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289 Cards in this Set

  • Front
  • Back
What is the Major Histocompatibility Complex (MHC) also known as?
The Human Leukocyte Antigen (HLA).
Describe positive and negative selection in the immune system:
a)Positive selection- T-cells with the host's MHC antigens and T-cell receptors for non-self antigens are allowed to MATURE.
b)Negative selection- T-cells with a high affinity for attacking host cells are sorted out and undergo APOPTOSIS (Fas+Fas Ligand).
What are the 4 proposed mechanisms behind A.I. (AutoImmune) disorders?
1. Failure of T-cell mediated suppression- failure to delete autoreactive immune cells. Will see an increasing ratio of CD4 to CD8 (normally 2:1).
2. Release of sequestered Ag (antigens)- i.e. sperm or occular tissue.
3. Molecular mimcry- foreign Ag. resemble self Ag.; or a B/T-cell response against Ag. in altered or damaged tissue.
4. Heredity/Genetics- some HLA types occur more with some A.I. dz. These dz are also more common in females (E2 [estrogen] correlation). Also can occur with some viral, bacterial, chemical, or hidden self Ag. exposure.
What are a few of the major characteristics of SLE (Systemic Lupus Erythematosus)?
-HLA DR2 & HLA DR3
-Female (85% of people w/SLE are female)
-More common in blacks (1:250) over whites (1:1000)
-Heritability w/in a family
-Production of Ab. (antibodies) to nuclear Ag.
-Effects multiple organs (systemic)
How do hormones affect SLE?
-E2 stimulates T/B-cells, macrophages, cell adhesion molecules, and some cytokines
-E2 increases macrophage protooncogene expression and decreases apoptosis in self reactive B cells
-Androgens are immunosuppressive
-Progesterone/Prolactin effect immune activity and favor auto Ab. production.
What are a few of the major characteristics of (RA) Rheumatoid Arthritis?
-Genetics: HLA-DR4 & HLA-DR1
-Angiogenic cytokines stimulate/attract new vessels
-TNF and substance P activated endothelial cells produce adhesion molecules
-Lymphocytes & PMN into synovial spaces
-Activated CD4 T-cells which activate macrophages/B-cells/other cells.
What is the most common rheumatic disease?
O.A. (osteoarthritis)
What do Herberden's and Bouchard's nodes effect?
Herberden's nodes- Enlarged DIP

