Rheumatology Flashcards
Fibromyalgia
- pathophys
increased pain perception, increased substance P
Fibromyalgia
- Dx
- diffuse pain
- 11+/18 trigger points for > 3 months
- Msk bx: “moth-eaten”
Fibromyalgia
- mgmt
- exercise (swimming best)
- TCAs (amytriptiline)
- SSRIs, SNRIs
- pregabalin
Gout
- medical causes
- thiazide and loop diuretics
- ACEi
- Arbs (except losartan)
- pyrazinamide
- ethambutol
- ASA
Gout
- MC joint
1st MTP joint “podagra”
knees, feet, ankles also common
Gout
- Dx
- arthrocentesis: negatively birefringent needle-shaped urate crystals
- xray: mouse/rat “punched-out” erosions, +/- tophi
- Lab: elevated ESR, WBC in acute attacks
Gout
- Tx
Acute
- NSAIDs (indomethacin, naprosyn)
- Colchicine 2nd line
Prophylaxis
- allopurinol: inhibits xanthin oxidase which increases uric acid excretion
- colchicine (only drug given both prophylactically and in acute attacks)
Pseudogout
- pathophys
- calcium pyrophosphate dihydrate deposition
Pseudogout
- Dx
- Arthrocentesis: rhomboid-shaped crystals
- Xray: chondrocalcinosis
Pseudogout
- mgmt
- 1st line: intra-articular steroids (differentiate from gout)
- NSAIDs
- Colchicine
Chronic: NSAIDs, +/- colchicine
Juvenile idiopathic/rheumatoid arthritis
- describe
- Autoimmune mono- or poly arthritis
- Children <16
- often resolves by puberty
Juvenile idiopathic/rheumatoid arthritis
- Three types
- Pauci-articular (oligoarticular)
- Systemic/acute febrile (still’s disease)
- Polyarticular
Juvenile idiopathic/rheumatoid arthritis
- Pauci-articular
- <5 joints involved
- MC large joints
- Associated with iridocyclitis (anterior uveitis)
- Inc risk ankylosing spondylitis
Juvenile idiopathic/rheumatoid arthritis
- Systemic/acute febrile
- daily arthritis with diurnal fever
- salmon/pink migratory rash
Juvenile idiopathic/rheumatoid arthritis
- Polyarticular
- > 5 small joints
- most similar form to adult RA
- increased risk of iridocyclitis (anterior uveitis)
Juvenile idiopathic/rheumatoid arthritis
- dx
Clinical
- inc ESR, CRP
- pauci-articular: +ANA
- RF only 15%
Juvenile idiopathic/rheumatoid arthritis
- Mgmt
- NSAIDs +/- steroids
- methotrexate or leflunomide
- Frequent eye exams to screen for iridocyclitis
Osteoporosis
- pathophys
- decreased bone density
- loss of both bone mineral and matrix
Osteoporosis
- kinds
- primary: postmenopausal/senile
RF: caucasian/asian, thin, smoker, steroids, renal dz, etoh, reduced ca/vitD, physical inactivity - secondary: chronic disease/meds
RF: drugs, high cortisol state seen in prolonged steroid use or cushing dz
Osteoporosis
- clinical
1st sx usu pathological fracture, back pain, deformity
- spine fracture MC in lumbar and thoracic spine
Osteoporosis
- Dx
- Labs: usu nl
- possible reduced Vit D
- DEXA scan: shows demineralization (normal ≥ -1.0, osteopenia -1.0 to -2.5, osteoporosis ≤ -2.5)
Osteoporosis
- Mgmt
- Exercise: weight bearing Drugs - bisphosphonates 1st line - Ergocalciferol: reduce progression - Selective estrogen receptor modulators: raloxifine (no inc risk - Estrogen: postmenopausal women only - PTH: teriperiwtide - calcitonin: last line
Bisphosphonate MOA
slow down bone loss by inhibiting osteoclast bone resorption
Polyarteritis Nodosa
- overview
