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Rheumatology Flashcards

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1
Q

what kind of crystals is gout caused by?

A

monosodium urate monohydrate cyrstals

NEGATIVE BIREFRINGENT CRYSTALS

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2
Q

what causes gout’s inflammatory reaction

A

urate crystal deposition

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3
Q

where do urate crystals deposit in gout

A

in the blood, joint, bursae, and tendon

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4
Q

how is uric acid formed?

A

end-stage by-product of purine metabolism

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5
Q

how is uric acid excreted

A

renally

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6
Q

hyperuricemia = uric acid above

A

6.8 mg/dL

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7
Q

why does uric acid accumulate

A

overproduction (increased consumption or endogenously)

underexcretion

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8
Q

causes of underexcretion of uric acid

A 
idiopathic
inability to excrete
meds
kidney disease
chronic ETHOH use
dehydration
starvation
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9
Q

causes of overproducers of uric acid

A 
ETOH use
myeloproliferative disorders
psoriasis
hemolytic anemais
cell-lysis chemo
excessive exercise
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10
Q

foods associated with higher incidence of gout

A 
seafood
meats
fructose
soft drinks
wine
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11
Q

causes of gout flares

A

acute increases or decreases in urate levels –> production, exposure, or shedding of crystals.

alchohol, high purine foods, rapid weight loss, dehydration

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12
Q

is gout genetic?

A

it can be.
heritability 62%
3 associated genes

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13
Q

gender and age predominance of gout

A

male

30-60

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14
Q

when is it least likely for women to get gout

A

before menopause

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15
Q

how dose gout start

A

monoarticularly

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16
Q

how soon does gout reach maximum intensity

A

12-24h

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17
Q

when dose gout improve?

A

in days to weeks

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18
Q

symptoms of an acute gout attach

A 
severe pain
redness
warmth
swelling of joint (most common MTP)
\+/- fever
arthritis in other sites (fingers, instep, ankle, knee)
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19
Q

gout of the 1st MTP

A

podagra

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20
Q

progression of gout

A

attacks more severe and slower to resolve if go untreated

more severe and polyarticular with time

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21
Q

what happens after 20 or so years of untreated urate deposition

A

chronic tophaceous gout

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22
Q

urate crystal masses surrounded by inflammtory cells and fibrosis which are firm, moveable, and yellowish. tend to ulcerate with a chalky material

A

chronic tophaceous gout

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23
Q

where do tophi usually appear in chronic tophaceous gout

A 
pinna of ear
other involved joints
extensor surfaces of forearm
olecranon
infrapatellar tendon
achilles tendon
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24
Q

