Rheumatology_UW Flashcards
What is pseudogout?
Form of acute arthritis induced by the release of calcium pyrophosphate dehydrate (CPPD) crystals from sites of chondrocalcinosis (calcification of articular cartilage) into joint space
How is pseudogout diagnosed?
Presence of rhomboid shaped, positively birefringent crystals on joint aspiration microscopy and radiographic evidence of chondrocalcinosis
How is pseudogout different from gout?
Gout = needle-shaped, negative birefringent crystals
Presentation of pseudogout?
Occurs in setting of recent surgery/medical illness and trauma. Acute pain, swelling, limited motion of involved joints (knee most common)
Hyperparathyroidism predisoposes to development what arthropathy?
Pseudogout. Hyperparathyoridism shows elevated calcium, depressed phosphorus levels.
Lumbar spinal stenosis is commonly caused by?
Degenerative joint disease in the spine
In lumbar spinal stenosis what alleviates/worsens pain?
Worsens when standing/walking downhill (due to extension of spine). Improves when sitting/walking uphill (due to flexion of spine)
How is lumbar spinal stenosis diagnosis confirmed?
MRI
What is polymyositis?
Slowly progrssive, inflammatory muscle disease that causes painless proximal muscle weakness (painless important)
What is the best diagnostic study for polymyositis?
Muscle biopsy. It shows mononuclear infiltrate around necrotic, regenerating muscle fibers.
Patients with RA are at increased risk for developing?
Osteopenia, osteoporosis and bone fractures espeically if other risk factors are present (postmenopausal state, smoking, osteporosis fam his, low body weight, xs alcohol intake)
What is the management of RA patients to reduce osteoporosis
Optimal Calcium and vit D intake, minimal steroids intake, increased physical activity and consideration of bisphophonate therapy
What are the common causes of avascular necrosis of the femoral head?
Chronic steroid use, alcoholism, hemoglobinopathies
What is the common presentation of avascular necrosis of the femoral head?
Progressive hip or groin pain without restriction of motion and normal radiograph of early stages.
What is the gold standard for diagnosis for avascular necrosis of the femoral head?
MRI
What population does fibromylagia present in? How does it present?
Young to middle-aged women. Presents with chronic fatigue, widespread pain and cognitive/mood disturbances. Clinical diagnosis.
How is diagnosis of fibromyalgia made?
Using widespread pain index and symptom severity score, which emphasize cognitive problems, fatigue and severity of somatic symptoms.
How does acute gout present
Acute monoarthritis affecting metatarsophalangeal joint or knees.
What does synovial fluid analysis show for acute gout?
Leukocytosis (50% neutrophils) and monosodium urate cyrstals that are negatively birefringent under polarizing microscopy.
What is the treatment for acute gout?
Drugs, Colchine, corticosteroids
Microscope with polarizer oriented North-south shows yellow needle-like cyrstals when parallel to polarizing axis and blue needelike cyrstals when perpendicular to polarizing axis: negatively or positively birefringent?
Negatively.
What are typical extra-pulmonary manifestations of sarcoidosis?
Anterior uveitis (red eye with leuckocytes in the anterior chamber), erythema nodosum in skin, arthitis in joints.
What are the classic lung findings on x-ray for sarcoidosis?
Bilateral hilar adenopathy and reticular opacities
“popping” sensation in the knee commonly occurs in what injury?
ACL injury
Injury of mechanism for ACL?
Rapid directional changes, pivoting on lower extremity with foot planted
What moves are highly sensitive for ACL injury?
Lachman test and anterior drawer sign. Laxity of tibia relative to the femur. Abilty to pull tibia forward easily.
Hemarthrosis usually occurs in ACL or MCL injuries?
ACL
Osteoarthritis aka degenerative joint disease presents in what age group and how?
Over 40. Indolesnt progressive anterior hip pain. Worsened by activity. Relieved by rest. Morning stiffness may occur but if it does, less thn 60 mninutes. Hip is not tener and systemic sx are absent.
Osteitis deformans is aka?
Paget’s disease of bone
What is the most common cause of asymptomatic elevation of alkaline phosphatase in an elderly patient?
Paget’s disease of bone
How is Paget’s disease of bone accidentally diagnosed in an elderly patient?
Elevation of alkaline phosphatase
What is Behcet’s syndrome?
Muti-systemic inflammatory condition
What is the criteria for diagnosis for Behcet’s sydnrome?
Recurrent oral ulcers plus two of the following - recurrent genital ulcers; eye lesions (including anterior and posterior uveitis); retinal vascularization; skin lesions including erythema nodosum, acneiform nodules and papulopustular lesions; and a positive pathery test.
