Rheumatology Flashcards
What causes slapped cheek disease and childhood?
Fifth disease also known as slapped cheek disease is caused by an infection with parvovirus B 19. This infection is sometimes complicated by severe aplastic anemia caused by lysis of early erythroid precursors. The virus is primarily spread by infected respiratory droplets; blood-borne transmission, however, has been reported. The secondary attack risk for exposed household persons is about 50%, and about half of that for classroom contacts.
Methotrexate is contraindicated to be used with sulfonamide antibiotics. True or false?
“Methotrexate is a folate antagonist. Antifolate medications, such as sulfonamide antibiotics, must be avoided in patients taking methotrexate; the combination “may result in pancytopenia. Supplemental folate, 1 mg daily, reduces the adverse effects of methotrexate. Patients with RA are often treated with aspirin or NSAIDs in combination with methotrexate. Penicillin antibiotics can be administered safely with methotrexate”
Children with fifths disease Are most infectious when they develop the characterstic rash of a slap cheek appearance. True or false?
False. Once infected, patients usually develop the illness after an incubation period of four to fourteen days. The disease commences with high fever and malaise, when the virus is most abundant in the bloodstream, and patients are usually no longer infectious once the characteristic rash of this disease has appeared
What are the signs of fifths disease?
A usual brief viral prodrome with fever, headache, nausea, diarrhea.
As the fever breaks, a red rash of the cheeks forms, with relative pallor around the mouth (“slapped cheek rash”), sparing the nasolabial folds, forehead, and mouth.
“Lace-like,(reticular)” red rash on trunk or extremities then follows the facial rash. Infection in adults usually only involves the reticular rash, with multiple joint pain predominating.
Exacerbation of rash by sunlight, heat, stress.
Teenagers or young adults may develop the so-called “Papular Purpuric Gloves and Socks Syndrome”.
Does parvovirus affect joints?
In adults (and perhaps some children), parvovirus B19 can lead to a seronegative arthritis which is usually easily controlled with analgesics. Women are approximately twice as likely as men to experience arthritis after parvovirus infection. Possibly up to 15% of all new cases of arthritis are due to parvovirus, and a history of recent contact with a patient and positive serology generally confirms the diagnosis. This arthritis does not progress to other forms of arthritis. Typically joint symptoms last 1–3 weeks, but in 10–20% of those affected, it may last weeks to months.
What are the recommendations for a couple who wish to have a baby and one of them is taking methotrexate for RA?
“RA is an autoimmune disease, and it tends to remit during pregnancy when a woman is relatively immunosuppressed. Methotrexate is class X for pregnancy and is actually used in ectopic pregnancy to arrest fetal growth. Women and men on methotrexate should use an effective form of contraception, and continue contraception for 3 months after stopping methotrexate”
What can you tell a patient with RA about disease progression when well-managed?
90% of all joints involve will manifest in the first year. Early treatment with DMARDS has better outcome.
What are the Jones criteria for rheumatoid fever?
“rheumatic fever, which is rare in developed countries, is recognized by the Jones criteria. The major Jones criteria consist of polyarthritis, carditis, Sydenham chorea, erythema marginatum, and subcutaneous nodules. (Here’s a fun mnemonic: “JONES” with a heart shape in place of the “O,” so that J = joints, O = carditis, N = nodules, E = erythema marginatum, and S = Sydenham chorea”
What are the diagnostic criteria for polymyalgia rheumatica?
“Age > 50 years
Pain/aching for at least 1 month involving 2 of the following areas: neck, shoulders/proximal arms, and pelvic girdle
Morning stiffness
ESR >40 mm/hr
Exclusion of other potential causes of the symptoms except giant cell arteritis”
What is the sensitivity of the ESR in giant cell arteritis?
Sensitivity = 85%. Up to 15% of patients with PMR or GCA (a closely related disorder—keep reading) have a false-negative ESR. Using ESR and CRP together is 97–99% sensitive for GCA. Double false negatives of ESR and CRP are uncommon, but do occur. Thus, in the patient in whom GCA is suspected but in whom there is a normal ESR and/or CRP, biopsy is still recommended. In those suspected of PMR, a trial of steroids is still recommended”
What causes polymyalgia rheumatica?
The cause of PMR is not well understood. The pain and stiffness result from the activity of inflammatory cells and proteins that are normally a part of the body’s disease-fighting immune system, and the inflammatory activity seems to be concentrated in tissues surrounding the affected joints.[8] During this disorder, the white blood cells in the body attack the lining of the joints, causing inflammation.[9] Recent studies have found that inherited factors also play a role in the probability that an individual will develop polymyalgia rheumatica. Several theories have included viral stimulation of the immune system in genetically susceptible individuals.[10]
What is the treatment of polymyalgia rheumatica?
