Rheumatology Step Up Flashcards
(152 cards)
1
Q
associated findings in ANA-negative lupus
A
- arthritis, Raynaud’s phenomenon, subacute cutaneous lupus
- risk of neonatal lupus in offspring
2
Q
serology in ANA-negative lupus
A
Ro (antiSS-A) positive
ANA negative
3
Q
CF in neonatal lupus
A
skin lesions
cardiac lesions - AV block, transposition
valvular and septal defects
4
Q
criteria for dx. SLE (11)
A
malar rash discoid lesions photosensitivity oral/nasal ulcers arthritis pericarditis/pleuritis hematologic disease - cytopenias renal disease - proteinuria CNS - seizures/psychosis ANAs other ab - dsDNA, Smith, FP on VDRL
5
Q
presence of what ab’s is diagnostic of SLE?
A
anti-dsDNA
anti-Smith
6
Q
how do you diagnose a flare of SLE?
A
rise in anti-dsDNA
fall in C3/C4 levels (CH50 is more sensitive)
7
Q
which ab’s are very SENSITIVE for SLE but not specific?
A
ANA
8
Q
when Ro (SS-A) and Lo (SS-B) ab’s are found in SLE, they are associated with…
A
neonatal lupus subacute cutaneous lupus sjogren's syndrome complement deficiency ANA-negative lupus
9
Q
major use of ESR
A
diagnose/rule out inflammatory processes
monitor the course of inflammatory conditions
10
Q
major use of CRP
A
mainly infection - much more sensitive and specific for ESR
- if > 15, bacterial infection is present
11
Q
best tx. for SLE pts with acute flare
A
steroids
12
Q
best long term tx. for constitutional, cutaneous and articular manifestations of SLE
A
hydroxychloroquine
NSAIDs for less severe symptoms
13
Q
what should you recommend for pts on hydroxychloroquine tx for SLE
A
yearly eye examination bc of retinal toxicity
14
Q
Tx. of active lupus nephritis
A
cyclophosphamide
azathioprine
15
Q
MCC of death in SLE
A
renal failure
infections
16
Q
drugs that may cause lupus-like syndrome
A
hydralazine
procainamide
isoniazid
quinidine
17
Q
which two organ systems does drug-induced lupus NOT affect?
A
CNS and renal
- if these sx are present, it is NOT drug-induced
18
Q
pathophysiology of scleroderma
A
cytokines stimulate fibroblasts to produce collagen; high quantity of collagen is responsible for symptoms
19
Q
what symptom(s) is/are present in almost all pts with scleroderma?
A
Raynaud’s
cutaneous fibrosis - thickening of skin of face and extremities
20
Q
how do you dx. Raynauds?
A
nail-fold capillaroscopy - look for evidence of vessel damage
21
Q
GI findings in scleroderma
A
dysphagia/reflux from esophageal immobility
delayed gastric emptying
abdominal distention
pseudo-obstruction
22
Q
MCC of death in scleroderma
A
pulmonary involvement - pulmonary fibrosis or HTN (diffuse form only)
23
Q
renal involvement in scleroderma
A
in diffuse form only
- renal crisis w/ rapid malignant HTN
24
Q
ab specific for limited form of scleroderma
A
anti-centromere ab
25
ab specific for diffuse form of scleroderma
anti-topoisomerase I (anti-Scl70)
26
findings in Barium swallow in scleroderma
absence of peristaltic waves in lower 1/3 of esophagus
| decreased LES tone
27
what predicts prognosis in scleroderma?
degree of skin involvement - difffuse form has worse prognosis than limited form
28
CREST syndrome
```
Calcinosis of digits
Raynaud's phenomenon
Esophageal dysmotility
Sclerodactyly
Telengiectasias
```
29
Tx. of scleroderma
symptomatic
- MSK = NSAIDs
- Raynauds = CCB
- skin findings = D-penicillamine
- renal = ACEi
- GI = PPIs/H2 blockers
30
20% of pts with scleroderma have...
Sjogrens syndrome
31
typical findings in anti-phospholipid syndrome
recurrent venous/arterial thrombosis
recurrent pregnancy loss
thrombocytopenia
livedo reticularis
32
lab findings in antiphospholipid syndrome
presence of lupus anticoagulant and/or anticardiolipin antibody
prolonged PTT or PT that is not corrected by adding plasma
33
Tx of antiphospholipid syndrome
anticoagulation - INR 2.5-3.5
34
primary Sjogren's syndrome
dry eyes and dry mouth, along w/ lymphocytic infiltration of minor salivary glands (histology)
35
secondary Sjogren's syndrome
dry eyes and dry mouth along with a connective tissue disease
36
MCC of death in Sjogren's
malignancy
| - increased risk of non-Hodgkin's lymphoma
37
what test has high sensitivity and specificity for Sjogren's syndrome?
