RHEUMATOLOGY

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RHEUMATOLOGY

• B. WAYNE BLOUNT, MD, MPH
• PROFESSOR, EMORY UNIVERSITY S.O.M.

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QUESTION 1 28
YO HISP F C/O 8 MO HX OF PAINFUL, SWOLLEN JOINTS

• AM STIFFNESS SEVERAL JOINTS IN HANDS ARM
  INVOLVED, BILATERALLY FATIGUE NO WGT LOSS,
  FEVER
• P.E. WNL EXCEPT JOINTS SWOLLEN, TENDER LEFT
  WRIST, 3 MCPs 2 PIPs
• TENDER RIGHT WRIST, LEFT ANKLE OTHER MCPs

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QUESTION 1

• WHAT TYPE OF ARTHRITIS DOES SHE HAVE ?
• A. MONOARTICULAR
• B. CRYSTAL INDUCED
• C. SYMMETRIC POLYARTICULAR
• D. ASYMMETRIC POLYARTICULAR

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AN APPROACH TO RHEUMATOID ARTICULAR DISEASE

• LOOK FOR THE PATTERN
• MONOARTICULAR
• SYMMETRIC POLYARTICULAR
• ASYMMETRIC POLYARTICULAR

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MONOARTICULAR

• SEPTIC
• GOUT
• CPPD
• TUMOR
• TRAUMA
• VIRAL

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SYMMETRIC POLYARTHRITIS

• R.A. GOUT
• SLE CPPD
• PSORIATIC HEPATITIC
• OSTEOARTHRITIS
• SCLERODERMA
• LYME
• RHEUMATIC FEVER

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ASYMMETRIC POLYARTHRITIS

• HLA B-27 DZ PSORIATIC, ANKYLOSING SPONDYLITIS,
  REACTIVE ARTH., IBD
• GOUT
• CPPD
• LYME
• VIRAL

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CONTD APPROACH

• PATTERN DX POSSIBILITIES
• P.E.
• LAB TESTING
• THERAPY

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THE PHYSICAL EXAM

• LOOK FOR EXTRA-ARTICULAR MANIFESTATIONS
• RASH NODULES
• EYES HAIR
• ENT GI
• NAILS GU
• CV NEURO

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QUESTION 2 WHICH
OF THE FOLLOWING FINDINGS IS MOST SPECIFICALLY
DIAGNOSTIC OF CLASSIC R.A.

• A. HIGH ESR
• B. POSITIVE ANA
• C. RHEUMATOID JOINT EROSIONS
• D. RHEUMATOID FACTOR

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ANSWER

• C RHEUMATOID JOINT EROSIONS
• ALL OF THE OTHERS ARE ASSOCIATED WITH R.A., BUT
  ONLY JOINT EROSIONS ARE SEEN ONLY IN CLASSIC R.A.

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OTHER TEST CONSIDERATIONS

• ANA
• ESR
• RHEUMATOID FACTOR
• CBC
• HLA B-27
• UA
• JOINT ASPIRATION

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RHEUMATOID FACTOR

• LACKS BOTH SENS SPEC.
• USEFUL IN RA FOR SEVERITY EXTRA SX, BUT NOT
  FOLLOWING DZ
• TESTING APPROPRIATE WHEN SUSPECT
• R.A. 50-90
• SJOGRENS 75-95
• CRYGLOBULINEMIA 40-100
• MCTD 50-60
• DOESNT RULE OUT CAN SUPPORT DX

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QUESTION 3

• TO DIAGNOSE RHEUMATOID ARTHRITIS, A POSITIVE ANA
  IS HELPFUL.
• A. TRUE
• B. FALSE

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ANA

• REPORTED AS TITERS gt 1320 MORE LIKELY TO BE
  TRUE DZ
• TITERS OF lt 140 UNLIKELY TO HAVE A RHEUMATOLOGIC
  DZ
• ANA PATTERN IS MORE SPECIFIC FOR DZ
• BEST FOR SLE, DRUG-INDUCED LUPUS, SJOGRENS,
  SCLERODERMA MCTD

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CHROMATIN ANTIBODIES

• ANTI-dsDNA RULE IN SLE
• ANTI-HISTONE RULE OUT DRUG-INDUCED LUPUS
• ANTI-SMITH R/I SLE
• ANTI-RO ASSOC. WITH SJOGRENS
• ANTI-CENTROMERE ASSOC. WITH SCLERODERMA
• cANCA SENS SPEC FOR WEGENERS

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HLA B-27

• ASSOC. WITH SPONDYLOARTHROPATHIES
• A.S. 95 SENS
• REITERS 80 SENS
• PSORIATIC 70 SENS
• IBD 50 SENS
• TESTING RARELY USEFUL. ONLY WHEN ABOVE ARE
  SUSPECTED.

