Rheumatology

Question 1

Differential dx of monoarthritis (list 8)

Answer 1

Trauma
Infection
- Acute: septic arthritis, osteomyelitis
- Chronic: remember TB and Lyme!
Inflammatory: transient synovitis (short duration), JIA
Tumor: localized bone tumor
Hemarthrosis: consider bleeding disorder (vWD, hemophilia)
Mechanical/orthopedic: overuse (ex. Osgood-Schlatter), AVN, SCFE, Chondromalacia patellae (patellar femoral syndrome)
Pain syndrome: conversion, CRPS

Question 2

Which organisms cause septic arthritis?

Answer 2

staphylococcus aureus
Streptococcus pneumoniae
Haemophilus influenza
GBS
E.coli
Nisseria Gonorrhea
Kingella Kingae

Question 3

Describe the synovial fluid seen in septic arthritis

Answer 3

Synovial fluid WBC count > 50,000 (mostly neutrophils)

Question 4

Kocher criteria?

Answer 4

fever > 38.5
ESR > 40 mm/hr
WBC > 12,000
refusal to weight bear

Question 5

Basic labs required for febrile child with joint pain

Answer 5

CBC and differential, CRP, ESR, blood culture

Question 6

Stages of Lyme disease, and their characteristics

Answer 6

o Early localized Lyme (< 30 days): erythema migrans + may have systemic symptoms, including arthralgia. Clinical diagnosis
o Early disseminated Lyme (skin – multiple EM, neuro – facial nerve palsy, meningitis, carditis – AV block, joints – migratory arthralgias).
o Late disseminated Lyme (4-6 weeks later): chronic intermittent arthritis, - usually monoarthritis of the knee; peripheral neuropathy, encephalomyelitis

Question 7

List 6 clinical criteria of SLE

Answer 7

• Acute cutaneous lupus (lupus malar rash; bullous lupus; TEN variant of SLE; photosensitive lupus rash or subacute cutaneous lupus)
• Chronic cutaneous lupus (discoid lesions local and generalized)
• Oral or nasal ulcers
• Non-scarring alopecia
• Arthritis
• Serositis (pleurisy or pulmonary effusion or pericardial pain or pericardial effusion or rub or pericarditis)
• Renal (urine protein to Cr 500mg/24 hours or red blood cell casts)
• Neurologic (seizures, psychosis, peripheral or cranial neuropathy, acute confusional state)
• Hemolytic Anemia
• Leukopenia or lymphopenia
• Thrombocytopenia

Question 8

List 4 immunologic criteria of SLE

Answer 8

• ANA
• Anti-DNA (specific)
• Anti-Sm
• Antiphospholipid antibody (lupus anticoagulant, false positive RPR, antiocardiolipid)
• Low complement (C3, C4)
• Direct Coombs test

Question 9

Xray findings seen in JIA

Answer 9

soft tissue swelling and periarticular osteopenia; later narrowing of joint spaces, bone cysts, erosions, subluxations, ankylosis

Question 10

Side effects of NSAIDS (list 5)

Answer 10

gastritis, headaches, dizziness, fatigue, hepatitis, nephrotoxicity (proteinuria or renal papillary necrosis), friability of skin, Reye syndrome

Question 11

Cardiac complications of JIA

Answer 11

pericarditis, myocarditis (in systemic onset JIA)

Question 12

Anterior uveitis most commonly occurs in which subtype of JIA?

Answer 12

oligoarticular JIA, ANA+

Question 13

Diagnostic criteria of HLH/MAS

Answer 13

Initial diagnostic criteria:

• Fever
• Splenomegaly
• Cytopenias
• Hypertriglyceridemia and/or hypofibrinogenemia
• Hemophagocytosis in bone marrow or spleen or lymph nodes (no evidence malignancy)

New diagnostic criteria:

• Low or absent NK cell activity
• Increased Ferritin greater/equal 500 mg/L (>10,000 is sensitive and specific)
• Elevated soluble CD25

Question 14

Diagnostic criteria for Kawasaki disease

Answer 14

Fever > 5 days
and at least 4/5 of:
- conjunctivitis
- rash
- adenopathy
- extremity changes
- oromucosal changes

Question 15

List 5 items in the DDx of Kawasaki disease

Answer 15

• Viral infections: measles, echovirus, adenovirus
• Toxin mediated illnesses: Toxic shock syndrome (strep, staph), scarlet fever (group A strep)
• Drug reactions: Steven Johnson syndrome, serum sickness
• Systemic-onset JIA

Question 16

Supplemental lab criteria for incomplete KD

Answer 16

If fever> 5 days, and 2-3 clinical criteria, ESR > 40, CRP > 3:

• Albumin < 3 g/dl
• Anemia for age
• Elevated ALT
• Platelets > 450,000 per mm3
• WBC > 15, 000
• Urine > 10 WBC/hpf

Question 17

Cardiac complications of Kawasaki

Answer 17

• Coronary artery aneurysms (independent RF = male gender, delay of treatment > 10 days and IVIG retreatment)
• KD shock syndrome
• Myocarditis (prolonged PR, nonspecific ST and T wave changes)
• Reduced LV function and contractility
• CHF, valvulitis
• pericardial effusion or tamponade
• MI, coronary artery thrombosis, sudden death
• Vascular obstruction (thrombolysis then heparin)

Question 18

Clinical features of JDM (Juvenile dermatomyositis)

Answer 18

• Phase 1: Prodromal phase: nonspecific aches and pains, low grade fever, edema hands/feet/eyelids, diffuse non-specific rash
• Phase 2: progression muscle weakness and rash (violaceous heliotrope rash, Gottron papules over extensor tendons, periungual erythema)
o Proximal muscle weakness
• Phase 3: persistent active disease and cumulative tissue damage
• Phase 4: indolent phase with contracture, muscle wasting, lipodystrophy, pigmentary changes and calcinosis

Question 19

List systemic complications of polyarteritis nodosa

Answer 19

Cardiac: pericarditis, cardiomegaly
CNS: seizures, hemiparesis
GI: gut vasculitis
Pulmonary: diffuse infiltrates, pulmonary hemorrhage, hemothorax
Renal: proteinuria, urine sediment, HTN
Arthritis, livedo reticularis, urticarial, petechial rashes

Question 20

List 5 complications of JDM (juvenile dermatomyositis)

Answer 20

• skin calcinosis
• proximal muscle weakness
• resp insufficiency (diaphragm weakness)
• contractures
• heliotrope rash
• Gottron papules
• GI bleed, perforation