Rheumatology Flashcards
(102 cards)
1
Q
Synovial fluid:
- Non-inflammatory
- Inflammatory
- Septic
A
Non-inflammatory:
-WBC <2000, <=50% PMNs, clear
Inflammatory
-WBC 10,000-100,000, >50% PMNs, turbid
Septic
- WBC >50,000 (bacterial), >80-90% PMNs, Cloudy/Pus
- WBC 10-30k (fungal or mycobacterial),
- High Sp if > 100,000
2
Q
Diagnosis of RA
A
> 6 weeks duration (cutoff for chronic)
Inflammation of multiple joints (small >large), symmetric
Elevated inflammatory markers
3
Q
Seronegative RA
A
- Seronegative RA of the elderly (age >60, shoulder and hip predominant + small joints
- RS3PE
4
Q
RS3PE features + Mx
remitting seroneg symmetrical synovitis w/ pitting edema
A
Male >70
Pitting edema over dorsum of the hands
Tx: Low dose steroids, NSAIDs, Plaquenil
5
Q
Extra-articular Manifestations RA
A
CV: Increased CAD risk, myopericarditis
Resp: ILD (NSIP>UIP), pleural effusions, pulm nodules, bronchiolitis obliterans
Eyes: Scleritis
Haem: Anemia chronic disease, Felty (neutropenia, splenomegaly, RA), Non-hodgkin’s lymphoma
Neuro: C1-2 instability/ subluxation, carpal tunnel
Skin/Mucous membranes: Sicca, nodules, vasculitis, raynauds
6
Q
Treatment acute RA flare
A
Steroids (PO/IM/IA)
NSAIDs
7
Q
Chronic RA Treatment
A
1st line: DMARDs (low dz activity =Plaquenil, Mod/High activity = MTX; other options SZS, LEF)
2nd line: Combine DMARDs *triple therapy no longer recommended
3rd line: Biologics (TNFi with MTX, then Toci/ abatacept/ ritux/ -tinibs / apremilast). Increase freq >dose when flare. Do not combine biologics.
*use ritux if pt also has lymphoproliferative d/i where ritux indicated
8
Q
Methotrexate toxicities
A
Mucositis, oral ulcers
Nausea, vomiting, GI upset
Hepatotoxicity - can still use MTX in NAFLD if LE and LFT N and no advanced fibrosis
Rash, Alopecia
Pancytopenia
Hypersensitivity pneumonitis
ILD (rare) - can still use MTX in parenchymal lung dz that is incidental, mild, stable
9
Q
Pre-MTX investigations
A
CBC, liver enzymes, Cr
CXR (get baseline)
Hepatitis B and C
10
Q
Management of MTX-related NV or stomatitis
A
Increase folate to 5mg
Start ranitidine/PPI - for NV/GI upset
Trial leukovorin post MTX dose
11
Q
Tx MTX related transaminitis
A
If <2x ULN: Decrease dose, do not need to hold
If >2x ULN: Hold, trend LE, resume at lower dose 1-2 wks post normalization
12
Q
Tx MTX related cytopenia
A
Mild: Decrease Dose
Moderate-Severe: Hold, resume at lower dose once recovered
13
Q
Tx MTX related pneumonitis
A
Discontinue permanently
14
Q
Side effects leflunomide
A
Teratogenicity Rash Hepatotoxicity Cytopenias Peripheral neuropathy GI: N/V/D, abdo pain, dyspepsia
15
Q
Side effects plaquenil
A
Retinotoxicity Photosensitivity Rash Myotoxic (rare) Cardiotoxic (rare)
16
Q
Pre-biologic work-up for rheumatology
A
TBST or IGRA (if prev BCG)
CXR (if + TBST or high risk for Tb), if + –> sputum AFB
Hepatitis B sAg, sAB, cAb, HCV (treat concurrently if +)
CBC, Cr, LFTs
17
Q
Pregnancy and RA
A
Plaquenil, SSZ, biologics safe
D/C methotrexate 1-3 months pre-conception (F)
D/C leflunomide 2 yrs pre-conception (or test lvls +/-cholestyramine washout)
Males preconception: Avoid Cyclo and thalidomide, MTX ok
