Rheumatology

Question 1

Define fibromyalgia

Answer 1

Chronic widespread muscular pain, tenderness, and fatigue for at least 3 months involving all 4 quadrants of the body

• pain above & below the waist
• pain on the left and right sides of body
• Pain in at least 11/18 discrete tender points

MC in middle-aged women

Question 2

What makes fibromyalgia symptoms worse/flare?

Answer 2

Physical and psychological stress

Question 3

How do you treat fibromyalgia?

Answer 3

Tricyclic antidepressants –> Cymbalta

Lyrica only med FDA approved to treat fibromyalgia

Neurontin

Question 4

Purine rich foods to warn patients with gout to avoid

Answer 4

• alcohol
• red meats
• liver
• seafood
• sugary foods & sodas
• yeasts

Question 5

What is gout? What is tophi?

Answer 5

Gout is an accumulation of uric acid in the tissue of joints & bones –> 80% monoarthropathy

Tophi is a collection of solid uric acid in soft tissue

Question 6

What medications can cause gout?

Answer 6

Diuretics- thiazide & loop
ACE-i
Ethambutol
ASA
ARBs

Question 7

What is pseudogout?

Answer 7

Calcium Pyrophosphate Dihydrae (CCPD) crystals in connective tissues

Knee most common

**associated with hyperparathyroidism

Question 8

What is a diagnostic uric acid level for gout?

Answer 8

> 7.5

Question 9

Acute gout management

Answer 9

• NSAIDs –> Indomethacin

- Colchicine = 2nd line

Question 10

Chronic gout management

Answer 10

Tophi and/or >2 gout flares per year

Allopurinol + NSAIDs or Colchicine for 6 months to prevent acute flares

Goal is uric acid <6

Question 11

Pseudogout treatment

Answer 11

Corticosteroids = 1st line

Colchicine = prophylaxis

Question 12

Polyarteritis Nodosa signs & symptoms

Answer 12

Inflammation of small & medium sized arteries ==> restricts blood flow ==> organ damage

• renal HTN
• myalgias & arthralgias
• peripheral neuropathy
• livedo reticularis / gangrene/ Raynaud’s

The inflammation weakens blood vessels which leads to the formation of aneurysms

MC in middle-aged men 40-60 years old

Question 13

Polyarteritis nodosa diagnosis

Answer 13

1. Tissue biopsy showing necrotizing arteries
2. Angiography = aneurysms
3. ↑ ESR

** ANA negative**

Question 14

Polyarteritis nodosa treatment

Answer 14

Prednisone +/- cyclophosphamide

Question 15

What other conditions is polyarteritis nodosa associated with?

Answer 15

• *Hepatitis B**

- Microaneurysms

Question 16

Polymyalgia rheumatica definition

Answer 16

An idiopathic inflammatory condition affecting the JOINTS –> PAINFUL synovitis, bursitis, and tenosynovitis

S/S

• proximal stiff joints in pts >50 years old
  - shoulders
  - hips
  - neck
• fatigue
• weakness
• “can’t lift arms over head to brush hair”

Question 17

Physical Exam findings in Polymyalgia rheumatica

Answer 17

• Normal strength

- Limited passive ROM in all directions

Question 18

What other condition is polymyalgia rheumatica closely related to?

Answer 18

Giant Cell Arteritis aka Temporal Arteritis

Question 19

How do you treat polymyalgia rheumatica?

Answer 19

-LOW dose corticosteroids

may be required for up to 2 years

Question 20

Define polymyositis

Answer 20

Chronic idiopathic inflammatory disease of MUSCLE

• symmetrical
• proximal
• PAINLESS
• *muscle weakness**

Question 21

Physical Exam findings in Polymyositis?

Answer 21

-Decreased strength

Question 22

Polymyositis diagnosis

Answer 22

• • creatine phosphokinase –> indicating muscle injury
• elevated ESR
• • ANA
• • anti-Jo-1

Confirmed by muscle biopsy

Question 23

How do you treat polymyositis?

