Rheumatology Flashcards
Gout: acute and chronic management
Acute
1) NSAIDs
2. Corticosteroid injection (use when no response to NSAIDS or can’t use 2/2 renal insufficiency)
3) Colchicine (SE: Bone marrow suppression, diarrhea)
Chronic
1) Diet: exercise, no alcohol, no meat/seafood
2) Stop thiazides, lasix, asprin, Anti-TB (PE), niacin (use losartan first for HTN)
3) Colchicine: prevents your 2nd attack
4) Allopurinol: decreases uric acid production. If C/I use Febuxostat (both are xanthine oxidase inhibitors)
5) Pegloticase: dissolves uric acid, increases uric acid metabolism
6) Probenecid and sulfinpyrazone: increase excretion in kidney (uricosuric)
note: for renal injury avoid NSAID, probenecid, sulfinpyrazone. Allopurinol is safe in renal injury
“Pseudogout”: Risk Factors and Associated with
Risk Factors:
Hemochromatosis
Hyperparathyroidism
Associated with:
Diabetes
Hypothyroidism
Wilson Disease
“Pseudogout”: what joints get hit first
large joints: knee or wrist
DIP and PIP are NOT affected
“Pseudogout”: treatment
1) NSAIDs
2) Corticosteroid injection (use when no response to NSAIDS or can’t use 2/2 renal insufficiency)
3) Colchicine prevents next attack (SE: Bone marrow suppression, diarrhea)
Epidural Abscess: treatment for MRSA, MSSA, Acute neurologic defects
MRSA: Vanc, Linezolid
MSSA: Oxacillin, Nafcillin, Cefazolin
Acute Neuro Defects: Systemic glucocorticoids
Motor Deficit, reflex lost, sensory lost
L4
L5
S1
L4: dorsiflexion foot, knee jerk, inner calf
L5: dorsiflexion toe, none, inner foot
S1: eversion of foot, ankle jerk, outer foot
systemic signs A/W: Sjogren
dry eyes (sicca) parotid enlargement
Polyarticular symmetric:
RA
SLE
Viral: EBV, HepB, Parvo B19
Monoarticular
OA
Septic Arthritis
Gout
Migratory
Lyme
GC
Rheumatic Fever
Oligoarticular Asymmetric
Spondyloarthropathies
- Ankylosing spondylitis: bamboo spine, uveitis, aortiis –> aortic regurg
- Reiter syndrome
- Psoriatic Arthritis
OA
Contraindications to Joint Aspiration
- Cellulitis (overlying)
- Bleeding Diathesis: patient has a high INR, on warfarin, etc.
Diseases with +RF
RA
Subacute Endocarditis
TB
Osteomyelitis
p-ANCA
PAN
Churg-Strauss
IBD
c-ANCA
Wegener’s
Antiphospholipid Abs: findings
- lupus anticoagulant
- Anticardiolipin Abs
- Increased PTT (lab phenomenon)
- false +VDRL
- Hypercoagulable: presents with arterial and venous thrombosis
- spontaneous abortions
4H’s of Pseudogout
MC elderly >50yo, pre-existing joint damage
- hemochromatosis
- hyperparathyroidsim
- hypophosphatasia
- hypomagnesemia
RA: diagnostic criteria
- Morning stiffness >1hr for 6wks
- swelling wrists, MCP, PIP for 6wks
- Swelling 3 joints for 6 weeks
- Symmetric joint swelling for 6 weeks
- Joint erosions on X-Rays
- RF+
- Rheumatoid nodules
Felty Syndrome
RA
Splenomegaly
Neutropenia
Caplan Syndrome
RA
Pneumoconiosis (coal miners lung)
Lung Nodules
MC cause of death in RA
Coronary Artery Disease (CAD)
MTX: S/E
- Liver Toxicity
- Bone Marrow suppression
- Pulmonary toxicity
need CBC and Liver panel every 3mo for 1st year
R/A DMARDs Treatment and S/E
1) MTX (lung, liver, BM)
2) TNFi (TB, PPD)
3) Rituximab (CD20+, infections)
4) Hydroxychloroquine (monotherapy, retinal toxicity
5) Sulfasalazine (Rash, hemolysis G6PD, BM)
Specific Ab’s for lupus
Anti-DS DNA
