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Summer FDTN Exam 4 > Rheum 1 > Flashcards

Rheum 1 Flashcards

1
Q

What is gout

A

metabolic disease with altered purine metabolism causing sodium urate crystal deposits in synovial fluid
Commonly familial
M >30
BUT- chronic uricemia does not mean you will get gout!

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2
Q

RF for gout are

A 
Male 
age >30 
genetics
obesity 
alcohol 
high purine diet 
high fructose/sucrose diet
HTN
CKD
Thiazides/loop diuretics
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3
Q

Etiology of gout is

A

Abnormal deposits of urate cause recurring acute arthritis attacks

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4
Q

What are the types of gout

A

Primary: occurs 2/2 genetic alterations in how kidneys process urate (under excreter)
Secondary: occurs 2/2 acquired causes of hyperuricemia (on meds, myeloproliferative Dz, hypothyroidism, alcohol abuse)

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5
Q

How does acute gout present

A

Acute onset intense pain, commonly at nigh t
Swollen, tender joint w/ red, warm overlying skin
Involves first MTP (MC), feet, ankles, and knees

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6
Q

What is Podagra

A

Gout of the first MTP

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7
Q

How does chronic gout present

A

Tophaceous gout after 10 or more years
Urate deposits (tophi) in subQ tissue, bone, cartilage, and joints
Surrounded by granulomatous inflammation
Can lead to deforming polyarthritis

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8
Q

How do you diagnose gout

A

Serum uric acid >6.8mg is supportive (- does not r/o gout)
Synovial fluid showing monosodium urate crystals (diagnostic)
Imaging

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9
Q

What do monosodium urate crystals look like

A

needle-like
rod shaped
negatively birefringement crystals

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10
Q

How can you tell the difference between gout and septic arthritis

A

Septic arthritis has way more WBC than gout

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11
Q

What are imaging findings in gout

A

New: no findings
Established: small, punched out erosions w/ overhanging edges

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12
Q

How do you treat an acute gout attack

A

Elevate, rest*
Decrease purine and alcohol intake (not suddenly)
Indomethacin 50mg (5-10d, until Sx gone)- or Naproxen 500
Colchicine (if attack w/in 24-36 hours)
Oral/IV corticosteroids, or injection (if 100% positive it is NOT a septic joint)

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13
Q

How do you prophylactically treat gout

A

Lose weight, avoid alcohol, restrict purine intake
Avoid thiazides, loop diuretics, Niacin, and low dose aspirin
Colchicine (prevent further attacks by lowering urate)
Xanthine oxidase inhibitors (Allopurinon)
Uricosuric agents (Probenecid)- increase uric acid excretion by blocking kidney reabsorption

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14
Q

Side effects of Xanthine oxidase inhibitors

A

Precipitate acute attack, rash leading to TEN

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15
Q

Dietary modifications to treat gout include

A

limit all meats (organ meat and seafood)
Cut back on fat
Limit alcohol, esp beer
Limit high fructose corn syrup
Drink plenty of fluids (8-16 cups of water)

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16
Q

High purine foods are

A 
all meats 
meat extracts 
yeast 
beer
beans
peas 
lentils, oatmeal, spinach, asparagus, cauliflower, mushrooms 
-AKA foods with many nuclei and growing
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17
Q

Complications of gout include

A

Nephrolithiasis

Chronic urate nephropathy

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18
Q

What is pseudogout

A

Calcium pyrophosphate dihydrate disease affecting peripheral joints with deposits of calcium pyrophosphate
Acute attacks mimic gout
Worse with ate (>60)
MC in knee, wrist, elbow

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19
Q

What are chondrocalcinosis

A

Calcium pyrophosphate deposits in cartilage

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20
Q

How does pseudogout present

A

Recurrent, abrupt onset of joint pain

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21
Q

How do you diagnose pseudogout

A

X-Ray shows fine, linear densities in articular tissues

Joint aspiration shows calcium pyrophosphate crystals- rhomboid shape crystals w/ + birefringement with light microscopy

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22
Q

How do you treat pseudogout

A

NSAIDs for acute attacks
Colchicine w/ prophylaxis
Intra-articular steroid injection

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23
Q

What is OA

A

MC joint disease, related to age
Occurs in weight bearing joints of knee (65+ y/o)
<50: M>W
>50: W>M

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24
Q

RF for OA are

A 
Age 
Women 
Excess weight 
Contact sports 
Bending or carrying occupation 
Injury 
Developmental deformities 
Low vitamin D/calcium intake
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25
Q

What is the pathophys of OA

A 
Progressive cartilage degeneration 
Reactive hypertrophy of bone 
Loss of articular bone space, joint destruction 
Osteophytes, Herbeden and Bouchard nodes
Sclerosis of subchondral bone 
(minimal inflammation)
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26
Q

How does OA present

A

Insidious onset joint pain, worse w/ activity, better with rest
<30 min morning stiffness
Decreased ROM
Crepitus
Varus knees
Fingers, wrists, hips, knees, and spine affected

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27
Q

How can you tell between OA and RA

A

OA there are no systemic symptoms!

