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131 Cards in this Set

  • Front
  • Back
What are the 3 arthritic emergencies?
septic arthritis
acute crystal induced arthritis
fractures
what are the inflammatory causes of rheumatic dz?
gout
RA
SLE
what are the noninflammatory causes of rheumatic pain?
OA
Which structres are involved in articular dz??
synovium
synovial fluid
articular cartilage
intraarticular ligaments
joint capsule
juxtarticular bone
how is articular pain described?
deep or diffuse pain
limited active or passive ROM
swelling (synovial fluid/capsule inflamed)
creptitation
lax joint (immobility)
locking
deformity
how is nonarticular pain described?
painful on active, but not passive ROM
point tenderness
remote from joint
what structures are involved in nonarticular pain?
extrarticular ligaments
tendons
bursae
muscle
fascia
bone
nerve
skin
4 local cardinal signs of inflammtory rheumatic dz?

Systemic signs?
erythema
warmth
pain
swelling

morning stiffness
fatigue
fever
weight loss
How long is the morning stiffness in RA? OA?
RA >30 mins
OA <30 mins
Presentation of noninflammatory rheumatic dz?
no erythema, warmth, pain, swelling
Brief period stiffness increased by activity
causes of noninflammatory rheumatic dz?
OA
Which rheumatic dzs have acute onset?
gout and septic arthritis
which rheumatic dzs have indolent course?
RA
OA
FM
Duration of acute rheumatic dz?
Duration of chronic?
<6 wks
>6 wks
Which rheumatic dzs have migratory presentation?
Rheumatic fever
Gonococcal dz
Which rheumatic dzs have additive arthralgia?
RA
Reiters
Which class of drugs can --> gout?
thiazide diuretics
How many joints are involved if arthritis is oligoarticular (pauciarticular)
Polyarticular?
2-4
>4
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)
What is the profile of a noninflammatory synovial fluid aspiration?
clear
viscous
WBC <2000
What is the profile of an inflammatory synovial fluid aspiration?
turbid
yellow
WBC 2000-50,000
reduced viscosity
What is the profile of an infectious synovial fluid aspiration?
opaque
purulent
WBC >50,000
Low viscosity
What is the profile of a hemorrhagic synovial fluid aspiration?
hemarthrosis
What is conventional radiology used to dx in rheum dz?
soft tissue swelling
demineralization
calcification
joint space narrowing
erosion
bony ankylosis
osteophytes
sclerosis
periositis
subchondral cysts
What is US used to dx in rheum dz?
synovial cyst
rotator cuff tear
tendon injury
What is radionuclide scintigraphy used to dx in rheum dz?
infection
PAget's disease
What is CT used to dx in rheum dz?
herniated disc
sacroilitis
spinal stenosis
trauma
What is MRI used to dx in rheum dz?
ABN
osteomyelitis intrarticuar dz
herniated disk
synovitis
muscle dz
soft tissue dz
general use of ct?
US?
MRI?
bony tissues
to examine organs
shows detail in soft tissue
Presentation of arthritis caused by parvovirus
joing pain 1-6 days after rash
symmetric arthralgia of many joints
RF can be present
How does non-gonococcal bacterial artheritis present
few joints involved
how does HIV related arthritis present?
few joints involved
What role does TGF-beta play in scleroderma?
TGFb activates CTGF --> overproduction of scar tissue and fibrosis
What role does endothelin play in scleroderma?
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!
What changes are seen in BV in SSc?
overmultiplication of ECs (only supposed to be 1 layer thick)
Adventitia is thickened --> thick BV --> pulm HTN
Small BVs are "gone" from kidneys
How can the loss of renal BV be reversed in SSc?
ACE I
What association with anti-Topo I is there in SSc?
diffuse skin dz
pulm fibrosis
What association with anti-centromere AB is there in SSc?
limited skin dz
pulm HTN
What association with anti-RNP
(RNA polymerase) is there in SSc?
scloroderma overlap w/ SLE, polymysoitis, MCTD
Basis for renal dz in SSc?
elevated AII/renin activity --> accelerated HTN
Renal crisis results: low RBF --> increased RAS --> vasoconstriction --> renal failure
What are tendon friction rubs?
inflammation of tendon that you hear/feel a “leathery rub” of the tendon
Pathoneumonic for SSc
Risk factors for SSc renal dz?
new cardiac events
new anemia
rapid skin progression
tendon friction rub
GI complications of SSc?
GERD (aspiration, Barret''s, d/o peristalsis, strictures --> dysphagia)
GAVE
Intestinal dysmotility
What is GAVE?
watermelon stomach
-->ectatic BV in submucosa of antrum
--> UGI bleed
Treatment of GI dz in SSc?
