rheum Flashcards
(86 cards)
1
Q
initial clin charac. of arthritis
A
-Acute duration (presenting within hours to
days) or chronic (persists for weeks or longer)
•Number of joints involved: monoarticular,
oligorarticular (2-4), or polyarticular (+5 joints)
-Symmetric or Asymmetric; Additive or
Migratory
•Accurate delineation of involved joints
•Inflammatory or Non-inflammatory
2
Q
monoarthritis: bacterial inf. of joint space
1. acute
(+ fever, *rapid! dx quickly)
2. chronic
(both can be polyarthritis via hematogenous spread)
A
- staph aureus, GABHS, strep pneumo, G- orgs, gonococcal (prec. by migratory tenosynovitis or oligoarthritis assoc. w/ charac. skin lesions)
chronic:
lyme disease (other spirochetes), mycobacterial (TB), fungal, viral
3
Q
monoarthritis: crystal-induced arthritis (painful!)
A
gout: monosodium urate crystals (hyperuricemia)in articular space–>rel. cytokines
pseudogout: calcium pyrophasphate dihydrate crystals (older, knee/wrist)
chronic:
calcium apatite crystals
4
Q
other common causes of acute monoarthritis
A
trauma hemearthrosis -older-falls, athletes -coagulopathies, anticoags. -dx: arthrocentesis
5
Q
chronic monoarticular pres. of oligoarthritis/polyarthritis
A
spondyloarthropathy (affect spine and joints) gout/pseudogout ulcerative arthritis rheumatoid arthritis (mostly poly) lupus, other syst. AI dis (mostly poly) foreign body pigment synovitis (tumor)
6
Q
psoriatic infection
A
commonly unilateral
7
Q
rheumatoid
A
symmetrical/bilateral
small jts in hands PIPs, MCPs, DIPs*rare
pas young women 20-30
8
Q
migratory polyarthritis
A
rheumatic fever, post streptococcal, GC (can start as tenosynovitis)
9
Q
osteoarthritis
A
around 50-70 yo (onset)
presents as unilateral painful hip, non-inflammatory,
10
Q
common ddx of acute polyarthritis >5 joints
A
acute viral inf. (parvovirus, influenza, chiquengunya) (+ fever)
early disseminated lyme disease
Hep B,C
rheumatoid arthritis (symm. PIPs) (y. women)
SLE
11
Q
uncommon ddx of acute polyarthritis
A
paraneoplastic polyarthritis
remitting seroneg. symm. polyarthritis w. pitting edema
acute sarcoidosis, (typ. w. erythema nodosum and hilar adenopathy)
adult: onset
still disease
secondary syphiilis
syst. AI diseases, vasculitides, whipple
12
Q
psoriatic arthritis
A
ask pt if have psoriasis
skin disease (elbows, knees, scalp) *can hide
acute, oligoarticular, asymmetrical
13
Q
SLE
A
AI, jt pain in young women, fever, malor rash (classic)
14
Q
palpable purpura
A
hemorrhagic
think vasculitis: inflamm. BVs, polyarthralgia (no inflamm), typ. LE, ulcerated
henochschonlein purpura: kids, abd pn, nephritis, hematopesia?
15
Q
GC infectious arthritis
A
pustule w/ arthritis
16
Q
reactive arthritis
A
had infection, reacted w. arthritis
“can’t see, can’t pee, can’t climb a tree”
diarrhea, urethritis, salmonella, w/ inflammatory arthritis
17
Q
think about septic joint w.
A
monoarticular arthritis
18
Q
Still disease
A
kids: acute polyarticular onset JRA, splenomegaly, fever, rheumocytosis, rash
adults: 20-30s, FUO 6 wks, 102-104 fever, typ. rash, neg labs, hepsplenmeg, look for inf. dis.? ca?