Bouchard's nodes- Enlarged PIP
T/F
The etiology of pain in Fibromyalgia is due to lack of Seratonin in the synaptic cleft, especially associated with depression.
False
The etiology of pain is unknown, however, there is a correlation with depression, along with other possible causes. Fibromyalgia can be treated w/SSRIs and tricyclic antidepressants.
T/F
There is a laboratory test that can help you reach a diagnosis of fibromyalgia.
False
What is the Reactive Arthritis (Reiter's) triad?
Arthritis
Urethritis
Conjunctivitis
What MHC is related to Reactive Arthritis?
HLA-B27
(However, There is NO gold standard for diagnosing reactive arthritis and therefore the provider is left to determining a “probability.”)
What does DMARDs stand for?
Disease-Modifying AntiRheumatic Drugs
Are ABX generally indicated for uncomplicated bacterial enteric infections?
No.
What is Sjogren’s Syndrome (SS)?
Chronic inflammatory disorder characterized by diminished lacrimal and salivary gland function.
What is a Sicca complex?
Combination of dry eyes (keratoconjunctivitis sicca)
and dry mouth (xerostomia)
Describe SS pathogenesis in 2 words.
lymphocytic infiltrative
What other disease are you worried about when a patient presents w/SS sx?
OR
What would you worry about most in a disease where you find aggressive lymphocytic infiltration into various tissues?
Lymphoma
What does dysfunctional tear syndrome refer to?
keratoconjunctivitis sicca (KCS)
What complications can come with KCS (dysfunctional tears)?
Corneal ulceration
Infection of the eyelids
What antibodies are commonly found in Sjogren’s Syndrome (SS)?
-Anti-Ro/SSA antibodies (best)
-Anti-La/SSB antibodies (not as important)
What group of drugs can exacerbate Sicca Symptoms in Sjogren’s Syndrome (SS)?
Anticholinergic drugs (i.e. Benadryl)
What Cholinergic drugs can help treat Sicca Symptoms in Sjogren’s Syndrome (SS)?
Muscarinic agonists (e.g. pilocarpine)
What is Scleroderma?
Thickened, hardened skin. (Scleroderma may be a clinical feature of limited anatomic extent affecting only the skin and adjacent tissues OR it may be associated with systemic involvement [systemic--> Systemic Sclerosis] )
What is it called when scleroderma is associated with internal organ involvement?
Systemic Sclerosis (SSc)
T/F
There is a treatment that comprehensively addresses Systemic Sclerosis.
False
What are the typical cutaneous manifestations in Scleroderma (a.k.a. where do you see it)?
Fingers, hands, and face
Most common initial manifestation of Systemic Sclerosis?
Raynaud’s Phenomenon
How is Raynaud’s Phenomenon manifested?
Manifested clinically by sharply demarcated color changes of the skin of the digits due to abnormal vasoconstriction of digital arteries and cutaneous arterioles.
How is a typical episode of Raynaud’s Phenomenon characterized?
Sudden onset of cold fingers (or toes) in association with sharply demarcated color changes of skin pallor (white attack) and/or cyanotic skin (blue attack)
With rewarming, the ischemic phase (white or blue attack) usually lasts for 15 to 20 minutes. The skin subsequently blushes upon recovery, thereby resulting in the erythema of reperfusion.
What three rashes are characteristic in Dermatomyositis?
1. Rash over PIP and MCP joints (Gottron’s sign)
2. Purple (heliotrope) eruption over the eyelids
3. Erythematous poikiloderma (pigmentation, telangiectasia, purpura, pruritus, and atrophy) over upper anterior chest and around over the shoulders [Shawl Sign]
What medications do we commonly associate with myalgia?
Cholesterol lowering drugs (statins)
What is Gottron’s sign?
Rash over PIP and MCP joints.
What is heliotrope?
Purple eruption over the eyelids.
What is Shawl Sign?
Erythematous poikiloderma (pigmentation, telangiectasia, purpura, pruritus, and atrophy) over upper anterior chest and around over the shoulders.
What enzyme tests may be elevated in Polymyositis/Dermatomyositis?
Creatine kinase (CK), lactate dehydrogenase (LD), aldolase, aspartate aminotransferase (AST), and alanine aminotransferase (ALT)
If a patient has muscle weakness and myalgias and something’s not making sense what should you order?
Muscle enzymes.
[Creatine kinase (CK), lactate dehydrogenase (LD), aldolase, aspartate aminotransferase (AST), and alanine aminotransferase (ALT)]
A 42yo female presents with an eight week history of morning stiffness, pain, swelling in her third through fifth proximal interphalangeal joints, and fatigue. On examamination, she has clinical evidence of bilateral arthritis in the affected joints. Labs reveal an elevated ESR at 59 and negative rheumatoid factor. Which of the following is the most likely diagnosis?
-Osteoarthritis
-Rheumatoid arthritis
-Fibromyalgia syndrome
-Gonococcal arthritis
-Polymyalgia rheumatica
Rheumatoid arthritis
A 72yo female comes in complaining of a several-month duration of a deep-aching, left knee pain of insidious onset. It is associated with morning stiffness of approx 20 minutes duration. There is no hx of trauma and she has no other complaints. What is the most likely diagnosis?
-Rheumatoid arthritis
-Gouty arthritis
-Osteoarthritis
-Patellar bursitis
-Chronic left knee sprain
Osteoarthritis
What is a better term for Temporal Arteritis?
Giant cell arteritis.
What is Polymyalgia Rheumatica (PMR)?
A milder form of GCA with minimal vasculitis injury.
About 1/2 of individuals diagnosed with GCA were initially afflicted by what condition?
Polymyalgia Rheumatica (PMR).
How does PMR usually present clinically?
Gradual onset, bilateral pain and stiffness, morning stiffness and pain with movement, and normal muscle strength (low grade fever, weight loss, and fatigue may accompany muculoskeletal symptoms).
Swelling of hands and feet occur in some
What is the formal criteria for dx of PMR?
Bilateral pain, in association with morning stiffness, at least one month duration in any two of the following (neck, should girdle, and hip girdle), ESR > 40, Age greater than 50, exclusion of other diagnoses (except for Giant-Cell Arteritis), marked clinical improvement in response to 1 week of treatment with less than 15mg of prednisone per day.
Which of the following tests would be the LEAST useful in evaluating for suspected PMR?
-CBC with diff
-C-Reactive Protein
-Rheumatoid factor
-Antinuclear Antibody Test
-Erythrocyte sedimentation rate
CBC with diff.
What class of drugs usually manage Polymyalgia Rheumatica (PMR)?
Steroids
What would you worry about most in a patient requiring prolonged steroid therapy (1 to 2 years)?
Osteoporosis
In PMR, as the sedimentation rate falls and symptoms clear what should you do?
