Rheumatology
Board Review
Part 1
“Just the Pearls Please”
Gerald Falasca, M.D.
Medical Specialists of Johnson City
April, 2015
Disclosure Statement of Financial
Interest
I, Gerald Falasca,
DO NOT have a financial
interest/arrangement or affiliation
with one or more organizations
that could be perceived as a real or
apparent conflict of interest in the
context of the subject of this
presentation.
Disclosure Statement of
Unapproved/Investigative Use
I, Gerald Falasca,
DO NOT anticipate discussing
the unapproved/investigative
use of a commercial
product/device during this
presentation.
Rheumatoid Arthritis
•
Which patient is most likely to have
rheumatoid arthritis?
A.
35 year old female with pain and swelling of wrists &
MCPs, two hours of morning stiffness, carpal tunnel
syndrome, and negative rheumatoid factor (RF).
B.
30 year old male with pain and swelling of wrists,
MCPs, and knees, one hour of morning stiffness,
diffuse rash in the afternoon, pharyngitis,
leukocytosis, negative rheumatoid factor (RF).
C.
20 year old male with chronic low back pain, swollen
left knee, chronic uveitis, negative RF.
Rheumatoid Arthritis
•
Which patient is most likely to have
rheumatoid arthritis?
A.
35 year old female with pain and swelling of wrists &
MCPs, two hours of morning stiffness, carpal tunnel
syndrome, and negative rheumatoid factor (RF).
B.
30 year old male with pain and swelling of wrists,
MCPs, and knees, one hour of morning stiffness,
diffuse rash in the afternoon, pharyngitis,
leukocytosis, negative rheumatoid factor (RF).
C.
20 year old male with chronic low back pain, swollen
left knee, chronic uveitis, negative RF.
Rheumatoid Arthritis
•
•
•
•
•
•
Symmetric, small joint polyarthritis
Morning stiffness >1 hour
Hand and wrist involvement
Fatigue
Greater than six weeks
Radiographs: Erosions, periarticular
osteopenia, joint space narrowing
Early Signs of Aggressive RA
•
•
•
•
•
•
•
>20 joints involved
High titer RF or anti-CCP
Anemia; smoking
High sed rate or CRP
Early erosions
Extra-articular features
High multi-biomarker disease
activity score*
*Ann Rheum Dis. 2014 May 8. Hambardzumyan K et al. doi:
10.1136/annrheumdis-2013-204986. [Epub ahead of print]
• Which genetic marker is most
strongly associated with seropositive
(RF positive), aggressive rheumatoid
arthritis in Caucasians?
• HLA-B27
• HLA-DR4
• PTPN22 (protein tyrosine phosphatase N22)
• Which genetic marker is most
strongly associated with seropositive
(RF positive), aggressive rheumatoid
arthritis in Caucasians?
• HLA-B27
• HLA-DR4
• PTPN22 (protein tyrosine phosphatase N22)
•
A.
B.
C.
D.
E.
Which of the following treatments for
rheumatoid arthritis could be used
during pregnancy if necessary (may
choose more than one)?
Prednisone
Etanercept
Methotrexate
Leflunomide
Hydroxychloroquine
•
A.
B.
C.
D.
E.
Which of the following treatments for
rheumatoid arthritis could be used
during pregnancy if necessary (may
choose more than one)?
Prednisone
Etanercept
Methotrexate
Leflunomide
Hydroxychloroquine
•
How would you treat this patient (she
had hysterectomy)? 35 year old female
with pain and swelling of wrists & MCPs,
two hours of morning stiffness, carpal
tunnel syndrome, and negative
rheumatoid factor (RF):
A.
B.
C.
D.
Methotrexate 15 mg once a week
Hydroxychloroquine 200 mg BID
Sulfasalazine 1000 mg BID
Etanercept 50 mg SC once a week
•
How would you treat this patient (she
had hysterectomy)? 35 year old female
with pain and swelling of wrists & MCPs,
two hours of morning stiffness, carpal
tunnel syndrome, and negative
rheumatoid factor (RF):
A.
B.
C.
D.
Methotrexate 15 mg once a week
Hydroxychloroquine 200 mg BID
Sulfasalazine 1000 mg BID
Etanercept 50 mg SC once a week
Swan neck deformities and MCP synovitis in
patient with RA/SLE overlap syndrome.
MTP erosions and joint space narrowing in RA.
Rheumatoid Arthritis
• 75-80% will have positive rheumatoid
factor.
• Anti-CCP is slightly less sensitive,
considerably more specific.
• CCP = cyclic citrullinated peptides
Management Tips
• Often improves during pregnancy.
• Neck pain or neurological symptoms
suggests need for C1-C2
flexion/extension views, espec preoperatively.
• Acceptable during pregnancy:
prednisone, hydroxychloroquine,
sulfasalazine, TNF inhibitors.
Rheumatoid Arthritis
• Flareup in a single joint?
– Always tap monoarthritis on the boards
(to rule out septic arthritis).
Sjogren syndrome
• Dry eyes (gritty sensation)
• Dry mouth
• Sometimes, parotid gland
enlargement.
• Gold standard: minor salivary gland
biopsy.
• Silver standard: salivary flow scan
Rheumatoid Lung & Heart
• Pleural effusions in RA are exudative
and have very low glucose ( < 20
mg/dl). If culture negative, treat with
steroids, not chest tube.
• Caplan’s syndrome (rheum nodules
in lung occurring in pt with RA and
pneumoconiosis). Usually need bx.
• Pericarditis/pleuritis
Caplan’s Synd.
Felty’s Syndrome
• RA plus neutropenia plus
splenomegaly +/- infections +/- leg
ulcers.
• Treat infections; sometimes use
GCSF
Rheumatoid Treatment
• NSAIDs do not slow progression of
disease; only the DMARDs do that.
• Treatment for the non-pregnant patient
begins with methotrexate.
• May add low-dose prednisone early on.
• If inadequate response, or if erosions/joint
damage progress, add a TNF inhibitor
usually.
Extensor tendon rupture from RA;
(Can’t extend 4th, 5th fingers)
•
A 55 year old male with a 10 year history of
rheumatoid arthritis presents with a one week
history of right swollen and moderately painful
calf as shown. No pulmonary symptoms. You
send patient for lower extremity ultrasound for
DVT which is negative. Most likely diagnosis is:
A.
B.
C.
D.
DVT missed by ultrasound
Lymphedema
Uncontrolled rheumatoid synovitis of knee
Bakers cyst
•
A 55 year old male with a 10 year history of
rheumatoid arthritis presents with a one week
history of right swollen and moderately painful
calf as shown. No pulmonary symptoms. You
send patient for lower extremity ultrasound for
DVT which is negative. Most likely diagnosis is:
A.
B.
C.
D.
DVT missed by ultrasound
Lymphedema
Uncontrolled rheumatoid synovitis of knee
Bakers cyst
Baker’s cyst in calf
Sjogren’s Syndrome
• Symptoms: dry eyes (presents as gritty
sensation) and dry mouth, sometimes parotid
gland enlargement
• Two kinds: secondary (associated with another
connective tissue disease, most commonly
rheumatoid arthritis) and primary Sjogren's.
• Hepatitis C can mimic Sjogren's, including
histology. Suspect it when there are liver
abnormalities and/or cryoglobulinemia.
• HIV infection can also mimic Sjogren's, complete
with lymphocytic infiltrates.
Sjogren’s Syndrome
• Other causes of parotid gland
enlargement are diabetes, sarcoid,
ethanol abuse, amyloid, lymphoma.
• Most common causes of dry
eyes/mouth are "senile atrophy" and
medications.
Sjogren’s Syndrome
• 20-30% of secondary and 70% of primary
forms will have +SSA antibodies. HIV type
does not have SSA.
• Important association of SSA antibodies
on the boards is with congenital heart
block in babies whose mothers (many of
whom have lupus) carry SSA. Risk is 2%
of CHB if mom carries SSA. Risk in
recurrent pregnancies is 15%.
