RHEUMATOLOGY

Four cardinal signs of inflammation

1. Erythema

2. Warmth

3. Pain

4. Swelling

Differentiate articular vs nonarticular disorders

When is synovial fluid aspiration indicated in MSK disorder

1. Acute monoarthritis (monoarthritis in patients with chronic polyarthritis)

2. Cases of trauma with effusion

3. Infectious or crystal-induced arthropathy suspected

How to assess viscosity of fluid

Study assessment of MSK complaint

Study interpretation of Synovial fluid aspiration and analysis

PIP joint hypertrophy

Bouchard’s nodes

DIP joint hypertrophy

Heberden’s nodes

Pathologic sine qua non of osteoarthritis

Hyaline articular cartilage loss

Morning stiffness in Osteoarthritis

Brief morning stiffness <30 mins

Radiographic finding in osteoarthritis

Sinovial fluid analysis

Joint space narrowing

Osteophytes (bone spurs)

Synovial fluid analysis non-inflammatory - WBC <2000mm3

Difference in joint affectation of RA and OA

• Morning stiffness

• DIP

• PIP

• MCP

• RF and anti CCP

• Joint fluid leukocyte count

• DIP affected in OA, RA not

Treatment of OA

Medication and dose for OA

• Oral NSAIDS 4

• Topical NSAIDS 4

• Intraarticular injections

Earliest joints involved in RA

Small joints of the hands and feet (EXCEPT DIP)

1. Distribution of RA

2. Frequent hallmark

1. Symmetric

2. Flexor tenosynovitis (trigger fingers)

Piano key movement

3 Pathologic hallmarks of RA

1. Synovial inflammation and proliferation

2. Focal bone erosions

3. thinning of articular car

Most common hematologic abnormality of RA

Most common pulmonary manifestation

Most common cardiac abnormality

Normochromic normocytic anemia

Pleuritis

• if with dry cough, progressive SOB in RA - think of interstitial lung disease

MC valvular abnormality

Joint finding in RA

Pannus formation - abnormal, aggressive growth of thickened synovial tissue filled with inflammatory cells and new blood vessels that invades and destroys adjacent joint cartilage and bone.

Joint deformities seen in RA

Xray findings in RA

Periarticular osteopenia - initial

Others:

• soft tissue swelling

• Joint space loss

• Subchondral erosions

Synovial fluid analysis in RA

Inflammatory: WBC 5000-50,000/uL

Overwhelming cell type: neutrophil

Diagnostic for RA

Rheumatoid factor and Anti-citrullinated peptide (anti-CCP antibodies)

Anti-CCP - single most accurate test - more specific than RF

Treatment of choice for RA 3

DMARD - Disease modifying anti-rheumatic agents

• slows or prevent structural progression

• Conventional DMARDs

  • Methotrexate with folic acid - first choice for the treatment of early ra

  • Leflunomide, hydroxychloroquine, sulfasalazine

• Biologic DMARDS

  • Anti-TNF agents (infliximab, etanercept)

  • Anakinra (IL-1_

  • Abatacept Rituximab tocilizumab

Glucocorticoids

• low moderate dose to control disease before full effect of DMARDS - given in acute flares

• Use:

  • Initial disease control before onset of fully effective DMARD therapy

  • Acute disease flares

  • Inadequate response to DMARD therapy

NSAIDs

• Other former core of RA therapy

• Adjunctive: symptom control

Most common early clinical manifestation of gout

Acute recurrent gout flare

Medication that can cause/trigger gout flare

Thiazide diuretics - decreases renal excretion of uric acid

What is pseudogout Vs gout

Pseudogout:

• Positively birefringent rhomboid shaped calcium pyrophosphate dehydrate (CPPD) crystals

Gout:

