Rheum Flashcards
Tetrad of purpura, abdominal pain, arthritis, glomerulonephritis
Henoch-Schonlein Purpura (HSP)
Immune mediated vasculitis associated with IgA deposition
HSP. A leukocytoclastic vasculitis
how do you dx HSP?
Skin biopsy. Clinical suspicion based on sxs i.e. palpable purpura, abdominal sxs, renal dz, some arthritis
antibodies positive in systemic sclerosis
anti-topoisomerase (SCL-70)
anticentromere
anti RNA polymerase III
features of scleroderma renal crisis
- abrupt onset malignant htn
- acute onset oliguric renal failure (UA reveals only mild proteinuria with few casts)
- MAHA and thrombocytopenia (schistocytes)
hilar adenopathy erythema nodosum acute polyarthritis (involving both ankles). Especially in africans/scandinavians
Lofgren’s syndrome. it is self-limited, try nsaids. Usually need chest imaging for hilar adenopathy
RA typically spares the *** joint
DIP
Behcet syndrome features
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
Throbbing pain, skin temperature changes, paresthesia after an injury
Complex regional pain syndrome. Tx with nerve block
Which infections typically precede Reactive arthritis?
Gastroenteritis (i.e shigella, salmonella) and genitourinary (chlamydia)
T/F: Conjunctival sxs are seen in both reactive arthritis (i.e. chlamydia) and disseminated gonococcal infection
False, usually suggest reactive arthritis, not seen in gonococcal
T/F: Serum uric acid levels are elevated during acute gouty attack
False, usually normal or low
tx of acute gout
1st line: nsaids, colchicine, glucocorticoids
*allopurinol not for acute flare
tx for raynauds
CCB (nifedipine, amlodipine)
Abnormal nailfold capillaroscopy test
suggests secondary Raynaud, associated with connective tissue disease
First-line drug for fibromyalgia
TCAs. Pregabalin/duloxetine/milnacipran = approved second line therapies
Goal uric acid for chronic gout mgmt
<6
if tophi, <5
Prophylaxis rules for gout, during urate-lowering therapy
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)
Crystals and birefringence in gout
Monosodium urate. Negative
What do you need to do in asians before starting allopurinol?
check HLA-B*5801. at risk for hypersensitivity syndrome
When would you use febuxostat for chronic gout mgmt?
Allopurinol and Febuxostat are both xanthine oxidase inhibitors. If can’t tolerate allopurinol especially CKD patients, use Febuxostat
When would you use Pegloticase for chronic gout mgmt?
Refractory tophaceous got
What is the big CI to using second line agent probenicid for chronic gout mgmt?
kidney stones, ckd
Linear calcifications of the meniscus and articular cartilage of the knee
Chondrocalcinosis = PSEUDOGOUT
Young patient (<50) presents with Pseudogout (chondrocalcinosis). What should you screen for?
- Hemochromatosis (iron studies, HFE gene)
- Hyperparathyroidism (ionized Ca, PTH). hint: pt with recent parathyroidectomy
- Hypothyroidism
- Hypomagnesium (CKD)
Shape, crystal and birefringence for Pseudogout
CPPD: Calcium pyrophosphate deposition
Rhomboid
Positive –> Blue
Which autoimmune disease has an association with non-hodgkin lymphoma?
Sjogren Syndrome. Normally these patients are fine, but associated risk with NHL–> esp B-cell lymphoma or Maltoma
T/F: Hip xray is usually sufficient to diagnose ankylosing spondylitis
true, showing erosions/arthritis of SI joint
initial tx for ankylosing spondylitis
NSAIDS and ROM exercises
when do you use pathergy testing
Behcet dz: apthous ulcers, genital ulcers, uveitis
Numbness/pain between 3rd and 4th toes, clicking sensation on palpation
morton neuroma
Anorexic female with pain in her foot
High risk of stress fracture (females with eating disorder). Xrays will be normal up to 6 weeks
Young patient with stroke, thrombocytopenia and isolated prolonged PTT
Antiphospholipid syndrome. Lupus anticoagulant causes isolated increase in PTT
How do loop diuretics increase risk for gout?
Volume depletion (inc serum urate) and increased urate reabsorption proximal tubule
How long for bisphosphonates to become effective?
6-12 months, so a fracture during this time = no change mgmt unless significant progression of bone loss
Options for osteoporosis
- Oral bisphosphonates
2. Add IV Zoledronic Acid, Teriparatide or Denosumab
Positive birefringence on light microscopy
cPPd aka Pseudogout
Who gets Charcot foot (arthropathy)
Long standing peripheral neuropathy, usually diabetic. acute warmth/swelling without pain in foot and ankle
AE of methotrexate
Stomatitis
Cytopenias
Hepatotoxiity
Vasculitis associated with Hepatitis B, C
Polyarteritis Nodosa
BPAN, CPAN
Vasculitis affecting small/medium mesenteric and renal vessels with pulm sparing, negative ANCA
PAN. associated with hep b, c and hairy cell leukemia
Purple rash around eyelids, purple papules on knuckles, photosensitive rash over face/torso, proximal muscle weakness
Gottron’s papules, Heliotrope rash and shawl sign for dermatomyositis.
What disease is Sjogren’s associated with?
Non-hodgkin lymphoma (B cell lymphoma, usually parotid gland). Also, fibromyalgia and acute interstitial nephritis/distal RTA
High prevalance of _____ in patients with reactive arthritis
HIV, rule this out
T/F: Dermatomyositis/polymyositis is associated with malignancy
True, well established. Patients need age-appropriate cancer screening at time of diagnosis
T/F: c-ANCA from PR3, p-ANCA from MPO
True
RBC casts with vasculitis
think GPA
recurrent self limited attacks of fever and serositis (abdominal, pleuritic pain) in patient from greece, syria, turkey, jordan etc
Familial Mediterranean Fever. Lab may have + ESR, CRP, proteinuria, serum amyloid A, MEFV gene.
