Rheumatology Flashcards
How do you differentiate articular vs non-articular complaints?
Gel phenomenon is seen in inflamm or non inflamm conditions?
NON-inflammatory
WBC of 2000-50000 with predominance of PMNs in synovial fluid analysis is commonly seen in what type of dse condition?
Inflammatory
Most potent risk factor for OA
Age
Joints usually spared in OA
Ankle
Wrist
Elbow
AWE-OA
most effective exercise regimens for OA
aerobic and/or resistance training
however No evidence that patients with hand OA
benefit from therapeutic exercise
Characteristic xray finding in gout
cystic changes, well-defined erosions, with sclerotic margins (often with overhanging bony edges), and soft tissue masses
Characteristic utz finding in gout
double contour sign overlying the
articular cartilage
Indications for starting hypouricemic tx in gout
After 2 acute attacks
Serum uric acid > 9.0 mg/dL (> 535umol/L)
Presence of uric acid stones (radiolucent)
Chronic gouty arthritis or presence of tophi
Hallmark of rheumatoid arthritis
Flexor tendon tenosynovitis
in RA, what do you call the Hyperextension of the PIP joint with flexion of the DIP joint
Swan-neck deformity
in RA, what do you call the Flexion of the PIP joint with hyperextension of the DIP joint
Boutonnière deformity
in RA, what do you call the Subluxation of the 1st MCP with hyperextension of the first IP joint
Z-line deformity
in RA, what do you call the Subluxation of the distal ulna due to inflammation of the ulnar styloid and tenosynovitis of the extensor carpi ulnaris
Piano-key movement
most common cardiac manifestation of rheumatoid arthritis?
pericarditis
most common pulmonary manifestation of rheumatoid arthritis?
pleuritis
DMARD of choice in the treatment of rheumatoid arthritis
Methotrexate
antibody is associated with neonatal
lupus with congenital heart block
Anti SSA (Ro)
antibody associated with drug induced lupus
anti histone
best screening test for SLE
ANA
Antibody that is disease specific and correlates with dse activity
dsDNA
Antibody that when positive in CSF correlates with active CNS lupus
antineuronal antibody including antiglutamate receptor 2
Antibody that when positive in serum correlates with depression or psychosis due to CNS lupus
anti ribosomal P
Among the different drugs being used to treat SLE, which drug is specifically indicated in the treatment of lupus dermatitis?
Methotrexate
Which features are more common in limited compared to diffuse cutaenous SSc
Critical ischemia in digits
Calcinosis cutis
Characteristic autoantibodies in
Limited cutaenous SSc?
diffuse cutaneous Ssc?
Limited cutaenous SSc- anticentromere
diffuse cutaneous Ssc - Anti topoisomerase I (Scl 70) and anti RNA pol III
yung may numbers sa diffuse
What is the mainstay of therapy of
scleroderma renal crisis?
ACE inhibitors
What is the most common route of
infection in infectious arthritis?
Hematogenous
What inflammatory myopathy is not responsive to corticosteroids
Inclusion body myositis
The only conventional NSAID for that appears to be safe from a cardiovascular perspective
Naproxen
Most frequent early clinical manifestation of gout
acute gout
uric acid excretion > ____ mg/day entails overproduction of uric acid
800
most frequently affected joint in CPPD
knee
________ deposition dse is associated with Milwaukee shoulder
Calcium Apatite
cell type that is a predominant source of proinflammatory cytokines (TNF-a, IL-1, IL-6) in the joint and thus considered as the major driver of rheumatoid arthritis
macrophage
major genetic risk factor for RA is the ___alleles
(HLA-DRB1)
What is the most common cause of
death among patients with RA?
cardiovascular dse
What constitutes CREST syndrome?
Calcinosis
Raynaud’s
Esophageal Dysmotility
Sclerodactyly
Telangiectasia
Laboratory and Clinical criteria for diagnosing APAS
See table
Dose of prednisone that can induce psychosis
pred > 40 mg
Most common causes of drug induced lupus
procainamide
disopyramide
propafenone
in psoriatic arthritis, which comes first? psoriasis or arthritis?
psoriasis
Which dse entity is arthritis mutilans associated?
Psoriasis
What are the causative agents associated with Reactive arthritis
Enteric causes: Shigella, Salmonella, Yersinia, Campylobacter
Urogenital: Chlamydia
Most serious complication of Ankylosing Spondylitis?
fracture
In AS, the earliest change in the sacroiliac joint demonstrable on x-ray is
blurring of the cortical margins of the subchondral bone
Which clinical feature of acute rheumatic fever can appear after months after an initial infection?
