Rheumatology - MTB ** Flashcards
Osteoarthritis: etiology
- directly proportional to increasing age and trauma to joint
- obesity increases risk of degenerative joint disease
Osteoarthritis
- degenerative joint disease
- chronic, slowly progressive, erosive damage to joint surfaces
- loss of articular cartilage causes increasing pain w. minimal/no inflammation
Most common cause of joint disease
- degenerative joint disease
Osteoarthritis: presenation
- commonly symptomatic in weight bearing joints (knee, hip, ankle)
- in hand, the DIP joint > PIP > MCP joints are more effected
- crepitations in joint
- stiffness < 15 minutes
Heberden nodes
DIP enlargement
Bouchard nodes
PIP enlargement
Osteoarthritis: diagnostic tests
Lab test are normal
- ESR
- CBC
- ANA
- Rheumatoid factor
Most accurate test for osteoarthritis
X-ray of affected joint shows
- joint space narrowing
- osteophyte
- dense subchondral bone
- bone cysts
Osteoarthritis vs Rheumatoid arthritis
- Absence of inflammation
- Normal lab tests
- Short duration of stiffness
Osteoarthritis: Treatment
- Weight loss and moderate exercise
- Acetaminophen (best initial analgesic)
- NSAIDS (sx not controlled w/ tylenol)
- Capsaicin cream
- Intraarticular steroids
- Hyaluranon injection in joint
- Joint replacement if severe disease
Gout
defect in urate metabolism with 90% cases in men
- can be overproduction or underexcretion
Overproduction causes of gout
- Idiopathic
- Increased turnover of cells*** (cancer, hemolysis, psoriasis, chemotherapy)
- Enzyme deficiency (Lesch-Nyhan syndrome, glycogen storage disease)
Underexcretion causes of gout
- Renal insufficiency
- Ketoacidosis or lactic acidosis
- Thiazides and aspirin
Man who develops sudden, excrutiating pain, redness and tenderness in big toe at night after binge drinking w. beer. Likely diagnosis?
Gout
Chronic gout features
- Tophi
- Uric acid kidney stones
- Long asymptomatic periods are common
Tophi
Tissue deposits of urate crystals with foreign body reaction.
- often tophi occur in cartilage, subcutaneous tissues, bone, and kidney
- often take years to develop
Most accurate test for gout
- ## Aspiration of joint showing NEEDLE SHAPED CRYSTALS w/ NEGATIVE BIREFRINGENCE on polarized light
Diagnostic features of Gout
- aspiration w/ needle shaped crystals w/ negative birefringence
- WBC on joint fluid is 2000 - 50K and predominantly neutrophils
- must tap joint to r/o infection
- elevated uric acid levels
- acute attacks have elevated ESR and leukocytosis
- X-rays are normal in early disease (cortical erosions occur later)
Acute gout: Treatment
- NSAIDS are superior to colchicine
- Corticosteroids by infection in single joint
- no response to NSAIDs
- Contraindication to NSAIDs such as renal insufficiency
- Colchicine - used in patient who can’t use NSAIDs or steroids
Chronic gout: management
- Diet
- decrease consumption of alcohol
- lose weight
- decrease high purine foods (e.g. meat and seafood) - Stop thiazides
- Colchicine
- Allopurinol
- Pegloticase
- Probenecid
Allopurinol
- decreases production of uric acid. Febuxostat is used if allopurinol is contraindicated. Febuxostat is a xanthine oxidase inhibitor.
Adverse effects of chronic treatment
- Hypersensitivity (rash, hemolysis, allergic interstitial nephritis) occurs with uricosuric agents and allopurinol
- Colchicine can suppress WBC
- TEN or Stevens-Johnson syndrome may occur from allopurinol
Pseudogout - calcium pyrophosphate deposition disease
- calcium-containing salts depositing in articular cartilage
Risk factors are pseudogout
- hemochromatosis*
- hyperparathyroidism*
- diaberes
- hypothyroidism
- Wilson disease
Calcium Pyrophosphate Deposition Disease: Presentation
- affects knee and wrist but not MCP of first toe
- does not affect PIP and DIP
Most common risk factors for pseudogout
Hemochromatosis
Hyperparathyroidism
Pseudogout: diagnostic tests
- uric acid levels are normal
- X-ray shows calfication of cartilaginous joints
- arthrocentesis shows POSITIVELY BIREFRINGENT RHOMBOID-SHAPED CRYSTALS
- synovial fluid shows WBC of 2K - 50K
Best BP med for gout
Losartan (ARB) - lowers uric acid
Gout treatment contraindicated in renal insufficiency
- Probenecid
- NSAIDS
- Sulfinpyrazone
Pseudogout: treatment
- NSAIDS (best initial therapy)
- Intraarticular steroids (severe disease) - as triamcinocline or colchicine
- Colchicine helps prevent subsequent disease
Rheumatoid arthritis
- young, female, morning stiffness better w/ use
- multiple joints of hands and feet
- synovial fluid contains anti-cyclic citrulinated peptide (anti-CCP)
Septic arthritis
- high fever, very acute
- single hot joint
- synovial fluid: > 50K neutrophils, fluid cx
Low Back pain
- common over lifetime
- in patients, DJD on X-ray or MRI of spine is nearly universal
Which patients who c/o lower back pain do you not do an imaging study on?
