UWorld 2 Flashcards
Behcet Disease
Epi - young adults, Turkish, Middle Eastern or Asian descent
Clinical
1) Recurrent, painful oral aphthous ulcers
2) Genital ulcers
3) Eye lesions (uveitis)
4) Skin lesions (EN, acneiform lesions)
5) Thrombosis (high risk of vasculitis)
Evaluation - dx is usually clinical. Bx not really needed.
1) Pathergy - exaggerated skin ulceration with minor trauma (needlestick)
2) Bx - nonspecific vasculitis of different sized vessels
What kind of anemia does MTX cause?
Macrocytic
Can also cause pancytopenia. Do routine peripheral blood counts every 3 months.
Pseudogout
Hyperparathyroidism with chronic hyperCa can cause it, presenting as acute, painful monoarthritis. Diagnostic findings include calcification of the articular cartilage*** (chondrocalcinosis) on XR and rhomboid-shaped positively birefringent calcium pyrophosphate crystals in synovial fluid.
Can also be associated with hypothyroidism and hemochromatosis.
Disseminated gonococcal infection overview
Clinical pres
1) Purulent arthritis without skin lesions OR
Triad of:
1) Tenosynovitis (wrist, ankles, fingers, knees)
2) Dermatitis (pustules, macules, papules, bullae)
3) Migratory asymmetric polyarthralgia without purulent arthritis
Diagnosis
1) BCx (2 sets) but may be negative
2) Synovial fluid analysis may show up to 50k cells/mm (a bit lower than other septic arthritis)
3) Urethral, cervical, pharyngeal or rectal cultures
4) Recommend HIV and syphilis screen
5) Recurrent DGI - check terminal complement activity (C5-9)
6) Dx is confirmed by NAATs as well
Tx
1) IV ceftriaxone 1g/day for 7-14d, switch to PO (cefixime) when clinically improved
2) Joint drainage for purulent arthritis
3) Empiric azithromycin (single 1g dose) OR doxycycline for 7d for concomitant chlamydial infection
4) Treat sexual partners*
Note: purulent arthritis in sexually active person is gonococcal until proven otherwise.
4 types of results for synovial fluid analysis
Normal
1) Appearance - clear
2) WBC - less than 200
3) PMNs - less than 25%
Noninflammatory (OA)
1) Appearance - clear
2) WBC - 200-2000
3) PMNs - 25%
Inflammatory (crystals, RA)
1) Appearance - translucent or opaque
2) WBC - 2000-100,000
3) PMNs - Often greater than 50%
Septic joint
1) Appearance - Opaque
2) WBC - 50-150k
3) PMNs - more than 80-90%
Primary Raynaud’s phenomenon
Etiology - no underlying cause
Clinical pres
1) Usually women age less than 30*
2) No tissue injury*
3) Negative ANA and ESR
Management
1) Avoid aggravating factors (cold, emotional stress)
2) CCB for persistent symptoms (esp dihydropyridine like nifedipine and amlodipine)
Some say B blockers may make condition worse
Secondary Raynaud’s
Etiology
1) Connective tissue diseases
2) Occlusive vascular conditions
3) Sympathomimetic drugs
4) Vibrating tools
5) Hyperviscosity syndromes
6) Nicotine
Clinical
1) Usually men over 40
2) Symptoms of underlying disease
3) Tissue injury* or digital ulcers
4) Abnormal nail fold capillary exam
Management
1) Evaluate and treat underlying disorder
2) CCB* for persistent symptoms, aspirin* for patients at risk for digital ulceration
Tx of pseudogout
Intrarticular glucocorticoids, NSAIDs, Colchicine
OA
Risk factors
1) Age over 50
2) Obesity
3) Prior joint injury
History
1) Chronic, insidious symptoms
2) Minimal/no morning stiffness
PE
1) Knees/hips, DIP joints, cervical/lumbar spine
2) Hard, bony enlargement of joints
3) Crepitus with movement
Radiology
1) XR - narrowed joint space, osteophytes, subchondral sclerosis
This is the most common joint disorder seen in clinical medicine.
Pes anserinus pain syndrome (Anserine Bursitis)
Localized pain and tenderness over the anteromedial tibia, just below the joint line. Pain is exacerbated by pressure from the opposite knee while lying on the side.
Iliotibial band syndrome
Common overuse injury characterized by poorly localized pain at the lateral knee.
Exam shows tenderness at the lateral femoral condyle during flexion and extension
LCL injury
Follows blow to medial aspect of knee.
Exam shows laxity of knee with varus stress
Medial meniscal injury
Occurs with twisting of knee and typically causes acute to subacute symptoms.
May show medial joint line tenderness, but can see a small effusion and painful/limited extension
De Quervain tenosynovitis
Classically affects new mothers who hold their infants with the thumb outstretched (abducted/extended).
