Podiatric Pearls - Cancer/tumor/rheumatology

Front 1

teenage male with night pain relieved by aspirin

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osteoid osteoma

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exapansile, oval, lucent lesion in prox phalanx of 35 yo female

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enchondroma

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large lesion: malignant or benign

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malignant

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onion skin in periosteum

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ewings sarcoma

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why are malignant bone tumors unlike to be expansile (cortex stays intact)

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they grow too fast

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ground glass tumor matriz

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fibrous dysplasia

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why do pathological fx and ricketts like bowing occur in fibrous dysplasia pts

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-normal osseous tissue is replaced by weak fibrous tissue

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intense periosteal reactions of malignant tumors

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-hair on end
-sunburst
-codmans triangle
-onion skin

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three patterns of osseous destruction in order from least agressive to most

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-geographic (benign) - smooth shape of lesion
-moth eaten (malig)
-permeative (malig)

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if a ST mass is assoc with osseous tumor; this indicates the tendency for the tumor to be bengin or malig

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malignant

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to prevent recurrence of osteoid osteoma, what must the surgeon do

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-excise the central lucent nidus

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can enchondroma convert to a malig lesion

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yes, chondrosarcoma

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disease manifested by multiple enchondromas

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ollier's dz

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mafuccis is characterized by

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multiple endchondromas and hemangiomas

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name 4 benign lesions that can convert to malig one

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-osteochondroma
-enchondroma
-giant cell
-fibrous dysplasia
- the two most commons, gct, and fibrous dysplasia

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list ten commonalities in clinical/xray/lab presentaton of osteogenic sarcoma and OM

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1. sick pt
2. calor at site
3. erythema at site
4. tenderness at site
5. edema at site
6. fever
7. bone destruction on xray
8. codmans triangle
9. pos bone scan
10. inc WBC

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pathological fracture of a UBC

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fallen fragment sign

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metatstatic lesions found in LE are from what primary tumor

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lung

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3 findings of McCune-Albright

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-fibrous dysplasia
-cafe au lait spots
-precocious puberty

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malignant bone tumor found in dispahysis

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ewings sarcoma

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why is osteoid osteoma pain worse at night

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-well vascularized central nidus
-night production of prostaglandins

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synovial chondromatosis

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-benign condition in which metaplasia of synovial tissue results in the prodcution of intra-articular loose bodies

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monostotic

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one bone is involved with tumors

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polyostotic

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multiple bones have tumors

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shepards crook deformity

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-fibrous dysplasia leads to varus deformity of femur

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MC malig bone tumor

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multiple myeloma

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MC benign bone tumor

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osteochondroma

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another name for primary non-hodgkins lymphoma (NHL)

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reticulum sarcoma of the bone

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multiple myeloma is a malig tumor of what

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plasma cells

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Bart Pumphrey Syndrome

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-knuckle pads on toes
-leukonychia
-impaired hearing

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periungual fibromas are assoc with

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tuberous sclerosis

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giant cell tumor involving the joint space

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PVNS

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MC malignant ST tumor in pts 0-25 yo

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rhabdomyosarcoma

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four types of kaposis sarcoma

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-classic
-african imuno-supressed pt
-AIDS related

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"rodent ulcer" is assoc with

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basal cell carcinoma

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most agressive: SCC or basal

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Squamous

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Bowen's dz

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SCC in situ

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what type of melanoma is most common in blacks and on the soles of the feet

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acral lentiginous melanoma

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what type of melanoma is most agressive: nodular or superficial spreading

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nodular

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two classification systems for melanoma

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Clarks: level of invasion
Breslows: tumor thickness

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mycosis fungoides

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cutaneous T cell lymphoma

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in asessing pigmented lesions; what does ABCDE refer to

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A - asymmetry
B - border
C - color
D - diameter
E - elevation

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what pre - existing condition can result in osteosarcoma

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pagets disease

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what malig tumor are pts with olliers disease at risk for

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chondrosarcoma

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which type of leukemia predominates in kids, in adults?

