Arthritis/ Spondylopathies Flashcards by Stephanie Escobar

characterized by progressive fissuring, flaking, and erosion (fibrillation) of articular cartilage

Osteoarthritis

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The etiology of Osteoarthritis is multifactorial, with excessive biomechanical stress and increased intraarticular ______ activity as the major contributors to cartilage destruction

metalloproteinase

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Better in the morning
Worse at end of day
Crepitus
Normal Range of Motion
No swelling/Warmth

Osteoarthritis

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Calcium pyrophosphate deposition disease presents with an acute inflammatory arthritis

pseudogout

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an inflammatory arthritis associated with synovial hyperplasia.

Rheumatoid arthritis

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symmetric joint involvement
prolonged morning stiffness

most commonly affects the PIP and MCP,
wrist, knee, and ankle joints.

Rheumatoid arthritis

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The preferred treatment to prevent recurrent gout attacks is _______, which decrease uric acid production.

Prophylactic therapy is usually initiated during between attacks because acute changes in serum ____ levels can worsen an acute attack.

xanthine oxidase inhibitors
(eg, allopurinol, febuxostat)

uric acid

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Oral or intraarticular _______ can be used for acute gout in patients who cannot tolerate NSAIDs or colchicine

glucocorticoids

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second-line drugs for chronic management of gout. These drugs increase renal excretion of uric acid and are therefore contraindicated in patients with a history of renal stones.

Uricosuric agents

probenecid

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Inflammatory back pain (onset at age <40)
morning stiffness that is better with activity and worse with rest
+/- fusion of the sacroiliac joints.
NSAIDs may help

ankylosing spondylitis (AS).

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inflammation at the bony insertions of tendons, ligaments, and joint capsules

a prominent manifestation of spondyloarthritis ( like ankylosing spondylitis)

Enthesitis

*can happen in achilles tendon, plantar fasciitis, dactyilitis

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COX-2 is an inducible enzyme that is undetectable in most tissues under normal conditions. During inflammation, infiltrating cells secrete cytokines
(___, ____)
that cause COX-2 upregulation in the inflamed tissue. COX-2 then drives the synthesis of pro-inflammatory arachidonic acid metabolites.

interleukin-1

TNF-α

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PTs with a PHx of PUD & GERD for acute gout attack should be treated with an agent that provides prompt pain relief without exacerbating GI problems.

Non-seletive NSAIDs can damage the gut.

Instead use:

Selective COX-2 inhibitors
(celecoxib)

*PUD co-morbidity CAME UP ALOT

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presents with localized swelling at the olecranon (ex: posterior elbow)

Range of motion is preserved and pain-free

Olecranon bursitis

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Preceding infections causing Reactive arthritis (5)

Chlamydia trachomatis
Salmonella, 
Shigella, Yersinia, 
Campylobacter, 
C. difficile

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The classic triad of ______ is nongonococcal urethritis, conjunctivitis, and arthritis.

HLA ___-associated arthropathy that occurs within several weeks following a genitourinary or enteric infection.

seronegative spondyloarthropathies that can cause:

reactive arthritis

HLA-B27

sacroiliitis (20%)

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middle-aged woman with polyarthritis, morning stiffness, and systemic symptoms =

rheumatoid arthritis (RA)

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1st line treatment for RA
a folate antimetabolite that halts purine and pyrimidine synthesis through competitive inhibition of dihydrofolate reductase.

Methotrexate

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List 5 adverse effects of Methotrexate which affects tissues with rapid cellular turnover

Methotrexate causes toxicity to tissues with rapid cellular turnover, such as oral and gastrointestinal mucosa (ulcerations), hair follicles (alopecia), and bone marrow (pancytopenia). Methotrexate can also cause hepatotoxicity (hepatitis, fibrosis, cirrhosis) and pulmonary fibrosis.

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Hydroxychloroquine is a well-tolerated antirheumatic drug used in mild RA and systemic lupus erythematosus. Its most significant toxicity is

irreversible retinopathy

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is characterized by stiffness and fusion (ankylosis) of the axial joints. The sacroiliac and apophyseal joints of the spine are the most commonly affected, leading to restricted spinal mobility.