Caused by inflammation of abductor pollicis longus and extensor pollicis brevis tendons as they pass through a fibrous sheath at the radial styloid process.
Tenderness can typically be elicited with direct palpation of the radial side of the wrist at the base of the hand.
Finkelstein test, which is conducted by passively stretching the affected tendons by grasping the flexed thumb into the palm with the fingers, elicits pain.
Prevention of future gout attacks
1) Weight loss to achieve BMI less than 25
2) Low fat diet
3) Decreased seafood and red meat intake
4) Protein intake preferably from vegetable and low fat dairy products
5) Avoidance of organ-rich foods (liver and sweetbreads)
6) Avoidance of beet and distilled spirits
7) Avoidance of diuretics when possible
Treatment of gout
For acute attacks, initial treatment can include NSAIDs (indomethacin), glucocorticoids or colchicine.
Urate lowering meds (allopurinol, febuxostat) are indicated for patients with recurrent attacks or complicated disease (tophi, uric acid kidney stones)
For first attack…counsel about lifestyle mods
Inflammation of ligamentous insertions
Enthesitis. Seen in Ankylosing spondylitis and the other spondyloarthropathies (PAIR)
Clinical features of psoriatic arthritis
Arthritis
1) DIP joints
2) Asymmetric oligoarthritis
3) Symmetric polyarthritis similar to RA
4) Arthritis mutilans (deforming and destructing arthritis)
5) Spondyloarthritides (sacroilitis and spondylitis)
Soft tissue and nail involvement
1) Enthesitis (inflammation of tendon insertion site to bone)
2) Dactylitis (sausage digits) of toe or finger
3) Nail pitting and onycholysis
4) Swelling of the hands or feet with pitting edema
Skin lesions
1) Arthritis precedes skin disease in 15% of patients
2) Skin lesions are present but not yet diagnosed in 15% of patients
Tx - NSAIDs, MTX, anti TNF agents
Heberden nodes vs bouchard nodes
Heberden - osteophyte at DIP
Bouchard - osteophyte at PIP
Charcot joint
Due to decreased sensation in lower extremity. Patients unknowingly traumatize the weightbaring joints (ankle), leading to joint degeneration, deformation, and functional limitation.
Most common in patients with diabetic neuropathy and is often seen in association with foot ulcers
Clinical features of dermatomyositis
Muscle weakness
1) Proximal, symmetric
2) Weakness in UE is same as LE
Skin findings
1) Gottron’s papules
2) Heliotrope rash (eye swelling and redness and cheek redness)
Extramuscular findings
1) Interstitial lung disease
2) Dysphagia
3) Myocarditis
Diagnosis
1) High CPK (sometimes 10x over normal), aldolase, LDH
2) Anti-RNP, anti-Jo-1 (anti-synthetase antibody), anti-Mi2 (against helicase)
3) Diagnostic uncertainty - EMG or skin/muscle Bx
Management
1) High dose glucocorticoids plus glucocorticoid sparing agent
2) Screen for malignancy - internal cancers are more common in these patients (more than 15% of adult patients). Most common are ovarian, lung, pancreatic, stomach, colorectal cancers, non-Hodgkin
DEXA screening (Dual Energy XR Absorptiometry Scan)
All women 65 and over. Screening can be considered for younger patients who have other risk factors.
Common features of Sarcoidosis
Epi - young adults and african americans
Clinical
1) Constitutional symptoms
2) Cough, dyspnea and chest pain
3) Extrapulm findings - skin lesions, anterior/posterior uveitis, Lofgren syndrome
Imaging
1) Bilateral hilar adenopathy*
2) Pulmonary reticular infiltrates
Lab
1) HyperCa/Hypercalciuria
2) Elevated serum ACE level
Path
1) Bx shows noncaseating granulomas that stain negative for fungi and acid fast bacilli
Hypercalcemia in sarcoid
Occurs in up to 20% of patients. Mechanism is granulomatous activity of 1-alpha-hydroxylase. This causes increased production of 1,25-dihyroxyvitaminD and increased intestinal absorption of calcium.
Hypercalciuria (up to half of patients) is present more often and can result in kidney stones.
Tx of Sarcoid
If they are ASx they are often followed without tx due to a high rate of spontaneous remission.
However, patients with symptomatic disease (cough, dyspnea, fatigue, hyperCa) are treated with systemic glucocorticoids.
It is important to rule out infectious granulomatous disease with similar presentations like TB and Histo prior to starting steroids
Viral arthritis
Can present with symmetric small joint inflammatory arthritis. It is distinguished from other causes of symmetric inflammatory arthritis by the fact that it tends to resolve within 2 months.
Positive inflammatory markers like ANA and RF may occur
Tx involves use of NSAIDs for resolution of symptoms. Antiviral therapy is unnecessary as the symptoms are self-limited.
