Rheum part 2 Flashcards
Dry eyes and mouth (sicca)
Keratoconjunctivitis
Burning, itching, FB sensation
Inability to tolerate contacts
Dry eyes → thick secretion in the AM
Photophobia → corneal ulceration
“Cotton mouth”, dysphagia with dry foods unless w/ liquids, persistent xerostomia → dental caries, trouble speaking
(caries at gum line)
Agnosia and loss of taste
Dysphagia, small vessel vasculitis, pleuritis, obstructive airway disease, ILD
Pancreatitis, neuropsych dysfunction, renal tubular acidosis (kidney dysfunction)
sjogren syndrome
RF for what
90% women
Can occur w/ other rheumatic disease (frequently RA)
Increased incidence of lymphoma
40-60y
sjogren syndrome
Systemic autoimmune disorder affecting glands that produce saliva and tears but can also develop extra-glandular involvement with joints, skin, lungs, GI tract, nervous system, and kidneys
sjorgen syndrome
PE: parotid enlargement
LABS: mild anemia, leukopenia, eosinophilia, polyclonal hypergammaglobulinemia
Rh + in 70%
ANA + in 95%
Antibodies against SS-A and SS-B
Schirmer test → testing quantity of tears
Lip biopsy
Parotid gland biopsy (only for unilateral enlargement)
sjorgen syndrome
how do you treat sjorgen syndrome
Artificial tears, topical cyclosporine, lifitegrast
Sipping water, sugar free gum, hard candies
Xerostomia = pilocarpine and cevimeline
Avoid taking decongestants and anticholinergics
Maintain good oral hygiene, including fluoride treatment
Prednisone for severe systemic inflammatory manifestations
Pain and stiffness in multiple joints, often w/ swelling and tenderness, lasting more than 30 minutes in the morning
Affects neck but spares spine + SI joints (can cause atlantoaxial subluxation w/ cord involvement)
MCJ: PIP, MCP, wrist, knees, ankles, MTP (OA spares wrist and MCP)
Chronic deformities: ulnar deviation, boutonniere, swan-neck, valgus of knee, volar subluxation of MCP
Females 40s-50s
Males 60s-80s (less)
Genetic
rheumatoid arthritis
Synovitis of multiple joints, symmetrically with predilection for small joints of hands + feet
– juxta-articular osteoporosis
– destruction of periarticular tissue
rheumatoid arthritis
PE: BOGGY, tender, warm joints with joint swelling, decreased ROM, episcleritis/scleritis, dry eyes/mouth/mucous membranes, fever, weight loss, rales
Rheumatoid nodules found at pressure points
LABS: anti-CCP antibodies (most specific) and + Rh factor
ESR and CRP elevated
XR tests are most specific for RA
rheumatoid arthritis
how do you treat rheumatoid arthritis
Refer
Steroids to bridge until DMARDs take effect
DMARDs → methotrexate
Can + sulfasalazine
Leflunomide, hydroxychloroquine, JK inhibits
Biologics if needed
NSAIDs can help with symptoms but don’t use alone
Use DAS28 score to monitor treatment response (swollen/tender joints, ESR/CRP, VAS)
Mouth ulcers (painless), oligoarthritis, conjunctivitis, urethritis, inflammation of entheses (insertion of tendons)
involving large joints (knee/ankle), fever and weight loss, mucocutaneous lesions, fingernail involvement, carditis, may persistent
reactive arhtritis
Young men 1-3 weeks after GI or GU infection, associated w/ chlamydia
HLA-B27 antigen
reactive arthritis
Asymmetric sterile oligoarthritis “reiter’s” after GI or GU infection (1-4 weeks)
reactive arthritis
XR: show joint disease, and rule out other joint diseases
Gonococcal arthritis: + culture and improve quickly after appropriate treatment
(arthrocentesis) – - culture (NOT septic)
Major criteria:
arthritis with 2 or more:
Asymmetry
Monoarthritis or oligoarthritis
Lower limb presence
Preceding symptomatic infection w/ either enteritis or urethritis
Minor criteria:
Evidence of triggering infection with + trach urine or stool culture for enterobacteria, or + PCR
reactive arthritis
What’s the criteria for reactive arthritis
Major criteria:
arthritis with 2 or more:
-Asymmetry
-Monoarthritis or oligoarthritis
-Lower limb presence
Preceding symptomatic infection w/ either enteritis or urethritis
Minor criteria:
-Evidence of triggering infection with + trach urine or stool culture for enterobacteria, or + PCR
How do you treat reactive arthritis?