• negatively birefringent needle-shaped monosodium urate crystals

3 diagnostics for gout

Mainstay for acute gouty attack

1. NSAID

2. Colchicine

3. Glucocorticoid

Most effective NSAID

1. Indomethacin

2. Naproxen

3. Inuprofen

4. Celecoxib

When to stop colchicine

At first sign of loose stool

4 considerations for urate lowering therapy

2 that SHOULD be initiated

1. More than 2 acute attacks yearly

2. Severity and duration of flares

3. Quality of life

4. Patient’s willingness to commit to lifelong therapy

1. Presence of uric acid stones

2. Tophi or chronic gouty arthritis

How to differentiate psoriatic arthritis vs RA

Psoriatic arthritis is seronegative often with DIP, spine, and sacroiliac joints; distinctive radiographic features; and familial aggregation

Clinical features of PsA

• psoriasis precedes joint disease in 70%

• Nail changes in fingers/toes in 90%

• Characteristic of PsA: shortening of digits because of underlying osteolysis

• Back and neck pain

Dactylitis - sausage digit inflammation of an entire digit

Enthesitis - inflammation of etheses (sites where tendons/ligaments insert into bone)

What is the CASPAR criteria

what is ankylosing spondylitis

Chronic inflammatory arthritis primarily affecting the spine and large joints causing pain, swelling, and potential bone fusion

Ankylosing Spondylitis shows striking correlation with what histocompatibility antigen?

HLA-B27

Most common extraarticular manifestation of Ankylosing Spondylitis?

Anterior Uveitis

When to suspect Ankylosing spondylitis

Sacroiliitis on imaging plus presence of spondyloarthritis such as inflammatory back pain and possible anterior uveitis

Young adult, fever, chills, rash (papules and pustules on extensor surface), and articular symptoms

Disseminated gonococcal arthritis

• most common route - -hematogenous

Gonococcal vs non-gonococcal arthritis

1. Joint involvement

2. Other manifestations

3. Synovial fluid analysis

4. Synovial fluid culture

5. Blood culture

Treatment for non-gonococcal arthritis

Treatment for gonococcal arthritis

Best initial diagnostic choice for SLE

Antinuclear antibody (ANA)

Most specific test for SLE

Anti-dsDNA (70%) or Anti-Sm (25%)

What test correlates with disease activity of SLE

Anti-dsDNA

Mainstay treatment for life threatening SLE

Systemic glucocorticoid

Most common chronic dermatitis in lupus

Discoid lupus erythematosus

Systemic Lupus International Collaborating Clinic (SLICC) Criteria for Classification of SLE

5 Clinical

5 Immunologic

Presence of any 4 criteria (must have at least 1 in each category) = SLE

Clinical Manifestations of SLE

BOSS BRAS

Nephritis in lupus

Asymptomatic, so urinalysis should be requested in SLE suspects

Understanding SLE

ANA in SLE

>98% positive during course of disease, repeated negative tests by IF suggest NOT SLE

Treatment of SLE

Non-Life threatening

• mainstay

• Arthritis/arthralgia

• Lupus dermatitis

Life threatening

• mainstay

• Lupus nephritis

• Severe thrombocytopenia

• Maintenance

Classification of Lupus Nephritis

I-VI

Meds that can cause Drug-induced lupus

LUPUS Makes My HIPS Extremely Painful:

1. Methyldopa

2. Minocycline

3. Hydralazine

4. Isoniazid

5. Phenytoin

6. Sulfa Drugs

7. Etanercept

8. Procainamide

A&B

B

C

D

D

A

E

C

B

Best treatment for Acute Rheumatic Fever

Aspirin

Best antibiotic for secondary prophylaxis of ARF

Benzathine Penicillin G

Definitive test for ARF

NONE

Evanescent migrating rash + first degree AV block

Rheumatic fever

Latent period in ARF between sore throat and ARF

Around 3 weeks (1-5 weeks) between precipitating group A streptococcal infection and the appearance of clinical features of ARF

Percent of ARF that proceed to RHD

60%

joint pain in ARF

ARF is unlikely if joint pain persists for more than 1-2 days after starting salicylates

Arthritis in ARF

Polyarthritis is migratory, asymmetric, and always affect large joints (knees, ankles, hips, elbows)

Hallmark of RHD

Valvular damage

JONES CRITERIA

Primary prevention of RF

Secondary prevention of RF

Treatment of RF