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Flashcards in Rheumatology Deck (331):


*most common cause of generalized musculoskeletal pain in women 20-55 yr of age, F:M ratio >6, 2% population


clinical features of fibromyalgia

*diffuse aches/pain > 3 months, arthralgias
*paresthesias(numb,tingle,burning,creepy/crawling sensation)
*fatigue,sleep and mood disturbance,depression/anxiety
*headache, IBS,no inflammatory muscle and joint disease
*tenderness >11 of 18 tender point sites


Tx fibromyalgia

*tx comorbid:mood disturbance, sleep disturbance
*regular aerobic exercise, cognitive behavioral therapy
*low dose amitriptyline 25-50mg or flexeril 10-30mg hs
*pregabalin, duloxetine or milnacipran (serotonin-norepi)
*ultram and or tylenol


septic joint fluid analysis

*glucose very low
*>80,000 leukocyte count (>75% PMNs)


joint fluid analysis in gout

*needle shaped
*negative birefringent under polarizing microscopy


Joint fluid analysis of pseudogout

*weakly birefringent under polarizing microscopy


pain in the buttock radiating to one leg with tendernes in the sciatic notch

piriformis syndrome


antibody assoc w SLE

dsDNA,Sm (smith)


antibodies assoc with drug induced SLE



antibodies assoc with subacute cutaneous SLE



antibodies assoc with scleroderma

Scl 70


antibodies assoc with CREST



antibody assoc with mixed connective tissue disease



antibody assoc with polymyositis, dermatomyositis

Jo1, anti-SRP, anti-Mi-2


antibody assoc with Sjogren syndrome



antibody assoc with Wegener granulomatosis

C-ANCA (Ab to proteinase-3)


antibody assoc with Churg-Strauss and microscopic polyangitis

P-ANCA (Ab to myeloperoxidase)


antibody assoc with Rheumatoid arthritis

RF, CCP (cyclic citrullinated peptide)


diagnostic criteria for Rheumatoid arthritis

*pt must have at least 1 swollen joint not explained by another disease plus 6 more point below:
*Joint involvement

*serologic studies
*acute phase reactants
*disease duratin


common joints involved in RA

*proximal interphalangeal
*metatarsophalangeal joints


Poor prognostic factors in RA
*early onset of severe synovitis w functional limitation
*older age, female sex, cigarette smoking
*bony erosions
*high titerrs RF or anti-cyclic citrullinated peptide antibodies

*elevated sed rate and c reactive protein
*family hx of severe RA
*extra articular manifestations
*positive HLA-DRB1 0401 or HLA-DRB1 0404


how to monitor acitvity of rheumatoid arthritis?

sed rate
c reactive protein


strong risk factor for development of RA


*smokeless tobacco does not increase the risk


poor prognastic factors in rheumatoid arthritis:
*early onset severe synovitis w functional limitations
*older age, female sex, cigarette smokers
*bony erosions
*high titers RF or anti-cyclic citrullinated peptide antibodies

*elevated sed rate and CRP
*extra articular manifestations
*family hx severe RA
*positive HLA-DRB1 0401 or 0404


How to monitor activity of RA?

sed rate and CRP


smokeless tobacco

does NOT increase risk of RA


Treatment of RA

*steroids-bridge to effective DMARDs, dose <10mg/d
*DMARDs-disease modifying antirheumatic drugs
*Biological agents


*initiate within 3 months after diagnosis
*prior to start of these, give patient:influenza, pneumococcal, hepatitis B and herpes zoster vaccines

*non biological agents: methotrexate (folate antagonist)**BEST initial therapy, others: sulfasalazine, hydroxychloroquine, minocycline, leflunamide
*biological agents: TNF antagonists and NON-TNF agents


methotrexate contraindications:

liver and kidney disease
heavy alcohol consumption
those that plan pregnancy in near future


TNF antagonists:






RA biologic agents

*not recommended to combine agents
*live vaccines are contraindicated, give vaccines one month prior to starting therapy
*goal of tx: no evidence of disease or inflammation


toxicity of methotrexate

*subacute pneumonitis-rare but can be fatal
*pulmonary fibrosis
*folic acid deficiency
*teratogenic-discontinue at least 3 months prior to pregnancy


hydroxychloroquin toxicity

*retinal toxicity-yearly eye exams



teratogenic-when stop drug to get pregnant cholestyramine is used to help eliminate the drug


side effects of TNF agents
*TB reactivation- do PPD prior to start of therapy
*SLE like autoimmune disease

*demyelinating disorder
*aplastic anemia
*severe allergy and aseptic meningitis
*hepatotoxicity,optic neuritis, interstitial lung disease


contraindications to TNF agents
*current or recurrent infections

*pregnancy or lactation
*uncompensated CHF
*active malignancy within 3-5 years (except skin cancers)


COX 2 inhibitors
*no effect on platelet function or bleeding time
*less GI toxicity
*renal toxicity similar to NSAIDS
*contraindicated if have Aspirin allergy

Side effects:
increase risk of Cardiovascular events-MI, CVA,HTN, heart failure, and death


complications of rheumatoid arthritis
*cardiovasc dz-#1 cause of death
*ruptured popliteal cyst-mimic DVT do ultrasound

*tendon rupture-unable to extend fingers
*atlantoaxial subluxation-may compress spinal cord, paresthesias, occipital headaches,urinary retention. do flexion xray cervical spine before intubation, do nasal intub w pt upright/neutral
*vasculitis-may see foot or wrist drop


Diagnostic criteria for SLE-4 or more of these required:
*malar rash
*discoid rash *non erosive arthritis
*photosensitivity *oral ulcers
*pleuritis or pericarditis

*persistent proteinuria or cellular casts
*seizures or psychosis
*cytopenias-hemolytic anemia,leukopenia/lymphopenia, thrombocytopenia *antinuclear antibodies
*anti-Sm, anti-dsDNA or antiphospholipid antibody


drugs that can cause drug induced Lupus:

*TNF agents
*interferon alpha


clinical features of drug induced lupus

*fever, arthralgia and serositis
*antibodies and complement are normal
*95% have antihistone antibody (>50% in SLE)
*NO kidney or CNS involvement


Anti-Ro/SSA antibody assoc with
*subacute cutaneous lupus
*neonatal lupus

*ANA negative lupus
*Sjogrens syndrome
*neonatal lupus dermatitis


Antiphospholipid Antibody syndrome

*anticardiolipin antibodies (IgG,IgM)
*lupus anticoagulant
*anti-beta2 glycoprotein 1 antibodies
*can occur as independent syndrome or secondary to SLE


Clinical features-antiphospholipid antibody syndrome
*venous thrombosis, arterial thrombosis
*pregnancy loss
*elevated PTT (normal PT), thrombocytopenia
*livedo reticularis

*cardiac valve disease
*thrombotic microangiopathy- renal failure,HTN,proteinuria
*Catastrophic syndrome- thrombosis in at least 3 organs, 50%mortality


treatment antiphospholipid syndrome
*asymptomatic-no tx
*thrombotic episode-heparin then warfarin

-no prior abortion-no tx
-hx preg loss=>aspirin plus heparin
-hx prior thrombus=>full anticoag w heparin


skin manifestations of SLE

*butterfly rash
*subacute cutaneous lupus
*discoid lupus
*mucosal ulcers, Raynaud's phenomenon


renal manifestations of SLE

*mesangial, focal proliferative, diffuse proliferative, membranous, advanced sclerosing


CNS mainifestations of SLE
*peripheral neuropathy
*mononeuritis multiplex
*cranial neuritis
*transverse myelitis

*aseptic meningitis


lung manifestations of SLE
*lupus pneumonitis
*alveolar hemorrhage
*pulmonary HTN

*interstitial lung disease


CVS manifestations of SLE



Joint manifestations of SLE



Hematologic manifestations of SLE

*autoimmune hemolytic anemia


Causes of death with SLE

*#1-coronary artery disease
*organ damage


tx of SLE

low to high dose steroids depending on location/type of symptom
hydroxychloroquine-skin rash w low dose steroid
immunosuppressive drug and high dose steroid-severe s/s
diffuse proliferative GN-see next card


SLE tx of diffuse proliferative glomerulonephritis

*Induction-prednisone + mycophenolate or cyclophosphamide
*Maintenance- mycophenolate


Scheroderma type and antibody assoc with that type

1. Limited scleroderma-anti=centromere
2.Diffuse scleroderma-SCL-70
3. Overlap-assoc w other rheumatic dz like polymyositis- RNP


Limited scleroderma

*distal to elbow and knees
*may affect face
*CREST syndrome
*pulmonary artery hypertension


Diffuse scleroderma

*proximal to elbow and knees
*may affect the face
*interstitial lung disease
*scleroderma renal crisis


CREST syndrome

*Esophageal dysmotility


skin manifestations of scleroderma

*swell and puffiness in digits & hands
*terminal digital pitting ulceration or gangrene


musculoskeletal manifestations of scleroderma

*inflammatory nonerosive arthritis
*loss of joint mobility due to fibrosis of the skin
*tendon friction rubs-predict the development of aggressive diffuse skin involvement and visceral complications


vascular manifestations of scleroderma

*raynauds phenomenon
*abnormal nailfold capillaries


GI manifestations of scleroderma
*GERD caused by lower esophageal sphincter tone
*dysphagia-stomach, sm bowel, colon may see ileus and pseudo-obstruction

