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Rheumatology USMLE Step 3 > Section 1: Rheumatoid Arthritis, Seronegative Spondyloarthropathies and Osteoarthritis > Flashcards

Section 1: Rheumatoid Arthritis, Seronegative Spondyloarthropathies and Osteoarthritis Flashcards

1
Q

Rheumatoid arthritis presents most often in women > 50. Patients have joint pain and morning stiffness that is symmetrical and in multiple joints of the hands lasting for more than 1 hour in the morning with the symptomatic episode going on for at least 6 weeks. There is often a prodrome of malaise and weight loss, but this is not enough to make a clear diagnosis.

List the symptoms and signs of RA (4 or more of it will define the disease)

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4135-4154). . Kindle Edition.

A
  • Morning stiffness lasting more than 1 hour
  • Wrist and finger involvement (MCP, PIP)
  • Swelling of at least 3 joints
  • Symmetric involvement
  • Rheumatoid nodules (not necessary to diagnose RA)
  • X-ray abnormalities showing erosions (not necessary to diagnose RA)
  • Positive rheumatoid factor or anti-CCP
  • C-reactive protein (CRP) or ESR

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4135-4154). . Kindle Edition.

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2
Q

List the other findings in RA:

Cardiac

Lung

Blood

A

Cardiac

  • Pericarditis
  • Valvular disease

Lung

  • Pleural effusion with a very low glucose level
  • Lung nodules

Blood

  • Anemia with normal MCV

Nerve

  • Mononeuritis multiplex

Skin

  • Nodules

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4155-4157). . Kindle Edition.

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3
Q

How is the diagnosis of RA made?

A

Rheumatoid arthritis is diagnosed with a constellation of physical findings, joint problems, and lab tests. There is no single diagnostic criteria to confirm the diagnosis. There is no single therapy to control and treat the disease

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4158-4177). . Kindle Edition.

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4
Q

A 34-year-old woman presents with pains in both hands for the last few months and stiffness that improves as the day goes on. Multiple joints are swollen on exam. X-rays of the hands show some erosion. What is the single most accurate test?

a. Rheumatoid factor
b. Anti-cyclic citrullinated peptide (anti-CCP)
c. Sedimentation rate
d. ANA
e. Joint fluid aspirate

A

B. Rheumatoid factor (RF) is present in only 75– 85 percent of patients with rheumatoid arthritis (RA). It can also be present in a number of other diseases; hence, the RF is rather nonspecific. Anti-cyclic citrulinated peptide (anti-CCP) is the single most accurate test for RA. It is > 95 percent specific for RA, and it appears earlier in the course of the disease than the RF. There is nothing specific on joint aspiration to determine a diagnosis of RA.

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5
Q

List the joint findings in RA

A
  • Metacarpophalangeal (MCP) swelling and pain
  • Boutonniere deformity: Flexion of the proximal interphalangeal (PIP) with hyperextension of the distal interphalangeal (DIP)
  • Swan neck deformity: Extension of the PIP with flexion of the DIP
  • Baker’s cyst (outpocketing of synovium at the back of the knee)
  • C1/ C2 cervical spine subluxation
  • Knee: Although the knee is commonly involved, multiple small joints are involved more commonly over time.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4177-4179). . Kindle Edition.

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6
Q

List the features of Felty syndrome

A
  • Rheumatoid arthritis
  • Splenomegaly
  • Neutropenia
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7
Q

What is the characteristic anemia in RA?

A

Normocytic normochromic anemia

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8
Q

List the new alternate diagnostic criteria for RA include

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4185-4198). . Kindle Edition.

A
  • Synovitis (a single joint is enough to diagnose RA)
  • RF or anti-CCP
  • ESR or CRP
  • Prolonged duration (beyond 6 weeks)

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4185-4198). . Kindle Edition.

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9
Q

Tests for swollen joint in CCS

A
  • X-rays
  • RF
  • Anti-CCP
  • CBC
  • ESR
  • C-reactive protein
  • If the case describes a swollen joint with an effusion, aspiration of the joint should also be done to establish the initial diagnosis.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4185-4198). . Kindle Edition.

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10
Q

List the joint spared in RA

A

The sacroiliac joint is spared in rheumatoid arthritis.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4185-4198). . Kindle Edition.

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11
Q

Which of the following will have the lowest glucose level on pleural effusion?

a. CHF
b. Pulmonary embolus
c. Pneumonia
d. Cancer
e. Rheumatoid arthritis
f. Tuberculosis

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4199-4216). . Kindle Edition.

A

E. Rheumatoid arthritis has the lowest glucose level of all the causes of pleural effusion described here. Treatment NSAIDs combined with a disease-modifying antirheumatic drug (DMARD) is the standard of care in patients with RA. There is no therapeutic difference among NSAIDs, and you may use ibuprofen for any of the rheumatological diseases described. There is no point in waiting to use a DMARD in a patient with severe RA or anyone with joint erosions. NSAIDs will not delay the progression of the disease. Eliminating an abnormal x-ray as a criterion for diagnosis allows earlier treatment with DMARDs. DMARDs The best initial DMARD is methotrexate. Add others if it is not effective.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4199-4216). . Kindle Edition.

