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151 Cards in this Set
- Front
- Back
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A patient comes in with acute monoarticular arthritis with swelling.
What should you do next? |
Arthrocentesis to examine the synovial fluid
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What is the content of joint fluid and what is its function?
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Conent:
- ultrafiltrate of plasma - hyaluronic acid Functions: - viscosity - nutrition - waste removal |
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Noninflammatory vs. inflamatory vs. septic: joint fluid
- color: yellow - clarity: cloudy - viscosity: low |
inflammatory
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Noninflammatory vs. inflamatory vs. septic: joint fluid
- color: variable - clarity: opaque - viscosity: low |
septic
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Noninflammatory vs. inflamatory vs. septic: joint fluid
- color: yellow - clarity: clear - viscosity: high |
non-inflammatory
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Describe the phases of OA.
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- endema of ECM, microscopic cracks, loss of chondrocytes
- fissuring and pitting: deepened cracks, chondrocyte clusters - cartilage erosion: cartilage looses bodies, subchondral cysts, local inflammation |
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T/F: Most OA are primary (idiopathic).
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T.
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What is this disease?
- eburnated surface - subchondral cytst - sclerosis of subchondral bone - osteophytes |
OA
These are secondary effects on bone. |
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What is the cause of cartilage loss in OA?
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mechanical wear and tear, genetics, aging -> abnormal chondrocyte synthesis proteinases and their inhibitors → loss of type II collagen, proteoglycans → bone erosion
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What is the hallmark of OA?
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progressive erosion of joint cartilage
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How do you treat mild OA?
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non-pharmcological:
- wt loss, muscle strengthening - physical therapy - assistive devices: cans, walkers Pharmacological: - acetaminophen - NSAIDs |
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How do you treat more severe OA?
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- steroid injection
- viscosupplents injection: high MW hyaluronic acid Last resort: surgery |
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What is this disease?
- Rheumatoid arthritis - splenomegaly - granulocytopenia |
Felty's syndrome
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What genetic susceptibility is involved in RA?
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HLA DRB1: 0401, 0404 alleles
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What is this?
IgM antibody directed agianst Fc portion of IgG. |
Rheumatic factor
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Is rheumatic factor diagnostic of RA?
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No. Many diseases are positive for RF.
But it correlates with RA's disease severity. |
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Name two diseases that have greater frequency of RF than rheumatic arthritis.
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- cryoglobulinemia
- Sjogren syndrome |
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How is rheumatic factor detected?
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Latex agglutination test
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Which disease is this?
- painful MCP, PIP, but not DIP joints |
RA
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What is the initila radiographic finding of RA?
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- soft tissue swelling
- juxta-articular osteopenia |
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If someone tells you a patient has rheumatic nodules, what disease should you think?
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RA
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What are some hand deformities in RA patients?
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- ulnar deviation at MCP
- swan neck deformties: contracture of interosseus and flexor muscles and tendons - boutonniere deformities: erosion/attenuation of lateral bands of central slip of the extensor tendon -> volar subluxation of lateral bands of extensor tendon -> flexion of PIP and hyperextension of DIP - arthritis multilans: nonfunctional joints |
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Which hand deformity is this?
- flexion at MCP, DIP - extension at PIP |
RA:
swann neck: contracture of interosseus and flexor muscles and tendons |
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Which hand deformity is this?
- flexion at PIP - extension at DIP |
RA:
Boutonniere: erosion of extensor tendon |
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What should you do if a RA patient with C1-C2 subluxation goes to surgery?
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- awake nasotracheal intubation or endoscopically-guided intubation
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Why should you worry about the head region in RA patient?
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Cervical spine deformity:
- tenosynovitis of transverse ligament which stabilizes odontoid process -> C1-C2 subluxation -> spinal cord compression |
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What are the criteria for RA diagnosis acording to American College of Rheumatology?
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S4R3
- stiffness - synovitis > 3 areas - synovitis of hand joints: MCP or PIP - symmetric arthritis - rheumatoid factor - rheumatoid nodules - radiographic changes: erosions or juxta-articular osteopenia |
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List general areas of extra-articular manifestations in RA.
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- skin: subcutaneous nodules, eccymoses
- eyes: Sjogren syndrome, scleromalacia - heart: inflammatory pericarditis, aortitis - lungs: Caplan's syndrome (coal miner's lung: multiple pulmonary nodules) - vessels: vasculitis -> ischemia |
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What is this?
- subcutaneous nodule: firm, nontender - central zone of fibrinoid necrosis surrounded by prominent rim of epithloid histiocytes - culture for organism is negative |
rheumatoid nodule
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Which joints do rheumatoid nodule often appear in?
