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Boards Basic > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

synovial fluid character normal

A

Leukocytes <200

PMNs < 25%

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2
Q

synovial fluid character Non-inflammatory

A

Leukocytes 200-2000

PMN <25%

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3
Q

synovial fluid character Inflammatory

A

Leukocytes 2000-100,000

PMNs> 50%

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4
Q

Synvovial fluid character septic

A

Leukocytes >100,000

PMNs >75%

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5
Q

narrow the differential acute inflamed and monoarticular

A

Bacterial infection

Crystal-induced

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6
Q

narrow the differential acute inflamed and oligoarticular

A

Disseminated gonococcal
infection
RF
Lyme disease

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7
Q

narrow the differential acute inflamed and polyarticular (>5)

A

Viral infections: hepatitis A and B,

parvovirus, rubella, HIV

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8
Q

narrow the differential Chronic inflamed and polyarticular (>5)

A

RA, SLE, psoriatic arthritis,

crystalline arthritis

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9
Q

narrow the differential chronic inflamed and oligoarticular

A

Spondyloarthropathies

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10
Q

narrow the differential chronic inflamed and oligoarticular

A

Infections related to fungi,
mycobacteria, spirochetes
(syphilis and Lyme disease)

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11
Q

SLE, SSc, Sjögren syndrome; titer does not correlate with disease activity

A

ANA

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12
Q

SLE; most specific for SLE but does not correlate with disease activity

A

Anti-Sm

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13
Q

MCTD

A

Anti–U1-RNP

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14
Q

CREST syndrome; SSc and PH

A

Anticentromere pattern of ANA

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15
Q

SLE; correlates with disease activity, especially kidney disease

A

Anti-dsDNA antibody

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16
Q

Autoimmune hepatitis

A

Anti–smooth muscle antibody

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17
Q

Sjögren syndrome; neonatal SLE

A

Anti-La/SSB antibody

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18
Q

SSc and pulmonary fibrosis/diffuse cutaneous SSc

A

Anti–Scl-70 antibody

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19
Q

Drug-induced SLE

A

Antihistone antibody

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20
Q

Sjögren syndrome, neonatal heart block, subacute cutaneous lupus

A

Anti-Ro/SSA antibody

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21
Q

Granulomatosis with polyangiitis

A

c-ANCA (anti-PR3 antibody)

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22
Q

Eosinophilic granulomatosis with polyangiitis and MPA

A

p-ANCA (anti-MPO antibody)

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23
Q

Polymyositis and antisynthetase syndrome

A

Anti–Jo-1 antibody

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24
Q

Rheumatoid arthritis

A

Anti–CCP antibody

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25
Q

xray findings in RA

A

erosions in first 2 years
- can aid in diagnosis and therapy progress
Other findings include periarticular
osteopenia and symmetric joint-space narrowing
(US is more sensitive for effusions )

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26
Q

MRI useful in RA to diagnose

A

for detecting cervical spine subluxation or myelopathy.

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27
Q

if you see symmetric arthritis and Skin rash and leukopenia think

A

SLE

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28
Q

if you see symmetric arthritis and Psoriasis or pitted nails think

A

Psoriatic arthritis

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29
Q

if you see symmetric arthritis and Day care worker or contact with small children

A

Parvovirus B19 infection (usually self-limited after 1-3 months)

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30
Q

if you see symm arthritis and 2nd and/or 3rd MCP and PIP joint arthritis with hook-like
osteophytes

A

Hemochromatosis

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31
Q

symmetric arthritis and Raynaud phenomenon and sclerodactyly

A

SSc

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32
Q

symmetric arthritis and Proximal muscle weakness

A

Polymyositis or dermatomyositis

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33
Q

symmetric arthritis and Recent immunization

A

Post–rubella immunization arthritis

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34
Q

if you see Tophi with symmetric small joint involvement of the hands and
feet think

A

Chronic tophaceous gout

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35
Q

RA and Arm paresthesias and hyperreflexia

A

C1-C2 subluxation (increased risk of cord compression with tracheal intubation)

