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Rheum Flashcards

1
Q

Define Sensitivity

Define Specificity

What is a good example of one of these types of tests

What is a good examples of these tests

A

Probability of correctly Dx PT w/ Dz

Probability of correctly r/o Dz in PTs w/out a Dz

Sen: ANA lupus
Spec: Anti-dsDNA lupus

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2
Q

What process causes the formation of acute phase responses?

What result is significant

When are ESR values more useful?

A

IL-6, cytokines stimulate liver to synthesize proteins

> 100= Ca, infection, renal/autoimmune dz

Normal (sensitivity test)

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3
Q

What are two presentations that may be normal variants with an increased ESR

When do ESRs have minimal use?

A

Obesity
Pregnancy

Nephrotic syndromes
End stage RDz

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4
Q

What lab result is better than ESR for inflammation/infection indications?

What is an example when a CRP result would be necessary and vital?

CRP is particularly good for tracking ? Dzs

A

CRP- better when accuracy is vital

Steroid tapers

GCA, RA

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5
Q

What are three Dzs that would have a minimal or no CRP elevation?

There is no elevated CRP in Lupus unless ? is present

? Dx can have an elevated CRP w/out any inflammation

A

Poly/Dermatomyositis
Scleroderma

Serositis, Synovitis

Renal failure

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6
Q

What are 3 examples of acute phase reactants?

Which one was used to track progression of COVID?

Define Complement System and number of proteins

A

Ferritin Fibrinogen Platelet

Ferritin, D-dimer

Aids immune system w/ inflammatory/immune response; >30 proteins

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7
Q

What are the functions of the complement system?

What are the 3 pathways of the Complement System

A 
Chemotaxis
Opsonization
Ab response
Leukocyte activation
Cell lysis
Clearing apoptotic cells

Classic Alternative
Mannose binding Lectin

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8
Q

Complement system tends to be reduced in chronic autoimmune and inflammatory states such as ?

These Complement measurements are usually used to monitor ? via ? results

Which part of the system screens for deficiency of the classical pathway?

A 
Cryoglobinemia
Serum sickness
SLE
Vasculitis
Glomerlonephritis
Subacute endocarditis

SLE w/ C3, C4

CH50- total deficiency= complete deficit early in cascade

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9
Q

Although rare, a complete deficiency of C3 is seen in ? PTs

ANA can detect autoantibodies against ?

A

Peds w/ recurrent pyogenic organisms

Histones, DNA, RNP via fluorescence microscopy

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10
Q

What are ANA Titers indicative of

What test is 97% specific for SLE and is rarely present in other conditions or healthy PTs

This result does not appear in drug induced lupus except for ?

A

High Sen, Low Spec:
>1:160- Pos
<1:80- Neg

Anti-dsDNA

Penicillamine
Minocycline
Antitumor necrosis factors

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11
Q

When is the indication to order an Anti-dsDNA

Define an Anti-Smith (Sm)

Define an Anti-U1-RNP

A

DDx of SLE and pos ANA

Abs recognize nuclear proteins that bind to RNA; specific for SLE

Abs recognize complex proteins and nuclear RNA in SLE, MCTDz

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12
Q

When are Anti-Sm and Anti-U1-RNP tests ordered

When are Anti-Ro (SS-A) or Anti-La (SS-B) ordered

When would these be ordered after a negative ANA

A

Concern of Mixed CT Dz

Primary concern for SLE or Sjogrens

Suspected subacute cutaneous lupus or PTs w/ recurrent photosensitive rashes

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13
Q

Mother of children w/ neonatal cutaneous lupus and congenital heart blocks may be ASx but need to be tested for ?

This also needs to be ordered for ? female PTs

A

SLE or Sjogrens

PTs w/ SLE and considering pregnancy

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14
Q

Anticentromere Abs occur in ?

What type of test is Anticentromere Abs

Rheumatoid factor is an Ab directed against ?

A

Scleroderma, CREST

98% specific

Fc region of IgG

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15
Q

Detection of IgM Rheumatoid Factor titers mean ?

Define Sero-Negative RA

A

> 1:40= latex fixation
20 or more= nephelometry

Ab against IgM

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16
Q

What non-RA conditions can have a positive RF?

A 
Cryoglubulinemia
Hep B/C
Elderly PTs
SLE/Sjogrens
Sarcoidosis
Primary biliary cirrhosis
Malignancy
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17
Q

Define Anti-CCP Ab

What is Anti-CCP Ab as strong predictor for?

What combo of lab results is nearly 100% indicative PT will develop RA?

A

Anti-Cyclic Citrullinated peptide Ab; rules RA in earlier than RF in true RA

RA progresstion, joint erosion in PTs w/ early onset, undifferentiated inflammatory arthritis

+ RF and Anti-CCP

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18
Q

What is encompassed in Anti-Neutrophilic Cytoplasmic Ab lab tests

These are highly specific but need ? test to confirm a ? Dx

A

Proteinase-3: GPA
Myloperoxidase- EGP, MPA

Biopsy for GPA Dx

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19
Q

Proteinase 3 is to ?

Myloperoxidase is to ?

A

Cytoplasmic

Perinuclear

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20
Q

Other autoantibodies that are associated w/ ?:

Scl 70
Anti-centromere
Anti-Jo-1
Anti-Mi-2
Anti-Histone
A

Scl: diffuse scleroderma

AC: limited scleroderma/CREST

AJ: dermatomyositis and polymyositis

AM: dermatomyositis

AH: drug induced lupus

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21
Q

Antiphospholipid Abs are AKA ?

What are these Abs associated w/

These contribute to the acceleration of ? and are ordered during ? work up

A

Lupus anticoagulant

Antiphospholipid syndrome- A/V thrombus
Possible SLE

Atherosclerosis
Hypercoagulable

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22
Q

Synovial fluid analysis is performed to exclude what three Dxs

Do not perform this procedure if ?

These results are not usefule for ?

A

Monoarthritis
Infections
Crystal induced arthritis

Bleeding risk
Overlying cellulitis/rash

Polyarthritis

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23
Q

What are the tests included when ordering synovial fluid analysis?

What does it mean if results come back w/ <2K cells, >2K cells or hemorrhagic?

A 
Gram stain
Culture
Cell count w/ diff
Polarized microscopy
Glucose/LDH/protein
<2K: OA
>2K: +crystal= pseudo/gout
- culture= RA AS PsA SLE
\+ Gram/Culture= SA
Hem: Tumor TB Trauma
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24
Q

What lab tests would be useful for monitoring SLE and are AKA the “Five fingers of Lupus?

What one would not be useful?

A 
Chemistry 
UA 
CBC 
Complement 
AutoAb (ds DNA)
((ESR C3 C4 Anti-ds DNA))

ANA

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25
Q

Pt w/ back stiffness, blurred vision, photophobia and uveititis needs ? lab ordered?

