Msk Week 4 Objective 1

Front 1

Drawing a flow chart, how would you classify inflammatory arthritis.

Back 1

Seropositive and Seronegative based on the absence of presence of RF antibodies.

Front 2

What type of nodules/deformities are found in someone with OA? RA?

Back 2

OA = Heberden's and Bouchard's nodes
RA = Swan neck and Boutonerrie deformities

Front 3

What are Heberden's nodes? Bouchard's nodes?

Back 3

They are bony prominences found on the DIP joints of someone with OA.
Bony prominences found on the PIP joints of someone with OA.

Front 4

What gold standard protocol should be performed on someone with a monoarthritis?

Back 4

Fluid aspiration to investigate the synovial fluid.

Front 5

What does normal synovial fluid look like?

Back 5

Colorless/straw color, viscous (due to HA) and has a WBC <200/mm3.

Front 6

What are the various types of synovial fluid, what disease is associated and how many WBC counts?

Back 6

Type 1 (Non-inflammatory)(OA) = <2000 WBC/mm3
Type 2 (Inflammatory)(RA) = >25,000 WBC/mm3
Type 3 (Septic) = >100,000 WBC/mm3
Type 4 (Hemorhagic) = RBC

Front 7

Compare and contrast the synovial fluid differences between Types 0-4?

Back 7

Front 8

What type of immune cells are found in Type 1- 4 synovial fluids?

Back 8

Type 1 = mononuclear (lymphocytes)
Type 2 & 3 = PMNs
Type 4 = RBC

Front 9

What sort of investigations should be performed on a synovial fluid?

Back 9

Naked eye inspection of color, viscosity and turbidity.
Gram stain, C&S, AFB and fungal
Microscopy looking for crystals
WBC count and differential.
Albumin and glucose concentration.

Front 10

Compare and contrast stiffness in RA and OA?

Back 10

RA stiffness has prolonged (>45min) in the morning that gets better with activity and worse with inactivity. Can cause night pain.
OA stiffness is also in the AM but only lasts for 10 minutes. Activity makes it worse.

Front 11

What type of diseases are expected with Type 2 synovial fluid?

Back 11

Inflammatory including RA, psoriatic arthritis, SLE.

Front 12

Why is Type 2 synovial fluid watery and turbid?

Back 12

Watery because the HA is being broken down by enzymes
Turbid because of the increased proteins and WBC

Front 13

What happens to the glucose and albumin (protein) levels in Type 2 & 3 synovial fluid?

Back 13

Protein levels increase, glucose levels decrease in both inflammatory and septic causes.

Front 14

What are the two classifications of arthritis?

Back 14

Inflammatory or Non-inflammatory

Front 15

How do you classify inflammatory arthritis?

Back 15

Seropositive (for RF) or Seronegative

Front 16

Give examples of non-inflammatory arthritis, seropositive and seronegative inflammatory arthritis?

Back 16

Non-inflammatory = OA
Inflammatory seropositive = RA, SLE, Collagen vascular diseases
Inflammatory seronegative - 15% of RA, psoriatic arthritis, ankylosing spondylitis, infection, crystal arthropathies

Front 17

What are some seronegative inflammatory arthritis?

Back 17

1) RA (15%)
2) Psoriatic
3) Ankylosing spondylitis
4) Infection
5) Crystal arthropathies

Front 18

What are some infectious agents that cause seronegative inflammatory arthritis?

Back 18

1) Bacteria - S.aureus, S.epidermidis, Strep and N.gonorrhea
2) Viral - rubella, parvovirus B19, HBV
3) Fungal
4) TB
5) Lyme

Front 19

How does subacute bacterial endocarditis cause inflammatory arthritis?

Back 19

Mimicry - infectious Ag must look like a self-Ag in the joints therefore creating antibodies to the infectious agent also causes you to attack your own joints.

Front 20

What are the three types of crystal arthropathies?

