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MSK Cramming > Arthritis, Connective Tissue Disease and Vasculitis > Flashcards

Arthritis, Connective Tissue Disease and Vasculitis Flashcards

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1
Q

Joints affected by Inflammatory arthritis (RA)

A

Small Joints, sparing the DIP

PIP, MCP, MTP, wrist

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2
Q

Pain pattern of an inflammatory arthritis (RA)

A

Improves with activity
Worse in the morning
>30 minutes of morning stiffness

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3
Q

Joints affected by Non-inflammatory arthritis (OA)

A

Large joints, and DIP

Knee, hip, shoulder, spine

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4
Q

Synovial fluid appearance in inflammatory arthritis

A

Cloudy, non-viscous (only non-infectious synovial is straw colored and clear)

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5
Q

Diseases that cause a cloudy, non-viscous synovial aspirate

A

RA, spondylitis, crystalline arthritis, viral/fungal infection
(inflammatory arthritis)

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6
Q

Joints most commonly affected by gout

A

Large toe
Knee
Ankle
Midfoot

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7
Q

Precipitating events for gout flares (9)

A 
Alcohol
Infection
Surgery
CKD
Diuretics
Aspirin
Obesity
High protein meals
Cyclosporine
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8
Q

Main characteristics of an inflammatory arthritis

A

Stiffness >30 minutes
Morning Pain
Better with activity
Affects small joints most

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9
Q

Symptoms of an acute gout flare

A

Pain, swelling, and warmth in affected joint
Fever or sweating
Leukocytosis

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10
Q

Tophi

A

Deposits of urate crystals within the body

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11
Q

Locations that tophi can occur in gout patients

A

Fingers
Wrists
Knees
Olecranon
Pressure points (ulnar forearm, achilles tendon)
Visceral locations (heart, kidney, sclera)

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12
Q

Birefingence of gout crystals

A

Negative (gout = doubt)

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13
Q

Birefringence of CCPA crystals

A

Positive

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14
Q

Radiographic findings of gout joints

A

Erosive arthritis: punched out joints with overhanging bone lesions

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15
Q

Mechanism of damage in CCPA (calcium pyrophosphate arthritis)

A

Neutrophils swallow crystals and cause inflammation

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16
Q

Drugs of choice for managing an acute gout flare

A

Colchicine
NSAIDs
Steroids

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17
Q

Primary symptoms of CCPA

A

Mimics gout in pain and presentation
Does not have tophi typically, but DOES have dactylitis AKA boxer glove swelling
(also seen in RA and psoriatic arthritis)

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18
Q

Other diseases associated with CCPA

A

Hyperparathyroidism (high levels of Ca –> CPP deposition)
Hypothyroidism
Hemochromatosis
Hypomagnesemia (Calcium absorbed preferentially due to low levels)
hypophosphatemia (consumed in CPP crystals)

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19
Q

Factors that can precipitate CCPA/Pseudogout

A

Surgery
Infection
Trauma

But NOT alcohol like GOUT

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20
Q

Joints most commonly affected by CCPA

A

Knee
Wrist
Hand
Ankles

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21
Q

Treatment of choice for an acute CCPA flare

A

Same as gout
NSAIDs
Steroids
Cholicine

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22
Q

Prognosis of pseudogout

A

Typically resolves within 5-14 days

Chronic CPPA increases risk of osteoarthritis

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23
Q

MoA of Colchicine

A

Arrests microtubule assembly and inhibits inflammatory cells (via inhibition of cell division)

