Rheumatology (5-10%) Complete Flashcards
Synovial fluid analysis for arthritis:
1. White Cell count in non-inflammatory arthritis?
- White Cell count in inflammatory/crystal?
- White Cell count in Septic arthritis?
- Less than or equal to 2000
- 10,000 to 100,000
- If greater than 50,000 keep septic arthritis high on the differential and treat it as septic arthritis until proven otherwise
Rheumatoid Arthritis
• Tender, swollen, ________ small joints (MCPs, PIPs, wrists)
• ________ weeks of arthritis
• Rheumatoid factor
Ø ________% RA are RF negative
Ø DDx – Other CTD, Hepatitis C/cryoglobulinemia, Endocarditis, Malignancy (B cell neoplasms most common), age, normal variation
• Anti-CCP
Ø ________ specificity, can precede arthritis, predicts ________
• Elevated ________, ________
• Do not need ________ or ________ for diagnosis, especially with early disease
Rheumatoid Arthritis
• Tender, swollen, symmetric small joints (MCPs, PIPs, wrists)
• >6 weeks of arthritis
• Rheumatoid factor
Ø 25% RA are RF negative
Ø DDx – Other CTD, Hepatitis C/cryoglobulinemia, Endocarditis, Malignancy (B cell neoplasms most common), age, normal variation
• Anti-CCP
Ø 95% specificity, can precede arthritis, predicts more erosive disease
• Elevated CRP, ESR
• Do not need serology or X-rays for diagnosis, especially with early disease
RA extra-articular manifestations MUST KNOW
Cardiac:
1. _______________
Lung
1. _______________
2. _______________• (rule out ______, can mimic _________)
Hematologic
1. _______________ syndrome = _______________ +
_______________ + _______________
Neurologic
1. _______________
2. _______________ = life-threatening
RA extra-articular manifestations
Cardiac
• Accelerated atherosclerosis
Lung
• Interstitial lung disease (NSIP, UIP)
• Pleural effusion (rule out infection, can mimic empyema)
Hematologic
• Felty’s syndrome = Seropositive RA + splenomegaly + neutropenia
Neurologic
• Carpal tunnel syndrome (one of the earliest signs of RA)
• C1-C2 instability/subluxation = life-threatening
(pre-op oral scenario)
RA Management: “Bridge” Therapy/Symptomatic Treatment (NOT disease modifying):
1. __________
2. __________
3. __________
- Steroids (PO, IM, IA) ≦ 3 months – use the lowest dose for the shortest possible time
- NSAIDs
- Analgesics
RA Management: Long-Term Therapy (Disease modifying)
• Step 1: ______________
• Low disease activity: ______________
• Moderate to high disease activity: ______________
• Step 2: ______________
• Use when failed ______________
• Usually start with ______________ and continue ______________
• Change medication classes to alternate ______________ if not at the target
• Dose can be reduced in patients with low disease activity or remission for ______________ months
• Step 1: Conventional DMARD
• Low disease activity: Hydroxychloroquine
• Moderate to high disease activity: MTX monotherapy (oral > subcut)
• Note: Triple therapy (MTX + PLQ + SFZ) no longer recommended as a preferred strategy
• Step 2: Biologic or Small Molecule
• Use when failed MTX monotherapy (preferred over triple therapy)
• Usually start with TNF inhibitor and continue MTX
• Change medication classes to alternate biologic or small molecule if not at target
• Dose can be reduced in patients with low disease activity or remission for >6 months
Conventional DMARD side-effects and monitoring:
- Hydroxychloroquine?
Common side effects for Methotrexate (MTX), Leflunomide?, Sulfasalazine?
Other side effects for Methotrexate (MTX), Leflunomide?, Sulfasalazine?
- Hydroxychloroquine: retinal toxicity due to accumulative dose over time. - Baseline and annual ophthalmologic exam
Common side effects for Methotrexate (MTX), Leflunomide?, Sulfasalazine?
- Infection risk (new and activation of latent infection)
- GI side effects (nausea, vomiting, diarrhea, occasionally dyspepsia)
Other side effects for Methotrexate (MTX), Leflunomide?, Sulfasalazine?
Sulfasalazine? Rash and sulfa allergy
Methotrexate (MTX) and Leflunomide?
- Hepato-toxicity
- Cytopenias
- Teratogenicity (need to be stopped prior to planned conception)
Methotrexate in addition? Hypersensitivity pneumonitis
Management of low-dose MTX toxicity:
- Nausea, vomiting, diarrhea? How to manage?
- Stomatitis? How to manage?
- Hepatotoxicity, Rash, and cytopenias? How to manage?
- Pneumonitis? How to manage?
- Nausea, vomiting, diarrhea? How to manage?:
- Split dose (eg 10mg bid once weekly instead of 20mg po weekly)
- change from oral to subcutaneous injection
- Increase the dose of folic acid or add folinic acid/Leucovorin rescue - Stomatitis? How to manage?
- Same as above - Hepatotoxicity, Rash, and cytopenias? How to manage?
- Dose reduction
- If severe hold the medication reintroduce it back at a lower dose - Pneumonitis? How to manage?
- stop methotrexate and DONOT restart
How long should you treat latent TB before starting biological therapy?
Complete at least one month of treatment
Non-live vaccines and Rheumatology and Musculoskeletal disease patients on immunosuppression
Safe to give only Methotrexate and Rituximab have to be adjusted
Live vaccines and Rheumatology and Musculoskeletal disease patients on immunosuppression
Usually avoid
Rheumatoid arthritis and pregnancy:
Avoid?