Anti-SM
Dx a SLE flare by finding
C3, C4 decreased
DS DNA elevated
Scleroderma vs. CREST (say abbreviation)
CREST: Calcinosis Raynaud Esophageal dysmotility Sclerodactyly Telangiectasia
Scleroderma: also involves lungs, heart, kidney (sudden hypertensive crisis)
Scleroderma: Most-specific test
SCL-70 (anti-topoisomerase)
Scleroderma: treatment
MTX
Renal crisis: ACE inhibitor (even if high Cr)
Esophageal dysmotility: PPI for GERD
Raynaud: CCB
Pulm Fibrosis: Cyclophosphamide
Pulm HTN: bosentan, sildenafil, prostacyclin analogs
Polymyositis/Dermatomyositis:
- Best initial Test:
- Most accurate:
- Best initial Test: CPK, aldolase
- Most accurate: muscle biopsy
Note: Anti-Jo Ab a/w lung fibrosis
Polymyositis/Dermatomyositis: Tx
Steroids, but if steroids don’t work
- MTX
- Azathioprine
- IVIG
- Mycophenolate
- Hydroxychloroquine helps skin lesions
Polymyositis/Dermatomyositis: Presentation
- proximal muscle weakness: difficulty getting up from seated position or walking up stairs
- Malar
- Shawl sign
- Heliotrope rash
- Gottron papules: PIP and MCP
- CA: ovary, lung, GI, lymphoma
Sjogren Syndrome:
- best initial test:
- best initial blood test:
- most accurate test:
- best initial therapy:
Sjogren Syndrome:
- best initial test: Schrimer test
- best initial blood test: SS-A and SS-B
- most accurate test: lip or parotid biopsy
- best initial therapy: water the mouth
need to evaluate for lymphoma
Behcet Syndrome
-What is “pathergy”:
-sterile skin pustules from minor trauma like needle stick
Behcet Syndrome:
presentation
treatment
Presentation:
- Asian or middle-eastern person
- painful oral and genital ulcers
- erythema nodosum-like skin lesions
- ocular lesions –> uveitis, blindness
- Arthritis
- CNS lesions mimicking MS
tx: steroids
Cryoglobuliinemia
- presentation
- a/w
- treatment
- presentation: palpable purpura, proteinuria, hematuria, arthralgia, hepatosplenomegaly, hypocomplementemia
- A/W: Hep C –> decreased C4
- Tx: Interferon, ribavirin, telaprevir or boceprevir
steroids are NOT effective
Lab tests: +RF, cold precipitable immune complexes
Churg-Strauss:
- presentation
- most accurate test
- treatment:
- presentation: asthma, eosinophilia
- most accurate test: biopsy
- treatment: prednisone, cyclophosphamide
Anklyosing Spondlyitis:
- best initial test:
- Most accurate test:
- Treatment
- best initial test: X-Ray sacroiliac joint
- Most accurate test: MRI
- Treatment: NSAIDs, exercise –> anti-TNF drugs
Psoriatic Arthritis
- best initial test
- treatment
- best initial test: X-ray of joint, pencil-in-cup
- Tx: NSAIDs –> MTX –> Anti-TNF
STEROIDS ARE WRONG
Reactive Arthritis
- Cause
- Test:
- Treatment:
- Cause: IBD, STD, GI infection (Yersinia, Salmonella, Camp)
- Test: none, tap joint to r/o septic joint
- Treatment: NSAIDs –> Sulfasalazine
Osteoporosis
- Most accurate
- T-score
- Treatment
- Most accurate: DEXA
- T-score: +2.5 SD
- Treatment: Vit D, Ca, Bisphosphonates, ERT, Raloxifene, Teriparatide,Calcitonin
Septic Arthritis
- best initial and most accurate test:
- best initial empiric therapy:
- treatment for prosthetic joint:
- best initial and most accurate test: arthrocentesis
- best initial empiric therapy: Ceftriaxone, Vanc
- treatment for prosthetic joint: remove joint, Rx ABX 6wks, replace joint
