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Musculoskeletal 1 > Rheumatological 1 > Flashcards

Rheumatological 1 Flashcards

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1
Q

Inflammatory response

  • morning stiffness lasts how long
  • synovial fluid analysis
  • other lab results
A
  • > 60 min
  • leukocyte ct >2,000/uL
  • elevated ESR and CRP
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2
Q

Non-Inflammatory response

  • morning stiffness lasts how long
  • synovial fluid analysis
  • other lab results
A
  • <30 min
  • leukocyte ct btwn 200 and 2,000/uL
  • nl ESR and CRP
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3
Q

Rheumatoid Arthritis

- etiology

A
  • risk increased in relatives: genetic
  • Heritability about 60%
  • 20 alleles IDed
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4
Q

Allele associated with RA

A

HLA-DRB1

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5
Q

List the 4 systems with extra-articular manifestations in RA

A
  • skin
  • eyes
  • pulmonary
  • cardiac
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6
Q

RA affects on skin

A
  • RA nodules, MC on pressure points like elbows
  • pyoderma gangrenosum
  • RA vasculitis (common)
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7
Q

RA affects on eyes

A
  • keratoconjunctivitis sick (dry eyes)

- episcleritis (sclera red and inflamed)

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8
Q

RA affects on pulmonary system

A
  • exudative pleural effusion

- interstitial lung disease

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9
Q

RA affects on cardiac system

A
  • CAD
  • CHF (dt CAD)
  • pericarditis (friction rub)
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10
Q

RA - felty syndrome

A
  • neutropenia
  • splenomegaly (MC)
  • RA (MC)
  • sometimes fever, anemia, thrombocytopenia
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11
Q

What is most appropriate autoantibody for RA

A

CCP

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12
Q

Is RA arthritis symmetrical or unilateral?

A

symmetrical

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13
Q

How does RA affect joints

A
  • small and large joints
  • small joints will be bilateral
  • might have single large joint
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14
Q

Osteoarthritis (OA)

  • how common
  • how relates to age
  • men vs. women
A
  • most common type of arthritis
  • incidence increases with age
  • men slightly more than women
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15
Q

Two classification for OA

A
  • primary: no specific predisposing event (injury for ex)

- secondary: degeneration of previously injured joint

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16
Q

OA

  • pain presentation
  • symmetry?
A
  • pain may be intermittent, occur with joint us
  • joints may be tender
  • asymmetric (diff from RA)
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17
Q

How does OA affect joints

A

oligoarthritic - 1 or 2 large joints or 1 or 2 small joints common

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18
Q

Two types of nodes found in OA

A
  • Bouchard: PIP joints

- Heberden: DIP joint

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19
Q

Baker cyst

A

chronic effusion of popliteal fossa

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20
Q

Lab and imaging for OA

A
  • no labs, may see elevated ESR during flair

- Imaging: plain film will show narrowing of joint space, subchondral sclerosis, osteophytes (bony outgrowths)

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21
Q

Overview of OA tx

A
  • NSAIDs
  • PT
  • Joint injection
  • steroids, esp with effusion
  • joint replacement
  • Glucosamine and chondroitin sulfate have little effect
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22
Q

Fibromyalgia

  • incidence
  • what is interesting about incidence
A
  • 0.06% to 10% WIDE range
  • misunderstanding about dx of fibromyalgia
  • many don’t believe it exists
  • many want to ignore
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23
Q

Fibromyalgia pathophysiology

A
  • aberrant chronic pain reflex arcs
  • centered on dorsal ganglia of spine
  • reflex arcs fn independently
  • may be exacerbated by acute or chronic pain inputs (arthritis or psych distress)
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24
Q