*diarrhea due to bacterial overgrowth due to dysmotility
*GI bleeding from mucosal telangiectasis and gastric antral venous ectasia
*wide mouth diverticula


Scleroderma renal crisis
*most common cause of death
*HTN, microangiopathic hemolytic anemia, proteinuria, azotemia, thrombocytopenia
**high dose steroids increases risk for this

ACE inhibitor w aggressive titration even if pt on dialysis
*even in pregnancy with this complication ACE is used


Pulmonary artery Htn and intersitial lung disease of scleroderma
*both are poor prognosis predictors
*detect by periodic PFT's and ECHO for early detection PAH

*right heart cath w suspected PAH on ECHO


cardiac manifestations of scleroderma

*cardiomyopathy w systolic or diastolic dysfunction


Primary Raynaud's phenomenon

*attacks are mild
*symmetrical involvement of both hands
*no digital ulcers or gangrene

*no clinical features suggestive of a secondary cause
*normal ESR
*negative ANA


Primary Raynauds-aggravating factors

*nicotine,narcotics,estrogen, interferon
*cocaine, sympathomimetic agents
*carpal tunnel syndrome
*use of vibrating tools


Work up of secondary raynauds



treatment of primary Raynaud's phenomenon

*stop smoking
*avoid cold exposure
*nifedipine, aspirin, topical nitrates- if it interferes with daily activity or assoc with digital tip ulcers


Seronegative Spondyloarthropathies-diseases in this group:

*ankylosing spondylitis
*psoriatric arthritis
*reactive arthritis

*enteropathic arthritis: Crohns
Ulcerative colitis
Whipple disease


Common feature of seronegative spondyloarthropathies

*sacroiliitis and spondylitis
*peripheral asymmetric arthritis

*HLA B27
*negative RF & ANA
*involvement of other organ systems: eye, aortic ring, skin, mucosa


clinical features of ankylosing spondylitis
*insidious onset
*low back pain and stiffness, worse in am, better w activity
*reduced forward flexion of the spine
*male preponderance, peak age onset age 20-30

*inflammatory asymmetrical peripheral arthritis:hips, shoulders and other peripheral joints
*decreased chest expansion
*elevated sed rate and CRP
*negative ANA, RF


diagnosis of ankylosing spondylitis
*xrays of sacroiliac joints showing sacroiliitis=>MRI if xray (-)
*spine: squaring of vertebral body
bamboo spine

*95% (+) HLA B27 but itself is not diagnostic


complications of ankylosing spondylitis

*aortic insufficiency
*pulmonary fibrosis
*spinal fracture with minimal trauma
*amyloidosis and cardiac conduction defects


Tx ankylosing spondylitis

*TNF agents


clinical features of Reactive arthritis
*spondyloarthropathy 1-3wks after enteric or urogenital infection - #1 chlamydia
*85% HLA B27 positive
*rash palms & soles, circinate balanitis

*severe if HIV pt- do HIV testing in all w this arthritis
*TRIAD:arthritis, conjunctivitis, urethritis or cervicitis
*acute, asymmetric inflam. oligoarticular arthritis of lower extremity
*pleuropericarditis, aortic regurg.,amyloidosis, neuro symptoms


Tx reactive arthritis

*intraarticular steroids
*cytotoxic tx: azathioprine, MTX-NOT IF HIV +


clinical features of Psoriatric arthritis

*erosive peripheral arthritis: symetrical or asymetrical
*involvement: DIP joints, spondylitis
*nail changes: pitting, onycholysis
*10% (+) RF or CCP antibodies
* (+) CCP correlates with erosive disease


treatment of psoriatric arthritis

*MTX for skin and erosive joint disease
*TNF agents
**NO anitmalarials or steroids=> may aggravate psoriasis


Inflammatory Bowel disease associated arthritis

*acute and remitting peripheral arthritis correlates w bowel inflam.
*spondylitis does NOT correlate with bowel inflammation

*relapsing or chronic peripheral arthritis w predominant involvement of MCP joints => less correlation w intestinal inflammation



acute inflammatory arthritis induced by deposition of monosodium urate crystals in synovial fluid and other tissues and is assoc with hyperuricemia


Risk factors for gout

*thiazides, cyclosporine, low dose aspirin
*increase dietary purines
*ethanol, soft drinks, fructose


treatment acute gout
*NSAID-tx of choice:naproxen 500mg BID x 5 days
indomethacin 50mg TID x 2 d then 25mg TID
x 3 days
*steroids-prednisone 30mg /d for 5 days

*colchicine 1.2mg at first sign of gout then 0.6 mg one hour later
*intraarticular steroids- if limited to one or two joints


indications for lowering uric acid
*frequent & disabling attacks of gouty arthritis =/> 2 per year

as above


begin uric acid lowering therapy

*not in acute gout
*start tx 2-4 weeks after flare of gout has resolved


goal of uric acid lowering meds

uric acid level <6


flare prophylaxis during initiation of urate lowering therapy

*colchicine 0.6 mg BID or naproxen 250mg BID x 6 months


Tx of hyperuricemia (gout)

*Probenecid: avoid if hx kidney stone, creatinine cl <30


Pseudogout (CPPD disease)
*may cause inflammatory or degenerative arthritis
*calcium pyrophosphate crystals: rhomboid shape, weakly birefrinent

*common: knees, wrists, hips,shoulders, elbows, MCP's
*xray: chondrocalcinosis
*eval: ca++, Phos, alk phos, ferritin, iron , TICB, TSH
*tx: NSAIDS, steroids - oral, IM, intraarticular
*recurrent-colchicine or low dose NSAIDS


causes of pseudogout

*hyperparathyroidism, hemochromatosis, hypothyroidism
*low P, low Mg, high calcium
*gout, amyloidosis, Wilson's disease


clinical features of polymyalgia rheumatica
*subacute or insidious onset pain & stiffness neck, shoulder, pelvic girdle muscles +/- local tenderness
*usually > age 50
*fatigue, low fevers, weight loss

*limit of active and often passive ROM of shoulder due to pain
*asymetric nonerosive peripheral arthritis, carpal tunnel syndr
*swell & pitting edema -dorsum of hands
*high sed rate and CRP
*no muscle weakness


treatment of polymyalgia rheumatica

*prednisone 15mg/day-dramatic response and taper slow as tol.
*follow sed rate and CRP
*MTX can be used as steroid sparing agent
*if no response to tx, consider temporal artery biopsy


Temporal arteritis (GCA)-giant cell arteritis

*patchy granulomatous vasculitis
*medium size and large arteries
*usually > age 50


clinical features of temporal arteritis
*headache, temporal artery tenderness, fever
*jaw, pharyngeal or tongue claudication
*symptoms of polymyalgia
*transient vision loss may go to blind,diplopia,ptosis, visual

*involvement of aorta and its branches can lead to : TIA, CVA, arm claudication, unequal BP's, aortic regurg, aortic aneurysm or dissection


diagnosis of temporal arteritis

*high sed rate and CRP
*color duplex U/S: dark halo around lumen of temporal artery
*temporal artery biopsy- if negative one side, biopsy the other
*MRA or CTA for large vesel vasculitis


treatment of temporal arteritis

*high dose prednisone and slow taper, usually 1-2 years!
*add aspirin if not contraindicated
*MTX if patient has difficulty getting off prednisone


Polyarteritis nodosa

*involves medium & small size arteries, systemic involvement
*mononeuritis multiplex with foot drop or wrist drop
*Dx: biopsy of involved area
*Tx: prednisone & cyclophosphamide


Allergic granulomatosis (Churg Strauss syndrome)

* predominant lung involvement
*with eosinophilic infiltrates and eosinophilia
*Tx: prednisone & cyclophosphamide


Wegeners granulomatosis
*granulomatous vasculitis of upper & lower resp. tract
*necrotizing glomerulonephritis, systemic symptoms
*recurrent: sinusitis, OM, bloody nasal discharge

*cough, dyspnea, hemoptysis, lung nodules
*Dx: C-ANCA, tissue biopsy (kidney, lung)
*Tx: prednisone, cyclophosphamide +/- plasmapheresis


Henoch-schonlein purpura
*see child after URI
*purpura, arthralgia, abdominal pain, GI bleeding

*renal involvement with IgA deposition
*normal serum compliment
*skin biopsy: leukocytoclastic vasculitis w IgA deposition
* Tx: analgesics, steroids for progressive disease


Leukocytoclastic vasculitis
*small vessels with predominant cutaneous involvement
*purpura, skin nodules, ulceration, urticaria, livedo reticularis

*causes: drug reaction, infections, serum sickness or autoimmune disorders
*Tx: antihistamine, colchicine, dapsone, steroids


Takayasu's Arteritis

*involves aorta and its branches
*patchy granulomatous vasculitis

*unequal or absent peripheral pulses, systemic symptoms
*affects young women


Microscopic Polyangitis

*most common cause of pulmonary-renal syndrome
*glomerulonephritis & pulmonary capillaries

