Rheum Flashcards
Risk factors for septic arthritis
Age >80
Diabetes mellitus
Prosthetic joints
Skin infection
Known abnormal joint (Rheumatoid joint)
What to rule out if you suspect acute monoarthritis
Septic until proven otherwise
If possible, hold antibx until fluid sent for culture
Which bacteria is often to blame for septic arthritis
Non-gonococcal (Staph, strep) - most common, most have fever
Gonococcal
-Need to have untreated disseminated gonorrhea
-Usually migratory arthritis
-Possible rash/lesion
Clinical management and Treatment of septic arthritis
Physical exam
Joint aspiration - send for cell count and diff
Blood cultures
GU cultures - gonorrhea
ESR/CRP
Imaging - XR to rule out fracture
Antibx: Broad spectrum while awaiting culture
-Ceftriaxone and Vanc
Causes of acute gout attack
Medical or surgical stress
Dehydration
Excessive ETOH
Changes in medications (particularly diuretics)
Family hx of gout
Males greater risk than females
Clinical presentation of gout attack
Attack typically comes on over hours
Acutely painful, red swollen joint
Possibly fever
Only way to diagnose it is through synovial fluid analysis - +crystals
Presence of tophi is also considered diagnostic
Serum uric acid will often be elevated (except during acute attack)
Treatment of acute gout
NSAIDs (2-3 days)
Colchicine (however can cause diarrhea and joint pain)
Steroids (PO prednisone or intra-articular)
ACTH
Anakinra
DO NOT START ALLOPURINOL
Considerations when starting Allopurinol
Good choice for treating chronic gout
-NEVER START DURING A GOUT ATTACK
Always start in combination with an anti-inflammatory agent
Recheck uric acid every 2-3 weeks and adjust to keep uric acid level less than 6.2
Avoid allopurinol with azathioprine
Avoid allopurinol with amoxicillin
Things to think about when treating someone on Etanercept
Entanercept is a more potent immunosuppressant
If treating someone with acute onset pain in a joint, concern that the joint could be infected. Should stop the immunosuppressant
Presentation of Human Parovirus B19 arthritis
Contact with someone (usually a child - 5ths disease) with a viral illness that then causes bilateral swelling of the wrists, metacarpophalangeal and proximal interphalangeal joints
Treatment is supportive care
Clinical features of rheumatoid arthritis
Polyarthritis (>5 joints)
Symmetrical
Small joint involvement (MCP, PIP, wrists, feet)
Can see ulnar deviation
Inflammatory joint pain (stiff after being sedentary for a bit and then they loosen up)
Worse in the AM but better as the day progresses
6+ weeks of symptoms
More common in women
Diagnostic testing for rheumatoid arthritis
Positive rheumatoid factor (RF)
Cyclic citrullinated peptide (CCP)
—More specific
Elevated ESR/CRP
Low Hgb, HCT (Anemia of chronic disease)
XR of hands and feet
Synovial aspirate would show WBC and inflammation
What are common X-ray findings for rheumatoid arthritis
Soft tissue swelling
Periarticular osteopenia (dark areas on bone)
Joint space narrowing
Marginal erosion
Treatment for rheumatoid arthritis
NSAIDS
Corticosteroids
Classic choice is DMARDs:
Low potency:
-Hydroxychloroquine (Plaquenil) - good for mild disease and safe during pregnancy
Medium potency:
-Methotrexate - once weekly, mouth sores, monitor LFTs
-Leflunomide (Arava)
High potency:
-Biologics and small molecules
—TNF inhibitors - improved when used with DMARDs (methotrexate)
—-Increase risk for infection
Use of Corticosteroids in Rheumatology
Useful first line agents
Often used for life threatening problems or when people are disabled by their problems