PT w/ suspected SLE from Sxs/PE needs ? test ordered w/ ANA for confirmation

A

HLA-B27- Ankl Spondyl

Anti-Smith Ab and,
Anti-ds DNA

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26
Q

Define Seronegative Spondyloarthropathy

This group is referred to as such based on the absence of ?

What are the 4 conditions within this category

A

Dzs characterized by inflammation of:
Uveitis Sacroiliitis Enthesitis Spondylitis

No RF or Abs associated w/ conditions

Psoriatic arthritis
Ankylosing spondylitis
IBS associated arthritis
Reactive arthritis

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27
Q

What is the epidemiology of Ankylosing Spondylitiis

What PT populations are at increased risk for developing this?

A

White M, possible Native American/Eskimo, w/ HLA-B27 w/ insidious onset in late teen/early 20s

1st degree relative w/ AS

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28
Q

How does Ankylosing Spondylitis present

What condition is rarely seen in PTs w/ Ankylosing Spondylitis

What are extra-articular manifestations that may be seen in Ankylosing Spondylitis

A

Worse w/ rest, pain at night
Abnormal FABER/Schober
Transient peripheral arthritis- hip, shoulder, knee

Cauda Equina

Ant uveritis- presenting Sx
AV blocks- MC 1*

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29
Q

What will be seen on lab results in PTs w/ suspected Ankylosing Spondyltitis

What causes the ‘bamboo spine’ appearance?

A

Inc ESR
Anemia
+ HLA-B27 90%

Syndesmophytes- bony growth from in ligament, leads to vertebral fusion

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30
Q

PT is Dx w/ Ankylosing Spond if one clinical and one radiological parameter including ?

What are the 4 grades for classifying Ankylosing Spondylitis

A 
Low back pain/stiff x 3mon 
Dec lumbar movement 
Limited 4th ICS expansion 
Sacroiliitis- unilateral 3-4
Bilateral grade 2-4

1: Irregular SI/facets
2: Erosion, sclerosis
3: Erosion, sclerosis w/ widening SI joints
4: ankylosis of both SI joints

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31
Q

How is Ankylosing spondylitis Tx

A

First line- NSAIDs

DMARDs: Early dz w/ peripheral joint involvement- Sulfasalazine

TNF-I: Etanercept I/A/G-umab (PT refractory/two NSAID trials)

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32
Q

? Ankylosing Spondylitis presentation has a worse prognosis

What environmental factor has large prevalence w/ AS back pain?

What is the phrase for Reactive Arthritis due to their post-infectious triad these presentation of ?

A

Hip dz <2yrs of onset

Tobacco cessation

Conjunctivitis- cant see
Arthritis- cant bend knees
Urethritis- cant pee

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33
Q

What are the essentials of Dx for Reactive Arthiritis

Where in the body/how do these cases present

A

Inflammatory arthritis triggered by GI/GU infection

Dactylitis
Oligoarthritis- MC in LE
Mucocutaneous lesion- variable
Enthesitis

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34
Q

? is the MC cause of inflammatory arthritis in young men

How does gender ratio differ for reactive arthritis epidemiology

What would be seen on joint fluid analysis?

A

Reactive arthritis

STI: M>F, chlamydia
Enteric: M>F,
Campylobacter Salmonella Dysentery Yersinia Ecoli Shigella

Bacterial Ags, not organisms

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35
Q

How long after infection does it take for Sxs to present and where

Reactive arthritis frequently has ? common recurrence and ? if frequent recurrence

? is the prominent feature of reactive arthritis and where/how is it seen on PE

A

<28d after Dysentery/Chlamydia
LE: knees, ankle, feet

Common: joint arthritis
Frequent= spondyl/sacroiitis

Enthesitis- Plantar fascia Achilles Pelvis w/ warm TTP

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36
Q

What causes Dactylitis in Reactive Arthritis

Dactylitis is a feature of spondyloarthropathies usually seen in ?

What are the three mucocutaneous features of Reactive Arthritis

A

Sausage digit- toe*/finger synovitis and enthesitis

Reactive/Psoriatic arthritis

Circinate balanitis- characteristic; painful inflammatory lesion of glans/shaft
Keratoderma blennorrhagica- papular waxy rash on palms/soles
Aphthous ulcer- shallow painless on mucosa

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37
Q

What microbes are tested for in STI etiology of Reactive Arthritis

What microbes are tested for GI etiologies

A

G/C, HIV

Salmonella Shigella Yersinia
Campylobacter

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38
Q

How is Reactive Arthritis Tx

What meds are considered if PT fails initial medical therapy

What part of Reactive Arthritis may relapse years later?

A

Ibuprofen: first line
Injections- peripheral joints
Systemic steroids- axial Sxs

Sulfasalazine or Methotrexate

Urethritis Uveitis Arthralgia

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39
Q

Define Psoriatic Arthritis

What would be seen on PE

In almost all cases ? precedes that arthritis

A

Chronic inflammation of skin/nail w/ DIP arthritis

Dactylitis- MC in toes
Nail dystrophy- characteristic

Psoriasis

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40
Q

What are the 5 patterns of Psoriatic Arthritis

A

DIP- distinguishes from RA

Arthritis mutilans

Psoriatic spondylitis

Asymmetric oligo- hand/feet (MC)

Symmetric polya- mimics RA

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41
Q

What will be seen on Psoriatic Arthritis x-rays?

How is Psoriatic Arthritis Tx

The use of ? med in psoriatic arthritis can precipitate severe flare ups

A

DIP w/ arthritis mutulans
MCP MTP Phalange- periostitis

NSAIDs- first step/mild case
DMARDs- second line: Methotrexate, Sulfasalazine
TNF inhibitors-
CAGI-umab/Etanercept

Systemic glucocorticoids w/ Rheum/Derm supervision

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42
Q

What is the difference in quality of arthritis between PA and RA

Define Enteropathic Arthritis

What are the two types of Enteropathic Arthritis

A

Less in PA than RA

Arthritis associated w/ Crohns>UC

Peripheral- acute, early; MC- knee
Flare ups parallel IBD severity

Spondylitis- indistinguishable from AS based on Sx/X-ray
Severity differs from IBD

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43
Q

How is Enteropathic Arthritis Tx

What needs to be avoided in these PTs

What is the prognosis for PTs Dx w/ Enteropathic Arthritis

A

Tx IBD
Persistent- Sulfasalazine
Sulfa failure- Anti-TNF

NSAID- exacerbates IBD

Excellent for arthritis
Poor for IBDz

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44
Q

Define Rheumatoid Arthritis

What part of the body does it cause destruction in?

This form of arthritis is the MC ?

A

Chronic systemic inflammatory dz targeting synovium

Juxta-articular erosion

Inflammatory arthritis in 1% of world population

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45
Q

What age prevalence does RA affect the most?

PTs w/ RA are at risk for ?

Why do these PTs have higher mortality rate?