But only effective if given within 48 hours of a flare

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24
Q

Precautions for Colchicine Use

A

Affects Highly dividing cells: GI upset, bone marrow suppression.
Myopathy

CI in kidney disease due to electrolyte imbalances

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25
NSAID of choice in treating gout
Indomethacin
26
Contraindications of indomethacin use in acute gout flares
``` Renal insufficiency (NSAIDs can precipitate renal hypoxia) Gastric ulcers ```
27
Treatment of choice for gout flares in patients with kidney disease or polyarticular manifestation
Steroids (colchicine and indomethacin are CI in kidney disease)
28
Drugs commonly used to treat chronic gout
Allopurinol (w/ colchicine) Febuxostat Uricase (uricosuric) Probenecid
29
MoA of febuxostat
Xanthine oxidase inhibitor similar to allopurinol but with low risk of hypersensitivity reaction
30
Criteria for chronic gout arthritis
3+ flares in a year or 5+ lifetime flares Urate level >13 Uric acid nephropathy Tophi or erosions on radiograph Prophylaxis to prevent tumor lysis syndrome when starting chemotherapy
31
Precautions in allopurinol use
Potential for hypersensitivity/SJS reaction (do not rechallenge) Can worsen flares (give with colchicine) Fever Cytopenia (risk increased with azathioprine for RA or organ rejection)
32
Probenecid MoA
Increases uric acid excretion (requires >700mg/day clearance to be effective)
33
Uricase contraindications
Anaphylaxis to IV infusion | Cost
34
Situations in which uricase would be used for gout
Severe tophaceous or refractory gout due to its price
35
"Shared epitope" that increases RA risk in smokers
HLA-DRB1
36
HLA isotypes associated with RA
HLA-DR 1, 4, 10
37
Serum markers for RA
Rheumatoid factor Anti-citrullinated protein antibody Elevated ESR and CRP
38
Polyarthritis options if the patient does not have synovitis (non-inflammatory polyarthritis)
``` Osteoarthritis Viral arthralgia (hepatitis especially) Mechanical damage ```
39
Characteristic symptoms of rheumatoid arthritis
``` Synovitis Pain lasting >6 weeks Pain is most often symmetric and proximal Joint erosion Extra-articular manifestations ```
40
Diseases in which rheumatoid factor may be positive
``` Rheumatoid arthritis Sjogren's syndrome sarcoid endocarditis hepatitis C infection (or hepatitis C arthritis) cryoglobulinemia ```
41
Diseaes in which anti-citrullinated protein antibodies may be positiveq
RA only, much more specific than RF and can predate symptoms by a few years
42
Characteristic radiographic findings for RA
``` Pannus formation within the joint space marginal erosions Symmetric joint space narrowing Ulnar deviation of joints Boutinniere joint (DIP extension) Swan neck (DIP flexion) Marginal erosions of bone near the synovium Rheumatic nodules ```
43
Extra-articular manifestations of RA
Skin: Nodules, scleritis, nail fold infarction, vasculitis ulcers Lung: ILD, pleurisy, pulmonary nodules Cardiac: accelerated CVD, myocardial nodules, aortitis (vasculitis) Felty's Disease: Anemia, thrombocytopenia, neutropenia, splenomegaly Rheumatoid vasculitis
44
Drugs of choice for RA
Immunosuppression Anti-inflammatories DMARDs (hydroxychloroquine, methotrexate, lefunamide, sulfasalazine) Anti-TNF agents
45
"Triple Therapy" of RA
Methotrexate + Sulfasalazine + Hydroxyquinone = Anti TNFa effectivness
46
MoA for hydroxychloroquine in mild RA and Lupus
Reduces lysosomal fusion Reduces DNA synthesis Reduces platelet aggregation Reduces cytokine release
47
Toxicity associated with hydroxychloroquine
``` Retinal or corneal deposits Vertigo Hypersensitivity reactions Neuropathy Cardiomyopathy ```
48
Toxicities associated with Methotrexate (non-obvious)
Acute or chronic pulmonary or liver toxicity Major teratogen CI in alcoholics
49
Mechanism of Leflunomide in RA treatment
