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1. Rheum RC > Infectious Arthritides - Septic, Lyme, TB, Viral, HIV, Whipple's, ARF > Flashcards

Infectious Arthritides - Septic, Lyme, TB, Viral, HIV, Whipple's, ARF Flashcards

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1
Q

Diff between gonococcal and nongonococcal septic arthritis

A

Gonococcal:
–Healthy young (vs children/elderly/ immunocompromised)
–Migratory arthritis (vs monoarthritis)
–Common Rash and Tenosynovitis (vs rare)
–Rare + blood/joint Cx (vs common)
–Good outcome (vs bad)

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2
Q

Septic arthritis RF

A

-Impaired host defense, old (>80), young (<5)
– Neoplastic disease
– Chronic illness (EtOH, DM, cirrhosis, CKD, HIV, IVDU, hyposplenia from Sickle cell)
– Immunodef: hypogammaglobulinemia, complement def
– Skin infxn
– Drugs: GC, chemo, biologic
– Iatrogenic: prosthetic joint, IA GC
– Chronic arthritis (i.e., RA, hemarthrosis, osteoarthritis)

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3
Q

**MTP involvement DDX **

A

Septic, osteomyelitis, cellulitis,
-Diabetic osteolysis/Charcot,
-Intertarsal bursitis,
-Freiberg infarction (infarct of the MT head, often the 2nd),
-Sesamoiditis,
-CRPS,
-Stress fracture

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4
Q

** Septic arthritis likely organisms in DM**

A

In order of freq:
-Staph Aureus
-Streptococci
-Gram negative bacilli
-Polymicrobial
-Coagulase (-) Staph
-Culture negative

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5
Q

When is surgical drainage absolutely indicated for a septic joint?

A

-* Infected hip/ shoulder joints.
-* Vertebral OM with cord compression.
-* Anatomically difficult-to-drain (eg SC), loculated
-* Too thick to aspirate
-* Ongoing sx despite needle drainage
-* Prosthetic joints or foreign body
-* OM requiring surgical drainage.
-* Delayed onset of therapy (>7d)

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6
Q

Poor prognostic factors nongonococcal septic arthritis

A

-Old
-Late diagnosis
-On Immunosuppression
-Transplant, IHD, cirrhosis
-RA
-Multiple joints involved
-Bacteremia
-Gram negative

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7
Q

IVDU septic arthritis presentation

A

More gram neg, but S Aureus still MC
-More insidious w/ LONGER duration fo sx
-More AXIAL (L spine, SI joint, SC, symphysis pubis)

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8
Q

PJI RF

A

Distant site of infection,
-Impaired host defense
-RA, diabetes mellitus,
-Revision arthroplasty (5–10 times increased risk),
-Prolonged operative time
-Superficial joint replacements (i.e., knee, elbow, ankle)

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9
Q

Pseudoseptic arthritis causes

A

-RA
-Crystal
-Seroneg, Behcet’s
-SLE
-HA injection
-Prosthetic joints
-Renal transplant

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10
Q

RF for disseminated gonococcal infxn

A

Women, menstruation, preg, postpartum (cervical pH)
-Non-white, Urban residence, Low SES and educational status,
-High risk sex (multiple partner, prostitute)

-Previous gonococcal infection

-Complement deficiency
-Asplenia (SLE, Sickle cell)

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11
Q

** DGI Sx **

A

Papular/pustular skin rash
-Tenosynovitis (dorsum wrists, fingers, toes, ankles)
-Arthralgia
-
-GU symptoms eg PID

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12
Q

** DGI Tx **

A

Local cervicitis:CTX 250mg IM x1 + Azithro 1g x1
-DGI: CTX 1g IV daily x7d + azithro 1g PO x1

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13
Q

** DGI workup **

A
  • Synovial cell count/culture/crystal/gram stain
    – Blood culture
    – urine NAAT testing for gonorrhea
    – urethral/endocervical NAAT testing for gonorrhea
    -
    -**Test for syphilis and HIV
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14
Q

