Last Rheum Sections

Question 1

What are the features that are characteristic of spondyloarthropathies?

Answer 1

It involves sacroiliac joints (uncommon in rheumatoid arthritis)
Peripheral arthritis that is usually asymmetric and oligoarticular
Absence of rheumatoid factor
Associated with HLA-B27 in more than 90% of the cases
It’s an enthesopathic (bone attachment) disorders

Question 2

What are the four diseases associated with an increased frequency of HLA-B27 and the frequency in each disease?

Answer 2

Ankylosing spondylitis (HLA-B27 90%)
Reactive arthritis (HLA-B27 80%)
Enteropathic spondylitis (HLA-B27 75%)
Psoriatic spondylitis (HLA-B27 50%)

Question 3

What are the joints affected in ankylosing spondylitis?

Answer 3

Affects the sacroiliac joints, the spring and the peripheral joints

Question 4

What are the Sx of ankylosing spondylitis?

Answer 4

It is a chronic systemic inflammatory disease. Low back pain and decreased spinal motion and reduced chest expansion. Insidious onset, duration of more than 3 months, morning stiffness, improvement with exercise, family history, involvement of other systems.

Question 5

What is the age of onset of ankylosing spondylitis?

Answer 5

15-40years old

Question 6

What are the radiographic findings of ankylosing spondylitis?

Answer 6

sacroiliac involvement with erosion, “pseudo widening” of joint space, sclerosis (both side of sacroiliac joint) and fusion. Spine involvement with squaring of superior and inferior margins of vertebral body, syndesmophytes and bamboo spring.

Question 7

What are the lab findings of ankylosing spondylitis?

Answer 7

Increased erythrocyte sedimentation rate. An anemia of chronic disease and rheumatoid factor is absent

Question 8

What are the extraspinal involvement seen in ankylosing spondylitis?

Answer 8

Enthesopathic involvement is characteristic of ankylosing spondylitis and the other spondyloarthropathies and consists of plantar fasciitis, Achilles tendinitis and costcochondritis
Hip and shoulder involvement are common (50%)

Question 9

What are the extraskeletal involvement seen in ankylosing spondylitis?

Answer 9

Fatigue, weight loss, osteoporosis, low grade fever and iritis (not in rheumatoid arthritis)
Late complication can include traumatic spinal fracture leading to cord compression, cauda equine syndrome, fibrotic changes in upper lung fields and aortic insufficiency

Question 10

What are the Tx of ankylosing spondylitis?

Answer 10

Physical therapy (upright position), exercise (swimming), cessation of smoking, genetic counseling and drug therapy with NSAIDs (indomethacine) and TNF α inhibitor

Question 11

What are the organisms of Reactive arthritis?

Answer 11

Salmonella, shigella, Yersinia, campylobacter, chlamydia and Ureaplasma

Question 12

What are the joints involved with Reactive arthritis?

Answer 12

Toes (sausage toes), asymmetric large joints in the lower extremities and distal interphalangeal joints in the hands

Question 13

What are the extra-articular conditions of Reactive arthritis?

Answer 13

Cardiac conduction disturbances and aortitis can develop, Sacroiliitis can occur.

Question 14

What are the Tx of Reactive arthritis?

Answer 14

NSAIDs (indomethacin).
Sulfasalazine and methotrexate are used in patients with chronic disease.
Tetracycline or erythromycin ab to decrease the duration and severity of illness caused by chalamydia triggered reactive arthritis

Question 15

What are the joints involved with psoriatic arthritis?

Answer 15

finger and toes

Question 16

What are the Sx of psoriatic arthritis?

Answer 16

Pitting of nails. Patients with more severe skin disase are at higher risk. “Sausage” finger or toe is characteristic of psoriatic arthritis. It develops in patients with psoriasis (7% or less)

Question 17

What are the radiological findings of psoriatic arthritis?

Answer 17

Distal interphalangeal joint with erosions. It can also cause “pencil-in-cup” deformity of the distal interphalangeal and proximal interphalangeal joints.

Question 18

What are the criteria for the diagnosis of SLE?

Answer 18

Malar rash
Discoid lupus
Photosensitivity
Oral ulcers
Nonerosive arthritis
Proteinuria ( protein > 0.5g/day) or cellular casts
Seizures or psychosis
Pleuritis or pericarditis
Hemolytic anemia, leukopenia, lumphopenia or thrombocytopenia
Antibody to native DNA, antibody Smith, IgG or M antiphospholipid ab, positive test for lupus anticoagulant or false-positive result of VDRL test
Positive results of fluorescent antinuclear ab test.

