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Step 3 > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

RA

  1. what is most accurate test
  2. what joint is spared in RA
  3. what do you need to check before starting mAb
  4. role of steroids
A 
1. RF is nonspecific
anti-CCP is >95% specific 
2.SI joint 
3. NSAIDS and DMARDS
1st: MTX 
2nd: if MTX fails add TNF antag: infliximab, adalimumab, cetrolizumab, etanercept
  • hydroxychloroquine for mid RA
  1. Hep B and Tb
  2. use acutely as bridge to DMARDs. don’t use long term
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2
Q

AE

  1. MTX
  2. hydroxychloroquince
A
  1. BM suppression, pneumonitits, liver dx

2. retinopathy (eye exams)

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3
Q

what do the following all have in common?

  1. Ankylosing Spondylitis
  2. Reactive Arthritis (aka reiters)
  3. Psoriatic Arthritis
  4. Juvenile rheumatoid Arthritis
A

they’re all inflammatory arthritic conditions that are RF negative, have predilection for the spine, involve SI joint and are associated with HLA-B27

  1. Ankylosing Spondylitis
    presentation: young, male pt with spine/back stiffness. pm pain worse. relief when leaning forward. can lead to kyphosis and diminished chest expansion. rare: uveitis, aortitis, restrictive lung disease

diag: MRI spine with attn. to SI joint
treatment: NSAIDs, infliximab/adalimumab
NO STEROIDS

  1. Reactive Arthritis
    presentation: symmetric arthritis with hx of urethritis/cervicitis or GI infection. +/- fever, fatigue, weight loss, penile head lesion, conjunctivitis, skin lesion

diag. can’t see, can’t pee, can’t climb a tree & hx of chlamydia, shigella, Yersinia, salmonells, campylobacter
treatment: NSAIDs

  1. Psoriatic Arthritis
    presentation: joint involvement + hx of psoriasis, dactylitis, DIP involvement, nail pitting, enthesitis
    no diag test
    treat: NSAIDs first, if fails then anti-TNF agents
  2. Juvenile rheumatoid Arthritis
    presentation: salmon colored rash, fever, polyarteritis, myalgias, lymphadenopathy. sometimes high LFTs and hepatosplenomegaly
    diag: super high ferritin, high WBC, RF (-), ANA (-)
    treatment: NSAIDS, if fails then steroid bridge to MTX or anti-TNF agents
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4
Q

Whipple dx

A

presents with diarrhea, fat malabsorption, weight loss, joint pain.
bowel biopsy with PCR shows PAS+
treat with TMX-SMX

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5
Q

SLE

  1. what is best test to follow the severity of a flare up
  2. serology to check
  3. treatment
  4. drug induced-common drugs
A
  1. complement levels drop during flare up
    anti-ds DNA rises during flare up
  2. ANA, RF, anti-ds DNA, Anti-smith, anti-RO (fetal heart block), anti SSA, complement, ESR

anti-ds DNA and anti-SM specific for SLE. anti smith more specific.

  1. acute flare up: prednisone
    joint pain: NSAIDs. hydroxychloroquine if NSAIDs fail
    severe: belimumab, cyclophosphamide, azathioprine

nephritis: steroids and MMF

  1. hydralazine, INH, procainamide
    will have +ANA and +anti-histone antibodies
    NO RENAL or CNS involvement
    normal complement and anti-ds DNA levels
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6
Q

Sjogrens Syndrome

  1. presentation
  2. diag
  3. treatment
A
  1. woman with dry mouth, dry eyes, sensation of sand under eyelids, poor sense of smell & taste
  2. most accurate: lip biopsy
    schirmer test: decreased wetting of paper help to eye
    serology: ANA, RF, anti-Ro/SSA, Anti-La/SSB
  3. treat by keeping eyes and mouth moist
    pilocarpine (everywhere) and cevimeline (salivary only) increase ACTH which increases oral and ocular secretions
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7
Q

Scleroderma
Systemic
Diffuse

A

Systemic
ususally woman; skin (tight, fibrous, sclerodactyly,
Raynauds, mild and symmetric joint pain

