Rheumatology

inflammatory joint disorders

RA, SLE, GOUT

monoarticular joint disorders

gout, trauma, septic arthritis, lyme, osteoarthritis

oligoarticular (2-4) joint disorders

reactive arthritis, psoriatic arthritis, IBD

polyarticular (≥5) joint disorders

RA, SLE

DIP involvement joint disorders

osteoarthriits, psoriatic arthritis

MCP involvement joint disorders

RA, SLE, pseudogout

first metatarsal phalangeal involvement joint disorders

gout, osteoarthritis

a degenerative arthritis and wearing down of the joints

osteorthritis

what are the sxs/s of osteoarthritis?

joint pain, crepitus, decreased mobility, pain with use and weight bearing, Heberden + Bouchard nodes

what is the diagnostic for osteoarthritis (and what would you expect to see?)

XR: sclerosis, osteophytes, decreased joint space

what is the treatment for osteoarthritis?

- moderate exercise, PT, assistive devices

- topicals (capsaicin cream, diclofenac gel)

- oral tylenol or NSAIDS (tylenol 1st line since it is safer)

- joint injections (steroid, hyaluronate, PRP)

- surgery (replacements)

gout

sxs/s?

diagnostics?

treatment? (acute attack and between attacks)

swelling, tenderness, redness, warmth, pain (great toe MTP is most common location), +- tophi

+ needle-shaped crystals in the synovial fluid (via arthrocentesis)

acute: rest, ice, NSAID + colchicine x 5-7 days (corticosteroid if can't have NSAID)

btw: allopurinol or febuxostat (1st line)

(can add probenecid if uric acid is >6)

when is ULT indicated for treatment of gout?

≥2 attacks/year, CKD, tophi, urolithiasis, chronic

gout in the big toe

podagra

gout prevention

low purine diet, avoid organ meats, avoid EtOh, high fluid intake, avoid thiazides and loops

Rhomboid-shaped, positively birefringent calcium pyrophosphate dihydrate (CPPD) crystals on joint fluid aspirate.

pseudogout

gout or pseudo gout

joint cartilage calcifications

psuedogout

gout or pseudo gout

spindle shaped crystals

gout

gout or pseudo gout

no birefringence under polarized light

gout

gout or pseudo gout

no bony changes

pseudogout

chronic systemic disease characterized by autoimmune inflammatory changes of multiple joints

rheumatoid arthritis (RA)

what are the sxs/s of rheumatoid arthritis?

symmetric swelling of multiple joints, tenderness, pain, morning stiffness, deformity

(PIP, MCP, wrists, knees, ankles, MTPs)

MC joint involved in RA

MTP

what labs/tests are diagnostic for rheumatoid arthritis?

+ RF (rheumatoid factor) and + anti-CCP antibodies

elevated ESR and CRP

XR: uniform joint space narrowing, erosions

osteoarthritis or RA?

multijoint involvement, symmetric

RA

osteoarthritis or RA?

bouchard and herbens nodes

osteoarthritis

osteoarthritis or RA?

PIP joint involvement

both

osteoarthritis or RA?

morning stiffness

RA

osteoarthritis or RA?

DIP joint involvement

osteoarthritis

osteoarthritis or RA?

monoarticular joint pain worse with activity, better with rest

osteoarthritis

osteoarthritis or RA?

hip or knee pain

osteoarthritis

osteoarthritis or RA?

wrist and MCP pain

RA

what is the first-line treatment for rheumatoid arthritis?

other treatment options?

methotrexate (MTX)

- other disease modifying antirheumatic drugs (sulfasalazine, hydroxychloroquine, janus kinase inhibitors, biologics)

- NSAIDs (can be added for pain relief)

- prednisone daily - bridge only

- steroid injections

(medications can be combined; but you cannot combine biologics)

the following are characteristic of what disease?

in young women

rash over sun-exposed areas

joint sxs

anemia, leukopenia, thrombocytopenia

ANAs, anti-double stranded DNA antibodies

SLE

inflammatory autoimmune disorder of autoantiboides to nuclear antigens that effects multiple organ systems

systemic lupus erythematosus (SLE)

what serology tests (antibodies) are diagnostic for SLE?

ANA (antinuclear antibody), anti-dsDNA, and anti-smith ab

diminished serum complement levels (esp during flare)

what physical exam findings can be found with SLE?

malar rash, discoid skin lesions, oral ulcers, arthritis

11 criteria for classification of SLE

malar rash

discoid rash

photosensitivity

oral ulcers

arthritis

serositis

kidney disease

neurologic disease (seizures)

hematologic disorders

immunologic abnormalities (antibodies)

positive ANA

*need 4/11 for positive diagnosis

what is the treatment for SLE?

