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Final Disease 3 > Rheumatoid > Flashcards

Rheumatoid Flashcards

1
Q

common signs of SLE

A
  • mouth and nose ulcers
  • face (butterfly rash)
  • joints (arthritis)
  • fingers and toes (poor circulation)
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2
Q

patient profile for SLE

A
  • women (8:1)
  • african american > asian > caucasian
  • 15-40 years old
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3
Q

what % chance does a pt with SLE will have Raynaud’s phenomenon?

A

20%

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4
Q

what are the most common 6 drugs that can cause drug induced SLE?

A
  • Procainamide
  • Hydralazine
  • Methyldopa
  • Isoniazid
  • Chlorpromazine
  • Quinidine
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5
Q

what is difference between drug-induced SLE and SLE?

A
  • brain/kidney are spared
  • sex ratio is 1:1
  • clinical features and lab testing revert to normal when drug is stopped
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6
Q

90% of patients have what as an early sign of SLE?

A

joint pain (Arthritis and Arthralgias)

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7
Q

what are the dermatological manifestations of SLE

A
  • malar “butterfly” erythematous rash is the most characteristic, but form and location of the eruption may be quite variable
  • discoid lupus (is a special form of the disease with manifestations limited to the skin)
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8
Q

what is the major cause of morbidity and mortality in SLE

A

renal involvement (either by hypertension or kidney dysfunction)

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9
Q

diagnosis for SLE is having 4 or more of the following criteria:

A
  • macular rash
  • discoid rash
  • photosensitivity
  • oral ulcers
  • arthritis
  • serositis
  • renal disease
  • (+) ANA
  • hemotologic disorders
  • neurologic disease
  • immunologic disease (antibodies to DNA)
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10
Q

what serologic tests tend to be higher in patients with SLE

A
  • anemia (leukopenia, thrombocytopenia)
  • antiphospholipid antibodies
  • ANA
  • anti-native DNA
  • hypocomplementemia
  • RF
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11
Q

3 main external ocular involvement in SLE

A
  1. keratoconjunctivitis Sicca (KSC)- 25% of patients
  2. nodular and diffuse anterior scleritis
  3. discoid lupus of the lids
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12
Q

3 main retinal involvement ocular manifestations of SLE

A
  1. lupus retinopathy: CWS surrounded by hemes
  2. lupus vasculitis: capillary non-perfusion
  3. large vessel disease
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13
Q

4 neuro-ophthalmic involvements in SLE

A
  1. optic neuritis and AION
  2. disc edema
  3. migraines and amourosis
  4. pupillary anomalies and oculomotor disturbances
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14
Q

when may you see a bull’s eye in SLE

A
  • drug induced maculopathy from chloroquinolone and hydroxychloroquinolone
  • < 6.5mg/kg/day is safe
  • usually >60, kidney dz
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15
Q

OCT shows how many % of people have drug-induced maculopathy? is it reversible?

A

1-3%

not reversible

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16
Q

what are the recommended screening tests for chloroquinolone and hydroxychloroquinolone maculopathy?

A
  • automated visual fields
  • SD OCT
  • mfERG
  • FAF
  • microperimetry
  • adaptive optics retinal imaging
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17
Q

treatments for SLE

A
  • NSAIDs
  • Aspirin
  • Methotrexate
  • Cell-Cept
  • TNF/ biologics
  • Benlysta (new FDE approved one for SLE)
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18
Q

patient profile for R.A.

A
  • women 3:1
  • 40-50 (but for men later)
  • maybe exposure to silica dust or cigarette smoking as a causative agent
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19
Q

what are some key features of RA

A
  • early synovial pathology
  • T/B cells continually activated by cytokines and TNF
  • chronic inflammation of joints (symmetrical)
  • MMP effects the destruction of joints and tissues
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20
Q

clinical manifestations of RA

A
  • symmetrical polyarthritis of peripheral joints
  • pain, tenderness, swelling of affected joints
  • worse in the morning, lasting more than 1 hr.
  • joint deformities may develop
  • subcutaneous nodules
  • pericarditis
  • pleural effusion
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21
Q