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Pressure areas:
- elbow - occiput - sacrum |
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Cutaneous lesion of RA: ecchymoses
What is usually the cause? |
- chronic steroid use -> fragile vessels
- NSAIDs -> platelet dysfunction |
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T/F: When you see Rheumatoid nodules, you are almost certain RF is positive in these patients.
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T.
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What are some occular manifestations of RA?
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- secondary sjogren syndrome
- scleromalacia: inflammations of scleral blood vessels |
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What is this disease called?
- rheumatoid arthritis - coal-miner's lung |
Caplan's syndrome
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What drugs provide immediate relief of RA?
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- NSAIDs
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What are DMARDs?
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Disease Modifying AntiRheumatic Drugs:
- methotrexate - leflunomide - azulfidine - hydroxyhcloroquine |
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What are some classes of drugs that prevent joint destruction in RA?
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1) DMARDs
- methotrexate - leflunomide - azulfidine - hydroxyhcloroquine 2) anti-TNF-alpha - etanercept - infliximab - adalimumab 3) anti-B cell: rituximab |
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What types of cells would you see in the synovium of a RA patient?
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- CD4 T cell
- B cell - plasma cell - macrophages |
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What types of cells would you see in the subsynovium of a RA patient?
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- lymphocytes
- plamsa cells |
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Pathogenesis of RA:
What do CD4 T cells do after being activated by unknown antigens? |
1) activate B cell: make RF -> immune complex
2) activate macrophages: make IL1, TNF -> activate fibroblasts, chondrocytes, synovial cells -> release collagenases, proteinases 3) activate endothelial cells: express adhesion molecules -> inflammatory cells -> proteinases 4) express RANKL -> osteoclasts activated -> bone resorption |
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What might be a good "bridging therapy" with DMARD?
What is its side effects? |
1. low dose corticosteroid
2. osteroporosis |
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What is this disease?
- fever, rash - multiple large joint affected: knees, wrists, elbows, ankles - RF negative - ANA positive - in children |
juvenile rheumatoid arthritis
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Which type of autoimmune hypersensitivity is SLE?
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Types II, III, IV.
But type III (immune complex is the major mechanism): IC -> deposit in organs -> C3a, C5a attract neutrophils -> degrative enzymes |
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What types of antibodies are there in SLE?
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- ANA
- anti-dsDNA - anti-Sm |
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What of joint problem do you see in SLE patients?
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Jaccouds arthropathy in MCP, PIP, wrists, knees: symmetrical, non-erosive, deforming
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How are joint deformities (ulnar deviation) in SLE and RA different?
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SLE: non-erosive, deformed
RA: erosive, deformed |
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What organs are involved in SLE?
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Almost all!
- skin and mucous membrane: rashes, photosensitivity, ulcers. - joints - kidney - CNS, PNS - serosa - blood |
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What is this disease?
- malar rash - decoid rash - Jaccoud's arthropathy |
SLE
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What is this disease?
- anti-dsDNA - ANA - anti-Sm |
SLE
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What is this disease?
- anti-SSA, anti-SSB - rash resemble psoriasis: annular ring, symmetric |
Subacute cutaneous lupus
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How to treat the skin rashes manifested in SLE?
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- sun avoidance
- topical steroids - hydroxychloroquine (Plaquenil): antimalarial |
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How to treat the joint symptoms of SLE?
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- NSAIDs
- hydroxycholoquine(Plaquenil) |
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What is neonatal lupus syndrome?
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- maternal anti-SSA, anti-SSB cross placenta to the fetus
- infant develop congenital heart block |
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T/F: If an infant has neonatal lupus syndrome, the mother definately has SLE.
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F.
Mother must have antibodies, not necessarily SLE. Others include: Sjogren, subacute cutansous lupus. |
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List the diseases that involve anti-SSA, anti-SSB.
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Sjogren's syndrome
subacute cutansous lupus (SCL) |
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Name this rash:
raised, erythematous, hyperkeratosis, central scarring, along hair line. |
Discoid rash
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A person presents with lups-like symptoms, but the antibodies detected are to the histones. What is the cause of this disease?
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Drug induced lupus.
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What type of cells are used in ANA tests?
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Hep2 cells
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Describe the ANA test.
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- patient serum placed on a side of Hep2 cells
- wash - incubate with florescent labeled IgG at Fc portion - wash - look under miroscope for florescent cells. |
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T/F: Raynauds syndrome is triggered by cold temperature only.
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F.
Also by stress. |
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What is the most common hematologic manifestaton in SLE?
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anemia of chronic diseases
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A person presents with white and red fingers. He mention the red region was blue 20 min ago. His hands are very painful.