Safe to use?
Breastfeeding:
Avoid?
Safe to use?
Rheumatoid arthritis and pregnancy:
Avoid? Methotrexate (MTX) and Leflunomide
Safe to use? Hydroxychloroquine and sulfasalazine
Breastfeeding:
Avoid? Methotrexate (MTX) and Leflunomide
Safe to use? Hydroxychloroquine and sulfasalazine
Male Pre-Conception and Methotrexate (MTX)?
MTX can be continued (previously recommended to hold)
Seronegative Arthropathies’ common features
Clinical?
_____ joint/_____ involvement
_______ joint
_____, _____, _____, _____
Skin:
Imaging?
HLA?
Clinical?
SI joint/Axial involvement
Peripheral joints
Enthesitis, dactylitis, uveitis, conjunctivitis
Skin: Erythema nodosum, Pyoderma gangrenosum
(IBD), Psoriatic skin, hair, and nail changes
Imaging?
Erosions, ankylosis periosteal new bone formation, and the fusion of the bones.
Joints: Peripheral joints, SI joints, Spine (Syndesmophytes)
HLA?
Often HLA B27 is positive but not diagnostic
Management of Seronegative Spondyloarthropathies: Axial Disease:
_________ first-line therapy
If failed then use _________
“We strongly recommend AGAINST treatment with _________ ”
If failed again then: _________
– NSAIDs are first-line therapy
If failed then use a second NSAID
• “We strongly recommend AGAINST treatment with systemic glucocorticoids”
If failed again then: BIOLOGICS/SMALL MOLECULE
• 1st line = TNF-α inhibitors: Etanercept (Enbrel), Infliximab (Remicade), Adalimumab
(Humira), Certulizumab (Cimzia), Golimumab (Simponi) or biosimilars
– If primary non-response -> progress to IL-17
– If secondary non-response (relapse after the initial response) -> change to alternate anti-TNF
• 2nd line = IL-17 inhibitors: Secukinumab (Cosentyx), Ixekizumab (Taltz)
• 3rd line = JAK inhibitor: Tofacitinib (Xeljanz)
Management of Seronegative Spondyloarthropathies: Peripheral Disease
_________ first-line therapy
If failed then _________?
If failed then _________?
NSAIDs first-line therapy
If failed then?
– CONVENTIONAL DMARDS: Methotrexate, Sulfasalazine, [Leflunomide, Cyclosporine, Apremilast in PsA]
CONVENTIONAL DMARDS Only in Peripheral disease
If failed then?
– BIOLOGICS/SMALL MOLECULES
Reactive Arthritis
• Occurs several days to ~4 weeks following __________ or __________
• Typically __________, mono- or oligoarthritis, __________ extremity predominant
• Can develop inflammatory back pain and sacroiliitis
• Causative agents: __________
• Eye (50-75%): __________, __________
• Reactive arthritis can recur/become chronic (>6mo)
Treatment:
• __________, __________
• Consider __________ in recurrent/chronic disease
• No role for __________
Reactive Arthritis
• Occurs several days to ~4 weeks following gastroenteritis or urethritis
• Typically asymmetric, mono- or oligoarthritis, lower extremity predominant
• Can develop inflammatory back pain and sacroiliitis
• Causative agents: C.trachomatis, Yersinia, Salmonella, Shigella& Campylobacter
• Eye (50-75%): Uveitis, conjunctivitis
• Reactive arthritis can recur/become chronic (>6mo)
Treatment:
• NSAIDs, intra-articular corticosteroids
• Consider DMARDs in recurrent/chronic disease, e.g. MTX, sulfasalazine; rarely TNFi
• No role for antibiotics (unless evidence of active infection)
Septic Arthritis:
Most common organism for both native and prosthetic joints?
__________ #1 in osteomyelitis and septic arthritis in Sickle Cell Disease
Definitive Management?
Dosage of Ceftriaxone in septic arthritis?
S. aureus #1 in both native and prosthetic joints
Salmonella #1 in osteomyelitis and septic arthritis in Sickle Cell Disease
Definitive management requires source control (Orthopedics joint washout and antibiotics)
Dosage of Ceftriaxone in septic arthritis? Ceftriaxone 2 g IV every 24 hours
Gonococcal Arthritis: Presentation
2 common syndromes:
1. Triad of __________, __________, __________ without
__________
- __________ without __________
2 common syndromes:
- Triad of tenosynovitis, vesiculopustular skin
lesions, migratory polyarthralgia without
purulent arthritis - Purulent arthritis without skin lesions –> requires
a longer course of antibiotics
Gonococcal Arthritis: Treatment
– Ceftriaxone
– Check Urine NAAT for Chlamydia and treat if positive (or tx empirically if delays to diagnosis or concern of compliance with follow-up)
• Doxycycline 100mg PO bid x 7 d, or single dose azithromycin
DO NOT ALWAYS CO-TREAT AS BEFORE: NEW GUIDELINES
Lyme Arthritis: Treatment?
Oral antibiotics x 28 days (doxycycline or Amoxil)
Crystals:
GOUT CRYSTALS (- birefringence):
YELLOW when parallel to polarized light
Crystals:
CPPD CRYSTALS (+ birefringence)
BLUE when parallel to polarized light
SLE Classification Criteria:
Entry Criterion?
Entry Criterion: ANA titre ≧ 1:80
High Yield Vasculitis Overview
Antibiotic summary
