Rheumatology Flashcards
Rheumatoid arthritis typically presents:
morning stiffness > 1 hour,
symmetric joint swelling of the MCP and PIP joints, and systemic symptoms
Rheumatoid arthritis most common affected joints:
wrists, metacarpophalangeal joints, proximal interphalangeal joints and metatarsophalangeal joints
Extra articular manifestations of RA leading cause pf death ?
anything with CARDIAC
Extra articular manifestations of RA
Extra articular manifestations of RA
A 39-year-old woman presents to the emergency department with** fever, cough, and shortness of breath. **She reports developing flu-like symptoms 7 days ago but progressively worsened to the point where she experiences dyspnoea on exertion. Her cough is accompanied by a mild amount of yellow sputum. Past medical history is notable for a previous admission to the hospital for pneumonia 4 months ago and an admission for bacteremia6 weeks ago. She additionally has a history of IV heroin abuse, but her last use of heroin was 3 years ago. Temperature is 101.2°F (38.4°C), blood pressure is 104/70 mmHg, pulse is 102/min, and respirations are 20/min. Physical examination demonstrates coarse upper airway breath sounds over the right lower lung field. A faint 1/6 non-radiating systolic flow murmur is auscultated at the first right intercostal space. Abdominal examination is significant for moderate splenomegaly. Tenderness of the wrists and fingers is elicited on palpation, and range of motion is restricted. The patient comments that her range of motion and pain usually improve as the day goes on. Which of the following laboratory abnormalities is most likely to be found in this patient?
1Decreased anion gap
2Flow cytometry positive for CD11c and CD2 3Leukocytosis with left-shift
4Neutropenia
5Positive HIV serology Rheumatoid Arthritis
45 year oldcoal mine worker presents with cutaneous nodules, joint pain and occasional cough with dyspnoea. His chest radiograph shows multiple small (1-4cm) nodules in bilateral lung fields Some of the nodules show cavitation and specks of calcification. Most likely these features are diagnostic of
:A)Sjogren syndrome
B)Caplan syndrome (ra+pneumoconiosis)
C)Silicosis D)Wegenersgranulamatosis(lung+renal+eye+joint) Rheumatoid Arthritis
What is Caplan syndrome ?
Caplan syndrome, also known as rheumatoid pneumoconiosis, is the combination of seropositive rheumatoid arthritis and a characteristic pattern of fibrosis
Which of the following is not considered an extra-articular manifestation of Rheumatoid Arthritis?
a) Osteoporosis
b) Peripheral neuropathy
c) Cutaneous nodules
d) Pericardial effusions
e) Hepatomegaly
Hepatomegaly
The diagnosis of RA is confirmed ?
- with imaging,
- positive rheumatoid factor (RF) and/or anti-citrullinated peptide antibody (anti-CCP),
- elevated C-reative protein or erythrocyte sedimentation rate
clinical presentation + autoantibodies + systemic inflammation
RF is present in about 70% of patients with established rheumatoid arthritis, it is detected less frequently in early disease.
*Antibodies toCCP are usually present before the development of symptoms and have a 96% specificity for rheumatoid arthritis.
*However, up to 30% of patients with rheumatoid arthritis never develop RF or antibodies to CCP and are said to have seronegative disease
The radiographic hallmarks of rheumatoid arthritis are:
- soft tissue swelling o fusiform and periarticular; it represents a combination of joint effusion, oedema and tenosynovitis o this can be an early/only radiographic finding
- osteoporosis: initially juxta-articular, and later generalised; compounded by corticosteroid therapy and disuse
-
* joint space narrowing: symmetrical or concentric
4.** * marginal erosions**: due to erosion by pannus of the bony “bare areas” periarticular bony erosions
There is a predilection for:
* PIP and MCP joints (especially 2nd and 3rd MCP)* ulnar styloid* triquetrum
As a rule, the DIP joints are spared.
RA treatment?
Therapy may be with either a single csDMARDor a combination of csDMARDs, with or without a corticosteroid. Methotrexate is the drug of choice for most patients,andshould form the backbone of the regimen
- CONSERVATIVE: education, exercise, physical therapy, smoking
- MEDICAL : metrotexate +- corticoseteroides
- OPERATIVE : join replacemente surgery (failed conservative and medical)
ra in pregnancy treatment?
