Rheumatology Flashcards
Rheumatology
- Study of rheumatism, including MSK disease, arthritis + systemic autoimmune conditions
- Study of joints, MM, and ligament problems
- DX joint pain
- Autoimmune conditions resulting in inflammation in areas of body where it’s not needed
- Maladaptive inflammatory response
Which parts of the body do rheumatic conditions affect?
- Typically affect joints, muscles, and bones
- May also affect eyes, skin, nervous system, and internal organs (systemically)
Common Rheumatologic characteristics
- Localized pain
- Diffuse mm/joint pain
- Stiffness, swelling and tenderness in joints and MMs
- Redness and warmth in joints and MMs
- Reduced mobility and ROM in specific joints and MMs
- Systemic s/s: fever, rashes, fatigue, etc
Rheumatologic testing: Challenges
What is rheumatologic testing centered on
- Few if any rheumatologic serologies track exactly with disease
- Can be (+) years before disease manifests
-
Disease can occur despite autoAb being absent
- (+) serologic test but may not have signs; test C-reactive protein too
-
Knowledge of underlying disease and a thorough history and physical examination
- Clinical references
- Curbside referrals
Signs of inflammatory arthritis
Think OLDCART
- Onset: ACUTE
- Location: Symmetric (BL) with SAME ONSET
- Duration: over weeks or months
-
Characteristics: Prolonged morning stiffness…See last slide (characteristics)
- Systemic s/s
- PAIN + SWELLING + WARMTH
- No trauma - spontaneous
- Aggravating: Getting up in AM
- Relieving: gets better with movement or rest after AM
Osteoarthritis VS. Rheumatologic arthritis
- Osteoarthritis - managed in primary care setting → ortho surgeon
- Happens later in life > 50 y.o.
- UL = if BL → different onset each side
- Insidious onset, gradual
- Effects bigger joints - knees, hips, shoulders
- Pain from wear and tear on joints (mechanical issue ) - BONE on BONE
- Rheumatologic Arthritis
- Extra-articular s/s: outside of joints, weight loss, fatigue, fever, rash
- Inflammation s/s in synovial membrane
- Stiffness lasting long in AM ( > 1hr/30m)
- More RA in smaller joints
- BL - same onset
- Extra-articular s/s: outside of joints, weight loss, fatigue, fever, rash
Xray imaging of OA vs RA
- X-ray imaging RA
- Normal in early stages of disease
- Soft tissue swelling and periarticular osteopenia/osteoporosis
- Joint erosion - ill-defined
- Jont space narrowing
- Can use MRI for ID erosions (NOT ROUTINE TEST)
- X-ray imaging OA
- Osteophytes or bone spurs in joints
- Joint space narrowing
- Subchondral sclerosis cysts
- DEXA scan to Dx
Rheumatological conditions differentials
- Rheumatoid arthritis
- Systemic Lupus Erythematous (SLE)
- Sjodren’s Syndrome
- Psoriatic Arthritis
- Polymyalgia Rheumatica (PMR)
- Spondyloarthritis
- Crystal Arthropathy (Cout/CCD)
- Infection
Gout: Etiology
- Due to buildup of uric acid or calcium crystals
- M > W
Meds associated with causing gout
Diuretics (pts w/HF on this)
Gout characteristics
- Usually affects one joint at a time
- MOST COMMON JOINT AFFECTED: BIG TOE
- 2nd most commonly effected: knee
- Asymmetrical soft-tissue swelling
- Causes swollen, hot, red, painful joint
- Painful to light touch
- ACUTE - usually w/in 24hrs of onset
Gout lab testing
Definitive dx?
- Uric acid level
- Joint aspiration most diagnostic!
- Aspirating effected joint during attack and finding monosodium urate crystals in fluid
- Culture → rule out infection
- 24-hr urine test, neutrophilia, elevated ESR and CRP
Questions to ask if patient has signs of inflammatory arthritis
- How old are they?
- Location of pain?
- How long have the symptoms been present
- Other systemic symptoms?
