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rheum Flashcards

1
Q

initial clin charac. of arthritis

A

-Acute duration (presenting within hours to
days) or chronic (persists for weeks or longer)
•Number of joints involved: monoarticular,
oligorarticular (2-4), or polyarticular (+5 joints)
-Symmetric or Asymmetric; Additive or
Migratory
•Accurate delineation of involved joints
•Inflammatory or Non-inflammatory

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2
Q

monoarthritis: bacterial inf. of joint space
1. acute
(+ fever, *rapid! dx quickly)
2. chronic
(both can be polyarthritis via hematogenous spread)

A
  1. staph aureus, GABHS, strep pneumo, G- orgs, gonococcal (prec. by migratory tenosynovitis or oligoarthritis assoc. w/ charac. skin lesions)
    chronic:
    lyme disease (other spirochetes), mycobacterial (TB), fungal, viral
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3
Q

monoarthritis: crystal-induced arthritis (painful!)

A

gout: monosodium urate crystals (hyperuricemia)in articular space–>rel. cytokines
pseudogout: calcium pyrophasphate dihydrate crystals (older, knee/wrist)
chronic:
calcium apatite crystals

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4
Q

other common causes of acute monoarthritis

A 
trauma
hemearthrosis
-older-falls, athletes
-coagulopathies, anticoags. 
-dx: arthrocentesis
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5
Q

chronic monoarticular pres. of oligoarthritis/polyarthritis

A 
spondyloarthropathy (affect spine and joints)
gout/pseudogout
ulcerative arthritis
rheumatoid arthritis (mostly poly)
lupus, other syst. AI dis
(mostly poly)
foreign body
pigment synovitis (tumor)
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6
Q

psoriatic infection

A

commonly unilateral

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7
Q

rheumatoid

A

symmetrical/bilateral
small jts in hands PIPs, MCPs, DIPs*rare
pas young women 20-30

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8
Q

migratory polyarthritis

A

rheumatic fever, post streptococcal, GC (can start as tenosynovitis)

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9
Q

osteoarthritis

A

around 50-70 yo (onset)

presents as unilateral painful hip, non-inflammatory,

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10
Q

common ddx of acute polyarthritis >5 joints

A

acute viral inf. (parvovirus, influenza, chiquengunya) (+ fever)
early disseminated lyme disease
Hep B,C
rheumatoid arthritis (symm. PIPs) (y. women)
SLE

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11
Q

uncommon ddx of acute polyarthritis

A

paraneoplastic polyarthritis
remitting seroneg. symm. polyarthritis w. pitting edema
acute sarcoidosis, (typ. w. erythema nodosum and hilar adenopathy)
adult: onset
still disease
secondary syphiilis
syst. AI diseases, vasculitides, whipple

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12
Q

psoriatic arthritis

A

ask pt if have psoriasis
skin disease (elbows, knees, scalp) *can hide
acute, oligoarticular, asymmetrical

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13
Q

SLE

A

AI, jt pain in young women, fever, malor rash (classic)

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14
Q

palpable purpura

A

hemorrhagic
think vasculitis: inflamm. BVs, polyarthralgia (no inflamm), typ. LE, ulcerated
henochschonlein purpura: kids, abd pn, nephritis, hematopesia?

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15
Q

GC infectious arthritis

A

pustule w/ arthritis

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16
Q

reactive arthritis

A

had infection, reacted w. arthritis
“can’t see, can’t pee, can’t climb a tree”
diarrhea, urethritis, salmonella, w/ inflammatory arthritis

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17
Q

think about septic joint w.

A

monoarticular arthritis

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18
Q

Still disease

A

kids: acute polyarticular onset JRA, splenomegaly, fever, rheumocytosis, rash
adults: 20-30s, FUO 6 wks, 102-104 fever, typ. rash, neg labs, hepsplenmeg, look for inf. dis.? ca?

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19
Q

inflammatory bowel–>arthritis

A 
ulcerative colitis, Crohn's
skin rash (erythema nodosum)
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20
Q

neodosum - sign of something else, can pres. w/ polyarthritis

A 
sarcoidosis
IBD (pres. w. polyarthralgia)
OTC
preg
follow strep, meds
med rxn
Sjogren's
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21
Q

sarcoidosis

Loepren’s? syndrome

A 
starts in lungs, get CXR
acute: arthritis in ankles, rash 
whites
diff than chronic
dx. with CXR, bilat hilar adenopathy
tx: steroids
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22
Q

paraneoplastic arthritis

A

remote effects of ca
HLA
(SmCC–>sec PTH, ACTH)
see clubbing, esp. w/ smoker–>CT/CXR