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28
Q

How do you diagnose OA

A

*X-Ray- Asymmetric narrowing of joint space, osteophytes, thick subchondral bone, bony cysts
Normal labs, synovial fluid non-inflammatory

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29
Q

How do you treat OA non-pharm

A 
Weight loss 
aquatic, cardio or resistance exercise
heat and cold 
PT
OT
bracing
canes
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30
Q

How do you treat OA pharm

A

APAP (good for old people at risk for ADE of NSAIDs
Oral NSAIDs
Topical NSAIDs (diclofenac)
Topical capsaicin (hand)
Intra-articular steroid injections (4xyr)
Intra-articular sodium hyaluronate injection (knee)

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31
Q

How do you treat OA surgically

A

Arthroscopy (go in and clean joint)

joint replacement

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32
Q

What is RA

A

Chronic, progressive inflammatory disease with synovitis of multiple joints
F>M
Peak 40-50 women, 60-80 men

33
Q

Untreated RA causes

A

joint destruction, disability, and shorter life expectancy

So… treat EARLY and AGGRESSIVELY

34
Q

What is the etiology of RA

A

Unknown! maybe due to multiple genetic susceptibilities

35
Q

What is the pathophys of RA

A

Chronic synovitis causing erosion or cartilage, bone, ligaments, and tendons

36
Q

How does RA present

A

> 30 min morning stiffness
Insidious onset symmetric swelling of multiple joints w/ ttp and pain
Symmetric polyarthritis of small joints or hands and feet (PIP, MCP, wristsm knees, ankles, MTP)
Synovial cysts
tendon rupture
entrapment

37
Q

RA spares

A

The spine and SI joints

does not spare the neck

38
Q

Extra-articular manifestations of RA are

A 
SubQ nodules 
Ocular Sx 
Mouth dryness 
interstitial lung dz 
pleural effusion 
pericarditis 
vasculitis
39
Q

Common RA complaints include

A 
Pain turning door knob- 
opening jars-
buttoning shirts-
in ball of foot
Widening of forefoot 
neck pain and stiffness 
constitutional Sx
40
Q

How do you diagnose RA

A

**X-Rays (most specific)
**Anti-CP antibodies (most specific blood test)- cyclic citrullinated peptides
Rheumatoid factor (- in many)
ANA +
ESR, CRP elevated
Anemia
inflamed joint fluid
+/- septic arthritis

41
Q

RA x-rays show

A

early: articular demineralization and soft tissue swelling
joint erosions
joint space narrowing

42
Q

2010 RA diagnostic criteria includes

A

and type of joints involved
Serology (RF or anti-CCP)
Acute phase reactants (ESR/CRP)
Sx duration (MIN 6 wks)

43
Q

RA treatment goals are

A

Reduce inflammation, pain
Preserve function
Prevent deformity

44
Q

How do you treat RA

A
  1. DMARDs as soon as Dx is confirmed; they take a while to work so in the meantime, also use
  2. NSAIDs, PO low dose Prednisone, Intra-articular corticosteroid (max 4xyr)
45
Q

What are the conventional DMARDs

A

Methotrexate
Sulfasalazine
Leflunomide
Hydroxychloroquin

46
Q

What are the biologic DMARDs

A
  • Tofacitinib (JAK inhibitor)
  • TNF-a inhibitor: Eternacept, Infliximab, Adalimumab, Golimumab, Certolizumab
  • Anakinra (IL-1 inhibitor)
  • Tocilizumab (IL-6 inhibitor)
  • Abatacept (T cell costimulation blocker)
  • Rituximab (anti-CD20 B cell depleting MAB)
47
Q

When choosing a DMARD, consider

A 
CBC, Cr, LFT, ESR, CRP 
Hep B/C screening 
Opthalmologic screening 
Latent TB test 
CXR
48
Q

Are NSAIDs magic

A

No- they can provide Sx relief, but do NOT prevent erosions or alter disease progression
they are NOT dmards and should not be used alone! only WITH dmards

49
Q

Conventional RA treatment (1st line) is

A

Methotrexate!
Takes 2-6 weeks
Suppresses bone marrow= low WBC and platelets
Teratogenic

50
Q

ADE of methotrexate are

A

GI upset
Stomatitis
Hepatotoxic w/ cumulative dosing

51
Q

Second line RA Tx used with Methotrexate or alone if Metho doesn’t work is

A

Sulfasalazine (avoid if ASA sensitivity)

Leflunomide (carcinogen, teratogen)

52
Q

ADE of second line RA drugs are

A

Sulfasalazine: Neutropenia, thrombocytopenia, hemolysis if w/ G6PD deficiency
Leflunomide: GI upset, rash, alopecia, hepatotoxic, weight loss

53
Q

What antimalarial is used to Tx RA

A

Hydroxychloroquin- MC with Sulfasalazine or Methotrexate

NEED yearly eye exams!

54
Q

ADE of Hydroxychloroquin are

A

Pigmentary retinitis- so get YEARLY eye exams!

