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MSK II - Exam 2 > SeroNegative Spondyloarthropathies (Darrow) - SRS > Flashcards

SeroNegative Spondyloarthropathies (Darrow) - SRS Flashcards

1
Q

What are the six spondyloarthropathies?

A
  1. Ankylosing Spondylitis
  2. Psoriatic Arthritis
  3. Reactive Arthritis (Reiter’s Syndrome)
  4. Arthritis associated with IBD
  5. Undifferentiated spondyloarthropathy
  6. Acute Anterior Uveitis
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2
Q

What is the gender preferance for seroneg. spondyloarthropathies?

Onset age?

A

Male preponderance

Onset before 40

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3
Q

Seronegative Spondyloarthropathies are inflammatory processes of the spine and SI joints. What HLA type are they associated with?

A

HLA-B27+

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4
Q

What is the serum profile of each of the Seronegative Spondyloarthropathies for:

RF

CCP

ANA

A

RF -, CCP -, ANA -

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5
Q

What are 6 non-vertebral symptoms of spondyloarthropathies?

A
  1. Asymmetric Peripheral Arthritis
  2. Arthritis of the Toe IP Joints
  3. Sausage Digits
  4. Enthesopathy
  5. Uveitis
  6. Mucocutaneous lesions
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6
Q

What is a bacteria that many AS patients have in their stools?

Why is this significant?

A

Klebsiella

This bacteria can express HLA-B27

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7
Q

What immunologic pathway and its cytokines are key in the pathophys of PsA, ankylosis spondylitis (AS) and other spondyloarthritides?

A

TH17

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8
Q

Which of the TH17 Interleukins is more potent than the others?

Where will it be found in patients who have spondyloarthritides?

A

IL-17

Found in…

  • circulation
  • joints
  • skin plaques
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9
Q

Is HLA-B27 necessary for development of spondyloarthropathies?

A

Neither necessary, nor sufficient to cause spondyloarthropathies.

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10
Q

What is the HLA - B27 assciation rate with each of the following?

  • AS
  • Reiter’s
  • IBS + Spondylitis
  • Psoriatic Arthritis
A
  • AS: 90%
  • Reiter’s: 75%
  • IBS + Spondylitis: 50%
  • Psoriatic Arthritis: 50%
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11
Q

So, HLA-B27 isn’t enough to dx. What must there be additionally?

A

HLA-B27 positive plus 2 features

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12
Q

If you have a patient with chronic low back pain and age of onset under 45 y/o, and find sacroiliitis on imaging, how many additional features of spondyloarthropathy must there be for a diagnosis?

A

Plus one feature

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13
Q

25 y/o male presents with a three year history of low back pain. The pain wakes him at night and he arises in order to exercise for relief. He has occasional loose stools. He is tender over the anterior chest wall and iliac crest. He is unable to put his occiput to the wall when standing with his back against the wall. There is a grade 2/6 diastolic murmur at the right intercostal area. Chest expansion is limited with a deep breath. The eyes are red with a ciliary flush. Sed rate is 40 mm/hr. To diagnose this disease, one needs the presence of (a); (an):

A.sacroiliitis.

B.enthesopathy.

C.aortic valve disease.

D.Iritis.

E.restricted neck flexion.

A
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14
Q

Identify each of the clinical complaints/findings indicated on Mr. Ankylosing Spondylitis.

A
  1. ‘Bamboo spine’ – brittle, rigid
  2. Sacroiliac inflammation/pain
  3. Increased kyphosis
  4. Fatigue (systemic symptom)
  5. Ocular inflammation, uveitis
  6. Reduced rib expansion - reduced inhalation
  7. Weight loss (systemic sym.)
  8. Possible atlantoaxial subluxation
  9. Pulmonary fibrosis
  10. Aortic insufficiency
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15
Q

What is one testing protocol for AS?

A

Schober’s test

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16
Q

What are the following in AS?

ESR

RF

CBC

A

ESR – increased in 85%

RF – characteristically negative (as is anti-CCP)

Mild anemia

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17
Q

Imaging studies for AS may involve X-ray, CT, or what modality which may be better?

Why is this preferable?

A

MRI (gadolinium) - whole body.

This may show edema at enthesitis sites

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18
Q

What is shown here?

A

Andersson Lesion simulating Diskitis

(AS)

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19
Q

What is indicated in these imaging studies from an AS patient?

A

Syndesmophytes - “Bamboo spine”

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20
Q

What sign is shown here in this radiograph from an AS patient?

A

“Shiny corner sign” = Reactive sclerosis

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21
Q

This patient has no SI Joint involvement, and you find this on x-ray.

