Rheumatology Flashcards
Pain and stiffness in shoulders and hips that last for several weeks and has no other determined cause.
Often coexists with Giant Cell Arteritis
Does NOT cause Blindness
Polymyalgia Rheumatica
Signs and Symptoms of Polymyalgia Rheumatica
Shoulder Pain
Pelvic Pain
Difficulties
- combing hair
- putting on a coat
- rising from a chair
Does NOT cause true muscle weakness
Lab findings of Polymyalgia Rheumatica
↑ ESR
↑ CRP
Anemia
Polymylagia Rheumatica Treatment
Prednisone
- if no improvement in 3 days → consider other diagnosis
Affects medium-sized and large vessels. Temporal Artery is frequently affected.
Causes headache, JAW CLAUDICATION, visual abnormalities, scalp tenderness, and throat pain.
CAN cause blindness and large artery complications.
Giant Cell Arteritis
Signs and Symptoms Giant Cell Arteritis
Thoracic Aortic Aneurysm (17x more likely)
Asymmetry of Pulses in Arm
Diagnosis of Giant Cell Arteritis
Temporal Artery Biopsy
Temporal Artery Ultrasound
- “Halo Sign” → dark hyper echoic non-compressible area around the vessel lumen representing the vessel wall inflammation
Giant Cell Arteritis Treatment
Prednisone
IV Methylprednisolone
- IF VISION LOSS
Diagnosis Criteria of Fibromyalgia
WPI of ≥ 7 + SS of ≥ 5
or
WPI of 3 - 6 + SS of ≥ 9
with pain for at least 3 months
Fibromyalgia Treatment
Multidisciplinary Approach
Limited or No Benefit
- Opiates
- Steroids
- Acupuncture
- NSAIDs
Necrotizing arteritis of medium-sized vessels. Can involve almost any organ. But usually NOT the lungs.
Commonly affects:
- Skin
- Peripheral Nerves
- Mesenteric Vessels
Polyarteritis Nodosa
Polyartritis Nodosa can be caused by what Virus?
Hepatitis B
Signs and Symptoms of Polyartertits Nodosa
Extremity Pain
Insidious Onset over Weeks to Months
- Fever
- Malaise
- Weight Loss
Skin Findings:
- Livedo Reticularis
- Subcutaneous Nodules
- Skin Ulcers
- Digital Gangrene
Most Commonly Occur in Lower Extremity
- Ulcerations near the Malleoli
HTN due to Renal Artery Dysfunction
Abdominal Symptoms
What is needed to Confirm the Diagnosis of Polyarteritis Nodosa?
Tissue Biopsy or Angiogram
First Line Treatment for Polyarteritis Nodosa
IV Methylprednisolone (High Dose)
Hepatitis B:
- Prednisone with Plasmapheresis
Disease characterized by:
MUSCLE SYMPTOMS + AUTOANTIBODIES
Causes bilateral proximal and progressive muscle weakness and inflammatory infiltrate in muscle tissue.
Polymyositis
Polymyositis Signs and Symptoms
Progressive Muscle Weakness (Weeks to Months)
NO FACIAL OR OCULAR WEAKNESS
Respiratory muscle weakness may require mechanical ventilation
Difficult diagnosis in Elderly
Lab findings of Polymyositis
↑ Creatinine Kinase
↑ Aldolase
How is Polymyositis diagnosed?
Biopsy
- MRI and EMG can help
What is the pathology of Polymyositis?
Inflammatory infiltrate of the Endomysium
Polymyositis Treatment
Prednisone
- may need Methotrexate, Azathioprine or Mycophenolate
An inflammatory autoimmune disorder → autoantibodies attacking nuclear antigens.
Clinical manifestation result of trapping of antigen-antibody complexes in capillaries of visceral structures or to autoantibody mediate destruction of host cells.
Systemic Lupus Erythematosus
When do most cases of Lupus develop?
After Menarche and Before Menopause
Signs and Symptoms of Lupus
Malar Rash (Butterfly Rash)
Panniculitis (inflammation of fat)
Splinter Hemorrhage
Alopecia
Raynaud Phenomenon
Joint Symptoms (earliest manifestation)
What lab test is almost 100% sensitive for Lupus but not specific?
