Rheumatology part I Flashcards Preview

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Flashcards in Rheumatology part I Deck (83):
1

What are the types of spondyloarthritis/spondyloarthropathy?

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

2

What type of spondyloarthritis/spondyloarthropathy is associated with IBD?

Enteropathic arthritis/spondylitis

3

How does spondyloarthritis differ from other types of arthritis?

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

4

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

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

5

What is the cause of ankylosing spondylitis?

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

6

Cause of enteropathic arthritis

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

7

Predominant axial manifestations of spondyloarthritis

Inflammation of sacroiliac joints
Inflammation of the spine

8

Predominant peripheral involvement in spondyloarthritis

Peripheral arthritis
Enthesitis
Dactylitis

9

Enthesitis

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

10

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

The heel, particularly the Achilles tendon

11

Sx of enthesitis

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

12

Diagnosis of spondyloarthritis

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

13

HLA-B27

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

14

Tx of spondyloarthritis

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

15

DMARDs

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

16

Epidemiology of ankylosing spondylitis

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

17

Populations with higher incidence of HLA-B27 positive

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

18

Low prevalence HLA-B27 groups

South American Indians
Japanese
African Americans

19

Back pain in ankylosing spondylitis

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

20

S/sx of ankylosing spondylitis

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

21

Other systemic signs of ankylosing spondylitis

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

22

Pulmonary involvement in ankylosing spondylitis

Restrictive lung dz
Restricted costovertebral mobility
Apical lobe fibrosis

23

Neurologic involvement in ankylosing spondylitis

Spine fxs or dislocations
Cauda equina syndrome
Altantoaxial subluxation

24

PE of ankylosing spondylitis

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

25

X-ray findings in ankylosing spondylitis

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

26

Special X-ray views in ankylosing spondylitis

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

27

Labs in ankylosing spondylitis

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

28

1st line tx ankylosing spondylitis

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

29

2nd line tx ankylosing spondylitis

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

30

Meds to avoid in ankylosing spondylitis

Long-term systemic corticosteroids

31

Epidemiology of reactive arthritis

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

32

Pathophysiology of reactive arthritis

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

33

Infectious agents in reactive arthritis diarrheal illness

Shigella
C. difficile
Salmonella
Yersinia enterocolitica
Campylobacter jejuni

34

Nonspecific urethritis in ankylosing spondylitis

C. trachomatis
Ureaplasma urealyticum

35

DDx of reactive arthritis

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

36

Clinical presentation of reactive arthritis

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

37

Classic clinical triad of reactive arthritis

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

38

Asymmetric oligoarticular arthritis in ankylosing spondylitis

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

39

Enthesitis in ankylosing spondylitis

Achilles tendonitis
Plantar fasciitis
Patellofemoral syndrome

40

S/sx of reactive arthritis

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

41

Other musculoskeletal involvement in reactive arthritis

Anterolateral ribs
Pubic symphysis
Iliac crest

42

GI and reactive arthritis

Precedes arthritis by 1-4 wks
Acute diarrhea

43

GU and reactive arthritis

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

44

Circinate blanitis in reactive arthritis

Shallow painless gray-border ulcer of glans penis

45

Skin changes in reactive arthritis

Keratoderma blenorrhagica
Hyperkeratotic papules on plantar foot surface

46

Ulcers in reactive arthritis

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

47

Eye changes in reactive arthritis

Conjunctivitis
Acute anterior uveitis

48

CV changes in reactive arthritis

Aortitis
Aortic insufficiency
Conduction abnormality with potential heart block

49

Work up for reactive arthritis

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

50

Joint fluid exam in reactive arthritis

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%

51

Management of reactive arthritis

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

52

Prognosis of reactive arthritis

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

53

Epidemiology of psoriatic arthritis

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

54

Pathophysiology of psoriatic arthritis

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

55

Distal interphalangeal arthritis in psoriatic arthritis

Adjacent nails may show psoriatic change
Progressive bony erosions occur

56

Arthritis mutilans- psoriatic arthritis

Severe ostolysis
Phalanges
Metatarsals
Metacarpals

57

Types of psoriatic arthritis

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

58

Differences between psoriatic and rheumatoid arthritis

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

59

Oligoarthritis in psoriatic arthritis

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

60

Arthritis mutilans in psoriatic arthritis

Severe deforming arthritis in which osteolysis is marked

61

Psoriatic spondylitis

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

62

Asymmetric oligoarthritis in psoriatic arthritis

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

63

Clinical presentation of psoriatic arthritis

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

64

DDx of psoriatic arthritis

Reactive arthritis
Ankylosing spondylitis
RA
Septic arthritis
Gouty arthritis
HIV infection

65

Classification criteria for psoriatic arthritis (CASPAR)

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

66

Labs for psoriatic arthritis

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

67

X-ray of involved joints in psoriatic arthritis

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

68

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

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

69

Management of psoriatic arthritis

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

70

EULAR recommendations for psoriatic arthritis tx

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

71

Examples of DMARDs

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

72

Example of TNF-a inhibitors

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

73

Example of PDE-4 inhibitor

Apremilast (Otezia)

74

General characteristics of OA

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

75

What the bone will look like in OA

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

76

RFs of OA

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

77

Primary OA

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

78

Secondary OA

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

79

Sx of OA

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

80

Clinical features of OA

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

81

Dx of OA

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

82

Tx of OA

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

83

NSAID risk in OA

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