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Ankylosing spondylitis: back pain onset ____ age

better with movement, not with rest. Pain at night

<40

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3 Extra-skeletal complications of Ankylosing Spondylitis

limited chest wall expansion, leading to hypoventilation (restricted lung disease)

ascending aortitis, which can lead to dilation of the aortic ring and aortic insufficiency.

Uveitis pain, blurred vision, photophobia, and conjunctival erythema

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Pt with hand joint pain and stiffness. Pain wakes them at night. Chronic fatigue and poor sexual performance (Hypopituitarism). X-rays reveal bilateral erosions and joint deformities involving the second and third MCP joints and calcifications. +/– Elevated liver enzymes/hepatomegaly, Heart problems

Hemachromatosis

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iron deposition in the articular cartilage and synovium, free radical damage and crystal deposition. X-ray findings include hook-like osteophytes)and deposition of calcium pyrophosphate dihydrate in the articular cartilage (chondrocalcinosis).

Hemachromatosis associated arthritis

Polyarticular arthritis mostly of the small hand joints ulnar deviation of the digits (fingers lean towards pinky)

rheumatoid arthritis (RA)

anti-CCP antibodies C-reactive protein & ESR correlate with disease activity X-ray: soft tissue swelling, joint space narrowing, bony erosions

rheumatoid arthritis (RA)

may also involve the wrists, elbows, knees, and ankles. Cervical spine involvement common in longstanding disease causing: pain, disability, Cord compression Hips and lumbosacral joints usually spared

rheumatoid arthritis (RA)

symmetric, polyarticular arthritis with joint swelling and stiffness

rheumatoid arthritis (RA)

Cervical spine involvement: subluxation, cord compression

rheumatoid arthritis (RA)

Activation of T lymphocytes in response to rheumatoid antigens (2) ______-. Activated T cells release cytokines (__ &__) that cause _____ The accelerated metabolic rate of the inflamed synovial tissue leads to local hypoxia and increased production of hypoxia-inducible factor 1 and ____ by local MQs and fibroblasts, resulting in __________. This facilitate expansion of inflammed synovium into a rheumatoid ______, an invasive mass composed of fibroblast-like synovial cells, granulation tissue, and inflammatory cells. Over time, the mass encroaches into the joint space and can destroy the articular cartilage and erode the bone. Ossification of the mass can lead to ____ of the bones across the affected joint (bony ankylosis).

citrullinated peptides type II collagen IL-1 & TNF-alpha synovial hyperplasia vascular endothelial growth factor (VGEF) synovial angiogenesis (neovascularization) pannus fusion

Osteoarthritis vs RA age of onset

OA: >40 RA: 40-60 or younger

Osteoarthritis vs RA joints involved

OA: knees, hips, DIPs RA: Wrists, MCP, PIP

Osteoarthritis vs RA length of morning stiffness

OA: none/less than 30 min RA: greater than 30 min

Osteoarthritis vs RA systemic symptoms

OA: none RA: Fever, Fatigue, Weight loss

Osteoarthritis vs RA exam findings

OA: hard bony masses/joints RA: Soft, spongy bones

Patients with OA of the hands may also have osteophyte formation leading to bony enlargement of the: ``` distal interphalangeal (DIP) joints ( _____ nodes) and proximal interphalangeal (PIP) joints ( _____ nodes) ```

Heberden Bouchard

Pt with recurrent acute severely painful monoarthritis and history of a myeloproliferative disorder (ET, PCV, Myelofibrosis, CML) Diagnosis of acute painful joint=

Gout attack

Needle shaped, negative biorefringent crystals

Gout

Tumor Lysis syndrome can cause | because of

Gout | increased uric acid production

Chronic kidney disease Volume depletion Diuretics (eg, thiazide, loops) Cyclosporine & tacrolimus (immunosuppresants) Risk factors for

GOut

firm, nontender, subcutaneous nodules that occur at pressure points such as the elbows or forearms.

Rheumatoid Nodules

an antibody (typically IgM) specific for the Fc component of IgG.

Rheumatoid factor

Anticentromere antibodies are found in the majority of patients with ...