A

M: 50-70s
F: 30-40s

Septic arthritis Osteoporosis
Lymphoma, NH/B-cell

CV dz

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46
Q

Genetic factors that cause RA mostly involve ?

Associated risks w/ Abs against ?

What are external triggers that could cause RA?

A

T-cell activation from cytokine signaling

Citrullinated protein epitopes
Citrullination- modified conversion arginine to citrulline

Smoking Infection Periodontitis

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47
Q

Since RA has a prevalence in twins, what type is more likely to develop it?

What autoimmune factors play a role in it’s development?

Once established in the body, what type of damage does RA cause?

A

Monozygotic>Dizygotic

RF/Anti-CCP Abs
Activated T/B cells and complement in synovium

Pannus- hypertrophy/inflamed synovium of RA

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48
Q

Direct synovial infections by ? microbes can cause RA?

How does RA present

What part of the body does it effect first?

A 
Parvovirus B19
Retrovirus
Enteric bacterial infection
Mycoplasma/bacterial
EBV

Symmetric polyarthritis w/ insidious onset and strong FamHx component

PIP MCP and MTP
(sero negative- in DIPs)

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49
Q

What PE finding is essential for RA Dx

What is the sequence of synovitis involvement of RA

What is the hallmark of RA

A

Bilateral symmetric hand/wrist arthritis worse in AM

Wrist Knee Elbow Ankle Hip Shoulder

Morning stiffness x hrs
Improve w/ movement

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50
Q

What are late complications of RA usually seen in the hands?

Why is the risk for neck involvement w/ RA so important to ID pre-op?

A

Boutonniere
Ulnar deviation- MCPs
Swan neck deformity

Cord injury w/ intubation
Prevent AAD/C1-2 subluxation

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51
Q

Tendon positioning of Swan Neck deformity

Tendon positioning of Boutonniere deformity

Define Felty’s Syndrome triad

A

DIP flexion/bent
PIP hyper extension

DIP hyper extension
PIP flexion

RA Splenomegaly
Luekopenia (neutro) <2000

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52
Q

What type of lab results would be seen in PTs w/ RA induced Sjogrens Syndrome?

RA PTs are at increased risk for ? post-op complication

They are also at risk for ? spontaneous infection especially if on ? med

A

Anti-Ro/La (SSA/SSB) negative

Knee/hip joint infections

Septic arthritis, A-TNFs

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53
Q

What are the old criteria used for Dx RA

What is the new criteria used?

A 
4 of 7, first 4 x 6wks:
Serum RF
Morning stiffness
Arthritis x 3 joint areas
Symmetric arthritis
Hand arthritis
Rheumatoid nodules
Radiographic changes
6 out of 9 points across four domains:
Joint involvement-5
Acute phase reactant-1
Serology- 3
Synovitis duration-1
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54
Q

What type of RA has a better prognosis

Felty’s Syndrome must be distinguished from ?

Felty’s PTs also have increased ? and ? related to leukopenia

A

Seronegative RF

Large Granular Lymphocyte Syndrome- indolent leukemia

Bacterial infections
Non-healing ulcers

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55
Q

What would be seen on PE of RA PTs

What labs are ordered

What x-rays should be ordered?

A

Synovitis Nodules Splenomegaly

RF Anti-CCP CBC ESR/CRP
ANA- r/o lupus

Hand/wrist

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56
Q

What do lab results for PTs w/ RA look like

When/how often are images needed for these PTs?

What do PTs need to do prior to starting DMARD medical therapy

A

RF
Anemia- proportional to Dz
Thrombocytosis
Synovial fluid w/ 5-50K WBCs

Onset, Q12mon

Update vaccines:
Zoster Influenza Yellow fever

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57
Q

How is RA Tx medically

What drug is the standard of care and approved for monotherapy in RA Tx

What med can be taken w/ monotherapy to reduce s/e?

A

Two total, DMARD and:
NSAIDs
GCCS- Prednisone bridge x 2-6mons
PPI if >65 and on NSAID

Methotrexate

PO Folate

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58
Q

What monitoring is done how often during RA Tx regimes?

What systemic dz needs to be r/o prior to starting Tx

What adverse effects occur during RA Tx

A

CBC BMP LFT SrCr q2-4wks initial, q12wks

TB Hep B/C HIV

Marrow suppression
Pneumonitis

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59
Q

What synthetic DMARDs can be used for Tx for RA

A

Hydroxychloroquine-
Least toxic/effective as mono
Retinal toxiciity over time
Monitor CBC

Minocycline:
Early seropositive Dz effective
Unknown MOA
Use >2yrs= hyper pigmentation

Sulfasalazine:
Combo w/ Metho/Hydroxy
Monitor: CBC LFT UA BMP

Leflunomide:
Comparable to Methotrexate
Teratogenic, hepatic toxicity
TB LFT CBC BP Preg Hepatitis
Use Cholestyramine to eliminate if considering pregnancy
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60
Q

Define a DMARD

What are the top four meds and their MOAs

DMARDs must be administered ? routes

A

Bioengineered by recombinant DNA to target cytokine surface molecules/receptors

Block IL-6: Tocilizumab
Inhibit T-cell- Abatacept
Deplete CD20- Rituximab
Inhibit TNF

SQ/IV infusion

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61
Q

All Pts need to be screened for ? prior to beginning a biologic because ?

? are absolute c/is for DMARDs

Biologics are not recommended for PTs w/ solid malignancy or non-melanoma skin Ca Tx <5yrs, Hx of Tx skin melanoma or lymphoproliferative malignancy except for ?

A

Latent TB
Inc risk for infections

Active/UnTx Latent TB
NYHA Class 3,4 HF or EF<50%- no anti-TNF

Rituximab

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62
Q

4 categories of biological DMARDs used for RA Tx

A

TNF- A inhibitors:
CAGI-mab/Etanercept

IL-1 receptor antagonist-
Anakinra

Other:
Rituximab, inhibits CD20
Tocilizumab, inhibits IL-6

Selective Costimulation mod-
Abatacept, alters T-cell activation

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63
Q

Biologic DMARDs inc risk for ? infections

There is a possible increased risk for ?

What lab results is used to correlate Dz activity and Tx efficacy

A

TB
HF exacerbation
MS flare up
Listeria/Histoplasma

Lymphoma

ESR/CRP

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64
Q

Before starting ImmSupp therapy for RA Tx, what screenings are recommended?

How early do RA PTs need to start DMARDs?

? is ubiquitous in PTs w/ RA

A

TST/Interferon G release
Hep B/C
HIV

At Dx

Osteoporosis

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65
Q

+RF test in PTs w/ suspected RA means ?

What joint would not be commonly involved w/ RA?

