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Summer FDTN Exam 4 > Rheum 1 > Flashcards

Rheum 1 Flashcards

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1
Q

What is gout

A

metabolic disease with altered purine metabolism causing sodium urate crystal deposits in synovial fluid
Commonly familial
M >30
BUT- chronic uricemia does not mean you will get gout!

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2
Q

RF for gout are

A 
Male 
age >30 
genetics
obesity 
alcohol 
high purine diet 
high fructose/sucrose diet
HTN
CKD
Thiazides/loop diuretics
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3
Q

Etiology of gout is

A

Abnormal deposits of urate cause recurring acute arthritis attacks

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4
Q

What are the types of gout

A

Primary: occurs 2/2 genetic alterations in how kidneys process urate (under excreter)
Secondary: occurs 2/2 acquired causes of hyperuricemia (on meds, myeloproliferative Dz, hypothyroidism, alcohol abuse)

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5
Q

How does acute gout present

A

Acute onset intense pain, commonly at nigh t
Swollen, tender joint w/ red, warm overlying skin
Involves first MTP (MC), feet, ankles, and knees

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6
Q

What is Podagra

A

Gout of the first MTP

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7
Q

How does chronic gout present

A

Tophaceous gout after 10 or more years
Urate deposits (tophi) in subQ tissue, bone, cartilage, and joints
Surrounded by granulomatous inflammation
Can lead to deforming polyarthritis

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8
Q

How do you diagnose gout

A

Serum uric acid >6.8mg is supportive (- does not r/o gout)
Synovial fluid showing monosodium urate crystals (diagnostic)
Imaging

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9
Q

What do monosodium urate crystals look like

A

needle-like
rod shaped
negatively birefringement crystals

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10
Q

How can you tell the difference between gout and septic arthritis

A

Septic arthritis has way more WBC than gout

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11
Q

What are imaging findings in gout

A

New: no findings
Established: small, punched out erosions w/ overhanging edges

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12
Q

How do you treat an acute gout attack

A

Elevate, rest*
Decrease purine and alcohol intake (not suddenly)
Indomethacin 50mg (5-10d, until Sx gone)- or Naproxen 500
Colchicine (if attack w/in 24-36 hours)
Oral/IV corticosteroids, or injection (if 100% positive it is NOT a septic joint)

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13
Q

How do you prophylactically treat gout

A

Lose weight, avoid alcohol, restrict purine intake
Avoid thiazides, loop diuretics, Niacin, and low dose aspirin
Colchicine (prevent further attacks by lowering urate)
Xanthine oxidase inhibitors (Allopurinon)
Uricosuric agents (Probenecid)- increase uric acid excretion by blocking kidney reabsorption

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14
Q

Side effects of Xanthine oxidase inhibitors

A

Precipitate acute attack, rash leading to TEN

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15
Q

Dietary modifications to treat gout include

A

limit all meats (organ meat and seafood)
Cut back on fat
Limit alcohol, esp beer
Limit high fructose corn syrup
Drink plenty of fluids (8-16 cups of water)

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16
Q

High purine foods are

A 
all meats 
meat extracts 
yeast 
beer
beans
peas 
lentils, oatmeal, spinach, asparagus, cauliflower, mushrooms 
-AKA foods with many nuclei and growing
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17
Q

Complications of gout include

A

Nephrolithiasis

Chronic urate nephropathy

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18
Q

What is pseudogout

A

Calcium pyrophosphate dihydrate disease affecting peripheral joints with deposits of calcium pyrophosphate
Acute attacks mimic gout
Worse with ate (>60)
MC in knee, wrist, elbow

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19
Q

What are chondrocalcinosis

A

Calcium pyrophosphate deposits in cartilage

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20
Q

How does pseudogout present

A

Recurrent, abrupt onset of joint pain

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21
Q

How do you diagnose pseudogout

A

X-Ray shows fine, linear densities in articular tissues

Joint aspiration shows calcium pyrophosphate crystals- rhomboid shape crystals w/ + birefringement with light microscopy

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22
Q

How do you treat pseudogout

A

NSAIDs for acute attacks
Colchicine w/ prophylaxis
Intra-articular steroid injection

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23
Q

What is OA

A

MC joint disease, related to age
Occurs in weight bearing joints of knee (65+ y/o)
<50: M>W
>50: W>M