Sjogren’s Syndrome
• Primary SS is a systemic connective
tissue disease similar to lupus. May
have fever, diffuse adenopathy,
peripheral neuropathy, pulmonary
symptoms, CNS symptoms,
polyclonal gammopathy, leukopenia,
pancreatic dysfunction, renal
abnormalities.
Sjogren’s Syndrome
• Definitive diagnosis is by minor salivary gland
biopsy (shows clumps of lymphocytes). In the 1°
and 2° forms the infiltrating cells are mostly CD4.
In the HIV type the cells are CD8, since HIV
patients are out of CD4 cells.
• A screening test for dry eyes is the Schirmer test;
it does not diagnose Sjogren's.
• Another useful approach is the Sjogren scan
(salivary flow scan)
• Treatment is symptomatic, also
hydroxychloroquine.
Still’s Disease
• Fever
• Evanescent, salmon colored, MP
rash, especially late afternoon
• Leukocytosis
• Elevated ferritin (in the 1000’s)
• Polyarthritis
Lupus
•
•
•
11 criteria (malar rash, discoid lesions, photosensitivity,
oral ulcers (hard palate usually), arthritis, serositis, renal
disorder (proteinuria or casts), neurological disorder
(seizure or psychosis), hematologic disorder (hemolytic
anemia (not any old anemia), leukopenia or
thrombocytopenia), immunologic disorder (anti-DNA, antiSmith, false positive RPR, positive LE prep), positive ANA) .
Diagnosis should include 4 or more criteria.
Note that alopecia, while common in lupus, is not an official
criterion for diagnosis.
Anti-cardiolipin antibody or a lupus anticoagulant is as
good as a false positive RPR).
Lupus
• ANA (on the boards) will almost
always be positive, moderate or high
titer (>1:320), usually homogenous or
rim (peripheral) pattern.
• The combination (on the boards) of
low C3, low C4, +ANA, +DNA is
highly suggestive of dx of SLE.
Lupus Nephritis
Which patient does not need kidney biopsy right
now?
•
20 y.o. female with polyarthritis, malar rash,
photosensitivity, +anti-DNA, +SSA, trace
proteinuria, trace hematuria, low C3, low C4.
•
20 y.o female with polyarthritis, malar rash,
+anti-DNA, +Smith, 2+ proteinuria, red cell
casts.
•
20 y.o. female with polyarthritis, malar rash,
+anti-DNA, low C3, low C4, 3+ proteinura.
Lupus Nephritis
Which patient does not need kidney biopsy right
now?
•
20 y.o. female with polyarthritis, malar rash,
photosensitivity, +anti-DNA, +SSA, trace
proteinuria, trace hematuria, low C3, low C4.
•
20 y.o female with polyarthritis, malar rash,
+anti-DNA, +Smith, 2+ proteinuria, red cell
casts.
•
20 y.o. female with polyarthritis, malar rash,
+anti-DNA, low C3, low C4, 3+ proteinura.
Lupus
• Use C3, C4, DNA titer to follow lupus
activity; they improve. anti-Smith
does not change with time (usually).
• Most persons with isolated discoid
lupus do not get SLE.
• P-ANCA are common in SLE.
•
A.
B.
C.
D.
E.
Which of the following antibodies is
most specific for SLE?
Anti-double stranded DNA
Anti-single stranded DNA
Anti-Smith
SSA
Anti-ribosomal P
•
A.
B.
C.
D.
E.
Which of the following antibodies is
most specific for SLE?
Anti-double stranded DNA
Anti-single stranded DNA
Anti-Smith (also most specific for
renal involvement)
SSA
Anti-ribosomal P
Lupus
• Use antimalarials for arthritis, skin and as a
steroid-sparing agent (nearly all lupus patients
should get an antimalarial).
• Use steroids for more serious manifestations.
• Do kidney biopsy if patient has cellular casts,
hematuria + proteinuria, proteinuria > 500 mg/d,
or elevated creatinine (next slide).
• Treat diffuse proliferative GN and membranous
GN with prednisone and monthly IV
cyclophosphamide or with mycophenolate mofetil
(CellCept).
• Serious CNS lupus: Tx with cyclophosphamide.
Indications for Initial Kidney
Biopsy in SLE
• Protein excretion > 500 mg/d OR
• Active sediment (>=5 RBCs/HPF,
most of which will be dysmorphic,
and cellular casts)
Indications for REPEAT Kidney
Biopsy in SLE
• Active sediment in previously
quiescent disease.
• Unexplained rise in creatinine.
• Worsening proteinuria despite tx.
Treatment of Diffuse Proliferative
Lupus Nephritis
ACEI or ARB with BP <= 130/80
Statin therapy
Hydroxychloroquine
Induction therapy with either IV
cyclophosphamide or with mycophenolate
mofetil.
• Prednisone 0.5 – 1 mg/kg/d x 2 weeks,
then tapered over months.
• Pulse steroids (500 – 1000 mg/d) x 3 days
for severe nephritis.
•
•
•
•
Lupus Pregnancy
• Your 22 y.o. lupus patient is 2 months into her
treatment for DPGN with MMF and prednsione.
Urinary sediment is still active. She finds herself
pregnant despite your warnings to the contrary.
Of the following options, which is optimal?
• D/C MMF, do not replace.
• D/C MMF, increase pred from 20 mg/d to 40 mg/d.
• Switch MMF to azathioprine.
• Switch MMF to cyclosphosphamide.
Lupus Pregnancy
• Your 22 y.o. lupus patient is 2 months into her
treatment for DPGN with MMF and prednsione.
Urinary sediment is still active. She finds herself
pregnant despite your warnings to the contrary.
Of the following options, which is optimal?
• D/C MMF, do not replace.
• D/C MMF, increase pred from 20 mg/d to 40 mg/d.
• Switch MMF to azathioprine.
• Switch MMF to cyclosphosphamide.
Which factor carries the worst
prognosis for renal survival at 5
years in lupus nephritis?
A. Blood pressure
B. Age
C. Chronicity index
D. Activity Index
E. Black race
Cyclophosphamide therapy for lupus nephritis: Poor renal survival in black Americans. Glomerular Disease
Collaborative Network. Dooley MA, Hogan S, Jennette C, Falk R Kidney Int. 1997;51(4):1188.
Which factor carries the worst
prognosis for renal survival at 5
years in lupus nephritis?
A. Blood pressure
B. Age
C. Chronicity index
D. Activity Index
E. Black race
Cyclophosphamide therapy for lupus nephritis: Poor renal survival in black Americans. Glomerular Disease
Collaborative Network. Dooley MA, Hogan S, Jennette C, Falk R Kidney Int. 1997;51(4):1188.
Lupus
• The rash of subacute cutaneous
lupus can mimic disseminated Lyme
disease, psoriasis.
• Anti-Smith correlates with serious
kidney involvement.
Subacute cutaneous
lupus (left).
Oral ulcers (above).
Discoid
lupus
Lupus
Not Lupus (but what?)
Livedo reticularis
Digital infarcts (antiphospholipid syndrome)
Alopecia (scalp) and
healed discoid
lesions (face)
CNS lupus
Drug-Induced Lupus
• Fever, serositis, arthritis, rash
• Hardly ever brain or kidney
involvement
• Classically: anti-histone
antibodies.
• TNFI: anti-DNA antibodies
DIL: The Big Four Culprits
• Procainamide (anti-histone)
• Hydralazine (anti-histone,
ANCA, anti-DNA)
• Minocycline (ANCA)
• TNF inhibitors (anti-DNA)
• Many others sometimes cause
DIL.
Anti Phospholipid
• “Clinical Finding” + Two positive
tests 12 weeks apart
– Medium to high titer anticardiolipin Ab
– Anti β2 glycoprotein I Ab
– Lupus anticoagulant (hexagonal phase
phospholipid assay, DRVVT, kaolin
clotting time.