Back 20

1) Monosodium urate (MSU)
2) Calcium pyrophosphate dihydrate (CPPD)
3) Calcium hydroxyapatite (HAA)

Front 21

How can you classify inflammatory arthritis based on # of joints?

Back 21

1) Monoarthritis - one joint involved
2) Oligoarthrits = <5 jts involved
3) Polyarthritis = >4 jts involved
Oligo and poly can be symmetrical or asymmetrical.

Front 22

What joints does RA usually affect?

Back 22

The small joints of the hand including PIP and MCP
The wrist, elbow, shoulder, hips knee, ankles and feet (MTP).
The DIP joints are NEVER involved in RA.

Front 23

What are some joint features of RA?

Back 23

Seropositive (85%) inflammatory arthritis
Symmetrical
Polyarthritis - can present as mono
Causes nodules, soft to palpate.
Causes joint erosion and deformity

Front 24

Define pannus?

Back 24

Pannus is the hypertrophied synovium (Type A and B cells) of RA that occur at the double reflection of the synovial membrane.
The pannus invades the cartilage and juxta-articular margins causing erosion = pocket erosions

Front 25

What changes does the pannus caused by RA cause on X-ray?

Back 25

Joint space loss (equally throughout the join unlike OA)
Joint erosion
Osteopenia or bite markings
Joints can b/c subluxed/ankylosed

Front 26

What type of deformities in the hand can be observed in RA?

Back 26

1) Swan neck deformities
2) Boutienneir deformities
3) Ulnar deviation
4) Z or duckbill deformity of the thumb

Front 27

What is Felty's syndrome?

Back 27

Triple syndromes
1) RA
2) Splenomegaly
3) leukopenia

Front 28

What is Sjogren's syndrome?

Back 28

Endocrine system attacks the salivary and tear glands therefore your eyes (xerophthalmia) and mouth (xerostomia) get very dry.
This can cause a huge issue with dental caries.

Front 29

How does lupus arthritis look?

Back 29

Lupus arthritis is associated with other features, never on its own.
Symmetrical and affects the small joints of the hands and knee - it doesn't affected the DIP joints.
It does NOT cause erosion of the joints (unlike RA)

Front 30

What is the Sicca syndrome?

Back 30

Sjogern's features of dry eyes (xerophthalmia) and dry mouth (xerostomia)
Is associated with RA, SLE and scleroderma

Front 31

What are the 11 criteria to diagnosis SLE? How many total do you need to diagnosis?
Need 4/11 to be +ve for SLE

Back 31

1) Malor rash (butterfly rash)
2) Photosensitivity rash
3) Maculopapular rash
4) Mouth ulcers
5) Inflammatory arthritis
6) Pleuritis or pericarditis
7) Nephrosis or Nephritis
8) CNS manifestations
9) +ve ANA
10) +ve Smith Ab (Sm) or DNA Ab or anti-phospholipid antibody
11) Lymphocytopenia or Coomb's positive hemolytic anemia or thrombocytopenia

Front 32

What is scleroderma?

Back 32

Idiopathic sclerosis (thickening/hardening) of the skin.

Front 33

What are the 2 types of scleroderma?

Back 33

1) Diffuse systemic
2) Limited cutaneous (CREST)

Front 34

What systemic diseases are found in scleroderma?

Back 34

1) Severe Raynauds
2) Hypertensive crisis
3) Renal failure
4) Interstitial lung disease

Front 35

What does CREST stand for in Limited cutaneous scleroderma?

Back 35

C - Calcinosis (Ca+2 deposits in soft tissue)
R - Raynaud's syndrome
E - Esophageal dilatation
S - sclerodactyly (binding at the knuckles)
T - Telangiectasia (small dilated blood vessels near the surface of skin or mucosa)

Front 36

What is mixed connective tissue disease (MCTD)?

Back 36

Mix of lupus, RA, scleroderma and polymyositis.

Front 37

What is psoriatic arthritis?

Back 37

Arthritis with psoriasis rash/nail changes (onycholysis)

Front 38

How does psoriatic arthritis affect the joints?

