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71 Cards in this Set

  • Front
  • Back

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




Caplan syndrome


restrictive lung dz bc of lung nodules

TNF-a inhibitors






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



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


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


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:


mycophenolate mofetil


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





p/w ONLY rash and anti-histone antibodies


Raynaud's Phenomenon

primary or idiopathic:

usually woman 20-40 otherwise normal


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


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




major joint trauma

repetitive stress


Osteoarthritis XRay

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


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)


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






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


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


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)


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