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36
Q

RA and Cough, fever, pulmonary infiltrates

A

Bronchiolitis obliterans organizing pneumonia (BOOP)

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37
Q

RA and Foot drop or wrist drop

A

Mononeuritis multiplex (vasculitis)

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38
Q

RA and horseness

A

Cricoarytenoid involvement

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39
Q

RA and Multiple basilar pulmonary nodules

A 
Caplan syndrome (pneumoconiosis related to occupational dust; characterized by rapid
development of multiple basilar nodules and mild airflow obstruction)
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40
Q

RA and Dry eyes and/or mouth

A

Sjögren syndrome

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41
Q

RA and Pleural effusion with low plasma glucose

<30 mg/dL

A

Rheumatoid pleuritis

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42
Q

RA and Pulmonary fibrosis

A

Rheumatoid interstitial lung disease

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43
Q

RA and Skin ulcers, peripheral neuropathy

A

Rheumatoid vasculitis

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44
Q

RA and Splenomegaly and granulocytopenia

A

Felty syndrome

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45
Q

RA and Red, painful eye

A

Scleritis, uveitis

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46
Q

RA and HF

A

Rheumatoid disease or anti-TNF therapy

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47
Q

quick symptomatic relief of RA

A

t NSAIDs and low-dose oral and intra-articular glucocorticoids for quick symptomatic relief; these agents do
not alter the course of the disease.

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48
Q

initial tx for RA

A

• Methotrexate is the initial DMARD for most patients with
RA and should be instituted immediately in patients with
erosive disease. It is continued indefinitely and can be used
in combination with other nonbiologic and biologic
DMARD

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49
Q

what if patient cannot take methotrexate

A

Leflunomide

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50
Q

early tx for patients with early mild nonerosive RA

A

hydroxychloroquine or sulfasalazine

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51
Q

which meds are okay to take during pregnancy for RA

A

hydroxychloroquine or sulfasalazine; discontinue methotrexate/leflunomide when trying to conceive

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52
Q

sjogren triad

A
  • keratoconjunctivitis sicca
  • xerostomia
  • salivary gland enlargement
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53
Q

what immunologic marker can you see in sjorgrens (not autoimmune marker)

A

Hypergammaglobinemia

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54
Q

what is gold standard for unclear cases of sjogrens

A

a lip biopsy of minor salivary glands is the gold standard for diagnosis.

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55
Q

what condition patient with sjogren most likely to get

A

44 times more likely than the general population to have a B-cell lymphoma

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56
Q

Erosive inflammatory OA

A

pain and palpable swelling of the soft tissue in the PIP and DIP joints. Not associated with any markers. Does not affect wrist

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57
Q

DISH OA

A

DISH is an often asymptomatic form of OA that causes flowing ossification along the anterolateral aspect of the vertebral bodies, particularly the anterior longitudinal ligament, in ≥4 contiguous vertebrae.

neither disk-space narrowing nor syndesmophytes are visible as they are in lumbar spondylosis or ankylosing spondylitis

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58
Q

characteristics of hypertrophic OA

A

digital clubbing, painful periostosis of long bones, synovial effusions, and new periosteal bone formation

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59
Q

distinguishing feature to help diagnose hypertrophic OA

A

pain improves when you lift affected limb

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60
Q

characteristics of arthritis in Psoriatic arthritis

A
  • asymmetric, lower extremity oligoarthritis (resembling reactive arthritis)
  • symmetric polyarthritis (resembling RA) involving the DIP, PIP, and/or MCP joints
61
Q

what hand arthritic/skin finding can distinguish Psoriatic arthritis from RA

A

Sausage-shaped fingers or toes (dactylitis), often involving the DIP joints

62
Q

Explosive onset or severe flare-up of psoriatic arthritis

should prompt testing for

A

HIV infection

63
Q

tx for psoriatic arthritis

A

initial NSAIDs
Add methotrexate for enthesitis or peripheral joint disease can improve skin too
Switch to tnf if axial disease resistant to nsaids or peripheral/skin not responsive to methotrexate

64
Q

newer biologics that can improve psoriasis and PA and decrease dactylitis and enthesitis

A

ustekinumab (anti-IL-12/23 antibody) and secukinumab (anti-IL-17A antibody)

65
Q

temporal period when Reactive arthritis starts

A

1 to 3 weeks after an infectious event originating in the

GU or GI tract.