Question 19

What are the most frequently affected gender, race, and age at onset of SLE?

Answer 19

Gender: Female during reproductive year
Race: American blacks, Native Americans and Asians.
Age at onset of SLE: second and fourth decades of life

Question 20

What are the human histocompatibility complexes seen with increased frequency seen in SLE?

Answer 20

HLA-B8
HLA-DR2
HLA-DR3

Question 21

What are the clinical manifestations of SLE?

Answer 21

Fever

Question 22

What are the articular manifestations of SLE?

Answer 22

It’s inflammatory but nondeforming and nonerosive. Avascular necrosis of one occurs and not only in patients taking steroids. The femoral head, navicular one and tibial plateau are most commonly affected.

Question 23

What are the cardiopulmonary manifestations of SLE?

Answer 23

Pericarditis, myocarditis, valvular involvement, accelerated coronary atherosclerosis and coronary vasculitis. There is an association between SLE and coronary artery disease. Risk factor for hypertension and hyperlipidemia.
Pleurisy, pleural effusion, pneumonitis, pulmonary hypertension, hemorrhage and diaphragmatic dysfunction.

Question 24

What are the neuropsychiatric manifestations of SLE?

Answer 24

Impaired cognitive function, seizures, long tract signs, cranial neuropathies, psychosis and migraine like attack happens in CNS lupus. Immune complexes in the choroid plexus happen in both CNS and non-CNS lupus. Increased CSF protein IgG, pleocytosis and antineuronal antibodies.

Question 25

What are the findings on lumbar puncture and MRI of neuropsychiatric SLE?

Answer 25

Lumbar puncture: Normal results of CSF MRI: Shows areas of increased signal in the periventricular white matter, similar to those found in MS. It is usually nonspecific and sometimes can be seen in patients who have SLE w/o CNS manifestation

Question 26

Pregnant women with SLE have higher chance of what?

Answer 26

Spontaneous abortion

Question 27

What are the lab findings and clinical manifestations in infants of SLE mothers?

Answer 27

Lab findings: Anti-SS-A (Ro) + but there is no HLA association in the child. Clinical manifestations in infants: Thromboyctopenia and leukopenia can develop. They also can have transient cutaneous lesions and complete heart block.

Question 28

What are the lab findings of SLE including anemias, ITP, ESR, and hypocomplementemia?

Answer 28

Anemia of chronic disease and hemolytic anemia (coombs positive) can occur. Anti-lymphocyte ab causes lymphopenia in SLE. Idiopathic thrombocytopenic purpura (ITP) with the presence of platelet Ab is initial manifestation of SLE. Polyclonal gammopathy due to hyperactivity of the humoral immune system is common The erythrocyte sedimentation rate (ESR) usually correlates with disease activity. Hypocomplementemia (CH50, C3,C4) usually correlates with active disease and hypocomplementemia with increased anti-native DNA abs usually implies renal disease or skin disease. A positive result of an antinuclear antibody test (ANA) is by no means specific for lupus.

Question 29

Why can patients with SLE may have false positive results of VDRL testing?

Answer 29

It will have false positive results of the VDRL test as a result of ab to phospholipid, which cross-reacts with VDRL

Question 30

What are the two drugs that are strongly implicated in drug-induced lupus?

Answer 30

Procainamide | Hydralazine

Question 31

What are the clinical features of drug-induced lupus.?

Answer 31

Arthralgia and polyarthritis. Malaise is common and 40% of the patients have fever. Cardiopulmonary involvement is common and 30% of patients have pleural-pulmonary manifestations as their presenting symptoms. Pericarditis-20% of pts. Diffuse interstitial pneumonitis. No involvement of CNS or renal.

Question 32

What are the lab findings of drug-induced lupus.?

Answer 32

Have antinuclear Abs. Abs to native DNA, Anti smith, SS-A, SS-B and RNP are not really found in drug induced lupus but found in SLE. Serum totally hemolytic complement C3 & C4 are usually normal in drug induced lupus in contrast to SLE. The frequency of antihistone Abs is high in drug induced. Positive LE preparation, positive Coombs test, positive rheumatoid factor, false positive result of serologic test for syphilis, circulating anticoagulants and croglobulins are less common abnormal laboratory results

Question 33

What are the Tx of drug-induced lupus.?

Answer 33

Stop using the drug. One can also take NSAID or possibly low dose prednisone if need.

Question 34

What are the Ig's involved with antiphospholipid syndrome?

