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Internal Medicine > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

ANA

A

SLE, SSc, Sjogren

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2
Q

Anti-Sm

A

SLE (most specific)

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3
Q

Anti-U1-RNP

A

MCTD (mixed connective tissue disease)

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4
Q

Anticentromere pattern of ANA

A

CREST Syndrome; SSc & Pulmonary HTN

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5
Q

Anti-ds DNA antibody

A

SLE; correlates with disease activity, especially kidney disease

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6
Q

Anti-smooth muscle antibody

A

autoimmune hepatitis

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7
Q

Anti-La/SSB antibody

A

Sjogren syndrome; neonatal SLE

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8
Q

Anti-Scl-70 antibody

A

SSc and Pulmonary FIBROSIS

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9
Q

Antihistone Ab

A

Drug-induced SLE

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10
Q

Anti-Ro/SSA Ab

A

Sjogren, neonatal heart block, subacute cutaneous lupus

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11
Q

c-ANCA (anti-PR3 Ab)

A

Granulomatosis with polyangiitis

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12
Q

p-ANCA (anti-MPO Ab)

A

Eosinophilic granulomatosis with polyangiitis and MPA (microscopic polyangiitis)

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13
Q

Anti-Jo-1

A

Polymyositis and antisynthetase syndrome

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14
Q

Anti-CCP Ab

A

Rheumatoid Arthritis

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15
Q

Only test for ANA sub-serologies if ANA is negative when you’re looking for __ & __

A

Subacute cutaneous lupus (anti-SSA)
&
Polymyositis (anti-Jo-1)

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16
Q

Diagnosis?

  • Morning stiffness >1h
  • 7 classic sites of symmetric joint pain (PIP, MCP, wrist, elbows, knee, ankle, and MTP)
  • synovitis characterized by soft-tissue swelling or effusion
  • subcutaneous nodules over bony prominences or extensor surfaces
  • symptoms present for >6 weeks
A

RA

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17
Q

Lab testing for RA (4)

A

+ RF (sensitivity 80%; specificity 87%) (can be negative)
Elevated ESR or CRP
Normocytic anemia
Positive anti-CCP Ab (sensitivity 70%; specificity 95%)

can have seronegative RA

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18
Q

Erosions on xray

A

RA

Other xray findings: periarticular osteopenia & symmetric joint space narrowing)

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19
Q

Dx to consider if symmetric arthritis and…

Skin rash and leukopenia

A

SLE

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20
Q

Dx to consider if symmetric arthritis and…

Psoriasis or pitted nails

A

psoriatic arthritis

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21
Q

Dx to consider if symmetric arthritis and…day care worker or contact with small children

A

Parvovirus B19 infection (self-limited 1-3 mo)

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22
Q

Dx to consider if symmetric arthritis and…2nd +/- 3rd MCP and PIP joint arthritis with hook-like osteophytes

A

hemochromatosis

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23
Q

Dx to consider if symmetric arthritis and…Raynaud phenomenon and sclerodactyly

A

Ssc

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24
Q

Dx to consider if symmetric arthritis and…proximal muscle weakness

A

polymyositis or dermatomyositis

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25
Q

Recent immunizations

A

Post-rubella immunization arthritis

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26
Q

Dx to consider if symmetric arthritis and…tophi with symmetric small joint involvement of the hands and feet

A

Chronic tophaceous gout

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27
Q

Consider this Dx if you see this in an RA patient…arm parasthesias and hyperreflexia

A

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

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28
Q

Consider this Dx if you see this in an RA patient…Cough, fever, pulmonary infiltrates

A

cryptogenic organizing pneumonia (formerly BOOP)

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29
Q

Consider this Dx if you see this in an RA patient…Foot drop or wrist drop

A

mononeuritis multiplex (vasculitis)

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30
Q

Consider this Dx if you see this in an RA patient…hoarseness

A

cricoarytenoid involevement

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31
Q

Consider this Dx if you see this in an RA patient…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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32
Q