SULFAZALAZINE
O
HIDROXYCLOROQUINE
RA TX
METROTEXATE SIDE EFFECTS
GI symptoms, oral ulcers, macrocytic anemia, and hepatotoxicity+ add folic acid
32 year old woman presented with bilateral joint swellings of her proximal interphalangeal joints associated with a 45 minutes period of early morning stiffness of joints. She has obvious rheumatoid nodules and a high rheumatoid factor assay. Which of the following is the best treatment of choice
a. infliximab
b. sulfasalazine
c. methotrexate
d. prednisolone
e. Hydroxyurea
c. methotrexate
A patient with rheumatoid arthritis got a flare up and doctor wants to administer azathioprine. which screening test should be done before starting this drug?
b) Thiopurine methyltransferas
Male patient with RA on methotrexate and hydroxychloroquine, planning to start a family, how to manage:
a. stop methotrexate and continue hydroxychloroquine
b. stop hydroxychloroquine and continue methotrexate
c. stop both
d. shift to leflunomide
a. stop methotrexate and continue hydroxychloroquine
Despite the lack of data, most societies recommend thatmenstopmethotrexate3 to 4 months before fathering children because of the potential for impairedfertility. 4 Given the therapeutic benefit ofmethotrexatein IBD, more data are needed regarding its effect onmale fertility.
Raynaud phenomenon is characterized by discoloration of the extremities as a physiologic response to cold temperatures or emotional stress. Initially, digits turn white (indicating ischemia), blue (indicating hypoxia and cyanosis), and finally pink with re-warming (indicating reperfusion). Raynaud can be idiopathic or associated with conditions such as systemic sclerosis/limited scleroderma, systemic lupus erythematosus, mixed connective tissue disease, and cryoglobulinemia
Conservative management involves avoidance of cold temperatures and smoking cessation.
First-line pharmacologic management is dihydropyridine-type calcium channel blockers (i.e., nifedipine, nicardipine, or amlodipine).
A 3-year-old boy presents to the emergency department due to worsening joint pain, fever, and a new rash. He is accompanied by his mother who reports that he has been pointing at his knee and hip while crying. She believes he has been having this symptom for approximately 2 months. He has been having 1-2 fevers a day, and she reports seeing a “pink-like” rash. On physical exam, there is an evanescent salmon-colored rash on the left thigh. There is tenderness to palpation of the left knee and hip with limited range of motion. Lab results show an elevated ESR, CRP, and negative RF, POSITIVE ANA. Most probable diagnosis?
1 Septicarthritis
2 Juvenile Rheumatoid arthritis
3Psoriatic arthritis
4Systemic lupus erythematosus (SLE)
5 Viral Arthritis
2 Juvenile Rheumatoid arthritis
Juvenile Idiopathic Arthritis: clinical definition?
- 1 or more joints are involved for atleast 6 weeks in patients< 16 years of age
- morning stiffness and joint pain*
*** visual changes -uveiti
** MOST COMMON
evanescent and salmon-colored macular ras
ANA ->typically, in systemic and polyarticular JIA positive ANA
*RF and CCP -> normally negative
A boy with joint pains. ANA +veand RF –e. What’s the long-term complications?
A. Cardiomyopathy
B. Uveitis
C. Small bowel ulceration
Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease of childhood, with JIA-associated uveitis its most common extra-articular manifestation. JIA-associated uveitis is a potentially sight-threatening condition and thus carries a considerable risk of morbidity
A child presents to ursurgery with c/o joint pains. You find out that he also suffers from iron deficiency anaemia. what could be the most appropriate diagnosis?
a) juvenile rheumatoid arthritis
b) HSP
c)haemophilia
d)thrombocytopenia
a) juvenile rheumatoid arthritis
Which is not criteria for juvenile rheumatoid arthritis?
- Arthritis
- Iridocyclitis
- Positive Rf
- Unexplained fever for few days
- Splenomegal
Positive Rf
Rheumatic fever clinic :
Migratory joint pains, especially in the knees, ankles, and elbows / chest discomfort / heart failures (rare) / fever/ dyspnea/ new murmur firm and painless subcutaneous nodules over bony prominences/ erythema marginatum/ chorea.
Rheumatic fever TX :
benzathine benzilpeniciline IM unique dose
OA x ray signs:
4
LOSS
OA Affects what parts ?
The proximal interphalangeal joint (PIP)/DIP, foot, knee,and hip joints are commonly affected, while the metacarpophalangeal (MCP), shoulder, wrist, and elbow joints are rarely implicated.
OA - arthritis characteristics
- Symmetrical and poly-oligo articular.
- Worsens on initiating movement and loading the joint and eased by rest.
