Rheumatology Flashcards
What is the next step in the management of chronic monoarthritis in a pt that has a joint drained twice and bloodwork is unrevealing?
Synovial Biopsy
What is this? What systemic disease is it ass’d with?
enthesitis (where the tendon inserts to bone)
Spondyloarthritis (ankylosing spondylitis, psoriatic arthritis, inflammatory bowel disease–associated arthritis, and reactive arthritis)
Spondyloarthritis refers to a group of disorders that share an overlapping set of features, including inflammation of the axial skeleton, tendons, and entheses (insertion of tendon to bone); tendon and enthesis calcification; an association with HLA-B27; and mucocutaneous, gastrointestinal, and ocular inflammation.
What are the 4 spondyloarthritis? What are the characteristic features of this group of disorders?
- ankylosing spondylitis
- psoriatic arthritis
- inflammatory bowel disease–associated arthritis
- reactive arthritis
Spondyloarthritis refers to a group of disorders that share an overlapping set of features, including inflammation of the axial skeleton, tendons, and entheses (insertion of tendon to bone); tendon and enthesis calcification; an association with HLA-B27; and mucocutaneous, gastrointestinal, and ocular inflammation.
65F with PMH Giant Cell Arteritis. On 60mg Prednisone and ASA81. DEXA 6mo ago based upon the results of the Fracture Risk Assessment Tool, the patient was classified as medium risk (10%-20%) for a major osteoporotic fracture in the next 10 years.
How do you interpret this and what is the mgmt?
10 year risk >20% need to be treated with bisphosphonates.
Especially this woman who is still on steroids.
What is the treatment for mono osteo-arthritis in an elederly patient with CAD and CKD3 on ASA81?
Topical NSAIDs
PO NSAIDs are first line, but they are not reccomended in patients >75 y/o d/t potential toxicity (age, CKD, CAD, and ASA intake)
What medications need to be avoided in a pt who is on colchicine?
CYP3A4 inhibitors
- clarithromycin
- fluconazole
This can cause a potentially fatal colchicine toxicity with kidney failure, rhabdo, BM suppression
78M PMH HTN and Gout (on lisinopril, colchicine and febuxostat) dx with CAP started on Clarithromycin 5d ago. Yesterday he developed generalized weakness and diarrhea.
On physical examination, temperature is 36.9 °C (98.4 °F), blood pressure is 104/60 mm Hg, pulse rate is 112/min, respiration rate is 18/min, and oxygen saturation is 98% breathing ambient air. There is no rash. The oropharynx appears dry. The chest is clear to auscultation. Tophi are noted at the olecranon processes. There are no swollen or tender joints. Neurologic examination is normal.
Laboratory studies;
- Absolute neutrophil count: 1300/µL (1.3 × 109/L)
- Hemoglobin: 9.8 g/dL (98 g/L)
- Leukocyte count: 2700/µL (2.7 × 109/L)
- Platelet count: 96,000/µL (96 × 109/L)
- Reticulocyte count (corrected): 1.2%
- Creatine kinase: 8433 U/L
- Creatinine: 1.7 mg/dL (150.1 µmol/L)
- Urinalysis: 4+ blood; 0-1 erythrocytes/hpf; 0-2 leukocytes/hpf
There are no schistocytes seen on peripheral blood smear.
What is this?
Colchicine toxicity 2/2 Clarithromycin initiation
- Both meds need to be discontinued
- Pathophys: CYP3A4 inhibition by clarithromycin -> colchicine toxicity
- Presenation is kidney failure, rhabdo, BM suppression
What are the ADRs of pregabalin?
Weight gain, peripheral edema, lethargy, dizziness.
What ADRs of MTX do you need to monitor?
Megaloblastic anemia or Pancytopenia
Periodic CBC is reccomended
What is leflunomide used to treat?
What are the ADRs?
RA & Psoriatic Arthritis
Uncommon ADR: Peripheral neuropathy (goes away when discontinued)
Common ADR: nausea, HA, rash, diarrhea, transaminitis
53M PMH CKD3 with 5y h/o recurrent gout attacks that are becoming more frequent and severe. Serum Urate is 9.2. He is of Thai descent. What is the next step in management?
HLA-B*5801 allele testing
This patient given his Asian background and CKD is at high risk for allopurinol hypersensitivity
Allopurinol hypersensitivity is characterized by DRESS (drug reaction, eosinophilia, and systemic symptoms) syndrome and can result in kidney failure and death; allopurinol should be discontinued at the first sign of a rash. The presence of the HLA-B*5801 allele is a contraindication to prescribing allopurinol
What are the risk factors for allopurinol hypersensitivity?
What test do you do to help evaluate risk?
