Flashcards in Rheumatology Deck (128)
What are the 4 basic questions that need to be answered to determine cause of arthritis?
2. acute vs. chronic
3. systemic symptoms
4. joint inflammation
What are causes of polyarticular (more than 4 joints) symmetric arthritis?
1. rheumatoid arthritis
2. lupus (scleroderma, sjogren)
3. viral (Parvovirus B19, hep B)
What are causes of monoarticular (1 joint) arthritis?
2. Gout/ Pseudogout
3. septic (gonococcal)
What are the causes of migratory (move from joint to joint) arthritis?
1. lyme disease
2. disseminated gonococcal
3. rheumatic fever
What are the causes of oligoarticular (few joints) asymmetric arthritis?
1.spondyloarthropathy (ankylosing spondylitis) (young)
2. osteoarthritis (old)
A pt presents with polyarticular symmetric arthritis with skin, lung, CNS, blood and/ or kidney manifestations most likely suffers from ...
What are signs of joint inflammation?
1. erythema, warmth
2. joint stiffness > 1 hour (better w/ exercise, mobility, as day goes by)
3. elevated ESR or CRP
4. elevated WBC in aspirate
What disease is suggested by < 2000 WBCs in synovial fluid of joint?
denegerative joint disease (osteoarthritis)
What disease is suggested by WBCs 5000-50,000 in synovial fluid of joint?
inflammatory disease (gout, pseudogout, rheumatoid arthritis)
What rheumatologic disease has needle-shaped negative birefringent crystals in joint aspiration?
What rheumatologic disease has rhomboid-shaped postivie birefringent crystals in joint aspiration?
What disease is suggested by > 50,000 WBCs in synovial fluid of joint?
When is joint aspiration contraindicated?
1. have overlying cellulitis
2. bleeding disorder
What disease is associated with peripheral (rim) patterned ANA?
What disease is associated with centromere patterned ANA?
What disease is associated with Nucleolar patterned ANA?
What disease is anti-dsDNA specific for?
lupus (indicator of disease activity & lupus nephritis)
What disease is anti-smith specific for?
What disease is ant-histone antibodies specific for?
What disease is anti-LA (SSB) is specific for?
What disease is anti-centromere antibodies specific for?
What disease is anti-RNP antibodies specific for?
Mixed Connective Tissue Disease
What autoimmunity antibody is used as a prognostic indicator in pts with rheumatoid arthritis?
Rheumatoid factor (autoantibody against Fc portion of IgG)
What disease is associated with elevated c-ANCA?
What diseases are associated with elevated p-ANCA?
2. Churg- Strauss
What disease are associated with anti-Ro (SSA) antibodies?
1. Neonatal lupus
3. ANA-negative lupus
A female presenting with elevated PTT, hx of spontaneous abortions (2 or more), hx of thromboembolism, hx of arterial thrombosis and false positive RPR/VDRL most likely suffers from ....
antiphospholipid antibody syndrome (lupus anticoagulant or anticardiolipin antibodies)
What is the diagnostic criteria for rheumatoid arthritis?
1. morning stiffness (>1 hr)
2. swelling of wrist, MCPs, PIPs
3. swelling of 3 joints
4. symmetric swelling
5. RF or anti-CCP positive
6. joint erosions on X-ray
7. rheumatoid nodules (bumps over joint)
(need 4 for at least 6 wks)
A female present with chronic morning stiffness and inflammatory swelling of wrist, MCPs and PIPS symmetrically most likely suffers from ...
What disease is associated with anti-cyclic citrullinated peptide (anti-CCP)?
What joints are never involved in rheumatoid arthritis?
1. DIP joint
2. lower back joints
What do X-rays show in a pt with rheumatoid arthritis?
done erosions and deformities
... is when PIP joint is flexed and DIP joint is hyperextened and develops in ... disease
Boutonniere deformity; Rheumatoid arthritis
... is when PIP joint is hyperextended and DIP joint is flexed and develops in .... disease
Swan-neck deformity; rheumatoid arthritis
... is a disease in which a pt has rheumatoid arthritis with splenomegaly and neutropenia
... is a disease in which a pt has rheumatoid arthritis with coal workers pneumoconiosis
What is the best initial DMARD treatment in rheumatoid arthritis?
