Rheumatology 2 Flashcards
Symptoms of fibromyalgia
MSK pain, fatigue, disordered sleep, multiple somatic symptoms, cognitive problems, psychiatric problems.
Fibromyalgia is more common at what age and in what gender?
20-50 year old women
What is allodynia?
Experiencing normal sensations as painful
What is hyperalgesia?
Pain is more intense and lasts longer
What is commonly the most bothersome area in fibromyalgia?
Around neck, shoulders, and low back
What amount of pressure should be applied when examining points of tenderness?
4kg/cm^2
enough to whiten the nailbed
Where are the fibromyalgia tender points?
Under sternomastoid muscle Near the second costochondral junction 2 cm distal to Lateral epicondyle Greater trochanter medial fat pad of knee Insertion of sub occipital muscle origin of supraspinatus upper outer quadrant of buttock
T/F? Fibromyalgia does not cause any lab abnormalities
True
Initial treatment for fibromyalgia?
Pt education, Good sleep hygiene, exercise, +/- CBT, +/- meds
What meds could be appropriate treatment of fibromyalgia?
TCAs (amitriptyline, nortripyline, desipramine) Cyclobenziprine SNRIs (duloxetine, milnacipran) SSRIs (fluoxetine- off label) Anticonvulsants (lyrica, gabapentin)
Symptoms of polymyalgia rheumatica?
Pain and stiffness of the hips and shoulders
Polymyalgia rheumatica is associated with what other condition?
Giant cell arteritis
GCA and PMR are more common in what gender and what age group?
Females >50, Northern Europeans
Smoking ______ risk for GCA, while DM ______ risk for GCA
Increases, decreases
What gene is associated with PMR and GCA?
HLA-DR
What type of cells are present in joints affected by PMR?
Lymphocytes and monoctyes
What is the pathophys behind GCA?
Infiltration of inflammatory cells into vessels causing vasculitis
Classic symptoms of GCA?
headache, scalp tenderness, jaw claudication, visual changes (amaurosis fugax or diplopia)
Physical exam findings for GCA?
Ill appearing +/- temporal artery changes
Fundoscopic exam: +/-edema of optic disc, cotton wool patches, small hemorrhages,
CV: asymmetry of pulses in arms, aortic regurg, bruits near clavicle
What labs will be elevated in GCR?
ESR, CRP
What is the gold standard for diagnosis of GCA?
Temporal artery biopsy
T/F PMR is a clinical diagnosis
True
Treatment of PMR?
Glucocorticoid therapy
Prednisone 10-20mg PO QD
If no improvement after 7 days, increase to 30.
Treatment for GCA?
Prednisone 40-60mg PO QD
Takayasu Arteritis mostly affects what vessels?
Aorta and its main branches
Describe the typical TA patient.
Asian women between 10 and 40 years old
Physical exam findings in a patient with TA?
BP differential between arms.
Asymmetrical arterial pulses.
Bruits.
Treatment for TA?
Prednisone 45-60mg. PO Qam.
Taper when symptoms are controlled and labs improved.
What surgical interventions are options for patients with TA?
PCTA (percutaneous transluminal angioplasty)
Bypass grafting
Aortic repair
What is reactive arthritis?
Asymmetric polyarthritis that develops after a GI or GU infection.
What joints are commonly affected by ReA?
Large lower extremity joints
What infections can trigger ReA?
GI infections - Shigella, salmonella, yersinia, campylobacter, E. coli, C. diff
STIs - Chlamydia, ureaplasma urealyticum
What gene predisposes people to having ReA?
HLA-B27
Patients with ReA may have enthesitis and/or dactylitis. What does this mean?
Enthesitis - swelling at tendon insertion
Dactylitis - sausage joint
What are the extra articular manifestations of ReA?
General - Fever, fatigue, weight loss
Eye - Conjunctivitis, anterior uveitis
Mucocutaneous - Balanitis, stomatitis, kertoderma blennorrhagicum
Nails - mimics psoriasis
T/F synovial fluid analysis will grow bacteria in ReA?
False.
Treatment for ReA?
Treat underlying infection
NSAIDs (naproxen, diclofenac, or indomethacin)
If a patients symptoms of ReA do not improve after treatment with NSAIDs, what are some other options?
