RHEUMATOLOGY AND IMMUNOLOGY Flashcards
Most common type of arthritis
Osteoarthritis (OA)
A 35-year-old woman presents with 6-month history of hand stiffness and symmetric polyarticular arthritis. The stiffness is worst in the morning. Joint examination reveals mild swelling and tenderness over MCP joints of both hands and knees. The ESR is elevated.
RA
Most serious manifestation of SLE
Lupus nephritis
Classification of Lupus Nephritis
A 55-year-old obese woman complains that her left knee occasionally “locks up” and hurts after long walks. On examination, there is crepitus and decreased range of motion of the left knee but not warm or erythematous. The right hand reveals non-tender enlargement of distal interphalangeal joint.
Osteoarthritis
A 40-year-old woman with morning joint stiffness and bilateral ulnar deviation.
Rheumatoid arthritis
NON-GONOCOCCAL ARTHRITIS
- 90% involves single joint– most commonly the knee;
- Polyarticular infection (in patients with rheumatoid arthritis)
- Sternoclavicular joints, spine and sacroiliac joints involvement among IV drug user
Formerly viewed as the core of all other RA therapy (but now an adjunct)
NSAIDs
SLE in pregnancy should be controlled with ___
hydroxychloroquine ± prednisone/prednisolone.
specific for SLE
Anti Sm
most common hematologic abnormality of RA
Normocytic normochromic anemia
Most useful for confirming an inflammatory arthritis (vs OA), while at the same time excluding infection or gout
Synovial fluid analysis
Defined as either keratoconjunctivitis sicca (dry eyes) or xerostomia (dry mouth) with another CTD, such as RA
Sjögren syndrome
Jones criteria for ARF
o Two major PLUS evidence of preceding GAS infection
o One major + two minor PLUS evidence of preceding GAS infection
What are the differentials for isolated DIP involvement?
o Osteoarthritis (Heberden’s nodes) is usually not inflammatory
o Gout involving > 1 DIP joint often involves other sites with tophi
o Others: multicentric reticulohistiocytosis, inflammatory OA
A 23-year-old female presents right arm claudication. She also complains of malaise, fever, and arthralgias. Right brachial and radial pulses are absent.
Takayasu arteritis
most popular drugs to treat osteoarthritic pain
NSAIDs
DISSEMINATED GONOCOCCAL ARTHRITIS
• Migratory arthritis and tenosynovitis (knees, hands, wrist, feet and ankle)
most common early clinical manifestation of gout.
Acute arthritis
Early sign of inflammatory joint disease and can predict subsequent development of erosions
Bone marrow edema
DMARD of choice for early RA
Methotrexate
Most common pulmonary manifestation of SLE
Pleuritis w/ or w/o pleural effusion
DURATION OF PROPHYLAXIS
RF with carditis and persistent residual valvular disease
10 years after last attack or until 40 years old (whichever is longer, sometimes lifetime)
A 20-year-old female presents with abdominal pain, joint pains, and palpable rashes on the buttocks up to legs
HENOCH-SCHÖNLEIN (IgA VASCULITIS)
Population most often affected by gout
Middle-aged to elderly men and postmenopausal women
Mainstay of treatment during acute gouty attack:
o NSAID (First-line)
o Colchicine
o Glucocorticoids
Commonly affected joints in OA include
Cervical/lumbosacral hip, knee, and 1 st MTP
Urticaria vs Angioedema
DISCUSS THE ALGORITHM FOR MUSCULOSKELETAL COMPLAINT
What is the single most accurate test for RA?
Anti-CCP antibodies
most common route of spread of gonococcal arthritis in all age groups.
Hematogenous route of infection
Clinical Features of Felty’s Syndrome
useful in distinguishing lupus cerebritis and steroid-induced psychosis
Anti-neuronal and anti-ribosomal P
negatively birefringent needle-shaped monosodium urate crystals
Gout
Simplest effective treatment for OA
Avoid activities that precipitate pain
Mainstay tx for Non-life threatening SLE
Analgesic and antimalarials
In SLE, most have intermittent polyarthritis, most commonly in _____
Hands, wrists, knees
Most popular drugs to treat osteoarthritic pain
NSAIDs
What is the pathologic sine qua non of OA?
Hyaline articular cartilage loss
Medications approved for use in SLE
NSAIDS, salicylates, Hydroxychloroquine, Oral steroids, IV Methylprednisolone
Periarticular osteopenia as the initial radiographic finding
RA
Most common affected artery in takayasu arteritis?