diagnosis of RA

A
  • X-rays of affected joints
  • RF
  • CCP-AB: early RA (85% showed this)
  • ESR/ C-reactive protein
  • uric acid levels
  • ANA
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22
Q

anterior seg involvement

A
  1. Dry eye (Sjogren’s and non-Sjogren’s): 15-25% of RA patients, KSC
  2. Keratitis (CUK)
  3. PUK (peripheral ulcerative keratitis)
  4. Episcleritis and Scleritis
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23
Q

what type of RA keratitis is associated with scleritis (anterior) and non-inflammed eyes without prominent infiltration

A

CUK (Central Ulcerative Keratitis/ Keratolysis)

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24
Q

what type of RA keratitis is associated with inferior cornea, guttering within the corneal limbus and corneal thinning and resolution is accompanied by corneal neo and subepithelial fibrosis

A

PUK (peripheral ulcerative keratitis)

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25
Q

treatment for CUK

A

restasis, amniotic membrane, biologics and surgical replacement

26
Q

treatment for PUK

A

PFAT, cyanoacrylate, topical antibiotics, systemic steroids, antimetabolites, T-cell inhibitors and biologics

27
Q

other ocular involvement with RA

A
  1. cranial nerve palsies
  2. ocular chrysiasis (very rare)
  3. bilateral brown syndrome (rare)
28
Q

associated diseases with Scleritis

A

“CIGMA”

  • Connective tissue disease (RA, SLE, PA, AS)
  • Infectious disease (Herpes Zoster, HS, Lyme Dz)
  • Granulomatous Disease (Sarcoidosis, Wegener’s)
  • Metabolic disease (thyroid, DM, gout)
  • Accidental (trauma, ocular surgeries)
29
Q

treatment for RA

A
  • NSAIDs
  • Methotrexate/ Leflunomide (primary)
  • TNF (enteracept, infleximab, adalimab)
    (other: antimalarials, minocyclines, gold salts, azathioprine, penicillamine, corticosteroids, surgery)
30
Q

what is the difference b/w primary and secondary Sjogren’s syndrome?

A

primary is dry mouth and eye without autoimmune dz (secondary has autoimmune dz)

31
Q

biggest clinical manifestations of Sjogren’s

A
  • destruction of exocrine glands leading to mucosal dryness
  • dry mouth (xerostomia)
  • parotid enlargement
  • severe dental caries (lipstick sign)
32
Q

what systemic condition can Sjogren’s patient be at a 16 fold increased risk of getting?

A

non-Hodgkin’s lymphoma

33
Q

what are the main ocular manifestations of Sjogren’s syndrome

A
  • lacrimal gland dysfunction causing decrease in aqueous layer dry eye symptoms
  • filimentary keratitis secondary to dry eye
  • corneal ulcers secondary to dry eye
34
Q

what other connective tissue diseases are associated w/ Sjogren’s

A
  • Rheumatoid arthritis (#1)
  • SLE
  • systemic sclerosis (scleroderma)
  • polymyositis
  • polyarteritis nodosa (PAN)
35
Q

lab testing for Sjogrens

A

-ANCA
-anti-Ro
-anti-La
-RF
-ANA
-Lyme titer
(Sjo- early detection in office)

36
Q

ocular treatment for Sjogrens

A
  • for dry eye: ATs, oral pilocarpine, punctal plugs, surgical
  • for filamentary keratitis: mucolytic agents
37
Q

patient demographics for Scleroderma

A
  • Oklahoma Choctaw indians and African Americans more common
  • 4-9x higher in women
  • 30-50 years onset is peak
38
Q

what type of scleroderma has “CREST syndrome”

A

limited cutaneous systemic sclerosis

39
Q

what does CREST stand for (in limited scleroderma)