- pts w/ idiopathic low back pain
- pts w/ lumbosacral strain
Compression of the Spinal Cord
- neurological emergency
- hx of cancer w. sudden onset of focal neurological deficits on sensory level
- point tendernss at the spine w/ percussion is highly suggestive of cord compresison
- hyperreflexia is found below level of compression
Compression at the level of 4th thoracic vertebrae
Loss of sensation below the nipples
Compression at the level of the T10
Sensory loss below the umbilicus
Epidural abscess vs. spinal cord compression
- epidural abscess from S. aureus
- presents similarly to cord cmprssion from cancer
- high fever and high ESR
Disk herniation
- herniations at L4/L5 and L5/S1 level account for 95%
- positive straight leg test
Straight leg test
- pain going into the buttock and below the knee when the leg is raised above 60 degrees
Best initial test for cancer with compresson
- Compression, infection, and fractures is a plain X-ray
Most accurate test for spinal cord compression
MRI
- can use CT if there is contraindication to MRI (e.g. pacemaker)
- if CT is used, must use contrast to increase accuracy
Imaging of disk herniation
“No”
- patient has low back pain and positive SLR alone, then no imaging is needed
L4
- dorsiflexion of foot
- affects knee jerk reflex
- provides senosry of inner calf
L5 deficit
- affects dorsiflexion of foot
- no reflexes affects
- no sensory in inner forefoot
Cord compression
- hx of cancer
- PE shows vertebral tendrenss, sensory level, hyperreflexia
S1 deficit
- affects eversion of foot
- affects ankle jerk reflex
- no sensationin outer foot
Epidural abscess
- fever, high ESR
- physical exam shows vertebral tenderness, senosry level deficit, hyperreflexia
Cauda equina
- hx of bowel and bladder incontinence and erectile dysfunction
- PE shows bilateral leg weakness, saddle area anesthesia
Ankylosing spondylitis
- under age 40
- pain worsens with rest and improves with activity
- physical findings: decreases chest mobility
Disk herniation
- hx of pain/numbness of medial calf or foot
- physical findings: loss of knee and ankle reflexes, positive straight leg test
Cord compression: treatment
- Systemic glucocorticoids
- Chemotherapy for lymphoma, radiation of solid tumors
- Surgical decompression if steroids and radiation not effective
Epidural abscess: treatment
- steroids used to control acute neuro deficits
- antistaph abx (vancomycin or linezolid) until sensitivity is known
- if sensitive staph is found, switch to B-lactam abx (e.g. oxacillin, nafcillin or cefazolin)
Epidural abscess
- use vancomycin or linezolid as empiric treatment
- if sensitive, switch to oxacillin
- drain if infxn is large enough to produce neuro symptoms
Cauda equina treatment
- surgical decompression
Disk hernation: treatment
- NSAIDS with continuation of ordinary activity
- DO NOT ANSWER BED REST!
- Steroids into epidural space achieves rapid and dramatic benefit for those with sciatica that doesn’t improve with conservative management
Man w/ hx of prostate cancer comes to ED w/ severe back pain and leg weakness. He has tendernss of spine, hyperreflexia and decreased sensation below umbilicus. What is the most appropriate next step?
Dexamethasone (steroids)
- if obvious neuro deficits, begin steroids ASAP to prevent permanent paralysis
Lumbar Spinal Stenosis
- narrowing of spinal canal leading to pressure on cord (often idiopathic)
- pain occurs during extension when cord presses against ligamentum flavum
Lumbar spinal stenosis: presentation
- pt > 60 with back pain while walking, radiating into buttocks and thighs bilaterally
- worse when walking downhill and better when sitting
- pedal pulses and ankle/brachial index are normal
- less pain when leaning forward
Spinal stenosis is often confused with what vascular disease?