What are four correct statements about Methotrexate

A

More severe case of RA,
Anti-CCP is specific

Sacroiliac

Monitor CBC/LFT
C/i w/ active hepatitis
Weekly dose, start 7.5mg
Suppressed marrow

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66
Q

SLE has a predilection for ? PT populations

Define SLE

What are the common manifestations of SLE

A

Female of child bearing age

Autoimmune dz characterized by multi-system involvement and production of autoantibodies

Serositis
Fatigue
Rash, photosensitive
Polyarthritis

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67
Q

What issue may occur during SLE flares?

What are the three types of Lupus?

A

Hypocomplenentemia

Drug-induced Neonatal SLE

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68
Q

What are the Lupus specific cutaneous involvements?

What are the Lupus non-specific cutaneous involvements?

A

ACLE- local/general rash
SCLE- torso/limb, no face; MOST photosensitive
CCLE- discoid plaque on scalp-neck

Livedo reticularis
Bullous Chilblain Periungual

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69
Q

Chronic systemic damage from SLE is usually mediated by ?

What causes organ destruction

How are RA and SLE similar

A

Abs to cells and soluble IgG/phospholipid Ags

Direct Ab binding
Immune complexes

Monozygotic twin prevalence

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70
Q

What genes are associated w/ SLE

The presence of ? will precede PTs clinical illness

What are SLE predisposing RFs for women

A

HLA Type DR2/3- encode complement pathway

Autoantibodies

High FSH/LH
OCP/hormone replacement
Low free androgen
Early menarche

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71
Q

What are the environmental factors that place PTs at risk for Lupus

Consider SLE in PTs w/ multisystem Dz and ?

SLE PTs w/ Lupus induced hair loss need ? education

A

Drug- hydralazine isoniazid procainamide
UV- exacerbates, not trigger
EBV- mimicry
Tobacco- inc anti-dsDNA

Pos ANA

Regrows 6-8wks after Dz activity/or d/c medication

72
Q

11 criteria for SLE

A

Neuro Dz

Heme d/o
ANA+
Malar rash

Arthritis
Immunologic abnormals (anti-Sm/dsDNA)
Renal Dz

Photosensitivity
Oral ulcer (painless)
Discoid rash- in PO, painful
Serositis

73
Q

When compared to other forms of lupus, SCLE is usually induced by ?

What type of Abs are associated w/ SCLE

What hematological d/os are seen in lupus

A

Meds- hydrochlorothiazide, terbinafine

Anti-Ro/SSA

Thrombocyto <100K
ACDz
Leuko <4K
Lympho <1500

74
Q

What can SLE PTs develop w/ or w/out a Hx of steroid therapy

? lupus complication can lead to life threatening hemodynamic complications

Define Libman-Sacks Endocarditis

A

Osteonecrosis

Pericarditis

Mitral/Aortic valve thickening

75
Q

What is a rare cardiovascular manifestation of SLE

What does SLE cause that can exacerbate the above rare manifestation

What parts of the body are MC involved w/ SLE related lymphadenopathy

A

CADz

Accelerated atherosclerosis

Cervical, Axillary

76
Q

What is the MC pulm manifestation of SLE

What are three rare but life threatening pulmonary manifestation of SLE

What would be seen on PFTs for PTs w/ SLE

A

Pleural involvement

Alveolar hemorrhage/Lupus pneumonitis
Interstitial lung dz
Vanishing lung syndrome

Restrictive w/ low diffusion

77
Q

What SLE manifestations are most difficult to assess

What test and images will be ordered for any suspected SLE PT w/ neuro involvement

Almost all SLE PTs will have ? but only half will it be clinically significant

A

Neuro, Central>Peripheral

LP, MRI

Lupus nephritis- develops first 36mon w/ hematuria/proteinuria

78
Q

Why does advancing renal dz make it difficult to track SLE progression

How often are SLE PTs screened because of this

How are these cases classified

A

Falsely inc ESR/CRP

Q3mon w/ 24hr urine

Renal biopsy

79
Q

SLE can cause ? types of abdominal pain

SLE Lab results would show ?

What lab results will correlate w/ SLE activity but ? is more accurate?

A

Peritonitis
Pseudo obstruction
Rarely: pancreatitis, mesenteric vasculitis

Chem: HyperK
LFT: Hep/Pancreatitis
UA: hematura proteinuria casts

Correlate: ESR but can also be d/t anemia/Renal failure
Better: complement/ds-DNA

80
Q

What is sensitive but not specific for SLE and which one is spec but not sens?

Anti-dsDNA correlates w/ the development of ?

? Abs are associated w/ development of neonatal lupus and heart blocks?

A

Sen- ANA
Spec- Anti-smit/ds-DNA

Lupus nephritis

Anti-Ro/La (SSA/SSB)

81
Q

What is a clinical indicator SLE is seen on lab results during flares and used as an indicator?

Female SLE PTs w/ ? anti-phospholipid Abs are at risk for ?

What images will be ordered for SLE Pts

A

Dec C3 C4 CH50

Lupus anticoagulant
Anti-Cardiolipin AB
Miscarriage

CXR- initial pleuritis
CT- pneumonitis, alverolar hemorrhage, fibrosis

82
Q

What complication screenings may fall to the primary level in SLE PTs

What low, med and high potency meds are used for cutaneous SLE

A

CAD- HTN/HLD
Vaccine- Flu/PPV-23
Bone- Vit D/Ca
Annual cervical Ca screen

First- low HCN

Limbs/trunk:
Triamcinol/Betamethasone

High- hypertrophic regions-
Clobetasol
Caution: adrenal suppresion

83
Q

What meds are second line agents for acute, SCLE and DLE?

Only use steroids on face for ? and preferably use ? base

? is used for scalp lesions or discoid lupus on scalp?

A

Tacro/Picrolimus
Retinoids

<2wks, Ointment

Lesions: Steroid lotions
Discoid: triamcinolone injection

84
Q

What med is the TxOC for systemic Lupus due to its ability to tx ? aspects

What is the most feared s/e of this Tx and needs ? steps taken

What are two additional benefits of using this TxoC

A

Hydroxychloroquine- Cutaneous Arthritis Fatigue Serositis

Retinopathy, baseline and annual eye exams

Anti-thrombotic
Lipid lowering

85
Q

What drug is used for Lupus PTs that don’t respond to Hydroxy?

What medication is especially useful for bullous lupus

When/why would systemic CCS be used

A

Chloroquine

Dapsone

CNS/Nephritis

86
Q

What medication or its alternative is the standard of care for proliferative lupus nephritis

What ImmSupp drugs may be used for lupus as steroid-sparing drugs?

What is the first and second line drug used for associated arthralgia/arthritis

A

IV Cyclophosphamide qMon
Mycophenolate mofetil

Belimumab
Cyclosporine
Rituximab
Azathioprine
Methotrexate

NSAIDs
Fail= steroid/HydroxyChlor

87
Q

What meds are used to control HTn and renal complications in Lupus?

Most PTs w/ Lupus end up dying from ? bimodal issues?