Consider this Dx if you see this in an RA patient…dry eyes and/or mouth

A

Sjogren

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33
Q

Consider this Dx if you see this in an RA patient…pleural effusion with low plasma glucose (<30 mg/dL)

A

Rheumatoid pleuritis

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34
Q

Consider this Dx if you see this in an RA patient…Pulmonary fibrosis

A

Rheumatoid interstitial lung disease

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35
Q

Consider this Dx if you see this in an RA patient… skin ulcers, peripheral neuropathy

A

Rheumatoid vasculitis

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36
Q

Consider this Dx if you see this in an RA patient…splenomegaly and granulocytopenia

A

Felty Syndrome

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37
Q

Consider this Dx if you see this in an RA patient…red painful eye

A

scleritis, uveitis

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38
Q

Consider this Dx if you see this in an RA patient…HF

A

rheumatoid disease or anti-TNF therapy

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39
Q

All RA patients undergoing anesthesia should have this study first

A

cervical spine xray to assess for atlantoaxial subluxation

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40
Q

Tx strategies in RA

  1. 1st line DMARD
  2. Drugs for mild/non-erosive disease (can also be combined with #1)
  3. Other drug that can be used in place of #1 or with #1
  4. For flares
A
  1. Methotrexate
  2. Hydroxychloroquine sulfasalazine
  3. Leflunomide
  4. NSAID and glucocorticoids
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41
Q

Biologic options for RA (which one is oral?)

MOA

A 
TNF-a inhibitors
Etanercept
Infliximab
Adalimumab
Certolizumab
Golimumab
Tofacitinib (oral)
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42
Q

Tests prior to starting biologic

A

TB

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43
Q

TNF-alpha toxicities (3)

A
  1. Pancytopenia
  2. Positive ANA associated with lupus-like syndromes
  3. Demyelinating disorders
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44
Q

Other things all RA patients need (preventative) (6)

A
  1. DEXA scan
  2. Vit D and Calcium
  3. Bisphosphonate if osteoporosis
  4. Eval and tx of CV risk factors
  5. Pneumococcal and yearly flu vax
  6. PT/OT
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45
Q

Which RA medications are CONTRAINDICATED in pregnancy

A

Methotrexate and leflunomide

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46
Q

Which RA medications are OK during pregnancy

A

hydroxychloroquine and sulfasalazine

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47
Q

Gold standard for Sjogren (but not needed)

A

lip biopsy of minor salivary glands

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48
Q

Malignancy associated with Sjogren

A

B-cell lymphoma (large B-cell and MALT most common)

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49
Q

Joint pain exacerbated by activity and improved with rest + morning stiffness <30 min

A

OA

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50
Q

Consider metabolic causes with OA develops in ____

A

MCP, shoulder, wrists (proximal joints)

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51
Q

Causes of secondary OA

A

trauma or hemochromatosis

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52
Q

What is hypertrophic osteoarthropathy and what is it associated with?

A

Clubbing of distal hand and feet (enlargement of distal extremities) caused by lung cancer or frequent lung infections.

Must get xray to rule out lung cancer

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53
Q

Monoarticular diseases

A

bacterial infection
crystal-induced
Infections related to fungi, mycobacteria, spiroochetes (syphillis/lyme), OA

54
Q

Oligoarticular disease (2-4 joints)

A 
Disseminated gonococcal infection
RF
lyme disease
spomdyloarthropathies (psoriatic arthritis, reactive arthritis, IBD-associated arthritis)
OA
55
Q

Polyarticular disease

A

Viral infections, Hep A and B, parvovirus, rubella, HIV
RA, SLE
Psoriatic arthritis, crystalline arthritis
OA

56
Q

Arthritis Mutilans (pencil in a cup)

A

psoriatic arthritis

57
Q

Dactylitis is associated with (2)

A

psoriatic arthritis

SSc or CREST

58
Q

Explosive onset of severe flare up of psoriatic arthritis should prompt testing for ____

A

HIV

59
Q

Treatment of Psoriatic Arthritis

A
  1. NSAIDs
  2. Methotrexate if doesn’t respond to #1
  3. TNF-a inhibitor
  4. Ustekinumab (anti-IL12/23 Ab), Secukinumab (anti0IL-17A Ab) –> improves dactylitis and enthesitis
60
Q

What drugs can exacerbate psoriatic arthritis

A

antimalarial drugs

withdrawal from oral glucocorticoids

61
Q

Does methotrexate reduce progression of joint damage in psoriatic arthritis?