19
Q
inflammatory bowel–>arthritis
A
ulcerative colitis, Crohn's skin rash (erythema nodosum)
20
Q
neodosum - sign of something else, can pres. w/ polyarthritis
A
sarcoidosis IBD (pres. w. polyarthralgia) OTC preg follow strep, meds med rxn Sjogren's
21
Q
sarcoidosis
Loepren’s? syndrome
A
starts in lungs, get CXR acute: arthritis in ankles, rash whites diff than chronic dx. with CXR, bilat hilar adenopathy tx: steroids
22
Q
paraneoplastic arthritis
A
remote effects of ca
HLA
(SmCC–>sec PTH, ACTH)
see clubbing, esp. w/ smoker–>CT/CXR
23
Q
familial mediterranean fever
A
uncommon,
acute mono arthritis in knee/hip, acute abdominal
24
Q
synovial fluid
A
made by synoviocytes
plasma infiltrate
lubricant/cushion
viscoelastic
25
arthrocentesis
```
sampling synovial fluid, looks turbent if abnormal (classed)
clear is normal (or noninflamm: OA, trauma)
Class I (WBC 2000 WBC: inflammatory
gout, pseudogout, rheum, psoriatic, reactive, colitic, etc.
```
26
higher white count
Class II +
| more turbent-septic if pustular (or crystals), higher WBC
27
*septic joint*
v. turbent, > 80,000 WBC
| dirty yellow
28
red-sanguinous or
| seroussanguinous
coag., trauma, blood disorders (hemophilia)
| WBC: 200-2000
29
may get PCR if suspect
lyme, TB
30
cytology
rarely unless suspect malignancy
31
normal synovial fluid does NOT
clot
| no clotting factors can get into synovial fluid unless inflammation
32
synovium
"egg-like"
33
major comps of syn. fluid analyses
fluid clarity and color
det. cell count
exam. for crystals
obtain Cx
34
joint aspiration and injection (if not septic)
Perform Aspiration when septic arthritis is suspected
because synovial fluid cell count, Gram stain, and culture
are necessary to establish or exclude joint space infection
• Analysis diagnostic in crystalline arthritis
• Synovial fluid white cell count most reliable means of
distinguishing inflammatory from other forms of arthritis
• Injections with glucocorticoids are swiftest way to provide
relief to patients with inflamed joints
35
eburnation
loss of cartilage, deteriorates
-PIPs, DIPs, almost never MCPs (exc. 1st MCP), hips, knees, lumbar, cervical spine
can form osteophytes--
->can cause reticulopathy, pinched nerve, sciatica, radiculopathy
36
osteoarthritis
-A degenerative disorder with minimal articular
inflammation
•No systemic symptoms, no fevers, rashes
•Pain relieved by rest; brief morning stiffness (60 w. rheum)
•X-ray findings: narrowed joint space (loss of cartilage), sclerotic (lose cushion): looks whiter
(bone on bone, abn. stress) osteophytes, increased density subchondral
bone, bone cysts
37
osteoarthritis continued
• Absence of prominent constitutional symptoms
• Examination notable for increased bony prominence at
the joint margins, crepitus or a grating sensation upon
joint manipulation, and tenderness over the joint line
of the symptomatic joint
• Diagnosis supported by radiographic features of joint
space narrowing and spur (or osteophyte) formation
38
s/s osteoarthritis
* Joint pain that increases with activity
* Morning stiffness that is relatively brief and self limited
* Crepitus(a grating sensation with motion)
* Bony enlargement at the joint margin
* Tenderness to palpation over the joint
* Non-inflammatory synovial fluid (
39
risk factors osteoarthritis-primary
```
age
female
obesity
high bone mass
occupations req. physical labor
fam hx
```
40
risk factors osteoarthritis-secondary
```
joint sx
crystal arthritis (chondocalcinosis, gout)
inflam. arthritis (RA, septic)
acromegaly
hemochromatosis
hyperchromatosis
hyperPTH
hypermobility (Ehlers-Danlos)
trauma, stress
Pagets
```
41
lumbar canal stenosis can cause pseudoclaudication
pressure on nerve roots, not vascular problem
42
2 helpful labs in RA
| many presentation, labs are supportive
ID crytalloid joint
Positive Cx
*need to be able to interpret, do not "shot-gun" labs
43
rheumatoid factor
IgM, IgG
order lab, but cons: lots of other disease cause + (list)
bac. endo, sarcoidosis, Sjogrens, TB, pulm. fibrosis, leprosy, silicosis, polymyositis*, dermatomyositis, syphilis, asbestosis, scleroderma, Hep C*,B, Ca, ANCA-assoc. vasculitis*, polyarteritisnodosa*, viral*, primary biliary cirrhosis, parasite
44
parvovirus
polyarthralgias, can pres. w. + RF
45
+ RF: always screen for
Hep C
46
ANAs
anti-nuclear Abs, ab in pt serum binds to hum epi cell (Ag)-->secondary Ab-->immunofluorescence
"ana patterns"
rim pattern: anti-DNA (SLE)
homogenous: non-spec.
