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Internal Medicine Board Review > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

Which 2 ANA subtypes are specific for a diagnosis of SLE?

A

The anti-DSDNA and anti-Smith antibodies are specific to lupus.

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2
Q

Anti-U1-RNP is a very sensitive indicator for which rheumatologic disorder?

A

Anti-U1-RNP is a sensitive but not very specific indicator of mixed connective tissues disease.

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3
Q

Which rheumatologic disease is associated with a positive c-ANCA and anti-PR3?

A

Granulomatosis with polyangiitis is associated with c-ANCA and anti-PR3.

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4
Q

Name 2 diseases that are p-ANCA+ and anti-MPO+.

A

Microscopic polyangiitis, eosinophilic granulomatosis with polyangiitis are associated with c-ANCA and anti-MPO+. Other diseases that are positive for these antibodies include pauci-immune RPGN, anti-GBM disease, and drug induced (PTU, methimazole, levamisol).

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5
Q

Name 2 diseases that consume complement during a flare

A

Hypocomplementemia is seen in SLE, vasculitis, RA, and infectious endocarditis.

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6
Q

Other than rheumatoid arthritis, a positive RF can be seen with which other diseases?

A

Other than RA, a positive RF can be seen in chronic infections (TB, HIV, viral hepatitis), chronic lung disease, Sjogren’s, SLE, infectious endocarditis, and hematologic malignancy.

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7
Q

What antibody test is more specific than RF for rheumatoid arthritis?

A

Anti-CCP (anticitrullinated cyclic peptide) is more specific for RA than the RF.

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8
Q

Compare and contrast “noninflammatory”, “inflammatory”, and “septic” joint fluid.

A

“Noninflammatory” joint fluid has <2000 WBC with clear to light yellow color and normal viscosity. “Inflammatory” joint fluid has 2,000-100,000 WBC with light yellow to cloudy color and low viscosity. “Septic” fluid has 15,000 and higher WBC with yellow to green color.

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9
Q

Describe gout crystals and their birefringence.

A

Uric acid crystals are needle shaped and exhibit negative birefringence (yellow) under polarized microscopy.

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10
Q

Describe calcium pyrophosphate (pseudogout) crystals and their birefringence.

A

Calcium pyrophosphate crystals are rhomboid-shaped and positively birefringent (blue) under polarized microscopy.

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11
Q

How long is the typical morning stiffness in RA vs. OA?

A

Morning stiffness last >1 hour in RA and less than 30 minutes in OA.

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12
Q

What are the essential diagnostic criteria for RA?

A

The diagnostic criteria for RA include: inflammatory arthritis (1 to 10 joints), positive RF and/or anti-CCP, increased ESR/CRP, and duration >6 weeks.

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13
Q

What imaging tests are mandatory before electively intubating a patient with RA?

A

Before electively intubating a patient with RA, flexion and extension cervical spine Xrays should be performed to rule out atlanto-axial instability.

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14
Q

What part of the spine is sometimes involved in RA? Which parts are not involved?

A

RA involves the cervical spine but does not involve the thoracic or lumbar spines or the SI joints.

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15
Q

Name the pulmonary manifestations of RA.

A

Pulmonary manifestations of RA include exudative pleural effusion, diffuse interstitial fibrosis, and intrapulmonary nodules.

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16
Q

What is Felty syndrome?

A

Felty syndrome is the triad of RA, splenomegaly, and neutropenia

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17
Q

Which DMARD is recommended by the American College of Rheumatology as 1st line for all moderate-to-severe cases of RA?

A

The ACR considers methotrexate to be the 1st line DMARD treatment for RA.

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18
Q

What follow up is required in patients treated with hydroxychloroquine?

A

The most common adverse effect of hydroxychloroquine is retinopathy. Therefore, baseline ophthalmology exam and annual exams once patient has been on MTX for 5 years are indicated.

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19
Q

What are the categories of biologics used to treat RA?

A

The categories of biologics used to treat RA include: anti-TNF alpha, CTLA-4/costimulator inhibitor, IL-6 inhibitor, IL-1 antagonist, and monoclonal Ab to CD20.

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20
Q

What are the representative drugs for each category of biologics?

