rheum Flashcards
You see a child with fever, arthralgias, and a rash on his lower limbs (see picture below). What test needs to be done now?
a) Abdominal ultrasound
b) Urinalysis
c) IgA
urinalysis HSP diagnosis Palpable purpura \+ one of the following: 1) abdo pain 2) arthritis/arthralgia 3) bx of tissue showing IgA deposition
- recommends no lab work as its clinical diagnosis but RECCOMEND BP and urinalysis for 6 months after diagnosis, especially those who had HTN/urine abn at presentation as 1-2% can have renal disease and 8% that have HSP nephritis get ESRD
A 3 year old has a history of recurrent fevers for the past year. They occur every 4-12 weeks for 1-4 days each. He has been treated for numerous otitis media and pharyngitis. She is growing well. The likely underlying cause is:
a. multiple viral infections
b. familial med fever
c. CVID
d. Ig deficiency (
viral infxn
The onset of fever and pain (due to serositis at one or more sites) is usually abrupt, peaking soon after onset. Some patients have a stereotypic prodrome before their attacks [2]. Episodes last for one to three days and then resolve spontaneously. Patients are asymptomatic between attacks. The frequency of attacks is highly variable, even in a given patient. The intervals between episodes are irregular, ranging from one week to several months or years.
2 year old child with fever for the past 2-3 weeks (up to 39 C), lymphadenopathy and mild hepatosplenomegaly presents complaining of joint pain. There is no true arthritis, but complains of pain with movement of joints. Hgb 91, WBC 9 (45% lymp, 55% PMN), platelets of 110. What is your next step in establishing diagnosis?
a. BMA
b. Blood culture
c. ANCA, ESR and RF
d. EBV serologies
BMA
the combination of two abnormal parameters on complete blood count (WBC count <4000/microL; platelet count 150,000 to 250,000/microL; hemoglobin <11 g/dL) was 96 percent sensitive and 88 percent specific for ALL.
Criteria for JIA
age onset <16yo
arhtirits
duration for more then 6w
onset type (poly more then 5, oligo 4 or less, systemic if rash and fever)
10 year old girl with migratory arthritis for last 10 days, now affecting left wrist. She is febrile, and has an ESR of 40. Most LIKELY diagnosis is
a. SLE
b. Rheumatic fever
c. JIA
d. Septic arthritis
RF (need GAS)
Jones criteria for RF
JONES CAFE PAL
major
Joint, O =mycarditis, N nodule, E erythema marginatum, Sydenham chorea
MINOR : CRP inc, Arthalria, Fever, elevated ESR, prolonged PR, anamess of rheumatism, leulocutosis
NEED
GAS/ASOT+ 2 major, OR 1 major 2 minor
Rhuematic fever diagnosis
JONES CAFE PAL
major
Joint, O =mycarditis, N nodule, E erythema marginatum, Sydenham chorea
MINOR : CRP inc, Arthalria, Fever, elevated ESR, prolonged PR, anamess of rheumatism, leulocutosis
NEED
GAS/ASOT+ 2 major, OR 1 major 2 minor
2 year old with mild metatarsus adductus and tibial torsion who has had intoeing since birth. There has been no improvement. They are presenting to your office today. The best advice is:
- Reassurance
- Hip, knee, tibia, foot x-rays
- Referral to orthopedics
- Advise them not sit in W position (common in femoral anteversion)
reassurance
INTOEING caused by the following (all, or seperate) 1) metatarsus adductus, tibial torsion and femoral anteversion
Increased femoral anteversion — The natural history of in-toeing secondary to increased femoral anteversion is that of spontaneous resolution, usually by 11 years of age.
TIbial torsion should go by 5yo
-metatarsus adductus - goes away by itself
You are treating a teenage boy with pericarditis. You suspect that his pericarditis might be secondary to SLE. Which of the following is most supportive of this diagnosis?
a. Positive RPR
b. Positive ANCA (
c. Positive HLAB27
d. Thrombocytosis
RPR - (test for syphillis, falsely elevated/positive in pt who have lupus due to elevated antintiphospholipid antibodies (lupus anticoagulant [LA], IgG and IgM anticardiolipin [aCL] antibodies; and IgG and IgM anti-beta2-glycoprotein [GP] I)
ANCA=usually GPA - granulomatosis polyangitis, can also be positive with lupus)
SLE diagnosis
SLE “SOAP BRAIN MD” need 4/11 Serositis – Pleurisy, pericarditis Oral ulcers Arthritis Photosensitivity Blood disorders Renal involvement Antinuclear antibodies (positive in <95%) Immunologic phenomena Neurologic disorder Malar rash Discoid rash
17 year old male with history of enthesis related JIA comes to your office. Just had a new baby girl with his girlfriend and would like to quit smoking for her sake. What puts him MOST at risk of not being able to quit
1) Chronic illness
2) Male gender
3) Older adolescent
4) Parenthood
chronic illness
5yo M with intermittent abdominal pain and purpuric rash on thighs. He has joint pains and hematuria. Which of the following lab abnormalities would likely be present?
