Rheumatology

Question 1

Difference between ESR and CRP

Answer 1

a. ESR: nonspecific indicator of inflammation

b. CRP: acute-phase reactant; levels ↑ w/ inflammation and infxn

Question 2

Rheumatic Factor increases in what 5 conditions

Answer 2

RA

↑ in Sjogren syndrome,

sarcoidosis,

vasculitis,

chronic infxns

Question 3

Highest specificity for dx of RA

Answer 3

Anti Citrullinated protein antibodies (ACPAs or anti-CCP): higher specificity for dx of RA
+ RF

Question 4

PE findings of RA ; TXM

Answer 4

PE: symmetrical soft, red, tender, swelling in joints (MCP, PIP, sparing DIP)

e. Bilateral ulnar deviation at MCP, boutonniere deformity, swan-neck deformity

TXM = 1st line = METHOTREXATE DMARDs “hydroxychloroquine”

Due to —> Autoimmune Destruction of Joints

Question 5

Pathophys of OA

Answer 5

OA is primarily a disease of cartilage

Presumably in response to this loss, chondrocytes initially proliferate and synthesize enhanced amounts of proteoglycan and collagen molecules.

As the disease progresses, however, reparative attempts are outmatched by progressive cartilage degradation.

Due to —> Wear and Tear on Joints

Question 6

RF for SLE

Answer 6

RF: early age at menarche, OCP use, postmenopausal hormone use, family hx, smoking

Drug induced causes: Hydralazine, INH, Procainamide, Phenytoin, Sulfonamides

Question 7

PE and Dz of SLE

Answer 7

PE: malar rash (“butterfly” rash) , discoid rash, photosensitivity, oral ulces, arthritis, serositis, renal dz, neurologic dz, hematologic d/o, immunologic abnormalities

Dx: + ANA, anti-dsDNA, anti-Smith antibodies, anti-histone antibodies

Question 8

TXM and goals SLE

Answer 8

h. Tx
i. NSAIDs ii. Steroids: mainstay and first line for most lupus manifestations → low dose prednisone daily
iii. Biologic therapies: Belimumab iv. Hydroxychloroquine: ↓ number of dz flares

Question 9

Scleroderma =

Answer 9

Scleroderma (systemic sclerosis): systemic autoimmune dz characterized by varying degrees of skin fibrosis, vascular damage, and organ dysfxn

a. S/Sx: fatigue, stiff joints, pain b. Pt may have tight skin on fingers, facial skin, elbows, knees etc.

Limited or Diffuse

Question 10

CREST syndrome and assoc w?

Answer 10

CREST syndrome:

calcinosis of skin,

Raynaud’s phenomenon,

esophageal dysmotility,

sclerodactyly,

telangiectasia

ASSOC = Scleroderma

Question 11

Dx labs for scleroderma

Answer 11

Dx: anti-Scl 70, anti-centromere antibody (specific for limited dz)

Question 12

Scleroderma TXM

Answer 12

Tx
i. Cyclophosphamide

ii. Tocilizumab and Nintedanib for ILD and IPF

iii. Nifedipine (CCB) for Raynaud’s

Question 13

S/Sx: low back pain that is worse in morning and improves w/ exercise c. Dx
i. XR shows multiple vertebral fusions (bamboo spine) ii. ↑ ESR

Think? TXM?

Answer 13

Ankylosing spondylitis

Tx
i. NSAIDs

ii. PT

Question 14

Reiters syndrome often has a preceding what infxn?