66
Q

characteristics of reactive arthritis

A

Characteristic findings include:
• monoarthritis or acute asymmetric oligoarthritis (usually in weight-bearing joints)
• dactylitis
• enthesopathy (especially of the Achilles tendon)
• sacroiliitis

67
Q

keratoderma blennorrhagicum

A

a psoriasis-like lesion on the palms and soles

68
Q

circinate balanitis

A

shallow, moist, serpiginous ulcers with raised borders on the glans penis

69
Q

characteristic pain of ax spa

A

Characteristic symptoms are pain and stiffness that

worsen at night and are relieved with physical activity or heat.

70
Q

physical exam findings (4) in ax spa

A

decreased hyperextension, forward flexion, lateral flexion, and axial rotation
• diminished chest expansion
• asymmetric peripheral arthritis involving the large joints
• painful heels (enthesitis)

71
Q

most common extra articular finding in ax spa

A

uveitis

72
Q

what should you be concerned about with pt with ax spa and pain with increased laxity of neck after minor accident

A

fracture

73
Q

scleroderma renal crisis is characterized by

A

hypertension with microangiopathic hemolytic anemia, thrombocytopenia, and
acute kidney injury with mild proteinuria and bland urine

74
Q

CREST stands for

A

calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, telangiectasia

75
Q

diffuse scleraderma skin findings

A

Skin thickening proximal to the elbows and
knees, including chest and abdomen; may affect
the face

76
Q

diffuse ssc autoantibodies

A

ANA and anti–Scl-70 antibodies

77
Q

lung disease in diffuse ssc

A

Interstitial lung disease

78
Q

which subtype of ssc do you get scleraderma renal crisis in

A

diffuse

79
Q

skin findings in limited ssc

A

Skin thickening distal to the elbows and knees;

may affect the face

80
Q

limited ssc autoantibody mark

A

ANA and anticentromere antibodies

81
Q

lung disease in limited ssc

A

PH

82
Q

tx for ssc raynauds

A

Use amlodipine, felodipine,

nifedipine, sildenafil, and nitroglycerin paste to manage symptoms.

83
Q

tx for scleraderma renal crisis

A

Prescribe ACE inhibitors for scleroderma renal crisis regardless of the serum creatinine level; continue even in the setting of kidney failure.

84
Q

diagnose sibo and tx

A

hydrogen breath test

prescribe broad-spectrum antibiotics for bacterial overgrowth.

85
Q

how to tx ssc alveolitis

A

mycophenolate mofetil

86
Q

what medication can actually harm patients with ssc

A

steroids may give them risk of ssc

87
Q

what is MCTD

A

SLE, SSc, and/or polymyositis in the presence

of anti–U1-RNP antibodies.

88
Q

htn med that can cause gout and htn med that can improve it somewhat

A

cause: hctz
improve: losartan

89
Q

what kind of crystals in gout

A

Monosodium urate crystals (needle-shaped, negatively
birefringent crystals) in the joint fluid and urate tophi are
diagnostic

90
Q

xray in gout

A

X-rays of patients with chronic gout show bone erosions with overhanging edges. Subcortical cysts and periarticular erosions may also be seen.

91
Q

can you start urate lowering med during acute gout attack

A

Urate-lowering therapy (see following) can be initiated during an acute attack if adequate anti-inflammatory therapy is
concurrently started. (overlap for 3-6mo)

92
Q

when should allopurinol be avoided

A

high-risk populations (Han Chinese, Taiwanese, Korean patients with kidney disease) if
positive for HLA-B*5801.