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24
Q

RF for OA are

A 
Age 
Women 
Excess weight 
Contact sports 
Bending or carrying occupation 
Injury 
Developmental deformities 
Low vitamin D/calcium intake
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25
What is the pathophys of OA
``` Progressive cartilage degeneration Reactive hypertrophy of bone Loss of articular bone space, joint destruction Osteophytes, Herbeden and Bouchard nodes Sclerosis of subchondral bone (minimal inflammation) ```
26
How does OA present
Insidious onset joint pain, worse w/ activity, better with rest <30 min morning stiffness Decreased ROM Crepitus Varus knees Fingers, wrists, hips, knees, and spine affected
27
How can you tell between OA and RA
OA there are no systemic symptoms!
28
How do you diagnose OA
*X-Ray- Asymmetric narrowing of joint space, osteophytes, thick subchondral bone, bony cysts Normal labs, synovial fluid non-inflammatory
29
How do you treat OA non-pharm
``` Weight loss aquatic, cardio or resistance exercise heat and cold PT OT bracing canes ```
30
How do you treat OA pharm
APAP (good for old people at risk for ADE of NSAIDs Oral NSAIDs Topical NSAIDs (diclofenac) Topical capsaicin (hand) Intra-articular steroid injections (4xyr) Intra-articular sodium hyaluronate injection (knee)
31
How do you treat OA surgically
Arthroscopy (go in and clean joint) | joint replacement
32
What is RA
Chronic, progressive inflammatory disease with synovitis of multiple joints F>M Peak 40-50 women, 60-80 men
33
Untreated RA causes
joint destruction, disability, and shorter life expectancy | So... treat EARLY and AGGRESSIVELY
34
What is the etiology of RA
Unknown! maybe due to multiple genetic susceptibilities
35
What is the pathophys of RA
Chronic synovitis causing erosion or cartilage, bone, ligaments, and tendons
36
How does RA present
>30 min morning stiffness Insidious onset symmetric swelling of multiple joints w/ ttp and pain Symmetric polyarthritis of small joints or hands and feet (PIP, MCP, wristsm knees, ankles, MTP) Synovial cysts tendon rupture entrapment
37
RA spares
The spine and SI joints | does not spare the neck
38
Extra-articular manifestations of RA are
``` SubQ nodules Ocular Sx Mouth dryness interstitial lung dz pleural effusion pericarditis vasculitis ```
39
Common RA complaints include
``` Pain turning door knob- opening jars- buttoning shirts- in ball of foot Widening of forefoot neck pain and stiffness constitutional Sx ```
40
How do you diagnose RA
**X-Rays (most specific) **Anti-CP antibodies (most specific blood test)- cyclic citrullinated peptides Rheumatoid factor (- in many) ANA + ESR, CRP elevated Anemia inflamed joint fluid +/- septic arthritis
41
RA x-rays show
early: articular demineralization and soft tissue swelling joint erosions joint space narrowing
42
2010 RA diagnostic criteria includes
and type of joints involved Serology (RF or anti-CCP) Acute phase reactants (ESR/CRP) Sx duration (MIN 6 wks)
43
RA treatment goals are
Reduce inflammation, pain Preserve function Prevent deformity
44
How do you treat RA
1. DMARDs as soon as Dx is confirmed; they take a while to work so in the meantime, also use 2. NSAIDs, PO low dose Prednisone, Intra-articular corticosteroid (max 4xyr)
45
What are the conventional DMARDs
Methotrexate Sulfasalazine Leflunomide Hydroxychloroquin
46
What are the biologic DMARDs
- Tofacitinib (JAK inhibitor) - TNF-a inhibitor: Eternacept, Infliximab, Adalimumab, Golimumab, Certolizumab - Anakinra (IL-1 inhibitor) - Tocilizumab (IL-6 inhibitor) - Abatacept (T cell costimulation blocker) - Rituximab (anti-CD20 B cell depleting MAB)
47
When choosing a DMARD, consider
``` CBC, Cr, LFT, ESR, CRP Hep B/C screening Opthalmologic screening Latent TB test CXR ```
48
Are NSAIDs magic
No- they can provide Sx relief, but do NOT prevent erosions or alter disease progression they are NOT dmards and should not be used alone! only WITH dmards
49
Conventional RA treatment (1st line) is
Methotrexate! Takes 2-6 weeks Suppresses bone marrow= low WBC and platelets *Teratogenic*
50
ADE of methotrexate are
GI upset Stomatitis Hepatotoxic w/ cumulative dosing
51
Second line RA Tx used with Methotrexate or alone if Metho doesn't work is
Sulfasalazine (avoid if ASA sensitivity) | Leflunomide (carcinogen, teratogen)
52
ADE of second line RA drugs are
Sulfasalazine: Neutropenia, thrombocytopenia, hemolysis if w/ G6PD deficiency Leflunomide: GI upset, rash, alopecia, hepatotoxic, weight loss
