Rheumatology Flashcards
most common form of arthritis
OA
OA in the hands is usually caused by
genetics
labs characteristic of OA
ESR<40 mm
OA is not found in
the MCP or the wrists
OA is found
i. Hands: DIP’s, PIP’s, 1st C-MC joint
ii. Hips
iii. Knees
iv. Feet: 1st MTP
v. Spine: Cervical and Lumbar
vi. Bumps on DIP in OA
Heberden’s nodes
vii. Bumps on PIP
Bouchard’s nodes
XR typical of OA
complete loss of joint space, cysts are seen, and bone on bone, extremely sclerotic
osteophytes on XRAY are not necessarily causing acute backpain
congenital cause of OA
i. Congenital dysplasia of hip where femur doesn’t develop normally
acetabulum is flatter and the joint wears out
secondary causes of OA
trauma
congenital
inflammatory disease (RA or Gout)
chondrocalcinosis
calcifications of the bone seen in pseudogout
these crystals are seen as invasive and can be targeted on the body
OA tx
NSAIDS
Corticosteroid
joint replacement
RA clinical features
sxs
morning stiffness
jointpain
swelling
usually seen in symmetrical fashion
soft squishy swelling
If people have RA and have back pain it is not the cause
areas affected by RA
o Hands: PIP's, MCP's (Osteoarthritis affects DIP but RA does not) o Wrists o Elbows o Shoulders o Knees o Ankles o Feet: PIP's, MTP's o Cervical spine (spares the rest of the spine)
DIP affected in RA with swan neck
tendons affected not actually the DIP jount
it is the tendon itself that is pulling on the joint
why should RA be called rheumatoid disease
it has a lot of systemic effects
i. Pulmonary: pleuritis, interstitial fibrosis, nodules
ii. Cardiac: pericarditis, premature CAD
iii. Hematologic: anemia of chronic disease
iv. Vascular: vasculitis
v. Muscle: muscle wasting
vi. Ocular: Sjögren’s syndrome (antibodies to lacrimal gland so pt’s don’t produce tears or saliva), episcleritis, scleritis, scleromalacia perforans
vii. Constitutional: fatigue, fever, weight loss (very common)
Cardiac sxs assoc with
pericarditis, premature CAD
pulmonary sxs associated with RA
pleuritis, interstitial fibrosis, nodules
PV affects seen with RA
vasculitis
ocular impacts of RA
Sjögren’s syndrome (antibodies to lacrimal gland so pt’s don’t produce tears or saliva), episcleritis, scleritis, scleromalacia perforans
subcutaneous nodules are seen most commonly where in RA
extensor surface of the elbow
really don’t bother people unless they are in pressure areas
greater likelihood of extra articular formations
RA dx tests
rheumatoid factor is foumd in 80-85% of people
but only 60% in the first 6 months
CCP is often positive even before pts develop RA but only 50% have it
RA dx criteria
morning stiffness lasting longer than an hour swelling in 3 or more joints symmetric joint swelling erosions or decalcification rhematoid nodules abnormal serum rheumatoid factor
need to have for longer than 6 weeks to establish and the
this is not
OR
ii. Synovitis is not better explained by “another disease”
tx of RA
education is extremely important aspect
NSAIDS-for sxs but not for dz progression
need to use iwht
disease modifying anti rheumatic drugs
DMARDS- hydroxychloroquine, sulfasalazine, methotrexate, leflunomide
corticosteroids can be used while you wait for DMARDS and biologics to work
surgery can be used for reconstruction
ACR classification of RA
iii. 6 or more points = definite RA
looking at joint distribution
Spondyloarthropathies
often affect the spins and periphery
all can cause inflammation of the spine
but doesn’t account for a lot of back pain (2%)
4 major
AS
reactive arthritis and Reiter’s
psoriatic arthritis
arthritis of IBD
enthesopathy
enthesis is where a tendon or ligament inserts on a bone
plantar fascitis
where the plantar fascia attaches to the calcaneous
usually see pain when initially beginning to walk
o Mucocutaneous effects of Spondyloarthropathies
- Psoriatic-like skin rashes
- Mucous membrane involvement
