Rheumatology/Musculoskeletal Flashcards
What is Felty syndrome?
- Rare complication (<1%) of rheumatoid arthritis:
- High titer rheumatoid factor
- Splenomegaly
- Neutropenia (<1500, <1000→↑risk of clinically significant infection)
Treatment for Felty syndrome
- Gold
- MTX (second-line Tx for RA)
- G-CSF for severe neutropenia or unresponsive to Tx for RA, and when splenectomy is contraindicated or not possible
Cardiac manifestation of ankylosing spondylitis
Chronic aortic regurgitation (complication)➡Heart failure▶⬇exercise capacity, shortness of breath
*Chronic inflammation of the aortic root and valve cusps▶retraction of valve cusps, impaired valve closure
Which risk of neoplasia do patients with Paget disease of bone have?
⬆Bone remodeling and overgrowth➡osteogenic sarcomatous transformation (⬆several thousand times than the general population)
Diseases associated with erythema nodosum
- Streptococcal infection
- Sarcoidosis
- Tuberculosis
- Endemic fungal disease (Histoplasmosis)
- Inflammatory Bowel Disease
- Behcet Disease
Primary mechanism underlying the most common cytopenias in SLE
Autoantibodies➡Immune-mediated peripheral destruction (in all 3 cell lines)
Which conditions you must study in a patient with pseudogout?
- Hyperparathyroidism
- Hypothyroidism
- Hemochromatosis
Sudden posterior knee and calf pain with “crescent sign” most probably may suggest.
Ruptured popliteal Baker cyst
*But rule out deep venous thrombosis as well with ultrasound
What should you think in a patient with Rheumatoid arthritis history and worsening of weakness and painless sensation of 4 extremities after intubation?
Worsening subluxation of the atlantoaxial joint➡cord compression➡cervical myelopathy
*Atlantoaxial instability due RA
What treatment you should add to treat hypercalcemia from sarcoidosis or any granulomatous disease?
Prednisone
Greatest risk factors for curve progression in adolescent idiopathic scoliosis
- Female
- Age <12 years
- Early pubertal status (premenarchal)
- Skeletal immaturity
- Severe curvature (Cobb angle ≥25 degrees)
Use of extremities arteriogram in a patient with Raynaud phenomenon
Diagnose Thromboangiitis obliterans (Buerger disease)
Drugs for chronic treatment of gout to control the high uric acid levels
- Allopurinol: ❌Xanthine oxidase; purine analogue➡inhibit other enzymes▶⬇production of uric acid (safe with renal injury)
- Febuxostat: ❌XO; not purine analogue➡only inhibit XO (if allopurinol is contraindicated)
- Pegloticase: dissolves uric acid
- Probenecid and sulfinpyrazone (uricosuric): ⬆excretion of uric acid in the kidney (contraindicated in renal insufficiency)
- Lesinurad: ❌reabsorption of uric acid in the proximal tubule
General recommendations to manage chronic gout and prevent attacks recurrences
- Diet: ⬇alcohol, lose weight, ⬇high-purine foods (meat, seafood)
- Stop thiazides, aspirin, and niacin
- Colchicine: prevent attacks because of sudden fluctuations in uric acid levels
- Drugs to control uric acid levels
Risk factors for calcium pyrophosphate deposition disease (CPDD) or pseudogout
- Hemochromatosis, Hyperparathyroidism (chronic hypercalcemia)
- Diabetes, hypothyroidism, Wilson disease
Most accurate test for pseudogout, and which is the finding?
Arthrocentesis➡positively birefringent rhomboid-shaped crystals
Best initial treatment for fibromyalgia
- Aerobic exercise
- Tricyclic antidepressant
Drugs options for fibromyalgia treatment
- Amitriptyline
- Duloxetine or venlafaxine (dual reuptake inhibitors)➡who do not respond to tricyclics
- Milnacipran (serotonin and norepinephrine reuptake inhibitor approved specifically for fibromyalgia)
- Pregabalin
Best initial test for antiphospholipid syndrome
Mixing study➡patient’s plasma is mixed with an equal amount of normal plasma:
- PTT will come down to normal▶⬆PTT is from clotting factor deficiency
- Remain ⬆PTT▶APL syndrome antibody is present in plasma
Most specific test for the lupus anticoagulant
Russell viper venom test (RVVT)➡prolonged with APL antibodies and does not correct on mixing with normal plasma
Coagulation tests results on antiphospholipid syndrome
⬆PTT, normal PT and INR➡only thrombophilia with abnormality in the PTT
*lupus anticoagulant is more often associated with ⬆PTT
Most specific antibody for Systemic sclerosis and CREST
- Systemic sclerosis: Anti-Scl-70 (anti-topoisomerase 1)
- CREST: Anti-centromere
Best initial test for inflammatory myopathies with proximal muscle weakness
CPK, Aldolase
Most accurate test for polymyositis and dermatomyositis
Muscle Biopsy
Most specific test for Mixed connective tissue disease
Anti-U1 ribonuclear protein (RNP)
Best initial test for seronegative spondyloarthropathies
X-ray of the sacroiliac joint▶Narrowing of the joint
Treatment options for Psoriatic Arthritis
- NSAIDs➡best initial therapy
- Methotrexate➡severe disease or no response to NSAIDs
- Anti-TNF (Etanercept, Infliximab, Adalimumab)➡methotrexate does not control
disease - Anti-IL17 medications (Secukinumab or Ixekizumab) or Anti-IL12/IL23 (Ustekinumab)➡if anti-TNF fails or resistance
- Apremilast➡oral phosphodiesterase inhibitor
*Steroids are a wrong choice
Chronic shoulder pain with decreased active and passive range of motion in multiple planes, with normal x-ray. Cause and risk factors.
- Adhesive capsulitis (“Frozen shoulder”)➡chronic inflammation, fibrosis and contracture▶loss of the distensibility of the glenohumeral joint capsule
- Diabetes mellitus, thyroid disorders, chronic immobility, rotator cuff tendinopathy, fracture of proximal humerus
Which lab test may help you differentiate granulomatosis with polyangiitis (Wegener granulomatosis) and eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)?
- Wegener granulomatosis➡C-ANCA
- Churg-Strauss syndrome➡P-ANCA
Biopsy findings of erythema nodosum
Septal panniculitis without vasculitis
Biopsy findings on a patient with PAH by CREST syndrome
Hyperplasia of the intimal smooth muscle layer of the pulmonary arteries
Most common cause of nephrotic syndrome in a patient with rheumatoid arthritis
Inflammatory Amyloidosis (AA)
Next best step in a patient with suspected active rheumatoid arthritis and knee effusion (erythema, swelling, ballotable patella)
- Arthrocentesis➡rule out septic arthritis. RA patients have ⬆risk of septic arthritis
- Start corticoids is wrong because septic arthritis should be rule out first
