Rheumatology Flashcards
Glucocorticoids associated osteoporosis
Current guidelines recommend that all men age >50 and postmenopausal women taking >7.5 mg/day of prednisone for an anticipated course >3 months should be started on bisphosphonates as initial therapy.
Alendronate and risedronate are preferred.
Parathyroid hormone (eg, teriparatide) is a second-line agent used in patients who cannot tolerate bisphosphonates.
Bisphosphonates are also recommended for patients with a 10-year fracture risk ≥20%, regardless of the anticipated dose or duration of glucocorticoid use.
Evidence to guide management of men age <50 and premenopausal women is limited, and care should be individualized.
Polyarteritis nodosa
Clinical presentation
• Systemic: Fever, weight loss
• Skin: Nodules, livedo reticularis, ulcers, purpura
• Renal: Hypertension, renal insufficiency, arterial aneurysms
• Nervous: Headache, seizures, mononeuritis multiplex
• Gastrointestinal: Mesenteric ischemia/infarction
• Musculoskeletal: Myalgias, arthritis
• Other: Myocardial ischemia, retinal ischemia, orchitis
Polyarteritis nodosa diagnosis
• Negative ANCA, ANA
• Association with hepatitis B, hepatitis C
• Microaneurysms on arteriography
• Tissue biopsy confirms vasculitis (nongranulomatous)
Polyarteritis nodosa treatment
• Prednisone & cyclophosphamide
• ACE inhibitors for hypertension
Psoriasis and HIV
Psoriasis can be a presenting feature of HIV infection. Psoriatic arthritis is more aggressive when associated with HIV infection and can include palmoplantar involvement and nail disease. Treatment involves methotrexate, sulfasalazine, or TNF inhibitors in some cases.
Rotator cuff impingement or tendinopathy
• Pain with abduction, external rotation
• Subacromial tenderness
• Normal range of motion with positive
impingement tests (eg, Neer, Hawkins)
Rotator cuff tear
• Pain with abduction, external rotation
• Subacromial tenderness
• Normal range of motion with positive impingement tests (eg, Neer, Hawkins)
• Weakness with abduction & external rotation
• Age >40
Adhesive capsulitis
• Decreased passive & active range of motion
• Initial painful phase followed by stiffness > pain
Parvovirus B19
-Most patients are asymptomatic or have flulike symptoms
-Erythema infectiosum (fifth disease): Fever, nausea & “slapped cheek” rash (more common in children)
-Acute, symmetric arthralgia/arthritis: Hands, wrists, knees & feet (resembles RA)
-Transient pure red cell aplasia; aplastic crisis in patients with underlying hematologic disease (eg, sickle cell)
Joint disease in hereditary hemochromatosis
Presentation
• Pain in the small hand joints (especially 2nd & 3rd MCP)
• Can involve wrists, hips, knees, & shoulders
• Mild nocturnal arthralgias
• Can resemble osteoarthritis or rheumatoid arthritis
Joint disease in hereditary hemochromatosis
Radiology
• Narrowed joint space
• Subchondral sclerosis
• Chondrocalcinosis
• Hooklike osteophytes on the metacarpal heads
Raynaud’s phenomenon
Investigation
Nailfold capillary examination can help differentiate between primary and secondary RP. It involves placing oil on the nailfold/cuticle and observing the capillaries with an ophthalmoscope.
Normal capillaries are fine loops, and abnormal ones are enlarged with disorganized architecture and microhemorrhages. Normal nailfold capillaroscopy suggests primary RP, which has a low risk for subsequent development of connective tissue disease.
Abnormal nailfold capillary structure suggests secondary RP, and the patient should be evaluated for an underlying disorder.
Hypertrophic osteoarthropathy
Hypertrophic osteoarthropathy usually involves distal parts of the extremities and is characterized by abnormal proliferation of the skin and osseous tissue. It presents with clubbing of the fingers and synovitis of knees, ankles, and fingers. The most common cause is an intrathoracic neoplasm.
