Rheumatology Flashcards
1
Q
What features are characteristic of osteoarthritis?
A
- typically presents in an older individual with a history of trauma or obesity
- will affect the weight bearing joints first but also affects the DIPs more than other hand joints
- pain worsens throughout the day and with use
- patients may have crepitus at affected joints
- DIP enlargement = Heberden nodes, PIP enlargement = Bouchard nodes
- laboratory testing is normal
- radiographs show joint space narrowing, osteophytes, and dense subchondral bone
2
Q
Describe the presentation, diagnosis, and treatment of osteoarthritis.
A
- presents as pain in weight-bearing and DIP joints, most often in older individuals with history of trauma or obesity
- patients may complain of crepitus in affected joints, pain that worsens with use, and DIP/PIP enlargement
- diagnosis is made with radiographs show joint space narrowing, osteophytes, and dense subchondral bone
- first line treatment is weight loss, moderate exercise, and acetaminophen
- NSAID and capsaicin cream are second line for pain followed by intra-articular steroids and joint replacement
3
Q
Describe the etiology, presentation, diagnosis, and treatment of gouty arthritis.
A
- secondary to urate overproduction (alcohol, cancer, hemolysis, chemotherapy, Lesch-Nyhan syndrome) or under excretion from renal insufficiency
- presents as sudden, excruciating pain with redness and tenderness, usually of the first MTP, along with fever, tophi, and uric acid stones
- the most accurate test is joint aspiration showing yellow, needle-shaped crystals with negative birefringence and a predominately neutrophilic infiltrate
- treat acute attacks with NSAIDs followed by corticosteroids and then colchicine
- don’t start maintenance therapy during an acute attack
- after resolution, limit alcohol and meat consumption, stop thiazides and transition to losartan, and add colchicine, allopurinol, febuxostat, pegloticase, probenecid, or sulfinpyrazone
- colchicine and allopurinol are safe in renal insufficiency
4
Q
Describe the mechanism of action for the following drugs in the treatment of gout:
- colchicine
- allopurinol
- febuxostat
- pegloticase
- probenecid
- sulfinpyrazone
A
- colchicine: microtubule inhibitor prevents neutrophil migration
- allopurinol: xanthine oxidase inhibitor inhibits urate production
- febuxostat: xanthine oxidase inhibitor inhibits urate production
- pegloticase: dissolves urate acid and accelerates metabolism
- probenecid: increases excretion by the kidneys
- sulfinpyrazone: increases excretion by the kidneys
5
Q
Describe the etiology, presentation, diagnosis, and treatment of pseudogout.
A
- calcium pyrophosphate deposition disease most often secondary to hemochromatosis and hyperparathyroidism
- presents with arthritis of the large joints
- diagnosis is supported by finding chrondrocalcinosis with radiographs but joint aspiration finding positively birefringent rhomboid crystals is most accurate
- treat acutely with NSAIDs and intraarticular steroids; use colchicine for maintenance therapy
6
Q
What is the most likely diagnosis for low back pain? What is first-line management?
A
most cases are lumbosacral strain and first-line treatment is NSAIDs with continued activity as tolerated
7
Q
What are the indications and imaging modalities used for assessing low back pain?
A
- get radiographs for those with high cancer risk or suspected compression fracture
- get MRI for spinal infection, cauda equina, and severe or progressive neurologic deficits
8
Q
What motor, reflex, and sensory deficit is expected for L4 nerve root impingement?
A
- weakness with dorsiflexion of the foot
- diminished patellar reflex
- anterior thigh and medial calf sensory loss
9
Q
What motor, reflex, and sensory deficit is expected for L5 nerve root impingement?
A
- weakness with dorsiflexion of the toe
- no associated reflex
- medial foot sensory loss
10
Q
What motor, reflex, and sensory deficit is expected for S1 nerve root impingement?
A
- weakness with eversion of the foot
- diminished achilles reflex
- lateral foot sensory loss
11
Q
Vertebral tenderness is suggestive of what etiologies for back pain?
A
vertebral compression fracture, cord compression, and epidural abscess
12
Q
What is the proper management for suspected epidural abscess?
