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Differential Diagnosis > Screening for Immunologic Disease > Flashcards

Screening for Immunologic Disease Flashcards

1
Q

what is immunology?

A

response to defend against attacks by “foreign invaders”

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2
Q

immunity is provided by ________

A

lymphoid cells

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3
Q

how are immune disorders classified?

A
  1. immunodeficiency disorder
  2. hypersensitivity disorder
  3. immunoproliferative disorder
  4. autoimmune disorder
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4
Q

List some patient interview questions that you should include when screening for immunologic disease

A
  1. how long have you had this problem? (acute or chronic)
  2. has the problem gone away and then recurred?
  3. have additional symptoms developed or have other areas become symptomatic over time?
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5
Q

_________ is important when assessing role of immune system

A

family history

(family history of systemic inflammatory disease may be only risk factor for immunologic disease)

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6
Q

list associated S/S of immunologic disease

A
  1. Soft tissue/joint pain
  2. stiffness
  3. swelling
  4. generalized weakness
  5. constitutional symptoms
  6. Raynaud’s phenomenon
  7. sleep disturbances
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7
Q

describe the S/S of soft tissue/joint pain associated with immunologic disease

A
  1. specific joints affected
  2. RA = wrist and proximal small joints of hands and feet
  3. Psoriatic arthritis = distal joints of hands and feet
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8
Q

describe the S/S of stiffness associated with immunologic disease

A
  1. marked by prolonged stiffness
  2. >1 hour
  3. gel phenomenon → symptoms relieved with activity but recurs after sitting and then attempting to resume activity
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9
Q

what is included in the immunologic ROS?

A
  1. skin or nail bed changes
  2. fever or other constitutional symptoms (especially recurrent or cyclical symptoms)
  3. lymph node changes (tenderness, enlargement)
  4. anaphylactic reaction
  5. symptoms of muscle or joint involvement (pain, swelling, stiffness, weakness)
  6. sleep disturbances
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10
Q

what is included in the rheumatologic ROS?

A
  1. presence/location of joint swelling
  2. muscle pain, weakness
  3. skin rashes
  4. reaction to sunlight
  5. Raynaud’s phenomenon
  6. nail bed changes
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11
Q

list several autoimmune disorders

A
  1. Fibromyalgia
  2. RA
  3. Polymyalgia Rheumatica
  4. Scleroderma
  5. SLE
  6. Ankylosing spondylitis
  7. Reiter’s syndrome or reactive arthritis
  8. Psoriatic arthritis
  9. MS
  10. Guillain-Barre syndrome
  11. Myasthenia Gravis
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12
Q

give an overview of the general pathophysiology behind most autoimmune disorders

A

occurs when the immune system fails to distinguish self from non-self and misdirects immune response against body’s own tissues

  • body manufactures autoantibodies directed against the body’s own cellular component or specific organs
  • results in abnormal tissue reaction and tissue damage
  • exact cause is not well understood
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13
Q

what is Fibromyalgia?

A

noninflammatory condition appearing when generalized MSK pain with associated tenderness to palpation in a large number of specific areas

women > men

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14
Q

recent evidence supports that chronic pain is __________

A

centrally mediated

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15
Q

what does the new set of diagnostic criteria require for the diagnosis of fibromyalgia?

A

focuses on measuring symptoms severity rather than relying on tender point examination alone

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16
Q

List some of the tender points that can occur in fibromyalgia

A
  1. Low cervical (bilateral at C5-C7)
  2. 2nd rib
  3. lateral epicondyle (2cm distal)
  4. Knees (fat pad proximal to joint line)
  5. occiput (suboccipitals insertions)
  6. trapezius (midpoint of upper border)
  7. supraspinatus (near medial border)
  8. gluteal (upper outer quadrants in anterior fold)
  9. greater trochanter (posterior to trochanteric prominence)
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17
Q

Clinical S/S and core features of Fibromyalgia

A
  1. aches and pains
  2. stiffness
  3. swelling in soft tissues
  4. tender points
  5. muscle spasms or nodules

fatigue, morning stiffness and sleep disturbances may be present but not necessary for diagnosis

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18
Q

what is RA?

A

chronic, systemic, inflammatory disorder

  • women 2-3x > men
  • most common between 20-40 years
  • affects various organs → predominately synovial tissues of synovial joints
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19
Q

what is the cause of RA?

