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Rheumatology Flashcards

1
Q

What are the WBC and morning stiffness cutoffs for inflammatory vs non inflammatory pain?

A

> 60 mins and >2k for inflammatory pain

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2
Q

What disease association?

ANA

A

SLE
SSc
Sjogren syndrome
titer doesn’t correlate with disease activity

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3
Q

What disease association?

Anti Sm

A

SLE

most specific but doesn’t correlate with disease activity

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4
Q

What disease association?

Anti-u1-RNP

A

MCTD

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5
Q

What disease association?

Anticentromere pattern of ANA

A

CREST; SSc and PH

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6
Q

What disease association?

Anti-dsDNA Ab

A

SLE

correlates with disease activity, especially renal

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7
Q

What disease association?

Anti smooth muslce AB

A

autoimmune hepatitis

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8
Q

What disease association?

Anti La, SSB

A

Sjogren, neonatal SLE

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9
Q

What disease association?

Anti SCL-70 Ab

A

SSc and pulmonary fibrosis/diffuse cutaneous SSc

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10
Q

What disease association?

antihistone Ab

A

drug induced SLE

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11
Q

Anti-Ro / SSA Ab

A

Sjogren syndrome, neonatal heart block, subacute cutaneous lupus

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12
Q

What disease association?

c-ANCA/ Anti-PR3 Ab

A

Granulomatosis with polyangiitis

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13
Q

What disease association?

p-ANCA / anti-MPO Ab

A

Eosinophilic granulomatosis with polyangiitis

MPA - microscopic polyangiitis

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14
Q

What disease association?

Anti-Jo-1 Ab

A

polymyositis and antisynthetase syndrome

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15
Q

What disease association?

Anti-CCP Ab

A

RA

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16
Q

What are the common features of RA?

A

morning stiffness > 1 hour
pain in PIP, MCP, elbow, wrist, knee, ankle and MTP joints
subcataneous nodules over bony prominences or extensor surfaces
synovitis - soft tissue swelling or effusion

symptoms > 6 weeks

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17
Q

What are common lab findings in RA?

A

70% of patients will have positive RF or anti-CCP Ab at time of diagnosis, elevated ESR and CRP, normocytic anemia

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18
Q

How can you trend response to therapy in RA

A

Xrays

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19
Q

What are common findings on Xray in RA?

A

joint space narrowing
bony erosions
periarticular osteopenia

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20
Q

does a negative RF exclude RA?

A

no, can have seronegative RA

don’t be tricked!

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21
Q

is a positive RF alone diagnostic of RA?

A

no

don’t be tricked!

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22
Q

Do fluctuations in RF mirror disease activity?

A

no

don’t be tricked!

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23
Q

If you see systemic arthritis and…

skin rash and leukopenia

What is the diagnosis?

A

SLE

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24
Q

If you see systemic arthritis and…

psoriasis or pitted nails

What is the diagnosis?

A

Psoriatic arthritis

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25
Q

If you see systemic arthritis and…

day care worker or contact with small children

What is the diagnosis?

A

Parvo B19 (usually self-limited after 3 months)

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26
Q

If you see systemic arthritis and…

2nd and or 3rd MCP and PIP joint arthritis with hook like osteophytes

What is the diagnosis?

A

hemochromatosis

photo of hook like osteophytes: https://prod-images-static.radiopaedia.org/images/4750489/8bbaca8e62d97ef4b31ba38c3500ea_jumbo.jpg

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27
Q

If you see systemic arthritis and…

Raynaud phenomenon and sclerodactyly

What is the diagnosis?

A

SSc (systemic sclerosis)

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28
Q

If you see systemic arthritis and…

proximal muscle weakness

What is the diagnosis?

A

Polymyositis or dermatomyositis

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29
Q

If you see systemic arthritis and…

recent immunizations

What is the diagnosis?

A

post-rubella immunization arthritis

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30
Q

If you see systemic arthritis and…

Tophi with symmetric small joint involvement of the hands and feet

What is the diagnosis?

