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71 Cards in this Set

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Morning stiffness duration

<15 min --> degenerative (eg osteoarthritis)



>30 min --> inflammatory



inflammatory conditions improve with usage so stiffness goes away during the day





SLE presentation

look for joint pain and rash




malar rash


photosensitivity rash


discoid rash

Inflammatory conditions that cause low back pain

1) ankylosing spondylitis


2) psoriatic arthritis


3) reactive arthritis


4) IBD

Rheumatoid arthritis physical exam findings

symmetric joint pain with distal interphalangeal joints unaffected




rheumatoid nodules --> nodules on extensor surface that are non-tender and rubbery

Criteria for RA

number of joints affected --> with 10 joints & 1 being a small joint, u get dx




elevated ESR




duration of Sxs >6 weeks

Cytokines involved in RA

TNF-a --> causes malaise, fatigue, and weight loss & leads to excessive bone erosions & cartilage damage




IL-1 --> local swelling & erythema




IL-6 --> up-regulates hepcidin that leads to iron sequestration and anemia of chronic dz

Tx of RA

start with NSAID or corticosteroid PLUS methotrexate




methotrexate takes ~6 months to start showing an effect




with MTX --> follow CBC & LFTs, if AST/ALT starts increasing, d/c immediately




MTX may cause flare-ups in process

Chronic RA joint deformity

ulnar deviation of digits




radial deviation of wrists

RA risk factors

HLA-DR1, DR4, DR14




MHC I --> HLA-A, B, C




MHC II --> HLA-D (subtypes are P, Q, R)




smoking is strongly assoc with RA




environmental and hormonal factors

Rheumatoid factor vs anti-cyclic citrullinated peptide

anti-cyclic citrullinated peptide is more specific than RF




neither are necessary nor sufficient

Felty syndrome

RA


splenomegaly


granulocytopenia

Caplan syndrome

RA


restrictive lung dz bc of lung nodules

TNF-a inhibitors

etanercept


infliximab


adalimumab


golimumab


certolizumab




use in combination with MTX if MTX doesnt work




have to get PPD prior to starting on TNF-a inhibitors

TNF-a inhibitor failure

if TNF-a inhibitors dont work then with MTX, try:




abatacept --> assoc with lymphoma, lung ca, & COPD exacerbation




OR




rituximab

Acute joint pain ddx

1) gout --> uric acid crystals


2) pseudogout --> calcium pyrophosphate crystals


3) septic arthritis


4) trauma

Joint aspiration WBC count

<5000 --> non-inflammatory




5000-50,000 --> inflammatory




>50000 --> septic

XRay finding in pseudogout

chondrocalcinosis

Septic or gonococcal arthritis

assoc with fever & leukocytosis




gonococcal --> migratory polyarthritis




Staph is most common cause of septic arthritis

Tx of gout

Acute tx:


NSAIDs (eg indomethacin) or colchicine until pain is no longer present




if above doesnt work, can try glucocorticoids orally or intra-articular injection




Long-term tx:


allopurinol (first line) or febuxostat




do not start allopurinol in acute setting bc it can make it worse but if already taking, then no need to d/c

Precipitating factors for gout

excessive etoh ingestion




trauma, surgery




infection




steroid w/d




medications (eg hydrochlorothiazide, furosemide, pyrazinamide, ethambutol)




serious medical illness

Gout microscopy findings

needle shaped negative birefringent crystals under polarized light microscopy

Goal of chronic tx of gout

decrease uric acid level to <6mg/dL




usually life long tx




start urate-lowering therapy AFTER acute phase




allopurinol is first line




probenecid is for those who have high serum uric acid with low urine uric acid --> but contraindicated in pts with renal insufficiency and nephrolithiasis

Gout with renal insufficiency

should not get NSAID or colchicine




tx with corticosteroids

Best screening test for SLE

ANA (<3% of SLE are negative)




if positive:


anti-dsDNA (very specific for SLE) --> may indicate renal involvement




anti-Smith (very specific for SLE)




Anti-Ro/SSA and anti-La/SSB --> assoc with neonatal lupus (heart block)




complement levels are decreased

Tx of SLE

start on prednisone



other immunosuppressants:


azathioprine


mycophenolate mofetil


MTX


cyclophosphamide --> only for lupus nephritis bc of severe toxicity




for rash --> hydroxychloroquine (but can cause retinitis so need to follow with optho)

Clinical criteria for SLE

need 4 of 11:




