Rheum HY Flashcards
Pt presents with:
HTN (200s/100s)
Low Platelets ( <50k)
Cr 3 elevated!
and has h/o Scleroderma (affects entire length of limb)
Dx/Treatment?!
Scleroderma renal crisis
Ace-I
(Lisinopril)
Nail pitting,
digital ischemia in cold weather (raynouads),
chronic heartburn (esophageal dysmotility).
Dx?
MCCOD?
CREST Scleroderma
Pulm HTN
(aka Limited Cutaneous Scleroderma)
Vasculopathy → pulmonary arteries lumen becomes fibrosed & narrowed.
Classic rheumatologic drug to avoid with scleroderma
Steroids
(increase risk of renal crisis)
Order of pulmonary manifestation of diffuse scleroderma
1st: Interstitial lung disease (fine crackles)
2nd: Pulm HTN
(s/t alveolar basement membrane fibrosis)
Hand ± wrist joint pain/swelling improves with use
Nail Pitting
Sausage digits (fingers or feet)
Dx?
psoriatic arthritis
40-50s Female
Finger (MCP/PIP) pain + Stiffness better w/ movement
Bilateral wrist/hand joint pain/swelling
No skin findings
↑ ESR
(–) Rheumatoid Factor
(+) Anti-CCP
Dx/Tx (1st/2nd line)?
Rheumatoid Arthritis
Methotrexate
TNF Inhibitors (if failed MTX)
*infliximab, etanercept, adalimumab
(negative Anti- RF/CCP/ANA do not r/o RA)
20-30s yo
Bilateral wrist/hand joint pain/swelling
Oral Ulcers
Dx/Tx?
SLE
Hydroxychloroquine
50+ yo Female
Bilateral pain & morning stiffness of, Neck, Shoulders, Hips, etc.
Joints have ↓ ROM
Fatigue, weight loss, ↑ ESR
Dx/Tx?
Polymyalgia rheumatica
Low Dose Prednisone (Glucocorticoid)
Methotrexate side effects (2)
screening (2)
Hepatotoxic
Pulmonary Fibrosis
(get initial LFTs & CXR)
Hydroxycholoquine side effect?
Screening?
Retinopathy
(get yearly eye exams)
TNF inhibitor side effects (2)
Malignancy (lymphoma)
Infections
(Granulomatous illness → Listeria; Legionella)
FYI: legionella tx FQ or Macrolide
25M with low back pain that is relieved with morning exercise.
Dx/Dxt/Tx
prognosis?
Ankylosing Spondylitis
X-Ray of Sacroiliac joints (Bamboo/fusion)
→ If negative, MRI of Sacroiliac Joints
NSAIDs
(Normal Life Expectancy)
29M with weeks of R knee pain, pain at the achilles tendon insertion (Enthacitis), psoriasiform lesions on the palms/soles
(+) recent h/o either:
- STI
- diarrhea
- glans penis ulcer
Dx/Tx?
Reactive Arthritis
NSAIDs
(only give ABxs if signs of infection: Fever, ↑ wbc, discharge)
Acute worsening of SLE symptoms
Dx/Tx?
Lupus Flair
IV Corticosteroids
Pt presents with new joint pain, pleuritic chest pain, and fever.
Recently placed on Hydralazine (Isoniazid)
Dx/Tx?
Drug-Induced Lupus
Stop the offending medication
(anti-Histone antibodies)
OTHERS: sulfonamides, Etanercept, phenytoin, procainamide
Neonate presents with Bradycardia (<60 bpm)
Dx/Etiology?
3rd degree heart block
Maternal SLE
(anti- Rho & anti-La IgG antibodies damage fetal conducting system)
Butterfly rash beneath the nose/lower lip that worsens with sun exposure + chronic joint pain.
Dx?
SLE
SLE pt with Hgb 8 & (+) Coombs test
Dx?
T__HSR
Auto-immune Hemolytic Anemia
(Type 2 HSR s/t ABs against own blood)
What SLE Antibody is associated with kidney damage/disease activity?
Anti DS–DNA antibodies
30s yo Female with:
Hypercoagulable (thromboembolic) state/sequelae
or
Unexplained Fetal loss
Positive ANA ± RPR
Dx?