What is the finding?

What is the disease?

A

Diffuse Interosseous Skeletal Hyperostosis (DISH)

Flowing ossification

No involvement of SI joints and syndesmophytes are more anterior and thicker.

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22
Q

What is shown in this x-ray of a patient with AS?

A

Osteitis condensans ilii

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23
Q

What are the main complications of AS? 5

A
  1. Uveitis
  2. Upper lobe PF
  3. Cauda Equina Fibrosis
  4. Aortic Regurgitation
  5. Heart Block
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24
Q

What are the components of the treatment protocols for ankylosing spondylitis?

A
  1. PT/OT
  2. Exercise
  3. NSAIDS (watch for CHF)
  4. Sulfsalazine
  5. Anti-TNF agents
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25
Q

A 35 y/o male presents with a markedly swollen and painful left middle digit. A migratory asymmetric polyarthritis was present 3-4 months ago. He complains of low back pain and stiffness as well. Exam shows the following skin findings. RF and CCP is negative. Sed rate is 48 mm/hr. Uric acid is elevated. There is a unilateral sacroiliitis. This patient has which type of arthritis?

A.Reactive

B.Psoriatic

C.SLE

D.Behcet’s

E.Kawasaki’s

A

B.Psoriatic

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26
Q

This patient is complaining of low back and right heel pain. He

has:

A.ankylosing spondylitis.

B.sarcoid.

C. Lyme disease.

D. nummular eczema.
E. psoriasis.

A

E. psoriasis.

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27
Q

Identify the arthritis based on the patterns shown.

A
  1. Left: RA
  2. Right: Psoriatic Arthritis
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28
Q

What are three buzz phrases for Psoriatic arthritis?

A
  1. Pencil in a cup deformity
  2. Opera Glass hand
  3. Arthritis mutilans (same thing as opera glass hand)
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29
Q

What is this finding?

Associated with?

A

Opera Glass hand - Arthritis mutilans

Associated with psoriatic arthritis

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30
Q

What is this deformity?

Associated with?

A
  1. Pencil in a cup deformity
  2. Psoriatic Arthritis
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31
Q

What are the 5 patterns of arthritis in psoriatic arthritis?

A
  1. Oligoarthritis
  2. SI
  3. Asymmetrical

polyarthritis

  1. DIP
  2. Opera glass “arthritis mutilans”
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32
Q

What will the following labs look like in psoriatic arthritis?

  • RF
  • CCP
  • Uric Acid
  • Fe++
A
  • RF - negative
  • CCP - negative
  • Uric Acid - increased
  • Fe++ - decreased
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33
Q

What organism is associated with psoriatic arthritis?

A

HIV

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34
Q

How often does psoriasis precede arthritis?

A

80% of the time

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35
Q

PsA is usually assymetric with what appearance of the fingers and toes?

A

Sausage appearance of fingers and toes

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36
Q

What type of sacroilitis is typical of PsA?

A

Unilateral

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37
Q

X-ray findings in PsA include? 5

A
  1. Osteolysis
  2. pencil in a cup
  3. lack of osteoporosis
  4. bony ankylosis
  5. atypical syndesmophytes
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38
Q

What are the components of the management of PsA?

A
  1. Topicals
  2. PUVA
  3. NSAIDs
  4. MTX
  5. Anti-TNF
  6. IL17/IL23 blockers
  7. PDE4 inhibitor
  8. Surgery
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39
Q

What should not be used in PsA?

A

Steroids

40
Q

What are the anti-TNF agents like etanercept and adalimumab especially good for as far as psoriasis?

A

nail and cutaneous lesions

41
Q

A 19 y/o male presents with left heel pain at the achilles insertion. He has pain in the knees, hips, and low back. He has a pustular geographic tongue. There is a rash on the soles of the feet. A month ago he had a slight, clear penile discharge for three days. Which of the following would be unusual in this patient?

A. Campylobacter

B. Death in 30%

C. “Lover’s heels”

D. C trachomatis

E. Low back pain

A
42
Q

What is this called?

A

Circinate balanitis

43
Q

What is this?

What does it look like?

A

Keratoderma blenorrhagicum

Looks like pustular psoriasis

44
Q

Reactive arthritis can be caused by what veneral organisms? 3

A
  1. Chlamydia trichomatis
  2. Ureaplasma urealyticum (men)
  3. Mycoplasma genitalium
45
Q

Reactive arthritis can be caused by what enteric organsims? 6

A
  1. Shigella flexneri
  2. Salmonella species
  3. Yersinia enterocolitica
  4. Yersinia pseudotuberculosis
  5. Campylobacter jejuni
  6. Clostridium difficile
46
Q

What is a “miscellaneous” organism that can cause reactive arthritis?

