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131 Cards in this Set
- Front
- Back
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What are the 3 arthritic emergencies?
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septic arthritis
acute crystal induced arthritis fractures |
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what are the inflammatory causes of rheumatic dz?
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gout
RA SLE |
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what are the noninflammatory causes of rheumatic pain?
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OA
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Which structres are involved in articular dz??
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synovium
synovial fluid articular cartilage intraarticular ligaments joint capsule juxtarticular bone |
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how is articular pain described?
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deep or diffuse pain
limited active or passive ROM swelling (synovial fluid/capsule inflamed) creptitation lax joint (immobility) locking deformity |
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how is nonarticular pain described?
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painful on active, but not passive ROM
point tenderness remote from joint |
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what structures are involved in nonarticular pain?
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extrarticular ligaments
tendons bursae muscle fascia bone nerve skin |
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4 local cardinal signs of inflammtory rheumatic dz?
Systemic signs? |
erythema
warmth pain swelling morning stiffness fatigue fever weight loss |
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How long is the morning stiffness in RA? OA?
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RA >30 mins
OA <30 mins |
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Presentation of noninflammatory rheumatic dz?
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no erythema, warmth, pain, swelling
Brief period stiffness increased by activity |
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causes of noninflammatory rheumatic dz?
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OA
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Which rheumatic dzs have acute onset?
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gout and septic arthritis
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which rheumatic dzs have indolent course?
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RA
OA FM |
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Duration of acute rheumatic dz?
Duration of chronic? |
<6 wks
>6 wks |
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Which rheumatic dzs have migratory presentation?
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Rheumatic fever
Gonococcal dz |
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Which rheumatic dzs have additive arthralgia?
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RA
Reiters |
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Which class of drugs can --> gout?
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thiazide diuretics
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How many joints are involved if arthritis is oligoarticular (pauciarticular)
Polyarticular? |
2-4
>4 |
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Which rheumatic dz is symmetric?
Asymmetric? Lower extremity arthritis? Axial skeleton? Weight bearing? |
RA
Gout Reiter's (see foot, heal, knee swelling), gout (big toes) OA, AS OA (knee, hip) |
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What is the profile of a noninflammatory synovial fluid aspiration?
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clear
viscous WBC <2000 |
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What is the profile of an inflammatory synovial fluid aspiration?
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turbid
yellow WBC 2000-50,000 reduced viscosity |
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What is the profile of an infectious synovial fluid aspiration?
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opaque
purulent WBC >50,000 Low viscosity |
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What is the profile of a hemorrhagic synovial fluid aspiration?
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hemarthrosis
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What is conventional radiology used to dx in rheum dz?
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soft tissue swelling
demineralization calcification joint space narrowing erosion bony ankylosis osteophytes sclerosis periositis subchondral cysts |
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What is US used to dx in rheum dz?
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synovial cyst
rotator cuff tear tendon injury |
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What is radionuclide scintigraphy used to dx in rheum dz?
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infection
PAget's disease |
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What is CT used to dx in rheum dz?
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herniated disc
sacroilitis spinal stenosis trauma |
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What is MRI used to dx in rheum dz?
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ABN
osteomyelitis intrarticuar dz herniated disk synovitis muscle dz soft tissue dz |
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general use of ct?
US? MRI? |
bony tissues
to examine organs shows detail in soft tissue |
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Presentation of arthritis caused by parvovirus
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joing pain 1-6 days after rash
symmetric arthralgia of many joints RF can be present |
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How does non-gonococcal bacterial artheritis present
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few joints involved
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how does HIV related arthritis present?
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few joints involved
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What role does TGF-beta play in scleroderma?
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TGFb activates CTGF --> overproduction of scar tissue and fibrosis
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What role does endothelin play in scleroderma?
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normally plays a role in monitoring BV tone and water balance
BUT, in SSc, it is over-expressed and --> fibroblast activation --> scarring and inflammation EVERYWHERE! |
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What changes are seen in BV in SSc?
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overmultiplication of ECs (only supposed to be 1 layer thick)
Adventitia is thickened --> thick BV --> pulm HTN Small BVs are "gone" from kidneys |
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How can the loss of renal BV be reversed in SSc?