* (+) P ANCA
*renal biopsy: pauci-immune necrotizing glomerulonephritis (similar to Wegeners)


types of polymyositis & dermatomyositis

*assoc w other collagen vasc dz (overlap myositis, +RNP)
*assoc w malignancy


Rashes assoc w dermatomyositis

*Grottons papules-scaly rash over extensor surface of hand joints
*Heliotrope rash-violaceous discolor of eyelid &periorbital area

*rash involving anterior neck and chest (V sign), photosensitive rash
*mechanics hands-scaly lesions w fissuring of the skin over the lateral margins of fingers


clinical features of Polymyositis & Dermatomyositis
*proximal muscle weakness
*elevated: CPK,aldolase,AST/ALT, LDH
*abnormal nail fold capillary changes
*oropharyngeal dysphagia if those muscles are involved

*antisynthetase syndrome
*anti-SRP(signal recognition particles)-assoc w severe polymyositis & aggressive disease
*anti-Mi-2 seen in dermatomysositis


Sjogrens syndrrroe
*lymphocytic infiltration of exocrine glands
*dry eyes, dry mouth & dental caries
*bilateral parotid enlargement
*interstitial lung disease

*cutaneous vasculitis, interstitial nephritis w distal RTA
* increased sed rat, and increased globulins
* (+) ANA, RF, antibodies to Ro/SSA & La/SSB
*increased risk of lymphoma
*Dx:lower lip bx-lymphocytic infiltration


septic arthritis-etiology

* N gonorrhea
*S. aureus
* gram (-) bacilli


septic arthritis-risk factors

*chronic arthritis
* diabetes
*steroid use

*GC-incr of dissemination during pregnancy & menses


septic arthritis- diagnosis

*synovial fluid cell count-25000-100,000 w >90% PMN's
* synovial fluid gram stain & culture
*blood culture
*culture other sites if GC is suspected


septic arthritis-treatment

*gram (+) cocci=vanco
*gram (-) bacilli= 3rd gen ceph + aminoglycoside

*gram stain negative-rocephin & vanco
*drug addict- ceftazidime +/- gentamicin


septic arthritis in prosthetic joint

*early (<3 months after surgery)-virulent organisms: S.aureus and gram (-) bacilli

*late (after 3 months)- coagulase negative staph


Lumbar nerve root compression

*L4: absent knee jerk
*L5:impaired dorsiflexion of foot and toes

*S1:impaired plantar flexion of foot & toes, absent ankle jerk
*SLR (+) L5-S1 nerve root involvement
*reverse SLR (+) L2-L4 nerve root involvement


Paget's disease

*osteoclast mediated bone resorption followed by imperfect osteoblast mediated bone repair


common bones involved with Paget's disease



symptoms of Paget's disease

*bone pain
*back pain
*bowing of tibia
*warmth over affected bones


diagnosis of Paget's disease

*elevated alk phos (r/o vit D deficiency)
*plain xrays: osteolytic areas, bone expansion, patchy osteosclerosis
*bone scan followed by radiography of hot spot


complications of Paget's disease

*deafness, fractures, osteosarcoma
*osteoarthritis, spinal cord compression
*high output cardiac failure


treatment of Paget's disease

*asymptomatic-no tx
*bisphosphonates-reduce pain and lowers alkaline phosphatase
*alk phos is useful marker of disease extent and activity


osteoarthritis risk factors

*age,gender,race,obesity, repetitive use
*prior inflammatory arthritis

*wilsons disease
*diabetes, hyperparathyroidism, acromegaly
*ehlos-danlos syndrome, Marfan syndrome


physical findings-osteoarthritis

*bony enlargement
*bone tenderness

*absence of palpable warmth
*normal sed rate
*noninflammatory synovial fluid w WBC <2000


common joint involvement in osteoarthritis

*hip, knee, DIP, PIP
*first carpometacarpal joints

*xrays show: joint space narrowing
subchondral sclerosis


patient with moderate-severe knee osteoarthritis what do you recommend?

*quadriceps strengthening exercises


32 y/o with 3 wk hx pain and swelling of joints hands/feet. tick bite 4 weeks ago. removed tick within 2 hours. afebrile, VSS.exam:swell & tender MCP and prox. interphalangeal joints of both hands, feet swollen & tender MCP & prox as well. 3 yr old w fever and rash cheeks reently.lab:elev.CRP, sed rate

how will you confirm the diagnosis?

*IgM antibody to Parovirus B19 virus


60 y/o hx DM,HTN,gout has fever/chills,swell behind right elbow. T103,hr 120, bp 110/70. exam:marked pain,swell,erythema that extends above & below the elbow. lab: wbc 20K with 80% PMNs
whats next appropriate step?

aspiration of the olecranon bursa and start IV vancomycin


50 y/o female one month of dyspnea on exertion,decr exercise tolerance, edema feet/ankles. 10yr raynauds, recur heartburn,thick skin both hands.exam: 2+ pit edema feet/ankles, engorged JVP,prominent a waves, loud P2,S4,grade 3/6 holosyst. murmur LLSB, sclerodactyly hands, cxr normal . PFT-DLCO 55%

whats most likely diagnosis?

*limited cutaneous scleroderma w pulmonary artery hypertension


16 y/o boy fell on outstretched hand and has pain left wrist. exam: tender lateral wrist in anatomical snuff box, xray-no fracture. splint to immobilize and 2 wks later still has pain and repeat xrays still negative. now recommend?

bone scan


20 y/o female w intermittent fever, macular rash abdomen and polyarthritis x 6 weeks. the rash appears during temperature spikes. exam: generalized lymphadenopathy, mild hepatomegaly, palpable spleen tip, swell of knees, left ankle and right wrist. Lab: WBC 18K, 80% neutr., sed rate 100, neg RF,ANA, bld cult

most likely diagnosis?

*adult onset stills disease


56 y/o male gradually incr pain and swelling hand joints few months and decr libido. brother died cirrhosis. exam: swell/tender few MCP's and prox. interphalangeal joints both hands in asymetrical fashion. skin is pigmented and liver slight enlarged. xray hands-OA. lab:glucose 175, mild incr AST/ALT,alk phos

what now recommended?

*serum iron, transferrin saturation and ferritin levels(hemochromatosis)


40 y/o male one week hx diffuse, intense burning right foot. severe pain w light touch of blanket. 2 wk age he fell and injured this foot. xray negative. exam: swollen tender w mottled cyanotic appearance and slight cold and moist compared to left foot. all pulses normal. likely diagnosis?

reflex sympathetic dystrophy syndrome


30 y/o female w weakness, low grade fever, pain right arm w sustained use for 3 months. exam: T100, bp 70/50 right arm, 130/80 left arm, bruit in right axilla. Lab: hgb 10, wbc 7K, sed rate 90, ANA & RF negative. likely diagnosis?

Takayasu arteritis


42 y/ofemale w burning pain fingers left hand, worse at night while on her computer. exam: decr sensation palmer surface thumb, index and middle fingers, and radial aspect ring finger. slight atrophy thenar muscles and all movement of thumb are normal. the symptoms are caused by ?

compression of the median nerve at the wrist


32 y/o female w swell right lower extremity for 4 days. hx arthralgias of mult joints and develops facial rash after exposure to sun for several yrs. no living children, 2 spont. abortions. exam:edema right leg and thigh, venous doppler positive for right femoral artery vein thrombosis. Lab: hgb 13, plt 70K, wbc 7K, ANA+, VDRL +, + cardiolipin antibody and lupus anticoagulant.

whats the most appropriate treatment for this patient?

*IV heparin followed by long term treatment with warfarin


80 y/o white male w 2 wk hx pain and stiff shoulders, hips, neck area, arthralgias, low grade fever and poor appetite, exam: no muscle weakness or joint swelling. basic lab is normal. what test to order to confirm the diagnosis

sed rate


45 y/o male w hx diffuse scleroderma x 3 years has marked weakness, severe headaches, blurring of vision over last 3 days. exam: bp 240/130, hr 90, skin changes of scleroderma, fundi w blurring of disc margeins and mult. retinal hemorrhages. lab: hgb 7, wbc 12K, retic ct 8%, peripheral smear-frag rbc's, LDL 700, bun 40, creatinine 2.5

what would you now recommend?

*ACE inhibitor


50 y/o male w long hx ankylosing spondylitis w sudden onset of sharp pain in upper back in the mid-thoracic region. exam: 160/60, hr 80 and bounding, early diastolic decrescendo murmur in aortic area and increased w expiration. marked tender over 6th thoracic vert. most likely diagnosis

vertebral compression fracture


60 y/o male w 3 mo hx bilateral leg pain,pain w ambulation, esp when descends stairs or walks on incline. pain is assoc w numb, tingling and weakness both legs. symptoms resolve within 5-10 min of resting. all peripheral pulses are normal and no neuro signs. you should now get what study?