What is this? |
Raynaud's syndrome
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What is the ACR criteria for SLE diagnosis?
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- Marlar rash
- Discoid rash - photosensitivity - oral ulcers - arthritis - serositis - nephritis - neurologic disorders - hemolytic disorders - immune disoders: anti-dsDNA, anti-Sm - ANA |
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What type of hypersensitivity is this?
Sjogren syndrome |
Type IV
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What is this disease?
- oral and occular dryness - enlargement of both parotid gland |
Sjogren's syndrome
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What can cause oral dryness?
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- Sjogren's syndrome
- drugs: antihistamine,decongestants, TCA,diuretics - hypothyroidism - infiltrative disorders of salivary gland: sarcoidosis, non-Hodgkin's lymphoma |
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What disease is this?
- anti-Jo1 |
Polymyositis
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Name the three types of scleroderma and differentiate them.
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- diffuse: CREST features(hands, wrists, trunk, face) and internal organ involvement: pulmonary fibrosis and hypertension
- limited: CREST(hands), pulmonary hypertension only - localized: skin only |
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What is this disease?
- anti-scl-70 (topoisomerase) |
diffuse scleroderma
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What is this disease?
- antibody to centromere |
limited scleroderma
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What is this disease?
- morphea on skin - hard skin |
localized scleroderma
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What does CREST stand for?
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Calcinosis
Raynauds esophageal dysmotility sclerodactyly telangiectasia |
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What drugs may cause SLE?
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- hydralazine: muscle relexant, treats HTN
- procainamide: anti-arrhythmia - isoniazid: mycobacteria infeciton - many others They all induce production of antibodies to histones |
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What is the common genetic predisposition for SNSAs?
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HLA B27 (MHCI)
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Gene for MHC molecules are on chromosome ___.
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6
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What is the pathogenesis/mechanism of SNSAs?
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Molecular mimicry -> T cell response -> inflammation in joints and tendon/ligament insertions.
antigens similat to shigella, salmonella, yersinia, campylobacter, chlamydia |
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What are some common joints features of SNSA?
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- sacroilitis
- spondylitis - enthesitis |
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What are the extra-articular features of SNSA?
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- skin rash
- mucous membrane - eye: uveitis - heart: aortic insufficiency - lungs - nervous system: cauda equina, spinal fracture, C1-C2 subluxation. |
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What is this disease based on these radiographic findings?
- bilateral sacro-ilial fusion - Boxcar spine - bamboo spine - calcaneal spurs |
ankylosing spondyloarthritis
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Describe the process of sacroiliac fuison in ankylosing sclerosis.
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sacroilitis -> symmetrical sclerosis -> erosion -> fusion
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What is "Romanus lesion"?
What is the cause? |
- romanus leison (aka boxcar spine): enthesopathic erosions at disco-vertebral junction.
- ankylosing spondyloarthritis (early stages) |
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What are syndesmophytes?
What is the cause? |
syndesmophytes (aka bamboo spine): ossification of spinal ligaments and fibers of annulus fibrosis -> bridges across discs -> bamboo spine
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What is Schober's test?
When is it used? |
Schober's test: measures the difference in the distance from posterior-superior iliac spine to 15 cm above that standing straight and benddown. Postive if the difference is <4cm.
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What is the cause of calcaneal spurs?
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enthesitis of achilis tendon or calcaneal fasciitis.
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What are some extra-articular manifestations in ankylosing spondyloarthritis?
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- eyes: ancute anterior uveitis
- heart: aortic insufficiency - neurologic: cauda equina, spinal fracture, C1-C2 subluxation. - renal: amyloidosis (AA type IgA nephropathy. - lungs: restricitve defects, apical fibrosis. |
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What is the prognosis of ankylosing spondyloarthritis?
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- most able to continue working
- 1st 10 yrs predictive |
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How to treat ankylosing spondyloarthritis?
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- physical therapy
- NSAIDs - sulfasalazine - pupil dilators, occular steroids for uveitis - AVR or [ace maker for heart problems |
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What is this disease?
- arthritis - bilateral conjunctivits - urethritis or cervivitis |
Reiter's syndrome
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Who are more likely to get ankylosing spondyloarthritis?
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young adult males
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Who are more likely to get Reiter's syndrome?
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young adult males
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What is the time lag between enteric infection and the manifestation of Reiter's syndrome?
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3-4 wks
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What is this disease?
- asymmetric joint stiffness in painankles, knee, feet - low back - dysuria - red eye |
Reiter's syndrome
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What disease would you think when you see these?