Back 38

1) Asymmetrical
2) Oligoarthritis (<5 jts)
3) Sausage digits
4) Involved the DIP joints
5) Sclerosis (thickening) and periostitis (inflammation of the periosteum) instead of osteopenia as seen in RA.

Front 39

What type of inflammatory arthritis causes the cup appearance or the "opera glass hand"

Back 39

Arthritis mutilans - a subset of psoriatic arthritis.

Front 40

What are the 5 subsets of psoriatic arthritis?

Back 40

1) RA-like Polyarthris (mimics RA but DIP involved)
2) Arthritis mutilans
3) DIP variant
4) Asymmetric oligoarthritis (most common)
5) Spondyloarthropathy

Front 41

What joints are inflammaed in seronegative spondylarthropathies?

Back 41

1) Inflammatory axial spine involvement
2) Peripheral joint involvement, oligoarthritis, large joints and asymmetric
3) Enthesisi is involved (where the tendon inserts into the bone)

Front 42

What mutation is observed in seronegative spondylarthropathies?

Back 42

HLA-B27

Front 43

What are the four subsets of seronegative spondylarthropathies (SSpA)

Back 43

1) Reactive Arthritis (AKA Reiters)
2) Ankylosing spondylitis (AS)
3) Spondylitis of psoriasis (PsorSp)
4) Spondylitis of IBD (IBD)

Front 44

What are some features of inflammatory back pain?

Back 44

1) Insidious onset before 40yo
2) Gets worse with inactivity and better with exercise
3) Night pain*
4) Morning stiffness >30min

Front 45

What is a defining feature to distinguish between seronegative spondylarthropies (SSpA) and anklyosing spondylitis (AS)?

Back 45

AS will have sacroilitiis, SSpA will not.

Front 46

What are some common features seen in anklyosing spondylitis (AS)?

Back 46

1) Sacroilitis
2) Syndesmophytes (new bone) bridging vertebral bodies
3) Enthesopathy (heel spurs)
4) Can get bamboo spine (fuse)

Front 47

What review of system questions should you ask if you suspect seronegative spondylopathies (SSpA)?

Back 47

1) Iritis
2) Conjuctivitis
3) Psoriasis
4) Inflammatory bowel diseases
5) Recent travel and dysentry
6) Urethritis, cervicitis

Front 48

What type of bugs commonly trigger dysentry and reactive (reiter's) arthritis?

Back 48

1) Salmonella
2) Yersinia
3) Shigella
4) Campylobacter
But any microorganism can trigger reactive arthritis

Front 49

What is the triad found in reactive (reiter's) arthritis?

Back 49

1) Arthritis
2) Conjuctivitis
3) Urethritis - chlamydia (can be associated with dysentry instead)

Front 50

Explain the concept of molecular mimicry and its role in inflammatory arthritis?

Back 50

Some bacterium express immune epitopes that are similar to self HLA-B27. If this occurs, your body will produce antibodies that will X-react with self auto-antibodies and cause a reactive arthritis.

Front 51

Compare the polymerized microscope results in someone with gout/pseudogout caused by MSU crystals and CPPD?

Back 51

Gout (MSU) will cause a -ve birefringement which produces yellow crystals that are parallel with the axis and blue that are perpendicular.
Pseudgout (CPPD) produces a +ve birefringment with yellow crystals perpendicular and blue parallel.

Front 52

What is a classic case of gout?

Back 52

Some has cardiac bypass surgery and they wake up with a inflammed toe - sheets can't even touch it.

Front 53

What does CPPD look like on X-ray?

Back 53

CPPD crystals cause chondrocalcinosis (cartliage becomes calcified)
CPPD can cause OA of a severe and inflammatory nature in atypical joints like the true wrist and shoulder.

Front 54

What causes calcified tendons to show up on X-rays and peri-arthritis?

Back 54

Calcium hydroxyapatite crystals (HAA)