** DGI List 4 sites you want to culture?
-Give % positive synovial fluid culture?
-**

A

Genitourinary 80%
-Synovial fluid 50%
-Rectum 20%
-Pharynx 10%
-Blood <30%
-Skin Rare

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15
Q

** 40 year old man who 2 years ago had bilateral ankle synovitis treated with intraarticular steroids – complete remission. Comes back with monoarthritis, mouth and genital ulcers.
-Ask 4 other pertinent questions on history?**

A

Infectious history and exposures including sexual history
-Ocular symptoms (photophobia, red eye, pain)
-GI symptoms (diarrhea, weight loss)
-Other rashes?

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16
Q

** 40 year old man who 2 years ago had bilateral ankle synovitis treated with intraarticular steroids – complete remission. Comes back with monoarthritis, mouth and genital ulcers.
-Name 3 possible diagnoses?**

A

Behcet
-IBD with associated aphthous ulcers and peripheral arthritis
-HIV
-HSV
-?sarcoid
-?SLE
-gonococcal

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17
Q

** 40 year old man who 2 years ago had bilateral ankle synovitis treated with intraarticular steroids – complete remission. Comes back with monoarthritis, mouth and genital ulcers.
-Name 4 investigations?**

A

CBC
-Arthrocentesis (cell count, culture, microscopy)
-Swab of ulcer
-CXR (screen for PA aneurysms in Behcet)
-General STI testing including HIV testing, chlamydia
-?Pathergy testing

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18
Q

** 40 year old man who 2 years ago had bilateral ankle synovitis treated with intraarticular steroids – complete remission. Comes back with monoarthritis, mouth and genital ulcers.
-Name 3 therapies of most likely diagnosis? **

A

Topical corticosteroids (for ulcers)
-Colchicine titrate up to 0.6 TID
-Prednisone
-AZAthiorpine (for refractory ulcers, arthritis)

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19
Q

Syphilis presentation

A

-Fever, H/A, LN
-Mucosal ulcers, Sore throat
-Polyarthritis
-Maculopapular rash(palms and soles)
-Condyloma lata.

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20
Q

Lyme pathophys

A

Host’s inflammatory response to the spirochete (B. burgdorferi)

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21
Q

Lyme 1st stage manifestations

A

Early localized ECM
–Erythema migrans - annular lesion w/ central clearing
–Flu-like symptoms (H/A, arthralgia, fever, Regional LN)

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22
Q

** Lyme 2nd stage manifestations **

A

Disseminated infection:
–Neuro: CN palsy, meningitis, radiculoneuritis, sensorineural hearing loss
–iritis/keratitis
–Cardiac: AV block, myo/pancarditis, NO VALVE involvement
–Skin - satellite lesion
–MSK: migratory arthralgia,
–Other: LN, splenomegaly, hepatitis,

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23
Q

**Lyme 3rd stage manifestations **

A

Persistent infection (late disease):
–MSK: asymmetric oligoarthritis large joints (knees) w/ inflammatory fluid
–Neuro: encephalomyelitis, stroke like presentation, encephalopathy, polyneuropathy

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24
Q

** Name 5 non-MSK features in early disseminated Lyme disease **

A

Carditis
-Heart block
-Erythema migrans
-Cranial palsy, radiculoapthy, encephalopathy
-Keratitis
-SNHL
-Hepatitis, HSM