Antiphospholipid antibody syndrome
(can also present w/ Mitral insufficiency: Holosystolic apex)
RPR is a false (+)
33F with a 2 week history of painful/burning neuropathy
(+) abdominal pain
(+) weight loss
Angiography → segmental aneurysmal dilation of the SMA & IMA.
Dx/NBSIM + classic finding?
organ spared?
Polyarteritis nodosa
Biopsy affected organ
Bx finding → HepB surface Ag
Lungs spared
─
(Extra info)
Tx: Steroids or HBV therapy , if (+)
Dry eyes/mouth
Parotid enlargement
Raynauds/ Interstitial lung dz
h/o auto-immune disease
Dx/Dxt/Tx? (lower yield)
(dry eyes + parotids = END of STORY)
Sjögren syndrome
Pilocarpine (+ Vit D)
Artificial tears/saliva
Anti Ro/La → Salivary gland biopsy
(Autoimmune destruction of exocrine glands)
Antihistone antibodies are specific for ____.
drug-induced lupus
African American patients are most commonly affected by limited cutaneous (CREST) Systemic Sclerosis.
_____ is present in approximately 90% of patients and typically precedes pulmonary HTN sxs by several years.
Raynaud phenomenon
Pulmonary arterial HTN → nl PFTs
Considerable overlap between diffuse cutaneous SS (dcSS) and limited cutaneous SS (CREAST).
Both may present with:
- Raynaud phenomenon
- esophageal dysmotility (+ GERD)
But dcSS has skin thickening of the ___ & interstitial lung disease.
thickening trunk
≥40F
proximal muscle weakness
otherwise normal neurologic exam
elevated creatine kinase
± elevated ESR
Dx/DxT/Tx?
dx can be s/t ___ do age appropriate screening
Polymyositis
Muscle Biopsy
Prednisone
(can be s/t paraneoplastic syndrome; do age-appropriate cancer screening)
50+ y.o. Female
Low grade fever + malaise
Stiffness in shoulders, hips, neck, or extremities
Elevated ESR/CRP
Normal CK
Dx/Tx/Association
Polymyalgia Rheumatica
Low dose Prednisone
Association w/ giant cell (temporal) arteritis
Presents with fever and the following triad of symptoms:
Migratory polyarthritis
Erythema nodosum
Bilateral hilar lymphadenopathy (fullness)
Dx/Tx
Lofgren syndrome (Sarcoidosis)
Glucocorticoids
Review Sarcoid Features
Flip card.
_____ antibodies are present in myasthenia gravis, which is characterized by muscle fatigability (weakness increases with repeated activity) and involves oculobulbar muscles in addition to proximal limb muscles.
Acetylcholine receptor
LOW YIELD: syndrome characterized by
recurrent oral and genital ulcers
+ Skin and ocular problems
MCCOD: Thrombosis
Behçet syndrome
Long-term cyclophosphamide use is associated with what 2 negative side effects?
Hemorrhagic cystitis
bladder cancer
Myopathies
* Dermatomyositis
* Polymyositis
* Inclusion body myositis
present with muscle weakness w/o pain
↑ CK
EMG: polyphasic, short-duration, low-amplitude APs
First-line tx:
Glucocorticoids
Symmetric proximal muscle weakness + skin findings
*Upper eyelids (heliotrope rash)
* Extensor surfaces of the hands rash
↑ CK
EMG: polyphasic, short-duration, low-amplitude APs
Dermatomyositis
(F>M)
50 yo Male pt Asymmetric proximal & distal muscles weakness
↑ CK
EMG: polyphasic, short-duration, low-amplitude APs
Inclusion body myositis
(M>F)
Symmetric proximal muscle weakness w/o skin findings
↑ CK
EMG: polyphasic, short-duration, low-amplitude APs
Polymyositis
(F>M)
For TNF inhibitors (RA or IBD pt on Infliximab, etc.)
Bugs to screen for before starting:
Malignant complication with chronic use:
2 classic opportunistic infections:
Tx for RA when pregnant:
Screen for Hep B, TB, Hep C, HIV
Chronic use → Lymphoma risk
Opportunistic infx → Legionella or Listeria (Granulomatous illness)
RA pregnancy tx→ Hydroxychloroquine
LUQ fullness and WBC of 1k
in a pt with Rheumatoid Arthritis
dx?
Felty Syndrome
(Triad: RA + Splenomegaly + neutropenia)
