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1
Q

Characteristics of Spondyloarthropathies

A 
Inflammatory axial spine involvement
Asymmetrical peripheral arthritis
Enthesitis
Inflammatory eye disease
Mucocutaneous features
Negative RF
High frequency of HLA-B27 antibodies
Familial aggregation
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2
Q

Define Spondyloarthropathies

A

Group of inflammatory arthropathies that share distinctive clinical, radiographic, & genetic features

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3
Q

Types of Spondyloarthropathies

A

Ankylosing spondylitis
Reactive arthritis (Reiter’s syndrome)
Psoriatic arthritis
Enteropathic arthritis (Crohn’s & UC)

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4
Q

Define Ankylosing Spondylitis

A

Chronic inflammatory disease of the joints of the axial skeleton

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5
Q

Describe Ankylosing Spondylitis

A

Changes in SI joints & hips

Inflammation around enethesis

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6
Q

Extra-Articular Manifestations of Ankylosing Spondylitis

A

Anterior uveitis
Aortic valvular disease
Restricted chest expansion
Skin rashes

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7
Q

Diagnostic Features of Ankylosing Spondylitis

A

Insidious onset low back pain >3 months
Improves with exercise
Morning stiffness >30 minutes
Awakened by pain during 2nd half of the night
Alternating buttock or posterior thigh pain
Sites of enthesitis
Sacroiliitis on x-ray

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8
Q

Radiographic Changes in Ankylosing Spondylitis

A

Erosion & sclerosis of SI joints
Involvement of apophysial joints of the spine
Ossification of the annulus fibrosus
Calcification of the anterior & lateral spinal ligaments
Squaring & generalized demineralization of the vertebral bodies
“Bamboo spine”

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9
Q

Characteristics of Ankylosing Spondylitis

A

Male 20-40
Insidious onset
Chronic pain & stiffness of middle spine- referred to one buttock or back of thigh
Morning stiffness that improves with exercise

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10
Q

Criteria for Diagnosing Ankylosing Spondylitis

A

Limited lumbar motion
Low back pain >3 months
Reduced chest expansion
Bilateral grade 2-4 sacroillitis on x-ray
Unilateral grade 3-4 sacroiliitis on x-ray

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11
Q

Define Reactive Arthritis

A

Acute inflammation arthritis occurring 1-3 weeks after infectious event

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12
Q

Reactive Arthritis TRIAD

A

Arthritis
Urethritis (cervicitis)
Conjunctivitis

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13
Q

Complications of Reactive Arthritis

A

Acute anterior uveitis
Myocarditis
Fasciitis

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14
Q

Signs/Symptoms of Reiter’s Syndrome

A 
Arthritis
Enthesitis
Dactylitis
Dysuria
Pelvic pain
Conjunctivitis
Oral ulcers
Rashes
Nail changes
Genital lesions
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15
Q

Common Pathogens of Reactive Arthritis

A 
Shigella
Salmonella
Yersinia enterocololitica
Campylobacter
Chlamydia trachomatis
C. pneumoniae
Ureaplasma urealyticum
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16
Q

Define Psoriatic Arthritis (PsA)

A

Chronic inflammatory arthropathy in setting of psoriasis

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17
Q

Nail Changes in Psoriatic Arthritis (PsA)

A

Pitting
Dystrophy
Onycholysis

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18
Q

Clinical Manifestations of Psoriatic Arthritis (PsA)

A 
Inflammatory arthritis in DIPs
Asymmetric arthritis
Sausage digits
Onycholysis
No rheumatoid nodules
RF negative
Erosive arthritis without osteopenia
Sacroiliitis
Paravertebral ossification
Enthesopathy
Pencil & cup deformity
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19
Q

Treatment for Spondyloarthropathies

A 
NSAIDs
PT, stretching & exercise
Maintain good posture
Sulfasalazine
Methotrexate
TNF inhibitors: Remicade, Humira, Enbrel
Prevent eye complications
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20
Q

NSAIDs effective for

A

Inflammatory back pain
Spinal stiffness
Peripheral arthritis
Enthesopathy

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21
Q

NSAIDs more Effective in Spondyloarthropathies

A

Penylbutazone
Indomethacine
Diclofenac

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22
Q

Use DMARDs When?

A

Anti-inflammatory therapy insufficient
Progression of inflammatory axial disease noted
Active persistent polyarthritis
Uncontrolled extra-articular disease