PPI
motility agents
AB (to help with bacterial overgrowth)
Fiber
Evaluate malabsorption
Muscoloskeletal d/o in SSc?
inflammation
pain
loss fo hand fxn (contractures)
muscle weakness
calcinosis (can be removed)
Inflammatory/Immunologic syndromes in SSc?
alveolitis
myositis
tendonitis
synovitis
Lung dz in SSc?
alveoilitis
interstitial fibrosis
recurrent aspiration (from esoph dz)
pulm vasculopathy
which aspect of the lung dz in Ssc is treatable?
alveolitis (appears as ground glass)
What is pulmonary vasculopathy?
arterioles to lungs are filled with scar tissue, so only small lumen
alveoli get filled with scar tissue
What is microchimerism and how does it relate to SSc?
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
Environmental factors that relate to SSc?
CMV
solvens and silica
Criteria for worse prog in SSc?
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
Ways to prevent fibrosis in SSc?
halofriginone
TGF-beta trapping
interferon
CTGF trapping
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
Differential Dx of Sjogrens
HIV- diffuse infiltration of lymphocytic syndrome
Infection
Infiltrative dz (sarcoid, amyloidosis, hemochromatosis)
T cell leukemia
MS
Anti-cholinergic meds
Which is the msot common cause of dry eyes/mouth
anti-cholinergic drugs and anti-HTN meds
What is a bursae?
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)
Where is septic bursitis normally found?
What is it infected with?
Treatment?
olecrenon or prepatellar
Staph
ABs
Causes of nonseptic bursitis?
Tx?
overuse
heat, reset, NSAIDS, steroid injections
What is a common cause of shoulder pain?
subacromial nonseptic bursitis
differntial for shoulder pain?
rotator cuff tear
shoulder joint pathology
subacromial nonseptic bursitis
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
Tx for tendonitis?
rest
heat
NSAIDS
local steroid injection
PT/OT
surgery for refractory cases
Pathogenesis of tendonitis?
Inflamed tendon sheaths
Overuse with microscopic tearing of tendon
Tendon compression by osteophyte (in rotator cuff)
2 examples of tendonitis and their causes?
Lateral epicondylitis (overuse)

Achilles tendinitis (inflammation), seen in Reiter's syndrome, psoriatic, or sero - spondylarthropathy
Diagnostic criteria for FM?
widespread pain/tenderness at muscle/tendon insertion (in 11/18 spots)
>3mo
associations with FM?
widespread pain
stage IV sleep disruption
major depression
incresaed migraines
IBS
panic d/o
Differential for FM?
PMR
thyrodi dz
myopathy
SLE
RA
What are the different SpAs?
Ankylosing spondylitis
Reactive arthritis (Reiters)
Psoriatic
Enteropathic arthritis (Crohn's, UC)
Epidemiology of SpAs
Seronegative (no RF or other AB)
Family h/o SpA may or may not be present
1-2% prevelence
Genetic links of SpAs
HLA B27
15% of ppl with HLA B27 get SpA
What are the theories surrounding SpAs wiht HLA B27
B27 might act as a receptor for a virus
Plays a rols in pathogenesis by presentation of microbial peptides
Environmental link with SpAs
may follow infection of GU or GI tract
What infection may be related to SpAs
chlamydia trachomatis
Features common to all SpAs
sacroiliitis (SI joint inflam)
spondylitis (spine inflam)
Enthesitis (inflam at site of insertion of tendons to bone)
Extra-articular manifrestations
what are some of the extra-articular manifestations of SpAs?
Uveitis (inflammation of anterior chamber of the eye, esp if B27+, can --> blindness)
Peripheral synovitis (sausage digits)
Skin dz (psoriasis,e tC)
Clinical presentation of ASp
low back pain (insidious, lasting more than 3 months and decreases with exercise)
si/sx of sacroiliitis
HLA B27 assoc with ASp
>90% have it
extra-artic manifestations of ASp
uveitis
pulmonary fibrosis
aortitis
What is seen on Xray of ASp
Sacroiliitis
bamboo spine
Classic triad in reiter's syndrome?
urethritis
conjunctivitis
skin probs
etiology of reiters?>
follows GI or GU infections (or other infections)
Chlamydia
Salmonella
Shigella
Campylobacter
Yersinia
HIV
Relapse rate of reiters?
15%
% of pts w psoriasis who get psoriatic arthritis?