93
Q

what can you use to lower urate in ckd patient

A

febuxostat

94
Q

what to use when chronic refractory gout or when standard urate-lowering therapy has been unsuccessful or not tolerated

A

IV pegloticase

95
Q

characteristics of pseudogout

A
  • inflammation localized to one joint, affecting the knee, wrist, shoulder, or ankle
  • acute onset of several painful joints following trauma, severe illness, or surgery
  • rhomboid-shaped positively birefringent synovial fluid crystals
96
Q

• chronic CPP crystal inflammatory arthritis resembles …

A

RA

97
Q

• OA with CPPD compared to regular OA

A

OA w/ CPPD exhibits OA findings in atypical locations

including wrist, MCP, or shoulder joints

98
Q

characteristic findings of cartilidge calcification

A

triangular fibrocartilage of the wrist joint (space between
the carpal bones and distal ulna)
• menisci of the knee joint (appearing as a line in the
cartilage)
• symphysis pubis

99
Q

CPPD may be associated with what underlying metabolic disorders

A
  • hemochromatosis
  • hypomagnesemia
  • hyperparathyroidism
  • hypothyroidism
100
Q

infectious arthritis should be considered in the following situations

A
  • sudden onset of monoarthritis
  • acute worsening of chronic joint disease
  • previously painless joint prosthesis that becomes painful
  • radiographic loosening or migration of a cemented prosthetic device
101
Q

what is the hallmark sign of infectious arthritis

A

hallmark of an infected joint is pain that worsens with passive extension or when the joint is held in fixed flexion; an
infected joint typically appears swollen and warm with overlying erythema.

102
Q

two syndromes of gynococcol arthritis

A

Patients with the tenosynovitis, polyarthralgia, and dermatitis syndrome have cutaneous lesions that progress from papules or macules to pustules that are sterile on culture. Fever and chills are common.

• Patients with purulent gonococcal arthritis do not have systemic features or dermatitis. Synovial fluid cultures for Neisseria gonorrhoeae are positive in 50% of infected patients. Obtaining culture specimens from the pharynx, GU system, and rectum, in addition to synovial fluid cultures, increases the diagnostic yield.

103
Q

Gottron papules

A

scaly, purplish

papules and plaques over the metacarpal and interphalangeal joints

104
Q

helicotropic rash

A

edematous lilac discoloration of

periorbital tissue

105
Q

what is antisynthetase syndrome

A

characterized by interstitial lung disease, inflammatory polyarthritis, fever, Raynaud phenom-
enon, “mechanic’s hands” can be seen in dermatomyositis and polymyositis

106
Q

how does inclusion body myositis present

A

insidious onset of symptoms, which involve proximal and distal muscles, fre-
quently with an asymmetric distribution. Quadriceps, wrist, and finger flexor muscle weakness is common.

107
Q

emg findings in inflammatory myopathy

A

short duration small, low-amplitude polyphasic potentials
• fibrillation potentials at rest
• bizarre, high frequency, repetitive discharges

108
Q

what is a well establish associated illness with patients who have inflammatory myopathy

A

malignancy, any kind usually age related but ovarian is more common

109
Q

tx for inflammatory myopathy

A

high dose steroids
methotrexate can be added if steroid assoc side effects
rituxin for refractory cases
and hcq for cutaneous lesions

110
Q

Giant Cell arteritis presentation and testing

A

Older adults with fever, headaches, scalp
tenderness, jaw claudication, and visual
symptoms

ESR (>50 mm/h) and temporal artery biopsy

111
Q

Polymyalgia rheumatica presentation and testing

A

Older adults with aching and morning stiffness in
the proximal muscles of the shoulder and hip
girdle
Muscle strength and muscle enzymes are normal
May develop in patients with giant cell arteritis or
as a primary condition

