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MSK 2 > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

Rheumatoid Arthritis is

A

A systemic auto-immune disease that manifests in the joints
Uncontrolled proliferation of synovial fluid
Synovitis, symmetrical, small joint

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2
Q

Genetics of RA

A

Shared epitope confers genetic risk
HLA-DRB1*04
Strongly associated with ACPA (+)

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3
Q

RA pathogenesis

A

ACPA
Anti-cutrullinated protein antibodies
Associated with RA
Anti-CCP

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4
Q

Why people get RA

A

Genetic susceptability
Insult/trigger

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5
Q

Criteria for RA

A

Morning stiffness
Arthritis in 3 joint areas
Arthritis in hand
Symmetrical arthritis
Rheumatoid nodules
Serum rheumatoid factors
Radiographic changes
must be present for more than 6 weeks

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6
Q

RA is

A

Small joint
Synovitis
Symmetrical

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7
Q

Small joint
Synovitis
Symmetric

A

Rheumatoid arthritis

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8
Q

RA deformity

A

Boutoniere Deformity
Swan neck
Ulnar subluxation

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9
Q

RA labs

A

Markers of inflammation
Anemia of chronic disease on labs
Thrombocytosis
Decreased albumin
***CCP

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10
Q

Rheumatoid factor

A

Autoantibody against Fc portion of IgG (IgM, IgG, IgA)
Higher titer= worse disease
Indolent infections (endocarditis, Hepatitis B and C virus)
B cell lymphomas
Mixed cryoglobulinemia (Hepatitis C virus)

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11
Q

RA X ray erosions

A

Located at articular surface

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12
Q

RA joint space

A

Symmetric joint space narrowing

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13
Q

C1-C2 subluxation

A

Significant risk for RA patients
Associated with RF and ACPA

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14
Q

RA nodules associated with

A

high titer RF

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15
Q

Other organ systems involved with RA

A

Caused by systemic inflammation
Lungs: nodules
Heart: pericardial effusions
RA: corneal melt
Skin: pyoderma gangrenosum

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16
Q

RA treatment

A

Many different treatment options
NSAIDS (bandaid, should not be used as monotherapy)
DMARDS
Early diagnosis and treatment to target is the GOAL
Use combinations to achieve disease remission when needed (synergistic at lower doses and result in less toxicity)

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17
Q

Methotrexate

A

ANCHOR drug for RA
Dose ONCE WEEKLY to avoid liver toxicity
Contraindicated in Renal Disease (kills bone marrow and will kill patient)

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18
Q

What must you screen for before giving a biologic

A

Tuberculosis and Hepatitis B

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19
Q

Triple therapy for RA

A

MTX + SSZ + HCQ

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20
Q

Raynaud’s Phenomenon (RP)

A

Exaggerated vascular response to cold temperature, emothional stree, vibration
tri-phasic color change with clear demarcation (white, blue, red)
Primary: younger, symmetric
Secondary: older, assymetric (may develop ulcers and secondary necrosis- autoamputation)

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21
Q

Raynaud’s phenomenon treatment

A

core body warming

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22
Q

Sjogrens Syndrome

A

systemic autoimmune disease associated with lymphocytic infiltration of exocrine glands
can be primary or secondary

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23
Q

Sjogrens Syndrome clinical presentation

A

Xerophthalmia (dry eyes)
Xerostomia (dry mouth)
Raynaunds phenomenon
vasculitis
Non-errosive inflammatory arthritis
Interstitial Lung disease
Type I renal tubular acidosis
Marked increase in risk on non-Hodgkin’s Lymphoma (heralded by decline in RF titer)
CT Scan of splenomegaly with lymphoma in SjS

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24
Q

Sjogrens Syndrome Serology

A

ANA
Anti-SSA/SSB (Ro/La)
Rheumatoid factor

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25
Q

Sjogrens Syndrome

A

Shirmer’s test: test for dry eye
Salivary Gland biopsy

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26
Q

Systemic Lupus Erythematosus

A

Prototypic immune complex deposition disease (low self tolerance)
Universally ANA Positive

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27
Q

For SLE you need how many criteria

A

4/11 positive

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28
Q

Photosensitive malar rash

A

Lupus

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29
Q

Lupus

A

Oral ulcers
photosensitivity
Lupus rash
alopecia
Discoud lupus
subacute cutaneous lupus
Jaccoud’s Arthropathy: non erosive inflammatory arthritis
pericarditis and valvular lesions
pleural effusions
pneumonitis (diffuse alveolar)
shrinking lung syndrome

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30
Q

SLE nephritis

A

look for active urinary sefiment on the urinalysis (blood and protein)
anti-dsDNA
low compliment
kidney biopsy: light miscroscapy, immunoflouresence, electron microscopy

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31
Q

SLE serology

A

Positive ANA
Suberologies:
anti-smith (most specific)
anti-dsDNA
renal disease
anti-phospholipid Abs
clotting risk

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32
Q

SLE Hematologic disease

A

lymphocytopenia

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33
Q

Drug induced lupus

A

Serology: ANA and anti-histone (in isolation)
Renal disease is very rare

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34
Q

Neonatal Lupus

A

autoimmune disease from passive transfer of autoantiboides from mother to fetus resulting fetal and neonatal disease
Anti-Ro (SSA) and Anti-La (SSB)
Rash and heart block

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35
Q

Anti-phospholipid antibody syndrome

A

pregnancy loss, vascular thrombosis, circulating anti-phospholipid antibodies
Antiphospholipid Abs include:
Lupus anticoagulent (clotting test with mix)
PTT or dRVVT (will be increased)
mix with normal serum
factor defiency (PTT corrects)
inhibitor (PTT won’t correct)
Anti-cardiolipin Ab
B2-Glycoprotein-I Ab

