Rheumatology Flashcards
synovial fluid character normal
Leukocytes <200
PMNs < 25%
synovial fluid character Non-inflammatory
Leukocytes 200-2000
PMN <25%
synovial fluid character Inflammatory
Leukocytes 2000-100,000
PMNs> 50%
Synvovial fluid character septic
Leukocytes >100,000
PMNs >75%
narrow the differential acute inflamed and monoarticular
Bacterial infection
Crystal-induced
narrow the differential acute inflamed and oligoarticular
Disseminated gonococcal
infection
RF
Lyme disease
narrow the differential acute inflamed and polyarticular (>5)
Viral infections: hepatitis A and B,
parvovirus, rubella, HIV
narrow the differential Chronic inflamed and polyarticular (>5)
RA, SLE, psoriatic arthritis,
crystalline arthritis
narrow the differential chronic inflamed and oligoarticular
Spondyloarthropathies
narrow the differential chronic inflamed and oligoarticular
Infections related to fungi,
mycobacteria, spirochetes
(syphilis and Lyme disease)
SLE, SSc, Sjögren syndrome; titer does not correlate with disease activity
ANA
SLE; most specific for SLE but does not correlate with disease activity
Anti-Sm
MCTD
Anti–U1-RNP
CREST syndrome; SSc and PH
Anticentromere pattern of ANA
SLE; correlates with disease activity, especially kidney disease
Anti-dsDNA antibody
Autoimmune hepatitis
Anti–smooth muscle antibody
Sjögren syndrome; neonatal SLE
Anti-La/SSB antibody
SSc and pulmonary fibrosis/diffuse cutaneous SSc
Anti–Scl-70 antibody
Drug-induced SLE
Antihistone antibody
Sjögren syndrome, neonatal heart block, subacute cutaneous lupus
Anti-Ro/SSA antibody
Granulomatosis with polyangiitis
c-ANCA (anti-PR3 antibody)
Eosinophilic granulomatosis with polyangiitis and MPA
p-ANCA (anti-MPO antibody)
Polymyositis and antisynthetase syndrome
Anti–Jo-1 antibody
Rheumatoid arthritis
Anti–CCP antibody
xray findings in RA
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 )
MRI useful in RA to diagnose
for detecting cervical spine subluxation or myelopathy.
if you see symmetric arthritis and Skin rash and leukopenia think
SLE
if you see symmetric arthritis and Psoriasis or pitted nails think
Psoriatic arthritis
if you see symmetric arthritis and Day care worker or contact with small children
Parvovirus B19 infection (usually self-limited after 1-3 months)
if you see symm arthritis and 2nd and/or 3rd MCP and PIP joint arthritis with hook-like
osteophytes
Hemochromatosis
symmetric arthritis and Raynaud phenomenon and sclerodactyly
SSc
symmetric arthritis and Proximal muscle weakness
Polymyositis or dermatomyositis
symmetric arthritis and Recent immunization
Post–rubella immunization arthritis
if you see Tophi with symmetric small joint involvement of the hands and
feet think
Chronic tophaceous gout
RA and Arm paresthesias and hyperreflexia
C1-C2 subluxation (increased risk of cord compression with tracheal intubation)
RA and Cough, fever, pulmonary infiltrates
Bronchiolitis obliterans organizing pneumonia (BOOP)
RA and Foot drop or wrist drop
Mononeuritis multiplex (vasculitis)
RA and horseness
Cricoarytenoid involvement
RA and Multiple basilar pulmonary nodules
Caplan syndrome (pneumoconiosis related to occupational dust; characterized by rapid development of multiple basilar nodules and mild airflow obstruction)
RA and Dry eyes and/or mouth
Sjögren syndrome
RA and Pleural effusion with low plasma glucose
<30 mg/dL
Rheumatoid pleuritis
RA and Pulmonary fibrosis
Rheumatoid interstitial lung disease
RA and Skin ulcers, peripheral neuropathy
Rheumatoid vasculitis
RA and Splenomegaly and granulocytopenia
Felty syndrome
RA and Red, painful eye
Scleritis, uveitis
RA and HF
Rheumatoid disease or anti-TNF therapy
quick symptomatic relief of RA
t NSAIDs and low-dose oral and intra-articular glucocorticoids for quick symptomatic relief; these agents do
not alter the course of the disease.