Behcet’s syndrome is most commonly seen in what populations?
Turkish, Asian and Middle Eastern.
What antibodies are most likely present in a patient with systemic sclerosis?
Anti-topoisomerase I and anti-nuclear antibodies
What is systemic sclerosis?
Form of scleroderma with widespread organ involvement
Ankylosing spondylitis most often occurs in patients what age/sex?
20-30s. Mostly male. Ratio is 2-3:1 male:female
What are the sx of ankylosing spondylitis?
Limited spine mobility, progressive back pain of greater than 3 months of duration. Pain and stiffnesss worse in the morning and improves with exercises.
What finding on film is diagnostic of ankylosing spondylitis?
bilateral sacroiliitis
What is the most prominent extraarticular manifestation of ankylosing spondylitis?
Anterior uveitis (25-40% of patients) presents with monocular pain, blurring, photophobia
Nature of the pain from bone metastases?
Progressive pain that is constant and wakes the patient at night.
What is charcot joint?
AKA neurogenic arthropathy is a complication of neuropathy and repeated joint trauma.
Neurogenic arthropathy affects which joints and how does it manifest?
Weight-bearing joints and manifests with functional limitation, deformity and degenerative joint disease and loose bodies on joint imaging.
What is more common (>15% of adult patients) in dermatomyositis patients compared to the general population?
Internal malignangies. Age appropriate cancer screening is essential in these patients.
Dermatomyositis is characterized by?
Cutaneous findings (heliotrope rash and gottron’s papules) and symmetric proximal muscle weakness.
What is used for prevention vs. acute attacks of gout?
Prevention: Allopurinol (xanthine oxidase inhibitor) decreases uric acid production and probenecid (uricosuric drug => increases urinary excretion of uric acid). Treatment: Colchicine, NSAIDs and steroids.
Subacromial bursitis is the result of what kind of motion?
Repetitive overhead motions. Patients complain of patin with active range of motion of the shoulder, and passive internal rotation and forward flexion also elicits tenderness
What are the sx of PMR?
Age>50, bilateral pain and morning stiffness that lasts more than 1 hour, involvement of 2 of the following: 1) shoulders 2) hip/proximal thigh 3) neck or torso 4) constitutional sx (malaise, fever, weight loss)
What are the lab findings for PMR?
Elevated ESR (>40mm/h, sometimes >100mm/h), elevated CRP, normocytic anemia possible
What is the treatment of choice for uncomplicated PMR?
Low-dose steroids prednisone which provides rapid relief
PMR is frequently associated with?
Giant cell arteritis aka temporal arteritis. It is treated with high dose prednisone.
Gouty arthritis may present similarly to?
Septic arthritis and pseudogout
What is critical to achieving diagnosis of gout?
Synovial fluid analysis
American College of Rheumatology suggets using what for diagnosis?
Widespread pain index and symptom severity scale
Which medications are reserved for patients failing initial PMR measures of exercise and good sleep hygiene?
Tricyclic anti-depressants
Patients with suspected giant cell arteritis should immediately receive?
High dose IV systemic glucocorticoids to reduce progression of visual complications
What is the most specific sx of giant cell arteritis?
Jaw claudication
What is secondary amyloidosis and how does it present?
Complication of a chronic inflammatory condition (for example, IBD, RA, chronic infections) resulting in extracellular tissue deposition of fibrils into tissues and organs. Presents with multi-organ dysfunction.
What is the treatment for secondary amyloidosis?
Treatment of underlying disease.
What is Raynaud’s phenomenon?
Abnormal vasoconstriction of digital areteries in response to cold or emotional distress
Patients with suspected secondary Raynaud’s phenomenon should be tested for?
Autoantibodies and inflammatory markers
What is the main differences in clinical presentation and lab findings between primary and secondary Raynaud’s phenomenon?
Primary: usually women 40, symptoms of underlying disease, tissue injuryor digital ulcers, abnormal nail fold capillary exam
What is the treatment for primary and secondary Raynaud’s
Primary: avoid triggers and calcium channel blockers (like nifedipine, amlodipines )for persistent symptons. Secondary: treat underlying. CCB and aspirinfor sx and risk for digital ulceration, respectively
What is the most modifiable risk factor for osteoarthritis?
Obesity (and therefore weight loss). Pharmacologic therapy and exercise play integral roles in osteoarthritis therapy
Narrowed joint space, osteophytes and subchondral sclerosis or cysts in plain films is indicative of?
Osteoarthritis
What is a good drug choice for SLE with skin and joint involvement?
