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Rheumatology > Rheumatoid Arthritis, Gout, and Pseudogout > Flashcards

Rheumatoid Arthritis, Gout, and Pseudogout Flashcards

1
Q

Rheumatoid Arthritis

  1. What is it?
  2. What pattern will it affect joints?
  3. Progresses how?
  4. Breakdown of immune tolerance to what?
A
  1. Autoimmune disease that primarily involves joints
  2. Multiple joints, often symmetrical
  3. Progresses from peripheral
    to proximal joints
  4. synovial inflammation
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2
Q

PATHOPHYSIOLOGY OF RA
1. Prominent ____________ abnormalities

  1. Plasma cells produce _________
  2. ____________ migrate to diseased synovium
  3. Macrophages and lymphocytes produce what in synovium? 2
  4. Over time synovium ________
  5. Synovial cells produce what? 2
  6. Hyperplastic synovial tissue (pannus) releases what?
A
  1. immunologic
  2. antibodies
  3. Macrophages
    • pro-inflammatory cytokines and
    • chemokines
  5. thickens
  6. collagenase and stromelysin
  7. inflammatory mediators
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3
Q

Major cell types affecting the RA joint?

A
  1. T lymphocytes

2. Macrophages

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4
Q

CLINICAL PRESENTATION RA

6

A
  1. Wide variability of symptoms
  2. Gradual, insidious onset
  3. Symptoms wax and wane
  4. Usually involves multiple joints (More with time and
    Characteristically symmetric)
  5. Can cause significant disability in 10 – 20 years
  6. May not respond to treatment in 10 - 20% of cases
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5
Q

Systemic Symptoms of RA? 3

Joint symptoms of RA? 4

A

Systemic symptoms

  1. early morning stiffness of affected joints
  2. generalized afternoon fatigue and malaise
  3. anorexia

Joint symptoms

  1. Pain
  2. Swelling
  3. Stiffness
  4. erythema
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6
Q

RA imaging:

  1. Xray where for initial W-U? 2
  2. Plain xray shows what? 6

MRI, ultrasound
Show more damage
Not clinically useful

A
  1. X-ray hands and feet
    - As part of initial W-U
  2. Plain x-rays show:
    - Joint space narrowing
    - Soft tissue swelling
    - Bony erosions
    - Osteopenia about joint
    - Laxity - - > deformity
    - Destruction/fusion late
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7
Q

RA hand:

  1. Which joints are swollen and painful? (tender, LROM)
  2. Reduced _______ strength
  3. What triggers joint deformities?
  4. Which deformorities are most common? 3
  5. Up to 5 percent have what?
A
  1. Swollen painful
    - MP,
    - PIP joints
  2. Reduced grip strength
  3. Tendon ruptures, triggering
    Joint deformities
    • Ulnar deviation at MP joints
    • Swan neck,
    • Boutonniere
  5. Up to 5% have carpal tunnel syndrome
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8
Q

RA
UPPER EXTREMITY
Whats the most common?

A

Wrist - most common

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9
Q 
RA
UPPER EXTREMITY 
1. Wrist: Characteristics? 3
2. Elbow nodules characteristics? 3
3. Shoulder- Late? 3
A
  1. Wrist - most common
    - Lost of extension
    - Carpal drift
    - Tendon rupture
  2. Elbow - nodules
    - Loss of extension
    - Olecranon bursitis
    - Ulnar neuritis
  3. Shoulder – late
    - Adhesive capsulitis
    - Rotator cuff disease
    - Joint destruction
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10
Q 
RA  
LOWER EXTREMITY
1. Foot characteristics? 3
2. Knee characteristics? 3
3. Hips-late? 2
A
  1. Foot – similar to hand
    - MP joint involvement
    - Toe deformities
    - Heel, ankle pain
  2. Knee - often
    - Synovitis and effusion
    - Baker’s cyst
    - Loss of flexion
  3. Hips – late
    - Groin pain
    - Loss of rotation
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11
Q

EXTRA-ARTICULAR
RA
1. Most common manifestation?
2. Other possible manifestations? 6

A
  1. Skin & Pulmonary nodules
    • Pericarditis
    • Splenomegaly
    • Neuropathy
    • Vasculitis
    • Episcleritis
    • lymphadenopathy
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12
Q

RA LABORATORY FINDINGS
Labs? 4

Synovial fluid will show?