• Arterial or venous thrombosis
Antiphospholipid Syndrome
• An acquired hypercoagulable state.
• Presentation with arterial or venous
thrombosis, pregnancy loss, or
thrombocytopenia.
• About 50% have systemic lupus
erythematosus.
• Antiphospholipid antibodies include the
lupus anticoagulant, anticardiolipin
antibody, and anti-beta 2 glycoprotein-1.
Antiphopholipid
•
A 25 year old patient with SLE has
moderate titer IgG anticardiolipin
antibodies. She has never had a
thrombotic episode or a miscarriage.
She is 8 weeks pregnant (P1G0). CBC is
normal. What do you recommend?
A.
B.
C.
D.
No additional medication
Low dose aspirin (81 mg)
Low molecular weight heparin
Warfarin
Antiphopholipid
•
A 25 year old patient with SLE has
moderate titer IgG anticardiolipin
antibodies. She has never had a
thrombotic episode or a miscarriage.
She is 8 weeks pregnant (P1G0). CBC is
normal. What do you recommend?
A.
B.
C.
D.
No additional medication
Low dose aspirin (81 mg)
Low molecular weight heparin
Warfarin
Management
• For events:
• Heparin or LMWH, then warfarin with
INR 2-3
• Asymptomatic: ASA
• Catastrophic: Heparin, corticosteroids, plasma exchange ± IVIG
Pregnant with APA Syndrome
• No previous miscarriages or
thromboses: ASA only
• Previous miscarriage: LMWH
therapeutic anti-factor Xa levels of
0.6 to 1.0 U/mL four hours after drug
administration ± ASA
Scleroderma
•
•
•
A 50-year-old man with a 1-year history of diffuse
cutaneous systemic sclerosis is hospitalized for new-onset
hypertension with anemia and thrombocytopenia. Vitals
are unremarkable except BP is 180/110 mmHg. There was
sclerodactyly and skin thickening elsewhere. Neurologic
examination was normal. Cardiac examination revealed a
normal S1, S2, and S4, and no S3. Abdominal examination
was unremarkable. There was 1+ edema of both lower
extremities.
HgB 9.8 g/dL with schistocytes. Platelets 100K. Creatinine
1.4 mg/dl. UA 1+ protein and small blood.
Best treatment:
A.
B.
C.
D.
Captopril
Metoprolol
Clonidine
Furosemide
Scleroderma
•
•
•
A 50-year-old man with a 1-year history of diffuse
cutaneous systemic sclerosis is hospitalized for new-onset
hypertension with anemia and thrombocytopenia. Vitals
are unremarkable except BP is 180/110 mmHg. There was
sclerodactyly and skin thickening elsewhere. Neurologic
examination was normal. Cardiac examination revealed a
normal S1, S2, and S4, and no S3. Abdominal examination
was unremarkable. There was 1+ edema of both lower
extremities.
HgB 9.8 g/dL with schistocytes. Platelets 100K. Creatinine
1.4 mg/dl. UA 1+ protein and small blood.
Best treatment:
A.
B.
C.
D.
Captopril
Metoprolol
Clonidine
Furosemide
Scleroderma
• Two major forms: diffuse (poorer
prognosis) and limited (CREST).
• CREST = calcinosis, Raynaud's,
esophageal dysmotility (solids get stuck),
sclerodactyly, telangiectasias.
• Both forms present with Raynaud's
(correct sequence of colors in Raynaud's
is white, blue, red).
Scleroderma
• In either form the presenting
complaint is often either Raynaud's
or puffy hands (not sclerosed
hands). Puffy hands precede
sclerosis.
• Telangiectasias are often found on
face or palms in CREST.
Scleroderma
• Pulmonary hypertension is now
treatable with bosentan, an oral
endothelin antagonist ($50,000 per
year), iloprost (inhaled) (costs more),
treprostinil (IV, SC), epoprostenol
(IV), sildenafil (oral).
Scleroderma
• Count on seeing scleroderma renal
crisis on boards.
• Schistocytes on peripheral smear
signal renal crisis.
• Use ACE inhibitor to control
scleroderma renal crisis, even if
patient has elevated creatinine. Push
dose of ACEI to max to control BP.
Courtesy of Amy Evangelisto, M.D.
Courtesy of Amy Evangelisto, M.D.
Courtesy of Dr. Amy Evangelisto
Rheumatic Fever
• In adults the arthritis is generally large
joint, asymmetric, lower extremity,
additive, with pain out of proportion to
objective inflammation.
• ASO titer usually quite high.
• Note that ASO titer (or the screening
streptozyme test) commonly positive in
normal persons since it merely indicates a
recent strep infection.
Rheumatic Fever
• Carditis less common in adults.
• Jones criteria:
– Major: arthritis, carditis (abnormal EKG alone
usually doesn't count), chorea, nodules,
erythema marginatum;
– Minor: fever, arthralgia, high ESR/CRP.
• Need two major, or one major with two
minor with evidence of preceding strep
infection (throat culture or high/rising ASO
titer).
Psoriatic Arthritis
•
Five types (these are important):
1. Oligoarticular (most common),
2. Polyarticular (mimics rheumatoid
arthritis but RF is negative),
3. DIP type
4. Arthritis mutilans (rare; causes opera
glass fingers).
5. Spondylitis
Psoriatic Arthritis
• Must know:
– sausage digits
– nail pits
– onychodystrophy.
• Patient may be unaware of presence
of psoriasis.
• Family history of psoriasis common.
Psoriatic Arthritis
• Tx serious psoriatic arthritis with
TNF inhibitors on boards.
– The TNFIs retard joint damage.
• NSAIDS, sulfasalazine or
methotrexate.
• (Not FDA approved for psoriatic, and
not as effective as in RA)
The Clue
•
•
A 25 year old woman comes in with fever
of 100°F, diffuse urticarial rash, anorexia,
nausea, and small joint polyarthritis of 3
days duration. CBC is unremarkable.
ALT is 350. AST is 250.
Most likely dx is:
A.
B.
C.
D.
E.
Acetaminophen OD
Hepatitis B
Hepatitis C
Parvovirus
Acute systemic lupus
The Clue
•
•
A 25 year old woman comes in with fever
of 100°F, diffuse urticarial rash, anorexia,
nausea, and small joint polyarthritis of 3
days duration. CBC is unremarkable.
ALT is 350. AST is 250.
Most likely dx is:
A.
B.
C.
D.
E.
Acetaminophen OD
Hepatitis B
Hepatitis C
Parvovirus
Acute systemic lupus
Hepatitis B
• Fever, anorexia, urticarial or vasculitic
rash with small-joint polyarthritis.
• Transaminases should be elevated at this
time (the clue!).
• Order HBsAg (not HBsAb) to confirm (but
occasionally negative).
• Note that patient is not yet jaundiced at
time of arthritis!
Papular acrodermatitis
of childhood (GianottiCrosti disease) can be
casued by several
viruses including
hepatitis B)
Hepatitis C
• Cryoglobulinemia, mixed. Usually asymptomatic
in hep C ; see low C4 (as in lupus). Hep C
commonly causes positive ANA (can be quite
misleading).
• Cryoglobulinemic vasculitis is much less
common; see peripheral ischemia (digits, ears).
Dx is by biopsy with positive serum
cryoglobulins.
• Associated with oligoarticular, mildly
inflammatory arthritis too (note difference from
rheumatoid arthritis)
• Transaminases can be normal, yet have
circulating virus.
Hepatitis C
• Associated with Sjogren-like
syndrome with parotid gland
lymphocytic infiltration.
• Some may be SSA positive.
Hepatitis C – Extrahepatic
Manifestations
• Cryoglobulins
• Cryoglobulinemic vasculitis
• Autoantibodies: 45-60%
– RF, ANA, anti-thyroid, anti-smooth muscle,
anti-cardiolipin
– Usually low titer
– Not clnically important
• Porphyria cutanea tarda
• Psoriasis-like lesions
Hepatitis C – Extrahepatic
Manifestations
• Hypothyroidism 13%
• Flares of autoimmune disease with
interferon treatment.