Hydroxychloroquine
What is the most serious side effect of hydroxychloroquine?
Retinopathy and corneal damage. Eye exams every 6 months is the only routine screening required with this drug use.
Synovial fluid analysis of osteoarthritis shows?
Fewer than 2000 WBC/ml, no organisms and no crystals
Bakers cysts commonly can occur in which diseases?
Osteoarthritis, RA, and cartilage tears
What is the pathophysiology of bakers cysts?
Inflamed synovium produces excess fluid => accumulates in popliteal bursa which expands and creates a tender mass. They ocassionally burst and release contents in the calf, resulting in a similar appearance to DVT
MOA for methotrexate
Inhibitor of dihydrofolate reductase. Interferes with cellular utilization of folic acid
Side effects of methotrexate
Macrocytic anemia (Hb100), stomatitis, nausea, rash, hepatoxicity, interstitial lung disease, alopecia and fever
What are the most common radiographic findings in patients with cervical spondylosis.
Osteophytes aka bony spurs (but specificity of these findings are low)
How can rotator cuff tendonitis differentation from other rotator cuff pathologies?
Injectin of lidocaine => resolution of any pain and limitation of motion
Rotator cuff tendonitis can be confirmed by what test on physical examination?
Neer test.
Definitive diagnosis for rotator cuff tendonitis? Also for rotator cuff tear?
MRI; MrI
What is dactylitis?
Sausage digit (diffusely swollen finger)
What is the classic presentation of psoriatic arthritis?
Involment of DIP, morning stiffness, defmority, dactylitis (sausage finger), and nail involvement (onycholysis)
What is the current treatments for psoriatic arthritis?
NSAIDS, methotrexate and anti-TNF agents
In SLE, what joints does it affect?
MCP and PIP joints
What are the systemic manifestations of SLE?
Fatigue, fever, weight loss, non-deforming arthritis, oral ulcers, serositis, hematologic abnormalities, proteinuria and rash.
What red flags when evaluating back pain suggests a systemic disorder?
Age>50, hx of previous cancer, constitutional symptoms (fever, unexplained weight loss), nighttime pain, pain duration > 1month, no response to previous therapy, neurologic symptoms.
What is the management step for patients with low back pain and red flags?
Back x-rays and ESR (inflammatory marker). If it’s normal, then conservative therapy. If no resolution => MRI. On another note, MRI is warranted if there is suspicious for serious anatomic pathology such as cord compression signs/cauda equina.
What is primary raynaud phenomenon?
Increased vascular response to cold temperature and emotional distress without an underlying reason.
Primary Raynaud phenomenon usually found in what age group/sex?
Women under 30
What are the symptoms of primary Raynaud’s phenomenon?
Sx of symmetric episodal attacks without evidence of peripheral vascular disease, tissue injury or abnormal nailfold capillary examination
Diagnosis of inflammatory myopathy is best supported by elevations in what levels? What test is it confirmed by?
Elevated ESR and CK; MRI
Inflammatory myopathies are best treated with?
High dose corticosteroids
What hand pathology occurs in 30% of patients with hypothyroidism?
Carpal tunnel syndrome
Rotator cuff tears result from?
Chronic rotator cuff tendonitis and shoulder trauma (falling on outstretched arm)
How can you differentiate between neurogenic and vascular claudication
Neurogenic claudication = has normal arterial pulses and ankle-brachial index whereas vascular claudication does not.
Tennis elbow aka
Lateral epicondylitis
What is the pathogenesis for carpal tunnel syndrome?
Deposition of mucopolysaccharides in the perineum and endoneurium of the median nerve, tendons and synvoial sheath => causes direct pressure on the median nerve within the carpal tunnel.
Lateral epicondylitis manifests as?
Pain with supination of extension of the wrist and point tenderness just distal to the lateral epicondyle.
Where is the anserine bursa location?
Anteriomedially over the tibial plateau, just below the knee joint line
Anserine bursitis can be caused by?
Abnormal gait, overuse or trauma
Anserine bursitis presents with? Radiographs show what?
Sharply localized pain over the AML part of the tibial plateau just below the joint line. Radiographs are classically normal. Negative Valgus stress test.
Positive valgus stress may indicate?
MCL pathology
What are the side effects of cyclophosphamide?
Bladder carcinoma and acute hemorrhagic cystitis.
What is enthesitis?
• Refers to inflammation and pain at sites where tendons and ligaments attach to bone
Enthesitis is commonly found in which disease? What are the typical sites?
Ankylosing spondylitis. Achilles tendon, tibial tuberosities and iliac crests
Back pain from inflammatory etiology improves/does not improve with rest and exercise?