Xrays of what?

A
  1. Labs
    - Rheumatiod Factor (RF)
    - Anti-CCP
    - ESR
    - C-reactive protein (CRP)
  2. Synovial fluid
    - inflammatory effusion with elevated WBCs
  3. X-rays
    Of affected joint
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13
Q

DIAGNOSIS OF RA
Clinical Dx can be made when? 3

Have excluded what? 5

Lab tests may be normal in what kinds of RA? 2

A
  1. Inflammatory arthritis in 3 or more joints for more than 6 weeks
  2. Positive RF and ACCP testing
  3. Elevated CRP and Sed Rate

Have excluded

  1. gout,
  2. CPDD,
  3. viral arthritis,
  4. SLE,
  5. psoriatic arthritis
  6. seronegative or
  7. inactive
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14
Q 
2010 ACR/EULAR Criteria for RA Dx
A. Joint involvement. How many points for the following?
0 points?
1 point?
2 points?
3 points?
5 points?

B. Serology (>/= 1 test result needed)
0 points?
2 points?
3 points?

C. Acute phase reactants (>/= 1 needed)
0 points?
1 point?

D. Duration of symptoms
0 points?
1 point?

Definite Dx requires a total score of?

A
  1. 1 large joint?
  2. 2-10 large joints?
  3. 1-3 Small joints
  4. 4-10 small joints
  5. > 10 joints(>/= 1 small joint)
  6. Neg RF and Neg ACPA
  7. Low pos RF or low pos ACPA
  8. High pos Rf or high Pos ACPA
  9. Normal CRP and normal ESR
  10. Abnormal CRP or ESR
  11. Less than 6 weeks
  12. > /= 6 weeks

> /= 6/10

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15
Q

RA GENERAL RX
1. Management of acute flares? 2

  1. Use DMARDs early– disease modifying anti-rheumatic drugs. Such as? 2
  2. Surgery for what? 2
  3. Supportive management includes? 3
A
  1. NSAIDs and glucocorticoids (relieve discomfort, don’t stop progression)
    • Nonbiologics
    • Biologics
  3. Surgery for
    - soft tissues and
    - joints
  4. Helping the patient manage
    -PT,
    -OT,
    -bracing
    Support groups
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16
Q

RA NONPHARMALOGICAL

4

A
  1. Heat/Cold
  2. Orthotics and splints
  3. Therapeutic exercise
  4. PT/OT
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17
Q

RA Rx ACUTE PAIN

2 choices?

A
  1. NSAIDS

2. Glucocorticoids

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18
Q

RA Rx ACUTE PAIN

  1. NSAIDS: Which ones? 3
  2. When do we give glucocorticoids?
  3. MOA?
  4. SE? 8
A
  1. NSAIDs
    - Aspirin,
    - ibuprofen,
    - naproxen
  2. Glucocorticoids – usually systemic (multiple joints)
  3. Part of the feedback of the immune system, turns activity down
    • Hyperglycemia,
    • skin fragility,
    • osteoporosis,
    • weight gain (moon facies)
    • adrenal insufficiency,
    • muscle breakdown,
    • euphoria,
    • glaucoma
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19
Q
  1. What does DMARDs stand for?
  2. What should we remember about their use?
  3. What are the nonbiological agents? 7
  4. Biological? 4
A
  1. Disease modifying antirheumatic drugs
  2. Early use - - > better results
  3. Nonbiologic agents
    - Methotrexate,
    - Sulfasalzine,
    - Leflunomide
    - Hydroxychloroquine,
    - Cyclosporine,
    - Gold Salts,
    - Azathioprine
  4. Biological agents –
    - macromolecules,
    - genetic engineering
    - TNF inhibitors
    - Entanercept (Enbrel), Infliximab (Remicade), Adalimumab (Humira)
20
Q

Most commonly used DMARD?

Also used for cancer treatment, terminating pregnancies

A

METHOTREXATE

21
Q
  1. METHOTREXATE
    MOA?
  2. Adverse effects? 10
  3. Contraindications? 2
A
  1. Antimetabolite that inhibits purine biosynthesis
    - essential to rapidly proliferating cells.
    • Ulcerative stomatitis,
    • leukopenia,
    • predisposition to infection,
    • nausea,
    • abdominal pain,
    • fatigue,
    • fever,
    • dizziness,
    • pneumonia,
    • pulmonary fibrosis
    • Renal dysfunction
    • Pregnancy or possible pregnancy
22
Q

RA and SURGERY

What are the two types of procedures?

