Rheum

Question 1

Red flags of MSK pain

Answer 1

Fever - acute joint pain and swelling (suspect infection!)
Pseudoparalysis in a single limb (refusal to move due to pain)
Bone pain (esp at night) deep gnawing - suspect malignancy
Stiffness after immobility.
Multisystem symptoms

Question 2

Slide 6 - add Table to Resource Bible

Question 3

STEP WaR acronym for MSK pain in rheumatologic disease

Answer 3

Swelling- effusion, synovial/capsular thickening, soft tissue induration
Tenderness- focal bony, tendon, ligament, synovium, allodynia (diffuse hyperesthesia)
Erythema
Pain in motion- try to recreate the symptoms (vs at rest)
Warmth
Range of motion- passive versus active

Question 4

Slide 22 add to RB

Question 5

What is the hallmark of inflammatory arthropathy?

Answer 5

Stiffness after immobility.

Question 6

Kawasaki more prevalent in kids ______

Answer 6

<5yo

Question 7

Morning stiffness present for _____ and _____ but not _____, ____ or _____

Answer 7

SLE, JIA
Rheumatic fever, Lyme, Gonococcal

Question 8

TMJ is really only usuallly affected in ____

Answer 8

JIA

Question 9

________ does not usually have any eye involvement. ___, ___ and _____ do

Answer 9

Rheumatic fever
SLE, JIA, Lyme and Kawasaki.

Question 10

SLE has a _____ % positive ANA rate, while JIA has a ____% positive rate.
SLE has a _____ RF while JIA has a ____ RF

Answer 10

99%
50%
POs or neg
100% positive.

Question 11

______ and ______ can lead to erosive arthritis.

Answer 11

JIA and gonococcal.

Question 12

Your patient has limb pain. What could be the different causes?

Answer 12

Orthopedic - pain associated with increased activity with no major trauma
Reactive arthritis - be preceded by a viral infx, strep or purpuric rash
Mono articular arthritis - pain in hip or LE - consider cancer
Bacterial arthritis - will see fever, leukocytosis, high ESR.
Arthritis of rheumatic fever - migratory and transient, more painful than JIA, rare in <5yo
Lyme arthiritis - resembles oligoarticular JIA.

Question 13

What are RF and ANA

Answer 13

Antibodies that indicate the presence of a rheumatological or autoimmune disease.

Question 14

For titres, a bigger number means a ______ disease. Eg: 1:80 titer is _____ a 1:1280

Answer 14

More severe
Not as severe as

Question 15

What is the most common chorionic arthritis in childhood?

Answer 15

JIA.

Question 16

JIA is thought to be a result of?

Answer 16

Defects in anti suppressor cell antibodies (TNF).

Question 17

JIA has 2 peaks:

Answer 17

1-3 years
8-12 years.
But can occur at any age.

Question 18

Fevers, stiffness, limb length discrepancies, rashes with fever signify ____

Answer 18

JIA

Question 19

Early JIA _____ lab evidence.

Answer 19

May not have. Many have normal IMs, RF neg and ANA neg.

Question 20

What are the different categories of JIA?

Answer 20

Oligoarticular (<=4 joints)
Polyauricular (>4 joints) RF negative
“” RF POs
Psoriatic
Enthesitis-Related arthritis. (Enteropathic)
Systemic
Undifferentiated

Question 21

Characteristics of Oligoarticular JIA and tx

Answer 21

Young kids (age 1-3 onset)
F:M 4:1
Knees > ankles, wrist, elbow, TMJ, c-spine
20% have uveitis
ANA POs in 60%, IM normal or slightly elevated (most have no lab abnormalities)
Growth disturbance with limb length discrepancy
Tx is NSAIDS, IA steroids, MTX

Question 22

Characteristics of Polyauricular (5 or more joints) JIA + Tx

Answer 22

Symmetric, small and large joints, c-spine and TMJ. Local growth disturbances and articular damage in RF positive.
Onset biphasicc. (1-3 and 9-14),
Elevated IMs and anemia of chronic disease
Tx: MTX and NSAIDs, may require anti-TNF or biologics.

Question 23

Characteristics and tx of psoriatic JIA

Answer 23

Biphasic onset 2-3 and mid adolescence
F:M 2:1 in younger, 1:1 in older
Asymmetric more Oligoarticular Polyauricular
Small and medium joints,
Psoriasis in 40-60%
Dactylitis, comorbid obesity
Tx MTX, anti-TNF, biologics. Consider anti IL

Question 24

What is a stand-out characteristic of systemic onset JIA?

Answer 24

Major: a salmon-pink macular rash that comes and goes, arthritis
Minor: hepatosplenomegaly, serositis, arthralgia lasting 2 weeks or longer (in absence of arthritis
Leukocytosis >= 15000 with neutrophilia.

Question 25

T/F: systemic onset JIA is episodic, and remission usually happens in 1 year.

Answer 25

True.

Question 26

What type of JIA is unresponsive to DMARDS and needs early TNF blockers and steroids?

Answer 26

Entithesitis/spondylitis-related (spondyloarthropathies)
AKA Enteropathic.

Question 27

Enteropathic arthritis can be triggered by _______ or ____

Answer 27

GI symptoms (salmonella, shigella, chlamydia)
IBD

Question 28

Erythema Nodosum are ________ and are associated with _______

Answer 28

Red, hard nodules on skin usually lower extremities
Enteropathic arthiritis

Question 29

Enteropathic arthritis should have frequent _____ because of the build up of ______ that can cause ______

Answer 29

Eye exams
Keratin precipitate and WBC clumps
Glaucoma, cataracts and blindness.

Question 30

Your patient is about to start taking a biologics medication. You know this will depress their immune system, so what do you want to make sure gets done first?

Answer 30

Administer live virus vaccines: HPV, Pneumonia
Get a TB test
Complete all abx
Pregnancy planning
Baseline eye exams.

Question 31

3 things need to be present for SLE to occur?

Answer 31

Stupid ts that cant tell self from non self, genes that make one more susceptible to having these stupid ts and inflammation from infection or trauma.

Question 32

SLE is more common in _____ and has an age of onset of ____ in kids.

Answer 32

Females (8:1)
9-15yo

Question 33

What do you need to check before you start an SLE patient on plaquenil?

Answer 33

G6PD status - this medication is an Antimalarial.

Question 34

Prognosis for SLE worsens with ______ involvement.

Answer 34

Renal.

Question 35

Some signs and concerns of Juvenile Dermatomyositis (polymyositis)
Tx?

Answer 35

Shawl sign, slapped cheek appearance. Inflammation of blood vessels, muscles, skin, kidney, retina and GI tract due to activation of T and B lymphocytes and immune complex deposition.
Calcinosis - stiffening of the skin.
Tx - prednisone, MTX, IVIG, cyclosporine, mycophenalate,

Question 36

Classic findings in IgA vasculitis Henoch-Schonlein Purpura (HSP)
Watch the _____!!

Answer 36

Nonthrombocytopenic purpura
On buttocks and lower extremities
W/wout joint inflammation
W/wo crampy abd pain and GI symptoms
Usually mild and self limiting, but can be severe and cause renal failure (watch the kidneys!!)

Question 37

What is chronic regional pain syndrome (CRPS)?

Answer 37

AKA reflex sympathetic dystrophy - severe extremity pain leading to loss of function, color change, temp differences, dyshidrosis of affected extremity, feet most common.