1) malar rash


2) discoid rash


3) photosensitivity


4) oral ulcers


5) arthritis


6) serositis


7) renal involvement


8) neuro d/o


9) hematologic d/o


10) serology


11) positive ANA

Discoid lupus rash

circular rash with raised rim over scalp and face




disfiguring bc of central atrophy and scarring




only 5% of pts with discoid rash will develop SLE

Drug-induced lupus

procainamide


hydralazine


isoniazid


methyldopa




p/w ONLY rash and anti-histone antibodies




DOES NOT AFFECT CNS OR KIDNEYS

Raynaud's Phenomenon

primary or idiopathic:


usually woman 20-40 otherwise normal




secondary:


nearly all pts with scleroderma


collagen vascular dz (eg SLE, polymyositis, RA, Sjogren's)


arterial occulsive dz (eg atherosclerosis)


drugs (b-blocker, ergot derivatives)




if pt p/w Raynaud's phenomenon --> check for ARF, arthritis, anemia, fever

Limited scleroderma (CREST)

CREST syndrome --> calcinosis, raynaud's, esophageal dysmotility, sclerodactyly, telangiectasia




affects face & skin distal to elbows & knees




high risk of developing pulm HTN




less risk of progressing to interstitial lung dz




anti-centromere Abs

Diffuse scleroderma

progressive form that affects skin proximal to elbows and knees




diffuse organ involvement affecting lungs (interstitial lung dz) & kidneys




diffuse pulm fibrosis, cardiac involvement, renal dz common




anti-topoisomerase I (Scl-70)

Tx of scleroderma

MTX




raynaud's --> CCB (eg nifedipine)




renal involvement & HTN --> ACEI (if pt enters renal crisis with scleroderma, increase ACEI)




esophageal dysmotility can lead to reflux -> Barrett's -> adenocarcinoma so tx with PPI




pulm alveolitis leading to interstitial lung dz --> cyclophosphamide




pulm HTN --> phosphodiesterase-5 inhibitors (eg sildenafil), prostacyclin analogs (eg siloprost, epoprostenol, or treprostinil)

Osteoarthritis characteristics

chronic asymmetric arthritis




oligoarticular arthritis or monoarticular




morning stiffness is <30 mins




no constitutional sxs

Tx of osteoarthritis

pt education for joint protection and assistive device (eg cane or walker)




diet for weight loss




if above not adequate --> trial of acetaminophen on PRN basis




if still not adequate --> trial of NSAIDs on PRN basis

Osteoarthritis pathology

target tissue is articular cartilage




failure of cartilage secondary remodeling and hypertrophy of the bone




NOT an inflammatory dz




severity of radiographs NOT related to severity of Sxs

Osteoarthritis risk factors

age


female


genetics


major joint trauma


repetitive stress


obesity

Osteoarthritis XRay

osteophytes (spurs) --> Bouchard's nodes (prox interphalangeal joint) or Heberden's nodes (distal phalangeal joint)




eburnation




loss of joint space

T score vs Z score on DEXA scan

T score:


compares bone density to young population


abnormal if < -2.5 STD below mean (sig risk for osteoporotic fracture)




Z score:


compares bone density to age-matched population


helpful when considering secondary osteoporosis (eg steroids, warfarin)

Osteoporosis w/u

x-ray is first test




DEXA scan (gold standard) --> T score < -2.5 means osteoporosis


T score < -1.1 means osteopenia



Tx of osteoporosis

oral Ca 1.5 g/day




Vit D supplementation




alendronate (bisphosphonate) --> can cause esophagitis

Type I osteoporosis

disproportionate loss of trabecular bone




assoc with fractures of vertebrae and distal forearms




occurs in middle-aged and postmenopausal women

Type II osteoporosis

occurs equally in men and woman age >75




assoc with fractures of femoral neck, prox humerus, prox tibia, & pelvis

Proximal muscle weakness Ddx

1) polymyositis




2) dermatomyositis (can have ocular manifestations)




3) inclusion body myositis (affects both prox & distal muscles)




4) steroid induced myositis




5) fibromyalgia

Proximal muscle weakness

difficulty combing hair




standing up




climbing stairs




lifting objects

Distal muscle weakness

buttoning shirt




difficulty writing




standing on tip toes

Presentation of different myopathies

dermatomyositis --> typical heliotrope rash (patchy purple/reddish rash)




polymyositis --> isolated muscle weakness and no evidence of dermatologic manifestations




inclusion body myositis --> affects both prox and distal muscles & typically affects older men