Chorea and indolent carditis
Treatment for severe chorea in acute rheumatic fever
Carbamazepine, Sodium Valproate
How long should you give prophylaxis for Acute rheumatic fever
Without carditis
With carditis,no valvular dse
With residual valvular dse
Without carditis - 5 yrs after last attack or until 21 yrs old which ever is longer
With carditis,no valvular dse- 10 yrs after last attack or until 21 yrs old which ever is longer
With residual valvular dse- 10 yrs after last attack or until 40 yrs old which ever is longer
in OA, what has the highest % inheritability based on joint involvement?
Hip and Hand (50%)
Earliest pathologic finding in OA
Fibrillation of cartilage surface
Initial analgesic of choice in px with OA
Paracetamol
Most common earliest manifestation of gout
Pai and swelling of 1st MTP
Target uric acid level for px with gout
5-6 mg/dL or < 300-360 umol/L
Most commonly involved joints in RA
wrist , PIP, MCP
Most common chronic dermatitis of SLE
Discoid
Circular lesions with slightly raised, scaly, hyperpigmented erythematous rims and depigmented, atrophic centers
Most common hematologic finding in SLE
normocytic normochromic anemia
Autoantibody seen in MCTD
U1RNP
Diagnostic test of choice for confirming PAH in SLE
Cardiac catheterization
Leading cause of death in px with systemic sclerosis
ILD
Mainstay of tx for inclusion body myositis
PT and OT
Antisynthetase syndrome is associated with this antibody
Anti-Jo1
Antisynthetase syndrome- presence of myositis, non erosive arthritis, Raynauds, mechanic hands, fever
Most sensitive laboratory marker of muscle destruction
CK
Characteristic laboratory finding in EGPA
Eosinophilia > 1000cells/uL
straight-leg-raising maneuver is a sensitive test for nerve root disease, and stretches which nerve roots?
L5-S1
Empiric tx for septic arthritis
3rd gen IV + Vanco
Most common valvular abnormality in RA
MR
earliest plain radiographic finding of
rheumatoid arthritis
Periarticular osteopenia
most common clinical presentation of
acute rheumatic fever (ARF)
polyrthritis (60-75%)
next is carditis (50-60%)
Sausage digits are associated with what condition?
reactive arthritis and psoriatic arthritis
antinuclear antibody (ANA) patterns is most
specific and suggestive of lupus
peripheral
In px with gout, when can you stop colchicine?
until the px is hypouricemic and without gouty attacks for 6mos or as long tophi is present
most commonly affected joint in patients
who develop hemarthrosis
knee
Most commonly affected tendon in rotor cuff tendinitis
supraspinatus
Most commonly involved part of the spine in psoriatic arthritis
cervical
All vasculitis patients receiving daily glucocorticoids and immunosuppressive should receive prophylaxis against which organism?
P. jiroveci
treatment regimen for Psoriatic Arthritis that can paradoxically trigger exacerbation of psoriasis
Anti TNF
When would you expect clinical response after treatment initiation with cyclophosphamide?
3-16 weeks
Based on the CASPAR Criteria, what characteristic of psoriasis is assigned 2 points
Typical psoriatic nail dystrophy
What constitutes the triad of reactive arthritis
arthritis, urethritis and conjunctivitis
Most common extraarticular manifestation of AS
Acute anterior uveitis
Chronic nasal carriage of ___ has been reported to be assoc with a higher relapse rate of GPA however there is no rol of this organism in the pathogenesis of this dse
S. aureus
Tissue that offers the highest diagnostic yield for GPA
Pulmonary tissue
Tx for GPA
Cyclophosphamide + Glucocorticoids
same with MPA
GPA is AKA Wegeners
Asians expressing this HLA phenotype has inc risk for allopurinol toxicity
HLA B*5801
Examples of non hypourecemic agents with mild uricosuric effects
Losartan, Amlodipine, Fenofibrate, SGLT2i
Most frequent extracutaneous complication of SSc
Raynaud’s phenomenon
What rare complication that presents as encephalopathy is associated with rituximab therapy
PML
Most serious manifestation of SLE
Nephritis
Most common manifestation of diffuse CNS lupus
cognitive dysfunction
most common type of arthritis
OA
pathologic sine qua non of OA
hyaline articular cartilage loss
What does FABER test stand for
Flexion, ABduction, External Rotation
Pathologies at the hip, lumbar and sacroiliac region
Entry criteria for 2015 ACR/EULAR classification of gout
The entry criterion for the new classification criteria requires the occurrence of at least one episode of peripheral joint or bursal swelling, pain, or tenderness.
