Seronegative spondylitis & MSK Flashcards
Osteoarthritis is thought to result from chronic mechanical stress +/- a decrease in [molecule]
Osteoarthritis is thought to result from chronic mechanical stress +/- a decrease in proteoglycans
Osteoarthritis is associated with decreased proteoglycans which results in decreased cartilage elasticity and [X-ray finding]
Osteoarthritis is associated with decreased proteoglycans which results in decreased cartilage elasticity and decreased joint space and subchrondral sclerosis
* It will affect the entire joint including the articular cartilage, synovium, and subchondral bone
Non-modifiable risk factors of osteoarthritis include _ ;
Modifiable risk factors include _
Non-modifiable risk factors of osteoarthritis include age, trauma, family history, female sex
Modifiable risk factors include obesity, overuse
Osteoarthritis is better with [use/rest]
Osteoarthritis is better with rest
* Pain increases with activity
Morning stiffness that lasts > 30 minutes is more likely [RA/ osteoarthritis]
Morning stiffness that lasts > 30 minutes is more likely RA
* Osteoarthritis stiffness will last less than 30 minutes
Osteoarthritis will be [symmetry], commonly of the [joints]
Osteoarthritis will be asymmetric, commonly of the hands, hips, knees
* Contrast this to RA which is symmetric
Osteoarthritis may present with nodes of the DIP called _ or of the PIP called _
Osteoarthritis may present with nodes of the DIP called Heberden nodes or of the PIP called Bouchard nodes
* Heberden are “high” and Bouchard are “below”
The first line diagnostic test for OA is _
The first line diagnostic test for OA is x-ray
* Irregular joint space narrowing, subchondral sclerosis, osteophyte formation, subchondral cysts
OA arthrocentesis will show [inflammatory/ non-inflammatory] synovial joint fluid
OA arthrocentesis will show non-inflammatory synovial joint fluid
* WBC < 2000/mm3
Gout is a joint disease that involves a precipitation of _ crystals
Gout is a joint disease that involves a precipitation of monosodium urate crystals
* The crystals deposit into the tissues and result in an inflammatory crystalline arthropathy
Gout is caused by either _ or _
Gout is caused by either increased uric acid production or decreased excretion
* Most commonly will see patients with underexcretion (kidney issues)
Risk factors of gout include:
Risk factors of gout include:
* Male sex
* High purine diet
* Tumor lysis syndrome
* CKD
* Genetic predisposition
Individuals with a defective HGPRT enzyme like in [condition] or lysosomal storage disease _ , are at an increased risk of gout
Individuals with a defective HGPRT enzyme like in Lesch-Nyhan or lysosomal storage disease Von Gierke , are at an increased risk of gout
* These lead to increased denovo purine synthesis
Name some medications that increase risk for gout:
Name some medications that increase risk for gout:
* Thiazide & loop diuretics
* Aspirin
* Niacin
Gout classically presents with acute pain of the [joint]
Gout classically presents with acute pain of the first MTP joint
* This is called podagra
* Typically remains mono-articular
Gout sx may include _ ; often precipitated by a trigger of increased uric acid levels, trauma, dehydration
Gout sx may include swelling, warmth, erythema, TTP, reduced ROM ; often precipitated by a trigger of increased uric acid levels, trauma, dehydration
* Symptoms may wake patient at night
_ are stone-like deposits of uric acid which are a late manifestation of chronic gout
Tophi are stone-like deposits of uric acid which are a late manifestation of chronic gout
* Classically of the olecranon, ear, achilles tendon
The gold standard for gout diagnosis is _
The gold standard for gout diagnosis is arthrocentesis/synovial fluid analysis
* Serum uric acid likely to be elevated
* Need synovial fluid analysis for definitive diagnosis
Classically, gout will present as [shape]-crystals and [+/-] birefrigence under polarized light
Classically, gout will present as needle-shaped crystals and (-) birefrigence under polarized light
Under parallel light, gout crystals appear [color] while under perpendicular light they appear [color]
Under parallel light, gout crystals appear yellow while under perpendicular light they appear blue
_ is a gout medication that binds tubulin in microtubules and inhibits neutrophil function
Colchicine is a gout medication that binds tubulin in microtubules and inhibits neutrophil function
* Does not alter urate levels
Acute management of gout includes [3 drugs]
Acute management of gout includes NSAIDs, colchicine, steroids
Allopurinol and febuxostat are classic gout medications that work by [MOA]
Allopurinol and febuxostat are classic gout medications that work by inhibiting xanthine oxidase
