Icm: Fibromyalgia, Etc.

Front 1

Fibromyalgia is the most likely dx for a 60 year old f/m w/ a 3-week hx of myalgia and arthralgias?

Back 1

false

Front 2

a positive ANA is a rqment to make a diagnosis of inflammatory myositis?

Back 2

flase

Front 3

all patients w/ inflammatory myositis have abnormal electromyographic findings?

Back 3

flase

Front 4

elevated ESR can be seen in at least 85% of patients w/ inflammatory myositis

Back 4

False

Front 5

The presence of interstitial lung dz in a patient w/ inflammatory myositis portends a good prognosis

Back 5

false

Front 6

Fibromyalgia is the most likely dx for a 60 year old f/m w/ a 3-week hx of myalgia and arthralgias?

Back 6

false

Front 7

a positive ANA is a rqment to make a diagnosis of inflammatory myositis?

Back 7

flase

Front 8

all patients w/ inflammatory myositis have abnormal electromyographic findings?

Back 8

flase

Front 9

elevated ESR can be seen in at least 85% of patients w/ inflammatory myositis

Back 9

False

Front 10

The presence of interstitial lung dz in a patient w/ inflammatory myositis portends a good prognosis

Back 10

false

Front 11

Fibromyalgia is the most likely dx for a 60 year old f/m w/ a 3-week hx of myalgia and arthralgias?

Back 11

false

Front 12

a positive ANA is a rqment to make a diagnosis of inflammatory myositis?

Back 12

flase

Front 13

all patients w/ inflammatory myositis have abnormal electromyographic findings?

Back 13

flase

Front 14

elevated ESR can be seen in at least 85% of patients w/ inflammatory myositis

Back 14

False

Front 15

The presence of interstitial lung dz in a patient w/ inflammatory myositis portends a good prognosis

Back 15

false

Front 16

routine testing of ANA is recommended for patients being evaluated for fibromyalgia?

Back 16

false

Front 17

How long must people w/ fibromyalgia have pain?

Back 17

at least 3 months

Front 18

What 3 things must be present in addition to pain for >3 mos?

Back 18

1. pain on left and right side of body
2. pain below and above the waist
3. axial pain must also be present (cervical spine, anterior chest, thoracic spine or low back)
4. 11/18 tender points must be present

Front 19

How many tender points must be present for dx fibromyalgia?

Back 19

11/18

Front 20

Why might one check TSH w/ diffuse pain syndromes?

Back 20

hyper or hypothyroidism may mimic fibromyalgia

Front 21

What are the 4 pieces of the fibromyalgia puzzle?

Back 21

Central sensitization
Pain generators
Dys-stress
Genetic factors

Front 22

"turning up the volume" on an amplifier resulting in lots of pain is?

Back 22

Central sensitization
-this may have a part in why patients w/ fibromyalgia have pain

Front 23

sensations that formerly were non-painful now become painful?

Back 23

Allodynia

Front 24

Sensations that formerly were mildly painful now become excessively painful

Back 24

Hyperalgesia

Front 25

After an initial painful stimulus, subsequent equal stimuli are perceived to be more intensely painful

Back 25

wind-up phenomenon

Front 26

Be aware of a few mechs. for CNS FMS

Back 26

-decreased SEROTONIN
-decreased DOPAMINE transmission
-Dysfuntion in Hypothalamic-pituitary-adrenal axis

Front 27

How may stress/physiological factors play role in FMS

Back 27

Predisposing factors like abuse

Triggering factors like life-threatening events (think of war vets.)

Front 28

Who are most commonly affected by FMS and what is the age?

Back 28

80-90% women
30-50 y/o

can have onset in childhood or be present people 60 y/o

Front 29

Secondary fibromyalgia most likely to affect?

Back 29

men as well as women

Front 30

Just to paint a clinical picture: what are some traits of FMS?

Back 30

fatigue
sleep disturbances
stiffness
paresthesias
headaches
IBS
depression (40%)
anxiety

Front 31

What are a few conditions in which secondary FMS can occur?

Back 31

Rheumatoid arthritis, lupus, scleroderma, and other connective tissue dzs
-hep C and HIV infections
-MS

Front 32

Are most patients w/ FMS clinically depressed?