What are the 3 complications associated with methotrexate treatment?
3. flare of rheumatoid nodules
(obtain CBC and LFTs q 1-2 months)
What is the second line DMARD treatment for rheumatoid arthritis?
TNF (tumor necrosis factor) inhibitors
(infliximab, adalimumab, etanercept)
What is the best initial treatment for rheumatoid arthritis?
NSAIDs or celecoxib (COX-2 inhibitor) with steroids (until methotrexate works)
What is the side effect associated with hydroxychloroquine (used in rheumatoid arthritis, lupus or malaria)?
retinopathy (screen w/ regular eye exam)
What are the complications of rheumatoid arthritis?
1. altantoaxial subluxation (C1-C2 subluxation)
2. Baker cyst
A pt with rheumatoid arthritis presenting with swollen painful calf most likely suffers from ...
ruptured Baker cyst (extension of inflamed synovium intor popliteal space)
A pt with rheumatoid arthritis preseningt with occipital headaches, neck pain, upper extremity tingling and numbness most likely suffers from ....
Altantoaxial (C1-C2) subluxation
Before starting TNF inhibitors as treatment for rheumatoid arthritis, what should be done?
PPD (test for TB)
When should a pt with rheumatoid arthritis be screened for C1-C2 subluxation?
before intubation and anesthesia (use X-ray of cervical spine)
What environmental factor has been found to invoke lupus flares?
UV B light
What is the diagnostic criteria for lupus?
1. malar rash
2. discoid rash (well defined w/ raised edges; scars)
4. oral ulcers
5. serositis (pleuritis or pericarditis)
6. renal involvement
7. neuro deficits (seizures, psychosis, altered mental status, personality change)
8. hematologic (hemolytic anemia, leukopenia, thrombocytopenia)
9. immunologic (anti-dsDNA, anti-SM, ANA)
What type of arthritis occurs in lupus?
polyarticular, symmetrical, inflammatory arthritis that is non-erosive
.... is a type of non-infectious endocarditis that occurs in pts with lupus
What should be done if a pt with lupus has signs of renal involvement?
renal biopsy (to distinguish the cause)
What is the treatment for discoid rash associated with lupus?
antimalarial drugs (hydroxychloroquine) and steroids
What are diagnostic tests used to detect lupus flare in pt with hx of lupus?
1. decreased C3 and C4 (CH50)
2. elevated anti-dsDNA
What is the most common cause of disability in pt with lupus?
Lupus nephritis (associated with anti-dsDNA)
What should a pregnant pt with lupus be screened for?
anti Ro (SSA) antibodies (cross placenta to cause neonatal lupus and heart block)
What is treatment for lupus flare in pregnancy?
What is treatment for increased spontaneous abortions and still birth in pt with lupus?
low-molecular weight heparin during pregnancy
What are the 4 drugs commonly associated with drug induced lupus?
What is treatment for drug induced lupus?
stop offending agent (symptoms resolve w/in 1-2 weeks)
A pt presents with arthritis, fever, fatigue and possibly pleurisy after starting medication (hydralazine, isoniazid, procainamide, qinidine) most likely suffers from ...
drug induced lupus
A pt presents with shiny, skin thickening, raynaud phenomena, and positive Scl-70 most likely suffers from ...
What are the viseral organ involvement associated with scleroderma?
1. GI: esophageal dysmotility, hypomotility of small intestine, diverticula
2. Pulm: pulmonary fibrosis (lead to death)
3. renal crisis
What is scleroderma renal crisis?
development of malignant HTN leading to acute renal failure
What is the treatment for hypertension and scleroderma renal crisis?
What is the treatment for Raynaud's phenomena associated with scleroderma?
calcium channel blockers (nifedipine)
What is the treatment for skin thickening of scleroderma?