What do MRI studies show about fibromyalgia

A
  • pain is same as other pain perception but more easily triggered
  • elevation in pain-facilitating neurotransmitters (glutamate and substance P)
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25
Fibromyalgia tx
- validation is important - aerobic exercise - PT - SNRIs (duloxetine and milnacipram)
26
Spondyloarthritis | - three types
- Ankylosing spondylitis - Psoriatic arthritis - Inflammatory bowel disease-associated arthritis (reactive arthritis)
27
Spondyloarthritis | - gene
- HLA-B27 (MC with ankylosing spondylitis) | - insufficient to make dx
28
Ankylosing spondylitis | - m vs. f
3:1 M:F
29
Ankylosing spondylitis | - presentation
- insidious low back pain MC - stiff worse after rest, better with use - bilateral buttock pain, sacroiliitis (XR of SI joint helpful)
30
Psoriatic arthritis - describe - seen with what co-morbidity
- Severe inflammatory arthritis - like RA permanent destruction of joint - Oncholysis (painless separation of nail from nailbed) - oligo or symmetric - dactylitis (diffuse swelling of joint, tendon, ligament of digit) in 50% - 15-20% of people with psoriasis
31
Psoriatic arthritis | - dx
- don't use antibodies for dx
32
Inflammatory bowel disease related arthritis - incidence and progression - location of arthritis
- 20-30% of people with Crohn's or UC - up to 50% resolve in 6 months - axial or peripheral
33
Inflammatory bowel disease related arthritis is dt what
- autoimmune, non-infectious BUT, associated with a few orgs: MC: Yersinia also: salmonella, shigella, campylobacter, rarely E. Coli
34
For each type of spondyloarthritis, what is the main thing to look for?
- ankylosing spondylitis: pain in sacroiliac joint - psoriatic arthritis: psoriasis of skin, hand findings - Inflammatory bowel: Sx of Crohn's or UC
35
Management of spondyloarthritis
- NSAIDs - glucocorticoid injections - DMARDS? - TNF-alpha inhibitors
36
Systemic Lupus Erythematosis - describe - inheritance - M vs. F
- multi-organ - caused by auto-antibodies including antibodies vs. intranuclear antigens - polygenic inheritance - 90% women
37
Systemic Lupus Erythematosis | - list the 7 organ systems involved
- MSK - renal - neuropsychiatric - cardiovascular - pulmonary - hematologic - GI
38
SLE | - MSK sx in acute, sub-acute, chronic dz
- Acute: malar skin rash (butterfly) on face - Sub-acute: polycyclic rash with hyperpig. circular plaques - Chronic: infiltrative papules, plaques, red plaques on sun-exposed surfaces
39
SLE | - other MSK sx
- painless oral ulcers - alopecia - Raynaud's (hypersensitive vascular endothelium) - 85% report myalgia
40
SLE | - MSK joint involvement
- 90% have joint issues - 40% get osteonecrosis of hips - peripheral or lrg joints - usually symmetrical but can be single
41
SLE - Renal incidence - what is MC issue
- up to 70% - usually glomerular dz - renal bx usually indicated - have a nephrologist do this!
42
SLE | - What two markers associated
- Anti-double stranded DNA | - Anti-smith antibody
43
SLE | - neuropsychiatric involvement
- vasculitis of the brain: common and hard to dx - esp difficult w/o arthritis or skin sx - 19 possible manifestations, be careful to not write off as psych issue - Can present with peripheral nervous dz
44
Examples of peripheral nervous dz in SLE
- mononeuropathy multiplex or single - autonomic lesions - cranial lesions - polyneuropathy
45
What is mononeuropathy multiplex
- Peripheral neuropathy that presents with numbness - Generally comes and goes - Caused by small vessel inflammation of peripheral nerves. Vessels get clogged up from autoimmune response and then reopen, clog and reopen again. - Pts most likely won't tell you "I have numbness that comes and goes" - more likely to catch on ROS if ask
46
SLE cardiovascular involvement
- 40% pericarditis: find via exam, echo, MRI/CT | - cardiac valve thickening called "Libman-Sacks endocarditis": non-infectious vegetations on valves
47
SLE pulmonary involvement
- pleuritis +/- effusion - interstitial lung dz - shrinking lung syndrome
48
Define shrinking lung syndrome
- pleuritic pain - SOB - progressive decrease in lung volume - unknown cause
49
SLE hematologic involvement
- All three cell lines possible (anemia, leukopenia, thrombocytopenia) - hemolytic anemia - pure red cell aplasia - aplastic anemia
50
Describe warm antibodies in hemolytic anemia
- attach to the cell membrane of the red cell - when cells try to get through sinusoids of spleen, spleen takes chunks of the membrane off - cell folds up on itself, no longer biconcave discs, now spherocytes - spherocytes seen on peripheral smear
51
What do you always test for that is related to SLE if someone has a clot/DVT from unknown cause?
- antiphospholipid antibody syndrome / lupus anticoagulant syndrome (APLA/LAC) - antibodies to endothelium, monocytes, platelets, which produce a pro-coagulant state
52