Subclavian
_____ is more common with mycophenolate mofetil.
______ is more common with cyclophosphamide.
Diarrhea is more common with mycophenolate mofetil.
Nausea is more common with cyclophosphamide.
Differentiate OA from RA
initial radiographic finding of RA
Periarticular osteopenia
Other x-ray findings: Soft tissue swelling, joint space loss, subchondral erosions
Characteristic radiographic features (distinguish PsA from RA)
o DIP involvement or Pencil-in-cup deformity
o Marginal erosions with adjacent bony proliferation (“whiskering”)
o Small joint ankylosis
o Osteolysis of phalangeal and metacarpal bone, with telescoping of digits
o Periostitis and proliferative new bone at sites of enthesitis
o Characteristics of axial PsA: asymmetric sacroiliitis
DURATION OF PROPHYLAXIS
RF without carditis
5 years after last attack or until 21 years old (whichever is longer)
Frequent hallmark of RA and leads to decreased ROM, reduced grip, and trigger fingers
Flexor tendon tenosynovitis
What is the mainstay treatment for life-threatening SLE?
Systemic glucocorticoid
Most commonly used hypouricemic agent & is the best drug to lower urate in overproducers, stone formers, and renal disease
Allopurinol
Clinical Manifestations of Rheumatoid arthritis
• Early morning joint stiffness lasting more than 1 hour (eases with physical activity)
- Swelling of the hand joints (MCP, PIP) and feet (MTP)
- Symmetric distribution
- Flexor tenosynovitis (frequent hallmark)
• “Swan-neck deformity”
• “Boutonniere deformity”
• “Z-line deformity”
- Ulnar deviation from subluxation of the MCP joints
- Piano-key movement of ulnar styloid (inflammation about ulnar styloid & tenosynovitis of extensor carpi ulnaris – leads to subluxation of distal ulna)
Marginal erosions with adjacent bony proliferation (“whiskering”)
Psoriatic arthritis
What is your initial treatment of choice for RA?
DMARDs (Methotrexate)
A 40-year-old man with swollen and painful 1 st MTP joint after a binge drinking.
gout
most common pulmonary manifestation of RA
Pleuritis i
How is diagnosis confirmed in takayasu arteritis?
Characteristic pattern on arteriography (e.g. irregular vessels walls, stenosis, aneurysm, occlusion)
Most important autoantibody to detect in SLE
ANA
positively birefringent rhomboid-shaped calcium pyrophosphate dehydrate (CPPD) crystals
Pseudogout
What is the best antibiotic for secondary prophylaxis ARF?
Benzathine penicillin G
Most common acute rash of SLE
Butterfly rash (photosensitive, raised erythema, scaly, on cheeks/nose, ears, chin, V region of neck and chest, upper back, extensor surface of arms)
Multiple target-appearing plaque + drug exposure
Think of Erythema multiforme
Most serious cardiac manifestation
Myocarditis, LiebmanSacks endocarditis
Sicca syndrome, subacute cutaneous lupus, neonatal lupus with CHB
Anti-Ro (SS-A)
Anti-La (SS-B) same as anti-RO (both are associated with DECREASED risk for nephritis)
“CREST” syndrome
Pathologic hallmarks of RA
o Synovial inflammation
o Focal bone erosions
o Thinning of articular cartilage
differentiate Erythema marginatum vs migrans vs multiforme.
A 60-year old woman with left hip pain during walking stairs and bony enlargement of the first DIP.
OA
What is the best initial treatment of OA?
Pain management (Acetaminophen or Paracetamol)
What test correlates with disease activity in SLE?
Anti-dsDNA
best screening for SLE
ANA
Expanding bull’s eye rash + complete heart block + tick bite
Think of Lyme disease (Borrelia burgdorferi)
Gives examples of MSK disorders according to predilection sites on the hand.
Clinical manifestations of OA
- Joint pain is activity related.
- Morning joint stiffness is brief (<30 min)
- Knee pain arise from knee flexion (stair climbing, arising from chair); knee buckling may occur.
- Commonly affected joints: Cervical and lumbosacral spine, Hip, Knee, first MTP joint, hand joints (DIP, PIP)
- Usually spared joints: Wrist, Elbow, Ankle
Most common chronic dermatitis in lupus (lesions: circular, slightly raised, scaly hyperpigmented erythematous rims and depigmented, atrophic centers)
Discoid lupus erythematosus (DLE)
most common clinical features of ARF
Polyarthritis (60-75%) and carditis (50-60%)
Offers greatest sensitivity for detecting synovitis & joint effusions; and early bone/bone marrow changes
MRI
Most common form of chronic inflammatory arthritis and often results in joint damage and disability
Rheumatoid arthritis
hallmark of rheumatic carditis
Valvular damage (Mitral valve and sometimes aortic valve)
Joint space loss or narrowing
OA
A 30 year old male with a history of psoriasis sought consult for joint pains, including the DIPs. There is note of dactylitis, with pronounced telescoping of the 2 nd left finger. Hyperkeratosis and onycholysis, nail dystrophy are also noted.
