Rheumatology 2 Flashcards
Treatment of ILD associated with systemic sclerosis
Mycophenolate
Specific lab feature for diagnosis of TB in pleural effusion
HIGH adenosine deaminase
Most common pulmonary manifestation of RA
Rheumatoid pleuritis
Specific lab feature of adult still disease
Extremely high serum ferritin
SE’s of lyrica
- weight gain, peripheral edema, lethargy, dizziness
HSP diagnosis
Skin biopsy with immunofluorescence
Treatment of relapsed GPA
Rituximab
management of refractory SLE
Belimumab
what is acute cutaneous lupus erythematosus?
- derm presentation of SLE – classic malar (butterfly) rash
clinical description of malar rash
bright patches over both cheeks AND nasal bridge
*No nasolabial fold involvement
What is subacute cutaneous lupus erythematous in general?
- different subtype of cutaneous lupus
Rosacea vs. SLE
rosacea = inflammatory papules, pustules, telangiectasisas
*nasolabial fold involvement
Treatment of primary angiitis of the CNS
Cyclophosphamide
When patients on chronic steroids need to be on bisphosphonates
*moderate or high 10 yr risk of major fracture + at least 2.5 mg of pred daily for 3 months
subacute cutaneous lupus erythematosus clinical features
young woman with lupus features + annular rash with central clearing or papulosquamous with patchy erythematous plaques and papules
Treatment options for chronic calcium pyrophosphate arthropathy
- low-dose steroids
- low dose colchicine
- NSAIDS
- you don’t use allopurinol because allopurinol is urate-lowering therapy, but calcium pyrophosphate deposition results from calcium pyrophosphate rather than uric acid deposition
medical term for pseudogout
acute calcium pyrophosphate crystal arthritis
good treatment option for OA with NSAID contraindications
Duloxetine
c-ANCA (GPA) antigen
proteinase 3 (PR3)
p-ANCA antigen
myeloperoxidase (MPO)
CREST syndrome is
Calcinosis
Raynaud’s
Esophageal dysmotility, Sclerodactyly
Telangiectasias.
anti synthetase syndrome clinical features
- myositis + raynaud’s + mechanic’s hand + ILD
- 1/3 of patients with immune-mediated myopathy have constellation of findings termed “antisynthetase syndrome”
Mechanic’s hands + clinical association
- thickened skin resembling skin of mechanic
- feature of patients with myositis
Polyarteritis nodosa clinical features
He is pissing blood + has a BP cough around his neck + right foot and left hand in bowling water + covered in darts + in a wheelchair/presentation is multi-systemic: renal: glomerulonephritis + hypertension, nervous: peripheral neuropathy + mononeuritis multiplex, GI: mesenteric ischemia/bowel infarction, bleeding, Musculoskeletal: myositis, arthritis.
Medical term for Churg-Strauss
Eosinophilic granulomatosis with polyangiitis
Eosinophilic granulomatosis with polyangiitis clinical features
Poly Nichols laying in bed. Andrew purpura to the right of the bed + has big headphones on + red eyes + + feet and hands in a bucket. Polly Nichols has nails driven into her sinuses and wrist/foot drop + she’s using a huge inhaler/presentation = asthma + sinusitis + skin nodules or purpura + peripheral neuropathy (eg wrist/foot drop) + uveitis + conductive/hearing loss + muscle/joint pain.
