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UWORLD ABIM > Rheum > Flashcards

Rheum Flashcards

1
Q

Tetrad of purpura, abdominal pain, arthritis, glomerulonephritis

A

Henoch-Schonlein Purpura (HSP)

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2
Q

Immune mediated vasculitis associated with IgA deposition

A

HSP. A leukocytoclastic vasculitis

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3
Q

how do you dx HSP?

A

Skin biopsy. Clinical suspicion based on sxs i.e. palpable purpura, abdominal sxs, renal dz, some arthritis

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4
Q

antibodies positive in systemic sclerosis

A

anti-topoisomerase (SCL-70)
anticentromere
anti RNA polymerase III

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5
Q

features of scleroderma renal crisis

A
  • abrupt onset malignant htn
  • acute onset oliguric renal failure (UA reveals only mild proteinuria with few casts)
  • MAHA and thrombocytopenia (schistocytes)
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6
Q 
hilar adenopathy 
erythema nodosum 
acute polyarthritis (involving both ankles). Especially in africans/scandinavians
A

Lofgren’s syndrome. it is self-limited, try nsaids. Usually need chest imaging for hilar adenopathy

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7
Q

RA typically spares the *** joint

A

DIP

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8
Q

Behcet syndrome features

A

Recurrent oral apthous ulcer (>3x/year) + eye/genital/skin (i.e. acne, genital ulcers) lesions.

Unique feature of Positive Pathergy: >2mm papule forming 24-48 hrs after needle inserted into skin

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9
Q

Throbbing pain, skin temperature changes, paresthesia after an injury

A

Complex regional pain syndrome. Tx with nerve block

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10
Q

Which infections typically precede Reactive arthritis?

A

Gastroenteritis (i.e shigella, salmonella) and genitourinary (chlamydia)

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11
Q

T/F: Conjunctival sxs are seen in both reactive arthritis (i.e. chlamydia) and disseminated gonococcal infection

A

False, usually suggest reactive arthritis, not seen in gonococcal

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12
Q

T/F: Serum uric acid levels are elevated during acute gouty attack

A

False, usually normal or low

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13
Q

tx of acute gout

A

1st line: nsaids, colchicine, glucocorticoids

*allopurinol not for acute flare

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14
Q

tx for raynauds

A

CCB (nifedipine, amlodipine)

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15
Q

Abnormal nailfold capillaroscopy test

A

suggests secondary Raynaud, associated with connective tissue disease

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16
Q

First-line drug for fibromyalgia

A

TCAs. Pregabalin/duloxetine/milnacipran = approved second line therapies

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17
Q

Goal uric acid for chronic gout mgmt

A

<6

if tophi, <5

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18
Q

Prophylaxis rules for gout, during urate-lowering therapy

A

Prevent gout flare while getting to target levels.
Use nsaids, colchicine or low dose prednisone.

No Tophi: Pick whichever is longer

  • 6 months past last acute gout flare
  • 3 months past target urate level (<6)

Tophi:
-6 months past target urate level (<5)

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19
Q

Crystals and birefringence in gout

A

Monosodium urate. Negative

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20
Q

What do you need to do in asians before starting allopurinol?

A

check HLA-B*5801. at risk for hypersensitivity syndrome

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21
Q

When would you use febuxostat for chronic gout mgmt?

A

Allopurinol and Febuxostat are both xanthine oxidase inhibitors. If can’t tolerate allopurinol especially CKD patients, use Febuxostat

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22
Q

When would you use Pegloticase for chronic gout mgmt?

A

Refractory tophaceous got

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23
Q

What is the big CI to using second line agent probenicid for chronic gout mgmt?

A

kidney stones, ckd

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24
Q

Linear calcifications of the meniscus and articular cartilage of the knee

A

Chondrocalcinosis = PSEUDOGOUT

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25
Q

Young patient (<50) presents with Pseudogout (chondrocalcinosis). What should you screen for?

