest
3. reduced chest expansion
4. bilateral grade 2-4 sacroiliitis on xray
5. unilateral grade 3-4 sacroiliitis on xray
Reactive Arthritis
- what is this
- triad of sx
- what is Reiter’s?
- course
- complications
- common pathogens
What
-acute inflammatory arthritis occurring 1-3 weeks after infectious event (GU, GI, idiopathic)
Triad
-arthritis + urethritis (cervicitis) + conjunctivitis
Reiters
-post-venereal onset (MC in males)
Course
- usually self limiting (less than 6 months), can become chronic without tx
Complications
-Acute anterior uveitis, myocarditis, fasciitis
Common pathogens
- Enteric: shigella, salmonella, yersinia enterocololitica, campylobacter
- Urogenital: chlamydia trachomatis, C. pneumoniae
Reiter’s Syndrome
- MS signs and sx
- Extra-articular signs and sx
MS
- arthritis
- enthesitis (heel tendonitis)
- dactylitis
Extraarticular
- GU: dysuria and pelvic pain
- conjunctivitis
- oral ulcers (tongue lesions, palate erosion)
- rashes (pustules, keratoderma blenorrhagica)
- nail changes (onycholysis)
- genital lesions
Psoriatic Arthritis
- What is this
- etiology
- course
- clinical characteristics
- what is seen on xray?
What
-chronic inflammatory arthropathy in setting of psoriasis
Etiology
-unclear!
Course
-chronic, destructive arthritis in 30-50%
Clinical Characteristics
- inflammatory arthritis in DIPs
- asymmetric arthritis
- sausage digits
- nail pitting (onycholysis)
- no rheumatoid nodules
- RF test negative
- erosive arthritis without osteopenia
- sacroiliitis, often asymptomatic
- paravertebral ossification
- enthesopathy
Xray
-pencil and cup deformitiy
Spondyloarthropathies
- Tx
- when to consider DMARDs
Tx
- NSAIDs for Sx (no evidence that NSAIDs inhibit disease progression): naproxen, sulindac, indomethacin
- PT, stretching, exercises to preserve spine and joint function
- sulfasalazine and methotrexate found to be beneficial
- Anti-TNF (TNF inhibitors): Remicade, Humira, Enbrel)
- prevent eye problems with early recognition and tx
Consider DMARDs when
- antiinflammatory therapy is insufficient to control sx
- progression of inflammatory axial disease noted
- active persistent polyarthritis
- uncontrolled extra-articular disease
Polymyalgia Rheumatica
- What
- characterized by
- MC in what age and gender
- related to what condition
- clinical manifestations
What
-inflammatory condition of unknown etiology (probably polygenic, possible infectious triggers)
Characterized by
-aching and stiffness in the shoulder and pelvic girdles and neck
MC in people older than 50, females more than males
related to
-giant cell arteritis
Clinical manifestations
- persistent pain (more than 1 month): aching and morning stiffness in neck, shoulder, and pelvic girdles lasting 30 min
- discomfort is bilateral, worse with movement, and usually interferes with ADLs
- shoulder pain is presenting sign, hips and neck, usually radiates distally
- systemic signs (seen in 1/3 of pts): fever, malaise/fatigue, anorexia, weight loss
- distal manifestations (seen is 1/2 pts): nonerosive, self-limiting asymmetric* peripheral arthritis (knee, wrist), carpal tunnel syndrome, distal extremity swelling and pitting edema over dorsum of hands and wrists, ankles and feet
Polymyalgia rheumatica
- labs
- tx
Labs
- ESR greater than 40 mm/hr
- CRP (may be more sensitive)
- anemia of chronic disease
- mildly abnormal LFTs
Tx
- corticosteroids are DOC (dont forget to taper)
- trial of NSAIDs for 2-4 weeks if mild
- should see a complete or nearly complete resolution of sx in a few days, but relapses do occur
- tx for 1-2 years is often required
Giant Cell Arteritis
- what is this
- MC age and gender
- cause
- Presentation and sx
What
-chronic vasculitis of medium and large vessels
MC in women around 70-80
Cause
- genetic and environmental factors, no evidence of autoantibodies
- cellular immune response involving T cells, APCs, mfgs
Presentation
- onset is usually gradual, but may be abrupt
- HA (MC sx)
- syndrome of systemic inflammation: fever, malaise, weight loss, anorexia
- jaw claudication
- transient visual sx
- fixed visual sx
- CNS abnormalities
- swallowing claudication/dysphagia
- tongue claudication
- decreased temporal artery pulsations
- artery tenderness, erythema, or swelling
Giant Cell Arteritis
- complications
- lab findings
- Dx
- Tx
Complications
- blindness
- aortic aneurysms
- stroke
Lab findings
- ESR greater than 50 (normal ESR does not rule OUT GCA)
- anemia of chronic disease
- elevated LFTs
Dx
- Bx!!!! (DO NOT DELAY TX FOR BX)
- MRI/MRA may be used to dx large vessel GCA
Tx
- ***glucocorticoids are the established tx (dont forget to taper)
- IV methylprednisolone of vision loss present
- anti-platelet agents reduce ischemic events (low dose aspirin recommended)
Fibromyalgia Syndrome (FMS)
- What is this?
- cause
- sx
What
- a clinical syndrome characterized by widespread muscular pain (usually chronic), fatigue and muscle tenderness. (everything hurts)
- NOT an inflammatory condition
Cause
- abnormal sensory processing in the central nervous system
- unknown cause, some pts have abnormally high levels of substance P (Substance P is important in transmission and amplification of pain signals to and from brain)
- familial tendency suggests genetic role
Sx
- extreme sensitivity to pain and other unpleasant sensations
- poor sleep (almost always)
- HA
- IBS
- cognitive and memory problems
- numbness and tingling in fingers and toes
- irritable bladder
- temporalmadibular joint disorder
- restless leg syndrome
- dry eyes and dry mouth
- morning stiffness
- anxiety and depression
- -sx including pain may wax and wane over time
FMS
- MC in who
- dx
- commonly occurs with what other dx?
MC in middle aged women
Dx -xrays, blood tests, specialized scans, bx are all NORMAL -A plus (B or C) and explained by no other condition=FMS A. generalized, chronic pain (more than 3 months) affecting the axial, plus upper and lower segments, plus left and right side of the body B. 11 of 18 reproducible tender points C. at least four of the following: -generalized fatigue -HA -Sleep disturbance -neuropsychiatric complaints -numbness, tingling sensations -IBS
Commonly occurs with a mood disorder (depression)
FMS
-Tx
Tx
- referral to sleep clinic, psychiatry, etc.
- education
- assess stressors, level of fitness…
- medication trial (antidepressants, anticonvulsants)
- CBT, counseling
- physical rehab, therapeutic massage, myofascial release therapy, acupuncture, support groups
- no definitive treatment cure :( (but it can be managed)
- amitriptyline (TCA)
- other TCA, SSRI, SNRI, anti seizure meds
- Lyrica (anticonvulsant)
- jdont give opioids
*You’re going to be doing this with someone above your paygrade