Intraarticular glucocorticoids
PO glucocorticoids
DMARD(sulfasalazine or methotrexate)
How long does a typical case of ReA last?
3-5 months
Most patients remit within 6-12?
What is Sjogrens syndrome?
Autoimmune disease that effects the lacrimal and salivary glands.
What are the symptoms of Sjogrens?
Xerostomia and keratoconjunctivitis sicca
T/F? Sjogrens is always secondary to another disease.
False, can be primary or secondary
Describe the typical Sjogrens patient.
Middle aged female
Women:men = 10:1
What genes are involved in Sjogrens?
HLA-DQ, HLA-DB
What test is used to check tear production?
Schirmer test
What tests can be used to check for saliva production?
Saxon test
Saliometry
What lab tests should be positive in a Sjogrens patient?
ANA
Anti-Ro
Anti-La
RF
Gold standard of diagnosis for Sjogrens?
Salivary gland biopsy
Treatment for oral symptoms of Sjogrens?
Regular dental visits with fluoride treatment
Artificial saliva
Pilocarpine or cevimeline
Treatment for ocular symptoms of Sjogrens?
Artificial tears Q2-4 hours
Ocular ointment at night
Cyclosporine eye drops if artificial tears doesn’t help
Topical steroids if Cyclosporine doesn’t help
Punctal plugs
Treatment of systemic manifestation of Sjogrens?
Hydroxychloroquine or methotrexate
Is RA more common in women or men?
Women
What genes are associated with RA?
HLA-DR MHC
Morning stiffness lasts how long in RA?
> 30 minutes
IS RA symmetric or asymmetric?
symmetric
Joints commonly affected by RA?
PIP joints, MCP joints, wrist, elbow, shoulder, hip, knee, MTP joints, PIP joints of foot
Joints commonly affected by OA?
DIP joints, 1st MCP joint, C-Spine, L-spine, hip, knee, 1st MTP joint
Describe the hands of a patient with RA.
Ulnar deviation of MCP joints
Swan neck deformity
Boutonniere deformity
Z deformity
Your patient with RA develops hard sub Q nodules on extensor surfaces of forearms. What are these called?
Rheumatoid nodules
What secondary syndrome can be due to RA?
Secondary Sjogrens
Felty syndrome is a complication of RA. What are the symptoms?
SANTA Splenomegaly Anemia Neutropenia Thrombocytopenia Arthritis
What labs are likely to be positive in RA?
Anti-CCP
RF
Elevated ESR/CRP
What is the most specific bloodwork for RA?
Anti-CCP
What imaging modality is most specific for RA?
Radiographs
What is needed to dx RA?
Inflammatory arthritis of > 2 joints
Positive RF and or CCP
Elevated ESR and/or CRP
Duration> 6 weeks
What does a patient with RA need screening for before treatment is initaited?
Hep B and C Baseline CBC, Cr, LFTs, ESR, CRP Ophthalmic screening Latent TB screening Baseline radiographs
What medication helps with symptoms but not with disease course in RA?
NSAIDs
What medication is good for symptoms relief and slowing rate of joint damage while bridging to a DMARD?
Corticosteroids 5-20mg PO QD
What is the initial DMARD of choice in RA?
Methotrexate 7.5mg PO weekly
What supplement should be prescribed to patients on methotrexate?
Folic acid 1mg PO QD
What is the first choice TNF inhibitor for RA treatment?
Etanercept
What is the downside to TNF inhibitors?
Expensive
SQ or IV
What is PAN?
Polyarteritis nodosa
It is a systemic nercrotizing vasculitis
What arteries are affected by PAN?
Medium or small muscular arteries
What organ is usually spared by PAN?
Lungs
PAN is associated with what infection?
Hepatitis B
What are common clinical features of PAN?
Lower extremity ulcers
Hypertension and renal insufficiency
Abd pain
Mononeuritis multiplex
What organ is most commonly affected by PAN?
Kidneys
How does mononeuritis multiplex present?
Foot drop
What are some diagnostics that can be used for PAN?
Biopsy of organ showing necrotizing inflammation of medium sized arteries
Angiogram
What angiogram finding is seen in PAN?
Rosary sign
PAN treatment
If patient has viral hepatitis, treat with antiviral
Mild disease - high dose corticosteroids
Mod-severe - high dose corticosteroids and immunosuppressant (cyclophosphamide)