Answer 34

IgG or IgM

Question 35

What are the lab findings for antiphospholipid syndrome?

Answer 35

Prolongation of all phospholipid dependent coagulation tests in laboratory is hallmark of the syndrome Activated partial thromboplastin time is prolonged and not corrected by adding normal plasma but it is corrected with the addition of platelet rich plasma, this is the laboratory hallmark of a lupus anticoagulant

Question 36

What are the clinical features seen in antiphospholipid syndrome?

Answer 36

There is an association between the presence of the lupus anticoagulant & antiphospholipid Ab and recurrent venous or arterial thrombosis. (they all provoke blood clots) Stroke, MI, transient ischemic attack, brachial artery thrombosis, deep venous thrombophlebitis, retinal vein thrombosis, hepatic vein thrombosis resulting in Budd-Bhiari syndrome & pulmonary hypertension. Recurrent fetal loss, thrombocytopenia, positive Coombs test, migraines, chorea, epilepsy, chronic leg ulcers, livedo reticularis and progressive dementia from cerebrovascular accidental. Acquired valvular heart disease, especially aortic insufficiency has been described.

Question 37

What is the treatment of antiphospholipid syndrome including the INR goal and duration?

Answer 37

Warfain is prescribed in doses sufficient to yield international normalized ratio (INR) values close to 3 and will need to be taken for life. Low-dose aspirin and subcutaneous heparin have been used in pregnant women to prevent fetal loss

Question 38

How do you treat antiphospholipid syndrome in pregnancy?

Answer 38

Low-dose aspirin and subcutaneous heparin have been used in pregnant women to prevent fetal loss

Question 39

What are the symptoms of Raynauds?

Answer 39

pallor, cyanosis, erythema accompanied by pain and numbness in the hands or feet.

Question 40

What is a common precipitating factor for Raynauds?

Answer 40

Cold

Question 41

What is the treatment of Raynauds?

Answer 41

Smoking cessation Wearing gloves Biofeedback 2% nitrol paste Antihypertensive agents ( Prazosin or Ca+ ch blockers) Stellate ganglion block, digital nerve block or surgical digital sympathectomy if ischemia is severe.

Question 42

What is the gender, age at onset, symptoms, precipitating factors of primary Raynaud disease?

Answer 42

``` Females are usually affected Onset is at menarche Usually all digits are involved Attacks are very frequent Severity of symptoms is mild to moderate They can be precipitated by emotional stress Digital ulceration and finger edema are rare, as is periungual erythema Livedo reticularis is frequent ```

Question 43

What is the gender, age at onset, symptoms, precipitating factors of secondary Raynaud disease?

Answer 43

Both male and females are affected Mid 20s of later Beings in a single digits and attacks are usually infrequent (0-5 a day) It is moderate to severe Not precipitated by emotional stress Digital ulceration, finger edema and periungual erythema are frequent Livedo reticularis is un common It is caused by chemotherapeutic agents, toxins, vibration induced injuries, vascular occlusive disorders, CT disease or increased blood viscosity, cold agglutinin and cryglobulinemia.

Question 44

What is criteria needed for the diagnosis of Scleroderma?

Answer 44

One major criterion or two or more minor criteria needs to be present. Major criterion: symmetric induration of the skin of the fingers and the skin proximal to metatarsophalangeal or metatarsophalangeal joints Minor criterion: sclerodactyly, digital pitting scars or loss of substance from the finger pad and bibasilar pulmonary fibrosis.

Question 45

What are the clinical manifestations affecting the skin in scleroderma?

Answer 45

Risk for development of rapidly progressive acral and trunk skin thickening and early visceral abnormalities. Raynaud phenomenon occurs in almost all pts.

Question 46

What are the clinical manifestations affecting the joints in scleroderma?

Answer 46

Non deforming symmetric polyarthritis similar to rheumatoid arthritis. Pts can have both articular erosions and nonarticular bony resorptive changes in ribs, mandible, radius, ulna and distal phalangeal tufts which are unique to systemic sclerosis.

Question 47

What are the clinical manifestations affecting the tendons in scleroderma?

Answer 47

Up to 60% of pts have “leathery” crepitation of the tendons of the wrist

Question 48

What are the clinical manifestations affecting the cardiopulmonary systems in scleroderma?

Answer 48

Considerable decrease in diffusing capacity present with a normal radiography. Diffuse interstitial fibrosis occurs in 70% of pts and is the most common pulmonary abnormality. Pleuritis is very rare. Cardiac abnormalities in 70% of pts. Pulmonary hypertension with cor pulmonale is a serious potential problem. But pulmonary hypertension by itself is more common in pts with CREST variant.

Question 49

What is esophageal involvement and Tx in scleroderma?

Answer 49

Esophageal dysfunction is the most frequent GI abnormalities and is asymptomatic. Lower esophageal sphincter incompetence with acid reflux may produce esophageal strictures or ulcers. Tx: Medications to reduce acid production. Reduced motility: Metoclopramide, cisapride or erthromycine

Question 50

What is small bowel hypomotility and Tx in scleroderma?

Answer 50

Small bowel hypomotility may be associated with pseudo-obstruction, bowel dilatation, bacterial overgrowth and malabsorption Tx: Tertracycline. Promotility agents are less effective

Question 51

What is renal involvement and Tx in scleroderma?

Answer 51

Renal involvement may result in fulminant hypertension, renal failure and death if not treated aggressively. Tx: aggressive early antihypertensive therapy Renal involvement with hyperreninemia treatment is angiotensin-converting enzyme inhibitor

Question 52

What is the lab finding seen in Scleroderma and treatment?

Answer 52

Antinuclear antibodies positive Antitopoisomerase I Ab (Anti-Scl-70) found in 25% pts Anticentromere Abs 10-20% pts Tx: No remissive or curative therapy is available. Aggressive nutritional support and hyperalimentation for GI disease associated with systemic sclerosis.

Question 53

What are the characteristic findings of CREST?

Answer 53

