Immunology & Inflammatory & Dermatology Flashcards
This deck covers Chapters 106-110 in Rosens, compromising all of rheumatology, dermatology, and immunology.
List 2 causes for each:
- Acute Monoarticular
- Chronic Monoarticular
- Polyarticular
- Periarticular
Acute Monoarticular
- Septic
- Gout
- Crystalline (Gout, Pseudogout)
- Rheumatic fever
- Lyme
- Reactive arthritis
- Viral arthritis
Chronic Monoarticular
- Still’s disease
- Osteoarthritis
- Post-traumatic
- Seronegative spondyl
Polyarticular
- RA
- PMR
- SLE
- Lyme
Periarticular
- Tendonitis
- Bursitis
- Periosteal hematoma
- Tenosynovitis
What is Nikolsky’s Sign? List 4 conditions that are Nikolsky +
Nikolsky’s Sign
- Easy separation of the outer portion of the epidermis from the basal layer when pressure is applied
Conditions
- SJS
- TENS
- SSS
- Pemphigus Vulgaris
Compare and Contrast
SSSS vs. TEN
SSSS
- Mucosal sparing
- Tender
- Not shocky
- Not multisystem
- Involves desmosomes from exotoxin
- Epidermolytic toxin A or B
TEN/SJS
- Typically drug-induced
- Unwell
- MM involved
- Full-thickness skin
- SJS< 10% TBSA, otherwise TENS
- Medications: NSAIDs, sulfa, allopurinol.
- Dx: Mycoplasm, HIV, malignancy
Describe the most common bug that causes septic arthritis for each age group and one bug that commonly tested and sorta pathognomonic for this condition
- Neonates
- Rest of pediatrics
- Adults
- Oldies
- Sicklers
- IVDU
Neonates
- Staph, GBS, E. coli
Children
- Staph, H. flu
Adolescents
- Neisseria, Staph
Older adults
- Staph, Strep, E. coli
Sickler
- Staph (MCC), Salmonella
IVDU
- Pseudomonas, Staph, Strep, E. coli
A patient was prescribed amoxicillin and developed this rash within 48 hours. What is it? How do you treat it?
Acute Generalized Exanthematous Pustulosis (AGEP)
- Remove offending agent
- Topical steroids
- Rule out DRESS/SJS
- Causes: Antibiotics, Anti-Malarials, Diltiazem
How is the diagnosis of eczema made?
Itchy skin + 3 or more of:
- History of skin crease involvement
- Generalized dry skin
- History of asthma or hay fever
- Rash onset <2 yo
- Flexural surfaces involved
Diagnostic criteria
- Sensitivity 85%
- Specificity 96%
Treatment
- Avoid irritants, perfumes, scented creams
- Lubricating ointments
- Vaseline
- Antihistamines
- Topical corticosteroid
- Hydrocortisone 1-2.5% cream/ointment
- Betaderm 0.05-0.1% ointment severe cases
List 6 causes of a bullous rash
- Bullous Impetigo
- Pemphigous Vulgaris
- Bullous Pemphigoid
- Staph Scalded skin
- Burns
- Dermatitis Herpetiformis
List THREE risk factors for having anaphylaxis
List THREE risk factors for increased severity & mortality from anaphylaxis
Risk Factors for Having
- Men <16, women >30
- Higher SES
- History of atopy
Risk Factors for Severity
- Extremes of age
- Comorbid disease (heart /pulmonary)
- On beta-blockers
- Drug use
Differentiate:
- Macule
- Papule
- Patch
- Vesicle
- Bullae
- Petechiae
- Macule < 1cm flat
- Papule <1 cm raised
- Patch >1 cm flat
- Vesicle: <1 cm fluid filled
- Bullae : >1 cm fluid filled
- Petechiae: tiny, non-blanchable
What is the typical story of this disease? What is the causative organism?
Roseola
- High fevers for 2-3 days then rash starting on the trunk
- HSV 6/7
- Supportive care
Compare and Contrast
DRESS, SJS/TENS, AGEP, and Erythroderma with respect to onset, duration, mortality, the appearance of the rash
Briefly describe the clinical features of RA. Why are they difficult to intubate?