A
- first step is steroids to limit cord compression
- should start vancomycin pending cultures and sensitivities
- get an MRI and surgical consult
13
Q
What is the best first step in managing low back pain suggestive of cord compression?
A
glucocorticoids with MRI and surgical consult to follow; add vancomycin if suspecting an epidural abscess
14
Q
Describe the presentation, diagnosis, and treatment of lumbar spinal stenosis.
A
- presents with back pain that radiates to the buttocks and thighs bilaterally and is worse with back extension; may be accompanied by unsteady gait and leg weakness
- diagnosis is with MRI
- treatment begins with weight loss, analgesics, and PT followed by steroid injections and eventually surgery
15
Q
Describe the presentation and treatment of fibromyalgia.
A
- presents with widespread pain, fatigue, and sleep disturbance, and cognitive or mood symptoms
- exam is normal apart except point tenderness over the trapezius, medial fat pad of the knee, and lateral epicondyle
- treatment involves aerobic exercise, good sleep hygiene, and TCAs
16
Q
Describe the presentation, diagnosis, and treatment of carpal tunnel syndrome.
A
- presents with pain in the hand worse at night along the median distribution and atrophy of the thenar eminence
- most accurate test for diagnosis is EMG/NCS
- best initial therapy is wrist splints and NSAIDs followed by steroid injections
- surgery is indicated for refractory disease and muscle wasting
17
Q
Describe the pathophysiology, associations, and treatment of a Dupuytren contracture.
A
- associated with alcoholism and cirrhosis
- due to hyperplasia of the palmar fascia
- treat with triamcinolone, lidocaine, or collagenase injections followed by surgery if there is functional impairment
18
Q
What is the most accurate test for rotator cuff injury and how is it treated?
A
- MRI is the most accurate diagnostic test
- treat with NSAIDs, rest, and PT; second-line is steroid injection
- surgery is reserved for complete tears and refractory cases
19
Q
Describe the presentation and treatment of plantar fasciitis.
A
- presents with severe pain in the bottom of the foot near the calcaneus which is worst in the morning and first few steps of the day
- treat with stretching exercises, arch supports, and NSAIDs followed by steroid injections if refractory
20
Q
What are the signs & symptoms of rheumatoid arthritis.
A
- symmetric involvement of the joints with sparing of the DIPs
- cervical joint involvement leading to C1/C2 subluxation
- morning stiffness that improves with activity
- fever, malaise, weight loss, and myalgias
- rheumatoid nodules
- vasculitis
- baker cysts
- pericarditis and pleuritis
- anemia of chronic disease
21
Q
Describe the diagnosis of rheumatoid arthritis.
A
- anti-CCP is far more specific and sensitive than rheumatoid factor
- patients likely have an elevated ESR and CRP as well as labs consistent with anemia of chronic disease
22
Q
Describe the treatment of rheumatoid arthritis.
A
- the best initial therapy is methotrexate
- every patient needs a DMARD as part of initial therapy: this may include methotrexate, TNFa inhibitors, rituximab, hydroxychloroquine, or sulfasalazine
- NSAIDs and steroids are used for acute pain management while waiting for DMARDs to take effect and neither prevents disease progression
23
Q
What is Felty syndrome?
A
combination of RA, splenomegaly, and neutropenia
24
Q
What is Caplan syndrome?
A
combination of RA, pneumoconiosis, and lung nodules
25
Name the five TNFa inhibitors as well as their mechanism of actions and indications.
- adalimumab, certolizumab, golimumab, and infliximab are all TNF-a antibodies indicated for RA, ankylosing spondylitis, and IBD
- etanercept is a TNF-a decoy receptor indicated only for RA and ankylosing spondylitis
26
What is the side effect associated with each of the following immune modulators:
- TNF-a inhibitors
- hydroxychloroquine
- sulfasalazine
- rituximab
- gold salts
- methotrexate
- TNF-a inhibitors: reactivation of TB
- hydroxychloroquine: retinopathy
- sulfasalazine: rash and hemolysis
- rituximab: recurrent infections
- gold salts: nephrotic syndrome
- methotrexate: lung, marrow, and liver toxicity
27
Describe the presentation and treatment of juvenile rheumatoid arthritis.
