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CK IM > Rheuma > Flashcards

Rheuma Flashcards

1
Q 
Polyarticular symmetric involvement is characteristically seen with 
1
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A 
rheumatoid arthritis (RA),
systemic lupus erythematosus (SLE), parvovirus B19, and hepatitis B
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2
Q 
monoarticular arthritis is consistent with 
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A

osteoarthritis, crystal-induced arthritis (gout, pseudogout), septic arthritis (gonococcus), trauma, and hemarthrosis

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3
Q 
Migratory arthropathy (inflammation and pain migrates from joint to joint, while the previous
involved joints improve) is caused by 
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3
A

rheumatic fever, disseminated gonococcal infection, and Lyme disease.

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4
Q

Oligoarticular asymmetric arthritis is common with the
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A

spondyloarthropathies (ankylosing spondylitis) and osteoarthritis involving the small joint of the upper extremities and rarely as a presentation of polyarticular gout

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5
Q

Does the patient have systemic symptoms (beyond the arthritis)?

_____ has keratoconjunctivitis sicca (dry eyes/mouth) and parotid enlargement.

A

Sjögren syndrome

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6
Q

Does the patient have systemic symptoms (beyond the arthritis)?

________presents with upper respiratory (sinusitis and rhinitis), lower respiratory (lung nodules and hemoptysis), and renal (necrotizing glomerulonephritis) involvement.

A

Wegener granulomatosis

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7
Q

Does the patient have systemic symptoms (beyond the arthritis)?

_______ has skin involvement and Raynaud phenomenon

A

Systemic sclerosis

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8
Q

What are the Evidence of joint inflammation includes:

A

joint stiffness in the morning >1 hour, joint erythema

and warmth, and elevated erythrocyte sedimentation rate (ESR) and C-reactive protein

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9
Q

The basic tests to run on the synovial fluid are the

A

3 Cs (cell count, crystals, and cultures) and the Gram stain

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10
Q

Synovial fluid may be stratified according to the number of cells

_________ have 200–2,000 WBCs/mm3 in the synovial fluid

A

OA and traumatic arthritis

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11
Q

Synovial fluid analysis

• _______ have 5,000–50,000 WBC/mm3

A

Inflammatory diseases (RA, gout)

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12
Q

Synovial fluid analysis

________ has >50,000 WBC/mm3

A

Septic arthritis

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13
Q

Septic arthritis may sometimes present with <50,000 WBC/mm3 in the joint aspirate if ________

A

antibiotics are given before the joint aspiration.

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14
Q

Septic arthritis should be considered a possibility in a patient with >5,000 WBC/mm3 in the synovial fluid, monoarticular arthritis, but_________

A

absence of crystals

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15
Q

Culture of joint fluid is positive in only 50% or less of ________

A

gonococcal arthritis.

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16
Q

When ANAs are present in normal people, they are usually in low titers (_______

A

<1:80).

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17
Q

ANAs present in different patterns depending on the staining of the cell nucleus

the peripheral (rim) pattern may be seen with \_\_\_\_\_
 while the nucleolar pattern is more commonly seen in \_\_\_\_\_\_\_
A

SLE,

systemic sclerosis

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18
Q

What ANA

SLE only (60%); an indicator of disease activity and lupus nephritis

A

Anti-ds-DNA (native DNA)

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19
Q

What ANA

Drug-induced lupus (95%)

A

Anti-histone

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20
Q

What ANA

Neonatal lupus, Sjögren and in the 3% of ANA-negative lupus

A

Anti-Ro (SSA)

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21
Q

What ANA

Sjögren

A

Anti-LA (SSB)

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22
Q

What ANA

CREST

A

Anti-centromere

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23
Q

What ANA

Anti-RNP

A

100% mixed connective tissue disease (MCTD)

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24
Q

_______) is an autoantibody against the Fc portion of IgG.

A

Rheumatoid factor (RF

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25
Q

T or F

RF is neither sensitive nor specific for the diagnosis of RA.

A

T

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26
Q

The presence of RF can be of prognostic significance, since patients with high titers tend to
have_______

A

more aggressive disease with extraarticular manifestations.