initial tx for RA
• 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
what if patient cannot take methotrexate
Leflunomide
early tx for patients with early mild nonerosive RA
hydroxychloroquine or sulfasalazine
which meds are okay to take during pregnancy for RA
hydroxychloroquine or sulfasalazine; discontinue methotrexate/leflunomide when trying to conceive
sjogren triad
- keratoconjunctivitis sicca
- xerostomia
- salivary gland enlargement
what immunologic marker can you see in sjorgrens (not autoimmune marker)
Hypergammaglobinemia
what is gold standard for unclear cases of sjogrens
a lip biopsy of minor salivary glands is the gold standard for diagnosis.
what condition patient with sjogren most likely to get
44 times more likely than the general population to have a B-cell lymphoma
Erosive inflammatory OA
pain and palpable swelling of the soft tissue in the PIP and DIP joints. Not associated with any markers. Does not affect wrist
DISH OA
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
characteristics of hypertrophic OA
digital clubbing, painful periostosis of long bones, synovial effusions, and new periosteal bone formation
distinguishing feature to help diagnose hypertrophic OA
pain improves when you lift affected limb
characteristics of arthritis in Psoriatic arthritis
- asymmetric, lower extremity oligoarthritis (resembling reactive arthritis)
- symmetric polyarthritis (resembling RA) involving the DIP, PIP, and/or MCP joints
what hand arthritic/skin finding can distinguish Psoriatic arthritis from RA
Sausage-shaped fingers or toes (dactylitis), often involving the DIP joints
Explosive onset or severe flare-up of psoriatic arthritis
should prompt testing for
HIV infection
tx for psoriatic arthritis
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
newer biologics that can improve psoriasis and PA and decrease dactylitis and enthesitis
ustekinumab (anti-IL-12/23 antibody) and secukinumab (anti-IL-17A antibody)
temporal period when Reactive arthritis starts
1 to 3 weeks after an infectious event originating in the
GU or GI tract.
characteristics of reactive arthritis
Characteristic findings include:
• monoarthritis or acute asymmetric oligoarthritis (usually in weight-bearing joints)
• dactylitis
• enthesopathy (especially of the Achilles tendon)
• sacroiliitis
keratoderma blennorrhagicum
a psoriasis-like lesion on the palms and soles
circinate balanitis
shallow, moist, serpiginous ulcers with raised borders on the glans penis
characteristic pain of ax spa
Characteristic symptoms are pain and stiffness that
worsen at night and are relieved with physical activity or heat.
physical exam findings (4) in ax spa
decreased hyperextension, forward flexion, lateral flexion, and axial rotation
• diminished chest expansion
• asymmetric peripheral arthritis involving the large joints
• painful heels (enthesitis)
most common extra articular finding in ax spa
uveitis
what should you be concerned about with pt with ax spa and pain with increased laxity of neck after minor accident
fracture
scleroderma renal crisis is characterized by
hypertension with microangiopathic hemolytic anemia, thrombocytopenia, and
acute kidney injury with mild proteinuria and bland urine
CREST stands for
calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, telangiectasia
diffuse scleraderma skin findings
Skin thickening proximal to the elbows and
knees, including chest and abdomen; may affect
the face
diffuse ssc autoantibodies
ANA and anti–Scl-70 antibodies
lung disease in diffuse ssc
Interstitial lung disease
which subtype of ssc do you get scleraderma renal crisis in
diffuse
skin findings in limited ssc
Skin thickening distal to the elbows and knees;
may affect the face
limited ssc autoantibody mark
ANA and anticentromere antibodies
lung disease in limited ssc
PH
tx for ssc raynauds
Use amlodipine, felodipine,
nifedipine, sildenafil, and nitroglycerin paste to manage symptoms.