Answer 23

High dose corticosteroids

Question 24

Define Reactive Arthritis

Answer 24

Autoimmune response to an infection

Common Triggers

• Salmonella
• Shigella
• Chlamydia trachomatis
• Neisseria gonorrhea

Question 25

Reactive Arthritis symptoms

Answer 25

* *Triad** - inflammatory arthritis of large joints - inflammation of eyes = conjunctivitis, uveitis - urethritis "Cant see, pee, or climb a tree"

Question 26

Reactive Arthritis labs

Answer 26

++ HLA-B27 CBC: ↑ WBC, ↑ ESR, ↑ IgG

Question 27

Treatment of Reactive Arthritis

Answer 27

- NSAIDs | - ABX to treat infection

Question 28

Define Rheumatoid Arthritis

Answer 28

A chronic autoimmune inflammatory disease with persistent, symmetric polyarthritis - bone erosion - cartilage destruction - joint structure loss

Question 29

Signs & Symptoms of rheumatoid arthritis

Answer 29

``` Joint stiffness worse in the morning, >30 minutes…improves throughout the day • Worse with rest • Prodrome -Fevers -Fatigue -Weight loss -anorexia • Small symmetric joint stiffness -MCP -PIP -WRIST -Knee ```

Question 30

Rheumatoid Arthritis Diagnosis

Answer 30

Morning stiffness + arthritis in >3 joints for > 6 weeks + RF (80%) +anti-CCP (60%-- more specific) Xrays --> narrowed joint space - ulnar deviation - swan neck deformity (DIP) - boutonniere deformity (PIP)

Question 31

Rheumatoid Arthritis Treatment

Answer 31

1. Methotrexate +/- hydroxychloroquine +/- sulfasalazine 2. NSAIDs & low dose corticosteroids for pain control

Question 32

Sjogren Syndrome definition

Answer 32

Chronic systemic autoimmune inflammatory disorder that affects the exocrine glands Relatively common -- 2nd MC autoimmune disease Unknown cause

Question 33

Sjogren Syndrome symptoms

Answer 33

``` -Parotid gland = dry mouth --> loss of teeth & cavities ==> difficulty swallowing & talking -enlarged -nontender -firm ``` -Lacrimal gland = dry eyes Extra glandular symptoms - arthralgias - Raynaud's - Lymphadenopathy - Vasculitis - peripheral neuropathy

Question 34

What is Shirmer's test & what condition is it used to diagnose??

Answer 34

-Tear test --> positive if <5mm lacrimation in 5 minutes **Sjogrens Syndrome**

Question 35

How is Sjogren Syndrome diagnosed

Answer 35

+ANA +anti-SSA (anti-Rho) +anti-SSB (anti-La) +RF Salivary gland biopsy

Question 36

Treatment of Sjogren Syndrome

Answer 36

- Artificial tears - Pilocarpine = cholinergic - Cevimeline = cholinergic

Question 37

What is scleroderma?

Answer 37

Systemic connective tissue disorder causing... - tight shiny thick skin due to collagen build up - systemic involvement --> heart, lungs, kidney, GI

Question 38

What is CREST syndrome?

Answer 38

another name/form of scleroderma C= calcinosis cutis => calcium salt crystals in the skin R= Raynaud's E= esophageal motility disorder & GERD S= Sclerodactyly => claw hand T= Telangiectasias => dilated capillaries

Question 39

How is Scleroderma diagnosed?

Answer 39

+ anti-centromere Ab = limited CREST disease, better prognosis + Anti-SCL-70 Ab = diffuse disease with multiple organ involvement +ANA

Question 40

How do we treat scleroderma?

Answer 40

- DMARDs ==> methotrexate - Steroids - Raynauds = calcium channel blockers to vasodilate - GERD = PPI or H2 blocker