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Adult Clinical Medicine > Rheum 2 (SLE, AS, Reactive, Psoriatic) > Flashcards

Rheum 2 (SLE, AS, Reactive, Psoriatic) Flashcards

1
Q

What are ANA (anti-nuclear antibodies)

A

Protein antibodies that react against cellular nuclear material.

Found in 95% of patients with autoantibodies to nuclear material

Not specific to lupus

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2
Q

What type of ANA should you draw

A

IFA

**DO NOT DRAW DIRECT (ie. EIA) or ELISA–> very high false positive

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3
Q

When should you order an ANA?

A
  1. Confirmatory test- Help establish a diagnosis of a CT disease or autoimmune disease
  2. Exclude a disorder when findings are inconclusive
  3. Subclassify with an established diagnosis
    SSA, SSB, anti-RNP
  4. Monitor disease activity (Anti -double stranded DNA antibody levels in lupus nephritis)
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4
Q

Conditions with positive ANA

A
  1. SLE – 93%
  2. Sjogren’s Syndrome – 48%
  3. RA – 41%
  4. Hashimoto’s thyroiditis – 46%
  5. Primary biliary cirrhosis – 10-40%
  6. Autoimmune hepatitis – 63-91%
  7. HepC
  8. TB
  9. Mono
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5
Q

When should you draw ANA specific antibodies

A

1:160 titer

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6
Q

What diseases do the following ANA Ab suggest?

  1. Anti-dsDNA
  2. Anti-RNP (ribonuceloprotein)
  3. Anti-Sm (smith)
A
  1. Anti-dsDNA: SLE, monitor lupus nephritis
  2. Anti-RNP (ribonuceloprotein): Mixed CT dz
  3. Anti-Sm (smith): SLE, marker of dz
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7
Q

What diseases do the following ANA Ab suggest?

  1. Anti-SSA (Ro)
  2. Anti-SSB (La)
  3. Anti-Centromere (Scl-70)
A
  1. Anti-SSA (Ro): Sjogren’s syndrome, subacute cutaneous lupus, neonatal lupus
  2. Anti-SSB (La): Sjogren’s syndrome, SLE
  3. Anti-Centromere (Scl-70): scleroderma
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8
Q

Describe the use of ANA titers

A

The most dilute serum in which ANA is detected

Helpful to use as an adjunct to clinical evidence– Is less helpful if the clinical evidence is strong for an autoimmune disease

The presence of a titer alone is not diagnostic of the disease

In general, the higher the titer the more likely the disease exists and the more active it may be

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9
Q

Malar vs rosacea rash

A

Malar: spares nasal labial folds
Rosacea: can cross lines

*both have dry eyes

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10
Q

Risk factors of SLE

A
  1. F>M (8:1)–> but males have worse dz
  2. 20-30s
  3. nonwhite: white 3:1–> nonwhites have worse dz
  4. etiology unknown but possible genetic, hormonal, immunologic, environmental
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11
Q

Antibody formation with the creation of immune complexes which deposit in tissues–> complement cascade and immune activation
Affects virtually every organ

A

SLE

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12
Q

Describe the initial lab workup of SLE

A
  1. CBC
  2. CMP
  3. creatine kinase
  4. ESR, CRP
  5. UA
  6. 24 hr urine for creatinine clearance
  7. ANA
  8. ANA profile (anti-dsDNA)
  9. Anti-phospholipid Abs
  10. +/- C3, C4, CH50 (lupus nephritis)
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13
Q

What imaging could you get wtih SLE

A

Not routinely recommended unless specific concerns

  1. Pleuritic chest pain–> chest x-ray
  2. Renal impairment –> renal ultrasound
  3. Echocardiogram
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14
Q