``` Calcinosis cutis Raynaud phenomenon Esophageal dysmotility Sclerodactyly Telangiectasias ```

Question 54

Lung involvement is in what % of CREST pts?

Answer 54

70%

Question 55

When is the onset of Raynauds in CREST?

Answer 55

< 2 yrs

Question 56

What is the lab finding most commonly associated with CREST?

Answer 56

Anticentromere Ab present, Antiscleroderma-70 ab in 10% pts and increased incidence of piary biliary cirrhosis

Question 57

What is a aggravating factor for eosinophilic fasciitis?

Answer 57

Polyvinyl chloride disease, organic solvents jackhammer disease, silicosis and toxic oil syndrome

Question 58

What are the Sx for eosinophilic fasciitis?

Answer 58

Tight bound-down skin of the extremities, characteristically sparing the hands and feet. Peau d’orange skin changes can develop. Onset after vigorous exercise is common. Raynaud phenomenon does not occur and there is not visceral involvement. Flexion contractures and carpal tunnel syndrome can develop.

Question 59

What are the lab findings for eosinophilic fasciitis?

Answer 59

Peripheral eosinophilia, increased sedimentation rate and hypergammaglobulinemia

Question 60

What are the Dx for eosinophilic fasciitis?

Answer 60

Findings of inflammation and thickening o the fascia on deep fascial biopsy

Question 61

What are the Tx for eosinophilic fasciitis?

Answer 61

Prednisone (40mg/daily)

Question 62

What are the clinical manifestations and lab findings of polymyositis?

Answer 62

Inflamed myopathy characterized by proximal muscle weakness.

Question 63

What shows on the electromyogram seen in inflammatory myopathies?

Answer 63

It is characteristic but not diagnostic. | It shows decrease amplitude and increased spike frequency it is polyphasic and conduction speed is normal.

Question 64

What shows on the muscle biopsy findings seen in inflammatory myopathies?

Answer 64

Degeneration, necrosis and regeneration of myofibrils with lymphocytic and monocytic infiltrate in perivascular or interstitial distribution

Question 65

What is the treatment of polymyositis including dosage?

Answer 65

Prednisone (60mg daily) for 1-2months then dosage is reduced. In severe or steroid-resistant cases: azathioprine (1-2mg/kg daily) or methotrexate

Question 66

What are the presentation and lab findings seen in drug-induced myopathy?

Answer 66

Associated with colchicine mimics polymyositis. Muscle weakness and increased creatine kinase level.

Question 67

What are the drugs implicated in drug-induced myopathy?