Taper pred to <20 mg/day (<20 ok in preg)
Avoid NSAIDs esp in T3
Breastfeeding: Biologic and SFZ ok (risk of kernicterus), avoid MTX and LFD
Can flare postpartum (remission intrapartum)
18
Q
Joint distribution in AS
A
Symmetrical Axial and SI involvement
Asymetrical large joints (if present)
19
Q
Joint distribution in PsA
A
Asymmetrical axial/SI involvement (if present)
Peripheral can be either:
1) Asymmetric large joint
2) Symmetric small joint
20
Q
Joint distribution in Reactive arthritis
A
Asymmetric large joint (mono or oligo)
+/- Asymmetric SI involvement
21
Q
Joint distribution in IBD-associated arthritis
A
Type 1= Asymmetric large joint, assoc’d w/ bowel activity
Type 2= Symmetric small joint, indep of bowel
22
Q
X-ray features in seronegative arthritis
A
SI: Sclerosis, Erosions, Ankylosis
Spine: syndesmophytes
23
Q
MRI features in seronegative arthritis
A
Bone marrow edema
Syndesmophytes
Periosteal new bone formation (PsA)
24
Q
Treatment seronegative arthritis
A
PT/Exercise/Smoking cessation for all
1st line: Trial of NSAIDs max dose daily x1 month
2nd line: Alternate NSAID x1 month
3rd line:
- If axial: anti-TNF –> IL-17 (secukinumab or ixekizumab) –> JAKi (Tofa)
- If peripheral: DMARDs (MTX, Sulfasalazine) - no role in axial
25
Risk factors for gout
```
M or Post-menopausal F
Obesity, Metabolic syndrome
CKD
Hyperuricemia: TLS, hemolysis, polycythemia
Meds: HCTZ, ASA, Pyrazinamide
Diet: beer, meat, seafood
```
26
Treatment of Gout flare
NSAIDs
Colchicine (1.2mg load --> 0.6mg 1 hr later --> 0.6 BID till Sx resolve) - S/E: N/V?D, myopathy, renal dose
IA/PO steroid (if contraindications to above)
Anakinra (IL-1 blocker) - if frequent flares and C/I to above
27
Indications for urate lowering therapy
1) 2+ gout flares/year
2) Erosive gouty arthropathy
3) Tophi
4) 1 gout attack +
- Stg 3+ CKD
- Urolithiasis
- Uric acid >535
28
Urate lowering therapy
Overlap w/ NSAID/colch x 3-6mo:
1st line: Allopurinol* 100mg/d (50mg if CKD IV)
2nd line: Febuxostat (increased CV and all cause mortality, ie not if hx CVD or new CVD event)
Target uric acid <356
*In SE asian or african - test HLA-B 5801 1st bc risk SJS
29
CPPD features and RF
Rhomboid shaped, positively birefringent (blue parallel)
Chondrocal on XR
```
RF:
Hypothyroidism,
HyperPTH, HypoMg, HypoPO4
Hemochromatosis, Wilsons
Amyloidosis
Acromegaly
```
30
Acute destructive calcific tendinitis in older patient
Hydroxyapetite crystal arthropathy
31
SLE ACR Criteria
+ ANA 1:80 + Score >= 10 points from crit below
1) Constitutional Sx- Fever >38.3
2) Mucocutaneous: Non-scarring alopecia, discoid rash, malar rash, oral ulcers, photosensitive rash
3) Haem: low WBC <4, low plts <100, AIHA
4) Serosal: Pericarditis, pleuritis, effusions
5) CNS: Seizures, psychosis, delirium
6) Renal: Class II-V, proteinuria >0.5g/d
7) MSK: synovitis, arthalgias with morning stiffness
8) Serology +: Anti-dsDNA, Anti-Sm
9) Complements low
10) Positive APLA
*req 1 clinical criteria, and occurrence at least once is sufficient. Count highest score in each domain.
32
Lupus serology
ANA - sensitive, not spec
Anti-dsDNA - spec, not sensitive. Specific for SLE nephritis. Can be used to monitor dz activity.