- Symptoms acute or self-limiting
Purpose of ultrasound in inflammatory arthritis
Can show inflammatory + structural changes in joints and tendons
RA imaging
Ultrasound
Giant Cell arteritis
Diagnosis s/s
- DO NOT MISS → can lead to BLINDNESS
- Vasculitis
- Associated w/PMR; > 50
- UNL H/A w/visual difficulty
- Jaw pain
- Scalp tenderness
- Systemic s/s: mild fever, fatigue, loss of appetite, wt. loss in limbs, worse s/s in AM
Giant Cell Arteritis Labs
Diagnostic test?
- ESR negative → rule this out
- GOLD STANDARD DX TEST: temporal artery biopsy (not true dx)
- Part of artery may not be inflamed, can biopsy wrong part
- CRP elevated in acute phase
- U/S
Giant Cell Arteritis
Treatment
High dose and long-term prednisone
Psoriatic arthritis
Lab reading
- MRI - early dx
- Can differentiate btwn synovitis (synovial membrane) and (enthesitis) inflammation where tendons + ligaments
- Rheumatoid factor (-) + 40% pts w/elevated ESR
Rheumatologic Laboratory work-up in Primary Care
- ESR, CRP
- ANA
- sub-serologies
- RF
- CCP
- Uric acid
Non-rheum etiologies
- Lyme
- Viruses
- Parovirus
- Hepatitis C
- HIV
- Osteoarthritis
- Neuropathy
- Medications
Inflammatory Labs: ESR
- Measured by how fast RBCs settle to bottom of a test tube (60m)
- In presence of increased acute phase reactants (proteins), RBCs settle faster
- Non-specific
- NOT DIAGNOSTIC - normal ESR does not rule out disease
- Less reliable in acute s/s than CRP
Inflammatory labs: CRP
- Acute phase reactant - protein made by liver released into blood w/in few hrs of tissue injury/infection
- Can elevate in rheumatic, malignant, infectious and allergic conditions
- GCA - elevated in acute phase
Are ESR and CRP measured in tandem?
YES
Follow disease activity + response to meds (want levels back in range)
Both are non-specific and non-diagnostic on their own
Autoimmune labs: RF
- IgM protein produced in several inflammatory and autoimmune processes
- Elevated in
- Sjrogen’s
- RA
- Chronic infections Hep C, TB
- SLE
- Vasculitis (not specific to RA)
Autoimmune labs: CCP
- Peptide formed during metabolism of arginine
- In RA this metabolism happens more quickly causing increased levels of Citrulline triggering an immune reponse
- More specific than RF for RA
- Correlates w/errosive disease
If you suspect RA, which two labs should you check?
RF + CCP = 90% sensitive
If positive → most likely RA
Elevated RF + (-) CCP →
less likely RA
Autoimmune Labs: ANA
What is it; diseases associated; S+S
-
If (+) → most likely have RA
- But there can be false positives
- Group of antibodies produced in autoimmune disease states
- Associated w/several autoimmune disorders: SLE, drug induced lupus, Sjrogen’s, Scleroderma, Mixed connective tissue disease
- Can be negative in early stages of disease
- Low specificity, highly sensitive in presence of SLE, false positives and borderline tests possibility
If ANA not detectable in 1:40 first mix
NEGATIVE RESULT
IF ANA 1:40 mix positive
larger the bottom number → more (+) the test
aka more parts needed to dilute substance
Lupus
4 types
- Chronic autoimmune disorder that can affect multiple body systems
- Skin, MSK, renal, neuro, heme, CV, pulmonary, reproductive
- Skin: mallar/butterfly rash, specific
- Skin, MSK, renal, neuro, heme, CV, pulmonary, reproductive
- Types
- Systemic
- Cutaneous
- Drug-induced - s/s similar to SLE but rarely affects major organs
- Neonatal
Systemic Lupus Erythematous
S/s
- Most common
- Difficult to diagnose
- Nonspecific s/s: fatigue, weight loss, fever, joint and mm aches (constitutional symptoms)
- Less common - rash, photosensitivity, pleuritic chest pain, Reynaud’s, mouth sores
If you suspect it’s lupus, which test do you order first?