Symmetrical swelling + inflammation of joints
- Hands (MP + PIP) >>> wrists > elbows
- DIP is spared
Hands
- Ulnar deviation
- Swan-neck deformity
- Boutonniere deformity
Extra-articular
- SC nodules
- Vasculitis of skin
- Pulmonary fibrosis
- Mononeuritic multiplex
Airway Issue = Atlanto-axial instability
List 4 mechanisms for epinephrine in a patient with anaphylaxis
- α1 - vasoconstriction, increased SVR, decreased edema
- β1 - inotropy + chronotropy
- β2 - bronchodilation
- β2 - stabilization of mast cells & basophils
Describe the following tests when assessing the shoulder for rotator cuff tendinopathy or impingement syndrome:
- Jobe’s test/Empty can test
- Neer test
- Hawkins test
- Push-off test
- Drop arm test
- Shrug sign
- Jobe’s/Empty can: supraspinatus
- Neer’s: subacromial impingement
- Hawkin’s: subacromial impingement
- Push off: subscapularis
- Drop arm: supraspinatus
- Shrug: rotator cuff
What family of local anesthetics can result in allergic reactions?
Two families of local anesthetics:
-
Esters (procaine, tetracaine, benzocaine)
* More likely to have an allergic reaction - Amides (lidocaine, bupivacaine, mepivacaine
* Rare to have an allergic reaction
What’s the pathophysiology of vasculitis?
List 2 examples of each:
- Large-cell vasculitis
- Medium-cell vasculitis
- Small-cell vasculitis
Pathophysiology of Vasculitis
- Immune complexes deposited in vessel walls
- Complement activation –> accumulation of PMNs
- Eventual vessel wall damage & necrosis
Large-Vessel Vasculitis
- Takayasu
- Giant Cell
Medium-Vessel Vasculitis
- PAN
- Buerger’s
- Kawasaki
Small-Vessel vasculitis
- HSP
- Wegener’s
- Churg-Strauss
- Goodpasture’s
Describe Yergasons and Speeds test
Yergasons
- Resisted supination
- Pain = Biceps tendonitis
Speeds
- Straight arm in front, supinated
- Push arm down against resistance
- Pain = Biceps tendonitis
What is the treatment of scabies/head lice and bed bugs?
Scabies
- Agent: Sarcoptes Scabiei
- Treatment: Permethrin 5% at night x1, wash off in AM,
- Repeat in 1 week
Head Lice
- Agent: Pediculus humanus capitis
- Treatment: Permethrin 1% at night x1, wash off in AM,
- Repeat in 1 week
Bed Bug
- Agent: Cimex lectularius
- Treatment: Heat, Insecticide, Itching relief
Negatively-birefringent crystals are associated with what? List 3 treatment options.
Gout
- NSAIDs
- Prednisone 30 mg x7-10d
- Colchicine 1.2 mg once, then 0.6 mg in 1 hour, then daily
- PPI for GI protection
- May consider allopurinol - not in acute flare
Four Joints Most Commonly Affected
- 1st MTP (podagra)
- Tarsal joints
- Ankle
- Knee (gonagra)
Outline 6 steps in the management of anaphylaxis
- Monitors, Oxygen, Vitals
- Epinephrine 0.3-0.5 mg IM
- Benadryl 50mg IV
- Salbutamol +/-
- Steroids (Solumedrol 125mg IV)
- H2 blockers +/-
Describe the pathophysiology, clinical features, and treatment of Polyarteritis Nodosa (PAN)
Pathophysiology
- Necrotizing vasculitis of medium-sized vessels
- Immune deposits minimal/absent; ANCA negative
- Peak age: 5th or 6th decade; M>F
Symptoms
- Early
- Constitutional Weight loss (fever, malaise, arthralgias, myalgias)
- Cutaneous (1/3 patients) livedo reticularis
- PALPABLE PURPURA (sometimes with ulcerations)
- Late: peripheral neuropathy, bowel ischemia, HTN, renal impairment, mononeuritis multiplex
Treatment
- No organ involvement: corticosteroids
- Organ involvement: add immunosuppressive agent
List 5 causes of viral arthritis
- Rubella
- Parvovirus
- West Nile
- Chikungunya
- Dengue
- HIV
- Hep B
- Hep C
List 6 complications of chickenpox
- Bacterial superinfection
- Cerebellar ataxia
- Reye syndrome
- Encephalitis
- Pneumonia
- Hepatitis
Compare and Contrast
Strep Toxic Shock & Staph Toxic Shock in relation to the organism, toxin, source, appearance, mortality, and treatment
Differentiate periorbital and orbital cellulitis
Periorbital
- Anterior to the orbital septum
- Non-toxic
- Nothing from the list below
- Amox-Clav
- Sinusitis, FB, Dental
Orbital
- Pain with EOM
- Possible double vision
- Globe may be involved
- Proptosis possible
- Admit (IV ABx) / Ophthal
Who would you consider PEP if exposed to VZV?