Anti-Sm - specific, not sens
Other: histone, RNP, Ro, La
33
DDX ANA Positivity
```
AI Dz: RA, MCTD, Scleroderma, Myositis
GI: Autoimmune hepatits, IBD, PBC
Endo: AI thyroid disease
Resp: IPF
ID: HepC, TB, Parvovirus
```
34
Treatment SLE Nephritis
Class I/II: Supportive +/- immunosuppress if proteinuria >3g/d
Class III/IV (proliferative)
- Induction: Pulse steroids + Cyclo or MMF (if African or Hispanic) + ACEi if proteinuria
- Maintenance: MMF or Azathioprine, low dose pred. Ritux if refractory + ACEi if proteinuria
- In pregnancy: Stop ACEi, continue HCQ (+/- Aza for severe flare) and start ASA 12-36wks GA
Class V (membranous): BP Control, ACEi, consider immunosuppression if progressive renal function decline (re-bx)
35
SLE Manifestations and Tx: Mild, Mod, Severe
Mild: fever, mild arthritis, rash, mild cytopenias, plt 50-100
- HCQ +/- PO/IM steroid
- If refractory: +/- MTX or Aza
Moderate: RA-like arthritis, cutaneous vasculitis, serositis, moderate cytopenias Plt 20-50
- HCQ +/- PO/IM steroid +/- MTX or Aza
- If refractory: MMF or cyclosporin or Belimumab
Severe: CNS, class 3/4 nephritis, myelitis, pneumonitis, mesenteric vasculitis, severe cytopenias Plt <20, TTP, AIHA
- HCQ +/- PO/IM steroid +/- MMF or Cyclo
- If refractory: cyclo or ritux
36
Treatment Thrombotic-APS
Lifelong anticoagulation with warfarin
| Transition to therapeutic LMWH in pregnancy and add ASA
37
Treatment OB-APS
Only requires prophylactic LMWH in pregnancy and post-partum + ASA
38
Management of SLE in pregnancy
- Meds
- Ro/La
- Positive aPL
HCQ in all, ASA 81 prior to 16wks GA for preeclampsia ppx
Azathioprine + steroid reasonable in severe disease
If Ro/La+: serial fetal echo from wk 16-26wks;
q1w if previous neonatal lupus.
-Dex if 1st/2nd deg heart block, not for 3rd
Positive aPL:
- No APS = ASA
- OB APS = ASA + ppx heparin until 6-12 wks pp
- Thrombotic APS = ASA + therapeutic heparin during preg and PP
39
Manifestations of Sjogren's
```
Xerostomia (unstim saliv flow dx)
Keratoconjunctivitis (Schirmer's test <5mm in 5 min)
Arthritis
Parotiditis (salivary gland bx shows focal lymphocytic sialadenitis)
Peripheral neuropathy
Type 1 RTA
Secondary vasculitis
B cell lymphoma (40x risk)
```
40
Diffuse Scleroderma - Manifestations
```
Sclerodactyly proximal to elbows/knees
Face tightening
Raynauds
ILD > PH (TTE and PFTs for all pt)
Scleroderma renal crisis
```
41
Limited Scleroderma- Manifestations
```
CREST
Calcinosis
Raynauds
Esophageal dysmotility, GAVE (GIB)
Sclerodactyly (distal to elbows/knees)
Telangiectasias
```
Associated with PH >ILD (TTE and PFTs for all pt)
42
Scleroderma - Serology
Anti-centromere = limited (CREST; C for centromere)
Anti-Scl70 (aka anti-topoisomerase) - diffuse
43
Raynayds - red flags for secondary cause
```
Older age of onset (>40)
Male
Asymmetric, progressive
Ulceration/pitting/ischemia
Abnormal nailfold capillaries
Positive serology
```
Secondary causes: SSc, MCTD, SLE, HypoT4, Carcinoid, pheo, HBV, HCV, Parvo, Heme Ca
44
Scleroderma renal crisis - features
Renal failure
+/-Hypertension
+/- proteinuria
MAHA, thrombocytopenia
Compared to TTP: less fever, purpuric rash
45
Treatment of Raynauds
1st line - CCB
2nd line- topical nitrates, PDE5 inhibitor
~to mx for chilblains (smoking cessation, cold avoidance, +/- topical steroid or CCB)
46
Inflammatory Myopathies (ie. myositis)
Dermatomyositis
Polymyositis
Necrotizing Auto-immune Myositis (secondary to statin)
Inclusion body myositis
47
Drug-induced myopathies
```
Statin
Colchicine
HAART
EtOH
Anti-psychotics, SSRIs, Li
```
48
Metabolic myopathies
Hypothyroidism
HypoPO4
HypoK
49
Infectious causes of myopathy
```
Influenza
HIV
Hep B
CMV
Bacterial pyomyositis
```
50