The steroids should be tapered slowly (e.g. 1 – 2.5 mg/d every 2 weeks).
What would happen with exogenous administration of corticosteroids, too much for too long?
The adrenal cortex atrophies (goes night, night).
50% of patients with GCA present with what sx?
Polymyalgia
What sx could you find in GCA in relation to the muscles of mastication?
Masseter claudication
What vessels of the eye can GCA effect?
Ophthalmic and/or posterior ciliary arteries
What is amaurosis fugax?
Transient blindness
GCA leads to what in 50% in untreated pts?
Vision loss
If histologic confirmation should be obtained even if we are strongly suspecting temporal arteritis, do we wait to initiate steroids?
No, the 1st priority is to establish control of the disease quickly to limit risk for irreversible blindness!
Will initiation of steroids interfere with results of a temporal artery biopsy?
No, high dose empiric steroid therapy for 1 to 2 weeks prior to biopsy will NOT compromise diagnosis
No single laboratory test can rule in or rule out Giant-Cell arteritis, therefore what is usually required?
Biopsy
What else causes fever other than infection?
Cancer and AutoImmune Dz
What is characteristic in kids with Kawasaki dz?
Persistently elevated, unexplainable fever for 5+ days.
Every kid with Kawasaki dz is at a high risk for what?
Kawasaki Disease is the leading cause of acquired heart disease in children in the US and Japan.
What is the leading cause of acquired heart disease in children in the US and Japan?
Kawasaki Dz.
What rx do we use to treat Kawasaki dz?
High-dose ASPIRIN (benefits outweigh the risks) and 2 days of IV immunoglobulin
What is Polyarteritis Nodosa in general?
A systemic necrotizing vasculitis that typically affects medium-sized arteries, with occasional involvement of small arteries
What viral infection is correlated with Polyarteritis Nodosa?
Hep. B
What is the preferred method for dx Polyarteritis Nodosa?
Biopsy
In the absence of an obvious site for tissue biopsy what is the second most perferred method for dx of Polyarteritis Nodosa?
Angiography (sometimes reveals microaneurysms of blood vessels in the renal, hepatic, or mesenteric circulations).
In which rheumatologic dz is poor sleep almost always present?
Fibromyalgia
What condition requires elicitation of pain by manual pressure at 11 or more defined tender points to be diagnosed?
Fibromyalgia
What is one of the safest, least invasive tx for fibromyalgia?
Exercise and cognitive behavioral therapy
Besides palliation of pain, in patients with fibromyalgia what other beneficial effects can the recommended psychotherapeutic drugs possess?
Can help alleviate depression and associated sleep problems.
What is the standard tx of chronic pain in fibromyalgia pharmacologically?
Any one or a combination of the following: Tricyclic Antidepressants (in combination with SSRIs), Gabapentin, and Anxiolytics.
Gout is secondary to what condition?
Purine metabolism disorders.
What are the two major etiologies of gout (preceded by purine metabolism disorders) and which one is more common?
Under-excretion of uric acid (most common, makes up 90% of all cases) and overproduction uric acid.
What drug decreases uric acid secretion?
Asprin
Asprin results in: a)Under-excretion of uric acid b)Overproduction uric acid
a)Under-excretion of uric acid
What drug is used in acute attacks of gout?
Colchicine
In gout prophylaxis, which drug affects overproduction uric acid?
Allopurinol
In gout prophylaxis, which drugs affect under-excretion of uric acid?
Uricosuric drugs
How do Uricosuric drugs work?
They decrease tubular uric acid reabsorption.
What are two common Uricosuric drugs?
Probenecid and sulfinpyrazone
How does Allopurinol work?
It is a Xanthine oxidase inhibitor (decreases production) which in turn lowers serum uric acid levels.
What are two major side effects of Allopurinol?
1) Leukocytosis 2) Decreased Renal function
What is pseudogout also known as?
Calcium Pyrophosphate Dihydrate Deposition (CPPD) (← yeah, that’s what it’s called CPPD [not CPDD]) disease. It is also known as chondrocalcinosis.
What will an x-ray of pseudogout reveal?
Radiologic findings: Chondrocalcinosis with calcium deposits in the tendons, ligaments, and cartilage.
What are some of the general characteristics of Polyarteritis nodosa?
1. Vasculitic dz involving medium-sized arteries.
2. Primarily affects middle-aged MEN.
3. Commonly affects the skin, joints, nerves, and kidneys.
What laboratory findings can help reach a diagnosis of Polyarteritis nodosa?
1. Lab: elevated ESR, leukocytosis, anemia, and thrombocytosis.
2. Urinalysis: positive for protein and blood if kidneys are involved.
3. Diagnosed by tissue biopsy.
What are two major complications associated with Polyarteritis nodosa?
1. Aneurysms
2. Areas of vessel occlusion
What is the standard of pharmacologic tx in Polyarteritis nodosa?
1. Steroids
2. Immunosuppressive therapy
What is Polymyositis in general?
An acquired, systemic connective tissue disease.
What happens to the subchondral bone in Rheumatoid Synovium (part of RA)?
It is destroyed as osteoclasts and osteoblasts are simultaneously activated by synovial cytokines.
What connective tissues does rheumatoid synovium (in RA) destroy?
Cartilage and tendons.
What do the cytokines IL-1 and TGF-alpha do in RA?
Cause synovial and chondrocyte proliferation.
What is Rheumatoid Factor (RF)?
An IgM autoantibody that attacks IgG.
What type of hypersensitivity is associated with RF?
Type 3, "antigen antibody complexes"
What type of hypersensitivity is GCA?
Type 4, (lymphocyte) "cell-mediated hypersensitivity."
What is tophi and what rheumatologic disease is it associated with?
1) Crystallised monosodium urate deposits in the joints, cartilage, bones, and other places throughout the body.
2) Gout
What is the most common joint affected by gout?
MTP joint
Who is most commonly affected with gout?
Men over 40
What are some major risk factors for gout?
-Heredity
-Obesity
-High levels of meat and seafood consumption
-Alcohol (particularly beer, increases urate production and decreases renal excretion of uric acid)
-Trauma
-Diuretics (inhibit renal excretion of uric acid)
-ASA (precipitates uric acid)
-Rapid changes in serum urate level (Surgery, Drinking bouts, Dehydration, Therapy with allopurinol)
What other conditions is gout associated with?
Renal insufficiency, Pre-eclampsia/eclampsia, Hypothyroidism, and Malignancies (Myeloma or Lymphoma).
What is uric acid?
The metabolic breakdown product of purine metabolism.