If healthy:
- Immunize
If pregnant/immune-compromised:
- Check titers: if negative, give Varicella Ig
- Can’t give the vaccine to pregnant/immune comp
Susceptibility
- No previous infection
- No vaccine
- No lab evidence of immunity
High-risk groups
- Pregnant women
- Cystic fibrosis
- HIV/AIDS
- Chemo
- Steroid tx
- Newborns of mothers who have active VZV
- BMT/SCT patients
What is antiphospholipid antibody syndrome (APS)?
Diagnosis of APS
- Clinical event (e.g. thrombosis or pregnancy loss) +
- Anti-phospholipid Ab, an inhibitor of phospholipid-dependent clotting (lupus anticoagulant) or BOTH
List 5 causes of desquamating rash
- SSS
- TSS
- TENS/SJS
- Kawasaki
- Exfoliative Erythroderma
- Radiation burns
What are the FOUR types of immune reactions? Give ONE example of each type
Type 1 Hypersensitivity Reaction
- IgE-mediated mast cell degranulation
- Anaphylaxis
Type 2 Hypersensitivity Reaction
- Cytotoxic reaction
- Antibodies against cell surface antigens
- ABO incompatibility
Type 3 Hypersensitivity Reaction
- Immune complex
- Deposition causes complement activation
- Serum sickness
Type 4 Hypersensitivity Reaction
- Delayed T cell-mediated response
- Poison Ivy
A 3-year-old boy with 4 days of fever has the following rash around his perioral region, hands, feet, and buttocks. Diagnosis and treatment?
_Hand, Foot, & Mouth Disease_
Diagnosis
- Coxsackie Virus
- Enterovirus
Treatment
- Supportive
Compare the H1/H2 effects on the body re: anaphylaxis
H1 effects
- Pruritis
- Rhinorrhea
- Bronchospasm
- Tachycardia (Cetirizine, diphenhydramine)
H1 and H2 effects
- Flushing
- Hypotension
- Headache
This man presents with facial swelling. He’s on an ACEi. What is the diagnosis and treatment?
ACEi-induced Angioedema
- 1% of people on ACE will get this
- Can randomly get it, even when on forever
- Bradykinin mediated
- Urticaria and itch is absent
Treatment
- Stop the ACEi
- Can give C1 esterase treatment
- Consider plasma
- TXA also promising for treatment
If a patient is allergic to contrast dye, what type of allergic reaction is it? Outline your management steps to prevent an allergic reaction if CT is critical.
Anaphylactoid mechanism
- Direct degranulation of mast cells + basophils
Protocol
- Institution specific
- Prednisone 50 mg
- 13 hours before
- 7 hours before
- 1 hour before
- Benadryl 1 hour before
A 45-year-old male presents with fever, weight loss, and general malaise. He has a history of asthma. A CXR shows patchy infiltrates. On the CBC differential, you note there is hypereosinophilia. Diagnosis and treatment?
Granulomatous small-vessel vasculitis of multiple organs
- Previously called Churg-Strauss syndrome
- Asthma + allergic rhinitis (often with nasal polyps)
- High eosinophils
- Mean age = 44 years; M>F
- Multiple organs can be involved: lungs, skin, CV, GI, neuro
Treatment
- Prednisone 60 mg/day
A 24-year-old female presents with painful red nodules on her legs (shown below). She has the same lesions on the extensor surfaces of her forearms. The patient also complains of knee and ankle joint pain. Given a DDx of 6.
- Viral URTI
- Streptococcal infection
- Sarcoidosis
- TB
- Drugs (PCN, sulfa, aspartame, phenytoin, OCPs)
- IBD
- Histoplasmosis
- Yersinia
- Salmonella
- Chlamydia
- Coccidioidomycosis
- Psittacosis
- Autoimmune diseases (SLE)
Patient on Septra a few weeks ago. Diagnosis and treatment?
Exanthematous (Morbilliform) drug eruption
- Type IV hypersensitivity reaction
- Typically 1-4 weeks after a drug started
- Morbilliform (starts on the trunk)
Treatment
- Rule out DRESS (no fever, no face swelling, get B/W)
- Remove the offending agent
- Cetirizine up to 20 mg BID
- Betaderm 0.1% twice daily
- Protopic 0.1% twice daily on face
Describe your approach to interpreting a radiograph of a joint
SECONDS
- Soft tissue swelling
- Erosions
- Calcifications
- Osteoporosis
- Narrowed joint space
- Deformity
- Separation (fractures)
List 3 different types of yeast skin infections and treatment
Tinea corporis
- Small lesion on the body
- Topical terbinafine
Tinea capitis
- On head
- Kerion if severe (systemic antifungals)
- Keflex
Tinea versicolor
- Extensively covers body
- Topical terbinafine
- Fluconazole 300 mg PO weekly x2
What causes reactive arthritis?