- Stiffness after activity (Mechanical pain)
- Affected joints: CMC of thumb, MTP great toe, DIP hands/ also Knee, hip, PIP, Cervical and lumbar Spine
OA - physical exam
bony swelling
*swelling of the distal interphalangeal (Herberdennodes)
*swelling of the proximal interphalangeal **(Bouchard nodes) **
OA - tx
Conservative= exercise and weight lossindicationfirst-line in the management of osteoarthritis*
Medical=
*Topical capsaicin or oral nonsteroidal antiinflammatorydrugs (NSAIDs)
*Paracetamol 1 gr PRN
*Duloxetine sss
*Intra-articular corticosteroid injection
Operative=orthopedic surgeryindicationin patients with advanced pain who are unresponsive to conservative and pharmacologic therapy
Gout
Gout occurs when the serum uric acid concentration is sufficiently elevated (usually greater than 0.42 mmol/L [7 mg/dL])
Physical exam ?
acute gout
** **typicallymono-articular
*e.g.,involvement of the first metatarsophalangeal joint(podagra)
** chronic tophaceous gout
** *subcutaneous nodules
*typically non-tender
*overlying skin can be taut
*abnormal color
*white or yellow deposits
Gout (Monosodium urate crystal disorder) diagnosis?
Aspiration of an affected joint, bursa or tophus is required to confirm the diagnosis of gout.
Synovial fluid analysis joint fluid aspiration and crystal analysis is the gold-standard negatively birefringent needle-shaped crystals under polarized light
Serum uric concentration should be measured in all patients with suspected gout. However, the presence of hyperuricaemiaalone is insufficient to diagnose gout. Monosodium urate crystals are not seen on plain X-ray because they are not radiopaque; however, a plain X-ray may be useful to identify joint damage due to goutXray findings: joint effusion (earliest sign)/ preservation of joint space until late stages of the disease/ an absence of periarticular osteopenia/ eccentric erosions the typical appearance is the presence of well-defined “punched-out” erosions with sclerotic margins in a marginal and juxta-articular distribution, with overhanging edges , also known as rat bite erosions
GOUT DX?
Making the diagnosis
*demonstrating monosodium urate crystals in an affected joint via polarizing light microscopy
*when this is not possible, the diagnosis can be clinically made.
GOUT TX
ACUTE =
local corticosesteorid inyection
colchicina NOT in kidney or heptatic disfunction
not allopurinol in acute
CHRONIC =
allopurinol (yes for renal impairment , just modify dose)
Pseudogout joint analysis =
caused by deposition of calcium pyrophosphate crystals
*crystal analysis will demonstrate weakly positive birefringent rhomboid crystals under polarized light
Pseudogout associated with other disease ?
Pseudogout is associated with hemochromatosis which presents with bronzing of the skin and diabetes from pancreatic damage.
** Bronzing of the skin and elevated blood glucose levels**
Clinical presentation pseudogout ?
chondrocalcinosis (cartilage calcification)
asyntomatic in most cases
syntomatic = acute
affects mostly the knee
joint pain and morning stiffness (pseudo rheumatoid arthritis)
Diagnosis Pseudogout=
A definitive diagnosis of calcium pyrophosphate deposition is made by identifying calcium pyrophosphate dihydrate crystals in synovial fluid.
*Radiography = to assess the affected joint: chondrocalcinosisand degenerative changes
*Arthrocentesis *confirms the diagnosis
*Gram stain and culture should always be performed since infection could co-exist
*leukocyte count is 2,000-100,000/mm3
*> 50% polymorphonuclear cells
*polarized microscopy demonstrates weakly positively birefringent rhomboid crystals
Treatment Pseudogout =
- Conservative
observationindication*in patients with asymptomatic chondrocalcinosis - Medical
nonsteroidal anti-inflammatory drugs (NSAIDs) Indomethacin / Paracetamol indication=
an initial treatment option for pseudogout
colchicineindication=an initial treatment option for pseudogout
glucocorticoidsindications=
*injections of the affected joint is typically used in patients with < 2 involved joints
*oral medications are typically used in patients with > 2 involved joints
GOUT VS SEUDOGOUT
SLE symptoms
serositis, oropharyngeal ulcers, anti-nuclear antibodies (ANA), photosensitivity (including a malar or discoid rash), hemolytic anemia, kidney disease among many other possible presenting symptoms
SLE antibody used to monitor disease activity?