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25
Lyme Diagnosis
1) Enzyme immunoassay (EIA) OR Immunofluorescence (IFA) -- Negative = consider alternate dx OR too early (<30d) → get Western Blog (WB) -- Positive/Equivocal = get IgG Western blot (IgM too if <30d) - -*if IgM + but NOT IgG likely false+ IgM
26
** Reasons for Lyme False + **
- Previously treated -- Subclinical past infxn bc in endemic area -- AB against other spirochetes, syphilis, leptospirosis (eg >1mo sx w/ +IgM ELISA and -IgG ELISA) -- Cross-reactivity with other diseases: IE, SLE, RA, MS, HPylori, EBV, CMV, malaria, non lyme spirochetes, -- Interpretation error of faint band
27
** Lyme Tx **
Early/Disseminated/Late: -Doxycycline 100mg po BID x 14d - -*if CNS: CTX 2g daily
28
** Antibiotic-refractory Lyme arthritis pathophys and Tx **
HLADR4 and DR2 alleles bind B Burgdorferi and cross react w/ human protein → autoimmune inflamm -Tx: No more abx --NSAID --IA GC --HCQ --Arthroscopic synovectomy
29
Post treatment Lyme disease syndrome (PTLDS) presentation
>6mo of Fibro/ fatigue symptoms -Cog dysfunction -Widespread pain -Sleep disturbance -Faituge
30
Post treatment Lyme disease syndrome (PTLDS) Tx
Treat as Fibro
31
When to give Lyme PPX
OLDER than 8yo (ppx not effective) -Endemic area -Confirmed adult or nymph Ixodes tick Attached for at least 36 hours PPX can be given within 72 hours of tick removal
32
** Other bugs transmitted by ticks and their sx**
B miyamotoi: similar as lyme but NO RASH -Babesiosis: thrombocytopenia, hemolysis, liver enzymes, intraerythrocytic org on smear -Human granulocytic anaplasmosis - leukoepenia, thrombocytopenia
33
RF for osteoarticular TB
Female sex -Old > 65yo -Endemic country immigrant -Immunosuppressed eg biologics, EtOH, IVDU, HIV
34
Osteoarticular TB MSK involvement
Spine (pott’s): disk narrowing, vertebral collapse, kyphosis, abscess ,neuro compromise -Hip, SI joint, knee, ankle, hand/wrist -OM (lytic lesion w/o periosteal rxn) -Dactylitis -Tenosynovitis -Bursitis
35
What is Poncet’s disease
Culture negative polyarthritis (reactive/immune mediated) in TB of LN or pulmonary -Tx w/ antiTB meds
36
** Osteoarticular TB Ix **
Synovial fluid smear, culture or adenosine deaminase -Synovial biopsy: caseating granuloma -Nucleic acid amplification tests (NAAT) -CXR -Bone biopsy -Blood Cx
37
** Osteoarticular TB XR findings **
- Lytic lesions with little periosteal reaction -- Juxtaarticular osteoporosis -- Osteomyelitis -- Joint space narrowing -- Vertebral scalloping and collapse -- Paravertebral abscess
38
Osteoarticular TB Tx
RIPE x 6-9mo -DC pyrazinamide after 2 mo -DC ethambutol once TB confirmed sensitive to isoniazid
39
NTM risk factors
* Prior surgery/trauma. -* Direct inoculation / environmental exposure (soil, water). -* IA GC -* Preexisting joint disease. -* Open wounds -* Immunosuppression: eg biologic
40
Positive TBST
PPD>5mm at 48h -If negative, do IGRA (immunosuppressants can cause false negative)
41
Biologics highest risk for NTM/ TB
TNFi (especially Infliximab )
42
Biologics lowest risk for NTM/ TB
Abatacept , Ritux -*ritux highest risk of hepatitis B reactivation
43
What to do w/ biologic start if latent MTB and normal CXR
1 month of latent TB Tx before biologic start -Complete 9mo of isoniazid
44
What to do w/ biologic start if active TB
Complete TB tx before starting biologic
45