MRI of lumbar spine


16 y/o boy w 4 day hx of pain in legs & abdomen, rash over both legs and pain & swelling of right ankle and left knee. 10 days ago had URI. exam: T100.5, extensive purpuric rash both legs, swollen right ankle and left knee. Labs: cbc,bun/cr,ANA,ASLO,throat culture all negative. urine 3+ protein, 10-20 RBC/hpf. best tx?

acetaminophen and add prednisone if symptoms persist


30 y/o woman w 6 mo hx diffuse musculoskeletal pain, recur HAs, fatigue and insomnia. exam: no muscle weakness or atrophy. palpation has mult tender points neck, scapula, butt, elbows and knees. lab-cbc,sed rate, cpk normal. best course of action?

start low dose amitriptyline


30 y/o female 3 mo hx RA. Ibuprofen 1600mg/d-some improvement.exam: swell, tender wrists, MCPs prox interphal. joints. Lab: +RF, sed 50. xray no bone erosions of hands. now what to recommend?

add weekly MTX


50 y/o male long hx RA, has sudden onset pain and swell of right leg. exam:erythema, edema, tender right calf. Homans + on right side. now request?

U/S of popliteal area and calf


70 y/o female w pain L knee for 3 days. has long hx OA and knee replacement Left 2 years ago. takes naproxen. exam: T 100, bp 150/80 , pain w movement left knee and effusion. Lab: CBC, CMP normal, sed rate 70 , xray moderate effusion. most likely dx?

septic arthritis in the prosthetic joint


28 y/o male w 4 day hx pain and swell of L ankle, R knee, toes of L foot. 2 wk ago episode of urethritis - tx w doxycycline. exam: swelling and tender above areas, sausage edema toes , ulcer of palate, conjunctival injection of L eye, scaly papular rash on palms and soles & clear urethral dischg-culture of dischg and synovial fluid are negative. you now request what test?



70 y/o female w right side HA, jaw pain w eating, pain & stiff neck muscles for 1 week. Intermittent blur of vision in R eye for 2 days. exam: tender R parietal area. muscle strength normal. lab: Hb 10, WBC 10K, sed 94, CPK normal. whats best course of action?

start high dose prednisone and sched temporal artery Biopsy


56 y/o male w one wk hx muscle weakness & fatigue, hx HTN and hypercholesterolemia on propranolol, lovastatin and niacin for 2 mo. exam: gen weakness, lab: CBC, CMP wnl, CPK 1200. now you recommend??

discontinue lovastatin


32 y/o male w fever, weak, arthralgia and abd pain for 3 weeks. 2 days ago sudden onset weak of R hand. exam: bp 170/100, hr 80. diffuse abd tenderness no rebound, weak extensors or R hand.Lab: hb 9, wbc 14K, sed rate 110, urine 1+ protein, 50-100 rbc/hpf. chest and abdominal xrays normal . Diagnosis?

polyarteritis nodosa


acceptable treatment of ACUTE gouty arthritis

*oral or intraarticular steroids
*oral colchicine



*specific for SLE
*indicator of disease activity (as are complement levels)
*identifies SLE patients with potential for significant renal dz
*Not present in drug induced lupus


70 y/o male presents w progressive loss of hearing in both ears assoc w enlargement of the skull and low back pain. x rays of pelvic brim show coarse trabecular pattern in lumbar spine & pelvis and area of localized osteoporosis of the skull. what complications are assoc w this condition

* osteogenic sarcoma
*deafness due to compression of the 8th cranial nerve
*cardiac failure


side effects of long term tx with oral cyclophosphamide

*chronic cystitis
*carcinoma of urinary bladder


anticentromere antibodies are found in

CREST variant of scleroderma
limited scleroderma
increase risk of pulm. artery hypertension and improved survival


anti-DS DNA antibodies are highly specific for



Jo 1 antibodies (type of anti-synthetase antibody) assoc with

dermatomyositis & polymyositis


anti RNP antibodies are found in

mixed connective tissue disorders


anti histonne antibody

*drug induced lupus and SLE
*mainly used to rule out drug induced lupus due to procainamide, hydralazine, chlorpromazine & quinidine


anti-Scl-70 antibody

*diffuse scleroderma
*identifies increase incidence of interstitial lung disease and reduced survival


ANA patterns are pretty much ignored as to diagnosis except this pattern

*centromere-see in limited scleroderma (CREST) and primary biliary cirrhosis


rheumatologic diseases that may be ANA+ and the frequency of ANA positivity

*drug induced lupus 100%
*SLE 98%

*polymyositis/dermatomyositis 40-60%
*RA 40%
*MCTD 95%
*limited scleroderma( previously called CREST) & diffuse sclero 60-90%
*sjogren syndrome 70%


a positive ANA is not specific enough to

diagnose any disease, need to do further


c-ANCA + plus anti-PR3+ when both + are very specific for:

wegeners granulomatosis


diseases assoc with p-ANCA + and anti-MPO +

**Churg-strauss vasculitis
*pauci-immune glomerulonephritis
*anti-glomerular basement membrane antibody


p-ANCA + plus anti-MPO (-) assoc with

**PAN-polyarteritis nodosa
*crohn dz and ulcerative colitis
*chronic active hepatitis
*microscopic polyangitis w kidney involvement
*anti-glomerular basement membrane antibody


positive c ANCA and positive PR3 think Wegeners

positive p-ANCA think Churg-Strauss and PAN


dx drug induced lupus

*anti-histone +
*and no other autoantibodies
*and they are taking one of the drugs that can cause


low complement is seen in

*HELLP (hemolysis, elevated liver enzymes, low platelets), eclampsia
*vasculitis (rheumatoid and other)


complement levels that are decreased with SLE and are used to follow disease activity

C3, C4, CH50



*rarely used clinically as it is fairly common in normal healthy white population

but high percentage of pts with spondyloarthropathy/Reiters syndrome and ankylosing spondylitis as well as psoriasis and inflammatory bowel disease


HLA-DR 2,3,4

DR2 & DR3-assoc more often with SLE
DR3 occasionaly found in sjogrens and polymyositis
DR4 associated with SEVERE RA


although it does not cause Reiters syndrome, Klebsiella pneumoniae has an enzyme that cross-reacts with the

HLA-B27 test


normal joint fluid aspirate

*wbc 0-200
assoc dx: normal, OA, internal derangement


Non inflammatory joint fluid aspirate

*wbc 200-2000
*may see RBC's
*assoc dz: OA, internal derangement, TB, PVNS (pigmented villonodular synovitis)


Inflammatory joint fluid aspirate

*WBC 2000-50,000
*may see yellow (gout) or blue (CPPD) crystals, RBC's
*assoc dz: inflam arthropathy - RA, gout , CPPD, TB or fungal infection


septic joint fluid aspiration

* WBC 50,000-100,000
*may see crystals, organisms on gram stain
*assoc dz: very inflammed RA, gout, CPPD, bacterial infection


crystals of CPPD (calcium pyrophosphate disease)

* (+) bifringement


crystals of gout

* (-) bifringent


initial diagnostic test of choice for non-traumatic knee disorders (RA or OA)

weight bearing knee xrays


genetic collagen disorders

*Marfan syndrome
*Osteogenesis imperfecta
*Pseudoxnthoma elasticum


osteogenesis imperfecta

*defect in procollagen gene
*osteopenia w brittle bones
*blue sclerae, teeth problems
*hearing loss


S/S of Rheumatoid arthritis
*morning stiffness > 1hour
*fatigue, low grade fever, anorexia , weight loss
**symmetric and polyarticular (RA & SLE)
*hands-DIP joints are spared- see in MCP & PIP

*boutonniere deformity-advanced disease but not specific of RA


common causes of symmetric, polyarticular hand arthritis



arthropathy of hemochromatosis

*commonly involves 2nd and 3rd MCP & PIP joints
*hook like osteophytes on the MCP joints


most common single joint initially involved in RA



site of earliest radiographic changes in RA

forefoot, head of 5th metatarsal may be location of earliest erosion


if a patient w inflammatory knee arthritis presents with a swollen calf, suspect

ruptured Bakers cyst causing pseudo-phlebitis


cervical spine problems of RA:

*severe RA often see C1-C2 subluxation-may see separation of the atlanto-odontoid process >3mm.
*seen best on lateral flexion & extension c-spine xrays

*suspect in RA pt with complaints of recur headache that starts base skull and radiates to scalp,unexplained dizzy, arm tingling
**get these xrays prior to intubation-normal intubation they are at high risk spinal cord injury!!!


areas that are spared in RA

*thoracic, lumbar, sacral spine and SI joints


Diagnostic criteria for RA (4 or more needed for diagnosis)
*morning stiffness >1hour for 6 weeks
*swelling of wrists, MCPs, PIPs for 6 weeks
*swellin of 3 joints for 6 weeks