A
  1. SOFT TISSUE PROCEDURES

2. JOINT PROCEDURES

23
Q

What are the following used for:
1. SOFT TISSUE PROCEDURES? 3

  1. JOINT PROCEDURES? 2
A

SOFT TISSUE PROCEDURES

  1. Synovectomy
  2. Tendon repairs
  3. Removal of nodules

JOINT PROCEDURES

  1. Total joint replacements
  2. Fusions
24
Q

Gout is characterized by what?

A

Characterized by painful joint inflammation in the first metatarsophalangeal joint

25
Q

PATHOPHYSIOLOGY OF GOUT

  1. Precipation of what in joint space?
  2. What joint space is damaged?
  3. What is pathogomic and may form in the joint space?
  4. What is the most commonly affected joint?
  5. PP? 3
A
  1. Precipitation of monosodium urate crystals in joint space
  2. Overtime joint space is damaged
  3. Tophi may also form in the joint space
  4. First metatarsophalangeal joint most commonly affected
    - Podagra
    • Decreased excretion
    • Increase production
    • Increase purine intake
26
Q

DIAGNOSIS OF GOUT

4

A
  1. Clinical criteria
  2. Synovial fluid analysis- Needle-shaped negative birefringent urate crystals
  3. Elevated serum urate level
  4. X-rays
27
Q

RX ACUTE GOUT

  1. Resolves when?
  2. First line?
  3. Second line? 2
A
  1. Resolves in a few days to weeks
  2. NSAIDs usual first choice now
    3.
    -Colchine main Rx for many years
    -Glucocorticoids
28
Q
  1. NSAIDs usual first choice now. Which one do we use? 2
  2. Colchine derived from what?
  3. Colchine SE? 4
  4. Types of glucocorticoids? 2
A
  1. Early use of Naproxen or Indomethacin can be helpful
    Beware GI and CV effects
  2. Derived from plants, known in antiquity, inhibits mitosis
    Low dose regimes effective with fewer side effects
    • GI upset,
    • neutropenia,
    • peripheral neuropathy
    • Do not use IV, serious even fatal side effects
    • Intraarticular: injections often quickly resolve symptoms
    • Oral: multiple joints and can’t use NSAIDs or colchicine
29
Q

RX HYPERUCEMIA

3

A
  1. REDUCED INTAKE OF PURINES - diet
  2. XANTHINE OXIDASE INHIBITORS – Allopurinol
  3. URICOSURIC DRUGS – Probenecid
30
Q

First choice of drug to lower serum urate levels?

A

XANTHINE OXIDASE INHIBITORS – Allopurinol

31
Q

RX HYPERUCEMIA
XANTHINE OXIDASE INHIBITORS – Allopurinol
1. MOA?
2. SE? 3

A
  1. Decreases purine synthesis, thus lowers monosodium urate
    • Arthralgias,
    • diarrhea,
    • rash
32
Q

URICOSURIC DRUGS – Probenecid

  1. MOA?
  2. What will it increase?
A
  1. Decreased uric excretion - - > up to 90% of hyperurecemia

2. Probenecid will increase urinary excretion

33
Q

PREVENTING RECURRENT ATTACKS

  1. Life style changes? 2
  2. Diet? 2
  3. Lowering serum uric acid levels? 2
A
  1. Life style changes
    - Weight loss
    - Decreased alcohol intake
  2. Diet
    - Decreasing meat and fish
    - Increase dairy products
  3. Lowering serum uric acid
    - Uricosuric agents
    - Xanthine oxidase inhibitors
34
Q

PSEUDOGOUT

  1. What is it?
  2. Etiology? 3
A
  1. Calcium pyrophosphate dehydrate (CPPD) crystal deposition disease
    - Chondrocalcinosis
  2. Etiology
    - Trauma
    - Hypomagnesemia
    - hyperparathyroidism
35
Q

PSEUDOGOUT

  1. Clinical presentation? 2
  2. Diagnosis? 2
A
  1. Clinical presentation
    - Similar to gout but less severe
    - Usually occur in the knee or other large peripheral joints
  2. Diagnosis
    - Synovial fluid
    - X-rays
36
Q

