Lecture 16: Rheumatology

Non-Inflammatory Arthritis

AM stiffness < 1 hour

Pain

Worst at end of day

Worsens with activity

Improves with rest

Normal ESR/CRP

WBC less than 2000

Inflammatory Arthritis

AM stiffness > 1 hour

Pain

Worst at start of day

Improves with activity

Worsens with rest

Elevated ESR/CRP

Osteoarthritis

Can involve any articular joint (from c-spine down to toes)

Mono especially in cases of post-traumatic OA

Polyarthritis more common in hands

Heberden (DIP) vs Bouchard Nodes (PIP) (bony enlargement)

Associated w/ obesity

Osteoarthritis Treatment

Lifestyle Modification: Weight Loss, Diet, Exercise

Tylenol

NSAIDs (PO and topical)

Intraarticular Steroids

Duloxetine

Osteoarthritis

Rheumatoid Arthritis

Polyarticular Symmetric Inflammatory arthritis

Small joints of hands (spares DIPs)

Affects most joints (not DIPs or Lumbar/Thoracic Spine)

Leads to joint destruction if untreated

Chronic, systemic inflammatory disorder

Extraarticular manifestations

Swan neck deformity, Boutonniere deformity, Ulnar Deviation

Autoantibodies: Rheumatoid Factor (RF) and Cyclic citrullinated Peptide (CCP): more specific

Genetic Association: HLA-DR4, Female, Smoking

Rheumatoid Arthritis

periarticular osteopenia

erosions

joint space narrowing

Rheumatoid Arthritis Extraarticular Manifestations

SubQ Nodules

Pericarditis

Interstitial Lung Disease

Scleritis

Felty’s Syndrome

Rheumatoid Arthritis + Neutropenia + Splenomegaly

Caplan’s Syndrome

Rheumatoid Arthritis + pneumoconiosis

Coal-miners

pneumoconiosis

Rheumatoid Arthritis Treatment

NSAIDs: Renal (CKD, AIN), GI (PUD, gastritis), CV (MI)

Glucocorticoids: Weight gain, insulin resistance, “buffalo hump”, cushingoid features, osteoporosis, psychosis, acne, adrenal insufficiency if ill or med abruptly withdrawn

Methotrexate (1st line DMARD): teratogenic, hepatotoxic, ILD

Anti-TNF (1st line biologic): Etanercept, Infliximab, Adalimumab

Biologic DMARDs

Adverse Effects:

Increases susceptibility to Infection

TB

Endemic Fungi

Drug-induced lupus (dsDNA)

Contraindications:

Active infection

Malignancy

CHF

Demyelinating disorders (MS)

Seronegative Spondyloarthropathies

Back pain (inflammatory axial arthritis): chronic, insidious, AM stiffness, better with exercise

Inflammatory arthritis

Imaging: Sacroiliitis on XR or MRI

Labs: HLA B27

Uveitis

Enthesitis

Dactylitis (sausage digits)

Psoriatic Arthritis

Psoriasis + Psoriatic Arthritis

Inflammatory axial arthritis (back pain)

Inflammatory polyarthritis

Can affect DIPs (unlike RA)

Arthritis mutilans subtype (very rare)

Nail Pitting

Sausage Digits

Psoriatic Arthritis

DIP Involvement → Pencil in Cup Deformity

Psoriatic Arthritis Treatment

Methotrexate

TNF inhibitors (1st line): Adalimumab, Etanercept, Infliximab

Ankylosing Spondylitis

diagnosis is confirmed by spine radiographs (especially of SI joints)

Bamboo Spine

Minor trauma → vertebral fractures

Aortic Regurgitation

Apical pulmonary fibrosis

Ankylosing Spondylitis

Ankylosing Spondylitis Treatment

First line Therapy: NSAIDs, Physical Therapy

Inadequate Response to NSAIDs → TNF inhibitors: Adalimumab, Etanercept, Infliximab

IBD-Related Arthritis

IBD + Ankylosing Spondylitis

Reactive Arthritis

Conjunctivitis, Uveitis, Urethritis

Circinate Balanitis

Oligoarticular Arthritis (knee>ankle)

Back pain

Most patients spontaneously remit

>2-3 weeks following GI or GU infection

Patient with joint pain + h/o infectious diarrhea or an STI

Screen all patients for STI’s!