A

TNF-alpha inhibitors: Infliximab, Adalimumab, Golimumab, Certolizumab

TNF-alpha inhibitor (small molecule): Etanercept

CTLA-4/costimulator inhibitor: Abatacept

Monoclonal AB to CD20: Rituximab

IL-1 antagonist: Anakinra

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21
Q

Name some serious complications of the various biologics.

A

All biologics are associated with increased risk of infection. The monoclonal AB TNF-alpha inhibitors are associated with lymphoma and skin cancers, reactivation of TB, heart failure.

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22
Q

Which DMARDs are relatively safe during pregnancy?

A

Hydroxychloroquine and sulfasalazine are safe in pregnancy. TNF-inhibitors are generally safe in pregnancy, but consider stopping at 30 weeks gestation to decrease risk of infection and placental transfer of drug.

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23
Q

Characterize the pattern of arthritis in SLE.

A

The arthritis of SLE is inflammatory and nonerosive. It can be symmetrical or asymmetrical, oligoarticular or polyarticular, and can affect large or small joints.

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24
Q

What are the patterns of skin rashes in SLE?

A

Chronic cutaneous lupus erythematosis (aka discoid lupus) is localized with central scarring/atrophy. It portends a more benign course of lupus. Acute cutaneous lupus erythematosis (ie. malar rash) flares with disease activity. Subacute cutaneous lupus erythematosis is an annular rash seen in SLE, Sjogrens and with certain medications including calcium channel blockers.

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25
Q

Which autoantibodies are associated with the development of glomerulonephritis?

A

The presence of anti-DS-DNA is associated with glomerulonephritis and nephrotic syndrome.

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26
Q

Which classifications of SLE kidney disease require treatment with cytotoxics?

A

Cyctoxic therapy is required for class 3 and 4 lupus nephritis and also should be considered in class 5.

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27
Q

What hematologic abnormalities are seen in SLE?

A

Immune cytopenias are common in SLE including leukopenia, thrombocytopenia, and hemolytic anemia.

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28
Q

A pregnant woman with SLE has SSA (Ro) and SSB (La) antibodies. What abnormality can occur in the fetus?

A

The fetus of a woman with SLE with SSA and SSB antibodies is at risk for congenital heart block. This risk rises with subsequent pregnancies.

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29
Q

What are potential complications of chronic corticosteroid treatment in patients with SLE?

A

Up to ⅓ of SLE patients on chronic steroids develop avascular necrosis of the hip/knee/humerus.

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30
Q

Which drugs classically cause drug-induced lupus?

A

The classic drugs that cause drug-induced lupus are procainamide and hydralazine.

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31
Q

What are the common features of spondyloarthropathies?

A

Seronegative spondyloarthropathies share some common features. These include: predilection for spine and SI joints, enthesitis, asymmetric, large-joint oligoarthritis, dactylitis, circinate balanitis, uveitis or iritis, bowel inflammation, genitourinary (urethritis or balanitis), skin lesions (keratoderma blennorrhagicum or psoriasis), association with GI or GU infections, and association with HLA-B27 (variable).

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32
Q

“Sausage-shaped digits” are seen in which arthritides?

A

“Sausage-shaped digits” (dactylitis) is associated with reactive arthritis and psoriatic arthritis.

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33
Q

“Bamboo spine” is typically associated with which disease?

A

“Bamboo spine” is seen in ankylosing spondylitis.

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34
Q

How does a patient with ankylosing spondylitis present?

A

Onset of AS is usually in young adulthood with peak age of 20 to 30. It affects men more than women (2-3:1). AS has a 90% incidence of positive HLA-B27.

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35
Q

Which organisms are associated with reactive arthritis?

A

Reactive arthritis is commonly associated with GU infections (Chlamydia) and GI infections (Salmonella, Shigella, Yersinia, Campylobacter, and C. diff. It can also be seen with the viral illnesses enterovirus and HIV.

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36
Q

What is the classic triad of findings seen in reactive arthritis?

A

The classic triad of reactive arthritis is inflammatory oligoarthritis, urethritis, and conjunctivitis.

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37
Q

What are the patterns of arthritis seen with psoriasis? Name some other associated features.