Does not improve with rest. Improves with exercise.
What is patellofemoral syndrome?
Pain arising from contact of the posterior patella to the femur
What are the symptoms of patellofemoral syndrome?
Chronic knee pain, a/w activities such as climbing stairs, squatting, running, prolonged sitting.
How do you diagnose patellofemoral syndrome?
Patellofemoral compression test (pain elicited by extending the knee while compressing patella), reproduction of paitn with squatting, history
What is the treatment of patellofemoral syndrome?
Streching and strenthening the thigh muscles in addition to avoiding activities that worsen the pain
What are the most common causes of nontraumatic vertebral compression fracture?
Osteoporosis and osteomalacia
Acute back pain and point tenderness after strenuous activity is indicative of?
Vertebral compression fracture
Risk factors for vertebral compression fractures include?
Trauma, osteoporosis or osteomalacia, infection (like osteomyelitis), malignancy with bone metastases, and metabolic abnormalities (hyperparathyroidism)
What are important preventative measures for acute attacks of gout?
Cessation of alcohol and staying on low purine diet
What is the treatment of choice for acute gout attack?
NSAIDs, colchicine and steroids
What is crest syndrome and its findings?
Limited form of systemic sclerosis. Esophageal dysmotility, Raynaud’s phenomenon, cutaneous calcinosis, sclerodactyly, telangiectasias
What is the initital DMARD of choice for RA?
Methotrexate. Supplement with folic acid to reduce adverse effects without loss of efficacy
What are the common side effects of methotrexate?
Oral ulcers/stomatitis, GI sx, rash, alopecia, hepatotoxicity, pulmonary toxicity, and bone marrow suppression (cytopenias - such as leukopenias, thrombocytopenias and macrocytic anemias)
Which findings are highly suggestive of sarcoidosis on chest x-ray?
Paratracheal (hilar) adenopathy and reticulonodular infiltrates
What are the major radiographic findings of osteoarthritis?
Joint space narrowing, subchondral sclerosis, osteophytes, and subchondral cysts
Osteoarthritis predominantly affects which joints?
DIP
How does septic arthritis present?
Acute monoarthritis often with fever and restricted range of motion. More common in patients with underlying disease.
What should be done promptly to confirm diagnosis of septic arthritis?
Synovial fluid analysis
What is the initial treatment for septic arthritis?
Antibiotics. Gram positive cocci: vancomycin. Gram negative rod: third generation cephalosporine. Negative microscopy: vancomycin (+ third generation cephalosporin if immunocomprosmied)
In Paget’s disease, what are the levels of the following 1) calcium 2) phosphate 3) alkaline phosphatase 4) hydroxyproline
Normal, Normal, Elevated, Elevated
Erythema nodosum presents in which diseases, commonly?
Recent streptococcal infection, sarcoidosis, TB, histoplasmosis, and IBD
What are the common findings of sarcoidosis (PE and Chest x-ray)
Cough, anterior uveitis, polyarthritis, hilar adenopathy/reticulonodular infiltrates (chest x-ray)
What should be tested before starting methotrexate?
Tested for Hep B, C and TB
Methotrexate is contraindicated in which patients?
Patients that are pregnant, planning to get pregnant soon, renal insufficiency, liver disease or XS alcohol intake.
How is the presentation of viral arthritis different from rheumatoid arthritis/other causes of symmetric arthritis?
Acute onset, lack of elevated inflammatory markers (although inflammatory markers such as RF and ANA can be elevated) and resolution within 2 months
What is one of the most common causes of viral arthritis?
Parvovirus - particularly likely in adults who come in frequent contact with children.
What are rheumatoid nodules
Occurs in 30-40% of patients. Flesh colored, firm and non tender subcutaneous noduels usully close to pressure points like elbows
What is De Quervain’s tenosynovitis?
Inflamation of the extensor pollicis brevis and abductor pollicus longus tendons as they pass through fibrous sheath at radial styoid process
What is the test used to De quervain’s tenosynovitis?
Finkelstein test => positive => De Quervain’s
Is HLA-B27 testing done to make diagnosis of AS?
No. It is not a specific test.
What finding on X-ray is diagnostic for ankylosing spondylitis
Fused sacroiliac joints / bamboo spine
How is Whipple’s disease diagnosis made?
Small intestinal biopsy and PCR. Biospy shows PAS-positive macrophages in the lamina propria containing non-acid fast gram positive bacilli (Tropheryma whippelii)
What are the most common presenting symtpoms of Whipple’s disease?
