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Rheumatology Board Review

Rheumatology Board Review. Arthritis affecting DIP Joint. Osteoarthritis (Heberden’s nodes) Psoriatic arthritis. Arthritis affecting PIPs. OA (Bouchard’s nodes) RA SLE Scleroderma. Arthritis affecting MCPs. RA SLE Scleroderma Hemachromatosis. Causes of Monoarticular Arthritis.

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Rheumatology Board Review

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  1. Rheumatology Board Review

  2. Arthritis affecting DIP Joint • Osteoarthritis (Heberden’s nodes) • Psoriatic arthritis

  3. Arthritis affecting PIPs • OA (Bouchard’s nodes) • RA • SLE • Scleroderma

  4. Arthritis affecting MCPs • RA • SLE • Scleroderma • Hemachromatosis

  5. Causes of Monoarticular Arthritis • Trauma • Infection • Crystals • AKA 3 Bs: blood, bugs, birefringence • Key to diagnosis: arthrocentesis!!

  6. 64 M with chronic gout presents with swollen right elbow of two days duration. No trauma. Last gout attack involved right knee 4 months ago. On exam, Temp 38.1. No LAD. Right elbow warm with minimal erythema. MSK exam reveals fullness and tenderness over right olecranon process. Which is most important next step in patient’s management? • A> Right elbow joint aspiration • B> Right olecrenon bursa aspiration • C> Radiography of right elbow and forearm • D> Erythrocyte sedimentation rate

  7. B> Immediate aspiration of olecranon bursa • Olecranon bursitis may be infectious, crystalline, or traumatic • Bursa aspiration is indicated for patients with acute olecranon bursitis to guide therapy • Trauma is the most common cause of olecranon bursitis, but other causes must be ruled out.

  8. 45 F has 6-month history joint pain and fatigue. First she developed pain, then swelling and redness of fifth right hand DIP, 4th DIP left hand, right wrist, third and fourth left toes. Which is most likely diagnosis? • A> Rheumatoid arthritis • B> Sarcoidosis • C> Wegener’s granulomatosis • D> Psoriatic arthritis

  9. D> Psoriatic Arthritis • Photo demonstrates dactylitis (sausage digit), which is common in psoriatic arthritis (also sometimes present in sarcoidosis) • PA is classically found in distal joints, in asymmetric pattern • 15% develop joint involvement before skin involvement • 20% are HLA-B27 positive • Bonus: What is treatment for PA?

  10. Treatment of psoriatic arthritis • Like RA, disease is T-cell mediated, so therapy is similar to RA • NSAIDS and low-dose prednisone • Methotrexate • TNF-alpha antagonists

  11. 67 M has three-month history of painful paresthesias on dorsum of right foot. He now stumbles because he is unable to fully raise foot. Also complains of fevers, night sweats, arthralgias, myalgias. On physical exam, he has livedo reticularis on LEs. On MSK exam, unable to dorsiflex right foot. Labs: Hgb 10.5 g/dLESR 98 mm/hANA negativeANCA negativeHBV Sag positiveHBV S Ab negativeHBV core Ab positiveHCV Ab negativeCryoglobulins negativeDiagnosis? • A> polyarteritis nodosa • B> Acute Hepatitis B infection • C> Scleroderma • D> Wegener’s granulomatosis • E> Cryoglobulinemic vasculitis

  12. Polyarteritis Nodosa • Necrotizing vasculitis of small and medium-sized arteries • Mononeuritis Multiplex- common presenting symptom, present in 60% • Associated with HBV • Other clinical signs: HTN, fever, MSK symptoms, involvement of GI, nervous system, heart, nonglomerular renal vessels • Other: how do you make diagnosis? • How to treat?

  13. PAN • Diagnosis: biopsy or arteriography if biopsy not possible. Arteriography usually done of visceral and renal vessels • Treatment: cyclophosphamide, prednisone, and antiviral tx of HBV or HIV

  14. 51 M with 4-year history of diffuse cutaneous sytemic sclerosois is hospitalized for new-onset HTN associated with anemia and thrombocytopenia. At time of admission, captopril 6.25 mg q8 hrs was initiated, which was titrated up to 25 mg q8. Three days later, BP down to 140/80 but Cr increased from 1.4 to 2.1 mg/dL. What is the most appropriate management? • A> Discontinue captopril, start calcium channel blocker • B> Continue to increase captopril dose • C> perform plasmapheresis • D> perform captopril renography

  15. B> continue to increase captopril dose • Pt has Scleroderma Renal Crisis • SRC is characterized by HTN, hemolytic anemia, thrombocytopenia, non-oliguric renal failure • ACE Inhibitors are the most effective for improving renal function in SRC • ACE-I should be continued even when creatinine levels continue to rise and patient requires hemodialysis

  16. Scleroderma • Most frequent in ages 30-50, 3:1 female • Diffuse vs limited (CREST) • In CREST, skin thickening found only distal to elbows and knees • Diagnosis is clinical, supported by positive ANA, Anti-Scl-70 abs, anti-centromere abs • Anti-inflammatory treatment not useful. Treat individual complications

  17. Scleroderma Pulmonary Disease • Primary cause of mortality • Interstitial lung disease and pulmonary artery HTN (PAH) • Tx for ILD: cyclophosphamide • Tx for PAH: warfarin, home O2, endothelin-receptor antagonist (bosentan) or prostacyclin analog