A
  • Calcinosis
  • Raynaud’s (90%+)
  • Esophageal dysmotility
  • Sclerodactyly,
  • Telangiectasia
40
Q

ocular involvement of Scleroderma

A
  • eyelids (very tight) lose elasticity becoming thin, smooth, shiny, and retracted
  • Ptosis (early edema)
  • Blepheraphimosis
  • Dry eye
  • CWS
  • hypertensive retinal changes
  • bacterial keratitis w/marginal ulceration from dry eye
41
Q

lab testing for scleroderma

A
  • ANA (+) 90%
  • Anticentromere antibody (1%- diffuse, 50% limited)
  • Antitopoisonmerase (30% diffuse, 20% limited)
  • RF (+)- 30%
  • clinical signs (X-ray)
42
Q

treatment (medical) for Scleroderma

A
  • penicillamine
  • Nifedipine (for Raynaud’s)
  • omeprazole (prilosec for reflux)
  • IV iloprost for digital ulcers
  • Bosentan
  • Antimetabolites and biologics
43
Q

what condition is temporal arteritis frequently associated with

A

polymyalgia rheumatica

44
Q

clinical manifestations of temporal arteritis

A
  • fever (low grade)
  • headache
  • neck pain
  • night sweats/anorexia
  • joint swelling
  • jaw claudication (90% +)
  • temporal artery tenderness
45
Q

anterior segment ophthalmic involvement in GCA

A
  • uveitis
  • ocular ischemic syndrome
  • 4th/6th nerve palsies
  • pupil abnormalities
  • Horner’s
  • Tonic pupil
  • Ptosis
  • Episcleritis/Scleritis
  • Cataract
  • Hypotony
46
Q

posterior seg ophthalmic involvement in GCA

A

-AAION (78-99%)
-CRAO (2-18%)
potential for PION, BRVO, or choroidal ischemia

47
Q

ocular manifestations of AAION

A
  • devastating vision loss
  • TMVL or Amaurosis Fugax or just blur
  • diplopia
  • color vision loss
  • +APD of affected eye
  • swollen disc with or without flame heme
  • altitudinal vision loss (or any other VF loss)
48
Q

what do you have to do in a pt >50 y.o. with CRAO w/o evidence of embolic material

A

GCA workup should be done

49
Q

what lab testing do you need to do on GCA pt

A
  • immediate Westergren ESR
  • C-reactive protein
    other: CBC w/differential, CD4/8, anticardiolipin AB, temporal artery biopsy (within 1 week of starting steroids)
  • possible ocular pneumo.
  • color doppler ultrasono
50
Q

without steroids, what can happen in unilateral presenting GCA and how fast

A

contralateral eye (75%) can become involved in 24-72 hours

51
Q

other than high dose steroids for tx or GCA, what recent med was FDA approved for it

A

Actemra (tocilizumab)

-biologic for this specific type of vasculitis

52
Q

what is lyme disease caused by (pathogen and its name)

A
  • spirochete

- Borrelia burgdorferi

53
Q

what are the 3 stages of lyme

A

1: local
2: disseminated
3: persistent or late

54
Q

what is the characteristic rash in lyme and what % have it

A

ECM, 85%

55
Q

what is the most common ocular finding in “early” lyme disease

A

-conjunctivitis

56
Q

ocular signs with lyme

A
  • facial weakness (7th nerve)
  • optic neuritis
  • vitritis
  • iritis
  • exudative RD
  • 3rd/4th/6th CN palsy
  • conjunctivitis
  • episcleritis
  • exposure keratopathy (Bell’s)
  • inflammatory pseudotumor (IOIS)
57
Q

work up for lyme

A
  • serum antibody levels against B. burgdorferi using IFA or ELISA
  • serum RPR and FTA-ABS
  • lumbar puncture if neurologic signs
  • consider HLA DR 2+4
58
Q

3 antibiotics you can use for Lyme

A

-doxycycline, amoxicillin, or cefuroxime axetil

IV if neurologic -> send out

59
Q

what % of untreated ECM progress to stage 2

A

40%

60
Q

does antibiotic therapy help with arthritis in lyme

A

not always

61
Q

what % of Lyme patients experience chronic arthritis or neurologic disease

A

3-10%

Final Disease 3 (1 decks)

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