Chronic malabsorptive diarrhea, weight loss, migratory non-deforming arthritis,lymphadenopathy and low grade fever
How is diagnosis of Sjogren’s syndrome made
Diagnosis: subjective and objective evidence of dry mouth and eyes in the presence of Histologic evidence of lymphocytic infiltration of salivary glands Or serum antibodies against Ro (SSA) or La (SSB)
What is the most common cause of septic arthritis in young, sexually active patients?
Neisseria gonorrhoeae
What is the presentation of gonococcal arthritis?
Isolated prurulent mono or polyarthritis OR triad of dermatitis, tenosynovitis (wrist, ankles, fingers and knees), and migratory asymmetric polyarthralgias without purulent arthritis.
What are the criteria used to establish OA diagnosis in setting of painful knee?
o Age>50 o Crepitus o Bony enlargement o Lack of warmth/morning stiffness o If more than 3 are met, the specificity for OA is 69%
High index of suspicion for vertebral osteomyelitis should be present for patients with history of?
Injection drug use or recent distant infection (UTI, for example)
What is the most reliable PE sign for spinal osteomyelitis?
Tenderness to gentle percussion over the spinous process of the involved vertebra.
In acute mechanical back pain, straight leg test is?
Positive.
What is the treatment approach for acute ‘mechanical’ back pain without signfiicant neurologic deficit?
Conservative approach preferered for a period of 4-6 weeks. Early mobilization, muscle relaxants and NSAIDs. Bed rest and physical therapy not shown to be helpful. Note: it is important to ensure that patient does not have neurologic deficit
What are the common findings of reactive arthritis?
Classic triad: nongonococcal urethritis, arthritis, conjunctivitis. Other common findings: enthesitis (achilles tendon pain, eg), mucocutaneous lesions. The triad doesn’t always appear so have high index of suspicion.
What is the first line of therapy for reactive arthritis?
NSAIDs
Lumbar stenosis is characterized by?
Common cause of back pain in patients over 60. Pain radiates to buttocks and thighs.
What is the treatment for fibromyalgia?
Initial - conservative: exercise, sleep hygiene etc. Afterwards tri-cyclic antidepressants such as amitryptiline.
What are the alternative treatments for fibromyalgia?
Pregabalin, duloxetine, milnacipran.
IBD and inflammatory arthritis both may have positive what levels?
p-ANCA
What accounts for more than 90% of cases of avascular necrosis of the bone?
Chronic corticosteroid use and excessive ingestion of alcohol.
How does osteonecrosis in the hip present?
Slowly progressive anterior hip pain with limited range of motion.
What is the pathophysiology of osteonecrosis?
Vasculature to the affected bone disrupted => bone and bone marrow infarction => bone unable to remodel and trebecular thinnging => collapse of infected bone.
What is the most senstive test for osteonecrosis?
MRI
Branches of which blood vessels are commonly affected in giant cell / temporal arteritis?
Aorta. Aortic aneurysms are well known complications. Patients should be followed with chest x-rays
Antimitochondrial antibodies a/w
primary biliary cirrhosis
Anti-smooth muscle antibobodies a/w
Autoimmune hepatitis
rheumatoid factor a/w
RA, but also in SLE, Sjogren’s, dermatomyositis, HCV infectio and others
ANCA a/w
Wegener’s - granulomatosis with polyangiitis
Dermatomyositis is a/w which antibodies?
Anti-jo-1 (antisythetase) and anti-Mi-2 (against helicase)
Antibodies a/w Sjogren’s syndrome
Against SSA (Ro) / SSB (La)
Mesna is used for?
To prevent hemorrhagic cystitis caused by certain chemotherapuetic agents (cyclophosphamide)
N acetylcystein is used for?
Antidote for acetominophen overdose and nephroprotective agent to prevent radiocontract induced nephropathy
What are Janeway Lesions
Painless erythematous lesions on palms or soles
What are Osler’s Nodes
Painful, papular pustules on pulp of finges or toes
What is chondrocalcinosis?
Calcification of cartilaginous structures
What are osteophytes
Bony spurs
What is the Neer test?
Passive motion of the arm above the head
What is the Phalen test?
Flexion of wrist. Pain and paresthesias -> positive test.
Rotator cuff injury is due to impingement of what?
Supraspinatus tendon
What drugs cause cochlear dysfunction?
Cisplatin and carboplatin
What drugs cause optic neuritis?
Ethambutol and hydroxychloroquine
What drugs cause peripheral neuropathy?
Phenytoin, isoniazid, vincristine, heavy metal and chronic alcoholism
What drugs cause thryoid dysunfction?
Amiodarone and lithium
