USMLE Rheum Flashcards
(97 cards)
1
Q
Adhesive capsulitis
A
Causes:
Rotator cuff tendinopathy, subacromial bursitis, stroke, diabetes, humeral head fx
Tx:
Self limited condition / responds well to conservative managemnt / Complete rest may worsen joint stiffneing and promote adhesions, NSAIDs 1-2 weeks to decrease pain.
Recommend RANGE OF MOTION excercises to prevent worsening of AC
2
Q
anti-U1-ribonucleoprotein (RNP) antibodies
A
mixed connective tissue disease
Pulmonary arterial hypertension is the most common disease-related cause of death
Right heart cath - yah bitch
3
Q
Antiphospholipid antibody syndrome
Treatment for following:
First venous thrombosis:
Recurrent venous thrombosis:
Arterial thrombosis:
CVA:
A
- First venous thrombosis: INR of 2-3
- Recurrent venous thrombosis: INR > 3
- Arterial thrombosis: INR > 3
- CVA: 81 mg/day ASA
4
Q
Asthma and
- Pulmonary opacities on CXR, sinusitis and peripheral eosinophillia,no renal Sx
- Chronic rhinosinusitis, nasal polyposis, esosinophillia, no pulmonary infiltrates or renal envolvement
- Cough, fever, dypnea 50% asthma but no other organ involvment
- Renal involvement (GN), Vasculitis (granulomatosis w polyangitis, mononeuritis multiplex and Upper resp dz (sinus, ear, nose and throat involvemnt), peripheral eosinophilia
- Renal involvemnet / UPPER respiratory ANCA Sinusitis
A
- Allergic bronchopulmnoary aspergillosis
- Aspirin exacerbated respiratory dz
- chronic eosinophilic pneumonia
- Churg Strauss vasculitis Ashtma
- Wegener’s granulomatosis Sinusitis
5
Q
Axial (spine) involvment
A
- Spondyloarthropathy
- Rheumatoid Arthritis (cervical spine)
- OA
- Infection (TB, Fungus, Staph, etc.)
6
Q
Back pain Red Flags
A
- > 50 yrs
- Hx of Cancer
- Unexplained weight loss
- Pain greater then one month
- Night time pain
- Unresponsive to prev therapy
- Neurlogic Sx
- Hx IV Drug use
- Recent UTI
7
Q
Best geriatric preoperative assessment?
A
Frailty determination:
Cardiovascular health study index:
- Weight loss of > 5 % over the last year
- Exhaustion with normal activity
- physical weakness
- slow walking speed (walking 15 fee in > 6-7 sec)
- Decreased physical acitivity
Frail : 4-5 points
Non frial: 0-1 piont
8
Q
Charcot joint : Diabetic neuropathic arthropathy
Tx:
A
- Casting and avoiding weight bearing
- Anti resorption therapy with bisphosphonates is also useful in some patients.
9
Q
Churg-Strauss syndrome
A
Systemic vasculitis that most often occurs in the setting of antecedent asthma, allergic rhinitis
Eosinophilia / migratory pulmonary infiltrates / purpuric skin rash / and mononeuritis multiplex; fever, arthralgia, and myalgia also are common presenting features.
Up to 40% have p-ANCA w antimyeloperoxidase antibodies. Patients who have positive ANCAs are more likely to have glomerulonephritis, alveolar hemorrhage, mononeuritis multiplex, and purpura
10
Q
Churg-Strauss Syndrome:
A
Middle-aged pt with allergies/asthma
eosinophilia > 10% WBC
and systemic illness
Dx: Obtain biopsy of any involved tissue
Tx: Steroids
11
Q
Classification of Synovial Effusions
A
Normal
- Clear - < 25% PMN)
Noninflammatory
- Clear-Yellow - 200-2,000 (< 25% PMN)
Inflammatory Cloudy
- Yellow - 2,000-100,000 (> 50% PMN)
Septic
- Purulent > 50,000 - (> 75% PMN)
12
Q
Compression Fx
Most are silent / some experience pain for 2-6 weeks.