When do we initiate urate lowering drugs?
> Hyperuricemia cannot be corrected by nonpharmacological interventions
Consider in those with CKD Stage >3, serum urate levels >9mg/dL, urate nephrolithiasis
More than 2 gout attacks yearly
Those who already has subcutaneous tophi or chronic gouty arthritis
Radiographic evidence of gout arthritis
punctate or linear deposits withing the menisci/ articular cartilage in CPPD are AKA
Chondrocalcinosis
Autoantibodies that are specific and associated with SLE nephritis and correlates with dse activity
anti dsdna
antismith–> does not correlated with dse activity
Autoantibody in SLE associated with Sicca syndrome
Anti Ro
Also assoc in neonatal lupus heart block
Autoantibody that correlates with dse in activity of nephritis but NOT specific to SLE
AntiC1q
Autoantibody more frequent in drug induced lupus than SLE
Anti histone
positive test in CNS correlates with active CNS lupus
Anti neuronal includes antiglutamate receptor 2
positive test in SERUM correlates with depression or psychosis in CNS lupus
Antiribosomal P
**take note: found in serum not CSF unlike anti neuronal antibody
Most serious cardiac manifestation of SLE
Myocarditis, Libman Sacks endocarditis
Next step when ssx suggestive of SLE but negative ANA, CBC, plt, UA
Repeat ANA, add dsDNA and anti Ro
if all negative- not SLE
2nd agents that may be used in addition to glucocorticoids in px with SLE with life threatening organ dysfunction
MMF/ Cyclophosphamide
in SLE nephritis, may also add calcineurin inhibitors like tacrolimus
Treatment for SLE assoc with higher incidence of aseptic meningitis
NSAIDs
Treatment for SLE assoc with bladder CA
cylocphosphamide
Treatment for SLE assoc with diffuse yellowing of the skin
Quinacrine
Treatment for SLE assoc with Progressive multifocal leukoencephalopathy
Rituximab
Treatment for SLE assoc with hypercholesterolemia
MMF
Most common venous and aterial consequences of APAS
DVT, Stroke
Hallmark of rheumatic carditis
Valvular damage affecting mitral valves and aortic valves
eg. MR and AR
Characteristic echo findings in RHD
___% of those with chore have carditis
50
Subcutaneous nodules are Delayed manifestation of RHD occuring __ weeks after the onset of disease last for 3 weeks associated with carditis
2-3
Lab tests that could signify evidence of strep infection
Positive throat swab/ rapid antigen
Anti ASO, anti DNAse
Treatment for Acute rheumatic fever
Antibiotics: Amoxicillin, 50 mg/kg [maximum, 1 g] daily, for 10 days OR Benzathine Pen G 1.2 million units IM
Salicylates and NSAIDS- Aspirin 50-60mg/kg per day Max 80-100mg/kg/day divided into 4-5 doses; Decrease dose after 2 weeks to 50-60mg/kg/day for 2-4 weeks
Others: Naproxen 10-20mg/kg/day
most common form of chronic inflammatory arthritis
RA
What constitutes Felty’s syndrome?
neutropenia, splenomegaly, and nodular RA
Oral microbiome associated with RA
P. gingivalis
Pathologic hallmark of RA
Synovial inflammation and proliferation, focal bone erosions, thinning of articular cartilage
The presence of serum ____ antibodies has about the same sensitivity as serum RF for the diagnosis of RA.
anti CCP
However, its diagnostic specificity approaches 95%, so a positive test for these antibodies in the setting of an early inflammatory arthritis is useful for distinguishing RA from other forms of arthritis
ACR/Eular criteria for remission in RA
Only biologic for RA that is not approved for monotherapy
Infliximab
Safest DMARD to use in pregnancy
HCQ and Sulfasalazine
Wright and Moll 5 patterns of psoriatic arthritis
(1) arthritis of the DIP joints
(2) asymmetric oligoarthritis
(3) symmetric polyarthritis similar to RA
(4) axial involvement (spine and sacroiliac joints)
(5) arthritis mutilans
(3)- most common, occurs in 40%
Radiographic findings associated with peripheral psoriatic arthritis
DIP involvement, classic “pencil-in-cup” deformity; marginal erosions with adjacent bony proliferation (“whiskering”); small-joint ankylosis; osteolysis of phalangeal and metacarpal bone, with telescoping of digits; periostitis, “ray” distribution of lesions.