What to do w/ biologic start if previously treated NTM
Consult ID -Can consider Ritux or Abatacept -Avoid TNFi
46
Leprosy symptoms
Erythema nodosum 2/2 ReA -Subcutaneous nodules -Necrotizing vasculitis - -Symmetric small joint polyarthritis (can be RF+) -Neuropathic acroosteolysis: Charcot, resorption distal metatarsals, aseptic necrosis, “claw” hands - -Infection of bone (distal phalanges)
47
Viral arthritis characteristics
Acute self-limited (weeks/months) -Nonerosive, -Inflammatory arthritis -Can be RF and ANA+
48
Acute Hep B serology
Positive: HBcAb IgM, HBcAb IgG,HBsAg, HBeAg, HBV DNA -Negative: Anti HBs, Anti HBe
49
Cleared Hep B serology
Positive: HBcAb IgG, Anti HBs, +/-Anti HBe -Negative: HBcAb IgM, HBsAg, HBeAg, HBV DNA
50
Chronic HBV infection serology
Positive: HBcAb IgG, HBsAg, HBeAg, HBV DNA, Anti HBs, +/-Anti HBe -Negative: HBcAb IgM -*same as acute with negative HBcAb IgM
51
HBV Vaccine serology
Only Anti-HBs
52
RF chronic HBV
Male -Immunocompromised
53
HBV rheum manifestations
Symmetric migratory polyarthralgia/itis (~RA) - resolves w/ jaundice onset -Dermatitis - maculopapular, urticarial, petechial -Membranous nephropathy -HBV-associated polyarteritis nodosa
54
HBV PAN Tx
Immunosuppression -PLEX -Antiviral
55
HBV labs
Hep B serologies -Positive RF -Hypocomplementemia -
56
When to give ppx antiviral for HBV with biologics
Chronic inactive with TNFi, Ritux, or other biologic -Past resolved infxn with Ritux
57
** List 5 rheumatologic conditions that can accompany Hepatitis C.**
Nonerosive polyarthritis -Cryo vasculitis -Autoimmune conditions caused by interferon alpha (no longer used) -Keratoconjunctivitis sicca -Fibromyalgia
58
HCV serology
ANA, RF, Ro, La (if cryo: low complements and cryo+) -Celiac -Anticardiolipin -Antithyroid, Antismooth, AntiLKM
59
Differentiate HCV arthritis from RA
HCV nonerosive and usually CCP negative
60
Differentiate HCV sicca from SS
Both hv Ro/La -MSG biopsy shows CD8+T cells (vs CD4+ T cells in SS)
61
Treating Rheum pt w/ HBV or HCV infection
Use HCQ, SSZ, and AZA over MTX/LFN -TNFi are safe
62
Parvovirus B19 sx & labs
Hydrops fetalis in infected mothers -Erythema infectiosum (fifth disease) in children -Aplastic crisis in adults -pseudo rheumatoid inflammatory arthritis -fever, rash, myalgia, arthritis (adults > children) -Mimicking lupus: cytopenia, hypocomplementemia, a positive ANA, and transient aPL antibodies
63
Parvo B19 labs
Cytopenia,aplastic crisis -Hypocomplementemia, -Positive ANA, RF, dsDNA, ENA, APLA
64
Mech of viral arthritis eg Hep, Parvo
Immune complex deposition causing nonspecific inflammatory response
65
How to distinguish dengue fever from CHIK infection?
Dengue -- Arthralgia WITHOUT synovitis -- Abdo pain -- Leukopenia -- Hemorrhagic manifestations -- Breakbone fever
66
What NOT to give in Zika infection
NSAIDs and ASA bc can cause bleeding in patietns with other flaviviridae infections
67
** Rheum Manifestations assoc’d w/ HIV **
Arthralgia/Arthritis -Seroneg: ReA, PsA, undiff SpA bc CD8+ -Myalgia, PM, IBM -Diffuse infiltrative lymphocytosis syndrome -Vasculitis (all types: LVV, PAN, AAV, HSP, PVCNS, Behcets, Cryo2/3) -Fibro
68
** Why test HIV in psoriasis **
As CD4 drops, can flare psoriasis
69
** Rheum Manifestations assoc’d w/ ART **
CD4 mediated: RA, Sjogren’s, SLE, SCLE, Sarcoid -ReA -Gout (hyperuricemia) -Grave’s -AVN, OP, osteomalacia -OM -Rhabdo, lipodystrophy, mitochondrial myopathy