use of serum uric acid elevation in gout

A

not sufficient

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25
how to diagnose an acute attack of gout
arthrocentesis- rule out septic joint negatively birefringent crystals (get sample to lab quickly before they dissolve) high WBC count in synovial fluid on plain radiograph: erosions with overhanging edges
26
WBC count in synovial fluid of gout
>15,000 but usually
27
gout on plain film
overhanging edges with erosions
28
3 steps of managing gout
treat acute attack provide prophylais lower excess stores of urate to prevent flares and tissue deposition
29
NSAIDs for how long in acute gout attack
7 days
30
NSAIDs used for gout
indomethacin | naproxin
31
precautions with indomethacin
GI upset | give pepcid and take with food
32
contraindications to indomethacin and naproxin
CKD with Cr clearance
33
med used for pts with gout who have NSAID intolerance or contraindication
colchicine
34
MOA of colchicine
inhibits neutrophil chemotaxis and inflammatory mediator release
35
how does colchicine help gout
only helps inflammation so need something else for pain
36
3rd line treatment of gout
glucocorticoids prednisone (oral) triamcinolone (intrarticular)
37
risk reduction of recurrence for gout
weight loss reduce ETOH discontinue diuretics discontinue ASA
38
period between gout attacks
intercritical period
39
when should urate lowering therapy be started
at least 2 weeks after a flare has resolved. | otherwise can precipitate a gout attack
40
should we start prophylaxis tx for gout if there is a known cause
nope!
41
3 prophylactic meds for gout
probenecid allopurinol febuxostat
42
MOA of probenecid
promotes renal clearance of uric acid. | inhibits urate-anion exchangers in proximal tubule that mediates urate reabsorption.
43
contraindication of probenecid
nephrolithiasis (never restart if they get a kidney stone) | impaired renal function
44
how is probenecid dosed
multiple doses per day
45
MOA of allopurinol
xanthine oxidase inhibitor (inhibits production of uric acid)
46
allopurinol side effects
``` mild rash may disappear GI distress/diarrhea hypersensitivity syndrome (eospinophilia, fever, hepatitis, poor renal function, erythematous desquamative rash) SJS, TEN ampicillin + allopurinol --> rash in 20% ```
47
what other med in conjunction with allopurinol causes a rash
ampicillin
48
the "new xanthine oxidase inhibitor"
febuxostat (Uloric)
49
which med is more effective for hyperuriciemia: uloric or allopurinol
uloric and doesn't have any hypersensitivity side effects but is super expensive
50
CPPD
pseudogout | calcium pyrophosphate deposition disease
51
presentation of CPPD
monoarticular or polyarticular. involves the knee as the initial joint in 50% of the time. slower onset than gout
52
joint fluid in CPPD
rhomboid crystals
53
tx for CPPD
aspiration and NSAIDs
54
does CPPD recur?
yes, but not typically like gout
55
three major types of inflammatory myopathies
polymyositis dermatomyositis inclusion body myositis
56
general features of inflammatory myopathies
progressive and symmetric muscle weakness proximal muscle weakness facial muscles unaffected dysphagia or headrop
57
describe polymyositis
subacute inflammatory myoapthy affecting adults
58
is polymyositis associated with other autoimmune/connective tissue disease
commonly, yes
59
where does weakness start in polymyositis
distally
60
how soon does polymyositis progress?
weeks to months
61
elevated levels of ____ in polymyositis
CK
62
characteristic rash with associated muscle weakness
dermatomyositis
63
3 signs of dermatomyositis
heliotripic discoloration of upper eyelids and edema gottron's sign (flat red rash on face and knuckle scales) V sign
64
does dermatomyositis occur with other autoimmune/inflammatory disorders?
not usually but sometimes scleroderma or mixed connective tissue disease
65
pathophys of dermatomyositis
unknown but WBC spontaneously invade muscles
66
positive diagnostic workup dermatomyositis
+CK + jo-1 Ab MRI --> inflammation muscle biopsy (CONFIRMATION)
67
confirmatory test for dermatomyositis
muscle biopsy
68
treatment of dermatomyositis
oral corticosteroids (months to years) immunosuppressive drugs IVIG PT
69
how does death occur usually in dermatomyositis
pulmonary, cardiac, or other systemic complications
70
scleroderma aka
systemic sclerosis
71
gender and age predominance of scleroderma
female | 30-50
72
two types of scleroderma
diffuse cutaneous SSc | limited cutaneous SSc
73
3 cardinal features of the disease
vasculopathy cellular and humoral autoimmunity progressive visceral and vascular fibrosis
74
explain vasculopathy in scleroderma
intimal proliferation in the small and medium sized arteries resulting in luminal narrowing and an obliterative vasculopathy
75
explain cellular and humoral autoimmunity in scleroderma
activated T cells and macrophages accumulate in the affected organs. they have an enhaced ability to bind to the epithelium and fibroplasts and promote collagen synthesis
76
explain progressive visceral and vascular fibrosis in scleroderma
follows vasculopathy and cellular and humoral autoimmunity. it's a replacement of normal tissue architecture with dense connective tissue which results in irreversible accumulation of scar tissue.
77
what puts scleroderma patients at risk for visceral organ involvement
diffuse cutaneous Ssc
78
is the interval between raynad's and other manifestations brief or prolonged in DSSc
brief
79
symptoms of diffuse cutaneous DSSc
arthralgias muscle weakness decreased joint mobility stiffness
80
how does diffuse SSc present