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23
Q

familial mediterranean fever

A

uncommon,

acute mono arthritis in knee/hip, acute abdominal

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24
Q

synovial fluid

A

made by synoviocytes
plasma infiltrate
lubricant/cushion
viscoelastic

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25
Q

arthrocentesis

A 
sampling synovial fluid, looks turbent if abnormal (classed)
clear is normal (or noninflamm: OA, trauma)
Class I (WBC 2000 WBC: inflammatory
gout, pseudogout, rheum, psoriatic, reactive, colitic, etc.
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26
Q

higher white count

A

Class II +

more turbent-septic if pustular (or crystals), higher WBC

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27
Q

septic joint

A

v. turbent, > 80,000 WBC

dirty yellow

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28
Q

red-sanguinous or

seroussanguinous

A

coag., trauma, blood disorders (hemophilia)

WBC: 200-2000

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29
Q

may get PCR if suspect

A

lyme, TB

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30
Q

cytology

A

rarely unless suspect malignancy

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31
Q

normal synovial fluid does NOT

A

clot

no clotting factors can get into synovial fluid unless inflammation

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32
Q

synovium

A

“egg-like”

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33
Q

major comps of syn. fluid analyses

A

fluid clarity and color
det. cell count
exam. for crystals
obtain Cx

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34
Q

joint aspiration and injection (if not septic)

A

Perform Aspiration when septic arthritis is suspected
because synovial fluid cell count, Gram stain, and culture
are necessary to establish or exclude joint space infection
• Analysis diagnostic in crystalline arthritis
• Synovial fluid white cell count most reliable means of
distinguishing inflammatory from other forms of arthritis
• Injections with glucocorticoids are swiftest way to provide
relief to patients with inflamed joints

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35
Q

eburnation

A

loss of cartilage, deteriorates
-PIPs, DIPs, almost never MCPs (exc. 1st MCP), hips, knees, lumbar, cervical spine
can form osteophytes–
->can cause reticulopathy, pinched nerve, sciatica, radiculopathy

36
Q

osteoarthritis

A

-A degenerative disorder with minimal articular
inflammation
•No systemic symptoms, no fevers, rashes
•Pain relieved by rest; brief morning stiffness (60 w. rheum)
•X-ray findings: narrowed joint space (loss of cartilage), sclerotic (lose cushion): looks whiter
(bone on bone, abn. stress) osteophytes, increased density subchondral
bone, bone cysts

37
Q

osteoarthritis continued

A

• Absence of prominent constitutional symptoms
• Examination notable for increased bony prominence at
the joint margins, crepitus or a grating sensation upon
joint manipulation, and tenderness over the joint line
of the symptomatic joint
• Diagnosis supported by radiographic features of joint
space narrowing and spur (or osteophyte) formation

38
Q

s/s osteoarthritis

A
  • Joint pain that increases with activity
  • Morning stiffness that is relatively brief and self limited
  • Crepitus(a grating sensation with motion)
  • Bony enlargement at the joint margin
  • Tenderness to palpation over the joint
  • Non-inflammatory synovial fluid (
39
Q

risk factors osteoarthritis-primary

A 
age
female
obesity
high bone mass
occupations req. physical labor
fam hx
40
Q

risk factors osteoarthritis-secondary

A 
joint sx
crystal arthritis (chondocalcinosis, gout)
inflam. arthritis (RA, septic)
acromegaly
hemochromatosis
hyperchromatosis
hyperPTH
hypermobility (Ehlers-Danlos)
trauma, stress
Pagets
41
Q

lumbar canal stenosis can cause pseudoclaudication

A

pressure on nerve roots, not vascular problem

42
Q

2 helpful labs in RA

many presentation, labs are supportive

A

ID crytalloid joint
Positive Cx
*need to be able to interpret, do not “shot-gun” labs

43
Q

rheumatoid factor

A

IgM, IgG
order lab, but cons: lots of other disease cause + (list)
bac. endo, sarcoidosis, Sjogrens, TB, pulm. fibrosis, leprosy, silicosis, polymyositis, dermatomyositis, syphilis, asbestosis, scleroderma, Hep C,B, Ca, ANCA-assoc. vasculitis, polyarteritisnodosa, viral*, primary biliary cirrhosis, parasite

