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Flashcards in rheum Deck (86):
1

initial clin charac. of arthritis

-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

monoarthritis: bacterial inf. of joint space
1. acute
(+ fever, *rapid! dx quickly)
2. chronic
(both can be polyarthritis via hematogenous spread)

1. 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

monoarthritis: crystal-induced arthritis (painful!)

gout: monosodium urate crystals (hyperuricemia)in articular space-->rel. cytokines
pseudogout: calcium pyrophasphate dihydrate crystals (older, knee/wrist)
chronic:
calcium apatite crystals

4

other common causes of acute monoarthritis

trauma
hemearthrosis
-older-falls, athletes
-coagulopathies, anticoags.
-dx: arthrocentesis

5

chronic monoarticular pres. of oligoarthritis/polyarthritis

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

psoriatic infection

commonly unilateral

7

rheumatoid

symmetrical/bilateral
small jts in hands PIPs, MCPs, DIPs*rare
pas young women 20-30

8

migratory polyarthritis

rheumatic fever, post streptococcal, GC (can start as tenosynovitis)

9

osteoarthritis

around 50-70 yo (onset)
presents as unilateral painful hip, non-inflammatory,

10

common ddx of acute polyarthritis >5 joints

acute viral inf. (parvovirus, influenza, chiquengunya) (+ fever)
early disseminated lyme disease
Hep B,C
*rheumatoid arthritis* (symm. PIPs) (y. women)
SLE

11

uncommon ddx of acute polyarthritis

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

psoriatic arthritis

ask pt if have psoriasis
skin disease (elbows, knees, scalp) *can hide
acute, oligoarticular, asymmetrical

13

SLE

AI, jt pain in young women, fever, malor rash (classic)

14

palpable purpura

hemorrhagic
think vasculitis: inflamm. BVs, polyarthralgia (no inflamm), typ. LE, ulcerated
henochschonlein purpura: kids, abd pn, nephritis, hematopesia?

15

GC infectious arthritis

pustule w/ arthritis

16

reactive arthritis

had infection, reacted w. arthritis
"can't see, can't pee, can't climb a tree"
diarrhea, urethritis, salmonella, w/ inflammatory arthritis

17

think about septic joint w.

monoarticular arthritis

18

Still disease

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

inflammatory bowel-->arthritis

ulcerative colitis, Crohn's
skin rash (erythema nodosum)

20

neodosum - sign of something else, can pres. w/ polyarthritis

sarcoidosis
IBD (pres. w. polyarthralgia)
OTC
preg
follow strep, meds
med rxn
Sjogren's

21

sarcoidosis
Loepren's? syndrome

starts in lungs, get CXR
acute: arthritis in ankles, rash
whites
diff than chronic
dx. with CXR, bilat hilar adenopathy
tx: steroids

22

paraneoplastic arthritis

remote effects of ca
HLA
(SmCC-->sec PTH, ACTH)
see clubbing, esp. w/ smoker-->CT/CXR

23

familial mediterranean fever

uncommon,
acute mono arthritis in knee/hip, acute abdominal

24

synovial fluid

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*