A

chronic tophaceous gout

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31
Q

If you see this in an RA patient you should think of what diagnosis?

arm parestehsias and hyperreflexia

A

C1-2 subluxation (increase risk of cord compression with tracheal intubation)

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32
Q

If you see this in an RA patient you should think of what diagnosis?

cough, fever, pulmonary infiltrates

A

BOOP

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33
Q

If you see this in an RA patient you should think of what diagnosis?

foot drop or wrist drop

A

mononeuritis multiplex

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34
Q

If you see this in an RA patient you should think of what diagnosis?

hoarseness

A

cricoarytenoid involvement

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35
Q

If you see this in an RA patient you should think of what diagnosis?

multiple basilar pulmonary nodules

A

Caplan syndrome

pneumoconiosis related to occupational dust, characterized by rapid development of multiple basilar nodules and mild airflow obstruction

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36
Q

If you see this in an RA patient you should think of what diagnosis?

dry eyes or mouth

A

Sjogren’s

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37
Q

If you see this in an RA patient you should think of what diagnosis?

pleural effusion with low plasma glucose <30mg/dl

A

rheumatoid pleuritis

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38
Q

If you see this in an RA patient you should think of what diagnosis?

pulmonary fibrosis

A

rheumatoid ILD

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39
Q

If you see this in an RA patient you should think of what diagnosis?

skin ulcers, peripheral neuropathy

A

rheumatoid vasculitis

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40
Q

If you see this in an RA patient you should think of what diagnosis?

splenomegaly and granulocytopenia

A

Felty syndrome

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41
Q

If you see this in an RA patient you should think of what diagnosis?

red, painful eye

A

scleritis or uveitis

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42
Q

If you see this in an RA patient you should think of what diagnosis?

HF

A

rheumatoid disease or anti-TNF therapy

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43
Q

All RA patients undergoing general anesthesia should have what test done?

A

cervical xrays to assess for atlantoaxial subluxation

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44
Q

What is the goal of RA treatment?

A

treat to target with the target being remission or low disease activity

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45
Q

What is the treatment for quick symptomatic relief for RA?

A

NSAIDs and low dose oral and intra-articular glucocorticoids

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46
Q

What is the treatment for RA for most patients?

A

MTX

start immediately if signs of erosive disease

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47
Q

What is the treatment for RA in early, mild, non-erosive disease?

A

HCQ
sulfasalazine
combo therapy with these agents

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48
Q

When should you use biologics for RA?

A

when disease control is not achieved with oral DMARDs

add TNF-a inhibitor to MTX

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49
Q

What are common toxicities with TNF-a therapy

A

pancytopenia
positive ANA associated with SLE like symptoms
demyelinating disorders

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50
Q

Should you use combo biologic therapy to treat RA?

A

No, not recommended

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51
Q

What additional meds should all patients with RA receive?

A

calcium and Vit D supplementation

bisphosphonates for osteoporosis and DEXA scans

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52
Q

Can pregnant patients take MTX or leflunomide?

A

NO!

don’t be tricked!

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53
Q

What meds are safe for pregnant patients with RA to take?

A

hydroxychloroquine and sulfasalazine

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54
Q

What are the hallmark features of Sjogren’s syndrome

A

keratoconjunctivitis sicca
xerostomia
salivary gland enlargement

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55
Q

What illness are patients with Sjogren syndrome much more likely to get?

A

B cell lymphoma, specifically large B-cell and MALT lymphoma

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56
Q

What is the treatment for: Sjogren syndrome

A

symptomatic: artificial tears and saliva

57
Q

What are the main features of OA?

A

joint pain worse with activity
reducted joint motion
crepitus
tenderness along the joint line
bony enlargement. - Heberden and Bouchard nodes
involvement of first CMC joint with squaring of the base of the thumb

58
Q

When should you think of secondary OA?

A

think of a metabolic cause when OA develops in atypical joints: MCP, shoulder or wrist

59
Q

When should you consider surgery for OA?