nucleolar: scleroderma, sjogrens
speckle: SLE, sjogrens, MCTD
others: ELISA
*can get false neg., highly sensitive, low specificity
-DNA is more specific (+ is helpful) but maj. of + SLE pts will have - DNA (not v. sense)
47
"CREST" acronym
```
anti-centromere pattern (local slceroderma)
Calcinosis
Esophageal dysmotility
Sclerodactyly
Telangectasia
w. centromere staining pattern
```
48
drug induced lupus
ANA +, DNA -, anti-histone +
| i.e. hydrolyzine for heart failure/HTN
49
RA
AI, inflamm. of synovium, infilt leukocytes
highly destructive, cytokines/ILs produced, unknown cause
periosticular ostepenia: bone loss, cartilage destroyed, narrow/closed joints
*tx as fast as you can!
can alter not cure process
50
meds in RA
anti-TNFs: infliximab, etanercept, adalimumab, certolizumab, golimumab
anti-IL-1s: anakinra
anti-IL-6s: tocilizumab
51
RA
young women, 20-30s Chronic symmetric polyarthritis
•Symptoms start in PIP, MCP, and MTP joints
•Serum rheumatoid factor, antibodies to *anti-
CCP*(specific), or both in 70%
•Radiographic changes include juxtaarticular
erosions and joint space narrowing (early on normal)
52
RA manifest.
Gender: Female (3:1 ratio)
• Age: Late childbearing years in women (60s-80s in
men)
• Insidious onset
• Symmetric distribution in small joints (MCP, PIP, and
MTP joints)
• **Spares DIP joints
• Joint stiffness worse in morning, pain, swelling
• Fatigue, weight loss, occasional low grade fevers
53
RA Lab tests
anemia, elevated ESR or CRP or both, elevated platelets,
| thrombocytosis, positive rheumatoid factor in 60-80%
54
DMARDS: RA tx
```
hydroxychloroquin
sulfasalazine
*methotrexate* (anti-folate)-most common, anchor drug
lefunomide
azathioprine
```
55
steroids: RA tx
methylprednisolone:
sev. organ-threatening disease flare: RA, SLE, syst. vasculitis
prednisone:
giant cell arteritis, inflamm. myopathy, polymyalgiarheumatica, RA flare or bridge tx for SLE flare
*long-term high dose: many SEs
56
biologic drugs if DMARD unsucc: RA tx
```
infliximab
etanercept
adalimumab
golilmumab
certolizaumab
rituximab
abatacept
tocilizumab
```
SEs: fever, bad cough-->call! sig. risk of bac/fungal inf
$$
highly effective
usually added when not responding to methotrexate
earlier the better, but don't give out readily
57
suggested monitoring guide for RA drug tx (RA)
```
(may include CBC, BUN, Cr, LFTs, UA, eye exam, BP, bone dens, glucose, fasting lipids, Hep B,C, albumin)
NSAIDs
glucorts
hydroxychloroquine
methotrexate
sulfasalazine
leflunomide
azathioprine
mycophenolatemofetil
cyclophosphamide
biol. tx (immun. stat, PPD/Quant)
```
58
other conditions can look like RA
```
arthritis with...
radiographic erosions
+ rheumatoid factor
nodules
MCP and wrist joints (hemochromatosis, Ca phos deposition)
```
59
pts. w/ lupus, RA
at risk for dev. secondary sjogren's
60
primary sjogren's
```
dry eyes, dry mouth
see chart
*more serious than primary
interstitial lung disease, kidneys, brain
AI-->lymphoma*
women in 20-30s
can be manifest. of RA
```
61
SLE
• Predilection for females of childbearing age
• Multi-system disease, often with a relapsing-remitting course
• Photosensitive rash, polyarthritis, serositis, and fatigue
• Renal disease and central nervous system involvement
are important causes of morbidity
-CNS: psychosis, hallucinations, seizures, depression, dementia
• Presence of antinuclear antibodies
• Certain autoantibodies(anti-dsDNAand anti-SM) have
a greater specificity for diagnosis of SLE, but lack
sensitivity
• Hypocomplementemiamay occur during flares
62
clin manifest of SLE
see chart
"great masquerader"
i.e. rash, lymphad, polyarthritis, pericarditis, endocarditis, pleurisy, pneumonia, peritonitis, hep, pancreatitis, glomnephritis, leukopenia, anemia, etc.