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27
Q

The cytoplasmic (c) ANCA refers to the diffuse staining
pattern observed when serum antibodies bind to indicator neutrophils; it is seen in >90% of
patients with

A

Wegener granulomatosis

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28
Q

Perinuclear (p) ANCA refers to a localized staining
pattern observed on the indicator neutrophils, the major target of these antibodies being the enzyme myeloperoxidase; found in ______

A

it is found in PAN and Churg-Strauss but is a nonspecific test.

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29
Q

Antiphospholipid antibody syndrome (lupus anticoagulant or anticardiolipin antibodies) is a hypercoagulable state associated with a group of antibodies that are directed against

A

phospholipids or cardiolipins

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30
Q

APAS

The nature of these antibodies causes the common laboratory abnormalities associated with the syndrome, i.e.,

A

elevated partial thromboplastin time (PTT) and false-positive RPR or VDRL

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31
Q

The hallmark of RA is

A

inflammatory synovitis that presents in a symmetric

distribution.

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32
Q

______ is also positive in RA and carries a very high specificity.

A

Anti-CCP (cyclic citrullinated peptide)

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33
Q

The cause of RA is unknown. RA may be triggered as a reaction to an infectious agent________in a susceptible host

A

(mycoplasma, parvovirus)

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34
Q

Of the environmental factors, only ______seems to be associated with RA.

A

cigarette smoking

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35
Q

Pathogenesis of RA

An initiation phase of nonspecific inflammation occurs, followed by an amplification phase resulting from ________and finally the stage of chronic inflammation
and tissue injury.

A

T-cell activation,

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36
Q

Diseases like human immunodeficiency

virus (HIV), in which T cells are decreased, will ___________

A

characteristically improve preexisting RA

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37
Q

Recent studies have shown that excessive amounts of the pro-inflammatory cytokines—_____, _______, _______—mediate most of the pathogenic features of rheumatoid arthritis

A

tumor necrosis factor alpha (TNF-a), interleukin-1, and interleukin-6 (IL-6)

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38
Q

Dx criteria of RA

Diagnostic criteria—need 4 of the following diagnostic criteria.

A
  • Morning stiffness (>1 h) for 6 weeks
  • Swelling of wrists, MCPs, PIPs for 6 weeks
  • Swelling of 3 joints for 6 weeks
  • Symmetric joint swelling for 6 weeks
  • RF positive or anti-cyclic citrullinated peptide
  • CRP or ESR
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39
Q

some joints are never involved in RA:
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A
  • DIPs

* Joints of the lower back

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40
Q

Extraarticular Manifestations of RA

Damage to the ligaments and tendons

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A

–– Radial deviation of the wrist with ulnar deviation of the digits
–– Boutonnière deformity
–– Swan-neck deformity

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41
Q

Extraarticular Manifestations

RA + splenomegaly + neutropenia

A

Felty syndrome

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42
Q

Extraarticular Manifestations

RA + pneumoconiosis

A

Caplan syndrome

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43
Q

RA Tx

The best initial DMARD is ________.

A

methotrexate (MTX)

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44
Q

RA Tx

If MTX does not control disease, an _______is added to treatment.

A

anti- TNF medication

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45
Q

SE of HQ

A

Retinopathy

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46
Q

SE od MTX

A

Rapid onset of action; hepatitis and hepatic

fibrosis; pneumonitis; may flare rheumatoid nodules

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47
Q

_______ relieve the signs and symptoms of RA, and slow or halt radiographic damage. These drugs have been shown to be effective in patients who were thought to be resistant to all methotrexate

A

TNF inhibitors

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48
Q

There are 3 TNF inhibitors approved for the treatment of RA:

A

Infliximab (Remicade)
Adalimumab (Humira)
Etanercept (Enbrel)

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49
Q

_________is a monoclonal antibody to TNF-α that binds to TNF-α in the joint and in the circulation

A

Infliximab (Remicade)

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50
Q

The combination of _________ and ______ is very

effective in reducing clinical manifestations of disease

A

infliximab and methotrexate

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51
Q

______) is an anti-TNF mAb that differs from infliximab in that its sequences are entirely human

A

Adalimumab (Humira

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52
Q

________ is a human fusion protein that is entirely human. Ab against it are usual

A

Etanercept (Enbrel)

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53
Q

CX of RA

the incidence of cervical involvement has been reported to be 25–80% and results from pannus formation at the synovial joints between C1 and C2

A

Atlantoaxial subluxation

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54
Q

If a patient with RA presents with a swollen painful calf, consider a _______. It is the extension of inflamed synovium into the popliteal space.