What is the criteria for PT to have met lupus remission

A

ACEI/ARB

Early- Infection, SLE
Late- atherosclerosis, Ca

> 5yrs w/ no clinical/lab evidence and no Tx

88
Q

What is drug-induced Lupus classically associated with

Which one is associated with Subacute Cutaneous Lupus

A 
Anti-TNFs
Chlorpromazine
Hydralazine
Isoniazid
Methyldopa/Minocycline
Procainamide
Interferon Alpha
Quinidine

Hydrochlorothiazide

89
Q

How does drug induced lupus present

There is increased risk for poor maternal/fetal outcomes if ? coexists

What is the PATH acronym for Lupus and pregnancy outcomes

A

Fever Myalgia Polyarthritis Serositis w/ anti-histone Abs

Antiphospholipid syndrome
Active lupus nephritis

During first trimester: 
Proteinuria
Antiphospolipid syndrome
Thrombocytopenia
HTN
90
Q

? contraception is safe for PTs w/ SLE

When can OCPs be used?

? anticoagulants need to be recommended for SLE PTs that are pregnant and have Antiphospholipid Syndrome

A

Levongestrel IUD

Stable low dz and documented negative antiphospholipid Abs

Heparin, ASA

91
Q

Antiphospholipid Syndrome is a ? d/o and means PTs have ? Abs to phospholipids

What type of anticoagulation issue can PT w/ APS have?

This is usually associated w/ ? cardiac Dx

A

Acquired, usually w/ SLE-
Anticardiolipid (IgG/IgM)
B2-glycoprotein 1

Prolonged aPTT

Libman Sacks endocarditis

92
Q

How is APS Dx

A

Antiphospholipid Abs or clinical presence of lupus anticoagulant and,

Vascular thrombosis
Pregnancy morbidity

93
Q

How are APS Tx

What needs to be avoided

All PTs w/ antiphospholipid Abs should have aggressive management of ? three things

A

Heparin INR goal 2-3
Rivaroxaban

Estrogen contraception
Solo ASA therapy

HTN Cholesterol Smoking

94
Q

Define Scleroderma

Scleroderma has a strong association w/ ?

When/who is it seen

A

Heterogenous rheumatic dz w/ thick skin and lung/kidney lesions

Raynaud’s Phenomenon

50y/o Choctaw Native American females in OK

95
Q

If AfAm have Scleroderma, there is higher prevalence of ? compared to Caucasians that have ?

PTs w/ Scleroderma usually have 1* relatives w/ ?

What is considered the strongest RF for this Dz

A

AfAm: younger w/ lung dz
Cau: Milder, limited Dz

Thyroiditis 
Raynauds
Interstitial lung dz
MS 
RA

FamHx

96
Q

Rheum Classification of scleroderma includes ? criteria

What are the two classification forms and their associated syndromes

A 
Thickened skin proximal to MCP joint or,
Two of:
Bibasilar fibrosis
Digital pitting
Sclerodactyly

Systemic- Limited/Crest, Diffuse
Localized- Morphea, Linear

97
Q

What is the difference in location of Diffuse or Local Scleroderma

What is the unique exception to this rule?

? Abs are associated with each of these types?

A

Limited- below elbow/face, slow
Diffuse- above elbow, rapid

Limited w/ PA-HTN

Limited- Anti-centromerase
Diffuse- Scl-70, anti-RNA polymerase 3

98
Q

What viruses are thought to cause scleroderma?

What is the sub-group of limited scleroderma?

A

CMV

CREST:
Calcinosis cutis
Raynauds
Esophageal dysmotility
Sclerodactyly
Telangectasis
99
Q

? type of scleroderma has a better prognosis

Where does calcinosis appear

Where does the Telangectasis appear

A

CREST

Extensor surface of forearm

Palmar hand

100
Q

Scleroderma PTs w/ ? are more likely to develop telangectasis

Skin Morphea is more likely to present in ? type

What is the MC Tx for Raynauds

A

PHTN

Localized

Cold avoidance
Topical CCBs

101
Q

Pts >30y/o w/ first Raynauds should have ?

What are the two forms of pulmonary issues seen with different types of scleroderma

A

ANA
Nail capillary exam (primary- normal capillaries, no abs)

Diffuse- inflammatory alveolitis leading to pulmonary fibrosis/interstitial lung dz; in first 4yrs of dz

Limited/CREST- vascular dz leading to PAHTN
Seen w/ long standing dzs; morbidity

102
Q

What is the MC cause of scleroderma related death

What would be seen on PFTs in PTs w/ diffuse sclerdoerma induced interstitial lung dz

What monitoring do these PTs need?

A

Diffuse scleroderma PHTN

Restrictive pattern

PFTs
Echos

103
Q

What type of upper GI issues do scleroderma PTs have

What lower GI issues can they have?

What renal issue can present in a minority of sclerodermis PTs and how is it Tx

A

GERD w/ dysphagia

Alternating diarrhea/constipation

Sclerodermal Renal crisis- more common in Diffuse as sudden onset HTN/malignant HTN
Tx w/ Captopril, ACEI

104
Q

What are the 3 high RFs for developing sclerodermal renal crisis

What type of MSK issues is common in diffuse scleroderma

Define Sicca Complex

A

Early diffuse scleroderma
CSS
RNA Polymerase 3 Abs

Tendon friction rub- ankle knee wrist

Dry eyes/mouth seen in Scleroderma PTs

105
Q

Diffuse Scleroderma will have ? presentations

A

Rapid onset
Weight loss
Dyspnea w/ exertion
Skin texture change- pain edema pruritis

106
Q

What lab results help confirm clinical Dx of Scleroderma

What two images are ordered for these PTs

How often do they need PFTs

A

ANA- 95%
Antipoisomerase 1 Abs (Anti-SCL 70)- specific, diffuse
Anticentromere- limited*

Chest CT- activity/severity
EKG/Echo- PHTN screening

Baseline
Q4-12mon

107
Q

When does a Scleroderma PTs PFT suggest PHTN has developed?

What PT education goes w/ Tx goals

What meds are used for Scleroderma to protect internal organs and which ones are avoided?

A

Isolated reduction of DLCO
Reduction OOP to decline of FVC

No proven medication
Skin worst by 24mon, improves from there

Cyclophosphamide- only one, protects pulmonary; Avoid CCS

108
Q

What meds are given for scleroderma induced GI issues w/ PPIs

What motility agents and ABX are used?

What is the best predictor of prognosis

A

Metoclopramide
Domperidone

Octerotide- motility
Rotate- Tetracycline Metronidazole

No severe organ invovlement in first 3-5yrs of Dx

109
Q

What are the most frequent Sxs of Scleroderma from most to least?

What is the best lab test to differentiate between diffuse and limited sclerosis?

What lab finding is MC associated w/ scleroderma?