Tx:
A
Supportive Care:
- no evidence that Back brace or Vaertebroplasty does any good
Pain Tx:
- NSAIDS / Opioids
- If fails then intranasal calcitonin for 2-4 weeks can provide help
13
Q
contraception options for a woman with systemic lupus erythematosus
A
Consider
- systemic lupus erythematosus (SLE)
- antiphospholipid syndrome
- osteoporosis
NO Estrogen-containing hormonal contraceptives are contraindicated in patients with antiphospholipid antibodie
_YES _Progesterone-containing intrauterine device
14
Q
CREST syndrome greatest risk of developing?
- Calcinosis
- Raynaud’s phenomenon
- Esophageal dysmotility
- Scalerodactyly
- Telangiectasias
A
Pulmonary hypertension often without interstitial fibrosis
15
Q
Cryoglobulinemic vasculitis
A
Cryoglobulinemic vasculitis is characterized by
- Cutaneous palpable purpura
- Mononeuritis multiplex
- an immune complex glomerulonephritis; serum C3 and C4 levels are usually low
16
Q
de Quervian tenosynovitis
A
- Due to thickening and stenosis of the synovial sheath from chronic overuse of the wrist or hand, trauma or repetitive activity
- pain on the radial side of the wrist and positive Finklestien maneuver.
17
Q
Diagnose adult-onset Still disease
A
Quotidian fever, evanescent rash, arthritis, and multisystem involvement.
Diagnosis is based on typical clinical presentation with exclusion of infection and malignancy, particularly leukemia and lymphoma.
Laboratory abnormalities in patients with leukocytosis, anemia, thrombocytosis, elevated erythrocyte sedimentation rate, elevated serum ferritin level (≥1000 ng/mL [1000 µg/L]), and abnormal liver chemistry tests; antinuclear antibodies and rheumatoid factor typically are negative.
18
Q
Diagnose Löfgren syndrome.
Type of acute sarcoidosis
A
Triad
- Bilateral hilar LAD
- Oligoathritis
- Erythema nodosun
19
Q
DIPS Involvement - NO RA
A
- Spondyloarthropathy (Reiter’s, Psoriatic)
- OA
- Crystalline
20
Q
Enthesitis, dactylitis, tenosynovitis, and cutaneous involvement such as nail pitting
A
Psoriatic arthriti
21
Q
Familial Mediterranean fever
A
- Abdominal pain / in 95% of all patients and may lead to unnecessary laparotomy.
- Joint attacks mainly occur in One large joints 75%
- Chest attacks 40%
- Scrotal attacks 5%
- Myalgia (rare in isolation)
- Erysipeloid (a skin reaction on the legs, rare in isolation)
- Fever (25%)
22
Q
Felty’s Syndrome
Triad
A
-
RA
- Sever erosive joint dz
- Rheumatoid nodules
- Vasculitis
- Neutropenia
- Splenomegaly
- DX
- Anti CCP/RA
- Elevated ESR
23
Q
GOT Hip pain ?
- Osteoarthritis
- Trochanteric bursitis (Most common)
- Meralgia paresthtica
- Occult hip fx
A
Osteoarthritis
- Groid pain / morning stiffness / aggrevated with movement
Trochanteric Bursitis
- Point tenderness in mid or superior trochanger / Lateral hip pain aggravated by direct pressure / normal ROM
Meralgia paresthetica
- Burning pain and paresthesia over the upper outer thigh
Occult hip fracture
- Severe and acute pain with internal and/or external hip rotation
- Unable to bear weight
24
Q
Drug induced lupus
Meds?
