Rheumatology Flashcards by Dylan Null

Pain and stiffness in shoulders and hips that last for several weeks and has no other determined cause.

Often coexists with Giant Cell Arteritis

Does NOT cause Blindness

Polymyalgia Rheumatica

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Signs and Symptoms of Polymyalgia Rheumatica

Shoulder Pain
Pelvic Pain
Difficulties
- combing hair
- putting on a coat
- rising from a chair

Does NOT cause true muscle weakness

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Lab findings of Polymyalgia Rheumatica

↑ ESR
↑ CRP
Anemia

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Polymylagia Rheumatica Treatment

Prednisone
- if no improvement in 3 days → consider other diagnosis

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Affects medium-sized and large vessels. Temporal Artery is frequently affected.

Causes headache, JAW CLAUDICATION, visual abnormalities, scalp tenderness, and throat pain.

CAN cause blindness and large artery complications.

Giant Cell Arteritis

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Signs and Symptoms Giant Cell Arteritis

Thoracic Aortic Aneurysm (17x more likely)
Asymmetry of Pulses in Arm

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Diagnosis of Giant Cell Arteritis

Temporal Artery Biopsy

Temporal Artery Ultrasound
- “Halo Sign” → dark hyper echoic non-compressible area around the vessel lumen representing the vessel wall inflammation

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Giant Cell Arteritis Treatment

Prednisone

IV Methylprednisolone
- IF VISION LOSS

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Diagnosis Criteria of Fibromyalgia

WPI of ≥ 7 + SS of ≥ 5

WPI of 3 - 6 + SS of ≥ 9

with pain for at least 3 months

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Fibromyalgia Treatment

Multidisciplinary Approach

Limited or No Benefit
- Opiates
- Steroids
- Acupuncture
- NSAIDs

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Necrotizing arteritis of medium-sized vessels. Can involve almost any organ. But usually NOT the lungs.

Commonly affects:
- Skin
- Peripheral Nerves
- Mesenteric Vessels

Polyarteritis Nodosa

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Polyartritis Nodosa can be caused by what Virus?

Hepatitis B

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Signs and Symptoms of Polyartertits Nodosa

Extremity Pain
Insidious Onset over Weeks to Months
- Fever
- Malaise
- Weight Loss

Skin Findings:
- Livedo Reticularis
- Subcutaneous Nodules
- Skin Ulcers
- Digital Gangrene

Most Commonly Occur in Lower Extremity
- Ulcerations near the Malleoli

HTN due to Renal Artery Dysfunction
Abdominal Symptoms

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What is needed to Confirm the Diagnosis of Polyarteritis Nodosa?

Tissue Biopsy or Angiogram

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First Line Treatment for Polyarteritis Nodosa

IV Methylprednisolone (High Dose)

Hepatitis B:
- Prednisone with Plasmapheresis

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Disease characterized by:

MUSCLE SYMPTOMS + AUTOANTIBODIES

Causes bilateral proximal and progressive muscle weakness and inflammatory infiltrate in muscle tissue.

Polymyositis

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Polymyositis Signs and Symptoms

Progressive Muscle Weakness (Weeks to Months)

NO FACIAL OR OCULAR WEAKNESS

Respiratory muscle weakness may require mechanical ventilation

Difficult diagnosis in Elderly

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Lab findings of Polymyositis

↑ Creatinine Kinase
↑ Aldolase

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How is Polymyositis diagnosed?

Biopsy
- MRI and EMG can help

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What is the pathology of Polymyositis?

Inflammatory infiltrate of the Endomysium

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Polymyositis Treatment

Prednisone
- may need Methotrexate, Azathioprine or Mycophenolate

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An inflammatory autoimmune disorder → autoantibodies attacking nuclear antigens.

Clinical manifestation result of trapping of antigen-antibody complexes in capillaries of visceral structures or to autoantibody mediate destruction of host cells.

Systemic Lupus Erythematosus

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When do most cases of Lupus develop?