A 
Raynauds
GERD
Skin 
Finger swelling
Arthralgia

Anticentromere antibodies

+ ANA

110
Q

Define Sjogren’s Syndrome

What is the difference between Primary and Secondary

What is the key feature of a Sjogrens presentation w/ ? subjective Sx/complaint

A

Chronic inflammatory d/o of lymphocytic infiltration of exocrine glands

P: no other rhem dz
S: associated, RA, systemic sclerosis, SLE

Xerostomia
Keratoconjunctivitis Sicca/xerophthalmia

111
Q

Often PTs have Primary Sjogrens w/ ?

What is the common MSK complaint?

Sjogren’s PTs are more likely to develop ? form of Cutaneous Vasculitis if they are ? Pos

A

Fibromyalgia

Arthralgia

CLV, Ro/SSA+

112
Q

What is the MC cardiovascular manifestation PTs w/ Sjogrens can develop?

What are the two types of pulmonary complications Sjogrens PTs can develop

Since it rarely presents, PTs that have pleurisy may have ?

A

Raynauds

Bronchial>Interstitial

SLE

113
Q

What GI issue may be associated w/ Sjogrens?

What is the MC Neuro complaint?

What is the MC complaints for the Dz overall?

Sjogrens PTs have a 44x greater risk for developing ?

A

Primary Biliary Cirrhosis

Peripheral neuropathy

Fatigue

Lymphoma

114
Q

Sjogrens have an association w/ ? thyroid dz or ? Psych d/o

What may be seen on seroogical results in these TPs

What are the MC serological findings?

A

Subclinical hypothyroid
Dep/Anx

ANA Pos
RF Pos
Anti Ro/La*(SSA/SSB)

Cytopenia- normocytic anemia, leuko/thrombocytopenia
Inc ESR
Hypergammglobulinemia- monoconal IgG

115
Q

How is Sjogrens Dx

What meds can be used for Sx Tx of Dry eyes

What can be done for Sx relief of dry mouth

A 
Schirmer test- pos dye stain
Abnormal scintigraphy, sialography, sialometry
Dry eyes/mouth x 3mon
Pos Biopsy
Pos SSA/SSB

Topical cyclosporine/glucocorticoids

Pilocarpine Cevimeline Lemon drops

116
Q

What 3 drugs are used for potentially severe scenario Txs

Prognosis w/ Sjogrens is good except for the development of ?

How are inflammatory muscle dzs characterized

A

Hydroxychloroquine- fatigue/arthralgia
Prednisone- arthritis
Prednisone and Methotrexate- internal organs

Lymphoma

Bilateral proximal muscle weakness over wks/months

117
Q

Dermatomyositis has a significant increased risk for ? two malignancy

Since the etiology is unknown, what would be seen on muscle biopsies of these Dzs

? is pathognemonic for dermatomyositis

A

Hematologic lymphoma
Malignant tumors

Lymphocytic infiltrates

Perifascular atrophy
Gottron sign
Perifascicular atrophy

118
Q

What is the MC presenting Sx of Dermatomyositis

Define Heliotrope Rash

Define Mechanics Hands

A

Symmetric prox muscle weakness-
Neck Pelvic Thigh Shoulders

Eyelid rash of red/violet color
Covers areas spared by Lupus, over joints

Cracked skin w/ dirty lines, especially PTs w/ Antisynthetase Syndrome

119
Q

PTs w/ Antisynthetase Syndrome have autoimmune myopathy and ? features

What type of pulmonary involvement do most PTs have

A 
One Ab and Two of:
Non-erosive arthritis
Fever
Interstitial lung dz
Raynauds
Mechanic hands

Weakness/inflammation=
Interstitial (inflammation) pneumonia
Aspiration (weakness) pneumonia

120
Q

What is the classic presentation of Dermatomyositis

How is it Dx

What Neuro test can help confirm Dx

A

Proximal muscle weakness
Heliotrope
Gottron Sign

Muscle biopsy
Rash (Dermatomyositis)
Elevated CK Aldolase LDH AST/ALT

Abnormal EMG

121
Q

Inflammatory Muscle Dz related Anti-Jo Abs are more likely to be in ? PTs

What other serological result is likely to be seen

How are suspected Inflammatory Muscle Dzs evaluated in order?

A

Interstitial lung Dz

+ ANA

Hx/Physical Labs EMG MRI Biopsy

122
Q

During an Inflammatory Muscle work up, why would GGT finding be significant

What are two different MRI findings for Inflammatory Muscle Dz that mean different time frames

Why would this imagine be needed for final Dx

A

GGT released w/ AST/ALT from liver Dz, not muscle damage

Muscle edema- active inflammation
Fatty infiltration- chronic dz

Site for biopsy- deltoid or biopsy w/ 4/5 strength

123
Q

What is the mainstay of therapy for PTs w/ Inflammatory Muscle Dz

What is the s/e

When is the prognosis of Inflammatory Muscle Dz poor

A

Prednisone:
1-2mg/kg/day x 28d, taper

Steroid induced myopathy

Underlying malignancy

124
Q

Define Gout

This is characterized by ?

Gout is more common in men until women reach ? age

A

Heterogenous metabolic d/o of elevated uric acid

Monoarthritis
Extra-articular complication
Deformity

65

125
Q

What do WBC ranges from synovial fluid analysis correlate to

Gout is the MC ?

Hyperuricemia starts at ? lab level

A

Norma: <150
Non-inflamm: <3K
Inflamm: >3K
Septic: >50K

Cause of inflammatory arthritis in men >40

6.8mg

126
Q

Gout is caused by what two issues

What are the 3 stages of gout

What leads to bone/cartilage erosion in gout and what are they AKA ?

A

Under secretion/Over production of uric acid from purine metabolism

1: ASx hyperuricemia, no arthritis
2: acute gouty arthritis, intercritical gout
3: Continuous arthritis w/ attacks, tophi

Chronic inflammatory response Macrophages cytokine/enzymes- Rat Bite lesions

127
Q

What type of kidney issue can develop due to hyperuricemia

This risk doubles at ? level

A

Nephrolithiasis

> 13mg

128
Q

PTs that are over producers are classified as ? and is due to ? enzyme deficiencies

How are under excretors classified?

What drugs can cause gout?

A

Metabolic classification:
HGP- Lesch Nyhan
G6PD- von Gierkes Dz

Majority, Renal

CANT LEAP
Cyclosporine Alcohol Nicotinic acid
Thiazide diuretic Lasix Ethamutol ASA
Pyrazinamide

129
Q

What is the most susceptible joint to gouty attacks that presents w/ half of first attacks?

What are the next most likely joints to be involved

Almost all gout PTs will have a second attack w/in ?

A

MTP- podagra

Ankle Knee Wrist Finger Elbow

2yrs

130
Q

What types of extra-articular mainfestations can occur from gout?

Initial podagra attacks have dramatic responses to ? Tx meds

What 3 medications are known for causing gout

A

Nephrolithiasis
Tophi- finger elbow great toe
Skin desquamation w/ pruritus

NSAID, Colchicine

Niacin
ASA
HCTZ/Lasix

131
Q

How is a definitive Dx of gout made?

