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Neuromusculoskeletal & Psychiatry II Exam #3 > Clinical Approach to RA, Seronegative Arthropathies and Gout > Flashcards

Clinical Approach to RA, Seronegative Arthropathies and Gout Flashcards

1
Q

What produces RF?

What does RF do?

A

B-cells of RA synovium.

RFs fix complement, which recruits PMNs.

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2
Q

What imaging modality is most sensitive in detecting erosions in hands and feet?

A

CT

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3
Q

What ethnicity tends to have the greatest amount of people affected with RA?

A

Yakima and Intuit NA tribes

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4
Q

When does RA tend to improve? When do symptoms recur?

Which infections are associated with RA? (3)

A

Pregnancy; flares begin 4-6 wks.

Periodontal disease bacteria (?), EBV and Parvovirus B19.

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5
Q

What 2 features should suggest testing for RA?

A

Patients with at least 1 joint with definite clinical synovitis.

The synovitis is not better explained by another disease.

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6
Q

What 2010 RA classification scales score suggests definite RA?

A

Score >6/10 = definite RA.

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7
Q

How many “points” are given for the following:

1 large joint
2-10 large joints
1-3 small joints
4-10 small joints
> 10 joints (at least 1 small)
A 
1 large joint = 1 pt.
2-10 large joints = 2 pt.
1-3 small joints = 2 pt.
4-10 small joints = 3 pt.
>10 joints (at least 1 small) = 5 pt.
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8
Q

How many “points” are given for the following:

-RF and - anti-CCP
Low +RF or low +anti-CCP
High +RF or high +anti-CCP

Acute phase reactants:
NL CRP and NL ESR
Abn. CRP or Abn. ESR

Duration of symptoms:
< 6 wks.
> 6 wks.

A

-RF and - anti-CCP = 0
Low +RF or low +anti-CCP = 2
High +RF or high +anti-CCP = 3

NL CRP and NL ESR = 0
Abn. CRP or Abn. ESR = 1

< 6 wks. = 0
> 6 wks. = 1

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9
Q

What is the use of monitoring acute phase reactants in RA?

A

To track the response to treatment.

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10
Q

Which hand joint does RA typically spare?

What part of the spine does it tend to affect?

A

DIPs.

C1-C2

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11
Q

What is pannus?

A

An abnormal layer of fibrovascular tissue overlying the synovial joint.

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12
Q

If you see this, the patient is ALWAYS RF+:

A

Rheumatoid nodules

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13
Q

In RA, active signs of inflammation last at least…

A

> / 6 wks.

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14
Q

Which patients are more likely to have extra-articular RA symptoms?

A

Those with +RF or +anti-CCP.

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15
Q

What vascular/skin lesions may be seen in RA? (2)

A

Pyroderma gangrenosum: a tender purple papule that leads to a necrotic, non-healing ulcer.

Rheumatoid vasculitis: purpura, petechial, splinter hemorrhages leading to digital infarct.

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16
Q

What cardiac diseases can be seen in patients with RA?

A

CAD, HF, pericarditis all due to chronic endothelial inflammation.

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17
Q

What pulmonary diseases can be seen in patients with RA? (4)

A

Pleuritis - most common.

Interstitial lung disease (ILD)

Caplan syndrome - nodular densities after exposure to coal or silica dust.

Pulmonary fibrosis

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18
Q

What is keratoconjunctivitis?

What disease is it seen in?

A

Dryness of conjunctiva and cornea (most common eye manifestation in Sjogren’s or SLE).

Sjogren syndrome (Sjogren’s exists in up to 35% of patients with RA).

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19
Q

What ANA positivity suggests Sjogren syndrome?

What 2 other tests can be done to test for it?

A

Anti-Ro/SS-a, Anti-La/SS-B (salivary gland involvement).

Schirmer’s test
Slit-lamp exam

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20
Q

What are features of Feltys syndrome? (4)

A

RA
Splenomegaly
Neutropenia, Anemia, Thrombocytopenia
+RF and +anti-CCP

21
Q

What may cause peripheral neuropathy and cervical myelopathy in RA patients?

A

Atlantoaxial subluxation (C1-C2) due to erosion of the odontoid process.

22
Q

What is the role of TNF in RA?

A

It stimulates synovial cell proliferation and collagenase (destroys cartilage).

23
Q

Spondylitis

Spondylolistesis

Spondylolysis

A

Spondylitis = vertebral inflammation.

Spondylolistesis = anterior displacement of a vertbral body.

Spondylolysis = defect of the portion of bone between the inferior and superior articular process of the vertebrae (pars interarticularis).

24
Q

What is the most common inflammatory disorder of the axial skeleton (and SI joints)?

Which sex is more common?

When does it onset?

A

Ankylosing spondylitis

Males 3:1

2nd to 3rd decade

25
Q

What joint is classically involved in ankylosing spondylitis?

What cells are involved?

What may play a role in its pathogenesis?

A

SI joint.

CD4 and CD8 cells that secrete TNF-a.

Enteric bacteria.