A

Streptococcus

47
Q

What is a virus that is noteably able to cause reactive arthritis?

A

HIV

48
Q

If a genital chlamydia infection contains ocular forms of the organism, by what process does a chlamydia induced arthritis arise?

4 steps

A
  1. The ocular forms are snatched up by monocytes
  2. The monos foolishly take them to joints
  3. They make them their home and begin a constitutive TH1 reaction
  4. IL-1, TNF-alpha, IFN-gamma, and HSP are produced
49
Q

In addition to the ocular form of chlamydia what other form can cause Reiter’s syndrome?

A

The pneumonic forms of Chlamydia

50
Q

Each arrow indicates a chlamydia pneumonia. Which is associated with what organism?

A

Left: Chlamydophila psittaci

Right: Chlamydophilia pneumonia

51
Q

What do the following serovars of chlamydia trachomatis cause?

  1. strains A-C =
  2. Strains D-K =
  3. Strains L1-L3 =
A
  1. strains A-C = trachoma
  2. Strains D-K = NGU
  3. Strains L1-L3 = LGV
52
Q

Reactive arthritis (aka Reiter’s syndrome) is a seronegative asymmetric arthritis arising most often following one of what three infection types?

A
  1. Urethritis
  2. Cervicitis
  3. Infectious diarrhea
53
Q

What are some examples of physical findings associated with Reiter’s syndrome?

7

A

Enthesopathy - “Lover’s heels”.

Inflammatory eye disease.

Palmar pustulosis.

Circinate balanitis.

Keratoderma blenorrhagicum.

Oral ulcers (painless unlike Behcets).

Sacroiliitis in 20%.

54
Q

Describe the joint involvement in reactive arthritis.

A

Large joint oligoarthritis or sacroiliitis

55
Q

Reiter’s syndrome classically presents with what triad?

A

Uveitis/conjunctivitis

Urethrtitis

Arthritis

(can’t see, can’t pee, can’t climb a tree)

56
Q

What cardiac findings may be present in a patient with reactive arthritis?

A
  1. Carditis
  2. Aortic reguritation
57
Q

What are the key aspects of managing reactive arthritis syndrome?

5 with 2 bold

A
  1. Antibiotics
  2. NSAIDs
  3. Sulfasalazine
  4. anti-TNF
  5. Ophthalmic meds
58
Q

Specifically what antibiotics does Darrow recommend for Reactive arthritis?

A

Doxycycline + Rifampin

Or

Azithromycin + Rifampin

59
Q

IBD with Arthritis is typically of which type?

A

Crohns mostly

60
Q

IBD arthritis is a Nondeforming asymmetric oligoarthritis that parallels bowel disease. Usually acquired after bowel disease is apparent.

What is the sacroiliitis like in this?

A

Bilateral and symmetrical sacroilliitis (as in AS)

61
Q

What should you tx IBD arthritis with?

4

A
  1. Sulfasalazine
  2. Corticosteroids
  3. Aza or 6-MP
  4. TNF inhitors
62
Q

A 22 y/o hemophiliac male presents with right knee arthralgias and pain for the past 3 weeks. He takes on-demand clotting factor concentrate. He has had an occasional episodes of non-bloody diarrhea over the past few years. He has had multiple episodes of bilateral ankle and elbow synovitis. He had an episode of bilateral heel pain 6 months ago that took 4 months to clear. His mother had psoriasis. An uncle had some eye disease. Joint exam showed bilateral boggy synovitis of the elbows and ankles. An effusion was present in the right knee from which joint fluid was taken. Joint fluid showed no crystals, no organisms and 300 WBCs and no RBCs. Serum Hb was 10.6 gm Hb with MCV of 68. WBC was 11,500 x 109/L. What is the most probable cause of his elbow and ankle arthritis?

A.RA

B.Psoriatic arthritis

C.IBD arthritis

D.Hemarthrosis

E.Adult onset Stills disease

A

Hemarthrosis

63
Q

Hemarthrosis is a recurrent hemorrhage typically seen in what joints?

A

Elbows

Knees

Ankles

64
Q

What is typically hypertrophied in hemarthrosis?

What is seen to be deposited in this condition in the joint?

A
  • Synovial hypertrophy.
  • Hemosiderin deposition
65
Q

Hemarthrosis comes with fibrosis and ankylosis. Describe each of these things as seen in hemarthrosis.