“Steroids are the treatment of choice in PMR. The disease is usually self-limiting, lasting only 1-2 years. Doses of prednisone ranging from 10 to 20 mg QD usually control the disease. Higher doses (up to 30 mg/day) should be tried if there is no response in 1–2 weeks. If the patient fails to respond to low-dose steroids, the diagnosis of PMR should be reconsidered”
How should steroid management be utilized in the treatment of polymyalgia rheumatica?
The goal of treatment with PMR is to use the least amount of steroids possible. In order to do this, a taper of 10% should be done every 1 to weeks as soon as symptomatic control has been achieved. Monitor the ESR every 2 to 4 weeks. An asymptomatic patient with an ESR of 40 needs to be managed judicially. “However, an isolated elevation in ESR without symptoms is not a reason to increase the steroid dose.”
During the course of treatment of PMR how often does a relapse occur?
“Relapses occur in 30–50% of patients after induction of a remission and should be treated by resuming or increasing prednisone. Usually, successful treatment of a relapse requires increasing the prednisone dose by a few milligrams.”
What’s the story with the relationship between giant cell arteritis and polymyalgia rheumatica?
Most experts agree that they are generally different presentations of the same disease. About 15% of people who are diagnosed with polymyalgia rheumatica also have temporal arteritis, and about 50% of people with temporal arteritis have polymyalgia rheumatica. Some symptoms of temporal arteritis include headaches, scalp tenderness, jaw or facial soreness, distorted vision or aching in the limbs caused by decreased blood flow, and fatigue.
What is the visual loss pattern or giant cell arteritis compared to macular degeneration?
“The initial visual loss in temporal arteritis is peripheral, while the vision loss in macular degeneration is initially central. If you think about it, this makes sense. GCA basically causes an anterior ischemic optic neuropathy (AION) secondary to involvement of the retinal artery by vasculitis. The further you are from the artery, the poorer the perfusion”
The patient presents with visual loss inspected giant cell arteritis, what is the treatment?
“When symptoms of vision loss occur, aspirin 81 mg daily and IV methylprednisolone 1 g daily for 3 days, followed by aspirin and prednisone 40–60 mg daily is the standard of care. Compared to PMR, higher doses of steroids are necessary to treat GCA. In the absence of vision loss, prednisone doses of 40–60 mg QD are usually required to relieve symptoms”
Which life-threatening condition that presents with severe upper thoracic pain that feels like a ripping sensation is associated with polymyalgia rheumatica five years after its onset and how is it diagnosed?
“Thoracic aortic aneurysm is a late complication of GCA; aortic aneurysms generally occur an average of 6–7 years after the initial diagnosis of GCA. Thoracic aortic aneurysms occur 17 times more often in patients with GCA when compared to the general population. The diagnosis of thoracic aortic aneurysm is confirmed by CT scan of the chest”
In the patient with suspected gonococcal arthritis how often is gonococcus aspirated and cultured from joint fluid?
“Gonococcus is cultured from the joint fluid only about 50% of the time in patients with gonococcal arthritis. Thus, a PCR of the joint fluid and urethral cultures should be done if the Gram stain is negative”
The patient has a hot knee most likely from a joint infection. What is the recommended treatment?
“In order to ensure the best outcome, this patient should be admitted for monitoring and repeated joint aspiration. Purulent fluid tends to collect rapidly in the joint spaces in patients with septic arthritis, necessitating frequent drainage until antibiotics work and inflammation begins to subside. Most cases of gonococcal arthritis respond to needle aspiration, but arthroscopic or open debridement is occasionally necessary. Because IV antibiotics have good penetration into synovial fluid, intra-articular antibiotics are not recommended. When culture, PCR, and sensitivity results become available, antibiotic therapy should be tailored to the sensitivities”
The patient has gonococcal joint infection what is the antibiotic regimen of choice?
“The initial antibiotic of choice in gonococcal arthritis is ceftriaxone, administered IV. In cases in which drug allergies or other contraindications prohibit the use of ceftriaxone, IV spectinomycin is an acceptable alternative. Remember that there is now fluoroquinolone-resistant gonococcus. Because of this, fluoroquinolones are no longer recommended as treatment of gonorrhea”
What is the treatment for gonococcal infection with suspected chlamydia too,.?
“cefixime 400 mg PO BID and doxycycline 100 mg b.i.d. for 7 to 14 days.
What kinds of joints does septic arthritis occur in and what are the predisposing factors?
“Septic arthritis occurs most often in large joints, such as the knee and hip. Factors that predispose a patient to septic arthritis include advancing age (especially >80 years), rheumatoid arthritis, joint prostheses, recent joint surgery, diabetes, and skin infection”
What is the mortality rate of septic arthritis?
“The mortality rate of septic arthritis is 10%, with up to one-third of survivors having persistent joint problems, such as limited range of motion, pain, and swelling. Note that the mortality is probably not due to the infection alone but rather to a combination of the underlying illness (e.g., immunosuppression) plus the infection.”