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12
Q

Rx of Rheumatoid Arthritis

A
  • NSAIDs combined with a disease-modifying antirheumatic drug (DMARD) is the standard of care in patients with RA
  • Methotrexate: This is the best-tolerated and most widely used DMARD
    • Adverse effects are bone marrow suppression and pneumonitis
  • Biological agents (infliximab, adalimumab, etanercept)
  • Hydroxychloroquine: Use with mild disease
  • Sulfasalazine: This is the same drug that was used in the past for ulcerative colitis. It can suppress the bone marrow.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 4209-4210). Kaplan Publishing. Kindle Edition.

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13
Q

Rheumatoid arthritis

  1. What test should be done before initiating Rx with TNF inhibitors
  2. Why does infliximab have to be given with methotrexate?
A
  1. Associated with reactivation of latent TB
  2. Methotrexate prevents anti-infliximab antibody formation
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14
Q

List alternatives to DMARDs

A
  • Rituximab: Anti-CD-20 antibody
  • Anakinra: IL-1 receptor antagonist
  • Tocilizumab: IL-6 receptor antagonist. Added to methotrexate if it is ineffective
  • Leflunomide: Pyrimidine antagonist that is similar in effect to methotrexate, with less toxicity
  • Abatacept: Inhibits T-cell activation
  • Gold salts: Rarely used because of toxicity, such as nephrotic syndrome

Use the mnemonic “RAT LAG”

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 4226-4231). Kaplan Publishing. Kindle Edition.

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15
Q

What is the place of steroids in the Rx of RA?

A

Steroids are a bridge to DMARD therapy. They are the answer for an acutely ill patient with severe inflammation.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 4234-4235). Kaplan Publishing. Kindle Edition.

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16
Q

List the seronegative spondyloarthropathies

A
  • Ankylosing spondylitis
  • Reactive arthritis (formerly known as Reiter’s syndrome)
  • Psoriatic arthritis
  • Juvenile rheumatoid arthritis (adult-onset Still’s disease)

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 4239-4245). Kaplan Publishing. Kindle Edition.

17
Q

Characteristics of seronegative spondyloarthropathies

A
  • Negative test for rheumatoid factor
  • Predilection for the spine
  • Sacroiliac joint involvement
  • Association with HLA– B27

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 4239-4245). Kaplan Publishing. Kindle Edition.

18
Q

Diagnosis:

  • A young (< 40) male patient with spine or back stiffness
  • Peripheral joint involvement is less common
  • The pain is worse at night and is relieved by leaning forward
  • Can lead to kyphosis and diminished chest expansion

Rare findings in above condition

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 4246-4252). Kaplan Publishing. Kindle Edition.

A

Ankylosing Spondylitis (AS)

Rare findings are

  • Uveitis (30 percent)
  • Aortitis (3 percent)
  • Restrictive lung disease (2– 15 percent)

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 4246-4252). Kaplan Publishing. Kindle Edition.

19
Q

A 27-year-old man presents with months of back pain that is worse at night. He has diminished expansion of this chest on inhalation and flattening of the normal lumbar curvature. What is the most accurate of these tests?

a. X-ray
b. MRI
c. HLA-B27
d. ESR
e. Rheumatoid factor

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 4253-4263). Kaplan Publishing. Kindle Edition.

A

B. MRI of the SI joint is more sensitive than an x-ray, detecting edematous, inflammatory changes years before an x-ray in ankylosing spondylitis (AS). HLA-B27 can be present in 8 percent of the general population and is not necessary to confirm a diagnosis of AS. The ESR is not always elevated and is a nonspecific test. The rheumatoid factor will be negative in AS. In a CCS case, all of performed, with the x-ray done first and then going on to the MRI if the x-ray is negative.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 4263-4268). Kaplan Publishing. Kindle Edition.

20
Q

Rx for ankylosing spondylitis

A
  • NSAIDs
  • Biological agents, such as infliximab or adalimumab
  • Sulfasalazine

Do not use steroids. The most common wrong answer for ankylosing spondylitis treatment is steroids. They do not work.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 4263-4268). Kaplan Publishing. Kindle Edition.

21
Q

Reactive arthritis (formerly known as Reiter’s syndrome) presents with an asymmetric arthritis with a history of urethritis or gastrointestinal infection. There may be constitutional symptoms, such as fever, fatigue, or weight loss.

List the CF of reactive arthritis

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 4270-4274). Kaplan Publishing. Kindle Edition.