anti-dsDNA antibody can be used to monitor disease activity
Major cause of death in SLE ?
with atherosclerotic cardiovascular disease the major cause of mortality in patients with SLE
same as RA, SLE, AND squizofrenia
Difference between RA and SLE arthritis ?
joint deformities in SLE are often reducible and infrequently erosive on plain radiographs
autoantibodies and disease associated
SLE diagnosis clinical + lab
clinical?
diagnosis confirmed with 4 or more criteria from RASHNIA4**
**Renal disease
A**rthralgias
**Serositis
H**ematologic abnormalities
**Neurologic abnormalities
I**mmunologic derangements
**Antinuclear antibodies
*4 types of rashes:
*Malar
*discoid
*photosensitive
*oral ulcers
SLE diagnosis clinical + lab?
lab=
-
antinuclear antibody (ANA)best initial test*
high sensitivity but low specificity -
anti-double-stranded DNA (dsDNA) antibodyoften rises during flares*high specificity but low sensitivity
MONITOR -
anti-Smith antibody (antibody to snRNPs)
*high specificity (more than anti-dsDNA) but low sensitivity - LOW complement levels during a flare*↓C3, C4, and CH
SLE TX =
antimalarials are often used alongside steroids for acute flares
*management is often dictated by specific organ involvement
Conservativeuse sunscreen and avoid sun exposureindicationsfor all patients
*Medical
A =non-steroidal anti-inflammatory drugs (NSAIDs)
indicationsarthralgias
B= antimalarialsindicationsdermatologic findings and joint painoften used in conjunction with other medications, including steroids
**hydroxychloroquinechloroquineside effectsrisk of retinopathy
C=steroidsindications*acute flares *prednison
DRUG INDUCED LUPUS
**(mnemonic: Cute CHIMPPP)
**
Common drugs that cause drug-induced lupus include
CUTE CHIMPPP
quinidine,
chlorpromazine,
hydralazine,
isoniazid,
methyldopa,
primaquine,
penicillamine,
procainamide
Antiphospholipid antibody syndrome
Prolonged ?
PTT (intrinsico) PROLONGED
all factor except VII and VIII
PT extrinsico 1,2,5,7,10
Antiphospholipid antibody syndrome
LAB
- Lupus anticoagulant
- anti b2 glycoprotein (IgG and IgM)
- anticardiolipin
Antiphospholipid antibody syndrome
TX
warfarin
*indications
*for non-pregnant patients
*prevention of thrombosis
*target INR 2-3
aspirin plus unfractionated heparin
indicationsfor pregnant patients
*prevention of pregnancy loss
Scleroderma (Systemic sclerosis)
arthirtis clinic=
utoimmune skin diseasecharacterized byprogressive hardening and induration of the skin and/or other structures, such as the subcutaneous tissues, muscles, andinternal organs.
It can present as a polyarthritis affecting the fingers in 25%
Scleroderma (Systemic sclerosis) triad
*autoimmunity
*noninflammatory vasculopathy
*collagen deposition with fibrosis
Scleroderma (Systemic sclerosis)
limited cutaneos scleroderma -> subtype is CREST syndrome=
Calcinosis cutis
*anti-Centromere antibody
*Raynaud
*↓ blood flow to skin from either cold temperatures or stress, which causes vasospasms
*colors of affected area, commonly the digits, change from white (ischemia) to blue (hypoxia) to red (re-perfusion)
*Esophageal
dysmotility
*Sclerodactyly
*Telangiectasia
keratoderma blennorrhagica. This is a pustular hyperkeratotic rash typically affecting the palms and soles of the feet
3 DISEASEAS THAT HAVE THIS :
- REACTIVE ARTHRITIS
- PSORIASIS
- SIFILIS
The radiograph of both hands demonstrates pencil-in-cup deformities of both thumbs and erosion of the DIP joint of left middle finger, making** psoriatic arthritis** (in the context of the scaly rashes on the bilateral elbows) the most likely diagnosis.
**acro-osteolysis **(resorption of the distal phalanx tuf
Dermatomyositis is an autoimmune disorder that is 2-3 times more common in females. The classic presentation is proximal muscle weakness in the setting of a characteristic rash. The most commonly seen cutaneous features include :
- Erythema of the eyelids (heliotrope
- Thickened, red, scaly plaques of the knuckles and dorsal hands (Gottron’spapules;
-
Erythema of the elbows and knees (Gottron’ssign;
4.Erythema of the upper back/chest (shawl sign)
PAN SUMMARY
