Rheumatology Flashcards
- women greater than 50 yoa
- joint pain
- MORNING stiffness; SYMMETRICAL, multiple joints of hands, LASTS MORE THAN 1 HOUR
- symptomatic episodes last for at least 6 weeks
rheumatoid arthritis
how is rheumatoid arthritis (RA) defined?
4 or more of the following:
- morning stiffness more than 1 hour
- wrist and finger involvement
- swelling of at least 3 joints
- SYMMETRIC involvement
- rheumatoid nodules
- XR showing erosions
- POSITIVE RF, or anti-CCP Ab
- elevated CRP, or ESR
- synovitis
cardiac findings in RA
- pericarditis
- valvular disease
pulmonary findings in RA
- pleural effusion with VERY LOW glucose level
- lung nodules
hematological findings in RA
anemia with NORMAL MCV
neurological findings in RA
mononeuritis multiplex
dermatological findings in RA
nodules
Felty’s syndrome
- RA
- splenomegaly
- neutropenia
joint findings in RA
- MCP (metacarpophalangeal) swelling and pain
- Boutonniere deformity
- swan neck deformity
- Baker’s cyst
- C1/C2 cervical spine subluxation
Boutonniere deformity
PIP flexion with DIP hyperextension
swan neck deformity
PIP extension with DIP flexion
Baker’s cyst
outpocketing of synovium at back of knee
treatment for RA
NSAIDs with DMARD
disease-modifying antirheumatic drug
which joint is SPARED in RA?
sacroiliac joint
what should be started to eliminate XR abnormalities in RA?
DMARDs
BEST INITIAL DMARD to start in RA
methotrexate
adverse effects of methotrexate
- bone marrow suppression
- pneumonitis
- liver disease
name the DMARDs
- methotrexate
- biological agents (infliximab, adalimumab, etanercept)
- hydroxychloroquine
- sulfasalazine
name the alternate DMARDs
- rituximab
- anakinra
- tocilizumab
- leflunomide
- abatacept
- gold salts
MOA of rituximab
anti-CD20 Ab
MOA of anakinra
IL-1 receptor antagonist
MOA of tocilizumab
IL-6 receptor antagonist
MOA of leflunomide
pyrimidine antagonist (similar to methotrexate)
MOA of abatacept
inhibits T-cell activation
MOA of biological agents (infliximab, adalimumab, etanercept)
block TNF-a
what could be added if methotrexate alone fails?
biological agents (infliximab, adalimumab, etanercept)
patient being treated with hydroxychloroquine, should get?
regular eye exams
adverse effect of sulfasalazine
bone marrow suppression
adverse effect of gold salts
nephrotic syndrome
what is the role of steroids in RA?
- BRIDGE to DMARD therapy
- to treat acutely ill pt with severe inflammation
name the seronegative spondyloarthropathies (4)
- ankylosing spondylitis
- reactive arthritis
- psoriatic arthritis
- juvenile rheumatoid arthritis
characteristics of seronegative spondyloarthropathies
- RF NEGATIVE
- predilection for SPINE
- sacroiliac joint INVOLVEMENT
- association with HLA-B27
- young male, less than 40 yoa
- back stiffness, worse at NIGHT, relieved by LEANING FORWARD
- kyphosis = diminished chest expansion
ankylosing spondylitis
rare findings in ankylosing spondylitis
- uveitis
- aortitis
- restrictive lung disease
best INITIAL test for ankylosing spondylitis
CXR
MOST ACCURATE test for ankylosing spondylitis
MRI of SI joint
treatment for ankylosing spondylitis
- NSAIDs
- biological agents (infliximab/adalimumab)
- sulfasalazine
- asymmetric arthritis with h/o URETHRITIS, or GI INFECTION
- fever
- fatigue
- weight loss
- circinate balanitis
- conjunctivitis
- keratoderma blenorrhagicum
reactive arthritis
diagnostic triad for reactive arthritis
- knee (joint)
- pee (urinary)
- see (eye)
- h/o Chlamydia, Shigella, Salmonella, Yersinia, Campylobacter
treatment for reactive arthritis
reactive arthritis
- h/o psoriasis
- sacroiliac spine involvement
- nail pitting
- DIP involvement
- dactylitis (“sausage-shaped” digits)
- enthesis (inflammation of tendon insertion sites)
psoriatic arthritis
diagnostic test for psoriatic arthritis
NONE
best INITIAL treatment for psoriatic arthritis
NSAIDs
treatment for RESISTANT psoriatic arthritis
methotrexate
other treatment for psoriatic arthritis
infliximab
- fever
- salmon-colored rash
- polyarthritis
- lymphadenopathy
- myalgias
- hepatosplenomegaly
- elevated transaminases
juvenile rheumatoid arthritis (JRA)
diagnostic test for JRA
NONE
characteristic diagnostic tests for JRA
- very high ferritin
- elevated WBCs
- NEGATIVE RF
- NEGATIVE ANA
treatment for JRA
NSAIDs
treatment for JRA unresponsive to NSAIDs
steroids
treatment for JRA with persistent symptoms
methotrexate, or anti-TNF medications
- diarrhea
- fat malabsorption
- weight loss
whipple disease
MOST COMMON PRESENTING SYMPTOM OF WHIPPLE DISEASE
JOINT PAIN
MOST SPECIFIC test for whipple disease
bowel biopsy showing PAS positive organisms
- morning stiffness LESS THAN 30 MINUTES
- CREPITUS on moving joints
- DIP joints
osteoarthritis (OA)
name of DIP osteophytes in OA
Heberden’s nodes
name of PIP osteophytes in OA
Bouchard’s nodes
best INITIAL test for OA
joint XR
diagnostic tests that should be ordered for OA
- ANA
- ESR
- RF
- anti-CCP Ab
treatment for OA
acetaminophen
how many criteria for systemic lupus erythematosus (SLE) are there, and how are needed to confirm the diagnosis?