Describe the ACR criteria for dx of SLE

A

4+ manifestations

  1. Malar rash
  2. Discoid rash
  3. photosensitivity
  4. oral ulcers (painless)
  5. polyarthritis (2+ peripheral joints w/o erosions, tenderness, swelling)
  6. Serositis (pleuritis, pericarditis)
  7. Renal (proteinuria 3+, cellular casts)
  8. Neurologic (seizure, psychosis w/o cause)
  9. Hematologic (anemia, leukopenia, thrombocytopenia)
  10. ANA titers >1:160
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15
Q

Common constitutional and mucocutaneous manifestations of SLE

A

Constitutional: Fatigue, fever, weight loss

Mucocutaneous: Alopecia, Raynaud’s, Subacute Cutaneous Lupus

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16
Q

Common MSK and Neurologic manifestations of SLE

A

Musculoskeletal: Avascular necrosis, myositis, joint laxity/disability

Neurologic: Cognitive dysfunction, stroke, peripheral neuropathy

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17
Q

Common CVP, hematologic, and manifestations of SLE

A

Cardiopulmonary: Acute pneumonitis, interstitial lung disease, myocarditis, PHTN

Hematologic: LAD

Gastrointestinal: Esophageal dysmotility, ascites, hepatitis

Vasculitis: Medium and small vessel

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18
Q

How do you monitor SLE with labs

A

Dependent on the patients disease activity (monitored by rheum)

  • CRP and ESR may be normal during a flare or elevated when not flaring
    1. CBC,
    2. . ESR, CRP,
    3. U/A, serum creatinine with eGFR,
    4. anti-dsDNA,
    5. C3 and C4
    6. Kidney involvement -> spot urine protein and creatinine and serum albumin
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19
Q

Describe the tx of SLE

A

*No cure–> need to educate
1. Non-pharm: sun precautions/fluorescent lights–RIT dye, filters, SPF sunscreen, sun protective clothes
and exercise
2. NSAIDS
3. Antimalarials (hydroxychlorquine)
4. systemic steroids
5. Immunosuppresants (methotrexate)

*If pts are on these immunosupressants and come in with a sore throat, you need to start these patients on ABX sooner BC they are immunocompromised

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20
Q

SLE death is secondary to: a

A
  1. organ failure

2. infection secondary to immunosuppresion

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21
Q

SLE has an increased risk of what CA

A
  1. non-Hodgkin Lymphoma– B cell associated
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22
Q

Antibodies directed against either phospholipids or plasma proteins bound to phospholipids
Most of the antigens are involved in coagulation

A

Anti-phospholipid syndrome (APS)

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23
Q

What is the difference between primary APS and secondary APS

A

Primary: Presence of anti-phospholipid (aPL) in the setting of thrombosis
The other components of “CLOT” may be present
2/3 of clots are VENOUS; 1/3 are arterial

Secondary: Presence of aPL without manifestations or in conjunction with SLE
Up to 50% of SLE patients have one or more antiphospholipid antibodies

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24
Q

What are the clinical features of APS: “CLOT”

A

C = Clot

  • Both venous and arterial
  • Lupus anti-coagulant
  • Risk factors: infection, surgery, smoking, OCPs

L = Livedo Reticularis/Lacy rash

O = Obstetrical complications
Recurrent miscarriages >10 weeks

T = Thrombocytopenia
Not severe: 50,000-140,000/microL

25
Q

When do you check for aPLs

A
  1. Standard work-up for hypercoagulation
    (DVTs, PEs, early onset of stroke or MI)
  2. Women with recurrent miscarriages
  3. Patients with SLE

*Refer to hematology or rheumatology for further evaluation

26
Q

Linda is a 45-year-old woman who presents with complaints of dry eyes and dry mouth. She also has noticed a “growth” on both of her cheeks that are not tender but “annoying”. She is concerned because she needs most of her bottom teeth removed due to decay and is worried that she will eventually need her top teeth pulled too.