Peripheral artery disease
- spinal stenosis is called pseudo claudication
Best test for lumbar spinal stenosis
- MRI
Lumbar spinal stenosis: treatment
- Weight loss and pain meds (NSAIDs, opiates, and asprin) - first line
- Steroid injections can improve 25 - 50% of cases
- Surgical correction to dilate the canal
Best initial therapy for lumbar spinal stenosis
Weight loss and pain meds (NSAIDS, opiates, and aspirin)
Fibromyalgia
- young woman w/ chronic musculoskeletal pain and tenderness w/ trigger points of focal tenderness at trapezius, medial fat pad of knee, and lateral epicondyle
- cause not knonw
- associated w/ stiffness, numbess, headaches, and sleep disorder
Best test to confirm fibromyalgia
None
- dx based on symptoms with trigger points at predictable points
- all lab tests are normal (e.g. ESR, C-reactive protein, rheumatoid facor, and CPK levels)
Best therapy for fibromyalgia
Amitryptiline
Fibromyalgia: treatment
- Amitryptiline (best therapy)
2. Milnacipran (serotonin and NE uptake inhibitor)
Carpal Tunnel Syndrome
- peripheral neuropathy from compression of median nerve as it passes under flexor retinaculum
- pressure on nerve interferes w/ both and motor fxn of nerve
Carpal tunnel syndrome: etiology
- overuse of hand and wrist
- pregnancy
- diabetes
- rheumatoid arthritis
- acromegaly
- amyloidosis
- hypothyroidism
Carpal Tunnel Syndrome: presentation
Person with pain in hand affecting palm, thumb, and index finder and the radial half of ring finger with muscle atrophy of the thenar eminance
- pain is worse at night and is more frequent when using the hands
Tinel sign
- seen in carpal tunnel syndrome
- reproduction of pain and tingling w/ tapping or percussion of median nerve
Phalen sign
- seen in carpal tunnel syndrome
- reproduction of symptoms w/ flexion of wrist to 90 degrees
Carpal Tunnel Syndrome: Diagnosis
- Aside from Tinel and Phalen signs, compression of nerve by squeexing
Most accurate test for carpal tunnel syndrome
- Electromyography and nerve conduction testing
Best initial therapy for carpal tunnel syndrome
Wrist splint to immobilize hand to releve pressure
- avoiding manual activity
- steroids if NSAIDs and wrist splint don’t work
- Surgery is curative by mechanically decompressing the tunnel such as cutting open the flexor retinaculum
Dupuytren Contracture
- hyperplasia of the palmar fascia leading to nodule formation and contracture of the 4th and 5th fingers
- associated w/ alcoholism and cirrhosis
- lose the ability to extend their fingers
Dupuytren Contracture: Treatment
- Triamcinolone
- Lidocaine
- Collagenase injection
Rotator Cuff Injury
- damage to rotator cuff leads to inability to flex or ABduct the shoulder
- shoulder pain worse at night when lying on affected shoulder
- severe tenderness at insertion of supraspinatus
Most accurate test for rotator cuff injury
MRI
Rotator cuff injury: treatment
- NSAIDS, rest, physical therapy
- Surgery if complete tears or if not responding to NSAIDS, steroids, and physical therapy
Patellofemoral syndrome
- cause of anterior knee pain 2/2 trauma, imbalance of quad stremgh or meniscal tear
- pain is in front of knee or under patella
- bad when walking up or down stairs
- symptoms are worse just after starting to walk or having been seated for long period of time
Patellofemoral syndrome: diagnosis
- exam reveals crepitus, joint locking and instability
- X-rays are normal
- treat w/ physical therapy and cycling
Plantar Fascitis
- very severe pain in bottom of foot near calcaneus where fascia inserts
- pain worse in morning and improves w/ walking a few steps
- point tendernsess at bottom of foot where fascia inserts at calcaneus
Plantar fascitis vs. tarsal tunnel syndrome
plantar fascitis clearly improves w/ use
Plantar fascitis
Stretching exercises, arch supports and NSAIDS
- steroids injection as 2nd line treatment
Are X-rays useful for diagnosis of plantar fascitis?
