Rhematology Flashcards
Rheumatology
- Fibromyalgia
- Gout/psuedogout
- Juvenile Rheumatic arthritis
- Osteoporosis
- Polyarteritis nodosa
- Polymyalgia rheumatica
- Polymyositis & dermatomyositis
- Reactive arthritis
- Rheumatoid arthritis
- Sjogren Syndrome
- Systemic Sclerosis (scleroderma)
- Systemic Lupus Erythematous (SLE)
Fibromyalgia
(Female with normal labs & shows 3 months of widespread MSK pain —> give TCA medication)
- chronic disorder of widespread Musculoskeletal pain + somatic symptoms ( fatigue, cognitive disturbance, psychiatric symptoms) —> for few months & other identifiable cause
- women 20-55 years
PE:
- 11 OF 18 defined tender points
Diagnosis:
- clinical diagnosis ( normal lab tests)
Treatment:
- conservative ( exercise program with aerobic conditioning )
- TCA (amitriptyline) or duloxetine
Gout
(Monosodium urate crystal deposition)
( sharp needle shape crystal deposit in the joint lead to severe pain, swelling, effusion)
- condition of hyperuricemia & deposition of (monosodium urate crystals) causing attacks of acute inflammatory arthritis.
Risk factors:
1. Male sex (older men)
2. Diet (purine rich food—> seafood, red meat, alcohol)
—> purine break down into uric acid
3. Medication (PLATE)
- pyrazinamide (for TB)
- ethambutol (For TB)
- loop diuretic ( furosemide)
- Thiazide (hydrochlorothiazide)
- aspirin (low dose)
Symptoms:
1. Severe pain, redness, warmth, swelling
2. Monoarthritis (single joint)
3. Lower-extremity involvement ( Podagra = gout of big toe)
Diagnosis:
1. Arthrocentesis ( negatively birefringent needle shaped crystal = monosodium urate crystal, yellow when parallel)
- X-ray shows sclerotic over-hanged edges (erosive appearance + punched out)
Treatment:
1. Acute —>
- NSAIDs, Steroid, colchicine
- Chronic —>
- allopurinol or feburostat
- probenecid
- colchicine
Note:
- Avoid NSAIDs, if Bad kidney, bad heart, bad GI tract ( renal insufficiency, active duodenal or gastric ulcer, Cardiovascular disease)
- avoid steroid, if diabetic, active infection, post-operation (impaired wound healing) —> can be used in CKD
- Colchicine can be used for acute or chronic treatment, can lead to diarrhea
- allopurinol —> (can lead to SJS, < 10% )
- allopurinol & febuxostat —> are xanthine oxidase inhibitors
- probenecid —> promote renal clearance uric acid secretion (make you pee uric acid)
Pseudogout
( calcium pyrophosphate dihydrate crystal deposition disease, mostly knee, positively birefringent, chonedrocalcinosis, Intraarticular GC injection )
- deposition of calcium pyrophosphate dihydrate in the joint & soft tissue
- knee most common joint affected
Diagnosis:
- arthrocentesis ( positively birefringent calcium pyrophosphate crystal, rod/rhomboid shape, blue when parallel)
- x-ray shows chondrocalcinosis (like a white-line in joint space)
Treatment:
- similar to acute gout treatment ( NSAIDs, steroid, colchicine) but emphasis on first line of Intraarticular Glucocorticoid injection ( when less joints are involved, 1-2 joint
Juvenile idiopathic arthritis
( polyarticular subtype = at least 5 or more joints)
(Oliguarticular subtype = less than 5 joints)
- chronic pediatric inflammatory arthritis + onset before 16 years of age + presence of arthritis for at least 6 weeks
- peak incident between age of 1-5 years (< 16 years old)
—> if after is known as adult onset
Symptoms:
1. Fever (Quotidian pattern) ( persistence for 2 weeks, then everyday spike a fever than return to normal)
