Lab: Joint Disease 2 Flashcards
(80 cards)
1
Q
Where is rheumatoid arthritis often seen first?
A
Small joints of hands and feet
2
Q
Is rheumatoid arthritis bilateral/symmetrical?
A
Yes
autoimmune etiology and inflammatory
3
Q
Are rheumatoid arthritis lesions osteolytic or osteoblastic?
A
Osteolytic
4
Q
rheumatoid arthritis
Blue arrows:
Red arrow:
Purple arrows:
Green arrow:
A
Blue arrows: uniform loss of joint space/fibrous ankylosis
Red arrow: prearticular erosions
Purple arrows: swan neck deformity (fibrous ankylosis)
Green arrow: Boutonniere deformity (fibrous ankylosis)
5
Q
What are some radiographic features of rheumatoid arthritis?
A
- Osteolytic lesions (juxta-articular/periarticular)
- Juxta-articular osteoporosis
- Decreased joint space
- Subluxation/dislocation of joints
- Fibrous ankylosis (swan neck and Boutonniere)
6
Q
What are some symptoms of rheumatoid arthritis?
A
- Cardinal signs in affected joints
- Tenosynovitis and tendon rupture
- Fibrinoid necrosis (rheumatoid nodules)
- Necrotizing vasculitis (vascular stenosis, ischemia and necrosis in tissues supplied)
7
Q
Are spondyloarthropathies inflammatory?
A
Yes
8
Q
Which joints are primarily involved in spondyloarthropathies?
A
Primarily spine
Asymmetrical peripheral joint involvement possible
9
Q
The following are all symptoms of which joint pathology?
- Cardinal signs of inflammation
- Tenosynovitis and tendon rupture
- Fibrinoid necrosis
- Necrotizing vasculitis
A
Rheumatoid arthritis
10
Q
Generally, spondyloarthropathies are HLA-B27 ___ and rheumatoid factor ___
A
HLA-B27 positive and rheumatoid factor negative
spondyloarthropathies are seronegative
11
Q
Spondyloarthropathies involve ___ ankylosis of affected joints
A
osseous
12
Q
What is ankylosing spondylitis?
A
Progressive ankylosis of the spine beginning in the sacral and lumbar regions
13
Q
What are some signs of ankylosing spondylitis?
A
- Postural changes
- Sacroiliitis
- Bamboo sign (radiograph)
- Trolley track sign (radiograph)
- Dagger sign (radiograph)
14
Q
The following are all signs related to which joint pathology?
- Postural changes
- Sacroiliitis
- Bamboo sign
- Trolley track sign
- Dagger sign
A
Ankylosing spondylitis
15
Q
Is psoriatic arthritis more often seen in the spine or extremities?
A
Frequently extremities
16
Q
What is noticeable in this radiograph?
What pathology is present?
A
Reactive bone formation (blue arrows), and osseous ankylosis
Psoriatic arthritis
17
Q
This pathology likely previously had what visible presentation?
A
Psoriatic arthritis rash
psoriatic arthritis
18
Q
Psoriatic arthritis has a similar pathogenesis to, but different presentation from ___
A
rheumatoid arthritis
19
Q
How might the spine be affected by psoriatic arthritis?
A
- May or may not have sacroiliac involvement
- Paravertebral ossifications
20
Q
What is the triad of symptoms related to reactive arthritis/Reiter’s syndrome?
A
- Conjunctivitis
- Urethritis
- Arthritis
21
Q
If a patient presents with the following, what is their most likely diagnosis?
- Conjuctivitis
- Urethritis
- Arthritis
A
Reactive arthritis/Reiter’s syndrome
22
Q
Enteropathic arthritis is associated with previous ___ issues such as ___
A
previous gastrointestinal issues such as ulcerative colitis or Chron’s disease
23
Q
With enteropathic arthritis, exacerbations of ___ can lead to increased arthritic symptoms
A
gut symptoms
24
Q
How many joints are affected by enteropathic arthritis?
A
Monoarthritic: pain in one joint
25
What is the nature of the pain associated with enteropathic arthritis?
Migratory and transient pain in one joint
26
Persistent cases of enteropathic arthritis may resemble changes associated with ___
ankylosing spondylitis
27
Which joints are most affected by degenerative joint disease?
Which are most affected by rheumatoid arthritis?
DJD: weight bearing joints
RA: small joints
28
80% of those with rheumatoid arthritis are positive for RF
66% of those with rheumatoid arthritis are positive for ___
ACPA
29
What is indicated by the pale areas found in the joint?
