Week 13 Rheumatology Flashcards
1
Q
osteoarthritis
A
- progressive degenerative joint disease
- degeneration of the hyaline cartilage layers in the joints from repetitive use or repetitive trauma
- increasing thickness in the growth plate.
- mono-articular or poly-articular
- asymmetric
- not a systemic disease
- women
- > 50 yrs, obese
2
Q
OA sx’s
A
- gradual onset of symptoms.
- joint pain, stiffness, swelling, tenderness
- fingers, shoulder, hip, knee, or ankle.
- minimal stiffness in the morning → lasts 30
- no redness or warmth
- functional impairment
- gel phenomenon stiffness (“car” moves better when warmed up)
- Pain worse later in the day and after activity, relieved by rest
3
Q
deformities of OA
A
- in OA
- hard bony swellings
- Heberden nodes in DIP joints
- Bouchard’s nodes in PIP joints
- Changes in carpometacarpal (CMC) joint common - base of thumb
4
Q
OA diagnosis
A
- NO xray except for considering joint replacement [xray normal in early stages]
- mod - severe → xray shows joint space narrowing
- osteophyte
- no lab testing
5
Q
OA management
A
- early OA:
- # 1: acetaminophen
- exercise - aerobic
- educate nature of disease
- physical therapy
- tai chi, stretching
- 2nd line: NSAID
- gi bleeding
- CVD
- mod - severe: tramadol
- joint replacement
- corticosteroids
5
Q
what is the grind test?
A
- CMC test
- if pain and crepitus with passive ROM of the thumb
- specific to OA
6
Q
rheumatoid arthritis (RA)
A
- systemic inflammatory arthritis
- Autoimmune
- Often viral trigger
- Leads to erosions of cartilage and bone → deformity
- increases with age
- Women >
7
Q
RA Sx’s / Exam
A
- bilateral & symmetric
- initially in small joints of hands (MCP, PIP), wrists, small joints of feet
- hips, knees, ankles, shoulders, cervical spine
- Morning stiffness lasting longer than 1 hour = inflammatory
- warmth, tenderness, decrease ROM, boggy swelling
- pain and stiffness worse in the morning & better with activity.
- 1st sx → joint pain/stiffness → then systemic symptoms like fatigue, weight loss, numbness and tingling in the hands.
8
Q
rheumatoid factor lab value for RA
A
- Early on in RA, RF can be negative but after 6 months, can be positive for RF
- RF can be elevated in viral hepatitis, lupus, sjogren’s disease
- CCP antibody has higher sensitivity early on in the dz
- Higher than RF in 3 months
9
Q
deformities of RA
A
- Boutonniere: non reducible flexion of the PIP joint; hyper extension of the DIP joint
- Swan neck deformity: hyper extension of the PIP joint with flexion of the DIP joint.
- Result of synovitis stretching, the rupturing the PIP joint through the central extensive tendon.
- subcutaneous nodules over pressure points
10
Q
RA diagnostics
A
- Inflammatory markers = disease activity
- CBC
- Rheumatoid factor
- ANA is usually negative.
- Anti-cyclic citrullinated peptide and anti-mutated citrullinated vimentin
- more sensitive for detecting/diagnosing RA
- develop earlier in the disease process vs RF
- # 1: X-ray
- show articular erosions, osteopenia, and joint space narrowing.