A

NO

just joint PAIN and skin disease

62
Q

Skin finding related to reactive arthritis

A

keratoderma blennorrhagicum

circinate balanitis

63
Q

Characteristic pain in Ankylosing Spondylitis

timing, alleviating, age, location

A
  1. > 1h morning stiffness, worse at night
  2. Alleviated with physical activity or heat
  3. <40 yo
  4. Low back pain +/- shoulders and hips
64
Q

Extra-articular manifestation of ankylosing spondylitis

A 
anterior uveitis
aortic valve regurg
aortic aneurysm
cardiac conduction defects
apical pulmonary fibrosis and cavitation
cauda equina syndrome
65
Q

Diagnosis of Ankylosing spondylitis

A

xray of sacroiliac joints –> show sacroiliitis with erosions, pseudowidening of the joints, sclerosis and ankylosis

xray of spine –> subchondral bony sclerosis, vertebral body squaring, bony ankylosis (bamboo sign)

Can proceed to MRI if radiographic findings are equivocal

66
Q

Treatment of Ankylosing spondylitis

A

Exercise to preserve range of motion and strengthen the spine extensor muscles to prevent kyphosis

67
Q

Diagnosis of SLE

A

Need at least 4 of the following:

    • ANA
  2. Malar rash that SPARES nasolabial folds and areas beneath nose and lower lip
  3. Discoid rash (keratotic scaling and follicular plugging)
  4. Photosensitivity
  5. Oral ulcers
  6. Arthritis
  7. Serositis
  8. Kidney disorder
  9. Neurologic disorder (aseptic meningitis, cranial neuritis, encephalitis, mononeuritis multiplex, peripheral neuropathy, psychosis, seizures, stroke, transverse myelitis)
  10. Hematologic disorder (autoimune hemolitic anemia, leukopenia, lymphopenia, thrombocytopenia)
  11. Immunologic disorder (antiphospholipid ab syndrome)
68
Q

Drug that commonly causes SUBACUTE CUTANEOUS SLE

A

hydrochlorothiazide

69
Q

anti-ds DNA is a good marker for what specific organ function in SLE?

A

Kidney disease

70
Q

What autoantibodies help diagnose neuropsychiatric SLE

A

antineuronal
anti-NMDA receptor
antiribosomal P
APLA/LAC (lupus anticoagulant)

71
Q

Newborns of mothers with Anti-Ro/SSA and Anti-La/SSB Ab are at risk for developing ___

A

neonatal SLE

manifests as neonatal heart block

72
Q

Drug induced SLE is usually caused by (5)

A
  1. hydralazine
  2. procainamide
  3. isoniazid
  4. micocycline
  5. TNF-a inhibitors
73
Q

Patient has facial rash that INVOLVES nasolabial fold and + ANA. What Dx to consider?

A

Rosacea

74
Q

What labs are positive in drug-induced SLE?

A

ANA and ANTIHISTONE Ab

Anti dsDNA and Anti-smith are negative

75
Q

Tx of SLE:

  1. Chronic
  2. Life-threatening disease
A
  1. Hydroxychloroquine

2. Glucocorticoids +/- Cyclophosphamide or mycophenolate mofetil

76
Q

Diagnosis of Systemic Sclerosis (SSc)

A

typical skin findings + one of more of below:

  1. Sclerodactyly
  2. Digital pitting
  3. interstitial lung disease
  4. Raynaud
  5. pulm HTN
  6. GERD / esophageal dysmotility
  7. Pseudo-obstruction (small bowel)
  8. Calcinosis
  9. Inflammatory arthritis (DIP and wrists)
  10. Kidney disease
  11. malabsorption owing to bacterial overgrowth
77
Q