*symmetric joint swelling for 6 weeks
*rheumatoid nodules
*erosive synovitis xray changes of the hands
*positive rheumatoid factor


extraarticular manifestations of rheumatoid arthritis



cardiac manifestations of RA

*pericarditits & myocarditis
*rheumatoid nodules on the valves
*atherosclerosis-3X increase risk of atherosclerotic cardiovasc. disease--sudden death and MI


renal manifestations of RA

*drug related renal disease
*amyloid renal disease


lung manifestations of RA
*males more often

*exudative pleural effusion w low glucose (<30) and low pH
*diffuse interstitial fibrosis and intrapulmonary rheumatoid nodules


vasculitis as manifestation of RA

*may resemble polyarteritis nodosa and cause nailfold infarcts
*necrosis w ulcer -esp. over the malleoli


nerve manifestation of RA

*mononeuritis multiplex-may see as wrist or foot drop
*carpal tunnel
*cervical myelopathy


eye manifestations of RA



skin manifestations of RA

rheumatoid nodules-25% -indicates potential for more severe dz
*usually extensor surfaces
*can occur lungs & heart valves


blood manifestations of RA

*anemia of chronic disease
*neutropenia-Felty & LGL syndrome


Felty syndrome

*assoc with RA
*TRIAD: RA, splenomegaly, neutropenia

*these pts have long standing RA and high titers of rheu. factor
and subcutaneous nodules
*increased mortality from infection, tx is like RA
*if splenectomy needed and ineffective -prognosis is poor


LGL syndrome (large granular lymphocyte)

*neutropenia, splenomegaly, incr susceptibility to infection

**less assoc with RA
*tends to progress to LGL leukemia
**these patients do POORLY with splenectomy


RA patients with the following should receive early treatment with a DMARD such as methotrexate:
*constitutional symptoms
*progressive synovitis
*rheumatoid nodules

*extraarticular manifestations
*high ESR or high titer rheum. factor
*joint space loss or erosions on plain xrays
*HLA-DR4-not usually necessary to evaluate


antibody that predicts future erosive RA disease

anti-CCP antibody


seronegative spondyloarthropaties

*group of common inflammatory arthrides
*ANA & RF are usually negative in these


seronegative spondyloartropathies include

*ankylosing spondylitis
*"reactive" spondyloarthropathy (aka Reiter syndrome)
*psoriatric arthritits
*enteropathic arthropathy assoc w imfla. bowel disease


common features seronegative spondyloarthropthies
*affects spine, SI joints, entheses-
*asymmetric oligoarthritis-usually lower extremities
*variable assoc w HLA B27
*enthesopathy-inflam at insertion site of ligament or tendon

*sausage shaped digits are common-due to enthesopathy of finger
*immune mediated disorders


buzzwords: sausage digits and pitted nails

its psoriasis



is common in 60-80% of patients with spondyloarthropathies but 6-8% of healthy population is positive for it so is not used diagnostically as is not specific enough. if see it on boards it really tells us nothing


Ankylosing spondylitis
*systemic dz marked by eventual spinal and SI joint fusion="bamboo spine" seen on xrays
*pain is ALWAYS decreased by exercise
*most aduls have symptomatic painful sacroiliitis

*onset typically early adulthood
*30% have uveitis:unilateral pain, photophobia, incr lacrimation
*3% aortitis: aortic insuff.,Heart block, CHF
*apical pulm. fibrosis-rare, late, but pathognomic=cavity>fungus ball can develop


Dx of ankylosing spondylitis

*symptomatic symmetric sacroiliitis confirmed on xrat in the absence of inflammatory bowel dz or psoriasis


Tx ankylosing spondylitis

*stretching and posture training, proper pillow positioning
*DMARDS and biologics
**goal is to prevent fusion and peripheral joint damage
* NSAIDS for pain management


Reactive arthritis
*most common cause of acute, nontraumatic arthritis in person *immunologic reaction to an infection elsewhere in the body

*any recent illness, especially diarrhea, urethritis/STD in prior 2-4 weeks, can also be viral.
*tx NSAIDS, and tx causative infection if indicated


Reactive spondyloarthropathy (prior called Reiters )
*causes:GU:chlamydia, ureaplasma, GI:salmonella, shigella, yersinia, campylobacter, clostridium difficile, C. pneumoniae, viral and HIV

TRIAD: urethritis, conjunctivitis, asymmetric arthritis
*usually large joints of the lower extremity
*skin lesions: keratoderma blennorrhagicum and genital &/or oral ulcers. like pustular psoriasis


enteropathic arthropathy

*peripheral oligoarthritis that occurs w flare ups of inflammatory bowel disease, and improves and remission when bowels clear

*involves only a few joints in lower extremity
*may see erythema nodosum or pyoderma gangrenosum
*tx of bowel dz w sulfasalazine may control peripheral joint S/S


Psoriatic arthritis

*nail pitting, onyholysis(separation of nail from nail bed), and "oil spots"-brownish discoloration under the nails, sausage fingers

*Hand DIP joints common involved in pt w psoriatric nail dz
*TX: NSAIDS, DMARDS in refractory cases, and biologics are highly effective. Cyclosporine A-highly effective and may combine w MTX to control both joint and skin disease


things that exacerbate psoriatric arthritis

*infection - viral, strep pharyngitis
*Beta blockers


causes of osteoarthritis

*idiopathic (primary)
*gout, pseudogout
*joint damage due to hemochromatosis, diabetic neuropathy (charcot joints) and trauma

*characteristics: worse with activity, very slow, progressive onset
*most common joints: hand, feet, knee, hip, spine
*tx:wt loss, exercise, shoe insoles, acetaminophen &/or NSAID, intraarticular injection of hyaluronic acid.
**studies show NO benefit to glucosamine & chondroitin


Gout-hyperuricemia is caused by either:
*increased production of uric acid:
*idiopathic, leukemia, hemolytic anemia, psoriasis, exercise, fructose ingestion , G6PD deficiency

*decreased excretion of uric acid: (90% in this category)
*idiopathic, chronic renal disease, lead nephropathy, alcohol, drugs, DKA


how to tell the cause of gout:

measure uric acid in 24 hour urine collection:
*decreased excretion: normal 24hour urine levels but increased serum levels
*increased production: 24hour urine >800 mg/24hrs uric acid


gout facts/gen info
*onset typically for idiopathic is man age 45, women after menopause
*diuretics, and nicotinic acid increase uric acid levels so are relatively contraindicated in gout pt. ie thiazide in elderly female

*acute renal failure can occur due to precipitation of urate crystals in the collecting ducts-usually due to acute tumor lysis syndrome
*dx by joint fluid analysis -MUST see crystals INTRACELLULAR
*gout can cause fiver
*RA and gout never coexist, premenopausal women rarely get it


CPPD deposition disease facts:
*causes chondrocalcinois-calcium in the cartilage
*most >age 60, and have underlying joint damage from OA or trauma
*crystals are blunt,rhomboid, weak + bifring-blue

*if see in someone


if you see patient on board question with patient with wrist arthritis

think CPPD-and screen for hemochromatosis, hypothyroidism, hyperparathyroidism


HAA-hydroxyapatite arthropathy
*calcium arthropathy
*hydroxyapatite is primary mineral in bone and teeth
*can occur:idiopathic, hypercalcemia/hyper parathyroid states, damaged tissue

*think this dx in elderly patient with very destructive arthropathy of the shoulders,hips, knees, and hands with a noninflammatory synovial fluid and no visible crystals


predisposing factors to disseminated gonorrhea



presentation of disseminated gonorrhea

*fever,migratory polyarthritis,tenosynovitis, dermatitis-red papules that become pustular
*consider in adolescent with knee pain
*joint fluid:mild infla. wbc 10,000-20,000, culture usually sterile
*culture all mucosal surfaces that could have organism
*joint fluid do gonococcal PCR


Whipple disease
*intermittent, inflammatory arthropathy
*recurrent diarrhea over years assoc w malabsorption, fever,neurologic, lymphadenopathy, hyperpigmentation

*memory loss is main neuro symptom-slow progressive dementia
*tropheryma whippleii
*dx-organism in tissue bx of involved system
*tx-bactrim ds for 1 year, recur common


Parvovirus B19
*common cause of aseptic synovitis in adult
*think this in young adult female with school age child hx of "slapped cheek" viral illness several weeks ago with reticular rash and now she has symmetric synovitis of the hands.

as above


causes of aseptic synovitis

*parvo B19
*acute hep B and chronic hep C


acute rheumatic fever

*previous group A strep infection
*fever and polyarthritis
*may see assoc chorea , erythema marginatum, nodules, cariditis-ie prolonged PR interval


lyme arthritis

*tx antibiotics to appropriate duration, then STOP tx, even if pt still has arthralgias

*manifests in stage 3 lyme dz,few months to years after tick bite and is untreated
*asymmetric, one or few large joints
*dx:serum ELISA, confirm western blot, joint fluid for B.burgdorferi by DNA byPCR-use in lyme arthritis only


Adult Still disease
*very distinct "evanescent" macular salmon pink rash that coincides with a daily, high, spiking fever and disappears as fever goes away

*think in FUO patients as well
*other s/s: sore throat, lymphadenitis, myalgia, arthralgia, serositis
*lab: chronic dz anemia, reactive polycythemia, low titer ANA, incr ESR or CRP, elevated transaminase, **serum ferritin 10X normal and this correlates w dz severity,tx is like RA


hemochromatosis arthritis
*occurs 20-40% w hemochromatosis
*often presenting symptom
*affects small joints first, then knee, ankle, shoulders
**esp synovitis of 2nd & 3rd MCPs