After Menarche and Before Menopause

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Signs and Symptoms of Lupus

Malar Rash (Butterfly Rash)
Panniculitis (inflammation of fat)
Splinter Hemorrhage
Alopecia
Raynaud Phenomenon
Joint Symptoms (earliest manifestation)

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What lab test is almost 100% sensitive for Lupus but not specific?

Anti-Nuclear Antibody (ANA) Test - using HEp-2 cells

How is Lupus treated?

Hydroxychloroquine → rash and joint symptoms Avoid Sun Exposure Rest and NSAIDs Corticosteroids (acute exacerbation)

Patient's with Lupus are at a higher risk of developing what comorbidity?

Malignancy

What medications are most likely to cause Drug Induced Lupus?

Hydralazine Isoniazid Minocycline Sulfasalazine Quinidine

Syndrome of paroxysmal digital ischemia. Commonly caused by an exaggerated response of digital arterioles to cold or emotional stress. Usually symmetric involvement.

Raynaud Phenomenon

What are the 2 Phases of Raynaud's?

Initial Phase → Excessive Vasoconstriction - digital pallor or cyanosis Recovery Phase → Vasodilation - hyperemia and rubor

Raynaud's Treatment

Keep Warm Calcium Channel Blockers

Diffuse fibrosis of the skin and internal organs

Scleroderma (Systemic Sclerosis)

Form of Scleroderma where the skin thickening is confined to the face, neck, and distal extremities. Increases susceptibility to digital ischemia, leading to finger loss and life-threatening pulmonary HTN Also known as CREST Syndrome

Limited Form Scleroderma

Which form of Scleroderma can have small and large bowel hypo-motility?

Both

Form of Scleroderma that involves the Trunk, proximal extremities, lungs, heart, and Kidneys. Causes tendon friction rubs over the forearm and shins. → leathery, crepitus feel

Diffuse Form Scleroderma

Signs and Symptoms of Scleroderma

Rayunaud is usually initial sign Polyarthralgia Telangiectasia Calcifications and Ulcerations of Fingertips Pulmonary Fibrosis

Scleroderma Diagnosis

Skin Thickening of Fingers Raynauds SS Related Antibodies When diagnosis is made, must have screening for organ complications.

Scleroderma Treatment

Symptomatic and Supportive - focuses on organ systems involved Methotrexate - Skin Disease, Arthritis, Myositis Bosentan - Digital Ulceration Sildenafil or Prostaglandins - Pulmonary HTN

What is the #1 cause of Mortality in patients with Scleroderma?

Lung Disease

Systemic autoimmune disorder that affects the glands that produce Saliva and Tears Dry Eyes and and Dry Mouth → Sicca: Most Common Feature

Sjogren Syndrome

Patients with Sjogren Syndrome have an increased incidence of what?

Lymphoma

Signs and Symptoms of Sjogren Syndrome

Xerostomia (Dry Mouth) Loss of Taste Parotid Enlargement Keratoconjunctivitis Peripheral Neuropathies Vasculitis

Labs for Sjogren Syndrome

Schirmer Tear Test - ocular test which measures quantity of tears Parotid Gland Biopsy - cancer doesn't typically occur bilaterally

Sjogren Syndrome Treatment

Artificial Tears Cyclosporine Pilocarpine or Cevimeline Sip Water Frequently

Chronic symmetric polyarthritis with predilection for small joints of the hands and feet. Characterized by synovitis of multiple joints. - Juxta-articular osteoporosis - Destruction of periarticular tissue

Rheumatoid Arthritis

What is important about Rheumatoid Arthritis treatment?

Early Aggressive Treatment is Important

Signs and Symptoms of Rheumatoid Arthritis

Stiffness that lasts more than 30 minutes Affects Neck - spares rest of Spine and SI Joints Boggy, Tender, Warm Joints Episcleritis + Scleritis Rheumatoid Nodules Extra-articular symptoms most common in seropositive RA

What is the most specific blood test for Rheumatoid Arthritis?

Anti-Cyclic Citrullinated Peptide (Anti-CCP)

What is the MOST SPECIFIC TEST for Rheumatoid Arthritis?

Radiographic Tests

What deformities are commonly caused by Rheumatoid Arthritis?

