James Heilman, MD, CC BY-SA 3.0, via Wikimedia Commons
  • Px:
    • Sudden onset of severe pain in the toe at night
    • Precipitated by:
      • Binge drinking alcohol
      • Thiazides
      • Nicotinic acid
  • Dx:
    • Initial- arthrocentesis
    • Most accurate – polarized light examination (negative birefringent needles)
  • Acute Tx:
    • Acute Flare: NSAIDs (1st line), colchicine (2nd line), steroids (if kidneys suck)
    • Colchicine alternative for when pt has contraindications for NSAIDs (not in RF as well) and pt doesn’t have renal disease
    • Corticosteroids: when pt has RF, injected locally for mono-articular or give orally for multiple joints
  • Maintenance (Chronic) tx:
    • Allopurinol (Febuxostat is an alt), probenecid
    • Decrease alcohol and protein in the diet

Calcium Pyrophosphate Deposition Disease (Pseudogout)

Paget disease of bone

Systemic Lupus Erythematosus (SLE)

Symptoms of SLE
By Mikael Häggström, used with permission., Public domain, via Wikimedia Commons
  • Px:
    • Affects multiple organ systems, rash + joint pain + fatigue = lupus
    • Malar rash, discoid rash, serositis (pleuritis, pericarditis), oral ulcers, photosensitivity, anemia, thrombocytopenia, leukopenia, renal failure, psychosis, seizure, alopecia, endocarditis (Libmans), arthritis
  • Dx:
    • Initial ANA
    • Most accurate: anti-DS DNA or anti-Sm
    • CCS: complement levels, anti-Sm, and anti-DS DNA should be performed in all patients
  • Tx:
    • NSAIDs and Hydroxychloroquine initially
    • Acute flares: steroids( Prednisone), immunosuppressants for refractory cases
    • Pregnant women have a risk of their infant getting a fatal congenital heart block.
    • IV cyclophosphamide then oral mycophenolate (lupus nephritis or cerebritis)

Drug-induced lupus


Rheumatoid Arthritis-pannus formation, joint destruction and erosion
-hands/feet, 3+ joints involved, symmetric, spares DIPs; cervical spine
-morning stiffness >60 mins
-x-ray- erosions, periarticular osteopenia
-NSAIDs (symptoms) + DMARDs (everybody)
+/- biologics (TNFa inhibitors) (severe)

-steroids for flares
-DMARDs- methotrexate (preferred)
-leflunomide (2nd line)
-hydroxychloroquine (pregnancy)
Felty’s SyndromeRA + neutropenia + splenomegaly
Psoriatic Arthritis-nail pitting, psoriasis, arthritis (hands, symmetric, PIP and DIP)NSAIDs, DMARDs, anti-TNF
Reactive Arthritis-urethritis + arthritis (asymmetric bilateral lower back, hands) + conjunctivitisarthrocentesis negative, find infectionantibiotics if find infection, if not then NSAIDs and time
IBD-Related Arthritis-symmetric bilateral peripheral (fingers) and migratory arthritis, also involve lower backtreat IBD–>arthritis improves

Rheumatoid Arthritis

  • Px:
  • Dx:
    • Positive RF or anti-CCP (single most accurate test)
  • Tx:
    • 1st methotrexate (DMARD) combined with NSAIDs
    • anti-TNF inhibitors for refractory cases (check PPD prior to starting)
    • Acute flare – short course of prednisone
    • MC extra-articular manifestation is skin nodules.
    • Presents with normochromic, normocytic anemia of chronic disease

Osmosis / CC BY-SA

Seronegative Spondyloarthropathies

Ankylosing spondylitis

Reactive arthritis

Psoriatic arthritis

Osteoarthritis (OA)

Viral arthritis

Septic arthritis

Gonorrhea Septic Joint-hematogeneous
-migratory polyarthralgias, tenosynovitis, pustules
gram stain likely negative (gram negative cocci in chains), so NAATceftriaxone 1-2 weeks + azithromycin (or doxycycline)
Staph Septic Joint1) Direct inoculation/trauma
2) Hematogenous spread via IVDU/endocarditis
gram stain (gram + cocci in clusters)nafcillin (MSSA), vancomycin (MRSA)

Scleroderma (Systemic sclerosis)

“CREST” Syndrome (limited Scleroderma)



  • Px:
    • a chronic autoimmune inflammatory condition primarily affects the lacrimal and salivary glands
    • -lymphoplasmacytic infiltration of exocrine glands
    • -dry eyes, dry mouth, parotid swelling
    • tight skin + heartburn + Raynaud’s = scleroderma
  • Dx:
    • ANA (90-95%, not specific)
    • Anti-RO/SSA and Anti-La/SSB (50-65%)
    • most accurate test salivary gland biopsy
    • -Schirmer test (tear production test)
    • – increase risk of B cell lymphoma secondary to activation of B lymphocytes
  • Tx:
    • Keep eyes and mouth moist
    • Pilocarpine and cevimeline to increase secretions



Polymyalgia Rheumatica

Rotator Cuff Injury


Osgood-Schlatter Disease

Legg-Calve-Perthes Disease

Slipped capital femoral epiphysis


  • Häggström, Mikael (2014). “Medical gallery of Mikael Häggström 2014″. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.008. ISSN 2002-4436. Public Domain. or By Mikael Häggström, used with permission., Public domain, via Wikimedia Commons”