No
- no correlation with presence of heel spurs
Rheumatoid arthritis
- autoimmune disorder predominantly of joints but w/ many systemic manifestations of chronic inflammation
- associated w/ specific HLA types
- more common in women
Chronic synovitis
- leads to overgrowth or pannus formation, which damages all structures surrounding the joint (bone, ligaments, tendons, and cartilage)
Rheumatoid arthritis: presentation
- B/l symmetrical joint involvement (PIP, MCP and wrist, knee, ankle involvement)
- Morning stiffness lasting > 30 minutes
- Rheumatoid nodules
- Ocular symptoms
- Lung involvement ( pleural effusions and nodules of lung parenchyma)
- Vasculitis
- Cervical joint involvement (C1 and C2)
Rheumatoid arthritis: Diagnostic tests
- Rheumatoid factor
- anti - CP
- X-rays (erosion of joints and osteopenia)
- elevated ESR and C-reactive protein
- Normocytic anemia
Diagnostic criteria for Rheumatoid Arthritis
> 6 points = RA
- joint involvement (up to 5 points)
- elevated ESR or CRP (1 point)
- duration longer than 6 weeks (1 point)
- RF or anti-CCP (1 point)
Which joints are spared in rheumatoid arthritis?
DIP
Sicca syndrome
- dry eyes, mouth, and other mucous membranes
Felty syndrome
- rheumatoid arthritis
- splenomegaly
- neutropenia
Caplan syndrome
- rheumatoid arthritis
- pneumoconiosis
- lung nodules
Most important concern for treatment of rheumatoid arthritis
Stopping progressing of disease
- any patient w/ erosive disease or X-ray abnormalities needs at least methotrexate
Most common cause of death in rheumatoid arthritis
- Coronary artery disease
Rheumatoid arthritis
DMARDS (disease modifying antirheumatic drugs)
- Methotrexate, TNF inhibitors, Rituximab, Hydrochloroquine, Sulfasalazine
- DON’T USE NSAIDS or STEROIDS – they don’t work in RA
Pt w/ longstanding Ra is to have coronary bypass surgery. Which of the following is most important prior to surery?
Cervical spine x-ray
- to detect possible instability of vertebrae essential to hyperextension of neck which is critical w/ endotracheal intubation
Erosive disease
- joint space narrowing
- physical deformity of joints
- X-ray abnormalities
Methotrexate
- best initial DMARD
- adverse effects: liver toxicity, bone marrow suppression, pulmonary toxicity
Tumor Necrosis Factor Inhibitors (e.g. influximab, adalimuzab, etanercept)
- first line DMARDs for those unresponsive to methotrexate or intolerant of methotrexate
- often used initially combo w/ methotrexate to prevent disease progression
Toxicity of anti-TNF drugs
- reactivation of TB: screen w/ PPD prior to use
- infection
Rituximab
- non-Hodgkins lymphoma drugg
- effective by removing CD20 lymphocytes from circulation
- excellent long term control of RA
- used in combo w/ methotrexate
Hydroxychloroquine
- can be used as monotherapy as a DMARD in cases of mild disease to avoid toxicity of methotrexate
- used in combo with methotrexate as DMARD
Hydroxychloroquine: toxicity
Toxic to retina
Sulfasalazine, leflunomide, and abatacept
- alternative DMARDS to add to methotrexate if anti-TNF don’t control disease
Sulfasalazine toxicity
- bone marrow toxiciry
- hemolysis with G6PD deficiency
- rash
Sympatomatic control of RA
- NSAIDS are good for pain control in RA
- improve pain but don’t improve prgression disease
- can use steroids in patients refractory to NSAIDS or as bridge to DMARDS
Juvenile rheumatoid arthritis
- high, spiking fever (above 104F) in young persion
- “salmon colored” rash on chest and abdomen
- splenomegaly
- pericardial effusion
- mild joint symptoms
Juvenile Rheumatoid Arthritis: Diagnosis
No clear diagnostic tests
- Anemia, hypoalbuminemia, and leukocytosis
- normal ANA
- elevated ferritin
Juvenile rheumatoid arthritis: treatment
- Aspirin or NSAIDS
Systemic Lupus Erythematous
- autoimmune disorder w/ a number of autoantibodies (ANA, dSDNA)
- causes inflammation diffusely through body and blood
- abnormal tests aassociated w/ anemia, anti-Sm, anti-phospholipid antibodies
SLE: Presentation
Skin: malar rash, discoid rash, photosensitivity, oral ulcers
Joint: arthritis (90%)
Serositis: pleural and pericrdial inflammation, chest pain
Renal: glomerulonephritis
Neuro: psychosis, seizures, stroke from vasculitis
Hematologic: hemolytic anemia
Most common type of glomerulonephritis
Membranous glomerulonephritis
Immunologic (lab) abnormalities
- anti-ds DNA**
- anti-Sm**
- false positive test for syphillis
- positive LE cell preparation
SLE: diagnostic tests
- ANA: 95-99% cases
- anti-ds DNA (60%) and anti-SM
- decreased complement levels
- anti-SSA and anti-SSB
34 y/o F with a hx of SLE is admitted w/ pneumonia and confusion. As you were wrestling w/ the decision over a bolus of high dose steroids in a person w/ an infection, you need to determine if this is a flare of lupus or simply an infection w/ sepsis causing confusion. Next step?