Where is uric acid (or any water soluble solute) filtered at?
The glomerulus.
Where is uric acid (or any water soluble solute) reabsorbed?
In the proximal tubule.
Where is uric acid (or any water soluble solute) actively secreted?
In the distal tubule and collecting tubule.
Why are the lower extremities predominantly afflicted in gout?
Gravity.
T/F
Gout patients will almost always present afebrile.
False. (Low grade fever is common)
What is podagra?
Gout of the foot (typically in the big toe).
What is the most common digit affected by gout?
The Big toe (MTP).
Besides uric acid crystals, what other atypical arthrocentesis findings will you see in gout?
~10,000 WBC’s, 90% PMN’s
T/F
Needle shaped negatively birefringent crystals are Pathognomonic for and essential to the definitive diagnosis of acute gout.
True.
You order an x-ray for a patient and you observe “rat bite” marginal joint erosions with sclerotic borders on the radiograph, what is #1 in your differential?
Gout.
In gout, tophi can deposit on all visceral organs except which ones?
Muscle, liver, spleen, and lung (also, none in the CNS).
What is the precipitation of uric acid crystals in a protein matrix in renal pelvis, ureters, or bladder?
Uric acid urolithiasis.
What joints are most commonly affected in pseudogout?
The large joints (i.e. unilaterally in the: knees, ankles, triangular fibrocartilage of the wrists, and symphysis pubis).
In pseudogout, what is the definitive dx test and what lab results will you see?
1) Arthrocentesis.
2) Intracellular, positively birefringent, rhomboid-shaped crystals in synovial fluid aspirates
What is Chondrocalcinosis?
The presence of calcium-containing salts in the articular cartilage.
T/F
Elevated serum urate levels are pathognomic for pseudogout.
False.
What are the standard tx for pseudogout?
NSAIDS and Intra-artiuclar corticosteroids
An asymptomatic patient presents to your clinic for a a physical and you order a general lab work up. Her/his labs show an elevated uric acid level in the blood (Hyperuricemia). Should you start this patient on a drugs to either correct the hyperproduction and/or hypoexcretion of uric acid?
No.
What is Osteoarthritis?
A degenerative joint disease, characterized by whole joint failure, with deterioration in most joint structures, including cartilage, bone, synovium and joint capsule.
What is the most common joint disorder, occurring radiologically in 60-90% of individuals older than 45, and symptomatically with increasing age.
Osteoarthritis
Knee OA more debilitating in which population?
African American women.
Hip OA more prevalent in which population?
Asian populations.
OA is more common in which gender after 55 years old?
Women.
What is the cardinal feature of OA?
Progressive loss of articular cartilage with associated remodeling of subchondral bone.
When does pain most commonly occur in OA?
Evening.
What hand joints are commonly affected in OA?
Distal interphalangeal (DIP, hands) joints, Proximal interphalangeal (PIP, hands), Carpometacarpal joint (CMC, at the base of the thumb).
What is the best way to see patellofemoral disease radiologically?
Sunrise view (knee x-ray).
What type of decreased ROM is in the hip in OA?
Loss of internal rotation during flexion.
What type of pain is associated with the cervical spine in OA?
Radicular pain.
What types of neck motion are especially restricted in OA?
Lateral flexion and extension.
What radiologic findings could you find in OA?
Irregular joint space narrowing, Sclerosis of subchondral bone, Bony cysts, Marginal osteophytes, Buttressing of adjacent bone.
What is a common intraarticular procedure is used to improve viscosity and elasticity of synovial fluid?
Hyaluronic acid to knees (Synvisc).
Who does RA affect most?
Women in their 3-5th decades.
What population is least affected by RA?
Asians.
What is the hallmark of joint involvement in RA?
Synovial pannus formation.
What is a synovial pannus formation?
The destructive vascular granulation tissue extending from the synovium to involve the "bare area" (a region of unprotected bone at the junction between cartilage and subchondral bone).
Where does the pannus invade?
At bone-cartilage-synovium interface.
For tx of RA, what is the best order?
DMARDs, NSAIDs, Biological Agents, Leukocorticoids, and Combo Therapy.
1. NSAIDs
2. Steroids
3. DMARDs
4. Biological Agents
5. Combination Therapy
What are the clinical features of RA?
Symmetrical polyarthritis involving, typically, the small joints of the hands and feet, wrists and ankles.
What sized arteries do the following conditions mainly affect?
Raynaud's Phenomenon
Anaphalyaxis
Polyarthritis Nodosa
Raynaud's Phenomenon- small arteries
Anaphalyaxis- LARGE Arteries
Polyarthritis Nodosa- Medium Arteries
T/F
Distal phalanges are usually affected in RA.
False (distal phalanges rarely affected).
Where do we typically see Rheumatoid nodules in RA?
Elbows.
RA increases the risk for what category of disease?
Vascular Diseases (inc. risk for CVD, Atherosclerosis, renal artery disease, Vasculitis, etc.)
In which rheumatologic dz can we see muscle atrophy leading to imbalance of opposing muscle?
RA
What wrist/hand sx are commonly seen in RA?
Ulnar deviation of the MCP joints, Boutonnier deformities of PIP joints, Swan neck contractures of the fingers, Permanent loss of wrist extension, Boggy tender dorsal wrist mass may lead to reversible carpal tunnel syndrome, and Nerve damage may cause wasting of the thenar eminence.
What is pannus? (simple definition)
A growth composed of thickened synovial tissue.
What are the criteria required for diagnosis of RA?
1. Morning stiffness lasting 1 hour or more
2. Arthritis in at least 3 joints
3. Arthritis of hand joints
4. Symmetrical arthritis
5. Rheumatoid nodules
6. Positive RA test
7. X-Ray changes typical of RA
T/F
A negative RF will rule out RA.
False
T/F: DMARDs are able to reverse the damage caused by Rheumatoid Arthritis.
False. DMARDs slow the damaging processes of RA. However, damage that has already occurred is permanent.
Name the TNF inhibitor that can only be used in combination with methotrexate in treating Rheumatoid Arthritis.
Infliximab (Remicade)
Name a medicine that may cause lupus-like symptoms.
Procainamide
Hydralazine
T/F: In general, androgens tend to stimulate the immune response whereas estrogen is immunosuppressive.
False: Estrogen is able to stimulate the immune response. Androgens are considered immunosuppressive. This is why so many autoimmune diseases are more common in women.
Which of the following HLA genes are associated with Rheumatoid Arthritis? Lupus?