A
- Procanamide
- Hydralazine
- Lower risk Infliximab
- Etanercept
- Isoniazid
- Minocycline
25
_Gout treatment_
**NSAIDs**
* first line / CI in CKD, CHF, PUD
**Colchicine**
* CI CKD
**Steriods intra articular** 1-2 inflamed joints
**Steriods systemic**
26
Gout Treatment (Acute / Chronic)
Acute Treatment
* NSAIDs
* Intraarticular corticosteroid injection
* Oral or intramuscular corticosteroids
* Oral high-dose colchicine is rarely used as initial tx
No allopurinal
27
Gout Treatment (Acute / Chronic)
Chronic Therapy
* Colchicine
* NSAIDs
* Xanthine Oxidase Inhibitors vs. Uricosurics Uricosurics
28
HEEL PAIN DDx
1. Plantal fascitis
2. Ruptured plantaf fascia
3. Bone infection
4. Calcaneal stress
5. Tarsal tunner syndrome
**_Plantar fascitis_**
* Pain maximum upon first stepping out of bed
* Local point tenderness with dorsiflexion of the toes
**_Ruptured plantal fascia_**
* Sudden pain / loss of arch hight
* Visible swelling ecchymosis
**_Bone infection_**
* Constant throbbing pain / nucturnal worsening
**_Calcaneal Stress fx_**
* Worse with activity
* Palpation of the bone elicits tenderness
* visible on xray
**_Tarsal tunner syndrome_**
* Pain paresthesia and numbness on the sole of the foot
* percussion tenderness over the posterior tibial nerve in the tarsal tunnel
29
Henoch-Schönlein purpura
**_purpuric rash predominantly affecting**_ the distal lower extremities, arthritis, _**abdominal pain, and hematuria.**_ Skin biopsy specimens reveal the presence of leukocytoclastic _**vasculitis with deposits of IgA.**_ Kidney biopsies obtained in patients with persistent hematuria and proteinuria or kidney disease following an attack reveal a _**glomerulonephritis with IgA deposition_** consistent with lesions seen in IgA nephropathy
30
HLA-B27 testing
HLA-B27 testing may be useful in patients with inflammatory back pain but no radiologic evidence of sacroiliitis or spondylitis.
31
HSC
Henoch-Schonlein Purpura
* **Skin**: Ecchymoses, _petechiae or purpura_
* **Musculoskeletal** : Arthritis/arthralgia involving 1-4 joints
* **GI** : N/V, Abdominal pian, _GI hemorrhage_
* **Renal** : _Hematuria_, proteinuria, _renal insuff_
* **IgA depositions** in organs / an i_mmune mediated vasculitis _
32
Hydroxychloroquine & SLE
* Indicated for this patient w SLE
* Recent studies document significant benefits of this agent.
* High levels of evidence show that hydroxychloroquine prevents lupus flares and increases survival in patients with SLE
* There also is moderate evidence suggesting protection against irreversible organ damage, thrombosis, and bone mass loss.
33
Interventions for Fall preventions in Elderly
* Exercise (gait / balance, strenght, physical activity
* _Withdrawal of offending meds_
* _Vit D supplement 800 IU_ dialy with calcium
* Non slip devices on shoes
* Home hazard assessment
34
Joint dz in hemochromatosis
* Pain while flexing small joints of hand (2nd 3rd MCP)
* Chondrocalcinosis on Xray
* Hook like osteophytes on the metacarpal heads
35
Joint pain / Skin changes
1. HEP B
2. HEP C
3. HIV
4. Neisseria gonorrhoeae
**Hep B**
* **_Polyarthritis_** (symmetric) and skin change in LE / urticaria or maculopapular rash
**HEP C**
* **_Like RA_,** due to immune comples deposition results in mix _cryoglobulinemia_ with arthritis GN and vasculitis
**HIV**
* **_Psoriatic lesions**_ and _**seborrhetic dermatitis_**
**Neisseria Gonorrheae**
* **_diffuse pustular rash_** with polyarthralgias and tenosynovitis
36
Methotraxate - What to do?
prior to start
after start
Common Toxicities
**prior to start**
Chest Xray / Viral hep panel / periodic monitor of serum amino transferase albumin compelte blood count
**after starting **
Vitamin supplement / folic acid
**Common toxicities**
Fever / stomatitis / macular rash, GI disturbances, Hematologic abnormalities
Stomatitis and hematologic abnormalities are preventable
37
Milwaukee shoulder
Basic calcium phosphate crystals are commonly associated with chronic and highly destructive inflammatory arthritis such as Milwaukee shoulder.
* *_Basic calcium phosphate deposition disease_**
* *_Not :_** Calcium pyrophosphate deposition disease
38
Gout prevention
* **_Need BMI \< 25_**
* Low fat diet
* Decreased Seafood / red meat
* **_Protien intake from veg source_**
* Avoid organ rich foods (liver)
* Avoid **_beer and distilled spirits_**
* Avoid Diuretics
39
Most appropriate class of pharmacologic treatment for **_Fibromyalgia_**?
