Rheumatology Flashcards
TNF adverse effects to know
1) hold in severe infections
2) reactivation of hepatitis B, which can be fatal
3) check for latent TB and screen regularly
4) avoid in class III/IV heart failure
5) Considered safe in pregnancy
6) positive ANA, with lupus-like syndromes
7) demyelination, similar to MS
Warning for lymphoma risk, though this is controversial
anti-smith
SLE (specific for diagnosis)
- do not correlate with disease activity, use to diagnose
anti-U1-RNP
MCTD
Anticentromere pattern of ANA
CREST syndrome, SSc and PH
anti-dsDNA ab
correlates with SLE disease activity
anti-smooth muscle
autoimmune hepatitis
anti-La/SSB
Sjogren syndrome, neonatal lupus
anti-Scl70
SSc, pulmonary fibrosis, diffuse cutaneous SSc
Antihistone
drug-induced SLE
Anti-Ro/SSA
Sjogren syndrome, subacute cutaneous lupus
c-ANCA (anti-PR3)
GPA
Need a GPA of 3 to Pass Rheumatology (PR3)
p-ANCA (anti-MPO)
Eosinophili granulomatosis with polyangiitis, and MPA
Anti-Jo-1
Polymyositis, and antisynthetase syndrome
Anti-CCP
RA
Anti-TNF biologics used in RA
1) Enteracept
2) Adalimumab
3) infliximab
4) Golimumab
5) Certolizumab
increased risk of infection, avoid live vaccines
Non-TNF biologics used in RA
1) Tocilizumab/sorilumab (Anti- IL-6)
2) Abtacept (CTLA-4 IgG)
3) Ritixuimab (B cell agent)
4) Anakinra (IL-1 inhibitor)
Findings in microscopic polyangiitis
nongranulomatous necrotizing pauci-immune vasculitis of the small vessels or pauci-immune necrotizing crescenteric GN
Clinical findings: pulmonary hemorrhage, pauci-immune small-vessel necrotizing vasculitis of the skin, proteinuria, inflammatory arthritis, positive p-ANCA (MPO, perinuclear)
histology differences between GPA, MPA, Eosinophilic GPA
GPA: granulomatous pauci-immune vasculitis
MPA: nongranulomatous pauci-immune vasculitis
E GPA: granulomatous pauci-immune vasculitis with eosinophilia
In severe refractory tophaceous gout, which IV therapy is indicated
Pegloticase infusion (porcine-derived uricase enzyme)
Stop other uric acid treatments, as serum urate levels are trended to screen for antibody development, and this may obscure this screening
Start prophylaxis for gout flares with either NSAIDs, glucocorticoids, or colchicine
Is the presence of HLA-B27 a diagnostic criterion for ankylosing spondylitis?
NO
It may be helpful with clinical presentation c/w ankylosing spondylitis, but without classic imaging findings
Diagnostic criteria for Ankylosing Spondylitis
- younger than 45
- inflammatory back pain >3 months duration
- bilateral sacroiliitis on imaging
What GI finding is seen in diffuse cutaneous systemic sclerosis?
GAVE: Gastric Antral Vascular Ectasia
- proliferation of blood vessels typically in the antrum, appears like watermelon stripes
- treat with APC or laser coagulation
What agent can be used off label for refractory gout?
Anakinra/canakinumab (IL-1 inhibitors)
Antibodies associated with neuropsychiatric SLE disease
1) antineuronal
2) anti-NMDA receptor
3) antiribosomal P
4) antiphospholipid
5) lupus anticoagulant
Drug-induced lupus (antihistone Ab +), culprit drugs
1) Hydralazine
2) Provainamide
3) INH
4) Minocycline
5) TNF-alpha inhibitors
Drug-induced cutaneous lupus, culprit drugs
1) ACE inhibitors
2) HCTZ
3) Hydralazine
4) Griseofulvin
5) NSAIDs
6) PPIs
7) Terbinafine
8) TNF-alpha inhibitors
Triad that makes up Felty Syndrome
1) Rheumatoid arthritis (usually aggressive, long-standing)
2) Neutropenia
3) Splenomegaly
Other clinical findings:
- Mononeuritis multiplex
- Necrotizing skin infections
- pleuropericarditis
- lymphadenopathy
- episcleritis
Associated risk for:
- severe infections
- lower extremity ulcers
- lymphoma
- vasculitis
Causes of acquired PAN
1) HBV
2) HIV
3) Hairy cell leukemia
Inclusion body myositis findings
An inflammatory myopathy involving the proximal and distal muscles
- typically symmetric (though muscle redistribution may be asymmetric)
- usually >50 years old
- Serum CK: 10-12x ULN
- insidious in onset (different from inflammatory myopathies)
- EMG: myopathic, neurogenic or mixed changes
- muscle biopsy: muscle fibers with multiple rimmed vacuoles
When to consider systemic therapy for Sjogren syndrome
1) Evidence of joint disease (erosions, bone damage)
2) CNS or systemic disease
Consider methotrexate for arthritis
Cyclosporine/rituximab for severe or systemic CNS disease
Findings in scleritis
1) eye pain
2) pain with gentle palpation of the globe
3) photophobia
4) scleromalacia (thinning of the sclera -> dark area), may lead to perforation
Rheumatoid arthritis is a common inflammatory cause
Note that episcleritis is infrequently associated with inflammatory/rheumatological disease
What makes up the arthritis-dermatitis syndrome of disseminated gonococcal infection?