PTs having a gout flare will have ? level serum uric acid?

When are these serum levels most important?

A

Negative birefringent, needle sodium-urate crystals in neutrophils

Low or Norm

Monitoring urate lowering therapy

132
Q

Lab results of an acute gout attack will show elevation in ? 3 things?

How long do PTs need to use medical therapy for gout flares?

What is the level PTs want to keep uric acid at to prevent further attacks

A

WBC ESR CRP

2-3 days after flares resolve

6mg or less
<5mg if tophi present

133
Q

What drug is used for acute gout attacks and prophylaxis

What medication is used for PTs who are refractory to or c/i to taking NSAIDs or prophylaxis drug

What drugs can be used for injections

A

Colchicine- 1.2mg first Sx, 0.6mg 1hr later
Max 1.8mg in 60min
Wait 12hrs for prophylaxis (max 1.2mg/day)

CCS- prednisone

Methylpred/Triamcinolone

134
Q

What are the indications PTs w/ gout need urate lowering therapy

What drugs are used for lowering therapy

A

Tophi
2+ attacks/yr
CDK Stage 2 or worse
Nephrolithiasis

XOIs:
Allopurinol- DOC, rash means stop med
Febuxostat- safe for PTs w/ renal insufficiency/Allopurinol reactions

Uricosurics, only for <65y/o:
Probenecid, if renal function preserved
Inc Methotrexate/Ketorolac to toxic levels

135
Q

What drug is reserved for gout PTs w/ severe cases and abundent tophi?

Destructive arthropathy is rarely seen in PTs that have first gout attack after age ?

Leukocyte count >5K and rhomboid shaped crystal in synovial fluid means ?

A

Pegloticase

50y/o

Pseudogout (Ca Pyrophosphate Dihydrate Deposition Dz)- weakly positive birefringent

136
Q

What part of the body is pseudogout likely to infect?

This Dx is commonly associated w/ what two Dzs?

Pseudogout is MC associated w/ acute medical illnesses and ? and needs to be considered ?

A

Knee, Wrist

Hemochromatosis
Hyperparathyroidism
Hypothyroid

Surgeries
Elderly hospitalized PT w/ new acute monoarthritis post-op/ortho/MI

137
Q

How is Pseudogout Tx

What drug is used for resistant cases

Define Vasculitis

A

NSAIDs/Colchicine
GCSS if intolerant to PO meds

Methotrexate

Heterogenous d/os of inflammation and destruction of vessels

138
Q

What are the MC forms of primary vasculitis

Why are these d/os one of the great Dx challenges of medicine

Vasculitis is associated w/ ? Ab and due to ? infection

A

GCA
Granulomatosis w/ polyangitis
Microscopic polyangitis

Non-sepcific Sxs
Slowly developing

ANCA, Hep B/C

139
Q

What are the large vessel vasculitis’?

What drives the pathophysiology of these conditions?

What are the medium vessel dzs

A

Takayasus GCA/PMR Behcet dz

T-cell mediated Ag driven

PAN
Buergers Dz, Thromboangitis Obliterans
Kawasakis Dz- MLNS

140
Q

What are the two categories of small vessel vasculitis

A

Immune mediated:
Cutaneous (hypersensitive)
HSP
Cryoglobin

ANCA-
GPA (Wegeners)
EGP (Churg Strauss Synd)
Microscopic

141
Q

Behcets Dz is found in ? country

Polyarteritis Nodosa is associated w/ ? infection

In vasculitis what happens when the inflammatory cells invade the vessel?

A

Turkey

Hep B/C

Fibrinoid necrosis, panmural destruction

142
Q

What is the name of the type of damage that occurs from leukocytes in vasculitis

Since so many vasculitis criteria overlap, what is needed for definitive Dx

A

Leukocytoclasis

Biopsy/Radiological evidence (tawasakus)

143
Q

Define Mononeuritis Multiplex

What are the characteristic derm findings?

A

Vascular neuropathy: peripheral neuropathy due to damage to sciatic/peroneal nerve

Palpable purpura
Urticaria x 24hrs
Punched out ulcers
Livedo Reticularis (precedes ulcers)

144
Q

Half of GCA PTs also have ?

What PE finding is found in a quarter of GCA PTs

What is needed for Dx?

When does the biopsy need to be done by?

A

Polymyalgia rheumatica- ache/stiff shoulder, neck, hip girdle

Aortic involvement, asymmetric pulses

3 of 5:
>50y/o HA Abnormal artery
ESR elevated Abnormal biopsy

Within 2wks of steroids

145
Q

Why would PMR and GCA Dxs be confused/mixed

What is a differentiator?

Since PMR can mimic GCA and RA stiffness, what med is used for these PTs

A

15% of PMR have abnormal temporal artery biopsies

No blindness w/ pure PMR

Prednisone 15-20mg/day

146
Q

When does a Dx of PMR need to be reconsidered?

What are two late complications seen in GCA

A

No improvement after one week on steroid

Thoracic aortic aneurysms
Aortic dissections

147
Q

Define Tkayasu Arteritis

How does it present

Most PTs respond to ? med

A

Granulomatos vasculitis of aorta in young Asian women

Bruit Absent pulse Claudication HTN
FOUO

Prednisone +/- Methotrex or Mycophenolate
Relapse is common though

148
Q

Behcet Syndrome is common in ? ethnic backgrounds due to ? gene

What does this type of inflammatory vasculitis involve

What is this conditions hallmark presenting feature

A

Asian Turkish MidEast 25-35
HLA B51

Both art/vein of all sizes

Painful aphthous ulcers on mouth/genitals
Eye ball pain
Erythema nodosum that ulcerates

149
Q

What Neuro Dz can Behcet syndrome mimic

What two TNF inhibitors are effective for Tx

A

MS due to white matter involvement

Inflixi/Adalimumab

150
Q

Define Polyarteritis Nodosa

What part of the body does this Dz spare

What unique constitutional Sx does it present w/

A

Necrotizing inflammatory vasculitis of medium arteries and muscular arterioles

Venous circulation/capillaries

Post-randial pain (intestinal angina)

151
Q

How is Polyarteritis Nodosa Dx

What would be seen as lacking on lab results?

This Dz can be associated w/ ? infection

A

Angiogram
Biopsy (lung sparing)

Absent granulomatous inflammation

Hep B
Appears <6mon from infection

152
Q

What PE finding is common w/ Polyarteritis Nodosa

True PAN cases are ? negative

What would be seen on biopsy and angiography results

A

Mononeuritis multiplex- foot drop
Digital gangrene

ANCA negative

B: fibrinoid necrosis
A: microaneurysms

153
Q

How is Polyarteritis Tx if PT is refractory to GCSS or major organ involvement

Small Vessel vasculitis Dzs include ? structures

How are these broadly classified

A

Cyclophosphamide

Arteriole
Venule
Capillary

Immune complex mediated
ANCA

154
Q

What are the pathological hallmarks for Henoch-Schonlein Purpura and it’s MC?