A

ruptured Baker cyst.

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55
Q

SLE Etiology

A

The abnormal immune response probably depends on interactions between a susceptible
host and environmental factors.

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56
Q

SLE

_______ is the only environmental factor known to cause flares

A

Ultraviolet (UV)-B light

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57
Q

SLE

Arthritis is identical to that of RA except that it is______

A

non-erosive

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58
Q

The ________is a circular rash with a raised rim that occurs over the scalp and face; it can be disfiguring because of central atrophy and scarring.

A

discoid lupus (DLE)

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59
Q

Only _____of patients with DLE will go on to develop SLE

A

5%

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60
Q

________is a noninfectious endocarditis that is occasionally seen in lupus patients

A

Libman-Sacks endocarditis

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61
Q

• Elevated levels of ds-DNA antibodies are seen with

A

active lupus

62
Q

SLE

______ and ______may also be used for skin and arthritic symptoms.

A

Antimalaria drugs (hydroxychloroquine) and oral corticosteroids

63
Q

_________are used with severe symptoms (lupus nephritis, heart and lung involvement, hemolytic anemia, central nervous system involvement, etc.),

A

Cytotoxic drugs (azathioprine, cyclophosphamide)

64
Q

SLE Tx

_____ is an IgG monoclonal antibody given intravenously to prevent B-cell activation.

A

Belimumab

65
Q

The prognosis of patients with SLE has improved significantly in recent years with a 10-year survival rate ______

A

> 85%.

66
Q

Lupus nephritis is probably the most common cause overall of disability in patients with ______

A

SLE.

67
Q

Fertility rates are normal in patients with SLE, but ______

are more common when compared with normal patients

A

spontaneous abortions and stillbirths

68
Q

Pregnancy and SLE

One reason for the spontaneous abortions in these patients may be _______, which cause placental infarcts. This is treated with low-molecular weight heparin (LMWH) during pregnancy

A

anti-phospholipid antibodies

69
Q

MCC DRUG-INDUCED LUPUS

A

hydralazine, isoniazid, procainamide, and quinidine

70
Q

MC Sx of DRUG-INDUCED LUPUS

A

arthritis, fatigue, fever, and rarely pleurisy

71
Q

Acute onset SLE is usually not confused with drug-induced lupus, due to
1
2
3

A

the lack of skin disease, kidney disease, and the milder symptoms seen in the latter.

72
Q

Patients with drug-induced lupus develop ANAs, although those with drug-induced lupus related to quinidine often are _______

A

ANA-negative

73
Q

The ANAs in drug-induced lupus are autoantibodies

that react with a ________, which is the major component of the nucleus (anti-histone antibodies).

A

histone-DNA complex

74
Q

_______ is a sensitive marker for the diagnosis of drug-induced lupus.

A

Anti-histone antibody testing

75
Q

________) is a chronic multisystem disease characterized clinically by thickening of the skin caused by accumulation of connective tissue and by involvement of visceral organs (GI, lungs, kidneys).

A

Systemic sclerosis (SSc

76
Q

SSc

All patients have

A

Raynaud phenomenon and skin thickening

77
Q

The Raynaud phenomenon occurs because of _______ and ______

A

vascular damage and diminished blood flow to the extremities

78
Q

SSc

Pulmonary features include
1
2
3

A

pulmonary fibrosis with restrictive lung disease and cor pulmonale.