70
Pathophys of HIV rheum syndromes
CD4 depletion = T reg cell depletion (for self tolerance and avoiding autoimmunity)
71
HIV autoimmune serologies
RF, ANA, Anticardiolipin, Cryo, ANCAs
72
HIV assoc’d arthritis manifestations and Tx
Seroneg oligoarticular knees/ankles -Noninflammatory, culture neg, synovial fluid -Normal XR -Tx: NSAID, steroid, PT - -Prolonged: -- RA like erosions and joint space narrowing --Jaccoud’s -Tx: NSAIDs, HCQ, SSZ
73
Diff between HIV assoc’d arthritis and painful articular syndrome
Painful articular syndrome lasts <24h -- Occurs late in HIV -- Due to transient bone ischemia (no synovitis) -- Tx = narcotics
74
When to give DMARDs in pt w/ HIV
Adherence to ART -Viral load is low -CD4 T cell count >200/uL
75
HIV related wasting syndrome - sx and bx
Noninflamm necrotizing myopathy -Bx: atrophy and necrosis WITHOUT inflamm
76
HIV associated PM vs PM
HIV assciated PM: -- Lower CK (can be normal) -- NO autoantibodies -Otherwise, EMG, MRI, biopsy is the same - -Tx: Steroids+ART (2nd line = MTX)
77
AZT induced myopathy vs PM
AZT induced myopathy -- Biopsy shows AZT induced toxic mitochondrial myopathy with RAGGED RED FIBERS - -Tx: Hold AZT x4wks and monitor
78
** Diffuse infiltrative lymphocytosis syndrome vs Sjogren’s **
DILS: -- CD8+ predominant lymphocytic infiltration of salivary/lacrimal gland (vs CD4 in sjogrens) -- COMMON parotid swelling and extraglandular mx (less common in SS) -- RARE AB (RF, ANA, Ro/LA) -- Steroids help glandular (less helpful in SS) -
79
** Name the rheumatic diseases that may improve in association with AIDS **
SLE and RA are CD4 driven, thus IMPROVE with AIDS -Can worsen with ART
80
MoA of IRIS
Increasing CD4 counts w/ Tx exacerbates preexisting RA, SLE, Sarcoid -CD4 and cytokines can cause new RA, SLE, Sarcoid, PM, ReA, SCLE, GBS, autoimmune thyroid
81
IRIS Tx
Self limited, continue ART unless ocular or CNS symptoms → then DC and give GC
82
When should screening for HIV be considered by the rheumatologist?
1) Diagnosis of ReA with sexual or unknown mode of acquisition, -2) IVDU -3) Septic arhtiris/pyomositis -4) PsA w/ refractory or atypical rash -5) atypical SLE or unexplained autoantibody -6) Sicca without Ro/La -7) Autoimmune dz refractory to usual tx
83
HTLV1 (human T lymphotropic virus type 1) disease association
-T cell leukemia and NHL - hyperCa, skin involvement -Chronic inflamm syndrome - seroneg oligo/polyarthritis w/ tenosynovitis and nodules w/ fibrinoid necrosis
84
HTLV1 smear cells
Flower cells
85
** Whipple’s pathogen**
Tropheryma whipplei
86
** Whipple’s symptoms**
-Wasting/weight loss, abdo pain, Steatorrhea, diarrhea, malabsorption -Arthritis (seroneg palindromic rheumatism of knees, ankles, wrists, SI joints, spine) -Eye inflammation (Panuveitis, keratitis, retinitis, optic neuritis, orbital pseudotumor) , Supranuclear ophthalmoplegia -Hyperpigmentation of skin, skin lesions - Encephalopathy, Psychiatric symptoms -Interstitial nephritis -Pancytopenia, Lymphadenopathy -Endocarditis (cultre negative)
87
Whipple’s CNS sx
Dementia -Psych -Myoclonus -Oculomasticatory or oculofacial-skeletal myorhythmia (pathognomonic)
88
Whiples triad
Dementia, -Supranuclear ophthalmoplegia -Myoclonus
89
Whipples Dx