Back 32

No, only about 40% on the high end
-Despite substantial overlap, most patients w/ FMS are not clinically depressed

Front 33

Why might you order lab tests if you think you're dealing with FMS?

Back 33

Exclude medical condtions that may be presenting as FMS
-thyroid
-glucose
-creatinine, creatinine phosphokinase (CPK) and SGPT
-blood count
-other tests should be ordered AS INDICATED by their hx and/or physical

Front 34

if patient presents w/ muscle weakness, what test should order?

Back 34

CPK
-creatinine phosphokinase

Front 35

General tx principle fibromyalgia?

Back 35

education
improve sleep
increase level of physical activity (to a point-GRADED)
pharm. treatment

Front 36

Why do you want to do GRADED physical activity?

Back 36

avoid post-exertional exacerbation of pain via IL-1

Front 37

Is fibromyalgia some made up dz?

Back 37

NO- CNS mechanisms of FMS exist, we're just not fully aware of them yet

Front 38

What kind of treatment want and what are goals for fibromyalgia?

Back 38

-multimodal tx is best
-improvement in level of physical education and reduction in pain intensity

Front 39

idiopathic inflammatory myopathies characterized by distal or proximal m. weakness? - what kind of m.?

Back 39

Proximal muscle weakness

non-suppurative inflammation of skeletal muscle

Front 40

Just for info, here's some inflammatory myopathies

Back 40

polymyositis
dermatomyositis
amyopathic dermatomyositis
juvenile dermatomyositis
myositis associated w/ neoplasia
myositis associated w/ collagen vascular dz
inclusion body myositis (IBM)

Front 41

Age of onset inflammatory myopathies?

Back 41

bimodal distribution
-10 to 15 y/o
-45-60 y/o

Front 42

IBM and myositis associated w/ MALIGNANCY are more common when?

Back 42

after age of 50

Front 43

inflammatory myopathies more common in women or men?

Back 43

women

except IBM is men to women 2:1

Front 44

What HLA types are inflammatory myopathies assoc. w/?

Back 44

HLA-B8
DR-3
DRW52

Front 45

inflammatory myopathies have insidious or gradual onset?

Back 45

insidious onset over 3-6 months

Front 46

What is affected most (location) w/ inflammatory myopathies?

Back 46

Shoulder
Pelvic girdle
Neck flexors (50%)

Front 47

inflammatory myopathies is ocular and facial ever involved?

Back 47

NO!
this is how you can tell it's not a neurological dz of the cranial nerves

Front 48

What region of the head may be affected by inflammatory myopathies

Back 48

technically the neck
pharynx - dysphonia and difficulty swallowing

esophageal or cricopharyngeal obstruction: dysphagia

Front 49

inflammatory myopathies affect distal or proximal muscles?
-what type of muscle?

Back 49

proximal m. weakness

skeletal m.
*non-suppartive inflammation of skeletal m.

Front 50

A few example of inflammatory myopathies

Back 50

polymyositis
dermatomyositis
amyopathic dermatomyositis
juvenile dermatomyositis
myositis associated w/ neoplasia
myositis assoc. w/ collagen vasc dz
Inclusion body myositis (IBM)

Front 51

Is inflammatory myopathies rare or common

Back 51

rare

Front 52

Age of onset inflammatory myopathies?

Back 52

Bimodal

10-15 years children
45-60 years adults

Front 53

IBM (inclusion body myositis) associated w/ malignancy is more common at what age?

Back 53

after age 50

Front 54

Is inflammatory myopathies more common in women or men?

Back 54

women normally

IBM men 2:1

Front 55

HLA types associated w/ inflammatory myopathies

Back 55

HLA-B8
DR-3
DRW52

Front 56

inflammatory myopathies have insidious or gradual onset?

Back 56

insidious onset over 3-6 months

Front 57

What is affected most w/ inflammatory myopathies

Back 57

SHOULDER
PELVIC GIRDLE
- neck flexors involved in 50%

Front 58

What is never involved w/ inflammatory myopathies?

Back 58

Facial and ocular
*these would be indicative of some type of primary neurological dz

Front 59

What parts of the neck could be affected by inflammatory myopathies?