Anti-Nuclear Antibody (ANA) Test
- using HEp-2 cells
How is Lupus treated?
Hydroxychloroquine → rash and joint symptoms
Avoid Sun Exposure
Rest and NSAIDs
Corticosteroids (acute exacerbation)
Patient’s with Lupus are at a higher risk of developing what comorbidity?
Malignancy
What medications are most likely to cause Drug Induced Lupus?
Hydralazine
Isoniazid
Minocycline
Sulfasalazine
Quinidine
Syndrome of paroxysmal digital ischemia. Commonly caused by an exaggerated response of digital arterioles to cold or emotional stress. Usually symmetric involvement.
Raynaud Phenomenon
What are the 2 Phases of Raynaud’s?
Initial Phase → Excessive Vasoconstriction
- digital pallor or cyanosis
Recovery Phase → Vasodilation
- hyperemia and rubor
Raynaud’s Treatment
Keep Warm
Calcium Channel Blockers
Diffuse fibrosis of the skin and internal organs
Scleroderma
(Systemic Sclerosis)
Form of Scleroderma where the skin thickening is confined to the face, neck, and distal extremities.
Increases susceptibility to digital ischemia, leading to finger loss and life-threatening pulmonary HTN
Also known as CREST Syndrome
Limited Form Scleroderma
Which form of Scleroderma can have small and large bowel hypo-motility?
Both
Form of Scleroderma that involves the Trunk, proximal extremities, lungs, heart, and Kidneys.
Causes tendon friction rubs over the forearm and shins.
→ leathery, crepitus feel
Diffuse Form Scleroderma
Signs and Symptoms of Scleroderma
Rayunaud is usually initial sign
Polyarthralgia
Telangiectasia
Calcifications and Ulcerations of Fingertips
Pulmonary Fibrosis
Scleroderma Diagnosis
Skin Thickening of Fingers
Raynauds
SS Related Antibodies
When diagnosis is made, must have screening for organ complications.
Scleroderma Treatment
Symptomatic and Supportive
- focuses on organ systems involved
Methotrexate
- Skin Disease, Arthritis, Myositis
Bosentan
- Digital Ulceration
Sildenafil or Prostaglandins
- Pulmonary HTN
What is the #1 cause of Mortality in patients with Scleroderma?
Lung Disease
Systemic autoimmune disorder that affects the glands that produce Saliva and Tears
Dry Eyes and and Dry Mouth → Sicca: Most Common Feature
Sjogren Syndrome
Patients with Sjogren Syndrome have an increased incidence of what?
Lymphoma
Signs and Symptoms of Sjogren Syndrome
Xerostomia (Dry Mouth)
Loss of Taste
Parotid Enlargement
Keratoconjunctivitis
Peripheral Neuropathies
Vasculitis
Labs for Sjogren Syndrome
Schirmer Tear Test
- ocular test which measures quantity of tears
Parotid Gland Biopsy
- cancer doesn’t typically occur bilaterally
Sjogren Syndrome Treatment
Artificial Tears
Cyclosporine
Pilocarpine or Cevimeline
Sip Water Frequently
Chronic symmetric polyarthritis with predilection for small joints of the hands and feet. Characterized by synovitis of multiple joints.
- Juxta-articular osteoporosis
- Destruction of periarticular tissue
Rheumatoid Arthritis
What is important about Rheumatoid Arthritis treatment?
Early Aggressive Treatment is Important
Signs and Symptoms of Rheumatoid Arthritis
Stiffness that lasts more than 30 minutes
Affects Neck
- spares rest of Spine and SI Joints
Boggy, Tender, Warm Joints
Episcleritis + Scleritis
Rheumatoid Nodules
Extra-articular symptoms most common in seropositive RA
What is the most specific blood test for Rheumatoid Arthritis?
Anti-Cyclic Citrullinated Peptide (Anti-CCP)
What is the MOST SPECIFIC TEST for Rheumatoid Arthritis?
Radiographic Tests
What deformities are commonly caused by Rheumatoid Arthritis?
