Rheuma Flashcards
1
Q
Transient Synovitis
A
Hip pain with limp
Recent viral Infection
Normal to mildly elevated CBC, CRP, ESR
Well appearing child, Afebrile ( or low grade fever)
Able to bear weight
2
Q
CF of septic Arthritis ?
A
Monoarticular Joint pain erythema
warmth
Decreased ROM
Febrile ( high grade fever)
Ill-appearing
high WCC and Infl. markers
Unable to bear weight
3
Q
If CF are unclear, how to diff. between Transient synovitis and SA ?
A
Ultrasound
In transient synovitis: bilateral joint effusion
In SA: Unilateral joint effusion that will need arthrocentesis.
4
Q
MC infective organisms of SA ?
A
Staph Aureus
Group A strep
N. gonnorhhea (g-ve).
5
Q
Rx of SA ?
A
Vancomycin, to cover gram -ve add Ceftriaxone
6
Q
DD of a limp
A
- Transient Synovitis
- leg-calve-perthes disease
- Slipped capital femoral head
- SA
- Juvenile Idiopathic Arthritis
- Developmental Dysplasia
7
Q
DD Diagnosis of Swollen Knee
A
- Juvenile Idipathic Arthritis
- SA
8
Q
CF of JIA ?
A
MC oligoarticular joint pain, in a toddler that is worse in the Morning and a limp, swelling of joint
9
Q
What are the 3 major types of JIA?
A
Oligaarticular <4
Polyarticular multiple
systemic
10
Q
What is Oligoarticular JIA asc with ?
A
Uveitis with positive ANA abs.
11
Q
Lab Results in case of JIA ?
A
high WCC, ESR and CRP
-ve RF, ANA ( if positive increases risk of Uveitis)
HLA-B27
12
Q
Rx of JIA ?
A
To restrict Inflammation
NSAID, Joint Injection of CS, Methotrexate in later stages
13
Q
What does the Systemic JIA involve
A
Fever, salmon rash on the body
fever spike only x1/ day
14
Q
What is the pre-requiste of Diagnosis of JIA ?
A
A prerequisite for the diagnosis of all forms of JIA is:
arthritic symptoms begin before the age of 16 and last ≥ 6 weeks.
15
Q
What is the Other name of Systemic JIA ?
A
Still disease
16
Q
What is sensitivity
A
Among the patients with a disease how many will have a positive test
Sen= TP/ TP+FN
sensitive means it will be detected
17
Q
What is specificity
A
among the patients with no disease how many have a negative test
Spec= TN/ TN + FP
18
Q
What type of Ab. is seen in Diffuse scleroderma ?
A
SCL-7 or topoisomerase I or Anti-RNA polymerase III and ANA positive
19
Q
What type of Ab. do we see in limited Scleroderma
A
Anti-centromere Ab.
20
Q
What is Ankylosing spodylitis
A
Seronegative inflammation of the joints, that decreases joint mobility and causes its fusion. Mainly affects Axial spine and sacroiliac joint
21
Q
How does Ankylosing Spondylitis present ?
A
Lower back pain
Improves with Excericise however not with rest
worse a night
Sacroiliac joint pain, limited chest expansion
MC in patients <40 y.o
symptoms > 3 weeks
22
Q
What is Enthesitis ?
A
Inflammation of tendons and ligaments where they attach to bones.
Common in Ankylosing Spondylitis
23
Q
What is the MC enthesitis ?
A
Achilles Tendon
24
Q
What are the Radiographic features of Ankylosing Spondylitis ?
A
Bamboo spine ( fusion of intervertebral discs)
Syndesmophytes (paravertebral ossification)
ossification of intervertebral discs
25
What are the seronegative spondyloarthropathis
PAIR
p: Psoriatic arthritis
A: Ankylosing spondylitis
I: IBD asc Arthritis
R: Reactive Arthritis
| they are RF -ve, but HLA B-27 positive
26
In which population is Ankylosing Spobdylitis MC in ?
Young patients
27
Lung ft. test in ankylosing spondylitis ?
Restrictive lung disease
with decreased FEV1 and FVC
Normal lung compliance and elasticity
Normal DLco
28
CF of systemic sclerosis
Shiny skin
tight skin,
Initial presentation: Raynaud phenomena
ILD
pericarditis or Pericardial effusion
Esophageal Dysmotility
Tighter/ smaller Mouth
29
What is the pathogenesis. of SSC
Endothelial dysfuction, activation of Fibroblasts by realease of FGF and IL13 that activates B-cells and release Immunoglobulins.