A

Sjogren’s Syndrome (SS)

27
Q

Immune-mediated chronic inflammatory disorder directed against the exocrine glands of the eyes and mouth. (can be vaginal dryness or anywhere there are secretions)
May involve other organs – hematologic changes, lymphoproliferative disorders, neuropathies, interstitial pneumonitis

A

Sjogren’s syndrome

28
Q

What is the difference between primary and secondary SS

A

Primary: anti-SSA or anti-SSB

Secondary: in conjunction with an autoimmune disease (SLE, RA)

Ie. Primary dx is RA but they have the symptoms of SS

29
Q

Sx of Sjogren’s Syndrome

A
  1. Gritty or FB senstation in eyes
  2. “Sicca complex”–> keratoconjunctivitis sicca (xeropthalmia - dry eyes)
  3. Dry mouth (Xerostomia)
  4. Vaginal dryness
  5. swollen parotid or submandibular glands (non-tender, firm)
30
Q

How can you test tear production for Sjogren’s syndrome

A

Schirmer test

*If <10 then they have a positive Schirmer test and decreased tear production

31
Q

Complications of Sjogren’s syndrome

A
  1. Keratoconjunctivitis sicca leads to Corneal abrasions
  2. Xerostomia (caries, thrush, gingival recession, dysphagia, parotid enlargment)
  3. Vaginal dryness (dysparenuia, bacterial/fungal infection)
32
Q

Describe localized tx for Sjogren’s syndrome

A

Xerostomia: Sugar free lozenges; Oasis; Biotene

Keratoconjunctivitis sicca: Artificial tears; punctoplasty

Vaginal Dryness: Vaginal Lubricants

33
Q

What are systemic tx for Sjogren’s syndrome

A

Xerostomia: Pilocarpine or cevimeline
*Avoid anticholinergic agents

Overall for Exocrine or Inflammatory Disorders: Hydroxychloroquine; glucocorticoids

34
Q

Seronegative Spondyloarthropathies includes a group of chronic inflammatory diseases including:

A
  1. Ankylosing Spondylitis
  2. Reactive arthritis
  3. Psoriatic arthritis
  4. IBD
35
Q

Similar Clinical Characteristics of seronegative sponyloarthropathy conditions

A
  1. Sacroiliitis and spondylitis
  2. Negative RF
  3. Asymmetrical arthritis
  4. Enthesitis (inflammation where tendon/lig inserts on bone)
  5. Extraarticular manifestations
  6. Uveitis
  7. HLA-B27
  8. ANA negative
36
Q

Ankylosing Spondylitis MC occurs in who?

A
  1. M>F 3:1
  2. 20-30s
  3. HLA-B27+ and 1st degree relative with AS = 10-20% develop AS
  4. Most common in Caucasians
  5. SX start in teens
37
Q

Hallmark of AS

A

sacroilitis

38
Q

Describe the inflammatory back pain SX of AS

A
  1. Age <45
  2. Insidious onset
  3. Chronic > 3 months
  4. Morning and nighttime stiffness
  5. Improves with activity
  6. No neurologic symptoms
39
Q

Describe the extraarticular manifestions of AS

A
  1. Uveitis
  2. Aortic insufficiency
  3. IBD
  4. Crohn’s
  5. Restrictive lung disease
  6. Osteoporosis
40
Q

Describe the PE findings of AS

A
  • *Global loss of range of motion in the spine
    1. Schobers (line on back test)
    2. Occiput to wall (cannot stand up bc back is fused)
    3. Chest expansion
    4. Patrick test – Fabers Maneuver: Flexion, abduction of hip laying down and push down on hip
41
Q

Describe the Schobers test for AS

A
  • Find the dimples of venus and put a line on their back
  • Use a ruler and go 5 cm down and then go 10 cm above the line
  • Then have them bend down and touch toes and the top line should grow 5 cm for a total of 20cm or more from stretching
42
Q

How do you dx AS

A
  1. CRP
  2. HLA-B27 (2% of HLA-B27+ develop AS)
  3. Xrays
    - Abnormal appearing SI joint = Hallmark
    - Widening, erosions, sclerosis or ankylosis
    - If normal x-rays but high index of suspicion –>
  4. MRI WITH CONTRAST (if they have inflammation it will light up)
43
Q

