Rheumatology

Antibodies

• 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

• Px:
  • The knee and wrist are involved but not the toes
  • Slower onset
  • Not as severe pain
    
• Associated with other conditions:
  • Hemochromatosis
  • Hypothyroidism
  • Hyperparathyroidism
  • Hypomagnesemia
• Dx:
  
  • Initial- arthrocentesis
    
  • Most accurate: polarized light examination (positive birefringent rhomboid-shaped crystals)
    
• Tx:
  
  • Acute Flare: NSAIDs (1st line), colchicine (2nd line), steroids (if kidneys suck)
  • Chronic- allopurinol, probenecid
  • Prophylaxis- colchicine

• Px:
  • Due to an increase in bone turnover
• Complications:
  • Hearing loss
  • Cardiovascular disease (high output heart failure)
    
• Dx:
  
  • Elevated ALP, normal calcium
    
  • CT: thickened caladium w/an increase homogenous bone density
    
  • Radionuclide bone scan
    
• Tx:
  
  • Bisphosphonate
  • Calcitonin

• 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)

• Etiology:
  • MC causes are:
    • Hydrazine, procainamide, and isoniazid
      
    • Carbamazepine, Methyldopa
• Px:
  • Polyarthritis and rash
  • But no cerebritis/nephritis/serositis/anemia (spares the visceral organs)
• Dx:
  • Anti-histone Ab and positive ANA
    
  • Normal complement level and anti-DS DNA
    
  • Never gives renal or CNS involvement

• Px:
  • present in women >50, joint pain and morning stiffness lasting more than one hour ongoing for at least 6 weeks
  • Bouchard’s nodule – arthritic swelling of proximal interphalangeal joints, assoc. with OA and RA
• 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

• Px:
  • Group of inflammatory arthritic conditions:
    
    • – ankylosing spondylitis
      
    • – reactive arthritis
      
    • – psoriatic arthritis
      
    • – juvenile rheumatoid arthritis
      
  • Conditions have following in common:
    
    • -negative test for RF
      
    • -predilection for spine
      
    • -sacroiliac join involvement
      
    • -association with HLA-B27

• Px:
  • young male patient with spine or back stiffness, pain worse at night, relieved by leaning forward, can lead to kyphosis and diminished chest expansion
    
• Dx:
  
  • MRI (most sensitive for sacroiliac joint)
    
• Tx:
  
  • NSAIDs (steroids do not work)
    
  • Biological agents (etanercept, infliximab, adalimumab)
    
  • Associated with restrictive lung disease, MC manifestation outside of spine is uveitis

• Px:
  • presents with asymmetric arthritis with h/o urethritis or GI infection
    
• Dx:
  
  • no specific test
    
  • look for Knee, urinary, eye symptoms with h/o GI infection
    
• Tx:
  
  • NSAIDS
    
  • Intraarticular injection of steroids for refractory cases

• Px:
  • joint involvement with h/o psoriasis, nail pitting, DIP involvement, dactylitis
    
• Dx:
  
  • No specific test
    
• Tx:
  
  • initial – NSAIDs
    
  • Methotrexate for resistant disease

• Px:
  • MC joint abnormality, moving stiffness is <30 minutes, crepitus on moving joint, affects DIP
    
  • Heberden’s nodule – arthritic swelling of distal interphalangeal joints, assoc. with OA
  • Bouchard’s nodule – arthritic swelling of proximal interphalangeal joints, assoc. with OA and RA
• Dx:
  
  • initial – X-ray of the joint
    
  • no specific test
    
• Tx:
  
  • weight loss and exercise
    
  • acetaminophen (ibuprofen for long term)

• Px:
  • presents RA-like symptoms with small joint involvement and weakly positive RF test
    
  • is a self-limiting and short duration
    
  • RA would be symptoms for more than 6 weeks.

• Px:
  • swollen, red, immobile, tender joint
    
• Etiology:
  
  • staph aureus
    
  • strep
    
  • gram-negative bacilli
    
• Dx:
  
  • initial arthrocentesis (>50,000 WBC is consistent with infection)
    
  • most accurate: culture (never back in time to make decisions
    
• Tx:
  
  • Empiric therapy (ceftriaxone and vancomycin IV)

• Px:
  • tight skin + heartburn + Raynaud’s = scleroderma
    
• Dx:
  
  • no specific test
    
  • ANA, anti-topoisomerase (anti-Scl 70)
    
• Tx:
  
  • no specific treatment
    
  • treat symptoms
  • CCB (Raynauds)
  • PPI
  • penicillamine (skin changes)
  • ACEI (HTN, renal crisis)

• Px:
  • Calcinosis of the fingers
    
  • Raynaud’s
    
  • Esophageal dysmotility
    
  • Sclerodactyly
    
  • Telangiectasia
    
• Dx:
  
  • anti-centromere Ab (anti-Scl 70 less often present)
    
  • Isolated pulmonary HTN is more common here than with systemic sclerosis

• Px:
  • MC in women, muscle aches and stiffness with trigger points on palpation, psych problems common (depression and anxiety)
    
• Dx:
  
  • all blood test are normal
    
  • based off of clinical trigger points
    
• Tx:
  
  • exercise
    
  • initial: milnacipran, duloxetine, or pregabalin

• 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

• Px:
  • symmetric proximal muscle weakness, elevated muscle enzymes, highly characteristic skin lesions (Gottron’s papule, heliotrope rash, shawl sign)
    
• Dx:
  
  • elevated CPK and aldolase
    
  • abnormal EMG
    
  • Biopsy single most accurate
    
• Tx:
  
  • glucocorticoids
    
  • increase the risk of malignancy (greater than polymyositis)
    
  • The presence of anti-jo is associated with interstitial lung disease.

• Px:
  • proximal muscle weakness, signs of muscle inflammation on a blood test (elevated CPK and aldolase), abnormal EMG and biopsy (single most accurate)
    
• Tx:
  
  • glucocorticoids
    
  • increase the risk of malignancy
    
  • The presence of anti-jo is associated with interstitial lung disease.

• Px:
  • presents with pain in the large muscle of the shoulder and pelvic girdle
    
  • -symmetric proximal muscle pain and stiffness in shoulder, neck, and hip
• Dx:
  
  • clinical, ESR confirms (elevated)
    
  • normal CK
• Tx:
  
  • low dose prednisone follow by long taper
    
  • associated with giant cell arthritis

• Px:
  • presents with pain upon movement, weakness, and instability of shoulder
    
• Dx:
  
  • MRI (confirms)

• Px:
  • overuse injury in an active adolescent boy who has pain and swelling over the tibial tuberosity, worse with physical activity
    
• Dx:
  
  • clinical
    
• Tx:
  • Rest (physical restriction)
    
  • knee immobilization if needed
    
  • resolves completely in 12-24 months

• Px:
  • affect young boys, characterized by hip and knee pain, a limp and decrease range of motion, an idiopathic avascular necrosis of femoral head
    
• Dx:
  
  • frog leg, abdomen/pelvic X-ray – showing collapse, compression, or deformity of the femoral head

• Px:
  • seen mostly in pt age 9-13, MC IN AA boys that are obese, b/l involvement, complication -> AVN
    
• Dx:
  
  • Xray of the pelvis and b/l hips
    
• Tx:
  
  • Non weight bearing
    
  • Immediate fixation with a single screw