Rheumatology Flashcards
approach to joint: single joint
septic
crystals
approach to joint: multiple joints
osteoarthritis lupus rheumatoid scleroderm myositis seronegatives
approach to joint pain: chronic
osteoarthritis, lupus, rheumatoid, scleroderma, myositis, seronegatives
approach to joint pain: acute
septic, trauma, crystal, reactive
approach to joint pain: isolated
septic, crystal
approach to joint pain: systemic manifestations
seronegative (IBD)
lupus (face, CNS, renal, heart, lung)
rheumatoid (nodules, serositis)
reactive (oral + genital ulcer)
approach to joint pain: degenerative
osteoarthritis
approach to joint pain: inflammatory
everything else
normal joint serology
clear
<2% wbcs
<25% polys
no gram/cx/dx
non-inflammatory joint serology
clear <2% wbcs <25% polys no gram/cx dz osteoarthritis
inflammatory joint serology
yellow, white >2, <50 wbcs >/= 50% polys no gram/cx dz everything but OA/infection
sepsis joint serology
opaque >50 wbcs >/= 75% polys \+ gram/cx dz infection
antinuclear antibodies
sensitive lupus
anti-histone antibodies
specific drug-induced lupus
anti-ds-DNA antibodies
specific lupus + renal involvement
anti-smooth muscle antibodies
autoimmune hepatitis
anti-mitochondrial antibodies
primary biliary cirrhosis
anti-centromere antibodies
scleroderma (CREST)
anti-Ro+La antibodies
sjogren’s
anti-CCP antibodies
rheumatoid arthritis
anti-RF antibodies
rheumatoid arthritis
anti-Jo antibodies
polymyositis
anti-topoisomerase antibodies
systemic scleroderma
lupus path
autoimmune, complex formation
lupus pt
women > men
blacks > whites
lupus pt
MD SOAP BRAIN Malar rash Discoid rash Serositis Oral ulcers Arthritis Photosensitivity Blood Renal failure ANA Immunologic Neurology
lupus dx
1st: ANA
then: ds-DNA
- anti-smith
- anti-histone (drug induced)
lupus nephritis
- U/A -> bx kidney
flare
- complement levels decrease in flare
- complement levels increase in infection
lupus tx
reduce flares: hydroxychloroquine control symptoms: NSAIDs flare: prednisone severe: mycophenolate mofetil nephritis: IV cyclophosphamide
drug-induced lupus path
drugs
procainamide
α-methyldopa
hydralazine
drug-induced lupus pt
NO visceral involvement
skin and joints only
drug-induced lupus dx
anti-histone
drug-induced lupus tx
remove drug
antiphospholipid antibody (APLA) syndrome path
lupus “anticoagulant” (in the lab) actually causes coagulation (in the body)
anti-cardiolipin antibodies
anti-cardiolipin antibodies
antiphospholipid antibody (APLA) syndrome
antiphospholipid antibody (APLA) syndrome pt
arterial AND venous clots
lupus
false + RPR … negative FTA-abs
antiphospholipid antibody (APLA) syndrome dx
increase PTT, normal INR
mixing study fails to correct
Russell Viper Venom tests
antiphospholipid antibody (APLA) syndrome tx
warfarin + aspirin
rheumatoid arthritis path
autoimmune disease
women > men
age > 40
panes formation -> joint destruction
RA pt
Nobody Should Have Rheumatoid Symptoms 3 times (x) N: nodules S: symmetric H: hands R: RF or CCP S: stiffness 3: 3 or more joints, spares DIP X: xray shows erosions
RA dx
1st RF or CCP
RF tx
DMARDs (everyone and early) biologics (severe) ... NSAIDs (sxs) steroids (flare)
DMARD = methotrexate NSAID = ibuprofen/meloxicam biologics = etanercept, infliximab
RF f/u
screen for TB and fungus before biologics
spine involvement = C1 and C2
bilateral carpal tunnel syndrome could be early RA
Felty syndrome = RA + neutropenia + splenomegaly
Giant cell Arteritis path
multinucleated giant cells in large vessels like the temporal artery
GCA pt
age > 50
unitemporal head pain
tender jaw claudication
vision loss
GCA dx
biopsy (skip, treat first)
GCA tx
give steroids before biopsy
GCA f/u
