Rheumatology Board Review

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Rheumatology Board Review

• AM Report 6/19/09

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(No Transcript)
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Arthritis affecting DIP Joint

• Osteoarthritis (Heberdens nodes)
• Psoriatic arthritis

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Arthritis affecting PIPs

• OA (Bouchards nodes)
• RA
• SLE
• Scleroderma

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Arthritis affecting MCPs

• RA
• SLE
• Scleroderma
• Hemachromatosis

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Causes of Monoarticular Arthritis

• Trauma
• Infection
• Crystals
• AKA 3 Bs blood, bugs, birefringence
• Key to diagnosis arthrocentesis!!

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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 patients
management?

• Agt Right elbow joint aspiration
• Bgt Right olecrenon bursa aspiration
• Cgt Radiography of right elbow and forearm
• Dgt Erythrocyte sedimentation rate

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Bgt 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.

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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?

• Agt Rheumatoid arthritis
• Bgt Sarcoidosis
• Cgt Wegeners granulomatosis
• Dgt Psoriatic arthritis

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Dgt 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?

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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

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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?

• Agt polyarteritis nodosa
• Bgt Acute Hepatitis B infection
• Cgt Scleroderma
• Dgt Wegeners granulomatosis
• Egt Cryoglobulinemic vasculitis

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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?

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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

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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?

• Agt Discontinue captopril, start calcium channel
  blocker
• Bgt Continue to increase captopril dose
• Cgt perform plasmapheresis
• Dgt perform captopril renography

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Bgt 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

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Scleroderma

• Most frequent in ages 30-50, 31 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

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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

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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?

• Agt sacral fracture
• Bgt ankylosing spondylitis
• Cgt osteoarthritis
• Dgt metastatic cancer

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Ankylosing Spondylitis

• 91 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

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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 (Reiters)
• Psoriatic arthritis
• Enteropathic arthritis

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39 F presents with 2-month history of PIP and
wrist swelling, pain. Some AM stiffness. PE
mild symmetric synovitis of MCPs, wrists,
kneesLabsHgb 10.9 g/dLRheumatoid Factor
negativeANA negativeAnti-CCP PositiveWhat
is most likely diagnosis?

• AgtOsteoarthritis
• BgtPsoriatic arthritis
• CgtRheumatoid arthritis
• DgtCalcium Pyrophosphate Deposition Dz

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Cgt 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

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Diagnosis of RA Need 4 of 7

• Symptoms gt 6 weeks
• Morning stiffnessgt 1 hour
• 3 or more affected joints
• Joints include wrists, MCP, PIP
• rheumatoid nodules
• rheumatoid factor
• Radiographic changes

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75 F presents with fever, malaise, severe HA, jaw
pain when chewing. PE T 100.1. scalp
tendernessLabsESR 30Temporal artery biopsy
will be performed in four days. What is most
appropriate management until biopsy is performed?

• Agt Low molecular weight heparin
• Bgt Prednisone
• Cgt Methotrexate and prednisone
• Dgt Acetaminophen
• Egt No therapy until biopsy results available

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Bgt 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

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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?

• Agt Discontinue colchicine
• Bgt D/c colchicine, increase allopurinol to 400
  mg/d
• Cgt Increase allopurinol to 400 mg/d
• Dgt Obtain 24 hr urine urate excretion

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Cgt 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 gt6.8 mg/dL
• A follow-up urate level should be checked
• Cochicine should be continued because increasing
  allopurinol may trigger a gout attack

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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?

• Agt CPPD
• Bgt Osteoarthritis
• Cgt Anserine bursitis
• Dgt Gout
• Egt Gonococcal arthritis

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Agt 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!!

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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.LabsCBC normal.
Creatinine normal.ESR 24CK 4250 U/LANA
1160Diagnosis?

• Agt polymyalgia rheumatica
• Bgt SLE
• Cgt MCTD
• Dgt Polymyositis
• Egt Scleroderma

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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,
  Raynauds