30
Difference between DCSSC and LcSSC
Diffuse: high risk of affecting the viscera
Anti-scl 70 and Anti RNA polymerase III
Interstitial lung Disease
Limited: less risk to affect the viscera
Anti-centromere Ab.
Pulmonary HTN.
31
What is a metaphyseal corner fracture of the humerus a sign of
Non-accidental Trauma
32
What are the drugs used as Disease Modifying
Methotrexate
Hydroxychloroquine
Sulfazaline
33
Mechanism of action Methotrexate ?
Inhibits folate reductase, that inhibits DNA synthesis
34
SE of Methotrexate ?
Folate deficiency ( Stomatitis, Macrocytic anemia)
hepatotoxicity
Pulmonary fibrosis
35
SE of Hydozychloroquine ?
Retinopathy
36
What is RA ?
Chronic, inflammatory rheumatoid disease
symmetrical
symp > 6 weeks
Affects small joints (wrists, hands, feet) / PIP and MCP
elevation of ESR and Crp
Cardinal signs of erythema, fever, swelling, pain loss of function
Worse in the morning better with movement ( as you move you are washing out the inf. debris).
Joint effusion: mainly neutrophils. ( in Acute flares).
37
What is the RF ?
IgM Abs. against Fc postion of IgG.
38
CF of RA ?
Joint pain ( PIP,MCP and wrist) Ulnar deviation
stiffness worse in the morning than in the evening
Rheumatoid nodule ( in skin and lungs)
Pulmonary fibrosis ( basal)
pan carditis
Scleritis and episcleritis (and not uveitis).
Baker's cyst
Carpal tunnel syndrome
39
Pleural effusion in RA are of what type
| Transudate or exudate ?
Exudate
40
Lab in RA ?
+VE RF and Anti-citrullinated Protein
41
What are the infl. cytokines released in RA ?
TNF-alpha and IL-1
42
What are patients with RA at risk of ?
Osteopenia and osteoporosis
(because of pannus that is inflammatory, releasing Inf. markers that erode)
| Producing proteases that destruct cartilage and Bones.
43
What Interleukin is released with Ankylosing Spondylitis
IL-17
( treat with NSAID, celexocib, if not efficient can use TNF-alpha inh etanercept)
44
What is Osteoarthritis ?
Non-inflammatory, chronic disease of the joints as a result of wear and tear.
No cardinal signs, no constitutional symptoms, nomrla WCC and inf. markers.
Joint aspiration shows WCC >200, <2,000 ( mainly Lymphocytes because its chronic).
Morning stiffness < 30mins.
Pain worsens with use i.e worse in the evening
45
RF increase risk of OA ?
Obesity, age, repeated Trauma and Occupation
46
With OA the pain is ----- in the evening ?
worse
47
What is the Radiologic Findings of Osteoarthritis ?
Osteophytes ( bony projections)
Subchondral bony sclerosis
joint space narrowing
48
What are the findings of OA on Physical Examination ?
Crepitus
Osteophytes
Bouchard ( PIP) and heberden nodes (DIP)
Non-inflammatory effusion
Limited ROM.
49
Management of OA ?
1. NSAID/ COX 2- Inhibitor
2. Acetaminophen
3. exercises and Quads strengthening
3. Tramadol
4.Opiates
5.Last resort: Arthroplasty
50
Patients with APS can be misdiagnosed with ?
Syphillis
| Because both test for cardiolipin, positive VDRL and PRP.
51
What is APS ?
Autoimmune disease, related to presence of Abs against phospholipid layer of anti-coagulants
| like C-protein, S-protein and Anti- thrombin III.
52
CF of APS ?
Thrombosis ( DVT, arterial thrombosis, TIA and CVA)
Recurrent miscriages and pre-eclampsia
53
What is APS associated with ?
Other AI diseases like SLE
54
What are the Abs. seen in APS ?
Anti-cardiolipin
Anti-Beta2 glycoprotein
Anti-lupus anticoagulant
55
What type of thrombosis is seen in APS ?
Unprovoked thrombosis ( young age < 50, no malignancy, no recent histroy of immobilization)
56
Features of Anti-phospholipid syndrome
spontaneous abortion
hypercoagulable state ( thrombosis)
Prolonged aptt ( because of Lupus anti-coagulant).
57
Rx of APS ?
Life-long Heparin/ Warfarin
58
Abs of SLE ?