- pt education and emotional support

- avoid sun

- NSAIDs (minor joint involvement)

- topical steroids (for rashes)

- hydroxycholoroquine (DOC for rashes and joints)

- corticosteroids (for other organ involvement)

- immunosuppressants (long-term control)

- cyclophosphamide (refractory dz)

which SLE antibody is most sensitive for SLE?

ANA

which SLE antibody is most specific for SLE?

anti-smith

paroxysmal digital ischemia, most commonly caused by an exaggerated response of digital arterioles to cold or emotional stress

Raynaud's phenomenon

what are the sxs/s of Raynaud's phenomenon?

treatment?

pallor, bluish discoloration of fingers, toes (pulses intact), pain, bilateral

CCB (1st-line)

avoid cold exposure

a rare chronic disorder characterized by diffuse fibrosis of the skin and internal organs

systemic sclerosis (scleroderma)

skin thickening confined to the face, neck, and distal extremities (a type of systemic sclerosis)

limited disease (CREST syndrome)

widespread thickening of skin with area of increased pigmentation and depigmentation (a type of systemic sclerosis)

diffuse disease

what are the sxs/s of limited systemic sclerosis?

diffuse?

Raynaud's initially, then 1 or more CREST features (calcinosis, raynauds, esophogeal dysmotility, sclerodactyly, telangiectasias)

polyarthralgia, weight loss, malaise, skin changes of trunk + proximal ext, non-pitting edema

what positive serology can you see with diffuse systemic sclerosis?

limited?

ANA, anti-SCL-70

ANA, anti-SCL-70, anti-centromere

T or F:

there is no effective treatment for the underlying disease process of systemic sclerosis

T

(treatment focuses on the organ systems involved)

what is the treatment for systemic sclerosis?

(skin, renal, GI, lung, pulmonary HTN, refractory diffuse systemic)

MTX or mycophenolate

ACEI

PPI

mycophenolate or cyclophosphamide

CCB or PDE5 inhibitors

myeloablation then stem cells OR immunosuppression w/ cyclophosphamide

(refer all to rheumatology)

systemic autoimmune disorder due to the immunedysfunction of the lacrimal and salivary glands

Sjogren syndrome

what are the sxs/s of Sjogren syndrome?

dry eyes and mouth

systemic: dysphagia, vasculitis, pleuritis, ILD, neuropathies, pancreatitis, kidney dysfunction

what positive serology tests can you see with Sjogren syndrome?

what other diagnostics can be done?

ANA, RF, anti-SS-A, anti-SS-B

Schirmer test, biopsy

what is the treatment of Sjogren syndrome?

artificial tears, lacrimal plugs, cyclosporine drops, pilocarpine PO

keep mouth moist (sip water, gum/candy)

syndrome of pain and stiffness involving the proximal muscles mainly, neck, shoulders, and hips

polymyalgia rheumatica (PMR)

what are the sxs/s of polymyalgia rheumatica (PMR)?

symmetrical muscle pain/stiffness in shoulder and hips with abrupt onset

nocturnal pain, AM stiffness

fever

what is the diagnostic test for polymyalgia rheumatica (PMR)?

elevated ESR and CRP

what is the treatment for polymyalgia rheumatica (PMR)?

prednisone 10-20 mg x 2-4 weeks, then taper

*patient should improve remarkably in 3 days

(sarilumab if refractory)

systemic panarteritis affecting medium and large sized vessels; often coexists with PMR

giant cell arteritis

what are the sxs/s of giant cell arteritis?

HA, scalp tenderness, visual (amaurosis fugax or diplopia), jaw claudication

what diagnostics can help in the diagnosis of giant cell arteritis?

elevated ESR and CRP, definitive: temporal artery biopsy, imaging

what is the treatment for giant cell arteritis?

