What is a type of non-inflammatory arthritis?
What are the inflammatory arthridities?
Rheumatoid arthritis, Juvenile idiopathic arthritis, System lupus erythematosus, Crystal induced arthritis, sponydloarthropathies (ankylosing spondy, psoriatic, reactive)
What is the distribution of osteoarthritis?
Knees, hips, spine (cervical and lumbar), hands (DIP, PIP), feet (first metatarsophalangeal)
How does osteoarthritis advance?
progressive loss of articular cartilage
What is the clinical presentation of osteoarthritis?
>50 yo, Gradual onset, initially intermittent and self-limited, Use-related pain (knees and hips worse w/ weight bearing, hands worse w/ over use), Relieved by rest, morning stiffness less than 30 mins
What are risk factors for osteoarthritis?
Increasing age, major joint trauma, obesity (knees), repetitive activities, genetic predisposition, congenital/developmental defects, females
What is most common arthritis?
What arthritis do you think when you hear "bone on bone"?
How long is the stiffness for osteoarthritis?
only 30 minutes
What does the physical exam of osteoarthritis look like?
Localized pain, limited ROM, bony enlargement, soft tissue swelling
T/F: Osteoarthritis patients have heat in their affect joints?
What are x-rays of osteoarthritis?
new bone formation in subchondral trebeculae, osteophyte formation at joint margins, loss of cartilage
How do you treat osteoarthritis (non-drug treatments)?
Weight reduction, exercise helps a lot, physical therapy for ROM, assistive devices, joint replacement
What are the drugs to treat osteoarthritis?
Acetaminophen, NSAIDs, alagesics, some topical agents, joint injections, hyaluronic derivative injections
When is the onset of rheumatoid arthritis?
30-50 years old
T/F: more women have rheumatoid arthritis than men?
what are the risk factors of rheumatoid arthritis?
smoking, periodontal disease
What does rheumatoid arthritis present as?
symmetric inflammation (insidious and erosive), chronic and progressive, positive rheumatoid factor, positive anti-CCP Ab, systemic factors
What are some extra-articular manifestations of rheumatoid arthritis?
subcutaneous nodes, pericarditis, pulmonary nodules, interstitial fibrosis, inflammatory eye disease, vasculitis
T/F: stiffness of rheumatoid arthritis in the AM lasts longer than osteoarthritis?
True, lasts at least 1 hour
What is the classification criteria of rheumatoid arthritis?
Morning stiffness for 1 hour, swelling in 3+ joints, swelling in hands, symmetric joint swelling, erosions/decalcification of hand on x-ray, rheumatoid nodules, + rheumatoid factor
What joints are affected by rheumatoid arthritis?
Wrists, MCP, PIP, MTP, ankles, knees, elbows, shoulders
What are the treatments of rheumatoid arthritis?
patient education, PT/OT, exercise/rest, medications (NSAIDs, steroids, DMARD's (disease modifying anti-rheumatic drugs))
What are some DMARD options for rheumatoid arthritis pts?
Hydroxychloroquine, minocycline, gold, slfasalazine, TNF-blockers, B-cell blockers, T-cell costimulators, anti-interleukins
What are differential subtypes of juvenile idiopathic arthritis?
systemic onset, polyarticular onset, pauciarticular onset
When is the onset of juvenile idiopathic arthritis?
typically 1-6 years old
What are systemic features of juvenile idiopathic arthritis systemic onset?
lymphadenopathy, hepatosplenomegaly, pericardial/pleural effusions, fatigue, muscle atrophy, weight loss, leukocytosis, anemia
T/F: juvenile idiopathic arthritis polyarticular onset can be divided into rheumatoid factor positive/negative individuals?
true (mostly RF-negative)
What is the clinical feature of juvenile idiopathic arthritis polyarticular onset?
malaise, weight loss, low grade fever, lympadenopathy, anemia
T/F: juvenile idiopathic arthritis oligoarticular/pauciarticular onset has a positive ANA?