- sausage toes - calcaneal spurs - achilis tendonitis - keratoderma blenorrhagia - onycholysis |
Reiter's syndrome
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What is the cause of sausage digits?
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inflammation of tendon insertions and synovium.
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In which disease do you see these extra-articular manifestations?
- oral ulcers - keratoderma blenorrhagia - onycholysis - balanitis circinata - heart block, aortitis |
Reiter's syndrome
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How to treat Reiter's syndrome?
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- NSAIDs
- physical therapy - intraarticular steroid injections - sulfasalazine - topical steroid for keratoderma blenorrhagia - treat underlying infections |
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What are some extra-articular manifestions seen in Reiter's syndrome?
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- oral ulcers
- keratoderma blenorrhagia - onycholysis - balanitis circinata - heart block, aortitis |
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What is this disease?
- skin rash - DIP sausage fingers - pencil-in-cup deformity on x-ray - onycholysis |
psoriatic arthritis
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What are the five subgroups of psoriatic arthritis?
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1) asymptomatic: Reiter's like
2) DIP disease 3) arthritis mutilans: pencil-in-cup, telescoping digits, opera-glass hands 4) seronegative polyarthritis 5) sacroilitis: most seen with 4), least seen with 2) |
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How to treat psoriatic arthritis?
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- same as Reiter's
- methotrexate for skin and joint in some patients. |
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What are some skin manifestations seen in arthritis assciated with IBD?
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- erythema nodosum: inflammation of fat cells under the skin
- pyoderma gangrenosum - erythema multiforme: deposition of immune complex ( mostly IgM ) in the superficial microvasculature of the skin and oral mucosa |
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What joint problems are seen in arthritis accosiated with IBD?
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- symmetrical sacroilitis
- spondylitis - little joint destruction |
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What is this called?
Aggregates of crystals surrounded by giant cells, macrophages, lymphocytes. |
Tophus
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How long does hyperuricemia take to deposit in soft tissue in gout?
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20-30 years
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What is the difference in the age onset of acute gouty arthritis between men and women?
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Men: in the 50s
women: 70s |
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When dose hyperuricemia develop in men and women if they do not have enzyme defect?
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men: at puberty
women: at menopause (estrogen is uricosuric) |
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If someone develops acute gouty arthritis at age 25, what can you say about the cause of hyperuricemia? (primary enzyme defect or secondary cause)
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possible primary enzyme defect:
- HGPRT deficiency (X-linked) - PRPP overactivity (X-linked) - G6PD deficiency (AR) |
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List the uricoretentive drugs that may precipitate gout attacks.
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- Nictotinic acid
- Loop diuretics - Thiazide - PZA: pyrazinamide - Ethambutol - Aspirin: low dose - Cyclosporin - Ethanol |
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Besides uricoretentive drugs, what other medications may precipitate gout attacks?
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- heparin
- allopurinol - lead |
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What stage of gout is this?
- hyperuricemia - no attacks |
Asymptomatic stage
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What stage of gout is this?
- monoarticular(1st MTP joint) gout |
acute gouty arthritis stage
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What stage of gout is this?
- negatively birefrigent crystals found in joint fluid but not intracellularly. - no active gout attack - history of gout attacks before |
intercritical gout stage
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What stage of gout is this?
- juxta-articular bone erosion - olecranon bursitis - pannus - ankylosis - tophi |
chronic tophaceous gout stage
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Which gout complication is this?
- crystals deposit in renal medullary interstitium - usually associated with lead toxicity |
chronic gouty nephropathy
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Which gout complication is this?
- crystals deposit in renal tubules |
acute urate nephropathy: these people do not develop acute gouty arthritis
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Which gout complication is this?
- stones in the urine |
uric acid renal caliculi
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Complications in gout involve which two organs?
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Kidney: acute, chronic gouty nephropathy
Heart: athrosclerosis, HTN |
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What treatment can be used during intercritical gout stage?
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- allopurinol: xathine oxidase inhibitor, increase urate excretion.
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What drugs can be used during acute gout attacks?
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- colchicine
- indocine |
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Do you see joint space narrowing on x-ray in gout patients?
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only in late stages
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What are some secondary causes of gout?
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- medication: uricoretentive(Never Loose The PEACE), heparin, allopurinol
- leukemia: high nucleic acid turn over - chronic renal disease |
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What is this disease?
- hyperuricemia - mental retadation - self mutilation |
Lesch-Nyhan syndrome: X-linked complete HGPRT deficiency.
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What are the three variants of CPPD(calcium pyrophosphate deposition disease)?
