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ITE Board Review: Rheumatology Part II

Terms in this set (14)

• Acute polyarthritis (>4 joints): caused by viral infxn (parvovirus B19, HIV, hepatitis B, rubella) or early manifestation of chronic inflammatory polyarthritis
• Chronic inflammatory polyarthritis: RA, SLE, spondyloarthritis (psoriatic)

• RA: symmetric, small joints (wrist, MCP, PIP, MTP) > hips, knees, elbows, shoulders, c-spine.
o Extra-articular feat.: rheumatoid nodules, dry eyes/mouth, ILD, Felty Syndrome (splenomegaly, leukopenia, leg ulcers)
o Dx: RF, anti-CCP, acute phase reactants, erosive changes on radiograph

• SLE: symmetric w/ large + small joint involvement
o Extra-articular feat.: F, rash, serositis, kidney disease, neurologic dz
o Dx: ANA and other serologies, no erosions on radiograph

• Spondyloarthritis
• Ankylosing: sacroiliac + spinal involvement; symmetric, large joints (shoulders, hips)
o Extra-articular feat.: uveitis
o Dx: calcification of anterior longitudinal ligament of spine on radiograph, sacroilitis, HLA B27 +

• Psoriatic Arthritis: asymetric oligoarthritis or polyarthritis, DIP joint preference, dactylitis (sausage digits)
o Extra-articular feat.: psoriasis
o Dx: "Pencil-in-cup" deformities, erosions, osteophytes on radiograph

• Reactive arthritis: aka Reiter syndrome, asymmetric oligoarthritis, knee and ankle involvement, enthesitis, Achilles tendinits, plantar fasciitis, sacroilitis
o Extra-articular feat.: uveitis, keratoderma blennorrhagicum, Chlamydia, enteropathic infxn
o Dx: HLA B27 positive, sacroilitis

• IBD-associated arthritis: asymmetric, sacroiliac joints, knees, feet
o Extra-articular feat.: Crohn disease, ulcerative colitis
o Dx: sacroilitis, HLA B27 + in cases of axial involvement
• Progresses thru 3 stages: asymptomatic hyperuricemia → acute intermittent gout → chronic tophaceous gout
• Monosidum urate crystals (needle-shepaed, negatively birefringent crystals) in joint fluid and uric acid tophi are diagnostic
• Usu. acute intermittent gout → monoarticular (first MTP, tarsal joints), self-limited, hyperuricemia
• If at first MTP joint (podagra) → synovial fluid analysis is not required
• Polyarticular: occurs w/ time/frequency
• Tx:
o Mild hyperuricemia + symptomatic gout → dietary purine restriction, weight loss, discontinuation of alcohol
o D/c meds that raise serum uric acid levels (thiazide diuretics, low-dose salicylates)
o Acute gouty flare: NSAIDs =1st line, oral corticosteroids if NSAIDs not safe (older pts, postoperative, pts requiring anticoagulation, those w/ CKD or peptic ulcer disease)
o Single joint if other interventions ineffective/contraindicated: intra-articular corticosteroids
o 2 > attacks each year w/ presence of tophi or kidney stones → require allopurinol, goal uric acid level <6 mg/dL
o >50% pts require allopurinol, >300 mg/d, to reach target serum uric acid level
o Lower doses for pts w/ kidney impairment
o When starting allopurinol, begin low-dose colchicine to prevent acute gout → d/c colchicine when UA level stabilies
o Febuxostat if pt cannot tolerate allopurinol, CKD
o CKD and taking HCTZ → allopurinol → incr. risk for rare but potentially fatal hypersensivitiy syndrome characterized by severe dermatitis, fever, eosinophilia, hepatic necrosis, acute nephritis