Describe the tx of AS

A
  1. PT and ROM exercises
  2. Stop smoking
  3. NSAIDs initially
  4. Sulfasalazine and methotrexate for peripheral arthritis (Ineffective for axial disease)
  5. Anti-TNF alpha therapy for axial arthritis

*rheum should manage

44
Q

What are poor prognostic factors for AS

A 
1. HIP INVOLVEMENT* OR
3+ of the following
2. Onset < 16 years of age
3. Limitation of spine motion
4. Oligoarthritis
5. Sausage digit
6. High ESR or CRP
7. Poor benefit from NSAIDs

*~35% of patients have an aggressive course

45
Q

Descibe some of the major differences btwn AS and low back pain

A
  1. frequent nocturnal pain,
  2. improve w/ exercise,
  3. morning stiffnes >1hrs
  4. SI joint tenderness
  5. Decreased chest expansion
  6. loss of back mobility in all planes (not just flexion)
46
Q

reactive arthritis most commonly occurs in who

A
  1. M>F 10:1
  2. 20-40s
  3. Caucasians> other races
47
Q

Signs/sx of reactive arthritis

A 
Initially:
1. GI Infection (salmonella, shigella, campylobacter, yersinia) OR
2. GU Infection (chlamydia)
Followed by:
3.Urethritis
4. Conjunctivitis
5. Arthritis (enthesitis)

*ASK ABOUT TRAVEL AND STD HX

48
Q

PE Findings with reactive arthritis

A
  1. Asymmetrical LE involvement
  2. Asymmetrical sacroiliitis
  3. Sausage digits
  4. Enthesitis
  5. Rash (keratoderma blennorragica, circinate balanitis, oral, nails)
  6. Sores on penis
49
Q

Tx of reactive arthritis

A
  1. PT
  2. intraarticular steroids
  3. NSAIDs
  4. Sulfasalazine, methotrexate (used less frequently)
  5. Anti-TNF alpha agents
50
Q

How do you tx Chlamydia that causes reactive arthritis

A
  1. Treat with doxycycline for 3 months
  2. More likely to have recurrent attacks
  3. Check for HIV
51
Q

Psoriasis is usually present __ years prior to the development of psoriatic arthritis (70% of the patients)

A

10

M=F (30-50s)

Genetic component
1st degree relatives of a patient with psoriatic arthritis have a 50x increased risk

52
Q

Severity of skin disease ___ correlate with the severity of arthritis

A

does NOT

53
Q

What are MSK findings of psoriatic arthritis on PE

A
  1. Arthritis (DIP**)
  2. Oligoarthritis
  3. Symmetric polyarthritis
  4. Dactylitis/sausage digits
  5. Enthesitis
  6. Tenosynovitis
  7. Sacroiliitis/spondylitis

*It can look like RA but the DIP Is affected (DIP is not affected In RA)

54
Q

What are Cutaneous and extraarticular findings of psoriatic arthritis on PE

A
  1. Psoriasis
  2. Nail pitting
  3. Onycholysis
  4. Conjunctivitis/uveitis/iritis
55
Q

Tx of Psoriatic arthritis

A
  1. Joints: NSAIDs or Methotrexate
  2. Skin: Hydroxyurea-
    Antineoplastic agent used for skin disease
  3. Joints and Skin: Anti-TNF alpha agents (Enbrel, Humira, Remicade)
56
Q

Describe the prognosis of psoriatic arthritis

A

40-50% have deforming arthritis

Increased mortality compared with the general population

57
Q

What is the association between IBD and arthritis

A

39% of Ulcerative Colitis and Crohn’s patients have peripheral inflammatory arthritis

  • Possible infectious trigger
  • Association with HLA-B27
58
Q

Peripheral arthritis w/ IBD tends to be in __

A

large joints and is not severely destructive

Adult Clinical Medicine (26 decks)

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