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kids - ALL (acute)
adults - CLL (chronic)

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diagnosis for lesion overlying the IPJ that appears to be a ganglion of the skin

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mucoid cyst (myxoid cyst)

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gender most affcted by plantar fibromatosis

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male

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be careful of what nerve when removing the plantar fascia for multiple plantar fibromatosis

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MPN

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neurofibroma vs neurilemmoma

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-neurofibroma; axons course throuh the tumor
-neurilemmoma; axons are pushed to the side

Front 50

pyogenic granuloma of the nailbed is often confused with what

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proud flesh
-pyogenic granuloma is a vascular lesion of skin, cauterize with silver nitrate

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Popoff tumor

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-small, blue red papules

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list the 4 terms to describe a bone tumors position

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central
eccentric
cortical
peristeal

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three benign tumors with soap bubble matrix

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-ABC
-Giant cell tumor
-chondromyxoid fibroma

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chicken wire calcification of a bone tumor

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chondroblastoma

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two most common bones of the foot affected by primary bone tumors

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-calcaneus
-metatarsals

Front 56

what can chronic ulcers develop into

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SCC (Marjolins ulcers)

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systemic sclerosis (scleroderma) is divided into two subsets: cutaneous systemic and limited cutaneous systemic; what is the limited cutaneous aka

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CREST variant

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what does CREST of limited cutaneous systemic sclerosis

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C - calcinosis
R- raynauds
E -esophagitis
S - sclerodactyly
T - telangiectasias

Front 59

observation of capillary dilation, capillary destruction, capillary hemorrhage in the nailfold; what should you suspect

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systemic sclerosis

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in what % does psoriatic arthritis precede psoriatic skin lesions

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15-20%

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describe psoriasis in the nails

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-pitting
-ridging
-oil droplet discoloration
-subungual hyperkeratosis
-onycholysis

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sero negative arthritides (non-Rh)

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CRAP
-crohns
-reiters
-ankylosing spondylitis
-psoriatic

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plaques of psoriasis contain large amts of what bacteria

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strept (group A)

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criteria for RA

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- morning stiffness + 6 wks
-arthritis of >3 joints for +6 wks
-arthritis of hands + 6 wks
-symmetric arthritis + 6 wks
-RA nodules
-serum Rh factor
-radiographic changes
-pt must have 4 of the 7 criteria

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DMARD and examples

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-disease modifying anti-rheumatic drug
-ex methotrexate and plaquenil
-meant to slow the progression of joint erosion

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most common cause of septic arthritis in immunocompetant pts under 40 yo

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disseminated gonococcal infection

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classic triad seen in disseminated gonococcal infection

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-migratory tenosynovitis
-vesiculopustular skin lesions
-oligoarthralgia
---this triad only occurs in 50% of pts

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list the characteristics of normal synovial fluid (color, compostion, etc)

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-clear
-colorless to straw
-viscous
-less then 200 WBC/mm
-no bacteria, no crystals
-glucose equal to that of the blood

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characteristics of inflammatory joint fluid

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-translucent to opaque
-yellow to yellow green
->2000 WBC/mm of which >50% are PMN
-may contain bacteria or crystals depending on etiology

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pannus

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proliferating synovium seen in RA

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complication seen in cervical spin in RA pts

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-erosion of the cervical vertebra leads to subluxation and spinal cord compression

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most common lesion of calc in RA pts

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-retrocalcaneal bursitis

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criteria for classification of SLE (pt must have 4 of 11 criteria)

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-malar rash
-discoid rash
-photosensitivity
-oral or nasopharyngeal ulcers
-arthritis
-pleuritis or pericarditis
-renal dz
-neurological dz
-hematological disorder (anemia, leukopenia etc)
-immunologic disorder
-anti nuclear antibody (ana)

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which drug is the most frequent cause of drug induced Lupus

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procainamide

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what is the std screening test for SLE

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-ANA test (anti nuclear antibody)

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Morphea

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-scleroderma which begins with one or more areas of red/purple discoloration - which evolve and become sclerotic and waxy

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Churg - Strauss

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-systemic vasculitis

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Henoch- Schonlein Purpura

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-first manifestation is palpable purpura of the LE
- anaphalactoid or allergic purpura
-in kids and young adults

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goodpastures syndrome

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glomerulonephritis and pulmonary hemorrhage

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cryoglobins

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-immunoglobin molecules that have the unusual property of reversibly precipitating at low temps

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clinical manifestations of cryoglobulinemia

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-vascular occlusive problems such as raynauds phenom, cutaneous ulcers, gangrene of fingers and toes, cold induced uticaria, purpura, nephritis, neuropathy

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what is sicca complex

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-diminished salivary gland and lacrimal secretion

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triad of Sjorgens syndrome

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-dry eyes
-dry mouth
-RA, SLE, systemic sclerosis or polymyositis

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lab test used to measure lacrimal gland secretion

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Schirmer filter paper test

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Lyme dz: bacteria and carrier

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Spirochete Borrelia burgdorferi transmited by Ixodes tick

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manifestations of lyme dz

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-skin rash
-erythema chronicum migrans