Similar to methotrexate but affects dihydrooate and not foalte metabolism
50
Toxicities of Leflunomide in RA treatment
``` GI upset Alopecia HTN cytopenia liver toxicity (CI in alcoholics) teratogen (all similar to methotrexate except hypertension) ``` Can be easily reversed by cholestyramine in the case of an acute infection
51
Toxicities associated with sulfasalazine in RA treatment
GI upset, headache Aplastic anemia, hepatitis, nephritis, pancreatitis are all rare. Cannot be used with sulfa allergy CAN be used in alcoholics
52
Review the biologic agents for RA
Review the biologic agents for RA
53
Primary concern in treating RA with rituxumab
Risk of hepatitis B reactivation or progressive multifocal leukoencephalopathy
54
Primary concern of anti-TNFa biologics
formation of anti-dsDNA and Lupus drug reaction
55
Unique features of Systemic Onset JIA
Least common JIA Presents with fever, rash, and nodules (systemic part) Affects any joint Destructive arthritis, leukocytosis, anemia, and ESR are all marked ANA is absent
56
Unique features of Pauciarticular JIA
Most common JIA but hard to diagnose due to relative lack of symptoms (Pauci) Occurs early in childhood and is rare over age 10 Affects large joints but spares the hip (other JIAs will affect hip) Uveitis +ANA
57
Unique features of polyarticular JIA
Affects any joint, but the hip is never first (vs pauciarticular, which always spares hip) Has less destructive arthritis, anemia, and ESR than systemic JIA Only JIA that can possibly have a +RF
58
HLA isotype associated with ankylosing spondylitis and reactive arthritis
HLA-B27 (explains male gender preference in AS and reactive arthritis)
59
Shober manuver
Reduced back flexibility indicative of splondyloarthropathy
60
Common features of spolyloarthropathies
Very responsive to NSAIDs Dactylitis (some) Uveitis (ALL) Strong association with HLA-B27
61
Features of Psoriatic Arthritis
Low Back Pain Psoriasis Asymmetric distribution of spondylitis Dactylitis (sausage fingers)
62
Features of Aknylosing Spondylitis
``` Higher incidence in males High corellation with HLAB27 Symmetric sacroilitis Enthesitis (not seen only in IBD) Anterior uveitis Prostatitis (unique) ```
63
Features of Reactive Arthritis
``` Male predominancce Often occurs after an STI or GI infection Anterior uveitis, conjunctivitis Commonly affects large joints High HLA-B27 assocaiation SKIN LESIONS: Circinate balatitis, keratoderma Urethritis Oncholysis ``` Can't see, can't pee, can't bend my knee
64
Symmetric spondylopathies (2)
AS and Reactive
65
Asymmetric spondylopathies (2)
Psoriatic and IBD associated
66
Only spondyloarthritis without enthesis
IBD
67
Therapeutic options for ankylosing spondyltitis
ROM excercises to avoid spinal fusion by syndesmophytes NSAIDs Sulfasalazine or methotrexate TNF inhibitors
68
Presenting Symptoms of Lupus
``` SOAP BRAIN MD Serositis Oral and nasal ulcers (PAINLESS) Arthritis Photosensitivity ``` Blood dyscrasias (anemia, thrombocytopenia, hemolysis is Coombs positive) Renal disease Autoimmune studies (+ANA) Immunologic (anti-smith, anti-dsDNA, anti-PL) Neurologic (seizures, psychosis) Malar rash Discoid rash Also libman sacks endocarditis (vegetations on valves)
69
Number of SOAP BRAIN MD symptoms needed to Dx Lupus
4/11 of these symptoms are needed to diagnose Lupus
70
Risk factors for developing Lupus
Genetic factors on X chromosome (all females, males with Kleinfelter) Estrogen therapy or early menarche Childhood EBV infection Exposures to smoking, silica, dust, UV light OOPHORECTOMY can alleviate some risk in females
71
Primary mechanism of kidney disease in Lupus
Type III: immune complex deposition
72
Antibodies positive in Lupus
ANA (non-specific, highly sensitive) Anti-dsDNA Anti-phospholipid Anti-smith Anti-cardiolipin (causes cross reactions in VDRL and falsely prolongs PTT) Anti-histone (in drug-induced lupus only) Hypocomplementemia
