Rheum Flashcards
causes of acute joint pain (typically just 1 joint)
trauma
infection
crystal
reactive
athrocentesis of OA
serous
<2000 WBCs, 25% PMNs
no crystals
athrocentesis of septic joint
pus opaque white fluid
>50,000 WBCs
+ gram stain and culture - if no staph check for gonorrhea
arthrocentesis of inflammatory joint
cloudy
>2000 - <50,00 WBCs (10,000)
>50% PMNs
+/- crystals
+ ANA =
SLE
+ RF
RA
+ anti citrullinated c peptide
RA
+ ds DNA ab
SLE and lupus nephritis
+ Anti histone ab
drug induced lupus
+ anti centromere
scleroderma
CREST
+ topoisomerase (Scl 70)
systemic scleroderma
+ smooth muscle ab
autoimmune hepatitis
anti Ro
anti La
sjogrens
anti Jo ab
polymyositis
dermatomysositis
anti mitochondrial ab
Primary biliary sclerosis
SLE path
autoimmune complex
F > M
Black > white
SLE presentation
4/11
Malar rash - butterfly - (spares nasolabial folds) Discoid rash Serositis (pleuritic CP) Oral ulcers Arthritis (large joints) Photosensitivity (sunburn) Blood (amenia, thrombocytopenia) Renal failure (nephritis) ANA + Immunologic Neuro (cerebritis, psychosis, AMS)
complications of SLE
endocarditis - vegetations on both sides of the valve
ESRD
Miscarriages
dx of SLE
1st - ANA (sensitive but not specific)
2nd - ds DNA (nephritis), anti smith, antihistone (drug induced)
ESR and CRP
complement levels - low C3 and low C4
tx of SLE
hydroxychloroquine - ADR - retinopathy
steroids (flare)
nephritis - IV cyclophospamide –> oral mycophenolate
drug induced lupus
path and pt presentation
path - antihistone
presentation - rash and pain after taking a medication
dx and tx of drug induced lupus
- medication reconciliation
- antihistone ab
tx - remove offending agent
medications that cause drug induced lupus
hydralazine
procainamide
methyldopa
lupus nephritis
path and pt presentation
path - ds DNA abs
pt - asx - U/A micro –> proteinuria
or
pt - HTN, massive proteinuria, hematuria
dx and tx of lupus nephritis
dx - biopsy
tx - IV cyclophosphamide –> oral mycophenolate
path of RA
autoimmune (F>M) [45 years old]
pannus grows –> erosions of joint
Dx criteria for RA
joints morning stiffness >60min nodules imaging blood - CCP>Rf
joints in RA
small joints affected - hands and feet
swanneck deformities
crooked bent fingers
> 3 joints = symmetric
NO DIP involvement
nodules in RA
late finding in dz
biopsy –> cholesterol
imaging in RA
morning stiffness + C1 and C2 pain –> c spine x-ray
erosions, periarticular osteopenia
tx of RA
NSAIDs (ibu, meloxicam) - (never monotherapy)
+
DMARDs - 1) MTX, 2) leflunomide, 3) hydroxycholoroquine 4) sulfasalizine
- combine DMARDS before you go to biologics
- pregnant use (3) or if no erosion present
tx of Severe RA
NSAIDS + DMARDs + Biologics (TNF alpha inhibitors) - inflixumab, rituximab, etanerept)
before giving biologics - vaccinate, test for tb, fungal exposure?
+/- steroids if flare (prednisone)
FELTY syndrome
splenomegaly
RA
Neutropenia
scleroderma path
collagen deposition
anti centromere - CREST
anti topisomerase - scl 70
scleroderma CREST
C - calcinosis - HTN
R - raynauds
E - esophageal dysmotility - unrelenting GERD
S - sclerodactyl - no wrinkles, tense,
T - telengiectasias - gi bleed/iron def anemia
complications of scleroderma
Pulmonary arterial HTN
Constrictive pericarditis
Slceroderma renal crisis - tx = ACE -I
tx of scleroderma renal crisis
ACE-I
diffuse cutaneous systemic sclerosis
CREST + visceral involvement
tx of CREST ISSUES
Raynauds –> CCV
esophageal dismotility —> PPI
Sclerodactyl –> Penicillamine
Nephrogenic systemic sclerosis
occurs after receiving Gallidinium and MRI
sjogrens path
lymphoplasmocytic infiltration of the exocrine glands
pt presentation of sjogrens
dry eyes - keratoconjuctivitis - SICA
dry mouth - Xerostomia
parotid swelling
sjogren dx
1st - ANA
2nd - Ro and La abs
3rd schimer test –> can they make tears
tx of sjogrens syndrome
artificial tears
artificial saliva
path behind dermatomyositis and polymyositis
dermatomyositis –> complex deposition dz - risk of malignancy
polymyositis –> T cell dz
presentation of polymositis and dermatomyositis
proximal muscle weakness
heliotrope rash - face
gottrons papules
dx of polymyositis and dermatomysotis
increased CK –> EMG –> biopsy (best)
abs - anti Mi and anti Jo
things that increase uric acid
etoh
red meat/ seafood
fructose
pseudogout
(+) birefringent
rhomboid shape
costocalcinosis
calcium pyrophosphate
tx of pseudogout
colchicine
NSAIDs
Steroids
gout
(-) birefringent
needle shaped
monosodium urate
- decreased elimination - tx - propenecid
- increased production - tx - rasbirucase
tumor lysis syndrome can lead to
increased production of uric acid
prophylaxis with IVF and allopurinol
management of Gout
lifestyle modifications
allopurinol or febuxostat
colchicine (#1), NSAIDs, steroids
things that lead to gout
Tumor lysis syndrome
CKD
alcohol
thiazide diuretics
management of staph infected septic arthritis
naficillin
- unless MRSA –> vanco or linezolid
what type of joints does SLE have a predilection for
