Rheumatology Flashcards
Fibromyalgia treatment
Best initial- amitryptyline
Other treatments- milnacipran (serotonin and norepinephrine uptake
inhibitor), pregabalin
Fibromyalgia diagnosis
Clinical
Causes of carpal tunnel syndrome
Pregnancy Diabetes RA Acromegaly Amyloidosis Hypothyroidism
Nerve involved in carpal tunnel syndrome
Most commonly median nerve
Diagnosis of carpal tunnel syndrome
Mostly clinical to confirm
-Tinel sign: pain with tapping of median nerve
-Phalen sign: pain with flex ion of wrist to 90 degrees
Most accurate test: electromyography and nerve conduction testing.
Carpal tunnel treatment
Best initial: wrist splints
First line medical therapy: NSAIDs
If no response to NSAIDs, use STEROID injections
LAST RESORT: surgery
What is Dupuytren contracture?
Nodule formation and contracture of the forth and fifth fingers.
Associated with alcoholism and cirrhosis
Patients lose ability to extend their fingers
Dupuytren contracture treatment
Triamcinolone
Lidocaine
Collagenase injections- helpful in early stages
Rotator cuff injury diagnosis
Mostly clinical-inability to flex or abduct shoulder
Most accurate: MRI- tear of primal end of long head of bicep tendon
Treatment of rotator cuff injury
Best initial: NSAIDs, rest and PT.
If above fails: STEROID injections
SURGERY for complete tears and those not responding to the above
Patellofemoral syndrome
Anterior knee pain secondary to trauma, imbalance of quadriceps strength, or meniscus tear.
Pain is in front of the knee and under the patella
Symptoms worse walking just after having been seated for a long time
PE: crepitus, joint locking, instability
Diagnosis and treatment of patella femoral syndrome
DX: X-ray are normal
Tx: physical therapy, strength training with cycling
Diagnostic tests for RA
Rheumatoid factor ( nonspecific) Anti-CCP - most specific Radiographs: erosive joints, osteopenia Diagnosis is based on point system: 6 or more points needed -joint involvement (up to 5 points) -ESR or CRP (1 point) -duration longer than 6 weeks (1 point) -RF or anti-CCP (1 point)
What is the most common cause of death in RA patients?
Coronary artery disease
A patient with long standing RA is having a coronary bypass surgery. Which of the following is the most important prior to surgery? A. Cervical spine X-ray B. Rheumatoid factor C. Extra dose of methotrexate D. ESR E. Pneumococcal vaccination
A. Cervical spine X-ray
RA is associated with C1/C2 subluxation. Cervical spine imaging to detect possible instability of thr vertebra is essential prior to the hyperextension of the neck that typically occurs with endotracheal intubation.
RA treatment
Best initial DMARD: methotrexate
Tumor necrosis factor inhibitors -1st line if no response to MTX
- infliximab, adalimumab, etanercept
Rituximab (removes CD20 positive lymphocytes from circulation)
- used in combination with MTX if no response to TNF agents
Hydroxychloroquine- mild disease. Used in combination with MTX
Sulfasalazine, leflunomide, abatacept- combined with MTX
Symptomatic and pain control: NSAIDs and steroids
Methotrexate- folate antagonist
Toxicity?
Liver toxicity
Bone marrow suppression
Pulmonary toxicity
Folic acid supplements required
TNF alpha toxicity
Reactivation of TB: screen with a PPD prior to their use
Infection
Hydroxychloroquine toxicity
Retinal toxicity
Sulfasalazine toxicity
Bone marrow toxicity
Hemolysis with G6PD deficiency
Rash
Juvenile rheumatoid arthritis treatment
Best initial: aspirin or NSAIDs
If no response to either, STEROIDS
If fails: TNF drugs
What 2 changes are seen in acute lupus flare?
Complement levels drop and anti-DS DNA levels rise
Treatment of acute lupus flare
Bolus of STEROIDS
When is kidney biopsy recommended in lupus patients?