Biopsy showing organism in one involved tissue by 2 methods (PAS stain, PCR, immunohistochemical stain OR -PCR testing in 2 involved sites (eg synovial fluid and CSF) -*always test CNS regardless of neuro symptoms
90
** Whipple’s Tx **
CTX 2g x14d (up to 28d for neuro or IE) then longer term Septra DS BID fora year -*can cause IRIS (esp if CNS involved or previous immunosuppression)
91
** Rxn when taking abx for Whipple **
Jarisch-Herxheimer reaction within 24h (in pt w/ spirochete infxn): fever, chills, headache, hypotension, severe abdominal or pleuritic chest pain. -IRIS- Immune reconstitution syndrome within weeks: disease symptoms and high fever
92
Rheumatic fever symptoms
J—joints (migratory NONEROSIVE arthritis) -♥—carditis (peri/myocardium, valves - MV, AoV, CHF, heart block) -N—nodules (subcutaneous) -E—erythema marginatum (irreg serpignous nonpruritic rash sparing face) -S—Sydenham’s chorea (asymmetric movement face/hands/feet) -Fever
93
Rheumatic fever Jones criteria
Initial ARF = 2 major or 1 major + 2 minor -Recurrent ARF = 2 majr or 1 maj + 2 minor or 3 minor -Major Carditis -Arthritis Chorea -EM -Subcutaneous nodule -Minor -Arthralgia -Fever -ESR >60, CRP >3 -Prolonged PR (unless carditis is present already)
94
Situations in which a diagnosis of ARF might be made without strict adherence to the Jones criteria
1. Isolated chorea months after initial strept infxn & negative serology 2. Indolent carditis and/or typical mitral/aortic valve lesion as only manifestation 3. Previous rheumatic heart disease
95
GAS Lab tests
Throat cx for GAS -Rapid Strep Ag test -*neither tell you if carrier vs active infxn and can be negative if in latent period - -Preferred: -Antistreptolysin test or antideoxyribnuclease B test
96
How does GAS cause ARF
Molecular mimicry -- Ig against GAS peptidoglycans cross react w/ cardiac myosin - -GAS protein can also bind collagens to create immune rxn
97
ARF exam test
Milkmaid grip = involuntary grasp/release when trying to hold constant grip (pathognomonic) -Jaccoud’s if recurrent ARF
98
ARF prevention
ABX for strep pharyngitis - -ABX PPX 5y (or 10Y if mild cardiac sx) from last attack or until age 21 -Severe carditis w damage = PPX for 10 years or until age 40 (can consider lifelong ppx -Abx PPX for ARF pt if frequent exposure to children until exposure ends
99
Complications of Strep infxn
ARF -PANDAS (pediatric autoimmune neuropsych d/o assoc’d w/ strep) eg OCD, Tic
100
ARF Tx
Azithro, Clinda -Penicillin G or V or Amox if carditis/neuro -Arthritis: ASA or Naproxen
101
**List the main type/pattern of arthritis and 1 skin manifestation for each of the following infections -Lyme -Gonorrhea -Parvo -Mycobacterium -**
Lyme: early migratory arthralgia, late mono>oligoarhtritis -- erythema migrans - -Gonorrhea: tenosynovitis and migratory polyarthralgia -- pustular dermatitis - -Parvo: symmetric polyarthalgia/arthritis -- facial erythema (slapped cheek) - -Mycobacterium: Tenosynovitis, OM, dactylitis, septic arthritis -- Subcutaneous nodules
102
** How does HIV, syphilis, and lyme arthritis present with **
HIV: Seronegative, oligoarticular, non-destructive, lower extremity predominant arthritis -Syphilis: symmetric polyarthritis involving knees/ankles > small joints of hands -Lyme: migratory arthralgia → late asymmetric oligoarticular arthritis of large joints (knees)

1. Rheum RC (23 decks)

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