Schirmer test - filter paper inserted into eye to measure lacrimal gland output
38
most accurate test for dx Sjogren's
salivary gland biopsy (lip or parotid)
| - not needed for diagnosis
39
Tx. for Sjogrens
1. pilocarpine or Cevimeline
2. artificial tears
3. NSAIDs/ steroids - arthritis
40
ab found in mixed CT disease
anti-U1-RNP ab
41
predom. cells implicated in RA
T helper cells - therefore, RA is not seen in pts with HIV/AIDs
42
which joints are characteristically NOT involved in RA?
DIP joints
43
what symptom is present in all patients?
morning stiffness
44
cutaneous finding that is pathognomic for RA
subcutaneous rheumatoid nodules (sacrum, elbows, occiput, achilles tendon)
45
pulmonary findings in RA
pleural effusions (low glucose)
pulmonary fibrosis
rheumatoid nodules in lung
46
cardiac findings in RA
rheumatoid nodules - conduction block
| pericarditis
47
eye findings in RA
scleritis
scleromalacia - softening of sclera
dry eyes and mucous mbs
48
nervous system findings in RA
mononeuritic multiplex - damage to one or more peripheral nerves
49
Felty syndrome
triad of RA, splenomegaly and neutropenia
50
associated clinical findings in Felty's syndrome
anemia, thrombocytopenia
LAD
recurrent infections
high titres of RF
51
type of anemia seen in RA
normocytic, normochromic anemia
52
what must you screen for in every pt with RA prior to undergoing surgery or intubation?
cervical radiograph of spine to assess for evidence of C1-C2 subluxation/instability
53
poor prognostic indicators in RA
high RF titres
subcutaneous nodules
autoantibodies to RF
erosive arthritis
54
lab findings in RF
high titres of RF - more severe disease
anticitrullinated peptide (ACPA)
elevated ESR/CRP
normocytic, normochromic anemia
55
what are pts with positive RF and ACPA at risk for? how should you intervene?
erosive joint damage
| - early tx. with DMARDs indicated
56
criteria for dx. of RA
1. inflammatory arthritis > 3 joints
2. sx. lasting 6 weeks
3. high ESR/CRP
4. serum RF or ACPA positive
5. radiographic changes
57
general tx. approach to RA
when pt presents with sx, start them on NSAIDs (steroids if NSAIDS not adequate relief); at the same time, start pt on DMARD therapy, taper NSAIDs/steroids after approx 6 weeks of tx and then use those PRN
58
first-line DMARD to start in RA
Methotrexate/Folate
59
side effects of Methotrexate
```
GI upset, oral ulcers
mild alopecia
bone marrow suppression
hepatocellular injury
pulmonary fibrosis
```
60
what should the patient have monitored while on Methotrexate therapy?
CBC every 2-3 months
LFTs
renal function
61
alternate first-line DMARD agents
leflunomide - same efficacy
hydroxychloroquine
sulfasalazine
62
when can you consider using anti-TNF inhibitors in RA?
if methotrexate cannot control disease - i.e. resistant RA
63
what can you do for a pt with severe RA with severe pain unresponsive to conservative measures?
joint replacement surgery
64
clear synovial fluid with < 200 WBCs and PMNs < 25%
normal
65
clear/yellow synovial fluid with < 2000 WBCs and < 25% PMNs
noninflammatory - OA/trauma
66
cloudy yellow synovial fluid with > 5000 cells and 50-70% PMNs
inflammatory arthritis
67
turbid, purulent synovial fluid with > 50 000 WBCs and > 75% PMNs
septic arthritis
68
what cell type plays key role in acute inflammation of gout?
PMN
69
radiographic changes in gout
punched out erosions with overhanging rim of cortical bone
| - if no Hx of trauma, do not need XR for diagnosis
70
what happens if you do not treat an acute gouty attack?
nothing really...it lasts 7-10 days and resolves
71
pt comes in because of severe pain in his foot that caused him to awake from sleep; the joint appears erythematous, swollen and tender..what should you consider?
gout!!!