- 11
- 4 NEEDED TO CONFIRM DIAGNOSIS
diagnostic criteria for SLE
- malar rash
- discoid rash
- photosensitivity rash
- oral ulcers
- arthritis
- serositis
- kidney d/o
- neurological d/o (seizures/psychosis)
- blood d/o (anemia/leukopenia/lymphopenia/thrombocytopenia)
- anti-DNA, anti-Smith, or anti-phospholipid Abs
- ANA
best INITIAL test for SLE
ANA
MOST SPECIFIC test for SLE
anti-dsDNA Ab, or anti-Smith Ab
what is the best to follow the severity of a lupus flare-up?
complement levels (drop), and anti-dsDNA Ab (rise)
the presence of anti-Ro, or anti-SSA Abs is a risk for development of?
heart block
joint XR finding in SLE
normal
type of anemia in SLE
ACD is more common than hemolysis
only test MORE specific for lupus than anti-dsDNA Ab
anti-Smith Ab
other findings in SLE NOT part of diagnostic criteria
- fatigue
- hair loss
- antiphospholipid syndrome
- elevated sedimentation rate
treatment for ACUTE FLARE in SLE
steroids
treatment for joint pain in SLE
NSAIDs
treatment for rash and joint pain NOT responding to NSAIDs
hydroxychloroquinolone
treatment for SEVERE DISEASE UPON CESSATION OF STEROIDS for SLE
- belimumab
- azathioprine
- cyclophosphamide
MOA of belimumab
inhibits B cells
treatment for nephritis in SLE
- steroids and mycophenolate, OR
- steroids and cyclophosphamide
MOA of mycophenolate
inhibits B- and T-lymphocyte proliferation
MOA of cyclophosphamide
alkylates and crosslinks DNA
MCC’s of drug-induced lupus
- hydralazine
- procainamide
- isoniazid
drug-induced lupus ALWAYS has
- anti-HISTONE Ab
- POSITIVE ANA
drug-induced lupus NEVER has
renal, or CNS involvement
complement level, and anti-dsDNA Ab are what in drug-induced lupus?
NORMAL
- women (9:1 female predominance)
- dry eyes
- dry mouth
- “sand under eyelids”
- loss of taste and smell
- loss of teeth at an early age
Sjogren’s syndrome
MOST ACCURATE test for Sjogren’s syndrome
lip biopsy
other diagnostic test for Sjogren’s syndrome
Schirmer test (paper held to eye to test lacrimation)
serologic testing for Sjogren’s syndrome
- ANA (95% +)
- RF (70% +)
- anti-Ro/SSA Ab (50-65% +, but specific)
- anti-La/SSB Ab (30-65% +, but specific)
treatment for Sjogren’s syndrome
- pilocarpine
- cevimeline
(keep eyes and mouth moist)
MOA of pilocarpine, and cevimeline
increase acetylcholine
cevimeline is specific to salivary glands
- woman with tight, fibrous thickening of skin
- tight, immobile fingers (sclerodactyly)
- Raynaud’s phenomenon
- digital ulceration
- joint pain (mild and symmetrical)
scleroderma (systemic sclerosis)
lung involvement in scleroderma
fibrosis and pulmonary hypertension
leading cause of death
GI involvement in scleroderma
- esophageal dysmotility
- PBC (primary biliary cholangitis in 15% of patients)
heart involvement in scleroderma
restrictive cardiomyopathy
renal involvement in scleroderma
may lead to malignant hypertension
diagnostic test for scleroderma (systemic sclerosis)
- NO single diagnostic test
- ANA
- anti-topoisomerase Ab (anti-Scl 70)
treatment for scleroderma
NO treatment (no treatment is effective in stopping it)
treatment for renal involvement and HTN in scleroderma
ACEI
treatment for pulmonary HTN in scleroderma
- bosentan (endothelin antagonist)
- prostacyclin analogs
- sildenafil
treatment for Raynaud’s phenomenon in scleroderma
CCB
treatment for GERD in scleroderma
PPI
treatment for lung fibrosis
cyclophosphamide
CREST syndrome (limited scleroderma)
- Calcinosis of fingers
- Raynaud’s
- Esophageal dysmotility
- Sclerodactyly
- Telangiectasia
diagnostic testing for CREST syndrome
anti-centromere Ab
thickened skin that looks like scleroderma, WITHOUT:
