Rhematology

Question 1

What drugs can induce SLE?

Answer 1

Procainamide (anti arrhythmic)
hydralazine (Direct vasodilation of arterioles)
isoniazid (bacterial cidial against TB)

Question 2

Systemic Lupus Erythematous

Clinical manifestations

Answer 2

Joint pain 90%
fever
Rash
Serositis: pericarditis, pleuritis

Question 3

Systemic Lupus Erythematous

systemic signs

Answer 3

CNS involvement
cardiovascular
glomerulonephritis
retinitis
oral ulcers

Question 4

Systemic Lupus Erythematous

Best tests

Answer 4

ANA is best initial test (sensitive not specific)

Anti double stranded DNA and Anti-smith Ab

Question 5

Sjrogen’s syndrome

Etiology and organs involved

Answer 5

Autoimmune d/o attacking exocrine glands: salivary glands, lacrimal glands and parotid enlargement

Question 6

Sjrogen’s syndrome

primary symptoms

Answer 6

Dry eyes and dry mouth
Can be associated with other autoimmune conditions:
- SLE and RA etc.

Question 7

Sjrogen’s syndrome

diagnosis

Answer 7

Anti-SSA (Ro) autoantibodies: anti-sjogren syndrome related antigen A
AntiSS-B (La): Anti-Sjogren syndrome antigen B
Rheumatoid factor
Shirmer test

Question 8

Sjrogen’s syndrome

Tx

Answer 8

Pilocarpine: cholinergic drug that increases lacrimation and salviation
Cevimeline: stimulates muscarinic cholinergic receptors

Question 9

Fibromyalgia symptoms

Answer 9

fatigue, muscle tenderness, headaches, poor sleep and memory, increased pain perception

Question 10

Fibromyalgia treatment

Answer 10

TCA’s, cymbalta, SSRI’s, exercise

Pregabalin only drug FDA approved

Question 11

Polymyalgia Rheumatica

Etiology

Answer 11

Etiology unknown
Closely liked to giant cell arteritis
Prevalence in Northern european heritage suggests genetic component

Systemic macrophage and T-cell activation

Question 12

Polymyalgia Rheumatica

s/s

Answer 12

Pain and stiffness of the shoulder and hip girdle

• May have difficulty rising from a chair or raising arms above shoulder.
• Gelling: Stiffness after periods of rest
• Morning stiffness
• No severe muscle weakness

Question 13

Polymyalgia Rheumatica

Dx and Tx

Answer 13

Dx: ESR, normochronic normoctyic anemia

Tx: Prednisone 10 - 20mg/day
- Lack of response suggests alternative diagnosis

Question 14

Polymyositis definition and

Etiology

Answer 14

Inflammation of many muscles

-Evidence currently points toward T-cell mediated cytotoxic process directed against unidentified muscle antigens.

Question 15

Polymyositis s/s

Answer 15

• symmetrical, proximal muscle weakness with insidious onset
• Muscles usually painless
• Dysphagia (30%)
• Difficulty kneeling, climbing or descending stairs
• Weakness in neck extensors

Question 16

Polymyositis workup

Answer 16

• CBC: may show leukocytosis and thrombocytosis
• ESR or CRP elevated 50% time
• Elevated muscle enzymes levels
• Positive rheumatoid factor: 50% time
• Anti-SRP Ab (signal recognition particle Ab): specific for PM

Question 17

Dermatomyositis definition and etiology

Answer 17

Idiopathic inflammatory myopathy with characteristic cutaneous findings.

Eti: unknown
implicated: genetic, immunologic, infectious, environmental

Question 18

Dermatomyositis skin manifestations

Answer 18

Skin disease is often initial manifestation

• Heliotrope rash: purple eyelids which resemble heliotrope flower.
• Gottron’s papules: raised violaceous scaly eruptions on the knuckles
• malar erythema
• poikiloderma in photosensitive distribution

Question 19

Dermatomyositis work up

Answer 19

Labs: elevated muscle enzymes

• autoantibodies: ANA
• elevated urine myoglobin

Question 20

Dermatomyositis non derm s/s

Answer 20

Usually: history of insidious muscle weakness

• Difficulty climbing stairs, getting up from chair
• Proximal muscle involvement

Question 21

Treatment of dermatomyositis and polymyositis

Answer 21

Systemic glucocorticoids: prednisone tapering doses for a years
2nd line alternatives: azathioprine or methotrexate

Question 22

Rheumatoid arthritis
Definition
Etiology

Answer 22

Chronic inflammatory disease with persistent symmetric polyarthritis and bone erosion.
- T-cell mediated

Question 23

Rheumatoid arthritis

clinical manifestations

Answer 23

Prodrome: systemic sx: fevers, fatigue, wt loss

• Small joint stiffness: MCP, wrist, PIP, knee, MTP, shoulder, ankle
• > 30 minutes after initiating movement, improves later in the day.
• Symmetric arthritis: swollen, tender, erythematous, boggy joints
• Boutonniere deformity, swan neck deformity

Question 24

Rheumatoid arthritis

workup

Answer 24

rheumatoid factor: best initial test, sensitive not specific
Anti-citrullinated peptide antibodies: most specific
- Arthritis: 3 joints, morning stiffness, disease duration >6 weeks.

Question 25

Rheumatoid arthritis

management

Answer 25

DMARDs: methotrexate, hydroxychloroquine, leflunamide, minocycline, azathioprine
NSAIDs for pain, low dose corticosteroids