5-8%
Dx of psoriatic arth
inflamm arthritis and psoriasis
what are the possible clinicla presentation of psoriatic arthritis
DIP involvement with nail pitting
asymmetrical oligoarthropathy
symmetrical polyarthritis
arthritis mutilans
spondyloarthropathy
Features of eneteropathic arthritis
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)
Use of radiographic damage to treat SpA
doesn't prevent progression
effective tx for SpA
Etanercept slows progression of erosions in psoriatic arthritis
Tx for ASp
NSAIDS
MTX or sulfasalazine
oral corticosteroids
anti-TNF
Tx for reiters
AB to tx infection (if present)
NSAIDS
Tx for psoriatic arthritis
NSAIDS
MTX
steroids
anti-TNF
topical or systemic tx for skin dz
Tx for enteropathic arthritis
NSAIDS
tsx of IBD (steroids)
Gottrons papules
on knuckles
in idiopathic inflam myop
heliotrope facial rash
purple skin rash on face of pts iwht idiopathic inflam myopathies
Signs of idiopathic inflamm myopathies
Gottrons papules
heliotrope facial rash
vasculitis
subQ calcifications
livedo ulceration
photosensitivity
Nail BV cchanges
periungual telangiectasias
mucosal ulcers
farmer's hand
examples of idiopathic inflam myopathies
primary idiopathic polymyositis
primary idiopathic dermatomyositis
PM/DM assoc w malig
Juvinile PM/DM
PM/DM assoc with autoimmue CT dz
Inclusion body myositis
phsyical sings in idiopathic inflam myo
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
what si the pattern of weakness seen in idiopathic myo
symmetrica
proximal him > shoulder
distal muscles only in advanced
EYES NEVER INVOLVED
rare facial weakness
muscle tenderness and wasting and contractures
pattern of weakness in IBM (inclusion body myositis)
focal
distal
asymmetric
Extramuscular manifestations of PM/DM
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)
Features of DM
Age
Associated condition overlap
systemic
malignant
Familial
Adult and child
SSc and myositis
infrequent
probably
no
Features of PM
Age
Associated condition overlap
malignant
Familial
systemic
>18
Yes
no
no
yes
Features of IBM
Age
Associated condition overlap
malignant
Familial
Systemic
>50
Yes <15%
n o
yes, some
infrequent
which idiopathic myo is systemic?
malignant?
familial
PM
DM
IBM
lab abnormalities assoc with idiopathic myo
elevated serum enzymes from muscle
(CK, aldolase, AST, ALT, ADH)
Typical EMG features of PM/DM?
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)
which ABs are specific to myositis?
anti-synthetase
signal recognition particle (SRP)
helicase
which AB are associated wiht myoissitis?
RNP
Fer
Mas
KJ
PM-sci
Ku
ML
what does the helicase AB do?
it's specific for rash and acute presentation
which is the best AB to screen for in myositis?
Jo1 (an anti-synthetase), also have lung involvement
whihc AB for myositis syndromes has moderate course?
Poor prognosis?
Good prognosis
Anti-Jo
Anti-SRP
Anti-Mi2
what is the gold standard for myositis dx?
muscle biopsy of a weak muscle that hasnt' been injected with EMG
What will muscle biopsy show in myositis?
varied stages of necrosis and regeneration
inflamm infiltrate, focal endomsial, perivascular
what inflammatory cells are found in PM muscle biopsy?
T cell (CD8)
what inflammatory cells are found in DM muscle biopsy?
T4 and B cell
Ig complexes
complement
what things are seen in childhood DM muscle biopsy?
vasculitis
calcification
lipodystrophy
what inflammatory cells are found in IBM muscle biopsy?
minimal infiltrate
rimmed vacuoles
amyloid
Pathogenesis of DM
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
PAthogenesis of PM
mediated by autoagressive T cells
CD 8+ cells predominatte in endomysium
Pathology of myositis?
inflammation
size changes
necrosis
degeneration adn regen
phago
vasculitis
Suggestion of autoimmune basis of myositis?
T cell mediated myocytotoxicity
auto-AB presence
response to immunotx
What is diff dx for myositis?
infection
drug induced myopathy
endocrine/metabolic
neruomuscular d/o
what are the different drgs that can induce myositis?
antiarhtritic
lipid lowering (incresaes CPK)
cocaine addict
Endo/metabolic d/o that resemble myositis?
thyroid/parathyroid dz
Cushings
treatment of myositis
muslce rest, passive ROM in acute phase
Recovery is gradual, passive and active motion
what are some other conditions in differential of myositis?
PMR- polymyalgia rheumatica
Giant cell myositis
what is PMR?
proximal muslce pain
periarticular pain
morning stiffness
Treatment for myositis
corticosteroids = gold standard
if no response, give immunosuppressants
who has the highest morbidity/mortality from myositis?
Blacks
children