L19. Medical Management of Rheumatologic and Connective Tissue Disorders

What type of disorder is rheumatoid arthritis?

systemic autoimmune disorder

Rheumatoid arthritis is characterized by ---- inflammation of joints, especially of the hands, feet, and knees

What population is rheumatoid arthritis more present in?

Females

Rheumatoid arthritis is --- involving --- of the hands, feet, wrists, and ankles

symmetric polyarhthritis involving small

What is a morning symptoms associated with rheumatoid arthritis?

prolonged morning stiffness > 1hr

True / False: the TMJ is involved in rheumatoid arthritis

true

Rheumatoid arthritis results in --- deviation and --- deformatity

ulnar devaition

swan neck deformity

Rheumatoid Arthritis Diagnosis

morning stiffness

arthritis in 3 or more small joints

symmetric arthritis

rheumatoid nodules

serum rheumatoid factor

radiographic changes

Rheumatoid factor is positive in 85% of patient population with rheumatoid arthritis . Other elevated laboratory findings include --- and ---

ESR and C reactive protein

What are citrullinated proteins?

arginine in proteins is converted to being citrullinated

antibodies develop to citrullinated proteins

What syndrome is consistent with rheumatoid arthritis?

Sjorgen syndorme

What is a classic radiographic finding of rheumatoid arthritis?

erosion of small joints

True / False: there is a cure for rheumatoid arthritis

false - no cure

can control disease by reducing pain/inflammation, preserving function, and improve outcome

True / False: non-steroidal anti-inflammatory drugs and aspirin change the progression / limit rheumatoid arthritis continuation

false = do not change natural course of rheumatoid arthritis

What medications help change the natural course of rheumatoid arthritis?

disease modifying anti rheumatic drugs

---- slow down the damaging components of the rheumatoid arthritis disease process

disease modifying anti rheumatoid drugs

Examples of disease modifying anti-rheumatic drugs

methotrexate

anit-malarials

steroids

TNF-a inhibitors = etanercept / infliximab

What drugs used in the management of rheumatoid arthritis disorders increase infection risk?

Gold compounds (gold sodium thiomolate)

How long do symptoms have to last to be diagnosed with rheumatoid arthritis?

> 6 weeks

Osteoarthritis

degenerative joint disease

True / False: osteoarthritis has systemic manifestations

false

- rheumatoid arthritis has systemic manifestations

- osteoarthritis has local manifestations

What are the morning symptoms of osteoarthritis

brief morning stiffness

There is --- inflammation with osteoarthritis

minimal

In contrast with rheumatoid arthritis, osteoarthritis has a --- prognosis and less serious complications, depending on the joints involved

more favorable

The two most important complications associated with osteoarthritis are --- and ---

pain and disability

What joints does osteoarthritis affect?

Large joints = hips, feet, spines, hands, TMJ

What syndromes are associated with osteoarthritis?

Heberden's nodes = DIP joint

Bouchard nodes = PIP join

Heberdin's nodes refers to --- joint

DIP

Bouchard's nodes refers to --- joint

PIP

Radiographic diagnosis of osteoarthritis

joint space narrowing

ankylosis

remodeling = osteophytes and spurs

True / False: ESR and C reactive protein are elevated with osteoarthritis?

false = not a systemic inflammatory disease but a localized degenerative disease

Treatment of osteoarthritis

NSAIDS

steroid injections into joint

physical therapy

surgery

What is the first line treatment therapy for osteoarthritis?

NSADS and physical therapy

Which arthritis is surgery (joint replacement) a treatment option: rheumatoid arthritis or osteoarthritis?

osteoarthritis

What needs to be completed prior to joint surgery?

Dental examination / procedures

Increased risk of infection if dental infections are not addressed prior to joint surgery

Lupus Erythematosus types

Discoid

Systemic

Lupus Erythematosus Discoid predominantly affects ---

skin

Lupus Erythematosus Systemic predominantly affects ---

multiple organ systems

Lupus Erythematous is a --- disorder

auto-immune

Lupus erythematous systemic disorder has a female to male ratio of --- that rises to ---

3:1

10:1

What patient population is systemic lupus erythematous predominant in?

hispanics and African Americans

What happens in lupus erythermous systemic disorder

antibody and immune complex deposition results in inflammation / vasculopathy

What is a clinical presentation of lupus erythematous?

butterfly rash across nose/cheeks

Systemic lupus erythematous presents as ulcerations on the ---

buccal mucosa

What helps to different lupus erythematous from rheumatoid arthritis and osteoarthritis?

joint pain out of proportion to signs

non-deforming

What is an indicator of a poor prognosis of lupus erythematous?

renal abnormalities

What is associated with anti-phospholipid antibodies in systemic lupus erythematous?

thromboembolism

Libman Sacks endocarditis

nonbacterial verrous endocarditis on mitral valve

Libman Sacks endocarditis is a common finding associated with ---

systemic lupus erythematous

What is the best screening tool for lupus erythematous?