Ulnar Deviation Boutonniere Deformity Swan-Neck Deformity Valgus Deformity of Knee Volar Subluxation of MCP Joint

What is the most common cause of Mortality from Rheumatoid Arthritis due to?

Cardiovascular Disease

Rheumatoid Arthritis Treatment

Methotrexate NSAIDs Corticosteroids

Asymmetric Sterile Oligoarthritis → Reiter Syndrome Usually occurs after GI or GU infection → Often Associated with Chlamydia → Usually occurs 1 - 4 weeks after

Reactive Arthritis

What is very commonly associated with Reactive Arthritis, besides Chlamydia?

HLA-B27 Antigen

Reactive Arthritis Signs and Symptoms

Conjunctivitis Urethritis Arthritis "Can't See, Can't Pee, Can't Climb a Tree" Fever + Weight Loss Mucocutaneous Lesion Fingernail Involvement

Reactive Arthritis Treatment

NSAIDs Rifampin + Doxycycline → Chlamydia

Acute monoarticular arthritis caused by overproduction or under excretion of uric acid.

Gout

What joint does Gout usually affect?

MTP Joint (Podagral)

What can increase uric acid production and decrease renal excretion?

Alcohol

What medications can trigger Gout flares?

Diuretics ASA Niacin (Vitamin B) Cyclosporine

Nodular deposit of urate crystals with an associated foreign body reaction → Gout

Tophus

Patient's with Gout are at increased risk of what?

Uric Acid Kidney Stones - avoid Thiazide Diuretics

Common Clinical Findings of Gout

Sudden Onset Alcohol Medication Changes Hospitalization Fever up to 39C is Common

What is diagnostic of Gout?

Joint or Tophus Aspiration → Needle-like negatively birefringent under polarized light microscopy

What can be seen on X-Rays of patients with Gout later in the disease process?

Punched-out erosions with overhanging rim of cortical bone

Acute Gout Treatment

Naproxen or Indomethacin Colchicine (if less than 36 hours) Corticosteroids - if intra-articular → joint aspiration and Gram stain first

Chronic Gout Treatment

Diet Avoid Hyper-uricemic Meds Colchicine Prophylaxis (anti-inflammatory) - doesn't affect uric acid Allopurinol → do not start urate lowering treatment during acute attack!

Calcium Pyrophosphate Deposition - fibrocartilage and hyaline cartilage are affected → chondrocalcinosis Often occurs after surgery

Pseudogout

What joints does Pseudogout usually affect?

Knees and Wrists

Psuedogout of the Atlantoaxial Junction

Crowded Dens Syndrome

Pseudogout Treatment

NSAIDs + Colchicine

Arthritis that has an onset before 16 years old and lasts for at least 6 weeks.

Juvenile Idiopathic Arthritis

What is a common manifestation of Juvenile Idiopathic Arthritis?

Chronic Synovitis

Type of Juvenile Idiopathic Arthritis: Fewer than 5 joints affected within 6 months of diagnosis. Some will progress later to polyarticular disease → Extended Oligoarthritis

Oligoarticiular JIA (40 - 60%) - best prognosis

Type of Juvenile Idiopathic Arthritis: 5 or more joints are affected in first 6 months. Classified as RF Positive or Negative

Polyarticular JIA (20 - 35%)

Type of Juvenile Idiopathic Arthritis: Present with systemic inflammation - Recurring spiking fever - Rash (salmon pink macular) - Appear Sick - Arthritis appears within 6 weeks to 6 months

Systemic Onset JIA (10-15%)

Type of Juvenile Idiopathic Arthritis: Tenderness at Insertion Sites → Especially ACHILLES TENDON Lower Extremities are Most Affected HLA-B27 (+) NO PSORIASIS

Enthesitis Related JIA (5-10%)

What should all pediatric patients with bone or joint pain receive?

CBC → Exclude Leukemia

What is the GOLD STANDARD for Juvenile Idiopathic Arthritis?

MRI

Juvenile Idiopathic Arthritis Treatment

NSAIDs Corticosteroids DMARDs Eye Monitoring PT

Rheumatology Flashcards

(80 cards)