What joints does juvenile idiopathic arthritis oligoarticular/pauciarticular onset affect?
knees, ankles, wrists, elbows
What are the subgroups of juvenile idiopathic arthritis oligoarticular/pauciarticular onset?
Psoriatic (nail pitting, dactylitis, sacroiliitis), Enthesitis-related JIA (Negative RF and ANA, older than 6 males, Positive HLA-B27, ocular inflammation, sacroiliitis), Undifferentiated
What is the treatment of juvenile idiopathic arthritis oligoarticular/pauciarticular onset?
Pt/parent education, PT/OT, NSAIDs, Steroids (intra-articular/oral), DMARDS (methotrexate, sulfasalazine, leflunomide), Biological DMARDS (anti-TNF, anti-IL-1)
What is systemic lupus erythematosus?
autoimmune disease with ANA
T/F: systemic lupus erythematosus affects more females than males?
What are clinical features of systemic lupus erythematosus?
Butterfly rash, discoid rash, photosensitivity, oral ulcers, arthritis, serositis, POSITIVE ANA
What are the genetic links of systemic lupus erythematosus?
most cases are sporadic, strong familial aggregation, can strong link in twins (especially monozygotic)
What is the treatment of systemic lupus erythematosus?
NSAIDs, corticosteroids, antimalarials (hydroxychloroquine), methotrexate, leflunomide, cyclophosphamide, dapsone, sunscreen
What are the clinical presentations of drug-induced SLE?
fever, malaise, arthritis/arthalgias, serositis, rash
What is the therapy for drug-induced SLE?
stop the medication
What medications is drug-induced SLE associated with?
procainamide, hydralazine, methyldopa, chlorpromazine, isoniazid, quinidine, minocycline
What are the two forms of crystal-induced arthritis?
Gout (uric acid), pseudogout (calcium pyrophsophate deposition)
What does gout cause when it deposits in the joints, skin and kidneys?
Joints: acute imflammatory arthritis, Skin: accumulation of crystals (tophi), Kidney: uric acid urolithiasis, nephropathy
What are the stages of gout?
asymptomatic hyperuricemia, acute intermittent gout, chronic tophaceous gout
What are the causes of gout
Uric acid overproduction (HGRT, PRPP synthetase overacticity, psoriasis, alcohol), Uric acid underexcretion (90%) (hypertension, obesity, lead, low dose aspirin)
What does acute intermittent gout usually start?
between fourth and sixth decade of life
T/F: women have a later onset of acute intermittent gout?
True (after menopause)
What is the clinical story or a pt with acute gouty arthritis?
Often occurs at night, pain escalates very highly in 8-10 hours, may subside in 3-10 days, fever, chills, malaise
What structures are involved in acute gouty arthritis?
Pariarticular structure (bursa, tendons), Joints
Where does acute gouty arthritis affect individuals?
Lower extremeties (podagra first MTP), usually monoarticular but may be polyarticular, can involve other MTPs, midfoot, ankles, wrist, fingers
How do you diagnose gout?
Serum uric acid levels (not often specific enough for an acute attack), HISTORY AND PHYSICAL for clinical manifestations. SYNOVIAL FLUID ANALYSIS IS GOLD STANDARD
What is the cut off of leukocytes when you are looking at a joint effusion for non-inflammatory and inflammatory joints?
What are triggering factors of gout?
Alcohol ingestion, trauma, sever illness, IV hydration, Medications (thiazide diuretics, low dose aspirin, cyclosporine), Dietary excess (high purine foods like red meat), IV contrast dye
What can advanced gout lead to?
Chronic arthritis leading to joint destruction that is polyarticular (both upper and lower extremities)
What are tophi?
Solid uric acid deposits (white chalky material) that are a result of advanced gout
How do you decrease the levels of uric acid in a patient to prevent the formation of tophi?
xanthine oxidase inhibitor
Where are tophi usually found?
helix of ear, periarticular regions (fingers, wrist, olecranon bursa)
What are the pearls of Gout arthritis?
can have NORMAL uric acid levels, hyperuricemia results from diuretic therapy, allopurinol is NOT appropriate initial therapy during acute attack of gout, try to keep uric acids levels below 6
What should acute gout be treated with (pharma)?