- associated with what other dz
- systemic vasculitis if the small/medium arteries
- assoc with HBV
Polyarteritis Nodosa
- pathophysiology
- Leads to necrotizing inflammatory lesions
- Micro aneurysms rupture
- Hemorrhage, thrombosis
- Organ ischemia and infarction
Polyarteritis Nodosa
- Clinical
- renal: HTN (inc renin), renal failure
- constitutional: fever, myalgias, arthritis
- lung usually spared
- CNS: neuropathy, mononeuritis multiplex
- Derm: livedo reicularis, purpura, ulcers
Polyarteritis Nodosa
- dx
- inc ESR
- usually ANCA negative
- biopsy: necrotizing lesions
- renal/mesenteric angiography: microaneuryisms with small artery cut-off
Polyarteritis Nodosa
- mgmt
- steroids
- plasmapheresis if HBV pos
Polymyalgia rheumatica
- overview
- idiopathic inflammation which leads to synovitis, bursts, tenosynovitis
- pain and stiffness of proximal joints
- Usu >50 yo
- closely related to giant cell arteritis
Polymyalgia rheumatica
- Clinical
- bilateral, proximal joint aches/stiffness
- Worse in the morning
- No severe muscle weakness
Polymyalgia rheumatica
- dx
- clinical
- Inc ESR
- normochromic normocytic anemia
Polymyalgia rheumatica
- mgmt
- low dose steroids
- NSAIDs
Polymyositis
- overview
- idiopathic inflammatory muscle disease of proximal limbs, neck, pharynx
- may affect heart, lung, GI
Polymyositis
- Clinical
- progressive, symmetrical proximal muscle weakness
- usu painless
Polymyositis
- dx
- Lab: inc aldolase*, CK, ESR
- Positive muscle biopsy
- abnl EMG
- anti-Jo
- mechanics hands
- interstitial lung fibrosis
Polymyositis and dermatomyositis
- Antibodies
Polymyositis - Anti-SRP - Anti-Jo Dermatomyositis - Anti-mi-2
Polymyositis
- mgmt
- high dose steroids
Dermatomyositis
- clinical
- heliotrope upper eyelide discoloration
- Gottron’s papules (raised violacious scaly eruptions on knuckles)
- Malar rash which includes nasolabial folds
- Photosensitive “shawl” sign
- Diffuse alopecia
Dermatomyositis
- dx
- increased aldolase, CK, ESR
Reactive arthritis
- overview
- autoimmune response to infection elsewhere in the body
- MC 20-40 yo male
Reactive arthritis
- clinical
- arthritis: asymmetric
- conjunctivitis/uveitis
- urethritis
Reactive arthritis
- associated dzs
- time frame
- MC chlamydia
- gonnorhea
- GI infections
- usu 1-4 weeks post infection
Reactive arthritis
- dx
- HLA-B27
- WBC: 10-20k
- IgG
- synovial fluid WBC 1-8K, aseptic
Reactive arthritis
- mgmt
- NSAIDs
- no response > methotrexate, sulfasalazine, steroids
Scleroderma
- overview
- systemic connective tissue disorder
- thickened skin
Scleroderma
- clinical
- tight, shiny, thick skin
Scleroderma
- 2 types
- limited cutaneous systemic sclerosis (CREST)
- Diffuse cutaneous systemic sclerosis
Scleroderma
- Limited cutaneous systemic sclerosis
- calcinosis cutis
- Raynauds
- esophageal motility disorders
- sclerodactyly
- telangeictasias
Scleroderma
- Diffuse cutaneous systemic sclerosis
trunk and proximal extremities effected
Scleroderma
- dx
- Pos anti-centromere Ab (More associated with CREST, better prognosis)
- Pos anti-scl-70
Scleroderma
- mgmt
- DMARDs
- Steroids
- Raynauds: CCB, prostacyclin
Sjogren’s Syndrome
- overview
Autoimmune reaction vs. exocrine glands