A

when pain doesn’t respond to nonsurgical treatment, especially when lifestyle or ADLs are affected

60
Q

What diseases are associated with hypertrophic osteoarthropathy?

A

lung cancer
chronic pulmonary infections
R to L cardiac shunts

61
Q

What are common characteristics of spondyloarthritis?

A

inflammatory spine and SI disease
asymmetric inflammation in <4 peripheral joints, usually large joints
- inflammation at the sites of ligament and tendon insertion
- HLA B27
- negative RF and anti-CCP

62
Q

Can HLA-B27 independently confirm or exclude a diagnosis of ankylosing spondylitis or other spondyloarthirtis?

A

no

63
Q

What is the diagnosis?

patient with nail pitting, joint pain and stiffness

A

psoriatic arthritis

64
Q

How can you distinguish RA from psoriatic arthritis on exam?

A

sausage fingers - dactylitis is commonly seen in psoriatic arthritis

65
Q

Explosive onset of psoriatic arthritis should prompt workup for what disease?

A

HIV infection

66
Q

What is the treatment for psoriatic arthritis

A

NSAIDs initially
MTX for peripheral joint disease if not responding to NSAIDs, will also treat skin
- TNF-a inhibitor for AXIAL disease unresponsive to MTX, unlike RA, often discontinue MTX once TNF-a inhibitor shows improvement

67
Q

What medications for psoriatic arthritis can exacerbate psoriasis?

A

NSAIDs
antimalarials
withdrawal from steroids

68
Q

Is there a relationship between the extent of joint disease and skin disease in psoriatic arthritis?

A

no

don’t be tricked!

69
Q

has mtx been shown to reduce progression of joint damage in psoriatic arthritis?

A

no, only joint pain and control of skin disease

70
Q

What infection is commonly found in patients with reactive arthritis?

A

HIV

71
Q

What are common manifestations of reactive arthritis?

A
  • monoarthritis or acute asymmetric oligoarthritis (usually in weight bearing joints)
  • dactylitis
  • enthesopahty of achilless tendon
  • sacroiliitis
72
Q

What is the workup for reactive arthritis?

A

HIV
GC
Stool cultures for GI pathogens ifdiarrhea is present
if no pathogen is found, reactive arthritis is usually self-limited

73
Q

What is the diagnosis?

35M with back pain with 2 hours of morning stiffness, worse at night, improves with activity and heat

A

ankylosing spondylitis

74
Q

What are extra-articular manifestations of ankylosing spondylitis?

A 
acute anterior uveitis
aortic valvular regurgitation
aortic aneurysm
cardiac conduction defects
apical pulmonary fibrosis and cavitation
cauda equina syndrome
75
Q

A patient with ankylosing spondylitis shows up to the ER after a minor fall with neck pain, what’s the next step?

A

urgent CT C Spine to rule out a fracture

76
Q

What is the treatment for ankylosing spondylitis?

A

NSAIDs - mainstay of treatment

glucocorticoid injections

TNF-a inhibitors if not responding to NSAIDs

MTX, sulfasalazine and HCQ for peripheral joint disease

Ca and Vit D supplementation for all patinets

77
Q

Should you prescribe MTX, sulfasalazine or HCQ to patients with ankylosing spondylitis for AXIAL pain?

A

No, they are ineffective, use a TNF-a inhibitor

don’t be tricked!

78
Q

What medications are effective at treating IBD associated arthritis?

A

TNF-a inhibitors infliximab and adalimumab

79
Q

nonscarring alopecia is common in what disease

A

SLE

80
Q

Subacute cutaneous SLE is commonly a result of what?

A

drug induced and not related to systemic disease

81
Q

Pain or decreased ROM of hips in a patient with SLE suggests what?

A

osteonecrosis

82
Q

lung infiltrates in SLE are more likely to be related to SLE lung parenchymal involvement or infection?

A

infection, parenchymal involvement is rare

83
Q

Patient with a positive ANA and a facial rash that involves the nasolabial folds - is this lupus?

A

No! malar rash doesn’t involve the nasolabial folds

don’t be tricked!