• Myasthenia gravis, sarcoid – case reports
• Corneal ulcer (Mooren’s ulcer), scleritis,
Sjogren’s
• Membranoproliferative (usually with LCV),
membranous nephritis
Leukocytoclastic vasculitis with nuclear dust
Parvovirus Arthritis
A board exam favorite.
• Classic patient is young woman who works with
children.
• Caused by parvovirus B-19 which also causes
fifth disease, aplastic crisis in sicklers, other
things.
• Fever followed by diffuse maculopapular rash
followed by small joint polyarthritis, sometimes
with AM stiffness.
• Self-limited in 4 - 8 weeks (usually).
• Confirm diagnosis by ordering IgM parvovirus
titer (IgG titer not helpful since indicates old
infection).
Reiter’s
• Classic triad is arthritis (large joint,
asymmetric, oligoarticular), urethritis,
conjunctivitis (latter may be quite mild and
transient).
• Urethritis usually due to chlamydia
infection, but will be sterile urethritis if
Reiter's is due to enteropathic infection
(always culture it).
• When due to chlamydia, Reiter's
frequently has associated keratoderma
blennorrhagicum and balanitis circinata.
Reiter’s
• Treating infection is good to do but
classically doesn't hasten resolution of
Reiter's (though this is controversial).
• Relapses and chronic smoldering course
are common in this disease.
• Treat initially with NSAID.
• Only a minority develop spondylitis or
sacroiliitis, and this may take
months/years to show up.
Keratoderma
blennorrhagicum
Ankylosing Spondylitis
• Classic patient will be a young (teens,
twenties) male with nagging low back pain
that improves with exercise. Sed rate
usually increased. Order sacroiliac films
or MRI (most sensitive) to confirm
diagnosis.
• If fever present, rule out infection
(osteomyelitis) first.
• 90% of patients will be HLA-B27 positive.
Bone marrow edema
surrounding left
sacroiliac joint on
MRI (T2 weighted).
Irregular sacroiliac
joints on plain
films.
Ankylosing Spondylitis
• Mild disease can be treated with
NSAIDs.
• More serious disease is treated with
a TNFI.
• Anterior uveitis is fairly common.
• Aortic valve disease also associated
with B27.
Lyme
• Look for the big things like erythema
chronicum migrans (ECM), monarthritis
mimicking septic arthritis, Bell's palsy,
heart block.
• An early Lyme presentation (fever,
headache, mylagias, arthralgias – but with
low WBC and elevated transaminases
suggests Erlichiosis. (Also responds to
doxycycline).
• Fever, headache, myalgias and a rash in
the summer should always suggest Rocky
Mtn spotted fever (even w/o the rash).
Lyme
•
•
•
•
•
Remember that Lyme titer is frequently negative during the
ECM phase; just treat ECM presumptively. Lyme titer may
stay negative or may turn positive after successful Tx of
ECM.
Always base treatment on Western blot, not on serology.
Pearl: Do a Lyme titer for any "culture negative" septic
arthritis and for most cases of Bell's palsy.
Don't treat fibromyalgia patient with borderline Lyme titer
for Lyme (won't get better). Confirm all borderline titers
with a Western blot. If WB negative, it's a false positive.
Treat most late manifestations with 3-4 weeks of
doxycycline. Exception: CNS disease. Also, may wish to
treat arthritis initially with IV ceftriaxone.
Sarcoid
• Lofgren's syndrome: bilateral ankle periarthritis, fever, erythema nodosum. To
confirm diagnosis, order chest
radiograph. Most cases resolve
spontaneously; avoid steroids.
• Treatment is NSAID initially (such as
indomethacin), not steroids initially. Use
steroids only for resistant cases.
• Steroids may increase the conversion rate
to chronic sarcoid.
Lofgren’s syndrome
(note the
periarticular
distribution of
the erythema
nodosum)
Gonorrhea
• There are two distinct rheumatologic
presentations: a) migratory
tenosynovitis with skin lesions, and
b) septic arthritis, usually
monoarticular.
• Much more common in women;
classically disseminates during or
just after menses.
What’s
this?
Gout
•
•
•
•
•
Pearl: wrist inflammation occurring acutely in an elderly,
hospitalized female is usually pseudogout, but always tap
to rule out septic arthritis (on the boards)
Remember that crystal arthritis (especially when
polyarticular) commonly causes fever, sometimes high.
Allopurinol is not a treatment for acute attack of gout (may
make acute attack worse).
Treat acute attack with colchicine, NSAID, intra-articular
corticosteroid or systemic corticosteroids. Make sure
cultures are negative before injecting joint (on boards).
Probenecid is hypouricemic drug of choice (when one is
needed). Use allopurinol if pt is overproducer, has hx
stones, hx renal insufficiency or tophi.
• You are asked to see an 80 y.o. lady admitted to
the hospital for pneumonia 4 days ago. She has a
painful swollen knee with no history of a fall.
Radiograph is shown on next slide. The
pneumonia is improving and she was looking
forward to being discharged on oral antibiotics.
She mentioned that she had bumped her knee on
the dresser two days ago.
• T99.9F, WBC 12,000, Uric acid 4.8 mg/dl
• Synovial fluid WBC 20,000 with 90% polys. Gram
stain negative. No crystals were seen.
•
Most likely diagnosis is:
A. Septic arthritis, same organism as
pneumonia.
B. Septic arthritis, different or resistant
organism.
C. Gout
D. Pseudogout
E. Lyme disease
•
Most likely diagnosis is:
A. Septic arthritis, same organism as
pneumonia.
B. Septic arthritis, different or resistant
organism.
C. Gout
D. Pseudogout
E. Lyme disease
•
Best treatment is to:
A. Aspirate, then inject with depot
corticostreroid.
B. Give prednisone taper.
C. Change antibiotics.
D. Rest, ice, elevation.
E. Arthroscopic drainage.
•
Best treatment is to:
A. Aspirate, then inject with depot
corticostreroid.
B. Give prednisone taper.
C. Change antibiotics.
D. Rest, ice, elevation.
E. Arthroscopic drainage.
Clinical Associations with
Pseudogout
• Aging
• Previous joint
surgery
• Previous joint
trauma
• Familial types
• Gout
• Amyloidosis
Hyperpara
Hemochromatosis
Hypomagnesemia
Familial
hypocalciuric
hypercalcemia
• Hypophosphatasia
• Wilson’s disease
• Ochronosis
•
•
•
•
Clinical Associations with
Pseudogout
• Aging
• Previous joint
surgery
• Previous joint
trauma
• Familial types
• Gout
• Amyloidosis
Hyperpara
Hemochromatosis
Hypomagnesemia
Familial
hypocalciuric
hypercalcemia
• Hypophosphatasia
• Wilson’s disease
• Ochronosis
•
•
•
•
Rheumatology
Board Review
Part 2
“Just the Pearls Please”
Gerald Falasca, M.D.
Medical Specialists of Johnson City
April, 2015
Polymyalgia Rheumatica
• See accompanying table (last page) to know how
to differentiate PMR from polymyositis and from
fibromyalgia. Key points below.
• PMR presents with diffuse myalgias and (less
commonly) arthralgia in the elderly. Often wgt
loss, fever. Muscle weakness is not a feature. On
the boards, sed rate will be very high ( ~ 100
mm/hr).
• 10 - 15% of patients develop temporal arteritis.
So, you should have low threshold to do biopsy.
• Treatment is low dose steroids (10 - 20 mg/d
prednisone), unless patient has temporal arteritis.
Dermatomyositis
• Risk of malignancy is substantial in
older patients (especially > 65).
• Colon cancer especially common
Inclusion Body Myositis
• Uncommon (except on boards).