Skin manifestations of dermatomyositis
```
Gottren's papules
Heliotrope rash
Shawl Sign
Mechanics hands
Periungal erythema
Calcinosis Cutis
```
51
End organ complications of dermatomyositis
CV: Myocarditis, CHF, arrhythmia
Resp: Diaphragmatic weakness, resp failure, Aspiration risk, ILD (NSIP, UIP), PH
Malignancy (DM>PM around dx)
52
Anti-Jo1
```
Anti-synthetase syndrome:
Rapidly progressing ILD
Mechanics hands, Raynaud's, skin ulceration
Arthritis
B-symptoms
```
53
Anti-Mi2
Classical dermatomyositis
| Good response to tx/prognosis
54
Anti-NXP2 and TIF gamma
Strong association with underlying malignancy
55
Treatment of dermatomyositis (and IBM)
Steroids 1mg/kg then taper
DMARDs: MTX or Azathioprine
-Cyclo/MMF if ILD
-Plaquenil for skin only
2nd line: Ritux or IVIG for refractory disease
56
Clinical manifestations of Inclusion Body Myositis (IBM)
Distal + Proximal muscle weakness (distal>proximal)
Lower CK than DM
Progressive dysphagia and bulbar symptoms
Older, M>F, insidious
57
Treatment of statin associated muscle diseases
Myalgias (normal CK) - improves with d/c, can trial lower dose or alternate agent
Myopathy (weakness but normal CK) - D/C
NAM - D/C, requires imunosupression - confirm with HMG-CoA reductase antibody
Rhabdo - D/C, fluids and supportive care
58
Clues to Takayasu's Arteritis
Female <40
Asian
Pulseless arm, BP differential
Subclavian steal
59
Features of PAN
HepB+ (in some)
B Sx: Fever, weight loss >4kg
Neuro: Mononeuritis multiplex/polyneuropathy
GI: Mesenteric arteritis - post-prandial abdo pain
GU: Orchitis - testicular pain/ tenderness, AKI
Derm: Livedo reticularis
60
cANCA/anti-PR3 positivity
GPA (few FPs)
| MPA
61
pANCA/anti-MPO Positivity
| incl false + causes
```
eGPA and Microscopic Polyangiitis
False +:
- IBD
- Other CTDs
- PTU use
- Malignancy
- HBV/HCV/HIV
```
62
Small vessel vasculitidies
ANCA-associated: GPA, eGPA, MPA
Anti-GBM (renal isolated or Goodpasture's)
IgA (renal isolated or HSP)
Cryoglobulinemia - T1 = MM, T2/3 = HepC/mixed
Secondary SVV: Drugs (Levamasole), Infectious (Hep B, C), CTD Associated (SLE, Sjogren's, RA), Malignancy (paraneoplastic, MM)
63
Variable sized vessel vasculitities
Buergers (thromboangiitis obliterans) - male smokers w/ hand/foot claudication
Behcets
Cogan
64
Treatment of GCA
Visual sx or critical cranial ischemia = IV pulse steroids 1gx3d then pred 1mg/kg + toci (for steroid free remission)
No visual sx: pred 1mg/kg daily + toci
No ASA unless critical or flow limiting involvement of carotid or vertebral arteries
Steroids x1mo then taper
65
Diagnosis PMR
- Bilateral shoulder and hip girdle pain
- 45 minutes or more am stiffness
- Elevated ESR/CRP, normal CK
- Negative RF/CCP
- US criteria: shoulder/hip bursitis/tenosynovitis
- Age >50
66
Treatment PMR
Prednisone 12.5-20 mg/day x2-4 wks then taper to 10mg/d within 1-2mo if response
If difficulty tapering, add MTX
67
Treatment of HepB Related PAN
Steroids + Anti-viral
| +/- Plex if severe
68
Treatment of PAN (not-hepB associated)
Mild: Steroids +/- AZA or MMF
| Moderate-Severe: Steroid + Cyclo --> Aza or MMF
69
Treatment of HepC Associated Cryoglobulinemia
| *also describe features of mild/mod, severe, life threatening dz
If non-severe (non-ulcerating skin lesions, non-debilitating neuropathy, GN without renal failure): Induce: Antiviral +/- Steroid
Maintenance: Antiviral alone
```
If severe (ulcerating skin lesions, debilitating neuropathy, GN with renal failure, nephrotic syndrome, GI involvement):
Induce: Steroid + Ritux 1st (alt= Steroid + Cyclo)
Maintain: Antiviral alone
```
If life threatening (RPGN, CNS, DAH, GI ischemia):
Induce: Plex + Steroid pulse + Ritux or cyclo
Maintain: Antiviral alone
70
GPA Manifestations