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- sporadic
- hereditary, AD: ANKH gene (transmembrane inorganic pytophosphate transport channel) - secondary: 6 Hs, wilson's disease, ochronosis, diabetes. |
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What are some secondary causes of CPPD?
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think Hs.
- hypothyroidism - hyperparathyroidism - hypophosphatasia: low serum alkaline phosphatase - hemochromatosis - hypomagnesemia - hypocalciruric hypercalcemia - wilson's disease - ochronosis - diabetes |
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What is this disease?
- postively birefringent cristals, rhomboid shaped - little inflammatory response |
CPPD
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What is being calcified in the joints in CPPD patients?
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cartilage (chondrocalcinosis)
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What size(s) of vessels are affected in the following vasculitis?
- Giant cell arteritis - Takayasu's arteritis - isolated angitis of CNS |
large/medium
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What size(s) of vessels are affected in the following vasculitis?
- polyarthritis nodosa - microscopic polyarthritis - Wegener's glanulomatosis - Churg-Stauss syndrome |
medium/small
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What size(s) of vessels are affected in the following vasculitis?
- Henoch-scholein pupura - hypersensitivity vasculitis - essential mixed cryoglobulinemia |
small
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Name some vasculitis that are ANCA(anti-neutrophil cytoplasmic antibody) associated.
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- microscopic polyarthritis
- Wegener's granulomatosis - Churg-Strauss syndrome |
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These symptoms are common to what type of joint diseases?
- fever, night sweats, weight loss - rashes - arthralgia - elevated ESR |
vasculitis
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What is this disease?
- history of asthma, allergic rhinits - eosinophila on WBC - pulmonary infiltrate - GI ischemia |
Churg-Strauss vasculitis (small-medium vessels)
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What is this disease?
- fever, weight loss - livedo reticularis - subcutaneous nodule - mesenteric vascularis - mononeuritis multiplex -> wrist drop, foot drop - necrotizing glomerulonephritis (proteinuria, RBC casts) |
polyarthritis nodosa (small-medium vessels)
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What are causes of livedo reticularis?
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- polyarthritis nodosa (small-medium vessels)
- septic shock - severe dehydration |
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What is this disease?
- unilateral headache - scalp pain - night sweats - visual disturbance |
Giant cell arteritis (tempotal arteritis)
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How do you treat giant cell arteritis (tempotal arteritis)?
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high dose prednisone
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What is this disease?
- saddle nose deformity - serous otitis media - multiple nodular densities in the lung - glomerulonephritis |
Wegener's granulocatosis (think ELK: ENT, Lung, Kidney)
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What will vessel biopsy show for Wegener's granulomatosis?
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- granulomas
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What is this disease?
- skin rash in lower extremity, palpable pupura - abdominal pain - hematuria - prior respiratory infection |
Henoch-schonlein purpura (small vessels): usually in children
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What is this disease?
- cyst under the skin due to myxoid degeration of connective tissue - no true cellular lining - common around wrists - |
ganglion cyst (benign joint tumor)
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What is this disease?
- synovium: tangled mat with red-brown folds - finger-like projections and nodules - affect one or more joints diffusely |
Pigmented villonodular synovitis (PVNS): due to clonal proliferations of synoviocytes.
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What is this disease?
- painless, discrete nodule attached to tendon sheath of wrists - slow growing - well circumscribed |
Giant cell tumor of tendon sheath: clonal proliferation of synoviocytes.
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What is this disease?
- older kids, adults - sudden onset of hot, red, painful joint - limited ROM - fever, high ESD, leukocytosis |
supprative infectious arthritis: S. aureus
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What is the causative organism in supprative infectious athritis for this age group?
- under age 2 |
H. influenza
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What is the causative organism in supprative infectious athritis for this age group?
- older kids, adults |
S. aureus
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What is the causative organism in supprative infectious athritis for this age group?
- adolescents, young adults |
gonococcal
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What is the causative organism in supprative infectious athritis for this group?
- sickle cell anemia |
salmonella
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What is this disease?
- insidious, gradually worsening monoarticular pain - pannus synovium erode into bone (hip>knee>ankle) - fibrous ankylosis - obliteration of joint space - confluent granuloma with central caseating necrosis |
Tuberculous infectious arthritis
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What is this disease?
- migratory, remitting joint pain: knee>shoulder>elbow>ankles - chronic papillary synovitis - synoviocyte hyperplasia - onion skin thickening of arterial walls |
Lyme disease
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What is the cause of arthritis in lyme disease? which organism and which animal?
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- antigen OspA crossreact with proteins in the joint.
- borrelia burgdoferi - ixodes ricinus |
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What are some viral causes of infectious arthritis?
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- parvovirus B19
- rubella - hepatitis C |