Complement levels in mixed cryoglobulinemia
- C3 is unaffected
- C4 is low
- CH50 is low (CH50 is total hemolytic complement)
anti-centromere antibodies association
CREST syndrome
antibody associated with systemic sclerosis
anti-topoisomerase
Principles of RA care
1) Care by rheumatologist
2) DMARD ASAP
3) Tight control, treat to target strategy (adjusting therapy to treat a composite clinical outcome)
Management of RA patient resistant to initial DMARD therapy
Combination of DMARDS
- MTX + sulfasalazine and hydroxychloroquine
OR
- MTX + TNF inhibitor
Screening prior to starting DMARD
- Hep B AND C
* latent TB
Hep B testing prior to starting DMARD
Hep B surface antigen and HBV core antibody
Screening prior to starting hydroxychloroquine
- baseline optho exam
Management of active RA
- anti-inflammatory therapy with NSAID or steroid (depending on degree of disease activity)
- start DMARD therapy with MTX (may take weeks to months to achieve optimal effects)
contraindication to DMARD
active infection
RA during pregnancy
RA often improves or remits completely during pregnancy
HPV screening age interval
21 to 65
HPV testing for different age groups per USPSTF
21-29 = Pap test q 3 years
30 and over = Pap test q 3 years OR primary HPV testing alone (only certain tests are approved) q 5 years OR contesting (Pap and HPV testing) q 5 years
*can cotest once you’re 30
Behcet’s disease clinical features
recurrent and painful oral ulcers + genital ulcerations + ocular disease (uveitis) + skin lesions, gastrointestinal involvement, neurologic disease, vascular disease, or arthritis
Countries where Behcet’s incidence is higher
- Turkey (80 to 370 cases per 100,000) while the prevalence ranges from 13.5 to 35 per 100,000 in Japan, Korea, China, Iran, Iraq, and Saudi Arabia
Treatment of Behcet’s syndrome
IF oral or genital ulcers –> topical steroids
For prevention of recurrent oral and genital ulcers –> colchicine
IF more severe disease –> systemic steroids
Anti-GBM disease is
Goodpasture’s
Anti-GBM disease clinical features
Lungs on + and attacking the basement membrane with a pickaxe + pissing blood all over the place + coughing up blood all over himself (NEPHRITIC)/patients are typically young men with onset of pulmonary symptoms like fatigue, dyspnea, and hemoptysis and renal symptoms – dysuria, hematuria, and renal failure.
Anti-GBM disease treatment
Diego hooked up to plasmapheresis machine/treatment = emergent plasmapheresis.
Treatment of MPGN
IF immune complex-mediated (hep C or b associated) – treat underlying disease
Initial treatment of GPA
steroids = rituxan
Serology in RA
- Many patients have “seronegative” RA, typically early on in disease course (thus often have negative ANA, RF, and CCP
- RA is A CLINICAL DIAGNOSIS
RA presentation
- morning stiffness improving with activity
- small joint involvement (PIP, MCP, MTP) sparing DIP
- joints are warm and tender to touch
- rheumatoid nodules
- symmetric, polyarticular joint pain
Derm presentation of systemic sclerosis
- skin thickening over hands and fingers + digital ulceration
Presentation of ILD associated with systemic sclerosis
- basilar crackles
- interstitial markings on CXR
alopecia areata clinical features
- commonly associated with other autoimmune disorders
- chronic, recurring, often spontaneously recover but commonly relapse
- smooth, circular patches of hair loss
- exclamation point hairs seen at margins (larger on top than at their base) + extractable with minimal traction
management of alopecia areata
- intralesional steroid injections (or topical if refusing steroids)
- sometimes no treatment
Management of AIHA
First line = steroids
Second line = splenectomy
MAHA on peripheral smear
red cell fragmentation (schistocytes)
Peutz-Jeghers syndrome presentation
- mucocutaneous pigmentation (multiple brown spots on lips and buccal mucosa)
- multiple hamartomatous GI tract polyps and pigmented mucocutaneous papules
- GI symptoms: rectal bleeding, obstruction, abdominal pain
- young age
Peutz-Jeghers syndrome is associated with increased risk for what?
