Rheumatology Flashcards
What are extra-articular manifestations which may be seen in RA?
Pleural effusion Normocytic anemia Pericarditis/valvular disease Mononeuritis multiplex Rheumatoid skin nodules
What is the single most accurate test for RA?
Anti-CCP
What is Felty’s syndrome?
RA
Splenomegaly
Neutropenia
What spinal joint finding may be seen in RA which affects management of the airway?
C1-C2 subluxation
Check for before intubating if you can
Baker’s cyst may be assd with what condition?
RA
What are adverse effects of MTX?
Pneumonitis, Liver toxicity, BM suppression
For what severity level of disease is hydroxychloroquine used in RA? What should patients routinely followup with if on this drug?
For mild disease
Eye exams to look for retinopathy
What is Anakinra?
IL-1 receptor antagonist
What is Tocilizumab?
IL-6 receptor antagonist
What is Leflunomide?
Folate antagonist similar to MTX but less toxic
What is Abatacept?
Inhibits T-cell activation
When are steroids the answer in RA?
For acute disease to control the inflammation and be a bridge to DMARD therapy
Are the seronegative spondyloarthropathies positive for rheumatoid factor?
No
When is the pain worse in AS? What relieves it, positionally?
Worse at night
Flexion relieves
What are rare associated findings with AS?
Aortitis
Uveitis
Restrictive lung disease
What are treatment options for AS?
NSAIDs
Biologics
Sulfasalazine
*Steroids are NOT used
How does reactive arthritis present?
Tx?
Monoarticular arthritis Hx urethritis or GI infection Fever, fatigue, weight loss Genital lesions (circante balantis - around head of penis) Keratoderma blenorrhagicum
Tx: NSAIDs
How does psoriatic arthritis present?
Joint pain in setting of psoriasis
Nail pitting
Dacylitis (“sausage fingers”)
Enthesitis: inflammation at tendonal insertion sites
DIP involvement
What is the best initial therapy for psoriatic arthritis?
What other agents are used in resistant cases?
NSAIDs
If resistant or need additional control, MTX and/or anti-TNF agents
Why do patients test positive for TB when placed on anti-TNF drugs?
TNF helps maintain granulomas which encase TB. Giving anti-TNF drugs allows the granulomas to be “leakier” and cause TB to release
What presents with fever salmon-colored rash, polyarthritis, lymphadenopathy, and myalgias?
Juvenille RA (AKA adult-onset Still’s disease)
*May also have hepatosplenomegaly and elevated transaminases
What are essential labs to making the diagnosis of juvenille RA?
Very high ferritin
Leukocytosis
Negative ANA and RF are critical to making dx
What is tx of juvenille RA?
NSAIDs
If unresponsive can consider giving steroids, if they continue to persist then may give MTX or anti-TNF agents
What is the most common presentation of Whipple’s disease?
Joint pain actually
Of course it can present with diarrhea, fat malabsorption, and weight loss
Tx is TMP/SMX
What is the best initial test for OA?
X-ray of joint
*Of course order ESR, CBC, ANA, RF, anti-CCP to rule out RA
Is glucoasamine helpful in OA?
It is not clearly established so it can’t be recommended. It is basically a placebo
What is the best initial test for SLE?
Most accurate?
Initial: ANA
Accurate: Anti-dsDNA; anti-Smith a bit less accurate
What tests would you order if looking for an SLE flair up and what happens to those tests?
Anti-dsDNA will increase in flair
Complement levels will decrease in flair
What does the presence of anti-Ro or anti-SSA in pregnant woman put the fetus at risk for?
Heart block
Does lupus cause destruction of the synovium when causing joint pain?
No
How is an SLE flaire up treated?
Prednisone
How is SLE joint pain managed? What if resistant to the aforementioned?
NSAIDs
Add hydroxychloroquine if not responding to above
If there is severe disease relapse when steroids stopped in SLE what is appropriate treatment?
Belimumab, azathioprine, cyclophosphamide
How is lupus nephritis managed?
Steroids and mycophenolate
What are the most common causes of drug-induced lupus?
Hydralazine
INH
Procainamide
What is positive in drug-induced lupus?
Anti-histone antibodies
What is the most accurate test for Sjogrens Syndrome?
Lip biopsy
What is Schiermer’s test and what is it used for?
Shows reduced lacrimation from eye when a piece of paper is held near the eye
Sjogrens
What are specific Abs for Sjogrens?
Anti-Ro (SSA)
Anti-La (SSB)
What are appropriate treatments for Sjogrens?
Keep eyes and mouth moist
Pilocarpine and cevimeline both may increase ACh
What are the main symptoms of scleroderma?
Skin “tightness”
Raynaud’s
Joint pain
(additional symptoms in CREST)
In diffuse scleroderma what is the leading cause of death?
Fibrosis and pulmonary HTN
What Ab is fairly useful in diagnosing in scleroderma?
Anti-Scl70 (topoisomerase)
Scleroderma does not have many broadly useful treatments. What are specific treatments used in situations with each of the following symptoms:
Renal involvement/HTN: Pulm HTN: Raynaud's: GERD: Lung Fibrosis:
Renal involvement/HTN: ACEi Pulm HTN: Bosentan (endothelin antagonist), prostacyclin analogs (e.g. epoprostenol), sildenafil Raynaud's: CCB GERD: PPIs Lung fibrosis: cyclophosphamide
What does CREST stand for?