Decrease in complement and rise in anti-D5 DNA shows an acute lipid flare
SLE: Treatment
- treated w. high dose boluses of steroids
- hydroxychloroquine can control mildly chronic disease
Lupus nephritis: treatment
- steroids alone OR combination w/ cyclophosphamide or mycophenolate
Lupus nephritis
- biopsy is the only way to determine severity of lupus nephritis
- biopsy can tell if there is simple glomerulosclerosis or scarring of the kidney
Most common cause of death in young pts w/ lupus nephritis
Infection
Most common cause of death in older patients w/ lupus nephritis
Accelerated atherosclerosis
Antiphospholipid syndrome
- treated as separate topic b/c majority cases not associated w/ SLE
- idiopathic disorder w/ IgG and IgM antibodies made against negatively charged phospholipids
2 main types of antiphospholipids
- Lupus anticoagulant
- Anticardiolipin antibodies
Antiphospholipid syndrome: presentation
- thromboses of both arteries and veins
- recurrent spontaneous abortions
Antiphospholipid Syndrome: Diagnostic Tests
- clotting
- elevated aPTT with normal PT
- normal INR
- false positive VDRL or RPR w. normal FTA
Anticardiolipid antibodies are associated w/
spontaneous abortions
Lupus anticoagulant is associated w/
elevated aPTT
Best initial test for antiphospholipid syndrome
Mixing study
- patient’s plasma is mixed w/ an equal amt of normal plasma
- if aPTT elevation is from clotting factor deficiency, the aPTT is normal post mixing study
- if aPTT elevation is from APL, the aPTT remains elevated
Most specific test for APL
Russell viper venom test
- most specific for lupus anticoagulant
- prolonged w. APL antibodies and doesn’t correct w/ mixing studies
Antiphospholipid Syndrome: Treatment
- asymptomatic APL antibody doesn’t need to be treated
- DVT or PE treated w/ heparin and warfarin w/ INR (2-3)
What should be investigated for anticardiolipin antibody as cause of spontaneous abortion?
- Two or more first trimester events or single second trimester event
What is the treatment to prevent recurrent of spontaneous abortion?
- Heparin and aspirin
Scleroderma
- unknown etiology
- diffuse in 20% of cases
- limited in 80% of cases
Scleroderma
young (20s - 40s) woman (F>M) with fibrosis of skin and internal organs such as lung, kidneys, and GI tract
Limited scleroderma
- aka CREST syndrome
- Calcinosis
- Raynaud
- Esophageal dysmotility
- Sclerodactyly
- Telangiectasia
Reynaud syndrome
- increased vascular reactivity of fingers beginning w/ pain and pallor (white) or cyanosis (blue) followed by reactive hyperemia (red)
- precipitated by cold and emotional stress
Scleroderma: skin manifestation
- Fibrosis of hands, face, neck and extremities
- Telangiectasia and pigment abnormalities
Renal features of scleroderma
sudden hypertensive crisis
Lung features of scleroderma
Restrictive lung disease and pulmonary hypertension
Scleroderma: diagnostic tests
- ANA (85 - 90% )
- normal ESR
- SCL-70 (anti-topoisomerase)
- Anticentromere
Most specific test for scleroderma
SCL-70 (anti-topoisomerase)
Anticentromere antibodies are specific for …
CREST syndrome
Scleroderma: Treatment
Methotrexate slows progression of limited scleroderma.