55
Q

Are biologics good drugs

A 
Well tolerated usually 
Increased risk of infection 
NEED to screen for TB before giving 
\+/- causes malignancy 
CAUTION with HF 
costs 10K/yr
56
Q

What is the prognosis of RA (after years of Dz)

A

Chronic systemic inflammation
Ulnar deviation of fingers
Boutonniere deformity (hyperextend dip, flex pip
Swan neck deformity (flex dip, extend pip)
Valgus knees
Volar sublux of MCP
Mortality associated w/ RA 2/2 CVD

57
Q

What are subtypes of systemic juvenile idiopathic arthritis

A 
Systemic 
Polyarthritis 
Oligoarthritis 
Enthesitis 
Psoriatic 
-they are all autoimmune
58
Q

How does sJIA present

A 
Fever 
Arthritis (mono, oligo, or poly) 
Rash 
LAD
ANA &amp; RF rarely see
59
Q

How do you diagnose sJIA

A 
Diagnosis of exclusion! 
*Intermittent daily fevers and arthritis 
Fever 2+ weeks 
Arthritis 6+ weeks 
Onset prior to 16 y/o
60
Q

How do you manage sJIA

A

Difficult remission.. Send to peds rheumatology!

PT, OT, Dietician, support groups

61
Q

What are seronegative spondyloarthropathies

A

Ankylosing spondylitis, psoriatic arthritis, reactive arthritis
M>W
<40
inflammatory arthritis of spine and SI joints
Asymmetric
No antibodies in serum
Associated with HLA-B27 gene

62
Q

What is ankylosing spondylitis

A

Chronic inflammatory disease of joints of axial skeleton

M>W, teens-late 20’s

63
Q

How does ankylosing spondylitis present

A

Gradual, intermittent back pain
worse in morning (after rest)
better with activity
radiates to buttocks

64
Q

How does ankylosing spondylitis present

A 
Progressive stiffening of spine 
Sx start at low back, move towards head 
Flattening of lumbar lordosis 
Exaggeration of thoracic kyphosis 
Decreased chest expansion 
Total spine fusion 
Peripheral joint arthritis 
Swelling of achilles tendon and plantar fasciitis (enthesopathy) 
Anterior uveitis
Cardiac,pulmonary, GI Sx
65
Q

How do yuo diagnose ankylosing spondylitis

A 
Elevated ESR* 
Negatie RF and anti-CCP 
Mild anemia on CBC 
HLA B27 + (92% of white, 50% of black) 
Imaging
66
Q

What are imaging results of ankylosing spondylitis

A

Early: SI joint erosion, sclerosis (b/l and symmetric)

Bamboo spine: vertebral bodies fuse together

67
Q

How do you treat ankylosing spondylitis

A

1** NSAIDs
TNF inhibitors
Corticosteroids (can cause steopenia, not great)
Sulfasalazine
Surgery: Fracture stabilization or joint replacement
PT
Swimming

68
Q

How does psoriatic arthritis present

A 
Skin psoriasis before arthritis (usually) 
Nail pitting 
Onycholysis 
Asymmetric 
SI joint involvement 
Sausage digits
69
Q

How do you diagnose Psoriatic arthritis

A

Elevated ESR
RF negative
Imaging (helps differentiate it from others!)

70
Q

What imaging findings are present with psoriatic arthritis

A

Erosion and destruction of bone
Osteolysis
Pencil in a cup deformity
Asymmetric sacroilitis

71
Q

How do you treat psoriatic arthritis

A

1* NSAIDs
2: Methotrexate (if NSAIDs don’t work)
PDE4 inhibitor (not if erosive dz)
Biologics: TNF-a inhibitors, MAB

72
Q

What Tx do you avoid in psoriatic arthritis

A

Corticosteroids

They are less effective, and tapering can trigger a flare

73
Q

What is Reactuve arthritis (Reiter syndrome)

A

MC in young men
Usually 1-4 weeks after bacterial GU or GI infection (diarrhea, Chlamydia t, Salmonella, Shigella)
HLA B27 +

74
Q

How does Reactive arthritis present

A

Asymmetric oligoarthritis of LE (knee, ankle)
Fever, weight loss
Extra-articular: Urethritis, conjunctivitis, uveitis, balanitis, stomatitis, Keratoderms blennorrhagicum**, cardiac Sx

75
Q

How do you diagnose reactive arthritis

A 
Synovial fluid is sterile, no cultures!
No specific XR findings 
Stool cultures (if diarrhea) 
Chlamydia testing 
\+/-: CBC, ESR/CRP, renal/liver tests, UA, HLA B27, RF, anti-CCP
76
Q

How do you treat reactive arthritis

A

NSAIDs
Antibiotics for STI are somewhat prophylactic
Sulfasalazine, Methotrexate, TNF inhibitors

77
Q

What is the prognosis of reactive arthritis

A

most SF signs of reactive arthritis clear in days-weeks

Arthritis can last for months

78
Q

Think of this triad for Reiters/reactive arthritis***

A

Can’t SEE, can’t PEE, can’t CLIMB A TREE
Uveitis/conjunctivitis
Urethritis
Arthritis

Summer FDTN Exam 4 (14 decks)

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