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ESR

• LOW SPECIFICITY
• CORRELATES WITH CLINICAL ACTIVITY IN R.A.
• BEST WHEN USED FOR
• PMR SENS 80
• TA SENS 95
• USUALLY QUITE HIGH VS. ELEVATED (NOT 20-50)

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USE OF RHEUM BLOOD TESTS

• SELECTIVE ORDERING
• INTERPRETED CAUTIOUSLY
• INTERPRET WITHIN INDIVIDUAL PATIENTS CLINICAL
  SITUATION
• MOST HELPFUL TO CONFIRM YOUR CLINICAL DIAGNOSIS
• ORDERING PANELS IS DISCOURAGED

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Question 4

• To diagnose R.A., one needs which of the
  following
• A. 3/6 criteria fulfilled
• B. 4/6 criteria fulfilled
• C. 4/7 criteria fulfilled
• D. 5/7 criteria fulfilled
• E. 5/8 criteria fulfilled

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DIAGNOSIS OF R.A.

• gt 4 OF 7 CRITERIA
• AM STIFFNESS gt 1 HR
• gt 3 SWOLLEN JOINTS
• SWELLING IN HAND JOINTS
• SYMMETRIC JOINT INVOLVEMENT
• EROSIONS ON X-RAY
• RHEUM NODULES
• ABN R.F.
• MUST BE PRESENT AT LEAST 6 WEEKS

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What About anti-CCP

• Good Question !
• Anti-cyclic citrullinated peptide antibodies
• New!
• As sensitive more specific than RF
• Appears earlier in disease
• A marker for more severe disease
• Not part of criteria, yet.
• Wont be on the boards this year.
• Good clinical test when you arent certain

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Question 5

• To diagnose S.L.E., one needs the following of
  criteria fulfilled
• A. 4/7
• B. 5/7
• C. 3/9
• D. 3/11
• E. 4/11

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DIAGNOSIS OF SLE

• MALAR RASH DISCOID RASH
• PHOTOSENSITIVITY ORAL ULCERS
• ARTHRITIS SEROSITIS
• RENAL DZ NEURO DZ
• HEME DISORDER ANA ABN
• IMMUNLOGIC DISORDER (ANTIBODY)
• 3/11 PROBABLE 4/11 DEFINITE

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Question 6

• In treating R.A., DMARDs should be started when?
• A. As soon as the diagnosis is made
• B. After 3 months of therapy with NSAIDs
• C. Only after NSAIDs have failed
• D. Only by a rheumatologist

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TREATMENT OF R.A.

• DMARDs SHOULD BE STARTED AS EARLY AS POSSIBLE TO
  DELAY DZ PROGRESSION (A REC)
• USE NSAIDS IN LOWEST DOSE FOR RELIEF CUT BACK
  WHEN DMARDs WORK (A REC)
• CORTICOSTEROIDS ARE EFFECTIVE BUT HAVE HIGH
  TOXICITY. USE LOWEST DOSE POSSIBLE FOR SHORTEST
  TIME (A REC)
• COMBO RX MORE EFFECTIVE THAN MONOTHERAPY (A
  REC) But do not combine biologic agents combine
  with MTX

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DMARDs

• DISEASE-MODIFYING ANTIRHEUMATIC DRUG
• ADALIMUMAB
• ANAKINRA
• AURANOFIN
• AZATHIOPRINE
• CYCLOSPORINE
• D-PENICILLAMINE
• GOLD
• ABATACEPT
• USE WITH CONTRACEPTION
• TNF inhibitors 2-fold increase in skin cancer
• Biologics are TNFI, T-cell I, B cell Modulators
  and Interleukin Modifiers

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DMARDs

• ETANERCEPT
• HYDROXYCHLOROQUINE
• SULFASALAZINE
• INFLIXIMAB
• LEFLUNOMIDE
• METHOTREXATE
• MINOCYCLINE
• STAPHYLOCOCCAL PROTEIN A
• Several more coming
• MOST COMMONLY USED

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Dont Forget About Associated Issues

• Insulin Resistance in both RA SLE
• 50 60 IN RA
• 30 in SLE
• Neuropsych issues in SLE
• Occur in 80 of all SLE patients
• Can occur early, in absence of systemic Dz
• HAs, Seizures, psychosis, cognitive dysfxn.
• Mortality is increased 2 3 X

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QUESTION 7
67 YO WF C/O 1 MO OF FATIGUE, WGT LOSS,
ACHING/STIFFNESS IN UPPER BACK SHOULDERS

• WHICH OF THE FOLLOWING IS THE NEXT MOST
  APPROPRIATE DIAGNOSTIC STUDY ?
• A. X-RAYS
• B. ESR
• C. FEBRILE AGGLUTINS
• D. ANA