Inflammatory infiltrate in myopathies

dermatomyositis --> perimysial inflammatory infiltrate




polymyositis --> endomysial inflammatory infiltrate




inclusion body myositis --> inclusions of amyloid in muscle fibers and diffuse inflammatory infiltrate in muscle cells

anti-Jo1 Abs

found in dermatomyositis and polymyositis




very specific but not very sensitive so negative test does not r/o dz




ANA, however, are positive in 80% of cases

Tx of dermatomyositis

high dose corticosteroids until CPK normalizes then gradually taper




in refractory cases, can give MTX or azathioprine




hydroxychloroquine is effective for the rash

Cancer and dermatomyositis

perform UA (bladder cancer), CXR, colonoscopy, PSA, Pap smear (cervical cancer), and CA-125 (ovarian cancer) in woman




pelvic u/s or CT to exclude ovarian cancer

Temporal arteritis with polymyalgia rheumatica

new onset of headache in a pt >50




scalp tenderness




jaw claudication




decreased or blurry vision




polymyalgia rheumatica:


hip & shoulder stiffness




prox muscle weakness

Temporal arteritis w/u

ESR (if elevated & you suspect temporal arteritis, treat immediately)




temporal artery bx (gold standard)

Temporal arteritis pathology

segmental granulomatous inflammation of the media of lg vessels causing narrowing of the lumen




can lead to possible thrombosis of the affected section of the vessel leading to distal ischemia and necrosis

Tx of temporal arteritis

start prednisone (60mg daily) prior to bx results




follow ESR and taper steroids once ESR normalizes




can develop aortic aneurysm so should be followed

Ankylosing spondylitis

p/w lower back pain




X-ray shows bamboo spine and b/l sacroiliitis




ESR is elevated




90% are HLA-B27 (on chr 6)




seronegative

Tx of ankylosing spondylitis

NSAIDs are main stay tx




MTX, sulfasalazine, cyclosporine, azathioprine, retinoic acid derivatives, anti-TNF-a can also be considered

Seronegative arthropathies

1) ankylosing spondylitis


2) reactive/Reiter arthritis


3) psoriatic arthritis


4) IBD assoc arthritis




absence ANA and RF




involve lower back and sacroiliac joints




extra-articular manifestations include aortic valve, lung parenchyma, the eye (uveitis), and skin

Reiter's syndrome

following non-gonococcal urethritis --> conjunctivitis and arthritis




can also have mucocutaneous manifestations such as keratoderma blennorrhagica (scraping of palms), circinate balanitis, and oral/genital ulcers




pts with HIV can have a particularly aggressive form especially the mucocutaneous parts that resolve with HAART

Livedo reticularis

mottled reticulated vascular pattern




lace-like purplish discoloration

Polyarteritis nodosa

assoc with Hep B




medium sized vasculitis




p/w fever, weight loss, myalgias, arthralgias, cutaneous nodules and livedo reticularis




HTN secondary to renal artery involvement




Will never get glomerulonephritis or lung involvement bc those are with capillaries




dx is suspected with angiography of mesenteric and renal arteries with evidence of aneurysms




bx show segmental transmural necrotizing inflammation forming aneurysms with fibrinoid necrosis

Hep B titers

HBsAg --> active infection




HBc IgG --> chronic infection




HBeAg --> sign of infectivity & assoc with HCC

Hep B drugs

entecavir




tenofovir




adefovir




telbivudine




lamivudine

Polyarteritis nodosa organ manifestations

kidney: renovascular HTN




GI: abdominal pain and melena




skin: cutaneous and livedo reticularis




nervous system: peripheral neuropathies (tingling/numbness) & pain in hands, arms, feet, & legs

PAN tx

corticosteroids




cyclophosphamide for refractory cases




If HbsAg positive --> treat active Hep B

Hepatitis vaccination

all Hep B infected individuals should get Hep A vaccine




household contacts should get Hep B vaccine, if they are not immune




any chronic liver pt should get both Hep A & Hep B

Small vessel vasculitis

Granulomatosis with polyangiitis (Wegener's)




Henoch-Schonlein purpura --> younger pts with abd pain & purpura




Churg-Strauss syndrome --> middle aged p/w new onset asthma & eosinophila

ANCA

c-ANCA --> anti-proteinase 3 Abs




p-ANCA --> anti-myeloperoxidase

p-ANCA / anti-myeloperoxidase positive

Churg-Strauss syndrome




Microscopic polyangiitis

Granulomatosis with polyangiitis (Wegener's)

affects small vessels




p/w palpable purpura




RBC casts in urine




upper respiratory tract complaints




destruction of the cartilage of the nose --> saddle nose deformities




Sxs similar to chronic sinusitis




can also affect eyes --> scleritis, uveitis, & keratitis




c-ANCA/anti-proteinase 3 Ab positive




p-ANCA/anti-myeloperoxidase negative




dx is made via bx




tx with high-dose corticosteroids with cyclophosphamide then taper & d/c cyclo & continue tx with MTX or azathioprine for 18 months

Methotrexate monitoring

monthly LFTs and CBC (anemia due to folate def)

TMP-SMZ ppx

any patient on immunosuppression medications should be treated TMP-SMZ for prevention of Pneumocystis jirovecii