- the most important feature is a high spiking fever in a young person accompanied by a rash and without a clear etiology
- STILLS: salmon-colored rash, temperature elevation, ill-appearing patient, lymphadenopathy, leukocytosis, and splenomegaly
- labs demonstrate anemia, hypoalbuminemia, leukocytosis, and elevated ferritin
- treat with aspirin or NSAIDs then use steroids
28
What are the potential manifestations of SLE?
```
MD SOAP BRAINS
Malar
Discoid
Serositis
Oral ulcers
Arthritis
Photosensitivity
Blood (anemia, thrombocytopenia)
Renal failure
ANA
Immunologic (other antibodies)
Neuro
```
29
Describe the presentation, diagnosis, and treatment of SLE.
- presesents with skin, joint, pleural, pericardial, renal, neurologic, vascular, and hematologic manifestations
- young patients die of infection while older die of accelerated atherosclerosis and MI
- ANA is highly sensitive while anti-dsDNA and anti-Sm antibodies are specific; anti-histone is specific for drug-induced lupus
- decreased complement and rising anti-dsDNA levels correlate with disease activity
- ribosomal P suggests cerebral lupus and anti-SSA/SSB increases the risk for neonatal lupus manifesting as heart block
- everyone should get hydroxychloroquine for maintenance therapy and steroids for flares
- do a renal biopsy to diagnose nephritis, give IV cyclophosphamide then PO mycophenolate
30
Describe the role each of the following plays in SLE:
- ANA
- anti-dsDNA
- anti-Sm
- anti-histone
- anti-SSA/SSB (aka Ro and La)
- ribosomal P
- complement levels
- ANA: very sensitive
- anti-dsDNA: very specific, correlates with disease activity, and predicts lupus nephritis
- anti-Sm: very specific but doesn't correlate with disease activity
- anti-histone: specific for drug-induced lupus
- anti-SSA/SSB (aka Ro and La): predicts the risk of neonatal SLE but more common in Sjogren's
- ribosomal P: higher risk for cerebral lupus
- complement levels: correlates with disease activity
31
SLE patients with anti-SSA and anti-SSB antibodies have what risk? How is this managed?
there is a higher risk of passing on neonatal SLE which manifests as neonatal heart block and should be evaluated for with EKG
32
Describe the pathophysiology, presentation, diagnosis, and treatment of anti-phospholipid syndrome.
- lupus anticoagulant, anticardiolipin antibodies, and beta-2 glycoprotein mediate the disease as they target negatively charged phospholipids
- presents with venous and arterial thrombosis, elevated PTT, and recurrent spontaneous abortions
- the best initial test is the mixing study looking for correction of PTT with mixing
- the most specific test is the Russell viper venom test which is prolonged and does not correct with mixing
- treat thromboses with anticoagulation and recurrent pregnancy loss with heparin and aspirin
33
When should you consider anti-phospholipid syndrome as the cause of recurrent pregnancy loss? What tests are used for this? How is it treated?
- consider for 2 or more first-trimester events or a single a single second-trimester event
- best initial test is PTT mixing study and most specific is the Russell viper venom test which doesn't correct with mixing
- treat with heparin and aspirin
34
What are the features of CREST syndrome?
- calcinosis
- raynaud
- esophageal dysmotility
- sclerodactyly
- telangiectasia
35
Describe the presentation, diagnosis, and treatment for scleroderma.
- presents with Raynaud syndrome, skin fibrosis, esophageal dysmotility, sudden hypertensive crisis, restrictive lung disease and pulmonary hypertension, pericarditis, and heart block
- ANA is highly sensitive but anti-topoisomerase (SCL-70) and anti-centromere are more specific test
- treat with methotrexate, ACEi for renal crisis, PPIs for GERD, CCBs for Raynauds, and cyclophosphamide for pulmonary fibrosis
36
How are CREST and diffuse scleroderma differentiated?