large joints
ankylosing spondylitis
M > F
sacroilitis - low back pain - gets better with use - morning stiffness
dx - lumbar spine - bamboo spine
tx - NSAIDs, local steroids, TNF alpha I
psoriatic
psoriasis and arthritis
M > F
nail pitting
tx - NSAIDs, local steroids, DMARDs, TNF alpha I
Reactive
M > F
STD hx
urethretis + arthritis
tendon pain
if conjuctivitis present = reiters syndrome
tx of reactive arthritis
if infectious - azithro or doxy + ceftriaxone
if not infectious - NSAIDs + time
IBD related arthritis
hx of crohns or UC + arthritis
tx - treat the IBD arthritis gets better
giant cell arthritis
path - large vessel dz
Arteries : external carotid, ophthalmic, temporal
Women >50 y/o
jaw claudication, vision changes (amarosis fugax) , temporal tenderness
dx and tx of giant cell arthritis
dx - biopsy granulomas but dont wait for this begin tx
tx - steroids
takaysu arteritis
<40 y/o, also large vessel
aorta and its branches - femoral, subclavian
pulselessness
dx - angiogram
tx - steroids
Polyarteritis nodusa (PAN)
medium vessels, gut renal skin
ASSOCIATED WITH HEP B
mesenteric ichemia, renal failure, purpura or painful nodules
dx and tx of PAN
dx - angiogram -> aneurysms of medium vessels
tx- steroids + cyclophosphamide
mononeuritic multiplex
associated with PAN
painful asymmetric peripheral nerve pain
cryoglobulinemia
small vessel
ASSOCIATED WITH HEP C
palpable purpura
dx –> cryoglobulins, decreased complement
tx - plasmophoresis if severe
steroids and cyclophosphamide
Wegeners
small vessel
ANCA associated
Hemoptysis, hematuria, nose issues
dx -C-ANCA, biopsy –> lung
tx - steroids + cyclophosphamide
Henoch Schloein Purpura
palpable purpura, GI symptoms
dx - biopsy - leukocytoclastic vasculitis
tx - steroids
neonatal lupus
skin lesions cardiac abnormalities (av block, transposition of great vessels) valvular and septal defects
SLE valve issues
libman sacks endocarditis
vegetations on both sides of the valve
C-ANCA
wegeners granulomatosis
P-ANCA
polyarteritis nodusa
lupus anticoagulant
antiphospholipid syndrome
ADR of hydroxchloroquine
retinal toxicity
the most common cause of death in SLE pts
opportunistic infections and renal failure
diffuse scleroderma
rapid onset
widespread skin involvement - more skin involved worse prognosis
antitopoisomerase (scl 70) ab
antiphospholipid syndrome
hypercoagulable states recurrent venous thrombosis recurrent arterial thrombosis recurrent fetal loss thrombocytopenia
anticentromere antibody
limited CREST scleroderma
most common cause of death in scleroderma
pulmonary involvment
complication of scleroderma
occult malignancy
increased risk for NHL
deformities in RA
boutonnier deformities (PIP) swan neck
C1-C2 subluxation and instability
felty syndrome
S- splenomegaly A- arthritis (RA) N- neutropenia T- thrombocytopenia A- anemia
ADR of MTX
bone marrow suppression
elevated LFTs - hepatocellular injury
GI upset, ulcers, stomatitis
mild alopecia
precipitants of acute gouty attack
decreased temperature stress dehydration starvation excessive alcohol intake
features of OA
heberdens nodes
brouchard nodes
radiograph of gout
punched out erosions with an overhanging rim of cortical bone in advanced disease
complications of gout
nephrolithiasis
degenerative athritis
medications to avoid in gout
aspirin - can aggravate it
tynelol no anti inflammatory properties
uricosuric drugs
probenecid
sulfinpyrazone
indicated if <800mg/day uric acid
xanthine oxidase inhibitor
allopurinol
> 800mg/day
dx of pseudogout
joint aspirate - weakly positively birefringet, rod shaped and rhamboid crystals in synovial fluid
calcium pyrophosphate
radiographs of pseudogout
chondrocalcionosis
cartilage calcification
muscles affected in both polymyositis and dermatomyositis
proximal muscle
neck flexors
shoulder girdle
pelvic girdle muscles
unique features of dermatomyositis
heliotrope rash - face - on nasal bridge
gottrons papules - scaly lesions over the knuckles
dermatomyositis has an increased risk for
malignancy
muscle biopsy of polymyositis
endomysial
muscle biopsy of dermatomyositis
perivascular and perimysial
tx of fibromyalgia
exercise low intensity
TCS (amitryptilline)
Most common extra articular manifestations in ankylosing spondylitis
anterior uveitis
cardiac (AV heart block and aortic insufficiency)
complications of ankylosing spondylitis
restrictive lung dz cauda equina syndrome spine fracture with cord injury osteoporisis spondylodisetis
reiter syndrome
athritis
conjuctivitis
urethritis
signs of psoriatic arthritis
sausage digits
nail pitting
churg strauss syndrome
vasculitis of multile organts
prominent resp tract findgins (asthma)
eosinophilia
p-ANCA
wegeners granulomatosis
renal dz - mcc of death
vasculitis predmoninantly involving kidneys and upper and lower resp tract
sinusitis
glomerulonehpritis
ESR high and C-ANCA
behcet syndrome
autoimmune
painful sterile oral and genital ulcerations
eye involvment
bergers diz
smoker
phlebitis
autoamputationa and gangrene risk