A
  • Hemochromatosis (iron studies, HFE gene)
  • Hyperparathyroidism (ionized Ca, PTH). hint: pt with recent parathyroidectomy
  • Hypothyroidism
  • Hypomagnesium (CKD)
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26
Q

Shape, crystal and birefringence for Pseudogout

A

CPPD: Calcium pyrophosphate deposition
Rhomboid
Positive –> Blue

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27
Q

Which autoimmune disease has an association with non-hodgkin lymphoma?

A

Sjogren Syndrome. Normally these patients are fine, but associated risk with NHL–> esp B-cell lymphoma or Maltoma

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28
Q

T/F: Hip xray is usually sufficient to diagnose ankylosing spondylitis

A

true, showing erosions/arthritis of SI joint

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29
Q

initial tx for ankylosing spondylitis

A

NSAIDS and ROM exercises

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30
Q

when do you use pathergy testing

A

Behcet dz: apthous ulcers, genital ulcers, uveitis

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31
Q

Numbness/pain between 3rd and 4th toes, clicking sensation on palpation

A

morton neuroma

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32
Q

Anorexic female with pain in her foot

A

High risk of stress fracture (females with eating disorder). Xrays will be normal up to 6 weeks

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33
Q

Young patient with stroke, thrombocytopenia and isolated prolonged PTT

A

Antiphospholipid syndrome. Lupus anticoagulant causes isolated increase in PTT

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34
Q

How do loop diuretics increase risk for gout?

A

Volume depletion (inc serum urate) and increased urate reabsorption proximal tubule

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35
Q

How long for bisphosphonates to become effective?

A

6-12 months, so a fracture during this time = no change mgmt unless significant progression of bone loss

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36
Q

Options for osteoporosis

A
  1. Oral bisphosphonates

2. Add IV Zoledronic Acid, Teriparatide or Denosumab

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37
Q

Positive birefringence on light microscopy

A

cPPd aka Pseudogout

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38
Q

Who gets Charcot foot (arthropathy)

A

Long standing peripheral neuropathy, usually diabetic. acute warmth/swelling without pain in foot and ankle

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39
Q

AE of methotrexate

A

Stomatitis
Cytopenias
Hepatotoxiity

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40
Q

Vasculitis associated with Hepatitis B, C

A

Polyarteritis Nodosa

BPAN, CPAN

41
Q

Vasculitis affecting small/medium mesenteric and renal vessels with pulm sparing, negative ANCA

A

PAN. associated with hep b, c and hairy cell leukemia

42
Q

Purple rash around eyelids, purple papules on knuckles, photosensitive rash over face/torso, proximal muscle weakness

A

Gottron’s papules, Heliotrope rash and shawl sign for dermatomyositis.

43
Q

What disease is Sjogren’s associated with?

A

Non-hodgkin lymphoma (B cell lymphoma, usually parotid gland). Also, fibromyalgia and acute interstitial nephritis/distal RTA

44
Q

High prevalance of _____ in patients with reactive arthritis

A

HIV, rule this out

45
Q

T/F: Dermatomyositis/polymyositis is associated with malignancy

A

True, well established. Patients need age-appropriate cancer screening at time of diagnosis

46
Q

T/F: c-ANCA from PR3, p-ANCA from MPO

47
Q

RBC casts with vasculitis

48
Q

recurrent self limited attacks of fever and serositis (abdominal, pleuritic pain) in patient from greece, syria, turkey, jordan etc

A

Familial Mediterranean Fever. Lab may have + ESR, CRP, proteinuria, serum amyloid A, MEFV gene.

Tx: Colchicine (prevent attacks and development of AA amyloidosis)

49
Q

xray findings for osteoarthritis

A

L-loss of joint space
O-osteophytes
S-subchondral sclerosis
S-subchondral cysts

50
Q

palpable purpura, low complement, high RF, arthralgias and fatigue

A

Cryoglobulinemia from HCV. often have FP RF

51
Q

Treatment for patellofemoral pain syndrome

A

Physical Therapy (not bracing). strengthen quad and hip abductor

52
Q

palpable purpura, arthritis, abdominal pain, renal disease/hematuria

53
Q

Leukocytoclastic vasculitis

A

either hypersensitivity (drug induced/viral induced) vasculitis or HSP

54
Q

length of arthritis after viral infection

55
Q

RA patient undergoing general anesthesia

A

need C-spine xray to assess atlantoaxial subluxation/risk for cord compression

56
Q

DMARDS, nonbiologic

A

Methotrexate, can use leflunomide as substitute
Hydroxychloroquine
Sulfasalazine

can do RA monotherapy with these, usually metho

57
Q

DMARDS, biologic

A 
Certolizumab
Adalimumab 
Infliximab
Golimumab
Etanercept

These are TNF inhibitors. The Next Fix after metho.
screen for and tx latent TB before biologics.

