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Flashcards in Polymyalgia Fibromyalgia HLAB27 Deck (14)
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1

Spondyloarthropathies
-definition
-characterized by
-diseases included in this

Definition
-a group of inflammatory arthropathies that share distinctive clinical, radiographic, and genetic features

Characterized by
-inflammatory axial spine involvement
-asymmetrical peripheral arthritis
-enthesitis
-inflammatory eye disease
-mucocutaneous features
-negative rheumatoid factor
-high frequency of HLA B27 antibodies
-familial aggregation

Diseases
-ankylosing spondylitis
-reactive arthritis
-psoriatic arthritis
-enteropathic arthritis (crohns and UC)

2

Ankylosing Spondylitis
-what is this
-high incidence where
-MC in who
-diagnostic features
-first sx

What
-chronic inflammatory disease of the joints of the axial skeleton
-changes are seen in sacroiliac joints and hips, inflammation around enthesis (where tendons and ligaments attach to bones), and extra-articular manifestations (anterior uveitis, aortic valvular disease, restricted chest expansion)

Higher incidence at higher latitudes, scandinavian countries

MC in men aged 20-40

Diagnostic features
-insidious onset low back pain for greater than 3 months
-improves with EXERCISE (not rest)***
-morning stiffness more than 30 min
-awakened by pain during the 2nd half of the night
-alternating buttock or posterior thigh pain
-sites of enthesitis
-sacroiliitis on xray

First sx are typically chronic pain and stiffness in the middle spine associated with referred to one or the other buttock or the back of the thigh

3

Ankylosing spondylitis
-extra-articular manifestations
-imaging and what is seen
-Dx criteria

Extra-articular manifestations
-skin rashes
-eye inflammation- especially uveitis
-lung involvement
-cardiac involvement- with aortic valve disease

Imaging
-**radiographs are the single most important imaging technique for dx and follow up**
-early changes at the sacroiliac joints: erosion and sclerosis
-involvement of the apophysial joints of the spine
-ossification of the annulus fibrosus
-clacification of the anterior and lateral spinal ligaments
-squaring and generalized demineralization of the vertebral bodies (bamboo spine)

Dx criteria
-definite if: criteria 4 or 5, plus 1, 2, or 3
1. limited lumbar motion
2. low back pain for more than 3 months- improved with exercise, not relieved by rest
3. reduced chest expansion
4. bilateral grade 2-4 sacroiliitis on xray
5. unilateral grade 3-4 sacroiliitis on xray

4

Reactive Arthritis
-what is this
-triad of sx
-what is Reiter's?
-course
-complications
-common pathogens

What
-acute inflammatory arthritis occurring 1-3 weeks after infectious event (GU, GI, idiopathic)

Triad
-arthritis + urethritis (cervicitis) + conjunctivitis

Reiters
-post-venereal onset (MC in males)

Course
- usually self limiting (less than 6 months), can become chronic without tx

Complications
-Acute anterior uveitis, myocarditis, fasciitis

Common pathogens
-Enteric: shigella, salmonella, yersinia enterocololitica, campylobacter
-Urogenital: chlamydia trachomatis, C. pneumoniae

5

Reiter's Syndrome
-MS signs and sx
-Extra-articular signs and sx

MS
-arthritis
-enthesitis (heel tendonitis)
-dactylitis

Extraarticular
-GU: dysuria and pelvic pain
-conjunctivitis
-oral ulcers (tongue lesions, palate erosion)
-rashes (pustules, keratoderma blenorrhagica)
-nail changes (onycholysis)
-genital lesions

6

Psoriatic Arthritis
-What is this
-etiology
-course
-clinical characteristics
-what is seen on xray?

What
-chronic inflammatory arthropathy in setting of psoriasis

Etiology
-unclear!

Course
-chronic, destructive arthritis in 30-50%

Clinical Characteristics
-inflammatory arthritis in DIPs
-asymmetric arthritis
-sausage digits
-nail pitting (onycholysis)
-no rheumatoid nodules
-RF test negative
-erosive arthritis without osteopenia
-sacroiliitis, often asymptomatic
-paravertebral ossification
-enthesopathy

Xray
-pencil and cup deformitiy

7

Spondyloarthropathies
-Tx
-when to consider DMARDs

Tx
-NSAIDs for Sx (no evidence that NSAIDs inhibit disease progression): naproxen, sulindac, indomethacin
-PT, stretching, exercises to preserve spine and joint function
-sulfasalazine and methotrexate found to be beneficial
-Anti-TNF (TNF inhibitors): Remicade, Humira, Enbrel)
-prevent eye problems with early recognition and tx

Consider DMARDs when
-antiinflammatory therapy is insufficient to control sx
-progression of inflammatory axial disease noted
-active persistent polyarthritis
-uncontrolled extra-articular disease