Anti ANA ( specific)
anti-dsDNA
Anti-smith
activation of Antibody and immune complexes lead to decreased c3 and c4.
59
What Abs are positive in neonatal lupus syndrome ?
Anti Rho-SSA Abs.
60
What is Takayasu arteritis ?
Inflammation and sclerosis of large arteries like aorta and its branches
61
CF of Takayasu arteritis ?
BP discrepencies
Pulslesness
arterioocclusive manifestation (claudication, syncope, ..)
Impaired vision
Raynaud Phenomena
HTN
62
Vessel Diseases based on Vessel Size ?
1. Large vessels: Takayasu arteritis
2. . Medium vessels: Polyarteritis nodosa
3. Small vessels: Thromboangitis Obliterans
63
Giant Cell Arteritis
Headaches with decreased temporal pulses
Asc with Polymyalgia rheumatica ( stiffness of the shoulders and neck)
Increases the risk of irreversible vision loss and aortic aneurys.
64
What are the drug that induce LE ?
My two Hips
Minocyline/ Methyldopa
TNF-alpha (infliximab and adalimumab)
Hydralazine with Mono-nitrates
Isoniazid
penicillamine/ procainamide
Sulfa-drugs
| Related to Abs (similar to Lupus) increased on the background of medicat
65
What are the causes of Gout ?
Increased Urate production:
Myeloproliferative disorders
Tumor lysis syndrome
Decreased Urate excretion:
Chronic Kidney disease
Thiazide/ loop diuretics
66
What is Fibromyalgia
Wide sprain chronic pain, that woresens with exercise.
Fatigue and impaired concentration
Tenderness at triger zones ( Midtrapezius, Chostochondral jt).
67
In what population is Fibromyalgia MC in ?
young- middle aged females
68
What is Polymyalgia Rheumatica
Inflammatory disease ( elevated esr, crp) that involves stifness in shoulders, Hip girdle and neck
| Asc with Giant cell Arteritis
## Footnote
Difficulty getting out of chair and lifting arms above head
69
RF of Gout ?
Meat and alcohol
age > 40 y.o
obesity
male
70
What is Gout ?
Inf. arthritis with cardinal signs of inflammation, mainly affects the first metatarsophalangeal joint (podagra), caused by deposition of crystal ( urate crystals)
Monoarthritis (assymetrical)
high CRP and ESR
71
What type of crystals are there
Gout: mono sodium urate
Pseudogout: CPPD ( calcium pyrophosphate dihydrate crystals)
hydroxyapetite arthropath: hydroxyapatite crystals
72
Management of Acute Gout
NSAID ( Indomethecin, celexocib), Colchicine ( if multiple joints are involved) and steroids
73
Management of Chronic Gout
Increase excretion.
Allopurinol: xanthine oxidase inhibitor and Feuxostat
probenecid and uricase ( rasburicase and Pegloticase).
74
What is the main Joint affected in Pseudogout ?
Knee
75
What is Pseudogout associated with ?
Hemochromatosis
Primary Hyperparathyroidism
76
What happens if you give Allopurinol with Azathioprin or 6-MP
Those drugs are metabolized by XO. and Allopurinol inhibits XO. which will increase the toxicity of Azathioprine and 6-MP. So we will need to decrease dose of azathioprine and 6-MP
77
Name one Uricosuric agent and how it works ?
Probenecid: inhibits URAT1 ( uric acid transport one) and increase Uric acid excretion
78
SE of probenecid ?
Uric acid stones
| radiolucent ( cannot be seen on XRAY)
79
Shall we use high or lose dose Aspirin in Gout ?
High dose Aspirin cause it is uricosuric.
80
When does Acute Rheumatic Fever Occur ?
after a streptococcal infection that has not been treated (2-4 weeks)
81
CF of Acute rheumatic fever
Major signs: Migratory arthritis, nodules, carditis (pan carditis and involves Mitral Valve), sydneham chorea, erythema mariginatum
Minor signs: Fever, arthralgia, high CRP/ESR, Prolonged PR interval
82
What predisposes people for Acute Rheumatic fever ?
HLA-DR 7
HLA0DR 53
83
Diagnosis of Acute Rheumatic Fever ?
Anti-Strep O Ab
Anti DNase Ab.
84
Rx of Rhematic fever ? and for how long
Penicillin G/ V, if no valvular damage for 10 years or until age of 21.
85
MC pathogen causign septic arthritis of prosthetic joint ?
Staph aureus. ( less 3 months or more than 12 months of infection)
Staph epidermidis b/w 3 and 12 months
86
Strep Pyogenes that causes pharyngitis will also cause ?