ESR > 50

112
Q

Takayasu arteritis presentation and testing

A

Young women with fever, malaise, weight loss,
and arthralgia preceding arm/leg claudication,
pulse deficits, vascular bruits, and asymmetric arm
BP readings

Aortography

113
Q

Polyarteritis nodosa presentation and testing

A

Nonglomerular kidney disease, hypertension,
mononeuritis multiplex, and skin lesions (nodules,
livedo reticularis, palpable purpura)

Hepatitis B serologic studies, biopsy of involved
tissue (usually skin or testicle), and mesenteric or
renal angiography (aneurysms and stenoses)

114
Q

Primary angiitis of the CNS presentation and testing

A

Recurrent headaches, stroke, TIA, and progressive
encephalopathy

LP, MRI, cerebral angiography, and brain biopsy
(granulomatous vasculitis)

115
Q

Granulomatosis with

polyangiitis presentation and testing

A

Recurrent middle ear infections, destructive
rhinitis or sinusitis, saddle-nose deformity,
tracheal collapse, pulmonary infiltrates/cavities/
hemoptysis, and pauci-immune GN

C-ANCA and anti-PR3 antibody assay
Biopsy skin or kidney

116
Q

Microscopic polyangiitis presentation and testing

A

Pulmonary infiltrates, palpable purpura, and
rapidly progressive pauci-immune GN

P-ANCA and anti-MPO antibody assay
Biopsy skin, lung, or kidney

117
Q

Eosinophilic granulomatosis

with polyangiitis presentation and testing

A

Asthma, eosinophilia, elevated IgE, and
pulmonary infiltrates/hemoptysis

P-ANCA and anti-MPO antibody assay and biopsy

118
Q

Henoch-Schönlein purpura presentation and testing

A

Palpable purpura, joint, and gut involvement
(abdominal pain), and GN

Skin biopsy (IgA immune complex deposition) or
kidney biopsy (IgA nephropathy)
119
Q

Hypersensitivity vasculitis

(leukocytoclastic vasculitis) presentation and testing

A

Palpable purpura (lower legs), cutaneous vesicles,
pustules, maculopapular lesions, urticaria, recent
viral infection, drug exposure, or diagnosis of
malignancy

Skin biopsy

120
Q

Cryoglobulinemic vasculitis presentation and testing

A 
Skin lesions (red macules, palpable purpura,
nodules, or ulcers), GN, mononeuritis multiplex,
and elevated serum aminotransferase levels

Serum cryoglobulins and hepatitis C serologic
studies

121
Q

Behçet syndrome presentation and testing

A

Oral and genital ulcers; uveitis; pathergy;
nonerosive, asymmetric oligoarthritis; CNS or
large artery vasculitis

Clinical diagnosis

122
Q

complications of giant cell artertitis

A

aortic dissection or aneurysm

123
Q

what is unique about kidney disease in polyarteritis nodosa

A

does not affect glomerulus so no cast blood or protein in urine

124
Q

treatment of Giant cell arteritis

A

Initial high-dose glucocorticoids; tocilizumab may be steroid sparing; low-dose aspirin; treat immediately
to prevent blindness and obtain biopsy in <2 weeks

125
Q

Treatment of Polymyalgia rheumatica

A

low dose prednisone; relapse common and prolonged courses typically (1-3 years)

126
Q

Treatment of Takayasu arteritis

A

Prednisone

127
Q

Treatment of Polyarteritis nodosa

A

Prednisone and cyclophosphamide for severe organ-threatening disease; treat concomitant HBV infection

128
Q

Treatment of Primary angiitis of the CNS

A

Prednisone and cyclophosphamide

129
Q

Treatment of Granulomatosis with polyangiitis

A

Prednisone and either cyclophosphamide or rituximab

130
Q

Treatment of Microscopic polyangiitis

A

Prednisone and either cyclophosphamide or rituximab

131
Q

Treatment of Henoch-Schönlein purpura

A

Typically self-limited; glucocorticoids or cyclophosphamide for severe, persistent GN