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36
Q

Clinical findings APS

A

DVT
recurrent fetal loss or other OB complications
livedo reticularis
Avascular necrosis
CAPS

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37
Q

Avascular necrosis

A

cellular death in bone due to the loss of blood supply
cause by glucocorticoid use
inflammatory/autoimmune disease

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38
Q

Inflammatory Myopathies

A

indifious, progressive and usually painless proximal muscle weakness
immune mediated myopathies
polymyositis (PM) and dermatomyositis (DM)
noted to coexist with cancer especially DM

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39
Q

Dermatomyositis

A

Heliotrope rash on eye lids
gottrons papules on knuckles
Rash can occur at any time
V sign or shawl sign around the neck
periungual erythema
mechanics hand

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40
Q

Clinical findings of PM and DM

A

dysphagia
dyspnea from interstitial lung disease (ILD)
Antisynthetase syndrome (subset of PM with rapidly progressive ILD and mechanics hands)
Anti-Jo-1
mechanics hands

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41
Q

PM and DM labratories

A

Elevated markers of muscle damage: CPK, aldolase, LDH
LTFs may also be up (AST and ALT are released by muscle)
Anti-Jo-1 is an antisynthetase Ab

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42
Q

DM and PM diagnosis

A

MRI or MRI STIR
Muscle biopsy
cancer testing

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43
Q
A

left-Polymyositis: perifascular inflammation
right- dermatomyositis: perivascular inflammation

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44
Q

Progressive Systemic Sclerosis (Scleroderma or PSS)

A

multisystem disease resulting in fibrosis of the skin, internal organs, and other connective tissues
Abnormal pathways:
vasculopathy
Inflammation: cell mediated and humoral
Fibrosis: fibroblast undergo permanent changes

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45
Q

Scleroderma clinical findings

A

RP, GERD, arthralgia/myalgias
puffy painful skin
sclerodactyly
telangiectasia
end stage leads to contraction and ulcers
RP is nearly universal
fibrosis or pulmonary hypertension
Gastrointestional: reflux, GAVE leading to bleeding
malignant hypertension
Scleroderma renal crisis which is treated with ACE inhibiots (life saving)
onion skin appearancw of renal blood vessels

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46
Q

Scleroderma diagnosis

A

positive ANA
Diffuse:
Centromere: CREST syndrome
Limited:
Scl-70: systemic sclerosis (scleroderma or PSS)
RNA Polymerase III (anti-POL III): rapidly progressive scleroderma

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47
Q

Spondyloarthritis (SpA)

A

Ankylosing spondylitis (AS)
Reactive Arthritis (ReA)- formerly Reiter’s syndrome
Psoriatic arthritis (PsA)
Arthritis associated with inflammatory bowel disease

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48
Q

SpA has a strong association with

A

HLA-B27

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49
Q

SpA: etiology and Pathogenesis

A

higher prevelance in males

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50
Q

Reactive arthritis is tiggered by

A

Salmonella, Shigella, Campylobacter, Yersinia, chlamydia

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51
Q

SpA common features

A

inflammatory low back pain
insidious onset
duration greater than 3 months
significant morning stiffness and improvement with exercise
SIJ involvement
Associated findings: Ocular (Uveitis), Dactylitis (sasuage digit), Enthesopathy

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52
Q

Dactylitis

A

flexor tenosynovitis
SpA common feature

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53
Q

Ankylosing Spondylitis

A

spinal fusion
SIJ inflammation and fusion
Inflammatory arthritis (large joint below the belt)
Head to wall test, bamboo spine

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54
Q

SpA: reactive arthritis

A

Classic Triad: Conjunctivitis, urethritis, and arthritis (cant see, pee, or climb a tree)
asymmetric arthritis
enthesopathy and achilles tendonitis (lovers heel)
circinate balanitis/keratoderma blennorrhagica (rash)
oral ulcers

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55
Q

Psoriatic Arthritis characteristics

A

enthesopathy
dactylitis
exuberant syndesmophytes
nail pitting and onycholysis
DIP joint affected
pseudorheumatoid
oligoarticular
arthritis mutilans (pencil in cup erosions
oil spots and nail pitting

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56
Q

IBD arthritis

A

sacroiliitis
enthesitis
uveitis
stomatitis
pyoderma gangrenosum
erythema nodosum
panniculitis on LLimb

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57
Q

Vasculitis

A

inflammation in blood vessels
always try to biopsy for diagnosis
biopsy tissues fed by artery when vessel can’t be biopsied

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58
Q

Giant cell (temporal) arteritis

A

headaches, vision loss, jaw claudication, constitutional symptoms (fever, weight loss, malaise)
Lab: Elevated ESR/CRP
Diagnosis: biopsy temporal artery
ultrasound arteries (non-compressible)

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59
Q

Anti-neutrophil cytoplasmic antibodies (ANCA)

A

C=cytoplasmic
P=perinuclear
C3PO
C-ANCA PR3
P-ANCA MPO
small to meduim sized blood vessels
GPAl MPA, EGPA
pulmonary renal involvement
must biopsy for disgnosis (lung is ideal)

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60
Q

GPA

A

sinusitis
tracheitis
ocular involvement
C-ANCA (PR3)

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61
Q

MPA

A

P-ANCA (MPO)

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62
Q

EGPA

A

Asthma
Eosinophilia
P-ANCA (MPO)

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63
Q

Mixed cryoglobulinemia

A

Cyroglobulins (IgGs that precipitate below 37 degrees and dissolve upon rewarming
HCV
B cell cancers

