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38 Cards in this Set
- Front
- Back
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important considerations in evaluating arthritis
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1. distribution and number of joints involved
2. acute or chronic 3. systemic symptoms 4. signs of inflammation |
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important tests in rheumatologic disease
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joint aspiration (cell count, crystals, cultures, Gram)
antinuclear antibodies rheumatoid factor antineutrophil cystoplasmic antibodies antiphospholipid antibodies |
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joint aspiration test
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arthrocentesis; synovial fluid tests to run:
cell count crystals cultures Gram stain hemogram (anemia) ESR if <2,000 WB consider OA or trauma if 5,000-50,000 WBCs probable inflammatory etiology but also consider septic if > 50,000 WBCs consider septic etiology; |
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ANAs
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seen in 5% of normal people
95% of SLE as well as Sjogren, CREST, systemic sclerosis, MCTD ANA subsets: anti-ds-DNA (60% of SLE, indicates diseae activity and nephritis) anti-Smith (SLE 25-30%) anti-histone (drug-induced lupus, 95%) anti-Ro/SSA (neonatal lupus, Sjogren, ANA-negative lupus) anti-LA/SSB (Sjogren) anti-centromere (CREST) anti-RNP (MCTD, 100%) |
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rheumatoid factor
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IgM against Fc portion of IgG found in 70% of patients of RA and 5% of healthy adults
neither sensitive nor specific for RA but has prognostic significance |
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ANCAs
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cANCA are diffuse antibodies against neutrophils seen in 90% of Wegner cases
pANCA are localized in around the neutrophil nucleus and atacks myeloperoxidase and it's seen in PAN and Churg-Strauss |
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antiphospholipid antibodies
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also called lupus anticoagulant or anticardiolipin antibodies
associated with hypercoagulable state of antiphospholipid syndrome high PTT false-positive VDRL spontaneous abortions thromboembolism |
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rheumatoid arthritis etiology
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unknown (most cases) or due to mycoplasma or parvovirus infection
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rheumatoid arthritis presentation
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need four of the following criteria:
morning stiffness > 1h swelling of wrists, MCPs and PIPs swelling of three joints symmetric involvement joint erosions on x-rays RF positive rheumatoid nodules constitutional symptoms: fatigue, anorexia, weight loss, generalized wekness DIPs and lower back joints are not involved signs: radial deviation of wrist with ulnar deviations of digits Boutonniere and Swan-neck deformities nodules are usually on olecranon, occiput or Achilles tendon Felty syndrome (RA, splenomegaly, neutropenia) Caplan syndrome (RA, pneumoconiosis) |
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rheumatoid arthritis management
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aspirin
celecoxib (other COX-2 recalled due to increased risk of cardiac ischemia and stroke) glucocorticoids disease modifying agents: hydroxychloroquine gold salts methotrexate TNF inhibitors (infliximab, adalimumab, ethanercept) |
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rheumatoid arthritis complications
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alantoaxial subluxation
pannus formation at C1-C2 with neurologic symptoms (paraplegia, paresthesias of hands and feet, myelopathy) cervical x-ray is initial screening test rupture of Baker cyst manifests with swollen painful calf |
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systemic lupus erythematosus presentation and diagnosis
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four diagnostic criteria are needed:
malar rash discoid rash photosensitivity oral ulcers arthritis serositis renal involvement neurologic disorder hematologic disorder (hemolytic anemia, leukopenia, thrombocytopenia) immunologic disorder (anti-ds DNA, anti-SM) best screening test: ANAs anti-ds-DNA and anti-SM are specific for SLE |
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systemic lupus erythematosus management
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symptomatic
NSAIDs for arthritis corticosteroids for rashes cytotoxics (azathiorpine, cyclophosphamide) for severe synptoms (nephritis, endocarditis, pleuritis, hemolytic anemia, CNS) also wear sunglasses and sunscreen |
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drug-induced lupus
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reactions to hydralazine, isoniazid, procainamide and quinidine
presents with fever, arthritis, fatigue and rarely plurisy severe symptoms of lupus are not seen including skin disease and photosensitivity anti-histone antibodies are present in hydralazine-induced lupus only 1/3 have anti-histone antibodies present manage by withdrawing causing drug which confirms diagnosis when symptoms subside within 2 weeks |
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diffuse scleroderma presentation
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raynaud phenomenon
skin thickening throughout the body esophageal dysmotility achalasia intestinal hypomotility malabsorption large intestine diverticula lung fibrosis malignant hypertension acute renal failure Scl-70 antibodies are present |
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limited scleroderma presentation
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CREST syndrome: calcinosis, raynaud, esophageal dysmotility, sclerodactily, telangiectasia
skin involvment is in distal extremities pulmonary artery hypertension in 25-50% interstitial lung disease in 10% anticentromere antibodies are present |
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scleroderma management
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d-penicillamine for skin; CCB for raynaud; ACEIs for hypertension
"sCleroDermA" Calcium, D-penicilamine, ACEIs |
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Sjogren syndrome
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lymphocytic infiltration of exocrine glands seen alone or in association with RA, PBC, SLE
presents with itchy eyes with sandy feeling (keratoconjunctivitis sicca) and difficulty swallowing food, parotid enlargement and dental caries advanced stages affects lungs and kidneys and predisposes to malignant lymphoma screen with anti-Ro/La antibodies confirm with biopsy of salivary glands |
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diseases associated with symmetrical polyarthritis
