Rheumatology Flashcards
In a patient with a prosthetic hip, who is currently undergoing chemotherapy and presents with pain, warmth & effusion in the joint along with fever, what’s the diagnosis?
Prosthetic joint infection
A biopsy demonstrating nongranulomatous necrotizing pauci-immune vasculitis of small vessels or pauci-immune necrotizing crescentic glomerulonephritis in the kidney, with a positive p-ANCA (directed against myeloperoxidase), is the diagnostic gold standard of?
Microscopic polyangiitis (MPA)
Note: Granulomatosis with polyangiitis (GPA) can cause the same lung, skin, joint, and kidney findings but is usually associated with a positive c-ANCA (directed against proteinase-3). Furthermore, GPA causes granulomatous inflammation; absence of granulomas distinguishes MPA from GPA.
This medication is strongly recommended for patients with severe recurrent and/or tophaceous gout that is intolerant or resistant to standard therapies?
Pegloticase
Note: Probenecid is not appropriate for those with an estimated GFR of <60 mL/min/1.73 m2 or with a history of kidney stones; this patient has both.
This patient has the triad of conjunctivitis, urethritis, and arthritis seen in a subset of patients with chlamydial reactive arthritis, what’s the next diagnostic step?
Nucleic acid amplification urine testing is the appropriate diagnostic test
Note: HLA-B27 antigen may be present in those with reactive arthritis, but it has little diagnostic specificity in this disorder. The presence of HLA-B27 antigen would neither rule in nor rule out reactive arthritis.
A diagnosis of ankylosing spondylitis can be made in a patient younger than age 45 years with symptoms of inflammatory back pain for 3 months or more and bilateral sacroiliitis on imaging. Is HLA-B27 antigen testing needed for diagnosis?
No
The presence of HLA-B27 antigen is not a diagnostic criterion for ankylosing spondylitis. However, such testing may be particularly helpful in patients with inflammatory back pain and other manifestations of ankylosing spondylitis but without evidence of sacroiliitis on imaging.
Patients with diffuse cutaneous systemic sclerosis are at risk for acute and chronic gastrointestinal bleeding secondary to?
Gastric antral vascular ectasia (GAVE)
For patients with severe and refractory gouty attacks or with contraindications to other treatments, off-label use of?
interleukin-1 inhibitors (anakinra or canakinumab) can be considered
Patient with osteoarthritis on Celecoxib, with continued severe pain, what’s the next step in management?
Physical therapy
_____ is more sensitive than radiography for detecting early spine and sacroiliac joint inflammation and may be indicated in the evaluation of suspected spondyloarthritis if radiographs are normal.
MRI of the sacroiliac joints
In patient with no clinical findings suggestive of a connective tissue disease with noninflammatory (pain with use, no warmth or swelling, and only minimal morning stiffness) hand joint pain in the distribution consistent with a diagnosis of osteoarthritis, what’s the next step in management?
No further testing
Is characterized by interstitial lung disease, myositis, Raynaud phenomenon, nonerosive inflammatory arthritis, constitutional findings such as low-grade fever, and mechanic’s hands; anti-aminoacyl-tRNA synthetases antibodies, such as anti–Jo-1, are highly suggestive of what diagnosis?
Antisynthetase syndrome
In genetically susceptible individuals at risk of developing Rheumatoid arthritis, what’s the most appropriate preventive measure?
Smoking cessation
Is a rare but severe presentation of SLE characterized by shortness of breath, hypoxia, & diffuse pulmonary infiltrates, ESR, hypocomplementemia, as well as lymphocytic predominance on bronchoalveolar lavage?
Lupus pneumonitis
In patients with systemic sclerosis, gastrointestinal dysmotility can result in chronic diarrhea & malabsorption, what’s the most likely diagnosis?
Small intestinal bacterial overgrowth
Triad of long-standing aggressive rheumatoid arthritis, neutropenia, & splenomegaly and is associated with the risk for serious infections, lower extremity ulcers, lymphoma, and vasculitis, what’s the likely diagnosis?
Felty syndrome
Chronic monoarticular arthritis with a large effusion and stiffness but minimal pain is characteristic of Lyme arthritis; diagnosis is made by
Serologic testing for Borrelia burgdorferi (enzyme-linked immunosorbent assay followed, if positive, by Western blot).
Clinical signs include painless enlargement of lymph nodes or the thyroid, parotid, or submandibular glands; proptosis w/ orbital pseudo-tumor; back or chest pain from aortic involvement; & abdominal pain from pancreatic or biliary tree disease. Patient presents w/ a classic picture of retroperitoneal fibrosis w/ back pain & kidney failure from the periaortic mass that is large enough to encase the ureters resulting in obstructive uropathy & kidney injury?
IgG4-related disease
Note: The patient’s history of a fibrotic thyroid gland is also a feature of IgG4-RD.
Elevated antinuclear antibodies in a centromere pattern have a 90% specificity for systemic sclerosis, and in particular for?
The nailfold capillaries are shown below.