- hand involvement
- Raynaud’s
- heart, lung, or kidney involvement
- MARKED EOSINOPHILIA
- “orange peel” (peau d’orange)
- symptoms are worse with exercise
eosinophilic fasciitis
treatment for eosinophilic fasciitis
steroids
- cannot get up from seated position
- muscle pain and tenderness
- PROXIMAL muscle weakness
- signs of muscle inflammation
polymyositis
- muscle pain and tenderness
- PROXIMAL muscle weakness
PLUS
- Gottron’s papules (metacarpophalangeal joint surfaces)
- heliotrope rash (periorbital purplish rash)
- Shawl sign (shoulder/neck erythema)
dermatomyositis
tests for polymyositis and dermatomyositis
CPK and aldolase
MOST ACCURATE test for polymyositis and dermatomyositis
muscle biopsy
the presence of anti-Jo 1 Abs is a risk for development of?
interstitial lung disease
MC serious complication of PM/DM
malignancy
treatment for PM/DM
steroids
- women, with muscle aches and stiffness with TRIGGER POINTS on palpation and nonrefreshing sleep
- depression, and anxiety
fibromyalgia
blood tests for fibromyalgia
ALL NORMAL
what objective evidence is there for fibromyalgia?
NONE
best INITIAL treatment for fibromyalgia
- milnacipran
- duloxetine
- pregabalin
- patient 50 years or older
- profound pain, and stiffness of proximal muscles
- stiffness worse in morning
- elevated ESR
polymyalgia rheumatica (PMR)
on presentation, all forms of vasculitis can have
- fatigue, malaise, weight loss
- fever
- skin lesions
- joint pain
- neuropathy (mononeuritis multiplex)
common laboratory features in all forms of vasculitis
- normocytic anemia
- elevated ESR
- thrombocytosis
MOST ACCURATE test for all forms of vasculitis
biopsy
best INITIAL treatment for all forms of vasculitis
steroids
if steroids are not effective, what alternate treatment and/or additional treatment can used for all forms of vasculitis
- cyclophosphamide
- azathioprine/6-mercaptopurine
- methotrexate
adverse effect of methotrexate
liver, and lung fibrosis
PAN features:
- abdominal pain
- renal involvement
- testicular involvement
- pericarditis
- HTN
best INITIAL test for PAN
abdominal vessel angiography
MOST ACCURATE test for PAN
skin, muscle, or sural nerve biopsy
treatment for PAN
prednisone and cyclophosphamide
PAN does NOT affect what?
LUNGS
is found in 30% of PAN
hepatitis B
name the vasculitides (7)
- polyarteritis nodosa (PAN)
- Wegener’s granulomatosis (granulomatosis with polyangiitis)
- Churg-Strauss (eosinophilic granulomatosis with polyangiitis)
- temporal arteritis (giant cell arteritis)
- Takayasu’s arteritis
- cryoglobulinemia
- Behcet disease
Wegener’s granulomatosis (granulomatosis with polyangiitis)
- UPPER AND LOWER respiratory findings
- c-ANCA
MOST ACCURATE test for Wegener’s granulomatosis (granulomatosis with polyangiitis)
biopsy
treatment for Wegener’s granulomatosis (granulomatosis with polyangiitis)
prednisone and cyclophosphamide
Churg-Strauss (eosinophilic granulomatosis with polyangiitis)
- vasculitis
- EOSINOPHILIA
- ASTHMA
MOST ACCURATE test for Churg-Strauss (eosinophilic granulomatosis with polyangiitis)
biopsy
treatment for Churg-Strauss (eosinophilic granulomatosis with polyangiitis)
steroids
temporal arteritis (giant cell arteritis)
- headache
- jaw claudication
- visual disturbance
- scalp tenderness
- ASSOCIATED WITH POLYMYALGIA RHEUMATICA
MOST ACCURATE test for temporal arteritis (giant cell arteritis)
biopsy
treatment for temporal arteritis (giant cell arteritis)
steroids
- young Asian female
- diminished pulses
- TIA/stroke (from vascular occlusion)
Takayasu’s arteritis
how is Takayasu’s arteritis diagnosed?