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64
Q

Polyarteritis Nodosa (PAN)

A

systemic vasculitis affecting medium sized muscular ateries
can be triggered by Hepatitis B

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65
Q

Takayasu’s Arteritis (TA)

A

systemic vasculitis of the aorta and its branches
extremity claudication “pulseless disease”

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66
Q

Rheumatoid factor

A

RA
SjS
HCV
Cryo
B-cell malignancy

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67
Q

Anti-Pol III

A

scleroderma

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68
Q

Anti-centromere

A

CREST

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69
Q

C-ANCA (PR3)

A

GPA

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70
Q

HLA B27

A

Seronegative SpA

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71
Q

Anti-CCP

A

RA

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72
Q

Anti-Smith

A

SLE

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73
Q

LAC

A

APS

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74
Q

P-ANCA (MPO)

A

MPA
EGPA

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75
Q

Anti-Scl 70

A

Scleroderma

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76
Q

Anti-DS DNA

A

SLE nephritis

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77
Q

Anti-histone (in isolation)

A

Drug induced lupus

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78
Q

In inflammatory arthritis joints are

A

Warm, swollen, erythematous
AM stiffness
Gelling phenomenon (pain better with activity)

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79
Q

Non-inflammatory arthritis joints are

A

Cool
Bony
Pain is worse with activity and better with rest

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80
Q

Key questions to determine if arthritis is inflammatory or non-inflammatory

A

What time of day is the pain the worst?
Is your pain better or worse with activity?

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81
Q

Arthritis lab evaluation

A

Urinalysis to look for blood or protein
Inflammatory marjers

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82
Q

Markers of inflammation

A

IL-6
Albumin should decrease

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83
Q

Westergren Sedimentation rate (ESR)

A

Blood placed in verticle tube and measure distance RBC fall over an hour
-fibrinogen
-immunoglobulin

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84
Q

Rheumatic factor

A

Autoantibody against Fc portion of IgG
Prognostic of RA

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85
Q

Anti-CCP antibody

A

High specificity for RA

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86
Q

Anti-Nuclear antibody

A

NOT A SCREENING TEST
Flourescent ANA test is the gold standary

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87
Q

SLE

A

dsDNA= renal disease
Smith= specific for SLE
Ro/SSAand La/SSB= cutaneous SLE and neonatal SLE
histone alone= drug induced SLE

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88
Q

Scleroderma

A

centromere= CREST
Scl-70 (topo-isomerase) & RNA pol III

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89
Q

Myositis

A

Jo-1 (tRNA synthetase)

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90
Q

Myositis

A

Jo-1 (tRNA synthetase)

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91
Q

Sjogren’s Syndrome

A

Ro/SSA & La/SSB

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92
Q

Anti-Phospholipid Ab Syndrome

A

lupus anti-coagulant
anti-cardiolipin

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93
Q

ANCA (anti-nuclear cytoplasmic antibody)

A

antibodies directed to cytoplasmic enzymes
P-ANCA and myeloperoxidase (AGPA and MPA)
C-ANCA and serine protease 3 (GPA)

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94
Q

Arthrocentesis

A

fluid obtained and sent for gram stain, cell count, crystal analysis, PCR
low risk of infection

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95
Q

Normal synovial fluid is

A

see through

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96
Q
A

MSU

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97
Q
A

CPPD

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98
Q

RA radiologic findings

A

Marginal (joint line) erosions

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99
Q

OA radio graphic findings

A

Osteophytes

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100
Q

EOA radio graphic findings

A

Gull-wing central erosions

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101
Q

Gout radiographic findings

A

Juxta-articular erosions with sclerotic and over-hanging edges

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102
Q

Pseudogout radiographic findings

A

Punctuate or linear densities in fibro or hyaline cartilage
Hooking on radial side of MCP

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103
Q

SLE radiographic findings

A

Jaccoud’s arthropathy

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104
Q

Psoriatic Arthritis

A

Pencil in a cup body erosion

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105
Q

Ankylosing spondylitis radiographic findings

A

symmetric sacroiliitis (iliac side, distal 1/3 of joint)= fusion
Syndesmophytes

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106
Q

RA vs OA

A

RA affects any joint other than DIP
OA affects hips, knees, spinal, all hand joints, and the MTP joint of big toe

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107
Q

Acute Monoarticular arthritis

A

Septic or crystalline arthritis

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108
Q

Signs and symptoms of septic arthritis

A

Fever
Rigor
Heart murmur
Cellulitis
Instrumentation
Guarding ROM

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109
Q

Syngs and Symptoms of crystalline Arthritis

A

Tophi

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110
Q

Labs and imaging for acute monoarticular arthritis

A

CBC
ESR, CRP
Blood, urine cultures
Serum creatine and urin acid
Imagining (yield is generally disappointing)

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111
Q

What is central to the evaluation of an inflamed joint

A

Synovial fluid analysis
Cell counts with diff, gram stain, culture, crystal analysis

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112
Q

Synovial fluid WBC

A

Normal <200 WBC <25% PMN
Non-inflammatory <2000 WBC <25% PMN
Inflammatory 1,000 to 75K WBC >50% PMN
Septic 50K to 100K WBC >85% PMN

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113
Q

Light microscopy

A

WBC
fibrillation materials= rice bodies
Phagocytized WBCs
Crystals

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114
Q

Yellow parallel crystal

A

Gout
mono sodium rate mono hydrate
Negative birefringence

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115
Q

Blue arrow

A

CPPD
Positive birefringence

116
Q

Gout

A

M-males, monosodium urate crystals, monoarticular
E-episodic
N-negative birefringent