- malignancy (both GI and non-GI malignancy)
Screening for Peutz-Jeghers
- c-scope at age 18
- EGD and small-bowel series starting at age 8
- early mammograms
- testicular exam starting at age 12
ovarian cancer presentation
- subtle (bloating, pelvic pressure)
Other clinical + lab features of eosinophilic granulomatosis with polyangiitis
CLINICAL: - ***asthma - chronic rhinosinusitis with nasal polyps - necrotizing glomerulonephritis - tender subcutaneous nodules - migratory polyarthritis LAB: - eosinophilia - granulomatous
Treatment of churg strauss
- systemic steroids with or without cyclophosphamide
Diagnosis of churg strauss
- tissue biopsy (lung or kidney)
GPA vs. churg-strauss
Churg-strauss = asthma + nasal polyps + eosinophilia
Management of joint destruction in RA causing refractory pain, functional disability
refer to orthopedics (pain is typically from mechanical stress of joint deformities and or destruction)
Reactive arthritis features
- asymmetric oligoarthritis
- enthesisitis
- conjunctivitis
- OR oral ulcers
First line therapy for reactive arthritis
NSAIDS
Most common complications of tattoos
1) local staph infections
2) hypersensitivity reactions from metals in ink
Variable correlated with poorer functional outcomes in RA
- High titer CCP
- higher number of involved joints
- positive RF
- higher inflammatory markers
Presentation of septic olecranon bursitis
- warmth, swelling, fever of elbow joint
- synovial fluid count greater than 3K
- gram stain may be negative
Treatment of septic olecranon bursitis
drain fluid + systemic anti-staphylococcal abx
Finding that commonly causes DXA result to be inaccurate
osteophytes + other abnormal calcifications (this is why treatment decisions should be based on lowest bone density measurement)
Antihypertensives of choice for patients with gout
Losartan
CCBs
Meds that can increase risk of gout flair
- diuretics
* beta blockers
Next step after suspected Raynaud’s
Nailfold capillary examination (differentiates between primary and secondary raynaud’s – normal nail fold capillaroscopy suggests primary reynaud’s, abnormal suggests secondary, so patient should be evaluated for an underlying disorder)
HSP clinical features
- renal dysfunction
- palpable purpura
- abdominal pain
- arthritis
- can be in adults too
description of palpable purpura
- multiple raised, erythematous, non blanching lesions on lower extremities
PMR clinical features
- elevated ESR
- elderly patient
- neck, shoulder, proximal thigh or hip involvement (may not have hip)
- decreased ROM in shoulders, neck, and hips
- constitutional symptoms
Diabetic amyotrophy clinical features
- acute asymmetrical pain followed by gradually worsening proximal lower extremity and back weakness
atypical features of hyperthyroidism in elderly patients
- dyspnea, apathy (rather than hyperactivity), paradoxical constipation
- Afib
Long term complication of Sjogren syndrome
- NHL
What is a pleomorphic adenoma?
Common benign salivary gland tumor
Treatment of Lofgren syndrome
NSAIDs
Lofgren syndrome clinical features
- erythema nodosum + bilateral ankle arthritis + hilar adenopathy
(variant of sarcoidosis)
Sjogren syndrome clinical features
- chronic dry eyes + dry mouth
- 25% have extra glandular manifestations: *RTA + DI, chronic interstitial nephritis, lung, nervous system, heart involvement, *Rayonouds
clinical features of mixed cryoglobulinemia
- palpable purpura, arthralgias, MPGN, neuropathy
- can see skin necrosis and gangrene in some patients
mixed cryoglobulinemia lab features
- positive ANA + RF
- low C3 + C4 (confirm)
Other presentation of GPA
- ocular involvement
Drugs causing drug-induced SLE
- hydralazine
- procainamide
- minocycline
- anti-tumor necrosis factor agents
drug-induced SLE clinical and lab features (distinct from SLE
- normal complement
- less likely to cause CNS, heme, or renal abnormalities
autoantibodies positive in drug-induced SLE
histone autoantibodies
Sarcoidosis diagnosis
- requires biopsy (demonstrating pathologic evidence of noncaseating granulomas)
- biopsy most accessible site of disease involvement, which is typically endobronchial ultrasound with nodal aspiration for mediastinal lymph node sampling
pseudogout caveat
- crystal microscopy has low sensitivity (CPPD crystals are small and often scarce)
Preferred antihypertensive for suspected aortic dissection
First line: Beta blockers (labetalol) (you also want to decrease LV contractility to reduce aortic wall shear stress)
Second line: nitroprusside
Symptomatic PDA presentation
- continuous murmur
- wide pulse pressure
- bounding pulses
- best auscultated pulmonic position
Sequela of unprepared PDA
Increased risk of infective endarteritis
description of murmur from PDA
- continuous murmur in the left infraclavicular region
Allopurinol titration in gout
- never adjust dose or discontinue until 3-4 weeks after the acute inflammation subsides
- typically increased until serum uric acid is below 6
Management of dermatitis associated with SLE
Mild – topical steroids
Moderate – plaquenil
Severe – immunosuppressive drugs
Limited cutaneous systemic sclerosis features
- puffy fingers distal to MCP joints
- sclerosis distal to elbows and knees, sparing trunk and proximal extremities