Psoriatic arthritis
most common valvular abnormality in RA
Mitral regurgitation
Most common manifestation of diffuse CNS lupus
Cognitive Dysfunction
drug induced lupus (MC: hydralazine, procainamide, quinidine, INH, minocycline)
Anti-histone
What is the best initial diagnostic step in OA?
X-ray of the affected joint
Most common cardiac manifestation of SLE
Pericarditis
Hallmark features of psoriatic arthritis
dactylitis and enthesitis
The drug of choice for anaphylaxis is:
Epinephrine 0.3 – 0.5 mL 1:1000 IM
DIFFERENTIATE ARTICULAR VS NON-ARTICULAR DISORDERS.
ARTICULAR DISORDERS
• Deep/diffuse pain or limited ROM during passive and active movement
• Swelling, crepitation, instability, deformity
NONARTICULAR DISORDERS
- Painful on active (but not passive) ROM
- Seldom with swelling, crepitus, instability
- Examples: trauma/fracture, fibromyalgia, polymyalgia rheumatica, bursitis, tendinitis
Cystic changes with well-defined erosions and overhanging sclerotic margins and soft tissue masses
GOUT
Drug-induced lupus causes
procainamide, hydralazine, propylthiouracil, lithium, phenytoin, isoniazid, nitrofurantoin, sulfasalazine, statins
characteristic radiologic features of gout
Cystic changes with well-defined erosions and overhanging sclerotic margins and soft tissue masses
Most frequently involved joints in RA
- Wrists, MCP, PIP
- DIP involvement is usually a manifestation of coexistent OA
increased in SLE with overlap features of other CTD’s
Anti-RNP
Most common cause of death in those with RA
Cardiovascular disease
DMARDs safe in pregnancy:
Hydroxychloroquine and sulfasalazine
What joint is not affected in RA?
DIP
Most frequent site of cardiac involvement in RA
Pericardium
Most common musculoskeletal manifestation of SLE
Arthralgia/ Myalgia
A 22-year-old woman cervical discharge, rashes on forearms and elbow swelling and tenderness.
Gonococcal arthritis
What is the pathophysiology of takayasu arteritis?
Inflammation (panarteritis) and stenosis of medium/large sized arteries with predilection for aortic arch and branches
differentiate Psoriatic arthritis from RA
In psoriatic arthritis: seronegative, often with DIP, spine, and sacroiliac joints; distinctive radiographic features; and familial aggregation
Leading causes of mortality on the first decade of SLE
Nephritis and infection
the most common cause of chronic knee pain in persons >45 years old
Osteoarthritis
Joint most frequently affected in calcium pyrophosphate deposition disease (CPPD)
Knee
Most common early clinical manifestation of gout
Acute arthritis; usually only 1 joint is affected (metatarsophalangeal joint of 1st toe is often involved)
Worst prognosis type of lupus nephritis
Crescentic Lupus Nephritis
Most common cutaneous manifestation of SLE
Photosensitivity
Initial analgesic of choice for patients with OA
Acetaminophen (Paracetamol)
Mainstay tx for Life threatening SLE
Systemic glucocorticoids PO/IV
Evanescent migrating rash + first degree AV block
Think of Rheumatic fever
(Erythema Marginatum)
DURATION OF PROPHYLAXIS
RF with carditis, but no residual valvular disease (no clinical or echocardiographic evidence of valvular disease)
10 years after last attack or until 21 years old (whichever is longer)
Endocardial involvement in SLE can lead to valvular insufficiencies, most commonly of the _____
Mitral or aortic valves
Most cases of chronic urticaria are
Idiopathic
Most common of all drug-induced reactions
Morbilliform or maculopapular reactions
Extent of epidermal detachment in Stevens-Johnson Syndrome:
< 10% body surface area
A complication of systemic sclerosis presenting with blurring of vision, severe headache and chest pain
Scleroderma Renal Crisis
The histocompatibility antigen with striking correlation with Ankylosing Spondylitis
HLA-B27
Punched out lytic lesions with overhanging edges as radiographic findings
Gout
Most common manifestation of tuberculous arthritis
Chronic monoarthritis of large, weight-bearing joints