117
Q

Uris acid is

A

End produce of purine degradation

118
Q

Hyperuricemia

A

Serum urate concentration in excess or urate solubility
Gout= deposition of monosodium urate crystals in tissues

119
Q

_ catalyzes the final conversions to urine acid

A

Can think oxidases

120
Q

What is the most common inflammatory arthritis

A

Gout

121
Q

Gout diagnosis

A

Joint tapping
A clinical diagnosis can be made without joint tapping based on typical features and no evidence of alternative diagnosis
Uris acid level (normal 1/3 of time)
X-rays are rarely helpful

122
Q

Gout flare

A

Occurs in bursa, tendon, joints
First MTP joint most common initial site
rapid onset and escalation

123
Q

Gout flare treatments

A

Colchicine
Prednisone NSAIDS

124
Q

Characteristics of Advanced gout

A

Tophi

125
Q

Advanced gout imaging

A

X ray: rat bite
Dual energy CT: detect uric acid deposition
Ultrasound of 1st MTP joint: double contour sign

126
Q

Uric acid can be increased by

A

Diuretics: increased uric acid reabsorption
Low dose aspirin
Pyrazinamide, ethambutol, niacin
Cyclosporine and tacrolimus

127
Q

Urate lowering drugs

A

DO NOT start during an acute attack
1st line: Xanthine Oxidase inhibitors
2nd line: Uricosuric drugs
Serum uric acid goal:<6 mg/dL

128
Q

Caveats to Allopurinol (xanthine oxidase inhibitors)

A

Allopurinol hypersensitivity syndrome (HLA-5801 is a risk factor)

129
Q

Peloticase

A

Uric are enxyme
For treatment failure gout
Highly immunogenicity
Increased rate of CV events

130
Q
A

CPPD Deposition disease (Pseudogout)

131
Q

Pseudogout (CPPD deposition disease)

A

High calcium and low phosphorus
Chondrocalcinosis (radiographic finding)
Most common affects wrists and knees
Risk factors: older age. hemochromatosis, hyperparathyroidism, hypothyroidism, hypomagnesemia
treatment: NSAIDS, steroids, colchicine

132
Q

Disseminated gonorrhea infection

A

Low yield synovial fluid
Culture is critical
Treatment: antibiotics

133
Q

Viral arthritis

A

Parvovirus: Fifth’s disease in children, arthritis and rash in adults
Increased IgM anti-Parvovirus
Can also happen with HIV, influenza, Hep B/C

134
Q

Chikingunya virus

A

Transmitted through mosquito bite
Fever and arthralgia
1/3 have chronic rheumatic manifestations
elevated ESR

135
Q
A

Tick borne illness (Borrelia burgdorferi)
Northern United States
Testing: ELISA and western blot
Treatment: antibiotics

136
Q

Traveling joint pain and swelling following Strep infection
Maculopapular rash with central clearing
murmur

A

Acute rheumatic fever
carditis
Rash
Management: antibiotics

137
Q

Jones criteria

A

for patients with preceding Group A strept infection
2 major or 1 major (carditis, arthritis, chorea, erythema marginatum, subcutaneous nodules) and 2 minor (arthralgia, fever, elevated ESR/CRP, prolonged PR interval)

138
Q

There is an increase in _ in patients with autoimmune diseases

A

Levels of autoantibodies
Mostly IgM antibodies (aids in clearance, stops activation of phagocytes through DAMPs, and inhibits binding of antigens to sIgs resulting in no B cell responses

139
Q

T cell help causes

A

Isotope switches
Memory
Increased concentration of antibodies

140
Q

Usually the determinant of autoimmune disease is unknown because

A

Patients present to clinic years after symptoms start
Initiating agent is gone

141
Q

Autoantibodies are good biomarkers that are helpful in diagnosing and monitoring disease (epiphenomenon)

A

ANA
Rheumatoid factor
ACPA
Other disease specific antibodies (ex. Pemphigus vulgaris)
Epiphenomenon: secondary effect or byproduct that arises from but does not causally influence a process

142
Q

Sedimentation rate

A

High- indication of high levels of inflammation
Can be used to determine how well treatment is working

143
Q

CRP

A

Acute phase protein
Made by liver in response to IL-6
CRP levels increase as a result of inflammation

144
Q

Rheumatoid factor

A

Autoantibodies that bind to Fc portion of Ig
Enhances phagocytosis/opsonization
Immune complexes deposited in kidney

145
Q

How are CRP and RF measured

A

Nephelometry (looks at light deflection)
Form immune complexes (cause light deflection)
Measures how fast complexes form and the amount present

146
Q

Antinuclear antibodies

A

Not specific for any one disease but indicate autoimmune disease
Are epiphenomenon (not damaging)

147
Q

ANAs are measured by

A

Indirect immunoflouresence assay (used for viral serology, rapid viral diagnosis, rental pathology, and the detection of antibodies)

148
Q

Antibody detection is performed using an

A

Indirect ELISA

149
Q

ANA is run on

A

Hep-2 cells to determine ANA positivity
Dilute serum and add to slide
Wash using fluorescently labeled anti-Human IgG
Wash off antibody
Last dilution of serum that gives a positive result is the dilution reported (is significant when greater that 1:160)

150
Q

Rim patterm

A

anti-dsDNA (SLE)

151
Q

Homogenous pattern

A

Anti-histone antibody
drug induced SLE

152
Q

Speckled pattern

A

Anti-Sm and/or anti-
Ro/SSA and/or anti-
La/SSB and/or anti-
UIRNP
Sjögren’s syndrome

153
Q

Nucleolar pattern

A

Anti-Th or anti-
fibrillarin/anti-U3RNP
or anti-U17RNP
May think of Scleroderma or polymocysitis