- CREST typically involves the extremities distal to the elbows and knees, may cause hypertension, and has a an association with anti-centromere
- diffuse scleroderma involves the proximal extremities, causes pulmonary fibrosis as well as hypertension, and has an association with anti-topoisomerase (SCL-70) antibodies
37
What are each of the following associated with:
- ANA
- Rheumatoid Factor
- anti-CCP
- anti-dsDNA
- anti-Sm
- anti-SSA/SSB (aka Ro and La)
- ribosomal P
- anti-topoisomerase
- anti-SCL-70
- anti-centromere
- anti-Jo
- anti-U1 RNP
- ANA: nonspecific for several rheumatological diseases
- Rheumatoid Factor: sensitive but non-specific for RA
- anti-CCP: highly specific for RA
- anti-dsDNA: highly specific for SLE and correlates with disease activity
- anti-Sm: highly specific for SLE
- anti-SSA/SSB: most associated with Sjogren's but conveys a risk for neonatal SLE and heart block
- ribosomal P: associated with cerebral lupus
- anti-topoisomerase: associated with diffuse scleroderma
- anti-SCL-70: associated with diffuse scleroderma
- anti-centromere: associated with CREST
- anti-Jo: lung fibrosis in those with dermatomyositis
- anti-U1 RNP: mixed connective tissue disease
38
Describe the presentation and diagnosis of polymyositis and dermatomyositis.
- both present with proximal muscle weakness but dermatomyositis also has dermatologic manifestations: malar and heliotrope rashes as well as Gottron papules
- the best initial tests are CPK and aldolase, next is EMG, and most accurate is muscle biopsy
- anti-Jo antibodies are associated with lung fibrosis
- treat with steroids for muscle weakness and hydroxychloroquine for skin lesions
39
Describe the pathophysiology, presentation, diagnosis, and treatment of Sjogren syndrome.
- due to antibodies against lacrimal and salivary glands
- presents with dryness of the mouth and eyes including dysphagia, keratoconjuncitivits, and dental carries
- the most dangerous complication is lymphoma
- best initial test is the Schirmer test for tears ut most accurate is a lip or parotid gland biopsy
- anti-SSA/SSB are common
- treat with artificial tears, pilocarpine, frequent watering of the mouth, and fluoride treatments; evaluate for lymphoma
40
Describe the presentation, diagnosis, and treatment of polyarteritis nodosa.
- many of the symptoms are non-specific, but it notably spares the lungs and is associated with chronic hepatitis
- may have GI pain worse with eating, lower extremity ulcers, mono neuritis multiplex with foot drop, and stroke
- the most accurate test is biopsy; angiography shows "beading"
- treat with prednisone and cyclophosphamide
41
Describe the presentation and treatment of polymyalgia rheumatica.
- presents with pain and stiffness in proximal muscles with an elevated ESR but normal CPK and aldolase
- treat with steroids and look for temporal artertitis
42
Describe the presentation and treatment of temporal arteritis.
- presents with visual symptoms, jaw claudication, and headache and is associated with polymyalgia rheumatica
- treat with prednisone before biopsy results are back
43
Describe the presentation, diagnosis, and treatment of granulomatosis with polyangiitis.
- also known as Wegener's granulomatosis, it involves the oropharynx, lungs, and kidneys
- typically with sinusitis, otitis, pharyngitis, nasopharyngeal ulcers, hemoptysis, and glomerulonephritis
- the best initial test is c-ANCA and the most accurate is biopsy
- treat with prednisone and cyclophosphamide
44
Describe the presentation, diagnosis, and treatment of Churg-Strauss syndrome.
- now called eosinophilic granulomatosis with polyangiitis
- it is a pulmonary-renal syndrome with asthma and eosinophilia as the hallmark features
- the most accurate test is biopsy, also may find p-ANCA
- treat with prednisone and cyclophosphamide
45
Describe the presentation, diagnosis, and treatment of Henoch-Schonlein purpura.
- presents with GI pain, purpura on the lower extremities, arthralgias, and IgA nephropathy; there is also an association with intussusception
- it is a clinical diagnosis but the most accurate test is biopsy showing leukocytoclastic vasculitis
- it is self-limited but use steroids for severe disease
46
Describe the pathophysiology, presentation, diagnosis, and treatment of cryoglobulinemia.
