Rheumatology Flashcards
What is gout?
How is it caused?
Who is it most common in?
An Altered purine metabolism that results in sodium urate crystal deposition in synovial fluid
Abnormal deposits of urate cause recurring, acute arthritis attacks
MC in Men >30
Which medications put a patient at an increased risk for Gout?
Thiazide/loop diuretics
What can cause Secondary Gout?
Meds: diuretics, low dose ASA, cyclosporine, niacin
Myeloproliferative disorders
Hypothyroidism
Alcohol ingestion –> increase urate
How is Primary gout classified?
linked to genetic alterations in how the kidney handles urate
How does acute Gout present
Acute intense pain AT NIGHT
Swollen, tender joint with overlying skin that is red and warm
Often involves first MTP joint (called podagra)
Is gout considered polyarticular or monoarticular?
Monoarticular (only affects one joint)
How long must you have Gout in order to be considered chronic?
10 years
What occurs in patients with chronic Gout?
Urate deposits in subcutaneous tissue, bone, cartilage, joints
Surrounded by granulomatous inflammation
Deposits are called tophi and are diagnostic
Create a deforming polyarthritis
What labs can be used to diagnose Gout?
Which is most definitive
Serum uric acid
WBC
Synovial fluid analysis**
In a synovial fluid analysis what findings will indicate Gout under polarizing light microscopy?
monosodium urate crystals are diagnostic
needle like crystals
What are radiographic findings with Gout?
small, punched-out erosions with overhanging edges (“rat-bite”)
Treatment for Gout
Which is 1st line
- Elevation, rest
- Diet modifications- decreases purines and alcohol to lower urate
- NSAIDS***
Which NSAIDS are used for GOUT
Indomethacin (classically used)
Naproxen
Colchicine - if attack is less than 24-36 hours old
What meds should be avoided with Gout?
Avoid thiazide and loop diuretics – inhibit renal excretion of uric acid
Niacin – raises serum uric acid levels
Low dose aspirin +/-
What prophylactic medications can be used for Gout
Colchicine
Xanthin Oxidase inhibitors
Uricosuric agents
Treatment for Pseudogout?
NSAIDs – acute attacks
Colchicine – prophylaxis
Intra-articular corticosteroid injection
What is Pseudogout and what is deposited?
Who is this most common in?
Affects peripheral joints
Deposits of calcium pyrophosphate
MC in elders 60+
What imagine tool is used to assess Pseudogout?
What findings are diagnostic?
X-ray
Calcium pyrophasphate crystals
Rhomboid shaped crystals that are positively birefringement
What is the ideal way to diagnose Pseudogout?
Joint Aspiration
Id of calcium pyrophosphate crystals is diagnostic: rhomboid-shaped crystals that are positively birefringent with light microscopy
“think P” = Pyrophosphate and Positve
Where is the MC area that Pseudogout affects?
Knee
Wrist
Elbow
What is the MC joint disease?
Which age group is most affected?
Osteoarthritis
Older >65
Clinical presentation of Osteoarthritis?
Joint pain
- Insidious onset
- Worsens with activity, relieved with rest
- Brief morning stiffness (< 30 minutes)
Crepitus (grinding noise)
Loss of ROM
Different between Heberden nodes and Bouchard nodes
Heberden nodes – bony enlargements of DIPs
Bouchard nodes – bony enlargements of PIPs
What are X-ray findings you will see with Osteoarthritis?
Asymmetric narrowing of joint space
Osteophytes
Thickened subchondral bone
Bony cysts
What Labs would you grab for Osteoarthritis?
synovial fluid
What are 1st line pharmacologic treatments for Osteoarthritis
- Acetaminophen or NSAIDS***
If initial treatment for Osteoarthritis does not work what kind of injections are available?
Corticosteroid injections - 4x per year
Sodium Hyaluronate
What are surgical options for Osteoarthritis?
Arthroscopy
Joint replacement
What is Rheumatoid Arthritis?
Chronic, progressive, systemic inflammatory disease
Synovitis of multiple joints
What is the clinical presentation of Rheumatoid Arthritis
Morning stiffness (>30 minutes)
Insidious onset
Symmetric swelling of multiple joints with tenderness and pain
Symmetric polyarthritis of small joints of hands and feet
What is the cause of Rheumatoid arthritis?
Unknown
Genetic susceptibility due to multiple genes
What Labs can be used to diagnose Rheumatoid arthrititis?
