Rheumatology Flashcards
Overview
Joint Pain
categorize by symptoms of morning stiffness, fatigue, activity (make it better or worse), rest (make it better or worse), steroid response
Articular vs nonarticular
Articular, periarticular (tendon/bursa), or non-articular (active movement, radiate)
OA
degenerative disease, on one side, women over 65 are likely for it (post menopause), DIP joints, PIP joints, thumb joints, knee/hip/low back/big toe, cartilage loss, pain worse later in day, Heberden nodes at DIP joint, Bouchard nodes at PIP joint, osteocytes are bone spurs outside of vertebrae but they do not touch, treat with NSAIDs/PT/steroids/surgery in order as needed
- Asymm, Non-inflammation, DIP (herben), PIP (bouchard), 1st CMC, Worsen as the day goes on, Treat (NSAIDS/PT/Irrevirsble)
Crystal Arthritis - Gout, Calcium pyrophosphate deposition disease, hydroxyapatite crystals
o gout is monosodium urate crystals (under excretion of uric acid) negative birefringent needles running parallel on path and yellow, on x-ray it looks like a little bite is taken out of it,
- Negative Birefringement, Large cells, 1 MTP,
o calcium pyrophosphate deposition disease (pseudogout) elderly female with wrist swelling, chondrocalcinosis is finding of calcium in the joint, triangular fibrocartilage of wrist, blue positive birefringent rhomboid and parallel on path
- Positive Birefringement, Blue rhomboids, knee
o hydroxyapatite crystals – shiny coins, deposits in tissues/skins/arteries, Milwaukee shoulder, aggressive and sudden, associated with rotator cuff, remove fluid and conservative management
- Shiny coin, Milwake Shoulder
Septic Arhtirits
can’t miss it, send fluid for analysis,
RA
- Rheumatoid arthritis – progressive autoimmune inflammatory arthritis, 16 goes from child to adult, females more, significant disability, morning stiffness > 30 mins, symmetric presentation, MCP/wrist/elbow/shoulder/tarsal, inflamed synovium, look for 4th and 5th digit, V shaped thumb, atlantoaxial subluxation (cervical radiograph before intubation), ulnar deviation, black thinning of bone by joints, other things can happen from it: rheumatoid nodules (+RF), interstitial lung disease, Felty’s syndrome (RA, splenomegaly, low WBC), and carpal tunnel, RF autoantibodies bind Fc of IgG and CCPs are more specific for RA, glucocorticoids, DMARDs (methotrexate), targeted DMARDs
- Symm, Inflammation, Younger women, systemic,
- RF,+ACPA,PIP,MCP
- Treat: DMARDS (MET)
Spondyloarthritis
inflammatory arthritis involving the spine, HLA-B27 (MHC I) does not guarantee it because they may not get it even though positive for this, seronegative (no RF), IL-17/23, ligament involvement (enthesitis), NSAIDs/methotrexate
Ankylosing Spondylitis
B27, 20-30 y/o male, bamboo spine, do touch on x-ray unlike OA
Spondyloathropathies
asymmetric, sausage digits, enthesopathy
Reactice Arhitis
arthritis+uveitis+urethritis, camping
“can’t see/can’t pee/cant climb a tree”
Psoratic Arhtirtis
uniform swelling, asymmetric, psoriasis, blood test negative for RF/CCP more likely psoriatic, saggy 5th digit, sausage digit, progressive joint change, pencil in cup deformity
nail, HLA B27, ASSYM, Sausage Digits, pencil cup
- Polymalgia rheumatica
F over 50, elevated sedimentation/CRP with normal CK, Giant Cells, shoulders
- Fibromyalgia
tender points, variable, normal inflammatory, treat with exercise, F
SLE
o Systemic Lupus Erythematosus – systemic inflammation, type III hypersensitivity, people present differently, F in menstrual year more common in African American/Hispanics, malar rash (spares the nasal fold goes over cheeks and nose), discoid rash (white scarring and posterior thorax), photosensitivity towards V-neck, oral ulcer, non-erosive arthritis, serosal, urinalysis protein 3+ or >.5gm/day, dsDNA positive for these antibodies, false positive syphilis testing, antiphospholipid syndrome involves thrombosis or spontaneous abortion and treat with systemic anticoagulation, many different symptoms not related to the 11 diagnosis type
o 5% ANA + patients get lupus, risk of early death from coronary artery disease
o Treat with sun protection, vitamin D, good diet/exercise and no smoking, prednisone and hydroxychloroquine
- Young F
- Feature (4/11) - Seositis, Oral Ulcers, Arthritis, Photosensitivity, Blood Disorders, Renal Disorders, ANA, Anti - Smith, Neuro, Malar Rash, Discord Lesions (SOAP BRAIN MD)
- Treat: Prednisone, HCQ
Drug Induced Lupus
definitive with hydralazine/procainamide, equal M=F more common in older and lots of meds, cutaneous over systemic feature
Sjogren
chronic inflammatory disease affecting exocrine organs, female dominant, positive SSA/SSB, misery index is high because treatment is tough, everything is dry and glands are full, pregnant females and SSA + is scary for child having this, Schirmers test, antibody testing (SSA/SSB), minor salivary gland biopsy, eyedrops
- Inflammation + exocrine glands
- Lymphocte infiltration
- SSA/SSB
- Schimer (Eye test)
Scleroderma - Diffuse vs. Limited
autoimmunity + noninflammatory vasculopathy + collagen,
o diffuse scleroderma - widespread skin involvement/rapid/ organ involved, Scl 70 antibody, anti RNA polymerase III, pulmonary fibrosis,
o Limited sclerosis – CREST, calcinosis cutis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, telangiectasis, pulmonary HTN,
Inflammatory Myositis VS. Dermatomysositis
o Inflammatory myositis – progressive symmetric proximal muscle weakness, inflamed CD8 T cells
- CD8, Endomyseal
o Dermatomyositis – inflamed CD4 T cells, increased risk of occult malignancy, rough skin
- CD4, perimyseal, gottron pup, shawl rash, photosensitivity, anto-JO
o Mixed connective tissue disease – anti U1 RNP antibodies
- Female
- Both Clinical
o Muscle Weakness, symmetric - Dermatomyositis
o Gatton Papules (Hands)
o Heliotrope Rash (Eyes)
o Shawl Sign - Diagnosis
o CK – HIGH
o Anti-Jo & Anti-M2 - Treat: GC
Recall the definitions of arthritis, synovitis, enthesitis, myositis, serositis, and vasculitis.
