Rheumatology part I

Question 1

What are the types of spondyloarthritis/spondyloarthropathy?

Answer 1

Ankylosing spondylitis (MC)
Axial spondyloarthritis
Peripheral spondyloarthritis
Reactive arthritis (formerly known as Reiter's syndrome)
Psoriatic arthritis

Question 2

What type of spondyloarthritis/spondyloarthropathy is associated with IBD?

Answer 2

Enteropathic arthritis/spondylitis

Question 3

How does spondyloarthritis differ from other types of arthritis?

Answer 3

It involves the sites where ligaments and tendons attach to bones- enthesitis

Question 4

What are the two main ways in which sx present in spondyloarthritis?

Answer 4

Inflammation causing pain and stiffness, most often of the spine. Some forms can affect the hands and feet or arms and legs
Bone destruction causing deformities of the spine and poor function of the shoulders and hips

Question 5

What is the cause of ankylosing spondylitis?

Answer 5

Hereditary
Many genes cause it
The major gene involved is HLA-B27

Question 6

Cause of enteropathic arthritis

Answer 6

Unclear

Ppl with HLA-B27 are more likely to have this form of arthritis than those without the gene

Question 7

Predominant axial manifestations of spondyloarthritis

Answer 7

Inflammation of sacroiliac joints

Inflammation of the spine

Question 8

Predominant peripheral involvement in spondyloarthritis

Answer 8

Peripheral arthritis
Enthesitis
Dactylitis

Question 9

Enthesitis

Answer 9

Inflammation of the entheses, the sites where tendons or ligaments insert into the bone
Entheses:
-Where recurring stress or inflammatory autoimmune dz can cause infammation
-Or occasional fibrosis
-And calcification

Question 10

What is the one of the primary entheses involved in inflammatory autoimmune dz

Answer 10

The heel, particularly the Achilles tendon

Question 11

Sx of enthesitis

Answer 11

Multiple points of tenderness at the heel, tibial tuberosity, iliac crest and other tendon insertion sites

Question 12

Diagnosis of spondyloarthritis

Answer 12

Pelvic X-ray looking for inflammatory changes in the sacroiliac joints
X-ray changes of the sacroiliac joints, known as scoroiliitis, are a key sign of spondyloarthritis
Spinal X-rays
For more definitive assessment, order MRI
CXR
ANA
ESR
CBC
CMP
UA
CRP
HLA-B27 marker

Question 13

HLA-B27

Answer 13

A specific type of protein that contributes to immune system dysfunction.
The presence of HLA-B27 on WBCs can cause the immune system to attack otherwise healthy cells

Question 14

Tx of spondyloarthritis

Answer 14

PT and do joint-directed exercises
NSAIDs (naproxen, ibuprofen, meloxicam or indomethacin)
For joint swelling that is localized, injections of corticosteroids into joints or tendon sheaths can be effective quickly.
For pts who do not respond to the above lines of treatment, disease modifying antirheumatic drugs, such as sulfasalazine (Azulfidine) might be effective
Oral corticosteroids are not advised

Question 15

DMARDs

Answer 15

Group of meds commonly used in pts with RA
Also used in treating other conditions, such as ankylosing spondylitis, psoriatic arthritis, and SLE
Work to decrease pain and inflammation, to reduce or prevent joint damage, and to preserve the structure and function of the joints
Work to suppress the body’s inflammatory systems
Take effect over weeks or mos

Question 16

Epidemiology of ankylosing spondylitis

Answer 16

Chronic inflammatory disorder of the joints of the axial skeleton strongly associated with HLA-B27

Question 17

Populations with higher incidence of HLA-B27 positive

Answer 17

Native Americans
Asian populations (except Japanese)
European and US Caucasian

Question 18

Low prevalence HLA-B27 groups

Answer 18

South American Indians
Japanese
African Americans

Question 19

Back pain in ankylosing spondylitis

Answer 19

Starts with dull low back radiating to gluteal area
Progresses up spine to ultimately involve neck
Accompanied with constitutional sx:
-Anorexia
-Malaise
-Low-grade fever

Question 20

S/sx of ankylosing spondylitis

Answer 20

Onset before age 40
Insidious onset
Duration longer than 3 mos
Pain worse in morning
Morning stiffness lasts longer than 30 mins
Pain decreases with exercise or activity
Pain provoked by prolonged inactivity or lying down
Normal lumbar curve is flattened and thoracic curvature exaggerated

Question 21

Other systemic signs of ankylosing spondylitis

Answer 21

Acute anterior uveitis (nongranulomatous)
Microscopic colitis (often asymptomatic)
Cardiac involvement rare
-Aortic insufficiency
-Aortitis
-Conduction defects
Arrhythmias

