Rheumatology Flashcards
What features are characteristic of osteoarthritis?
- 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
Describe the presentation, diagnosis, and treatment of osteoarthritis.
- 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
Describe the etiology, presentation, diagnosis, and treatment of gouty arthritis.
- 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
Describe the mechanism of action for the following drugs in the treatment of gout:
- colchicine
- allopurinol
- febuxostat
- pegloticase
- probenecid
- sulfinpyrazone
- 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
Describe the etiology, presentation, diagnosis, and treatment of pseudogout.
- 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
What is the most likely diagnosis for low back pain? What is first-line management?
most cases are lumbosacral strain and first-line treatment is NSAIDs with continued activity as tolerated
What are the indications and imaging modalities used for assessing low back pain?
- 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
What motor, reflex, and sensory deficit is expected for L4 nerve root impingement?
- weakness with dorsiflexion of the foot
- diminished patellar reflex
- anterior thigh and medial calf sensory loss
What motor, reflex, and sensory deficit is expected for L5 nerve root impingement?
- weakness with dorsiflexion of the toe
- no associated reflex
- medial foot sensory loss
What motor, reflex, and sensory deficit is expected for S1 nerve root impingement?
- weakness with eversion of the foot
- diminished achilles reflex
- lateral foot sensory loss
Vertebral tenderness is suggestive of what etiologies for back pain?
vertebral compression fracture, cord compression, and epidural abscess
What is the proper management for suspected epidural abscess?
- first step is steroids to limit cord compression
- should start vancomycin pending cultures and sensitivities
- get an MRI and surgical consult
What is the best first step in managing low back pain suggestive of cord compression?
glucocorticoids with MRI and surgical consult to follow; add vancomycin if suspecting an epidural abscess
Describe the presentation, diagnosis, and treatment of lumbar spinal stenosis.
- 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
Describe the presentation and treatment of fibromyalgia.
- 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
Describe the presentation, diagnosis, and treatment of carpal tunnel syndrome.
- 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
Describe the pathophysiology, associations, and treatment of a Dupuytren contracture.
- 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
What is the most accurate test for rotator cuff injury and how is it treated?
- 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
Describe the presentation and treatment of plantar fasciitis.
- 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
What are the signs & symptoms of rheumatoid arthritis.
- 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
Describe the diagnosis of rheumatoid arthritis.
- 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
Describe the treatment of rheumatoid arthritis.
- 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
What is Felty syndrome?
combination of RA, splenomegaly, and neutropenia
What is Caplan syndrome?
combination of RA, pneumoconiosis, and lung nodules
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
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
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
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
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
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
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
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
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
What are the features of CREST syndrome?
- calcinosis
- raynaud
- esophageal dysmotility
- sclerodactyly
- telangiectasia
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
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
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
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
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
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
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
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
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
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
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
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
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
What is pathergy?
the presence of sterile skin pustules from minor trauma like a needle stick, seen in those with Behcet syndrome
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
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
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
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
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
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
What are the benefits of raloxifene?
- improves bone denisty
- lowers LDL
- reduces risk for breast cancer
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
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
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
If a patient presents with recurrent gonorrheal infection, what is the best next step?
look for terminal complement deficiency
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