Primary cause of morbidity/mortality in SSc

A

pulmonary disease

78
Q

Scleroderma renal crisis (4)

A
  1. HTN
  2. microangiopathic hemolytic anemia
  3. Thrombocytopenia
  4. AKI with mild proteinuria and bland urine
79
Q

Cause of recurrent bleeding and chronic anemia in Ssc

A

GAVE (gastric antral vascular ectasia (“watermelon stomach”)

80
Q

Diffuse vs. Limited Cutaneous Ssc

A 
Diffuse:
ANA + Anti-Scl-70
Skin thickening PROXIMAL to elbows and knees including chest, abd, +/- face
Interstitial lung disease
\+Scleroderma renal crisis
No CREST
Limited
ANA + Anticentromere Ab
Skin thickening DISTAL to elbows/knees +/- face
Pulm HTN
- Scleroderma renal crisis
\+ CREST sd
81
Q

Things that mimic Scleroderma:

Waxy, yellow-red papules over thickened skin of face, upper trunk neck and arms

A

Sleromyxedema

- associated with MM and AL Amyloidosis

82
Q

Things that mimic scleroderma

- Lichen Planus-like skin lesions or localized or generalized skin thickening

A

Chronic graft v. hose disease

- Occurs most commonly after HSCT

83
Q

Things that mimic scleroderma:

- edema of proximal extremities; sparing of hands and face; peripheral eosinophilia

A

Eosinophilic fasciitis

  • skin biopsy shows lymphocytes, plasma cells and eosinophils
  • Tx: steroids
84
Q

Things that mimic scleroderma:

Indurated plaques/patches on back, shoulder girdle and neck

A

Seen in long-standing diabetes

85
Q

Tx for Raynaud phenomenon

A
  1. Avoid cold
  2. Reduce smoking
  3. Amlodipine, flodipine, nifedipine, sildenafil
  4. Topical: nitroglycerin paste
86
Q

Tx for scleroderma renal crisis

A

ACE-i regardless of creatinine level and continue even in the setting of kidney failure

87
Q

Tx for Interstitial lung disease in SSc

A 
mycophenolate mofentil (cellcept) 
or cyclophosphamide (less preferred)
88
Q

What medication should you NOT use in scleroderma and why not

A

glucocorticoids

- can precipitate scleroderma renal crisis

89
Q

Diagnosis/Features of Mixed connective tissue disease

A

At least two of:

  1. SLE
  2. Ssc
  3. Polymyositis

has to have Anti-U1-RNP antibodies

Should not have anti-Sm or Anti-ds DNA (just clinical criteria)

90
Q

mortality in patients with MCTD is attributable to

A

Pulm HTN

91
Q

Clinical features of MCTD

A
  1. Raynaud
  2. arthritis
  3. Puffy giners
  4. Sclerodactyly
  5. Serositis
  6. Esophageal dysmotility
  7. Myositis
  8. Interstitial lung disease
  9. Pulm arterial HTN
92
Q

FDA approved meds for Fibromyalgia

A

pregabalin
duloxetine
milnacipran

93
Q

Common trigger of gout.

What about in transplant patients.

A

hydrochlorothiazide

calcineurin antagonists (cyclosporine)

94
Q

Synovial fluid findings in Gout

A

monosodium urate crystals (needle-shaped, negatively biirefringent crystals) within neutrophils

  • extracellular crystals = chronic gout
  • 2000-75,000 leukocytes
95
Q

Xray findings of gout

A
  • erosions of bone with OVERHANGING edges

- Subcortical cysts and periarticular erosions

96
Q

Target Uric acid level for those with chronic gout & those with tophaceous gout

A 
Chronic = <6
Tophaceous = <5
97
Q

Urate lowering drug for those with CKD or can’t tolerate allopurinol but has increased CV risk

A

Febuxostat

98
Q

In refractory tophaceous gout, what med is available?

