Arthritis Part 2 Flashcards
(63 cards)
1
Q
chronic arthritis in +1 joints for at least 6 wks
A
Juvenile Idiopathic Arthritis (JIA)
2
Q
4 main subtypes of JIA?
which is MC?
A
- oligoarticular (MC)
- polyarticular
- systemic
- enthesitis-associated
3
Q
what is the enthesis?
A
the site of insertion of a tendon, ligament, fascia, or articular capsule into bone
4
Q
- arthritis of < 4 joints
- medium to large joints
- asymmetrical → leg-length discrepancy - involved leg grows longer d/t inc blood flow and growth factors
- synovitis - mild, painless
- systemic sx uncommon except for inflammation in eye
which type of JIA?
A
oligoarticular JIA
5
Q
- arthritis >5 joints
- Both large and small joints are involved - symmetrical pattern
- low-grade fever, fatigue, rheumatoid nodules, and anemia possible
- Further divided into rheumatoid factor (RF)–positive and RF–negative disease
which type of JIA?
A
polyarticular
6
Q
difference between presentations of RF+ vs RF-
polyarticular JIA
A
RF+ disease resembles adult RA w/ more chronic, destructive arthritis
7
Q
- More rare
- can involve any number of joints and affects both large and small joints
- high F (39–40°C) 1-2x per day - nml temp in between fevers
- evanescent, salmon-pink macular rash MC on pressure areas when fever is present
- systemic: HSM, LAD, leukocytosis, and serositis
which type of JIA?
A
systemic
8
Q
- MC males, >10 y/o, MC LE, large joint arthritis
- inflammation of tendinous insertions (enthesopathy), such as the tibial tubercle or the heel
- Low back pain and sacroiliitis
which type of JIA
A
Enthesitis-associated
9
Q
w/u for JIA
A
no diagnostic test
- Inc ESR CRP, WBCs, platelets
- RF (+): MC polyarticular if onset >8 y/o
- Anti–CCP ab: MC RA, and may be detectable prior to RF
- ANA (+): MC late-onset RF (+)
- HLA B27 antigen: enthesitis-associated
- joint fluid analysis: inflammation
- XR; MRI
10
Q
- RBC > WBC; < 2,000 WBC
- Glu nml
this joint fluid analysis is indicative of what disorder?
A
trauma
11
Q
- 3,000–10,000 WBC, mostly mononuclear cells
- Glu nml
this joint fluid analysis is indicative of what disorder?
A
Reactive arthritis
12
Q
- 5,000–60,000 WBC, mostly NEUT
- Usually normal or slightly low glucose
this joint fluid analysis is indicative of what disorder?
A
Juvenile idiopathic arthritis and other inflammatory arthritides
13
Q
- > 60,000 WBC, > 90% NEUT
- Low to normal glucose
this joint fluid analysis is indicative of what disorder?
A
Septic arthritis
14
Q
how may a later course of JIA with +RF present on XR?
A
joint space narrowing due to cartilage thinning and erosive changes of the bone related to chronic inflammation
15
Q
tx for JIA
A
- NSAIDs (1st line)
- DMARDs: MTX (2nd)
- TNF inhibitors: etanercept (Enbrel), infliximab (Remicade)
- CS - severe, systemic
- injections - TAC
- Topicals - uveitis; MTX, cyclosporine for failed topicals - rehab
16
Q
which type of JIA has the highest rate of remission?
A
oligoarticular
17
Q
which type of JIA has the highest risk for chronic, erosive arthritis that may continue into adulthood
A
RF positive disease
18
Q
A group of diseases involving theaxial skeleton
A
spondyloarthritis
19
Q
what makes seronegative spondyloarthritis diffrent from RA?
A
negative forrheumatoid factor
different pathophys than what is commonly seen in RA
20
Q
- Male, onset < 40 y/o
- inflammatory arthritis of spine and SI joints
- Asymmetric oligoarthritis of large peripheral joints
- Enthesopathy
- Major association with the HLA-B27 gene
A
Seronegative Spondyloarthritis
20
Q
- infection plays a key role in which spondyloarthropathy MC?