• Presents just like polymyositis, but the
clues are presence of distal weakness in
addition to prox. weakness, and lack of
response to steroids. More atrophy.
• M>F. CK < 10x ULN.
• Light microscopy shows typical
intranuclear or intracytoplasmic
inclusions. Dx confirmed by electron
microscopy.
• There’s no good treatment.
POLYMYOSITIS/DERMATO-MYOSITIS
POLYMYALGIA
RHEUMATICA
Proximal muscle weakness
(relatively painless). Often fever,
arthralgias, weight loss, fatigue.
Proximal muscle pain
(shoulders, hips)
with little or no
true weakness.
Often fever,
weight loss,
fatigue.
Generalized pain, fatigue, "nonrestorative" sleep; the
"fibrositic personality"
DEMOGRAPHICS
Middle age, F slightly > M
Age >50, 2F:1M
Young adult or middle aged females
PHYSICAL EXAM
Proximal muscle weakness (ie., can't
get out of chair). Gottron's
papules, heliotrope and
periorbital edema in
dermatomyositis.
Proximal muscle
tenderness;
strength normal
Characteristic "tender points" (see
figure)
SED RATE
Elevated
Elevated > 40-50
mm/hr; often
>100 mm/hr
Normal
CPK
Elevated; often in the thousands;
rarely can be normal.
Normal
Normal
TREATMENT
High dose prednisone (40 - 80
mg/day)
Low dose prednisone
(5 - 15 mg/d)
Patient education; low dose
amitriptyline (10-50 mg HS);
duloxetine; pregabalin;
milnacipran; cyclobenzaprine
ASSOCIATED
DISORDERS
Malignancy in 10 - 15% of adults (up
to 50% if >65 yrs). Increased in
polymyositis, but less so. Other
connective tissue diseases such
as SLE, scleroderma.
Temporal arteritis in
10 - 15%
Irritable bowel, headaches,
dysmenorrhea, irritable
bladder, depression.
SYMPTOMS
FIBROMYALGIA
Osteoporosis Tx
NSAIDS
• Risk factors for NSAID-induced ulcers are
advancing age, debilitating disease, CHF, prior
history of ulcers, coagulopathy (or warfarin).
• All NSAIDS cause stomach ulcers, but some
cause fewer ulcers (i.e., non-acetylated salicylates,
nabumetone, celecoxib, meloxicam, etc).
• The risk of superficial erosions is approximately
20% after 1 - 4 weeks with traditional NSAIDS
• Risk of serious complications (significant
bleeding or perforation) is only 2% - 4% per year
(higher with risk factors above).
NSAIDSs
• Only aspirin irreversibly inhibits platelet function
(i.e., a single 80 mg baby aspirin inhibits platelet
function for 7 - 10 days).
• Some NSAIDS (i.e., ibuprofen) reversibly inhibit
platelet function
• Some NSAIDs do not inhibit platelet function:
non-acetylated salicylates, nabumetone (Relafen),
meloxicam (Mobic), celecoxib (Celebrex)
• Ibuprofen (but not other NSAIDs) NEGATES the
anti-platelet effect of ASA if given before the ASA
– Give the ASA first, wait 1-2 hours, then give ibuprofen.
NSAIDs
• Don't give NSAIDS on the boards to
persons with renal insufficiency or with
recent CHF.
• Don't give NSAIDS on the boards to
persons with history of peptic ulcers,
unless there's a very good reason, and
person is also given misoprostol or PPI
(H2 blockers don't reliably prevent NSAID
ulcers)
• Use one of the less toxic NSAIDS. (Best
not to give NSAIDs at all to these pts)
NSAIDs
• NSAIDS cause mainly gastric ulcers, but
can also cause duodenal ulcers and
intestinal ulcers. NSAID ulcers are not
associated with H. pylori.
• Never give NSAIDS on the boards with
warfarin.
• Watch for NSAID induced interstitial
nephritis (clue: electrolyte abnormalities,
rising BUN or creat and urine eosinophils),
nephrotic syndrome, hepatitis.
NSAIDs
• Most NSAIDs can cause heart failure (Celecoxib
is possible exception).
• Some NSAIDs are associated with MI (high dose
ibuprofen, diclofenac, high dose celecoxib (200
mg bid), rofecoxib (off the market), but NOT
naproxen, ?others (not enough data).
• Most NSAIDs can cause hypertension (happens
in first week) and mild transaminases elevation
(10-15%).
– Serious hepatitis is rare.
• NSAIDs may cause non-unions and failure of
bone grafts!
Methotrexate
• Common side effects are nausea,
diarrhea, stomatitis, mild transaminase
elevation, mild bone marrow suppression.
• Folate supplementation prevents some of
these.
• 3%: pneumonitis and rarely pulmonary
fibrosis.
– Dry cough, fever, dyspnea, crackles
Methotrexate
•
•
•
•
Absolutely contraindicated in
pregnancy.
Avoid in drinkers and in those with
chronic liver disease.
Don’t use if creatinine > 2.0 mg/dl.
Increasing MCV in a patient on
methotrexate may be harbinger of
more serious toxicity.
Prednisone
• Lupus patient receiving prednisone
who develops "hip" pain (pain in
groin and anteromedial thigh)
• Get plain films followed by MRI to
look for avascular necrosis.
• Get MRI both sides (often
asymptomatic on other side)
Prednisone
• Post-menopausal women receiving
pred are at especially high risk or
getting compression fractures.
• Always get baseline DEXA.
• Start alendronate or risedronate if
osteopenic (T-score < -1).
Prednisone
• Steroid myopathy: patient on
steroids is getting weaker (no pain).
• CK is normal in steroid myopathy.
• If appropriate do muscle biopsy (will
show type II atrophy alone which is
non-specific, but helpful to rule out
other causes of myopathy).
Prednisone
• Serious long-term side effects include
osteoporosis (with fractures, especially
spinal compression fractures), cataracts
(posterior sub-capsular if asked),
glaucoma, poor healing, infections,
avascular necrosis (up to 15% of lupus
patients). Compression fractures can
occur in 3 months in post-meno. women
on pred.
• A 30 year old woman with lupus limps into your
office with right groin pain of 2 weeks duration.
Meds include prednisone 10 mg/d and
mycophenolate mofetil 1000 mg BID for lupus
nephritis for the past six months. She is afebrile.
Physical exam reveals severe pain with hip
rotation. Right groin is tender to palpation
overlying the hip joint. You order a radiograph
which is read as normal. The most likely
diagnosis is:
A.
B.
C.
D.
Iliopsoas bursitis
Avascular necrosis
Septic arthritis
Trochanteric bursitis
• A 30 year old woman with lupus limps into your
office with right groin pain of 2 weeks duration.
Meds include prednisone 10 mg/d and
mycophenolate mofetil 1000 mg BID for lupus
nephritis for the past six months. She is afebrile.
Physical exam reveals severe pain with hip
rotation. Right groin is tender to palpation
overlying the hip joint. You order a radiograph
which is read as normal. The most likely
diagnosis is:
A.
B.
C.
D.
Iliopsoas bursitis
Avascular necrosis
Septic arthritis
Trochanteric bursitis
The “crescent sign” of AVN
Bilateral hip AVN
Prednisone
• Watch on the boards for signs of
acute adrenal insufficiency (ie.,
patient comes to ER having stopped
prednisone (forgot to tell doctor)
including nausea/vomiting,
abdominal pain, hypotension,
hypoglycemia, hyperkalemia, hi
BUN, eosinophilia. Give saline and
hydrocortisone.
Chloroquine and
Hydroxychloroquine
• Useful for arthritis, skin.
• Effective for prevention of renal relapses.
• Common side-effects are blurry vision lasting two
weeks at beginning of therapy (not serious), and
generalized rash (stop drug).
• Important: Serious but rare side-effect is
maculopathy causing loss of central vision.
Patient will notice that parts of words are missing
when he/she reads.
