Vikas Majithia

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SUBJ ECTIVE COMPLAINTS OF WEAKN ESS
Excl ude:
Anemia
Card iopulmonary disease
Chronic infections
Malignancy
Depression
Fibro mya lgia
Malingering
Deconditioning
AS YMMETRIC
Regional neuro logical disorders
Cerebrovascular disorders
Spinal cord and spinal root disorders
De myelinating disease
Co mpression neuropathy
Mononeuropathy/mononeuritis multip le x
Disuse atrophy
Myasthenia gravis
OBJ ECTIVE MUS CLE WEAKNESS
SYMMETRIC
SPECIFIC PATTERN
Muscular dystrophy
Hereditary neuropathies
Myasthenia gravis
PROXIMAL
Infla mmatory myopathy
Metabolic myopathy
Endocrine myopathy
Glucocorticoid myopathy
Mitochondrial myopathy
Drug-induced myopathy
HIV-related myopathy
Duchene’s muscular dystrophy
Myasthenia gravis
DISTAL
Periphera l polyneuropathy
Motor neuron disease
Myasthenia gravis
Inflammator y Myopathy:
• Symmetric pro xima l muscle wea kness
•
Elevated plasma muscle en zy mes
• Myopathic changes on electromyography
• Characteristic muscle biopsy abnorma lities and the absence of histopathologic signs of other myopathies
• Typical rash of dermato myositis
Management includes complete laboratory profile, EM G, Biopsy. Work-up for underlying ma lignancy. Start prednisone at .5 mg/kg- 1 mg/kg initia lly.
Needs appointment in rheumatology in 4-6 wee ks or earlie r.

Classification Criteria
Five criteria for DM and PM were proposed in 1975
 Symmetric proximal muscle weakness
 Elevated plasma muscle enzymes
 Myopathic changes on electromyography
 Characteristic muscle biopsy abnormalities and the absence of histopathologic signs of other myopathies
 Typical rash of dermatomyositis

Other clinical features
1. fever and weight loss,
2. A nonerosive inflammatory polyarthritis,
3. Raynaud's phenomenon
4. Cardiopulmonary abnormalities also may occur.
5. Congestive heart failure due to myocarditis
6. Interstitial lung disease
MYOSITIS SPECIFIC ANTIBODIES:
Anti T Rna Synthetases : Anti Jo-1: associated with
ILD
Anti Mi-2 (Dm)
Anti Pm-SCL
Anti SRP: associated with cardiac disease

©Copyright Science Press Internet Services

DIFFERENCES BETWEEN DM AND PM
Clinically, DM is associated with certain skin manifestations.
Ocular muscles are more frequently involved in DM.
DM Has a higher incidence of malignancy, although various cancers (GI, Lung, Ovary) can be associated with both DM and PM.
Pathogenetically, DM is associated with immune complex deposition in the vessels, whereas PM appears to reflect direct T cell-mediated muscle injury.

TREATMENT
Corticosteroids 1 mg/kg are medications of choice
IV pulse steroids may be needed
Usually needed for a long duration: months to years.
Immunosuppressive therapies:
Azathioprine (Imuran)
Methotrexate
Combination of MTX and imuran
IV cyclophosphamide
IVIG
Biologics- TNF blockers, Rituximab

Questions asked
1.
Patient scenario: middle aged or elderly female. Male age above 50.
2.
Patient presents with weakness, hand and eyelid rash.
Work-up should include? Likely diagnosis?
3.
Same patient is at risk for what? What tests to do?
Additional tests in female patient?
4.
Patient with myositis presents with cough, SOB. What test? Antibody? Diagnosis?
5.
Patient with myositis responded to steroids and MTX now weak again, CPK is 650. Diagnosis? Management?
6.
65 year-old-male comes with weakness, CPK 600, abnormal EMG. Treated with prednisone, MTX for 5-6 months but no response. Diagnosis? Appropriate test?
Treatment?
7.
Myositis patient with left hip pain and abnormal exam.
What test? Likely diagnosis?