8

Polymyalgia Rheumatica
-What
-characterized by
-MC in what age and gender
-related to what condition
-clinical manifestations

What
-inflammatory condition of unknown etiology (probably polygenic, possible infectious triggers)

Characterized by
-aching and stiffness in the shoulder and pelvic girdles and neck

MC in people older than 50, females more than males

related to
-giant cell arteritis

Clinical manifestations
-persistent pain (more than 1 month): aching and morning stiffness in neck, shoulder, and pelvic girdles lasting 30 min
-discomfort is bilateral*, worse with movement*, and usually interferes with ADLs
-shoulder pain is presenting sign, hips and neck, usually radiates distally
-systemic signs (seen in 1/3 of pts): fever, malaise/fatigue, anorexia, weight loss
-distal manifestations (seen is 1/2 pts): nonerosive, self-limiting asymmetric* peripheral arthritis (knee, wrist), carpal tunnel syndrome, distal extremity swelling and pitting edema over dorsum of hands and wrists, ankles and feet

9

Polymyalgia rheumatica
-labs
-tx

Labs
-ESR greater than 40 mm/hr
-CRP (may be more sensitive)
-anemia of chronic disease
-mildly abnormal LFTs

Tx
-corticosteroids are DOC (dont forget to taper)
-trial of NSAIDs for 2-4 weeks if mild
-should see a complete or nearly complete resolution of sx in a few days, but relapses do occur
-tx for 1-2 years is often required

10

Giant Cell Arteritis
-what is this
-MC age and gender
-cause
-Presentation and sx

What
-chronic vasculitis of medium and large vessels

MC in women around 70-80

Cause
-genetic and environmental factors, no evidence of autoantibodies
-cellular immune response involving T cells, APCs, mfgs

Presentation
-onset is usually gradual, but may be abrupt
-HA (MC sx)
-syndrome of systemic inflammation: fever, malaise, weight loss, anorexia
-jaw claudication
-transient visual sx
-fixed visual sx
-CNS abnormalities
-swallowing claudication/dysphagia
-tongue claudication
-decreased temporal artery pulsations
-artery tenderness, erythema, or swelling

11

Giant Cell Arteritis
-complications
-lab findings
-Dx
-Tx

Complications
-blindness
-aortic aneurysms
-stroke

Lab findings
-ESR greater than 50 (normal ESR does not rule OUT GCA)
-anemia of chronic disease
-elevated LFTs

Dx
-Bx!!!! (DO NOT DELAY TX FOR BX)
-MRI/MRA may be used to dx large vessel GCA

Tx
-***glucocorticoids are the established tx (dont forget to taper)
-IV methylprednisolone of vision loss present
-anti-platelet agents reduce ischemic events (low dose aspirin recommended)

12

Fibromyalgia Syndrome (FMS)
-What is this?
-cause
-sx

What
-a clinical syndrome characterized by widespread muscular pain (usually chronic), fatigue and muscle tenderness. (everything hurts)
-NOT an inflammatory condition

Cause
-abnormal sensory processing in the central nervous system
-unknown cause, some pts have abnormally high levels of substance P (Substance P is important in transmission and amplification of pain signals to and from brain)
-familial tendency suggests genetic role

Sx
-extreme sensitivity to pain and other unpleasant sensations
-poor sleep (almost always)
-HA
-IBS
-cognitive and memory problems
-numbness and tingling in fingers and toes
-irritable bladder
-temporalmadibular joint disorder
-restless leg syndrome
-dry eyes and dry mouth
-morning stiffness
-anxiety and depression
--sx including pain may wax and wane over time

13

FMS
-MC in who
-dx
-commonly occurs with what other dx?

MC in middle aged women

Dx
-xrays, blood tests, specialized scans, bx are all NORMAL
-A plus (B or C) and explained by no other condition=FMS
A. generalized, chronic pain (more than 3 months) affecting the axial, plus upper and lower segments, plus left and right side of the body
B. 11 of 18 reproducible tender points
C. at least four of the following:
-generalized fatigue
-HA
-Sleep disturbance
-neuropsychiatric complaints
-numbness, tingling sensations
-IBS

Commonly occurs with a mood disorder (depression)

14

FMS
-Tx

Tx
-referral to sleep clinic, psychiatry, etc.
-education
-assess stressors, level of fitness...
-medication trial (antidepressants, anticonvulsants)
-CBT, counseling
-physical rehab, therapeutic massage, myofascial release therapy, acupuncture, support groups
-no definitive treatment cure :( (but it can be managed)

-amitriptyline (TCA)
-other TCA, SSRI, SNRI, anti seizure meds
-Lyrica (anticonvulsant)
-jdont give opioids

*You're going to be doing this with someone above your paygrade