- it is associated with chronic hepatitis C and results from the precipitation of serum proteins at cold temperatures
- presents with arthralgia, glomerulonephritis, purpuric and ulcerative skin lesions, and peripheral neuropathies
- labs demonstrate positive RF and cold-precipitable immune complexes
- treatment consists of treating the underlying hepatitis
47
Describe the presentation and treatment of Behcet syndrome.
- presents with painful oral and genital ulcers in association with erythema nodosum-like lesions
- pathergy, sterile skin pustules from minor trauma like a needle stick, is also a hallmark feature
- treat with corticosteroids
48
What is pathergy?
the presence of sterile skin pustules from minor trauma like a needle stick, seen in those with Behcet syndrome
49
What features are common to all seronegative arthropathies?
- tend to present in men under the age of 40 who are of the HLA-B27 genotype
- presentation involves the spine as well as enthesopathy and uveitis
- patients are negative for rheumatoid factor
50
Describe the presentation, diagnosis, and treatment of ankylosing spondylitis.
- hallmark is low backache and stiffness worsened by rest and relieved by activity along with flattening of the normal lumbar curvature and decreased chest expansion
- other symptoms are enthesopathy, uveitis, and cardiac involvement (AV block and aortic insufficiency)
- the best initial test is SI radiograph but the most accurate is MRI
- treat with exercise and NSAIDs before moving on to TNFa inhibitors
51
Describe the presentation, diagnosis, and treatment of psoriatic arthritis.
- presents with SI joint pain, sausage digits, and nail pitting
- the best initial test is a radiograph of the hands showing "pencil in a cup" deformity
- treat with NSAIDs, methotrexate, or TNFa inhibitors
52
Describe the presentation and treatment of reactive arthritis.
- presents with joint pain, ocular findings, and genital abnromalities; "can't pee, can't see, can't climb a tree)
- typically in those with IBD or STI
- treat with NSAIDs, sulfasalazine, and steroids
53
How are osteopenia and osteoporosis diagnosed?
the most accurate test is a bone denisometry scan (DEXA) showing a T-score 1-2.5 SD below the mean for osteopenia and more than 2.5 SD below for osteoporosis
54
What is the first line treatment for osteoporosis? What are other options?
- best initial therapy is vitamin D, calcium, and bisphosphonates
- can use denosumab (RANK-L inhibitor), raloxifene, teriparatide (parathyroid analog), or calcitonin
55
What are the benefits of raloxifene?
- improves bone denisty
- lowers LDL
- reduces risk for breast cancer
56
Describe the etiology, presentation, diagnosis, and treatment of septic arthritis.
- most commonly caused by staphylococcus, streptococcus, or gram-negative rods
- presents with a warm, red, immobile joint with palpable effusion, fever, and chills
- the best initial and most accurate test is arthrocentesis showing more than 50K WBCs with a neutrophil predominance
- empiric treatment is with ceftriaxone and vancomycin
57
How does prosthetic joint infection differ from natural joint infection?
- more commonly due to Staph epidermidis infection if the joint was recently placed
- need to get a CT or radiograph to look for surrounding lucency or physical loosening of the prosthetic which are signs of infection
- treat with joint removal, antibiotics, and then joint replacement
58
Describe the presentation, diagnosis, and treatment for gonococcal arthritis.
- presents with polyarticular arthritis, tenosynovitis, and a petechial rash
- diagnosis begins with an arthocentesis, typically with 30-50K WBCs; gram stain isn't very sensitive so must culture multiple diffuse sites
- treat with ceftriaxone
59
If a patient presents with recurrent gonorrheal infection, what is the best next step?
look for terminal complement deficiency
60
Describe the etiology, presentation, diagnosis, and management of osteomyelitis.
- most commonly caused by S. aureus in the general population and Salmonella in patients with sickle cell
- children get it through hematogenous spread while adults get it from contiguous spread
- presents with overlying warmth, redness, and swelling
- radiograph is the best initial test, MRI is the next step, and culture is the most accurate test
- use ESR to follow response to treatment
