Rheumatologic Precision & Pearls #1 Flashcards by Tyler Cichowski

Fibromyalgia is a disorder in which the patient has abnormal pain perception. It is MC in _______ and is characterized by

Women ages 20-55

Chronic, widespread MSK pain in 11 of 18 points and pain for 3 or more months

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Sleep studies in a patient with fibromyalgia shows…

no REM sleep cycle

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Treatment for fibromyalgia

-Conservative: sleep hygiene, low impact exercise

-Amitriptyline (1st line)
-SSRI’s
-Pregabalin (FDA approved for Fibro)

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Gout is ______ deposition in a joint or bone. 90% of this condition occurs in ____.

Name some triggers for gout.

uric acid

90% in men

-Purine rich foods (beer, yeast, alcohol, seafood, liver)
-Medications: Thiazides, Loop diuretics, ACE Inhibitors, ARBs (not Losartan), Aspirin, Ethambutol

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What are the symptoms of gout

-Podagra (first MTP joint of the great toe)
-Lower extremity MC affected
-Erythema, pain, warmth, tenderness, fever

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Initial diagnostic for gout and what does it show?

What do the radiographs of a gouty joint show?

Arthrocentesis: negatively birefringent needle shaped crystals

Radiographs: mouse or rat bite lesions (punched out erosions with sclerotic and overhanging margins)

Increased WBC, Primarily neutrophils

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For an acute gout attack, what is the treatment?

-NSAIDs
-Corticosteroids if unable to take NSAIDs (renal problems)
-Colchicine last line

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For chronic gout, what should you do?

Lifestyle changes: diet, no alcohol

Allopurinol (xanthine oxidase inhibitor) or Febuxostat = both decrease uric acid production

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Gout is a problem with the metabolism of what type of molecule?

In gout, what compound precipitates into the synovial fluid?

Purine

Sodium Urate

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Pseudogout, also known as Calcium Pyrophosphate Dihydrate Deposition Disease (CPPD), is the deposition of _____ in the joint. It occurs MC in what joint? Even though it mimics gout symptoms, what does the arthrocentesis show in this condition?

calcium pyrophosphate dihydrate

MC in Knee

Positively birefringent rhomboid shaped crystals

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Treatment for pseudogout

-Intraarticular steroids if 1-2 joints
-NSAID if > 2 joints
-Colchicine an option as well

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Polymyositis is an inflammatory disorder of striated muscle involving ____________. Explain symptoms of this condition.

proximal limbs, neck, and pharynx

-Progressive symmetric proximal muscle weakness (shoulders, hips) - combing hair, rising from chair, etc.
-Dysphagia, fever, weight loss
-Decreased muscle strength
-NO RASH!

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What diagnostics can be done for polymyositis and what do they show?

-Increased CK and aldolase
-Antibodies: Anti-Jo 1, anti signal recognition protein (most specific)

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What is the most specific marker for polymyositis?

Anti-signal recognition protein

Anti Jo-1 as well is included in this diagnosis

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What is the DEFINITIVE diagnostic for polymyositis?

Muscle biopsy = endomysial inflammation

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Treatment for polymyositis

High dose corticosteroids
-Methotrexate if no response to steroids

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On the other hand, what is dermatomyositis?

Explain the symptoms of this condition

Polymyositis + skin involvement

-Progressive symmetric proximal muscle weakness
- Decreased muscle strength
-Skin:
–Heliotrope rash: edema/blue eyelids
–Gottron’s Papules: on knuckles
–Shawl Sign: rash of upper back, shoulders, and chest

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Diagnostics for dermatomyositis are similar to that of polymyositis. Name them and tell what you find including the tumor markers

-CK and aldolase are elevated (muscle enzymes)
-Muscle biopsy = definitive
-Anti Jo-1 and Anti-Mi 2

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True or False: Dermatomyositis has an increased risk of malignancy

True

25% of cases are associated with cancer

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Treatment for dermatomyositis

-High dose glucocorticoids
-Methotrexate, Azathioprine, IVIG are other options

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Polymyalgia Rheumatica is inflammation of the joints, bursae, and tendon. It is HIGHLY associated with what other condition?

What are the symptoms of PMR?

GCA (Temporal arteritis)

-Pain and stiffness in proximal muscles and joints
-NORMAL muscle strength
-May have decreased ROM

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Furthermore, to differentiate PMR from polymyositis, what do the labs show?

PMR:

-Normal muscle enzymes
-Markedly elevated ESR and -CRP
-Increased platelets (acute phase reactants)

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What is the treatment for PMR?

Low dose corticosteroids, or Methotrexate

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Reactive arthritis, also known as Reiter Syndrome, may be seen 1-4 weeks after _________

However, it also has a high association with….

Chlamydia or GI infection

HLA-B27 positivity

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Name the triad of symptoms associated with reactive arthritis as well as other symptoms of this condition.

