SMB Week 4 Flashcards
Things to ask in a history for arthritic pain, in addition to LOCATES questions:
- Swelling, heat, redness, trauma
- Morning stiffness
Sources of joint pain that are not “true arthritis”:
- referred pain: visceral, neurologic
- non-articular: muscle bone
- periarticular: muscle, tendon, tenosynovium, bursa, enthuses, bursa, ligament
Signs of true arthritis:
- swelling/tenderness of entire joint line
- limited ROM in all directions
- pain with AROM = PROM
Signs of periarticular pain:
- swelling/tenderness in area around joint
- limited ROM in some directions
- pain with AROM > PROM
What factor reliably distinguishes inflammatory vs. non-inflammatory arthritis?
Synovial fluid analysis
What do you look for in a synovial fluid analysis?
- volume/appearance/viscosity
- cell count/differential
- crystal examination
- stains/cultures
WBC seen in inflammatory arthritis
- Inflammatory:
2000 - 75000/mL
% PMN > 75% - Septic:
> 50000/mL
% PMN > 90%
Crystals in gout and pseudo gout :
- Yellow “needles” parallel to polarization, blue needles perpendicular = GOUT
- “rhomboid” blue crystals parallel to polarization, yellow perpendicular = PSEUDO GOUT
What is the most common spondyloarthritis?
Ankylosing spondylitis
Which joints are commonly affected in RA?
- MCPs and PIPs
- DIPs not usually affected
Which joints are commonly affected in osteoarthritis of the hands?
- DIPs and PIPs
- MCPs not usually affected
How sensitive and specific is an RF test for RA?
- sensitivity 70 - 85%
- specificity 48 - 92%
“Bamboo spine”
- Ossification of outer fibrous ring of intervertebral disks, seen in severe cases of ankylosing spondylitis
Radiographic findings with advanced gout:
- extra-articular erosions
- sclerosis
- “overhanging edge”
Rheumatoid factor:
- Antibody against the Fc portion of IgG antibodies.
- RF/IgG complexes lead to disease
True or false: both rheumatic and non-rheumatic diseases (other than RA) can cause a positive RF test
True: numerous infections and non-rheumatic diseases, as well as SLE, Sjogrens and other connective tissue diseases can cause a + RF test.
True or false: a + ANA test is specific to SLE
False: although 99% of SLE pts will have a + ANA, many other rheumatic and non-rheumatic diseases will cause it (i.e., it’s sensitive but not specific).
Two tests used with ANA to rule in SLE:
- anti-ds DNA
- anti-Sm
What is HLAB27 used for?
Used to help rule out ankylosing spondylitis
How sensitive is the HLAB27 test?
95%
True or false: SLE occurs more commonly in Caucasians than in Blacks, hispanics and asians.
False
Mnemonic for clinical features of lupus:
MD SOAP BRAIN
Malar rash, Discoid rash, Serositis, Oral ulcers, Arthritis, Photosensitivity, Blood Dyscrasias, Renal, ANA +, Immunologic, Neurologic
Musculoskeletal manifestations of SLE:
- Polyarthralgias/polyarthritis
- Soft tissue pain
- Myositis
- Osteonecrosis
What % of SLE patients have renal involvement?
- 100% on biopsy
- 50-65% clinically
Manifestations of SLE serositis:
- Pericarditis
- Pleurisy, effusions
- Peritonitis
Which antibody is seen in almost 100% of patients with drug-induced lupus?
Anti-histone antibody
What are the 3 phases of scleroderma?
- Inflammatory edematous phase (few months: non-pitting edema, mistaken for RA)
- Fibrotic phase (few years: tightening/thickening/salt & pepper skin, lower oil, sweat production)
- Atrophic phase (skin thinning, contractures)
Leading cause of death in scleroderma:
Pulmonary hypertension
GI Sx in scleroderma:
- esophageal hypomotility (reflux, dysphagia)
- bloating, diarrhea & constipation
- malabsorption, weight loss
- GI bleed due to telangiectasias
Another name for GAVE (gastric antral vascular ectasia):
Watermelon stomach
Treatment for renal disease in scleroderma:
ACE inhibitors
Tx for pulmonary hypertension in patients with scleroderma:
- Parenteral epoprostanol
- Bosanten
- Iloprost
- Sildenafil
CREST Syndrome in scleroderma:
C: calcinosis R: Raynaud's phenomenon E: Esophageal dysmotility S: Sclerodactyly T: Telangiectasias
Sjogren’s syndrome:
- Inflammatory d/o of the exocrine glands
- Lymphocytic infiltration of salivary and lacrimal glands
- progressive glandular destruction
Antibodies seen in Sjogren’s syndrome:
SSA and SSB
Acute vs. chronic arthritis:
Mono vs. oligo vs. polyarthritis:
- Mono = 1 joint
- Oligo = 2 - 4 joints
- Poly = > 4 joints
Polymyalgia rheumatica:
- Proximal muscles (shoulders, hips, neck, thighs)
- fever, weight loss, malaise
- profound morning stiffness
- almost exclusively in whites > 50
- ESR > 50 mm/hr.
