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67 Cards in this Set
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Passive vs Active Range of Motion |
Active- Patient moves limb on own Passive - Examiner moves limb Pain with active only implies peri-aurticular problem Pain with both implies intrinsic aurticular problem |
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Monoaurticular Arthritis examples |
Crystal Arthropathies, bacterial |
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Oligoaurticular Arthritis |
Involves 2-4 joints and is usually from spondyloarthropathies, Lymes |
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Polyarticular arthritis |
5 or more joints RA, SLE, Parvo B19, HIV |
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Scleritis vs Episcleritis |
Episcleritis: Inflammation of the connective tissue between sclera and conjunctiva. Looks like conjunctivits without discharge.(Localized between sclera and conjunctiva, with no inflammation above pupil) Painless and self-limiting. Scleritis: Infection of the sclera (Deeper than episcleritis) Associated with pain,photophobia and vision changes and needs an urgent ophthalmologist consult Both associated with connective tissue d/o (Especially RA, SLE) |
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ESR and estimated normal level |
measures the rate at which RBC settle with gravity Male: Age/ 2 Females: Age + 10 / 2 |
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Colchicine |
Drug used for Gout and Familial Mediterranean Fever and Behcet's It inhibits microtubule formation and inhibits mitosis and therefore inhibits leukocyte aggregation. It's cleared by kidneys. Side Effects: Diarrhea, myopathy, bone marrow suppresion |
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Hydroxychloroquine |
Antimalarial that prevents antigen recognition. Used as adjuvent therapy in RA and SLE. Needs an opthalmic exam annually to prevent retinitis pigmentosa |
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Cyclophosphamide |
DNA alkylating agent that acts as immunosuppressant. Used in life-threatening manifestations of SLE as well as in pulmonary HTN in scleroderma patients Can cause bone marrow suppression, hemorragic cystitis/ bladder cancer, lymphoma |
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Mycophenolate |
(CellCept) inhibits nucleotide synthesis and is used as immunosuppresion for transplant patients and autoimmune conditions such as SLE. Side effects: Diarrhea, bone marrow suppresion |
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Cyclosporine |
Calcineurin inhibitor (Calcineurin activates T-cells) which is an immunosuppressant used in autoimmune diseases Nephrotoxic, HTN, Hirsutism are side effects |
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immunizations and DMARDS |
Live attenuated vaccines are contraindicated in biologic DMARDS. Non-biologic DMARDS can get any type of vaccine . |
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Screening tests before starting DMARD |
TB, Hepatitis B and C, HIV |
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When to initiate Gout Treatment |
2 attacks occuring with 1 year, 1 attack with CKD, 1 attack with history of nephrolithiasis, evidence of tophi |
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Febuxostat |
Non-competitive xanthine oxidase inhibitor. Less likely to cause hypersensitivity reaction than allopurinol (If having hypersensitivity reaction to allopurinol you can still take febuxostat.)
**Does not need dose adjustment to patients with mild to moderate kidney disease and contraindicated in azathioprine |
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Probenicid |
Medication that is used to increased uric acid excretion. (2nd line) Can't be used if GFR < 50, and can't be used if elevated uric acid in urine (indicating overproduction and has many drug interactions |
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Pegloticase |
Married with children and gout (peg bundy) Recombinant uricase which breaks down uric acid into allantoin. Used in patients with gout who have failed standard therapy.