Serotonin and norepinephrine reuptake inhibitor (SNRI)
**Venlafaxine** (Effexor) / **Desvenlafaxine** (Pristiq) / **Duloxetine** (Cymbalta)
40
Myobacterial infection
1. in upper lobe dz
2. Perihilar infiltrate
Uppoer lobe dz reactivation TB
Perihilar infiltrate primary TB
41
Mythology of Gout
**Low uric acid no gout**
**Acute gout does not require uric acid measurement**
* Uric acid should be lowered to \< 6 in pt with recurrent or tophaceous gout
* High Uric acid levels more likely suggest gout even if no crystals in joint
**Colchicine should be dosed hourly**
* 0.6 mg two or three times daily better tolerated and effective
**Allopurinol should be discountinued during acute attack**
* Dose should not be change untill after 3-4 weeks after attacks
42
NE / NEE / KNEE
Components and injuries/sx
* Meniscal
* Cruciate ligaments
* Collateral Ligaments
**Meniscal**
* _Locking / pain swelling and stiffness_
* Joint line tenderness
* Loss of smooth passive motion (clicks)
* +ve McMurry test
**Cruciate ligaments**
* No joint line tnederness
* large effusion
* **_+ve drawer _**
**Collateral Ligament**
* No joint line tenderness
* noramal ROM
* No effusion
* Medial and lateral instability
43
OA
Morning stiffness \< 1 hour / Worsen with use NO constitutional symptoms (fever, malaise, fatigue) Bony joint enlargement Heberden and Bouchard nodes Labs Usually normal / ESR / Joint fluid \< 2,000 WBC / CBC - nl Radiographs / Asymmetric/non-concentric space narrowing / Osteophytes / Bone enlargement
44
OA Tx
* Oral / Acetaminophen (needs not to be prn but scheduled)
* COX-2-specific inhibitor Nonselective NSAID plus misoprostol or a proton + pump inhibitor
* Tramadol & Opioids Intraarticular Glucocorticoids
* Hyaluronan
* Topical Capsaicin
* Methylsalicylate
45
Neurogenic caludication
**vs.** Vascular calaudication
Neurogenic claudications:
* _Pain with walking downhill_ / relieved with rest or bending forward
* **_LE numbness and tingling_**
* **LE weakness**
* LBP
Vascular claudications
* _Pain with walking_
* relieved with rest
* _no LE weakness_
* **_pain in the butt / calf / foot_**
46
Osteitis fibrosa cystica
* Bone pain and xray showing subperiosteal bone resorption on the radials aspect of middle phalanges
* Salt and pepper on scull, bone cysts / brown tumor of long bones
* Due to sever **_primary hyperparathyroidism_** or parathyroid carcinoma
47
Osteoporosis
If patient has 1 or more risk factors may screen for osteoprosis earlier.
**Risk factors**
* Advanced Age
* Hx of Fx
* **_Low body weight \< 127 lbs_**
* Family hx hip fx
* Current smoking
* **_Excessive ETOH_**
* Meds (steriods / **_anticonvulsants_**)
* Secondary causes
* Premature manopause
* hypogonadism
* malabsorption
* inflammatory do
* hyperthyroidism / hyper para
* cushings syndrome
* vit D def
* Chronic Liver
48
Complications of dermatomyositis
Interstitial lung Dz
Malignancy
Esophageal dz
Myocarditis
49
Osteoprosis Tx
Drug class
1. Bisphosphonates (**alendronate / risedronate**)
2. SERM (**_Raloxifene_**)
3. Recombinant PTH (**Teriparatide**)
4. RANKLE (**Dnosumab**)
**Bisphosphonates** - **Alendronate / Risedronate**
* Osteoprosis (T score \< 2.5) or fracture (hip or vertebral)
* High Risk for Fx(T score between -1 to -2.5)
* AE: *UPPER GI irritation / Jaw necrosis (w IV formulations)*
**SERM** - Raloxifene (**_Tamoxifene is breast cancer)_**
* Osteoporosis, no fx, can not tolerate bisph
* AE: *Thromboembolic dz*
**Recombinant** PTH - Teriparatide
* Sever Osteoprosis (T \< -2.5 and at least 1 fx) Unable to tolerate bisphos
* AE: *Transient hypercalcemia*
**RANKL (**Dnosumab**)**
* High risk (-1 to -2.5) failing other therapies
* Cystitis / hypocalcemia
50
Paget Disease
Dx:
Tx:
* Bone pain, spinal stenosis, bowing deformitisy with increase fx in long bones
* Bone tumors: Osteosarcoma, giant cell tumors
* ALK elevated (bone specific)
* Calcium and phosphate usually normal
* Xray Osteolitic or mix lytic lesions
* Dx
* Xray/ALK
* Bone Scan
* Treatment
* Bisphosphonates
51
**_Physical Exam and Dz_**
1. Arm span to hight ratio
2. Chest exapansion
3. Dix Hallpike maneuver
4. Drop arm test
5. Romberg test
1. Marfans
2. Ankylosing spondylitis
3. Benign paroxysmal positional vertigo
4. integrity of the supraspinatus tendon for rotator cuff injuries
5. To test proprioception (dorsal columns of the spinal cord)
52
polyarteritis nodosa
**Arterial aneurysms**, it typically affects **_medium-sized mesenteric and renal arteries_** rather than pulmonary arteries
Commonly results in **_intestinal ischemia and renovascular hypertension_**.