A

unknown but there is support for genetic predisposition

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20
Q

clinical S/S of RA

A

“SERIOUS”

  1. Swelling in one or more joints
  2. Early morning stiffness (lasting >1 hour)
  3. Recurring pain/tenderness in any joint (MTP, MCP)
  4. Inability to move a joint normally
  5. Obvious redness and warmth in a joint
  6. Unexplained weight loss, fever or weakness combined with joint pain
  7. Symptoms such as these that last for more than 2 weeks
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21
Q

why is early referral/diagnosis important in RA?

A

studies show that 70-90% of people with RA have sig joint erosion 2 years after onset

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22
Q

list early inflammatory symptoms of RA

A
  1. sig discomfort with compression of metacarpal and metatarsal joints
  2. presence of 3 more swollen joints
  3. more than 1 hour of morning stiffness
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23
Q

list joints affected by RA

A
  1. hands/feet
  2. Cervical spine
  3. shoulder
  4. elbow
  5. wrist
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24
Q

describe how RA affects the hands/feet

A
  1. forefoot pain often first complaint
  2. hammer-toe deformities
  3. volar subluxation of MCP joint and ulnar deviation
  4. Swan neck and boutonniere deformities may also be present
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25
Q

how does RA affect the Cervical spine?

A
  1. neck stiffness may be reported in early onset of disease
  2. C1-C2 laxity secondary to inflammation of ligaments
    1. occurs more often late in disease
    2. could result in atlantoaxial subluxation with resultant spinal cord compression
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26
Q

how does RA impact the shoulder?

A
  1. chronic synovitis may result in:
    1. limitation of shoulder ROM
    2. dislocation
    3. spontaneous tears or rotator cuff
    4. adhesive capsulitis
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27
Q

how does RA impact the elbow?

A

destruction or articulation may result in:

  1. flexion contracture
  2. loss of supination/pronation
  3. subluxation
  4. ulnar nerve neuropathy
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28
Q

how does RA impact the wrist?

A

frequently affected and may result in:

  1. interosseous muscle atrophy
  2. ankylosis
  3. carpal tunnel syndrome (due to volar synovitis)
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29
Q

list extraarticular manifestations of RA

A
  1. Rheumatoid nodules
  2. Arteritis
  3. Neuropathy
  4. Scleritis
  5. Pericarditis
  6. Splenomegaly
30
Q

list the diagnosis criteria for RA

A
  1. morning stiffness
  2. arthritis of 3 or more joint areas
  3. arthritis of hand joints
  4. symmetric arthritis
  5. Rheumatoid nodules
  6. serum rheumatoid factor
  7. radiographic changes

a diagnosis is made when an individual has 4 out of 7 criteria

31
Q

what is polymyalgia rheumatica?

A

systemic, rheumatic inflammatory disorder with unknown cause

  • occurs almost exclusively in people >50
  • 2x women > men
  • predominately in Caucasians
32
Q

polymyalgia rheumatica is characterized by what?

A

severe aching and stiffness primarily in the muscles as opposed to joints

33
Q

Clinical S/S of polymyalgia rheumatica

A
  1. muscle pain or aching (proximal muscles)
    1. neck, shoulder, and pelvic girdle
  2. stiffness upon arising in the morning or after rest
  3. weakness, fatigue, malaise
  4. low-grade fever, sweats
  5. HA
  6. weight loss
  7. depression
  8. vision changes
34
Q

describe management of polymyalgia rhemuatica

A
  1. condition is typically self limiting
  2. typically lasts 2-3 years
  3. oral corticosteroids used to suppress inflammation, treat symptoms, and provide remission but DO NOT CURE
  4. important for PT:
    1. alert for possible steroid-induced osteopenia and diabetes
  5. most pts with condition do not have lasting effects w/medical intervention
35
Q

what is scleroderma?

A

chronic multisystem disease

characterized by skin inflammation and fibrosis of many body parts including skin, blood vessels, synovium, skeletal muscle, and certain internal organs (ie kidneys, lungs, heart, and GI tract)

36
Q

what are the 2 major categories of scleroderma?