79
Q

SSx

_____ is now the leading cause of death in SSc.

A

Pulmonary involvement

80
Q

Tx of malignant HPN from SSc

A

angiotensin-converting enzyme (ACE) inhibitors

81
Q

CREST syndrome, a variant of scleroderma, is now called ______ or ________

A

limited scleroderma or limited cutaneous systemic sclerosis.

82
Q

CREST

______ is
a condition in which calcium deposits occur in soft tissues usually in the fingers (especially proximal inter-phalangeal joints), knees, and elbows.

A

Calcinosis

83
Q

Patients with limited scleroderma generally have skin involvement that does not extend _________

A

above

the elbow or above the knee

84
Q

In patients with limited scleroderma, the ______test is positive, showing a pattern of anticentromere
antibodies in up to 90% of patients

A

ANA

85
Q

_________ are usually negative in limited

scleroderma and positive in diffuse scleroderma

A

Antibodies to Scl-70

86
Q

One test that allows the differentiation between primary and secondary Raynaud is the _______

A

nailfold capillaroscopy test (done by placing a

drop of oil on the patient’s nailfold at the base of the fingernail).

87
Q

nailfold capillaroscopy test in pts with scleroderma and other autoimmune diseases.

A

Enlarged, dilated, or absent nailfold capillaries are noted among patients with scleroderma and other autoimmune diseases.

88
Q

There is no cure for SSc. For the skin manifestations, _________may be used.

A

d-penicillamine

89
Q

For severe Raynaud phenomenon, use _______

A

calcium-channel blockers, specifically nifedipine;

90
Q

_________is a chronic autoimmune disease characterized by lymphocytic infiltration of the exocrine glands, resulting in xerostomia and dry eyes. Sjögren may be seen alone (primary) or with other autoimmune diseases (secondary) such as RA, primary biliary
cirrhosis, or SLE.

A

Sjögren syndrome

91
Q

The spondyloarthropathies are a group of disorders that share certain clinical features and an association with the B-27 allele

A

SERONEGATIVE ARTHROPATHIES, SPONDYLOARTHROPATHIES

92
Q

SERONEGATIVE ARTHROPATHIES, SPONDYLOARTHROPATHIES examples

A

Ankylosing spondylitis
Reactive arthritis
Psoriatic arthritis
Enteropathic arthropathy

93
Q

SERONEGATIVE ARTHROPATHIES, SPONDYLOARTHROPATHIES characteristics

A
  • Seronegative (ANA negative, RF negative)
  • Involve lower back and sacroiliac joints
  • HLA-B27
  • Extraarticular manifestations
94
Q

MC presentation of AS

A

AS will usually present with chronic lower back pain in a young man (in his late twenties to early thirties). The giveaway is the morning stiffness lasting at least 1 h that
improves with exercise.

95
Q

Extraarticular manifestations are common in AS:
1
2
3

A

anterior uveitis, aortic insufficiency sometimes

leading to CHF and third-degree heart block

96
Q

AS

X-rays show evidence of ______ (this is the earliest finding) and eventual fusing of the sacroiliac
joint

A

sacroiliitis

97
Q

AS

The diagnosis of AS is based on clinical and x-ray findings. The ______ is not commonly used as a diagnostic test

A

HLA-B27

98
Q

The most promising medications used in the treatment of AS and other spondyloarthropathies are the _______

A 
TNF blockers (infliximab, adalimumab,
etanercept).
99
Q

_________ is a seronegative arthropathy that occurs as a complication from an infection somewhere in the body.

A

Reactive arthritis (ReA)

100
Q

There are 2 types of infection causing 2 different syndromes of reactive arthritis

A
  1. One (Reiter syndrome) occurs after a nongonococcal urethritis (chlamydia, ureaplasma).
  2. The other ReA occurs after an infectious diarrhea caused by Campylobacter, Shigella,
    or Salmonella organisms
101
Q

What syndrome

These patients have distinct mucocutaneous manifestations: keratoderma blennorrhagica,
circinate balanitis, oral or genital ulcers, conjunctivitis, and arthritis

A

(Reiter syndrome)

102
Q

TX of reactive arthritis

A

Treatment is the same as for AS.