-Arthritis + urethritis + conjunctivitis (can't see, can't pee, can't climb a tree) -Lower extremity MC affected -Oral lesions -Keratoderma blennorrhagicum: hyperkeratotic lesions on palms and soles

Treatment for Reactive Arthritis

NSAIDs -Methotrexate if needed -ABX if chlamydia related

Pathophysiology of Rheumatoid Arthritis What are some risk factors?

Chronic, progressive cartilage destruction and joint structure loss due to destruction by pannus. T Cell mediated Females, smoking

Symptoms of Rheumatoid Arthritis

-Morning stiffness > 1 hour, improves throughout the day -MC affects small joints (wrist, MCP, PIP, spares the DIP) -Symmetrically inflamed joints, warm boggy -Ulnar deviation of the hand at MCP joint -Swan neck/Butonniere deformities -Nodules over bony prominences

Regarding RA, what is Felty Syndrome? What is Caplan Syndrome?

Felty Syndrome: RA + neutropenia + splenomegaly Caplan: RA + pulmonary nodules + pneumoconiosis

Labs (which is the most specific) for RA. What do XR's show?

Rheumatoid Factor positive Anti-CCP (most specific) XR: symmetric joint narrowing, osteopenia, erosions, C1-C2 subluxation if the spine is affected

Treatment for RA Which is the first line for symptom control? Which drug is safe in pregnancy?

-DMARDs: Methotrexate, Leflunomide (first line), + NSAIDs NSAIDs Hydroxychloroquine

Methotrexate drug facts (MOA and adverse effects)

Folic acid antagonist Hepatitis, bone marrow suppression, interstitial pneumonitis

What is the MC type of Juvenile Idiopathic Rheumatoid Arthritis? What are the symptoms?

Still's Disease (Systemic): -Daily spiking fevers -Polyarthralgias -Salmon colored migratory rash at night

Treatment for JRA?

NSAIDS, PT -Anakinra, Methotrexate are also options

Lupus (Systemic Lupus Erythematosus) is a chronic multi-organ disorder of connective tissues. It is also a Type _____ hypersensitivity reaction. What are some risk factors for Lupus/SLE?

Type III Female, sun exposure, African American, estrogen use

Symptoms of SLE including the triad, as well as other systemic symptoms

Triad: joint pain + fever + butterfly malar rash -Constitutional symptoms, oral ulcers, pleuritis -If discoid in nature: annular patches on face that heal with scarring

What labs are drawn for SLE and what are the specific ones for this condition?

-ANA (initial) -Anti double stranded DNA and Anti Smith -Antiphospholipid antibodies = increased risk of arterial and venous thromboses -Decreased complement levels (C3 and C4) mark progression of disease

Treatment for SLE

-Skin: Sun protection, Hydroxychloroquine for lesions -Arthritis: NSAIDs or Acetominophen -+/- pulse-dose corticosteroids -Methotrexate, Belimumab if no response to other treatments

Drug Induced Lupus is SLE caused by drugs such as

Quinidine, Hydralazine, Isoniazid, and Procainamide

What labs are drawn for drug-induced SLE?

Positive ANA Anti-histone antibodies (hallmark)

Antiphospholipid syndrome is a disorder of thromboses due to antibodies against negatively charged phospholipids. This results in what symptoms?

-Increased risk of thromboses: DVT, PE, recurrent miscarriages, atherosclerosis, stroke, TIA, cognitive deficits

What diagnostics are done to prove the patient has antiphospholipid syndrome?

-Lupus anticoagulant: increased PTT -Failure to correct PTT with mixing studies -Prolonged Russell Viper Venom Test: most specific

Treatment for antiphospholipid syndrome

-Lifelong Warfarin Therapy or LMWH for pregnant

Scleroderma (Systemic Sclerosis) is a connective tissue disorder in which collagen deposition leads to fibrosis of skin and internal organs. Explain what CREST (Limited) is and what Diffuse types are.

-Limited (CREST): tight, shiny, thick skin on face, neck, and distal to knees and elbows. Spares trunk. --Calcinosis Cutis: calcium spots under skin --Raynaud's --Esophageal motility disorder --Sclerodactyly --Telangiectasias Diffuse: shiny, thick skin of trunk and proximal extremities. Greater organ involvement.

What labs are specific to scleroderma?

Anti centromere antibodies (CREST) Anti SCL 70 antibodies & anti-topoisomerase (diffuse) ANA positive

Sjogren Syndrome is an autoimmune disorder of the ________ (_____) Symptoms of this condition include

Exocrine glands (salivary and lacrimation) -Dry mouth (xerostomia), dry eyes, dry vagina (dyspareunia) -Parotid gland enlargement -Dental caries

What diagnostics are done for Sjogren's (which labs are specific, what eye test is done, and what is definitive?)