CREST syndrome Calcinosis, Raynouds, Esophageal Dysmotility, Scleradactyly, Talengtasias

Antiphospholipid antibodies can be found in patients with ____& ____. cause a hypercoagulable state with paradoxical PTT prolongation.

SLE | antiphospholipid antibody syndrome

The Monospot test assesses the serum's ability to agglutinate ____. Positive in the presence of heterophile antibodies (Mono–EBV diagnosis)

sheep erythrocytes

a disease caused by tissue deposition of monosodium urate crystals.

Gout

occurs with increased frequency in patients with activating mutations involving phosphoribosyl pyrophosphate synthetase (PPRP) due to increased production and degradation of purines

Gout

____ are first-line therapy for treating acute gouty arthritis. If they are contraindicated (eg, peptic ulcer disease, renal impairment), ______ is useful in the acute management of gout as it inhibits neutrophil chemotaxis and phagocytosis by preventing _______ formation.

NSAIDs --> inhibits neutrophils. colchicine --> Inhibit microtubules

In RA: The proteases ( ___ & ___ ) contribute to cartilage destruction. Cytokines indirectly activate ____, resulting in bony erosions. Monoclonal antibodies that inhibit TNF-alpha ( __ & ___) or IL-1 receptors (___) are widely used to slow progression of the disease.

collagenase, metalloproteinase osteoclasts adalimumab, etanercept Anakinra

Digital clubbing Joint pain Periostosis (tender thickening of periosteum) Joint effusions

Hypertrophic OA

Associated with Malignant: lung adenocarcinoma, metastases Nonmalignant lung disease (eg, cystic fibrosis, bronchiectasis, lung abscess) Cyanotic heart disease (ToF, TA, TGV, TAPVR)

Hypertrophic OA

Pathogenesis of HOA: Due to AV shunting, ____ bypass lung and skip fragmentation into platelets & deposit in peripheral tissues & distal bone casuing focal hypoxemia & release of _____ leading to fibrovascular hyperplasia & _____

Megakaryocytes PDGF & VEGF abnormal bone formation

a syndrome characterized by painful bone and soft tissue enlargement in the distal extremities

hypertrophic osteoarthropathy (HOA)

Avascular necrosis (AVN) of the femoral head can be caused by

glucocorticoids

Decreased spinal range of motion & chest expansion Stiff or stooped posture Tenderness at spine & peripheral tendon insertions (Achilles, plantar fasciitis) Dactylitis (swelling of fingers & toes) Uveitis

Due to: Increased osteoclast activity & bony erosions due to cytokines __ & __ Increased bone/syndesmophyte formation causing a bamboo spine appearance

AS TNF, IL-17

Elevated ESR & CRP | HLA-B27

Intervertebral disc protrusion and thickening of the ligamentum flava can lead to _____. The pain in this disorder typically radiates to the posterior thighs and legs and is relieved by sitting and flexion of the spine

spinal stenosis

Intervertebral disc protrusion and thickening of the _____ can lead to spinal stenosis

ligamentum flava

In spinal stenosis the pain in this disorder typically radiates to the ______ and is relieved by sitting and ____ of the spine

posterior thighs and legs | flexion

In Pseudo-gout synovial fluid analysis shows rhomboid-shaped crystals (looks like a rectangles toppling over to one side) formed from _____ These crystals are ____ birefringent under polarized light. The knee joint is involved in >50% of cases.

calcium pyrophosphate positively

Clochicine causes gastrointestinal mucosal function to also be impaired by microtubule disruption, leading to _____ and, less commonly, nausea, vomiting, and abdominal pain.

diarrhea

Swan neck deformity (hyperextension of PIP and flexion of DIP). Ulnar deviation of fingers (MCP joints) Radial deviation of knuckles

RA (advanced)

Calcific degeneration of the articular cartilage (______) is a characteristic feature of calcium pyrophosphate dihydrate deposition disease (pseudogout)

chondrocalcinosis

Autoimmune complex deposition (type III hypersensitivity) plays a significant role in the arthritis associated with

systemic lupus erythematosus

Diuretics (eg, hydrochlorothiazide, furosemide) Salicylates (eg, low-dose aspirin) ACE inhibitors (eg, lisinopril) Cyclosporine cause GOUT via

decreased Uric acid urinary excretion

Dietary sources Purine-rich foods (eg, seafood, red meat) Fructose-containing & alcoholic beverages (beer) ↑ Cell turnover (eg, tumor lysis syndrome) Lesch-Nyhan syndrome (deficiency of HGPRT) ↑ Phosphoribosyl pyrophosphate activity cause GOUT via