154
Q

Centromere pattern

A

CREST/pulmonary hypertension

155
Q

Anti-dsDNA

A

Used when SLE is suspected (test using Crithidia)

156
Q

When looking at an ANA are the proteins abnormal

A

No, normal proteins inside the cell

157
Q

CCP is diagnostic for

A

RA

158
Q

Test immunomarkers using

A

ELISA

159
Q

Yellow parallel

A

Gout

160
Q

Blue crystals

A

Pseudogout

161
Q

Primary bone tumors

A

Common before 30 years old
Most common around knee/humerus

162
Q

Common tumors metastasizing to bone in adults

A

P T Barnum Loves Kids
Prostate
Thyroid
Breast
Lung
Kidney

163
Q

Symptoms of bone tumors

A

Pain: deep, constant, worse at knight
Most benign tumors found incidentally

164
Q

Trivial trauma causes

A

Pathological fracture

165
Q

Evaluation of bone tumor

A

Plain X ray (first)
MRI for staging or surgery planning
Biopsy may not be necessary

166
Q

Ultimate diagnosis of bone tumors requires

A

Radiologic histologic correlation

167
Q

Benign primary bone tumors are often

A

Incidental

168
Q

Osteochondroma

A

Most common benign bone tumor
Mushroom shaped
Start at epiphyseal line
Excision only if symptomatic

169
Q

Osteoid osteoma

A

Hound patients
INTRAcortical tumor (diaphysis of long bones)
Sudden onset of pain (worse at night) that is very sensitive to NSAIDS (PGE2 release)
Conservative treatment (radio frequency ablasion)

170
Q

Chondroma

A

Arises in childhood junction of diaphysis and metaphysics in long bones or short tubular bones of hand and foot

171
Q

Fibrous dysplasia

A

Weaker bone susceptible to deformities or fractures
GNAS mutation
Proximal femur, jaw, and ribs
Ground glass appearance
McCune-Albright syndrome
Chinese letter trabrculae
Treatment: conservative

172
Q

Non-ossifying fibroma

A

Common-most incidental
Seen in children
Error in remodeling metaphysical cortices in growth
Eccentric lesion in metaphysical cortex of tibial and fibula
Round or oval defects in sclerotic rim of metaphysis
Swirling of bland spindle cells with admired osteoclasts
Treatment: reassurance

173
Q

Osteosarcoma

A

Tumor of osteoblasts
May be primary in kids or secondary in adults (caused by chemo)
Reported in most bones
In metaphysis
20% metastatic at presentation
Presentation: pain, soft tissue mass, pathological fracture
Aggressive radiodense lesion on x ray
Periosteal reaction: Codman’s triangle, Sunburst pattern (seen in rapidly growing lesions that can’t lay down new bone fast enough)
Atypical spindle cells
Diagnosis: XR, chemotherapy, neuadjuvant chemotherapy

174
Q

Chondrosarcoma

A

Malignant tumor of chondrocytes
Stipples/popcorn appearance on X ray
Grade important for prognosis
Treatment: surgery

175
Q

Ewing sarcoma/primitive neuroectodermal tumor

A

2nd or 3rd decade of lime
Any bone (Askin tumor ES/PNET involving rib)
More likely in diaphysis than other bone tumors
Pseudorosettes
CD99
Recurrent chromosomal translocation t(11;22)
Treatment: neoadjuvanct chemotherapy and surgery

176
Q

Periosteal reaction

A

Bad sign suggestive of malignant bone tumor
Most commonly osteosarcoma

177
Q

Benign soft tissue tumors

A

Outweigh malignant

178
Q

Things causing soft tissue abnormalities

A

Abscess/folliculitis
Cysts
Hematomas
Fibrosis
Tumors

179
Q

Connective tissue accounts for

A

70% of body mass
Tumors are rare
1,600 malignant tumors per year
5-10 benign for every malignant
Begin a spindle cell lesions

180
Q

Divisions of soft tissue tumors

A

Benign: Do not reoccur after excision
Intermediate: high risk of recurrence or rare ability to metastasize
Malignant: substantial risk of metastasis

181
Q

Malignant is different from epithelial tumors

A

Invasion not as important
Many are malignant by definition
Metastasis almost always a good indicator

182
Q

Histologic markers of aggressive behavior

A

Mitotic activity
Nuclear pleomorphism
Necrosis
Infiltrative growth

183
Q

CD31

A

Vascular

184
Q

SMA

A

Smooth muscle

185
Q

S100

A

Nerve/fat
Melanoma

186
Q

Myogenin

A

Skeletal muscle

187
Q

Keratin

A

Synovial sarcoma

188
Q

_ is very important in the diagnosis of soft tissue tumors

A

Cytogenetics

189
Q

What does tumor grade refer to

A

How dysplastic cells are

190
Q

For malignant tumors, histologic grade

A

Is as important or more important than subtype (based on differentiation, mitoses, necrosis

191
Q

-sarcoma

A

Malignant soft tissue tumor
Spreads hematogenously
VERY RARE for benign tumor to transform
Expansile growth with pseudocapsule (can look well encapsulated and still be very bad)
A/w prior radiotherapy

192
Q

Soft tissue tumors are usually

A

Painless

193
Q

Rumor, dollar, calor, fever

A

Abscess

194
Q

Fluctuate/compressible

A

Cyst

195
Q

Transluminates

A

Cyst

196
Q

Direct history or trauma/anti coagulation with overlying ecchymosis

A

Hematoma

197
Q

Key features of soft tissue neoplasms

A

Size
Depth
Mobility
Growth

198
Q

<5 cm, mobile, superficial

A

Benign

199
Q

> 5 cm, fixed, deep

A

Higher risk of malignant

200
Q

Growth may be a marker of

A

Malignancy

201
Q

Soft tissue tumors are common components of

A

Tumor syndromes
neurofibromatosis, tuberous sclerosis, Li fraumeni, FAP

Key features: multiple tumors, strong family history, young age, skin manifestations