elevated ESR, CRP, low-grade possible findings
polymyalgia rheumatica path
similar pathology to GCA, large-vessel vasculitis
polymyalgia rheumatic pt
symmetric pain and stiffness of neck, shoulder, and hip girdle
proximal muscle weakness but normal CK (idiopathic inflam myop)
polymyalgia rheumatica dx
clinical (normal CK, high ESR)
polymyalgia rheumatica tx
steroids
polymyalgia rheumatica f/u
angiogram rules out other diseases
takayasu arteritis path
giant-cell arteritis of the aorta, subclavian, or axillary arteries
takayasu arteritis pt
asymmetric pulselessness, discordant BPs left to right arm
pulseless disease
< 40
takayasu arteritis dx
angiogram (CT, MRI, direct)
takayasu arteritis tx
high-dose prednisone
polyarteritis nodosa path
medium-vessel vasculitis
HepB-related, maybe
polyarteritis nodosa pt
infarction of multiple organs without common vascular distribution
purpura, mesenteric ischemia, non-glomerulonephritis, renal failure
polyarteritis nodosa dx
angiogram = micro aneurysms and stenosis
polyarteritis nodosa tx
high-dose steroids and cyclophosphamide
Kawasaki disease path
medium-vessel vasculitis
kawasaki pt
asian child, strawberry tongue, truncal rash, palmar erythema, desquamation
kawasaki dx
clinical
kawasaki tx
IVIG and ASA
cryoglobulinemia path
HepC, cryoglobulins
small vessel, complex deposition
cryglobulinemia pt
palpable purpura, decreased complement, elevated RF
cryoglobulinemia dx
clinical
cryoglobulinemia tx
steroids, plasmapheresis
IgA vasculitis path
small vessel, IgA deposition
Henoch-Schonlein Purpura
IgA vasculitis pt
palpable purpura, abdominal pain, abdominal bleeding
IgA vasculitis dx
biopsy = leukocytoclastic vasculitis with immune complexes
IgA vasculitis tx
steroids
ganulomatosis with polyangiitis path
c-ANCA positive, small vessel
necrotizing vascuitis
ganulomatosis with polyangiitis pt
hematuria, hemoptysis, sinuses
ganulomatosis with polyangiitis dx
biopsy
ganulomatosis with polyangiitis tx
steroids and cyclophosphamide
ganulomatosis with polyangiitis f/u
‘eosinophilic’ if p-ANCA, asthma, allergies, and similar presentation
polyangiitis if p-ANCA and no granulomas with similar presentation
scleroderma path
collagen deposition disease replaces smooth muscle and skin
scleroderma pt
diffuse cutaneous systemic sclerosis: face, hands, feet - above elbow and knee
visceral inolvement - kidney and interstitial lung disease
scleroderma dx
anti-topoisomerase = anti-Scl-70
scleroderma tx
no tx available
NO steroids = harmful!
scleroderma f/u
renal crisis = ACE-I
reflux = PPIs
Raynaud’s = CCB
ILD = cyclophosphamide
CREST path
same as scleroderma
CREST pt
limited cutaneous systemic sclerosis C: calcinosis R: Raynaud's E: Esophagus S: Sclerodactyly T: Telangiectasia
CREST dx
anti-centromere antibodies
CREST tx
no treatment available
CREST f/u
pulmonary HTN without parenchymal disease
Sjogren’s path
lymphocytic infiltrates of exocrine glands
Sjogren’s pt
dry eyes
dry mouth
parotid swelling, dental caries
Sjogren’s dx
anti-Ro, anti-La
Schirmer test
Sjogren’s tx
artificial tears
artificial saliva
idiopathic inflammatory myopathy path
dermatomyositis = inflammation epimysium, skin findings
polymyositis = inflammation perimysium, central necrosis
inclusion body myositis = vacuoles
idiopathic inflammatory myopathy pt
skin findings = Gottron’s papule, heliotrope rash, shawl sign
proximal muscle weakness (myo-pathy)
AND
painful tender muscles (myo-sitis)
idiopathic inflammatory myopathy dx
1st: elevated serum CK, adolase
then: EMG
best: biopsy of muscle
idiopathic inflammatory myopathy f/u
anti-Mi, anti-Jo, associated antibodies
monoarticular arhtropathies
gout gonorrhea septic joint pseudogout tumor lysis syndrome staph septic joint