Question 22

Pulmonary involvement in ankylosing spondylitis

Answer 22

Restrictive lung dz
Restricted costovertebral mobility
Apical lobe fibrosis

Question 23

Neurologic involvement in ankylosing spondylitis

Answer 23

Spine fxs or dislocations
Cauda equina syndrome
Altantoaxial subluxation

Question 24

PE of ankylosing spondylitis

Answer 24

Lumbar lordosis flattened
Thoracic kyphosis exaggerated
Cervical spine hyperextended
Test for ROM loss at lumbar spine
-Decreased lateral bending and lumbar extension
Enthesopathy- hallmark of spondyloarthopathies- can manifest as swelling of Achilles tendon or plantar fasciitis

Question 25

X-ray findings in ankylosing spondylitis

Answer 25

``` Initially: bony sclerosis appears as squaring of vertebrae Next: osteitis of vertebral margins Late: annulus fibrosus ossifies Syndesmosphytes between vertebrae Classic bamboo spine apearance Progresses up spine ```

Question 26

Special X-ray views in ankylosing spondylitis

Answer 26

Ferguson's view (specialized sacroiliac view) Bone scan MRI spine

Question 27

Labs in ankylosing spondylitis

Answer 27

``` HLA-B27- found in 90% of Caucasian pts CRP- usually elevated in 75% ESR- usually elevated in 75% ANA CBC CMP UA ```

Question 28

1st line tx ankylosing spondylitis

Answer 28

NSAIDs Indomethacin (up to max 50 mg PO TID) Tolmetin 400 mg PO TID-QID

Question 29

2nd line tx ankylosing spondylitis

Answer 29

TNF-alpha inhibitors- Etanercept (Enbrel)- helps best to reduce inflammatory activity of spinal dz and improve mobility DMARDs -Sulfasalazine --Effective peripheral arthritis pain reduction --Less effective for axial skeleton sx and not shown to improve mobility -Inflixamab (Remicade) --For ankylosing spondylitis plus IBD and iritis better than Enbrel

Question 30

Meds to avoid in ankylosing spondylitis

Answer 30

Long-term systemic corticosteroids

Question 31

Epidemiology of reactive arthritis

Answer 31

MC autoimmune inflammatory polyarthritis in young men | More commonly affect men by ratio of 9:1

Question 32

Pathophysiology of reactive arthritis

Answer 32

Associated with HLA-B27 genotype in approximately 50-80% of pts Oligoarthritis, conjunctivitis, urethritis, and mouth ulcers most common features Usually follows dysentery (shigella, salmonella, campylobacter) or an STI, but could follow other infections such as strep A within 1-4 wks

Question 33

Infectious agents in reactive arthritis diarrheal illness

Answer 33

``` Shigella C. difficile Salmonella Yersinia enterocolitica Campylobacter jejuni ```

Question 34

Nonspecific urethritis in ankylosing spondylitis

Answer 34

C. trachomatis | Ureaplasma urealyticum

Question 35

DDx of reactive arthritis

Answer 35

``` Ankylosing spondylitis Colitic arthritis Gonococcal arthritis SLE Lyme dz Psoriatic arthritis Rheumatic fever Rheumatoid Arthritis Juvenile rheumatoid arthritis Gouty arthritis ```

Question 36

Clinical presentation of reactive arthritis

Answer 36

Constitutional -Wt loss -Fever up to 102 -Mild conjunctivitis in some pts/possible anterior uveitis -Watch for carditis and aortic regurg Arthritis onset 1-4 wks after GI or GU infection is cleared- can persist for mos

Question 37

Classic clinical triad of reactive arthritis

Answer 37

Infrequently present-only 1/3 of the time Arthritis Conjunctivitis Urethritis

Question 38

Asymmetric oligoarticular arthritis in ankylosing spondylitis

Answer 38

2-4 joints Affects lower extremities most commonly Large knee effusion/ankle Sausage-shaped fingers and toes

Question 39

Enthesitis in ankylosing spondylitis

Answer 39

Achilles tendonitis Plantar fasciitis Patellofemoral syndrome

Question 40

S/sx of reactive arthritis

Answer 40

``` Seronegative asymmetric arthritis following: -Urethritis or cervicitis -Infectious diarrhea Often associated with: -Inflammatory eye dz -Balanitis, oral ulceration or keratodermia -Enesthopathy -Sacroiliitis ```

Question 41

Other musculoskeletal involvement in reactive arthritis

Answer 41

Anterolateral ribs Pubic symphysis Iliac crest

Question 42

GI and reactive arthritis

Answer 42

Precedes arthritis by 1-4 wks | Acute diarrhea

Question 43

GU and reactive arthritis

Answer 43