*joint fluid is non inflammatory
*morning stiffness , xrays narrow joint spaces, CPPD deposits occur in 50% so may see chondrocalcinosis and the blue crystals
*tx: phlebotomy-doesnt help the arthropathy, tx NSAID,tylenol


acromegaly arthritis

*growth hormone cartilage expansion
*affects large joints and hands
*xray looks like OA-joint space narrow and osteophytes

*look for soft tissue enlargement feet and hands
***carpal tunnel and CPPD are both assoc w acromegaly
*screening test-IGF-1, then growth hormone after given oral glucose if screening is +


neuropathic joints (charcot joints)

*joints destroyed by repeated trauma because of loss of pain sensation and /or proprioception ie: diabetes

*joint findings like severe OA
**terrible looking joint but little pain


HPOA-hypertrophic pulmonary osteoarthropathy

**joint effusion in a smoker who has clubbing of the digits**
* can be familial but most have lung cancer, can be caused by lung infection, TB other lung conditions

*see dull, achy pain thats intense when examine arms/legs with pressure
*noninflammatory effusion wbc


meds assoc with increased risk of SLE

estrogen replacement


SLE and pregnancy

*higher risk of failed pregnancy or complications-flare or fetal problems, esp if disease is active or if she has anti-ds-DNA or antiphospholipid antibodies (APS)

women w APS and hx recur miscarriages-tx during preg w heparin and asa 81mg-lessens risk miscarriage
*heart block in 3rd trim. an be seen in baby of mom w SSA ro and SSB la antibodies
*if mom flares-tx w corticosteroids


APS (antiphospholipid syndrome)
*patients do not necessarily have SLE
*can have IgG, IgM, or rarely IgA
*beta-2 glycoprotein-1 is cofactor necessary
*normal PT, Prolonged PTT,prolonged plasma clot time

*PTT does NOT correct with mixing
*these pts are HYPER coagulabe, (long PTT is only in vitro)
*risk of recur arterial and venous thrombosis, spont. miscarriages
*also see heart valve abnl, livedo reticularis,thrombocytopenia
*tx: lifelong anticoagulants


Sjögren's syndrome

*primary-not assoc with rheumatologic disease
*secondary-may be assoc with any rheum. dz

*assoc w DR3 (as seen in SLE and occ. polymyositis)
*>40X increase risk of lymphoma
*no set diagnostic criteria
*tx symptomatic


if buzz words : heliotrope/violaceous rash or photosensitive rash-esp in the V of the neck

think dermatomyositis


colchicine myopathy/neuropathy

*mimics polymyositis-proximal muscle weakness, paresthesia and elevated CPK
*suspect in gout pt with renal insuff who is taking long-term colchicine


drug induced myopathy
*lipid lowering drugs(statin,fibrates,ezetimibe)
*chronic corticosteroids-these 2 drugs most common cause

*pt presents w muscle pain
*if severe, stop the drug (weakness, CPK>3X normal, myoglobinuria)
*steroid usually presents muscle pain & weaknes not assoc w CPK elevation and EMG usually normal


*tx: stress reduction, routine exercise, tricyclic & in some SSRI add to TCA helps fatigue, neurontin, non narcotic like ultram

Dx-pain in 11 or more of 18 tender points
*control points:forehead, digit, anterior thigh
*all labs and inflam markers are normal
*eval for underlying: TSH, hep B&C, vit D, sleep apnea


Complex regional pain syndrome (RSD-reflex sympathetic dystrophy prev name)
*freq hx of trauma to extremity and the trauma can be minor
*shoulder-Hand syndrome after MI is a form of this

*rule out other causes-bone scan most sensitive, MRI also useful
*Tx: NSAIDS, pain modifiers (TCA, neurontin), physical therapy, short course glucocorticoids, nerve blocks prn


Other causes of nonarticular rheumatism

*alcohol: most common myotoxin
can cause acute rhabdomyolysis, very high CPK-MMs

*hypothyroidism-myalgias and stiffness, may have an elevated CPK-MM
*polymyalgia rheumatica-discussed under vasculitis


vasculitis-most often result of an immune reaction caused by

*immune complex deposition
*complement activation

*can affect small, medium, or large vessels
*often hard to diagnose


frequent presenting S/S of vasculitis

*fever, malaise, weight loss (in ddx for FUO)
*palpable purpura-think vasculitis!!


frequent lab findings with vasculitis and diagnosis

*increased sed rate, thrombocytosis (poor mans sed rate), anemia, decreased albumin
*biopsy the most involved tissue when able


Large artery vasculitis includes

*giant cell arteritis +/- polymyalgia rheumatica
*takayasu arteritis


Giant cell (temporal) arteritis
*>age 50
*female:male 3:1
*sed rate always >60
*is part of systemic inflam. dz assoc w polymyalgia rheum (PMR)

*multinucleated giant cells infiltrate blood vessels from aortic arch
*s/s:temporal headache, diploplia,amaurosis fugax, scalp tenderness and jaw claudication
*untx-can have unilateral irreversible blindness
*dx: temporal artery bx, tx high dose steroids -start if suspect!


on boards if elderly patient with shoulder ache, headache and vision complaints and high sed rate

**PMR with giant cell arteritis!!


Polymyalgia rheumatica
*20% with this develop giant cell arteritis
*think this in elderly pt w profound morning stiffness, bilateral shoulder-girdle and hip aching and hand swelling.
*sed rate usually >50, 10% have normal

*tx:dramatic response to 10-20mg prednisone in just a day or two, for cure needs slow taper over 12-18 months


Takayasu arteritis "pulseless disease"
*young female, esp Asian
*may present as FUO then months/yrs later claudication or renovascular HTN w bruits
*may have raynauds syndr and erythema nodosum

*dx: angiogram or MRA-can see inflammaion of artery wall
*tx: glucocorticoids, calcium channel blocker (vasospasms), anticoagulant may be needed if very stenotic vessels
*tends to recur
*guarded prognosis



*common assoc w these systemic inflammatory diseases: syphyllis (tertiary-form aneurysm and valve regurg-dissection/rupture aneurysm is very rare), endocarditis w mycotic aneurysm, giant cell arteritis, spondyloarthropathies


medium/small artery vasculitis

*polyarteritis nodosa
*Wegener granulomatosis
*Microscopic polyangiitis


PAN-polyarteritis nodosa
**assoc w Hep B infection
*can affect all organ systems-but doesnt cause dz of pulm.vessels
*but pt may present with pulm. edema from Left heart failure, not assoc w pulm hemorrhage

*s/s:anorexia, wt loss, fever, malaise, arthralgia, mononeuritis multiplex, CNS, abd s/s-due to mesenteric arteritis-perforation or infarct, rash(livedo retic., palp. purpura).
*suspect if multiple symptoms: chest pain (pericarditis), abd pain (mesenteric arteritis), foot drop (mononeuritis multiplex)


Dx of PAN

if no obvious peripheral involvement (nerve, muscle, testicle) do angiogram
if peripheral involvement do biopsy of affected site


Tx of PAN

*tx chronic HBV if present
*prednisone plus cyclophosphamide

*PAN is severe disease, patients die if not treated!!


Churg-Strauss vasculitis
*necrotizing, pulmonary-renal vasculitis
*marked by eosinophilic granulomas
*ALWAYS history of asthma +/- sinus disease or allergies (allergic rhinitis and nasal polyps)

*lab: peripheral eosinophils
p-ANCA +
*Tx: same as PAN, many respond to steroids alone


Wegener granulomatosis
*necrotizing granulomas, esp sinus, lungs, kidneys
*classic pulm-renal syndrome
*sinus tissue bx-may see vasculitis, necrosis, granulomatous chgs

dx: bx sinus, nasal or oral abnl-preferred site as least invasive, if these not involved do bx of kidney or lung
*c-ANCA+ and anti-PR3+


wegeners granulomatosis tx

*rapidly progresses to death if not treated!
*tx: cyclophosphamide and high dose corticosteroids
*bactrim given to all with wegeners as they are at increased risk of pneumocystis pneumonia


side effects of cyclophosphamide

*bone marrow suppression and infection
*bladder cancer, hemorrhagic cystitis


small vessel vasculitis-called leukocytoclastis or hypersensitivity vasculitudes
*CLASSIC: PALP. PURPURA-crops purple papules or lg, petechiae
*often involves the skin (small vessels) and leukocytoclastic (PMNs permeating thru vessel walls w cellular death & debris)

-drug reaction-usual cause-1-10 day p drug started
-virus- incl HCV associated cryoglobulins
-SLE,RA,Henoch-Schonlein purpura, cryoglobinemia
-in assoc w necrotizing vasculitides


Henoch-Schonlein Purpura
*IgA mediated, sm vessel vasculitis
*involves:skin from waist down (crops of papules), kidneys, GI- abdominal pain and bleeding
*occurs in children, most assoc w viral URI & strep infections

*dx: IgA in skin biopsy
*illness usually benign w spontaneous resolution
*occ renal failure
*corticosteroids and cytotoxic agents only for life threatening dz


Goodpasture syndrome
*small vessel vasculitis of lungs and kidneys
*think this w pt w rapidly progressive pulmonary-renal syndrome
*pt may present w hemoptysis or acute pulmonary hemorrhage and/or s/s of rapidly progressive glomerulonephritis