If patients present with anti double-stranded DNA
Lupus treatment mostly recommended for skin and joint manifestations
Hydroxychloroquine
Drug that controls progression of lupus
Belimumab
Treatment of lupus NEPHRITIS
Steroids + Cyclophosphamide/mycophenolate
Hydroxychloroquine toxicity
Retinal toxicity therefore need eye exams every 6 months
Most common cause of death in elderly SLE patients
MI due to accelerated atherosclerosis
Coagulation studied in Antiphospholipid syndrome
Elevated PTT
Normal: PT and INR
Is VDRL positive or negative in antiphospholipid syndrome
Usually false positive VDRL or RPR seen with normal FTA (distinguishes APS from syphillis)
Antibodies responsible for spontaneous abortions in antiphospholipid syndrome
Anticardiolipin antibody
Best initial test for antiphospholipid syndrome
mixing study-to distinguish between clotting factor deficiency and APL.
Patients plasma is mixed with an equal amount of normal plasma. In clotting factor deficiency, PTT will normalize after mixing study.
In APL, antibody present in the patients plasma will keep PTT elevated.
The mot specific test Lupus anticoagulant in APL
Russell viper venom test- prolonged with APL antibodies
Treatment of asymptomatic Antiphospholipid antibody syndrome
asymptomatic disease does not need to be treated
treatment of first thrombotic episode of APL syndorme
wrfarin and heparin with INR target of 2-3
treatment of recurrent thrombotic episdes
LIFELONG treatment of warfarin
treatment of recurrent spontaneous abortions due to APL syndrome
heparin and Aspirin
avoid warfarin and steroids!!!!
treatment of scleroderma that slows the process
methotrexate
scleroderma treatment
- renal crisis
- esophageal dysmotility
- raynauds
- pulmonary fibrosis
- pulmonary hypertension
-renal crisis:ACE inhibitor
-esophageal dysmotility: PPI
-Raynauds: CCB
-Pulmonary fibrosis: Cyclophosphamide- improves dyspnea and PFTs
-pulm HTN: Bosertan ambrisentan (endothelin antagonist), sildenafil,
postacyclin analog (ilopost, treprostinil, epoprostenol)
cancers associated with dermatomyositis
ovary
lung
GI
Lymphoma
best initial test of polymyositis and dermatomyositis
CPK and aldolase
most accurate test for polymyositis and dermatomyositis
muscle biopsy–> mononclear infiltrate surrounding necrotic and degenerating muscle fibers
antibodies associated with lung fibrosis in polymyositis and dermatomyositis
Anti- Jo antibodies
Labs associated with polymyositis and dermatomyositis
increase ESR/CRP/RF
treatment of polymyositis and dermatomyositis
STEROIDS -if unresponsive or intolerant: Methotrexate Azathioprine IVIG Mycophenolate Hydroxychloroquine- helps with skin lesions
most dangerous complication of sjogren syndome
Lymphoma
sjogren syndrome: best initial test
Schirmer test (measures the amount of tears)
sjogren syndrome: most accurate test
Lip or parotid gland biopsy ( lymphoid infiltration in the salivary gland)
sjogren syndrome: best initial blood test
SS-A and SS-B (Ro and La)
What disease is Rose bengal stain used to diagnose
Sjogren syndrome
- it shows abnormal corneal epithelium
Sjogren syndrome: treatment
drinking lots of water, use sugar free gum, and fluoride treatment.
Use artificial tears
Pilocarpine and cevimeline increases acetylcholine :
stimulates production of saliva
common presentation of all vasculitis
fever
malaise/fatigue
weight loss
arthralgia/myalgia
Polyarteritis Nodosa includes all organ systems EXCEPT
Lungs
PAN is associated with
Hepatitis B and C
2 neurologic features associated with PAN
- peroneal neuropathy leading to foot drop
- stroke in a young person
PAN: most accurate test
biopsy of a symptomatic site
What does angiography of a patient with PAN show
abnormal dilation or beading
PAN treatment
STEROIDS and CYCLOPHOSPHAMIDE
Polymyalgia rheumatica treatment
LOW dose STEROIDS
complication of temporal arteritis
Irreversible Blindness
Temporal arteritis: Labs
elevated ESR and CRP
Temporal arteritis: most accurate test
Temporal artery biopsy
Temporal arteritis: treatment
Steroids ( should be stated right away instead of waiting for biopsy confirmation)
Wegener Granulomatosis: best initial test
C-ANCA
wegener granulomatosis: most accurate test
Biopsy (most commonly lung)
Wegener granulamatosis: treatment
Steroids and Cyclophosphamide
Churg-stauss syndrome buzz words
Asthma and eosinophilia
Diagnosis and treatment of Churg-Stauss Syndrome
Dx: most accurate- Biopsy
Tx: steroids and cyclophosphamide
Henoch-Schonlein Purpura diagnosis and treatment
Dx: most accurate- biopsy (leukocytoclastic vasculitis)
Tx: Can resolve spontaneously
- Steroids for abdominal pain or progressive renal insufficiency
Cryglobulinemia is associated with what diseases
Most commonly with :Chronic Hepatitis C
Other diseases: endocarditis and Sjogren syndrome
cryglobulinemia treatment
Interferon
Ribavirin
Telaprevir
Boceprevir
Presentation of Behcet syndome
Painful oral and genital ulcers + skin lesions can also present with: -ocular finding -arthritis -CNS lesions
Behcet syndrome: “Pathergy”
Sterile skin pustules from minor trauma like a needle stick
Bachet syndrome treatment
STEROIDS
-to wean patients off of steroids, use: Azathioprine Cyclophosphamide Colchicine Thalidomide
Ankylosing spondylitis diagnosis: best initial and most accurate
Best initial test: X-ray of the sacroiliac joint.