tx for scleraderma renal crisis
Prescribe ACE inhibitors for scleroderma renal crisis regardless of the serum creatinine level; continue even in the setting of kidney failure.
diagnose sibo and tx
hydrogen breath test
prescribe broad-spectrum antibiotics for bacterial overgrowth.
how to tx ssc alveolitis
mycophenolate mofetil
what medication can actually harm patients with ssc
steroids may give them risk of ssc
what is MCTD
SLE, SSc, and/or polymyositis in the presence
of anti–U1-RNP antibodies.
htn med that can cause gout and htn med that can improve it somewhat
cause: hctz
improve: losartan
what kind of crystals in gout
Monosodium urate crystals (needle-shaped, negatively
birefringent crystals) in the joint fluid and urate tophi are
diagnostic
xray in gout
X-rays of patients with chronic gout show bone erosions with overhanging edges. Subcortical cysts and periarticular erosions may also be seen.
can you start urate lowering med during acute gout attack
Urate-lowering therapy (see following) can be initiated during an acute attack if adequate anti-inflammatory therapy is
concurrently started. (overlap for 3-6mo)
when should allopurinol be avoided
high-risk populations (Han Chinese, Taiwanese, Korean patients with kidney disease) if
positive for HLA-B*5801.
what can you use to lower urate in ckd patient
febuxostat
what to use when chronic refractory gout or when standard urate-lowering therapy has been unsuccessful or not tolerated
IV pegloticase
characteristics of pseudogout
- 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
• chronic CPP crystal inflammatory arthritis resembles …
RA
• OA with CPPD compared to regular OA
OA w/ CPPD exhibits OA findings in atypical locations
including wrist, MCP, or shoulder joints
characteristic findings of cartilidge calcification
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
CPPD may be associated with what underlying metabolic disorders
- hemochromatosis
- hypomagnesemia
- hyperparathyroidism
- hypothyroidism
infectious arthritis should be considered in the following situations
- 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
what is the hallmark sign of infectious arthritis
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.
two syndromes of gynococcol arthritis
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.
Gottron papules
scaly, purplish
papules and plaques over the metacarpal and interphalangeal joints
helicotropic rash
edematous lilac discoloration of
periorbital tissue
what is antisynthetase syndrome
characterized by interstitial lung disease, inflammatory polyarthritis, fever, Raynaud phenom-
enon, “mechanic’s hands” can be seen in dermatomyositis and polymyositis
how does inclusion body myositis present
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.
emg findings in inflammatory myopathy
short duration small, low-amplitude polyphasic potentials
• fibrillation potentials at rest
• bizarre, high frequency, repetitive discharges
what is a well establish associated illness with patients who have inflammatory myopathy
malignancy, any kind usually age related but ovarian is more common
tx for inflammatory myopathy
high dose steroids
methotrexate can be added if steroid assoc side effects
rituxin for refractory cases
and hcq for cutaneous lesions
Giant Cell arteritis presentation and testing
Older adults with fever, headaches, scalp
tenderness, jaw claudication, and visual
symptoms
ESR (>50 mm/h) and temporal artery biopsy
Polymyalgia rheumatica presentation and testing
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
Takayasu arteritis presentation and testing
Young women with fever, malaise, weight loss,
and arthralgia preceding arm/leg claudication,
pulse deficits, vascular bruits, and asymmetric arm
BP readings
Aortography
Polyarteritis nodosa presentation and testing
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)
Primary angiitis of the CNS presentation and testing
Recurrent headaches, stroke, TIA, and progressive
encephalopathy
LP, MRI, cerebral angiography, and brain biopsy
(granulomatous vasculitis)
Granulomatosis with
polyangiitis presentation and testing
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
Microscopic polyangiitis presentation and testing
Pulmonary infiltrates, palpable purpura, and
rapidly progressive pauci-immune GN
P-ANCA and anti-MPO antibody assay