  • Synovitis
  • Cartilage
A
  • Persistent “boggy” synovitis.
  • Cartilage erosion.
66
Q

What is the best way to dx hemarthrosis early?

What can be seen on x-ray?

A
  • MRI better than Xray for early damage.
  • Xray can show hemosiderin.
67
Q

What should be the tx for hemarthrosis?

A

Prophylactic clotting factors (QOD) rather than on-demand.

68
Q

A 22 y/o hemophiliac male presents with right knee arthralgias and pain for the past 3 weeks. He takes on-demand clotting factor concentrate. He has had an occasional episodes of non-bloody diarrhea over the past few years. He has had multiple episodes of bilateral ankle and elbow synovitis. He had an episode of bilateral heel pain 6 months ago that took 4 months to clear. His mother had psoriasis. An uncle had some eye disease. Joint exam showed bilateral boggy synovitis of the elbows and ankles. An effusion was present in the right knee from which joint fluid was taken. Joint fluid showed no crystals, no organisms and 300 WBCs and no RBCs. Serum Hb was 10.6 gm Hb with MCV of 68. WBC was 11,500 x 109/L. What is the most probable cause of his elbow and ankle arthritis?

Most likely diagnosis for the acute knee finding would be:

A.undifferentiated spondyloarthropathy.

B.enteropathic (IBD) arthritis.

C.juvenile idiopathic arthritis.

D.pseudogout.

E.reactive arthritis.

A

A.undifferentiated spondyloarthropathy.

69
Q

A 35 y/o male IV drug abuser is admitted with pain and swelling in the right sternoclavicular area. He is febrile and states the pain started 3 days ago. He has pain using his right arm. Examination of the sternoclavicular area shows severe tenderness and the area is fluctuant. The left wrist is painful to motion.

Aspiration of the fluctuant area shows a WBC of 30,000 with 90% neutrophils. Gram stain is shown.

Most likely organism?

A

Strep - based on gram stain and strips.

70
Q

A 35 y/o male IV drug abuser is admitted with pain and swelling in the right sternoclavicular area. He is febrile and states the pain started 3 days ago. He has pain using his right arm. Examination of the sternoclavicular area shows severe tenderness and the area is fluctuant. The left wrist is painful to motion.

Aspiration of the fluctuant area shows a WBC of 30,000 with 90% neutrophils. Gram stain is shown.

You end up being right, and the organisms showed the group B lancefield antigen. Meaning this is what specific type of strep?

A

Agalactiae

71
Q

Monoarthritis is what until proven otherwise?

A

Septic

72
Q

The more joints involved, the less likely it is septic arthritis, with what three specific exceptions?

A
  1. RA - (not sure what he is getting at here. maybe he will clarify in lecture)
  2. Group B strep
  3. Endocarditis
73
Q

Persons using what type of therapy are 2x more susceptible to septic arthritis?

A

Those using anti-TNF therapy

74
Q

What are the essentials of dx for septic arthritis?

A
  1. Sudden onset of acute arthritis
  2. monoarticular
  3. large, weight bearing joints
  4. previous joint damage or IV drugs
  5. Infection with causative organisms elsewhere in the body
75
Q

Characterize the size of joint effusions seen in septic arthritis.

What is the WBC?

A

Large

Over 50,000

76
Q

Blood cultures will be positive in over 50% of septic arthritis cases. If your patient with septic arthritis is on anti-TNF drugs or has HIV, what should you check for?

A

AFB

77
Q

What percent of septic arthritis is caused by Gram +?

Gram -?

A

+ = 90%

  • = 10%
78
Q

What are the main gram + organisms responsible for septic arthritis?

A
  1. Staph aureus - 50%
  2. MRSA
  3. Group B Strep (multi joint as is RA and endocarditis)
  4. Pneumococcal (associated pulmonary or CNS)
79
Q

What are the main gram - organisms that cause septic arthritis?

A

E coli

Pseudomonas

DGI – septic or sterile immune complex mediated

Salmonella

80
Q

What organisms tend to infect prosthetic joints?

A

Staph and pseudomonas

81
Q

What are the elements of tx for septic arthritis?

A
  • 3rd generation cephalosporin: ceftriaxone 1 gm daily, cefotaxime 1 gm q 8 hrs.
  • Vancomycin 1 g q 12 hrs.
  • Treat for 4-6 weeks.
  • Drainage
82
Q

This patient presented with fever and the following changes. She also has migratory polyarthgralgias, meningitis and pancarditis. She also most likely has:

A.Behcets syndrome.

B.RA.

C.inflammatory DJD.