Monoarthritis
Monoarthralgia
Exclude Periarticular Disease
Tendonitis, Bursitis, Bone lesion,
Myofascial Pain, Sprain/Overuse, soft tissue infection, peri-articular GC infection
Monarticular Arthritis/ Arthalgia
Always consider Aspiration of joint for diagnosis
Cell count, Crystals, Gram stain, Culture
Infection
Gonococcus
Staphylococcus
Streptococcus
Diagnostic features:
True joint Inflammation with pain, swelling, erythema, Leukocytosis and fever, Synovial fluid cell count >50,000,
Positive gram stain and culture
Crystalline disease
Gout/pseudo gout
True inflammatory changes in joint with urate or CPPD crystals on synovial fluid examination; cell count of 2000-50,000;
Cystic erosions (gout) or chondorcalcinosis
(pseudgout) on X-ray
Osteoarthritis/trauma
Absence of inflammatory changes and <30 minutes
AM stiffness with the presence of pain, crepitus, mild swelling, osteophytes;
X-ray changes of joint narrowing, osteophytes formation, sclerosis;
Joint fluid aspirate either bloody or cell count<2000;
If diabetic, consider neuropathic joint
Seronegative spondyloarthropathy
Inflammatory changes of joint (particularly knee or ankle);
Synovial fluid cell count of 2000- 50,000; involvement of eyes
(conjunctivitis or uveitis) or back/sacroiliac joints with prolonged (>1 hour AM stiffness)
Early onset inflammatory arthritis
RA or SLE
Inflammatory joint changes with other etiologies excluded; with prolonged (>1 hour AM stiffness); with positive RF or
ANA

Normal
Clear/Yellow
Transparent
<2K
Inflammatory
Yellow/ White
Translucent/ opaque
2K-50K
Septic
Yellow/White
Opaque
>50K
Hemorrha gic
Red
Opaque
N/a
Crystal
Induced
Yellow/
White,
Translucent
/opaque
10K-50K
-ve Gm stain
& Culture (Cx)
-ve Gm stain &
Culture
+/- Gm stain, +/-
Culture
-ve Gm stain, Cx.
-ve Gm stain, Cx.
+ Crystals

Questions asked
1. Patient scenario: Male, Acute symptoms
(sub-acute female in DGI)
2. Elderly male presents to the ER with acute R knee pain/swelling: Next test,
Results abnormal- What to do?
3. 20-40 year old F with migratory arthritis:
Knee-ankle-wrist, Tap shows 15,000 wbc. Has a rash. Diagnosis?
4. Travel to Connecticut, rash, fatigue, myalgia? History? Diagnosis? Treatment?
5. Same patient (did not get treatment)1 year later has CN palsy/knee arthritis.
What to do?

Polyarthritis/ Polyarthralgia
Determine by History and Physical if inflammatory
(Prolonged AM stiffness, erythema, swelling, warmth, pain)
Evaluation dictated by history and physical may include CBC, urinalysis, liver and kidney function, RF, ANA,
ANCA, ESR, TSH, CPK, HBA1C, CXR and regional/back/SI joint X-rays
Non- Inflammatory
AM stiffness < 1 hour
No joint erythema, swelling and
Normal ESR
Negative RF or ANA
Implies a differential diagnosis of
Myofascial pain
Fibromyalgia
Osteoarthritis
Endocrinopathy
Pain syndrome
Does not clearly fit into either category,
Consider:
Seronegative RA
Seronegative spondyloarthropathy
Inflammatory
AM stiffness > 1 hour
Joint erythema, swelling, or pain
And
Elevated ESR (must exclude other inflammatory diseases such as infection or cancer)
Or
Positive RF
Positive ANA
Implies a differential diagnosis of:
Rheumatoid arthritis
Connective tissue disease (lupus, PSS, PM/DM,
Sjogren’s)
Viral infection
Seronegative spondyloarthropathy
Sarcoidosis

 Ankylosing spondylitis
 Reiter's syndrome or reactive arthritis
 Arthropathy of inflammatory bowel disease
 Psoriatic arthritis
 Undifferentiated spondyloarthropathies
 Juvenile chronic arthritis and juvenileonset ankylosing spondylitis

CLINICAL CHARACTERISTICS OF
SPONDYLOARTHROPATHIES
 Tendency to cause sacroiliitis
 Tendency to cause spondylitis
 Association with enthesopathy (enthesitis)
 Typical pattern of peripheral arthritis: usually lower limb, asymmetric, tenosynovitis (sausage digits)
 Absence of rheumatoid factor (RF)
 Absence of subcutaneous nodules and other extraarticular features of rheumatoid arthritis (RA)
 Overlapping extra-articular features characteristic of the group (e.g., anterior uveitis)
 Significant familial aggregation and association with
HLA-B27

 Physical modalities
 NSAIDS
 DMARDs
 New treatments- TNF alpha blockers.