- develops 1–4 wks after bacterial dysentery or nongonococcal STI
A
reactive arthritis
21
Q
RF for reactive arthritis
A
- 0.2% in the general population
- 2% in HLA-B27 individuals
- 20% in pts with HLA-B27 infected w/ Salmonella, Shigella, or enteric organisms
22
Q
- A chronic inflammatory disease of the joints of the axial skeleton
- onset late teens or early 20s
A
Ankylosing Spondylitis
23
Q
- onset gradual
- intermittent periods of back pain that may radiate to butt
- Back pain worse AM w/ stiffness that lasts hours - improve w/ activity
- Severe: progressive sx in cephalad direction, entire spine becomes fused, allowing no motion in any direction
- Lumbar curve flattens, thoracic curvature exaggerates
- SOB
- Absent Constitutional sx
A
Ankylosing Spondylitis
24
associated findings of Ankylosing Spondylitis
* acute arthritis of **peripheral joints**
* Enthesopathy - Achilles tendon, plantar fasciitis, or “sausage” swelling of a finger or toe
* Anterior uveitis
* Spondylotic heart disease - AV conduction defects and aortic regurg (severe)
* Pulmonary fibrosis (late disease)
* Cauda equina fibrosis (late)
25
w/u for Ankylosing Spondylitis
* **Elevated ESR**
* **(-) RF and anti-CCP**
* CBC - Anemia
* **HLA-B27** MC in white pts; not diagnostic
* **XR**, MRI - SI joints, later, erosion and sclerosis of SI joints (**BL and symmetric**); Fusion of posterior facet joints of spine
26
imaging shows:
“The shiny corner sign”
“Bamboo spine”
dx?
Ankylosing Spondylitis
27
tx Ankylosing Spondylitis
1. **NSAIDs** (1st line)
2. _TNF inhibitors_ (2nd)
3. PT
3. *CS ineffective!! Can worsen osteopenia*
28
what worsens the prognosis of Ankylosing Spondylitis
Developing hip disease < 2 yrs of onset
29
what comes first in Psoriatic Arthritis, psoriasis or arthritis?
MC psoriasis
arthritis can precedes/occur simultaneously - arthritis can occur up to 2 years before skin disease
30
1. Symmetric polyarthritis that resembles RA but fewer joints
1. Oligoarticular form
1. MC DIP joints - asymmetric early; nail pitting, and onycholysis; "sausage" swelling
1. Arthritis mutilans
1. Spondylotic form - MC sacroiliitis and spine
- HLA-B27-positive
Psoriatic Arthritis
31
Arthritis is at least ? times MC in pts with severe skin disease than in those with only mild skin findings
| Psoriatic Arthritis
5x
32
w/u for Psoriatic Arthritis
* **Inc ESR**
* RF **(-)**
* possible inc Uric acid levels
* possible reduce iron stores
* **XR**
33
T/F: increased uric acid levels can cause gouty attacks in psoriasis arthritis
F
34
XR findings of psoriasis arthritis
* marginal erosions and irregular destruction of joint and bone - **"sharpened pencil"**
* Fluffy periosteal new bone, esp at insertion of muscles and ligaments into bone
* Psoriatic spondylitis = asymmetric sacroiliitis and syndesmophytes - coarser than ankylosing spondylitis
35
tx for psoriasis arthritis
* **NSAIDs (1st line)**
* _MTX_ (2nd) - Can improve both cutaneous and arthritic manifestations
* _TNF inhibitors_ - if refractory to MTX; effective for both arthritis and psoriasis
* CS - less effective; may precipitate _pustular psoriasis_ during tapers
36
what medication to avoid in psoriasis arthritis as it may exacerbate the psoriasis
antimalarial
37
1. Precipitated by **GI and GU infections**
1. **Asymmetric** sterile oligoarthritis, **MC LE**
1. MC associated with **enthesitis**.
1. **Extra-articular sx common** - urethritis, conjunctivitis, uveitis, and mucocutaneous lesions.
1. **Triad: arthritis, conjunctivitis/Uveitis, and urethritis**
1. MC young men
1. Associated with **HLA-B27**
Reactive Arthritis
38
* Develop within 1–4 weeks after either: GI infection or STI
* Synovial fluid from affected joints is culture-negative
* **Asymmetric** arthritis, MC large weight-bearing joints (knee and ankle)
* Sacroiliitis or ankylosing spondylitis if frequent recurrences
* **Fever and wt loss at onset**
Reactive Arthritis
39
extraarticular manifestations of Reactive Arthritis
* Ocular - conjunctivitis, anterior uveitis episcleritis, and keratitis; chlamydia
* GU - dysuria, pelvic pain, urethritis, cervicitis, prostatitis, salpingo-oophoritis, or cystitis. Urethritis can occur even when arthritis is induced by enterobacteriaceae
* GI - diarrhea.
