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43 terms

Rheum review

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Amyloid AA
Assoc inflammatory disorder / APR
Less cardiac
Amyloid AL
Plasma cell dyscrasia / MM
Cardiac
Liver
Renal
Neuropathy
CONGO RED...apple green birefring
Cardiac amyloid
Fat pad bx
PAN serology
None
PAN
Assoc active HBV 30% cases
Chronic vague sx
Abdom pain
Headaches
HTN
MULT ANEURYSMS S-M ARTS
Neurogenic thoracic outlet synd
4th & 5th fingers
Waxy papules in skin folds
Amyloid
Who gets RA?
Peak onset 25-50 yo
F 3:1
RA spares what joints
L-S spine
Most freq extra-articular manifestations of RA
Pulm
Vasculitis
Polyarthritis differential in general
RA**
PMR / GCA in elderly
Psoriatic
Crystal
SLE / vasculitis
Sjogren's
Any immune complex disease
Spondylitic variant
Paraneoplastic
Viral---Parvo, HepB, HCV, Rubella
Lyme (rarely diffuse)
Polyarthritis in elderly
RA
PMR / GCA
Polyarticular gout / pseudogout
Paraneoplastic
Psoriatic Arthritis
Extent of psoriasis unrelated to extent of arthritis
3 types manifestations
1. Looks like seroneg RA
2. Looks like spondylopathy (RA spares)
3. Pauciarticular...assym, 3-4 joints

DIP without involvement of PIP / MCP...characteristic

Nail pitting, onycholysis
Lupus arthritis
Bland, mild, generally
Subset looks like RA....but labs look like SLE
Lyme arthritis
Acutely can be diffuse
Chronically, PAUCIARTHRITIS...usually hip or knee.
RA xrays
Early...osteopenia near joints
Erosions later usually
DX of RA
There are criteria, but...
Have to have stiffness > 1hr
polyarthritis >3 areas
involvement of hands
symmetric swelling
ALL PRESENT >6 WKS
ANA patterns not helpful except...
centromere---limited scleroderma (CREST)
and-------------primary biliary cirrhosis
ANA centromere pattern association
1. CREST (which is limited scleroderma)
2. PRIMARY BILIAR CIRRHOSIS
anti-topoisomerase I
also called anti-Scl-70
DIFFUSE SCLERODERMA
specific
only occurs in 30%
anti-histone
r/o drug-induced lupus...95% positive

only for procainamide, hydralazine, chlorpromazine, quinidine
ANA Subtypes...ANA profile
ds DNA.............SLE
Sm (smith)........SLE
SSA..................SLE & Sjogrens
SSB..................SLE & Sjogrens
U1-RNP............MCTD
Scl-70................Diffuse scleroderma
Antibodies seen mainly in VASCULITIDES
ANCA
anti-NEUTROPHIL cytoplasmic antibodies
histone-negative drug-induced lupus...which drugs
ANCA POSITIVE
minocycline
hydralazine (also causes histone positive)

dsDNA POSITIVE
Anti-TNF drugs
4 ANCA's
2 from immunofluorescentn (pts never both)
1. c-ANCA
2. p-ANCA

2 from ELISA
1. anti PROTEASE 3 (PR 3)
2. myeloperoxidase (MPO)
c-ANCA means...
Wegener Granulomatosis

(Usually also PR3+)
50% sensitivity
90% specificity
p-ANCA positive diagnoses
depends on MPO (myeloperoxidase antibody)
pANCA alone is very nonspecific (pANCA +/ MPO-)
pANCA + and MPO+
98% specific for KIDNEY...
1. Idiopathic crescentic GN
2. Churg-Strauss
3. MPA (microscopic polyangiitis) w/ kidney involv
Low complements in Rheum
SLE
Rheumatoid VASCULITIS
Complements decreased with SLE
C4
CH50
anti CCP
anti-citrullinated cyclic peptide
EARLIER in RA than RF
More SPECIFIC for RA than RF (97%)

MORE AGGRESSIVE / EROSIVE RA
HLA- B27 incidence
A.S............................................90%
Reactive / Reiter's.....................80%
IBD, Psoriasis
Yers, Shig, Salm arthropathy.....80%
Uveitis........................................60%
RA, OA.......................................10%
Normal pop................................6-8%
HLA-D assoc
DR2-----SLE
DR3-----SLE, Sjog, Polymyos
DR4-----Severe RA
Joint aspirate with WBC > 100K
Infection
Reactive spondyloarthropathies
RA
Gout
Joint aspirate with low wbc but mostly monos and lymphs
DJD
SLE
trauma
Markers for more aggressive RA....
(therefore treat early, agressively)
antiCCP
HLA-DR4
high titer RF
constitutional sx
insidious onset
early erosions on xrays
early appearance of nodules
SYMMETRICAL & POLYARTICULAR ARTH
RA
SLE
RA DX
morning stiff 1 hr
wrists, mcp, pip...no dip
3 jts
symmetric
(6 weeks)
nodules
xrays
RF pos
Looks like RA joints but assym
(MCP, PIP, no DIP)
Hemochromatosis
RA and CAD
3X increased risk of atherosclerosis CAD
RA
Splenomegaly
Neutropenia
FELTY'S
Long-standing dz
high RF
nodules
**Splenectomy

LGL (Lg granular lymphocyte) SYNDROME
Infection suscetibility
progresses to leukemia
*No Splenectomy--makes it worse*
DMARDS FOR RA
Hydroxychloroquine
Sulfasalazine
Methotrexate

No antiinflammatory action...use concurrent NSAIDS
anti TNF
infliximab and adalimumab--monoclonal ab...
etanercept--TNF receptor blocker

ANTI-TNF...MOST BENEFICIAL COMBINED WITH MTX
HALT / POSS HEAL EROSIONS FROM RA

Histone neg anti-dsDNA+ lupus syndrome