  18. 22 F evaluated for 12 month history of worsening low back stiffness which is present for two hours each AM. +fatigue. No fever, chills, weight loss, night sweats. One year ago, had uveitis of right eye.PE: mild forward bending of spine. L-spine and SI joints are tender. Decreased chest expansion.Labs: hgb 12.5 g/dL. ESR 85 mm/hr. Diagnosis? • A> sacral fracture • B> ankylosing spondylitis • C> osteoarthritis • D> metastatic cancer

  19. Ankylosing Spondylitis • 9:1 male predominance • Systemic: fatigue, weight loss, anemia, elevated ESR and CRP • Primarily affects spine and SI joints • Extraspinal: uveitis (40%), enthesitis/heel pain, hip or shoulder pain • Treatment: NSAIDS, anti-TNF

  20. Seronegative Spondyloarthropathies: group of sytemic inflammatory joint disorders that share clinical, radiologicial, genetic features. Strong correlation with HLA-B27 antigen. Commonly have back pain with morning stiffness and sacroiliitis • Ankylosing spondylitis • Reactive arthritis (Reiter’s) • Psoriatic arthritis • Enteropathic arthritis

  21. 39 F presents with 2-month history of PIP and wrist swelling, pain. Some AM stiffness. PE: mild symmetric synovitis of MCPs, wrists, kneesLabs:Hgb: 10.9 g/dLRheumatoid Factor: negativeANA : negativeAnti-CCP: PositiveWhat is most likely diagnosis? • A>Osteoarthritis • B>Psoriatic arthritis • C>Rheumatoid arthritis • D>Calcium Pyrophosphate Deposition Dz

  22. C> Rheumatoid Arthritis • RF is present in 85% of patients with RA, but only 33% are positive within first six months months of disease • Anti-CCP is 95% specific for RA

  23. Diagnosis of RA: Need 4 of 7 • Symptoms > 6 weeks • Morning stiffness> 1 hour • 3 or more affected joints • Joints include wrists, MCP, PIP • + rheumatoid nodules • +rheumatoid factor • Radiographic changes

  24. 75 F presents with fever, malaise, severe HA, jaw pain when chewing. PE: T 100.1. +scalp tendernessLabs:ESR 30Temporal artery biopsy will be performed in four days. What is most appropriate management until biopsy is performed? • A> Low molecular weight heparin • B> Prednisone • C> Methotrexate and prednisone • D> Acetaminophen • E> No therapy until biopsy results available

  25. B> prednisone • Pt likely has GCA (temporal arteritis), a vasculitis of branches or carotid artery • Immediate prednisone therapy is indicated for any pts with strong clinical suspicion • Diagnosis is by temporal artery biopsy • Prednisone therapy up to two weeks prior to biopsy will not affect biopsy results • MTX has no role in treatment of GCA • GCA has strong correlation with PMR

  26. 48 M evaluated for annual physical. He has history of HTN and tophaceous gout. Last gout attack was mild and happened six months ago. Meds: enalapril 20 qd, colchicine 0.6 mg qd, allopurinol 300 mg qdExam: non-tender olecranon nodules and slightly tender first MTPLabs: urate 7.2 mg /dLWhat is appropriate next step in management? • A> Discontinue colchicine • B> D/c colchicine, increase allopurinol to 400 mg/d • C> Increase allopurinol to 400 mg/d • D> Obtain 24 hr urine urate excretion

  27. C> Increase allopurinol dose to 400 mg/d • Goal of hypouricemic therapy is to reduce urate to 6 mg/dL • Urate will continue to deposit in tissues when serum urate >6.8 mg/dL • A follow-up urate level should be checked • Cochicine should be continued because increasing allopurinol may trigger a gout attack

  28. 62 M presents with right knee pain and swelling for three days. He has had recurrent episodes lasting several days for past five years. Exam: moderate synovitis and joint effusion.Diagnosis? • A> CPPD • B> Osteoarthritis • C> Anserine bursitis • D> Gout • E> Gonococcal arthritis

  29. A> CPPD • Chondrocalcinosis: calcification of cartilage, here in knee meniscus, pathognomic for CPPD • Diagnosis of CPPD: calcium pyrophosphate crystals on fluid analysis (weakly birefringent) • CPPD may occur with normal serum calcium levels • Treatment: prednisone, colchicine • Remember: acute monoarticular arthritis requires arthrocentesis!!

  30. 32 F presents with 5 months of pain and swelling in hands, progressive weakness. Difficult to get in bathtub, hold hairdryer, walk up stairs due to weakness. PE: puffy hands with scaly, darkened fingers. Bibasilar crackles. Proximal weakness upper and lower extremities.Labs:CBC normal. Creatinine normal.ESR 24CK 4250 U/LANA 1:160Diagnosis? • A> polymyalgia rheumatica • B> SLE • C> MCTD • D> Polymyositis • E> Scleroderma

  31. Polymyositis • Proximal muscle weakness without pain (contrast to PMR) • Diagnosis: elevated CK, ANA (80%), EMG, Muscle biopsy • Anti-Jo-1 Abs: found in variant of polymyositis with ILD, mechanics’ hands, polyarthritis, Raynaud’s

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