84
Q

What antibodies correlate with SLE disease activity?

A

anti-dsDNA ab

85
Q

What lab findings often accompany SLE flares?

A

low complement levels

86
Q

What are the common lab findings in drug-induced lupus?

A

Pos ANA
negative Anti- Smith and anti-dsDNA ab

anti-histone may be positive

87
Q

Is an isolated ANA 1:40 to 1:80 likely to be SLE?

A

no

don’t be tricked!

88
Q

Are myalgia, arthralgia and fatigue enough reasons to check an ANA?

A

no, not according to boards basics!

don’t be tricked!

89
Q

should you monitor serial ANA titers in patients with SLE?

A

no, doesn’t correlate with disease activity

don’t be tricked!

90
Q

What is the treatment for SLE for arthritis?

A

NSAIDs and HCQ - keep going with HCQ even if they have quiescent disease in order to prevent flares

91
Q

What is the treatment for photosensitive cutaneous lupus

A

sun block
topical steroids
HCQ

92
Q

What is the treatment for life-threatening SLE

A

high dose steroids and cyclophosphamide or mycophenalate mofetil

93
Q

what supplements should patients with SLE be taking?

A

vit d and Ca

94
Q

What do patients on HCQ require for monitoring?

A

annual optho exams

don’t be tricked!

95
Q

what medications can be used in pregnant patients with SLE?

A

HCQ

prednisone

96
Q

What is the treatment for SLE flare with isolated class V nephritis and withOUT kidney dysfunction

A

in isolated class V lupus nephritis, especially without kidney dysfunction, mycophenolate mofetil is the most appropriate initial immunosuppressive therapy

IF the patient had evidence of kidney dysfunction, they cyclosporine would be be used initially with mycophenolate mofetil as maintenance therapy. Cyclosporine has more side effects

97
Q

What is the primary cause of morbidity and mortlity in patients with systemic sclerosis

A

pulmonary disease

98
Q

Anti-centromere Ab is associated with what form of systemic sclerosis?

A

limited cutaneous

99
Q

Anti-Scl-70 Ab is associated with what form of systemic sclerosis?

A

Diffuse cutaneous systemic sclerosis

100
Q

Is skin tightening without Raynaud’s scleroderma?

A

no, another scleroderma-like condition

101
Q

What is the treatment for scleroderma

A

nothing systemic is available

do not treat with steroids - can precipitate scleroderma renal crisis

102
Q

What is the main cause of mortality in patients with MCTD

A

pulmonary HTN

103
Q

Should you use NSAIDs or opiates to treat fibromyalgia?

A

no

104
Q

What is a common drug trigger of acute gout?

A

HCTZ

Losartan is a better HTN drug for these patients due to its mild uricosuric effect

105
Q

Do you need a synovial fluid analysis to diagnose gout if the patient presents with podagra?

A

no

106
Q

Patient with CKD with gout - what long term med is useful

A

Febuxostat

107
Q

What medication is a contraindication to allopurinol or febuxostat

A

azathioprine

don’t be tricked!

108
Q

can patients wtih kidney failure take colchicine?

A

no!

don’t be tricked!

109
Q

Patients with CPPD who are less than 50 should be screened for what illnesses?

A

hemochromatosis
hypomagnesemia
hyperPTH
hypothyroidism

110
Q

Does the absense of chondocalcinosis on x ray rule out CPPD?

A

no

don’t be tricked!

111
Q

What is the treatment for pseudogout?

A

intra-articular steroids (after infection ruled out with arthrocentesis) if 1-2 joints involved

NSAIDs if multiple joints involved

colchicine if no response to NSAIDs, steroids if can’t tolerate those 2 meds

112
Q

What is a hallmark physical exam finding of infectious arthritis?

A

pain with passive extension of joint or when the joint is held in flexion

113
Q

What is the most common organism identified in infectious arthritis?

A

staph aureus

gonorrhea in young sexually active individuals

114
Q

Patients with recurrent gonococcal infections should be evaluated for what?