RENAL CRISIS: ACEis ESOPHAGEAL DYSMOTILITY: PPIs for GERD RAYNAUD: CCBs PULMONARY FIBROSIS: Cyclophosphamide PULM. HTN: Bosentan, sildenafil, prostacyclin
Polymyositis
- inflammatory myopathy that presents with PROXIMAL MUSCLE WEAKNESS leading to difficulty getting up from seated position or walking up stairs
- dysphagia occurs involves skeletal muscle in pharynx
Dermatomyositis
- proximal muscle weakness, dysphagia
- malar involvement
- SHAWL SIGN: erythema of face, neck, sholders
- HELIOTROPE RASH: edema and purplish discoloration
- GOTTRON PAPULES: scaly patches on backs of hands
Common cancers associated with dermatomyositis
- Ovary
- Lung
- Gastrointestinal
- Lymphoma
Best initial test for dermatomyositis/polymyositis
- CPK and aldolase
Most accurate test for dermatomyositis/polymyositis
Muscle biopsy
Dermatomyositis/ Polymyositis: Diagnostics
- elevated CPK and aldolase
- Anti-Jo antibodies associated w/ lung fibrosis
- MRI shows patchy involvement
- occasionally abnormal ESR, C-reactive protei, and RF
Dermatomyositis/ Polymyositis: Treatment
Steroids are usually sufficient. If patients are unresposive to steroids, use:
- Methotrexate
- Azathioprine
- IV immunoglobulin
- Mycophenolate
** Hydroxychloroquine helps the lesions
Sjorgen Syndrome
- idiopathic autoimmune disorder 2/2 to antibodies predominantly against lacrimal and salivary glands
Sjorgen Syndrome: Presentation
- dryness of mouth and eyes (sicca)
- patient c/o of constantly needing to drink water
- loss of saliva means rampant dental caries
- loss vaginal secreetion leads to dyspareunia
Sjorgen Syndrome associated with which conditions?
- RA
- SLE
- PBC
- Polymyositis
- Hashimoto thyroiditis
Less common manifestations of Sjorgen’s Syndrome
- Vasculitis
- Lung disease
- Pancreatitis
- Renal tubular
Most dangerous complication of Sjorgen Syndrome
Lymphoma
Best initial test for Sjorgen’s Syndrome
- ## Schirmer tests (filter paper placed against eye and then observed for tears )
Most accurate test for Sjorgen syndrome
Lip or parotid gland biopsy
- reveals lymphoid infiltration in the salivary glands
Best initial test on blood
SS-A (Ro) and SS-B (la)
Sjorgen’s Syndrome: Diagnostic Tests
- SS-A (Ro) and SS-B (La)
- Positive Schirmer test (no tears on filter paper)
- Lip / parotid gland bx: lymphoid infiltration
- Rose bengal stain shows abnormal corneal epithelium
Best initial therapy for Sjorgen’s syndrome
Water the mouth
Sjorgen’s Syndrome Treatment:
-PILOCARPINE and CEVIMELINE -
increase acetylcholine, stimulant for production of saliva
- No cure, but no effect on lifespan
EVALUATE FOR LYMPHOMA
Vasculitis: Common presentation
- Fever
- Malaise
- Weight loss
- Arthralgia/myalgia
Polyarteritis Nodosa
- disease of small and medium sized arteries leading to diffuse vasculitis that SPARES LUNGS
- Chronic Hep B and C are associated with PAN
Polyarteritis Nodosa: Presenation
- nothing distinguishing for PAN
- glomerulonephritis
- foot drop or stroke in young person
- abdominal pain worse by eating (if mesenteric vessels are involved)
- livedo reticularis, purpura
- mononeuritis mulitplex: involvement of nerves large enough to have a name
Polyarteritis Nodosa: Diagnostic Tests
- Biopsy of symptomatic site
- Angiography of renal, mensenteri or hepatic artery shows dilation or “beading”
- Anemia, leukocytosism ERS
Most accurate test for PAN
Biopsy of symptomatic site
Polyarteritis Nodosa: Treatment
Prednisone and cyclophosphamide
- treat hepatitis when found
Polymyalgia Rheumatica
- occurs in those over age 50 w/
- pain and stiffness in shoulder and pelvic girdle muscles
- difficulty combing hair
- elevated ESR
- normochromic, normocytic anemia
- normal CPK and normal aldolase
Polymyalgia Rheumatic: Treatment
- Low dose steroids
Giant Cell (Temporal) Arteritis
May see shoulder and pelvic girdle muscle weakness AND
- visual symptoms
- jaw claudication (pain when chewing)
- scalp tenderness
- headache
- elevated ESR and C-reactive protein
Most accurate test for Giant Cell (Temporal) Arteritis
Biopsy affected artery (likely temporal artery)
Giant Cell (Temporal) Arteritis: Treatment
Prednisone
- *Starting steroids is more important than biopsy**
- Blindness is not reversable!!**
Wegener Granulomatosis
- combo of upper and lower respiratory tract findings plus renal insufficiency
