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31 Cards in this Set

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1. What is the most common form of arthritis?
Osteoarthritis (at least 75% of cases), which is also called "degenerative" joint disease. Degenerative joint disease of the knee. Significant joint space narrowing at the medial compartment of the knee is combined with osteophyte formation at the medial tibia] plateau and femoral condyle. The joint space narrowing results in varus alignment at the knee (normal = slight valgus alignment).
2. If the cause of arthritis is in doubt, what should you do?
When in doubt, or if you suspect something other than osteoarthriti, perform an x-ray of and aspirate fluid from the affected joint. Examine the fluid for cell count and differential, glucose, bacteria (Gram stain and culture), and crystals.
3. How do you distinguish among the common causes of arthritis?
OA RA GOUT PSEUDOGOUT SEPTIC Usual age/sex Older adults Women 2045 y.o. Older men Older adults Any age Classic joints DIE PIE hip, PIP, MCE wrist Big toe Knees, elbows Knee knee Joint fluid WBC < 2,000 > 2,000 > 2,000 > 2,000 >50,000 % Neutrophils < 25% > 50% > 50% >50% > 75% OA = osteoarthritis, RA = rheumatoid arthritis, DIP = distal interphalangeal joints, PIP = proximal interphalangeal joints, MCP = metacarpophalangeal joints, WBC = white blood cells.
4. What other clues point to a diagnosis of osteoarthritis?
Osteoarthritis typically occurs in those over the age of 40 and has few signs of inflammation on exam, thus the joints are not hot, red, or tender like in the other four types of arthritis above. Look for Heberden's nodes (visible and palpable distal interphalangeal joint [DIPs] osteophytes) and Bouchard's nodes (proximal interphalangeal joint [PIPs] osteophytes), worsening of symptoms after use and in the evening, bony spurs, and increasing incidence with age. Treat with weight reduction and as-needed nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen.
5. What clues point to a diagnosis of rheumatoid arthritis?
Rheumatoid arthritis often causes systemic symptoms (fever, malaise, subcutaneous nodules, pericarditis or pleural effusion, uveitis), prolonged morning stiffness, and swan neck and boutonniere deforaties. The buzz word is pannus (articular cartilage that looks like granulation tissue due to chronic inflammation). The diagnosis is often made by a positive rheumatoid factor, which is present in most adults but often negative in children. Radiographs can also support the diagnosis. Treatment includes pain control (NSA1Ds) and disease-modifying agents such as hydroxychloroquine. Etanercept and infliximab are newer disease-modifying anti-tumor necrosis factor-alpha agents.Sulfasalzine,penicillamine, gold salts and corticosteroids have also been used with varying success.
6. What clues point to a diagnosis of gout?
Gout classically begins with podagra (gout in the big toe). Also look for high uric acid levels (not always present), tophi (subcutaneous uric acid deposits that look like punched-out lesions on bone radiographs), needle-shaped crystals (often inside leukocytes) in joint fluid with negative birefringence, and male gender (more commonly affected than female gender). Alcohol and protein-rich foods may precipitate an attack. Colchicine or NSAIDs (but not aspirin, which causes decreased excretion of uric acid by the kidney) are used for acute attacks. For maintenance therapy, high fluid intake, alkalinization of the urine, and/or probenicid or allopurinol neither drug is for acute attacks) may be used.
7. What causes pseudogout? How is it diagnosed?
Pseudogout is caused by deposition of calcium pyrophosphate crystals into joints. Look for rhomboid crystals with weakly positive birefringence (vs. negative birefringence with gout crystals).
8. What clues point to a diagnosis of septic arthritis? What are the common causes?
In septic arthritis, Gram stain usually reveals bacteria in the synovial fluid. Staphylococcu. ureus is the most common organism except in sexually active young adults, in whom the most common bug is Neisseria gonorrhoeae. Do blood cultures in addition to joint cultures, because the bug usually reaches the joint via the hematogenous route. Also do urethral swabs and cultures in appropriate patients.
9. Name some other causes of arthritis.
* Prior trauma * Lupus and other collagen vascular diseases (e.g., scleroderma) * Psoriasis *Inflammatory bowel disease *Lyme disease *Ankylosing spondylitis *Reiter syndrome *Hemophilia *Paget disease *Hemochromatosis, Wilson disease *Neuropathy (i.e., Charcot joint)
10. True or false: Psoriasis can cause an arthritis that resembles osteoarthritis.
False. The arthritis resembles rheumatoid arthritis. On the Step 2 exam, look for psoriatic skin lesions to make an easy diagnosis (see figure). The arthritis usually affects the hands and feet and though it resembles rheumatoid arthritis, the rheumatoid factor is negative. Treat with rheumatoid arthritis agents (e.g., NSAIDs, gold, penicillamine, corticosteroids).