In some rare cases, (PMR) can be used as monotherapy however usually utilized as adjunct
Mostly safe during pregnancy (at lower doses)
Hydroxychloroquine: Uses, common side effects
Anti-malarial drug
Used to treat mild to moderate RA and Lupus
Can cause hyperpigmentation
Rare visual field loss
Well documented safe in pregnancy
Methotrexate: Uses and considerations
Cornerstone of treatment in moderate to Severe RA
Also used in lupus, psoriatic arthritis, myositis, vasculitis
Given once weekly PO or SC
Onset is 4-8 weeks
Can cause painful oral mucosal ulcers
- Folic acid given for side effects
Can cause LFT elevation
Sulfasalazine: Uses and considerations
Used to treat mild-moderate RA and psoriatic arthritis
Side effects: Rash, granulocytopenia, nausea, abd bloating
Mycophenolate (Cellcept): Uses and considerations
Used in lupus nephritis (induction and maintenance) and ANCA positive vasculitidies
Side effects: Increase in infection, malignancy, teratogenic
Better tolerated than cytoxan for lupus
Cyclophophosphamide (Cytoxan)
Used in life threatening lupus (proliferative nephritis, CNS involvement)
Very toxic: increased risk for malignancy, infection, teratogenic
Can cause sterility
Anti TNF alpha antagonist (TNFs): Uses and considerations
Etanercept, Infliximab, Adalimumab
Approved for use in RA, spondyloarthropathies, psoriasis, Crohn’s, UC
Inhibits structural damage from RA
Improves efficacy when co-administered with traditional DMARDs - methotrexate
Risks:
Opportunistic infections
Autoimmune phenomenon: Lupus-like syndrome
Exacerbation of MS
Malignancy: Lymphoma
JAK kinase inhibitors: Uses and considerations
Tofacitinib (Xeljanz)
Upadacitnib (RInvoq)
Baricitinib (Olumiant)
Approved for all the same things as TNFs but should only start these if you have failed TNFs
Diagnostic testing for lupus
ANA
-Seen in 95% of those with SLE
-Not specific for SLE
-Once it is found to be positive, no need to ever check it again
-Not positive until 1:160
Anti dsDNA
-Seen in 60% of those with SLE
-Highly specific for SLE
Anti Sm (Smith)
-Highly specific for SLE
C3 and C4
-Compliment cascade in lupus resulting in low C3 and C4
Anemia, leukopenia and thrombocytopenia often present
Clinical presentation of Lupus
Usually seen in women of childbearing age
-Constitutional symptoms, fever, weight loss, malaise, severe fatigue
-Skin rash and/or stomatitis (oral ulcers)
-Arthritis
—Usually in hands, wrists, knees
—Does not cause joint destruction
-Renal disease
-Cytopenias
Treatment of Lupus
Hydroxychloroquine - main treatment
Corticosteroids
Methotrexate
Cellcept
Scleroderma presentation
2 forms
Connective Tissue Disease
Thickening of the skin caused by accumulation of connected tissue
Inflammation and fibrosis
Limited Cutaneous systemic sclerosis
-Skin thickening distal to the elbows and knees
-Can involve peri-oral skin thickening (pursed lips)
-Less organ involvement
-Isolated pulmonary hypertension can occur
-Part of CREST syndrome
Diffuse cutaneous systemic sclerosis
-Skin thickening proximal to the elbows and knees, involving truck
-More likely to have organ involvement
-Pulmonary fibrosis and renal crisis are more common
CREST Syndrome
Part of Limited cutaneous system sclerosis
Calcinosis - calcium deposits in the skin
Raynauds Phenomenon
Esophageal dysfunction - GERD, decreased motility
Sclerodactyly - thickening and tightening of the skin on the fingers and hands
Telangiectasias - dilation of capillaries causing red marks on surface of skin
What is a lethal complication of scleroderma
interstitial lung disease
Isolated pulmonary hypertension
Scleroderma Renal Crisis
What is a rheumatological emergency?