Increased Uric acid productions

In treating gout ____ is used in patients with contraindications to both NSAIDs and colchicine (due to renal dysfunction, the elderly) but it is CONTRAINDICATED in patients with _____

Glucocorticoid Diabetes

Uric acid-lowering therapy with uricosuric agents (probenecid) or xanthine oxidase inhibitors (allopurinol, febuxostat) is used to prevent acute attacks in patients with recurrent gouty arthritis and those with

macroscopic tophi *These drugs should not be initiated during an acute gout attack as they can exacerbate acute arthritis.

____ binds to the intracellular protein ___ and inhibits its polymerization into microtubules. This, in turn, disrupts cytoskeletal-dependent functions such as chemotaxis and phagocytosis. Its administered initially at the first signs of a gout flare It may also be used for prophylaxis

Colchicine | tubulin

Associated with: keratoderma blennorrhagicum (keratinized skin lesions on palms and soles that can ooze or spread) circinate balanitis (dick skin inflammation- tip) Oral ulcers conjunctivitis, anterior uveitis urethritis, cervicitis, prostatitis

Reactive Arthritis Can't see, Can't pee, Can't climb a tree

Patient with Bell's Palsy in the past and presents with asymmetric large joint arthritis (painful knee swelling) probably has:

Late Lyme disease can cause chronic asymmetric large joint arthritis and encephalopathy. * Early Lyme disease= flu-like symptoms and erythema chronicum migrans (Target). * Second stage of Lyme disease may involve atrioventricular block and facial palsy

Tumor necrosis factor-alpha (TNF-α) inhibitors impair cell-mediated immunity. All patients beginning treatment with TNF-α inhibitors for RA should be evaluated for

latent tuberculosis

Tumor necrosis factor-alpha (TNF-α) inhibitors impair cell-mediated immunity. All patients beginning treatment with TNF-α inhibitors for RA should be evaluated for

latent tuberculosis

The foundation of management for RA is disease-modifying antirheumatic drugs (DMARDs), which alleviate pain and inflammation and reduce long-term joint destruction and disability. Examples of DMARDS are

``` Methotrexate (typically first-line), Sulfasalazine, Hydroxychloroquine, Minocycline, TNF-alpha inhibitors ```

DMARDs can alleviate pain and inflammation and reduce long-term _____ and disability in RA

joint destruction

For RA, DMARD therapy typically takes weeks therefore, short-term treatment with ____ (2) can provide rapid, temporary relief.

Glucocorticoids (prednisone) | NSAIDs

Colchicine disrupts cytoskeletal-dependent functions such as _______ (3). It also reduces the formation of ____.

chemotaxis, phagocytosis, and degranulation *leukocyte attraction leukotriene B4

Altered gut biome/defective mucosal barrier Increased production of IL-17, TNF-α &______ what disease?

Ankylosing Spondylitis prostaglandins

What is the most sensitive test to diagnose AS?

X-rays of the spine and pelvis Can see sacroiliitis (eg, joint erosions with subchondral sclerosis and eventual ankylosis) and bridging syndesmophytes (heterotopic ossification affecting vertebral body margins).

In AS common X-Ray findings include _____ (joint erosions with subchondral sclerosis and eventual ankylosis) ____ (heterotopic ossification affecting vertebral body margins).

sacroiliitis bridging syndesmophytes

_____ is an autosomal-recessive disorder caused by a deficiency in an enzyme involved in tyrosine metabolism that can cause osteoarthropathy of the spine and large joints.

Alkaptonuria

____ causes erythema infectiosum (fifth disease) in children and arthritis in adults. It can mimic rheumatoid arthritis but is usually self-resolving

Parvovirus B19

Arthritis/ Spondylopathies Flashcards

(84 cards)