A
  1. limited cutaneous
  2. diffuse cutaneous scleroderma
37
Q

describe limited scleroderma

A
  1. characterized by long history of Raynaud’s phenomenon
  2. skin thickening is limited to hand
  3. esophageal dysmotility is common
38
Q

describe diffuse scleroderma

A
  1. more acute onset
  2. many constitutional symptoms, arthritis, carpal tunnel and marked swelling of hands and legs
  3. wide-spread skin thickening occurs and progresses from fingers to trunk
  4. internal organ problems are common
    1. GI effects and pulmonary fibrosis common
    2. severe life threatening involvement of heart and kidney occurs
39
Q

clinical S/S of limited scleroderma

A

“CREST”

  1. Calcinosis
  2. Raynaud’s phenomenon
  3. Esophageal dysmotility, dysphagia, heartburn
  4. Sclerodactyly
  5. Telangiectasia
40
Q

Clinical S/S of diffuse cutaneous scleroderma

A
  1. Raynaud’s phenomenon
  2. trunk and extremity skin changes
  3. ulcerations of fingers
  4. polyarthralgia
  5. flexion contractures of large and small joints
  6. visceral involvement
    1. interstitial lung disease, esophageal involvement, renal failure, GI disease, myocardial involvement
41
Q

describe Systemic Lupus Erythematosus (SLE)

A

in family of autoimmune rheumatic disease

chronic, systemic, inflammatory condition affecting skin, joints, kidneys, heart and blood-forming organs, nervous system and mucous membranes

42
Q

SLE is characterized by ________

A

butterfly rash across cheeks and nose

43
Q

what are the 2 primary forms of SLE?

A
  1. discoid lupus
  2. systemic lupus
44
Q

list risk factors for SLE

A
  1. appears to be result of immunoregulation disturbance caused by interplay of genetic, hormonal, chemical and environmental factors
  2. environmental factors may trigger include infections, antibiotics/other meds, exposure to UV light and extreme physical and emotional stress (like pregnancy)
  3. known genetic predisposition but no known gene identified
  4. may occur at any age but most common 15-40 yo
  5. women 10-15x > men
45
Q

Clinical S/S of SLE

A
  1. Arthralgia
  2. Arthritis
  3. constitutional symptoms (low-grade fever and fatigue)
  4. skin rash (malar) → butterfly rash
  5. pulmonary involvement
  6. anemia
  7. kidney involvement
  8. sun or light sensitivity
  9. hair loss
  10. Raynaud’s phenomenon
  11. nervous system involvement
    1. seizures, HA, peripheral neuropathy, cranial neuropathy, CVA, psychosis
  12. mouth, nose or vaginal ulcers
46
Q

what is a spondyloarthropathy?

A

group of noninfectious, inflammatory, erosive rheumatic disease

targets SI, bony insertion of annulus fibrosis of IV discs and facets joints

more common in men

47
Q

spondyloarthropathies include what conditions?

A
  1. Ankylosing spondylitis
  2. Reiter’s syndrome
  3. Psoriatic arthritis
48
Q

what is ankylosing spondylitis?

A

chronic, progressive inflammatory disorder of undetermined cause

inflammation of fibrous tissue affecting insertions of ligaments, tendons and capsules into bone resulting in fusion over time

49
Q

what joints are primarily affected in ankylosing spondylitis?

A

SI, spine and large peripheral joints

50
Q

Clinical S/S of early stages of ankylosing spondylitis

A
  1. intermittent LBP
  2. sacroiliitis
  3. spasm of paravertebral muscles
  4. loss of normal lumbar lordosis
  5. painful limitation of cervical joint motion
  6. intermittent, low-grade fever
  7. fatigue
  8. anorexia, weight loss
  9. anemia
51
Q

Clinical S/S of advanced stages of ankylosing spondylitis

A
  1. constant LBP
  2. loss of normal lumbar lordosis
  3. ankylosis of SI joints and spine
  4. muscle wasting in shoulder and pelvic girdle
  5. marked dorsocervical kyphosis
  6. decreased chest expansion
  7. arthritis involving peripheral joints
  8. hip flexion in standing
52
Q

complications to ankylosing spondylitis?

A
  1. prone to fracture from even minor trauma
  2. most common fracture site is lower cervical spine
  3. myelopathy
  4. spondylodiscitis → erosive and destruction lesion of vertebral bodies
  5. cauda-equina syndrome
  6. spinal stenosis
53
Q

describe Reiter’s syndrome

A

type of reactive arthritis → characterized by triad of arthritis, conjunctivitis and nonspecific urethritis

occurs mainly in young adult men 20-40 yo

genetic predisposition → HLA-B27

54
Q

how is Reiter’s syndrome differentiated from ankylosing spondylitis?