 Inflammatory back pain
 HLA B-27 associated
 Symmetrical Sacroilitis
 Spondylitis: erosion, squaring of the vertebrae
 Uveitis; symmetrical
 Atypical presentations: female, older age
 Occiput to wall test
 Schobere’s test
 Enthesopathy.

 Inflammatory oligoarticular arthritis in the setting of previous or intercurrent nongonococcal urethritis and/or conjunctivitis is characteristic of patients with
Reiter’s syndrome.
 It is important to recognize that the majority of patients with this disorder present with just one or two features of the triad.
 Clinical triad of urethritis, conjunctivitis, and inflammatory arthritis.
 Mucocutaneous manifestations of Reiter’s syndrome: Circinate Balanitis and keratoderma
 Enthesopathy.

Questions asked
1. Patient scenario: Male, sub-acute symptoms
2.
Patient with back pain worse in AM and better with activity. What test? What eye manifestation (different in RA)? Differentiate from non-inflammatory back pain?
3. AS patient come with widened pulse pressure, heart murmur. What test? Diagnosis?
4. AS patient comes with weakness in legs, BB incontinence. Diagnosis? Treatment?
5. AS patient with pain/numbness affecting all 4
Ext UE>LE? Recently rear-ended? Next test?
Diagnosis?
6. AS patient with SOB? Diagnosis?

Questions asked
7. Patient with R knee arthritis, h/o STD.
Diagnosis? Eye manifestation? Associated
Disease?
8. Patient with painful DIP, swollen 2 nd toe. Exam has nail pitting, What else to look for?
Diagnosis?
9.
Japanese patient with recurrent oral/genital ulcers, arthritis. Diagnosis? Treatment?
10.
Cruise ship (trip to Mexico etc) had diarrhoea,
Now with 1-2 joint arthritis +/- sausage toe.
Likely diagnosis? Associated organisms?
11. AS patient with back pain not responding to
NSAIDs and SSZ. Treatment?

 SIZE OF THE VESSELS INVOLVED
 ORGAN SYSTEMS INVOLVED

 Large vessel: GCA and temporal arteritis,
Takayasu ’ s arteritis, Primary angitis of CNS
 Medium size vessels: PAN, Kawasaki disease,
Churg strauss syndrome, Wegener ’ s granulomatosis
 Small vessels: CS syndrome, Wegener ’ s granulomatosis, HSP, Microscopic angitis, Mixed cryoglobulinemia, Hypersensitivity vasculitis/leukocytoclastic vasculitis, Vasculitis associated with rheumatic diseases- RA,SLE
 Misc. : Behcet ’ s disease, Relapsing polychondritis, Lymphomatoid granulomatosis

CLINICAL MANIFESTATIONS
 NON SPECIFIC:
Fatigue and weakness
Fever, skin rash
Arthralgias and/or arthritis abdominal pain hypertension neurological dysfunction/neuritis.
 SPECIFIC: PERTAINING TO THE ORANS INVOLVED
Pulmonary nodules
Sinus /nasal inflammation
Gastrointestinal inflammation with its presenting symptoms
Glomerulonephritis/renal insufficiency with an active sediment.

Hypersensitivity /leukocytoclastic vasculitis
 Age >16
 a possible offending agent in temporal relation to the symptoms
 Palpable purpura
 Maculopapular rash
 Biopsy of a skin lesion showing neutrophils around an arteriole or venule
 ANY OF THE VASCULITIDES WHICH CAN INVOLVE
SMALL VESSELS CAN PRESENT AS PALPABLE PURPURA
& HAVE A PATHOLOGY OF LEUKOCYTOCLASTIC
VASCULITIS

 Hypersensitivity vasculitis –
 Discontinuing the offending agent may be adequate
 NSAIDS,Antihistamines.
 Colchicine, dapsone
 Corticosteroids as needed
 Occasionally cytotoxic agents are required.
 Systemic vasculitis :
 Corticosteroids are almost always needed.
 Cytotoxic agents have to be used in a number of instances.
 Rituximab in ANCA associated Vasculitis (AAV)

 Nasal or oral inflammation (painful or painless oral ulcers or purulent or bloody nasal discharge)
 Abnormal chest radiograph showing nodules, fixed infiltrates, or cavities
 Abnormal urinary sediment (microscopic hematuria with or without red cell casts)
 Granulomatous inflammation on biopsy of an artery or perivascular area
 C-ANCA (anti proteinase-3) is now an important diagnostic test.
 Up to 90% sensitive in active systemic disease.
 Tissue biopsy can be diagnostic--A nasopharyngeal lesion, Renal biopsy, Lung biopsy