*Nasal crusting, sinusitis, granulomas
Hearing loss
*Pulmonary nodules/ DAH/ Cavitary lung lesions
Subglottic stenosis
*Pauci-immune RPGN - hematuria, proteinuria
*Mononeuritis multiplex
Skin: Palpable purpura, nodules, PG, mucosal ulcers
Pericarditis/Myocarditis (rare)
71
Microscopic polyangiitis Manifestations
*Pauci-immune RPGN
*DAH, Pulmonary infiltrates, Fibrosis
Palpable purpura, nodules, lived reticular, necrotic ulcers
Symmetric peripheral neuropathy
72
eGPA Manifestations
Asthma, eosinophilia, Nasal polyps
Myopericarditis, arrythmias
Pauci immune GN
Mononeuritis multiplex, peripheral neuropathy
73
Induction ANCA Associated SVV
Induction:
-Pulse steroids 500-1000 mg IV x 3-5d + Ritux q4wks OR 1g IV day 1 and day 15
2nd line: Cyclo if C/I or failed ritux
-Cyclo preferred for RPGN with Cr >354
*No role for PLEX in DAH unless critically ill, or in RPGN unless high risk ESRD and accept infxn risk (KDIGO says PLEX for Cr >500)
74
Non-pharmacologic Tx of OA
For all: Exercise, self-efficacy program, arthritis society
Hip/knee: Weight loss, tai chi, cane, physio
*do NOT do transcutaneous electrical nerve stimulation in hip/knee OA
75
Pharmacologic Tx of OA
```
NSAIDs if no C/I
Topical NSAIDs (evidence in knee OA only)
IA Steroid (knee, hip, hand)
Can consider: Tylenol, Duloxetine, Tramadol (caution if other SSRIs, hx of seizure or hypoglycemia)
```
NO: opioid, glucosamine, DMARDs, biologics, PRP, stem cell injxn, intra-articular hyaluronic acid
76
Diagnosis of Adult Onset Stills Disease (AOSD)
```
Dx >= 5 criteria (2 must be major)
Major:
- Fever >=39 x 1+ week
- Non pruritic salmon rash
- Arthritis or arthralgia >2weeks
- WBC >10 with neuts >80%
```
Minor:
- Sore throat
- Splenomegaly or hepatomegaly
- Lymphadenopathy
- High liver enzymes
- High ferritin
- Negative ANA and RF
77
RF positive ddx
```
CTD
Hep C
Cryo
IE
Malignancy
Older age
```
78
JAKi (-tinibs) side effects
Increased risk of MORTALITY, MACE, thrombosis, cancer
79
Biologic side effects and considerations
```
Infection (new/reactivation)
Drug induced lupus (TNFi)
Local skin rxn
Malignancy eg non-melanomatous skin Ca
PRES (IL12/23)
```
Considerations:
- TNFi: Heart failure - do not start if NYHA III/IV; switch to another agent if patient develops HF on TNFi
- Active hepatitis - start hep tx first, consult GI
- Use cDMARDs if prior skin Ca or serious infxn w/i 12mo
- Consult Onc if prior solid organ malignancy
80
Vaccinations on DMARDs or biologics (except Ritux)
Vaccinate during quiescent disease
If ritux, vaccine 4wks b4 starting or 6mo after last dose and 4wks before next dose
No live vaccine except HZV and possibly MMR booster
No live vaccine in 1st 6mo of newborns for mothers on biologics (eg no rotavirus vaccine)
Household members get normal vaccine except oral polio if living with immunosuppressed pt
Recommended vaccines:
Yearly influenza (hold MTX 2 weeks before and after)
Pneumococcal - PCV13 and PPSV23 8wks later
HPV, Tetanus toxoid - same as general popln
Hep A and B - only if high risk exposure
HZV - Shingrix preferred; live only if NOT on biologic or >4 weeks prior to biologic
81
Extraarticular features of seronegative arthropathies
- Enthesitis, dactylitis
- Uveitis, conjunctivitis
- Skin: erythema nodosum, pyoderma gangrenosum (IBD), keratoderma blenorrhagicum, circinate balanitis (reactive), psoriatic skin and nail changes (PsA)
82
Septic Arthritis Tx for G+, GPB/GPC
G+ community: Ancef
G+ hospital: Vanco
GNB: CTX + antipseudomonal if risk (DM, IVDU, hospitalized)
GNC (eg neisseiria, gonorrhea): CTX + tx chlamydia
Nothing on stain: Vanco + CTX
Source control: washout
83
Gonococcal arthritis
Triad: tenosynovitis, vesiculopustular skin lesions, migatory polyarthralgias (WITHOUT purulent arthritis)