A
  1. presence of urethritis and conjunctivitis
  2. prominent involvement of distal joints
  3. presence of asymmetric radiologic changes in SIJ and spine
55
Q

clinical S/S of Reiter’s syndrome

A
  1. Plantar fasciitis
  2. polyarthritis
  3. SIJ changes
  4. low back and buttock pain
  5. small joint involvement
  6. low-grade fever
  7. urethritis
  8. conjunctivitis and iritis bilaterally
  9. skin involvement (resembling psoriasis)
  10. may be preceded by bowel infection
  11. anorexia and weight loss
56
Q

describe psoriatic arthritis

A

chronic, recurrent, erosive, inflammatory arthritis

  • associated w/skin disease psoriasis
  • affects both genders equally
  • can occur at any age but usually in 20-30s
  • arthritis is usually preceded by skin condition
  • causes and risk factors are unknown
  • presence of HLA-B27 also common
57
Q

Clinical S/S of Psoriatic Arthritis

A
  1. Fever
  2. fatigue
  3. polyarthritis
  4. psoriasis
  5. sore fingers
58
Q

unique clinical features of psoriatic arthritis

A
  1. DIP joint involvement
  2. nail changes
  3. dactylitis (sausage fingers)
  4. spondylitis
  5. iritis
59
Q

describe Multiple Sclerosis

A
  1. most common inflammatory demyelinating disease of the CNS
  2. affects brain and spinal cord
  3. symptoms appear between 20-40
  4. women 2x > men
  5. family hx of MS increases risk 10x
  6. 5x more prevalent in colder climates of North America and Europe
  7. characterized by inflammatory demyelinating lesions that form scars scattered in CNS white matter
    1. especially optic nerve, cerebrum, and cervical spinal cord
60
Q

Clinical symptoms of MS

A
  1. unilateral visual impairment
  2. paresthesia
  3. ataxia
  4. vertigo
  5. fatigue
  6. muscle weakness
  7. bowel/bladder dysfunctions
  8. speech impairment
61
Q

Clinical signs of MS

A
  1. optic neuritis
  2. nystagmus
  3. spasticity or hyperreflexia
  4. Babinski’s sign
  5. absent abdominal reflexes
  6. dysmetria or intention tremor
  7. labile or changed mood
  8. Lhermitte’s sign
62
Q

describe Guillain-Barre Syndrome

A

AKA acute idiopathic polyneuritis

an acute, acquired autoimmune disorder that causes demyelination of peripheral nervous system and by abrupt onset of paralysis

63
Q

causes and risk factors for Guillain-Barre Syndrome

A
  1. risks
    1. affects all age groups
    2. not related to race or sex
  2. causes
    1. exact cause is unknown but frequently occurs after an illness
    2. immune system attacks it own myelin cells b/c they look similar to molecules of infecting virus
64
Q

Clinical S/S of GBS

A
  1. muscular weakness
    1. bilateral
    2. progressing from legs and arms to chest and neck
  2. diminished DTR
  3. paresthesia (w/o loss of sensation)
  4. fever, malaise
  5. nausea
65
Q

describe myasthenia gravis

A

develops when antibodies produced by immune system blocks receptors in muscles that receive signals of acetylcholine

results in impaired muscle function

(may occur at anytime)

66
Q

what are the 2 peak onsets for myasthenia gravis?

A

20-30 years

after 50 years

67
Q

clinical S/S of myasthenia gravis

A
  1. muscle fatigue and proximal muscle weakness aggravated by exertion
    1. worsens w/reps and improves w/rest
  2. respiratory failure
  3. ptosis
  4. diplopia
  5. dysarthria
  6. alterations in voice quality
  7. dysphagia
  8. nasal regurgitation
  9. choking, difficulty in chewing
68
Q

list clues to immune system dysfunction

A
  1. insidious onset of episodic back pain in patient younger than 40 with family history of spondyloarthropathy
  2. joint pain preceded or accompanied by burning and urinary frequency (urethritis) and/or accompanied by eye irritation
  3. joint pain preceded or accompanied by a skin rash or lesion → psoriatic arthritis
  4. development of neurological symptoms 1-3 weeks after infection → suspicious of GBS
69
Q

guidelines for immediate medical attention

A
  1. dusky blue discoloration or erythema with exquisite tenderness in a joint → could be a sign of a septic joint
  2. evidence of spinal cord compression
  3. presence of incontinence in pts with ankylosing spondylitis
70
Q

guidelines for MD referral

A
  1. new onset of joint pain within 6 weeks of surgery accompanied by constitutional symptoms
  2. symmetric swelling and pain in peripheral joints
  3. development of progressive neurologic symptoms within 1-3 weeks of previous infection or recent vaccination

Differential Diagnosis (16 decks)

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