A

deficiencies in terminal complement components

115
Q

How do you diagnose TB as a cause of infectious arthritis?

A

synovial biopsy

116
Q

Does the presence of crystals in synovial fluid exclude an infectious process?

A

no, can have both!

don’t be tricked!

117
Q

What is the treatment for infectious arthritis due to gonorrhea?

A

IV CTX for 7 days + 1g oral azithro x1

do not step down to oral meds without sensies due to increasing resistance patterns

118
Q

If a patient is treated for infectious arthritis with antibiotics and the therapy is unsuccessful what diagnosis should you suspect?

A

TB

don’t be tricked!

119
Q

What is the treatment for: dermatomyositis and polymyositis

A
  1. high dose oral steroids
  2. add MTX or azathioprine if refractory dz
  3. ritux if refractory to above

*HCQ can help with derm manifestations of dermatomyositis

120
Q

What diagnosis should you suspect in a patient with continue or new onset prox muscle weakness despite normalization of muscle enzyme levels?

A

steroid induced myopathy

don’t be tricked!

121
Q

What lab test should you always check as part of a mypoathy workup?

A

TSH

don’t be tricked!

122
Q

if a patient has muscle pain are they likely to have a myopathy

A

no

muscle pain = myalgia

dermatoMYOSITIS and polyMYOSITIS refer to inflammation, not pain - so use the name to help you out!

123
Q

how do you diagnose takayasu’s

A

aortography

124
Q

woman with morning stiffness in proximal muscles and hips, normal muscle strength, no tenderness over muscles, normal CK, elevated ESR - what’s the diagosis

A

polymyalgia rheumatica

treat with low dose pred

relapses are common

125
Q

What labs are associated with granulomatosis with polyangiitis

A

c-ANCA

Anti PR3

126
Q

What labs are associated with microscopic polyangiitis

A

p-ANCA

Anti-MPO Ab

127
Q

What labs are associated with eosinophilic granulomatosis with polyangiitis

A

p-ANCA

Anti-MPO Ab

128
Q

What are possible complications of GCA?

A

aortic aneurysm and aortic dissection

don’t be tricked!

129
Q

Does PAN renal disease involve the glomerulus?

A

no

don’t be tricked!

130
Q

Do you need ot have eosinophilia to diagnose eosinophilic granulomatosis with polyangiitis?

A

Yes!

don’t be tricked!

131
Q

What is the treatment for relapsing polychondritis

A

NSAIDs, colchicine or dapsone

glucocorticoids if severe diseaes

132
Q

recurrent, self limited fevers and abdominal and pleuritic chest pain in man from lebanon with associated rash and arthritis - diagnosis?

A

familial Mediterranean fever

elevated ESR, CRP
positive amyloid A (AA)
postivie for mediterranean fever gene (MEFV)

133
Q

What is the treatment for familial Mediterranean fever ?

A

colchicine

134
Q

Patient with daily fever, fatigue, arthralgias and ferritin 2700 - diagnosis and treatment?

A

Adult onset stills

NSAIDs first line, can also use steroids

if refractory can use MTX, TNF-a inhibitors, or anakinra

135
Q

patient with vasomotor changes, skin chagnes and pain in extremity after surgery - what’s the diagnosis and mgmt?

A

complex regional pain syndrome

Dx: neuropathic pain, autonomic dysfunction, swelling, dystrophy, movement disorder and evidence of altered bone metabolism on bone scan, x ray or MRI

tx: PT, steroids, gabapentin and TCAs, can also use bisphosphonates for PAIN even if no signs of osteoporosis

136
Q

What is a common side effect of topical diclofenac?

A

skin reactions (rash, itch, and burning) than placebo (rate ratio, 1.14 [95% CI, 0.51-2.55]).

137
Q

What medications are FDA approved for fibromyalgia?

A

pregabalin
duloxetine
milnacipran

138
Q

bilateral hilar LAD
erythema nodosum
migratory polyarthralgia

What is the diagnosis?

A

Lofgren syndrome

highly specific for sarcoid. obviates need for tissue biopsy.

high value care

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