2. Arthritis ( at least for 6 weeks)
3. Rash ( salmon-colored rash)
4. Uveitis (only seen with oligo/polyarticular subtypes, & ANA )
Treatment:
1. NSAIDS
Osteoporosis
- metabolic bone disease characterized by deterioration of bone tissue leading to low bone mass & increased skeletal fragility
Risk factors:
1. Advanced age
2. Females
3. Glucocorticoid therapy (long term) ( decrease Ca absorption from GI)
4. Cigarette, alcohol
5. Physical inactivity
6. Celiac, Cushing, diabetes
Symptoms:
1. Silent disease ( no obvious symptoms)
2. Vertebral compression fracture (painless) —> assess of loss of height & kyphosis
3. Hip fracture
4. Distal radius fracture
Diagnosis:
1. DEXA scan (evaluation of bone density via T-score)
1. (-2.5 or less) —> osteoporosis
2. (-2.5 to -1) —> osteopenia
- Fragility fracture test —> fracture occurs with minor trauma ( as fall from standing height)
Treatment:
1. Lifestyle + vitamin D/calcium supplement
2. Bisphosphonate (alendronate, risedronate)
—> (ends with -dronate)
Note:
- bisphosphonate inhibits osteoclastic bone resorption
- adverse drug rxn —>
- lead to pill-induced esophagitis (remain upright at least 30 min, take with 6-8 ounces of water)
- Osteonecrosis of the jaw & atypical femur fracture
Polyarthritis nodusa (PAN)
( screw up arteries & blood supply to organ, does not involve lung or ANCA )
- systemic vasculitis characterized by necrotizing inflammatory lesions that primarily affect medium-sides arteries with occasional involvement of small arteries.
Etiology:
1. Hepatitis B & C
Symptoms:
1. renal disease ( HTN)
2. Dermatology ( purpura, livedo reticularis/ blue-purple discoloration of skin/due to vessel ischemia, ulcers, pigmentation)
3. Neurologic (mononeuropathy multiplex )
4. Tendency to spare the lungs (opposite to granulomatosis with polyangitis —> ANCA positive)
Diagnosis:
- ANCA negative
- CT angiography —> see a lot of aneurysm due to fibrotic changes (weaken vessels)
Treatment:
- glucocorticoid
Polymyalgia Rheumatica (PMR)
( normal muscle strength, involve joint, bursa, tendon)
- chronic inflammatory condition of unknown etiology leading to pain & stiffness in the neck, shoulder, hip
- > 50 years old women (70-80 years)
- associated with Giant Cell Arteritis & aortic aneurysm
—> headache, jaw claudication, transient vision loss
—> lead to blindness if not treated
Symptoms:
1. Aching & stiffness involving the neck, bilateral shoulder, hip, torso —> worse in the morning, or any period of inactivity
Diagnosis:
1. Increase ESR & CPR
Treatment:
1. Low-dose Glucocorticoid ( response well to treatment !!!!)
Laboratory findings
- Rheumatoid factor & anti- CCP —> Rheumatoid arthritis
- Creatinine Kinase (muscle enzyme) —> polymyositis
- ESR & CRP (increase) —> polymyalgia rheumatica
- Anti-Cardiolipin antibody—> in anti-phospholipid syndrome ( arterial/venous thromboembolism + miscarriage )
- Anti-mitochondrial antibody —> primary biliary cholangitis (PBC) ( fatigue + pruritus + RUQ pain + high ALP)
- Anti-neutrophil cytoplasmic antibody (ANCA)—> granulomatosis with polyangiitis
- Anti-smooth muscle antibody —> autoimmune hepatitis ( asymptomatic elevation of aminotransferase to hepatosplenomegaly +cirrhosis + liver failure)
Polymyositis & dermatomyositis
(Idiopathic inflammatory myopathy)
(dermatomyositis is polymyositis with rash)
- common in female
Symptoms:
1. Muscle weakness (proximal, progressive, symmetric)
—> difficulty climbing stairs, raising arms above head..