53
What antimalarial is used to Tx RA
Hydroxychloroquin- MC with Sulfasalazine or Methotrexate | **NEED yearly eye exams!**
54
ADE of Hydroxychloroquin are
Pigmentary retinitis- so get YEARLY eye exams!
55
Are biologics good drugs
``` Well tolerated usually Increased risk of infection NEED to screen for TB before giving +/- causes malignancy CAUTION with HF costs 10K/yr ```
56
What is the prognosis of RA (after years of Dz)
Chronic systemic inflammation Ulnar deviation of fingers Boutonniere deformity (hyperextend dip, flex pip Swan neck deformity (flex dip, extend pip) Valgus knees Volar sublux of MCP Mortality associated w/ RA 2/2 CVD
57
What are subtypes of systemic juvenile idiopathic arthritis
``` Systemic Polyarthritis Oligoarthritis Enthesitis Psoriatic -they are all autoimmune ```
58
How does sJIA present
``` Fever Arthritis (mono, oligo, or poly) Rash LAD ANA & RF rarely see ```
59
How do you diagnose sJIA
``` Diagnosis of exclusion! *Intermittent daily fevers and arthritis Fever 2+ weeks Arthritis 6+ weeks Onset prior to 16 y/o ```
60
How do you manage sJIA
Difficult remission.. Send to peds rheumatology! | PT, OT, Dietician, support groups
61
What are seronegative spondyloarthropathies
Ankylosing spondylitis, psoriatic arthritis, reactive arthritis M>W <40 inflammatory arthritis of spine and SI joints Asymmetric No antibodies in serum Associated with HLA-B27 gene
62
What is ankylosing spondylitis
Chronic inflammatory disease of joints of axial skeleton | M>W, teens-late 20's
63
How does ankylosing spondylitis present
Gradual, intermittent back pain worse in morning (after rest) better with activity radiates to buttocks
64
How does ankylosing spondylitis present
``` Progressive stiffening of spine Sx start at low back, move towards head Flattening of lumbar lordosis Exaggeration of thoracic kyphosis Decreased chest expansion Total spine fusion Peripheral joint arthritis Swelling of achilles tendon and plantar fasciitis (enthesopathy) Anterior uveitis Cardiac,pulmonary, GI Sx ```
65
How do yuo diagnose ankylosing spondylitis
``` Elevated ESR* Negatie RF and anti-CCP Mild anemia on CBC HLA B27 + (92% of white, 50% of black) Imaging ```
66
What are imaging results of ankylosing spondylitis
Early: SI joint erosion, sclerosis (b/l and symmetric) | Bamboo spine: vertebral bodies fuse together
67
How do you treat ankylosing spondylitis
1** NSAIDs TNF inhibitors Corticosteroids (can cause steopenia, not great) Sulfasalazine Surgery: Fracture stabilization or joint replacement PT Swimming
68
How does psoriatic arthritis present
``` Skin psoriasis before arthritis (usually) Nail pitting Onycholysis Asymmetric SI joint involvement Sausage digits ```
69
How do you diagnose Psoriatic arthritis
Elevated ESR RF negative Imaging (helps differentiate it from others!)
70
What imaging findings are present with psoriatic arthritis
Erosion and destruction of bone Osteolysis Pencil in a cup deformity Asymmetric sacroilitis
71
How do you treat psoriatic arthritis
1* NSAIDs 2: Methotrexate (if NSAIDs don't work) PDE4 inhibitor (not if erosive dz) Biologics: TNF-a inhibitors, MAB
72
What Tx do you avoid in psoriatic arthritis
Corticosteroids | They are less effective, and tapering can trigger a flare
73
What is Reactuve arthritis (Reiter syndrome)
MC in young men Usually 1-4 weeks after bacterial GU or GI infection (diarrhea, Chlamydia t, Salmonella, Shigella) HLA B27 +
74
How does Reactive arthritis present
Asymmetric oligoarthritis of LE (knee, ankle) Fever, weight loss Extra-articular: Urethritis, conjunctivitis, uveitis, balanitis, stomatitis, Keratoderms blennorrhagicum**, cardiac Sx
75
How do you diagnose reactive arthritis
``` Synovial fluid is sterile, no cultures! No specific XR findings Stool cultures (if diarrhea) Chlamydia testing +/-: CBC, ESR/CRP, renal/liver tests, UA, HLA B27, RF, anti-CCP ```
76
How do you treat reactive arthritis
NSAIDs Antibiotics for STI are somewhat prophylactic Sulfasalazine, Methotrexate, TNF inhibitors
77
What is the prognosis of reactive arthritis
most SF signs of reactive arthritis clear in days-weeks | Arthritis can last for months
78
Think of this triad for Reiters/reactive arthritis***
Can't SEE, can't PEE, can't CLIMB A TREE Uveitis/conjunctivitis Urethritis Arthritis

Summer FDTN Exam 4 (14 decks)

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