DR1, DR2, DR3, DR4, B27
DR2 and DR3 are associated with lupus. DR1 and DR4 are associated with RA. B27 is associated with something else that I can't remember!
Which of the following best describes scleroderma?
a) IgM antibodies are formed against IgG and deposit in the joint
b) it is considered the "great imitator"
c) development of a "pannus" in the joint space
d) fibroblast dysregulation
d is correct. a and c describe rheumatoid arthritis. b refers to lupus.
In which of the following samples of synovial fluid would you expect to find the highest number of WBCs?
a) osteoarthritic joint
b) Reiter's syndrome/Reactive Arthritis
c) joint affected by RA
C.
Which of the following labs/tests would be considered "acute phase reactants"? CBC w/diff, CCP antibody, ESR, complement/C3/C4, CRP, ANA, serum albumin
ESR, CRP, C3/C4
What is the one single test that can definitively diagnosis SLE?
Trick question. There isn't one test that can do this. You must look at the complete picture.
What percentage of people 45 years old and older have radiological evidence of osteoarthritis?
a) 10-20%
b) 25-50%
c) 60-90%
c. can you believe it? of course we don't actually have these x-rays of everyone, but if we did these are the numbers. Fortunately, most people will not have symptoms for a long, long time if ever.
What other lab test can be better than RF in diagnosing RA?
Anti-cyclic Citrullinated Peptide (anti-CCP).
T/F
Anti-CCP antibodies and RF indicate a mild, early RA prognosis.
False.
Anti-CCP antibodies and RF indicate a worse prognosis.
What could we possibly find in the synovial fluid in RA?
Exudate, WBC (5000-20,000), Predominance of PMN’s (80% or more), Protein > 3.5 g/dl., Glucose low to normal.
You have a pt who presents with arthritis. You decide to do an x-ray and the radiograph reveals: soft tissue swelling, onset of pannus in joint margin, uniform joint space narrowing. What is highest on your differential?
RA
What are some Non-Pharmacologic Measures that you can use to treat RA?
Exercise (early PT, OT), Rest and splinting, Dietary Measures and supplements (Diet free of additives, preservatives, fruit, red meat herbs and dairy products; Adequate calcium and Vitamin D intake; Fish Oil supplements).
Which rheumatologic dz is also known as the “great imitator”? Why?
SLE.
Because it affects may different body systems.
What type of hypersensitivity is SLE?
Type 3 hypersensitivity
What anti-nuclear antibodies (ANA) are associated w/ SLE?
Anti dsDNA [BEST!] (ds- double stranded) (anti-deoxyribonuclic acid); Anti ssDNA (ss- single stranded) (Anti-deoxyribonuclic acid); Anti Sm (Smith).
You suspect a rheumatologic disease and order an ANA panel. It is positive for the following: Anti dsDNA; Anti ssDNA; and Anti Sm. What is the biggest blip on your radar screen?
SLE
Before you give a TNF inhibitor what do you have to test for?
TB
Which feature is most closely associated with pseudogout?
a. osteophytes
b. negatively birefringent crystals
c. positively birefringent crystals
d. needle-shaped crystals
c.
T/F. Bouchard's nodes are found on the PIP joints of people suffering from Rheumatoid Arthritis.
False. Bouchard's nodes are found on the PIP joints of people suffering from osteoarthritis. In RA the nodes on the PIP are Boutenniere deformities.
What is the best treatment course for a person with Asymptomatic Hyperuricemia?
Do not treat asymptomatic hyperuricemia. In fact, you pretty much do not treat asymptomatic anything. However, in someone with a family history of gout you may want to do some prophylaxis.
What is Libman-Sacks Endocarditis?
Warty, rough appearing deposits (Verruca) on the heart valves. (Seen in SLE)
What can make blood more coagulatable in SLE?
Anti-phospholipid antibodies.
Why could the PTT be prolonged in SLE?
Anti-phospholipid antibodies.
What are some of the major physical findings in SLE?
Butterfly (malar rash)‏, Hypertension, Alopecia, and Discoid lesions.
You diagnose a pt w/ SLE. When you educate you patient what are some major points that you want to stress?
Wear sunscreen and protective clothing in the sun, wear protective and warm clothing in the cold, avoid vasoconstrive drugs, give psychologial support, and get routine immunizations.
T/F
Oral Contraceptives with high dose estrogen can be safely used in patients with Raynaud's and/or antiphopholipid antibodies.
False.
Oral contraceptives w/ high dose estrogen should NOT be used and OCP not at all in pts w/ migraines, Raynauds, phlebitis or antiphopholipid antibodies
What are the standard rx tx for SLE?
-NSAIDs
-Glucocorticoids (topical and systemic)
-Antimalarials
-Immunosuppresants
-IV Immunoglobulin
-Plasmapheresis (lupus nephritis)
What are the most common culprits for Drug Induced Lupus Syndromes?
Procainamide and hydralazine.
What 2 classes of drugs show a definite association with Drug Induced Lupus Syndromes?
Antihypertensives (Hydralazine and Methyldopa); Antiarrhythmics (Procainamide and Quinidine).
The goals of management in Discoid Lupus?
Improve the patient's appearance, to control existing lesions and limit scarring, and to prevent the development of further lesions.
What therapies are usually effective in the tx of Discoid Lupus?
Sunscreens, topical corticosteroids, and antimalarial agents.
Manifestation of what 4 sx constitutes dx of RA?
Morning stiffness (at least 6 mos)‏
Arthritis in 3 or more joint areas of 14 possible areas (at least 6 mos)‏
Arthritis of hand joints (at least 6 mos)‏
Symmetric arthritis (at least 6 mos)‏
Rheumatoid nodules
Serum RF (20% are neg for this)
Radiographic changes
If a pt presents with any 4 of the following sx what do they most likely have?
Morning stiffness (at least 6 mos)‏
Arthritis in 3 or more joint areas of 14 possible areas (at least 6 mos)‏
Arthritis of hand joints (at least 6 mos)‏
Symmetric arthritis (at least 6 mos)‏
Rheumatoid nodules
Serum RF (20% are neg for this)
Radiographic changes
RA
A highly sensitive test is used for ruling____?
A highly sensitive test is used for ruling out (SNOUT).
A highly specific test is used for ruling____?
A highly specific test is used for ruling in (SPIN).
C-Reactive Protein (CRP)‏ is produced in response to_______?
Produced in response to inflammation
(Infections or Long-term chronic inflammatory illness).
An elevation of both ESR and CRP are strong evidence for what?
An autoimmune disease.
The presence of very high concentrations of ANA, a titer greater than 1:___, arouse suspicion of autoimmune disorder.
titer > 1:640
What conditions may the RF be elevated in?
RA, SLE, Sjogren's syndrome, malaria, rubella, and hepatitis C (and following some vaccinations).