58
Q

RA tx in pregnancy

A

Can use Hydroxychloroquine and Sulfasalazine after Having Sex.

No methotrexate or leflunomide, no MiLfs

59
Q

how to treat axial disease in spondyloarthritis i.e. PAIR ankylosing spondylitis

A

NSAIDS and TNF (methotrexate only for peripheral joint and skin)

60
Q

diagnostic xray for ankylosing spondylitis

A

Sacroilitis (hip xray shows erosions of SI joint). syndesmophytes = bamboo spine.

61
Q

tx of IBD associated arthritis

A

Methotrexate, sulfasalazine. Don’t pick NSAIDS b/c they can worsen the IBD

62
Q

painful hip in SLE patient

A

osteonecrosis

63
Q

antiribosomal P and anti-RNP in SLE

A

antiribosomal P - poor prognosis, neuropsychiatric dz.
Poor, Psych

anti-RNP - good prognosis. found in MCTD also.
No Problem.

don’t confuse with anti-RNA polymerase III, which is for scleroderma renal crisis. III for htn emergency

64
Q

T/F: anti-dsDNA correlates with SLE disease activity

65
Q

Which med should all SLE patients be on indefinitely?

A

hydroxychLoroquinE. including in pregnancy.

66
Q

monitoring in patients with systemic sclerosis

A

annual PFTs and echo, high risk of ILD and pHTN. can do RHC also..

tx ILD with mycophenolate mofetil or cyclophosphamide

67
Q

why do you avoid glucocorticoids in scleroderma?

A

can cause scleroderma renal crisis

68
Q

DCSSc vs LCSSc antibodies and lung disease

A

anti-Scl-70: ILD

anti-centromere: Pulmonary Hypertension

this is why you do annual PFTs and ECHO. if pHTN, RHC

69
Q

Gold standard for Sjogren diagnosis

A

Lip biopsy of minor salivary glands

usually don’t need if + sxs and + anti-SSA, SSB

70
Q

RA patient not responding to methotrexate

A

Use this TNF alpha inhibitor: Tofacitinib

71
Q

common toxicity of TNF alpha inhibitors

A

pancytopenia
Lupus-like syndrome with + ANA
demyelinating disorders

72
Q

Hypertrophic osteoarthropathy

A

proliferation of skin/osseous tissue @ distal hands/feet. Digital clubbing, pain, new bone formation. pain alleviated by elevated the affefted limbs. Associated with lung cancer, R->L shunts. Get a CXR to r/o lung cancer.

73
Q

explosive onset/severe disease for psoriatic arthritis should prompt

A

HIV testing

74
Q

Systemic Sclerosis, RA and Gout can all have nodules

A

True:

  • RA: nodules over extensor surfaces
  • SS: Calcinosis (white lumps, usually hands and forearms at are Ca2+)
  • Gout: Tophi on extensor surfaces, finger pads (monosodium urate)
75
Q

Gastric antral vascular ectasia

A

watermelon stomach in Systemic Sclerosis resulting in recurrent bleeding and chronic anemia

76
Q

Primary cause of morbidity and mortality in systemic sclerosis

A

pulmonary disease: ILD in diffuse, pHTN in limited

Annual PFTs

77
Q

T/F: Skin thickening/tightening without Raynaud is not scleroderma

A

True. Other conditions:

  • Eosinophilic fasciitis (eosinophilia, edema of extremities. tx steroids)
  • Nephrogenic Systemic Fibrosis
  • Scleredema (DM patient, plaques/induration on back/shoulder/neck)
  • Scleromyxedmea (MM and Amyloid pt, waxy, yellow-red skin face/upper trunk/neck)
  • Chronic GVHD (Lichen plan, skin thick after HSCT)
78
Q

anti-U1-RNP antibodies

79
Q

T/F: Don’t use nsaids in fibromyalgia

A

true, or opioids. Pick exercise, CBT, sleep hygiene. Meds approved = duloxetine, pregabalin, milnacipran

80
Q

T/F: Autoimmune and hormone disease must be first ruled out if you suspect Fibromyalgia

A

false.