- Dermatomyositis:
- Gottron papules (psoriasis in dorsum of hand)
- Heliotrope rash (rash on around eyes)
- Photodistributed poikiloderma (shawl sign or V-sign)
(pigmentation in sun exposed area) (upper back/neck/chest) - Can lead to adenocarcinoma (malignancy)
Diagnosis:
1. Elevated muscle enzyme ( Creatine kinase & aldolase)
2. Myositis-specific antibodies ( anti-Jo-1, & anti-Mi 2)
—> anti-Mi-2 is highly specific for dermatomyositis
3. Biopsy to confirm if needed
Treatment:
- glucocorticoid (prednisolone) ( 9-12 months)
- glucocorticoid-sparing agent (methotrexate) to minimize the side effect of glucocorticoid
Reactive arthritis
- starts after infection of GI, or genital urinary
1. GI: salmonella, shigella, Campylobacter, C.diff
2. Genital: chlamydia
Symptoms: (can’t PEE, can’t SEE, can’t CLIMB the tree)
1. Peripheral arthritis (asymmetric, oligarthritis of lower extremities/knee)
2. Ocular symptoms (conjunctivitis, uveitis)
3. Genitourinary symptoms (urethritis)
Diagnosis:
- clinical diagnosis
- arterocentesis to rule out septic arthritis
- HLA-B27
Treatment:
- Treat underlying cause infection
- NSAIDs ( for arthritis)
Rheumatoid arthritis (RA)
(Cytokines allow pannus to grow bigger in the synovial space & break stuff inside joint)
- chronic, systemic, inflammatory, autoimmune disease of unknown etiology that can lead to the destruction & deformity of joint due to erosion of cartilage & bone
- female
Symptoms ( 7 S)
1. Symmetric (joint involvement)
2. Swollen (tender & warm)
3. Soft (boggy joint)
4. Small (joint of hand, feet, wrist)
5. Spares the DIP ( the last knuckle) (osteoarthritis involves DIP)
6. Sixty min of more ( morning stiffness for extended period of time) (osteoarthritis morning stiffness lasts for minutes)
7. Swan neck deformity (DIP flex, PIP hyperextend)
Diagnosis:
1. Positive Rheumatoid factor (not specific)
2. Positive Anti-CCP (specific for RA) (anti-cirullinated peptide)
Treatment:
1. NSAIDs ( treat inflammation & pain)
2. Methotrexate (DMARDS) ( reduce the irreversible joint damage) —>
Note:
1. Rheumatoid factor can also be positive in hepatitis C & SLE
2. Seronegative RA (when anti-CCP & rheumatoid factor are negative) —> FAVORABLE PROGNOSIS
- Methotrexate side effect:
- hepatotoxicity: measure LFT before initiating drug
- oral ulceration:
- macrocytic anemia: due to folate depletion & impaired DNA synthesis - better combine folic acid with methotrexate for better use
Sjogren syndrome
(Anti-Ro & anti-La) ( dry eyes, dry mouth & parotid swelling)
- systemic autoimmune disease characterized by lymphocytes (T/B cells) infiltration of exocrine glands (lacrimal & salivary).
Symptoms:
1. Dry eyes
2. Dry mouth
3. Parotid gland swelling
Diagnosis:
1. Positive ANA
2. Anti-Ro (SSA) & anti- La (SSB)
3. Schirmer test (put paper in eye and see how much it gets wet)
4. Biopsy ( if needed)
Treatment:
1. Muscurinic agonist (pilocarpine, cevimeline)
Avoid use of atropine & atrovin because they cause dryness
Systemic sclerosis (scleroderma)
(Too much collagen leads to fibrosis)
- systemic connective tissue disease, where excessive collagen deposition leads to progressive fibrosis of the skin & internal organs. (Reduce blood flow & result in ischemic damage)
- female
Types:
1. Limited cutaneous systemic sclerosis ( CREST Syndrome)
- distal limbs & spares the trunk
- calcinosis cutis + Raynaud phenomena + esophageal dysmotility + sclerodactyly (claw hand) + telangiectasia
- Diffused cutaneous systemic sclerosis
- proximal limbs, trunk & organ involvement (heart, lung, kidney)
Diagnosis:
1. Anti- Centromere antibody ( associated with limited disease)
2. Anti-topoisomerase 1 (anti-SCL-70) antibody ( associated with diffused disease)
Treatment:
1. Treat symptoms of Crest signs
2. Treat sclerodermal renal crisis ( acute HTN + AKI) with ACE-i (captopril)
3. Treat Raynaud phenomenon with CCB (amlodipine)
Systemic lupus erythematosis (SLE)
( treat with hydroxychloroquine)
- multi-systemic immune-mediated disorder characterized by autoantibodies to Nuclear & Cytoplasmic antigens.