Biopsy skin, lung, or kidney
Eosinophilic granulomatosis
with polyangiitis presentation and testing
Asthma, eosinophilia, elevated IgE, and
pulmonary infiltrates/hemoptysis
P-ANCA and anti-MPO antibody assay and biopsy
Henoch-Schönlein purpura presentation and testing
Palpable purpura, joint, and gut involvement
(abdominal pain), and GN
Skin biopsy (IgA immune complex deposition) or kidney biopsy (IgA nephropathy)
Hypersensitivity vasculitis
(leukocytoclastic vasculitis) presentation and testing
Palpable purpura (lower legs), cutaneous vesicles,
pustules, maculopapular lesions, urticaria, recent
viral infection, drug exposure, or diagnosis of
malignancy
Skin biopsy
Cryoglobulinemic vasculitis presentation and testing
Skin lesions (red macules, palpable purpura, nodules, or ulcers), GN, mononeuritis multiplex, and elevated serum aminotransferase levels
Serum cryoglobulins and hepatitis C serologic
studies
Behçet syndrome presentation and testing
Oral and genital ulcers; uveitis; pathergy;
nonerosive, asymmetric oligoarthritis; CNS or
large artery vasculitis
Clinical diagnosis
complications of giant cell artertitis
aortic dissection or aneurysm
what is unique about kidney disease in polyarteritis nodosa
does not affect glomerulus so no cast blood or protein in urine
treatment of Giant cell arteritis
Initial high-dose glucocorticoids; tocilizumab may be steroid sparing; low-dose aspirin; treat immediately
to prevent blindness and obtain biopsy in <2 weeks
Treatment of Polymyalgia rheumatica
low dose prednisone; relapse common and prolonged courses typically (1-3 years)
Treatment of Takayasu arteritis
Prednisone
Treatment of Polyarteritis nodosa
Prednisone and cyclophosphamide for severe organ-threatening disease; treat concomitant HBV infection
Treatment of Primary angiitis of the CNS
Prednisone and cyclophosphamide
Treatment of Granulomatosis with polyangiitis
Prednisone and either cyclophosphamide or rituximab
Treatment of Microscopic polyangiitis
Prednisone and either cyclophosphamide or rituximab
Treatment of Henoch-Schönlein purpura
Typically self-limited; glucocorticoids or cyclophosphamide for severe, persistent GN
Treatment of Hypersensitivity vasculitis
Stop affending agent
Treatment of HCV-associated cryoglobulinemic vasculitis
Treat underlying HCV infection
If organ dysfunction is severe, also treat with prednisone, cyclophosphamide, and
plasmapheresis
Treatment of Behçet syndrome
Prednisone; steroid-sparing agents may be required for major disease manifestations
(uveitis, CNS, GI, or large artery involvement)
Treatment of Eosinophilic granulomatosis with polyangiitis
Prednisone; cyclophosphamide added for severe, multiorgan disease
what is relapsing polychondritis
systemic inflammatory connective tissue disease characterized by inflammation and destruction
of cartilaginous structures
signs of relapsing polychondritis
- red, hot, painful ears (most common presenting feature)
- respiratory stridor caused by tracheal collapse
- saddle nose deformity
testing in relapsing polychondritis
Relapsing polychondritis is often a clinical diagnosis, and biopsy of affected cartilage is confirmatory.
conditions associated with saddle nose deformity
Saddle nose deformity can
also occur in syphilis, cocaine use, leprosy, and granulomatosis with polyangiitis.
signs of Familial Mediterranean Fever
- recurrent, self-limited attacks of fever and serositis (abdominal or pleuritic pain)
- arthritis
- rashes that last 3 to 4 days
testing of FMF
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
tx of FMF
Select colchicine for confirmed or suspected FMF to prevent symptomatic attacks and development of AA amyloidosis.
signs of Adult stills disease
- 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
diagnose adult stills disease
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.
treatment of adult stills
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.
what is complex pain syndrome
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
associated symptoms with pain in complex pain syndrome
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)
diagnosis of complex pain syndrome
The finding of abnormal bone metabolism and osteoporosis by bone scan, bone densitometry, MRI, or plain x-ray supports the
diagnosis.
treatment of complex pain syndrome
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.