*Oral ulcers, uveitis, and erythema nodosum typically do not occur.*
53
Behcet Disease - Manifestations
* **_Recurrent oral ulcers_** \> 3 x year
* **_Urogenital lesions_** / scrotal / vulvar
* Skin
* Ocular anterior or posterior **_uveitis_** / hypopyon, retinal vasculitits
* CNS (focal lesions)
* Vascular Ds (venous thrombosis)
* Renal Dz (glomerulonephritis / amyloidosis)
* GI (N/V)
54
polyarteritis nodosa
Prednisone who also has hepatitis B virus add Entecavir
TX with
* TNF inhibitor CI due to Hep B active
* If not planning to use steriods can start with Cyclophosphamid then Mycophenolate
55
Polyarteritis Nodosa (PAN)
* Middle-aged pt with
* weight loss/ fever/ fatigue/ multiple organ involvement (PNS, GU, Skin, Gl)
* **spares the lungs**
* inflammatory labs
* **HBsAg+**
_Dx:_ Obtain **biopsy of any involved tissue or angiogram**
_Tx:_ **steroids and cyclophosphamide** (Cytoxan®) Or steroids for 2 weeks followed by plasmapheresis and antiviral agents (lamivudine) (if Hep B)
56
Polymyalgia rheumatica PMR
1. Common cause of proximal muscle aching and stiffness
2. Age\> 50 / B/L pain and stiffness
3. infolves 3 of the following
1. **Neck** or torso
2. **shoulders** or proximal arms
3. **proximal** thigh or hip
4. **_ESR \> 40 CRP \> 22_**
5. Tx low dose prednisone 10-15 mg / daily for 1-2 yrs
57
* Polymyositis= proximal weakness nor rash
* Dermatomyositis + **_Rash + Gottron papules_**
* Inclusion body myositis =**_proximal and distal muscle weakness_** no rash
_Similarities_ : Older fellows + proximal and distal muscle weakness
* proximal muscle weakness **_without rash_** or distal muscle involvement
* Muscle biopsy is the gold standard for diagnosing
* predominantly **_Lymphocytic muscle infiltration with evidence of necrosis_** and regeneratio
**Infiltration pattern and cell markers** allows for the diagnosis
* **_Polymyositis_**: CD8-positive T-cell _infiltration of the endomysium_, often with invasion of intact major histocompatibility complex–I-expressing muscle fibers
* **_Dermatomyositis_**: CD4-positive T cells in _perivascular and perimysial_ area
* **_Inclusion body myositis_**: similar to that of polymyositis but also include rimmed _vacuoles and reddish inclusions_; in addition, deposits of amyloid
58
Pregnancy RA
Women with rheumatoid arthritis who are taking _methotrexate must discontinue the medication 3 months before conception_.