Back 59

Esophagus or cricopharyngeus: dysphagia

Pharynx: dysphonia and difficulty swallowing

Front 60

Dx criteria: how many out of these 4

1. Symmetrical Proximal m. wekaness shoulder/pelvic girdle and neck flexors
2. elevated serum levels of enzymes (CPK, aldolase, SGOT, SGPT)
3. Myopathic changes demonstrated by electromyography: motor unit potentials of short duration and low amplitude
4. Muscle bx: muscle fiber necrosis and regeneration, inflammatory cellular infiltration

Back 60

3 of 4

Front 61

Myositis-specific autoantibodies associated w?
-PM or DM with acute onset, interstitial lung dz, fever, arthritis, raynaud's phenomenon

Back 61

Anti-synthetase (Jo-1)

Front 62

Knowing the person has anti-synthetase (Jo-1), what is the prognosis?

Back 62

intermediate

Front 63

Myositis-specific autoantibodies associated w?
-PM w/ very acute onset, severe weakness, palpitations

Back 63

Anti-SRP

Front 64

Knowing the person has anti-SRP, what is the prognosis?

Back 64

poor prognossi

Front 65

Myositis-specific autoantibodies associated w?
-DM w/ V sign and shawl sign, cuticular overgrowth

Back 65

Anti-Mi2

Front 66

Anti-Mi2 prognosis?

Back 66

good prognosis

Front 67

What is dermatomyositis in adults, and what may it indicate?

Back 67

polymyositis+cutaneous infection
-predate muscle inolvement by a year or more

Front 68

Name this dermatomyositis rash:
-Lilac (purple/erythematous rash of the EYELIDS, usually w/ swelling

Back 68

Heliotrope rash
"BUZZWORD!!!"

Front 69

Name this dermatomyositis rash:
-erythematous dermatitis over the dorsum of the hands, especially the MCP and PIP joints

Back 69

Gottron's sign

Front 70

Name this dermatomyositis rash:
-can also be present over the anterior chest and neck, shoulders and proximal arms anf face (*SHAWL SIGN or V SIGN)

Back 70

Erythematous rash

Front 71

Are subcutaneous calcifications common w/ dermatomyositis in adults?

Back 71

Yes

Front 72

What is the most sensitive and specific muscle enzyme to test for myopathy? how often elevated?

Back 72

CPK
-most sensitive and specific
-elevated at some point during the dz in >90% patients

Front 73

Will CPK levels tell you anything about the patients response to therapy

Back 73

yes, you should follow these levels during the course of treatment

Front 74

Are these enzyme abnormalities very specific?
-aldolase
-Serum glutamic-oxaloacetic transaminase (SGOT) and SGPT
-Lactate Dehydrogenase (LDH)

Back 74

No, these may be abnormal, but not specific to dz

Front 75

Sedimentation rate elevated in about what percentage of cases of myositis?

Back 75

only 50% of cases
-therefore, these also are not the best to use to dx

Front 76

How can EMGs help dx myositis?

Back 76

changes are characteristic of dz but not diagnostic
40% have 3 changes
10-15% have normal EMGs

Front 77

Myositis muscle biopsy
-what are predominant inflammatory cells?

Back 77

lymphocytes and plasma cells

Front 78

Myositis muscle biopsy
-what happens to muscle fibers?

Back 78

muscle fiber necrosis and degeneration occur, w/ loss of x-striations and variation in size

Front 79

Myositis muscle biopsy
-polymyositis or dermatomyositis?
CD8+ cells infiltrate muscle fibers

Back 79

polymyositis

Front 80

Myositis muscle biopsy
-polymyositis or dermatomyositis?
*CD4+ cells cluster around the vessels

Back 80

dermatomyositis

Front 81

what is the main cell invovled in driving the immune process?

Back 81

CD4 cell

Front 82

Extra-muscular manifestations of myositis?
-is myalgia common?

Back 82

NOT UNCOMMON
=common

Front 83

Extra-muscular manifestations of myositis? others?

Back 83

Arthralgia/arthritis
Pulmonary (interstitial lung dz, resp m. weakness, aspiration pneumonitis)
Cardiac (dysrhythmia, conduction blocks, myocarditis)

Front 84

How is Amyopathic dermatomyositis diff. from dermatomyosits

Back 84

-Classic cutaneous finding of dermatomyositis but w/ NO CLINICAL EVIDENCE OF MUSCLE DZ
-fatigue may be present even if over muscle weakness is not

Front 85

What are some key ways Juvenile dermatomyositis is diff. from adult?
-what system
-calcinosis?
-remission?