* Hypoxanthine –> Xanthine –> Uric acid (blocked by XO inhibitors)
_ is gout-like joint disease that involves crystal deposition in the tissues
Calcium pyrophosphate deposition disease is gout-like joint disease that involves crystal deposition in the tissues
* Involves the deposition of calcium pyrophosphate dihydrate crystals
* Also called pseudogout
Calcium pyrophosphate deposition disease is often idiopathic but more common in older adults and may be associated with _
Calcium pyrophosphate deposition disease is often idiopathic but more common in older adults and may be associated with hemochromatosis, hyperparathyroidism, joint trauma
* Hypothyroidism can also be associated
Pseudogout classically presents with [shape] crystals and [+/-] birefringence under polarized light
Pseudogout classically presents with rhomboid-shaped crystals and (+) birefringence under polarized light
Pseudogout will appear [color] under parallel light and [color] under perpendicular light
Pseudogout will appear blue under parallel light and yellow under perpendicular light
* This is opposite of gout
X-ray of CPPD will show _ and serum uric acid will typically be _
X-ray of CPPD will show chondrocalcinosis and serum uric acid will typically be normal
Septic arthritis occurs secondary to _
Septic arthritis occurs secondary to infection (leads to inflammation of the joint)
* Can result from hematogenous infection or direct contamination
Name some risk factors for septic arthritis:
Name some risk factors for septic arthritis:
* Underyling joint disease
* IVDU
* Prosthetic implants
* Immunosuppression
* Diabetes
* Advanced age
The most common organism responsible for septic arthritis is _ ; others include _
The most common organism responsible for septic arthritis is staph aureus ; others include streptococcus, gonorrhea, pseudomonas aeruginosa
Septic arthritis is typically [joint pattern] and most commonly affects the [joint]
Septic arthritis is typically monoarticular and most commonly affects the knee
Septic arthritis will present with [symptoms]
Septic arthritis will present with decreased ROM, swelling, warmth, erythema, TTP, and fever due to infection
Disseminated gonococcal infection involves a triad of _ , _ , and _
Disseminated gonococcal infection involves a triad of polyarthralgias , tenosynovitis , and dermatitis
* It will be a migratory/ asymmetric polyarthralgia
* If there is an overlying infection arthrocentesis is contraindicated
Septic arthritis is associated with a purulent synovial fluid and increased WBC > [number]
Septic arthritis is associated with a purulent synovial fluid and increased WBC > 50,000 (neutrophil dominant)
* Also want to get blood cultures and gram stain
* X-ray may show soft tissue swelling or be unremarkable
Fibromyalgia is most common in [population]
Fibromyalgia is most common in females, 20-50 years old
Fibromyalgia requires the presence of _ for diagnosis
Fibromyalgia requires the presence of 3 months duration of pain in all quadrants of the body with profuse “tender points” on exam for diagnosis
Fibromyalgia will have a _ ESR, no specific autoantibodies, and _ imaging
Fibromyalgia will have a normal ESR, no specific autoantibodies, and normal imaging
Treatment for fibromyalgia may include:
Treatment for fibromyalgia may include:
* Exercise
* Duloxetine, amitriptyline
* Gabapentin, pregabalin
_ is heterotopic ossification of skeletal muscle that results from repeated or blunt msk trauma
Myositis ossificans is heterotopic ossification of skeletal muscle that results from repeated or blunt msk trauma
* It is a benign bony formation of soft tissue
* May be seen in athletes
* Often from overuse injuries
Myositis ossificans will present as a [painful/painless] soft tissue mass
Myositis ossificans will present as a painful soft tissue mass
* Also local swelling, tenderness, decreased ROM
Myositis ossificans is associated with increased ESR and increased [LFT]
Myositis ossificans is associated with increased ESR and increased alkaline phosphatase
* Alk phos is elevated due to the increased bone turnover
Myositis ossificans is [prognosis]
Myositis ossificans is often self-limiting
* Over time the body can resorb the calcium
* Treat with sx management (e.g. rest, activity modification, PT)
Seronegative spondyloarthropathies include various forms of chronic inflammatory arthritis that are all _
Seronegative spondyloarthropathies include various forms of chronic inflammatory arthritis that are all negative for RF
* PAIR: psoriatic arthritis, ankylosing spondylitis, IBD-associated, reactive arthritis
Seronegative spondyloarthritis is associated with [HLA marker]
Seronegative spondyloarthritis is associated with HLA-B27
OA or RA?