What tetrad may be seen?

Nearly all cases occur in ? PTs w/ ? rare complication

A

Vasculitis w/ IgA depositions
MC vasculitis in Peds

Glomerulonephritis Abdominal pain Purpura Arthritis

Peds,
IgA glomerulonephritis in adults

155
Q

HSP can follow viral URIs or ?

? is a mandatory PE finding for Dx Henoch-Schonlein Purpura

How is it Tx

A 
EBV
Mycoplasma
Varicella
Parvo
Strep/Staph

Palpable purpuric rash

NSAIDs, avoid if Renal Dz
Steroids for arthralgia/GI Sxs
Severe/RF: admit, methylpred or,
Pred w/ Azathioprine/Cyclophos

156
Q

What is a poor prognosis sign for PTs w/ HSP and the silver lining

? is the MC organ involved in Cryoglobin w/ nearly all PTs being _Pos

What causes this organ involvement to start

A

Perisistent renal involvement
No ESRDz progression

Skin, RF

IgG/IgM Abs from low temps <37*C
Cryoglobulins binds w/ Ag forms, immune complex leading to IC mediated vasculitis

157
Q

What 3 PTs are less likely to survive a Cryoglobulinemia Dx

What type is primarily caused by malignancy and manifests w/ hyperviscosity syndromes

How does Essential/Primary Cryoglobulinemia differ from other cases?

A

Male >60 w/ renal involvement

Type 1- plasma cell d/os

Non-Hep C
Others associated w/ SLE and Sjogrens

158
Q

What is the classic triad of Cryoglobulinemia?

How is Cryoglobulinemia Tx

What is used for PTs w/ essential cryoglobulinemia

A

Myalgia Arthralgia Purpura

Harvoni for Hep C w/ Rituximab

Rituximab

159
Q

Define GPA

What are the hallmarks

When/who does the usually infect

A

Necrotizing vasculitis w/ respiratory and renal manifestations

Necrosis
Vasculitis
Granulomatous inflammation

White, northern Europeans during 4-5th decade

160
Q

90% of PTs w/ Granulo w/ Poly have ? upper respiratory dz

How is this condition Dx

What type of image can help since most PTs will have ? finding

A

Nasal involvement

+cANCA highly specific
biopsy

Chest CT, pulm lesions

161
Q

How is Granulo w/ Poly Tx

All PTs should receive ? for prophylaxis

What meds are used for remission agents?

A 
Severe:
Rituximab w/ GCSS or
Cyclophosphomide w/ GCSS
Limited:
Methotrexate and GCSS

PCP/TMP-SMX

Rituximab
Azathioprine or Methotrex if Cyclophos was used for remission induction

162
Q

What are the 3 hallmarks for Eosinophil Granulo w/ Poly

Half will have EGPA w/ ? Abs

Why is this useful for lab Dx

A

Systemic vasculitis
Eosinophilia
Asthma, adult onset

ANCA w/ specificity for myeloperoxidase

P-ANCA pattern on fluorescence testing

163
Q

PT Dx w/ EGP should have ? HEENT exam done

What are the 3 clinical phases of this Dz

What is less common in this Dz compared to GPA

A

Nasal- almost all have allergic rhinitis w/ polyps

Prodromal- allergic dz
Eosinophilic- blood eosinophilia and infiltration
Vasculitic- necrotizing

Less renal involvement

164
Q

What is the MC cardiac manifestation of EGP

What neuro manifestations are seen in more than half of cases?

How is it Dx

A

CHF

Peripheral neuropathy
Mono multiplex

Biopsy- vascular and extravascular for pANCA

165
Q

How is EGPA Tx

What drug is used for remission induction strategy

A

GCSS alone
Azathioprine, Methotrexate or Mycophenolate added
Cyclophos for vasculitic neuoropathy, glomerulonephritis or cardiac involvement

Cyclophosph

166
Q

Define Microscopic Poly

This it the MC cause of ? syndrome

What PE finding is more prominent and unique w/ this form

A

Renal and Pulm involved systemic vasculitis

Pulm-renal syndrome of alveolar hemorrhage and glomerulonephritis

Hemoptysis

167
Q

How is Microscopic Poly Dx

How is it Tx

What is the drug of choice if PTs cant take/don’t respond to the previous Tx regime

A

Biopsy of lung kidney or skin w/ pANCA pos

Cyclophosph and GCSS

Cyclophosph

168
Q

How is Microscopic Poly maintained in remission

Define Hyperalgia

Define Allodynia

A

Cyclophos induced, switch to Azathiprine of Methotrexate

Excessive severe pain from noxious stimulus

Pain from innoculous stimulus, inc tenderness to light pressure

169
Q

Fibromyalgia frequently co-exists w/ ? conditions

This Dx needs to be reconsidered if PTs are older than ?

What is believed to be the reason for increased pain in these PTs

A

Depression IBS Chronic fatigue syndrome
Interstitial cystitis

> 55

Glutamate
Substance P

170
Q

Fibromylagia PTs nearly all have ? Sx that’s more bothersome than the pain

How many pressure points are needed on exam for Dx

A

Fatigue

11 out of 18 w/ enough pressure to blanch nails

171
Q

What labs are ordered for fibromylagia work up

What is the most effective Tx

If needed, what meds are used

A

CBC CMP ESR CK TSH

Non-pharm therapy

NSAIDs
Acetaminophen
Amitriptyline at bed
Nortriptyline
Tramadol
172
Q

What two med classes need to be avoided when Tx fibromyalgia

What med may be used for Tx that is also beneficial w/ Psych issues

What is the alternate to the above that is cheaper

A

Steroids
Opioids

Duloxetine

Milnacipran

173
Q

FDA Approved drugs for fibromylagia Tx

How is Rosacea malar rash different from ACLE malar rash?

How is Seborrheic Dermatitis rash different from ACLE rash

A

Duloxetine- SNRI
Milnacipran- SNRI
Pregabalin- anti-convulsant, GABA analogue

Rosacea- stinging telangiectasis and pustules, worse w/ heat/ETOH

Scaly plaques on nasolabial folds

174
Q

Why are Lupus PTs at increased risk for coagulation issues?

? is the MC manifestation of SLE

Tobacco can cause ? result to be high

A

Anti=phospholipid Abs-
IgG/IgM anti-cardiolipin
Lupus anticoagulant

Arthritis

anti-DNA

175
Q

What can cause false-pos of syphilis

Takayasu PTs w/ cardiac involvement tend to have ?

A

SLE
Lyme

AR
Angina from stenosis at coronary artery ostia

176
Q

HSP needs to have what two DDx r/o

A

GMP

Microvasvular

IPAP (212 decks)

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