Need to have serum urate levels checked before each infusion, as elevations in urate levels indicate antibodies formed against the medication. Can develop transfusion reactions . |
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Diseases with elevated Rheumatoid Factor |
RA, SLE, Cyroglobulenemia, Sjogren, |
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pyoderma gangrenosum |
manifestation of neutrophilic dermatosis that presents as non-healing ulcer seen in IBD, RA, hematologic malignancies, |
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Felty Syndrome |
Combo of neutropenia and splenomegaly in patients with RA |
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Fibromyalgia |
Chronic widespread pain associated with fatigue, cognitive impairment and exercise intolerance due to aberrant pain-reflex arc Diagnosis: Self-reported pain for 3 months at 19 different locations and physical exam will illict tendernes Need to rule out other disorders by checking ESR/CRP/TSH/. Only check ANA/RF if clinical suspicion is high. Tmnt: SNRI, Gabapentin |
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Spondyloarthritis |
Group of disorders that affect axial skeleton, tendon to bone insertion (Enthesis) and an association with HLA-B27 (Human Leukocyte Antigen found on WBC) Psoriatic Arthritis, Ankylosing Spondylitis, IBD, Reactive Arthritis (Reiters) |
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Ankylosing Spondylitis |
Inflammatory disorder (Immune mediateD) of unknown cause that affects the axial skeleton with extra-aurticular manifestations. **Most serious consequence is spinal fracture Symptoms: Initially presents as low back pain that is worst in the AM that gradually gets better. Eventually pain is contant and night time awakenings occur. Can also develop heel pain (Enthesitis) Tmnt: Start with NSAIDs, if no improvement can try TNF alpha inhibitors (Etanercept) |
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Ankylosis |
Bony bridging of vertebrae from chronic inflammation |
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dactylitis |
diffuse swelling of joints/tendons creating "sausage-like" digits associated with Spondyloarthropathies, Sarcoidosis, Gout |
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Reactive Arthritis |
Autoimmune Arthritis that develops after recent (1-4weeks) GU or GI infection. (Shigella, Samonella, Campylobacter, Chlamydia) |
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Pathophysiology of SLE |
Development of Antibodies to intranuclear antigens. Nuclear material of dying cells are improperly cleared which triggers an immune response. 90% of patients with SLE are women and there is a belief SLE is associated with sex hormones. |
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Libman Sacc Endocarditis |
Non-infectious endocarditis associated with lupus. Non-infective vegetations are found on aortic and mitral valves that can lead to embolic phenomenon (CVA) and are treated with steroids and AC. |
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Diagnosis of Lupus |
Need 4 of 11 Criteria Malar Rash, Discoid rash, Serositis, Oral Ulcers, Arthritis,Photosensitivity, ANA, Anti-DS DNA Ab, Kidney Dysfunction, Neurologic Dysfunction (Seizures, Pschosis) Hematologlic disorder (Leukopenia, Thrombocytonenia, Anemia) |
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Sjogren's Syndrome |
Autoimmune inflammatory disorder (T-cells) and B-cells characterized by destruction of exocrine glands (most commonly lacrimal and salivary glands (xerostomia) but can also involve pancrease) Patients present with dry eyes, dry mouth and have increased risk of B-cell Lymphoma Labs: + RF, Anti-Ro (SS-a) and Anti-La (SS-b), ANA, Only treatment are lubricant drops or topical immunosuppressants |
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Mixed Connective Tissue Disease |
Disease with overlapping features of SLE, Sclerosis, and Polymyositis. Diagnosed by having anti U1-RNP Ab |
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Treatment of Polymyalgia Rheumatica |
Steroids or Methotrexate Q2 9/27/16 |
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Another name for Churg-Strauss |
Eosinophilic Granulamotosis with polyangitis ***ANCA is negative in 40% of cases (but will still have elevated Eosinophils and IgE) |
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Pathophysiology of gout |
Purine metabolism end products are uric acid via Xanthine oxidase. Most mammals have uricase which breaks down uric acid into allantoin. In physiologic conditions uric acid is in its ionized form urate. When urate becomes saturated (@6.8) monosodium urate crystals form. Urate is cleared by kidneys to impaired GFR is risk factor for gout. |
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Tophi |
stone like deposits of monosodium urate surrounded by fibrounous material |
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Differentials when considering gouty arthritis |
Infectious arthritis, pseudogout, reactive arthritis, |
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Gold standard diagnosis of gout |
polarized light shows monosodium urate crystals with negative biferingence ***If the inflammation was due to monosodium urate crystals, the crystals would be INTRACELLULAR. If the crystals are extracellular then there is something else going on like septic arthrits. |
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Treatment of acute gout |
Colchicine, Indomethacin, or Steroids depending on comorbidities. with an overall goal of serum urate < 6. |
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Causes of gout |
CKD, increased cell turnover, diet rich in purines (alcohol, red meat, seafood) thiazides/loops), purine over production HRPT deficiency |
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Pathophysiology behind septic arthritis |
Joints become infected from hematogenous spread, direct innoculation (Surgery), contiguous spread from osteomyelitis/cellulitis. |
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Labs to order when septic arthritis suspected |
