CAM III - Rheumatology pt. 1

Genetic predisposition for RA

HLA-DRB1

Pt has insidious onset of symmetrical peripheral joint pain, > 30 min of morning stiffness, fatigue, fever, subcutaneous nodules. Joints are soft, warm, tender. What is suspected

Rheumatoid arthritis

MC joints affected by RA

MCPs, MTPs, wrists, ankles

RA, splenomegaly, neutropenia

Felty syndrome

Most specific lab for RA

Anti-CCP antibodies

X-ray findings of rheumatoid arthritis

Bone erosion/displacement, joint space loss, ulnar deviation of MCPs, periarticular osteopenia

Initial RA treatment

Steroids (short term until other meds titrated)

NSAIDs

Heat therapy

Activity modification

DMARDs

First line RA treatment

Methotrexate max 20mg/week

How would you treat a patient with RA

Prednisone -> Methotrexate 7.5 mg-15mg PO once weekly

Methotrexate CI

Pregnancy/breastfeeding

Alcoholic liver disease

Untreated hepatitis

Blood dyscrasias

Second line (or adjunct) RA tx

Hydroxychloroquine

Sulfasalazine

Leflunomide

ADE to tx RA w biologics

Reactivation of latent TB and hepatitis

Increased infection risk

Increased malignancy risk

Monitoring for biologic tx in RA

PPD or T-SPOT and hepatitis panel before starting

Quant Gold annually

CBC, LFTs, BMP q8-12 weeks

PE q 12 weeks

12 year old girl with joint pain, swelling, and tenderness lasting > 6 weeks. Patient is complaining of limited ROM and parents are worried about her short stature.

Juvenile idopathic arthritis

JIA - pain, stiffness, swelling affecting 1-4 joints. Most commonly affecting large joints (knee or ankle)

Oligoarthritis

8 y/o w reoccurring fevers 103+, intermittent salmon colored rash, anemia, pain in hands, wrists, knees, ankles. On PE you find hepatosplenomegaly & lymphadenopathy

Systemic onset JIA

Pts w oligoarthritis are at a higher risk of what?

Uveitis or Iritis

Compare and contrast oligoarthritis vs polyarthritis

Oligoarthritis: < 5 joints, often affecting one side of body only, particularly in the knee.

Polyarthritis: > 5 joints, affects weight bearing and other joints including hips, neck, shoulders, jaw. Affects same joint on both sides of body

10 y/o girl presenting with joint pain, back pain and stiffness. You note no obvious swelling on initial exam but further evaluation reveals inflammation where tendons attach to bones.

Enthesitis related arthritis

First line therapy for JIA

NSAIDs

Treatment options for JIA

NSAIDs

Prednisone PO or intra-articular joint injection

MTX

Anakinra (biologic)

Pt complains of episodes of fevers + joint pain (fingers/knees) lasting for days, symptoms disappear spontaneously

Palindromic Rheumatism

What might make a pt with palindromic rheumatism more prone to developing RA

CCP antibodies

Standard of care during palindromic rheumatism attacks

NSAIDs

What can you use to prevent palindromic rheumatism attacks/progression

Hydroxychloroquine

32 y/o female presents with fluctuating daily fevers > 102+. Pt complains of a sore throat, salmon-colored rash on chest, wrist arthritis. On PE she has hepatosplenomegaly

Adult still disease

Adult still disease triad

Spiking fever, arthritis, evanescent rash.

Adult still disease workup

CBC: Anemia + leukocytosis

CMP: elevated LFTs

Ferritin: extremely high > 3000 mg/mL

CRP/ESR elevated

CXR to eval for pericardial effusion

(ANA, CCP, RF will be negative)

Adult still disease 1st line treatment

Prednisone

DMARDs if refractory: MTX, Anakinra, Tocilizumab

Yamaguchi's criteria

Criteria for Adult Still Disease: 5 or more, two or more criteria must be major

Major: fever > 39 C x 7days+, arthralgias x 14days+, typical rash, WBC > 10,000 w > 80% neutrophils

18 y/o male presents with persistent worsening low back pain, prolonged morning stiffness, anterior uveitis. List labs that would support your suspected diagnosis?