1) Tenosynovitis
2) Dermatitis (painless pustular or vesiculopustular lesions)
3) polyarthralgia without frank athritis
Also will see fever, chills and malaise
Lofgren syndrome (seen in acute sarcoid arthritis)
1) hilar adenopathy
2) Acute arthritis
3) Erythema nodosum
The arthritis is usually oligoarticular
Takayasu arteritis vs. subcranial GCA
TA is seen in young women (9:1 ratio) between 15 and 24. Affects the aorta and major branches.
Subcranial GCA usually has preceding symptoms c/w PMR, as well as vasculitis affecting the large subcranial vessel. Seen in elderly patients and is a late feature of GCA. May cause heart failure.
Secondary causes of Calcium Pyrophosphate (CPP) arthritis (pseudogout)
1) hyperparathyroidism
2) Hypothyroidism
3) hypophosphatemia
4) hypomagnesemia
5) hemochromatosis
In GPA relapse, what medication is used to introduce remission
Rituximab
Shown to be superior to cyclophosphamide for relapsed ANCA vasculitis
Treatment for primary angiitis of CNS (PACNS)
Cyclophosphamide and high dose glucocorticoids
What are the features of Adult-Onset Stills Disease?
1) Spiking fevers
2) Pharyngitis
3) Evanescent salmon pink rash
4) Adenopathy, HSM
5) Elevated liver enzymes
6) leukocytosis with neutrophil predominance
7) inflammatory arthritis
8) Myalgias
9) extremely high ferritin
Look for this during pregnancy or in postpartum period
Anti-HMG Co-A reductase antibody
Seen in immune-mediated nectorizing myopathy
- consider in patient on a statin presenting with persistent myopathy following discontinuation of statin
- also use muscle biopsy to aid in diagnosis
Anti-cytosolic 5’-nucleotidase 1A antibodies
seen in inclusion body myositis (high specificity)
Treatment for undifferentiated connective tissue disease (UCTD)
Hydroxychloroquine
Recommended treatments for SLE nephritis
1) Mycophenolate mofetil (class V, if no renal dysfunction)
2) Cyclophosphamide (not preferred d/t SE)
3) Azathioprine
4) Rituximab
Mycophenolate mofetil is teratogenic, must be stopped 3 months prior to anticipated pregnancy
Side effects of DMARD therapy in RA
Methotrexate: hepatitis, bone marrow suppression
Leflunomide: GI upset, diarrhea, ALT elevation, cytopenias, infection, teratogenesis, and axonal neuropathy
RA patient recently started on leflunomide now with neuropathy symptoms -> stop the leflunomide
What class of drug is beliumumab? What is it used for?
B-lymphocyte stimulator (BLyS) protein inhibitor
Useful in mild to moderate SLE on glucocorticoids, especially in presence of mucocutaneous or joint symptoms .
What are the features of colchicine toxicity?
1) Rhabdomyolysis
2) AKI
3) Pancytopenia
Colchicine should be avoided in conjunction with CYP3A4 inhibitors (e.g. clarithromycin, fluconazole)
Skin findings in subacute cutaneous lupus
Annular with central clearing or papulosquamous with patchy erythematous plaques and papules.
~ 50% of patients with SCLE also have SLE
Drug-induced ANCA vasculitis. What drugs are implicated?
1) Hydralazine
2) Minocycline
3) PTU, Methimazole, Carbimazole (antithyroid drugs)
Look for double positive titers
Longstanding Systemic Sclerosis is a risk factor for what?
NHL (B-cell lymphoma)
Particularly if disease present for >6 years
How to differentiate between primary and secondary Raynaud’s on exam?
Nail fold capillary examination (normal in primary RP)
Signs of methotrexate toxicity
Somatitis
Megaloblastic anemia
Depletes folic acid stores, make sure folic acid is supplemented for all patients taking MTX