Treatment of septic arthritis
1) Gram positive cocci - vanc
2) Gram negative rod - 3rd gen cephalosporin
3) Negative microscopy - vanc (plus 3rd gen cephalosporin if immunocompromised)
Who is at risk of septic arthritis?
1) Underlying joint disease - OA, RA, prosthetic joint, gout
2) Age over 80
3) Diabetes
4) IV drug abuse, alcoholism
5) Intra-articular glucocorticoid injections
Felty Syndrome diagnosis
Clinical featurs
1) RA - severe erosive joint disease and deformity, rheumatoid nodules, vasculitis (mononeuritis multiplex, necrotizing skin lesions)
2) Neutropenia (ANC less than 1500)
3) Splenomegaly
Dx
1) Anti-CCP and RF are positive in more than 90%
2) Markedly elevated ESR, often over 85
3) Peripheral smear and bone marrow bx to rule out other causes of neutropenia
Clinical features of secondary amyloidosis
Epi
1) Extracellular deposit of insoluble polymeric protein fibrils in tissues and organs, elevated amyloid A
2) Can be secondary to chronic inflammatory conditions (inflammatory arthritis like RA; chronic infections like TB, osteomyelitis, bronchiectasis; IBD; Malignancy like lymphoma; Vasculitis)
Clinical
1) ASx proteinuria or nephrotic syndrome
2) Cardiomyopathy with HF
3) Hepatomegaly
4) Mixed sensory and motor peripheral neuropathy and or autonomic neuropathy
5) Visible organ enlargement (macroglossia)
6) Bleeding diathesis
7) Waxy thickening, easy bruising of skin
Dx
1) Abdominal fat pad aspiration bx
Tx
1) Tx of underlying condition
2) Colchicine for prevention and treatment
Myasthenia gravis
Site - ACh receptor in postsynaptic membrane
Clinical - fluctuating muscle weakness
1) Ocular - ptosis, diplopia
2) Bulbar - dysphagia, dysarthria
3) Facial, neck, limb muscles
Lamber-Eaton Syndrome
Site - Presynaptic membrane voltage gated calcium channels
Clinical
1) Prox muscle weakness
2) Autonomic dysfunction (dry mouth)
3) Cranial nerve involvement (ptosis)
4) Diminished or absent DTRs
Dermatomyositis/Polymyositis - site of involvement
Site - muscle fiber injury
Clinical
1) Symmetrical and more proximal muscle weakness
2) Interstitial lung disease, esophageal dysmotility, Raynaud
3) Polyarthritis
4) Esophageal dysmotility
5) Skin findings - Gottron papules, heliotrope rash - in dermatomyositis
Sicca syndrome
From Sjogren. This is generalized dryness of mucous membranes and leading to dry mouth, irritated/itchy eyes, cough, dyspareunia.
Ddx of anterior knee pain in the young patient
Patellofemoral syndrome
1) Young female athletes
2) Clinical - subacute to chronic pain increased with squatting, running, sitting, using stairs. Patellofemoral compression test.
Patellar tendonitis
1) Primarily athletes (jumper’s knee)
2) Episodic pain and tenderness at inferior patella
Osgood-Schlatter Disease - caused by chronic/repetitive strain at insertion of patellar tendon on tibial tubercle.
1) Preadolescent/adolescent athletes
2) Recent growth spurt
3) Increased pain with sports, relieved by rest
4) Tenderness and swelling at tibial tubercle.
Cyclophosamide
An alkylating agent frequently used as immunosuppressant in SLE, vasculitis and certain cancers.
For SLE, it is reserved for patients with significant renal or CNS problems.
It has a ton of side effects though. Acute hemorrhagic cystitis, bladder cancer, sterility, myelosuppression.
The acute hemorrhagic cystitis and bladder cancer are caused by acrolein - a bladder toxic metabolite of the drug.
Drinking plenty of fluids and taking MESNA are all helpful for preventing these complications
What drugs may cause Raynaud’s? (Digital vasospasm)
Beta blockers and ergotamine
Lab eval of SLE
Get blood counts to screen for cytopenias as well as UA and Cr to screen for nephropathy.
Get ANA (not anti dsDNA) bc it is very sensitive. If it is positive, then we can get other antibodies
Complement levels, ESR, and CRP can monitor ongoing disease activity
Anti-histone antibodies
Drug-induced lupus (very sensitive)
Anti-cyclic citrullinated antibodies
RA (specific)
Patients with pseudogout should be evaluated for what?
For secondary causes - Hyperparathyroidism, Hypothyroidism, Hemochromatosis
Initial eval of hereditary hemochromatosis
Starts with serum Fe studies, which will show increased levels of iron, ferritin, and transferrin saturation.