Labs: AntiSS-A (Ro) and AntiSS-B (La) Schirmer Test: <5mm after 5 minutes Lip or Parotid Biopsy: definitive

Treatment for Sjogren's Syndrome

-Increase fluid intake -Use of artificial tears -Pilocarpine or Cevimeline: cholinergic drugs that increase lacrimation and salivation

Pilocarpine increases salivation and lacrimation. However, what are some adverse effects of this medication?

Diaphoresis, bradycardia, flushing, diarrhea, nausea, vomiting, blurriness

What's one complication of Sjogren's (in other words, what does it increase the risk of?)

Non-Hodgkin Lymphoma

Behcet's Syndrome is characterized by

Recurrent, painful oral and genital ulcers, erythema nodosum, uveitis/conjunctivitis, arthritis, and CNS involvement (can mimic MS)

What population is at increased risk for Behcet's Syndrome? What diagnostic is definitive? What's the treatment?

Asians, Mediterranean, Middle Eastern Biopsy Corticosteroids

Takayasu Arteritis is a large vessel vasculitis that affects What diagnostic confirms this

aorta, aortic arch, and pulmonary arteries Angiography

What are some symptoms of Takayasu Arteritis?

-LE claudication -HTN crisis -TIA/Stroke -Asymmetric BP between arms -Decreased pulses -Bruits -Arm claudification Think of all the arteries and symptoms that would affect them

Treatment for Takayasu

High dose corticosteroids

What is Kawasaki Syndrome?

Small and medium vessel vasculitis involving the coronary arteries

Kawasaki Syndrome MC occurs in what population? What are the symptoms of this condition (think warm).

Children <5, Asian, boys Warm + CREAM --Fever >5 days + 4/5 of: ---Conjunctivitis ---Rash ---Edema/Erythema ---adenopathy (cervical) ---Mucositis (strawberry tongue)

Treatment for Kawasaki Syndrome

-IVIG + Aspirin

Eosinophilic Granulomatosis with Polyangitis can be a rare side effect of which two medications? What is the triad of symptoms with this condition?

Montelukast and Zafirlukast Asthma + Eosinophilia + Chronic rhinosinusitis

What labs are seen with Eosinophilic Granulomatosis with Polyangitis, what is the definitive diagnostic and treatment?

P-ANCA positive + Eosinophilia Biopsy = definitive Glucocorticoids + Cyclophosphamide

Granulomatosis with Polyangitis (GPA - Wegener's) is small vessel vasculitis of ..... This means the triad of symptoms with this condition is...

Nose, lungs, and kidneys -Upper Respiratory tract involvement (nasal congestion, otitis media) + lower respiratory tract involvement (cough, wheezing, hemoptysis) + glomerulonephritis (rapidly progressive with RBC casts)

What labs are seen with GPA, what is definitive, and what is the treatment?

C-ANCA positivity Biopsy Glucocorticoids + Cyclophosphamide

Microscopic Polyangitis (MPA), much like GPA, is small vessel vasculitis. However, what is the difference?

No naspopharyngeal symptoms and does affect the capillaries

Symptoms of MPA

-Fever, palpable purpura -Rapid acute glomerulonephritis with RBC casts

Diagnostics for MPA Treatment

-P-ANCA positive -Biopsy definitive Glucocorticoids + Cyclophosphamide

Immunoglobulin A Vasculitis (Henoch-Schonlein Purpur) is an Ig-A mediated small vessel vasculitis. This occurs MC in what population? What precipitates it?

90% in kids After infection (URI, GABHS, Parvovirus B-19)

Symptoms of HSP

HSPA -Hematuria -Synovial (arthritis or arthralgia) -Palpable purpura -Abdominal pain (GI bleed?)

A kidney biopsy is definitive for IgA vasculitis (HSP), what is shown on it? What is the treatment?

Mesangial IgA deposits Supportive

Anti-GBM Antibody Disease (Goodpasture's Disease) is IgG antibodies against Type IV collage of alveoli and glomerular basement membrane of kidneys. What are the symptoms?

Only in lungs and kidneys --Hemoptysis -Cough -Hematuria -Oliguria

UA for Anti-GBM shows: What antibodies are present? What is definitive and what is seen?

RBC casts Anti-GBM antibodies Linear IgG deposits

Treatment for Goodpasture's

Gluco + Cyclophosphamide + Plasmapheresis

Psoriatic Arthritis is associated with _______ and what labs?

HLA-B27 positivity RF -, ANA -

Name some symptoms of psoriatic arthritis

-Arthritis -Dactylitis -Sacroilitis -Chronic Uveitis -Psoriasis

What do radiographs of psoriatic arthritis show?

Pencil in cup deformities: thin end of one bone being inserted into a thicker bone

What is the treatment for psoriatic arthritis?

-Mild: NSAIDs -Moderate: Methotrexate -TNF Inhibitors (-mab): if no response

Rheumatologic Precision & Pearls #1 Flashcards

(75 cards)