72
what is a tophi?
aggregations of urate crystals surrounded by giant cells in an inflammatory reaction; occurs after years of uncontrolled gout
73
common locations of tophi
extensor surfaces of forearms, elbows, knees
achilles tendon
pinna of ear
74
definitive diagnostic test in gout
joint aspiration and synovial fluid analysis
75
tx. of choice in acute gout
NSAIDs - esp. indomethacin
| - avoid aspirin and acetaminophen
76
alternative drug in acute gout for pts who cannot take NSAIDs or did not respond to NSAIDs
colchicine
| - 2nd line due to common GI side effects which result in low compliance
77
colchicine is contraindicated in..
renal insufficiency
| cytopenia
78
when do you use oral steroids for acute gout?
if pt has no response to or cannot tolerate NSAIDs/colchicine
- 7-10 days of oral prednisone
79
what can probenicid or sulfinpyrazone be used for?
uricosuric drugs that increase renal excretion of uric acid; can use for gout prophylaxis in pts who are undersecretors
80
what are the uricosuric drugs contraindicated in?
if pt has history of renal stones
81
preferred drug for prophylaxis of gout
allopurinol - once daily dosing, 300 mg
82
what do you need to watch for when tx. pt with allopurinol?
Steven Johnson syndrome / rash
83
who can Febuxostat be Rx. to?
pts who are in need of gout prophylaxis but intolerant to allopurinol
84
what are serum uric acid levels useful for?
not used for diagnosis
| - can monitor response to chronic gout tx.
85
RF of pseudogout (6)
```
age
osteoarthritis
hypothyroidism
hemochromatosis
hyperparathyroidism
Bartter's syndrome
```
86
what can you see on radiograph in pseudogout?
chondrocalcinosis - linear radiodense deposits in dark joint space on XR
87
tx. of pseudogout
symptomatic tx. - same as gout
88
slowly progressive weaknes and wasting of both distal and proximal muscles (arms/legs), MC in men and associated with absence of autoab's and low CK levels
inclusion body myositis
89
characteristic clinical feature of polymyositis/dermatomyositis (4)
symmetrical proximal muscle weakness
decreased muscle strength on testing
fine motor tasks usually preserved
myalgia and dysphagia common
90
which muscles are never involved in polymyositis/dermatomyositis?
ocular muscles
| - ddx. w/ myasthenia and Lambert-Eaton
91
what features are unique to dermatomyositis?
Heliotrope rash
Gottron's papules
V sign/Shawl sign
92
associated findings in both dermatomyositis and polymyositis
conduction defects/ CHF
arthralgias
interstitial lung disease - one of leading causes of death
93
associated findings in dermatomyositis only
vasculitis - in children
| increased incidence of malignancy
94
what additional measures should you take with a dermatomyositis patient?
ensure patient undergoes age appropriate cancer screening
95
what is the first step in diagnosis in suspected dermatomyositis/polymyositis?
check aldolase and CPK levels - will be elevated
96
what lab test can be used to monitor disease severity in myositis?
CK level
97
nonspecific markers of cell injury in myositis
aldolase, LDH, AST, ALT
98
what kinds of antibdodies are found in the inflammatory myopathies? (3)
anti-Jo1
anti-signal recognition particle
anti-Mi-2
99
when do you do an EMG study in inflammatory myopathy?
when biopsy is inconclusive
| - will show short duration and low amplitude
100
definitive diagnosis of inflammatory myopathy
muscle biopsy
101
muscle biopsy showing perivascular and perimysial inflammation and fibrosis
dermatomyositis
102
muscle biopsy showing endomysial inflammation and fibrosis
polymyositis
103
earliest and severely affected muscle groups in poly/dermatomyositis
neck flexors
shoulder girdle
pelvic girdle
104
initial tx. in inflammatory myopathy
corticosteroids - monitor with CPK levels; continue until symptoms improve
105
what additional CF is found in inclusion body myositis that is not seen with dermato/polymyositis?
loss of deep tendon reflexes - nerves are not affected in the others
106
older female patient presents with stiffness in shoulder and hip regions after a period of inactivity; upon testing, you notice that muslce strength is normal - dx?
polymylagia rheumatica
107
what other disease is polymyalgia rheumatica associated with?
temporal arteritis
108
how can you diagnose polymyalgia rheumatica?
clinical diagnosis
109
what lab finding correlates with disease activity in polymyalgia rheumatica?
ESR - usually > 100
110
tx. of polymyalgia rheumatica
corticosteroids - response usually w/in 1-7 days; disease is generally self-limiting
111
CF in fibromyalgia
stiffness/body aches all over body
fatigue
disturbed sleep
anxiety/depression
112
diagnostic criteria of fibromyalgia
1. widespread pain including axial pain for atleast 3 months
| 2. pain in atleast 11/18 possible tender point sites
113
what drugs have shown beneficial in fibromyalgia?
