Rheumatology - Arthritis Flashcards
Discuss findings for arthrocentesis
- sent for cells, stain and culture and crystals
- Low WBC (<2x10^9 or <2000)
- osteoarthritis - High WBC (>2x10^9 or >2000)
- inflammatory arthritis including septic, crystal arthropathy, and rheumatologic arthritis
- high WBC >50,000 with 75% neutrophils suggest septic - Presence of Crystals
- gout: monosodium urate, needle shaped negatively birefirengent yellow crystals
- pseudogout: calcium pyrophosphate dihydrate = rhomboid-shaped, positively birefringent blue crystals - fat droplets suggest fracture
List the differential for acute monoarthritis and chronic monoarthritis
Acute - bacterial septic arthritis - gout, CPPD - dislocation, fracture, hemarthrosis - chrondrosarcoma, metastatic Chronic - gout, pseudogout - osteoarthritis
Discuss the presentation, diagnosis and management of septic arthritis
Pathology
- Staph aureus
- Strep
- Gonococcal infection in sexually active adults
Presentation
- most common in knee and hip
- fevers, chills
- sepsis
- leukocytosis
- gonococcal infection
- triad of tenosynovitis, dermatitis (painless vesiculo-pustular) and polyarthralgia
- purulent arthritis without skin lesions
Diagnosis
- Kocher criteria (1/2 have 40% risk)
- nonweightbearing on affected side
- ESR >40
- Fever
- WBC >12,000
- positive gram stain or culture on joint aspiration
Management
- Ancef 2g IV Q8H or Cloxacillin 2g IV Q4H
- Cipro or Gentamicin IV if high risk for Gram negative (elderly, immune compromised)
- gram positive: Vancomycin IV 15-20mg/kg/dose Q8-12H
- gram negative: Ceftriaxone IV 2g daily
List the risk factors for gout
- Elevated body mass index
- Hypertension
- Diuretic use
- Coffee consumption
- Alcohol intake
- Sweetened beverage consumption
- Meat/seafood consumption
- Dairy product consumption
- Vitamin C intake
List the Diagnostic Criteria for Gout
- one of the following
Presence of urate crystals in the joint fluid
Presence of tophus proven to contain urate crystals by chemical means or polarized light microscopy
Presence of 6 or more of the following - Asymmetric swelling within joint on radiograph
- attack of monoarticular arthritis
- culture of joint fluid negative for microorganisms
- development of maximal inflammation within one day
- hyperuricemia
- joint redness
- more than one attack of acute arthritis
- pain or redness in first metatarsophalangeal joint
- subcortical cyst without erosion on radiography
- suspected tophus
- unilateral attack involve first metatarsophalangeal joint
- unilateral attack involving tarsal joint
Discuss the management of gout
- begin treatment within 24 hours of symptom onset to achieve rapid and complete resolution of symptoms Medical Management for Mild-Moderate - NSAID monotherapy - Colchicine monotherapy - Corticosteroid monotherapy Medical Management Severe - Colchicine and NSAIDs - Colchicine and oral corticosteroids - Intra-articular steroids and all other modalities
Discuss the dosing of NSAIDs, colchicine and corticosteroids for gout treatment
NSAIDs
- Naproxen 500mg BID
- Indomethacin 50mg TID
- side effects: GI upset, worsen renal function
- contraindicated in patients with PUD, CKD, Heart failure or on anticoagulants
Colchicine
- 1.2mg intially then 0.6mg one hour later then 0.6-1.2mg OD
- side effects: GI, renal and hepatic risk
- contraindicated: clarithromycin
Corticosteroids
- Oral prednisone: 40mg for 4 days -> 20mg for 4 days -> 10mg for 4 days
- side effects: rebound flare when tapering
- contraindicated when already using NSAIDs and colchicine
Discuss the prevention of gout
Dietary Modifications
- reduce high fructose corn syrup
- reduce beef, lamb, pork, shellfish
- reduce alcohol
- increase vegetable and low fat dairy products
Pharmacologic (serum urate <6)
- First line: Allopurinol 300mg (Xanthine oxidase inhibitor)
- Second line: Probenecid 250mg BID (increase urinary uric acid so possible kidney stone risk)
- in addition use NSAID, colchicine 0.6mg and low-dose steroid (required when starting during flare) for 6 mon
Duration
- no ongoing symptoms continue for 3-6 months following flare
- ongoing symptoms continue indefinitely
Discuss epidemiology, risk factors and pathology of pseudogout
Epidemiology - common in elderly Risk Factors - advanced osteoarthritis, neuropathic joints - hyperparathyroidism - hypothryoidism - hypomagnesemia - diabetes - hemochromatosis Pathology - precipitation and deposition of CPPD crystals phagocytes by neutrophils in joints causing inflammation
Discuss the presentation, investigation, and management of pseudogout
Presentation
- trigger: dehydration, acute illness, surgery, trauma
- slow onset and last 3 weeks
- affect knee, wrist, MCP, hips, shoulders, elbows and ankles
- chronic arthritis with acute exacerbations
Investigation
- chrondrocalcinosis
- positive blue birefiregent rhomboid shaped crystals
Management
- acute flare with immobilization
- treatment same as gout
- prophylaxis when >=3 pseudo-gout flares in a year
- colchicine 0.6mg BID
- naproxen 500mg PO BID
Discuss the risks, presentation and investigations for osteoarthritis
Risks - older age - gender (<50 M>F, >50 F>M) - trauma - obesity - endocrine disorder Presentation - asymmetric joint pain - worsens with activity - relieved by rest - morning stiffness (<30 min) - joint swelling - Bouchard's nodes (PIP) - Heberden's nodes (DIP) Xray Findings - joint space narrowing - subchondral sclerosis - subchondral cysts - osteophytes