Ulnar Deviation
Boutonniere Deformity
Swan-Neck Deformity
Valgus Deformity of Knee
Volar Subluxation of MCP Joint
What is the most common cause of Mortality from Rheumatoid Arthritis due to?
Cardiovascular Disease
Rheumatoid Arthritis Treatment
Methotrexate
NSAIDs
Corticosteroids
Asymmetric Sterile Oligoarthritis → Reiter Syndrome
Usually occurs after GI or GU infection
→ Often Associated with Chlamydia
→ Usually occurs 1 - 4 weeks after
Reactive Arthritis
What is very commonly associated with Reactive Arthritis, besides Chlamydia?
HLA-B27 Antigen
Reactive Arthritis Signs and Symptoms
Conjunctivitis
Urethritis
Arthritis
“Can’t See, Can’t Pee, Can’t Climb a Tree”
Fever + Weight Loss
Mucocutaneous Lesion
Fingernail Involvement
Reactive Arthritis Treatment
NSAIDs
Rifampin + Doxycycline
→ Chlamydia
Acute monoarticular arthritis caused by overproduction or under excretion of uric acid.
Gout
What joint does Gout usually affect?
MTP Joint
(Podagral)
What can increase uric acid production and decrease renal excretion?
Alcohol
What medications can trigger Gout flares?
Diuretics
ASA
Niacin (Vitamin B)
Cyclosporine
Nodular deposit of urate crystals with an associated foreign body reaction
→ Gout
Tophus
Patient’s with Gout are at increased risk of what?
Uric Acid Kidney Stones
- avoid Thiazide Diuretics
Common Clinical Findings of Gout
Sudden Onset
Alcohol
Medication Changes
Hospitalization
Fever up to 39C is Common
What is diagnostic of Gout?
Joint or Tophus Aspiration
→ Needle-like negatively birefringent under polarized light microscopy
What can be seen on X-Rays of patients with Gout later in the disease process?
Punched-out erosions with overhanging rim of cortical bone
Acute Gout Treatment
Naproxen or Indomethacin
Colchicine (if less than 36 hours)
Corticosteroids
- if intra-articular → joint aspiration and Gram stain first
Chronic Gout Treatment
Diet
Avoid Hyper-uricemic Meds
Colchicine Prophylaxis (anti-inflammatory)
- doesn’t affect uric acid
Allopurinol
→ do not start urate lowering treatment during acute attack!
Calcium Pyrophosphate Deposition
- fibrocartilage and hyaline cartilage are affected → chondrocalcinosis
Often occurs after surgery
Pseudogout
What joints does Pseudogout usually affect?
Knees and Wrists
Psuedogout of the Atlantoaxial Junction
Crowded Dens Syndrome
Pseudogout Treatment
NSAIDs + Colchicine
Arthritis that has an onset before 16 years old and lasts for at least 6 weeks.
Juvenile Idiopathic Arthritis
What is a common manifestation of Juvenile Idiopathic Arthritis?
Chronic Synovitis
Type of Juvenile Idiopathic Arthritis:
Fewer than 5 joints affected within 6 months of diagnosis.
Some will progress later to polyarticular disease → Extended Oligoarthritis
Oligoarticiular JIA (40 - 60%)
- best prognosis
Type of Juvenile Idiopathic Arthritis:
5 or more joints are affected in first 6 months.
Classified as RF Positive or Negative
Polyarticular JIA (20 - 35%)
Type of Juvenile Idiopathic Arthritis:
Present with systemic inflammation
- Recurring spiking fever
- Rash (salmon pink macular)
- Appear Sick
- Arthritis appears within 6 weeks to 6 months
Systemic Onset JIA (10-15%)
Type of Juvenile Idiopathic Arthritis:
Tenderness at Insertion Sites → Especially ACHILLES TENDON
Lower Extremities are Most Affected
HLA-B27 (+)
NO PSORIASIS
Enthesitis Related JIA (5-10%)
What should all pediatric patients with bone or joint pain receive?
CBC → Exclude Leukemia
What is the GOLD STANDARD for Juvenile Idiopathic Arthritis?
MRI
Juvenile Idiopathic Arthritis Treatment
NSAIDs
Corticosteroids
DMARDs
Eye Monitoring
PT