Scleroderma Renal Crisis
-Abruptly develops severe hypertension
Plus one of the following:
-Increase in creatinine by >50% over baseline or >120% Upper limit of normal
-Proteinuria >2+
-Hematuria >2+ or >10 rbc on UA
-Thrombocytopenia <100,000
-Hemolysis
Can cause headache, seizure, LV failure, encephalopathy
Treatment of Scloerderma Renal Crisis
Initiation of ACE-I (captopril) and continuation on life long ACE-I
Of note, ACI-I do not prevent scleroderma renal crisis
Treatment of Scleroderma
No treatment that will treat all sxs
Mostly focused on symptom management
If stable - treat symptoms
If unstable
-Methotrexate
-Mycophenolate mofetil (Cellcept)
Giant Cell Arteritis vs Polymyalgia Rheumatica
GCA:
-Age of onset >50 - incidence increases with age
-Female>male
-Vision loss - can be perminent
-Amourosis fugax - monocular curtain falling into vision
-Headache
-Scalp tenderness
-Jaw claudication - lot of pain in jaw when chewing
-Fever
-Weight loss
PMR:
-Age of onset >50
-Female >male
-Pain in shoulder and hip girdle
-Stiffness
-Weight loss
-Malaise
-2-3 times more common
Diagnostics of GCA
Palpation of temporal arteries
-ESR/CRP - elevated
-Normochromic/hypochromic anemia
-Elevated platelets
-Normal WBC
GOLD STANDARD: Temporal artery biopsy
Can also get a temporal artery ultrasound or PET-CT Chest
Diagnostics of Polymyalgia Rheumatica
Largely a clinical diagnosis
-ESR/CRP elevated
-Give low dose steroids, usually better in just two days
Treatment of GCA and PMR
GCA:
-high dose steroids (1mg/kg)
-Start if suspicious
-Taper once sxs resolve
-Tocilizamab (Actemra) is helpful
-ASA
PMR:
Low dose steroids (10-20mg starting dose)
May need prolonged low dose steroids
Generally can taper off in 12-18 months
Clinical presentation of polyarteritis nodosa
Systemic complaints: Weight loss, fatigue, arthralgias
Renal vasculitis
GI: Mesenteric ischemia, liver involvement - n/v/d/hematochezia
Peripheral nervous system: Mononeuritis multiplex
Derm: Livedo reticularis, skin ulcers, erythematous nodules, ischemia
Other: Coronaries, testicles, ovary, breast, eye
Treatment of polyarteritis nodosa
Glucocorticoids: key compenent
-IV pulse of solumedrol in mild cases
-Cyclosphosphamide in more severe cases
Difference in clinical features of Granulomatosis Polyangiitis (GPA) and Microscopic polyangiitis (MPA)
GPA:
-ANCA positive
-Histology: GRANULOMATOUS INFLAMMATION
-ENT - chronic sinusitis, hearing loss
-Skin - cutaneous vasculitis
MPA:
-ANCA Positive
-Histology: No granulomatous inflammation
-ENT - not usually involved
-Neurologic: Vasculitic neuropathies common
Clinical presentation of Churg-Strauss Syndrome
Eosinophilic infiltrates/vasculitis: granulomas with eosinophil necrosis
ENT - nasal polyps, allergic rhinitis, conductive hearing
Eyes - Occassional inflammatory eye disease
Lung: Adult onset asthma
Renal: Segmental necrotizing glomerulonephritis
Cardiac: CHF
Neurologic: Vasculitis neuropathy prominent
What is the pathology of osteoarthritis?
Degenerative joint disease with slow destruction of the articular cartilage
Usually asymmetrical
Affects both men and women equally
Primarily occurs on the weight bearing joints (knees, hips), fingers, hands, wrists
Clinical presentation of osteoarthritis
Swelling and edema but no redness or heat to joints
Asymmetric joint involvement
Heberden’s nodes - DIPs (H is distal in the alphabet)
Bouchard’s Nodes - PIPs (B is proximal in the alphabet)
Pain and stiffness is better in the AM and becomes worse as the day progresses
–Aggravated by activity and relieved by rest
Limited ROM
Diagnostics for osteoarthritis: Labs and imaging
No real labs
Sinovial fluid is clear/yellow
X-ray shows narrowing of the joint space, osteophytes, juxta-articular sclerosis
Treatment of Osteoarthritis
ASA
Acetaminophen
NSAIDs
Cox 2 inhibitors (Celebrex)
Use of cane (put cane in OPPOSITE hand of affected leg)
Physical therapy
Refer for joint replacement
What is sarcopenia
Decreased muscle mass and strength
Seen in the elderly