* Third no meds usually needed
* Second can be on NSAIDs, steroids, sulfasalazine, hydroxychloroquine
59
Primary vs Secondary Raynaud's phenomenon
**Primary** Woman \< 30, no systemic symptoms no thumb infolvemnt, noraml ANA/ESR and normal **Nailfold capillaroscopy**
**Secondary** Man \> 40, tissue ischemia and ulceration, abnormal labs with abnormal nailfold capillaroscopy test and / or systemic symtpoms
60
Prevention of steriod indused osteoprosis
**_\> 7.5 mg /day steriods for \> 3 months_ = **high risk osteoprosis
* **_Ca and Vit D_**
* **_Bisphosphonates_**
* Parathyroid hormonre (Teriparatide) 2nd line
* General Measures
* use lowest dose possible
* Daily weight bearing exercise
* D/C Tobacco ETOH
* Fall prevention
61
Psoriatic Arthritis
Hep C
HEp B
Can use **_TNF inhibitors iwth HEP C_**
**_should not be used with HEP B_**
Methotrexate is CI in liver dz
62
Psoriatic arthritis
* DIP
* absence of psoriasis rash does not rule out this condition.
* the inflammation associated with psoriatic arthritis involves the **_tenosynovial junction_**, causing swelling beyond the affected joint (sausage digits)
63
RA
* Symmetric joint swelling
* warmth
* redness Morning stiffness \> 1 hour +/- constitutional symptoms
* Ill-appearing
* Ulnar deviation
* Boutonniere and swan-neck deformity
* Extra-articular manifestations:
* Rheumatoid nodule
* Ocular
* Pulmonary
* Nervous system
* Cardiac
* Vasculitis
64
RA LABS
* Normochromic normocytic anemia
* low Hct, low-normal MCV, low iron, and low/normal TIBC
* Elevated ESR CRP & Ig concentration
* Thrombocytopenia
* Joint fluid analysis
* inflammatory Rheumatoid factor (RF) antibodies
* Fc of IgG. Most common is IgM
* CCP antibody
65
RA LABS
**_Sensitivity (%) 33% Specificity (%) 99.6%_**
Anti-CCP + RF
**_anti-cyclic citrullinated peptide Sensitivity (%) 33% Specificity (%) 99.6%_**
66
RA Management Analgesics Inflammation-suppression medications:
DMARDs Immunosuppressants/Cytotoxics
_Analgesics:_ NSAIDs, acetaminophen, tramadol
_Inflammation-suppression medications:_
_DMARDs= Disease-Modifying Anti-Rheumatic Drugs_
* Methotrexate (MTX)
* Gold (Au)
* Sulfasalazine
* Hydroxychloroquine
* Minocycline
* Leflunomide (Arava)
_Immunosuppressants/Cytotoxics_
* Azathioprine
* Mycophenolate mofetil
67
Antibodies to antigens
* Drug induced lupus
* SLE
* Systemic sclerosis
* MCTD
* Sjogrens
* Limited Scleroderma
* Polymyositis / Dermatomyositis
* Microscopic polyangiitis
* Granulomatosis with polyangiitis (wegners)
* **Drug induced lupus:**
* DNA histone complex
* **SLE**:
* ds DNA, Smith (sm)
* **Systemic sclerosis:**
* RNA polymerase II and III
* Scl-70/anti topoisomerae I
* **MCTD**
* RNP
* **Sjogrens** sndrome
* SS-A/Ro SSB/La
* Limited **scleroderma**
* Centromere
* **Polymyositis**
* Aminoacyl-tRNA synthetases (J0-1)
* **Microsocopic polyangiitis**
* Myeloperoxidase
* **Wegners**
* Proteinase 3 (PR3)
* **Myositis**
* Anti Jo-1 (Antisynthetase antibodies)
68
RA Radiology
* Periarticular Osteopenia
* Marginal erosions — where synovium attaches to bone Target joints - MCPs / PIPs / Wrists (Carpal bones) / Cervical Spine / MTPs / Soft tissue swelling
69
RA treatment
RA
1. Start **_Methotrexate_**
2. Persisitent sx for \> 6 months (**may add another non boilogic _sulfasalazine / hydroxychloroquine_**)
3. Setup therpay **add _TNF inhibitors_** (need PPD prior to start) continue methotraxate
70
**Reactive Athritis**
Clinical Features
Tx:
**Preceding infections**
* GI symptoms due to salmonella, shigella, yersinia
* GU symptoms due to Chlamdia
**Symptoms**
* Asymmetric oligoarthritis
* Enthesitis (achilles tendon)
* Dactylitis
* GU Sx
* Conjuctivitis, Uveitis
* Oral Ulcers
71
Rheumatic diseases associated with uveitis:
* spondyloarthritis
* sarcoidosis
* Behçet disease
* juvenile inflammatory arthritis
* and granulomatosis with polyangiitis (also known as Wegener granulomatosis)
72
Screening for patients wiith Dermatomyositis and polymyositis