A

IV pegloticase

99
Q

Which uric acid lowering drug makes you pee it out?

A

Probenecid

100
Q

Don’t use ____ with allopurinol/febuxostat because it will raise ___ level

A

azathioprine (imuran)

101
Q

4 clinical presentation of calcium pyrophosphate deposition

A
  1. Asymptomatic cartilage calcification (chondrocalcinosis)
  2. Acute CPP crystal arthritis (pseudogout)
  3. Chronic CPP crystal inflammatory arthritis
  4. OA with CCP
102
Q

If you find CCP in patients <50 yo, screen for these metabolic conditions (4)

A
  1. hemochromatosis
  2. hypomagnesemia
  3. hyperparathyroidism
  4. hypothyroidism
103
Q

How do you diagnose tuberculous arthritis?

A

synovial biopsy

104
Q

If you have gout, what must you ALWAYS also have to rule out

A

septic arthritis (at least with MKSAP)

even with crystals on tap

105
Q

When do you suspect tubercular infectious arthritis

A

if abx not helping

106
Q

rash associated with dermatomyositis

A

Grotton papules (scaly, purplish, papules and plaques over the metacarpal and interphalangeal joints)

Heliotrope rash (edematous lilac discoloration of periorbital)

107
Q

Syndrome associated with interstitial lung disease, inflammatory polyarthritis, fever, Raynaud phenomenon, “mechanic’s hands” (scaly, rough, dry, cracked horizontal lines on palmar and lateral aspects of the fingers) and increased risk of sudden death

A

Antisynthetase Syndrome

108
Q

Painless proximal muscle, pharyngeal, respiratory muscle weakness

A

THINK POLYMYOSITIS AND DERMATOMYOSITIS

109
Q

What sets inclusion body myositis apart?

A

Weakness is asymmetric and can involve distal muscles.

110
Q

Diagnosis of inflammatory myositis

A

Definitive: muscle biopsy
Labs: CK, Aldolase, EMG , TSH
>80% of poly/dermatomyositis have +ANA
<20% of inclusion body myositis have +ANA
MRI of proximal musculature can be helpful

111
Q

What Dx to consider: proximal muscle tenderness

A

Polymyalgia rheumatica

112
Q

Tx of myositis

A

HD glucocorticoids
+/- methotrexate and azathioprine

Rituximab for refractory poly/dermatomyositis

hydroxychloroquine for cutaneous (dermatomyositis)

113
Q

Diagnosis, workup, tx?

Older adults, fever, HA, scalp tenderness, jaw claudication, visual symptoms.

A

Giant cell arteritis (large vessel)

Obtain ESR (>50) and temporal artery biopsy (within 2 weeks)

Tx: HD steroids, low dose ASA, tocilizumab (instead of steroids if needed).

114
Q

Diagnosis, workup, tx?
Older adults, aching/morning stiffness in proximal muscles of shoulder and hip girdle
Muscle strength, muscle enzymes normal

A 
Polymyalgia rheumatica (large vessel)
ESR

Tx: low dose prednisone

115
Q

Diagnosis, workup, tx?
Young woman, fever, malaise, weight loss, arthralgia preceding arm/leg claudication, pulse deficits, vascular bruits, asymmetric arm BP readings

A

Takayasu Arteritis (large vessel)

Aortography

prednisone

116
Q

Diagnosis, workup, tx?

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

A

Polyarteritis nodosa (medium vessel)

Hep B serology, biopsy of involved tissue (skin or testicle), mesenteric/renal angiography (aneurysms and stenoses)

UA without casts/proteinuria or erythrocytes (does not involve the glomerulus)

Tx: prednisone, cyclophosphamide for severe organ-threatening disease. Treat HBV

117
Q

Diagnosis, workup, tx?

Recurrent headaches, stroke, TIA and progressive encephalopathy

A

Primary angiitis of the CNS (medium vessel)

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

Tx: prednisone and cyclophosphamide

118
Q

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

A

Granulomatosis with polyangiitis (small vessel)

c-ANCA and anti PR3
Biopsy of skin or kidney

Tx: prednisone and rituximab (or cytoxan)

119
Q

Diagnosis, workup, tx?