``` Precedes arthritis by 1-4 wks Urethritis Cervicitis Cystitis Hematuria Hydronephrosis ```

Question 44

Circinate blanitis in reactive arthritis

Answer 44

Shallow painless gray-border ulcer of glans penis

Question 45

Skin changes in reactive arthritis

Answer 45

Keratoderma blenorrhagica | Hyperkeratotic papules on plantar foot surface

Question 46

Ulcers in reactive arthritis

Answer 46

``` Painless, shallow oral ulcers: Tongue Lip Pharyngeal Palate and buccal mucosa ```

Question 47

Eye changes in reactive arthritis

Answer 47

Conjunctivitis | Acute anterior uveitis

Question 48

CV changes in reactive arthritis

Answer 48

Aortitis Aortic insufficiency Conduction abnormality with potential heart block

Question 49

Work up for reactive arthritis

Answer 49

``` CBC ESR is increased CRP is increased Joint fluid exam Consider HLA-B27 testing, but dx is generally made by clinical findings ```

Question 50

Joint fluid exam in reactive arthritis

Answer 50

Synovial fluid WBC: 15-30K per mm cubed Neutrophils predominant on differential (>66%) Nl joint fluid glucose No synovial fluid crystals on polarized microscopy X-ray of sacro-iliac joint: pos in only 40-70%

Question 51

Management of reactive arthritis

Answer 51

NSAIDs: Indomethacin SR Consider DMARDs if not responding to NSAIDs Doxycycline for 3-6 mos -Indicated for suspected chlamydia etiology Topical corticosteroid cream for keratoderma blenorrhagica NO systemic corticosteroids

Question 52

Prognosis of reactive arthritis

Answer 52

Self-limited: resolves over 3-12 mos usually | Chronic arthritis may develop in up to 30% of cases

Question 53

Epidemiology of psoriatic arthritis

Answer 53

No gender predominance | Onset is usually 2 yrs after the 1st psoriatic skin lesions

Question 54

Pathophysiology of psoriatic arthritis

Answer 54

Spondyloarthropay- sacroiliac joint involved commonly | Seronegative inflammatory arthritis (only ESR may be elevated)

Question 55

Distal interphalangeal arthritis in psoriatic arthritis

Answer 55

Adjacent nails may show psoriatic change | Progressive bony erosions occur

Question 56

Arthritis mutilans- psoriatic arthritis

Answer 56

Severe ostolysis Phalanges Metatarsals Metacarpals

Question 57

Types of psoriatic arthritis

Answer 57

Symmetric polyarthritis -RA similarities: prominent metacarpal dz, prominent proximal interphalangeal joint dz Monoarticular with DIP joints mainly affected and nail pitting

Question 58

Differences between psoriatic and rheumatoid arthritis

Answer 58

``` Milder course than RA No extra-articular RA signs No subcutaneous nodules No vasculitis No pulmonary involvement RF seronegative ```

Question 59

Oligoarthritis in psoriatic arthritis

Answer 59

>50-70% of cases Asymmetric joint involvement (<4 joints) Often presents as arthritis in one knee

Question 60

Arthritis mutilans in psoriatic arthritis

Answer 60

Severe deforming arthritis in which osteolysis is marked

Question 61

Psoriatic spondylitis

Answer 61

``` Anklyosing spondylitis type spine involvement 50% associated with HLA-B27 Atypical axial skeleton involvement Lumbar spine most commonly affected Sacroiliitis (30%) ```

Question 62

Asymmetric oligoarthritis in psoriatic arthritis

Answer 62

Involves the knee or any large joint with a few small joints in the fingers and toes Metarsophalangeal Proximal and distal interphalangeal Dactylitis

Question 63

Clinical presentation of psoriatic arthritis

Answer 63

``` Inflammatory arthritis -Asymmetrical distal joint involvement often -Joint pain and tenderness to palpation -Peripheral joint and spine stiffness --Occurs >30 mins in morning and after inactivity Classic psoriatic plaques -Look at typical sites on extensor knee and elbow -Examine scalp, ears, trunk Nail pitting or onycholysis Dactylitis Enthesitis Other MS involvement: -Sternoclavicular joint involvement -Tempromandibular joint involvement ```

Question 64

DDx of psoriatic arthritis

Answer 64

``` Reactive arthritis Ankylosing spondylitis RA Septic arthritis Gouty arthritis HIV infection ```

Question 65

Classification criteria for psoriatic arthritis (CASPAR)

Answer 65

Established inflammatory articular dz with at least 3 points from the following features: Current psoriasis- 2 Hx of psoriasis (in the absence of current psoriasis)- 1 FHx of psoriasis (in the absence of current psoriasis and hx of psoriasis)-1 Dactylitis- 1 Juxta-articular new-bone formation- 1 RF negativity- 1 Nail dystrophy- 1