progressive skin induration starting in the fingers and ascending from distal to proximal extremities, face, and trunk
81
does diffuse or limited cutaneous SSc have a better prognosis
limited
82
what is CREST syndrome associated with?
limited cutaneous SSc
83
where does limited cutaneous SSc manifest
fingers, distal extremities, and face NOT trunk
84
is the interval between raynad's and other manifestations brief or prolonged in limited cutaneous SSc
years
85
CREST syndrome
``` Calcinosis Raynaud's phenomenon Esophageal dysmotility Sclerodactyly Telangectasias (need 3) ```
86
explain raynaud's
episodic vasoconstriction in the fingers and toes triggered by exposure to cold, change in temperature, emotional stress, or vibration. pallor followed by cyanosis.
87
is raynaud's painful?
yes
88
what causes raynaud's
vasoconstriction, ischemia, reperfusion
89
explain esophageal dysmotility in scleroderma
lower esophagus has prominent atrophy in the muscular layer, diminished peristaltic activity
90
three results of esophageal dysmotility in scleroderma
GERD dysmotility SBO
91
explain sclerodactyly in scleroderma
thickening of skin which is bl and symmetric | fixed flexion contractures of fingers with reduced hand motility. Skin looks tight and taught.
92
describe telangiectasias in scleroderma
dilated skin capillaries which are prominent on the face, lips, hands, or oral mucosa
93
organ involvement in diffuse scleroderma
``` skin features pulmonary features GI involvement renal involvement cardiac involvement ```
94
lab features of scleroderma
normochromic normocytic + ANA but not specific + anticentromere Ab in some
95
how to you absolutely diagnose scleroderma
skin biopsy
96
is scleroderma diagnosed clinically
mostly
97
treatment for scleroderma
there is none :( | treat the secondary problems
98
leading cause of disability in the elderly
osteoarthritis
99
the most common type or arthritis
osteoarthritis
100
age and gender predominance of osteoarthris
females over 60
101
definition of OA
articular cartilage loss increasing thickness and sclerosis of the subchondral bony plate outgrowth of osteophytes at the joint margin mild synovitis weakness of the muscle briding the joint
102
pathophysiology of OA
articular cartilage loss mild synovitis bone adcacent to the joint reinforces itself with subchondral scerlosis and cartilage loss
103
explain the changes of cartilage in OA
in OA cartilage is metabolically ative, this causes an unfurling of the tightly woven collagen matrix which causes increased vulnerability of cartilate- looses its compressive stiffness
104
is healthy cartilage metabolically fast or slow
slow
105
commonly affected joints in OA
``` cervical spine lumbosacral spine hip knee MTP DIP PIP base of thumb ```
106
OA risk factors
age, genetics, obesity past injury to a joint malalignment of joint repetitive joint use
107
is OA genetic
50% of the hand and hip OA is
108
clinical features of OA
joint pain that is activity related | joint stiffness
109
physical exam findings of OA
joint margin tendernses hip restricted internal rotation/adduction painful ROM in large joints crepitus when joint is ROM joints cool and bony hard, synovium normal bony joint enlargement from osteophytes
110
can osteophytes cause radicular symptoms
sure thang
111
blood tests for OA
nonezo
112
xray findings in OA
``` joint space narrowing asymmetric subchondral sclerosis marginal osteophytes subcondral cysts ```
113
treatment of OA
allieviate pain | minimize loss of physical function
114
what treatment for mild disease or intermittent symptoms of OA
reassurance or nonpharmacologic
115
nonpharmacologic treatment of OA
avoid aggrevating activities improve strength and conditioning of muscles that bridge the joint (PT) use splints, braces, or canes with weight bearing weight loss exercise
116
pharmacotherapy of OA
``` NSAIDs acetaminophen COX2 inhibitors intraarticular injections (glucocorticoid and hyaluronic acid) opiates ```
117
MOA of NSAIDs
decrease prostaglandins, COX1 and 2 inhibitors
118
how to dose NSAIDs in OA
initially prn then daily if ineffective, with food and possibly a PPI
119
side effects of NSAIDs
nausea dyspepsia GI bleeds ulcer dz
120
why are some hesitant about COX2 inhibitors
risk of cardiovascular events, prothrombic
121
COX2 is FDA approved for...
RA and OA
122
contraindications of celebrex
aspirin or sulfa allergy | third trimester of pregnancy
123
glucocorticoid injections good for what in OA
temporary effectiveness | acute flairs
124
intraarticular injections good for what in OA
still pretty short term in effectiveness | viscoelastic and lubricating properties
125
surgical tx for OA
arthroplasty
126
inflammatory disorder of unknown cause that affects the axial skeleton
ankylosing spondylitis
127
age and gender predominance in AS
males 10-30
128
antigen correlated to AS
HLA-B27
129
pathogenesis of AS
immune related begins where articular cartilage, ligaments, and other structures attach to bones. Inflamed joint infiltrated with CD4, CD8, and macrophages and TNFa
130
what is AS triggered by
absolutely nuttin
131
clinical manifestations of AS
``` bony tenderness systemic illness SI joint/spine inflammation persistent low back pain spinal ligament inflammation/dysmotility intercostal ligament inflammation minor back trauma --> fractures extraskeletal features ```
132
where is bony tenderness in AS
spinous processes illiac crests greater trochanter costosternal junctions
133
systemic illnesses associated with AS
fatigue anemia weight loss
134
is inflammation limited to the axial skeleton in AS