26
Q

What are the clinical manifestations of ankylosing spondylitis? (5)

A

LBP > 3 mo.

Morning stiffness that improves with exercise and worse with rest.

Fatigue, weight loss, fever.

Symmetrical SI joint pain.

Tendonitis/platar fasciitis/enthesitis

27
Q

What are some extra-articular manifestations of ankylosing spondylitis? (6)

A

Iritis (anterior uveitis)* - not found in RA, but common in SLE and HSV.

Photophobia

Aortic insufficiency/aneurysm

Pulmonary fibrosis

IBD

Psoriasis

28
Q

What tests are used to determine movement restriction in ankylosing spondylitis? (2)

A

Schober test - measures L-spine flexion.

FABER test - test SI joint pathology.

29
Q

What distance suggests decreased L-spine mobility with the Schober test?

What suggests decreased chest expansion?

A

< 4 cm. = decreased L-spine mobility.

< 5 cm. = decreased chest expansion.

30
Q

What are the lab findings in ankylosing spondylitis? (4)

A

Increased ESR, CRP

+ HLA-B27

Anemia of chronic disease

Negative RF, anti-CCP, ANA

31
Q

What changes to the vertebra are seen in XR in ankylosing spondylitis? (2)

A

Squaring - loss of anterior convexity.

Shiny corners - sclerosis at the edge of vertebral bodies.

32
Q

What feature is seen on XR in Diffuse Idiopathic Skeletal Hyperostosis (DISH)?

What is the diagnostic criteria?

A

Syndesmophytes - bridging of vertebra (connected vertebra).

Calcification along the lateral aspect of 4 contiguous vertebral bodies; Si joints are OK (different than AS).

33
Q

Reactive arthritis is associated with which gene?

A

HLA-B27

34
Q

What are clinical manifestations of Reactive Arthritis in young men? (8)

4 MSK

1 syndrome

2 integumentary

1 eye

A

Arthritis - asymmetrical involvement of the LE.

Enthesitis - Achilles t./plantar fasciitis.

Dactylitis - “sausage digit”.

SI joint involvement (asymmetrical)

Reiter’s syndrome

Skin - circunate balanitis (vesicle, ulcers on glans penis)

Keratoderma blennorrhagicum - painless eruption on palms/soles.

Eyes - conjunctivities/uveitis.

35
Q

What’s features are seen in Reiter’s syndrome? (4)

A

Urethritis
Arthritis
Conjunctivitis
Mucocutaneous ulcers (oral ulcers)

36
Q

What bones are most involved in Psoriatic Arthritis?

A

Axial spine and SI joint.

37
Q

What XR finding is seen in DIP arthritis in Psoriatic Arthritis?

A

“Pencil in cup” appearance.

38
Q

What is Enteropathic Arthritis (EA)/IBD-associated with Arthritis?

What bones are involved?

What is pattern of peripheral arthritis in the extremities? (2)

What gene is positive in 50-75% of patients?

A

Arthritis associated with CD or UC.

Axial spine involvement with asymmetric SI involvement.

Large joints of the LE.
Small joints of the UE.

+ HLA-B27

39
Q

When should the following treatments be used in seronegative spondyloarthropathies (SpA)?

Exercise

NSAIDs

Glucocorticoids

MTX

Sulfasalazine

DMARDs

Abx

A

Exercise - all; swimming, stretching, etc.

NSAIDs - all.

Glucocorticoids - flares.

MTX - used in peripheral arthritis, but NOT for axial disease or ankylosing spondylitis.

Sulfasalazine - Psoriatic arthritis.

DMARDs - Psoriatic arthritis.

Abx - Chlamydia urethritis.

40
Q

What is podagra?

A

Gout in the 1st MTP joint.

41
Q

What is tophi?

A

White chalky masses of uric acid.

42
Q

What can occur as a result of chronic gout? (2)

A

Tophi (ears, forearms, Achilles t.)

Renal insufficiency (urate stones)

43
Q

In general, asymptomatic hyperuricemia should…

What is the exception?

A

NOT be treated.

In patients about to receive cytotoxic therapy for neoplasm.

44
Q

What can be used to treat an acute gouty flare?

A

NSAIDs (Naproxen, Indomethacin)
Prednisone

*must be treated ASAP (12-36 hrs.)

45
Q

When is Colchicine effective?

A

Within the first 24 hrs. of the attack.

46
Q

What are the indications for used of uric acid lowering agents (xanthine oxidase inhibitors and uricouric drugs)?

A

Recurrent gouty attacks, tophi, kidnye stones, cytotoxic therapy.
-basically anything that is NOT acute, because it can precipitate a flare.

47
Q

What joints are more likely to be affected in Pseudogout (CPPD)? Which patients are more likely to experience vs. gout?

A

Large joints (i.e. knee); older patients.

48
Q

What is the treatment for CPPD?

A

NSAIDs
Steroids (inta-artcular)
Colchicine

Neuromusculoskeletal & Psychiatry II Exam #3 (12 decks)

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