Question 66

Labs for psoriatic arthritis

Answer 66

``` RF neg ESR increased CBC -Mild normocytic normochromic anemia Uric acid elevated (hyperuricemia) in severe psoriasis but gout risk is not increased ```

Question 67

X-ray of involved joints in psoriatic arthritis

Answer 67

Bony erosions Pencil-in-a-cup deformity at DIP joints -Whittling of proximal phalanx -Expanded base of distal phalanx

Question 68

Spine X-ray (cervical, thoracic, lumbar) in psoriatic arthritis

Answer 68

Bamboo spine of ankylosing spondylitis rarely occurs Asymmetric sacroiliitis Asymmetric paravertebral ossification

Question 69

Management of psoriatic arthritis

Answer 69

``` Treat underlying psoriasis PT -Learn to protect affected joints -Perform strengthening and ROM exercises NSAIDs in mild cases ```

Question 70

EULAR recommendations for psoriatic arthritis tx

Answer 70

NSAIDs for relief of MS s/sx Tx with DMARDs should be considered at an early stage for pts with active dz Adjunctive tx with local corticosteroids should be considered Cautious use of systemic steroids, if administered at the lowest effective dose, can also be considered If active psoriatic arthritis fails to adequately respond to DMARDs, TNF-inhibitor therapy should be employed

Question 71

Examples of DMARDs

Answer 71

Sulfasalazine (Azulfidine) Methotrexate (avoid in HIV infection) Cyclosporine (avoid in HIV infection) Leflunomide (Arava)- benefits some specifically with psoriatic arthritis

Question 72

Example of TNF-a inhibitors

Answer 72

Adalimumab (Humira) Etanercept (Enbrel) Infliximab (Remicade) Ustekinumabe (Stelara)- marketed specifically for psoriatic arthritis

Question 73

Example of PDE-4 inhibitor

Answer 73

Apremilast (Otezia)

Question 74

General characteristics of OA

Answer 74

Most common arthropathy among adults, particularly the elderly Progressive loss of articular cartilage with reactive changes in the bone 90% of ppl 40 yoa and older will have X-ray evidence of dz process

Question 75

What the bone will look like in OA

Answer 75

``` Bone and cartilage fragments Cartilage breaking down Eroded cartilage Joint fluid with low concentration of hyaluronan Osteophytes ```

Question 76

RFs of OA

Answer 76

Obesity- risk for OA in knee, hand, and hip Competitive contact sports (but not recreational running) Jobs with frequent bending and carrying can lead to knee osteoarthritis

Question 77

Primary OA

Answer 77

``` DIP, PIP joints CMC joint of thumb Hip Knee MTP joint of the big toe Cervical and lumbar spine ```

Question 78

Secondary OA

Answer 78

ANY JOINT, as an outcome of articular injury resulting from dzs such as RA or -Extra-articular causes: acute injury, or chronic overuse of joint

Question 79

Sx of OA

Answer 79

Insidious, with initial stiffness- lasting <15 mins Later develops pain on motion of affected joint and worse by activity or weight bearing and relieved by rest Flexion contracture or varus deformity, bony enlargements of DIP and PIP are prominent

Question 80

Clinical features of OA

Answer 80

``` Decreased ROM, joint crepitus and pain worsening throughout the day The fingers at the DIP joints with latter stage development of Heberden's nodes and the PIP joints with with Bouchard's nodes Hips, knees, and spine are commonly affected MCP joints (except the thumb) are spared as well as the ankles and elbows Joints can become unstable during the late stages of the dz ```

Question 81

Dx of OA

Answer 81

Lab tests are nonspecific-ESR is nl X-rays show asymmetric narrowing, subchrondral sclerosis, cysts and marginal osteophytes (bone spurs)- in mid to late stages

Question 82

Tx of OA

Answer 82

1st line- APAP 2nd line- NSAIDs (chronic use should be paired with PPI) 3rd line: intra-articular injections- can be repeated four times a year (not for use in hand) 4th line: surgical joint replacement

Question 83

NSAID risk in OA

Answer 83

Ultimately inhibit prostaglandins that will relieve inflammation and pain -Prostaglandins also help maintain homeostasis in several organs, esp the stomach where prostaglandin is needed for gastric mucosal cell protection Prostaglandin maintains homeostasis by regulation of COX-1. COX-2 is generally only expressed in inflammatory tissues. Most NSAIDs block both COX-1 and COX-2. -COX-2 inhibitors have been found to be less likely to cause GI events but still can produce renal toxicity in some pts and increase risk of CV events the same as NSAIDs