Back 85

-Multisystem vasculitis (skin, GI tract, muscle, heart, retina)
-Calcinosis MORE common
-w/ remission, children more likely to return to normal strength

Front 86

Myositis can do what to one's diff. dx of collagen vascular dz?

Back 86

low grade m. weakness may cloud one's thinking
-should consider scleroderma, SLE, mixed ct dz

Front 87

Is there an association between myositis and malignancy?

Back 87

Yes
-malignancy can PRECED or FOLLOW the onset of m. weakness by up to 2 years
-cancers, esp. ovarian cancer

Front 88

Inclusion body myositis more common in who?

Back 88

males > females, >50 years usually

Front 89

What cell type Polymyositis causes dz?

Back 89

CD8

-ag directed cytotoxicity mediated by cytotoxic tcells (CD8)

Front 90

What cell type Dermatomyositis causes dz?

Back 90

CD4

-humorally (ab and immune complex) mediated damage fo the microvasc. in m., followed by necresosi and marked reduction in # of capillaries per muscle fiber, w/ ischemia and muslce fiber destruction that resemble microinfarcts, exp. in Perifascicular regions

Front 91

Polyositis and dermatomyosits are immune-mediated processes that are triggered by?

Back 91

environmental factors (eg viruses) in GENETICALLY SUSCEPTIBLE individuals

Front 92

What might also consider w/ myositis tx?

Back 92

some drugs can induce myositis, take away drug and might retrun to normal

Front 93

What are a few factors associated w/ poorer outcome?

Back 93

-initiate tx > 6mos following onset symptoms
-severity of weakness
-dysphagia
-assoc. malignancy
-resp. m. weakness
-interstitial lung sz
-cardiac involvement

Front 94

T/F?
-Fibromyalgia is the most likely dx for a 60 y/o fm with a 3-week hx of myalgia and arthralgias

Back 94

false- longer time involvement

Front 95

T/F?
-a positive ANA is a requirement to mae a dx of inflammatory myositis?

Back 95

false

Front 96

T/F?

all patients w/ inflammatory myositis have abnormal electromyographic findings?

Back 96

false - 10-15% do not

Front 97

Elevated ESR can be seen in at least 85% of patients w/ inflammatory myositis

Back 97

False
-closer to 50%

Front 98

presence of interstitial lung dz in a patient w/ inflammatory myositis portends a good prognosis

Back 98

false

Front 99

What cell type Polymyositis causes dz?

Back 99

CD8

-ag directed cytotoxicity mediated by cytotoxic tcells (CD8)

Front 100

What cell type Dermatomyositis causes dz?

Back 100

CD4

-humorally (ab and immune complex) mediated damage fo the microvasc. in m., followed by necresosi and marked reduction in # of capillaries per muscle fiber, w/ ischemia and muslce fiber destruction that resemble microinfarcts, exp. in Perifascicular regions

Front 101

Polyositis and dermatomyosits are immune-mediated processes that are triggered by?

Back 101

environmental factors (eg viruses) in GENETICALLY SUSCEPTIBLE individuals

Front 102

What might also consider w/ myositis tx?

Back 102

some drugs can induce myositis, take away drug and might retrun to normal

Front 103

What are a few factors associated w/ poorer outcome?

Back 103

-initiate tx > 6mos following onset symptoms
-severity of weakness
-dysphagia
-assoc. malignancy
-resp. m. weakness
-interstitial lung sz
-cardiac involvement

Front 104

T/F?
-Fibromyalgia is the most likely dx for a 60 y/o fm with a 3-week hx of myalgia and arthralgias

Back 104

false- longer time involvement

Front 105

T/F?
-a positive ANA is a requirement to mae a dx of inflammatory myositis?

Back 105

false

Front 106

T/F?

all patients w/ inflammatory myositis have abnormal electromyographic findings?

Back 106

false - 10-15% do not

Front 107

Elevated ESR can be seen in at least 85% of patients w/ inflammatory myositis

Back 107

False
-closer to 50%

Front 108

presence of interstitial lung dz in a patient w/ inflammatory myositis portends a good prognosis

Back 108

false

Front 109

routine testing of ANA is recommended for patients being evaluated for fibromyalgia

Back 109

false