Rheuma Flashcards
Polyarticular symmetric involvement is characteristically seen with 1 2 3 4
rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), parvovirus B19, and hepatitis B
monoarticular arthritis is consistent with 1 2 3 4 5
osteoarthritis, crystal-induced arthritis (gout, pseudogout), septic arthritis (gonococcus), trauma, and hemarthrosis
Migratory arthropathy (inflammation and pain migrates from joint to joint, while the previous involved joints improve) is caused by 1 2 3
rheumatic fever, disseminated gonococcal infection, and Lyme disease.
Oligoarticular asymmetric arthritis is common with the
1
2
3
spondyloarthropathies (ankylosing spondylitis) and osteoarthritis involving the small joint of the upper extremities and rarely as a presentation of polyarticular gout
Does the patient have systemic symptoms (beyond the arthritis)?
_____ has keratoconjunctivitis sicca (dry eyes/mouth) and parotid enlargement.
Sjögren syndrome
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.
Wegener granulomatosis
Does the patient have systemic symptoms (beyond the arthritis)?
_______ has skin involvement and Raynaud phenomenon
Systemic sclerosis
What are the Evidence of joint inflammation includes:
joint stiffness in the morning >1 hour, joint erythema
and warmth, and elevated erythrocyte sedimentation rate (ESR) and C-reactive protein
The basic tests to run on the synovial fluid are the
3 Cs (cell count, crystals, and cultures) and the Gram stain
Synovial fluid may be stratified according to the number of cells
_________ have 200–2,000 WBCs/mm3 in the synovial fluid
OA and traumatic arthritis
Synovial fluid analysis
• _______ have 5,000–50,000 WBC/mm3
Inflammatory diseases (RA, gout)
Synovial fluid analysis
________ has >50,000 WBC/mm3
Septic arthritis
Septic arthritis may sometimes present with <50,000 WBC/mm3 in the joint aspirate if ________
antibiotics are given before the joint aspiration.
Septic arthritis should be considered a possibility in a patient with >5,000 WBC/mm3 in the synovial fluid, monoarticular arthritis, but_________
absence of crystals
Culture of joint fluid is positive in only 50% or less of ________
gonococcal arthritis.
When ANAs are present in normal people, they are usually in low titers (_______
<1:80).
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 \_\_\_\_\_\_\_
SLE,
systemic sclerosis
What ANA
SLE only (60%); an indicator of disease activity and lupus nephritis
Anti-ds-DNA (native DNA)
What ANA
Drug-induced lupus (95%)
Anti-histone
What ANA
Neonatal lupus, Sjögren and in the 3% of ANA-negative lupus
Anti-Ro (SSA)
What ANA
Sjögren
Anti-LA (SSB)
What ANA
CREST
Anti-centromere
What ANA
Anti-RNP
100% mixed connective tissue disease (MCTD)
_______) is an autoantibody against the Fc portion of IgG.
Rheumatoid factor (RF
T or F
RF is neither sensitive nor specific for the diagnosis of RA.
T
The presence of RF can be of prognostic significance, since patients with high titers tend to
have_______
more aggressive disease with extraarticular manifestations.
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
Wegener granulomatosis
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 ______
it is found in PAN and Churg-Strauss but is a nonspecific test.
Antiphospholipid antibody syndrome (lupus anticoagulant or anticardiolipin antibodies) is a hypercoagulable state associated with a group of antibodies that are directed against
phospholipids or cardiolipins
APAS
The nature of these antibodies causes the common laboratory abnormalities associated with the syndrome, i.e.,
elevated partial thromboplastin time (PTT) and false-positive RPR or VDRL
The hallmark of RA is
inflammatory synovitis that presents in a symmetric
distribution.
______ is also positive in RA and carries a very high specificity.
Anti-CCP (cyclic citrullinated peptide)
The cause of RA is unknown. RA may be triggered as a reaction to an infectious agent________in a susceptible host
(mycoplasma, parvovirus)
Of the environmental factors, only ______seems to be associated with RA.
cigarette smoking
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.
T-cell activation,
Diseases like human immunodeficiency
virus (HIV), in which T cells are decreased, will ___________
characteristically improve preexisting RA
Recent studies have shown that excessive amounts of the pro-inflammatory cytokines—_____, _______, _______—mediate most of the pathogenic features of rheumatoid arthritis
tumor necrosis factor alpha (TNF-a), interleukin-1, and interleukin-6 (IL-6)
Dx criteria of RA
Diagnostic criteria—need 4 of the following diagnostic criteria.