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23
Q

Medications for Uncontrolled Extra-Articular Disease

A

TNF inhibitors
Sulfasalazine
Methotrexate

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24
Q

Polymyalgia Rheumatica Characterized by

A

Aching & stiffness in the neck, shoulder & pelvic girdles

25
Epidemiology of Polymyalgia Rheumatica
Females > Males | Higher incidence at higher latitudes
26
Etiology of Polymyalgia Rheumatica
Polygenic Multiple environmental & genetic factors Possible viruses: adenovirus, RSV, parvovirus, parainfluenza Possible bacteria: mycoplasma, chlamydia pneumoniae
27
Clinical Manifestations of Polymyalgia Rheumatica
Persistent pain >1 month Aching & morning stiffness in neck, shoulders, & pelvis lasting 30 minutes Bilateral discomfort: interferes with ADLs
28
Systemic Signs of Polymyalgia Rheumatica
Fever Malaise/fatigue Anorexia, weight loss
29
Distal Manifestations of Polymyalgia Rheumatica
Nonerosive, self-limiting, asymmetric arthritis Carpal tunnel syndrome Distal extremity swelling & pitting edema
30
Labs for Polymyalgia Rheumatica
``` ESR >40 CRP Modest anemia Mildly abnormal LFTs RF & ANA negative CK & CPK normal ```
31
Differential Diagnosis for Polymyalgia Rheumatica
``` SLE RA Polymyositis Fibromyalgia Late-onset spondyloarthropathy Malignancy Infection ```
32
Things to Look for in SLE vs. PMR
``` Pleuritis Pericarditis Leukopenia Thrombocytopenia Anti-dsDNA antibodies Anti-ENA antibodies ```
33
Things to Look for in RA vs. PMR
Small joints of hands/feet Partially responsive to steroids Considerable overlap with PMR & seronegative RA
34
Things to Look for in Polymyositis vs. PMR
``` Symmetric proximal muscle weakness Pain not prominent Elevated CK, Alk phos. Abnormal EMG Myositis on muscle biopsy ```
35
Types of Malignancies That Would Present like EMR
Solid: kidney, ovary, stomach Heme: myeloma, primary amyloidosis
36
Infection to Rule out to Diagnose PMR
Bacterial endocarditis
37
Treatment of Polymyositis Rheumatica
Steroids | Trial of NSAIDs
38
Course of Polymyositis Rheumatica
Complete/nearly complete resolution of symptoms in a few days Relapses do occur Follow ESR or CRP Treat for 1-2 years Watch for steroid SE Methotrexate in refractory cases Methylprenisolone: similar efficacy, fewer SE
39
Define Giant Cell Arteritis (GCA)
Chronic vasculitis of medium & large vessels
40
Pathophysiology of Giant Cell Arteritis (GCA)
Vasculitis of extra-cranial branches of aorta, spares intracranial branches Transmural inflammation -> intimal hyperplasia -> luminal occlusion
41
Etiology of Giant Cell Arteritis (GCA)
Influenced by multiple genetic & environmental factors No evidence of autoantibodies Cellular immune response
42
Presentation of Giant Cell Arteritis (GCA)
``` Generally insidious onset Headache Fever Malaise Weight loss Anorexia ```
43
Symptoms of Giant Cell Arteritis (GCA)
``` Headache Jaw claudication Transient visual symptoms Fixed visual symptoms CNS abnormalities Dysphagia Tongue claudication Limb claudication ```
44
Signs of Giant Cell Arteritis (GCA)
``` Weight loss or anorexia Decreased temporal artery pulsations Fever Artery tenderness Erythematous or swollen scalp arteries Large artery bruits Fundoscopic abnormalities ```
45
Complications of Giant Cell Arteritis (GCA)
Blindness Aortic aneurysms Stroke
46
Lab Findings in Giant Cell Arteritis (GCA)
ESR >50 Mild-moderate anemia of chronic disease Elevated LFTs
47
Diagnosis of Giant Cell Arteritis (GCA)
Biopsy MRI/MRA Other options: arteriography, US, PET
48
Treatment of Giant Cell Arteritis (GCA)
Glucocorticoids Vision loss: IV pulse methylprednisolone Low dose aspirin
49
Define Fibromyalgia Syndrome (FMS)
Clinical syndrome characterized by widespread muscular pain, fatigue, & muscle tenderness
50
Cause of Fibromyalgia Syndrome
Abnormal sensory processing in the CNS Possible genetic role Triggered by physical, emotional, or environmental stressors
51
Symptoms of Fibromyalgia Syndrome
``` Poor sleep Headaches IBS Cognitive & memory problems Numbness & tingling Irritable bladder TMJ disorder Restless leg syndrome Dry eyes & mouth Morning stiffness Anxiety & depression ```
52
Who is more likely to develop fibromyalgia?
``` RA patients SLE patients Ankylosing spondylitis Family history Associations: lyme disease, OSA, sleep deprivation ```
53
Diagnosis of Fibromyalgia
4 symptoms Generalized, chronic pain >3 months affecting the axial, upper & lower segments, & left & right sides of the body
54
Shared Features of Fibromyalgia & Depression
``` Strong genetic predisposition Similar co-morbidity Similar sleep disturbances Similar cognitive disturbances Orthostatic features ANS dysfunction Childhood abuse, stress Can be debilitating Imaging studies Neuroendocrine studies ```
55
Diagnosis of Fibromyalgia
``` X-rays: normal Labs: normal Nuclear medicine & CT scans: normal ESR, CRP: normal Distinguish from RA, SLE, PMR & hypothyroidism ```
56
Treatment of Fibromyalgia
``` Medication trial CBT, counseling Physical rehab TCAs: amitriptyline, cyclobenzaprine Anticonvulsants: pregabalin, gabapentin SNRIs: duloxetine, milnacipran Diazepam & clonazepam 2nd line for restless leg syndrome & severe sleep disturbance Therapeutic massage Myofascial release therapy Acupuncture ```
57
Patient Self-Management of Fibromyalgia
``` Schedule time to relax, meditate Establish routine for going to bed and waking up Aerobic exercise on daily basis Self-education Support group CBT ```
58
Physical Medicine or Rehabilitation for Fibromyalgia
``` Avoid inactivity Analgesic advice & non-pharmacologic treatment CV fitness Stretching, strengthening OT Work rehab Ergonomics ```
59
Mental Health for Fibromyalgia
Psychopharmacology Counseling CBT

Rheumatology (8 decks)

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