202
Q

Lipoma

A

Most common benign soft tissue tumor
Made of mature adipocytes
Variants: angiolipoma, spindle cell/pleomorphic, intramuscular

203
Q

Liposarcoma

A

Malignant tumor of adipocytes
Deep extremities are common site
Fatty tumor with admixed atypical cells with or without lip oblasts
Variants: well differentiated/atypical. Lipomatous tumor, myxoid/round cell, pleomorphic

204
Q

WDLS/ALT

A

WDLS: complete excision not possible (retroperitoneum)
ALT: sites where wide excision is easy (extremity)
Genetics: MDM2 amplification (chromosome 12)

205
Q

Myxoid/round cell liposarcoma

A

Chicken fire vasculature
T(12;16) FUS-DDIT3 fusion

206
Q

Hemangioma

A

Benign vascular tumor
Appear around 1 month
3 phases: rapid growth, slow growth, involution
Treatment: none
30% resolve by 3 years
80-90% by 9 years
Laser therapy if impinging vital structure, ulceration, bleeding

207
Q

Kaposi sarcoma

A

Vascular tumor of intermediate malignant potential
Endemic- only Mediterranean men, leg lesions
Immunodefiency associated
Any musosal surface, lymph node, or visceral organ
HHV-8 driven
Slit like vessels

208
Q

Angiosarcoma

A

Malignant tumor of endothelium
Two types:
Cutaneous: sun exposed skin of elderly or irradiated skin
Long-standing lymphedema (Stewart-Treves syndrome)
Visceral
Pleomorphic endothelial cells with high mitotic rate
Poor prognosis

209
Q

Neurofibroma

A

Benign peripheral nerve sheath tumor that arises from Schwann cells
Associated with Neurofibromatosis
Shredded carrots with buckled nuclei
S100-positive

210
Q

Schwannoma

A

Benign peripheral nerve sheath tumor
Arise from Schwann cells
Associated with large nerve trunks
Most sporadic, seen in ND-2
S100-positive spindle cells
Antoni A (cellular), Antoni B (hypocellular) zones
Verrocay bodies

211
Q

Malignant peripheral nerve sheath tumor

A

Bulky, deep seated
Strong association with NF-1 and prior radiation

212
Q

Dermatofibroma

A

Benign fibrous histiocytoma
Thought to be associated with trauma
In women 20-50
Cellular dermal lesions surround adjacent thick collagen bundles

213
Q

Dermatofibrosarcoma protuberans

A

Intermediate malignant potential
Older men
subcutaneous tissues of back and upper extremities
Cart wheeling CD34-positive spindle cells, infiltrate underlaying dat
Need wide local excision
t(17;22) PDGFR-COL1A1

214
Q

Synovial sarcoma

A

Unknown histogenesis
Malignant soft tissue tumor affecting young adults
Arises in deep soft tissue around joint such as knee or ankle
monomorphic spindle cells
Biphasic- epithelial like structures
Monophonic- no epithelial like structures
t(x;18) SYT:SSX1 fusion

215
Q

High grade pleomorphic sarcoma

A

Malignant fibrous histocytoma
Most common type of malignant soft tissue tumor
Located in deep soft tissue/retroperitoneum of adults
High mitotic rate, marked pleomorphism
Negative for all IPX markers- no identifiable differentiation
Cytogenetically heterogeneous
Diagnosis of Exclusion

216
Q

Management of soft tissue lesions

A

Biopsy
MRI
Surgery:
benign- excise with negative margins
Intermediate- wide local excision (rim of normal tissue)
Malignant- neoadjuvant
Allows limb salvage
Done by specialists
Chemo only for some subtypes
Most people with sarcoma die of metastatic disease (found within 2-3 years of diagnosis in 80%)

217
Q

Skin Abscess

A

caused by S aureus
incision and drainage
sometimes antibiotics

218
Q

Diabetic foot ulcers

A

polymicrobial
adequate surgical debreadment and wound care is vey imporatant
Oral antibiotics for infection (culture guides therapy)
Duration of antibiotic therapy depends on osteomyelitis and debreadment

219
Q

Pyomyositis

A

pus within muscle groups
S. aureus
tropical pyomyositis (more common in temperate climates)
localized pain in muscle groups
surgical excision and drainage necessary
antibiotics depending on culture results

220
Q

Necrotizing fasciitis

A

Polymicrobial (mixed aerobic and anaerobic)- type I
Occurs commonly after surcial procedures in patients with diabetes and perephrial vascular disease
Monomicrobial- (group A streptococcus-S pyogens, S aureus)-Type II
can occur in any age group in patients without underlying medical conditions
Unexplained pain increasing rapidly overtime
Erythemia
Leukocytosis, elevated CK, elevated creatine
Woody feeling to subcutaneous tissues, blister, fever, hypotension and tachycardia, leukocytosis
Need blood cultures
Imaging not necessary unless questioning diagnosis
Surgical debridement
Blood cultures and emperic therapy
Adjunct therapy: hyperbaric oxygen therapy, IVIG for systemic infections to neutralize toxins

221
Q

Gas Gangrene

A

Clostritium
Severe penetrating wounds
Sever pain, gas in tissues, sepsis, treatment same as necrotizing fascitis

Water exposure: need to obtain history
Freshwater: vibrio vulnificus
Saltwater Aeromonas hyrophilia