Cell count (Usually neutrophil predominant, with >50,000), gram stain, culture |
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Chickengunya |
Virus endemic to Asia and Africa transmitted by mosquitos. Leads to fever, rash, myalgia with thrombocytopenia and/or leukopenia. Tmnt is supportive. |
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Types of Inflammatory Myopathies and pathophys |
Polymyositis, Dermatomyositis, Inclusion body myositis Polymyositis - CD 8 mediated direct muscle injury Dermatomyositis: Immune complex mediated vascular inflammation with muscle damage IBM - Unclear |
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Anti Jo Antibodies |
Ab against AminoAcyl Transfer tRNA synthetase enzymes found in dermatomyositis and polymyositis |
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Antisynthetase Syndrome |
characterized by having Ab against synthetase enzyme (Anti Joe) along with two of the following: Raynauds, ILD, myositis, arthritis, mechanics hand |
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Inclusion body Myositis |
Inflammatory myositis that has no extramuscular manifestations and has both proximal AND distal muscle weakness **No Ab has been found that's associated with IBM |
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Labs to look for when suspecting a myositis |
CK, aldolase, LDH, AST |
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Causes of myopathy |
Autoimmune Myositis : DM,PM,IBM Connective Tissue Dieases : SLE Endocrine : Hyper/hypothyroidism, Cushings Meds: Colchicine, Hydroxychloroquine, Statin, glucocorticoids |
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Treatment of Idiopathic Inflammatory Myopathies (DM, PM, IBM) |
Steroids during active flares, if no improvement methotrexate |
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How long do you have to biopsy lesion once you start steroids when you suspect giant cell arteritis? |
2 weeks |
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Dosage of steroid in giant cell arteritis |
60 mg of oral prednisone / day If visual invovlement, 1 gram solumedrol x 3 days Alternative: Methotrexate, Cyclophosphamide |
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heliotrope rash associated with dermatomyositis |
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systemic sclerosis |
autoimmune disease characterized by fibrosis and hardening of organs and skin due to excess collagen and fibroblast activation further characterized by diffuse cutaneous scleroderma and limited cutaneous (Both are still systemic) |
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Diffuse Cutaneous Scleroderma |
Associated with extensive skin induration (Hardening) from distal upper and lower extremities to proximal upper and lower extremities. **Associated with Interstitial Lung Disease and Renal Crisis |
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Limited cutaneous Scleroderma |
Associated with skin induration (hardening) limited to distal extremities (Elbows and knees extended) and face, trunk is spared. Associated with Calcinosis, Raynaud's, Esophogeal dysmotility, Sclerodactyly, Telangectasia |
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Diagnosis of scleroderma |
suspect in symmetic induration of extremities Labs: ANA + Scl-70 in diffuse cutaneous Anti-Centromere in limited cutaneous **Usually do NOT need skin biopsy |
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Scleroderma Renal Crisis |
Occurs more commonly in diffuse cutaneous systemic sclerosis (but can occur in limited) where the renal arteries undergo narrowing which leads to reduced renal blood flow. In turn, RAA system is activated excessively, and creates a viscious cycle (more vasoconstriction) On labs patient will have microangiopathic hemolytic anemia, thrombocytopenia and severe hypertension. ***Association between glucocorticoid use and development of renal crisis Tmnt: ACE/ARB |
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Behcet Syndrome |
believed to be an autoimmune vasculitis where patients present with recurrent painful oral and genital ulcer (Ulcers never on glans penis or urethra) Can present with pathergy |
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Pathergy |
Pustule like lesion that occurs about 48 hours after a skin prick associated with behcets |
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Tmnt of Behcet's |
Steroids or Colchicine |
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Stills Disease |
Inflammatory Disease characterized by salmon colored rash, high spiking fevers, arthritis, and high neutrophil count (>80%) Can be complicated by fulminant liver failure, cytopenias, elevated ferritin and hemophagocytic histiocytosis (diagnosed on bone marrow biopsy) Clinical diagnosis based on diagnosis of exclusion (rule out malignancy/infection) |
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Treatment of Still's Disease |
High dose NSAIDs, Steroids, MTX as second line |
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Lofgren Syndrome |
Manifestation of Sarcoid where patients present with hilar lymphadenopathy, E Nodosum and arthralgias When all are present do not need to do further work up to diagnose sarcoid Tmnt: NSAIDs |
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Heerfordt Syndrome |
Sarcoid Parotitis, uveitis, fever |
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Ehrlos Danlos Syndrome |
Autosomal dominant disorder which leads to defective collagen. Patients present with hyperelastaticity, hypermobile joints, |
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Marfan Syndrome |
Autosomal dominant disorder leading to mutation in fibrillin. (Structural protein found in some fibers such as arteries, tendons Tall stature, arachnodactyly (long fingers), Hyperextensible skin, aortic regurg/dissection/aneurysm, MVP, Pneumothorax |
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Igg4 related disease |
group of disorders with abundant plasma cells that produce IgG4 that infiltrate ANY tissue Biopsy shows lymphoplasmacytic infiltration **Normal IgG4 level does not rule out disease |