Fibrin deposition (nodules)
| rheumatoid arthritis
## Footnote
rice bodies when floating in joint
30
What is evidenced by the brownish color seen in this joint?
Old hemorrhage
| rheumatoid arthritis
31
What is pannus in regard to joint pathology?
Chronically inflamed "frond like" membrane with abnormal layer of fibrovascular/granulation tissue
| rheumatoid arthritis
32
How does this presentation affect structures of the joint?
* Enzymes and proteases increase, thus increasing vascularity of the joint
* Separates articular cartilage from synovial fluid, starving cartilage
* Symptoms of joint stiffness, decreased ROM, and achiness
| rheumatoid arthritis pannus
33
What are the terms for subcutaneous nodules in the following locations? What pathologies are associated with each?
Metacarpophalangeal joint:
Proximal interphalangeal joint:
Distal interphalangeal joint:
Metacarpophalangeal joint: Haygarth, **RA**
Proximal interphalangeal joint: Bouchard, **DJD, psoriatic arthritis, RA**
Distal interphalangeal joint: Heberden, **DJD, psoriatic arthritis**
## Footnote
everything likes the PIP joint
34
Image B is a histological tissue section of the rheumatoid nodule in image A.
What is seen at the green arrow?
Fibrinous necrosis
| characterized by presence of fibrinoid
## Footnote
due to acute necrotizing vasculitis
35
Which pathologies have we discussed that include vasculitis as part of their pathogenesis?
* Rheumatoid arthritis
* Lupus
* Systemic sclerosis
36
Inflammatory joint pathologies often have ___ etiologies.
autoimmune
37
What is the typical etiology of a non-inflammatory joint pathology?
Wear due to biomechanical stress
38
What type of primary bone changes occur with non-inflammatory joint pathologies?
Lytic change possible, but primarily **blastic** (subchondral sclerosing and osteophytes)
39
What type of primary bone changes occur with inflammatory joint pathologies?
Primarily **lytic**, but some blastic change in the form of ankylosis of joints possible
40
If a joint pathology is bilateral and symmetrical, is it more likely to be inflammatory or non-inflammatory?
Inflammatory
41
What are a patient's symptoms if they have degenerative joint disease, a non-inflammatory joint pathology?
Early may not present with many symptoms
Late can present with cardinal signs and dull aching pain that's worse with activity
42
What are a patient's symptoms if they have an inflammatory joint pathology?
Cardinal signs, including pain, may have remissions and exacerbations
Ankylosis of joint and other systemic symptoms possible
43
How does ESR/CRP compare between non-inflammatory and inflammatory joint pathologies?
Elevated with inflammation
Normal with non-inflammatory, but may increase later
44
What are 5 treatment/lifestyle recommendations for someone with an inflammatory joint pathology?
* Low impact activities/exercise
* Anti-inflammatory diet
* Maintain a healthy weight
* Stop smoking
* Drug therapies
45
Rheumatoid arthritis leads to proliferation of the synovium which will erode joint structures, sometimes with ___ ankylosis.
fibrous
46
A patient with rheumatoid arthritis has fibrous ankylosis in their fingers. Which deformities have likely occurred?
* Swan neck
* Boutonniere
47
Which arthritis pathologies have we discussed that are associated with acute necrotizing vasculitis?
* Rheumatoid arthritis
* Lupus
* Systemic sclerosis
48
What is acute necrotizing vasculitis?
Inflammation of blood vessel walls leading to necrosis
49
What types of complications are associated with acute necrotizing vasculitis?
* Bone and other tissue infarction
* Conjunctivitis and ulcers
* Ischemia/ichemic stroke
50
What complication of acute necrotizing vasculitis is shown?
Ulceration
51
What type of ankylosis is depicted in this radiograph?
Which pathologies that we have discussed will produce this type of ankylosis?
Osseous ankylosis
Long-standing psoriatic arthritis
| all seronegative arthritis will do osseous ankylosis; as can rheumatoid arthritis
## Footnote
DIP and PIP affected = psoriatic arthritis
52
The diagnostic lab results for this patient were RF-factor positive, HLA-B27 negative, ANA positive, and C-reactive protein elevated.
Which joint pathology best matches the patient's result?
Rheumatoid arthritis
## Footnote
ANA is usually lupus and systemic sclerosis, but can also be RA
HLA-B27 is usually spondyloarthropathies
53
What type of ankylosis is depicted in this radiograph?
Which pathologies that we have discussed will produce this type of ankylosis?
Fibrous ankylosis (joint still seen)
Rheumatoid arthritis
| wrists and MCPs are most affected
54
What type of deformity produced by this pattern of ankylosis indicated by the yellow arrow?