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ACE I
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What association with anti-Topo I is there in SSc?
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diffuse skin dz
pulm fibrosis |
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What association with anti-centromere AB is there in SSc?
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limited skin dz
pulm HTN |
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What association with anti-RNP
(RNA polymerase) is there in SSc? |
scloroderma overlap w/ SLE, polymysoitis, MCTD
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Basis for renal dz in SSc?
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elevated AII/renin activity --> accelerated HTN
Renal crisis results: low RBF --> increased RAS --> vasoconstriction --> renal failure |
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What are tendon friction rubs?
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inflammation of tendon that you hear/feel a “leathery rub” of the tendon
Pathoneumonic for SSc |
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Risk factors for SSc renal dz?
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new cardiac events
new anemia rapid skin progression tendon friction rub |
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GI complications of SSc?
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GERD (aspiration, Barret''s, d/o peristalsis, strictures --> dysphagia)
GAVE Intestinal dysmotility |
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What is GAVE?
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watermelon stomach
-->ectatic BV in submucosa of antrum --> UGI bleed |
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Treatment of GI dz in SSc?
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PPI
motility agents AB (to help with bacterial overgrowth) Fiber Evaluate malabsorption |
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Muscoloskeletal d/o in SSc?
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inflammation
pain loss fo hand fxn (contractures) muscle weakness calcinosis (can be removed) |
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Inflammatory/Immunologic syndromes in SSc?
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alveolitis
myositis tendonitis synovitis |
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Lung dz in SSc?
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alveoilitis
interstitial fibrosis recurrent aspiration (from esoph dz) pulm vasculopathy |
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which aspect of the lung dz in Ssc is treatable?
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alveolitis (appears as ground glass)
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What is pulmonary vasculopathy?
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arterioles to lungs are filled with scar tissue, so only small lumen
alveoli get filled with scar tissue |
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What is microchimerism and how does it relate to SSc?
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the idea that foreign DNA can --> SSC
In women, there is persistent fetal cells in maternal circulation GVHD can also cause similar sx In men with teh dz, there is abnormal DNA from mom |
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Environmental factors that relate to SSc?
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CMV
solvens and silica |
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Criteria for worse prog in SSc?
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recent increase in total skin score
multiple tendon friction rubs anti-topo I, RNAP-I and III (= kidney dz) Elevated soluble IL-2 receptor Inflammatory blood tests anemia |
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Ways to prevent fibrosis in SSc?
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halofriginone
TGF-beta trapping interferon CTGF trapping |
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What kind of lung and renal involvemet are seen in Sjogrens?
Other random clinical features? |
interstitial pneumonitis
pulm fibrosis RTA hematuria interstitial nephritis Autoimmune liver/pancreatitis peripheral neuropathy myelitis dementia polyarthritis, myopathy, chronic fatigue |
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Differential Dx of Sjogrens
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HIV- diffuse infiltration of lymphocytic syndrome
Infection Infiltrative dz (sarcoid, amyloidosis, hemochromatosis) T cell leukemia MS Anti-cholinergic meds |
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Which is the msot common cause of dry eyes/mouth
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anti-cholinergic drugs and anti-HTN meds
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What is a bursae?
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closed sac found in places to ease the gliding of tissues
Doesn't usually comunicate with joint (although 40% of the time in the popliteal bursa it does) |
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Where is septic bursitis normally found?
What is it infected with? Treatment? |
olecrenon or prepatellar
Staph ABs |
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Causes of nonseptic bursitis?
Tx? |
overuse
heat, reset, NSAIDS, steroid injections |
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What is a common cause of shoulder pain?
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subacromial nonseptic bursitis
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differntial for shoulder pain?
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rotator cuff tear
shoulder joint pathology subacromial nonseptic bursitis |
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Clinical presentaiton of trochanteric bursitis?
Etiology? |
lateral thigh pain (women>men)
from overuse, leg-length discrepancy which increases tension of glut max on IT band |
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Tx for tendonitis?
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rest
heat NSAIDS local steroid injection PT/OT surgery for refractory cases |
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Pathogenesis of tendonitis?
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Inflamed tendon sheaths
Overuse with microscopic tearing of tendon Tendon compression by osteophyte (in rotator cuff) |
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2 examples of tendonitis and their causes?