SSRIs/TCAs
114
what is a prerequisite for the diagnosis of ankylosing spondylitis?
bilateral sacroilitis
115
young male comes in with low back pain and stiffness that is worse in the morning and gets better with activity; he also appears to have inflammation of the achilles tendon..what should you consider?
ankylosing spondylitis
116
aside from low back pain/stiffness, what else do pts with ankylosing spondylitis experience?
fractures with minimal trauma in late disease
chest pain and diminished chest expansion
constitutional symptoms
acute anterior uveitis/iridocyclitis
117
Schober test
measures spinal flexion - positive in ankylosing spondylitis
118
what is diagnostic of ankylosing spondylitis?
imaging showing sacroilitis or bamboo spine
- ESR may be elevated
- HLAb27 not needed
119
Tx. of ankylosing spondylitis (3)
NSAIDs - indomethacin (Sx)
Anti-TNF meds - for axial disease
Physical therapy
120
patient presents with asymmetric inflammatory oligoarthritis of LE 2 weeks after enteric or genitourinary infection
reactive arthritis
121
what should you consider if any patient has acute asymmetric arthritis that progresses sequentially from one joint to another
Reactive arthritis
122
patient presents with arthritis, urethritis and ocular inflammation - dx?
Reiters syndrome
123
undifferentiated spondyloarthropathy
when a patient has features of reactive arthritis but not evidence of previous infection
124
diagnosis of reactive arthritis
synovial fluid analysis
125
first line therapy for reactive arthritis
NSAIDs
126
what should you give a pt with reactive arthritis if NSAIDs do not provide relief?
try sulfasalazine or immunosuppressives (azathioprine)
127
should you treat patient with reactive arthritis with antibiotics?
usually not given - but may be beneficial in non-gonococcal urethritis (tetracycline)
128
pt presents with arthritis involving mainly the DIP joints; his nails also show pitting - what should you look for in this patient?
psoriasis - usually have skin disease for months-years before arthritis
129
finding on biopsy of temporal artery in GCA
giant cells; mononuclear cell infiltration or granulomatous inflammation
130
first line tx. of temporal arteritis
high dose steroids
- IV if visual loss is notes
- oral if no visual symptoms
131
young Asian woman presents to you with constitutional symptoms and pain/tenderness over vessels; on P/E you note decreased peripheral pulses, discrepancies of BP as well as arterial bruits
Takayasu arteritis
132
what is Takayasu arteritis?
granulomatous vasculitis of aortic arch and its major branches leading to stenosis or narrowing of vessels
133
how do you diagnose Takayasu arteritis?
arteriogram
134
Tx. of takayasu arteritis
steroids
treat HTN
surgery or angioplasty/bypass grafting - if severe
135
middle aged pt presents with new onset asthma and skin lesions (palpable purpura) - what should you consider?
Churg Strauss
136
definitive diagnosis of Churg Strauss
biopsy of lung/skin - prominence of eosinophils
| positive p-ANCA
137
Tx. of Churg Strauss
steroids - prednisone
138
lab findings in Wegener's granulomatosis
```
elevated ESR
normochromic normocytic anemia
hematuria
positive C-ANCA
thrombocytopenia
```
139
how can you confirm diagnosis of Wegeners?
open lung biopsy
| - often biopsy of nasal septum is done (less invasive)
140
what Tx. is used to induce remission in Wegeners?
cyclophosphamide + corticosteroids
141
what drugs can be used in systemic resistant Wegener's?
rituximab or IVIG AND
| plasmaphoresis
142
CF in PAN
```
fever, weakness
weight loss
myalgias/arthralgias
abdominal pain - bowel angina
HTN
mononeuritic multiplex - foot/wrist drop
livedo reticularis
```
143
what should you consider in a diabetic with mononeuropathy (foot or wrist drop)?
PAN
144
which organ system is spared in PAN?
lungs
145
Dx. of PAN
nerve biopsy
| mesenteric angiography
146
what can PAN be associated with?
hep B
HIV
drug reactions
147
tx. of PAN
start with steroids
- if severe, add cyclophosphamide
- tx. underlying HepB
148
pt comes in with recurrent oral and genital ulcerations, arthritis, uveitis, CNS involvement, fever and weight loss - dx?
Behcet's syndrome
149
Tx. of Behcet's syndrome
steroids
150
young smoker presents with cold, cyanotic distal extremities, paresthesias and noticeable ulcerations of digits - dx?
Buergers disease
151
young child develops palpable purpura on butt/legs, arthralgias and GI symptoms following an upper respiratory infection
Henoch-Schonlein purpura
152
Tx of Henoch-Schonlein purpura
usually self limited
| - give steroids if severe