A

Psoriatic arthritis can present in many forms including: symmetric polyarthritis, asymmetric arthritis (oligoarthritis), spondylitis, DIP arthritis, and arthritis mutilans.

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38
Q

Acute onset of psoriasis in men having sex with men should make you think of what disease?

A

Acute onset of psoriasis in men having sex with men should prompt evaluation for HIV/AIDS.

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39
Q

What is the pattern of joint involvement in osteoarthritis?

A

The most commonly involved joints in OA are the carpometacarpal (CMC-1) joints of the hands, feet, knees, hips, and spine.

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40
Q

Which joints are typically spared in primary osteoarthritis?

A

Joints that are rarely involved with OA include the ankles, wrists, and elbows.

41
Q

Which joints of the hand are affected by primary osteoarthritis? What characteristic features are seen in the hands or patients with OA?

A

OA generally affects the hands in the CMC-1 joints, PIPs, and DIPs. This involvement can be associated with Bouchard (PIP) and Heberden (DIP) nodes.

42
Q

At what age does gout usually present?

A

Gout usually affects males starting at age 30-45 and increasing with age. Woman usually get gout following menopause as estrogen has protective effect due to its uricosuric properties.

43
Q

How is gout definitively diagnosed?

A

Gout is definitively diagnosed by seeing uric acid crystals on joint aspiration. Just 1 uric acid crystal in a neutrophil or >3 extracellular urate crystals is sufficient to make the diagnosis.

44
Q

Characterize the crystals of gout when observed under a polarizing microscope.

A

Uric acid crystals are needle shaped and negatively birefringent (yellow) under polarized light.

45
Q

How could you treat a gout flare in a single joint? In multiple joints?

A

A gout flare in a single joint may be best treated with intraarticular steroid injection. A flare in multiple joints is treated with NSAIDs, colchicine, or steroids.

46
Q

What drugs for chronic treatment of gout are contraindicated during an acute flare of gout?

A

Xanthine oxidase inhibitors are contrainidcated during an acute flare of gout as they may aggravate the flare.

47
Q

What is the goal uric acid in a patient who has >1 attack of gout per year?

A

A patient with >1 attack of gout per year should be treated to a uric acid level <6.

48
Q

Which drugs need a dose adjustment downward if a patient takes allopurinol?

A

Azathioprine and mercaptopurine must be decreased by 66-75% dose in those taking allopurinol.

49
Q

Which diseases are associated with CPPD?

A

Predisposing conditions for CPPD are primary hyperparathyroidism, hemochromatosis, hypothyroidism, hypomagnesemia, and hypophosphatemia.

50
Q

Inflammatory arthritis of certain joints should make you think of CPPD disease. Which joints are they?

A

You should consider CPPD disease in patients with arthritis of the 2nd and 3rd MCPs, shoulder, elbows, and ankles. These joints are all uncommonly involved in OA.

51
Q

What do CPPD crystals look like under polarized light?

A

CPPD crystals are rhomboid shaped and blue when parallel to polarized light.

52
Q

What is the typical cell count in the synovial fluid of a septic joint? What type of cells are they?

A

Most cases of septic arthritis have a cell count >50,000 (usually >100,000) with a predominance of neutrophils.

53
Q

What are the common pathogens associated with septic arthritis?

A

The most common pathogens in septic arthritis are S. aureus and S. viridans.

54
Q

How do you diagnose gonococcal arthritis?

A

Gonococcal arthritis can be difficult to diagnose. You should culture all mucosal surfaces that may be harboring the organism including cervix, urethra, rectum, and oropharynx. In addition culture skin lesions, joint fluid and blood.

55
Q

What is special about the approach to diagnosis of gonococcal arthritis compared to traditional septic joint workup?

A

In traditional septic arthritis only the joint involved is cultured. With suspected gonococcal arthritis all potential sources of infection should be cultured (mucosal surfaces, skin lesions, joints, blood).

56
Q

What are the presenting symptoms of Whipple disease? What organism is involved?