What constitutes CASPAR criteria for Psoriatic arthritis
Oral JAK inhibitor approved for psoriatic arthritis
Tofacitinib
Monoclonal antibodies approved for psoriatic arthritis
Secukinumab and ixekizumab, monoclonal antibodies to IL-17A;
ustekinumab, a monoclonal antibody to the shared IL-23/IL-12p40 subunit.
Triad of GPA
Upper respiratory tract involvement
Lower respiratory tract involvement
Glomerulonephritis
Most common presentation of MPA
Glomerulonephritis
does NOT have granulomas and pulmonary involvement
Histologic hallmark of GPA
Necrotizing small-vessel vasculitis + Granulomas (intravascular or extravascular)
Chronic nasal carriage of this bacteria is associated with higher relapse of GPA
S. aureus
Most common cause of mortality in GPA
Renal
Most common system involved in GPA
ENT particularly sinusitis
Most common renal manifestation in GPA
Glomerulonephritis
Most common lung manifestation in GPA
Pulmonary infiltrates
Most common eye manifestation in GPA
Scleritis
Important cause of mortality in EGPA
Heart disease (myocardial involvement)
2DECHO should be done in ALL newly diagnosed patients
Saddle nose deformity is seen in what ANCA associated vasculitis
EGPA
Venules are NOT involved in PAN. If present, this would suggest this condition
MPA
Most common CBC finding in PAN
Leukocytosis with neutrophilic predominance
Body tissues with the highest yield for biopsy in PAN diagnosis
Nodular skin lesions
Painful testes
Nerve/muscle
May be performed in the absence of biopsy for diagnosis of PAN
Angiographic studies
Mortality in PAN is usually due to:
GI complaints (bowel infarction, perforation)
Cardiovascular causes
Most common artery involved in giant cell arteritis
Temporal artery
Most common artery involved in takayasu arteritis
subclavian artery
Treatment for Giant cell arteritis
Prednisone (40-60 mg OD x 1 month then taper)
(first-line treatment for general presentation)
Methylprednisolone (1 gram OD x 3 days)
(first-line treatment for ocular presentation)
Treatment for Takayasu arteritis
Prednisone 40-60 mg OD for symptomatic treatment
Most commonly involved vessel in cutaneous vasculitis
Postcapillary venules
Typical presentation in cutaneous vasculitis
Palpable purpura
Most common site of cutaneous vasculitis
Lower extremities
Treatment of cutaneous vasculitis
Prednisone
Most effective therapy for systemic vasculitis but should almost never be used for cutaneous vasculitis
Cyclophosphamide
Syndrome that includes the ff ssx:
Interstitial keratitis
Vestibuloauditory symptoms
Aortitis (AV involvement)
Cogan syndrome
Most involved blood vessel in Kawasaki disease
Coronary arteries – beadlike aneurysms and thromboses
Drugs associated with ANCA-associated vasculitis
Hydralazine
Propylthiouracil
Most common clinical presentation of drug-induced vasculitis
Palpable purpura of the lower extremities
difference between serum vs serum like sickness
In patients with dermatomyositis, these refer to the raised erythematous rash over the knuckles.
Gottron papules NOT sign
autoantibody associated with more benign dermatomyositis and a favorable response to treatment
Anti-Mi2
Associated with increased risk of malignancies in dermatomyositis patients
Anti-TIF1 (p155)
Anti-NXP2
autoantibody Associated with amyopathic dermatomyositis (rash only) with severe palmar rash, digital ulcers, rapidly progressive ILD
Anti-MDA5
autoantibody Associated in immune-mediated necrotizing myopathy (NM) in patients taking statins >5 years
Anti-HMGCR
autoantibody Associated in patients with inclusion body myositis (IBM)
Anti-cytosolic 5’nucleotidase 1A (anti-cN-1A)
Inclusion body myositis has predilection for involvement of these muscles
flexor digitorum profundus, vastus medialis, vastus lateralis
Treatment for inflammatory myopathies
High-dose glucocorticoids (0.75 – 1 gram mg/kg/day- First-line treatment to steroid-responsive inflammatory myopathies
Methotrexate – second-line treatment