- Chlamydia
- Enteritis (Salmonella, Shigella, Yersinia, Campylobacter)
- Note: ‘lover’s heel’ = reactive arthritis of the heel
Describe the clinical sequelae and complications of Takayasu’s Arteritis
Pathophysiology
- Most commonly affects the aorta and its major branches
- Lymphocytic infiltration + vessel fibrosis
- Eventual obstruction of arteries & ischemic complications
Typical patient
- Adolescent girls
- Women in 20s + 30s
Symptoms
- HTN (aortic/renal involvement)
- Ischemic symptoms:
- Diminished or unequal pulses
- Claudication
- Retinopathy
- Lightheaded (think carotid/vertebral dissection)
- Visual loss
Complications
- HTN
- CHF
- Angina
- Aortic regurgitation
List one finding on x-ray for each of the following conditions:
- Acute arthritis (eg. gout)
- Late septic arthritis 8-10 days
- Late pseudogout
- Degenerative arthritis (eg. OA)
- Tuberculous arthritis
- Late rheumatoid arthritis
- Joint effusion
- Subchondral bone destruction
- Linear calcification in cartilage
- Joint space narrowing, sclerosis, bone spurs
- Marked demineralization
- Marginal erosions, joint space narrowing
What is De Quervain’s Tenosynovitis?
Stenosing tenosynovitis of the APL + EPB
- NOT an inflammatory condition
Exam
- Tender over radial styloid
- Pain is made worse with grasping maneuvers
- Finkelstein test
- Pathognomonic for De Quervain’s
- Patient holds the affected thumb in the palm by the fingers
- Patient asked to ulnar-deviate the wrist
- Positive test = PAIN near radial styloid
List antibiotics active against:
- MRSA (6)
- Pseudomonas (5)
- VRE (2)
- ESBL (1)
MRSA
- Doxycycline
- Vancomycin
- Clindamycin
- TMP/SMX
- Linezolid
- Daptomycin
Pseudomonas
- Ciprofloxacin
- Pip-Tazo
- Meropenem
- Ceftazidime
- Aminoglycoside
VRE
- Daptomycin
- Linezolid
ESBL
- Meropenem
- Nitrofurantoin
What is this? How do you treat it?
Erysipelas (Strep)
- Sharply demarcated border
- Raised skin
- Indurated (hard)
- Painful
- Deeply erythematous
Treatment
- PCN or Ceftriaxone
List 4 infectious rashes that involve the palms and soles
- Syphilis
- Disseminated gonorrhea
- Coxsackie
- RMSF
- Measles
- Infective endocarditis
What are the diagnostic criteria for GCA? How is it treated?
3+ of:
- Age >50
- ESR >50 mm/hr
- Pain on palpation of the artery
- New-onset headache
- Temporal artery biopsy positive
Treatment
- Prednisone 60 mg daily
Compare and Contrast
Buerger’s vs Serum Sickness vs Hypersensitivity vasculitis
Buergers:
- Small and medium vessels of extremities
- Smoking heavy implicated, cold exposure
- Digital ischemia
- Must quit smoking
Serum Sickness:
- 1-2 weeks after the offending agent
- PCN, Sulfa, Drugs, Vaccines (Rabies, Flu)
- Fever, arthralgia, erythema multiforme, myocarditis
Hypersensitivity Vasculitis
- Small vessels
- Causes: PCN, NSAIDs
- Usually just the skin
- Livedo, palpable purpura in dependent areas
This woman presents to your ED with facial swelling. She reports this happened to family members and it’s happened before. She is NOT on an ACEi. What is it? What is the pathophysiology?
Hereditary Angioedema
- C1 esterase inhibitor deficiency
- Excess bradykinins
- These patients DO NOT have hives/itch
- Prominent GI symptoms
Treatment
- C1 esterase inhibitor concentrate
- Icatibant (synthetic bradykinin receptor antagonist)
- FFP
- TXA?
List typical radiographic findings of a patient with CPPD (pseudogout)
Chondrocalcinosis
- Calcium deposited in linear densities within the articular cartilage
Treatment
- NSAIDs
- Colchicine
What FOUR vaccines commonly cause anaphylaxis?