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RA (involves mostly the joints), SLE, scleroderma, Sjogren
also parvoB19 and hepB |
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seropositive arthropathies
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RA, SLE, scleroderma, Sjogren
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seronegative arthropathies
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associated with HLA-B27 allele; ankylosing spondylitis, reactive arthritis, psoriatic arthritis, enteropathic arthropathy; PAIR
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ankylosing spondylitis
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3-4 times more common in men; 90% HLA-B27+
presentation --> chronic back pain and morning stiffness lasting >1h improves with exercise, decreased spine mobility, no lumbar lordosis anterior uveitis, aortic insufficiency and 3rd degree heart block X-rays show fusing of sacroiliac joint, sacroilitis, bamboo spine diagnose with clinical and x-ray, no HLA-B27 treat with NSAIDs, physical therapy, exercise and possibly TNF inhibitors "BEHNkylosing spondylitis needs x-ray" |
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reactive arthritis
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Reiter: nongonococcal urethritis (chlamydia, ureaplasma) with mucocutaneous manifestations (keratoderma blenorrhagica, circinate balanitis, genital ulcers, conjunctivits, arthritis)
ReA: after infectious diarrhea from campylobacter, shigella, salmonella diagnosis is clinical with x-ray findings of seronegative arthropathy |
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osteoarthritis etiology
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idiopathic (most common)
or secondary due to: gout, diabetes, acromegaly, hemochromatosis, mechanical factors |
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osteoarthritis presentation
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affects elderly with chronic asymetrical pain of weight bearing joints or PIPs, DIPs, which increases with excersise and decreases with rest
morning stiffness <30m crepitation no systemic nor inflammatory symptoms |
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osteoarthritis diagnosis
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clinical presentation + x-ray findings:
osteophytes and unequeal joint space osteophytes in PIPs are Bouchard nodules in DIPs are Heberden's nodules |
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osteoarthritis management
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reduce joint load, physiotherapy
NSAIDs specially acetaminophen (4,000mg/d, 1st line) ibuprofen (1,200mg/d) celecoxib used for patients with gastric side effects capsaicin cream depletes local nerves of substance P intraarticular hyaluronic acid injections are used also if no improvement or decreased quality of life then joint arthroplasty |
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gout presentation
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acute monoarthritis afecting first MTP (podagra) or other joints
signs of inflammation over joint precipitated by alcohol, trauma, surgery, steroid withdrawal and drugs (HCTZ, furosemide, pyrazinamide, ethambutol) chronic gout may involve monosodium urate deposition in connective tissue and kidneys |
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gout diagnosis
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clinical signs
erosive calcifications on x-ray negatively birefringent needle-shaped monosodium urate crystal in synovial fluid 5,000-50,0000 WBCs first step in diagnosis: joint aspiration |
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acute gout management
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indomethacin 50mg/8h
colchicine 0.6mg until symptoms resolve or GI upset if elderly with low NSAID toleration or renal impairment give steroids without NSAIDs or colchicine if previously using allopurinol, do not withdraw |
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chronic gout management
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low purine diet, limitation of alcohol and diuretics
if recurrent attacks: probenecid in undersecretors or allopurinol in undersecretors or overproducers or renal failure goal is to lower uric acid levels so monitor plasma uric acid |
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pseudogout
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same presentation as gout
diagnose with synovial fluid showing positively birefringent romboid calcium pyrophsphate crystals and condrocalcinosis in x-rays pseudogout raises suspicion of hyperparathyroidism, hemochromatosis, hypophsphatemia, hypomagnesemia management same as gout |
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septic arthritis
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due to gonococcus (young people) or staph (elderly) infection
presents with sudden onset monoarticular arthritis and signs of inflammation diagnose with arthrocentesis (gram stain, negative culture, no crystals and > 50,000 WBCs) treat with ceftriaxone (gonorrhea) or nafcillin/vancomycin (staph) |
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Wegener granulomatosis
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small vessel vasculitis
presents with rhinitis, sinusitis, nasal ulcers, hemoptysis, dyspnea, kidney involvement and arthritis cANCA+ diagnosis is made with biopsy of affected area treat with prednisone + cyclophosphamide |
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polyarteritis nodosa
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medium vessel vasculitis; presents with
nonspecific signs fever, malaise, anorexia, weight loss, abdominal pain does not affect lungs peripheral neuropathy (tingling, numbness, pain, mononeuritis) GI bleeds, 30% hepB kidney involvement diagnose with biopsy; can do angiogram treat with high dose corticosteroids + cyclophosphamide |
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Churg-Strauss syndrome
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affects medium vessels
adult-onset asthma, eosinophilia, neuropathy and non-specific symptoms diagnose with biopsy treat with prednisone + cyclophosphamide |
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temporal arteritis
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affects large vessels of head and neck
headache, jaw claudication, visual disturbances 25% polymyalgia rheumatica first test is ESR, if high give prednisone then biopsy of temporal arteries looking for giant cells |
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polymyositis/dermatomyositis
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proximal muscle weakness without eye muscle compromise (different than myasthenia and EDS)
dermatomyositis has heliotrope rash over face and eyelids screening: aldolase and CPK; anti-Jo-1 diagnose with electromyography (short-duration, low amplitude potentials) confirm with muscle biopsy treat with steroids |