Diffuse
lung: fibrosis, pulmonary HTN
heart: restrictive cardiomyopathy and premature CAD
renal: malignant HTN
GI: esophageal dysmotility, wide mouth colonic diverticula

diagnosis : no single test. look for + ANA, antiScl 70 (antitopoisomerase)

treatment: none will stop dx progression
renal: ACEI
pulmonary: bosetan, prostacyclin analogs, sildafenil
GI: PPIs
lung: cyclophosphamide
Raynauds: CCBs

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8
Q

CREST

A 
= limited scleroderma 
this form of scleroderma presents with 
Calcinosis of fingers
Raynauds
Esophageal dysmotility
Scleodactyly
Telangiectasia

anti-centromere antibodies more often than antiScl 70

doesn’t present with joint pain, heart/lung/kidney problems

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9
Q

eosinophilic Fascitis

A

looks like scleroderma but its not
high eosinophils
treat with steroids

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10
Q

Poly and Dermatomyositis
diag
significance of anti-Jo
what is most common serious complication

A

diag: abnormal EMG, high aldolase, high CPK
muscle biopsy is most accurate

anti-Jo-1 indicates higher risk of interstitial lung dx

malignancy is most common serious complication

treat with steroids

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11
Q

fibromyalgia

treatment

A

exercise
milnacipran, duloxetine, pregabalin
tricyclic antidepressants work but more side effects

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12
Q

Polymyalgia Rheumatica

presentation

A

women>50 lots of pain and stiffness of proximal MUSCLES! more pain than weakness! pain of muscles not joints

diag: high ESR
normal CPK, aldolase, EMG, muscle biopsy

treat with steroids

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13
Q

Vasculitis

treatment

A

steroids

if fail, then cyclophosphamide, azathioprine/6MP, MTX

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14
Q

Polyarteritis Nodosa

A

same stuff as vasculitis but following is different:

abdominal pain, pericarditis, HTN, renal involvement, testicular involvement

diag: angiography of abdominal vessels
most accurate skin/muscle/sural nerve biopsy

treatment :prednisone and cyclophosphamide

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15
Q

Granulomatosis with Polyangitis

A

vasculitis + upper & lower respiratory findings
+C-ANCA
treat with prednisone and cyclophosphamide

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16
Q

Allergic Angitis (Churg Strauss)

A

vasculitis + eosinophilia + asthma
biopsy
treatment: steroids

17
Q

Temporal Arteritis

A

is a type of Giant Cell Arteritis
if suspect –>steroids
don’t wait on biopsy results

18
Q

Takayasu Arteritis

A

young Asian female + diminished pulses

some patients will have vasculitis

risk TIA & stroke

diag AORTIC ARTERIOGRAPHY OR MRA
NOT BIOPSY

treat with steroids

19
Q

Cryoglobulinemia

A

vasculitis symptoms (skin lesions, malaise, joint pain, fatigue) + association with Hep C and renal involvement

treat Hep C and if cryo is severe add rituximab

20
Q

Behcet

A 
middle eastern or Asian
oral/genital ulcers
ocular involvement 
skin lesions
CNS dx

treat with prednisone and colchicine

21
Q

Gout

A

precipitant: thiazides, binge EtOH, nicotinic acid
diag: neg birefringence (yellow)

treat acute attack with NSAIDs and steroids
use colchicine if theres a contraind to NSAID/steroids
NO allopurinol acutely

preventative: 
allopurinol (rash, allergic intersitital nephritis, hemolysis) 
weight loss
no EtOH 
febuxostat ( if cant take allopurinol) 
uricase added if above fail

no probenecid. no sulfinpyrazone

22
Q

Pseudogout

A

hx hyperparathyroid, hypothyroidism, acromegaly, hemochromatosis
arthrocentesis: +birefringence , rhomboid crystals
treat with NSAIDs and steroids acutely

23
Q

Septic Arthritis

treatment

A

arthrocentesis : WBC >50000
want to coer for staph + gram neg
treat empirically with IV ceftriaxone and vanc

24
Q

Drugs for

  1. strep, staph
  2. gram neg rods
A
  1. oxacillin, nafcillin, cefazolin
    penicillin allergy then vanc, linezolid, clinda, daptomycin
  2. ceftriaxone, ceftazadine, gentamacin
    penicillin allergy then aztreonam, FQ
25
Q

Pagets

A

high alk phos
treat with calcitonin and bisphosphonates
will see osteoclytic lesions initially then osteoblastic

Step 3 (22 decks)

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