D.perihepatitis.

E.sarcoid.

A
83
Q

A disseminated gonococcal infection (DGI) presenting with Arthritis/Dermatitis syndrome may have what 5 presentation forms?

A

(1) Oligoarthritis form (usually preceeded by migratory polyarthritis).
(2) Tenosynovitis form.
(3) Rash –pustules especially palms and sole.
(4) Fever.
(5) May also get osteomyelitis,

84
Q

What are some risk factors for gonococcal arthritis?

A

Menstruation

Pregnancy

C5-9 deficiencies

85
Q

What test must you do if a patient gets gonococcal arthritis?

A

Complement assay, d/t the C5-9 deficiencies

86
Q

Where should you obtain cultures from to dx gonococcal arthritis?

A

Urethra

Throat

Cervic\x

Rectum

87
Q

What are the three elements of spinal septic arthritis (discitis)?

Where does it typically hit?

A

Chronic unrelenting back pain

Fever

Local tenderness

(thoracolumbar region)

88
Q

If spinal septic arthritis is caused by TB what is it called?

Where does it usually strike?

A

Pott’s Disease

T10-L2 region

89
Q

What are two findings you might see with spinal septic arthritis?

A

Gibbus deformity

Paraspinal cold abcess

90
Q

A 20 year old nursery nurse has recently been camping in Maine. She had also eaten cheese imported from Mexico. She presents with fever and migratory arthritis in the left ankle, right and left wrist and left and right MCP joints. She had an effervescent rash over the arms and legs one week ago. A sister had a history of rheumatic fever. The left knee is swollen and tender. RF and ANA are weakly positive. What would be a logical cause of her arthritis. Describe the reasons for consideration of each answer.

A.Viral

B.Reactive

C.Post Streptococcal

D.CTD

E.Bacterial arthritis*

A

A.Viral

91
Q

A 20 year old nursery nurse has recently been camping in Maine. She had also eaten cheese imported from Mexico. She presents with fever and migratory arthritis in the left ankle, right and left wrist and left and right MCP joints. She had an effervescent rash over the arms and legs one week ago. A sister had a history of rheumatic fever. The left knee is swollen and tender. RF and ANA are weakly positive. What would be a logical cause of her arthritis. Describe the reasons for consideration of each answer.

What infections specifically need to be considered here?

A

Brucellosis, lyme disease, GC

92
Q

What are 7 common agents for viral arthritis?

A
  1. Parvo B19
  2. HIV
  3. Hepatitis B & C
  4. EBV
  5. Adeno and coxsackie
  6. Rubella
  7. Mumps
93
Q

Viral arthritis may present as migratory arthralgia/itis or polyarthritis affecting the wrists, hands & knees. will be Frequently symmetric and a Rash may be present.

What does arthritis from Hep C look like?

A

RA – so differentiate with anti-CCP. Arthritis in Hep C may relate to cryoglobulins.

94
Q

What is Hepatitis B arthritis similar to?

A

Serum sickness with decreased compliment and urticaria

95
Q

A 40 y/o female has a history of dry eyes and dry mouth for a year. She has a dry cough. She has intermittent severe joint pains and myalgias with weakness. She has a psoriatic rash on her palms and feet. Exam shows palmoplantar pustular psoriasis and tender muscles. ALT and AST are mildly increased, CPK is elevated. U1-RNP is negative as is ANA, RF, ANCA, ENA, ACE and anti-CCP. There are mild bilateral pulmonary infiltrates.

What are the considerations in this case?

A.SLE

B.Primary Sjogrens

C.Polymyositis

D.Overlap syndrome

E.HIV

A

E.HIV

96
Q

What is Diffuse infiltrative lymphocytosis (DILS) syndrome?

A

HIV

97
Q

A 40 y/o female has a history of dry eyes and dry mouth for a year. She has intermittent joint pains and myalgias with weakness. She has a psoriatic rash on her palms and feet. Exam shows palmoplantar pustular psoriasis and tender muscles. CPK is elevated. U1-RNP is negative as is ANA, RF, ANCA, ENA, ACE and anti-CCP.

Further testing in this patient produced a positive HIV test with CD4 count of 190. Treatment with HAART was begun. One month later the patient developed lymphadenopathy, dyspnea and cough, symmetric ankle periarthritis, hepatosplenomegaly, and the following rash on each leg. Chest Xray showed hilar adenopathy. Which test was done at this point?

A.HLA-DR3

B.p-ANCA

C.ANA

D.ACE

E.ASOT

A

D.ACE

MSK II - Exam 2 (7 decks)

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