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QUESTION 8
70 YO WF C/O FEVER, NECK, SHOULDER AND
UPPER ARMS ACHE HA EVOLVING OVER 5 WEEKSTHE
MOST IMPORTANT DX TEST IS

• A. EMG
• B. CPK
• C. MUSCLE BIOPSY
• D. TEMPORAL ARTERY BIOPSY

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POLYMYALGIA RHEUMATICA TEMPORAL ARTERITIS

• CLOSELY REALTED INFLAMMATORY CONDITIONS
• PMR MORE COMMON, TA MORE DANGEROUS
• BOTH HAVE HIGH ESRs
• BOTH OCCUR USUALLY IN AGE gt 50
• TA also called cranial arteritis Giant Cell
  Arteritis

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DX OF PMR

• CLINICAL SYNDROME OF
• FEVER
• NONSPECIFIC SOMATIC COMPLAINTS
• PAIN STIFFNESS IN SHOULDER /OR PELVIC GIRDLE
  (Proximal muscle groups)
• ELEVATED ESR

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Question 9

• In treating a patient for PMR, if the patient has
  not dramatically improved within 48 hrs., an
  alternative diagnosis should be entertained.
• A. True
• B. False

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TREATMENT OF PMR

• CORTICOSTEROIDS 5-20 MG/DAY.
• RESPONSE IS DRAMATIC WITHIN 48 HRS.
• AFTER SX RESOLUTION, TAPER BY 2.5 MG Q 2-4 WEEKS
  TO 10 MG/DAY
• THEN TAPER _at_1MG Q 2-4 WEEKS TO 5 MG/DAY
• THEN LENGTHEN TAPER OVER 18-24 MONTHS

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Question 10

• The most specific symptom of Giant Cell Arteritis
  is
• A. High ESR
• B. Temporal headache
• C. Jaw claudication
• D. Vision changes

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DX OF TEMPORAL ARTERITIS

• PRESENTS WITH MANY OF FINDINDS IN PMR
• HIGH ESR
• HA
• TENDER SCALP
• JAW CLAUDICATION
• VISION CHANGES
• ARTERIAL BIOPSY

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RX OF TEMPORAL ARTERITIS

• CORTICOSTEROIDS (QUICKLY)
• DONT WAIT FOR BX, BUT GET BX WITHIN 72 HRS. OR
  LOSE SENSITIVITY
• W/O VISUAL SX, 40-60 MG/DAY
• WITH VISUAL SX, 250 MG SOLU-MEDROL Q 6 HRS X 3-5
  DAYS, THEN SWITCH TO PO

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TA RX

• SX RESOLVE ESR NORMAL WITHIN 2-4 WEEKS
• THEN BEGIN TAPER lt 10 DAILY DOSAGE Q 2 WEEKS
• MONITOR FOR SX OR ESR INCREASE IF STOP TAPER
  AWAIT RESOLUTION, THEN RESTART TAPER
• FURTHER TAPER IS SAME AS FOR PMR

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TREATMENT OF PMR TA

• WATCH FOR OSTEOPOROSIS
• BISPHOSPHONATES ARE RECOMMENDED IN ELDERLY WOMEN
  ON STEROIDS

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SUMMARY

• DIAGNOSTIC APPROACH TO RHEUMATOLOGIC DZ
• REVIEW OF COMMON RHEUM BLOOD TESTS
• USE OF DMARDS
• REVIEW OF PMR TA
• SEE YOU _at_ THE Q A SESSION

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BIBLIOGRAPHY

• EPPERLY TD, MOORE KE, HARROVER JD. POLYMYALGIA
  RHEUMATICA AND TEMPORAL ARTERITIS. AFP 2000
  62789-96
• GILL JM, QUISEL AM, ROCCA PV, WALTERS DT.
  DIAGNOSIS OF SYSTEMIC LUPUS ERYTHEMATOSUS. AFP
  2003 682179-86.
• SIVA C, VELASQUEZ C, MODY A, BRASINGTON R.
  DIAGNOSING ACUTE MONOARTHRITIS IN ADULTS. AFP
  20036883-90.
• RICHIE AM, FRANCIS ML. DIAGNOSTIC APPROACH TO
  POLYARTICULAR JOINT PAIN. AFP 2003 681151-60.
• LANE SK, GRAVEL JW. CLINICAL UTILITY OF COMMON
  SERUM RHEUMATOLOGIC TESTS. AFP 2002651073-80.
• COCHRANE REVIEW
• Rindfleisch JA, Muller D. Diagnosis Management
  of Rheumatoid Arthritis. AFP 2005721037-47.

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ANSWERS

• 1. C
• 2. C
• 3. B
• 4. C
• 5. E
• 6. A
• 7. B
• 8. D
• 9. A
• 10. C