Dx can be confirmed with genetic testing for hemochromatosis-associated mutations (HFE)
Liver bx is not required but may be useful to stage the extent of liver involvement (in patients with significant liver function test abnormalities) or to confirm the dx in patients who have iron studies indicating iron overload but negative results on classic HFE gene markers.
Long term management involves serial phlebotomy to deplete excess iron stores
Anti smooth muscle antibodies
Autoimmune hepatitis
Neurogenic claudication (pseudoclaudication)
Often seen in lumbar spinal stenosis (from OA of spine)
1) Posture dependent pain
2) Lumbar extension worsens pain (walking downhill)
3) Lumbar flexion relieves pain (walking while bent forward - shopping cart sign)
4) Lower extremity numbness and tingling
5) Lower extremity weakness
6) Low back pain
Exam
1) Normal pulses
2) Frequently normal exam
Dx - MRI of spine
Neurogenic arthropathy
AKA Charcot Joint
Associated conditions
1) Vit B12 deficiency**
2) Diabetes**
3) Peripheral nerve damage
4) Spinal cord injury
5) Syringomyelia
6) Tabes dorsalis (tertiary syphilis)
Clinical manifestations
1) Deformed joints*
2) Lacking/decreased sensation (proprioception, pain, temp) with loss of neurologic input*
3) Arhtritis or arthropathy
4) Mild pain*
5) Fractures (may be unsuspected by patient)
6) degenerative joint disease and loose bodies in joint imaging
Management
1) Treat underlying condition
2) Mechanical devices (assist in weight bearing, decrease further trauma, special shoes)
3) XRs (if trauma is present)
Prostate cancer with mets to bone
High alk phos plus bone pain or systemic symptoms (weight loss, fatigue).
Calcium is often high. PSA often above 4.
Most common cause of asymptomatic elevation of alkaline phosphatase in an elderly patient?
Paget Disease of Bone
First line therapy for reactive arthritis
NSAIDs
Triad of reactive arthritis
1) Nongonococcal urethritis
2) Asymmetric oligoarthritis
3) Conjunctivitis
In addition, mucocutaneous lesions and enthesitis of achilles are common findings.
Not all symptoms are present. That’s rare. So maintain a high suspicion in anyone with asymmetric oligoarthritis associated with urethritis, conjunctivitis or mouth ulcers
Synovial analysis is usually sterile
Giant cell arteritis - clinical manifestations
Systemic - fever, fatigue, malaise, weight loss
Localized
1) HA - located in temporal areas
2) Jaw claudication - most specific symptom of GCA**
3) PMR
4) Arm claudication - associated bruits in subclavian or axillary areas
5) Aortic wall thickening or aneurysms
6) CNS - TIAs/stroke, vertigo, hearing loss
Visual
1) Amaurosis fugax - transient vision field defect progressing to monocular blindness
2) AION - most common ocular manifestation (Anterior ischemic optic neuropathy - swollen and pale disc with blurred margins)
Labs
1) Normochromic anemia
2) Elevated ESR and CRP
3) Temporal artery bx
Tx
1) PMR only - low dose gluc (prednisone 10-20 daily)
2) GCA - intermediate to high dose oral gluc (pred 40-60)
3) GCA with vision loss - pulse high dose IV gluc (methylprednisolone 1000 daily) for 3d followed by intermediate to high dose oral gluc
Cervical spondylosis
Estimated that this affects 10% of people over 50. History of chronic neck pain is typical.
Limited neck rotation and lateral bending is due to OA and secondary muscle spasm. Sensory deficit is due to osteophyte-induced radiculopathy and isolated sensory abnormalities are associated with good prognosis.
Typical radiographic findings include bony spurs and sclerotic facet joints.
Specificity of those findings is low tho bc those osteoarthritic changes are actually common in asymptomatic patients over 50.
May also see narrowing of disk spaces and hypertrophic vertebral bodies
Pyoderma gandrenosum
Neutrophilic ulcerative skin disease. It starts as an inflammatory papule, pustule, vasicle or nodule, and progresses to form an expanding ulcer with a purulent base and ragged violaceous borders.
PG can present as single or multiple lesions, usually on the trunk or lower extremities.
Nearly 30% of cases are triggered by local trauma (pathergy)
Over half of PG patients have associated underlying systemic disorder such as IBD, arthropathies (RA), or heme conditions (AML). PG can present before or after diagnosis of these underlying conditions
PG is diagnosed clinically after excluding other diagnoses (venous ulcers, panniculitis, cutaneous cancers), usually with skin bx.
Tx - local or systemic steroids
Ecthyma gangrenosum
Typically presents as hemorrhagic pustules with surround redness that evolve into necrotic ulcers.
EG is a skin infection often due to Pseudomonas and occurs most commonly in setting of profound neutropenia and P aeuruginosa bacteremia