* Heliotrope rash (purpul eyes)
* Usual Mammogram / colonoscopy
* Additional screenings
* + CT of chest/abd/pelvis
* UA for blood
* CA 125 / 19-9
* PSA
* Upper GI endoscopy
73
Shoulder hurts // Shoulder hurts
* Rotator cuff impigment / tendinopathy
* Rotator cuff tear
* Adhesive capsulitis
* Biceps tendinopathy
**Rotator cuff impingement**
* **_Pain increase_** with reaching / due to repetitive acitviey
* Normal strech / **_pain_** with abduction and **external rotations**
**Rotator Cuff Tear**
* Similar to rotator cuff tendinopathy
* **_Weakness_** with external rotation / post trauma
**Adhesive Capsulitis / frozen shoulder**
* Decreased passive and active range of motion / **_more stiff then pain_**
* Similar to tendinopathy
**Biceps tendinopathy rupture**
* _Anterior shoulder pain with lifting_, carrying objects or overhead reaching
* _**weakness** less common_
74
Sjogren Syndrome
* Decreased circulating T cells (in glands)
* Increased circulating B cells Infiltration and destruction of glands by CD4+ T cells
* anti-SSA (anti-Ro) ab
* anti-SSB (anti-La) ab
Tx: Secretory stimulants **_Pilocarpine_** (Salagen®) 5-mg tablets qid and **_Cevimeline_** (Evoxac®) 30-mg capsules tid increase salivary flow rate
**Prednisone/immunosuppression** do not improve mucus membrane gland secretion.
Increased chance of **_Lymphoma_**
75
Sjogrens syndrome &
Cancer
How to Dx Sjogrens
Non hodgkin lymphoma (bcell)
risk factors Anti Ro/La, RF and cryoblobuinemia, hypocomplementemia and lyphocytopenia
Bx of lower lip
76
SLE Criteria
**SOAP BRAIN MD**
* Serositis
* Oral ulcers
* Arthritis
* Photosensitive
* Blood dyscrasias
* Renal disorder
* ANA \> 1:80
* Immunologic disorder
* Neurologic disorder
* Malar rash
* Discoid rash rash
77
Ankylosing spondylitis
* NSAIDS
* **TNF inhibitors** (Adalimumab)
* Methotrexate/Sulfasalazine
* Associated with Aortic Regurgitation / **Aortic root dilatation**
TNF inhibitors are k with HCV however can not give with HBV.
78
SLE Random facts
_**Anti-DS DNA** ab risk renal disease _
_**Antiphospholipid Ab **Prolong PTT_
* May have +ve antiphospholipid ab = anticardiolipin ab = anti-beta-2 glycoprotein ab
Presence of **_SS-A (Ro) / and SS-B (Ro)_** ab is associated with increased risk congenital heart block.
79
SLE - pregnancy
* Medicaitons?
* Significance of
* Anti phosopholipid
* Anti SSA / SSB
* **_Hydroxychloroquine_** is a safe drug and improves pregnancy outcomes in SLE
* Screen for **_antiphosopholipid syndrome_** / due to risk of poor maternal and fetal outcomes
* **_Anti SSA/Ro and Anti SSB/LA**_ associated with neonatal lupus and _**conginital heart block_**
80
SLE Therapy
Renal
Neurologic
Rash
Renal
* Corticosteroids
* Immunosuppressive
Neurologic Symptomatic
* Corticosteroids
* Immunosuppressive
Rash
* Topical Corticosteroids
* Systemic steroids
* Hydroxychloroquine
* Methotrexate
* Immunosuppressive drugs
81
_SLE Treatment:_
* _Serositis_
* _Arthritis_
* _Blood dyscrasias_
_Serositis_
* NSAID
* **Corticosteroids**
* **Immunosuppressive**
_Arthritis_
* NSAIDs
* Hydroxychloroquine (safe for pregnancy)
* DMARDs
* **Corticosteroids**
* **Immunosuppressive Drugs**
_Blood dyscrasias_
* **Corticosteroids**
* **Immunosuppressive Drugs**
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spondyloarthritis
At least one spondyloarthropathy feature or the presence of HLA-B27 and at least two additional spondyloarthropathy features. Spondyloarthropathy features include
* inflammatory back pain; arthritis; enthesitis; dactylitis; uveitis; psoriasis;
* Crohn disease or ulcerative colitis;
* family history for spondyloarthritis;
* presence of HLA-B27;
* elevated C-reactive protein level;
* and a good response to NSAIDs
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Spondyloarthropathies
* AS Ankylosing spondylitis
* Psoriatic arthritis
* Inflammatory bowel disease (enteropathic)
* Reactive arthritis
What is common in all?