a. Thrombocytopenia
b. Schistocytes
c. Elevated IgA
elevated IgA
4yo F with one very inflamed joint for over 1 month, ANA negative, no uveitis. What is the first line treatment for her condition?
a. Methotrexate
b. Systemic steroids
c. NSAIDs
d. IVIg
NSAID
Oligoarthritis defined as involving ≤4 joints within first 6 months of disease onset, often only single joint involved. Predominantly large joints of lower extremities such as knees and ankles.
Positive ANA = increased risk for asymptomatic anterior uveitis, requires periodic slit-lamp exam.
Positive ANA correlated with younger age at onset, female, asymmetric arthritis, and lower number of joints over time.
try injection of intraarticular steroids. Next line would be DMARDs, MTX, and last resort is TNF inhibitors.
NSAIDs rarely induce remission in polyarthritis or systemic JIA.
A 7 year old girl has oligoarticular JIA and has been on methotrexate as maintenance therapy for her disease. She has sudden onset high fever, anemia, thrombocytopenia, and hepatomegaly with elevated liver enzymes. Which of the following is the cause of her current condition?
a. Methotrexate toxicity
b. Macrophage activation syndrome
MAS
dec fibrinogen
dec counts plt/WBC
inc lfts
6-year-old with clinical and laboratory evidence consistent with systemic JIA develops persistent fever, extensive and fixed rash, thrombocytopenia and hyponatremia. What is most likely to decrease:
a) Triglyceride
b) Fibrinogen
c) LDH
d) Ferritin
fibrinogen
You want to start an 11 year old boy with JIA on Infliximab. Which is most important prior to starting this medication?
a) VZV vaccine
b) MMR vaccine
c) Checking for Mycobacterium Tuberculosis
check for mycobacterium
Do not initiate TNF blockade in subjects with history of chronic or frequent recurrent infections. TB should be tested for prior to initiation of therapy with TNF antagonists. If test results are positive, anti-TB treatment must be administered before starting anti-TNF therapy.
Child with recurrent fever, cervical adenitis, aphthous ulcers, pharyngitis. Normal immune work-up. Best treatment
a) oral colchicine x 5 days (FMF treatment)
b) oral prednisone x 1 day
oral predx1 day
PFAPA = periodic fever, aphthous stomatitis, pharyngitis, adenitis
Most common recurrent fever syndrome in children. Recurring episodes of fever, malaise, exudative tonsillitis with negative throat cultures, cervical lymphadenopathy, oral aphthae, and less commonly headache, abdo pain, and arthralgia. Episodes last 4-6 days regardless of treatment (antipyretic/antibiotic), occur regularly on 3-6 week cycles. During episode - mild HSM, mild leukocytosis, elevated acute-phase reactants.
Majority of patients show dramatic response to single oral dose of prednisone (0.6-2.0 mg/kg) although does not prevent recurrent and may shorten interval between flares.. Cimetidine (20-40 mg/kg/day) prevents recurrence in ⅓ of cases. Resolution possible after tonsillectomy.
Girl had fever then swollen extremities, cracked lips. Treated with IVig and ASA then developed anemia and hematuria.
a) Kawasaki IVIG hemolytic reaction
kawasaki IVIG hemolytic
Kid with fevers, salmon rash, HSM (no joint pain).