- soft tissue swelling
- ACR classification
- score 6 out of 10 diagnostic of RA
11
Q
RA management
A
-
Assess/manage cardiovascular risk factors yearly
- Leading cause of death
- Screen for infection (TB, hepatitis before starting treatments)
- Immunizations
- Screen osteoporosis, depression
- Non-pharm
- Ice heat
- PT, OT
- aerobic exercises, muscle strength
- improve QOL and reduce structural joint damage
- once dx → refer to rheumatology
12
Q
RA Treatment
A
- First line: methotrexate (DMARDs)
- Early treatment best
- other meds: leflunomide or sulfasalazine
- 2nd line: Biologic if can’t tolerate the DMARD
- DMARD are teratogenic (counsel conception)
- NSAID caution if hx GI bleeding (use Tylenol instead)
13
Q
Psoriatic arthritis
A
- inflammatory arthritis with dermatologic conditions of psoriasis
- 30-50 yrs old men & women
14
Q
Psoriatic arthritis sx’s
A
- DIP joints
- NO MCP involvement
- usually 5 or more joints affected
- asymmetric
- skin rash before onset of psoriasis
- dactylitis - sausage digits
- uveitis
- Enthesitis - inflammation at site where tendon inserts (Achilles tendon or plantar fascia)
- nail pitting (before rash), onycholysis, cracking
15
Q
psoriatic arthritis diagnostics
A
- if have joint inflammation with no rheumatoid factor + typical psoriatic and nail lesions = Caspar CRITERIA
- 3+ suggestive of PA
- Sed rate
- CRP
- Negative ANA
- Negative rheumatoid factor
- Uric acid
- Lipid profile
- HLA allele
- inflammatory markers elevated
- IgA can be elevated in up to 2/3 of patients.
- X-ray confirms
- erosions, osteolysis, and deformities
- Ultrasound/MRI
16
Q
Psoriatic arthritis management
A
1st line: NSAID but most need 2nd line DMARDs (methotrexate, sulfasalazine, leflunomide, azathioprine)
- Refer → rheumatology and dermatology.
- healthy lifestyle, weight loss, exercise, smoking cessation
- PT and OT
- acupuncture and massage
- screen for comorbidities
- higher risk cardiovascular disease.
- BP; diabetes screen
- higher risk cardiovascular disease.
- screen hepatitis and TB prior to the initiation of immunosuppressants
- screen depression.
17
Q
ankylosing spondylitis
A
- chronic inflammatory condition
- inflamed → bone erosion → spur formation
- fusion of bones in spine = bamboo spine
- Doesn’t affect distal joints (hands or wrists), but CAN affect knees, hips, shoulders
- involves the sacroiliac joint and the spine.
- Peaks 20 and 30
- genetics; positive for the HLA-B27 gene.
18
Q
ankylosis spondylitis sx’s
A
- 1st sx: low back pain/butt pain
- deep aching pain in gluteal area and SI joint
- TMJ, costosternal
- uveititis
- Stooping posture
- decreased chest expansion
- enthesitis
- worse in the morning/night
19
Q
ankylosis spondylitis diagnosis and workup
A
- To dx: pain > 3 months
- sacrolitiis on imaging + 1 or more SpA features or + HLA-B27 + 2 more
- Fever and weight loss
- workup
- CRP and sed rate elevated
- RA negative
- mild anemia (CBC)
- x ray not needed
20
Q
ankylosis spondylitis management
A
- First line: NSAIDs
- NO DMARDs
- non pharm same as psoriatic arthritis
- heat, massage
- biologic anti-TNF agents if NSAIDs don’t work
- etancercept
- infliximab
- adalimumab
- glolimumab
21
Q
most common type of juvenile idiopathic arthritis
A
Oligoarticular
- onset < 16 yrs old
- involves < 5 joints (usu knee or ankle)
- limited ROM
- systemic: fever
- persisting 6 weeks or longer
- pain stiffness of joints
- morning limp
- positive ANA
22
Q
Juvenile idiopathic arthritis on exam
A
- enthesitis
- uveitis
- positive ANA
- can be asymptomatic (TMJ/jaw)
- swelling of joint with effusion
- warmth over inflamed joint, tenderness
- loss of ROM → limp
- nail pits, onycholysis
- fleeting salmon color rash on trunk
- ciliary eye injection → uveitis
23
Q
Juvenile idiopathic arthritis diagnostics
A
- dx of exclusion
- HLA B27
- negative lab markers
- CBC, ESR, CRP
- lyme testing
- LFT
- at least 1 joint for over 6 wk period and r/o other causes
24
Juvenile idiopathic arthritis management
* Refer
* if polyarticular arthritis → DMARDs
* methotrexate, sulfasalizine, and hydrochloroquine
* Oligoarthritis → NSAID or corticosteroid injection
* **child with poly or oligo → higher risk of uveitis = MORE FREQUENT EYE EXAMS!**
* monitor growth, leg length discrepancy, osteopenia, immunizations
* PT/OT
25
Polyarticular destructive athritits
* 5 + joints
* uveitits
* slow growth, fatigue
* + ANA, mild anemia
* + RF
* NSAIDs, DMARDs (methotrexate), opthalamology referral, nutrition
26
systemic lupus erythematosus ROS
* chronic multi system inflammatory rheumatic disease
* most common symptom: cutaneous, musculoskeletal, and hematologic.