SLE | - GI involvement
- esophageal imotility - sterile peritonitis - mesenteric vasculitis - mesenteric thrombosis
53
What is mesenteric vasculitis often confused with?
acute appendicitis
54
What is much more common in SLE
malignancy. .. | - 7 times increase in non-hodgkin lymphoma
55
How to diagnose SLE
- consider in anyone with otherwise unexplained multi system dz - antibodies: many, Anti-double stranded DNA and Anti-Smith are two tow know
56
SLE how to interpret ANA results
- in light of pre and post test probability
57
ESR vs. CRP in SLE
- ESR preferred over CRP (CRP can be negative in acute flare)
58
What else should be tested for if suspect SLE
- C3 and C4 dt potetential for immune complex dz
59
Sjogren syndrome | - describe
- immune-mediated - unknown cause - infiltrative inflammation damages exocrine glands - major/minor salivary glands, lacrimal glands, possibly others like pancreas - 1.5% prevalence
60
Sjogren's pathophys
- inflammatory infiltrates of CD-4 positive T lymphocytes | - some B cell action
61
Sjogren's clinical manifestations
- Keratoconjunctivitis sick (dry eyes): dx via shimmer test (strip under lower eyelid) - Xerostomia (dry mouth)
62
What are the best markers for Sjogrens
- Anti-Ro / SSA | - Anti-La / SSB
63
What is the definitive dx test for Sjogrens?
Lip bx | - would do if still suspect but negative antibodies
64
Sjogren's management
- symptomatic | - local (eye drops, etc)
65
Mixed Connective Tissue disease (MCTD) - describe - markers
- overlap syndrome - includes features of SLE, systemic sclerosis, polymyositis - anti-U1-ribonucleoprotein (RNP) antibodies - ANA with speckled pattern
66
Mixed Connective Tissue disease (MCTD) | - presentation
- 50% hand swelling and synovitis | - also: esophageal reflux, interstitial lung dz, pulmonary HTN
67
Mixed Connective Tissue disease (MCTD) | - recommended testing
- high resolution CT of chest - PFTs - Cardiac echo
68
Mixed Connective Tissue disease (MCTD) | - management
- individualized - glucocorticoids, azathioprine, methotrexate - help from a rheumatologist!
69
what are the two crystalopathies?
- Gout | - Calcium pyrophosphate deposition (pseudo gout)
70
Gout | - description
- intermittent attacks of inflammatory arthritis | - results from crystallization of excessive levels of uric acid
71
Gout | - incidence
- increasingly common in older people | - 13% >80 yo
72
Gout | - pathophys
- Elevated serum uric acid - when in cooler joints, crystalizes - crystals recruit inflammatory response (IL-6 , IL-1B, TNF alpha, neutrophils) - uric acid is end product of purine metabolism
73
What do free purines arise from (3)
1. ATP turnover 2. purine metabolism 3. cell turnover
74
What is the rate limiting step to purine metabolism?
Xanthine oxidase **know this one
75
What is the saturation concentration of serum rate? what does this mean
- 6.8 mg/dL - crystals unlikely to form at concentration lower than 6.8 - above 6.8 is considered hyperuricemia
76
What 5 variables affect crystal formation in gout?
- serum concentration - temp - other unknowns - some people overproduce - some people underexcrete
77
Gout Pathophys | - what is the hallmark finding of established gout attack?
- neutrophil infiltration
78
Acute gout - when MC - presentation
- MC in early am (lowest temp of toe) - extreme pain, even sheet hurts - red toe
79
Gout | - dx
- clinical presentation - crystal analysis (microscope), gram stain, culture - Elevated ESR and CRP
80
What do gout crystals look like under microscop
- negatively birefringent urate crystals - yellow when parallel and blue perpendicular - long like a spear
81
Three gout presentations
1. acute - dx via microscopic exam of fluid 2. inter critical: time between acute attacks 3. chronic: frequent attacks
82
Gout | - acute management
- colchicine - once acute phase over, start allopurinol and treat until serum uric acid <6.5 mg/dL - continue allopurinol for life *allopurinol is a xanthine oxidase inhibitor
83
Gout | - common reasons for tx failure
- failure to treat to target (<6.5 mg/dL) | - not using high enough dose, can go up to 800 mg per day
84
What is the best name for pseudo gout?
osteoarthritis with calcium pyrophosphate deposition (CPPD)
85
CPPD pathophysiology
- mech not understood | - deposition of calcium pyrophosphate crystals in CT
86
What should consider if in young person who presents with CPPD?
- hyperparathyroidism - hemochromatosis** - hypomagnesemia - hypothyroidism
87
What physical finding is associated with CPPD?
- calcium deposits in cartilage | - linear density parallel to surface of cartilage
88
CPPD | - management
- symptomatic - decrease inflammation - nothing to reduce likelihood of crystal depostion
89
Why does acute mono-articular arthritis require needle aspiration for dx?
differentiate between - gout - CPPD - infection

Musculoskeletal 1 (14 decks)

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