- type 3 hypersensitivity reaction
- common in younger female
- African American female
Symptoms: (MD CHART)
1. Systemic symptoms: Fever, fatigue, weight loss
2. Malar rash ( spares nasolabial fold) (butterfly rash)
3. Symptoms occur with Photosensitivity ( after sun exposure)
4. Discoid lesion ( round erythematous patches)
5. Arthritis (similar to RA in erosion, but morning stiffness is 10-15 min —> similar to osteoarthritis in length)
6. Cardiovascular
7. Renal
8. Thromboembolic disease ( with anti-phospholipid )
9. Hematologic abnormality ( anemia, thrombocytopenia, leukopenia)
10. Low- complement protein
Diagnosis:
1. Screen first with ANA (anti-nuclear antibodies)
2. Anti-dsDNA
3. Anti-smith antibody
4. Anti-phospholipid antibody (high risk for arterial/venous thrombosis & miscarriages)
Treatment:
1. Hydroxychloroquine —> perform eye examination periodically (retinal toxicity with prolonged use )
Felty syndrome
- rheumatoid arthritis
- neutropenia ( low wbc) ( risk of increase infection)
- splenomegaly
—> anti-CCP & rherumatoid arthritis are positive
—> increase ESR
Diffuse proliferative glomerulonephritis seen in SLE patient
- treat with:
1. Cyclophosphamide & stop hydroxychloroquine
—> this new regimen increases the risk for developing bladder carcinoma & hemorrhagic cystitis
Drug adverse effect
- Bisphosphonate (-dronate) —> esophagitis
- Hydroxychloroquine —> retinal toxicity
- Cyclophosphamide —> bladder carcinoma & hemorrhagic cystitis
Cryoglobulinemia
(Immunoglobulin that precipitate at < 37 degree)
Mixed cryoglobulinemia syndrome (MCS)
—> Small vessel vasculitis
—> causes:
1. Palpable purpura
2. Glomerulonephritis (hematuria & proteinuria)
3. Arthralgia ( joint pain)
4. Peripheral neuropathy
—> laboratory:
1. Cryoglobulin
2. Rheumatoid factor
3. Low complement protein
4. Positive ANA
—> chronic hepatitis C is the most common cause
—> associated disease: SLE, sjogren
Drug-induced SLE
- associated with: anti-histone
- drugs:
1. Hydralazine ( treat HTN)
2. procainamide (Treat irregular heart rhythm)
3. Isoniazid ( treat TB)
—> lead to new onset of fever, arthralgia, & serositis (inflammation of serous surrounding organ) after initiation of causative medication
Takayasu arteritis
(Large-artery vasculitis)
- Female + asian + age (10-40)
- Symptoms:
- constitutional symptoms ( fatigue, fever, weight loss)
- arterioocclusion (claudication, ulcer) in upper extremity
- arthralgia/myalgia - Signs:
- blood pressure differences (in both arms)
- absent pulses
- arterial bruits
Diagnosis:
- increase ESR & CRP
- x-ray: widen mediastinum
- CT angiography: wall-thickening
Treatment:
1. Glucocorticoid
Psoriatic arthritis
- symptoms:
1. Involves DIP
2. Nail involvement
3. Deformity
4. Dactylitis ( sausage digit )
5. Morning stiffness
6. History of psoriasis - treatment: NSAIDs, methotrexate, & anti-tumor necrosis factor agent