Answer 14

GI or Chlamydia

Question 15

Reiters Sxs / Dx / TXM

Answer 15

b. S/Sx: asymmetric arthritis; conjunctivitis, arthritis, uveitis

c. Dx: + HLA-B27

d. Tx: NSAIDs

Question 16

Describe acute gouty arthritis

Answer 16

Acute gouty arthritis
1. S/Sx: pain and swelling, usually of single joint

2. MC joints: great toe MTP joint (podagra), ankle, knee, and wrist
3. Episodes often occur at night
4. Severe pain

Question 17

Gout Dx

Answer 17

Dx: polarized microscopy of synovial fluid showing bright, negatively birefringent, needle-shaped crystals

Question 18

Discuss urate lowering therapy and px txm

Answer 18

a. Colchicine 0.6mg daily

b. Low-dose NSAIDs

c. Xanthine oxidase inhibitors: reduce uric acid production
i. Allopurinol ii. Febuxstat

d. Uricosurics
i. Probenecid: enhance urinary excretion of uric acid

e. Biologic therapy
i. Pegloticase

Question 19

Acute gout flares TXM

Answer 19

a. NSAIDs (indomethacin, naproxen, ibuprofen, sulindac)

b. Colchicine

c. Glucocorticoids

Question 20

Describe pseudo gout / Dx / TXM

Answer 20

b. Pseudogout
i. Caused by calcium pyrophosphate crystals

ii. MC affects knee joint

iii. Dx: joint aspiration shows rhomboid-shaped, weakly positive birefringent crystals iv. Tx: NSAIDs

Question 21

PE of myositis ; Get what?

Answer 21

e. PE
i. Malar rash ii. Heliotrope rash: purple rash on or around eyelids
iii. Gottron’s papules: erythematous or violaceous atrophic macules and plaques overlying dorsal
interphalangeal joints of hands

Get = CK (elevated)

Question 22

Myositis TXM

Answer 22

Tx
i. Glucocorticoids

ii. Azathioprine

iii. Methotrexate

Question 23

sxs and PE of Fibromyalgia

Answer 23

10. Fibromyalgia syndrome
    a. S/Sx: widespread MSK pain for > 3 mo, nonrestorative sleep, and generalized fatigue

b. PE: tenderness to at least 9 out of 18 anatomic sites (trigger points)

Question 24

TXM Fibromyalgia

Answer 24

Tx
i. Education

ii. Antidepressants

iii. Avoid opioids

Question 25

i. S/Sx: monocular visual loss, unilateral HA, jaw claudication

ii. PE: tender, tortuous temporal artery

iii. Dx: ESR > 50

Think? TXM

Answer 25

GCA

TXM = High-dose steroids ASAP

Dx = Bx of temporal artery

Question 26

S/Sx: asx pulses or BP, HA, arm claudication, visual changes, arthralgia
Anterior Lead STE’s

Answer 26

Takayasu’s Arteritis

Question 27

S/Sx: HTN, glomerulonephritis, abd pain, testicular pain, mononeuropathy (wrist or foot drop)

Answer 27

Polyarteritis nodosa (PAN): rare, necrotizing inflammatory vasculitis

Question 28

Buerger’s disease (thromboangiitis obliterans): inflammatory vascular dz

Answer 28

Strongly assoc. w/ tobacco products iii. Dx
1. < 50 y/o

2. Current or recent hx of tobacco use
3. Distal extremity ischemia
4. Typical arteriographic findings of TAO
5. Exclusion of autoimmune dz, thrombophilia, DM, and proximal embolic sources

Question 29

Eosinophilic granulomatosis (Churg-Strauss)
Assoc with?
Sxs?

Answer 29

Assoc. w/ severe asthma and systemic eosinophilia

S/Sx: peripheral neuropathy, mononeuritis, and pulmonary and cutaneous involvement

Question 30

Abnml proteins in blood clump together at temperatures < 37C

S/Sx: arthralgia, purpura, skin ulcers, glomerulonephritis, peripheral neuropathy, clonal hematologic dz

Think? TXM?

Answer 30

Cryoglobulinemia

Tx
i. Rituximab

ii. Plasma exchange to prevent IgM flare

Question 31

Diseases assoc. w/ HLA-B27

Answer 31

PAIR:
psoriatic arthritis,

ankylosing spondylitis,

IBD,

reactive arthritis