* skin - malaria / butterfly rash over cheeks, spares nasal labial fold
* erythematous lesion on hard palate
* Alopecia
* Joint pain (90%) bilateral (non erosive arthritis)
* kidney involvement first presentation in 15% of patients.
* Chest pain or dyspnea.
* General: fever, anorexia, malaise, weight loss
* Skin: malar/butterfly rash, photosensitivity, alopecia
* Vascular: Raynaud’s phenomenon
* Stress, cold exposure
* Numbness and tingling
* Pale
* MSK: joint pain
* Eye: conjunctivitis, photophobia
* Pulmonary: pleurisy, pleural effusion, pneumonitis
* Cardiac: pericarditis, myocarditis, endocarditis
* Lymph: lymphadenopathy
* Neuro/psych: stroke, neuropathies, depression
* Renal: proteinuria from glomerulonephritis
* GYN: Recurrent Spontaneous Abortion/fetal loss
* Gingivitis, mucosal hemorrhage, erosions, ulcerations
27
SLE diagnostics
* **ANA** (anti-nuclear antibodies).
* 94% positive ANA with lupus
* *high false positives = doesn't mean + for Lupus & can be elevated for other reasons*
* Antibody testing for double stranded DNA
* Anti-Smith Antibody
* Anti-RNP antibody
* ANti-Ro and anti-La
* leukopenia/lymphopenia, anemia, thrombocytopenia common
* proteinuria/hematuria
28
SLE management
* refer → rheumatology, nephrology
* Educate healthy lifestyle, diet, exercise, sunscreen
* NSAIDs → joint pain, fever, serositis (monitor)
* **Hydroxychloroquine** (Plaquenil) → MK, cutaneous, serosal sx's
* reduce organ damage
* adjunct with antiphospolipid syndrome
* ophthalmology checks
* Belimumab
* **Low dose corticosteroids** → for skin lesions & joint pain
* Monitor BP (inc CVD risk), bone health (osteoporosis) → Ca, Vitamin D
* DMARDs, biologics
* Antibiotic prophylaxis before dental, GU, invasive procedures (inc risk infective endocarditis)
29
Lupus risk factors
women
asian, black, hispanic women
29
polymyalgia rhematica (PMR)
* Systemic inflammatory
* caucasian women
* peaks 70-80s
* **stiffness that lasts \> 1 hr after rest for \> 2 weeks**
* **non erosive, asymmetric, highly responsive to systemic corticosteroids**
* aching, painful ROM, stiffness in the bilateral shoulders, neck, and hips (LARGER joints)
* systemic symptoms,
* fever, malaise, or weight **loss**.
* develop giant cell arteritis
* inflamed arteries
* **medical emergency! sudden blindness**
30
polymyalgia rheumatica workup
* CBC → anemia, leukocytosis
* elevated ESR/SED rate to 20%
* **no** specific that dx
* Liver function tests
* TSH
* UA
* RF and/or anti-cyclic citrullinated peptide antibodies
* ANA negative
31
PMR managment
* **low dose oral prednisone daily**
* rapid response in 1 week; taper after 4-8 wks of therapy
* **_NO NSAIDS_**
* monitor pain, morning stiffness, OP, alternative dx
32
fibromyalgia risk factors
* abnormal pain processing in the nervous system and abnormal stress response access
* **Persistent widespread pain;**
* **chronic fatigue**
* deep ache in muscles pain, fatigue, and trouble sleeping
* generalized burning and tingling.