A pt presents with calcinosis, raynauds, esophageal dysmotility, sclerodactyly (skin thickening below elbow or knee), and telangiectasia most likely suffers from ...
CREST syndrome (Limited Scleroderma)
What diagnostic test can be done to distinguish between primary raynaud phenomenon?
Nailfold capillaroscopy test (place oil on nailfold at base of nail; if dilated-> secondary)
A pt presents with complains of itchy eyes, sandy feeling in eye, dry mouth, difficulty swallowing, dental caries and bilateral parotid enlargment most likely suffers from...
What is keratoconjunctivitis sicca syndrome and what disease is it associated with?
dry eyes and destruction of corneal epithelium due to decreased lacrimal production
What are diagnostic tests used for Sjogren syndrome?
1. schirmer's test (detect decreased tear production)
2. Rose Bengal stain (detect corneal ulceration)
3. salivary gland biopsy (detect lymphocytic infiltration)
What cancer is associated with Sjogren syndrome?
What are treatments used for Sjogren syndrome?
1. artificial tears
2. pilocarpine/ cevimeline (increase ACh -> increase tear and saliva production)
A man presents with chronic lower back pain associated with morning stiffness that improves with exercise and has aortic insufficiency most likely suffers from ...
What is treatment for Ankylosing spondylitis?
1. NSAIDs, PT and exercise
2. TNF inhibitors (infliximab, adalimumab, etanercept)
What is the finding on spine X-ray?
2. bamboo spine and squaring
A pt presents with seronegative, oligoarticular asymmetric arthritis with associated mucocutaneous manifestations (painful oral/genital ulcers) and conjunctivities most likely suffers from ...
Reiter's syndrome secondary to nongonococcal urethritis (chlamydia infection)
What a unique treatment used for Reiter's syndrome compared to other reactive arthritis?
prolonged tetracycline use (3 weeks)
What is keratoderma blenorrhagica and what disease is it associated with?
thickening of the palms an soles of the feet; Reiter's syndrome
What is circinate balanitis and what disease is it associated with?
erythema around tip of penis; Reiter's syndrome
A pt with a hx of psoriasis presents with complaints of oligoarticular asymmetric arthritis mostly involving DIP joint with associated sausage-shaped digits most likely suffers from ...
A pt with hx of inflammatory bowel disease who presents with oligoarticular asymmetric arthritis with associated pyoderma gangrenosum or erythema nodosum most likely suffers from ...
A pt presenting with chronic monoarticular or oligoarticular asymmetric arthritis that is not inflammatory and usually involves DIPs, pain worsens with exercise and relieved by rest most likely suffers from ..
What is the most common joint affected in osteoarthritis?
knee (followed by base of thumb)
What are the X-ray findings in osteoarthritis?
1. osteophytes (hypertrophy of bone)
2. unequal joint space
3. subchondral cysts
... are osteophytes that occur in PIP joints and associated with ... disease
Bouchard's nodes; osteoarthritis
... are osteophytes that occur in DIP joints and associated with ..... disease
Heberden's nodes; osteoarthritis
What are treatments for osteoarthritis?
2. capsaicin cream (associated with local burning)
3. surgery arthroplasty (if severe and debilating)
4. intraarticular injection of hyaluronic acid
A man presents with acute inflammation of MP joint of big toe that started in middle night and intensely painful most likely suffers from ....
Gout (monosodium urate deposition)
What are triggers for acute gouty arthritis?
2. red meat
3. anti-TB meds (pyrazinamide, ethambutol)
5. diuretics (hydrochlorothiazide, furosemide)
What are treatments for acute gouty arthritis?
2. Steroids (if pt has renal failure)
What are treatments for chronic treatment of gouty arthritis?
1. Allopurinol (Febuxostat if intolerant)
2. Pegloticase (if refractory)
3. Probenecid (in undersecretors; avoid in renal failure/ kidney stones)
What diagnostic test is used to distinguish between gout and pseudogout (due to calcium pyrophosphate crystal deposition?
arthrocentesis and synovial fluid analysis
What are the 4 diseases that are associated with pseudogout?