OA:
* Joint space narrowing with osteophytes
* Central erosion (OA) whereas RA tends to have marginal erosion of the joints
* Involvement of the DIPs
Colchicine has a narrow therapeutic window; side effects include:
Colchicine has a narrow therapeutic window; side effects include:
* GI toxicity: diarrhea even at low doses
* Marrow suppression at high doses
* Dose must be adjusted for renal insufficiency
Nodules at the elbow: think RA or _
Nodules at the elbow: think RA or gout
Xanthine oxidase inhibitors like _ or _ decrease the production of urate
Xanthine oxidase inhibitors like allopurinol or febuxostat decrease the production of urate
_ is a uricosuric agent that increases the excretion of urate but carries a risk of kidney stones
Probenecid is a uricosuric agent that increases the excretion of urate but carries a risk of kidney stones
* Only can be used in patients with normal kidney function
There is a risk of _ when beginning urate lowering therapy like allopurinol
There is a risk of precipitating acute attack when beginning urate lowering therapy like allopurinol
* All patients should be on prophylactic therapy with NSAIDs, colchicine, or steroids
Psoriatic arthritis involves the recruitment of [cells] which activate osteoclasts and lead to osteolysis
Psoriatic arthritis involves the recruitment of T-cells which activate osteoclasts and lead to osteolysis
* Increased IFN-a, IL-6, TNF-a brings in T cells to the skin and joints
Psoriatic arthritis usually affects individuals around age _
Psoriatic arthritis usually affects individuals around age 30-50
* It will often present in the beginning as asymmetric oligoarthritis and then progress to symmetric polyarthritis in late stage
Psoriatic arthritis symptoms include:
Psoriatic arthritis symptoms include:
* Skin psoriasis
* Pitting nail beds
* Enthesitis (inflammation at attachment sites)
* Dactylitis (sausage digits)
X-ray of psoriatic arthritis may show _ deformity of DIP joint
X-ray of psoriatic arthritis may show pencil-in-cup deformity of DIP joint
What do you expect to see on labs for psoriatic arthritis?
Elevated CRP, ESR, uric acid
HLA-B27 positive
RF negative
Bilateral low back pain that improves with activity but not rest (in 15-35 year olds) should give concern for _
Bilateral low back pain that improves with activity but not rest (in 15-35 year olds) should give concern for ankylosing spondylitis
* Commonly presents with decreased spine mobility and involvement of the sacroiliac joint
Ankylosing spondylitis involves T cell and macrophage recruitment by [cytokines]
Ankylosing spondylitis involves T cell and macrophage recruitment by TGF-b, TNF-a, IL-17, IL-23
* Leads to joint erosion and bone spur formation
In addition to low back pain and peripheral arthritis, ankylosing spondylitis causes [extra-articular manifestations]
In addition to low back pain and peripheral arthritis, ankylosing spondylitis causes anterior uveitis, restrictive lung disease, aortitis/aortic regurg, enthesitis
* The restrictive lung disease occurs because of costovertebral and costosternal ankylosis
_ is a classic finding of ankylosing spondylitis on X-ray
“Bamboo spine” is a classic finding of ankylosing spondylitis on X-ray
* Due to vertebral fusion
* Also may see erosion and sclerosis of SI joints on iliac side
Psoriatic arthritis and ankylosing spondylitis are often treated with _ or _
Psoriatic arthritis and ankylosing spondylitis are often treated with NSAIDs or TNF-alpha inhibitors
Reactive arthritis is caused by an increased immune response following infection, involving the recruitment of [cells]
Reactive arthritis is caused by an increased immune response following infection, involving the recruitment of T cells and macrophages
* These mediate the damage to the joint synovium, conjunctiva, urethra, and cutaneous infiltration
Reactive arthritis can be categorized as a [symmetry] migratory oligoarthritis
Reactive arthritis can be categorized as an asymmetric migratory oligoarthritis
* Most commonly affects the lower extremities
The classic triad associated with reactive arthritis is _ , _ , and _
The classic triad associated with reactive arthritis is conjunctivitis , urethritis, and arthritis