Which lab is most specific to diagnose with?
RF + anti-CCP
anti-CCP is most specific
What is the diagnostic criteria for Rheumatoid arthritis?
Number and type of joints involved
Serology (RF and anti-CCP [also called ACPA]
Acute phase reactants (CRP and ESR)
Symptom duration of at least 6 weeks
Treatment for Rheumatoid arthritis?
Start DMARDS therapy as soon as diagnosis is certain
Methotrexate
Sulfasalazine (Azulfidine)
Leflunomide (Arava)
Hydroxychloroquine (Plaquenil)
***Use NSAIDS in conjunction for pain relief
Which medication is the initial DMARD choice for RA?
What are side effects?
Methotrexate
GI upset, stomatitis
Decrease in WBCs and platelets due to bone marrow suppression***
Hepatotoxicity with cumulative dose
Teratogenic
What are adverse effects of taking 2nd line Sulfasalazine?
Neutropenia, thrombocytopenia
What are adverse effects of Hydroxychloroquine?
What must be done when taking this?
pigmentary retinitis in 2%
Eye exams are required yearly
What are risks associated when taking biologic DMARDS?
What precautions must be done before starting?
Increased risk for infection and malignancy
Must screen for latent TB before initiating
What is Systemic Juvenile Idiopathic Arthritis (sJIA)
Arthritis occurring in teens less than 16 years old
Presentation of sJIA?
Fever Arthritis (mono-, oligo-, or poly-arthritis) Rash Lymphadenopathy ANA & Rf rarely seen
Diagnostic criteria for sJIA?
intermittent, daily fevers and arthritis
Fever ≥ 2 weeks
Arthritis ≥ 6 weeks
Onset before 16 years
Treatment for sJIA?
Pediatric rheumatologist
Physical therapy
Occupational therapy
Registered dietician
What is Seronegative Spondyloarthropathies
What gene is associated with this?
Inflammatory arthritis of spine and sacroiliac joints
Asymmetric arthritis of large peripheral joints
HLA-B27 gene
What is Ankylosing Spondylitis?
Chronic inflammatory disease of joints of axial skeleton
Onset usually in teens or late 20’s
Male > female
Clinical Presentation of Ankylosing Spondylitis?
Gradual, intermittent back pain - Worse in morning - Radiation to buttocks - Improves with activity Progressive stiffening of the spine Anterior uveitis (25%) Arthritis of peripheral joints (50%)
Diagnostic labs for Ankylosing Spondylitis?
Elevation of ESR (in 85%)
Negative RF and anti-CCP antibodies
CBC – mild anemia
HLA B27 + in 92% of white patients and 50% of black patients with AS
What are findings you expect to see on imaging with Ankylosing Spondylitis
Earliest evidence is in SI joints – erosion, sclerosis
Bilateral, symmetric
Bamboo spine – appearance of spinal column when the vertebral bodies fuse together
Treatment for Ankylosing Spondylitis?
NSAIDs first line
TNF inhibitors
Corticosteroids – minimal impact, can cause osteopenia
Sulfasalazine (peripheral arthritis)
What is the cause of Psoriatic Arthritis
Skin psoriasis usually precedes arthritis
Clinical presentation of Psoriatic Arthritis?
Many forms – monoarthritis, polyarthritis Nail pitting, onycholysis Usually asymmetric SI joint involvement common Sausage swelling of digits
What labs can be used to diagnose Psoriatic arthritis?
Labs
Elevated ESR
RF negative
What image findings do you see in Psoriatic arthritis
Erosion and destruction of bone
Osteolysis
Pencil deformity
Asymmetric sacroilitis
Treatment for Psoriatic arthritis
NSAIDs
Methotrexate – for those who do not respond to NSAIDs
Can improve joint and skin symptoms
Phosphodiesterase-4 inhibitor
What is Reactive arthritis?
Who is it common in?
What is it precipitated from?
Asymmetrical oligoarthritis of lower extremity
Mostly knee and ankle
MC in young men
Precipitated by GI and GU infection
What are extra-articular manifestations that can happen with Reactive arthritis? (Think triad)
Urethritis
Conjunctivitis
Uveitis
What are mucocutaneous lesions that can happen from Reactive arthritis?
Balanitis
Stomatitis (mouth ulcers, painless)
Keratoderma blennorrhagicum
Treatment for Reiters arthritis?
NSAIDs
Antibiotics given for STI reduces chance of reactive arthritis occurring