Calcinosis Raynauds Esophageal dysmotility Sclerodactyly Telangiectasias
Differently than scleroderma, CREST has what Ab positive often?
Anti-centromere
What disease may mimic the skin findings of scleroderma?
What will the skin look like?
What is appropriate tx?
Eosinophillic fascitis
p’eau d’orange (thickened and orange); symptoms worse with exercise
Steroids
CPK and aldolase are elevated in which autoimmune disease?
Polymyositis and dermatomyositis
Anti-Jo1 is seen in …..
What may it confer?
Polymyositis and dermatomyositis
It’s presence indicates greater risk of interstitial lung disease
Tx of PM/DM
Glucocorticoids
What are appropriate therapies for fibromyalgia?
Exercise
Milnacriptan (SNRI), duloextine, or pregabalin (best initial)
TCAs can be used but have more side effects
Patient presents with profound pain of proximal muscles in setting of normal CPK, aldolase, EMG, and even muscle biopsy. But ESR is elevated. Dx and tx?
Polymyalgia rheumatica
Steroids
What is one difference between chronic fatigue syndrome and fibromyalgia?
CFS patients have much more fatigue and fail to have trigger points on exam
No real effective treatment
What are the best initial therapies for vasculitis?
Prednisone and gluococorticoids
What is the best initial test for diagnosing polyarteritis nodosa?
What is the most accurate test?
Initial: Abdominal angiography
Accurate: biopsy of appropriate tissue (e.g. sural nerve)
Tx for PAN
Prednisone and cyclophosphamide
Vasculitis + eosinophillia + asthma =
Churg-Strauss Syndrome
*pANCA positive but don’t rely on this
Young asian female comes in with diminished pulses. What is on the top of your differential?
Takayasu’s arteritis
Takayasu’s arteritis has unique vascular complications compared to some of the other vasculitidies. What are they?
Unlike other vasculitidies it is diagnosed differently, how?
TIA and stroke
Aortic arteriography or MRA
*Tx is steroids
What is treatment of cryoglobulinemia?
Interferon and ribavirin
What is the classic presentation of Behcet’s disease?
Often middle eastern or asian
Oral and genital ulcers Ocular involvement (e.g. uveitis, optic neuritis) Skin lesions (hypersensitivity to needle sticks) leading to sterile skin abscesses
What is tx for Behcet’s disease?
Prednisone
Colchicines (microtubule inhibitors)
What is the normal WBC count of synovial fluid?
How many seen in inflammatory conditions?
Infectious conditions?
NL: 50000
What drugs may precipitate gouty attacks?
Thiazides
Nicotinic acid
Also binge drinking and large meat intake
What is seen on polarized light exam for gout?
Negatively birefringent needles
What is seen on polarized light exam of pseudogout?
Positively refringent rhomboid-shaped crystals
What are vital examinations to conduct on CCS when given a patient case of gout?
Joint exam
Joint fluid examination (cell count, culture, protein level)
Serum uric acid (don’t overly rely on)
Xray of toe
What is the first medication you should try giving for acute gout?
What is next?
What is another commonly used agent if there are reasons not to use the above?
First: NSAIDs
Second: Steroids
If reason not to give the above then give colchicine
What is a key medication as part of preventive therapy for gout?
Colchicine
What are adverse effects of colchicine?
Nausea and vomiting
BM suppression
What are good meds to use for long-term prevention of chronic gout?
Allopurinol
Febuxostat
Uricase (if the above two are not enough)
*Also advise to avoid alcohol and lose weight
What are adverse effects of allopurinol?
Rash
Allergic interstitial nephritis
Hemolysis
At what joints does pseudogout often present?
What is appropriate tx?
Usually not the toe. Usually at the knees and wrist
Tx: NSAIDs or steroids. Colchicine is not as effective here
What are the most common pathogens causing septic arthrits?
What team should be consulted on CCS for a case of septic arthritis?
Commonly S. aureus, Streptococcus, Gram negative bacilli
Consult ortho
What is empiric therapy for septic arthrits?
IV ceftriaxone and vancomycin
Between Paget’s disease and prostate cancer mets which one presents with osteoblastic and which with osteoclastic lesions?
Paget’s: osteoclastic
Prostate cancer mets: osteoblastic
What is the best initial test for Paget’s disease of bone?
Most accurate?
Initial: ALP
Accurate: X-ray
What labs should be ordered when evaluating for Paget’s disease of bone?
Urinary hydroxyproline
Serum calcium
Serum phosphate
Bone scan
How do you want to treat Paget’s disease of bone?
Bisphosphonates (inhibits bone resroption) and calcitonin (promotes osteoblastic activity and lowers serum calcium)
Patient presents with OA (or RA) and has a swollen calf. What is one thing you suspect?
Baker’s cyst (posterior herniation of synovium of knee)
What is diagnostic testing used for a Baker’s cyst?
Ultrasound of lower leg to r/o DVT
How can you distinguish plantar fascitis and tarsal tunnel syndrome?
Tarsal tunnel syndrome gets worse with continued activity and may require surgical release (kind of like carpal tunnel syndrome)
What is a Morton neuroma?
Painful burning sensation in web space between 3rd and 4th toes. May present as a sharp, radiating pain into the toes which improves when shoes are taken off