Responds well to NSAIDs and time

Resistant cases (<25%) may require DMARDs/Biologics

Gout Overview

Abrupt onset of inflammatory joint pain, warmth, and swelling over the course of several hours to a day

Exquisite pain

Asymmetric joint involvement

MTP (podagra), ankles, knees, elbows, hands

Tophi (nodules filled with chalky-white uric acid crystal deposits) near affected joints (olecranon bursa, hands, etc) or on pinna of ear

Gout pathogenesis, epidemiology, and cause of flare ups

Under-excretion of uric acid

Males, CKD

Gout Flare Causes:

Intake of purine-rich foods (red meat, shellfish)

Alcohol (binge drinking)

Use of diuretics (furosemide or thiazides)

Pseudogout

acute calcium pyrophosphate (CPP) crystal arthritis

Knees >>> wrists > ankles > elbows > shoulders

Presents very similar to gout

Weakly positively birefringent rhomboid CPP crystals

Blue

Gout

Needle-shaped

Birefringence: Strongly Negative

Color when parallel to polarized light: Yellow

Septic Arthritis

Severely painful red, swollen joint held in slight flexion

Staph aureus (IV drug users), Streptococcus

R/o concomitant endocarditis

Neisseria gonorrhoeae (multiple partners)

Septic arthritis is an emergency!

Next step after arthrocentesis → Consult Ortho ASAP for surgical debridement

Systemic Lupus Erythematosus

Systemic autoimmune disorder characterized by immune-mediated damage (to kidneys, brain, blood cells, skin)

Young African American, Hispanic, or Asian Females

Rash (Discoid or Malar)

Arthritis

Serositis (pleuritis/pericarditis)

Hematologic Changes (low wbc/plt/hgb)

Oral Ulcers

Renal Disease (Lupus Nephritis) → UA: RBC’s or proteinuria

Photosensitivity

ANA Positive

Immune-mediated disorder (+dsDNA, +Sm, low c3/c4)

Neurological Changes (Seizures, psychosis)

Lupus presents with a facial droop, left-sided weakness, and a new murmur

Libman Sacks Endocarditis → Embolic CVA

Neonatal lupus

Heart Block + Rash

Dermatomyositis

Proximal muscle weakness + Rashs

Elevated CK, Aldolase, AST/ALT

anti-Jo-1

Imaging: Muscle inflammation on MRI

On boards, will be the quadriceps

Strongly associated with malignancy → Paraneoplastic syndrome

Order age-appropriate cancer screening

Heliotrope Rash

Gottron’s Papules

Sjogren’s Syndrome

Dry Eyes/Mouth + Inflammatory Arthritis

Decreased saliva → increased caries

Can co-exist with other rheumatic diseases

Labs: anti-SSA/SSB

10-20x increased risk of Non-Hodgkins Lymphoma (MALToma)

Associated with Type 1 RTA

Parotid Swelling

Lymphocytic Glandular Infiltration

Systemic Sclerosis (Scleroderma)

Limited: Associated with CREST syndrome

Calcinosis, Raynauds, Esophageal dysmotility, Sclerodactyly, Telangiectasias

+ Anti-Centromere

Pulmonary (MCC Death): ILD, pHTN

Sarcoidosis

Most common in African Americans

Dyspnea

Lymphadenopathy

RA-like arthritis

Hypercalcemia

Elevated ACE level

Non-caseating granulomas

Lofgren’s Syndrome

Type of Sarcoidosis

Hilar Adenopathy

Erythema Nodosum

Peri-ankle arthritis