103
Q

Psoriatic Arthritis

Commonly involves the DIP joints when associated with psoriatic nail disease (pitting of the
nails); this involvement may sometimes cause the characteristic _______

A

sausage-shaped digit.

104
Q

Occurs with ulcerative colitis and Crohn’s disease; sometimes the arthritis occurs with flares of the inflammatory bowel disease.

Patients sometimes develop characteristic skin lesions:
pyoderma gangrenosum and erythema nodosum.

A

Enteropathic Arthropathy

105
Q

______ is the most common joint disease in human

A

Osteoarthritis (OA)

106
Q

The target tissue in OA is_______

A

articular cartilage.

107
Q

______ is the leading cause of chronic disability in the elderly.

A

Knee OA

108
Q

RF for OA

A

age, female sex, genetic factors, major joint trauma, repetitive stress, and obesity (the last 3 factors are potentially modifiable).

109
Q

In OA, The most common joint to be affected is the ______the second most common joint affected is
the______

A

knee;

base of the thumb.

110
Q

The major joints involved in OA are the ___ and ____

A

weight-bearing joints (hip and knee) and

the small joints of the fingers (PIPs and DIPs

111
Q

In OA, Morning stiffness is always_____

A

<20–30 min.

112
Q

T or F,

ESR and C-reactive protein are always normal in OA.

A

T

113
Q

Osteophytes (spurs) are the reparative efforts by the bone; when these occur in the PIPs they are called ________ whereas similar changes occurring in
the DIPs are called ______

A

Bouchard’s nodes,

Heberden’s node

114
Q

In double-blinded placebo trials, there was no difference in relief of joint pain among

A

acetaminophen (4,000 mg/d), analgesic doses of ibuprofen (1,200 mg/d), and antiinflammatory doses of ibuprofen (2,400 mg/d).

115
Q

Another modality that has been shown to benefit patients with OA is the use of _______, which depletes local sensory nerve endings of substance P

A

capsaicin cream

116
Q

_______ has been approved for treatment of knee OA that hasn’t responded to pharmacologic treatment.

A

Intraarticular injection of hyaluronic acid

117
Q

Also, clinical trial results based on analysis of x-rays suggested the possibility of ________
being chondroprotective

A

glucosamine

118
Q

Gout

The________of the first toe is commonly affected (podagra), but other joints like the knee, ankle, PIPs, or DIPs may be initially involved

A

metatarsophalangeal joint

119
Q

Gout

Without treatment the joint pain goes away
spontaneously within _______

A

3–14 days.

120
Q

Certain events that precipitate gout sometimes precede the attack include:

A

excessive alcohol ingestion, red meat intake, trauma, surgery, infection, steroid withdrawal, drugs (diuretics, such as HCTZ [hydrochlorothiazide] and furosemide; anti-TB medicines, such as pyrazinamide and ethambutol),
and serious medical illnesses

121
Q

T or F

The serum uric acid during the acute attack may be normal or low. Thus, the serum uric acid level is of no value in the diagnosis of acute urate arthropathy

A

T

122
Q

Goal of Tx in acute gout

A

The goal is to decrease inflammation and thus prevent erosions and joint destruction; also in this stage it is very important to avoid any fluctuations in serum uric
acid level

123
Q

Tx of acute gout

A
  • NSAIDs
  • Steroids, oral, rarely intraarticular, in elderly patients who cannot tolerate NSAIDs or colchicine or in patients with renal impairment
  • Colchicine is rarely to be used in acute gout but is still available
124
Q

Chronic hypouricemic therapy

  • ________can be used in overproducers, undersecretors, or patients with renal failure or kidney stones
  • ______is used in those intolerant of allopurinol.
  • _____dissolves uric acid: used in refractory disease
  • ________ can be used in the undersecretors (>80% of adults) only. Rarely used today
A

Allopurinol

Febuxostat

Pegloticase

Probenecid

125
Q

T or F

Allopurinol should not be initiated during an acute crisis.
However, if a patient has been taking allopurinol and an acute attack occurs, it should not be discontinued

A

T

126
Q

On synovial fluid analysis, the MSU crystals are _______ birefringent and _____ shaped. The
number of WBCs should be between ______________

A

negative; needle; 5,000 and

50,000

127
Q

______ crystal deposition is more common in the elderly population and in people who have preexisting joint damage

A

CPPD/Pseudogout

128
Q

A small percentage of the patients have metabolic abnormalities that are associated with CPPD deposition (secondary). Remember the 4 Hs:

A

hyperparathyroidism, hemochromatosis,

hypophosphatemia, hypomagnesemia.