Treatment for polymyalgia rheumatica:
- Prednisone 7.5 - 20 mg/day
- Start low, increase dose until Sx controlled, then maintain 2 - 4 weeks
- Reduce dose 10% q 2 - 4 weeks
- Once below 10 mg/day, reduce max 1%/month
- May use MTX as well
What serologic test is used for vasculitis, especially small vessel vasculitis?
ANCA
Clinical features suggesting vasculitis:
General:
- multiple organ dysfunction
- constitutional Sx
- high ESR
- Ischemia
Organ Specific:
- Rapidly progressing organ dysfunction
- Skin: palpable purpura/hemorrhage
- Neurologic change: foot drop, mono neuritis multiplex
- ENT/lung: chronic inflammation
Manifestations of AAV:
- constitutional Sx
- migratory arthritis/arthralgia
- GI: bowel infarction, bleeding, perforation
- skin: leukocytoclastic vasculitis et al.
- neurologic: mononeuritis multiplex
- glomulonephritis
- granulomatous inflammation of respiratory tract
- ocular Sx
Mononeuritis multiplex:
Loss of both sensory and motor function in a major nerve/plexus/root.
Tests suggesting immune complex formation/deposition:
- RF
- ANA
- Low C3, C4
Tests suggesting vasculitis without immune complex deposition:
ANCA
- c-ANCA: Granulomatosis with polyangitis, AKA Wegener’s
- p-ANCA: Churg-Strauss and microscopic polyangitis
Tests suggesting systemic inflammation:
- CRP
- ESR
True or false: most patients with clinical signs and symptoms of vasculitis DO NOT have vasculitis
True: vasculitis is rare
Red flags suggesting vasculitis mimics:
- heart murmur
- lower extremity digit necrosis
- splinter hemorrhages
- liver dysfunction
- sexual activity/drug use
- high fevers
- prior cancer Hx
Viral infections that mimic rheumatic and vasculitic syndromes:
- HCV: cryoglobulinemia
- HBV: polyarteritis nodosa
- HIV: seronegative rheumatic syndromes
Drugs that can cause hyperuricemia:
- Thiazide diuretics
- Ethambutol (TB)
- Nicotinic acid (niacin)
- alcohol
- others (salicylates, cyclosporines, et al.)
Clinical diagnosis of gout:
Combination of crystals, tophi and/or 6 or more criteria.
1st line treatment for gout:
- NSAIDS
- Systemic corticosteroids
- Colchicine
When is colchicine the 1st line Tx for gout?
- Onset no greater than 36 hours prior to treatment
- Unable to take NSAIDS
MOA for colchicine:
- decreases leukocytes mobility
- reduces deposition of uric acid crystals
Side effects of colchicine:
- NVD very common (50 - 80%)
- bone marrow toxicity
- contraindicated in patients with: hepatobiliary dysfunction, hemodialysis, blood dyscrasias
Drug interactions with colchicine:
- CYP3A4 inhibitors
- clarithromycin
- cyclosporine
- statins
- others
Which combination treatment should you NOT use for gout?
NSAIDS + systemic corticosteroids
1st line treatment for prophylaxis of gout:
allopurinol
MOA of allopurinol:
- xanthine oxidase inhibitor
- blocks last 2 steps of uric acid synthesis
Axial vs. peripheral spondyloarthritis
Axial:
- predominantly involves the spine +/- peripheral joints
Peripheral:
- predominantly involves the peripheral large joints
5 diseases of spondyloarthritis:
- ankylosing spondylitis (spine is a must, often peripheral as well)
- psoriatic arthritis (mostly peripheral)
- reactive arthritis (mostly peripheral)
- IBD related arthritis (mostly peripheral)
- uveitis related arthritis (mostly peripheral)
Spondyloarthritis is defined by the inflammation of which joints?
Sacroiliac
What is the hallmark of spondyloarthritis?
Enthesitis/tendinitis
What is radionuclide scintigraphy used for?
- Detecting inflammatory or metabolic alterations in bone or periarticular soft tissue structures.
- Works by using radioactive molecules, which are preferentially taken up by certain inflammatory or pathological cells.