• Screen for maculopathy with ophthalmologic
exam with red visual field testing once or twice
yearly. Note that peripheral vision is not affected,
thus this disease is not like glaucoma or pituitary
tumor.
Leflunomide
A pyrimidine synthesis inhibitor.
Indicated for RA.
Very long half-life.
Contraindicated in pregnancy.
Not a good idea in liver disease or
drinkers.
• Side-effects very similar to methotrexate
(nausea, diarrhea, alopecia, liver enzyme
elevations, occasionally leukopenia.
•
•
•
•
•
The Biologics
• Infliximab, adalimumab, golimumab,
certolizumab, etanercept, anakinra,
rituximab, tocilizumab and abatacept.
• They are all expensive protein drugs.
• They should not be combined with
each other because of resulting
serious immunosuppression!
TNF Inhibitors
Infliximab, Adalimumab, Etanercept,
Certolizumab pegol, Golimumab
• Used for rheumatoid arthritis, psoriasis,
psoriatic arthritis, JRA, Crohn's disease
and ulcerative colitis.
• They retard joint damage and erosions.
• Increased risk of bacterial and fungal
infection. Discontinue during infections.
• Associated with reactivation of TB,
reactivation of hep B (but not hep C) and
with malignancy. Do PPD first.
TNF Inhibitors
• Associated with development or
reactivation of demyelinating disease
such as multiple sclerosis.
• Can cause heart failure (myocardial
depressant).
• May reactivate hepatitis B (not C).
• Associated with development of
anticardiolipin antibodies, ANA, anti-DNA
and lupus-like syndrome, acute
autoimmune hepatitis.
Rituximab (Rituxan®)
• B-cell killer.
• Is an anti-CD-20 antibody. Depletes blood
of B-cells for months. They eventually
return.
• Indicated for RA in combination with MTX,
in patients having failed a TNF inhibitor.
• Indicated for ANCA+ vasculitis.
• Also indicated for CD20 positive B-cell
lymphomas.
• May cause hypogammaglobulinemia.
Allopurinol
• Most common side effect is rash. Don't restart it
an allergic patient (could get Stevens-Johnson or
toxic epidermal necrolysis).
• Remember life-threatening interaction with
azathioprine or 6-mercaptopurine.
• "Allopurinol hypersensitivity syndrome" consists
of fever, rash (often Stevens-Johnson), hepatitis,
renal failure, leukocytosis, sometimes
eosinophilia (the clue).
• Reduce dose in renal insufficiency.
• Never treat asymptomatic hyperuricemia on the
boards (or in real life).
Temporal Arteritis
• Sed rate will almost always be very
high on boards.
• High sed rate, fever, weight loss and
amaurosis fugax = temporal artery
biopsy (even without headache).
• Treat with prednisone 20 mg bid or
tid to start.
• Taper slowly, following ESR monthly.
Temporal Arteritis
•
•
•
•
•
•
Always do biopsy on the boards (and in real life) to confirm
diagnosis.
If offered, do bilateral biopsy.
If only one side done and is negative, but patient really
seems to have temporal arteritis, always biopsy other side.
If neuro symptoms present (such as amaurosis fugax),
begin treatment while waiting for biopsy, but not if only
headache.
A new-onset headache in an elderly person is always an
indication for workup on the boards; it is never a tension
headache.
30-40% present as polymyalgia rheumatica.
A Case for the Boards
• A 60 y.o. male gave a 3 year hx recurrent sinus
congestion with crusting, conjunctival redness
diagnosed as episcleritis. 1 month ago he
developed acrocyanosis. 2 weeks ago he
developed polyarthritis of all small joints. 1 week
ago he developed fever and cough. CXR shows
RUL infiltrate and mass. Bx showed
granulomatous inflammation with negative AFB
stain. Creatinine is 1.5 mg/dl, up from baseline of
0.9 mg/dl, and UA showed 40-50 RBCs with casts.
Which of the following blood tests is
most likely to be abnormal?
A.
B.
C.
D.
E.
P-ANCA
C-ANCA
ANA
C3
Anti-MPO
Which of the following blood tests is
most likely to be abnormal?
A. P-ANCA
B. C-ANCA (and anti-PR3)
C. ANA
D. C3
E. Anti-MPO
Kidney biopsy would likely show:
A.
B.
C.
D.
Diffuse proliferative GN
Membranous GN
Paucimmune crescentic GN
Membranoproliferative GN
Kidney biopsy would likely show:
A.
B.
C.
D.
Diffuse proliferative GN
Membranous GN
Paucimmune crescentic GN
Membranoproliferative GN
Kidney biopsy would likely show:
A.
B.
C.
D.
Diffuse proliferative GN
Membranous GN
Paucimmune crescentic GN
Membranoproliferative GN
Definitive initial treatment would include:
A. Daily prednisone alone
B. Daily cyclosphosphamide alone
C. Both A & B
D. Pulse methylprednisolone alone
Definitive initial treatment would include:
A. Daily prednisone alone
B. Daily cyclosphosphamide alone
C. Both A & B
D. Pulse methylprednisolone alone
Wegener’s
• Usually presents with sinus or URI symptoms.
• Do c-ANCA (correlates with anti-proteinase 3
antibody).
• Make every effort to confirm diagnosis with
tissue before treating since treatment is not
benign and C-ANCA not always reliable.
• Biopsy sinus or lung usually.
• Kidney biopsy not helpful (just shows
glomerulonephritis).
Wegener’s
• Wegener's is the only vasculitis for which the
initial treatment is cyclophosphamide. (Start
prednisone with cyclophosphamide).
• Often can switch to methotrexate after remission
achieved.
• Interstitial pneumonia developing in Wegener's
patient on treatment is often P. carinii.
• Other pulmonary-renal syndromes to consider
include Goodpasture's (usually young men; antiGBM present), lupus, polyarteritis nodosa.
Polyarteritis Nodosa
• Key features will be mononeuritis multiplex
(multiple individual peripheral nerve lesions
[such as wrist drop, foot drop, patchy sensory
loss, etc.) with weight loss, fever, high sed rate,
abdominal pain, hypertension, hematuria,
leukocytosis.
• May have history IV amphetamine abuse or
hepatitis B. Usually males.
• Always biopsy (muscle, sural nerve, testicle) or
do A-gram (mesenteric or renal) to confirm
diagnosis. Don't biopsy kidney.
•
A.
B.
C.
D.
A 60-year-old male gives a one year history of
recurrent sinusitis with persistent rhinorrhea and
nasal crusting. He has had two episodes of otitis
media in the past year (none previously) and one
episode of chondritis of the helix that responded
to prednisone. Recent urinalysis showed
microscopic hematuria and 1+ proteinuria.
Serum creatinine is 1.40 mg/dl (was 0.8 mg/dl
last year). Which of the following antibodies is
most likely to be elevated?
Anti-DNA
Anti-myeloperoxidase
Anti-Smith
Anti-proteinase-3
•
A.
B.
C.
D.
A 60-year-old male gives a one year history of
recurrent sinusitis with persistent rhinorrhea and
nasal crusting. He has had two episodes of otitis
media in the past year (none previously) and one
episode of chondritis of the helix that responded
to prednisone. Recent urinalysis showed
microscopic hematuria and 1+ proteinuria.
Serum creatinine is 1.40 mg/dl (was 0.8 mg/dl
last year). Which of the following antibodies is
most likely to be elevated?
Anti-DNA
Anti-myeloperoxidase (and P-ANCA)
Anti-Smith
Anti-proteinase-3
• Diseases often associated with
positive ANCA include all of the
following EXCEPT:
– Wegener’s
– Glomerulonephritis (some types)
– Churg-Strauss vasculitis
– Takayasu vasculitis
– Microscopic polyarteritis
Behcet’s
Henoch-Schonlein
• Key features will be arthralgias/arthritis,
abdominal pain, heme positive stools,
hematuria and a palpable purpura rash
mainly on lower extremities and buttocks
in a young adult.