What causes the types of deformities seen here?
Boutonniere deformity
Due to tendon/ligament rupture
| hitch hiker at red arrow
## Footnote
Boutonniere and swan neck do not indicate specific pathology
55
What is the name for the reactive bone formation seen at the joint margins at the red arrows?
What pathology is this associated with?
Fluffy periostitis (mouse ear deformity)
Psoriatic arthritis
## Footnote
gout is not bilateral symmetric
rheumatoid does not do periostitis
56
This patient has psoriatic arthritis.
What is the name for this type of deformity?
Peripheral erosion on proximal bone, central erosion on distal bone: **pencil-in-cup deformity**
| not specific to psoriatic arthritis
## Footnote
aka mortar in pestal appearance
57
A 35-year-old female presents with cervical spine pain. She has had pain and stiffness in both hands and both feet. She's been more fatigued lately. She's felt tired for the past month but has had symptoms for at least several months with several bouts last year.
Based on this case presentation, what would you include on your differential diangosis and why?
* Rheumatoid
* Psoriatic
* Lupus
* Systemic sclerosis
| all are inflammatory
58
A 35-year-old female presents with cervical spine pain. She has had pain and stiffness in both hands and both feet. She's been more fatigued lately. She's felt tired for the past month but has had symptoms for at least several months with several bouts last year.
What types of diagnostic tests would you want to order to narrow your differential diagnosis?
* RF (rheumatoid arthritis)
* ANA (nonspecific autoimmune)
* ESR/CRP (nonspecific inflammation)
* HLA-B27 (risk for autoimmune) (overkill)
59
A 35-year-old female presents with cervical spine pain. She has had pain and stiffness in both hands and both feet. She's been more fatigued lately. She's felt tired for the past month but has had symptoms for at least several months with several bouts last year.
What are the relevant radiographic findings for bone or alignment?
* **Marginal erosions at MCPs**
* Wrist involvement
| red arrow
## Footnote
RA likes MCPs and wrists
60
A 35-year-old female presents with cervical spine pain. She has had pain and stiffness in both hands and both feet.
Blood work reveals the following:
* ANA positive
* ESR elevated
* RF factor positive
* HLA-B27 negative
What is your differential diagnosis?
Rheumatoid arthritis
61
Will all patients with rheumatoid arthritis have the same lab findings for ANA, ESR, RF, or HLA-B27?
No
## Footnote
RA can be present without RF positive
62
What percentage of patients with rheumatoid arthritis will show spinal involvement?
What region of the spine is commonly affected?
80%
Cervical involvement
63
What sort of diet would you recommend for someone with rheumatoid arthritis or a similar diagnosis?
Mediterranean diet:
* Fish
* Nuts and seeds
* Fruits and vegetables
* Olive oil
* Beans
* Whole grains
## Footnote
anti-inflammatory
64
A 25-year-old male presents with low back pain and stiffness that has reportedly lasted for several years. He also has pain in his feet and shoulders. His pain is achy, worse in the morning and at night, but a little better while at work. He broke his radius when he was 12-years-old but hasn't had major injuries since.
Does this seem inflammatory or non-inflammatory?
Inflammatory
| several joints affected, likely systemic
65
A 25-year-old male presents with low back pain and stiffness that has reportedly lasted for several years. He also has pain in his feet and shoulders. His pain is achy, worse in the morning and at night, but a little better while at work. He broke his radius when he was 12-years-old but hasn't had major injuries since.
What conditions would you include on your initial differential diagnosis?
**Ankylosing spondylitis**: pain pattern, low back, age and gender, shoulder involvement
**Enteropathic arthritis**: axial and extremity involvement
**Psoriatic arthritis**: progressive pain, SI involvement, foot involvement
**Reactive arthritis**: age and gender, lumbosacral pain, SI and distal lower extremity involvement
## Footnote
inflammatory sponydloarthropathies
66
A 25-year-old male presents with low back pain and stiffness that has reportedly lasted for several years. He also has pain in his feet and shoulders. His pain is achy, worse in the morning and at night, but a little better while at work. He broke his radius when he was 12-years-old but hasn't had major injuries since.
What feature is indicated by the green arrows?
What produces this feature?
Marginal syndesmophytes due to process of osseous ankylosis
| bamboo spine pictured
67
A 25-year-old male presents with low back pain and stiffness that has reportedly lasted for several years. He also has pain in his feet and shoulders. His pain is achy, worse in the morning and at night, but a little better while at work. He broke his radius when he was 12-years-old but hasn't had major injuries since.
What feature is indicated by the yellow arrows?
What produces this feature?