aortic arteriography or MRA
- ASSOCIATED WITH HEPATITIS C
- renal involvement
cryoglobulinemia
treatment if cryoglobulinemia is d/t hepatitis C
interferon and ribavirin
- Middle Eastern, or Asian ancestry
- oral AND GENITAL ulcers
- ocular involvement (uveitis, optic neuritis)
- hyperreactivity to needle sticks
Behcet disease
MOST ACCURATE test for inflamed joints
joint aspiration
best INITIAL test for septic arthritis
CELL COUNT
gram stain only positive 50-60%
(can be as few as 20,000, but usually > 50,000-100,000)
WBC count in normal joint
less than 2,000
WBC count in inflamed joint (gout/pseudogout)
2,000-50,000
WBC count in infected joint
more than 50,000
- male with sudden onset, severe pain
- toe, or knee (red, swollen, tender)
- at night
gout
precipitants of gout attacks
- binge drinking alcohol
- thiazides
- nicotinic acid (niacin)
best INITIAL test for gout
arthrocentesis (joint fluid aspiration)
MOST ACCURATE test for gout
polarized light exam; shows NEGATIVELY BIREFRINGENT NEEDLES
best INITIAL treatment for ACUTE gouty attack
NSAIDs
if NSAIDs are insufficient, or CI, what should be used for treatment of ACUTE gouty attack
steroids
treatment for ACUTE gouty attack if NSAIDs and steroids cannot be used
colchicine
adverse effects of colchicine
- N/V
- bone marrow suppression
what medication should NOT be started during an acute gouty attack?
allopurinol
management of prevention of gout attacks
- allopurinol
- weight loss and exercise
- febuxostat (if allopurinol is NOT tolerated)
- rasburicase/pegloticase (if allopurinol/febuxostat are not enough)
MOA of allopurinol
inhibits xanthine oxidase, decreasing uric acid production
adverse effects of allopurinol
- rash
- allergic interstitial nephritis
- hemolysis
MOA of febuxostat
inhibits xanthine oxidase
MOA of rasburicase/pegloticase
converts uric acid to allantoin, which can be excreted by the kidneys
- knee and wrist involvement
- NO toe involvement
- slow onset
- pt does NOT wake up with severe pain
- may have h/o hemochromatosis, hyperparathyroidism, acromegaly, or hypothyroidism
pseudogout
arthrocentesis shows what in Pseudogout?
POSITIVELY birefringent RHOMBOID-shaped crystals
best INITIAL treatment for pseudogout
NSAIDs
acute management for pseudogout if NSAIDs are ineffective
steroids
- swollen, red, immobile, tender joint
- arthritic and prosthetic joints are at higher risk
septic arthritis
risk of septic arthritis based on abnormality
prosthetic joint > RA > OA > normal joint
etiology of septic arthritis
- Staphylococcus aureus (40%)
- Streptococcus (30%)
- GNR (20%)
in addition to culturing the joint, in disseminated gonorrhea you must also
PANculture all mucosal surfaces ( oropharynx, rectum, urethra, cervix)
best INITIAL test for septic arthritis
arthrocentesis: > 50,000 WBCs
MOST ACCURATE test for septic arthritis
culture (> 90% sensitive)
empiric treatment for septic arthritis
ceftriaxone and vancomycin
- asymptomatic
- may have pain, stiffness, aching, fractures
- bowing of tibias
- sarcoma arises in 1% of patients
Paget’s disease of bone
if osteoLYTIC lesions, think
Paget’s, or OP
if osteoBLASTIC lesions, think
metastatic prostate cancer
best INITIAL test for Paget’s disease
AP level (elevated)
MOST ACCURATE test for Paget’s disease
XR
other tests that should be ordered for Paget’s disease
- urinary hydroxyproline
- serum Ca++ level (will be normal)
- serum phosphate level (will be normal)
- bone scan
treatment for Paget’s disease of bone
bisphosphonates and calcitonin
what is a Baker’s cyst?
posterior herniation of synovium of knee
Baker’s cysts are seen in which patients?
OA, or RA with a SWOLLEN CALF
diagnostic testing for Baker’s cyst
US to EXCLUDE DVT
treatment for Baker’s cyst
- NSAIDs
- steroid injection if needed
- pain on bottom of foot
- very severe in MORNING, better w/ ambulation
- resolves spontaneously over time
plantar fasciitis
- pain on bottom of foot
- more painful with use
- may have numbness of sole
- avoid boots/high heels
- may need steroid injection/surgery
tarsal tunnel syndrome
- painful burning sensation in INTERDIGITAL WEB SPACE between 3rd and 4th toes
- tenderness
- sharp, intermittent pain radiating toes that improves when shoes are removed
Morton’s neuroma