Saddle nose

Nodules

POLYARTERITIS NODOSA
 ACR Classification criteria: 3/10 + are 82% sensitive, 84% specific
• Otherwise unexplained weight loss greater than 4 kg
• Livedo reticularis
• Testicular pain or tenderness
• Myalgias (excluding shoulder and hip girdle), weakness of muscles, tenderness of leg muscles
• Mononeuropathy (Mononeuritis Multiplex) or polyneuropathy
• New onset diastolic blood pressure greater than 90 mmHg
• Elevated levels of serum blood urea nitrogen or creatinine
• Evidence of hepatitis B virus infection
• Characteristic arteriographic abnormalities
• A biopsy of small or medium-sized artery containing PMN’s.

Renal angiogram

 PMR is classically characterized by aching and morning stiffness in the shoulder, hip girdles, neck and torso in patients over the age of 50.
 The symptoms are usually symmetric and associated with a high ESR, but asymmetric pain and normal
ESR can occur.
 GCA (temporal) arteritis is a chronic vasculitis of large and medium size vessels which commonly occurs among individuals over 50 years of age.
 Polymyalgia rheumatica occurs in about 50 percent of patients with GCA, while approximately 15 percent of patients with PMR as the primary diagnosis develop GCA

• NON SPECIFIC: fatigue, weakness, fever, arthralgias.
• SPECIFIC: new headache(60-70 %) jaw claudication (30-40%)
Permanent partial or complete loss of vision in one or both eyes(15-20%) arm claudication (10 %)
Tender or thickened temporal arteries.
Bruits in cranial and upper extremity vessels
• Characteristic laboratory abnormality is a high ESR upto 100mm/h. normal values may occasionally be seen.

 Age greater than or equal to 50 years at time of disease onset
 Localized headache of new onset
 Tenderness or decreased pulse of the temporal artery
 Erythrocyte sedimentation rate greater than 50 mm/h
(Westergren)
 Biopsy which includes an artery, and reveals a necrotizing arteritis with a predominance of mononuclear cells or a granulomatous process with multinucleated giant cells

 Corticosteroids are the mainstay of treatment
 Prednisone is started in at 10-20 mg for PMR and titrated to a response in clinical and laboratory markers.
 For GCA prednisone is started at a higher dose of 0.5 to 1 mg/kg. IV steroids may be needed for acute visual changes.
Subsequently Slow taper is recommended.
 Usually treatment is continued for 1- 2 years after remission.
 Cytotoxic medications and methotrexate can be used and may be required both during acute and chronic phases.

• Recurrent chondritis of both auricles
• Nonerosive inflammatory polyarthritis
• Chondritis of nasal cartilage
• Inflammation of ocular structures, including conjunctivitis, keratitis, scleritis/episcleritis and/or uveitis
• Chondritis of the respiratory tract involving laryngeal and/or tracheal cartilages
• Cochlear and/or vestibular damage manifest by neurosensory hearing loss, tinnitus, and/or vertigo

Questions asked
1.
Elderly (>50) patient presents with fever, stiffness? Next test? Treatment?
2. Same patient has headache, visual loss. Next test?
Shortcoming of the test? Treatment?
3. Young Asian/Hispanic patient with pain, weakness in left arm. Finding on exam? Next test?
Diagnosis?
4. Male patient with abdominal pain, weight loss, arthritis, leg ulcers, purpuric rash. Next test?
Diagnosis? Associated findings?
5. Same patient also has history of IV drug abuse. underlying disease? What results on ANCA testing?
6.
Same patient with foot drop. Diagnosis? Next test?
7. 40-50 year old male patient with abdominal pain, arthritis, leg ulcers, purpuric rash. Next test?
Diagnosis? Associated findings?