* “Can’t see, can’t pee, can’t climb a tree
The cutaneous manifestation associated with reactive arthritis is called _
The cutaneous manifestation associated with reactive arthritis is called keratoderma blenorrhagicum
The classic infections that trigger reactive arthritis include:
The classic infections that trigger reactive arthritis include:
* Campylobacter
* Chlamydia
* C. diff
* E. coli
* Shigella
* Salmonella
* Ureaplasma
* Yersinia
Reactive arthritis has a high rate of recurrence, especially is the patient is positive for _
Reactive arthritis has a high rate of recurrence, especially is the patient is positive for HLA-B27
In antiphospholipid syndrome, platelet activity is _ and anticoagulant proteins are _
In antiphospholipid syndrome, platelet activity is increased and anticoagulant proteins are decreased
* This leads to a state of hypercoagulability and risk of thrombosis
Primary antiphospholipid syndrome is idiopathic; secondary is most commonly caused by _
Primary antiphospholipid syndrome is idiopathic; secondary is most commonly caused by SLE
* Others include RA, HIV, bacterial infections, HIV
Name (3) auto-antibodies associated with antiphospholipid syndrome
Name (3) auto-antibodies associated with antiphospholipid syndrome
1. Lupus anticoagulant
2. Anti-cardiolipin
3. Anti-B2-glycoprotein
Anti-cardiolipin can cause false negative syphilis
APS will have the following findings:
aPTT:
Platelets:
WBCs:
APS will have the following findings:
aPTT: prolonged
Platelets: low
WBCs: low
Hemolytic anemia may be present
In a patient suspected of APS who has a positive lupus anticoagulant, we expect the mixing study to [correct/ not correct]
In a patient suspected of APS who has a positive lupus anticoagulant, we expect the mixing study to not correct
* aPTT will remain prolonged
The most common pathogen responsible for osteomyelitis is _
The most common pathogen responsible for osteomyelitis is staph aureus
* Others: E.coli, pseudomonas, proteus mirabilis
Vertebral osteomyelitis caused by M. tuberculosis is called _
Vertebral osteomyelitis caused by M. tuberculosis is called Pott disease
What abx treatment is most appropriate for vertebral osteomyelitis?
Empiric coverage: vancomycin + ceftriaxone or cefepime
_ is the classic causative factor of infectious arthritis in the sternoclavicular joint
IVDU is the classic causative factor of infectious arthritis in the sternoclavicular joint
The most common source of infectious arthritis is _
The most common source of infectious arthritis is hematogenous seeding
* Can also occur secondary to penetrating trauma, or adjacent spread from osteomyelitis
Hematogenous osteomyelitis is most likely to affect the [bone region] in kids
Hematogenous osteomyelitis is most likely to affect the metaphysis in kids
* Rarely spreads to joints
* Metaphyses in kids see a lot of blood flow (since growth plates are still open and growing)
* Also metaphyseal vessels have sharp turns and turbulent flow which makes it an opportune location for bacteria to affect the bone
In adults, hematogenous osteomyelitis is likely to affect the vertebral _ and more likely to spread to the _ (compared to children)
In adults, hematogenous osteomyelitis is likely to affect the vertebral bodies and more likely to spread to the joints (compared to children)
Osteomyelitis mcc: [bug]
Associated with implants: [bug]
Sickle cell patient: [bug]
Osteomyelitis mcc: staph aureus
Associated with implants: staph epi
Sickle cell patient: salmonella
Vitamin D is a [type hormone] that gets synthesized in the [organ] and activated by the _ and _
Vitamin D is a steroid hormone that gets synthesized in the skin and activated by the liver and kidneys
(True/False) there are PTH receptors on osteoclasts
False; PTH and vitamin D bind to osteoblasts –> osteoblasts secrete RANKL –> activates the osteoclasts
In renal disease, we expect to see low Ca2+ for two reasons
1. ?
2. ?
In renal disease, we expect to see low Ca2+ for two reasons
1. Kidneys aren’t making enough 1-alpha-hydroxylase
2. Phosphate builds up and binds to all of the calcium
Long term the phos-calcium can end up depositing in the tissues and causing osteosclerosis
Osteogenesis imperfecta