a) Systemic JIA
b) ALL
systemic JIA
Systemic JIA characterized by:
arthritis - classically polyarticular and destructive
fever - spiking to >39 1-2X/day and returning to normal quickly, often in evenings
rash - classic evanescent salmon-colored lesions which are linear/circular and on trunk and proximal extremities
visceral involvement - HSM, lymphadenopathy, and serositis (pericarditis)
Girl walked and tripped on a curb now has cold, extremity painful to touch
a) CRPS
b) osteomyelitis
CRPS complex regional painn syndrome
noxious event/immbilization with continued pain,allodynia, hyperalgesia, out of proprtion to event
evidence of edema, skin blood flow abnormality, atrophy of hair and weakness
treat with OT/PT
Ankle injury-when to XR
a) Posterior tip of medial malleolus tenderness for XR
b) Anterior tip of lateral malleolus
c) Cant weight bare right after injury
ankle x-ray - if there is pain in the malleolar zone and any of the following:
1 Bone tenderness at the posterior edge or tip of the lateral malleolus, or
2 Bone tenderness at the posterior edge or tip of the medical malleolus, or
3 Inability to weight bear both immediately and in the emergency department
A foot x-ray series is only necessary if there is pain in the midfoot zone and any of the following:
1 Bone tenderness at base of fifth metatarsal, or
2 Bone tenderness at the navicular bone, or
3 Inability to bear weight both immediately and in the emergency department
Girl with JDM, what is the best diagnostic test
a) EMG
b) CK
EMG
Diagnostic criteria:
classic rash (heliotrope rash of eyelids or gottron papules)
plus 3 of the following:
weakness: symmetric, proximal
muscle enzyme elevation (≥1): CK, AST, LDH, aldolase
EMG changes: short small polyphasic motor unit potentials, fibrillations, positive sharp waves, insertional irritability, bizarre high frequency repetitive discharges
muscle biopsy: necrosis, inflammation
JDM criteria
Diagnostic criteria:
classic rash (heliotrope rash of eyelids or gottron papules)
plus 3 of the following:
weakness: symmetric, proximal
muscle enzyme elevation (≥1): CK, AST, LDH, aldolase
EMG changes: short small polyphasic motor unit potentials, fibrillations, positive sharp waves, insertional irritability, bizarre high frequency repetitive discharges
muscle biopsy: necrosis, inflammation
1. Boy with lupus. Most likely test consistent with this Dx A. ANCA+ B. Thrombocytosis C. HLAB27+ D. positive RPR
D. positive RPR
Child in rhythmic gymnastics. Has back pain that is worse on extension. On exam has exaggerated lumbar lordosis, hamstring tightness. Bone scan is positive. What does she have? Spondylolysis Posterior overuse sydnrome Herniated disc ring apophositis
Spondylolysis
14 year old female gymnasts presents with a 2months history of lower back pain on extension. She has tight hamstrings, spasm of her paraspinal muscles, normal sensations and motor function. A bone scan lights up her lumber vertebrae. What is the diagnosis? Spondylosis Posterior Element Overuse syndrome Disk herniation Vertebral body avulsion fracture
spondyloysis
treamtnet with JDM
MUSCLE ENZYMES -elevated alanine aminotransferase most commonly elevated on initial presentation and CK may be normal. Usually ANA positive in 80% of patients
MRI T2 = can be used to help with EMG and muscle biopsy location determination
Treatmentet- steroids and MTX +/- IVIG
. A term baby is born to a mother with maternal lupus. He is noted to have congenital heart block.
a) Name the 2 most common antibodies in congenital heart block.
Anti-Ro (SSA)
Anti-La (SSB)
Name 3 other manifestations of neonatal lupus.
characteristic annular/macular rash affecting face (especially periorbital area), trunk, scalp
hematologic manifestations: anemia, neutropenia, thrombocytopenia
hepatic manifestations: asymptomatic elevated LFTs, mild HSM, cholestasis, hepatitis
neurologic manifestations: hydrocephalus, macrocephaly, neuropsychiatric dysfunction
stippling of epiphyses (chondrodysplasia punctata) on radiographs
18 month old with missed developmental dysplasia of the hip:
a) Name two clinical features of this diagnosis (not sure exact wording)
b) Name one physical exam finding.
Breech presentation Female First born Family history of DDH Any condition that leads to tighter intrauterine space and consequently less room for normal fetal motion: oligohydramnios large birth weight multiples (twins/triplets/etc) Tight swaddling
which ECG change is characteristic of acute rheumatic fever?
A. Peaked T waves
B. Prolonged PR interval
C. Sinus tachycardia
Prolonged PR interval
A 3 year old girl presents with 7 day history of fever. She has bony pain but no arthritis on exam, but she has HSM and diffuse generalized lymphadenopathy. Her blood work shows WBC 18, Plt 110 and anemia. What is the next best step?