o Ocular - Conjunctivitis
- Uveitis
o Intestinal inflammation
o Aortic insufficiency
o HLA-B27
ankylosing spondylitis
why would you suspect it
insidious onset
age under 40 sometimes seen in teens or 20’s
usually seen as long standing back pain
morning stiffness and improvement with exercise are crucial
dx test for AS
getting an xray
can take up to 6 months so often times we will do an MRI before that
can see sclerosing an irregularity
or fusing
rigid spine see with loss of flexibility
what physical exam test can we do for AS
Diminished “Schober’s test”
<10cm suggest AS
psoriatic arthritis is usually seen
15% of the time arthritis precedes skin disease
does not relate to the severity
can be poly-articular but not as symmetrical as RA
can be squishy warm and red to the touch
psoriatic arthritis CAN affect DIP joint similar to OA
spondylitis
arthritis mutilans
can also see hyperkeratosis and onycholisis
nail pitting-20 or more
sausage digits
dx of psoriatic arthritis
pencil in a cup
reactive arthritis
follows GUI or infectious diarrhea
if you have just arthritis= reactive
reiter’s syndrome is seen with conjunctivitis or urethritis and arthritis
Precipitating Organisms of reactive arthritis
Precipitating Organisms –> Shigella, Salmonella, Campylobacter, Yersinia, Chlamydia, Ureaplasma, HIV
clinical features of reactive arthritis
unilateral or bilateral
o Oligoarthritis (usually in the LE) o Sacroiliitis (unilateral or bilateral) o Spondylitis o Sausage digits o Enthesopathy (particularly Achilles tendon)-ligaments attaches onto bone o Plantar fasciitis o Conjunctivitis o Uveitis-inflammation or iris o Urethritis-pain on urination w/o UTI o Prostatitis o Cystitis o Keratodermia blennorrhagicum- pustule lesions on palms and soles usually in HIV pts with reactive arthritis o Circinate balanitis-penis lesion o Oral ulcers o Aortic insufficiency
onycholysis and hyperkeratosis seen as well similar to psoriatic arthritis
if you have a pt with Keratodermia blennorrhagicum
reactive arthritis
test for HIV
Circinate balanitis
reactive arthritis
painless lesion of the penis
tx of reactive arthritis
DMARDS methotrexate leflunomide apremilast sulfsalizine azathhiopine biologics
Crystal-Induced Arthritis-MCC and presentation
MC -Gout
seen in women after menopause
men early on
seen in first MPP joint
self limited (6 months of big toe pain do not have gout)
more frequent gout attacks turn into
v. Attacks are self-limited and last 1-2 wks
vi. Attacks become more frequent and polyarticular
vii. Can develop chronic polyarticular polyarthritis
can lead to severe deforming arthritis that looks a lot like RA
Tophi
may be present (collection of uric acid)
uric acid susceptibility
ix. Uric acid > 6.8
can be falsely low serum level during acute attack because it is being consumed
need to check 2 weeks after the attack
ddx for gout
cellulitis
warm red
inflammation
low grade fever and peripheral leukocytosis
post gout scalding
can be seen after gout
crackling
collections of uric acid
seen in ear and elbow
tophi in the plural
tophus in the singular
collections of uric acid
tx of acute gout
naproxen 500mg BID or TID
sulindac 200mg
celecoxib 400mg BID
200 mg BID
avoid indomethacine
can use colchicine
chronic tx
need the uric acid below 6
allopurinol
febuxostat
probenecid
pseudogout presentation
red hot swollen joint
typically in the wrist we see this as the MCC of wrist swelling
many small joints can be affected
pseudo osteoarthritis form is very common
hallmark of pseudogout
chondrocalcinosis
pseudogout tx
NSAIDS
Colchicine
corticosteroids
rashes seen with lupus
discoid and malar
can have discoid withotu systemic
generalized symptoms of lupus
o Fever
o Fatigue
o Weight loss
o Oral ulcers
Hematologic Manifestations of lupus
o Leukopenia o Lymphopenia o Thrombocytopenia o Coombs-positive hemolytic anemia o Hypercoagulable state
CNS Manifestations LUS