What is a critical uric acid lab value?
>12.0 mg/dL
What syndromes are seen with HLA-B27?
Ankylosing spondylitis, Reactive arthritis (Reiter’s syndrome), Enteropathic spondylitis, and Psoriatic spondylitis.
What does C.R.E.S.T. stand for in Crest syndrome?
Calcinosis
Raynaud’s syndrome
Esophageal dysmotility
Sclerodactyly
Telangiectasia
What %age of patients with Scleroderma will have eosinophilia?
100%
What ANAs are associated with Sjögren’s Syndrome?
Anti-Ro (SS-A), Anti-La (SS-B).
In which rheumatologic dz do you usually see "bamboo spine" on the radiograph?
Ankylosing spondylitis.
What is "bamboo spine"?
Ossification of the annulus fibrosis.
What are some of the main goals of treatment in gout?
End the painful attack as quickly, Prevent further attacks, and Prevent complications of gout.
What are the 3 primary stages in the mgmt. of gout?
(1) treating the acute attack.
(2) providing prophylaxis to prevent acute flares.
(3) lowering excess stores of uric acid to prevent flares of gouty arthritis and to prevent tissue deposition of uric crystals.
What Anti-inflammatory agents are commonly used to treat gout?
NSAIDs, COX 2 inhibitors, Colchicine,
and Glucocorticoids.
What NSAIDs are commonly used to treat gout?
Indomethacin (Indocin), Ibuprofen, and Naproxen (Aleve).
T/F
Colchicine is used to treat acute flares of gout as it dramatically decreases uric acid levels.
False.
Colchicine has no effect on urate levels, just inflammation.
When should Colchicine not be used?
When a glomerular filtration rate (GFR) is less than 10 mL/min.
What gout tx medication should you get a CBC, liver, and renal functions prior to initiating and monitor for the first several months of treatment?
Allopurinol (Zyloprim)
What drugs does Allopurinol (Zyloprim) interact with?
Ampicillin (rash), Warfarin, and Immunosuppressants.
How does Probenecid work?
Inhibits renal tubular reabsorption of uric acid (Uricosuric agent, good for under-excretors).
Why must you ensure proper hydration in pts taking Probenecid?
Because kidney stones can form.
What are the goals of tx for Osteoarthritis?
The goals of treatment are pain alleviation and improvement of functional status.
What rx should you begin treating OA with?
Begin with Acetaminophen
When treating with generic nonselective NSAID’s what should you consider treating with to combat side effects?
PPI or Cytotec if needed for GI protection.
When treating OA should you use systemic glucocorticoids?
No Way Jose! Do not use systemic glucocorticoids; they have no role in the management of OA. However, you may want to contemplate intraarticular injections of glucocorticoids to improve symptoms.
What route of administration for steroids could you consider in the tx of OA?
Contemplate intraarticular injections of glucocorticoids to improve symptoms. (But not systemic glucocorticoids)
How does glucosamine work?
Stimulated chondrocytes to produce proteoglycans.
How does chondroitin work?
Promotes joint viscosity and cartilage repair; Prevents degradation of cartilage.
What is a major contraindication for administration of chondroitin?
Sea food allergies (Chondroitin is shark cartilage).
What are the main NSAIDs used to treat RA?
-Ibuprofen, Aleve, ketoprofen, etc.
-Cox 2 inhibitors
-Celebrex
What does SAARDs stand for?
Slow acting anti-rheumatic drugs.
What is the recommended pyramid approach to RA pharmacologic tx?
1. NSAIDS (right away)
2. DMARDS (within 3 months of diagnosis)
3. Combination therapy (for later stages or refractory RA)
What type of drug are DMARDs?
Immunosuppressant
What baseline labs should you order before rx of DMARDs?
-CBC with differential
-Renal and liver function
-Rheumatoid factor
-ESR
-CRP
What are the first line synthetic DMARDS (Xenobotics) in the tx of RA?
Methotrexate, Sulfasalzine, and Plaquinil
What is the most commonly used DMARD?
Methotrexate.
Which DMARD should also have concurrent use with Folic Acid to minimize side effects?
Methotrexate.
When you prescribe a patient Methotrexate, what supplement should you recomend?
Folic Acid.
What are the two major contraindications for Methotrexate use?
Renal dysfunction and Pregnancy. (Also no ETOH)
Regular ophthalmologic screening is recommended with long term use with what drug?
Hydroxychloroquine (Plaquinil)
What is the major contraindication of Hydroxychloroquine (Plaquinil)?
Pre-existing retinal field changes.
Leflunomide (Avara) is a long acting drug, what medication may need to be administered to eliminate it?
Cholestramine.
What are the contraindications of use with TNF inhibitors?
-Documented hypersensitivity
-Sepsis
-Pre-existing infections
-Use of concurrent live vaccination
What is the American College of Rheumatology's recommended "treatment pyramid" for RA?
-ASA
-NSAIDS
-Glucocortocoids (fast acting)
-DMARDS – early initiation
-Biological agents
-Combinations
What medication may need Cholestramine administeration to be eliminated?
Leflunomide (Avara).
What is Fibromyalgia?
Chronic widespread musculoskeletal pain syndrome with multiple tender points. Disorder of pain regulation.
Corticosteroids and Antimalarials are not typically used in the tx of what?
Psoriatic Arthritis.
In what rheumatologic dz can you see the following radiologic findings?:
Pencil-in-cup deformity, “Fluffy” periosteal new bone, and Marginal erosions of bone and irregular destruction of joint and bone.
Psoriatic Arthritis.
CREST syndrome is part of what diseases?
Scleroderma and systemic sclerosis.
What is dactylitis?
Sausage digits.
What happens in enthesitis?
Tendons join to bones.
What is Livedo reticularis? What rheumatologic condition is it related to?
Vascular condition characterized by a purplish mottled discoloration of the skin, usually on the legs.
SLE.
What are the major side effects Glucocorticoids?
Adrenal cortex atrophy (night, night), osteoporosis, increased blood sugar, increased bp, osteoporosis, weight gain, appetite increased, and cataracts .
What is the major treatment goal for Ankylosing Spondylitis?
Symptomatic relief.
“BAMBOO SPINE.”
Ankylosing Spondylitis.
What dz awakens the pt because of pain during the 2nd half of the night?
Ankylosing Spondylitis.
What are the main features of generalized connective tissue disorders?
-Raynaud phenomenon
-Absence severe renal & CNS dz
-Severe arthritis/pulmonary HTN
-Autoantibodies (anti-U1 RNP)
A 28 y/o male presents with low back pain of 4 months duration that improves with exercise. He also has left intermittent buttock pain and early morning stiffness lasting more than 30 minutes. What is the most likely diagnosis?
Ankylosing Spondylitis
Which of the following DMARD is not a TNF inhibitor