A. Bone Marrow Aspirate
B. EBV Serology
C. Work up for systemic JIA
bma
A kid has had 6 days of fever despite treatment with amoxicillin, with no response. He also has cracked lips, nonpurulent bilateral conjunctivitis, and a polymorphous rash. What would you expect to see on his labs?
a. Neutropenia
b. Hypoalbuminemia
c. Elevated ASOT
d. Elevated EBV titres
Hypoalbuminemia
KD-
Fever persisting at least 5 days †
Presence of at least 4 principal features:
Changes in extremities:
Acute: Erythema of palms, soles; edema of hands, feet
Subacute: Periungual peeling of fingers, toes in weeks 2 and 3
Polymorphous exanthem
Bilateral bulbar conjunctival injection without exudate
Changes in lips and oral cavity: erythema, lip cracking, strawberry tongue, diffuse injection of oral and pharyngeal mucosa
Cervical lymphadenopathy (>1.5 cm diameter), usually unilateral
Toddler comes to the ED refusing to weight bear. Xray of leg shows non-displaced spiral fracture of left tibia. Which is most likely? NAI Ricketts Toddler’s fracture Osteogenesis Imperfecta
Toddler’s fracture
8y boy had URTI two weeks ago; now presents with fever >40, unable to weight bear on right leg. WBC is 18, ESR 40 (? I think) and CRP 80. What is next step in management?
Admit and start IV abx
Nsaids
Urgent orthopedic consultation
Urgent orthopedic consultation
13 y.o. Girl presents with antalgic gait and pain for 2 weeks. She has difficulty with rotation and adduction of her leg. X-ray was similar to the one below. What is the diagnosis?
a) Septic joint
b) Calve-Perthes
c) SCFE
d) Fracture
e) Post-infectious
SCFE
14 year old adolescent girl who you haven’t seen in the last 2 years comes in for routine check-up. When she bends forward, you note a large thoracic asymmetry. Spine X-ray shows a Cobb angle of 50 degrees. What do you do next? Repeat X-ray in 3 months Custom thoracolumbar spine brace Spinal fusion Electro-something stimulation
spinal fusion
40 – 50 degrees or more: Surgery may be required to correct the curve. There are several surgical procedures. A frequent recurring procedure is the “spinal fusion”, to link the vertebrae together so that the spine cannot longer continue to curve
Those with Cobb angle of more than 60° usually have respiratory complications
6 yo girl with diagnosis of JIA and pain in one knee. CRP 58. Sedimentation 25. ANA negative. No uveitis. What is the next step in management
a. NSAIDS
b. Methotrexate
c. Intra-articular corticosteroids
d. Oral steroids
nsaids
Girl with systemic JIA well-controlled on methotrexate then re-presents with fever, unwell, rash, liver 3 cm below costal margin. What is the most likely diagnosis MAS Sepsis Methotrexate toxicity Autoimmune hepatitis
MAS
- Kid with JIA and MAS features, what is it?
a. MAS
b. Sepsis
mas
Picture of a 7y boy with completely erythematous face. He’s on fluticasone and phenytoin. What is the most likely diagnosis?
a. Drug hypersensitivity
b. SLE
c. JDM
d. JIA
a. Drug hypersensitivity
. Ankle injury. Indication for xray: [CPS]
a. posterior malleolus tenderness
b. can’t wt bear immediately
c. anterior medial malleolus
posterior mallelos
Kid with FMF, what to give?
a. Colchicine
colc
FMF attacks can last between 12 and 72 hours and consist of inflammation involving the peritoneum, pleura, joints, or skin; sometimes in combination. Between episodes, patients usually feel completely well and remain so for a few days to a few months.
In children, fever may be the only sign of FMF, although other symptoms typically develop progressively with time
Colchicine therapy is highly effective for most patients in preventing febrile episodes and systemic amyloidosis.
A 6y girl presents with arthritis of 3-4 joints at a time. Her ANA is positive. Which is the most likely associated finding?
a. Eye pain
b. Photophobia
c. Unequal pupil
unequal pupil
Synechiae - iris adheres to the cornea. Patients presenting with synechiae typically have an underlying inflammatory disease process such as uveitis
12y gymnast presents with 2mo of lower back pain. The pain is worse for 2-3 days after practice. Her sleep is ok. She gets spasms in her paraspinal muscles. On exam, she has tight hamstrings, normal sensation and motor function in her legs with normal anal tone and sensation. A bone scan lights up in her lumbar vertebra over the location of her pain. What is the diagnosis?
a. Spondylolysis
b. Posterior element overuse
c. Disk herniation
d. Vertebral body avulsion fracture
a. Spondylolysis
- Kid w knee pain
a. Patellofemoral syndrome
Most common symptom - pain beneath or near patella
Classically walking up/down stairs aggravates it
Pain after prolonged sitting with the knee in flexion (“theatre sign”)
(repeat) 148. 5 year old child with Kawasaki disease. What lab finding would you expect
a. Hypoalbuminemia
b. Thrombocyotpenia
c. Low liver enzymes
d. Leukopenia
hypoalbunimiea