** aggregation of lympocytes
Sjogren’s Syndrome
- clinical
- Xerostomia
- Dry eyes
- parotid enlargement
- commonly seen with thyroid disfunction
Sjogren’s Syndrome
- Dx
- pos ANA
- Pos Antiss-A (Ro)
- Pos Antiss-B (La)
- Pos RF
- Pos Shirmer test (reduced tear production)
SLE
- overview
chronic, systemic, multi-organ autoimmune disease of connective tissue
SLE
- RF
- genetic
- environmentla
- sun exposure
MC young, AA/hispanic/native american females
SLE
- drug causes
- procainamide
- hydralazine
- INH
- Quinidine
SLE
- clinical
- Triad: joint pain, fever, malar rash (spares nasolabial fold)
- Serositis - pleurites and pericarditis
- Discoid: annular, red patches on face and scalp, heal with a scar
- Systemic: CNS, cardiovascular, glomerulonephritis, retinitis, oral ulcers, alopecia
SLE
- Dx
- Pos ANA (best initial test)
- Pos anti-double stranded DNA
- Pos anti-Smith (100% specific)
- CBC: +/- anemia, leukopenia, lymphopenia, thrombocytopenia
SLE
- Mgmt
- Sun protection
- hydroxychloroquine
- NSAIDs
- +/- pulse steroids
- methotrexate
- cyclophosphamide
Antiphospholipid ab syndrome
- causes risk of what
- increased risk of arterial and venous thrombosis
Antiphospholipid ab syndrome
- Dx
- Anticardiolipin Ab (*assoc with false positive for VDRL/RPR)
- Lupus anticoag
- Increased risk of miscarriages
Rheumatoid Arthritis
- overview
symmetric polyarthritis, bone erosion, cartilage destruction, and joint structure loss (via pannus destruction)
Rheumatoid Arthritis
- autoimmune response
T-cell related
Rheumatoid Arthritis
- Clinical
- prodrome: systemic sx
- small joint stiffness (MCP, PIP, wrist, etc), worse with rest
- symmetric arthritis - swollen, tender, erythematous, “boggy” joint
- Boutonnierre and swan neck deformities
- MCP unlar deviation
Rheumatoid Arthritis
- dx
- RF positive (best initial test)
- Pos anti-cyclic citrullinated peptide Ab (most specific to RA)
- arthritis in ≥ 3 joints ≥ 6 weeks
- anemia of chronic dz
- XR: narrowed joint space
Rheumatoid Arthritis
- Mgmt
- prompt start DMARDS to reduce joint damage
- methotrexate first line
- +/- NSAIDs and steroids
DMARDS
- Nonbiologic (list 4)
- methotrexate
- leflunomide
- hydroxychloroquine (plaque nil)
- sulfasalazine
Methotrexate
- MOA
- SE
- reduces lymphocyte proliferation, immunosuppresant
- Hepatotoxicity, stomatitis, leukopenia, bone marrow suppression
Leflunomide
- MOA
reduces T cell activation, prevents new joint erosion
- use as an alternative to methotrexate
Hydroxychloroquine
- MOA
- when to use
- SE
- Reduces RF and active phase reactants
- use in mild disease
- Retinal toxicity- fundoscope q6-12 months
Sulfasalazine
- MOA
Anti-inflammatory
- use in mild cases, less effective than methotrexate or leflunomide
DMARDS
- list 5 biologics used
- Etanercept (Enbrel): usually first line drug
- Infliximab (Remicade): usually added to methotrexate, not usu mono therapy
- Adalimumab (Humira): usually added to methotrexate, not usu mono therapy
- Anakinra
- Rituximab
- What tests must be done prior to starting any biologic DMARDS?
- When to avoid TNF inhibitors
- PPD to screen for tuberculosis
- Also screen for HBV and HCV
- Avoid TNF inhibitors if active or chronic infection