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

A

Microscopic polyangiitis (small vessel)

p-ANCA and anti-MPO Ab assay
Biopsy skin, lung, or kidney

Tx: prednisone and rituximab (or cytoxan)

120
Q

Diagnosis, workup, tx?

Asthma, eosinophilia, elevated IgE, pulmonary infiltrates/hemoptysis

A

Eosinophilic granulomatosis with polyangiitis (small)

must have eosinophilia
p-ANCA, MPO
Biopsy

Tx: prednisone; cytoxan if severe, multiorgan disease

121
Q

Diagnosis, workup, tx?

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

A

Henoch-Scholein purpura (small)

skin biopsy (IgA immune complex deposition)

or Kidney biopsy (IgA nephropathy)

Tx: self-limited. If severe steroids/cytoxan for severe persistent GN

122
Q 
Diagnosis, workup, tx?
Palpable purpura (lower legs), cutaneous vesicles, pustules, maculopapular lesions, urticaria, recent viral infection, drug exposure, or diagnosis of malignancy
A

Hypersensitivity vasculitis (leukocytoclastic vasculitis) (small vessel)

Skin biopsy

Tx: withdraw offending agent

123
Q 
Diagnosis, workup, tx?
Skin lesions (red macules, palpable purpura, nodules, ulcers), GN, mononeuritis multiplex, elevated serum aminotransferase levels
A

Cryoglobulinemic vasculitis (small)

Serum cryoglobulins and hep C serology

Tx: treat underlying HCV. Add prednisone, cytoxan, plasmapheresis if there is organ dysfunction

124
Q

Diagnosis, workup, tx?

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

A

Behcet syndrome (small vessel)

Clinical Diagnosis

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

125
Q 
Red, hot painful ears
Respiratory stridor (tracheal collapse)
Saddle nose deformity
A

Relapsing polychondritis

–> biopsy

126
Q

Tx of relapsing polychondritis

A

NSAIDs
Colchicine
Dapsone

Severe: glucocorticoids

127
Q

Characteristics of Familial Mediterranean fever (timing & symptoms) and Tx

A

recurrent self-limited fevers and serositis
Arthritis
Rash lasting 3-4 days

Tx: colchicine

128
Q

Lab finding for FMF

A

Elevated ESR, CRP
+ serum amyloid A (AA) protein
Proteinuria

Gene: Mediterranean fever (MEFV) gene

129
Q

Characteristics of Adult-Onset Still Disease (timing & symptoms) and Tx

A 
Fever are DAILY
fatigue, malaise, arthralgia, myalgia
Proteinuria
serositis
evanescent pink rash
joint pain (nonerosive inflammatory arthritis)

Dx: Clinical must rule out other causes
Labs: Ferritin >2500 (specific) and reflects disease activity

Tx: NSAIDs 1st line
NSAID refractory –> prednisone, methotrexate, anti TNF-a, anakinra (IL-1 antagonist)

130
Q

Clinical diagnosis of Complex Regional Pain Syndrome

A

Usually after trauma, surgery, MI, or stroke.

At least two of the following:

  1. Neuropathic pain (including allodynia, hyperalgesia, herpathia)
  2. Autonomic dysfunction of the affected extremity (edema, color changes, sweating)
  3. Swelling
  4. Dystrophy (hair loss, skin thickening, ulcers)
  5. Movement disorder (difficulty initiating movement, dystonia, tremor, weakness)
131
Q

How to test for CRPS

A 
abnormal bone metabolism
osteoporosis by bone scan
bone densitometry
MRI
Plain x-ray
132
Q

Tx of CRPS

A

PT
prednisone if started after sx development
Early sympathetic blockade
Gabapentin & tricyclic antidepressants
Bisphosphonates for pain even in the absence of osteoporosis

Internal Medicine (6 decks)

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