NSAIDs and steroids
Should you treat acute gout with allopurinol?
What is the treatment of gout?
Aspiration of joint/analysis of fluid, dietary counseling (alcohol and obesity), NSAIDs, colchicine, allopurinol, glucocorticoids, analgesics
Where do you find calcium pyrophosphate dihydrate?
What can pseudogout be confused with?
gout, OA, RA
If a person is 95 years old, are they most likely to have gout or pseudogout?
Where is pseudogout most likely to affect patients?
knees (most common), wrists, hips, shoulders, ankles
What will x-rays of a pseudogout joint show?
chondrocalcinosis (wrist, knees, symphisis pubis)
What is the largest risk factor for pseudogout?
What is pseudogout associated with?
hyperparathyroidism, hemochromatosis, hypothyroidism, prior trauma
T/F: Gout has more men than women, while pseudogout has more women than men?
False, Gout: Men>>Women, psuedogout men=women
What joints is gout most likely to affect?
1st MTP, instep, ankles, knees
Does gout and pseudogout have renal complications?
only gout does
What is the differences of x-ray for gout and pseudogout?
Gout: soft tissue swelling/erosions, pseudogout: chondrocalcinosis, osteoarthritis
What are the treatments (pharma) for pseudogout?
NSAIDs, colchicine is kinda effective, not preventative drug, intra-articular steroids
What are spondyloarthropathies?
Multisystem inflammatory disorder
What do spondyloarthropathies usually affect?
spine, sacroiliitis, peripheral joints, periarticular structures
T/F: spondyloarthropathies are HLA B27 positive?
What are non-vertebral symptoms of spondyloarthropathies?
Plantar fasciitis, inflammatory eye disease, mucocutaneous lesions, asymmetric peripheral arthritis, sausage digits, achilles tenosynovitis
What are subcatagories of spondyloarthropathies?
ankylosing spondylitis, psoriatic arthritis, reactive arthritis (Reiter's syndrome), arthritis associated with inflammatory bowel disease
What disease are associated with HLA B27 positive gene?
ankylosing spondylitis (90%), Reactive arthritis (Reiter's sydrome) (85%), Psoriatic arthritis (spondylitis, peripheral arthritis), Inflammatory bowel disease (50%)
What is ankylosing spondylitis?
NOT mechanical back pain, inflammatory back pain
What does ankylosing spondylitis present with?
Back pain with onset before 40, gradual pain that progresses, indidious, >3 mos, Morning stiffness, pain decreases with exercise
What other arthritises/problems does ankylosing spondylitis present with?
Axial arthritis, sacroiliitis, peripheral arthritis (swollen knee/foot), aortitis, cardiac arrhythmias
What joints does psoriatic arthritis affect?
Peripheral arthritis at DIP joints
What can psoriatic arthritis patients present with?
psoriasis, arthritis at DIP joints, sausage toes, achilles tendinitis, plantar fasciitis, sacroiliitis, pits in finger nails
When does reactive arthritis develop?
after an infection (bowel with compylobacter, salmonella, shigella, yersinia), or genital (chlamydia)
Are pts who develop reactive arthritis usually HLA B27+?
Is reactive arthritis also an infection of the joint?
No, just triggers inflammation
What joints does reactive arthritis affect? When does it occur?
usually large joints of lower extremity (knees and ankles), usually within 1 month of infection
What are extra-articular manifestations of reactive arthritis?
conjuctivitis, urethritis or cervicitis, genital ulcers, rash on palms of soles
What is the treatment of spondyloarthropathies?
PT/ROM/good postures, Meds: NSAIDs, for peripheral arthritis: sulfasalazine, methotrexate, for axial arthritis: biologics (TNF blockers), Abx for chlamydia
Give an overview of osteoarthritis (clinical, lab, radiographic)