ANA
Complete lupus workup
What if it’s positive? Which other labs
ESR, CRP, ANA, RF, CCP
Check ANA subserologies (only if +)
Anti-phospholipid antibodies
Urine protein : Cr ratio
Complements C3 + C4 (low → lupus)
Spondyloarthritis (SpA)
types
- Type of arthritis that attacks the spine and in some cases joints of arms and legs
- Peripheral - more rare
- Axial
- Psoriatic arthritis
- IBD related
- Reactive
Spondyloarthritis (SpA) and types
- Type of arthritis that attacks the spine and in some cases joints of arms and legs
- Peripheral - more rare
- Axial
- Psoriatic arthritis
- IBD related
- Reactive
Axial Spondyloarthritis (axSpA)
What? Diseases associated?
- Chronic low bakc pain before age of 45 - insidious onset, improvement w/exercise but not with rest, pain at night
- No incident trauma/accident prior to onset of pain
- Often associated w/other inflammatory disorders - uveitis, psoriasis, IBD, inflammatory arthritis of other joints
- Visual issues: uveitis = DO NOT MISS
Axial Spondyloarthritis (axSpA)
Diagnosis and assessment
- Diagnosis focuses on differentiating mechanical and inflammatory back pain
- Early diagnosis is crucial
- Assessment: NEED 4/5 TO DX
- Onset < 40 y.o.
- Insidious onset: no incident of trauma or hx
- Improvement w/exercise
- No improvement with rest
- Pain at night (with improvement getting OOB)
Axial Spondyloarthritis
Lab Workup and Imaging
- 1st: ESR/CRP → checking inflammation
- 2nd: HLA-B27 present in 90% of AS, 50-70% of other syndromes
- $$$$ test, ALWAYS GET CONSULT 1st (rheumatology)
-
Check radiographs x-rays, MRI
- Normal in early disease
- Diagnosis based mainly on ASAS criteria and MRI - see abnormal darkening
Viral etiology workup (labs + questions)
When would you do infectious workup?
- Do infectious workup when patient presents with all over joint/body pain
- Have lived or have traveled to an area that’s endemic to particular infectious diseases
- Especially if duration of s/s < 6 weeks
- Check LFTs - ELEVATED abnormal
- HIV - RFs
- Parovirus Titres - initially starts as cold/viral illness (ask about exposure to children)
- Red cheeks in children; adults - overall joint pain
What if it’s Lyme? what do you look for?
- Inflammatory arthritis
- Exposure history, concurrent fever, rash, etc. Associated w/joint pain/inflammation
- Ticks, brush, woods
- Low threshold in this area of the country
- Exposure history, concurrent fever, rash, etc. Associated w/joint pain/inflammation
Fibromyalgia workup and s/s
- Widespread, diffuse mm pain w/palpation on trigger points throughout body
- WPI >/= 7; AND SSS >/= 5 OR
- WPI 3-6; SSS >/= 9
- > 3 months duration
- ESR, CRP, RF, CCP, ANA, xrays
- ESR and CP NORMAL LEVELS in fibromyalgia
WPI chart (not sure if we need to know this)
Assessment tool to assess fibromyalgia
What else can cause diffuse mm pain (confused w/Fibromyalgia)?
What drug hold to see if mm pain gets better
Hypothyroidism, Neuropathy
STATIN → rhabdomyolysis
Sjogren’s Syndrome
- Autoimmune disorder that attacks tissue in glands that produce moisture-tear and salivary glands
- Patients will complain of dry eyes and mouth, also possible dry skin, cough, fatigue, joint pain, swollen parotid glands, vaginal dryness
Sjogren’s Syndrome lab workup
- ANA (+)
- Add specific antibody testing: Anti-Ro/SSA, anti-La/SSB
- Can do direct testing (Shirmer test in eye, sialometry)
- Opthamology referral
Polymyalgia Rheumatica (PMR)
S/s
- Stiffness/pain at hip and shoulder girdle, often also the neck
- > 50y.o.; more common > 65, 70s, 80s
- Strength INTACT - just feel like they can’t lift their arms up, HEAVY/STIFF
- Associated w/temporal arteritis
- DON’T MISS GCA!
PMR lab workup
- DX: CLINICAL - can be vague on exam
- ESR/CRP - ALWAYS ELEVATED (ESR > 100 suggestive)
- Refer/rule out other conditions if negative