Discuss the management of osteoarthritis
Mild Arthritis - regular exercise - weight loss - physical therapy - bracing or splinting - Acetaminophen first and then move to OTC NSAID then prescription NSAID Moderate - Glucosamine injection - Corticosteroid injection - Hyaluronic acid injection Severe - joint replacement
Discuss the epidemiology and pathophysiology of rheumatoid arthritis
Epidemiology - commonly affect female at 40-50 - prevalence of 1% Pathophysiology - auto-immune response leading to inflammation in joint
Discuss the presentation and diagnostic criteria for rheumatoid arthritis
Presentation
- insidious onset over weeks to months
- symmetric polyarthritis
- joint stiffness in morning lasting >1hr better over the day with exercise
- distal joints and progress to more proximal joints
- radial deviation of wrist and ulnar deviation of MCP
- Boutonniere deformity: PIP flex and DIP hyperextension
- Swan neck deformity: PIP hyperextension and DIP flexion
- fever, fatigue, weight loss
- extra-articular
- Sjogren syndrome
- subcutaneous rheumatoid nodule
- tenosynovitis
- ketaroconjunctivitis, episcleritis, scleritis
- pericarditis
- interstitial lung disease
- Felty’s: arthritis, splenomegaly, neutropenia
Diagnostic Criteria
- inflammatory arthritis >=3 months
- positive rheumatoid factor or anti-cyclic citrullinated peptide
- elevated ESR or CRP
- duration of symptoms >6 weeks
- no other arthritis
Discuss the management of rheumatoid arthritis
DMARD + (NSAID or glucocorticoid) - methotrexate 10-25mg OD - sulfasalazine 1000mg BID NSAID - naproxen 500mg BID - celecoxib 200mg OD Glucorticoid - prednisone 5-15mg PO OD Biologics - Etanercept - Adalimumab
Discuss the definition and diagnostic criteria for fibromyalgia
- Chronic, widespread, multisite MSK pain with characteristic tender points associated with fatigue and sleep disturbance
Diagnostic Criteria - WPI >=7 and SSS >=5 OR WPI >=5 and SSS >=9
- symptoms present at same level for 3 months
- patient does not have any other disorder
Discuss the Widespread Pain Index
Number of Areas in Which Patient Had Pain Over Last Week
- shoulder L/R
- Upper arm L/R
- Lower arm L/R
- Hip L/R
- Upper leg L/R
- Lower Leg L/R
- Jaw L/R
- chest
- abdomen
- upper back
- lower back
- neck
Discuss the management for fibromyalgia
Bio - Duloxetine and Pregabalin - cannabinoids Psycho - CBT - coping skills - stress reduction - education Social - exercise - physical therapy for posture, stretching, strength
Discuss the Symptom Severity Score
0=none, 1=mild, 2=moderate,3=severe
- Severity of fatigue
- waking unrefreshed
- cognitive symptoms over the last week
- extent of somatic symptoms (IBS, cramps, dry mouth, fever)
Discuss the red flags for back pain
- NIFTI Neurological - diffuse motor/sensory loss - progressive neurological deficits - cauda equina syndrome (urinary retention, fecal incontinence, saddle paresthesia) - require MRI Infection - fever - IV Drug use (epidural abscess) - immunosuppression - Xray and MRI Fracture - trauma - osteoporosis - fragility fracture - Xray and CT Scan Tumour - History of cancer - unexplained weight loss - significant and unexpected night pain - severe fatigue - Xray and MRI Inflammation - Chronic low back pain >3 months - age <45 - morning stiffness >30 minutes - improves with exercise - disproportionate night pain - Rheumatology consultation
Discuss factors for initial bone mineral density testing
Age <50 - fragility fracture - high risk medication use - hypogonadism - malabsorption syndromes - chronic inflammatory conditions - primary hyperparathyroidism Age 50-64 - fragility fracture after 40 - prolonged glucocorticoid use - parental hip fracture - vertebral fracture or osteopenia on xray - high alcohol intake or current smoking - low body weight (<60kg) or major weight loss (>10% from age 25) Age >65 - all men and women
Discuss preventative measures for bone health
- active weight bearing exercise
- calcium 1200mg daily
- vitamin D 800-2000 IU >50 or 400-1000IU <50
- fall prevention
Discuss the FRAX fracture risk assessment
- Age
- Sex
- BMI
- Previous Fracture
- Smoking
- Alcohol
- Glucocoticoids
- Rheumatological disorder
- Secondary cause
- femoral neck bone density (osteopenia Tscore -1.0 to -2.5 and osteoporosis
Discuss when to start treatment for osteoporosis
Moderate risk when Fracture risk 10-20% Get Lateral Thorocalumbar Xray
- additional vertebral fracture
- previous wrist fracture in individual older than 65 and tscore =2 in 12 months)
High Risk if
- fracture risk >20%
- prior fragility fracture of the hip or spine
- more than one fragility fracture
Discuss treatment for osteoporosis
Lifestyle - Calcium and vitamin D - exercise - reduce caffeine - stop smoking - stop osteoporosis inducing medication Drug Therapy - Bisphosphonates (risedronate or alendronate) - RANKL inhibitor (denosumab) - Parathyroid hormone (teriparatide) - Calcitonin (2nd line) Therapy for Post-Menopausal Women - SERM - HRT
Discuss the signs of inflammatory arthritis
WARM(S) Joints
- worse with rest, better with activity
- awakening in the latter half of the night
- redness around joint
- morning stiffness >30 minutes
- soft tissue swelling, erythema