Limited cutaneous systemic sclerosis
Is a vasculitis affecting medium-sized arteries & is characterized by constitutional & neurologic symptoms, skin rashes, & kidney involvement that is renovascular rather than glomerular in origin?
Polyarteritis nodosa
Note: May occur in the setting of chronic hepatitis B virus infection, HIV infection, & hairy cell leukemia. The most common symptoms are: fever, malaise, & weight loss, & neurologic symptoms such as mononeuritis multiplex. Skin rashes, including purpura and necrotic ulcers, occur in more than half of patients. Kidney involvement manifests as HTN due to renal artery vasculitis with renal infarction, not glomerulonephritis. Orchitis, an uncommon manifestation, is usually unilateral and due to testicular artery involvement. Mesenteric vasculitis may cause abdominal pain, perforation, and bleeding.
Treat osteoarthritis in an elderly patient with CKD 3 using?
a topical NSAID
In patients w/ signs & symptoms that are highly suggestive of giant cell arteritis to prevent irreversible visual loss?
High-dose prednisone must be initiated immediately. The most appropriate treatment is prednisone, 60 mg/d.
Is an inflammatory myopathy that can involve both the proximal and distal muscles with typically symmetric muscle distribution?
Inclusion body myositis (IBM)
Note: Its insidious onset and distal muscle involvement help to distinguish IBM from the other inflammatory myopathies. Also, CK levels are typically less than 10 to 12 times the upper limit of normal.
ALS can be distinguished from IBM by the presence of fasciculations, & ALS does not raise CK levels.
Initial management of Sjögren syndrome typically involves treatment of sicca symptoms with?
Artificial tears & sugar-free candies, thus restoring moisture of the eyes and mouth.
Note: Pilocarpine is a muscarinic agonist that may stimulate saliva secretion. It is often poorly tolerated and would not be considered unless basic measures to treat oral dryness are insufficient.
Rheumatoid arthritis is one of the most common diseases associated with ________, which can be vision-threatening and lead to thinning of the sclera and perforation.
Scleritis, typical features include eye pain, pain with gentle palpation of the globe, and photophobia. The deep scleral vessels are involved and may lead to scleromalacia, which is characterized by thinning of the sclera and is seen as a dark area in the white sclera.
Note: Patients with episcleritis frequently present without pain or decreased visual acuity.
Is characterized by a triad of tenosynovitis, dermatitis, & polyarthralgia without frank arthritis; fever, chills, and malaise are common?
The arthritis-dermatitis syndrome of disseminated gonococcal infection due to Neisseria gonorrhoeae
Patients with systemic lupus erythematosus and positive antiphospholipid antibodies are at a high risk for developing valvular dysfunction/thickening, in some cases manifesting as?
Libman Sacks endocarditis
Can affect the great vessels of the chest causing upper extremity claudication and/or aortitis; aortitis may lead to aortic root dilation, aortic regurgitation, and heart failure?
Subcranial giant cell arteritis
Evidence of acute calcium pyrophosphate crystal arthritis (pseudogout) in a young person should always prompt an investigation for secondary causes such as:
Hyperparathyroidism (.i.e calcium), hypothyroidism, hypophosphatasia, hypomagnesemia, and hemochromatosis
This medication is an appropriate treatment for patients who experience a relapse of granulomatosis with polyangiitis (GPA), manifesting with pulmonary inflammation and nodules despite maintenance treatment with azathioprine.
Rituximab
Note: The choice of which therapy to use depends upon the individual patient presentation & comorbid conditions. Both rituximab & cyclophosphamide are efficacious for initial induction therapy in patients with severe GPA. Rituximab was also as effective as cyclophosphamide in the treatment of patients w/ kidney disease or alveolar hemorrhage. Methotrexate can be used alone either as maintenance therapy or for mild & limited disease.
Use of pregabalin is often limited by side effects, including
weight gain, peripheral edema, lethargy, and dizziness; discontinuation may be needed to manage the side effects.
A relapse of polymyalgia rheumatica should be treated with an increase in prednisone to the?
last pre-relapse dose at which the patient was doing well, followed by a gradual reduction within 4 to 8 weeks back to the relapse dose.
Patients with PMR experience symmetric pain and stiffness in the shoulder, neck, and hip regions, typically without synovitis.
What’s the treatment for primary angiitis of the CNS?
Patients have gradual progressive neurologic symptoms such as headaches, cognitive impairment, & other neurologic deficits such as strokes. Labs, including ESR, are typically normal, but 90% of patients have abnormal CSF w/ lymphocytic pleocytosis & elevated protein. MRI, MR angiogram, or CT angiogram often demonstrates nonspecific findings; cerebral angiogram sometimes reveals beading, or alternating stenosis & dilation of vessels consistent with vasculitis
Cyclophosphamide with high-dose glucocorticoids
NOTE: Glucocorticoids could be weaned over 3-6 months or longer, depending upon patient response to treatment. Cyclophosphamide could be discontinued after 3-6 months, & a maintenance drug such as azathioprine or mycophenolate mofetil could be started.