- 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
some joints are never involved in RA:
1
2
- DIPs
* Joints of the lower back
Extraarticular Manifestations of RA
Damage to the ligaments and tendons
1
2
3
–– Radial deviation of the wrist with ulnar deviation of the digits
–– Boutonnière deformity
–– Swan-neck deformity
Extraarticular Manifestations
RA + splenomegaly + neutropenia
Felty syndrome
Extraarticular Manifestations
RA + pneumoconiosis
Caplan syndrome
RA Tx
The best initial DMARD is ________.
methotrexate (MTX)
RA Tx
If MTX does not control disease, an _______is added to treatment.
anti- TNF medication
SE of HQ
Retinopathy
SE od MTX
Rapid onset of action; hepatitis and hepatic
fibrosis; pneumonitis; may flare rheumatoid nodules
_______ 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
TNF inhibitors
There are 3 TNF inhibitors approved for the treatment of RA:
Infliximab (Remicade)
Adalimumab (Humira)
Etanercept (Enbrel)
_________is a monoclonal antibody to TNF-α that binds to TNF-α in the joint and in the circulation
Infliximab (Remicade)
The combination of _________ and ______ is very
effective in reducing clinical manifestations of disease
infliximab and methotrexate
______) is an anti-TNF mAb that differs from infliximab in that its sequences are entirely human
Adalimumab (Humira
________ is a human fusion protein that is entirely human. Ab against it are usual
Etanercept (Enbrel)
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
Atlantoaxial subluxation
If a patient with RA presents with a swollen painful calf, consider a _______. It is the extension of inflamed synovium into the popliteal space.
ruptured Baker cyst.
SLE Etiology
The abnormal immune response probably depends on interactions between a susceptible
host and environmental factors.
SLE
_______ is the only environmental factor known to cause flares
Ultraviolet (UV)-B light
SLE
Arthritis is identical to that of RA except that it is______
non-erosive
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.
discoid lupus (DLE)
Only _____of patients with DLE will go on to develop SLE
5%
________is a noninfectious endocarditis that is occasionally seen in lupus patients
Libman-Sacks endocarditis
• Elevated levels of ds-DNA antibodies are seen with
active lupus
SLE
______ and ______may also be used for skin and arthritic symptoms.
Antimalaria drugs (hydroxychloroquine) and oral corticosteroids
_________are used with severe symptoms (lupus nephritis, heart and lung involvement, hemolytic anemia, central nervous system involvement, etc.),
Cytotoxic drugs (azathioprine, cyclophosphamide)
SLE Tx
_____ is an IgG monoclonal antibody given intravenously to prevent B-cell activation.
Belimumab
The prognosis of patients with SLE has improved significantly in recent years with a 10-year survival rate ______
> 85%.
Lupus nephritis is probably the most common cause overall of disability in patients with ______
SLE.
Fertility rates are normal in patients with SLE, but ______
are more common when compared with normal patients
spontaneous abortions and stillbirths
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
anti-phospholipid antibodies
MCC DRUG-INDUCED LUPUS
hydralazine, isoniazid, procainamide, and quinidine
MC Sx of DRUG-INDUCED LUPUS
arthritis, fatigue, fever, and rarely pleurisy
Acute onset SLE is usually not confused with drug-induced lupus, due to
1
2
3
the lack of skin disease, kidney disease, and the milder symptoms seen in the latter.
Patients with drug-induced lupus develop ANAs, although those with drug-induced lupus related to quinidine often are _______
ANA-negative
The ANAs in drug-induced lupus are autoantibodies
that react with a ________, which is the major component of the nucleus (anti-histone antibodies).
histone-DNA complex
_______ is a sensitive marker for the diagnosis of drug-induced lupus.
Anti-histone antibody testing
________) 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).
Systemic sclerosis (SSc
SSc
All patients have
Raynaud phenomenon and skin thickening
The Raynaud phenomenon occurs because of _______ and ______
vascular damage and diminished blood flow to the extremities
SSc
Pulmonary features include
1
2
3
pulmonary fibrosis with restrictive lung disease and cor pulmonale.