73
Treatment for Lupus
NSAIDs steroids Hydroxychloroquine Cyclophosphalmide/mycophenolate only if severe disease Rituxumab
74
Antibodies in Sjogren's syndrome
>90% have positive Rheumatoid factor Anti-SSA Anti-SSB ANA
75
Non-glangular complications of Sjogren's syndrome
Pancytopenia Arthritis lymphadenopathy (may be due to lymphatic blockage in swollen lacrimal/parotid glands) Increased risk for lymphoma, MALT
76
Antibodies positive in diffuse scleroderma
Anti-scl70 (DNA polymerase) Anti-nucleolar ANA
77
Antibodies positive in local scleroderma
ANA | Anti-centromere
78
Symptoms of diffuse scleroderma
Raynaud's Esophageal dysmotility Scleroderma (wide range) Telangectasias Widespread organ sclerosis with potential for pulmonary hypertension Fingertip pitting Mechanic hands (seen in both Limited and diffuse) Renal crisis
79
Symptoms of limited scleroderma
``` Calcinosis Raynaud's Esophageal dysmotility Scleroderma restricted to hands, feet and face Telangectasias ``` Interstitial lung disease and pulm hypertension occur in much later stages than in diffuse
80
Common symptoms of Polymyositis and Dermatomyositis
``` Symmetric proximal limb weakness Difficulty swallowing with possible nasal regurg due to involvement of esophageal skeletal muscle Lung disease Myocarditis Raynaud Mechanics hands ```
81
Features unique to polymyositis (vs dermatomyositis)
CD8+ (poly = more!) endomysial inflammation
82
Features unique to dermatomyositis (vs polymyositis)
``` CD4+ perimysial inflammation SKIN INVOLVEMENT - Grotton's sign" rash on knuckles - Periorbial rash - Nail abnormalities ``` -- Mechanic's hands are seen in both
83
Prognosis of dermato/polymyositis
Increased mortality from malignancy, infection, or pulmonary compromise
84
Diagnostic criteria of dermato/polymyositis
``` CK levels should be elevated Electromyogram abnormalities Anti-Jo Anti-SRP Anti-MI2 ``` Not to be confused with polymyalgia rheumatica which presents similarly but has normal CK
85
Treatment of dermato/polymyositis
Steroids for an acute flare | Long term immunosuppression
86
Large vessel vasculitides
Giant cell arteritis | Takayasu arteritis
87
Medium vessel vasculitides
Kawasaki | Polyarteritis nodosa
88
ANCA+ Small vessel vasculitides
Wegener's (granuloma polyangiitis) Churg-Strauss (Eos polyangiitis) Microscopic polyangiitis
89
ANCA- Small vessel vasculitides (immune complex)
IgA vasculitis Cryoglobulinemic vasculitis Anti-GBM disease
90
Required before beginning immunosuppression in vasculitis
Get biopsy. Immunosuppression can worsen many mimic diseases. Except with suspected GCA which gets empiric high dose steroids
91
Treatment options for small vessel vasculitis
Due to high mortality high-dose steroids are begun and tapered into a chronic immunosuppression with methotrexate or azathioprine. If disease is life threatening, can give pulsed high dose (>1g/day) steroids with rituximab or cyclophosphamide.
92
Treatment for large vessel vasculitides
High dose steroids
93
Conditions associated with positive C-ANCA (PR3)
Wegner's ONLY | Highly sensitive and specific
94
Conditions associated with P-ANCA (MPO)
Highly sensitive, but not specific ``` Non-Wegner's polyangiitis (Microscopic, Eosinophilic) IBD Liver disease HIV Lupus ```
95
Condition also associated with GCA
Polymyalgia rheumatica
96
Diagnostic features of takayasu's arteritis
Female, asian Narrowing of the aorta and proximal great vessels upper extremity claudication subclavian bruits
97
Diagnostic features of polyarteritis nodosum
Immune complex formation secondary to hepatitis B infection--> renal micro- anyrusms Typically affects young adults Renal involvement can cause hypertension Vascular purura

MSK Cramming (9 decks)

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