gout path
monosodium urate crystales
increased production -> allopurinol
decreased elimination -> probenecid
gout pt
podagra
single hot swollen painful joint
gout dx
arthrocentesis
negatively birefringent
needle-shaped crystal
gout tx: acute
flare mild = < 4 joints, digits only - NSAIDs (if not bleeding, CKD) - colchicine (not if chronic ppx) - steroids (last choice of three) mod = >/= 4 joints, or any non-digit joint - dual therapy: -- NSAIDs + colchicine (preferred) -- steroids + colchicine (ok) severe = same as moderate
gout tx: chronic induction
xanthine-oxidase inhibitor if:
- > 2 attacks/yr, goal uric acid < 6
colchicine-px until urate < 6 (NSAIDs ok)
gout tx: chronic stable
d/c colchicine ppx after urate < 6
do not stop allopurinol in flare
gout f/u
diet: decrease fructose, EtOH, red meat/seafood (purines)
xanthine-oxidase inhibitors: febuxostate = allopurinol but $$$
urate lowering agents: probenecid (rarely useful)
intra-articular glucocorticoids when in acute flare but unsafe for all else
gonorrhea septic joint path
STD -> hematogenous
intracellular organism
gonorrhea septic joint pt
STDs, lots of sex, no protection
urethritis, cervicitis
gonorrhea septic joint dx
arthrocentesis without organisms
NAAT to confirm
gonorrhea septic joint tx
ceftriaxone AND (azithro or doxy)
pseudogout path
calcium pyrophosphate
pseudo gout pt
single swollen joint
pseudo gout dx
positively birefringent
rhomboid shaped crystals
pseudo gout tx
NSAIDs (first)
colchicine (better as ppx)
steroids (CKD)
tumor lysis syndrome path
large tumor burden, cell turnover
blood cancers
tumor lysis syndrome pt
cancer getting chemo
tumor lysis syndrome dx
renal failure, lots of stones
tumor lysis syndrome tx
rasburicase
tumor lysis syndrome ppx
IVF and allopurinol
staph septic joint path
direct inoculation (wound) hematogenous spread
staph septic joint pt
penetrating trauma
IVDA, endocarditis
staph septic joint dx
arthrocentesis with organisms
staph septic joint tx
nafcillin…vancomycin
seronegative arthropathies
ankylosing spondylitis
psoriatic arthritis
reactive arthritis (Reiter’s)
IBD-related, enteropathic arthritis
ankylosing spondylitis path
sacroiliitis
ankylosing spondylitis pt
low back pain
morning stiffness
better with exercise, worse with rest
ankylosing spondylitis dx
lumbar lateral xray
‘bamboo spine’
ankylosing spondylitis tx
NSAIDs (first line)
methotrexate (peripheral skeleton)
intra-articular glucocorticoids (pain)
TNF-α inhibitors (severe or refractory)
psoriatic arthritis path
autoimmune
psoriatic arthritis pt
40-50 men
psoriasis + arthritis
‘nail pitting’ ‘sausage digits’
an arthritis question with a picture of a fingernail is psoriatic …. a picture of a deformity is RA
psoriatic arthritis dx
clinical
psoriatic arthritis tx
NSAIDs (mild arthritis)
methotrexate (moderate arthritis)
TNF-α inbhibitors (MTX failure)
psoriatic arthritis f/u
mild: < 4 joints, no erosion
mod: >/= 4 joints, no erosion
sev: any erosion, MTX fails
reactive arthritis
Reiter’s
reactive arthritis path
STD, non-gonococcal urethritis
reactive arthritis pt
cervicitis + arthritis
urethritis + arthritis
urethritis + arthritis + conjunctivitis
reactive arthritis dx
finding the STD
- swab everywhere semen can go
reactive arthritis tx
doxy OR azithro (chlamydia) IM ceftriaxone (gonorrhea)
IBD-related, enteropathic arthritis path
inflammatory, idiopathic
IBD-related, enteropathic arthritis pt
men = women
IBD (Crohn’s or UC) + arthritis
IBD-related, enteropathic arthritis dx
clinical
IBD-related, enteropathic arthritis tx
treat the enteropathy, treat the arthritis mild: 5-ASA mod: azathioprine or 6-MP severe: - UC = resection - Crohn's = anti-TNF