ANA = antinuclear antibody testing

True / False: anti-nuclear antibody testing is sensitive but not specific to systemic lupus erythematous

true

Lyme disease is a ---- disease caused by a tick borne spirochete ---

multi-inflammatory

borellia burgdorferi

What species carries Borrelia burgdorferi

Ixodes dammini

What is a classical patterns of Lyme disease is a characteristic macular skin rash called ---

erythema migrans

Where are deer ticks Ixodes Dammini found?

New York, Conneticut, Pennsylvania, Massachusetts, Rhode Island, New Jersey, Wisconsin, and Minnesota

What are the 3 stages of Lyme Disease:

early localized

early disseminated

late

Erythema migrans is a --- or --- lesion

target or bull

Ankylosing Spondylitis affects which young adult population?

Males

True / False: Lyme disease may or may not have erythema mirgrans (target/bull lesions)

true

What are the classifications of late disease of Lyme disease?

Musculoskeletal problems

Neurological problems

What is a common neurological symptoms of late lyme disease?

Fibromyalgia

True / False: late Lyme disease may not be preceded by earlier manifestations

true

Can Lyme disease be diagnosed with enzyme linked immunosorbent assay or western blot analysis on the early localized stages?

No relies on erythema migrans (target/bull lesion)

How to treat Lyme disease?

Doxycycline adults

Amoxicillin children

Scleroderma types

Limited: CREST SYNDROME

Diffuse

CREST syndrome

calcinosis

raynauds

esophageal dysfunction

scelrodactyl

telangiectasia

Scelerodactylyl

thickening of skin

Telangiectasia

small blood vessels grow near surface of the skin

Sjorgen Syndrome is a ---- disorder often associated with rheumatoid arthritis

auto-inflammatory

Sjorgen syndrome affects --- and --- glands

salivary and lacrimal

What is the triad of clinical conditions of Sjorgens syndrome?

Dry eyes

Dry mouth

Connective tissue disorder = rheumatoid arthritis

Sicca complex

dry eyes and dry mouth in Sjorgens syndrome

What is important in the treatment of sjorgens syndrome?

moisture and lubrication of salivary and lacrimal glands

treatment of secondary mucosal conditions

prevention of oral diseases

Mr. Jones presents with an abnormally highnumber of dental carries. He reports having increasingly dry eyes and mouth. He was recently diagnosed with rheumatoid arthritis.What is the most likely cause of his dental carries?

a) Systemic Lupus Erythematosus

b) Sjögren syndrome

c) Osteoarthritis

d) Fibromyalgia

b) Sjögren syndrome

--- is the most common cause of chronic pain in the US

fibromyalgia

What population does fibromyalgia primarily affect?

primarily woman

What are the clinical symptoms of fibromyalgia?

muscle pain

sleep disturbance

neuropathies

--- of the 18 points must be painful on application of only 4kg pressure

11

Successful management of FM requires a thorough analysis of patient's --- issues, including fatigue, sleep, pain, psychological distress etc.

biopsychosocial

What medications can be given for fibromyalgia?

amitryptyline

trazodone

nortriptyline

SSRI's

anticonvulsants such as gabapentin, topiramate, or pregabalin

True / False: opioids are an optimal treatment therapy for fibromyalgia

false = its a chronic pain and opioids should not be the first choice of therapy

Ehler Danlos Syndrome

---- is a regenerative injection therapy used to manage chronic TMJ dysfunction and pain, particularly when conservative treatments have failed.

Prolotherapy with 10% dextrose

What is the function behind prolotherapy with 10% dextrose

The hyperosmolar solution irritates the tissue, which can lead to strengthening of the joint capsule and ligaments, improved joint stability, and pain reduction over time

With fibromyalgia symptoms are --- and present for > -- months

Widespread

> 3 months

Amyloidosis

Group of diseases in which abnormal protein calledamyloid fibrils, builds up in tissue

What is the treatment for amyloidosis?

high dose chemotherapy

stem cell transplantation Ankylosing Spondylitis

Ankylosing Spondylitis

a form of rheumatoid arthritis that primarily causes inflammation of the joints between the vertebrae

Symptoms of ankylosing spondylitis is chronic pain and stiffness in the --- that usually develops slowly over several weeks or month

lower back, buttocks and hips

Ankylosing Spondylitis

90% of those affected have a specific human leukocyteantigen known as the ---- antigen

HLA-B27

What are treatment for Ankylosing Spondylitis

medication, exercise, and surgery

• Medications used: NSAIDs, steroids, DMARDs such as sulfasalazine, and biologic agents such as infliximab

True / False: There is no cure for ankylosing spondylitis

True