CKD, Asian, Diuretic use
The presence of the HLA-B*5801 allele is a contraindication to prescribing allopurinol
What RA meds are CI during pregnancy?
MTX and Leflunomide
Note: Hydroxychloroquine is safe
What is the most helpful AB used to dx RA?
Anti-cyclic citrullinated AB
Note: you would also get RF and inflammatory markers
53F with 15y h/o RA who presents with intermittent sensory loss in the hands and an occasional shock-like sensation from the neck down the back with neck flexion. She has not noted any weakness. Medications are methotrexate, etanercept, and folic acid.
Neck flexion triggers her symptoms. There is no muscle atrophy at the hands. Tinel and Phalen signs at the wrist are negative. Reflexes, strength, and sensation of the upper and lower extremities are normal.
What is this? What is the next step in mgmt?
C1-C2 Subluxation
Flexion/extensoin radiography of the cervical spine
Patients with long-standing (>10y) RA are at risk. nflammation from RA can lead to attenuation of the transverse ligament that normally limits the posterior motion of the odontoid process of the C2 vertebrae.
What eye disease is ass’d with RA?
Scleritis
Typical features include eye pain, pain with gentle palpation of the globe, and photophobia. The deep scleral vessels are involved and may lead to scleromalacia, which is characterized by thinning of the sclera and is seen as a dark area in the white sclera
What is the difference between scleritis and episcleritis?
Scleritis: eye pain, pain with gentle palpation of the globe, and photophobia. Scleritis can be vision-threatening and lead to blindness; it is therefore important to urgently refer the patient to an ophthalmologist for care. Ass’d with autoimmune diseases.
Episcleritis is an abrupt inflammation of the superficial vessels of the episclera, a thin membrane that lies just beneath the conjunctiva. Not ass’d with autoimmune diseases. Patients with episcleritis frequently present without pain or decreased visual acuity. On examination, the inflammation appears localized. White sclera can be seen between superficial dilated blood vessels. Episcleritis typically resolves spontaneously.
What type of pleural effusion is ass’d with RA?
Exudative
What is Light’s Criteria? Which type of pleural effusion is ass’d with RA?
Exudative
50M with 15y h/o worsening arthritis which has not been worked up. He has a lower extremity ulcer.
On physical examination, vital signs are normal. The spleen tip is palpable. There is swelling of multiple small joints at the hands, knees, and metatarsophalangeal (MTP) joints. There is ulnar deviation and subluxation of the metacarpophalangeal joints. Subcutaneous nodules are present at the elbows bilaterally. There is a 2- × 2-cm shallow ulcer at the medial left lower extremity just above the ankle.
Laboratory studies:
- Hematocrit: 33%
- Leukocyte count: 2100/µL (2.1 × 109/L), with 900 neutrophils
- Platelet count: 276,000/µL (276 × 109/L)
- Urinalysis: Normal
What is the most likely dx?
Felty syndrome
- Long-standing aggressive RA
- Neutropenia
- Splenomegaly
- Ass’d with the risk for serious infections, lower extremity ulcers, and vasculitis.
What is the initial monotherapy for RA?
Methotrexate
Methotrexate is an anchor drug in RA and is the preferred initial monotherapy, as it both controls symptoms and prevents joint damage. Clinical trials have demonstrated that 30% to 50% of patients treated with methotrexate monotherapy will show no disease progression as measured by hand and foot radiographs.
What is the main modifiable risk factor for OA?
Weight
patient’s with higher BMI have proprotionally higher risk of getting OA.
74M with pain and stiffness in the mid and lower spine that has progressively worsened over the past 10 years. The pain is worse with activity.
Limited range of motion and pain on motion of thoracic and lumbar spine are noted. There is no peripheral joint swelling or tenderness and no sacroiliac tenderness. The FABER test of the hip is normal.
Laboratory studies show a normal erythrocyte sedimentation rate.
Thoracolumbar spine radiographs reveal bridging ossification on the right side along the anterolateral aspects of the vertebral bodies of T9-L2. Radiographs of the sacroiliac joints are normal.
What is the dx?
Diffuse Idiopathic Skeletal Hyperostosis (DISH)
Diffuse idiopathic skeletal hyperostosis is a noninflammatory condition that involves ossification of spinal ligaments and entheses and usually presents as back pain and stiffness; characteristic radiographic changes include confluent ossification of at least four contiguous vertebral levels, usually on the right side of the spine.
Ankylosing spondylitis is characterized by bilateral sacroiliac joint abnormalities on spinal radiographs. Other spinal sections may also be involved, but sacroiliac joint involvement is cardinal for diagnosis. Inflammatory back pain is the most common symptom and is usually comprised of four of five of the following features: onset of back discomfort before the age of 40 years; insidious onset; improvement with exercise; no improvement with rest; and pain at night (with improvement upon arising).