44
Q

parvovirus

A

polyarthralgias, can pres. w. + RF

45
Q

+ RF: always screen for

A

Hep C

46
Q

ANAs

A

anti-nuclear Abs, ab in pt serum binds to hum epi cell (Ag)–>secondary Ab–>immunofluorescence
“ana patterns”
rim pattern: anti-DNA (SLE)
homogenous: non-spec.
nucleolar: scleroderma, sjogrens
speckle: SLE, sjogrens, MCTD
others: ELISA
*can get false neg., highly sensitive, low specificity
-DNA is more specific (+ is helpful) but maj. of + SLE pts will have - DNA (not v. sense)

47
Q

“CREST” acronym

A 
anti-centromere pattern (local slceroderma)
Calcinosis
Esophageal dysmotility
Sclerodactyly
Telangectasia
w. centromere staining pattern
48
Q

drug induced lupus

A

ANA +, DNA -, anti-histone +

i.e. hydrolyzine for heart failure/HTN

49
Q

RA

A

AI, inflamm. of synovium, infilt leukocytes
highly destructive, cytokines/ILs produced, unknown cause
periosticular ostepenia: bone loss, cartilage destroyed, narrow/closed joints
*tx as fast as you can!
can alter not cure process

50
Q

meds in RA

A

anti-TNFs: infliximab, etanercept, adalimumab, certolizumab, golimumab
anti-IL-1s: anakinra
anti-IL-6s: tocilizumab

51
Q

RA

A

young women, 20-30s Chronic symmetric polyarthritis
•Symptoms start in PIP, MCP, and MTP joints
•Serum rheumatoid factor, antibodies to anti-
CCP(specific), or both in 70%
•Radiographic changes include juxtaarticular
erosions and joint space narrowing (early on normal)

52
Q

RA manifest.

A

Gender: Female (3:1 ratio)
• Age: Late childbearing years in women (60s-80s in
men)
• Insidious onset
• Symmetric distribution in small joints (MCP, PIP, and
MTP joints)
• **Spares DIP joints
• Joint stiffness worse in morning, pain, swelling
• Fatigue, weight loss, occasional low grade fevers

53
Q

RA Lab tests

A

anemia, elevated ESR or CRP or both, elevated platelets,

thrombocytosis, positive rheumatoid factor in 60-80%

54
Q

DMARDS: RA tx

A 
hydroxychloroquin
sulfasalazine
*methotrexate* (anti-folate)-most common, anchor drug
lefunomide
azathioprine
55
Q

steroids: RA tx

A

methylprednisolone:
sev. organ-threatening disease flare: RA, SLE, syst. vasculitis
prednisone:
giant cell arteritis, inflamm. myopathy, polymyalgiarheumatica, RA flare or bridge tx for SLE flare
*long-term high dose: many SEs

56
Q

biologic drugs if DMARD unsucc: RA tx

A 
infliximab
etanercept
adalimumab
golilmumab
certolizaumab
rituximab
abatacept
tocilizumab

SEs: fever, bad cough–>call! sig. risk of bac/fungal inf
$$
highly effective
usually added when not responding to methotrexate
earlier the better, but don’t give out readily

57
Q

suggested monitoring guide for RA drug tx (RA)

A 
(may include CBC, BUN, Cr, LFTs, UA, eye exam, BP, bone dens, glucose, fasting lipids, Hep B,C, albumin)
NSAIDs 
glucorts
hydroxychloroquine
methotrexate
sulfasalazine
leflunomide
azathioprine
mycophenolatemofetil
cyclophosphamide
biol. tx (immun. stat, PPD/Quant)
58
Q

other conditions can look like RA

A 
arthritis with...
radiographic erosions
\+ rheumatoid factor
nodules
MCP and wrist joints (hemochromatosis, Ca phos deposition)
59
Q

pts. w/ lupus, RA

A

at risk for dev. secondary sjogren’s

60
Q

primary sjogren’s

A 
dry eyes, dry mouth
see chart
*more serious than primary
interstitial lung disease, kidneys, brain
AI-->lymphoma* 
women in 20-30s
can be manifest. of RA
61
Q

SLE

A

• Predilection for females of childbearing age
• Multi-system disease, often with a relapsing-remitting course
• Photosensitive rash, polyarthritis, serositis, and fatigue
• Renal disease and central nervous system involvement
are important causes of morbidity
-CNS: psychosis, hallucinations, seizures, depression, dementia
• Presence of antinuclear antibodies
• Certain autoantibodies(anti-dsDNAand anti-SM) have
a greater specificity for diagnosis of SLE, but lack
sensitivity
• Hypocomplementemiamay occur during flares

62
Q

clin manifest of SLE

A

see chart
“great masquerader”
i.e. rash, lymphad, polyarthritis, pericarditis, endocarditis, pleurisy, pneumonia, peritonitis, hep, pancreatitis, glomnephritis, leukopenia, anemia, etc.