A

Whipple disease presents with a nondestructive, seronegative, inflammatory arthritis of predominantly large joints. It is also associated with diarrhea, malabsorption, weight loss, fevers, lymphadenopathy, skin hyperpigmentation and neurologic findings. “Oculomasticatory myorhythmia” or nystagmus with chewing is pathognomonic.

57
Q

What is the most sensitive joint fluid test to diagnose tuberculous arthritis?

A

The most sensitive joint fluid test for TB arthritis is PCR.

58
Q

What test is used to confirm a parvovirus B19 synovitis?

A

The diagnosis of parvovirus B19 synovitis is confirmed with IgM against parvovirus B19.

59
Q

What are the Jones criteria for acute rheumatic fever?

A

Jones major criteria: Carditis, Chorea, Erythema marginatum, Polyarthritis, and Subcutaneous nodules. Jones minor criteria: fever, arthralgias, positive throat culture for Strep, prolonged PR interval. Must have 2 major of 1 major and 2 minor to make the diagnosis.

60
Q

How do you diagnose Lyme arthritis?

A

Diagnose Lyme arthritis with serum ELISA test for anti-Borrelia burgdorferi IgG.

61
Q

Does hemochromatosis initially affect large or small joints?

A

Hemochromatosis affects small joints before large joints.

62
Q

What are the features of antiphospholipid syndrome?

A

APS is characterized by the presence of >1 antiphospholipid antibodies along with findings of vascular thrombosis or pregnancy morbidity.

63
Q

Sjogren patients are at increased risk for what kind of malignancy?

A

Sjogren patients are at higher risk for B-cell lymphoma.

64
Q

Which autoantibodies are associated with diffuse SSc? What complications are the antibodies associated with?

A

Anti-SCL70 antibodies are associated with diffuse SSc. these antibodies are associated with interstitial lung disease and decreased survival.

65
Q

What are the key features of limited SSc?

A

Limited SSc used to be called CREST syndrome. Key features are calcinosis, Raynaud phenomenon, Esophageal dysmotility, Sclerodactyly, and Telangiectasias.

66
Q

Abnormal nailfold capillaries are more commonly seen in which autoimmune disease?

A

Abnormal nailfold capillaries are most closely associated with scleroderma.

67
Q

What lung manifestation is often the cause of death in patients with diffuse SSc?

A

Pulmonary hypertension is the most common cause of lung-related death in patients with diffuse SSc.

68
Q

Compare and contrast polymyositis and dermatomyositis.

A

Polymyositis and dermatomyositis are both associated with proximal muscle weakness and elevated CK. However, dermatomyositis also has associated skin abnormalities including “shawl sign”, heliotrope rash, and Gottron papules.

69
Q

Which autoantibodies are associated with poly- and dermatomyositis?

A

ANA is positive in 60% of patients with PM/DM. Other antibodies include anti-Jo-1, anti-Mi-2, anti-SRP, and anti-p155/p140.

70
Q

Which drugs cause myopathy?

A

The most common drugs to cause myopathy are statins and chronic corticosteroids. Also consider colchicine which can also cause neuropathy.

71
Q

Which drugs are used to treat fibromyalgia?

A

The main drug treatments for fibromyalgia are pregabalin, gabapentin (off-label), duloxetine, and milnacipran.

72
Q

What are the typical lab findings in a patient with vasculitis?

A

Typical lab findings in vasculitis are elevated ESR/CRP, thrombocytosis, anemia of chronic disease, and hypoalbuminemia.

73
Q

What is a typical presentation of GCA? What are the atypical presentations?

A

Typical presenting symptoms of GCA are temporal headache, diplopia, amaurosis fugax, scalp tenderness, and jaw claudication.

74
Q

How do you diagnose GCA? What is a serious complication of GCA within the first 5 years of diagnosis?

A

GCA is diagnosed by temporal artery biopsy. GCA patients are at risk for aortic aneurysms (particularly ascending) within the first 5 years of disease.

75
Q

What are the differences in the clinical presentations of myositis and PMR?

A

Myositis presents with weakness without pain whereas PMR is associated with proximal muscle pain and stiffness. In myositis the CK is elevated whereas it is usually normal in PMR.

76
Q

With which virus is PAN associated?

A

PAN is closely associated with hepatitis B virus.