11. Describe the hallmarks of ankylosing spondylitis.
Ankylosing spondylitis is associated with human leukocyte antigen B27 (HLA-B27). Most often a 20- to 40-year-old man with a positive family history presents with back pain and morning stiffness. Patients may assume a bent-over posture. The sacroiliac joints are primarily affected, and radiographs may reveal a "bamboo" spine (see figure). Patients have other autoimmune type symptoms, such as fever, elevations in erythrocyte sedimentation rate and C-reactive protein, and anemia. Some develop uveitis. Treat with exercise and NSAIDs.**Ankyklosing spondylitis--bamboo spine. Note the lateral marginal syndesmophytes and the longitudinal ligament calcification resulting in the bamboo appearance.**Psoriasis. The limbs are usually affected, as shown. Lesions are typically clearly delineated, deep red in color, and have a silvery scale.
12. How do you recognize Reiter's syndrome as the cause of arthritis?
Reiter's syndrome also is associated with HLA-B27. The classic triad of symptoms consists of urethritis (due to chlamydial infection), conjunctivitis, and arthritis ("can't pee, can't see, can't climb a tree"). Reiter's syndrome may also follow enteric bacterial infections. Superficial oral and penile ulcers are common. Diagnose and treat the sexually transmitted disease, and use NSAIDs for arthritis. Also treat the patient's sexual partners.
13. Why do patients with hemophilia get arthritis?
Recurrent hemarthroses (bleeding into the joints), which can cause a debilitating arthritis. Treatment is with acetaminophen, due to bleeding concerns with aspirin and other NSAIDs.
14. What clues point to Lyme disease as the cause of arthritis?
Look for a history of a tick bite or hiking in the woods, erythema chronicum migrans rash, and migratory arthritis (later). Treat Borrelia burgdoferi, the causative bacteria of Lyme disease, with doxycycline or tetracycline. Use amoxicillin in pregnant patients.
15. True or false: One of the major Jones criteria for the diagnosis of rheumatic fever is arthritis.
True. Migratory polyarthritis is one of the major Jones criteria. Look for a history of strep throat.
16. Why do patients with sickle cell disease often have arthritis?
Patients frequently experience arthralgias (pain) from ischemic sickle crises, but the classic cause of arthritis is avascular necrosis (e.g., hip arthritis from avascular necrosis of the femoral head).
17. Define Charcot joint. What clues point to its presence?
A Charcot joint is seen most commonly in diabetes but also occurs in other neuropathies. A lack of sensation causes the patient to overuse or misuse joints, which become deformed and painful. The best treatment is prevention. After even seemingly mild trauma, patients with neuropathy in the area of the trauma need radiographs to rule out fractures.
18. What about lupus erythematosus and other autoimmune disorders as a cause of arthritis?
With lupus ethematosus, inflammatory bowel disease, and other autoimmune diseases. Symptoms of the primary disease help make these diagnoses on the USMLE exam.
19. How do hemochromatosis and Wilson disease cause arthritis?
Via deposition of excessive iron or copper into the joints.
20. What generalized systemic signs of inflammation may suggest an autoimmune disorder?
Systemic signs and symptoms of inflammation include elevations in erythrocyte sedimentation rate and C-reactive protein, fever, anemia of chronic disease, fatigue, and weight loss. If these symptoms are present in a woman of reproductive age, you should consider the possibility of an autoimmune disease.
21. Describe the hallmarks of systemic lupus erythematosus (SLE).
SLE can cause malar rash, discoid rash, photosensitivity, kidney damage, arthritis, pericarditis and pleuritis, positive antinuclear antibody (ANA). positive anti-Smith antibody, positive syphilis results (on the Venereal Disease Research Laboratory and rapid plasmin reagin screening tests), positive lupus anticoagulant, blood disorders (thrombocytopenia, leukopenia, anemia, or pancytopenia), neurologic disturbances (depression, psychosis, seizures), and oral ulcers. Any of these may be presenting symptoms. Use the ANA titer as a screening test, and confirm with the anti-Smith antibody test. Treat with NSAIDs, hydroxychloroquine, and corticosteroids.
22. Describe the hallmarks of scleroderma.
Scleroderma (also known as progressive systemic sclerosis) classically presents with CREST symptoms (calcinosis, Raynaud's phenomenon, esophageal dysmotility with dysphagia, sclerodactyly, and telangiectasia), heartburn, and mask-like, leatheT facies. Use the ANA test for screening; confirm the diagnosis with the anticentromere antibody test (for CREST symptoms only) and the antitopoisomerase antibody (for full-blown scleroderma). Corticosteroids may help.