Cutaneous small vessel vasculitis
skin-isolated leukocytoclastic vasculitis that usually occurs 7-10 days after drug exposure (eg, penicillin, cephalosporin, phenytoin, allopurinol) or infection (eg, hepatitis B or C, HIV).
-Common findings include palpable purpura and a petechial rash.
-Systemic organ involvement should prompt evaluation for an alternate diagnosis.
-Spontaneous resolution typically occurs within days or weeks after the offending drug is discontinued (or the infection is treated).
Acute gout management
Acute gout is usually treated with NSAIDs as first-line therapy and colchicine as second- line therapy. Allopurinol is usually given for prophylaxis along with colchicine to patients with recurrent gout, tophaceous gout, nephrolithiasis, radiographic evidence of gouty arthritis, or urinary uric acid excretion > 1100 mg/day. Patients who develop a gouty attack while taking allopurinol should not undergo dose adjustments or drug discontinuation until 3-4 weeks after the acute inflammation subsides.
Acute osteoporotic vertebral fracture management
Initial management of mild to moderate pain from osteoporotic vertebral compression fracture includes nonsteroidal anti-inflammatory drugs and acetaminophen. In addition, intranasal calcitonin is associated with improvement of acute fracture-related pain when given shortly after fracture.
Rheumatoid arthritis poor prognosis factors
• Positive anti-CCP antibody with high titers
• Positive anti-CCP antibody and rheumatoid factor
• Early development of multiple-joint inflammation
• Radiographic erosions
• Severe functional limitations
• Lower socioeconomic status & less education
• Elevated ESR & CRP
• Persistent joint inflammation >12 weeks
Colchicine toxicity in CKD
Chronic accumulation of colchicine, often seen in patients with chronic kidney disease, can result in significant neuromyopathy. The cytoplasmic vacuolization seen on muscle biopsy is characteristic. This condition resolves on discontinuation of colchicine.
Parvovirus B19 infection
Manifestations in adults are often nonspecific, although arthralgias are typical.
Symptoms usually resolve quickly and rarely last for more than 6 weeks. Most adults in the general population have evidence of prior infection as indicated by a positive IgG titer, but IgM antibodies are more specific for acute infection.
Morphea
Morphea is a category of cutaneous sclerosis that involves only the skin in the absence of other systemic manifestations of systemic sclerosis.
Bechet syndrome treatment
Topical glucocorticoids are indicated for the treatment of Behçet syndrome−related oral and genital ulcers; colchicine is the drug of choice for the prevention of recurrent mucocutaneous lesions.
azathioprine, interferon-alfa, or tumor necrosis factor (TNF)-α inhibitors should be considered in recurrent and chronic arthritis
Gout prevention
For most patients, including those with stage 3 chronic kidney disease, allopurinol can be titrated to a maximum of 800 mg/d in 100-mg increments.
Drug induced ANCA vasculitis
Drug-induced ANCA-associated vasculitis has been reported with a number of agents, with the strongest associations found in patients using hydralazine, minocycline, and antithyroid drugs (propylthiouracil, methimazole, and carbimazole).
Of these, hydralazine is the most commonly reported agent to induce ANCA-associated vasculitis. Patients with a drug-induced ANCA-associated vasculitis usually manifest very high titers of antimyeloperoxidase antibodies, and can also display “double positive” ANCAs with concomitantly positive, low-titer antiproteinase 3 antibodies.
Long term complications of Sjogren’s Syndrome
Non-Hodgkin lymphoma is a long-term (> 6 years) complication of Sjögren’s syndrome. Risk factors include anti-Ro/SSA or anti-La/SSB antibody positivity, rheumatoid factor positivity, cryoglobulinemia, hypocomplementemia, and lymphocytopenia.
The primary NHL associated with SS usually presents extranodally (commonly in the parotid gland) and is a low-grade, marginal zone B-cell lymphoma. Diagnosis is made similarly to other NHLs with excisional biopsy of an intact node. Chemotherapy is usually efficient in treating these lymphomas.