* Oral - painless mucosal ulcers
* Cutaneous eruptions and other skin changes - keratoderma blennorrhagica, erythema nodosum
* Nail changes - similar w/ psoriasis
* Genital lesions - circinate balanitis
* CV - valve disease, aortic insufficiency, w/ greater chronicity of illness. Pericarditis very rarely
*Mucocutaneous or other manifestations are not specific for reactive arthritis*
40
hyperkeratotic skin lesions on soles and palms resembling pustular psoriasis
keratoderma blennorrhagica
41
painless erythematous lesions with small, shallow ulcers on the glans penis and urethral meatus
circinate balanitis
42
An inflammatory process affecting the mucous membranes of the mouth and lips, with or without oral ulceration
stomatitis
43
w/u for reactive arthritis
* Synovial fluid analysis - inflammatory, but no sign of active infection
* XR - permanent/progressive joint disease in SI as well as peripheral joints
44
tx for reactive arthritis
1. **NSAIDs (1st line)**
1. Preventing STD
- chronic reactive arthritis associated with chlamydial infection: abx x 6 mo
1. sulfasalazine or MTX (2nd)
2. Anti-TNF agents if refractory
45
IBD associated Arthritis is MC associated with what other condition?
**Crohns** > ulcerative colitis
46
* MC large joints of the arms and legs, including the elbows, wrists, knees, and ankles
* joint disease **parallels that of the bowel disease**
* The arthritis usually begins months to years after the bowel disease
Peripheral arthritis
47
* indistinguishable by sx or XR from ankylosing spondylitis
* Follows a course **independent of the bowel disease.**
* 50% of pts are HLA-B27-positive.
* These sx may come on months or even years before the symptoms of IBD appear
Spondylitis
48
tx for arthritis associated IBD
* Control intestinal inflammation
* Spondylitis - NSAIDs, may activate bowel disease in a few pts, use cautiously
* ROM exercises
* DMARDs
* Corticosteroids
49
Septic arthritis - Acute onset of inflammatory _____ arthritis, most often in large weight-bearing joints and wrists.
monoarticular
50
RF of septic arthritis
* Bacteremia - IVDU, endocarditis, infection at other sites
* Damaged or prosthetic joints - rheumatoid arthritis
* Compromised immunity - DM, advanced CKD, alcoholism, cirrhosis, and immunosuppressive therapy
* Loss of skin integrity – trauma, cutaneous ulcer or psoriasis
51
MCC of septic arthritis
1. **Staph**
1. MRSA and group B strep are also common
1. G- bacteria: _E.coli and pseudomonas, are MC in IVDU_
52
* acute, with pain, swelling, and heat of affected joint worsening over hours.
* Pain aggravated by motion
* MC knee; hip, wrist, shoulder, and ankle.
* Chills and fever
* Rarely More than one joint is involved -
septic arthritis
53
What RF causes septic arthritis to manifest in uncommon sites such as the sternoclavicular and SI joint?
IV drug users
54
pathogens that cause >1 joint involved in septic arthritis?
Patients with rheumatoid arthritis, associated endocarditis, and infection with group B streptococci.
55
w/u for septic arthritis
* **Synovial fluid analysis**
* Blood cx
* CBC
* XR; MRI/CT
56
synovial fluid findings indicative of septic arthritis?
* WBC >50,000; MC >100,000
* >90% PMN cells
* Gram stain and cx are positive
57
possible imaging findings of septic arthritis
* Demineralization may not develop for several days.
* MRI/CT - more sensitive in detecting fluid in joints not accessible to PE (eg, the hip).
* Bony erosions and narrowing of joint space followed by osteomyelitis and periostitis within 2 weeks possible
58
tx for septic arthritis
* Emmpiric - ceftriaxone / cefotaxime/ ceftazidime
* Vanc if suspected MRSA
* Urgent ortho surgery consult for drainage if needed
59
indications for open surgical drainage in septic arthritis
* if conservative tx fails
* concomitant osteomyelitis requiring debridement
* involved joint (eg, hip, shoulder, sacroiliac joint) cannot be drained by more conservative means.
60
Gonococcal arthritis MC affects what pt demographic?
* healthy
* female
* during menses and pregnancy
* < 40 y/o
61
1. 1-4 d of migratory polyarthralgias involving wrist, knee, ankle, or elbow
1. diverges into 2 different patterns
- first (MC): tenosynovitis MC wrists, fingers, ankles, or toes.
- second: purulent monoarthritis MC knee, wrist, ankle, or elbow
1. fever
2. GU sx
3. asx small necrotic pustules distributed over extremities, especially the palms and soles
dx?
w/u?
tx?
* Gonococcal arthritis
* CBC, blood cx, synovial fluid, mucosal cx, XR
* Admit, azithromycin + rocephin/ceftizoxime/cefotaxime
*responds fast, MC drainage not needed*
62
presentation and mgmt of nongonococcal arthritis?
1. newborn or nonsexually active elderly, immunocomp, rheumatoid or other arthritis
2. single hot, swollen, painful joint; MC knee
3. bacteria - 90% in synovial fluid, 50-70% in blood
4. longer abx tx, need joint drainage; poorer prognosis