Questions asked
8.
Male patient with SOB, cough, weight loss, active urinary sediment, + p-ANCA. Next test? Diagnosis?
Treatment?
9.
Patient with sinusitis, nasal ulcer. Next test? Diagnosis?
Treatment?
10.
Same patient with hemoptysis, cough, renal insufficiency? Next test? Diagnosis? Treatment?
11. Patient with h/o asthma, rhinitis, now has cough, purpuric rash. chest x-ray: infiltrates. Next test?
Diagnosis? Treatment?
12. Purpuric rash, URI, hematuria. Diagnosis? Treatment?
13.
Urticarial rash, hematuria- active urinary sediment- Dx &
Tx?
14.
Recreational drug assoc pseudovasculitis- clinically vasculitis, -ve imaging & bx. Serology- ANCAs may be +.
Culprit drugs? Cutting agents? Tests?
15. Patient started on HCTZ, now has a rash: palpable purpura. Diagnosis? Management?
16.
Patient of Mediterranean descent with recurrent abdominal pain, fever, arthritis. + family history.
Diagnosis? Treatment? Complication?

 Central DXA
(Dual Energy X-ray
Absorptiometry) remains the state-ofthe-art diagnostic standard
 Bone density is the most important predictor of fracture risk

 The BMD results are expressed as standard deviations from a comparison to the referent mean.
 A T-SCORE is the number of standard deviations the bone mineral density measurement is above or below the YOUNG-NORMAL MEAN bone mineral density.
 A Z-SCORE is the number of standard deviations the measurement is above or below the AGE-
MATCHED MEAN bone mineral density.

World Health Organization Interpretation of Bone
Density
Patient’s T-Score Classification
-0.5 T
-1.0 T
-1.5 T
-2.0 T
-2.5 T
Normal
Osteopenia
Osteoporosis
Severe Osteoporosis
(with fragility fractures)

National Osteoporosis Foundation
Who should be evaluated for OP.
• Bone density test vs Fracture risk assessment?
• Women: o Age > 65 without risk factors o Age > 50 with risk factors 1
• Men o Age > 70 o Earlier – if there are risk factors*- osteoporotic fracture, hypogonadism, malignancy etc.
1. Risk factors for osteoporotic fracture include: low body weight; history of fracture; Caucasian; cigarette smoking; estrogen deficiency, early menopause; low calcium intake; alcoholism; recurrent falls; and inadequate physical activity.
* Not well-defined

Fracture Risk Assessment Score- FRAX
• FRAX- Tool to assess fracture risk
( Developed by WHO)
• Decision making alogrithm for assessing the risk of fracture in an individual based on clinical information and using that to make therapeutic decisions.
• Can add BMD in the calculation
• Gives a 10-year risk
• A 10 year risk of overall fracture > 20% or hip fracture > 3% is felt to be significant.

National Osteoporosis Foundation
Who should be considered for treatment of
OP.
•
Complicated answer
• Women: o Age > 40 with low BMD (T-score <-2.5 i.e.
OP) or high FRAX (T-score>1&<2.5 i.e. osteopenia) o Age < 40- individualize (risk factors, fracture, steroid use)
• Men o low BMD (T-score <-2.5) or high FRAX o Younger patient, ?Age - individualize (risk factors, fracture, steroid use)

Traditional Nonpharmacological
Management for Prevention and Treatment
 Calcium (1200 – 1500 mg/day in divided doses)
 Vitamin D 400-800 IU/day*
 Weight-bearing exercise
 Fall-prevention techniques
*800 IU/day for patients over age 65

 Anti-resorptive therapies:
Hormone replacement therapy (HRT)
Raloxifene
Bisphosphonates
 Alendronate
 Risedronate
 Ibandronate
 Pamidronate
 Zolendronate
Calcitonin
RANK Ligand inhibitor- Denosumab (Prolia)
 Bone formative: PTH (Forteo)

 Primarily a disorder of cartilage associated with cartilage destruction and secondary bone changes
 Most Common rheumatic disorder
 Common cause of joint pain especially in elderly
 Joint Pain: weight bearing joints, worse with activity & better with rest
 AM stiffness is minimal
 Typically involves DIP and PIP
 Can have secondary synovitis (inflammation)
 Common cause of back pain: remember SPINAL
STENOSIS and its features
 Typically normal lab studies
 X-rays: joint space narrowing and osteophyte formation

 Management
• Acetaminophen
• NSAIDs: Any NSAID works fine
• Weight reduction and physical therapy
• Local therapy
• Intra-articular steroids
• Intra-articular viscous supplementation ( Hyalgan, Synvisc etc) only in knee OA
• Narcotics
 Role of joint replacement Surgery:
• Treat patient not radiograph
• Symptoms of Rest pain and night pain are indications for surgery
• Functional impairment is also indication for surgery
• Adequate medical work-up due to risk factors