Acute onset of small-joint symmetric polyarthritis following a febrile illness with rash, who have exposure to children, what test will most likely confirm the diagnosis?
Parvovirus B19 testing
Note: Parvovirus can cause polyarthralgia/arthritis but is generally transient, lasting 3 weeks or less.
Symmetric inflammatory polyarthritis involving the small joints of the hands and feet, which is highly suggestive of rheumatoid arthritis (RA). Lab studies, including rheumatoid factor &?
Anti–cyclic citrullinated peptide (CCP) antibody testing
Is FDA approved for chronic musculoskeletal pain & has been shown to have analgesic efficacy for multiple joint involvement including chronic low back pain & knee osteoarthritis pain?
Duloxetine
Characterized by spiking fever, an evanescent salmon-colored rash on the trunk and extremities that occurs in conjunction with fever, arthritis, lymphadenopathy, and leukocytosis; an extremely high serum ferritin level is characteristic?
Adult-onset Still disease (AOSD)
Note: AOSD may also be seen during pregnancy or in the postpartum period. The diagnosis is clinical, and other entities such as infection and malignancy must be excluded.
Long-term treatment options for bowel and joint symptoms associated with inflammatory bowel disease include sulfasalazine, azathioprine, 6-mercaptopurine, methotrexate, and?
The TNF α inhibitors adalimumab, certolizumab pegol, golimumab, and infliximab.
Synovial fluid analysis can confirm inflammation but may be inadequate for diagnosis of a chronic inflammatory monoarthritis (differential diagnosis includes mycobacterial, fungal, or Borrelia burgdorferi infection & other systemic rheumatologic diseases such as sarcoidosis); what’s the next best step?
Synovial biopsy may be required.
Based essentially on radiographic findings of articular surface erosions at the central portion of the joint; erosions are often symmetric and occur mainly in the distal interphalangeal joints, what’s the most likely diagnosis?
Erosive hand osteoarthritis
Is characterized by inflammation and damage of cartilaginous tissues; tissues most commonly affected include the cartilaginous portions of the external and middle ear, nose, tracheobronchial tree (can be life threatening), & joints?
Relapsing polychondritis (RP)
Note: nasal chondritis can result in collapse of the nasal bridge (saddle nose deformity), which can also be seen in trauma, granulomatosis with polyangiitis, cocaine use, congenital syphilis, & leprosy.
is characterized by the sudden onset of pain, warmth, tenderness, and swelling of the affected joint, usually a knee or wrist; attacks are typically longer than those of gout, what’s the diagnosis?
Acute calcium pyrophosphate crystal arthritis (pseudogout)
Note: Plain radiographs may demonstrate chondrocalcinosis, seen as a thin radiopaque line of CPP deposition at chondral surfaces (most easily appreciated in the knees, pubic symphysis, & wrists).
Enthesitis is highly suggestive of this diagnosis; when particularly severe, the inflammation may extend along the associated tendon and local ligaments, resulting in dactylitis (“sausage digits”)?
Spondyloarthritis
Note: Inflammation of the entheses (insertion of tendon to bone) is called enthesitis
8-week history of fatigue and low-grade fever. Last week she developed a facial rash, what’s the most likely diagnosis for the rash?
Acute cutaneous lupus erythematosus (ACLE); essentially all patients with ACLE have or will develop systemic lupus erythematosus.
Asymmetric, oligoarticular arthritis involving the small joints of the hands (particularly the distal joints) & feet, a history of dactylitis, negative autoantibodies. Plain radiographs of the hands show pencil-in-cup deformities of the DIP joints of the 3rd & 4th digits bilaterally. What’s the diagnosis?
Psoriatic arthritis
Note: Although the characteristic skin rash is absent, the patient did have psoriatic nail changes characterized by onycholysis, pitting, & trachyonychia (roughened surface). Patients without apparent psoriasis, should undergo a thorough examination for occult psoriatic skin changes (for example, scalp, umbilicus, gluteal cleft, genitals) & careful nail examination.
A photosensitive rash occurring especially on the arms, neck, and upper trunk, usually sparing the central face. The rash can be annular with central clearing or papulosquamous with patchy erythematous plaques and papules.
Subacute cutaneous lupus erythematosus (SCLE); about 50% of patients with SCLE also have SLE.
Note: ~100% of pts w/ acute cutaneous lupus erythematosus (ACLE) have SLE. ACLE may present in multiple forms, with the most common being a malar (butterfly) eruption. Less commonly it can appear as a generalized eruption, which typically appears as an erythematous maculopapular eruption of sun-exposed skin such as the extensor surfaces of the arms & hands. Discoid lupus erythematosus (DLE) occurs in 20% of patients with SLE but more commonly occurs as an isolated, nonsystemic finding; patients with isolated DLE usually do not go on to develop SLE. DLE usually affects the scalp & face & presents as hypo- &/or hyperpigmented, possibly erythematous, patches or thin plaques that may be variably atrophic or hyperkeratotic.