63
drug induced lupus
* Chlorpromazine
* Hydralazine** (vasculitis)
* Isoniazid
* Methyldopa
* Minocycline
* Procainamide
* quinidine
64
lupus nephritis
+proteinuria +hematuria
use steroids, tx early to prevent scarring of kidneys (glomeruli) from lupus, want to prevent
-->renal failure, need transplant
65
spinal tap in Lupus
look for neuropsychiatric syndromes (ddx from MS)
(elev. WBC: pleocytosis)
can be MS, many others
66
SLE tx
mild: NSAIDs, hydoxychloroquine
mod: corticosteroids, mycophenolate, azathoprine, cyclosporine
severe: IV pulse corticosteroids, cyclophaosphamide, mycophenolate, azathoprine
67
raynaud's
vasospactic
red-->white-->blue
s/s of another disease
think AI illness, thoracic outlet, carpal tunnel (vasc. occlusive disorders)
68
pregnancy
causes lupus flares
• The inherently hypercoagable state assoc. with pregnancy can be heightened in pts with the antiphosphoplipid syndrome, with risks for mom and fetus: @ risk for thrombosis, inf/hem. complications
• The diagnosis of anti-phospholipid syndrome is a strong contraindication
to pregnancy
69
rheumatoid arthritis attacks the
synovium
70
questions to ask
```
onset?
how many joints?
symm/asymm?
additive or migratory?
inflamm/noninflamm?
```
71
swollen painful big toe
gout
| acute,(pedagra), typ. 1 jt
72
asymmetric, oligoarthritix
psoriatic arthritis
73
rheumatoid arthritis
symmetrical
74
migratory polyarthritis
rheumatic fever
post-strep reactive arthritis
GC arthritis (GC in blood-->tenosynovitis (wrist, migrates to knees, hips)
75
most common non-inflammatory arthritis
typically manifests where?
mono/oligo/polyarthritis??
```
osteoarthritis
hands, DIP, PIP
>50 yo
monoarthritis (painful knee/hip)
+/- mild inflammation
```
76
ddx chronic noninflamm. monoarthritis
```
*osteo
internal derangements (torn meniscus)
chondromalacia patellae
osteonecrosis (trauma, steroids, etOH)
neuropathic (DM, charcot) arthropathy
sarcoidosis
amylodiosis
```
77
ddx acute inflamm. oligoarthritis: infectious
```
dissem. GC infection
non-GC septic arthritis (typ. mono)
bac endocarditis (prev. rheumatic fever, valv. disease) (may have rash)
*IR to bacteria*
viral
```
78
ddx acute inflamm. oligoarthritis: post-inf
reactive arthritis
rheumatic fever (post-strep)
psoriatic arthritis (ext. surface knees, elbow, scalp, CAN HIDE, pts often don't know)
IBD
79
ddx acute inflamm. arthritis: spondyloarthropathy
ankylosingspondylitis
80
anti-Ro/SSA
| anti-La/SSB
assoc. w. Sjogrens, SLE, neonatal lubus, cong. heart block
81
antiphospholipid
arterial, venous thrombosis
pregnancy morbidity
hypercoag, strokes
B2-GP
82
organ sp. AI dis. w/ +ANA test
AI hepatitis (looks like SLE)
Thyroid disease (Grave's/Hashimoto's)
Idiop. pulm. HTN
primary biliary cirrhosis
83
non-AI conditions w/ +ANA test
```
viral inf (HIV, Hep B,C, EBV)
bac inf (bac endocard)
MTB
blood Ca (AML)
age >65
healthy (up to 10% pop)
drugs (anti-TNFs)
```
84
SLE labs
typically +ANA, not DNA (+w. lupus nephritis)
| low complement levels
85
rheumatic dis. in pregnancy
most report IMPROVEMENT in jt pain and swelling during prey.
- pts w. mod-high disease activity do better than low disease (CI!)
- returns to prior state after giving birth
86
moms w/ anti-Sjogren Abs
| screen for SS-Ab
can cross placenta and binds heart tissue-->heart block
fetal echo: look for bradycardia, need to be paced when born
-born w/ SLE: fever, rash goes away, *heart block can be permanent*