 Mechanical Back Pain
Minimal AM stiffness
Intermittent
Improved with rest
Decreased ROM in all directions
 Inflammatory Back pain
Prolonged AM stiffness
Persistent
Improved with activity
Decrease in Flexion/extension of spine: Schobere’s test
 Remember symptoms and neurological signs of nerve impingement syndromes at various levels
 Remember back pain (typically at night time) in elderly could be sign of malignancy
 Remember back pain in elderly/immunosuppresed could be sign of chronic infection typically TB

 Clinical Syndrome not a disease
 Typically middle aged white females
 No objective sign of joint inflammation
 Associated with myofascial pain, fatigue, stiffness, lethargy
 Alterations in normal sleep pattern
 Associated with psychiatric syndromes, IBS, migraine, premenstrual syndrome
 No diagnostic test: must rule out a serious underlying disorder
 Tender points on examination ( 11 out of 18)
 Management includes: counseling, improving sleep hygiene, graded exercise, SSRIs, Muscle relaxants,
Ultram, treatment of psychiatry disorders

Questions asked
1.
Patient with severe, persistent knee/hip pain, night pain.
Treatment?
2.
X-Ray findings, Treatment algorithm for OA
3.
70-year-old female with back pain, night time worsening, point tenderness. Likely Diagnosis?
4.
30-year-old with back pain radiating to leg. No neurological deficit. Diagnosis? Treatment?
5.
45 year old with left sided back pain, radiation to foot, can not dorsi-flex big toe. What level is impingement?
What reflex to look for?
6.
35 year old female with fatigue, aching, poor sleep, ANA
1:40. Likely diagnosis? Treatment?
7.
50 year old with history of radius fracture? What to workup for? Test of choice?
8.
Male with OP? testing?
9.
Secondary causes of OP?
10.
Comparative efficacy of various agents, SE and C/I
11.
Fracture risk reduction of various agents

Other Board Pertinent Disorders
 Pain, swelling of extremity after trauma. Area cool to touch, edematous, Hyperalgesia? Diagnosis? Test of choice?
 Shoulder Injury and now pain in wrists/hands with above findings. Treatment?
 Lyme disease- Arthritis (2 nd stage), associated fibromyalgia. No ABX treatment of arthritis if treated in past
 Pain hip: remember back/spine origin, tender outside
(lateral side) of hips-diagnosis?
 Pain knee: Normal exam,, Look for hip abnormality.
 Pain knee: normal exam- ilio-tibial band syndrome.
Medial side of tibia. Diagnosis?

Other Board Pertinent Disorders
 Sarcoidosis: EN, Lofgren’s syndrome, others
 Obese or diabetic patient with pain/burning pain ant thigh. Mild Sensory loss. Normal EMG.
Diagnosis?
 60 year old, smoker with pain in ankles, hands.
Tender above ankle, clubbing, radiographs periosteitis. Diagnosis?
 Corticosteroid toxicities including associated myopathy, AVN and osteoporosis
 Carpal Tunnel Syndrome & association with hypothyroidism.

 Non-atherosclerotic, segmental, inflammatory disease that most commonly affects the small and medium sized arteries, veins, and nerves of the extremities
 Normal ESR & CRP
 Cellular/Inflammatory thrombus
 Normal: auto-antibodies/other serologic tests
 Cork screw blood vessels
 Stop smoking

 Usually, the cause of osteomalacia is a deficiency in vitamin D
 There are other causes: Low phosphate
 Normal 25-OH vitamin D levels: 30 ng/ml
 Replace with 50, 000 units once or twice a week for 3-6 months

 Calcification and ossification along the anterolateral aspect of at least four contiguous vertebral bodies
 Preservation of intervertebral disc height
 Lack of findings of AS

 Focal skeletal disorder characterized by an accelerated rate of bone turnover.
CLINICAL MANIFESTATIONS
 Pain
 Skeletal deformities and fractures
 Bone tumors (remember osteosarcoma)
 Neurologic complications (Hearing loss, CN Palsies)
 Cardiac complications: Heart failure, Aortic stenosis,
Conduction abnormalities
 Calcium and phosphate metabolism, Elevated Alkaline phosphatase.
Treatment:
 Bisphosphonates

Causes
 Idiopathic
 Sarcoidosis
 IBD
 TB
 Fungal
 URI: Viral/Bacterial
 OCs
 CTD
Treatment
 NSAIDs
 Potassium Iodide
 GCs
 Treat underlying disease

(REMEMBER DINNER AT
CHAR IS GOING TO AWAIT
YOU)