129
Q

Pseudogout

The______is the most commonly affected joint; other joints commonly affected are the wrist, shoulder, and ankle

A

knee

130
Q

Synovial fluid of pseudogout

A

Definitive diagnosis requires the typical rectangular, rhomboid, positive birefringent crystals on synovial fluid evaluation

131
Q

Radiographs of pseudogout

A

Radiographs may reveal linear radiodense deposits in joint menisci or articular cartilage (chondrocalcinosis)

132
Q

Tx of pseuodogout

A

The treatment is the same as gout. Prevention of frequent recurrences may be treated with low doses of colchicine

133
Q

The most common cause of infectious arthritis is

and accounts for 70% of episodes in patients age <40

A

gonorrhea, and gonococcal arthritis

134
Q

In older patients,_________ is a common cause of infectious arthritis and occurs in patients with preexisting joint destruction from other rheumatic diseases.

A

Staphylococcus aureus

135
Q

Patients with RA have the highest risk because of chronic inflamed or
1
2
3

A

destroyed joints, steroid therapy, and

frequent skin breakdown over deformed joints.

136
Q

______ may cause rapid cartilage destruction, and thus a patient presenting with monoarticular arthritis needs prompt diagnosis. This is done by arthrocentesis

A

Acute bacterial infection

137
Q

_______ is an inflammatory process involving the blood vessels that results in decrease of the lumen diameter and eventual ischemia of the tissues supplied

A

Vasculitis

138
Q

The most common sign of Wegener granulomatosis is involvement of the _____ which occurs in nearly all patients

A

upper respiratory

tract,

139
Q

Wegener

Kidney involvement occurs in ______ of people with
this disorder and is a major cause of morbidity and mortality. Arthritis occurs in about _____
of the cases.

A

> 80%

60%

140
Q

Patients with Wegener granulomatosis usually have the presence of ______

A

antineutrophil cytoplasmic

antibodies (C-ANCA

141
Q

Wegener

The only way to confirm the diagnosis is by performing a biopsy of an involved organ (usually the nasal septum), which demonstrates the presence of

A

vasculitis and granulomas

142
Q

Wegener Tx

The standard treatment consists of a combination of a

A

glucocorticoid and an immunosuppressive

agent (cyclophosphamide).

143
Q

Predisposition of PAN

The disease can affect nearly any site in the body,
except the ______

A

lungs.

144
Q

Predisposition of PAN

It has a predisposition for organs such as the

A

skin, kidney, nerves, and GI tract

145
Q

Dx of PAN

A

diagnosis is confirmed by a biopsy showing pathologic

changes in medium-size arteries.

146
Q

Effective treatment is now available for PAN and consists of

A

high doses of corticosteroids, along with immunosuppressive drugs (cyclophosphamide).

147
Q

How to remember pt with Churg Strauss

A

you may consider this Churg-Strauss as PAN in an asthmatic patient).

The typical patient with Churg-Strauss is a
middle-aged individual with new-onset asthma.

148
Q

PAN and Churg-Strauss syndrome both involve the ______

A

small- and medium-sized arteries

149
Q

______, is a vasculitis affecting the large arteries that supply the head, eyes, and optic nerves.

A

TA, also known as giant cell arteritis

150
Q

Sometimes the patient may have proximal stiffness (neck, arms, hips) due to______a coexisting condition with TA.

A

polymyalgia rheumatica,

151
Q

The ______ is the first test to do in patients suspected to have TA

A

erythrocyte sedimentation test (ESR)

152
Q

TA

The diagnosis is always confirmed by biopsy of the temporal arteries in which the
characteristic ______ are demonstrated

A

giant cells

CK IM (9 decks)

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