222
Q

Infections following bites

A

Dog and cat: Pasteurella, S aureus, Bacteroides, Fusobacterium, Capnocytophaga
Human: Eikenella

Treatment: antibotic prophylaxis (oral or IV)
Sometimes surgical intervention is required

223
Q

Acute Bacterial Arthritis (Septic arthritis)

A

Typically Staph infection
Hematogenously aquired
Direct innoculation
Spread from adjacent tissues
Risk factors: immunosuppression, diabetes, malignancy, chronic renal failure, IV drug abuse, HIV, joint disease, sickle cell disease, surgery, penetrating injury, prosthetic joint
Monoarticular
Pain, loss of function, decreased ROM, fever
Focal joint tendernedd, inflammation, joint effusion
Arthrocentesis
Labs based on epidemiologic history
Radiology not necessary for diagnoisis
Needle aspiration, arthroscopic drainage, arthrotomy
Antibiotic therapy delayed until arthrocentesis

224
Q

Gonococcal arthritis

A

Disseminated N gonorrheae infection (sexually active people)
Dermatitis, tenosynovitis, migratory polyarthralgia or polyarthritis, fever, malaise

225
Q

Osteomyelitis

A

Spread from adjacent soft tissue, hematogenous, direct innoculation
S. Aureus, coagulase - staph
Pain at site of infection, fevers, chills, erythemia
Chronic condition evolving over months to years, non-specific pain, sinus tract
Fevers, erythema, swelling not common
Diagnosis: inflammatory markers, histopathology, radiologic studies
MRI is standard of care for diagnosis
Bone biopsy, needle aspiration, culture
surgical debridement and antimicrobial therapy
withhold antibiotics until cultures have been obtained (6-8 weeks)

226
Q

Vertebal Osteomyelitis, Spondylodiskitis, Epidural Abscess

A

infection of intervertebral disk and adjacent vertebrae
pain and tenderness in spine
S aureus, coagulase - staphylococci
MRI standard of care for diagnosis

227
Q

Prosthetic joint infections

A

significant mortality risk
Risks: males, prior surgery at same time, rheumatoid arthritis, immunosuppression, diabetes, cancer, poor nutritional status, obesity, smoking, chronic medical problems
Can be early onset (S aureus): aquired during implantation
Delayed onset (3-24 months): less virulent organisms (coagulase - Staph) aquired during implantation
Late onset (>24 months after surgery: hematogenous spread (dental source, pyogenic skin infections, GI and GU infections), line sepsis
Usually caused by Staph
Indolent: progressive pain, chronic draining sinus,
NO fever, swelling, systemic toxicity
Acute: fever, joint pain, swelling, erythemia
Lab: ESR, CRP, synovial fluid anaysis
Intraoperative cultures
X ray not needed
Debridement and implant retention
stage 1 revision: extract joint and immediately reimplant
stage 2 revision: extract joint and treat with antibiotics for a while before now implant
Perminent resection arthroplasy for non-ambulatory
Ambutation

228
Q

What do you need for healing a fracture?

A

adequate blood supply and adequate mechanical stability

229
Q

Fractures stimulate the release of

A

growth factors that promote angiogenesis and vasodilation
increases blood supply to fracture site

230
Q

Intramembranous ossification

A

direct bone formation
requires rigid fixation, opposition of bone fragments

231
Q

Endochondrial ossification

A

cartilage (soft callus) transitions to bone (hard callus) tolerant of appropriate motioin, fracture hematoma critical for healing

232
Q

What stimulates callus formation and mineralization

A

molecular and mechanical factors

233
Q

Wolff’s law

A

bone is restructured in response to stress and strain

234
Q

Adavced Trama Life Support (ATLAS) Trama Evaluation

A

A establish an AIRWAY
B Breathe for the patient if they arent
C assess and restore Circulation
D assess neurologic Disability
E EXPOSE entire patient

235
Q

Inspection

A

Look
Feel
Move

236
Q

X rays should be

A

orthogonal
incude joint above and below fracture

237
Q

Fractures are classified by

A

bone involved, fracture pattern, displacement,
angulation (defined by position of distal fragment relative to proximal fragment)

238
Q

Angulation

A

distal fragment relative to proximal

239
Q

Naming a fracture

A

bone
location
fracture pattern
displacement
angulation

240
Q

Emergent skeletal issues

A

Unstable pelvic fractures (hemmorage control)
open fractures (hemmorage control)
realigning
compartment syndrome

241
Q

What is especially important for open fractures

A

ANTIBIOTICS

242
Q

Compartment syndrome

A

increased pressure in fixed compartments squeezing contents (compress/damages vessels and nerves)

243
Q

Muscle survival

A

3-4 hours- reversible
8 hours- irreversible

244
Q

Nerve survival

A

2 hours- lose nerve conduction
4 hours- neurapraxia
8 hours- irreversible changes

245
Q

When is a compartment pressure measure used?