- Upper resp tract findings (sinusitis, otitis media, mastoiditis, oral and gingival involvement)
- Lower resp findings (hemoptysis, etc)
Wegener Granulomatosis: Diagnostic Tests
- C-ANCA antibodies (cytoplasmic antibodies)
- Lung biopsy > Renal biopsy > Sinus biopsy
Best initial test for Wegener Granulomatosis
C-ANCA antibodies
Wegener Granulomatosis: Treatment
Prednisone and Cyclophosphamide
Pt c/o pneumonia that has NOT improved with antibiotics
– Add Wegener’s to differential
Churg Strauss
- Pulmonary-renal syndrome
- Asthma
- Eosinophils
- cane present w/ weight loss, fever, skin findings, and joint pain
Henoch-Schonelin Purpura
- vasculitis more frequently seen in children
- often has:
GI bleeding or Abdominal pain
Purpura (painless usually in buttocks and legs)
Arthralgia
Hematuria
Churg-Strauss: most accurate test
Biopsy of symptomatic area
Churg-Strauss Treatment
Prednisone and Cyclophosphamide
Henoch-Schonlein Purpura: Treatment
Most resolve spontaneously
- Use steroids if patient has severe abdominal pain or progressive renal insufficiency
Pt has leukoclastic vasculitis (painless, palpable purpura of butocks) w/ abdominal pain and worsening Cr
Think Henoch Schonlein Purpura
Cryoglobulinemia
- associated with Chronic Hep C infection
- found with endocarditis and other connective tissue disorders (e.g. Sjogren Syndrome)
- IgM antibodies
Cryoglobulins
- associated w/ Hep C
- manifest w/ joint pain, glomerulonephritis, purpuric skin lesions, and neuropathy
- IgM antibodies
Cryoglobulin: treatment
- Interferon, ribavirin, and either telaprevir or boceprevir
Cold agglutinin
- associated with EBV, Mycoplasma, Lymphoma
- manifests with hemolysis
Cold agglutinin: treatment
- Stay warm
- Rutixmab, cyclophosphamide, and cyclosporine
Cryoglobulinemia
- positive Rheumatoid factor
- cold precipitable immne complexes
- steroids not effective when associated w/ Hep C
- treat Hep C: interferon and ribavirin
SLE complement levels
- decreased C3 (SLE = 3 letters)
Hep C complement levels
- decreased C4 (Hep C = 4 letters)
Behcet Syndrome
- Asian or Middle Eastern person w/ painful oral and genital ulcers in association w/ erythema nodosum-like lesions of skin
Behcet Syndrome: Presentation
- Painful genital and oral ulcers
- ocular lesions leading to uveitis
- Arthritis
- CNS lesions mimicking multiple sclerosis
- sterile skin pustules from minor trauma (needle-stick)
Behcet Syndrome: Treatment
- Corticosteroids
- If refractory to steroids,
- Azathioprine
- Cyclphosphamide
- Colchicine
- Thalidomide
Seronegative Spondyloparthopathies
- Ankylosing spondylitis
- Psoriatic arthritis
- Reactive arthritis (Reiter syndrome)
Seronegative Spondyloparthropathies:
Disorders present w// joint pain in men < 40 w/
- involvement of spine and large joints
- negative Rh factor
- enthescopathy (tendon and ligament inflammatino)
- Uveitis
- HLA-B27
Ankylosing Spondylitis:
Young man w/ low backache and stiffness of his back and pain that radiates to buttocks
- stiffness worse in morning and improves w/ activity
- flatting of lumbar curvature
- decreased chest expansion
- may see AV block or aortic insufficiency
- Uveitis
Ankylosing Spondylitis: Diagnostic Test
X-ray of sacroilliac joint (narrowing of SI joint)
Bamboo spine: fusion of vertebral bodies (late finding)
Elevated ESR
HLA-B27
Best intial test for ankylosing spondylitis
X-ray of SI joint (shows narrowing of SI joint)
Most accurate test for ankylosing spondylitis
MRI - detects abnormalities before X-ray
Ankylosing spondylitis: treatment
- Exercise program and NSAIDS
- if NSAIDS are insufficient, etanercept, adalimumab, and infliximab
Psoriatic Arthritis
- 80% will have psoriasis
- SI involvement
- sausage digits from enthesopathy
- nail pitting
Psoriatic Arthritis: Tests
- elevated ESR
- X-ray of joint shows “pencil in cup” deformity
Psoriatic Arthritis: Treatment
- NSAIDS (best initial therapy)
- Methotrexate
- anti-TNF agents when methotrexate doesnt control disease
Reactive Arthritis (Reiter Syndromee)
Occurs secondary to:
- Inflammatory bowel disease
- STIs
- GI infection (Yersinia, Salmonella, Campylobacter)
Reactive Arthritis Triad
- Joint pain
- Ocular findings (uveitis, conjunctivitis)
- Genital abnormalties (urethritis, balantis)