*differentiate from Wegeners in that goodpastures have anti-glomerular basement membrane antibodies
*40% also have p-ANCA+


rheum diseases that can cause pulmonary hemorrhage

*microscopic polyangiitis (PMA)


*abnormal proteins that tend to precipitate in a serum specimen when chilled and redissolve when warmed
*in the body they can cause increased viscosity of the blood in cold temperatures

* 2 types: mixed and monoclonal
*viruses can cause either type
**very strong assoc with HEP C and MIXED type


Mixed cryoglobulinemia

*due to rheumatoid factor bound to both monoclonal and polyclonal IgGs
*vasculitis with purpura-most common presentation of this type
**glomerulonephritis if the most common cause of DEATH


monoclonal cryoglobulinemia

*usually due to Multiple Myeloma or Waldenstrom macroglobulinemia


Relapsing polychondritis

*is inflammation of the cartilage of ear, nose, larynx, trachea
*can cause arthritis, ocular dz (scleritis, iritis), vasculitis, aortic dilatation and aortic regurgitation

**suspect in pt with: hoarseness, saddle shaped deformity of the nose, swelling of the ear cartilage

**EAR LOBE spared-no cartilage!


Behcet Disease
*multisystem dz, cause unknown
*vasculitic syndrome, relapse is common
*painful, recurrent apthous stomatitis, genital ulcers, synovitis,cutaneous lesions, recurrent aseptic meningitis

*may see pulmonary artery aneurysm
*most have eye dz:uveitis, optic neuritis, retinal vasculitis
*skin is hyperreactive to NEEDLE STICKS-PATHERGY-leads to sterile abscess
*ulcers tx w colchicine, more severe dz-steroids , azathioprine...


what is cheirospasm

writers cramp


Paget's disease
**KEY s/s: hearing loss, low back pain, enlargement of skull
*common:osteoarthritis, fractures, stress fractures
*angioid streaks in fundus in 1/6patients

*hyperviscosity-can cause high output heart failure!
*lab: elevated alkaline phosphatase & urinary hydroxyproline-both indicate increased bone turnover
*SARCOMA occurs 1%
tx:calcitonin, bisphosphonates or teriparatide


*inflam of bursa due to mechanical irritation, bacterial infection, rheum arthritis, gout
*causes severe pain w active movement of the joint, esp against resistance, passive ROM may be painless or minimal

*knee has several bursa-pes anserine bursa located medial knee, just inferior to the knee about 2cm
*freq assoc serosanguineous effusion in bursa sac


if extremity joint is acutely swollen without hx of trauma you should

*tap and send for :crystals
cell count with differential
gram stain and culture



away from the midline



toward the midline



pulling foot upward



pressing the foot down


true shoulder pain extends from

acromion to insertion of the deltoid


thoracic outlet syndrome
*irritation of brachial plexus, impingement of the nerves can cause pain from shoulder to the hand as well as paresthesias and weakness, severe can have claudicaion

*dx is difficult as exam is usually normal unless certain maneuvers
*if suspect get CXR to look for cervical ribs that can cause it
*EMG can determine if brachial plexus affected
*tx-exercises, avoid postures that elicit symptoms, cervical ribs may be removed if they are the cause



*long term dialyis patients prone to this from amyloid deposition in the joints (beta 2 microglobulin)
*causes painful joints & tends to affect shoulder and wrist-causing carpal tunnel syndrome


Adhesive capsulitis "frozen shoulder"
*most age 40-60 w underlying predispositions: bursitis, froz shoulder, frature, diabetes is risk factor, can be no apparent cause

*s/s: shoulder pain & stiffness, decreased ROM of glenohumeral motion in ALL direction
*xrays are normal
*most resolve 6-12 months w return of ROM if the patient does shoulder exercises, refractory cases may need surgery


Impingement syndrome

*compression of the subacromial bursa
*pain w reaching overhead or at night-esp if laying on affected side
*dx is clinical
*tx conservative, if lasts p 3 mo phys therapy to ortho


Rotator cuff
*most common cause of shoulder pain
*think this in pt who plays overhead (baseball) sports,has had shoulder trauma or older than age 50
*classic:pain w overhead reach and night pain

*+/- weakness
*pt who cannot adduct smoothly may have a tear (drop-arm sign)
*get plain xrays, then MRI if need to make dx
*tx-conservative, rest,NSAID, physical therapy
*if full thickness tear in healthy person-surgery


olecranon bursitis
*traumatic, septic, gout, rheum dz
*traumatic-"student elbow"-due to chronic pressure

*uninfected-aspirate and NSAID or inject steroid
*infected-I&D plus antibiotic po if mild, IV in severe


lateral epicondylitis-"tennis elbow"

tenderness and pain well localized to the front of the lateral epicondyle

*usually resolve spontaneously if decrease use of elbow-may take months to a year to do so
*NSAID and splinting to prevent supination and pronation
*steroid injection


carpal tunnel syndrome
*paresthesias & dysesthesias of median nerve distribution-thumb to middle finger
*tinel sign-tap on volar surface of median nerve
*phalen test-flexion of wrist for up to 30 seconds

*more susceptible: pregnant, use of OCPs, dialysis pt, hypothyroidism, acromegaly, any arthropathy of wrist
*dx-nerve conduction study aids in dx
*tx-wrist splint day and night for 3-4 wks
*surgery if refractory or axonal loss (motor)


De Quervain tenosynovitis

*inflam of the flexor tendons or abductor pollicis longus tendon of the thumb

*pain and well localized tenderness over the styloid process of the distal radius
*due to repetitive stress of the wrist w certain motions ie wringing clothes



*suppuration of the finger around the cuticle
*causes: acute vs chronic

*acute: thumb sucking, trauma, chronic water immersion, neglected nails or manicured false nails
*acute infection usually S. aureus or oral flora
*chronic:immunocompromised states and usually candida


herpetic whitlow
*herpetic viral infection of the finger-anywhere on finger
*assoc with occupational exposures to the mouth:dentistry, anesthesia,, thumb sucking in child w recent herpetic stomatitis

*vesicles on erythematous base
*DO NOT I&D-makes it worse


Trigger finger-digital tenosynovitis stenosans

*swelling of flexor tendon
*splint and local steroid, simple surgery is required to cure


trochanteric bursitis

*most common cause of lateral thigh discomfort
*pain with lying on that side, draping leg over top non affected leg, weight bearing on affected side
*NSAID,local heat, phys therapy or steroid injection


avascular necrosis
*risk factors for it: chronic steroids, alcoholism, sickle cell dz, pregnancy, HIV, gaucher disease, hypercoagulable states, lupus-even with no use of steroids, idiopathic, post-traumatic

*blood supply to femoral head is disrupted,
*best dx-early MRI-might be able to revasc and save the joint
**risk of bilat AVN is high so image BOTH hips even if asymptomatic in other


Osteoarthritis hip
*increased pain with use and relieved with rest, maximum point of pain intensity is localized to the groin
*standing or wt bearing xrays-joint space narrowing, subchondral sclerosis,osteophytes

*tx: wt loss, non narc. analgesics, physical therapy, canes

*obesity does not contribute to development of OA


morton plantar neuroma

*pain, burning paresthesias and tenderness of interdigital webbing due to repeated nerve trauma
*unilateral between 3rd & 4th toes
*tx: metatarsal arch support or steroid injection, severe may need surgery


plantar fasciitis
*cause unknown
*most age 40-60, incr in runners, ballet, aerobic dancers

*pain worse with initiation of the footstep
*tx conservative-rest, NSAIDS, avoid heel impact, shoes with heal inserts. injection combo steroid/anesthetic in refractory


Lumbago-acute low back pain
*#1 reason for primary care doctor visits

*mult causes


Muscle strain
*pain worse with bend, lift, turning, cough
* no weakness, no neuro deficit, SLR is negative
*imaging does not assist in diagnosis or treatment***

*agonizing lbp w hx of lifting heavy object or making sudden movement
*40% better 1 wk, 90% in 2 months
*coontinue ordinary activity as tolerated leads to more rapid recovery than bed rest


disk herniation

*local or radicular pain, weakness if severe
*central disk herniation: saddle pain, anesthesia, +/- incontinence

*classic disk pain: worse w sit or bend, better stand or laying
*MRI if neuro deficit present


lumbar spondylolysis
*more prone to spondylolisthesis-spont subluxation(usually forward) on vertebrae over another
*can result in sciatica-usually doesnt affect nerves of cauda equina

*defect in isthmus of neural arch of the 5th (rarely the 4th) lumbar vertebra
*see on oblique view xrays
*likely due to stress fracture during childhood-prior thought congenital


SI joint pain

*not common and usually due to spondyloarthropathy

*other possible causes: osteoarthritis, TB, IVDU infection


19 y/o w hx kidney transplant has 3 wk hx of left knee pain. has hx of renal failure due to focal segmental glomerulosclerosis w nephrotic syndrome tx w high dose steroids x 1 year. creatinine stable at 1.9. exam no abnormality but has a limp w walking. Next step?