* Risk factors
* Females
* Middle age
* family history.
* Trauma
* Stress on body
* irritable bowel syndrome
33
fibromyalgia work up & management
* Lab testing is **not** needed
* Dx:
* sx's for least 3 month
* have 11 tender points out of 18
* Use widespread pain index _\>_ 7 and sx severity _\>_ 5
* no other disorders
* Reassure nothing is being damaged in body; body is sensing pain
* 1st line: exercise
* low impact - swimming
* Pharm
* Amitriptyline, Cyclobenzaprine
* SSRI - fluoxetine, duloxetine
* gabapentin, pregabalin
* trazodone - sleep
* Cognitive Behavioral Therapy
* coping skills
* relaxation
* visual imagery
* Acupuncture
* massage therapy
* group therapy
34
Acute gout risk factors & sx's
* common inflammatory arthritis
* Risk factors
* Men
* Diet high in purines (red meats, sea food, alcohol, fructose)
* Comorbidities
* HTN, Obesity, CVD, DM, diuretic use, menopause, renal disease, elevated trigs and LDL
* Sx's
* hyperuricemia
* sudden gout flares MTP joint (big toe) → *podagra*
* painful, warmth, redness, swellings
* No systemic sx’s
35
4 stages of gout
1. Asymptomatic hyperuricemia
* Deposit in blood when \> 6.8 uric acid
2. Acute gout
* Monoarticular (1st toe in joint)
* Ankle, knees
* Uncommon in axial joints
3. Intercritical or interval gout
* Periods between gout attacks
* Affect more than 1 joint
* Attacks longer and more severe
* Uric acid can persists in joint; joint erosion over time
4. Chronic tophaceous gout
* Years
* Tophi
* Structural joint damage
* Bone erosion
* Disabilitng arthritis
36
majority (80-90%) of those with hyperuricemia
**never go on to develop gout flare**
37
tophi
* Subcutaneous nodules
* Monosodium crystals mixed with lipids and proteins
* May not even be seen but be seen on imaging study
* Can also be in MTP and olecranon
* Resolve urate lowering therapy
* large → surgery
38
gout diagnostics
* **dx: joint needle aspiration of inflamed joint/tophus**
* US → double contour sign or rate icing
* criteria: 8 or more = diagnosis of gout
* xray → advanced gout
39
Gout management
* NSAID - w/o no comorbidities
* For early attack first 24 hrs
* improve in 2-3 days, resolve day 10
* Oral systemic corticosteroids
* Taper over 10-14 days to prevent rebound
* Intra Articular corticosteroids injection
* 1 time injection
* *Only* if it's 1 or 2 joints
* Oral Colchicine
* 2 doses in 1 day
* *Less effective if started \> 36- 48 hrs of sx onset*
* Don’t give if GFR \< 10
* Renally dose if GFR \< 50
* continue urate lowering therapy (ULT)
* Non pharm
* Weight loss
* Avoid diuretics
* DASH diet
* Avoid fructose
* Limit purine, carbs
* increase protein, unseat fats
* Encourage vegetables and low-fat dairy
* Limit alcohol
* Topical ice
40
most therapeutic success of gout attack is
* how soon NSAID therapy started at appropriate dose and duration of therapy
* resolves 5-8 days of starting
* but avoid NSAID in PUD, impair renal, liver dz, CHF, anticoagulant therapy, elderly
41
when to start urate lowering therapy?
* Start therapy after 2 + attacks a year or even 1st flare 6-8 wks after flare resolved
* don't START ULP during acute attack but if already on, CONTINUE it
* Start low then tirate up
* goal: uric acid lvl: \< 6
* check levels SU lvls q 3-6 months
* Xanthine oxidase inhibitors
* Allopurinol
* Febuxostat
* Probenecid
42
prophylaxis of ULT
* continuous use of anti-inflammatory drugs to prevent gout flares
* allopurinol AND:
* low dose oral colchicine or NAID with PPI or low dose prednisone
* continue prophylaxis until SU value \< 6 and no acute attacks for 3-6 months
* warn discontinuation can cause exacerbation of acute flares