• (Most cases actually occur in children, but
not on Internal Medicine boards). Initial
treatment is supportive in children, but
adults often require steroids.
Takayasu’s
• Key features will be upper extremity
claudication, paresthesias, perhaps TIAs
in a young woman with weight loss,
fevers, high sed rate.
• (These systemic features are often not
present in real life, but probably will be on
the boards).
• Do aortic A-gram or MRA to confirm
diagnosis.
• Initial treatment is with steroids.
Takayasu’s (left
subclavian is
missing)
Hypersensitivity Vasculitis
• Key features will be palpable purpura following
drug administration (usually ß-lactam, phenytoin,
sulfa, TNF inhibitors, etc.).
• Do appropriate tests to rule out endocarditis,
meningococcemia, RMSF (fever, myalgias,
headache, rash in the summer in the ER on the
boards is Rocky Mountain Spotted Fever until
proved otherwise).
• Treatment for hypersensitivity vasculitis due to
drug is supportive (stop the drug!), not steroids,
unless there is a clear indication.
Primary CNS Vasculitis
• Tip-off will be young person with
stroke, high sed rate (not always
present) and pleocytosis on LP. Note
that diagnosis is by A-gram, or
preferentially by leptomeningeal
biopsy.
Never Forgotten
• Vasculitic rash on palms and soles?
Always get RPR to rule out
secondary syphilis.
Multiple Cholesterol Emboli
• Rare. Fever, weight loss, high sed rate,
petechial rash on lower extremities,
eosinophilia, and often some blue toes.
Biopsy of the skin rash looking for
cholesterol clefts in the small vessels is
key to diagnosis. No effective treatment.
Usually fatal. Self-perpetuating.
• A "minor form" of this is the post-cath
"blue toe syndrome," which usually
resolves on its own.
Ischemic Digits? Look For:
• Vasculitis
• Embolization (septic, non-septic)
• Hypercoaguable state (including anti-cardiolipin
antibodies)
• Warfarin necrosis
• Thromboangiitis obliterans
• Scleroderma
• Vasospasm.
• In a word, blue digits can be vasculitic,
vasospastic, clotted or obliterated. Single best
test is an A-gram, but do as many blood tests as
necessary.
Pneumococcal sepsis
(vasculitis mimic)
Shoulder Pain
• Most common cause of shoulder pain is not
degenerative arthritis, but rather rotator cuff
tendinitis, often with secondary subacromial
bursitis.
• Rotator cuff tendinitis often accompanied by
impingement syndrome. Adduction of the raised
arm often causes pain (impingement test), as does
internal rotation while in abduction.
• Pain radiating into the deltoid area is usually
coming from the rotator cuff and/or subacromial
bursa. Classic finding (ie., on the boards) is a
"painful arc" between 60° - 120° of abduction.
Shoulder Pain
• Drop-arm test checks for large rotator cuff
tear, but misses small or partial tears.
• MRI is modality of choice to confirm tear;
arthrogram or ultrasound also acceptable.
• Not every rotator cuff tear needs
operation, especially if patient is older.
Conservative Rx first.
Shoulder Pain
• Oval, ill-defined, amorphous
calcifications in region of humeral
head are often seen in acute calcific
tendinitis. May resolve
spontaneously.
• OK to inject these.
Shoulder Pain
• Bicipital tendinitis: tenderness of
long head of biceps; positive
Yergason test (Pain on resisted
supination of forearm).
• Bicipital tendon rupture may be only
mildly painful; sudden appearance of
palpable mass in upper arm
(“Popeye sign”)
Knee Pain
• Patellofemoral pain syndrome:
Bilateral knee pain (especially while
descending steps) in young woman
who may have some "knock-knee"
deformity. May find patellofemoral
tenderness and crepitus on exam,
occasionally non-inflammatory
effusions. Tx with PT, analgesic.
Knee Pain
• Torn meniscus.
– Very common in elderly, usually nontraumatic. Sudden severe pain,
especially on twisting.
– Clue will be failure of DJD pain to
improve with corticosteroid injection.
– McMurray test
– Diagnose by MRI.
Knee Pain
• Anserine bursitis.
– Very common in middle-aged/elderly women with
osteoarthritis of knee.
– Key finding will be tenderness over medial tibia, about
2" below knee.
– Corticosteroid injection helpful.
• Prepatellar bursitis.
– Often confused with joint effusion/arthritis.
– Egg-shaped swelling superficial to patella. Usually
post-traumatic ("housemaid's knee")
– May also be septic or gouty.
– Always tap and culture (on the boards), and only inject if
certain no infection is present.
Knee Pain
• Baker's cyst - very popular on boards.
– Pain in popliteal fossa, sometimes with swelling and
paresthesias distally.
– Clue is presence of knee effusion. Occurs in
rheumatoid arthritis most commonly, but also in DJD.
– If cyst ruptures, it mimics acute DVT with acute pain,
redness, swelling (the fluid is very irritating to tissues).
– The clue to rupture is presence of ecchymoses at ankle
from blood/synovial fluid that flows along tissue plains
following rupture.
– Diagnose with MRI (best) or ultrasound (cheaper).
Thoracic Back Pain
• More ominous than low back pain!
• Think:
– Compression fracture
– Malignancy
– Dissecting aneurysm
– MI
•
A 45 year old male presents on Monday morning
with acute low back pain after digging six holes
to plant trees in his yard two days prior. Mild
radiation down right lower extremity to heel. No
weakness. No bowel/bladder symptoms. On
exam afebrile, reflexes intact. Mild spasm.
Positive right-sided straight leg raising test.
Which of the following is least appropriate at
this time?
A. 2 days of bedrest
B. NSAID for pain relief
C. Muscle relaxant for pain relief
D. Lumbar AP & lateral radiographs
E. Heating pad for pain relief
•
A 45 year old male presents on Monday morning
with acute low back pain after digging six holes
to plant trees in his yard two days prior. Mild
radiation down right lower extremity to heel. No
weakness. No bowel/bladder symptoms. On
exam afebrile, reflexes intact. Mild spasm.
Positive right-sided straight leg raising test.
Which of the following is least appropriate at
this time?
A. 2 days of bedrest
B. NSAID for pain relief
C. Muscle relaxant for pain relief
D. Lumbar AP & lateral radiographs
E. Heating pad for pain relief
Low Back Pain
• The important causes of LBP for the
boards are:
– lumbosacral strain
– spinal stenosis
– herniated disc
– Sacroiliitis
– Malignancy
– aortic aneurysm eroding vertebrae
Low Back Pain
• Initial treatment of uncomplicated back
pain is two days of bedrest, antiinflammatories, pain meds, etc. Don't
order x-rays for first episode of
uncomplicated low back pain in relatively
young, healthy persons.
• In uncomplicated LBP, treatment precedes
diagnosis (“lumbosacral strain”)!
Low Back Pain
• High risk persons with back pain:
alcoholic, age over 50, trauma,
corticosteroid use, high sed rate, fever.
• Order x-rays for these pts.
• If sed rate is very elevated in patient with
back pain, always look for osteomyelitis,
infectious discitis or malignancy.
Low Back Pain
• Spinal stenosis is common cause of LBP
in older adults.
• Presents with neurogenic claudication, a
sensation of pain/weakness/rubbery
feeling in buttocks and thighs on walking
(mimics vascular claudication) relieved by
sitting down or by bending forward.
• Key differentiating point is patient can
only stand 5-15 minutes in one place
(unlike vascular claudication).
• Diagnosis is by MRI. Tx is physical
therapy, epidurals, surgery
Low Back Pain
• A positive straight leg raising test is pain
going down leg (preferably to ankle) when
the hip and the knee are extended.
• Indicates nerve root irritation (most often
seen with herniated disc)
• Cauda equina syndrome is triad of
impotence, sphincter dysfunction and
"saddle anesthesia" occurring in setting
of LBP.
• Is usually neurosurgical emergency. Most
common cause is large central disc
herniation.