Acute Rheumatic fever and PSGN
87
Strep pyogenes that causes a skin infection will affect
PSGN only, can't affect the heart
88
What is Sydenham Chorea ?
involuntary, semi-purposeful movements that affects all muscles. Worse on movement
89
DD of Migratory Polyarthralgia
Acute Rheumatic fever
Dissiminated Gonococcal Arthritis
90
What is Dermatomyositis ?
Is an Idiopathic inflammatory disease that affects the muscle fibers.
CF: symmetrical proximal muscle weakness, erythematous rash on the fingers (Gottron sign) and rash on the eyelid (heliotrope eruption).
91
CF of Polymyositis
Weakness in the proximal muscle ( inability to get out of chair, inability to take the stairs)
Anti-Jo Abs. directed against skeletal muscles
Weaknes in proximal muscles ( thighs arms)
| It is dermatomyositis without the dermanl symptoms.
92
What is Duchenne Muscular Dystrophy ?
It is an X-linked recessive disorder, characterized by mutation in dystrophin protein in skeletal muscles and heart
93
CF of DMD ?
Calf pseudohypertrophy (muscle degeneration, fibrosis and fat take over) --> elevated ck
Proximal muscle weakness ( Positive Gower Sign)
Dilated Cardiomyopathy
94
What is Gower sign ?
when a toddler walks with his hands up his legs to compensate for proximal muscle weakness
95
Felty Syndrome ?
A complication of RA
- RA (nodular) (positive RF and Anti-CCP)
- Neutropenia ( recurrent medications)
- Splenomegaly ( neutrophils stuck in Spleen)
| Main Problem is Neutrophils binding IgG
96
CF of Psoriatic Arthritis
Symmetrical Polyarthritis ( wrists and DIP)
Nail pitting, dactylitis and Onycholysis
Enthesitis
Psoriatic skin lesions
Seronegative Arthropathy
Arthritis mutilans ( deforming and Destructive arthritis)
| looks like RA but involves joints of OA
97
Xray Finding of Psoriatic Arthritis ?
Pencil in Cup appearance ( erosion of one bone seems like its sitting in hallow bone cup like).
98
What is the Triad of Behcet Disease ?
1. Oral Ulcers
2. Genital Ulcers
3. Uveitis
| Erythema nodosum
99
What is Behcet Disease ?
AI inflammatory disease of vessels
100
Complications of Behcet
arterial/ Venothrombosis
101
What is Sjogren Syndrome ?
Sjogren is an AI disease directed against exocrine glands
102
What is the CF of Sjogren Syndrome
Dry eyes ( keratoconjunctivitis sicca)
Dry mouth (thrush, dental and peridental problems)
Arthritis
103
Abs in SJogren syndrome
Anti SSA ( Anti-Ro) and Anti SSB ( Anti-la)
104
What is the confirmatory test for Sjogren Syndrome ?
Lip Bx
105
Sjogren and Anti-SSA/ Anti- SSB increases the risk of ?
Non-Hodgkins lymphoma
106
What is a histologic evidence of Sjogren on Salivary gland ?
Lymphocytic infiltration
107
CF of Sicca Syndrome ?
Dry eyes
Dry Mouth
108
Difference between Osteogenesis Imperfecta and Ehlers Danlos Syndrome ?
OI: defect in collagen type 1 ( recurrent fractures)
EDS: Defect in Collagen type 4 ( no recurrent fractures)
109
Patients who develop henoch Schonlein purpura are at a great risk of developing ?
Intussuception
110
Difference between Systemic JIA and Acute Rheumatic Fever ?
both have fever and rash
s JIA: fixed arthritis
Acute Rheumatic fever: Migratory Arthritis
111
Cyclophosphamide increases the risk of ?
Bladder Cancer and acute hemorrhagic cystitis
112
Rx of Paget disease ?
Bisphosphonates ( inhibits osteoclast activity)
113
Treatment of Kawasaki disease
IVIG and IV pred as adjunct
114
CF of Kawasaki
Bilateral conjunctivitis without pus
Strawberry tongue/ pharyngeal erythema
Rash
Edema of palms and foot
Coronary artery aneurysm
115
DILE ( drug induced lupus erythematosus)
Features similar to SLE (fever , arthritis, malar rash,..)
usually after starting a drug like hydralazine, procainamide, sulfadrugs, methyldopa, isoniazid and phenytoin.
positive Antihistone Abs ( ANA positive).
116