What are X-ray findings associated with pseudogout?
linear radiodense deposits in joint menisci/ articular cartilage
What are X-ray findings associated with gout?
erosions in chronic
What is the most common cause of septic arthritis, especially in younger pt?
What is the most common cause of septic arthritis in elderly pt?
A young pt presents with acute monoarticular, inflammatory arthritis and found to have >50,000 WBCs in synovial fluid most likely suffers from ...
Gonococcal septic arthritis
What is the treatment for gonococcal septic arthritis?
When should one use oral steroids for acute gouty arthritis?
1. if pt has renal failure (avoid NSAIDs and Colchicine)
2. if polyarticular gout
An elderly pt with hx of rheumatoid arthritis with acute monoarticular, inflammatory arthritis and found to have > 50,000 WBCs in synovial fluid most likely suffers from ....
S. aureus associated septic arthritis (tx with vancomycin and nafcillin)
A pt presents with recurrent URI's (chronic sinusitis/ rhinitis), lung involvement (hemoptysis) and kidney involvement (nephritis) most likely suffers from ...
Wegener granulomatosis (small vessel vasculitis)
What is the confirmatory test for Wegener's?
biopsy of involved organ (vasculitis and granulomas)
What is the treatment for Wegener's?
steroids and cyclophosphamide
A pt presents with fever, malaise, weight loss, abdominal pain, and mononeuropathy (wrist/foot drop) (with involvement of skin, kidney, nerves and GI) found to have aneurysms of renal and GI arteries on angiogram most likely suffers from ...
Polyarteritis Nodosa (PAN)
(medium size arteries)
What is treatment for polyarteritis nodosa (PAN)?
steroids and cyclophosphamide
What infection is associated with polyarteritis nodosa?
An adult pt with new-onset asthma with associated eosinophilia, lung involvement and possibly mononeuritis multiplex most likely suffers from ...
Churg Strauss syndrome
(PAN in an asthmatic pt)
What is treatment for Churg Strauss?
steroids and cyclophosphamide
A elderly pt presents with new onset headache (usually unilateral) with associated scalp tenderness, jaw claudication and possibly polymyalgia rheumatica (proximal stiffness) most likely suffers from ...
Temporal arteritis (Giant cell arteritis)
What is the best initial test for temporal arteritis?
ESR (elevated >60 then start prednisone immediately to avoid blindness)
What is the most accurate test for temporal arteritis?
temporal artery biopsy (dont wait for this test to start prednisone)
A pt presents with progressive proximal muscle weakness not involving ocular muscle without skin manifestations most likely suffers from ...
polymyositis or inclusion body myositis
What is treatment for polymyositis?
A pr presents with progressive proximal muscle weakness not involving ocular muscle with skin manifestatins most likely suffers from ...
Dermatomyositis (elevated risk for common cancers- do age appropriate screening)
.... is purple-like discoloration of face, eyelids and sun-exposed areas and is associated with .... disease
Heliotrope rash; dermatomyositis
.... are scaly lesions present on the knuckle of pt with proximal muscle weakness and is associated with .... disease
Gottron's papules; dermatomyositis
What is treatment for dermatomyositis?
What autoimmune antibody is associated with inflammatory myopathies (polymyositis, dermatomyositis)?
what is the major complication associated with temporal arteritis?
What vasculitis disease is associated with polymyalgia (proximal stiffness and pain involving neck, hip)?
What is the objective way to monitor treatment of temporal arteritis?
What are the EMG findings for inflammatory myopathies?
short duration, low-amplitude units
(myopathic potentials-spike and drop pattern)
What is the most accurate test for inflammatory myopathies?
What causes proximal muscle weakness?
1. thyroid state
2. drugs (statin)
3. adrenal insufficiency
4. Eaton lambert
5. Myasthentia gravis
6. inflammatory myopathies
What is the initial test for inflammatory myopathies?
creatine phosphokinase (elevated CPK)