A

Arthritis: May be monoarticular, oligoarticular, or more diffuse

Genital lesions: Circinate balanitis (around head of penis); urethritis or cervicitis in women

Conjunctivitis

Keratoderma blenorrhagicum: A skin lesion characteristic of reactive arthritis

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 4270-4274). Kaplan Publishing. Kindle Edition.

22
Q

Diagnostic testing for reactive arthritis

Rx of reactive arthritis

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 4274-4281). Kaplan Publishing. Kindle Edition.

A

There is no specific diagnostic test.

Look for the triad of knee (joint), pee (urinary), and see (eye) problems with a history of Chlamydia, Shigella, Salmonella, Yersinia, or Campylobacter.

Treat with NSAIDs.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 4274-4281). Kaplan Publishing. Kindle Edition.

23
Q

Key features of psoriatic arthritis

A
  • Nail pitting
  • Distal interphalangeal (DIP) involvement (Remember: RA involves the proximal joint.)
  • “Sausage-shaped” digits (dactylitis)
  • Enthesitis: Inflammation of tendinous insertion sites

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4286-4289). . Kindle Edition.

24
Q

Diagnostic test for psoriatic arthritis

Rx of psoriatic arthritis

A

No single test is specific for psoriatic arthritis

Best initial therapy: NSAIDs

Methotrexate is used for resistant disease

Infliximab and the other anti-TNF agents are effective

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4290-4317). . Kindle Edition.

25
Q

CF of juvenile rheumatoid arthritis (JRA) or adult-onset Still’s disease

A
  • Fever
  • Salmon-colored rash
  • Polyarthritis
  • Lymphadenopathy
  • Myalgias

This can be a very difficult diagnosis to recognize. Additional minor criteria are the presence of:

  • Hepatosplenomegaly
  • Elevated transaminases

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4290-4317). . Kindle Edition.

26
Q

Diagnostic tests for JRA

Rx of JRA

A

There is no specific diagnostic test. JRA is characterized by the following:

  • Very high ferritin level
  • Elevated white blood cell count
  • Negative rheumatoid factor and negative ANA are essential to establishing the diagnosis

Treat with

  • NSAIDs
  • Unresponsive cases can be treated with steroids
  • Those with persistent symptoms need methotrexate or anti-TNF medications to get off steroids.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4290-4317). . Kindle Edition.

27
Q

Whipple Disease

  1. Most common presentation
  2. Other common features
  3. Most specific test
  4. Rx
A
  1. Joint pain
  2. Diarrhea, fat malabsorption, and weight loss
  3. Biopsy of the bowel showing PAS positive organisms
  4. TMP/ SMX is curative.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4290-4317). . Kindle Edition.

28
Q

Osteoarthritis, the most common joint abnormality, is associated with aging and increased use of a joint. The morning stiffness is < 30 minutes in duration and there is crepitus on moving the joint. OA affects the distal interphalangeal (DIP) joints (RA does not affect the DIPs)

What are Heberden’s nodes

What are Bouchard’s nodes

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4319-4324). . Kindle Edition.

A

Heberden’s nodes: DIP osteophytes

Bouchard’s nodes: PIP osteophytes

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4319-4324). . Kindle Edition.

29
Q

Best initial test of osteoarthritis

Other tests?

Rx

A

The best initial test is x-ray of the joint

  • ANA
  • ESR
  • Rheumatoid factor
  • Anti-CCP
  • All other inflammatory markers will be normal
  • Joint fluid will have a low leukocyte count < 2,000/ mm3

Treatment

  • Acetaminophen
  • Chondroitin sulfate is not clearly useful to slow joint deterioration
  • Weight loss and exercise help

Glucosamine is a wrong answer. Glucosamine = placebo

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4326-4337). . Kindle Edition.

30
Q

Compare osteoarthritis and rheumatoid arthritis

A

Morning stiffness in OA lasts < 30 minutes while it lasts > 1 hour in RA

OS involves the DIP but RA does not

Both OS and RA involves the PIP

OS does not involve the MCP but RA does

OS is negative for both RF and anti-CCP but RA is positive for RF (often) and anti-CCP

Joint fluid leukocyte count in OS is < 2,000 but between 5,000 and 50,000 in RA

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 4342-4361). . Kindle Edition.

31
Q

Rheumatoid Arthritis

  1. RA + pneumoconiosis
  2. RA + effervescent salmon-colored rash + high fever
A
  1. Caplan syndrome
  2. Still’s disease
32
Q

What is the most common cause of death in rheumatoid arthritis?

A

Coronary artery disease

33
Q

List the adverse effects of the following RA medications:

  1. Anti-TNF
  2. Hydroxychloroquine
  3. Sulfasalazine
  4. Rituximab
  5. Gold salts
  6. Methotrexate
A
  1. Reactivation of TB
  2. Ocular
  3. Rash, hemolysis
  4. Infection
  5. Nephrotic syndrome
  6. Liver toxicity, lung toxicity, and marrow suppression

Rheumatology USMLE Step 3 (5 decks)

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