Reactive Arthritis: Diagnostics:
No specific test for reactive arthritis
- r/o septic joint w/ swollen join
Reactive Arthritis: Treatment
- NSAIDS and correct underlying disease
- Sulfasalazine when NSAIDS don’t control it
Osteoporosis
- seen in older person (likely woman) with vertebral fx leading to loss of height or wrist fracture
- r/o in women > 65
Osteoporosis: Diagnostic
DEXA scan (best test) with T score < 2.5 SD - all blood levels are normal (Ca, P, PTH)
Osteopenia
DEXA scan shows T score -1 and -2.5
Osteoporosis: Treatment
- Vitamin D and Ca (best initial therapy)
- Bisphosphonates
- Raloxifene used in postmenopausal woeen
- Teriparatide (PTH analog) that stimulates bone matrix formation
- Calcitonin (as nasal spray) reduces vertebral fx risk
Bisphosphonates: adverse effects
- can cause esophagitis w/ prolonged contact
- rarely associated with osteonecrosis of jaw
Septic Arthritis
- infection of any kind finding its way into the joint space
Septic Arthritis: Etiology
- synovial lining has no BM and is relatively loose so bacteria and abx can easily get into joint space
- rare in undamaged joint
- risk is directly proportional to damage in joint
- ## RA risk of SA > OA risk of SA
Septic Arthritis: Organisms
Staphylococcus (40%) > Streptococcus (30%) > Gram negative rods (20%)
Septic Arthritis: Presentation
Warm, red, and immobile joint with palpable ffusion
- Chills and fever occur due to bacteremia
Best initial test for septic arthritis
Aspiration of joint
** don’t pick X-ray, MRI, or CT
Septic Arthritis: Diagnosis
- Leukocytosis: 50 - 100K WBCs
- Gram stain: Gram neg bacilli, with Staph
- Synovial fluid cx: 70 -90% sensitive
- Blood cx: 50% sensitive
Septic Arthritis: Treatment
Ceftriaxone and Vancomycin - best initial empiric therapy
Gram negative bacilli treatment
- Quinolones
- Aztreonam
- Cefotaxime
- Piperacillin
- Aminoglycosides
Gram negative cocci (sensitive)
- Oxacillin, nafcillin
- Cefazolin
- Piperacillin w/ tazobactam
Gram-positive cocci (resistant)
- Linezolid
- Daptomycin
- Tigecycline
- Ceftaroline
Most common organism for recently placed artificial joints
Staph epidermidis
Prosthetic Joint Infection
- warm, red, immobile, and tender joint
- need X-ray or CT scan to tell if infection is limited to joint space or involves bone around joint
- if joint is physically loose, infection is likely present
Prosthetic Joint Infection: Treatment
- Remove joint
- Treat w/ antibiotics for 6-8 weeks
- Replace joint
Gonococcal Arthritis (Gonorrhea)
hx of STDS or sexually active young person
- polyarticular involvement
- tenosynovitis (inflammation of the tendon sheaths, making finger movement painful)
- petechial rash
Gonococcal Arthritis: Diagnostics Tests
Culture the following sites:
- Pharynx
- Rectum
- Urethra
- Cervix
Synovial fluid: 30 -50K cells
What signs tell you to culture everywhere?
- Rash
- Tenosynovitis (tendon sheath inflammation)
- Polyarticular movement
If patient has recurrent gonorrhea infection, what should you also test for?
Terminal complement deficiency
Gonococcal Arthritis: Treatment
- Ceftriaxone, Cefotaxime, and Ceftizoxime (best initial therapy)
- Use quinone if organism is sensitive
Osteomyelitis
- look for diabetic patient w/ an ulcer from peripheral neuropathy or vascular disease w/ warmth, redness, and swelling in area
- may be draining purulent sinus tract in lesions
- most patients are afebrile
Best initial test for osteomyelitis
X-ray
Osteomyelitis: diagnostic tests
- X-ray (best initial test)
2. Biopsy (most accurate tests)
If pt has suspected osteomyelitis and X-ray looks normal, what is the most appropriate next step in management?
MRI
When is ESR indicated in osteomyelitis
To follow the response to therapy
Do you culture the drainage in osteomyelitis?
No b/c can’t distinguish superficial colonization from organism inside bone causing infection
Osteomyelitis: Treatment
- Obtain biopsy and then treat organism
- Sensitive staph best treated with oxacillin, cefazolin, nafcilli, or ceftriaxone
- Resistant staph treat with vancomycin or linezolid
- Gram negative rods: Floroquinolones
Floroquinolone Toxicity
- can cause Achilles tendon rupture from interfering with chrondocyte growth
- contraindicated in pregnancy and in children because they interfere with bone growth