**Dagger sign**: ossification of supraspinous and interspinous ligaments due to osseous ankylosis
| bamboo spine pictured
## Footnote
aka trolly track or rail road sign
68
A 25-year-old male presents with low back pain and stiffness that has reportedly lasted for several years. He also has pain in his feet and shoulders. His pain is achy, worse in the morning and at night, but a little better while at work. He broke his radius when he was 12-years-old but hasn't had major injuries since.
Besides the elements of the "bamboo spine" pictured, are there any other relevant findings on this radiograph?
What pathologies are associated with all of these radiographic findings?
Osseous ankylosis of SI joints bilaterally and symmetrically
Ankylosing spondylitis and enteropathic arthritis
69
A 25-year-old male presents with low back pain and stiffness that has reportedly lasted for several years. He also has pain in his feet and shoulders. His pain is achy, worse in the morning and at night, but a little better while at work. He broke his radius when he was 12-years-old but hasn't had major injuries since.
Patient adds that he does not remember a rash or a fever, nor any digestive issues.
Which diagnosis would be more likely if he had presented with chronic digestive issues?
Enteropathic arthritis
70
A 25-year-old male presents with low back pain and stiffness that has reportedly lasted for several years. He also has pain in his feet and shoulders. His pain is achy, worse in the morning and at night, but a little better while at work. He broke his radius when he was 12-years-old but hasn't had major injuries since.
Patient adds that he does not remember a rash or a fever, nor any digestive issues.
With this added information, which of your differential diagnoses is most likely?
Ankylosing spondylitis
71
Given that this is ankylosing spondylitis, what would be the expected blood results for the following?
* ESR
* Rheumatoid factor
* HLA-B27
ESR: **elevated**
RF: **negative**
HLA-B27: **positive**
72
What is the impact if the costotransverse ligaments are affected by ankylosing spondylitis?
Decreased chest expansion leading to a decrease in normal breathing without a history of smoking
73
What treatment options would you recommend for this patient with ankylosing spondylitis?
* Low impact, regular activity
* Anti-inflammatory diet
* NSAIDs early, maybe DMARDs
74
This patient has ankylosing spondylitis.
What will eventually happen to this patient's joints?
Osseous ankylosis with complete loss of ROM
75
A 12-year-old male is taken to the ER. He fell the day before and has pain in his right elbow with a visible wound in the skin. The joint is swollen and very sensitive to touch. His temperature is 100.2 F. He cannot move the elbow well and reports further pain. Radiographs are unremarkable.
What are the patient's relevant signs and symptoms?
* Fever
* Cardinal signs of inflammation
* Decreased ROM
76
A 12-year-old male is taken to the ER. He fell the day before and has pain in his right elbow with a visible wound in the skin. The joint is swollen and very sensitive to touch. His temperature is 100.2 F. He cannot move the elbow well and reports further pain. Radiographs are unremarkable.
What conditions would you include on your initial differential diagnosis?
* Lyme disease
* Acute pyogenic osteomyelitis
* Septic arthritis
* Seronegative pauciarticular juvenile idiopathic arthritis
77
A 12-year-old male is taken to the ER. He fell the day before and has pain in his right elbow with a visible wound in the skin. The joint is swollen and very sensitive to touch. His temperature is 100.2 F. He cannot move the elbow well and reports further pain. Radiographs are unremarkable.
Blood work comes back:
* Alkaline phosphatase normal
* HLA-B27 negative
* RF negative
Assuming ESR/CRP is elevated, what two diagnoses are at the top of your differential list?
* Acute osteomyelitis
* Septic arthritis
78
What would you do to differentiate between osteomyelitis and septic arthritis?
* Gold standard for septic arthritis is **joint aspiration**
* Osteomyelitis needs a bone biopsy to confirm
* Further imaging may be needed
| send to rheumatologist
79
A 45-year-old male with slightly high blood pressure was treated with antibiotics recently for a chlamydia infection. He is experiencing more than his usual amount of back pain and chiropractic appointments aren't relieving him as much as usual. His eyes are unusually red.
What condition could be associated with his case based on this information?
Reactive arthritis
## Footnote
20s-30s; almost exclusively men
80
A 45-year-old male with slightly high blood pressure was treated with antibiotics recently for a chlamydia infection. He is experiencing more than his usual amount of back pain and chiropractic appointments aren't relieving him as much as usual. His eyes are unusually red.
What tests or additional information would you recommend he get?
* Ask about urinating and lower extremity involvement
* Need radiographs of spine and SI joints
* CBC with diff and chem profile
* ESR/CRP
* Blood test for HLA-B27