Arthritis – painful inflammation of joints
Synovitis – inflammation of synovial membrane of joints
Enthesitis – inflammation at site of insertion of ligament and bone
Myositis – inflammation of muscle
Serositis – inflammation of serosal lining of organs
Vasculitis – inflammation of joint vasculature
Recall the key components/findings in history and physical examination.
Fever/pattern, malaise/anorexia/fatigue/weight loss, inflammation
Spleno/hepatomegaly
PEDS
Juvenile Idiopathic Arthritis (JIA)
most common, chronic synovitis, can lead to bone destruction, age 1-3 or 8-12 are key years and girls more common, oligoarticular presence of arthritis in less than 5 joints within 6 months without systemic involvement, polyarticular is 5 or more joints typically of hands and feet with systemic involvement, systemic-onset is autoinflammatory not autoimmune with daily fevers and sick with elevated labs/anemia and later arthritis, enthesis-related inflammation of axial skeleton and tendon insertions with HLA B27 positive
Diagnose with history/physical, labs normal olgio but need ANA, poly and systemic will have elevated reactant, with joint pain get CBC, early bone x rays normal
Differential – need arthritis for 6 weeks, less then 16
Treat with NSAID first, steroids or methotrexate later, tumor inhibitors can help, anakinra
Complication – loss of joint space, blindness, macrophage activation syndrome release cytokines constantly can lead to organ failure
Prognosis is good if noticed early
* MC * Girls 1-3,8-12 * Chronic Synovitis * Oligo: <5 joints, 1-3 year, knee, ANA * Poly: >5 joints, systemic, RF * Systemic: Inflammation w/o arthritis, fever, rash, high labs * Enthesis: inflammation axial skeleton, B27, Treat: TNF blockers * Complicaiton: Macrophage syndrome
16 years
* Fever (persistent/disappear), Arthritis, Rash, Uveitis
* Treat NSAID
PEDS
SLE
- multisystem, many autoantibodies, immune complex formation and ischemia, mainly women 20-40 years old 5% in childhood, many physical criteria but usually malar butterfly rash/discoid lupus/photosensitivity/nasopharyngeal or oral ulcer/serositis/seizue/arthritis
Lab – penias, +dsDNA, +anti-Sm, +ANA with absence of lupus inducing drug, need 4 of 11
Treat – corticosteroids is mainstay, hydroxycholoquine, avoid sun
Differential – systemic with protean manifestations
Prognosis – severe nephritis or cerebritis have worse - Renal
- corticosteroids, HCQ
SLE
* Women, AA,
* Clinical
o Malar Rash “butterfly rash:
o Discoid Lesions
o Arthritis
o Cardiovascular
o Renal
o Thromboembolic Disease
o Neuro
o Ulcers
* Diagnosis
o ANA
o Anti-Smith, Anti-dsDNA
o Antiphospholipid AB
* Treat: HCQ
PEDS
Juvenille Dermatomyositis
vasculitis of skeletal small vessels, rare peak age is 5-14 slightly more girls, slow progressive, fatigue/weakness, rash shawl sign (does not spare labial folds), arthritis in small joint, knees and elbows, trouble getting up from a squat
Labs – no evidence, myositis elevated muscle enzymes
Diagnose – rash, symmetric muscle weakness, elevated muscle enzymes, + muscle biopsy with chronic inflammation
Differential – MD
Treat – methotrexate, avoid sun supplement Ca and vit D
Complications – calcinosis, GI bleed, insulin resistance
Prognosis – monophasic is treated and no complications, chronic is recurrent course, chronic progressive leads to LOF
PEDS
Growing Pains
benign, 3-12 years old, boys, deep cramp pain in calves and thighs, more common in actives, treat with stretching and NSAIDS
Benign Hypermobility
– 3-10 years old, girls, excessive mobility of joints, pain is main, stretch and NSAIDs as needed
Myofascial Pain Syndromes and Fibromyalgia
noninflammatory, diffuse pain with many tender points, more common in girls and adults, family predisposition, many painful points, PT