132
Q

Treatment of Hypersensitivity vasculitis

A

Stop affending agent

133
Q

Treatment of HCV-associated cryoglobulinemic vasculitis

A

Treat underlying HCV infection
If organ dysfunction is severe, also treat with prednisone, cyclophosphamide, and
plasmapheresis

134
Q

Treatment of Behçet syndrome

A

Prednisone; steroid-sparing agents may be required for major disease manifestations
(uveitis, CNS, GI, or large artery involvement)

135
Q

Treatment of Eosinophilic granulomatosis with polyangiitis

A

Prednisone; cyclophosphamide added for severe, multiorgan disease

136
Q

what is relapsing polychondritis

A

systemic inflammatory connective tissue disease characterized by inflammation and destruction
of cartilaginous structures

137
Q

signs of relapsing polychondritis

A
  • red, hot, painful ears (most common presenting feature)
  • respiratory stridor caused by tracheal collapse
  • saddle nose deformity
138
Q

testing in relapsing polychondritis

A

Relapsing polychondritis is often a clinical diagnosis, and biopsy of affected cartilage is confirmatory.

139
Q

conditions associated with saddle nose deformity

A

Saddle nose deformity can

also occur in syphilis, cocaine use, leprosy, and granulomatosis with polyangiitis.

140
Q

signs of Familial Mediterranean Fever

A
  • recurrent, self-limited attacks of fever and serositis (abdominal or pleuritic pain)
  • arthritis
  • rashes that last 3 to 4 days
141
Q

testing of FMF

A

Laboratory findings include an elevated ESR and serum CRP concentration, positive serum amyloid A (AA) protein, proteinuria,
and presence of the Mediterranean fever (MEFV) gene

142
Q

tx of FMF

A

Select colchicine for confirmed or suspected FMF to prevent symptomatic attacks and development of AA amyloidosis.

143
Q

signs of Adult stills disease

A
  • quotidian fever in which the temperature usually spikes once daily and then returns to subnormal
  • fatigue, malaise, arthralgia, and myalgia
  • proteinuria
  • serositis
  • evanescent pink rash
  • joint manifestations include a nonerosive inflammatory arthritis
144
Q

diagnose adult stills disease

A

Diagnosis is clinical, and other possible causes must be ruled out, including infection, malignancy, vasculitis, and drug reac-
tion. Serum ferritin levels >2500 ng/mL are highly specific for this condition and reflect disease activity.

145
Q

treatment of adult stills

A

NSAIDs are generally used as first-line agents in management; glucocorticoids may be useful in patients whose disease is refractory to NSAIDs.

In patients with refractory disease, therapy with methotrexate, a TNF-α inhibitor, or the interleukin-1 receptor antagonist
anakinra may be helpful.

146
Q

what is complex pain syndrome

A

Complex regional pain syndrome is characterized by pain, swelling, limited range of motion, vasomotor instability, skin
changes, and patchy bone demineralization of the extremities. It typically follows an injury, surgery, MI, or stroke. Look for onset
of pain after injury, persistence of pain

147
Q

associated symptoms with pain in complex pain syndrome

A

neuropathic pain (allodynia, hyperalgesia, hyperpathia)
• autonomic dysfunction of the affected extremity (edema, color changes, sweating)
• swelling
• dystrophy (hair loss, skin thinning, ulcers)
• movement disorder (difficulty initiating movement, dystonia, tremor, weakness)

148
Q

diagnosis of complex pain syndrome

A

The finding of abnormal bone metabolism and osteoporosis by bone scan, bone densitometry, MRI, or plain x-ray supports the
diagnosis.

149
Q

treatment of complex pain syndrome

A

Physical therapy is essential to preserve joint mobility and prevent contractures and osteoporosis.

Glucocorticoids may abort the syndrome if started soon after symptom development.

Gabapentin and tricyclic antidepressants are adjuvants for pain control.

Bisphosphonates are effective treatment for pain, even
in the absence of osteoporosis.

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