peripheral oligoarthritis in 30%
135
does back pain improve or worsen with exercise in AS
improve
136
is spinal mobility and chest expansion affected in AS
YAS
137
signs of AS on xray
``` bamboo spine (syndesmophytes) squaring of anterior vertebrae ```
138
what causes chest expansion to be limited in AS
intercostal ligament inflammation
139
where is most of the osteoporosis and rigidity in AS
cervical spine
140
extraskeletal features of AS
fatigue weight loss anterior uveitis (pain, redness, photophobia, lacrimation) aortic root and valve thickening and inflammation AV conduction deficits and aortic insufficiency upper lobe pulmonary fibrosis radicular symptoms from cauda equina fibrosis colon or ileum inflammation
141
physical exam findings of AS
``` limitation of anterior and lateral flexion and extension of L spine and chest expainsion SI joint pain paraspinous muscle spasm lumbar lordosis is lost fixed forward flexion and hip and neck ```
142
AS lab findings
``` none are diagnostic CRP and SED elevated mild anemia synovial fluid non-specific inflammatory PFTs- dereased VC and increased residual capacity ```
143
criteria for chronic inflammatory back pain of AS
more than three months | age of onset
144
schober test
for AS mark L5 and measure 10cm above L5 patient flexes forward. look for an increase in space from mark to L5 by atleast 5cm
145
chest expansion test for AS
at fourth intercostal space look for
146
AS tx
``` stop smoking protect spine spinal extention exercises hard mattress (prevent spinal flexion) treat coexisting diagnoses ```
147
coexisting diagnoses of AS and their tx
uveitis-steroids | cardiac dz-pacemaker
148
mainstay of therapy (first line) for AS
NSAIDs | reduce pain and increase mobility
149
Anti-TNF for AS
cause dramatic radiologic and clinical benefits and reverse significantly need a definitive dx before you start need to test for TB first
150
three anti-TNF drugs for AS
infliximab (Remicade) etanercept (enbrel) adalimumab (humira)
151
toxicity of anti-TNF agents
``` serious infection pancytopenia demyelinating disorders exacerbation of CHF SLE-like illness hypersensitivity at infusion or injection site severe liver dz ```
152
acute nonpurulent arthritis complicating an infection elsewhere in the body
reactive arthritis
153
do all reactive arthritis pts have a preceeding clinical infection?
no!
154
antigen that reactive arthritis is associated with
HLA-B27
155
triad of reactive arthritis
arthritis conjunctivitis urethritis
156
reactive arthritis pathophys
AA sequences in microorganisms mimic those of human proteins | antibodies create autoimmune dz in those genetically predisposed
157
most common infections associated with reactive arthritis
GU: chlamydia GI: salmonella, yersinia, campylobacter
158
when does arthritis start in reactive arthritis
1-3 weeks after infection
159
is reactive arthritis symmetrical or asymmetrical
asymmetrical of large lower extremity joints
160
what other two manifestations are associated with reactive arthritis
dactylitis (sausage digit) sacroiliitis oral ulcers keratoderma blenorrhagica (vesicular skin lesions that become hyperkeratotic on hands and soles) circinate balanitis (painless vesicles --> erosions on the penis)
161
how long does reactive arthritis last
3-5 months but up to a year
162
urogenital symptoms of reactive arthritis
cervicitis salpingitis prostatitis
163
are the GU sx of reactive arthritis significant
either marked or asymptomatic
164
lab findings in reactive arthritis
``` ESR and CRP mild anemia HLA-B27 in 1/2 elevation of Ab to bacteria PCR for chlamydia ```
165
how to dx reactive arhritis
no definitive way
166
tx for reactive arthritis
NSAIDs | no benefit in tx infection if it's at this point
167
age and gender predominance of psoriatic arthritis
men = women | 4th-5th decade
168
location of psoriatic arthritis
DIP and SI joints
169
pathyphys of psoriatic arthritis
synovium infiltrates with T cells, B cells, and macrophages
170
clinical manifestations of psoriatic arthritis
``` assymetric oligoarthritis symmetric polyarthritis axial arthritis arthritis DIP nail pitting dactylitis enthesitis ```
171
enthesitis
inflammation of the ligaments or tendons where they insert on the bone
172
lab findings of psoriatic arthritis
no diagnostic tests ESR and CRP elevated HLA-B27 in most with axial dz
173
xray findings of psoriatic arthritis
pencil in cup deformity | telescoping digits
174
treatment of psoriatic arthritis
anti-TNF agents
175
enteropathic arthritis
IBD and arthritis | arthritis precedes onset of IBD by months to years
176
associated symptoms of enteropathic arthritis
dactylitis and enthesopathy uveitis erthyma noosum
177
what is erythema nodosum
red bumps on the shins
178
treatment for enteropathic arthritis
anti-TNF apha agents infliximab (remicade) etanercept (enbrel) adalimumab (humira)
179
lab elevations in enteropathic arthritis
HLA CRP SED
180
fibromyalgia
chronic widespread musculoskeltal pain and fatigue often accompanied by cognitive and psychatric probs
181
PE of fibromyalgia
TTP in 11/18
182
symptoms of fibromyalgia
``` widespread musclar pain fatigue fibro fog (attention deficit, difficulty completing tasks) headache in some paresthesias abdominal pain chest wall pain ```
183
criteria for fibromyalgia dx
TTP in 11/18 for >3 months normal PE except TTP normal lab tests (CBC, SED rate, TSH)
184
tx of fibromyalgia
challenging but... TCAs --> SSRIs --> SNRIs anticonvulsants
185
TCAs for fibromyalgia
amitriptyline (elavil) low and slow, QHS,

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