NSAIDs
Treat STIs
Chronic reactive arthritis associated w/ chlamydia may benefit from combo abx: rifampin + doxycycline/azithromycin
If NSAIDs don’t work, sulfasalazine, methotrexate, anti-TNF
Slow onset with acute swelling and fever, weight loss, failure to thrive/growth retardation, malaise, anemia of chronic disease, elevated markers of inflammation
Risk of chronic iritis/uveitis → blindness
Must last at least 6 weeks
(3) Systemic - systemic inflammation with fever, weeks-months with rash, organ involvement, appearing sick
(1) Oligoarthritis - <5 joints w/n 6 months of diagnosis, medium-large joints
Persistent
Extended
(2) Polyarthritis RF + - 5+ joints affected in first 5 months, small joints, involving cervical spine
Polyarthritis RF -
Psoriatic arthritis - + psorasis
(4) Enthesitis related - tenderness at insertion sites, HLA-B27 +, no psorasis
Undifferentiated
Fits none
More than one
juvenile idiopathic arthritis
age for juvenile idiopathic arthritis:
usually around six but MUST be <16
Chronic arthritis in childhood with familial factors and 7 subtypes – autoimmune and environmental triggers, abx exposure, c section risk
Protective = breastfeeding, household siblings
Types: <5 joints or >5 joints involved
juvenile idiopathic arthritis
LABS: CBC, ESR, CRP, ANA, RF, anti-CCP, HLA-B27
Acute onset = arthrocentesis
XR normal at first with indirect signs like soft tissue swelling, increased density, dislocation of fat folds → osteoporosis, joint space narrowing, bone erosion/deformity, joint subluxation
US
MRI is gold standard for joint study
Exclude other diagnoses, >6 weeks, presumptive can be made
juvenile idiopathic arthritis
How do you treat juvenile idiopathic arthritis?
NSAIDs for symptoms
DMARDs
Eye monitoring
PT/rehab
Avoid steroids except for extreme circumstances and bridge therapy (intra-articular)
Sudden onset, frequently nocturnal
Acute, monoarticular arthritis, often recurrent
MCJ = metatarsophalangeal joint (podagra) or ankle, tarsal, knee
Severe pain, redness, swelling, with maximum severity reached over several hours
Fever is common (up to 39)
gout
Alcohol excess, med changes, hospitalization, fasting before procedures
Mostly adult men
gout
Elevated levels of uric acid deposition due to overproduction or underexcretion of renal uric acid
– excess monosodium urate crystals depositing in tissue
Causing recurrent attacks of acute inflammatory arthritis, usually monoarticular
Tophi = masses from this with associated foreign body reaction
Triggers = thiazide/loop diuretics, ACEI, pyrazinamide, ethambutol, aspirin, purine rich foods
gout
PLATE gout
Pyrazinamide
Loop diuretics
Aspirin
Thiazides
Ethambutol
PE: Marked tenderness to palpation, swelling, erythema, limited ROM
Arthrocentesis → monosodium urate crystals in synovial fluid (birefringent needle shaped)
Labs: elevated ESR, WBC
XR: normal early, joint destruction later (punched-out erosions “mouse bite” w/ overhanging rim of cortical bone)
gout
gout tx
ACUTE:
NSAIDs first line (indomethacin and naproxen)
Colchicine if symptoms <36 hours
Oral steroids (intra-articular injection for monoarticular) If giving intra-articular steroids, do joint aspiration and gram stain first!
Steroids are used if colchicine was recently given
BETWEEN ATTACKS:
Avoid alcohol (beer), purines (liver, seafood, yeasts), avoid diuretics, niacin, aspirin
Colchicine + canakinumab prophylaxis
Urate lowering = allopurinol + febuxostat (NOT in acute attacks), probenecid (not in renal issues)
Pegloticase in hospital setting
IL-1 inhibitors in hospitalization
Asymptomatic – generally acute and recurrent in one joint, knee MCJ, with wrists 2nd
Uncommon in osteoarthritic joints, instead in
Glenohumeral, wrist, patellofemoral, usually knees and wrists
Crowded den syndrome = atlantoaxial junction
Female, elderly (>60)
Post surgery
pseudogout
Calcium pyrophosphate deposition disease, causing precipitation of these crystals in connective tissues
psuedogout
PE: Marked tenderness to palpation, swelling, erythema, limited ROM
Presence of CPPD crystals (positive birefringent rhomboid-shaped) in synovial fluid (joint aspiration to distinguish)
– XR evidence of CPPD crystals (chondrocalcinosis) to differentiate; calcification of cartilage
No bony erosions
pseudogout
pseudogout tx
NSAIDs for acute attacks
Joint aspiration + intra-articular steroid injection, triamcinolone in resistant cases
Colchicine w/n 24 hours and for prophylaxis if >3/year
Short term immobilization