Initial labs = CBC, CMP, TSH, ESR, CRP.
If normal and you suspect it and their are no red flags, don’t need ANA, RF or anti-CCP

81
Q

T/F: Lead toxicity may present with gout, AKI and abdominal pain

82
Q

T/F: Both RA and Gout can have x-rays showing bone erosions

A

True, especially periarticular. Mainly chronic gout and RA

83
Q

Which gout patients get urate-lowering therapy

A

Gout + any:

  • stage 2 CKD or worse
  • tophi
  • 2 or more attacks/year
  • uric acid stones
84
Q

when do you use febuxostat?

A

When Patient can’t tolerate allpurinol (Asian hypersensitivity syndrome) or in CKD. Allopurinol is ok in kidney impairment but lower dose

  • Febuxostat increases risk of heart-related deaths if prior CV hx
  • allopurinol hypersensitivity: dermatitis, fever, eosinophilia, hepatic necrosis, acute nephritis
85
Q

don’t do this for gout in kidney disease

A
  • don’t use probenecid (inc uric acid in urine) in patient with nephrolithiasis or CKD (STONES)
  • don’t prescribe colchicine for patients with kidney failure (use steroids)
  • don’t use nsaids if CKD or PUD
86
Q

Milwaukee shoulder

A

Hemmorhagic shoulder effusion. Tendinitis/bursitis. Xray shows joint destruction and periarticular calcification. Microscopy normal. Need special stain (Alizarin red stain) or electron microscopy to see Hydroxyapetite crystals aka Basic Calcium Phosphate Disease.

87
Q

pseudogout tx

A

nsaids, colchicine, steroids

88
Q

hallmark of an infected joint

A

pain worsens with passive extension or when held in fixed flexion

89
Q

most common bacterial arthritis in young sexual active

A

Gonococcal

90
Q

Disseminated gonococcal infection

A

-tensynovitis, polyarthalgia, dermatitis (papules/pustules that are sterile on culture). fevers, chills
OR
-purulent arthritis w/o systemic features/dermatitis; getting body cultures (pharynx, GU, rectum) + synovial fluid increases yield

91
Q

inflammatory myopathies vs PMR

A

myopathies: weakness, usually painless. if both prox and distal, inclusion body. LFTs elevated

PMR: Pain

92
Q

Takayasu

A

“Starts in Teens” usually women age 15-25. Fever, wt loss, arthalgia with arm/leg claudication, pulse deficits, vascular bruits, asymmetric arm BP readings. Need aortography. Large vessel vasculitis (others are GCA, PMR)

93
Q

Primary angiitis of the CNS

A

medium vessel vasculitis (the other is PAN) with recurrent HA, stroke, TIA. Need LP, MRI, cerebral angiography, brain biopsy would show granulomatous vasculitis.

94
Q

T/F: for GPA, can biopsy skin or kidney

95
Q

Hypersensitivity vasculitis (leukocytoclastic vasculitis)

A

Palpalble purpura, skin vesciles/pustules, urticaria, recent virus/drug or malignancy dx

96
Q

T/F: Henoch-schonlein purpura is usually self-limited

97
Q

T/F: Colchicine prevents development of AA amyloidosis in familial mediterranean fever

A

true . fever, serositis (abdominal/pleuritic pain), arthritis that is recurrent.

98
Q

T/F: Complex regional pain syndrome will shows osteoporosis on imaging and tx with bisphosphonates is effective for pain even without osteoporosis

A

true, can also use PT, steroids, sympathetic blockade, gabapentin and TCA

UWORLD ABIM (10 decks)

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