1. Association with HLDB27
2. Presence of enthesitis
3. Uveitis
4. Sacroiliitis
AS : Limited chest expansion, Chronic Low back pain
Psoriatic arthritis: Nail / DIP changes
IBD:
Reactive A: GI/GU infections prior
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Subacute cutaneous lupus erythematosus
**_Key Point_**
* Up to 50% of patients with subacute cutaneous lupus erythematosus do not develop systemic manifestations of lupus.
* Associated with anti RO and LA lesions that are scaly and evolve as polycyclic annular lesions or psoriasiform plaques
* Related to meds hctz / acei / ccb
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Takayasu's arteritis (pulseless disease):
Young Asian (Japanese) women with
* asymmetric pulses
* new HTN
* bruits
* vascular insufficiency symptoms
Dx: _Angiogram or Magnetic resonance angiography_
Tx: **_Steroids_** / Angioplasty (if not inflamed) / Bypass surgery
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Vaccines that are to be avoided with Biologics
MMR / Zoster / Nasal Infuenza
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Live attenuated vaccine should be avoided.
* Pregnant women
* diabetes mellitus
* kidney dysfunction
* hemoglobinopathies
* immunosuppression
* chronic diseases that can compromise respiratory function or the handling of respiratory secretions.
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Valgus Stress Maneuver
* Movement of medial joint \> 30 indicated an injured medial collateral ligament
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Wegener granulomatosis
* Granulomatosis with polyangiiti
* Uveitis, retinal vasculitis, arthritis, and oral ulcers, as seen in these patients
* However, the vasculitis associated with granulomatosis with **polyangiitis involves small, rather than large, blood vessels, and aneurysms are not seen.**
* Upper airway disease such as **_sinusitis or epistaxis _**
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Wegener Granulomatosis:
* Young/middle-aged pt with pulmonary Sxs, **_sinus_** Sxs
* **abnormal urinalysis**
* inflammatory labs + systemic illness.
* c-ANCA and **_anti-proteinase 3_** antibody
**_Tx_**: Steroids/ Cyclophosphamide (Cytoxan®) / Methotrexate (in absence of life-threatening lung or kidney disease)
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What is Get up and Go
* Fall assessment
* must be 7-10 sec (does not matter if pt fat)
* anything \> 20 sec problematic
* Check for Dizziness (meds), LE weakness, balance, arthritis, stroke
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Worst prognosis for RA
* **_+/High anti CCP and RA_**
* Early development of multiple joint inflammation
* radiographic erosions
* socioeconomics
* elevated ESR / CRP
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B19 infection
Test IgM or IgG
* _Treatment_ with ibuprofen.
* Parvovirus B19 infection is most common in children and manifests as erythema infectiosum, consisting of polyarthralgia, flu-like symptoms, and a characteristic facial rash (“slapped cheek”).
* IgM current dz
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Giant cell arteritis.
* Unexplained fever and polymyalgia rheumatica or for patients with suspected giant cell arteritis whose temporal artery biopsy results are negative.
* Fever of unknown origin in patients \>50 years.
* Hip and shoulder girdle stiffness and pain may be the predominant feature.
* Alendronate is indicated for this patient with giant cell arteritis (GCA) who is being treated with high-dose prednisone / corticosteroid treatment is expected to continue for at **_least 3 months at a dose of ≥7.5 mg/_**
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Kawasaki disease adults?
Although most commonly seen in young children, Kawasaki disease may occur in adults, in particular in those with HIV infection.
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