A) Entanercept (Enbrel)
B) Infliximab (Remicade)
C) Sulfasalazine (Azulfidine)
D) Adalimumab (Humira)
C) Sulfasalazine (Azulfidine)
Which of the following DMARD is a antimalarial?

Methotrexate (Rheumatrex)
Hydroxychloroquine (Plaquenil)
Sulfasalazine (Asulfidine)
Leflunomide (Avara)
Hydroxychloroquine (Plaquenil)
Which of the following medications would require a PPD before administering?

Hydroxychloroquine (Plaqueni)
Infliximab (Remicade)
Methotrexate (Rheumatrex)
Anakinra (Kineret)
Infliximab (Remicade)
Which of the following DMARD might require co-administration of Cholestryamine due to it’s long half life??

Adalimumab (Humira)
Leflunomide (Avara)
Penicillamine
Cyclosporine
Leflunomide (Avara)
Which of the following medications should NOT be used to in the treatment of an acute gout attack?

Indomethacin
ASA
Colchicine
Celebrex
ASA
Which medication for gout is a urate blocking agent??

Colchicine
Allopurinol (Zyloprim)
Probenecid
Sulfinpyrazone (Anturane)
Allopurinol (Zyloprim)
Which of the following medications has no place in the treatment of osteoarthritis?

Tramadol (Ultram)
Hydrocodone (Vicodin)
Intraarticular steroid injection
Systemic steroids (Prednisone)
Systemic steroids (Prednisone)
Which of the following medications as use for Viscosupplementation for the treatment of osteoarthritis?

Glucosamine
Capsaicin
Synvisc
Methlyprednisone
Synvisc
A 74 year old female is being treated for Temporal Arteritis/Giant cell arteritis. What consequence of this medication would we have to give prophylaxis for??

Blindness
Osteoporosis
GI bleed
Diarrhea
Osteoporosis
HLA-B27 is consistent with all of the following except?

Reiter’s syndrome (Reactive Arthritis)
Rheumatoid Arthritis
Psoriatic Arthritis
Ankylosing Spondylitis
Rheumatoid Arthritis
What characteristic xray finding is seen with ankylosing spondylitis??

Pannus
Bamboo spine
Osteophytes
Kyphosis
Bamboo spine
Reiters syndrome is most commonly associated with which infectious process?