63
Q

drug induced lupus

A
  • Chlorpromazine
  • Hydralazine** (vasculitis)
  • Isoniazid
  • Methyldopa
  • Minocycline
  • Procainamide
  • quinidine
64
Q

lupus nephritis

A

+proteinuria +hematuria
use steroids, tx early to prevent scarring of kidneys (glomeruli) from lupus, want to prevent
–>renal failure, need transplant

65
Q

spinal tap in Lupus

A

look for neuropsychiatric syndromes (ddx from MS)
(elev. WBC: pleocytosis)
can be MS, many others

66
Q

SLE tx

A

mild: NSAIDs, hydoxychloroquine
mod: corticosteroids, mycophenolate, azathoprine, cyclosporine
severe: IV pulse corticosteroids, cyclophaosphamide, mycophenolate, azathoprine

67
Q

raynaud’s

A

vasospactic
red–>white–>blue
s/s of another disease
think AI illness, thoracic outlet, carpal tunnel (vasc. occlusive disorders)

68
Q

pregnancy

A

causes lupus flares
• The inherently hypercoagable state assoc. with pregnancy can be heightened in pts with the antiphosphoplipid syndrome, with risks for mom and fetus: @ risk for thrombosis, inf/hem. complications
• The diagnosis of anti-phospholipid syndrome is a strong contraindication
to pregnancy

69
Q

rheumatoid arthritis attacks the

A

synovium

70
Q

questions to ask

A 
onset?
how many joints?
symm/asymm?
additive or migratory?
inflamm/noninflamm?
71
Q

swollen painful big toe

A

gout

acute,(pedagra), typ. 1 jt

72
Q

asymmetric, oligoarthritix

A

psoriatic arthritis

73
Q

rheumatoid arthritis

A

symmetrical

74
Q

migratory polyarthritis

A

rheumatic fever
post-strep reactive arthritis
GC arthritis (GC in blood–>tenosynovitis (wrist, migrates to knees, hips)

75
Q

most common non-inflammatory arthritis
typically manifests where?
mono/oligo/polyarthritis??

A 
osteoarthritis
hands, DIP, PIP
>50 yo
monoarthritis (painful knee/hip)
\+/- mild inflammation
76
Q

ddx chronic noninflamm. monoarthritis

A 
*osteo
internal derangements (torn meniscus)
chondromalacia patellae
osteonecrosis (trauma, steroids, etOH)
neuropathic (DM, charcot) arthropathy
sarcoidosis
amylodiosis
77
Q

ddx acute inflamm. oligoarthritis: infectious

A 
dissem. GC infection
non-GC septic arthritis (typ. mono)
bac endocarditis (prev. rheumatic fever, valv. disease) (may have rash)
*IR to bacteria*
viral
78
Q

ddx acute inflamm. oligoarthritis: post-inf

A

reactive arthritis
rheumatic fever (post-strep)
psoriatic arthritis (ext. surface knees, elbow, scalp, CAN HIDE, pts often don’t know)
IBD

79
Q

ddx acute inflamm. arthritis: spondyloarthropathy

A

ankylosingspondylitis

80
Q

anti-Ro/SSA

anti-La/SSB

A

assoc. w. Sjogrens, SLE, neonatal lubus, cong. heart block

81
Q

antiphospholipid

A

arterial, venous thrombosis
pregnancy morbidity
hypercoag, strokes
B2-GP

82
Q

organ sp. AI dis. w/ +ANA test

A

AI hepatitis (looks like SLE)
Thyroid disease (Grave’s/Hashimoto’s)
Idiop. pulm. HTN
primary biliary cirrhosis

83
Q

non-AI conditions w/ +ANA test

A 
viral inf (HIV, Hep B,C, EBV)
bac inf (bac endocard)
MTB
blood Ca (AML)
age >65
healthy (up to 10% pop)
drugs (anti-TNFs)
84
Q

SLE labs

A

typically +ANA, not DNA (+w. lupus nephritis)

low complement levels

85
Q

rheumatic dis. in pregnancy

A

most report IMPROVEMENT in jt pain and swelling during prey.

  • pts w. mod-high disease activity do better than low disease (CI!)
  • returns to prior state after giving birth
86
Q

moms w/ anti-Sjogren Abs

screen for SS-Ab

A

can cross placenta and binds heart tissue–>heart block
fetal echo: look for bradycardia, need to be paced when born
-born w/ SLE: fever, rash goes away, heart block can be permanent

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