- MMR*
- Yellow fever*
- Influenza*
- Rabies HDCV (human diploid cell vaccine)
*contain egg
Compare and Contrast
Scarlet Fever and Rheumatic Fever based on cause, presentation, and treatment
Scarlet Fever
- 48 hours post
- Sandpaper rash
- Pastia’s Lines
- Forschemier’s spots
- Associated with strep
- Treatment: Amoxicillin 40 mg/kg/day div BID (max 1 g/d)
Rheumatic Fever
- 4 weeks post GAS
- JONES criteria
- 2 major or 1 major and 2 minor
- Major (JONES)
- Joint, Heart, Nodes, Erythema, Sydenham
- Minor (F-PEARL)
- Fever, PR, ESR/CRP, Arthralgia, RF, Leukocytosis
- Treatment
- GAS - Amox 40 mg/kg/day div BID x10d (max 1 g/d)
- Arthritis - Naproxen 5 mg/kg/dose BID x10d
- Carditis - Prednisone if severe, otherwise support
List the 4 most important seronegative spondyloarthropathies. What characteristics do they share?
- Psoriatic Arthritis
- Ankylosing Spondylitis
- IBD-related
- Reactive Arthritis
Shared Characteristics
- SI involvement
- Peripheral inflammatory arthropathy
- Absence of RF (rheumatoid factor)
- Genetic HLA-B27 component
- Pathologic changes around the enthesis
- The ligamentous + tendinous insertions into bone
Which 3 viruses cause the highest number of viral exanthems?
- Coxsackievirus
- Echovirus
- Adenovirus
Note: These are all enteroviruses
List the diagnostic criteria for SLE
SOAP BRAIN MD
≥4 of the following:
- Serositis
- Oral ulcers
- Arthritis
- Photosensitivity
- Blood disorder
- Renal disorder (proteinuria of >0.5 g/d or casts)
- Anti-nuclear Ab
- Immune disorder (anti-dsDNA Ab, anti-sm Ab, etc.)
- Neurologic disorder (unexplained seizures or psychosis)
- Malar rash
- Discoid rash
What will the synovial fluid show for a septic joint? What about inflammatory? What about degenerative (OA)?
Septic Joint
- Cloudy
- >50,000 usually, likely if >25,000
- PMR >90%
- Gram stain +
- Culture +
Inflammatory
- >2000
- PMR >50%
- Gram stain -
- Culture -
- Crystals
Degenerative
- <2000
- PMR <25%
What is the typical story of measles? Where does the rash start? What is the name of the finding in the picture below?
Cough, coryza, conjunctivitis then Koplik spots… then skin
Cutaneous findings: 3-5th day, start on the face, upper neck
DDx: Rubella (German measles)
What are the diagnostic criteria for Polymyalgia Rheumatic? What condition is commonly associated with this?
- Age >50 (most >60; mean age 70)
- Bilateral pain in shoulders, hips, neck for 1+ month
- ESR > 40 mm/hr
50% are associated with temporal arteritis
List 5 ways in which one can develop septic arthritis
- Post-operative
- Traumatic
- Contiguous spread
- Hematogenous seeding
- Direct Inoculation (eg. psych patient)
List 5 drugs that can cause drug-induced lupus
CHIMP
- Chlorpromazine
- Hydralazine
- INH
- Methyldopa
- Procainamide
Define anaphylaxis
No clear exposure
Acute onset skin/mucosal involvement and
- Respiratory
- Hypotension
Likely allergen exposure
2+ of the following:
- Skin or mucosal involvement
- Respiratory
- Hypotension
- GI
Known allergen
Hypotension (eg. don’t wait for the hives)
A 15-year-old male presents with abdominal pain, vomiting, bloody diarrhea, and tea-colored urine. Two weeks ago he had a cold for 4 days. You note a rash on your exam (see pic). Diagnosis?
Henoch-Schonlein Purpura
- 50% have a recent URTI, really any virus can trigger this.
- Strep is also common.
Symptoms
- Arthritis
- Abdominal pain
- Purpuric rash
- Possible hematuria
Workup
- CBC
- Electrolytes
- BUN/Cr
- Urinalysis + casts
- Possible U/S of the abdomen
Treatment
- NSAIDs
- Steroids controversial
Must watch out for HTN and the development of glomerulonephritis. Associated with intussusception.
What preservative in local anesthetics can cause allergic reactions? Where is it found?
Methylparaben
- Preservative found in multidose vials of lidocaine
- Implicated in allergic reactions
