Rheumatology Flashcards
What is Systemic Lupus Erythematosus?
Chronic multi-organ autoimmune disorder affecting the skin, joint, kidneys, lungs, nervous and CV system
When is SLE seen most?
Young (reproductive) adult females (African American 4:1)
What are the clinical manifestations of SLE mediated by?
Antibody formation and creation of immune complexes (they deposit in and damage tissue)
What are general sx of SLE?
Fever, fatigue, weight loss, LAD
What is seen on the skin in SLE?
Malar (butterfly) rash, discoid rash, mucocutaneous lesions (painless oral or nasal ulcers), alopecia, raynaud phenomenon
Malar (butterfly rash)
Fixed erythema over nasal bridge and spares nasolabial folds!
Discoid rash of SLE
Erythematous patches with keratotic scaling in sun exposed areas
Raynaud phenomenon
Seen in 30% SLE pts
Episodic vasospasm of digital arteries with exposure to cold temps or stress
What is the bicentennial disease?
Raynaud phenomenon
White (pallor)
Blue (cyanosis)
Red (erythema following rewarming)
How do you treat Raynauds?
Calcium Channel Blocker
ACR criteria for SLE Dx (4 or more)
Malar rash, photosensitivity (rash), polyarthritis, renal disorders, hematologic disorders, + anti-DNA/Sm/Antiphosholipid Ab, mucosal ulcers, serositis, neurological disorders, +ANA
Why are SLE pts at risk for MI?
Accelerated atherosclerosis
How is ANA reported?
Titer of antibodies with serial dilution
Staining pattern of antibodies (loosely associated with underlying autoimmune disease)
ANA in SLE
Seen in 95% of pts
Cardinal feature but not specific to just SLE
Describe the nuclear staining patterns
Homogenous: entire nucleus stained
Speckled: fine, course speckles through nucles
Centromere: dots localize to chromosomes in dividing cells
Nucleolar: homogenous staining of nucleolus
What are the ANA subtype antibodies we test for?
Anti-dsDNA, anti-Sm, antiphospholipid (anticardiolipin Ab, beta 2 glycoprotein Ab, lupus anticoagulant)
What is seen in the diagnostic evaluation of SLE?
CBC: anemia, leukopenia, thrombocytopenia
Serum creatinine: elevated with renal dysfunction
U/A: hematuria, proteinuria, cellular casts
Liver function tests
ESR/CRP: elevated with inflammation
C3 and C4: low complement levels indicate active lupus
ANA and other specific antibodies done after + test
Nonpharmacologic tx of SLE
Sun protection, diet/nutrition, exercise, smoking cessation, immunizations, tx of cormobiditeis, pregnancy and contraception
How is SLE pharmacoligic tx tailored?
To match disease severity
What is the first line tx for SLE?
Antimalarials (hydroxychloroquine/Plaquenil daily)
What must you do to someone on Plaquenil?
Must have them do regular ophthalmologic follow up (also renal toxic)
What drugs can be added to tx of SLE based on severity?
NSAIDs, systemic corticosteroids, immunosuppressive agents (methotrexate, azathioprine etc)
What are some common drugs that may lead to drug induced SLE?
Procainamide, isoniazid, hydralazine
What is the different diagnostic seen in drug-induced SLE but not regular SLE?
Positive antihistone antibody
Will probably have + ANA but no other positives and complement levels are not low
Poor prognostic indicators of SLE
Renal disease, HTN, male, antiphospholipid Ab, high overall disease activity, low socioeconomic status
What is polymyositis?
Idiopathic progressive, inflammatory condition causing symmetric proximal muscle weakness
*deltoid and hip flexors are common sites
Presentation of polymyositis
Progressive symmetric muscle weakness of proximal upper and lower extremities (painless usually)
Cough or SOB (due to interstitial lung disease of scarring of lung tissue)
Raynauds
Dermatomysotis and the classic findings
All sxs/signs of polymyositis + cutaneous eruptions (heliotrope rash, Gottron’s papules, shawl sign)
May have occult malignancy
Heliotrope rash
Violet color rash around the eyes/eyelids
Gottron’s papules
Thickening on dorsal side of PIP, DIP and MDP joints
Labs for polymyositis (and dermatomyositis)
Muscle enzymes CK and aldolase elevated
ANA + in about 80%
First line tx of polymyositis and dermatomyositis
Glucocorticoids for the inflammation (azathioprine or methotrexate added in severe cases)
When is the initial dx of Sjogren’s usually?
40-60 yo (much more in females)
What is Sjogren’s?
Chronic dysfunction of the exocrine glands (primarily lacrimal and salivary)
Sicca complex
Sjogrens, combo of xerophthalmia (dry eyes) and xerostomia (dry mouth)
Constitutional sx of Sjogrens
Fatigue!
Presentation of Sjogrens
Keratoconjunctivitis sicca, parotid gland enlargement, dryness of other surfaces, athraligia/arthritis, Raynauds, LAD etc
Labs done for Sjogrens
Schirmer test for tear production \+ ANA in 95% ANA subtypes: anti-Ro/SS-A, Anti-La/SS-B Rf + 70% ESR and CBC etc
Tx for Sjogrens:
F/u with dentist and ophth.
Dry eyes: artificial tears, lubricating ointments, cyclosporine drops (Restasis)
Xerostomia: saliva substitute (Biotene OTC), water, sugarfree candy
Extraglandular: NSAIDs (may need steroids or immunosuppressive)
What is polyarteritis nodosa?
Systemic necrotizing vasculitis causing transmural inflammation of muscular arteries causing narrowing of lumen
Result in thrombosis, ischemia or infarct
Clinical presentation of PAN
Fever, weight loss, malaise Sensory and motor polyneuropathy Arthraligia/myalgia Nodules, ulcers, purpura Bx of lesions shows leukocytoclastic vasculitis (white cell debris)
What is the most common systemic involvement in PAN?
Renal (infarctions or hypertension)
Labs done in PAN
ESR, CRP elevated
Negative (antineutrophil cytoplasmic antibodies)
*positivie ANCA points to other types of vasculitis
Might see microaneurysms on arteriography
Initial tx for mild or cutaneous PAN
Glucocorticoids
Initial tx for moderate/severe PAN:
Glucocorticoids/ immunosuppressive meds
Initial tx for PAN associated with Hep B or C
Primarily antivirals and maybe glucocorticoids depending on severity
Initial tx for PAN associated with HTN
ACE-I
Maintenance of PAN
Steroid taper or immunosuppressants
What is systemic sclerosis (scleroderma)
Autoimmune disorder causing diffuse fibrosis (tightening and thickening) of the skin and internal organs
“Stone skin”
Immunologic mechanisms leading to vascular endothelial damage and activation of fibroblasts
When is the onset of scleroderma usually?
20-50 yo, more females
2 types of scleroderma
Limited cutaneous (80%) or diffuse cutaneous (20%)
Limited cutaneous SSc
CREST syndrome
Skin changes limited to hands, forearm, face, neck
Better prognosis
Diffuse cutaneous SSc
Sclerotic skin also on chest, abs, arms and shoulders
Increased risk of internal organ involvement