23. What are the hallmarks of Sjgren syndrome?
Sj6gren syndrome causes dry eyes (keratoconjunctivitis sicca) and dry mouth (xerostomia) and often is associated with other autoimmune diseases. Treat with eye drops and good oral hygiene.
24. What are the signs and symptoms of dermatomyositis?
Dermatomyositis causes polymyositis (see below) plus skin involvement (a heliotrope rasharound the eyes with associated periorbital edema is classic). Patients usually have trouble rising from a chair or climbing steps because of the effects on proximal muscles. Muscle enzymes are elevated, and electromyography is irregular. Muscle biopsy establishes the diagnosis. Affected patients have an increased incidence of malignancy.
25. With what is polyarteritis nodosa associated? How is it diagnosed?
Polyarteritis nodosa is a type of vasculitis classically associated with hepatitis B infection and cryoglobulinemia. Patients present with fever, abdominal pain, weight loss, renal disturbances, and/or peripheral neuropathies. Lab abnormalities include elevations in erythrocyte sedimentation rate and C-reactive protein, leukocytosis, anemia, and hematuria or proteinuria. Patients often have a positive antineutrophil cytoplasmic antibody (ANCA) titer. The vasculitis involves medium-sized vessels. Biopsy is the gold standard for diagnosis.
26. Describe the usual presentation of Kawasaki's syndrome. How is it treated?
Kawasaki's syndrome usually affects children younger than 5 years; it is more common in Japanese and female children. Patients present with truncal rash, high fever (which lasts > 5 days), conjunctival injection, cervical lymphadenopathy, strawberry tongue, late skin desquamation of palms and soles, and/or arthritis. Patients may develop coronary vessel vasculitis and subsequent aneurysms, which may thrombose and cause a myocardial infarction. Kawasaki's syndrome should be suspected in any child who has a heart attack. Treat during acute stage with aspirin and intravenous immunoglobulins to reduce the risk of coronary aneurysm.
27. How does Takayasu's arteritis present?
Takayasu's arteritis tends to affect Asian women between the ages of 15 and 30 years. It is called the "pulseless disease" because you may not be able to feel the pulse or measure blood pressure on the affected side. The vasculitis affects the aortic arch and its branches. Carotid involvement may cause neurologic signs or stroke, and congestive heart failure is not uncommon. Angiogram shows the characteristic lesions. Treat with steroids and/or cyclophosphamide.
28. How do you recognize Behet's syndrome on the Step 2 exam?
Behet's syndrome classically presents in young men in their 20s with painful oral and genital ulcers. Patients also may have uveitis, arthritis, and other skin lesions (especially erythema nodosum). Steroids may help.
29. How do you distinguish among fibromyalgia, polymyositis, and polymyalgia rheumatica?
FIBROMYALGIA POLYMYOSITIS POLYMYALGIA RHEUMATICA Classic age/sex Young adult women Location Various ESR Normal EMGPoiopsy Normal Classic findings Anxiety, stress, insomnia, point tenderness over affected muscles Treatment Antidepressants. NSAIDs, rest Female aged 40 60 yr Female > age 50 yr Proximal muscles Pectoral and pelvic girdles, neck Elevated Markedly elevated (often > 100) Abnormal Normal Elevated CPK, abnormal Temporal arteritis, great EMGBoiopsy, higher response to steroids, very risk of cancer high ESR, elderly patients Steroids Steroids ESR = erythrocyte sedimentation rate, CPK = creatine phosphokinase, EMG = electromyography.
30. Give the basic facts of Paget's disease. How is it linked with cancer?
In Paget's disease bone is broken down and regenerated, often simultaneously. It usually is seen in persons over 40 years old and is more common in men. Often il is discovered in an asymptomatic patient through a radiograph. Classic cases involve the pelvis and skull; watch for a person who has had to buy larger- sized hats. Patients may complain of bone pain. arthritis, or nerve deafness. Alkaline phosphatase is markedly elevated in the presence of normal calcium and phosphorus levels. The risk of osteosarcoma is increased in affected bones. Treat with NSAIDs; etidronate or calcitonin may be needed for severe disease.
31. If a pediatric patient has uveitis and an inflammatory arthritis, but the rheumatoid factor is negative, what disease should you suspect?
Rheumatoid arthritis. The rheumatoid factor is often negative in the pauciarticular variant. Affected patients commonly develop uveitis.