Rheumatology

Question 1

RA

1. what is most accurate test
2. what joint is spared in RA
3. what do you need to check before starting mAb
4. role of steroids

Answer 1

1. RF is nonspecific
anti-CCP is >95% specific 
2.SI joint 
3. NSAIDS and DMARDS
1st: MTX 
2nd: if MTX fails add TNF antag: infliximab, adalimumab, cetrolizumab, etanercept

• hydroxychloroquine for mid RA

3. Hep B and Tb
4. use acutely as bridge to DMARDs. don’t use long term

Question 2

AE

1. MTX
2. hydroxychloroquince

Answer 2

1. BM suppression, pneumonitits, liver dx

2. retinopathy (eye exams)

Question 3

what do the following all have in common?

1. Ankylosing Spondylitis
2. Reactive Arthritis (aka reiters)
3. Psoriatic Arthritis
4. Juvenile rheumatoid Arthritis

Answer 3

they’re all inflammatory arthritic conditions that are RF negative, have predilection for the spine, involve SI joint and are associated with HLA-B27

1. Ankylosing Spondylitis
   presentation: young, male pt with spine/back stiffness. pm pain worse. relief when leaning forward. can lead to kyphosis and diminished chest expansion. rare: uveitis, aortitis, restrictive lung disease

diag: MRI spine with attn. to SI joint
treatment: NSAIDs, infliximab/adalimumab
NO STEROIDS

2. Reactive Arthritis
   presentation: symmetric arthritis with hx of urethritis/cervicitis or GI infection. +/- fever, fatigue, weight loss, penile head lesion, conjunctivitis, skin lesion

diag. can’t see, can’t pee, can’t climb a tree & hx of chlamydia, shigella, Yersinia, salmonells, campylobacter
treatment: NSAIDs

3. Psoriatic Arthritis
   presentation: joint involvement + hx of psoriasis, dactylitis, DIP involvement, nail pitting, enthesitis
   no diag test
   treat: NSAIDs first, if fails then anti-TNF agents
4. Juvenile rheumatoid Arthritis
   presentation: salmon colored rash, fever, polyarteritis, myalgias, lymphadenopathy. sometimes high LFTs and hepatosplenomegaly
   diag: super high ferritin, high WBC, RF (-), ANA (-)
   treatment: NSAIDS, if fails then steroid bridge to MTX or anti-TNF agents

Question 4

Whipple dx

Answer 4

presents with diarrhea, fat malabsorption, weight loss, joint pain.
bowel biopsy with PCR shows PAS+
treat with TMX-SMX

Question 5

SLE

1. what is best test to follow the severity of a flare up
2. serology to check
3. treatment
4. drug induced-common drugs

Answer 5

1. complement levels drop during flare up
   anti-ds DNA rises during flare up
2. ANA, RF, anti-ds DNA, Anti-smith, anti-RO (fetal heart block), anti SSA, complement, ESR

anti-ds DNA and anti-SM specific for SLE. anti smith more specific.

3. acute flare up: prednisone
   joint pain: NSAIDs. hydroxychloroquine if NSAIDs fail
   severe: belimumab, cyclophosphamide, azathioprine

nephritis: steroids and MMF

4. hydralazine, INH, procainamide
   will have +ANA and +anti-histone antibodies
   NO RENAL or CNS involvement
   normal complement and anti-ds DNA levels

Question 6

Sjogrens Syndrome

1. presentation
2. diag
3. treatment

Answer 6

1. woman with dry mouth, dry eyes, sensation of sand under eyelids, poor sense of smell & taste
2. most accurate: lip biopsy
   schirmer test: decreased wetting of paper help to eye
   serology: ANA, RF, anti-Ro/SSA, Anti-La/SSB
3. treat by keeping eyes and mouth moist
   pilocarpine (everywhere) and cevimeline (salivary only) increase ACTH which increases oral and ocular secretions

Question 7

Scleroderma
Systemic
Diffuse

Answer 7

Systemic
ususally woman; skin (tight, fibrous, sclerodactyly,
Raynauds, mild and symmetric joint pain

Diffuse
lung: fibrosis, pulmonary HTN
heart: restrictive cardiomyopathy and premature CAD
renal: malignant HTN
GI: esophageal dysmotility, wide mouth colonic diverticula

diagnosis : no single test. look for + ANA, antiScl 70 (antitopoisomerase)

treatment: none will stop dx progression
renal: ACEI
pulmonary: bosetan, prostacyclin analogs, sildafenil
GI: PPIs
lung: cyclophosphamide
Raynauds: CCBs