Answer 67

``` Colchicine Statins Zidovudine D-penicillamine Hydroxychloroquine Heroin or cocaine Corticosteroids ```

Question 68

What are the causes of nongonococcal bacterial arthritis and the patients at risk?

Answer 68

It is caused by hematogenous spread of bacteria, direct inoculation (trauma), or extension of soft tissue infection with osteomyelitis into the joint space. Elderly or immunosuppressed pts. Pts with cancer, diabetes mellitus, chronic renal failure, liver disease, or sick cell anemia Pts with chronic inflammatory and degenerative arthritis

Question 69

What is the presentation of septic arthritis in a patient with arthritis?

Answer 69

Single joint flare that is out of proportion to the rest of their joint symptoms. There is possibility of infectious endocarditis, other septic joints or a disk space infection

Question 70

What is the most common pathogen involved in adults?

Answer 70

S. aureus

Question 71

What is the most common pathogen involved in sickle cells anemia?

Answer 71

Salmonella

Question 72

What is the most common pathogen involved in cat/dog bites?

Answer 72

Pseudomonas

Question 73

What is the most common pathogen involved in human bites?

Answer 73

Anaerobic infection

Question 74

What are the most common pathogens involved in IV drug users and the atypical joints that are involved?

Answer 74

IV drug users: Pseudomonas or Serratis @ sternoclavicular or sacroiliac joints

Question 75

What is the presentation of disseminated gonococcal arthritis syndrome?

Answer 75

Septic arthritis in younger, sexually active person. Fever, dermatitis and an inflammatory tenosynovitis. 50% have inflammatory arthritis (knee, wrist or ankle). Rash sometimes with pustules or hemorrhagic vesicles is common

Question 76

What is the treatment of gonococcal arthritis?

Answer 76

Later third generation cephalospsorin: ceftriaxone 1.0g daily and antichlamydial antibiotic.

Question 77

What are the clinical presentation, radiographic finding, and diagnostic testing of infected joint prostheses?

Answer 77

Clinical presentation: No fever, hard to detect. Return of pain and evidence of prosthetic loosening after some time. Radiographic finding: Lytic changes around the prosthesis. Negative bone scan. Diagnostic testing: Increased erythrocyte sedimentation rate. Aspiration of fluid from prosthetic joint to confirm infection.

Question 78

What are the organisms involved and symptoms of early versus late infected joint prostheses and know when these occur?

Answer 78

Before 6months after the replacement it is usually staph aureus and staph epidermidis. After 6months, it’s gram negative bacterial. Early infection: hard to detect and no fever. Late infection: return of pain and evidence of prosthetic loosening after some time

Question 79

What are the states where Lyme disease is endemic?

Answer 79

``` Connecticut Delaware Maryland Massachusetts New Jersey New York **Pennsylvania Rhode Island Minnesota Wisconsin California Nevada Oregon Utah ``` (NOT CALIFORNIA. HA. HAHA. HAHAHAHA)

Question 80

What are the symptoms occurring at each of the stages of Lyme disease?

Answer 80

Stage I: (several days to a month) Erythema chronicum migrans Flu like symptoms (fever, headache, malaise and adenopathy) Stage II (wks~months) Dissemination infection in the skin, MSK system, heart and nervous system Neurologic symptoms (Bell palsy, meningoencephalitis and sensory & motor radiculoneuritis) 15% Cardiac abnormalities including heart block (5% of pts) Arthritis (knees) with baker cysts 50% Stage III (several years) Arthritis that becomes chronic

Question 81

What are the diagnostic testing, results in patients previously treated with an antibiotic, and confirmatory testing used in Lyme disease?

Answer 81

Measure ab to spirochete via ELISA (other disease can be positive as well) so if ELISA is positive, confirm it with Western blot assay If patients are treated early with antibiotic, the results might never be positive

Question 82

What are the various treatments used in Lyme disease?

Answer 82

Early tx: Oral tetracycline or doxycycline or amoxicillin in children Pt w/ neurologic, cardiac and arthritic symptoms: add ceftriaxone

Question 83

What is the clinical presentation of poststreptococcal reactive arthritis?

Answer 83

It affects 2/3 of patients with rheumatic fever. Arthritis in large joints (knees, ankles, elbows and wrist). Arthritis may be migratory with each joint remaining inflamed for approx. 1 week. Repeated attacks may result in Jaccoud deformity (metacarpophalangeal joints are in ulnar deviation)

Question 84

What is the Tx of poststreptococcal reactive arthritis?

Answer 84

Joint symptoms without carditis may be treated with high-dose salicylates. Corticosteroids may be required if pts do not respond to salicylates.

Question 85

I like big butts and I can not lie

Answer 85

``` You other brothers can't deny That when a girl walks in with an itty bitty waist And a round thing in your face You get sprung, wanna pull out your tough 'Cause you notice that butt was stuffed Deep in the jeans she's wearing I'm hooked and I can't stop staring Oh baby, I wanna get with you And take your picture My homeboys tried to warn me But that butt you got makes me so horny ```