50F with 1mo h/o pain on the inner L knee. The pain is aggravated by ascending stairs and rising from a seated position. This is different than her OA knee pain.
Tenderness to palpation and slight swelling over the proximal medial tibia about 6 cm below the anteromedial joint margin of the knee are noted. Examination of the knee shows no crepitus, minimal pain along the medial joint line, and no pain on valgus stress; anterior and posterior drawer signs are negative.
What is this?
Pes anserine bursitis
How would you treat knee OA and low back pain in a 73F who has tried nonpharmacologic interventons, had minimal benefit from intra-articular glucocorticoid and hyaluronic acid injections and was recently dx with PUD?
Duloxetine
Note: Topical Capsaicin or NSAIDs would be an option if it was just her knee.
What ADR should you counsel your patient’s on when rx topical NSAIDs?
Localized skin rash
Note: they provide similar pain relief as oral medications with less risk for GIB
What are the 3 drugs used to treat fibromyalgia?
Pregabalin
Duloxetine
Milnacipran
Each drug has about a 30% reduction in pain. Note: NSAIDs are not part of the treatment. The above meds can be used in combination.
Do you need HLA-B27 testing to confirm AS?
No, it does not need to be checked if they have;
- Inflammatory back pain for 3 or more mo
- <45 y/o
- Limited lumbar spine motion
- Elevated inflammatory markers
- Bilateral sacroilitis on imaging
The only time it would be helpful if the case is less clear.
What is the difference between acute cutaneous lupus eythematosis (ACLE) and subacute cutaneous lupus erythematous (SCLE)?
ACLE:
- Almost 100% of these patients have SLE
- Most commonly presents as malar rash
SCLE:
- anti-Ro/SSA antibodies in 75% of cases
- 50% have SLE
- More mild symptoms
- Photosensitive rash that is most commonly on forearms, chest, upper back
34F w 2y h/o Lupus Nephritis on hydroxychloroquine, mycophenolate mofetil, and prednisone. She has had 6mo of worsening pain in the L groin and radiation to the L buttock, particularly with stair climbing.
She has weakness of the left hip flexors. Decreased passive range of motion of the left hip in both external and internal rotation with pain is noted.
What is the most likely dx? What is the next step in mgmt?
Glucocorticoid-induced osteonecrosis of the L hip
Mgmt: Plain radiography of the L hip. MRI only if plian radiograph is wnl.
Note: Both steroids and SLE itself are risk factors for osteonecrosis
47F with onset over 2 to 3 weeks of low-grade, intermittent fever; blanching of the second and third right fingertips in response to cold exposure; cracking and peeling of the skin on the sides of the second digits and palms; and pain and swelling of the second and fourth proximal interphalangeal joints bilaterally. She does not take any medications.
Erythema of the malar area, forehead, and chin is present. Pulmonary examination reveals crackles at the lung bases.
Skin findings are shown.
Laboratory studies:
- Creatine kinase: 115 U/L
- Antinuclear antibodies: Titer: 1:1280
- Anti–double-stranded DNA antibodies: Negative
- Anti–Jo-1 antibodies: Positive
- Anti-Smith antibodies: Negative
What is this?
Antisynthetase syndrome
- ILD
- Myositis
- Raynaud
- Arthritis
- Mechanic’s hands
- +Anti-Jo-1
43M with GIB. PMH diffuse cutaneous systemic sclerosis with Raynauds and GERD.
Upper gastrointestinal endoscopy demonstrates linear ectatic vessels resembling the stripes found on a watermelon that arise from the pylorus.
What is this?
Gastric Antral Vascular Ectasia
Proliferation of blood vessels typically in the stomach antrum. 60% of people with this finding have an underlying autoimmune disease.
26F with 3d h/o fatigue, chills, and joint pain in the fingers of the left hand, left wrist, and right ankle. There is no travel history. She is currently taking ibuprofen for her symptoms; she also takes an oral contraceptive pill.
temperature is 39.0 °C (102.2 °F), blood pressure is 114/72 mm Hg, and pulse rate is 106/min. Fusiform enlargement of the second and fourth digits of the left hand with pain on extension is noted. Tenosynovitis over the dorsum of the left wrist and at the right ankle is present.
A painless lesion on the palm is shown.
What is this?
Disseminated gonococcal infection
Triad of;
- Tenosynovitis
- Dermatitis (usually painless pustular or vesiculopustular lesion)
- Polyarthralgia without frank arthris
- Fever, chills, malaise