A

only in an obtunded patient

246
Q

Compartment syndrome

A

**pain out of proportion
rigid compartment with shiny skin

Pulselessness is not a characteristic of compartment syndrome

247
Q

treatment of compartment syndrome

A

fasciotomy
DO not close wounds

248
Q

degenerative disk diasease

A

cervical and lumbar spine
diagnois: physical exam and X ray
treated conservitavely (try to avoid narcotics

249
Q

cervical stenosis

A

narrowing of space avaliable for spinal cord
myelopathy and radiculopathy
exam and imaging
surgical and non surgical treatment

250
Q

Cervical Myelopathy

A

symptoms and phyical exam finding consistent with spinal cord compression
(balance problems, gait instability, hand dysfunction, neurogenic pain)
upper motor neuron findings: hyperreflexia, pathologic reflexes, coordination deficits

251
Q

Cervical Disc Herniation

A

presentation: radiculopathy (compression of nerve root)
unilateral arm symptoms
typically non-surgical treatment but sometimes surgical treatment is necessary

252
Q

Most common reason you see spin patients in clinic

A

Low back pain (most commonly due to degenative disc disease)

253
Q

Lumbar Degenerative Disc Disease

A

osteoarthritis of the lumbar spine
treated conservatively (try to avoid narcotics)

254
Q

Lumbar spine stenosis

A

narrowing of space avaliable for nerves commonly caused by arthritic changes
neurogenic claudication
conservative treatment

255
Q

Claudication

A

activity related leg pain that improves with rest
caused by perephrial vascular disease and lumbar spinal stenosis

256
Q

Neurogenic claudication (lumbar spinal stenosis)

A

pain bad when walking/standing
gets better with sitting/leaning forward

257
Q

Vascular claudication (periphreal vascular disease)

A

pain with walking that improves with standing

258
Q

Lumbar disk herniation

A

radiculopathy with or without paresthsia or weakness
conservative or surgical treatment

259
Q

Lumbar Spondylolisthesis

A

malalignment of the cephalad vertebrae in relation to the caudal vertebrae
presents as stenosis symptoms (neurologic claudication or radicular pain)
conservative or surgical treatment

260
Q

Common conditions of the thoracic spine

A

compression fractures

261
Q

Compresson fractures of thoracic spine

A

mid back pain after low energy trauma
symptoms of metabolic bone disease
conservative treament

262
Q

Number one reason people get joint replacements

A

Osteoarthritis
Must have pain, disability and functional limitations, failure of non-surgical treatment (must try conservative therapy before joint replacement

263
Q

When to use cementless vs cemented

A

cementless- younger age
cemented- femoral component in elderly

264
Q

Macrophages

A

eat up plastic particles from plastic wear causing bone lysis making it difficult to reconstruct

265
Q

Most common cause of revision after total knee replacement

A

Infection

266
Q

Subtypes of Cutaneous Lupus

A

Acute: butterfly rash
Subacute: photodistributed annular plaques
Chronic: discoid lupus erythematosus

267
Q

Differences between types of cutaneous lupus erthematosus rash

A

all have same histological features, but clinical presentation is different

268
Q
A

Lupus or Dermatomyositis
Vacuoles
Increased dermal mucin

269
Q

All people with _ have active systemic lupus erythematosus

A

Malar butterfly rash (acute cutaneous lupus erythematous)

270
Q

Lupus rash spares

A

Knuckles
Nasolabial fold

271
Q

Subacute cutaneous lupus

A

Photo distribution (annular)
Positive SS-A and SS-B

272
Q

Neonatal lupus

A

SS-A and SS-B antibodies
Annular rash on scalp and face
Congenital heart block, permanent

273
Q

Discoid lupus erythematous

A

Chronic
Scalp, face, and ears
Scarring with hyper-pigmented rim

274
Q

Dermatomyositis

A

photosensitive rash
Internal organ involvement
Histology (biopsy findings are identical to lupus)
Rely on clinical presentation
Diffuse scalp involvement, heliotrope rash, erythema in nasolabial folds, gottrons papules, gottrons sign on elbows and knees, V neck erythema, shawl sign, holster sign, periungual erythema, dialated capillaries
Mechanics hands (positive Jo-1 antibody)
Calcinosis
Ulceration (regions where gottrons papules would be present)

275
Q

Scleroderma categories

A

Diffuse- proximal to knees/elbows
Limited- distal to knees/elbows

276
Q
A

Sclerosis
Scarring

277
Q

Systemic sclerosis

A

Puffy hands
Sclerodactyly
Mask face, decreased oral aperture, radial perioral folds
Raynaud’s phenomenon, Digital ulcer, pitted scars, nail fold capillary changes, calcinosis (around hands)
Telangiectasia (matted or squared off)
Pigment changes (leukoderma of scleroderma, salt and pepper sign)

278
Q

Morphea

A

Localized scleroderma of the skin
Circumscribed, generalized, or linear variant (limb length variant)

279
Q

Systemic sclerosis vs Morphea

A

Head and neck and symmetric distal extremities
More than 90% have raynaud’s

Lacks distal involvement, no raynaud’s, no capillary changes, no systemic involvement, no autoantibodies

280
Q

Small Vessel Vasculitis

A

Purpuric papules on dependent areas or in areas of pressure or trauma

281
Q

Vasculitis diagnosis

A

Biopsy important
H&E
Direct immunoflouresence

282
Q

Hemlock Schonlein Purpura

A

IgA Vasculitis
Gastrointestinal
Joint
Renal involvement (IgA nephropathy)

283
Q

Granulomatosis with polyangiitis

A

C-ANCA (PR3)
Affects mixed medium and small vessels

284
Q

Microscopic polygangiitis
Eosinophilic granulomatosis with polyangiitis

A

P-ANCA (MPO)
Mixed small and medium vessels affected

285
Q

Medium vessel vasculitis

A

Livedo rash
Digital necrosis
SubQ nodules
Acrocyanosis

286
Q

Erythema nodosum

A

Panniculitis
Erythematous, painful nodules
Associated with streptococcal infection
Sarcoidosis
IBD

287
Q

Pyoderma gangrenosum

A

Pathergy
Ulcerations begin as violaceous or gray with undetermined borders
Criss-cross pattern (cribiform scarring)
Can be associated with disease about 50% of the time

MSK 2 (6 decks)

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