MRI of left hip and knee

*long term high dose steroids assoc w avascular necrosis of the hip
**may present with knee pain


15 y/o male runner has left heel pain on and off for a month. no known injury. pain mainly when he first gets out of bed in the morning and when he runs. located medial aspect of heel. exam is normal, gait is normal . likely dx?

plantar fasciitis

*tx: stretching gastrocsoleus, NSAID, arch supports


20 y/o man w back pain and stiffness for 8 months. OTC meds no help. pain initially in lower back that improved with exercise or movement. no radiation, he has itchy eyes that he thinks is due to allergies. exam-slight injected conjunctiva,II/VI early diast. murmur, tender both SI joint, normal Lumbar sacral motion, negative straight leg raising, No psoriasis. what to confirm dx?

xrays of the SI joints

he has s/s of early ankylosing spondylitis


40 y/o female w hx persistant joint pains, symmetrical swelling of her wrists, MCP,PIP. you start on NSAID with some relief but still complaints as one month ago visit. exam unchanged. xrays of hands show erosive synovitis in MCP & PIP both hands. what would be consist w her dx of rheumatoid arthritis?

*swell of wrist, MCP, PIP for 6 weeks
*erosive synovitis changes of hands on xray
*morning stiffness for longer than 45 minutes for 6 weeks
*mononeuritis multiplex


60 y/o male w left knee pain, chronic b/l hip,knee, shoulder pain for many months. joints stiff in am for about 20". L knee swelling for 3 days and is new, cant bear wt. exam-red,warm, swollen L knee. palp effusion .neuro/vasc/sensory intact. aspirate: 1800 wbc w 95% lymphocytes, no crystals. probable etiology?



what is initial treatment for rheumatoid arthritis?



synovial fluid findings most consistent with gout?

cloudy and watery fluid
*wbc 11,000
*needle like and strongly negative birefringent crystals


74 y/o female w 2 month hx bone pain, wt loss, night sweats. red swelling over her left index finger. Hx NIDDM and CAD. exam-asymmetric heberden and bouchard nodes w erythema and profound tenderness left 2nd DIP. lab: ESR 118, hgb 10, cr 2.4,serum protein electrophoresis-monoclonal spike. urine Bence Jones protein. whats cause of her acute left finger symptoms?

**she has multiple myeloma and osteoarthritis. fairly typical presentation of acute gout in setting of a non benign disease


60 y/o male w pain in hip. no other symptoms except occ. night sweats. calcium is elevated. what disease will have a normal bone scan?

multiple myeloma-lytic lesions do not enhance


50 y/o woman joint pain for several months. morning stiffness lasting more than an hour for 3 months and gradually improves thru the day. has swelling of her wrists and PIP joints for 2 months and swelling of her knees x 6 wks. nodules on dorsum hands, xrays show erosive synovitis. Dx?

rheumatoid arthritis


70 y/o white male w 3 mo of muscle pain, esp in shoulders and pelvic girdle. severe morning stiffness. exam is normal. ESR 120, ANA 1:40 speckled . likely diagnosis?

polymyalgia rheumatica


50 y/o male with acute swelling of first metatarsal joint. he drinks alcohol to excess and takes HCTZ for HTN. he is obese. tap of knee shows urate crystals in joint fluid. Dx?

gout- definately diagnosed-urate crystals=diagnosis


30 y/o black female new onset of serositis. has been well except cardiac arrhythmia and a few months ago was started on cardiovasc drug. exam- has serositis. no other and no rash. what do you suspect?

*likely drug induced lupus. procainamide is likely drug.
*she likely has anti-histone antibodies +
*serositis is most common presentation of drug induced lupus.
*fever is common as well


78 y/o female has severe headache. also has muscle aches in her thighs, loss appetite, malaise, jaw pain when eats or talks for long period of time. Exam: tender over temporal region, no focal findings on neuro exam. what to make definitive diagnosis?

temporal artery biopsy


27 y/o female with seropositive erosive nodular RA, on MTX and infliximab with good control. which vaccines should she NOT receive?

*varicella vaccine- **No live viral vaccines


47 y/o female w grittiness of her eyes and dry mouth. recently problems reading and eye doctor told her likely early Sjogrens. occasional pain in wrists, no other complaints. exam: normal except decreased oral pool of saliva, ANA strongly +. anti SSA+. she is at risk for many things including

*peripheral neuropathy
*renal tubular acidosis
*non Hodgkin's lymphoma
*lymphocytic interstitial pneumonitis


35 y/o male marathon runner w GERD on PPI. has 6 week hx of skin thickening on trunk and upper extremities, sparing his hands and fingers. this started after he completed a triathlon. what would you expect on exam and lab?

*he has eosinophilic fasciitis-scleroderma like condition
*chara by eosinophilia and skin thickening (hands spared)
*freq starts after vigorous exercise


woman presents to ER with her 3rd spontaneous abortion. what antibody is assoc with increase risk of this occurring?

*anticardiolipin antibody


You suspect a woman with recurrent spont abortions has anticardiolipen antibody, what do you expect her coagulation studies to show?

her PTT will NOT correct when her plasma is mixed with normal


62 y/o male with long hx of osteoarthritis of hips and knees presents with new onset of severe pain in right hip. he can not roll over to sleep on his right side due to pain. pain is worse with any movement of his right hip. exam: severe pain w palpation of lateral aspect of right hip and pain w abduction of hip. Best tx?

dx is trocanteric bursitis
Best tx is steroid injection


which tx for RA is associated with retinopathy?


*they need ophthalmologic exam every 6months


64 y/o woman w diabetes ha pain in right shoulder, worse at night. pacemaker 5 mo ago on right side, mastectomy 8 mo ago for breast cancer. she can only abduct right shoulder to 60 degrees when you stabilize her scapula. most likely dx?

*frozen shoulder-adhesive capsulitis
*inability to achieve the 90 degree arc w scapular stabilization is clue to diagnosis


50 y/o white female has aching in her bilateral shoulder muscles and hip joints for a month. OTC meds no help. also complains no energy, morning stiffness, pain in her fingers for many years. some decline in her vision and feels weak. exam normal. ESR 90. likely diagnosis?

Polymyalgia rheumatica


37 y/o black female w fatigue and new sob w exercise and aching finger joints and knees.exam vss, crackles bases, lab abnl:SGOT 127, SGPT 126, CK 17,300. what autoantibody most signif in dx of her disease process?

*anti Jo-1
*she has pulmonary fibrosis and dermatomyositis


45 y/o female w retinal vasculitis, venous system more involved p seeing eye dr. dx Behcets w iritis years ago. long hx ulcers-oral, labial. new onset of acne like rash face and trunk. joints fingers very tender. had subtotal thyroidectony 18mo ago and on meds. exam: ulcers oral/labial, hyperpignented acne-like rash face and chest. Lab:ESR 37, ANA/RF -, cbc ok what drugs to tx this?

*dx Bechets
*thalidomide-excellent option but needs contraception & nerve conduction studies on this med
*methotrexate and colchicine other options


37 y/o female w lupus has pain right deltoid area, progressive overr 2 months. prior hx synovitis of PIP joints. has been on hydroxychloroquine for 18month but off it now for 2 years. exam: ok except abduct of right shoulder only to 70 degrees. likely Dx?

*avascular necrosis of the shoulder
*likely she has been on steroids w lupus diagnosis, but any patient with vasculitis has an increased risk of avascular necrosis.
*xray would likely give dx


19 y/o male w low back pain and stiffness gradual onset last 6 months. shower in am helps and walking causes the stiffness to disappear. recently he has some pain in the left groin. no other symptoms. exam: pitting some nails, oncholysis several nails. ESR 97,other labs ok. xray hip (-), +bilateral asymmetric SI joint sclerosis and narrowing. drug of choice?

*dx is seronegative spondyloarthropathy-psoriatric arthritis
*drug of choice-anti-TNF agent

*do NOT respond to steroids


47 y/o male in ICU. short of breath and hemoptysis for 3 days, cardiac arrest and intubated. CXR-diffuse infiltrates bilaterally. bronchoscopy-serosanguineous fluid. sed rate 63, +ANA, UA 2 red cells per hpf, some red cell casts. what also likely to be positive?

*anti GBN antibody
*has Goodpastures syndrome
*tx high dose steroids, IV or oral cyclophosphamide, may need plasmapheresis


68 y/o female w hx of sjogrens has intermittent b/l parotid swelling, arthralgias, +anti Ro antibody and + lip biopsy. has signif sicca symptoms what can you recommend

*only effective tx is artificial tears and saliva, secretagogues such as pilocarpine or cevimeline. restasis is marketed for dry eyes but no studies show effectiveness for sicca of sjogrens
*steroids are ineffective for sicca symptoms


57 y/o female w 10yr hx RA, joints fairly asymptomatic but has new low back pain. tx MTX, prednisone 3mg , ibuprofen prn. on HCTZ for HTN. exam: minimal synovitis MCP and PIP, good grips. mild metatarsalgia both feet, nodules left olecranon. whats likely cause of LBP?

ddx mechanical low back pain, osteoporotic fracture

****RA NEVER affects the thoracic or lumbar spine-there is no synovial tissue there