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Lateral epicondylitis (overuse)
Achilles tendinitis (inflammation), seen in Reiter's syndrome, psoriatic, or sero - spondylarthropathy |
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Diagnostic criteria for FM?
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widespread pain/tenderness at muscle/tendon insertion (in 11/18 spots)
>3mo |
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associations with FM?
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widespread pain
stage IV sleep disruption major depression incresaed migraines IBS panic d/o |
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Differential for FM?
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PMR
thyrodi dz myopathy SLE RA |
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What are the different SpAs?
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Ankylosing spondylitis
Reactive arthritis (Reiters) Psoriatic Enteropathic arthritis (Crohn's, UC) |
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Epidemiology of SpAs
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Seronegative (no RF or other AB)
Family h/o SpA may or may not be present 1-2% prevelence |
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Genetic links of SpAs
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HLA B27
15% of ppl with HLA B27 get SpA |
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What are the theories surrounding SpAs wiht HLA B27
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B27 might act as a receptor for a virus
Plays a rols in pathogenesis by presentation of microbial peptides |
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Environmental link with SpAs
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may follow infection of GU or GI tract
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What infection may be related to SpAs
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chlamydia trachomatis
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Features common to all SpAs
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sacroiliitis (SI joint inflam)
spondylitis (spine inflam) Enthesitis (inflam at site of insertion of tendons to bone) Extra-articular manifrestations |
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what are some of the extra-articular manifestations of SpAs?
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Uveitis (inflammation of anterior chamber of the eye, esp if B27+, can --> blindness)
Peripheral synovitis (sausage digits) Skin dz (psoriasis,e tC) |
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Clinical presentation of ASp
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low back pain (insidious, lasting more than 3 months and decreases with exercise)
si/sx of sacroiliitis |
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HLA B27 assoc with ASp
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>90% have it
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extra-artic manifestations of ASp
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uveitis
pulmonary fibrosis aortitis |
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What is seen on Xray of ASp
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Sacroiliitis
bamboo spine |
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Classic triad in reiter's syndrome?
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urethritis
conjunctivitis skin probs |
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etiology of reiters?>
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follows GI or GU infections (or other infections)
Chlamydia Salmonella Shigella Campylobacter Yersinia HIV |
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Relapse rate of reiters?
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15%
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% of pts w psoriasis who get psoriatic arthritis?
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5-8%
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Dx of psoriatic arth
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inflamm arthritis and psoriasis
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what are the possible clinicla presentation of psoriatic arthritis
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DIP involvement with nail pitting
asymmetrical oligoarthropathy symmetrical polyarthritis arthritis mutilans spondyloarthropathy |
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Features of eneteropathic arthritis
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10-25% of pts with CD or UC
noneroisve nad oligoarticular spondylitis runs independent course compared to bowel dz, but extra articular manifestations may parallel dz) |
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Use of radiographic damage to treat SpA
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doesn't prevent progression
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effective tx for SpA
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Etanercept slows progression of erosions in psoriatic arthritis
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Tx for ASp
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NSAIDS
MTX or sulfasalazine oral corticosteroids anti-TNF |
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Tx for reiters
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AB to tx infection (if present)
NSAIDS |
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Tx for psoriatic arthritis
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NSAIDS
MTX steroids anti-TNF topical or systemic tx for skin dz |
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Tx for enteropathic arthritis
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NSAIDS
tsx of IBD (steroids) |
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Gottrons papules
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on knuckles
in idiopathic inflam myop |
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heliotrope facial rash
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purple skin rash on face of pts iwht idiopathic inflam myopathies
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Signs of idiopathic inflamm myopathies
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Gottrons papules
heliotrope facial rash vasculitis subQ calcifications livedo ulceration photosensitivity Nail BV cchanges periungual telangiectasias mucosal ulcers farmer's hand |
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examples of idiopathic inflam myopathies
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primary idiopathic polymyositis
primary idiopathic dermatomyositis PM/DM assoc w malig Juvinile PM/DM PM/DM assoc with autoimmue CT dz Inclusion body myositis |
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phsyical sings in idiopathic inflam myo
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no abnormalities on exam
easy fatiguability \ decreased exercise tolerance minimal atrophy of 1+ muscle grp waddling gait can't climb stairs w/o arm support accentuated lrodosis can't walk w/o assistance |
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what si the pattern of weakness seen in idiopathic myo
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symmetrica
proximal him > shoulder distal muscles only in advanced EYES NEVER INVOLVED rare facial weakness muscle tenderness and wasting and contractures |
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pattern of weakness in IBM (inclusion body myositis)
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focal
distal asymmetric |
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Extramuscular manifestations of PM/DM
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Pulm (resp muscle weakness, aspiration, interstitial lung dz, pulm htn and vasculitis)
Cardiac (heart block, arrhythmias, CMP) GI (esoph, stomach, small or large intestine dysmotitliyt) arhttirist (not erosive, symmetrical, small joints) |
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Features of DM
Age Associated condition overlap systemic malignant Familial |
Adult and child
SSc and myositis infrequent probably no |
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Features of PM
Age Associated condition overlap malignant Familial systemic |
>18
Yes no no yes |
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Features of IBM
Age Associated condition overlap malignant Familial Systemic |
>50
Yes <15% n o yes, some infrequent |
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which idiopathic myo is systemic?