Meningitis
Pneumonia
Chlamydia
Gonorrhea
Chlamydia
A patient presents with complaints of having trouble lifting her both her arms to comb her hair. You notice she has a purplish rash on both of her eyelids. She also points out a rash on her shoulders and upper chest. Based on this info, what lab tests would you run?

CBC and TSH
CBC and ANA
CPK, aldolase and ANA

What do you think she has??
-CPK, aldolase and ANA

-Dermatomyositis
Which disease exhibits the following:
Calcinosis
Raynauds
Esophageal motility disorder
Sclerodactyly
Telaniestasia
Scleraderma
Which of the following diseases are antigen-antibody complexes deposited along basement membranes of vasculature and tissue?

Rheumatoid Arthritis
Systemic Lupus
Psoriatic Arthitis
Raynauds
Systemic Lupus
A patient presents with complaints of morning stiffness in her MCP and PIP joints. The presentation is symmetrical. Palpation reveals a “gelling” feeling in those affect joints.

What do you think this is??
Rheumatoid Arthritis
Would ordering a Rheumatoid Factor be sufficient for positive diagnosis?
Not in itself
In trying to determine if the patient has RA or Osteoarthritis based on an xray of the affected joint, what would you expect to see with OA??

Name four things
-Osteophytes
-Irregular joint spaces
-Erosion of bone
-Joint space narrowing
What would you expect to find in a patient with RA?

Name three things
-Pannus formation
-Soft tissue swelling
-Uniform joint space narrowing
All are associated features of SLE except:

Raynauds phenomenon
Malar rash
Livedo rectiularis
Sausage toes
Sausage toes
Which of the following ANA presentations are most specific for SLE??

dsDNA
ssDNA
SmDNA
Anti-Ro
dsDNA

SmDNA
Which type of lupus would the patient likely have plaque-like lesion on head, scalp and neck, which could later scar?

Drug induced lupus
Discoid lupus
Discoid lupus
What is the most dreaded complication of temporal arteritis??

Renal failure
Blindness
Carotid artery stenosis
Inability to chew
Blindness
Which of the following vasculopathies has an association with Hep B

Kawaski’s
Polymyalgia Rheumatica
Polyarteritis nodosa
Wegners Granulamatosis
Polyarteritis nodosa
The most common dz associated with secondary SS is what?
RA
Patient complains of deep pain and stiffness in her right hand, especially after activity. You notice some nodules on her PIP joint. Palpation reveals crepitus.

What do you think she has??
OSTEOARTHRITIS
Would serologies show anything definitive??

What are the nodes called??

Would she be a candidate for treatment with steroids???
No.

Heberden’s nodes - bony protuberances in the DIP
Bouchards nodes – PIP deformities

ABSOLUTELY not
Which of the following is not a seronegative spondyloarthropathy??

Psoriatic Arthritis
Rheumatoid Arthritis
Ankylosing spondylitis
Reiters Syndrome
RA
Mom brings her 3 year old in because he has a fever of 39.9. He is crying and you notice a “strawberry tongue” and a maculopapular rash on his trunk. He has enlarged cervical lymph nodes.

What do you suspect??
Kawasaki’s
What is a major complication of Kawasaki’s?
-Coronary arteritis
-Coronary problems
What disease process would you see needle like negative birefringent sodium urate crystals????
Gout
Your 28 y/o male patient presents with
Urethritis
Conjunctivitis (or, less commonly, uveitis)
Weight loss and dysruia
He also has sores on the soles of his feet he says have been getting worse. Possible DX?

Would a particular HLA be suggestive??
Reiter’s Syndrome – Reactive Arthritis

HLA-B27
36 y/o female with HX SLE complains of dry mouth and itching eyes with roping excretions in the AM. She thinks she has conjunctivitis. What might she have??

What anitibodies might show up if we did an ANA??
Sjogren’s Syndrome

Anti-Ro
What specific lab would we draw if we suspected dermatomyositis in a patient who complains of a rash on the back of her hands along with proximal muscle weakness that makes it impossible for her to walk up the 3 steps to her doorway.
CPK
What disease process would you see rhomboid positive birefingent sodium urate crystals???
HHHMMMM?? Think!!!!!
Trick question!!!

-There is no disease with rhomboid positive birefringent SODIUM urate Crystals.

-Pseudogout would show rhomboid shaped positive birefringent calcium crystals
Low dose ASA, EtOH, caffeine and vitamin C each increase or decrease uric acid levels?
increase
High dose ASA, estrogens, diuretics and corticosteroids each increase or decrease uric acid levels?
decrease
T/F. Xersotomia is painful.
F. A dry mouth is not a painful mouth. Think candidiasis.
T/F. Sicca symptoms are a common complaint of the elderly.
T. But most of them DO NOT have Sjogren's.
In patients with systemic sclerosis, Raynaud's phenomenon (secondary) can lead to what?
Ulcerations, digital, infarction, and gangrene.
Inflammatory processes increase or decrease C3 and C4?
increase
What are some major side effects from Colchicine in patients with renal or hepatic insufficiency?
-Bone marrow suppression
-Myopathy
-Neuropathy
When is Prophylactic Therapy for gout necessary?
After a patient starts having 2 or 3 attacks per year, particularly if the attacks are debilitating.
What are some of the drugs that Probenecid interacts with (Drug-Drug interactions)?
PCN, Rifampin, Thiazides, and low dose ASA.