77
Q

How do you diagnose PAN?

A

If PAN is suspected and peripheral involvement is noted then biopsy the affected site. If there is no peripheral involvement then perform an angiogram.

78
Q

Which organs/tissues are commonly involved in GPA?

A

GPA commonly involves the respiratory tract including lungs and sinuses and the kidneys.

79
Q

Which antibodies are specific for GPA?

A

GPA patients are c-ANCA+ and anti-PR3+.

80
Q

Why is TMP/SMX given to patients with GPA?

A

TMP/SMX is given to GPA patients because they are at higher than usual risk for PCP pneumonia.

81
Q

Mixed cryoglobulinemia is associated with which hepatitis virus?

A

Mixed cryoglobulinemia is associated with hepatitis C virus.

82
Q

What are the clinical features of Behcet’s?

A

Behcet’s is associated with mucosal ulcerations, genital ulcerations, uveitis or retinal vasculitis, erythema nodosum, and with positive pathergy test.

83
Q

What complications can be seen with Behcet’s?

A

The most serious complications of behcet’s are blindness, CNS disease, and thrombosis or rupture of large aneurysmal vessels.

84
Q

Name some bursae that commonly become inflamed.

A

Some bursae that commonly become inflamed include the subacromial, trochanteric, pes anserine, prepatellar, and olecranon bursae.

85
Q

What is the workup of nontraumatic arthritis?

A

An acutely swollen joint without history of trauma should be aspirated and sent for the 3Cs: cell count, crystals, and culture.

86
Q

Olecranon bursitis is associated with which systemic diseases?

A

Olecranon bursitis is associated with gout, pseudogout, and rheumatoid arthritis.

87
Q

How is lateral epicondylitis treated?

A

Lateral epicondylitis is treated with NSAIDs and splinting. Steroid injection is no longer recommended as the mainstay of therapy.

88
Q

Carpal tunnel syndrome affects which fingers? What about ulnar entrapment neuropathy?

A

CTS affects the thumb through the inside of the 4th finger. Ulnar entrapment affects the 4th and 5th fingers.

89
Q

How does the pain from hip OA differ from pain from trochanteric bursitis?

A

Hip joint pain is located in the anterior groin. Trochanteric bursitis pain is lateral to the hip

90
Q

Which patients are at high risk for AVN (osteonecrosis) of the hip?

A

Patients on chronic steroids and alcoholics are at highest risk for AVN. Other risks include sickle cell disease, pregnancy, HIV/AIDS, Gaucher disease IBD, SLE, pancreatitis, and hypercoagulable states.

91
Q

Should MRI evaluation of AVN include 1 or both hips? Why?

A

You should perform MRI on both hips in patients with suspected AVN because bilateral involvement is common.

92
Q

What intervention can be used to treat a Baker cyst?

A

Treatment of a Baker cyst involves rest, NSAIDs, and addressing the underlying cause. If it is very large and symptomatic, aspirate the knee (anteriorly) and inject steroids.

93
Q

What is the specific presentation of pes anserine bursitis?

A

Pes anserine bursitis presents with pain and tenderness with possible swelling 2cm distal to and medial to the patella.

94
Q

Name the other disease that must be considered in a patient with plantar fasciitis.

A

Spondyloarthropathies can present with enthesopathies which can include the plantar fascia.

95
Q

Which patients should get urgent imaging of the spine if they present with lower back pain?

A

Patients with red flag symptoms or with urinary retention, fecal incontinence, or progressive motor weakness should undergo urgent imaging for low back pain.

96
Q

What are spondylosis, spondylolysis, and spondylolisthesis?

A

Spondylosis is arthritis of the spine. Spondylolysis is is a defect of the pars interarticularis of the 5th (and rarely 4th) vertebra. Spondylolithesis is an anterior shift of one vertebra on another.

97
Q

What are the symptoms commonly noted with lumbar stenosis?

A

Lumbar stenosis presents with pseudoclaudication and increased pain when walking uphill or down stairs.

98
Q

What is piriformis syndrome?

A

Piriformis syndrome is pain in the lateral margin of the sacrum with reproduction with Pace test.

Internal Medicine Board Review (13 decks)

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