SSx
_____ is now the leading cause of death in SSc.
Pulmonary involvement
Tx of malignant HPN from SSc
angiotensin-converting enzyme (ACE) inhibitors
CREST syndrome, a variant of scleroderma, is now called ______ or ________
limited scleroderma or limited cutaneous systemic sclerosis.
CREST
______ is
a condition in which calcium deposits occur in soft tissues usually in the fingers (especially proximal inter-phalangeal joints), knees, and elbows.
Calcinosis
Patients with limited scleroderma generally have skin involvement that does not extend _________
above
the elbow or above the knee
In patients with limited scleroderma, the ______test is positive, showing a pattern of anticentromere
antibodies in up to 90% of patients
ANA
_________ are usually negative in limited
scleroderma and positive in diffuse scleroderma
Antibodies to Scl-70
One test that allows the differentiation between primary and secondary Raynaud is the _______
nailfold capillaroscopy test (done by placing a
drop of oil on the patient’s nailfold at the base of the fingernail).
nailfold capillaroscopy test in pts with scleroderma and other autoimmune diseases.
Enlarged, dilated, or absent nailfold capillaries are noted among patients with scleroderma and other autoimmune diseases.
There is no cure for SSc. For the skin manifestations, _________may be used.
d-penicillamine
For severe Raynaud phenomenon, use _______
calcium-channel blockers, specifically nifedipine;
_________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.
Sjögren syndrome
The spondyloarthropathies are a group of disorders that share certain clinical features and an association with the B-27 allele
SERONEGATIVE ARTHROPATHIES, SPONDYLOARTHROPATHIES
SERONEGATIVE ARTHROPATHIES, SPONDYLOARTHROPATHIES examples
Ankylosing spondylitis
Reactive arthritis
Psoriatic arthritis
Enteropathic arthropathy
SERONEGATIVE ARTHROPATHIES, SPONDYLOARTHROPATHIES characteristics
- Seronegative (ANA negative, RF negative)
- Involve lower back and sacroiliac joints
- HLA-B27
- Extraarticular manifestations
MC presentation of AS
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.
Extraarticular manifestations are common in AS:
1
2
3
anterior uveitis, aortic insufficiency sometimes
leading to CHF and third-degree heart block
AS
X-rays show evidence of ______ (this is the earliest finding) and eventual fusing of the sacroiliac
joint
sacroiliitis
AS
The diagnosis of AS is based on clinical and x-ray findings. The ______ is not commonly used as a diagnostic test
HLA-B27
The most promising medications used in the treatment of AS and other spondyloarthropathies are the _______
TNF blockers (infliximab, adalimumab, etanercept).
_________ is a seronegative arthropathy that occurs as a complication from an infection somewhere in the body.
Reactive arthritis (ReA)
There are 2 types of infection causing 2 different syndromes of reactive arthritis
- One (Reiter syndrome) occurs after a nongonococcal urethritis (chlamydia, ureaplasma).
- The other ReA occurs after an infectious diarrhea caused by Campylobacter, Shigella,
or Salmonella organisms
What syndrome
These patients have distinct mucocutaneous manifestations: keratoderma blennorrhagica,
circinate balanitis, oral or genital ulcers, conjunctivitis, and arthritis
(Reiter syndrome)
TX of reactive arthritis
Treatment is the same as for AS.
Psoriatic Arthritis
Commonly involves the DIP joints when associated with psoriatic nail disease (pitting of the
nails); this involvement may sometimes cause the characteristic _______
sausage-shaped digit.
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.
Enteropathic Arthropathy
______ is the most common joint disease in human
Osteoarthritis (OA)
The target tissue in OA is_______
articular cartilage.
______ is the leading cause of chronic disability in the elderly.
Knee OA
RF for OA
age, female sex, genetic factors, major joint trauma, repetitive stress, and obesity (the last 3 factors are potentially modifiable).
In OA, The most common joint to be affected is the ______the second most common joint affected is
the______
knee;
base of the thumb.
The major joints involved in OA are the ___ and ____
weight-bearing joints (hip and knee) and
the small joints of the fingers (PIPs and DIPs
In OA, Morning stiffness is always_____
<20–30 min.
T or F,
ESR and C-reactive protein are always normal in OA.