Most accurate: MRI
Elevated ESR is seen in 85%
Ankylosing spondylitis treatment
Best initial: exercise and NSAIDs
If no response to above:
anti-TNF drugs (etanercept, adalimumab, infliximab)
Psoriatic arthritis diagnosis: best initial
best initial: X-ray (pencil in a cup)
Uric acid level is elevated form increased skin turnover!!!
Psoriatic arthritis treatment: best initial
Best initial: NSAIDs
No response to NSAIDs: Methotrexate
If no response to MTX: Anti-TNF agents are used
Skin lesion unique to reactive arthritis
Keratoderma blennorhagicum (looks like pustular psoriasis)
Reactive arthritis diagnosis
Mainly clinical (can't see, can't pee, can't climb a tree) -if hot swollen joint is present--> needs to tap to R/O septic joint
reactive arthritis treament
NSAIDs
If no response to NAIDS: Sulfasalazine
Steroid injections into the joint help!!!
Osteoporosis diagosis
Most accurate: DEXA scanning
Normal levels of: Calcium, phoshpate, PTH hormones
Osteoporosis treatment
Vitamin D and Calcium
Bisphophonates
Estrogen replacement (if postmenopausal)
Raloxifene (substitute for estrogen in posmenopausal)
Teriparatide (PTH analogue- stimulates new bone matrix formation)
Calcitonin nasal spray- decreases risk of vertebral fractures
Septic arthritis risk factors
Usually affects previously damaged joints: DJD, RA
Increased risk in endocarditis patients and IV drug users
Most common organism causing septic arthritis
STAPH
followed by strep and gram negative rods
Septic Arthritis diagnosis
Best initial and most accurate: aspiration of the joint
X-ray, CT and MRI are not useful
Joint fluid analysis in septic arthritis: Leukocytosis level
More than 50,000 to 100, 000
predominantly NEUTROPHILS
Septic arthritis treatment
Best initial: Ceftriaxone and vancomycin
Gram - bacilli: Quinolones, Aztreonam, Cefotaxime, Piperacillin,
Aminoglycosides
Sensitive Gram +: Ox/nafcillin, Cefazolin, Piperacillin + tazobactam
resistant Gram +: Linezolid, Daptomycin, Tigecycline, Ceftaroline
most common organism recently placed prosthetic joint
Staph Epidermidis
Management of prosthetic joint infection
Remove joint–> treat with antibiotics for 6-8 weeks–> replace joint
Presentation of Gonococcal Arthritis
Polyarticular involvement
tenosynovitis (inflammation of tendon sheaths)
petechial rash
Gonococcal arthritis diagnosis leukocytosis count
between 30,000-50,000
Gram stain and culture are not too sensitive
Gonococcal treatment
Ceftriaxone, cefotaxime, ceftizoxime
If recurrent gonorrhea infection occurs in a patient, what should be tested
Complement C5-C9 levels
osteomeylitis diagnosis: best initial and most accurate
Best initial test: X-ray (shows periosteal new bone formation)
Most accurate test: Biopsy
If X-ray is normal in osteomyelitis, the most appropriate next step in management is:
MRI
Bone scan is done if MRI is contraindicated
To follow response to therapy for osteomyelitis, check:
ESR level
Osteomyelitis treament
Check sensitivity after biopsy results return
sensitive Staph: Ox/nafcillin, cefazolin, ceftriaxone
resistant staph: vancomycin r linezolid
Gram - bacilli (E.coli)- Qinolones(cipro)