malignant? familial |
PM
DM IBM |
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lab abnormalities assoc with idiopathic myo
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elevated serum enzymes from muscle
(CK, aldolase, AST, ALT, ADH) |
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Typical EMG features of PM/DM?
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low amplitude, short duration AP
polyphasic potential asynchronous firing of fibers) increased insertional activity and fibrillation (damage to nerve endings and motor plates) complex repetitive discharge (result of inflammatory damage to sarcolemma) |
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which ABs are specific to myositis?
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anti-synthetase
signal recognition particle (SRP) helicase |
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which AB are associated wiht myoissitis?
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RNP
Fer Mas KJ PM-sci Ku ML |
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what does the helicase AB do?
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it's specific for rash and acute presentation
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which is the best AB to screen for in myositis?
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Jo1 (an anti-synthetase), also have lung involvement
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whihc AB for myositis syndromes has moderate course?
Poor prognosis? Good prognosis |
Anti-Jo
Anti-SRP Anti-Mi2 |
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what is the gold standard for myositis dx?
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muscle biopsy of a weak muscle that hasnt' been injected with EMG
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What will muscle biopsy show in myositis?
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varied stages of necrosis and regeneration
inflamm infiltrate, focal endomsial, perivascular |
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what inflammatory cells are found in PM muscle biopsy?
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T cell (CD8)
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what inflammatory cells are found in DM muscle biopsy?
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T4 and B cell
Ig complexes complement |
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what things are seen in childhood DM muscle biopsy?
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vasculitis
calcification lipodystrophy |
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what inflammatory cells are found in IBM muscle biopsy?
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minimal infiltrate
rimmed vacuoles amyloid |
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Pathogenesis of DM
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mediated by humoral factors
could be immune complex mediated or AB mediated against a vascular endothelial component Marked capillary loss with deposition of complement MAC |
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PAthogenesis of PM
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mediated by autoagressive T cells
CD 8+ cells predominatte in endomysium |
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Pathology of myositis?
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inflammation
size changes necrosis degeneration adn regen phago vasculitis |
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Suggestion of autoimmune basis of myositis?
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T cell mediated myocytotoxicity
auto-AB presence response to immunotx |
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What is diff dx for myositis?
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infection
drug induced myopathy endocrine/metabolic neruomuscular d/o |
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what are the different drgs that can induce myositis?
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antiarhtritic
lipid lowering (incresaes CPK) cocaine addict |
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Endo/metabolic d/o that resemble myositis?
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thyroid/parathyroid dz
Cushings |
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treatment of myositis
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muslce rest, passive ROM in acute phase
Recovery is gradual, passive and active motion |
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what are some other conditions in differential of myositis?
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PMR- polymyalgia rheumatica
Giant cell myositis |
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what is PMR?
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proximal muslce pain
periarticular pain morning stiffness |
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Treatment for myositis
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corticosteroids = gold standard
if no response, give immunosuppressants |
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who has the highest morbidity/mortality from myositis?
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Blacks
children |