Osteoarthritis
• Risk Factors
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–
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Age
Female versus male sex
Obesity
Family history
Lack of osteoporosis
Occupation
Sports activities
Previous injury
Muscle weakness
Calcium crystal deposition disease
Proprioceptive deficits
Acromegaly
DJD
• Most specific finding on physical
exam is crepitus.
• Knee effusion common, and will be
non-inflammatory (WBC < 250/mm3).
• Common trouble spots are base of
thumb (1st CMC joint), neck, lumbar,
knees.
DJD
• Treatment includes (in order of use):
– Acetaminophen
– Quadriceps strengthening exercises (such as
isometrics, swimming or bicycling)
– Glucosamine (analgesic effect only),
– NSAIDS
– Corticosteroid injections
– Viscosupplementation (intra-articular
hyaluronic acid)
– Cane
– Total joint arthroplasty.
DJD
• Viscosupplementation: best for younger
patients with mild-to-moderate cartilage
loss. Pain improvement up to a year.
• Has not been shown to decrease rate of
joint space narrowing.
• Given as a series of 3-5 intraarticular
injections one week apart. May be
repeated every 6-12 months.
Diabetes – Musculoskeletal
• Diabetics get frozen shoulder (also called
adhesive capsulitis or periarthritis) (often
bilateral).
• Carpal tunnel syndrome
• Ulnar neuropathy at elbow
• Stiff, painful fingers often associated with
sclerodactyly (diabetic cheiroarthropathy)
• Dupuytren's contracture
• Palmar tenosynovitis
Diabetes - More
• Charcot joint (mainly ankle and forefoot)
• DISH (diffuse, idiopathic, skeletal
hyperostosis [characterized by "candledripping syndesmophytes"]).
• Back pain with anterior thigh atrophy in a
diabetic is usually diabetic amyotrophy
(ischemic lumbosacral plexopathy);
usually resolves spontaneously, though
not completely (don't be fooled and
operate on "bulging discs" in such cases).
Diabetes
• Ischemic myopathy (thigh, forearm)
– Normal A-gram usually
– Very high CK
– Poorly controlled diabetes
Elbow pain
• Lateral epicondylitis: Pain in lateral
forearm while carrying objects with the
forearm partially pronated (such as frying
pans or milk bottles)
• Confirm by finding tenderness in region of
(and just distal to) the condyle.
• Sometimes there is an associated radial
nerve compression in the forearm also,
but probably not on the boards.
Elbow pain
• An egg-shaped collection of fluid on the elbow is
usually olecranon bursitis. It is usually painless.
Always tap (if offered) to rule out infection, gout,
rheumatoid arthritis, but most cases are posttraumatic or simply irritative in etiology.
• Aspirate, use elbow pads; beware of injecting the infection rate is higher for this bursa.
• Pain in 4th, 5th fingers raises question of ulnar
neuropathy. Do Tinel's sign at the elbow to
confirm diagnosis.
Elbow pain
• Radial nerve palsy will present with
wrist drop on boards.
• Patient may have fallen asleep on
his/her arm (especially if intoxicated;
“Saturday night palsy”)
• Or could have polyarteritis nodosa.
Carpal Tunnel Synd.
• Carpal tunnel syndrome:
Pain/tingling/numbness will be in first 3
fingers, not the wrist.
• Patients like to "shake out" the hands in
the morning, sometimes run under hot
H2O.
• Tinel sign: paresthesias in fingertips when
the carpal tunnel is percussed with finger.
• Phalen's test: Paresthesias when wrist is
held in flexion for 30-60 seconds. If either
positive, do EMG/NCS to confirm.
Carpal Tunnel Synd.
• Treatment is splinting first, not
surgery.
• Corticosteroid injection sometimes
useful as diagnostic test. Always
look for diabetes, hypothyroidism. In
dialysis patients, may have ß2
microglobulinemia.
Wrist Pain
• Ganglion: firm yet movable nodule (few
mm to 1 cm) on either side of wrist fixed to
a tendon sheath (note the tendon sheath
does not move with joint movement, only
the tendon).
• Treat conservatively or "needle" it.
• Often regress or rupture spontaneously.
Don't excise unless necessary.
Causes of Hand Pain
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•
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•
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Carpal tunnel
DJD
RA
Flexor tenosynovitis
Hypertrophic pulm. osteoarthropathy
Complex regional pain syndrome
Hip Pain
• Trochanteric bursitis.
– Very common.
– Often mistaken for DJD of hip joint.
– Major symptom is inability to sleep on that
side.
– Pain is on lateral aspect of hip. Trochanter will
be tender.
– Treatment is corticosteroid injection just
superficial to trochanter (and/or NSAID), rest.
Hip Pain
• Meralgia paresthetica:
– Burning pain/numbness/paresthesias on anterolateral
thigh due to compression of lateral femoral cutaneous
nerve. Usually seen in obese, pregnant or diabetic
patients, or due to tight belt or corset. Local measures
and reassurance helpful.
• Piriformis syndrome:
– sciatica and buttock pain due to compression of sciatic
nerve by piriformis muscle in mid-buttock. Look for in
young women with abnormal gait who have sciatica with
normal MRI of spine. Straight leg raising test usually
negative.
Plantar Fasciitis
• Treatment of plantar fasciitis may include
all of the following except:
• Rest, ice, elevation
• Stretching exercises
• Night extension splint
• Monthly corticosteroid injections
• Silicone gel shoe inserts
• Avoidance of barefoot walking
•
•
•
•
•
•
•
Your 65 y.o. patient with rheumatoid arthritis reports
burning pain and numbness in the sole and toes of right
foot after standing for 10 minutes, and at night. Inspection
reveals mild swelling of the right ankle and the MTPs.
Symptoms are reproducible by tapping with your finger
posterior to the medial malleolus. You suspect one of the
following:
Morton’s neuroma
Tarsal tunnel syndrome
Plantar fasciitis
Peripheral neuropathy
Subtalar synovitis
Carpal tunnel syndrome
ACR classification criteria:
Fibromyalgia
• Both criteria must be satisfied
– History of widespread pain for more than 3 months, on
both sides of the body, above and below the waist, and
axial skeleton (cervical spine, anterior chest, thoracic
pain, or low back)
– Pain in 11 of 18 tender point sites on digital palpation
with approximate force of 4 kg.
• Presence of second clinical disorder does not
exclude diagnosis of fibromyalgia.
NON-MUSCULOSKELETAL
SYMPTOMS
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•
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•
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•
Fatigue
Sleep Disturbance
Headaches
GI symptoms (IBS)
Irritable bladder
Panic attacks (20)
Vasospasm (40%)
Dysmenorrhea
Sicca symptoms
Subjective swelling
Numbness
Affected by
weather
• AM stiffness
•
•
•
•
•
Fibromyalgia Treatment
• Patient education; sleep
hygiene
• Pregabalin
• Duloxetine
• Tricyclics
• Cyclobenzaprine
• Note: SSRIs don’t work unless
patient is depressed.
Don’t Miss This Diagnosis
• 70 year old female had left carpal
tunnel surgery. One week later the
entire hand swelled, became
diffusely painful, became warm,
seaty. The nails grew longer. Bone
scan showed diffuse uptake (see
scan). Hand became diffusely tender
to palpation.
The most likely diagnosis is:
A. Carpal tunnel syndrome
B. Rheumatoid arthritis
C. Complex regional pain syndrome,
type 1.
D. Complex reginal pain syndrome,
type 2.
E. Pseudogout
CRPS
• Pain, burning
• Vasomotor changes
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–
–
–
Temperature
Color
Piloerection
Sweating
• Often swelling
• Type 1 – Trauma related
• Type 1 – Non-trauma related
CRPS
•
•
•
•
•
Early treatment is important
Physical therapy
Bisphosphonate
Short course of steroids
Anti-neuropathic (gabapentin,
phenoxybenzamine)
The End
The End