Front 87

rhematic dz characterized by progressive loss of articular cartilage and by reactive changes at the margins of hte joints and in subchondral bone

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osteoarthritis

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OA of the distal IPJ of hand

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Heberdens nodes

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stages of charcot

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1. precollapse
2. collapse
3. healing
4. arrest

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what is the most imp differential of an acute charcot joint

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septic arthritis

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how often is septic arthritis monoarticular

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90%

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MC bacteria of non gonococcal septic arthritis

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staph aureus and staph epidermis

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MC form of granulomatous arthritis

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joint sepsis with mycobacterium tuberculosis

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Lesch-Nyhan syndrome

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-inherited case of overproduction gout
-characterized by hyperuricemia, mental retardation. self mutilation, choreathetosis, uric acid nephrolithiasis

Front 95

Lesch Nyhan results from the deficiency of what enzyme

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Hypoxanthine guanine phosphoribosyl transferase (HGPRT)

Front 96

what joints are MC involved in pseudo gout

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Knee - 58%
wrist - 33%
ankle joint

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MC foot joint in pseudo gout

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TN

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does the finding of CPPD crystals in synovial fluid exclude the dx of gout, RA or infection

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no they can co exist

Front 99

gottrens papules and gottrens signs are pathognomonic for what inflammatory myopathy

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Dermatomyositis

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gottrens papules

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-flat purple papules over the dorsal surface of IPJ of hands

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Gottrens sign

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red scaly or smooth patches over the IPJ, MPJ, elbows, knees or medial malleoli

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clinical and laboratory hallmarks of polymyositis and dermatomyositis

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-proximal muscle limb and neck weakness/pain
-elevated CPK, alsolase, lactic dehydrogenase and the transaminases
-auto antibodies present

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Polymyalgia Rheumatica symptoms

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-aching and stiffness in the neck and shoulders
-malaise, low grade fever and weight loss
-elevated sed rate

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synonyms for Giant cell arteritis

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-temporal arteritis
-cranial artertitis
-granulomatous arteritis

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dreaded complication of ginat cell arteritis

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blindness due to narrowing of hte opthalmic or ciliary arteries

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treatment for polymyalgia rheumatica and giant cell arteritis

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systemic steroids

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tenderness or enlargement of invovled portions of the arteries in the head and neck

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temporal arteritis

Front 108

unexplained prtoteinuria, peripheral neuropathy, enlarged tongue and heart, intestinal malabsorption, carpal tunnel, orthostatic hypotension

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primary amylodosis

Front 109

what is different in the presentation of ankylosing splondylitis in men and women

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-men have arhtritis of lumbar spine
-women have more peripheral joint manifestations (MC hips and shoulders)

Front 110

why is reiters syndrome considered a reactive disease

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bc it usually follows an infectious episode either GU or GI

Front 111

Reiters triad

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-urethritis
-conjuncitivitis
-arhtritis

Front 112

cutaneous manifestations of reiters

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-circinate balanitis
-keratoderma blennorrhagicum
-oral ulcers

Front 113

MC location of keratoderma blennorrhagicum

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soles of the fet (looks like pustular psoriasis)

Front 114

Lovers Heel

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Reiters syndrome

Front 115

what percentage of general population is HLA-B27 postive

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6%

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what % of those with bowel dz will develop peripheral arthritis

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15-20%

Front 117

carditis, acute polyarthritis, chorea, erythema marginatum, subcutaneous nodules

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acute rheumatic fever

Front 118

MC etiology of acute rheumatic fever

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beta-hemolytic strept throat

Front 119

Lofgrens syndrome

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-form of sarcodosis
-triad of bilateral hilar adenopathy, erythema nodosum, arthritis

Front 120

Fibrositis

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-muscle pain, stiffness, fatigue, discrete tender points

Front 121

clubbing of the digits with periostitis of long bones

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Hypertrophic osteoarthropathy (HOA)
-assoc with bronchogenic carcinoma

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DISH

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-diffuse idiopathic skeletal hyperostosis
-calcification and ossification along the ant lat aspect of at least 4 verterbral bodies
-preservation of IV disc height
-absence of ankylosis of sacroiliac and apophyseal joints

Front 123

Schober test

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tests the restriction of lumbar motion in pts with spondylitis
-two midline points seperated by 10 cm are placed on the skin of the lower back while standing (PSIS and 10 cm above)
-when pt bends over the points should now seperate at least 5 cm, to a total distance of 16-22 cm

Front 124

what is the name of PVNS when it is manifested an an isolated, discrete lesion involving the tendon sheath

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Giant cell tumor of tendon sheath