HLA-B27+

Elevated ESR/CRP

Negative RF

*ankylosing spondylitis

list the HLA-B27 diseases

PAIR:

Psoriasis/Psoriatic arthritis

Ankylosis spondylitis

IBD

Reactive arthritis (reiter's)

Ankylosing spondylitis PE

Decreased axial ROM (schober test)

Reduced chest expansion

Flattened lumbar lordosis, exaggerated thoracic kyphosis

Tests for ankylosing spondylitis

Schober's Test

Flesche test

Enthesitis with ankylosing spondylitis

Inflammation where tendon meets bone

- achilles tendon common

Ankylosing spondylitis X-ray findings

Bamboo spine

Early changes indicate sacroilitis (Ferguson's view)

Ossification of annulus fibrosis -> bridging syndesmophytes

Calcification of anterior longitudinal ligament

Ankylosing spondylitis treatment

Exercise

NSAIDs (naproxen, ibuprofen, meloxicam, diclofenac)

Methotrexate or sulfasalazine if NSAIDs dont work

Steroids short term for flare ups

Age group that psoriatic arthritis typically presents

30-50 y/o

M=F

Psoriatic Arthritis: DIP joints type

Monoarticular, asymmetric. Inflammation of nail beds -> pitting and onycholysis

Symmetric polyarthritis

Prominent MCP disease, may mimic RA

Arthritis Mutalins (psoriatic arthritis)

Severe deforming arthritis in which osteolysis is marked

Psoriatic spondylitis

Association w HLA-B27 (50%)

Atypical axial skeleton involvement

Sacroilitis

Lumbar spine MC

Pt w psoriasis is complaining of chronic or acute onset peripheral joint sx +/- LBP. What are some physical exam findings you'd expect to see to support the suspected dx

Nail involvement

Dactylitis (sausage digit)

Enthesopathy (achilles tendonitis, plantar fasciitis, medial epicondylitis)

15 y/o girl presents with joint pain and silvery scales on her flexor surfaces

Psoriasis related JIA

CASPAR criteria

Criteria for psoriatic arthritis

Psoriatic arthritis X-ray findings

pencil in cup deformity

Asymmetric sacroilitis

Atypical syndesmophytes

Psoriatic arthritis treatment

NSAIDs, steroid inj, MTX 7.5-20 mg/week

- NO hydrochloroquine

Pt complaining of asymmetric joint pain in large weight bearing joints following GI infection or STI. On exam you note anterior uveitis, conjunctivitis, urethritis, and mouth ulcers

Reactive arthritis (reiter's syndrome)

Reiter's syndrome labs

HLA-B27+ (50%)

ESR/CRP elevated

RF/CCP negative

Sterile joint fluid

Reactive arthritis treatment

Initial: Doxycycline 100 x 6 mo for chlamydia infection

NSAIDs

SSA BID, MTX q wk

pt with chron's presenting with asymmetric oligoarthritis

IBD-associated spondyloarthritis

IBD-associated spondyloarthritis treatment

TNF inhibitors, Jak inhibitors, Anti-IL 12/23 Ustekinumab

*AVOID NSAIDs, IL-17i (cosentyx, taltz)

Pt presenting with acute onset of severe monoarticular inflammatory arthritis affecting peripheral joints (small joints of feet/hands, ankles, knees, elbows)

Gout

Podagra

gout in the big toe (MTPJ) -> intense pain/redness/swelling

Tophus

Nodular deposit of monosodium urate monohydrate crystals

Secondary causes of gout

CKD, hypothyroidism, HCTZ, alcohol, red meat, shellfish

Uric acid level suspicious for gout

Uric acid > 8 mg/dL

Gout diagnosis

CBC: WBCs high ~40,000

Gram stain, culture synovial fluid

X-ray -> tophi or rat bite marginal joint erosions

Diagnostic for gout

Joint fluid analysis -> rod or needle-shaped, negatively birefringent urate crystals on polarized microscopy

First line tx for gout

NSAIDs (indomethacin)

Gout treatment

Indomethacin (NSAID) -> prednisone -> colchicine

*goal serum uric acid ~6 mg/dL

Tx for acute gout attack

Colchicine (give immediately when sx start)

Gout management between attacks

Colchicine + Allopurinol

Septic arthritis triad

Fever, pain, impaired ROM

Pt is > 60 y/o w crystal-induced arthritis caused by calcium pyrophosphate dihydrate

Pseudogout

Pseudogout triggers

Hyperparathyroidism

Hemochromatosis

Wilson's

Hypomagnesemia

Infections

Pseudogout MC affects what joints

Large joints (knees, wrists)

pseudogout x-ray findings:

chondrocalcinosis (crystals in fibrocartilage/hyaline cartilage)

Pseudogout diagnosis

Light microscopy: weakly positive birefringent calcium pyrophosphate crystals (rhomboid) in joint aspirates.

Pseudogout treatment

NSAIDs, colchicine