Tx: Colchicine (prevent attacks and development of AA amyloidosis)
xray findings for osteoarthritis
L-loss of joint space
O-osteophytes
S-subchondral sclerosis
S-subchondral cysts
palpable purpura, low complement, high RF, arthralgias and fatigue
Cryoglobulinemia from HCV. often have FP RF
Treatment for patellofemoral pain syndrome
Physical Therapy (not bracing). strengthen quad and hip abductor
palpable purpura, arthritis, abdominal pain, renal disease/hematuria
HSP
Leukocytoclastic vasculitis
either hypersensitivity (drug induced/viral induced) vasculitis or HSP
length of arthritis after viral infection
<6 weeks
RA patient undergoing general anesthesia
need C-spine xray to assess atlantoaxial subluxation/risk for cord compression
DMARDS, nonbiologic
Methotrexate, can use leflunomide as substitute
Hydroxychloroquine
Sulfasalazine
can do RA monotherapy with these, usually metho
DMARDS, biologic
Certolizumab Adalimumab Infliximab Golimumab Etanercept
These are TNF inhibitors. The Next Fix after metho.
screen for and tx latent TB before biologics.
RA tx in pregnancy
Can use Hydroxychloroquine and Sulfasalazine after Having Sex.
No methotrexate or leflunomide, no MiLfs
how to treat axial disease in spondyloarthritis i.e. PAIR ankylosing spondylitis
NSAIDS and TNF (methotrexate only for peripheral joint and skin)
diagnostic xray for ankylosing spondylitis
Sacroilitis (hip xray shows erosions of SI joint). syndesmophytes = bamboo spine.
tx of IBD associated arthritis
Methotrexate, sulfasalazine. Don’t pick NSAIDS b/c they can worsen the IBD
painful hip in SLE patient
osteonecrosis
antiribosomal P and anti-RNP in SLE
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
T/F: anti-dsDNA correlates with SLE disease activity
true
Which med should all SLE patients be on indefinitely?
hydroxychLoroquinE. including in pregnancy.
monitoring in patients with systemic sclerosis
annual PFTs and echo, high risk of ILD and pHTN. can do RHC also..
tx ILD with mycophenolate mofetil or cyclophosphamide
why do you avoid glucocorticoids in scleroderma?
can cause scleroderma renal crisis
DCSSc vs LCSSc antibodies and lung disease
anti-Scl-70: ILD
anti-centromere: Pulmonary Hypertension
this is why you do annual PFTs and ECHO. if pHTN, RHC
Gold standard for Sjogren diagnosis
Lip biopsy of minor salivary glands
usually don’t need if + sxs and + anti-SSA, SSB
RA patient not responding to methotrexate
Use this TNF alpha inhibitor: Tofacitinib
common toxicity of TNF alpha inhibitors
pancytopenia
Lupus-like syndrome with + ANA
demyelinating disorders
Hypertrophic osteoarthropathy
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.
explosive onset/severe disease for psoriatic arthritis should prompt
HIV testing
Systemic Sclerosis, RA and Gout can all have nodules
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)
Gastric antral vascular ectasia
watermelon stomach in Systemic Sclerosis resulting in recurrent bleeding and chronic anemia
Primary cause of morbidity and mortality in systemic sclerosis
pulmonary disease: ILD in diffuse, pHTN in limited
Annual PFTs
T/F: Skin thickening/tightening without Raynaud is not scleroderma
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)
anti-U1-RNP antibodies
MCTD
T/F: Don’t use nsaids in fibromyalgia
true, or opioids. Pick exercise, CBT, sleep hygiene. Meds approved = duloxetine, pregabalin, milnacipran
T/F: Autoimmune and hormone disease must be first ruled out if you suspect Fibromyalgia
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
T/F: Lead toxicity may present with gout, AKI and abdominal pain
true
T/F: Both RA and Gout can have x-rays showing bone erosions
True, especially periarticular. Mainly chronic gout and RA
Which gout patients get urate-lowering therapy
Gout + any:
- stage 2 CKD or worse
- tophi
- 2 or more attacks/year
- uric acid stones
when do you use febuxostat?
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
don’t do this for gout in kidney disease
- 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
Milwaukee shoulder
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.
pseudogout tx
nsaids, colchicine, steroids
hallmark of an infected joint
pain worsens with passive extension or when held in fixed flexion
most common bacterial arthritis in young sexual active
Gonococcal
Disseminated gonococcal infection
-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
inflammatory myopathies vs PMR
myopathies: weakness, usually painless. if both prox and distal, inclusion body. LFTs elevated
PMR: Pain
Takayasu
“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)
Primary angiitis of the CNS
medium vessel vasculitis (the other is PAN) with recurrent HA, stroke, TIA. Need LP, MRI, cerebral angiography, brain biopsy would show granulomatous vasculitis.
T/F: for GPA, can biopsy skin or kidney
true
Hypersensitivity vasculitis (leukocytoclastic vasculitis)
Palpalble purpura, skin vesciles/pustules, urticaria, recent virus/drug or malignancy dx
T/F: Henoch-schonlein purpura is usually self-limited
true
T/F: Colchicine prevents development of AA amyloidosis in familial mediterranean fever
true . fever, serositis (abdominal/pleuritic pain), arthritis that is recurrent.
T/F: Complex regional pain syndrome will shows osteoporosis on imaging and tx with bisphosphonates is effective for pain even without osteoporosis
true, can also use PT, steroids, sympathetic blockade, gabapentin and TCA