ASAP high dose prednisone (40-60 mg) x 1 month then taper

necrotizing arteritis of medium vessels with predilection fro skin, peripheral nerves, renal arteries, heart, and brain (NOT the lungs)

polyarteritis nodosa (PAN)

what are the sxs/s of polyarteritis nodosa (PAN)?

fever, malaise, weight loss, pain in extremities (joints, muscles), skin findings (livedo reticularis, subQ nodules, ulcers), digital gangrene, HTN

what tests can help in the diagnosis of polyarteritis nodosa (PAN)?

labs: anemia, leukocytosis, elevated ESR and CRP

diagnose via biopsy or vascular imaging

what is the treatment for polyarteritis nodosa (PAN)?

methylprednisolone 1 gm IV x 3 days

cyclophoshamide followed by MTX

treat Hep B

an inflammatory myopathy characterized by chronic inflammation of skeletal muscle

polymyositis

what are the sxs/s of polymyositis?

painless, proximal muscle weakness (shoulder and hips), gottron papules, heliotrope eyes

+- rash (shawl sign) -> dermatomyositis

fatigue, fever, weight loss

what tests (and results) can be ordered for polymyositis?

elevated muscle enzymes (CK, aldolase, LDH)

muscle/skin biopsy

what is the treatment for polymyositis?

steroids, MTX, TNF-a inhibitors

arthritis without rheumatoid factor with strong association with HLAB27

seronegative spondyloarthropathies

• Ankylosing spondylitis

• Reactive arthritis

• Psoriatic arthritis

• IBD related arthritis

joint inflammation often triggered by an infection somewhere else (GU or GI; chlamydia, salmonella, parvovirus B19)

reactive arthritis

what are the sxs/s of reactive arthritis?

conjunctivitis/uveitis, urethritis/cervicitis, arthritis (knee or ankle)

keratoderma blennarrhagica

what tests should be ordered for reactive arthritis?

NAAT, HLA-B27, joint aspiration (would be sterile)

what is the treatment for reactive arthritis?

NSAID and treat underlying infection

what are the sxs/s of psoriatic arthritis?

preceding psoriasis (silver scales, nail pitting)

asymmetric arthritis, sausage finger and toe appearance (dactylitis)

what are the XR findings for psoriatic arthritis?

osteolysis, pencil-in-cup deformity, sacroilitis, relative lack of osteoporosis

(none sensitive or specific)

what are the treatment options for psoriatic arthritis?

TNF inhibitors, IL-23 inhibitors, PDE-4 inhibitors, MTX

a chronic disease of pain processing characterized by widespread MSK pain, fatigue, and painful localized soft tissue areas

fibromyalgia

what are the sxs/s of fibromyalgia?

widespread chronic pain, severe fatigue, sleep dysfunction, cognitive impairment, depression/anxiety, HA

tense, ropy muscles

no swelling, rash, deformity, mass

fibromyalgia diagnosis

painful tender points (need 11 of 18 for diagnosis; present for >3 months)

*diagnosis of exclusion

what are the treatment options for fibromyalgia?

non-pharmalogical and pharmacological (lyrica, cymbalta, savella)

loss of bone mineralization, reducing bone integrity and strength, increasing risk of fracture

osteoporosis

what pt population most often gets osteoporosis?

white women

what are the sxs/s of osteoporosis?

asx until fracture

can have height loss

what are some possible causes of osteoporosis?

aging, small body size, alcoholism, cigarette smoking, white ethnicity, female gender, genetics, hormone deficiency (estrogen), carbonated beverages, immobilization, long-term med use (steroids, PPIs, SSRIs)

what medications can cause osteoporosis?

corticosteroids, heparin, PPIs, SSRis, SGLT2-i, GnRH

what is the best test for osteoporosis diagnosis?

DEXA scan hip and spine (T-score of less than -2.5 S.D.)

normal DEXA t score

-1 and higher

osteopenia DEXA t score

-2.5 to -1

what is the treatment for osteoporosis?

weight bearing exercise, smoking/alcohol cessation, calcium + vit D

bisphosphonate

when do you treat osteopenia (pharmacologically?

if they get a fracture / have high FRAX score

Risk assessment tool that calculates a patients 10-year risk of developing an osteoporosis related fracture

FRAX score

what is the screening recommendation for osteoporosis?

women 65 year or older

(or younger women with more than 1 risk factor)

infection and inflammation of the bone and bone marrow

(acute or chronic)

osteomyelitis

what are the 3 mechanisms of infection for osteomyelitis?

bloodstream, local infection (cellulitis goes deep), penetrating trauma (or surgery)

what are some risk factors for osteomyelitis?

DM, sickle cell, HIV/AIDS, RA, IV drug use, alcoholism, long term steroid use, recent penetrating trauma

what is the treatment for osteomyelitis?

surgical debridement and IV abx for weeks

osteomyelitis diagnosis

XR -> bony erosions

osteomyelitis symptoms

localized bone pain, swelling, redness, and warmth at the infection site, often accompanied by fever, chills, and fatigue

*usually a cellulitis that has existed for weeks