o Peripheral neuropathy o Cranial neuropathy o Mononeuritis multiplex o Seizures o Stroke o Organic brain syndrome (dementia-like picture) o Headaches o Depression o Psychosis
ocular manifestations LUS
o Conjunctivitis o Episcleritis o Sjögren's syndrome o Central retinal artery occlusion o Cytoid bodies
Cardiac Manifestations of LUS
o Pericarditis o Myocarditis o Coronary vasculitis o Libman-Sacks endocarditis o Coronary artery disease
Pulmonary Manifestations LUS
o Pleuritis
o Pneumonitis
o Interstitial lung disease (pulmonary fibrosis)
Renal Manifestations LUS
o Focal proliferative glomerulonephritis
o Diffuse proliferative glomerulonephritis
o Membranous nephritis
o Mesangial nephritis
LUS dx
Need 4 out of the 11 to diagnose
malar rash discoid rash oral ulcers photosensitivity arthritis serositis renal disorder neurologic disorder hematologic disorder immunologic disorder antinuclear
ANA test for LUS
VERY nonspecific
99% sensitive; 10% specific
most common dz associated
- hashimotos
- RA
- LUS
dx tests for LUS
ii. Anti-ds DNA Ab: Present in 50%; very specific; correlates with disease activity
iii. Anti-Sm: Present in 10-20%; very specific
ANA-nonspecific
iv. Complement C3, C4 correlates with renal disease
LUS tx
o Prevention of flares: hydroxychloroquine
o Skin: hydroxychloroquine, topical steroids
o Joint: NSAIDs, hydroxychloroquine
o Renal, CNS: corticosteroids, cyclophosphamide, azathioprine, mycophenolate mofetil
o Hematologic: corticosteroids
o Serositis: NSAIDs, corticosteroids
o Steroid sparing: methotrexate, azathioprine, mycophenolate mofetil or belimumab
a. Age > 55
b. Shoulder and hip girdle aches
c. Fatigue, weight loss, fever
Polymyalgia Rheumatica And Giant Cell Arteritis
they exist together in 50% of the cases
tx of Polymyalgia Rheumatica And Giant Cell Arteritis
need prednisone
new onset headache in an older person
always suspect GCA
chronic widespread musculoskeletal pain for ≥ 3 mos.
Fibromyalgia
- Absence of other systemic condition accounting for pain
- Multiple tender points at characteristic locations í areas you put small amount of pressure but hurts the pt
theory behind fibromyalgia
abnormality of pain processing
abnormalities seen in pts with firbomyalgia
Lower levels of normal NT like Epi and Serotonin and substance P. A variety of things can trigger it
characteristics features of fibromyalgia
- Fatigue
- Sleep disturbances í are you refreshed in the morning when you wake up?
- Paresthesias, swelling sensations
- Headache
- Mood disturbance í depression and anxiety
- Irritable bowel syndrome í alteration of constipation and diarrhea
- Tender points í Lower sternomastoid, 2nd costochondral, lateral epicondyle, trochanter, knee, suboccipital, mid upper trapezius, supraspinatus, buttock
tx for fibromyalgia
o Exercise: aerobic and stretching
o Education; CBT
o Anticonvulsants: pregabalin, gabapentin
o SNRI: duloxetine, milnacipran
o Analgetics: tramadol
o Hypnotics: amitriptyline, nortriptyline, zolpidem (sleep)
ddx of mono-arthritis
o Crystal-induced arthritis
- Gout
- Pseudogout
o Infectious arthritis- do not miss this especially if pt has a fever. need to culture if suspected
o Reactive arthritis
seen in younger people in the LE
o Osteoarthritis
usually doesn’t present acutely
o Trauma
Oligoarthritis (few joints affected) DDX
o Osteoarthritis
-hard nodes, very common
o Psoriatic arthritis
DIP joints, look for hints of psoriasis
o Reactive arthritis
o Pseudogout
think about this in older pts
o Gout
typically these people have had multiple attacks
o Rheumatoid arthritis
Polyarthritis (soft squishy) ddx
o Rheumatoid arthritis
PIP MCP wrist, elbow shoulders
symmetrical
o Osteoarthritis (firm nodule) look for those hand nodes MCP joints spared (shoulders elbows and ankles are spared)
o Psoriatic arthritis
less symmetricle than RA and seen with DIP
o Pseudogout
o SLE
o Gonococcal arthritis