Question 8

CREST

Answer 8

= limited scleroderma 
this form of scleroderma presents with 
Calcinosis of fingers
Raynauds
Esophageal dysmotility
Scleodactyly
Telangiectasia

anti-centromere antibodies more often than antiScl 70

doesn’t present with joint pain, heart/lung/kidney problems

Question 9

eosinophilic Fascitis

Answer 9

looks like scleroderma but its not
high eosinophils
treat with steroids

Question 10

Poly and Dermatomyositis
diag
significance of anti-Jo
what is most common serious complication

Answer 10

diag: abnormal EMG, high aldolase, high CPK
muscle biopsy is most accurate

anti-Jo-1 indicates higher risk of interstitial lung dx

malignancy is most common serious complication

treat with steroids

Question 11

fibromyalgia

treatment

Answer 11

exercise
milnacipran, duloxetine, pregabalin
tricyclic antidepressants work but more side effects

Question 12

Polymyalgia Rheumatica

presentation

Answer 12

women>50 lots of pain and stiffness of proximal MUSCLES! more pain than weakness! pain of muscles not joints

diag: high ESR
normal CPK, aldolase, EMG, muscle biopsy

treat with steroids

Question 13

Vasculitis

treatment

Answer 13

steroids

if fail, then cyclophosphamide, azathioprine/6MP, MTX

Question 14

Polyarteritis Nodosa

Answer 14

same stuff as vasculitis but following is different:

abdominal pain, pericarditis, HTN, renal involvement, testicular involvement

diag: angiography of abdominal vessels
most accurate skin/muscle/sural nerve biopsy

treatment :prednisone and cyclophosphamide

Question 15

Granulomatosis with Polyangitis

Answer 15

vasculitis + upper & lower respiratory findings
+C-ANCA
treat with prednisone and cyclophosphamide

Question 16

Allergic Angitis (Churg Strauss)

Answer 16

vasculitis + eosinophilia + asthma
biopsy
treatment: steroids

Question 17

Temporal Arteritis

Answer 17

is a type of Giant Cell Arteritis
if suspect –>steroids
don’t wait on biopsy results

Question 18

Takayasu Arteritis

Answer 18

young Asian female + diminished pulses

some patients will have vasculitis

risk TIA & stroke

diag AORTIC ARTERIOGRAPHY OR MRA
NOT BIOPSY

treat with steroids

Question 19

Cryoglobulinemia

Answer 19

vasculitis symptoms (skin lesions, malaise, joint pain, fatigue) + association with Hep C and renal involvement

treat Hep C and if cryo is severe add rituximab

Question 20

Behcet

Answer 20

middle eastern or Asian
oral/genital ulcers
ocular involvement 
skin lesions
CNS dx

treat with prednisone and colchicine

Question 21

Gout

Answer 21

precipitant: thiazides, binge EtOH, nicotinic acid
diag: neg birefringence (yellow)

treat acute attack with NSAIDs and steroids
use colchicine if theres a contraind to NSAID/steroids
NO allopurinol acutely

preventative: 
allopurinol (rash, allergic intersitital nephritis, hemolysis) 
weight loss
no EtOH 
febuxostat ( if cant take allopurinol) 
uricase added if above fail

no probenecid. no sulfinpyrazone

Question 22

Pseudogout

Answer 22

hx hyperparathyroid, hypothyroidism, acromegaly, hemochromatosis
arthrocentesis: +birefringence , rhomboid crystals
treat with NSAIDs and steroids acutely

Question 23

Septic Arthritis

treatment

Answer 23

arthrocentesis : WBC >50000
want to coer for staph + gram neg
treat empirically with IV ceftriaxone and vanc

Question 24

Drugs for

1. strep, staph
2. gram neg rods

Answer 24

1. oxacillin, nafcillin, cefazolin
   penicillin allergy then vanc, linezolid, clinda, daptomycin
2. ceftriaxone, ceftazadine, gentamacin
   penicillin allergy then aztreonam, FQ

Question 25

Pagets

Answer 25

high alk phos
treat with calcitonin and bisphosphonates
will see osteoclytic lesions initially then osteoblastic