What will the synovial fluid oand Xrays show? 3

A
  1. Rhomboid-or-rod shaped crystals
  2. Positive birefringent crystals
  3. chondrocalcinosis
37
Q

What will the synovial fluid oand Xrays show? 3

A
  1. Rhomboid-or-rod shaped crystals
  2. Positive birefringent crystals
  3. chondrocalcinosis
38
Q

69

A

69

39
Q

Treatment for Pseudogout (specifically acute attacks although they dont happen very often)

  1. Single joint involved? 2
  2. Multiple joints involved? 3
  3. Prevention when and how?

Treatment of damaged joints same as for OA

A
  1. Single joint involved
    - Aspirate and inject with steroids
    - Immobilize and apply ice or cool pack
  2. Multiple joints involved
    - NSAIDs,
    - colchicine, or
    - systemic steroids
  3. Prevention
    - After 3 or more attacks,
    - daily colchicine

Treatment of damaged joints same as for OA

40
Q

Describe the major features of each:

  1. OSTEOARTHRITIS? 2
  2. RHEUMATOID ARHRITIS? 2
  3. GOUT AND PSEUDOGOUT? 2
A
  1. OSTEOARTHRITIS
    - Degeneration of cartilage leads to joint damage
    - Slowly hampers activities of daily living
  2. RHEUMATOID ARHRITIS
    - Autoimmune disease that attacks synovium and soft tissue
    - See swelling and damage/destruction of multiple joints
  3. GOUT AND PSEUDOGOUT
    - Deposition of crystals leads to joint inflammation and damage
    - Recurrent attacks, often the big toe in gout
41
Q

Describe the clinical features of the following:

  1. OSTEOARTHRITIS? 2
  2. RHEUMATOID ARHRITIS? 2
  3. GOUT AND PSEUDOGOUT? 2
A
  1. OSTEOARHTRITIS
    - Disease limited to the joint (one or several – more with age)
    - Can see osteophyte formation, creaking with motion
  2. RHEUMATOID ARTHRITIS
    - Generalized disease that results in multiple, swollen, painful joints
    - Usually starts in hands and feet and progresses proximally
  3. CRYSTALLINE ARTHRITIS
    - Red, hot swollen joint / skin sensitivity
    - Can have multiple episodes that resolve over time
42
Q

Imaging for OA? 4

Imaging for RA? 4

Imaging for GA? 1

A
  1. OSTEOARTHRITIS
    - Joint space narrowing
    - Subchondral sclerosis
    - Osteophytes
    - Subchondral cysts
  2. RHEUMATOID ARTHRITIS
    - Joint space narrowing
    - Soft tissue swelling
    - Bony erosions
    - Osteopenia about joint
  3. GOUTY ARTHRITIS
    - Can see erosions and joint destruction late
43
Q

Compare and Contrast the following in OA and RA in the hand:

  1. Swelling?
  2. Stiffness?
  3. Fingers?
A

Swelling:

  1. hard, bony
  2. soft, warm, tender

Stiffness:

  1. worse after use - PM
  2. worse after resting - AM

Fingers:

  1. DIP/PIP + nodes
  2. MP and PIP + deformity
44
Q

Lab results for:

  1. OA? 1
  2. RA? 4
  3. GA? 2
A
  1. OSTEOARHTRITIS
    Usually normal
2. RHEUMATOID ARTHRITIS
Can have 
-elevated ESR, 
-CRP
-Rheumatoid factor and 
-ACCP test
Both positive, probably RA
  1. GOUTY ARTHRITIS
    -May have elevated uric acid
    -Crystals in joint fluid
    Negative vs Positive
45
Q 
SYNOVIAL FLUID
ANALYSIS 
OA
1. What will it look like?
2. Negative for?

RA
1. What will it look like?

Crystalline Arthritis
1. What will be in it? 2

A

OSTEOARHTRITIS

  1. Clear synovial fluid
  2. Negative for crystals

RHEUMATOID ARTHRITIS
1. Slightly to moderately turbid

CRYSTALLINE ARTHRITIS
Turbid:
1. monosodium urate or
2. calcium pyrophosphate dehydrate

Rheumatology (11 decks)

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