If arthritis WITHOUT skin lesions = longer course of abx
84
Common bugs causing reactive arthritis
Chlamydia trachomatis, yersinia, salmonella, shigella, campylobacter
85
Reactive arthritis triad
Can't see (uveitis, conjunctivitis)
Can't pee (urethritis)
Can't climb a tree (asymmetric oligoarthritis, lower>upper, can develop SI-itis)
86
Reactive arthritis Tx
NSAIDs
IA steroids
Consider DMARDs in recurrent/ chronic dz (eg MTX, SFZ, TNFi)
No role for abx unless active infxn
87
Malar rash vs Rosacea
Malar rash - spares nasolabial fold and worse with sun
Rosacea: freq flushing (hours), telangectasias, papules, pustules, aggravated by sun/spice/EtOH, can cross nasolabial fold
88
Cyclophosphamide S/E
Infertility
Malignancy: bladder, skin, MPD
Hemorrhagic cystitis
Cytopenias
89
MMF S/E
Unsafe in preg --> miscarriage, cleft palate
cytopenias
GI S/E
90
APS Tx
Heparin f/b warfarin (DOAC not recommended)
If Libman Sacks --> steroids + anticoag
91
Drug induced lupus Meds
Hydralazine, Procainamide, TNFi, Isoniazid
92
DM/PM Investigations
CK (can be normal in amyopathic DM - ie no weakness)
ANA, myositis ABs, AST, LDH, ESR/CRP
MRI
Biopsy (Gold standard)
EMG (irritability, low amplitude, repetitive discharge)
Trop, ECG, Echo (r/ cardiac involvement)
SLP r/o oropharyngeal, esophageal involvement
PFT w/ MIP, MEPs to r/o diaphragmatic involvement
Age appropriate Ca screening (consider CT C/A/P)
93
GCA LR
LR+: jaw claudication, beaded/tender temporal arteries
| LR-: ESR
94
Maintenance ANCA Associated SVV
Maintenance:
- Severe dz: Steroid (reduced taper) + Ritux (if received for induction) or MTX/Aza > MMF or LFD
- Non-severe dz: Steroid (standard dose) + MTX
*In nonsevere: MTX preferred for induction & maintenance.
95
Relapse / Refractory ANCA Associated SVV
Relapse:
- If not on ritux maintenance --> Ritux
- If on Ritux maintenance --> Cyclo
Refractory :
- Switch agents to Ritux or Cyclo
- Add IVIG if refractory to remission induction
96
Medication management in COVID exposed and infected
Exposed:
- Continue NSAID and SFZ
- Hold Plaquenil, MTX, biologics pending 2wks symptom free observation
- Toci can be continued in some circumstances
Infected:
- Hold all meds except toci in some circumstances
- Hold NSAIDs if severe respiratory symptoms
97
Medication management in COVID vaccine setting
- Tylenol/NSAIDs - hold 24h prior to vaccination
- Plaquenil - no change
- DMARDs - hold 1-2 wks after vaccine
- Abatacept and Belimumab - 1-2 weeks btwn biologic and vaccine
- Other biologics: no consensus
98
Chilblains (aka pernio) Ddx
```
COVID 19
SLE, APS
Behcet's
Heme Ca (AML, CML, monoclonal gammopathy)
Cryoglobulinemia
```
99
Fibromyalgia Dx Criteria + Tx
1) Widespread pain index and symptom severity scale
2) Symptoms >3mo
3) No other explanation
Bloodwork must be normal
Tx:
-Nonpharm: exercise, CBT, sleep hygiene, Tai chi
-Pharm: SNRI (dulox), TCA (amitriptyline), gabapentin
100
Relapsing polychondritis Tx
Mild (nasal / auricular chondritis, arthritis)
- NSAID
- Steroids or dapsone if fails NSAID
Mild/Mod organ threatening:
-Steroids + MTX
Life threatening or severe organ threatening:
-Steroids + cyclo
101
Still's Disease Tx
Mild/Mod (nondisabling fever, rash, arthralgia, no MAS): NSAID
Mod/Severe (signif serositis, mod/severe polyarthritis, fevers despite NSAIDs, organ involved) or failed NSAIDs: Steroids or Anakinra
*if MAS present - etoposide + steroid
102
DDx scleritis (whites) and uveitis (middle; includes anterior iritis & posterior retinitis or choroiditis)
Scleritis: RA, polychondritis, SLE, reactive, Inxn (zoster, HSV, TB, syphilis), Sarcoid, IBD
Uveitis: Seroneg, HLAB27+, sarcoid, infxn (CMV, toxo, cat scratch, HSV)