T
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 ______
Bouchard’s nodes,
Heberden’s node
In double-blinded placebo trials, there was no difference in relief of joint pain among
acetaminophen (4,000 mg/d), analgesic doses of ibuprofen (1,200 mg/d), and antiinflammatory doses of ibuprofen (2,400 mg/d).
Another modality that has been shown to benefit patients with OA is the use of _______, which depletes local sensory nerve endings of substance P
capsaicin cream
_______ has been approved for treatment of knee OA that hasn’t responded to pharmacologic treatment.
Intraarticular injection of hyaluronic acid
Also, clinical trial results based on analysis of x-rays suggested the possibility of ________
being chondroprotective
glucosamine
Gout
The________of the first toe is commonly affected (podagra), but other joints like the knee, ankle, PIPs, or DIPs may be initially involved
metatarsophalangeal joint
Gout
Without treatment the joint pain goes away
spontaneously within _______
3–14 days.
Certain events that precipitate gout sometimes precede the attack include:
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
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
T
Goal of Tx in acute gout
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
Tx of acute gout
- 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
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
Allopurinol
Febuxostat
Pegloticase
Probenecid
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
T
On synovial fluid analysis, the MSU crystals are _______ birefringent and _____ shaped. The
number of WBCs should be between ______________
negative; needle; 5,000 and
50,000
______ crystal deposition is more common in the elderly population and in people who have preexisting joint damage
CPPD/Pseudogout
A small percentage of the patients have metabolic abnormalities that are associated with CPPD deposition (secondary). Remember the 4 Hs:
hyperparathyroidism, hemochromatosis,
hypophosphatemia, hypomagnesemia.
Pseudogout
The______is the most commonly affected joint; other joints commonly affected are the wrist, shoulder, and ankle
knee
Synovial fluid of pseudogout
Definitive diagnosis requires the typical rectangular, rhomboid, positive birefringent crystals on synovial fluid evaluation
Radiographs of pseudogout
Radiographs may reveal linear radiodense deposits in joint menisci or articular cartilage (chondrocalcinosis)
Tx of pseuodogout
The treatment is the same as gout. Prevention of frequent recurrences may be treated with low doses of colchicine
The most common cause of infectious arthritis is
and accounts for 70% of episodes in patients age <40
gonorrhea, and gonococcal arthritis
In older patients,_________ is a common cause of infectious arthritis and occurs in patients with preexisting joint destruction from other rheumatic diseases.
Staphylococcus aureus
Patients with RA have the highest risk because of chronic inflamed or
1
2
3
destroyed joints, steroid therapy, and
frequent skin breakdown over deformed joints.
______ may cause rapid cartilage destruction, and thus a patient presenting with monoarticular arthritis needs prompt diagnosis. This is done by arthrocentesis
Acute bacterial infection
_______ is an inflammatory process involving the blood vessels that results in decrease of the lumen diameter and eventual ischemia of the tissues supplied
Vasculitis
The most common sign of Wegener granulomatosis is involvement of the _____ which occurs in nearly all patients
upper respiratory
tract,
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.
> 80%
60%
Patients with Wegener granulomatosis usually have the presence of ______
antineutrophil cytoplasmic
antibodies (C-ANCA
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
vasculitis and granulomas
Wegener Tx
The standard treatment consists of a combination of a
glucocorticoid and an immunosuppressive
agent (cyclophosphamide).
Predisposition of PAN
The disease can affect nearly any site in the body,
except the ______
lungs.
Predisposition of PAN
It has a predisposition for organs such as the
skin, kidney, nerves, and GI tract
Dx of PAN
diagnosis is confirmed by a biopsy showing pathologic
changes in medium-size arteries.
Effective treatment is now available for PAN and consists of
high doses of corticosteroids, along with immunosuppressive drugs (cyclophosphamide).
How to remember pt with Churg Strauss
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.
PAN and Churg-Strauss syndrome both involve the ______
small- and medium-sized arteries
______, is a vasculitis affecting the large arteries that supply the head, eyes, and optic nerves.
TA, also known as giant cell arteritis
Sometimes the patient may have proximal stiffness (neck, arms, hips) due to______a coexisting condition with TA.
polymyalgia rheumatica,
The ______ is the first test to do in patients suspected to have TA
erythrocyte sedimentation test (ESR)
TA
The diagnosis is always confirmed by biopsy of the temporal arteries in which the
characteristic ______ are demonstrated
giant cells
