Osteoarthritis

Gouty Arthritis

Pseudogout

Septic Arthritis

Sicca

Scleritis

Sicca

Cotton Wool Spots

Uveitis

Retinal Arteritis

Scleritis

Episcleritis

Uveitis

Trauma

Age (joint use)

Bouchard=bony enlargement of Proximal Interphalangeal Joint

Heberden is the same except at the Distal Interphalangeal Joint

Proximal comes before Distal, as does B come before H....

Imaging studies are the best tool.

X-rays show joint space narrowing and new bone formation around the joint

NSAIDs

Acetaminophen

Opioids

Physical/Occupational Therapy

Surgery (Joint replacement)

Genetic

Hormones

Drugs

Renal function

Low-dose aspirin

Cyclosporine

Niacin

Renal insufficiency

Alcohol

NSAIDs 

Colchicine

Corticosteroids

Allopurinol

Probenecid

Pseudogout is caused by deposits of Calcium Pyrophosphate dihydrate (CPPD) crystals

Pseudogout often affects knee and wrist, gout starts in the distal joints

Anti-Inflammatory doses of NSAIDs

Colchicine

Corticosteroids if infection is not present

Typical Gout

Rheumatoid arthritis

Irreversible Joint destruction

Death

Rheumatoid Arthritis patients

Individuals with Prosthetic joints

Drainage

Intravenous antibiotics

Early Progressive Joint Mobilization

Acute onset of joint tenderness and restricted motion, typically monoarticular. Even more dangerous if polyarticular.

Widespread musculoskeletal pain/tenderness

Fatigue

Disturbed sleep

Cognitive Dysfunction/anxiety

Depression

1. Widespread Pain index and Symptom severity scores are 7 & 5 or 3 & 9

2. Symptoms present for at least 3 months

3. No other explanation for the pain

Tricyclic AntiDepressants

SSRIs/SNRIs

Heterocyclic antidepressants

Anticonvulsants

Numbness

Paresthesias (pins and needles feeling)

Pain

(include the fingers, hand and sometimes even forearm

1.  A splint to keep the wrist at 20 degrees for nighttime

2. Corticosteroid injection 

3. Amputation

Just kidding, surgery where they make an incision on the ligament that is compressing the nerve

CRPS (Complex Regional Pain Syndrome)

Type I-no nerve lesion

Type II-peripheral nerve lesion

-cold/warm feeling in affected area

-edema

Hyperhidrosis

-abnormal skin color

-Hyperalgesia

-Allodynia

-movement disorders

-Patch demineralization of bone

Trauma

Surgery

NSAIDs

Gabapentin

TCAs

Opioid analgesics

Physical Therapy

NSAIDs

Rest/stretching/strengthening

Massage

Heat/ice

Splinting

Corticosteroid

Surgery

Skin, bone (osteoporosis),

Blood,

Eyes,

Lungs (fibrosis, nodules)

 Heart

CNS & PNS

Polyarticular, small joints first

Symmetrical

Joint pain and swelling

Positive RF (rheumatoid factor) and CCP (cyclic citrullinated peptide) antibodies

Symptoms last more than 6 weeks, esp bad in am

Elevated ESR and CRP

Joint erosion

Analgesics

Nonbiologic DMARDs

Biologic DMARDs

DMARD=Disease Modifying Anti-rheumatic drugs

Sunlight Exposure

Viral infection (esp. Epstein-Barr)

Some Drugs

Abnormal apoptotic cell death occurs, self-DNA forms on the surface of dead cell.

The dead cell gets presented to T cells

Antibodies are then made to attack the dead cell.

Immune complexes deposit in the tissue

Butterfly rash/Malar flush

Low grade fever

Non-deformative arthritis

Photosensitivity

Scalp lesions

Mucocutaneous ulcers

These 5 Ocular signs may be indicative of which disease?

Episcleritis

Scleritis

Uveitis

Cotton Wool spots

Optic neuritis

Autoimmune disease

-attack on salivary and lacrimal glands resulting in persistent dryness of the eyes and mouth.

High ESR

leukopenia/thrombocytopenia

Positive ANA or RF

Salivary gland biopsy demonstrating high numbers of lymphocytes

Treat the symptoms of dryness and any underlying rheumatic diseases

-possibly cholinergic drugs to stimulate remaining gland function

DMARD if severe

Raynaud phenomenon (extreme vasoconstriction peripherally, leading to hypoxia)

Antinuclear antibodies

Types: Limited and Diffuse

Limited presents with a long history of Raynauds phenomenon and infrequent systemic symptoms

Diffuse however is characterized by recent onset of Raynauds and significant systemic symptoms

1. Thickened skin 

2. Sclerodactyly (thickening specifically on fingers and toes)

3. Digital pitting

4. Bibasilar pulmonary fibrosis

Polyarteritis Nodosa

Polymyalgia Rheumatica and GCA

Wegener Granulomatosis

Behcet disease

1. Only affects the arterial circulation and not the venous

2. No Granulomatous inflammation

Skin

Peripheral Nerves

Gastrointestinal tract

Kidneys (not the glomerulus)
 

Myalgias

Arthralgias (large joints)

Peripheral Nerve Infarction

Testicular Ischemia

Mesenteric Vasculitis

Fevers

Tachycardia

Skin Lesions

A vascular pattern on the skin, purple discoloration, caused by swelling of veins in the skin.

Seen in PAN

Necrosis of the myocardium 

Tachycardia either due to overall inflammation or direct cardiac involvement

Possible MI

Elevation of acute phase reactants

Thrombocytosis

Anemia

High doses of corticosteroids

Cytotoxic agents if corticosteroids do not work

A panarteritis (inflammatory disorder of all layers of arteries)

Occurs mostly in elderly populations

They are two separate diseases that can sometimes occur together

They share similar risk factors and pathogenesis but differ in clinical presentation.

Patients with PMR may also develop GCA

An inflammatory disorder characterized by soreness and stiffness of the head, neck and hip-girdle area. 

Accompanied by elevated Erythrocyte Sedimentation Rate (ESR)

On its own it does not put the patient at risk for losing their vision

Some unknown antigen in Vascular adventitia activates a T cell. The resulting inflammatory cascade causes recruiting of T cells and macrophages to all layers of the vessel.

Cytokines add to the inflammation and contribute to the tissue damage. 

(the different cytokines in different people may explain why some people go blind and others do not.) 

This inflammation is also in the synovial lining in PMR

Elevated ESR (>50mm/hr)

Headaches

A patient presents with:

Pain upon chewing

Anemia

Fever

history of PMR

Episodes of blurred vision

What should you worry about

Patient presents with:

Arthritis

Ulcers on Tongue and breasts

unequal arm blood pressure

Anemia

What should you worry about?

Pain or discomfort when using a limb/muscle.

Generally due to poor circulation

1. New headaches

2. Abnormal temporal artery

3. Older than 50 years

4. ESR >50 mm/hr

5. Positive temporal artery biopsy

1. Older than 50 years

2. R/O all other disease except GCA

3. Aching stiffness for 1 month in 2/3 of hip, shoulder, neck

4. Morning stiffness

5. ESR> 40mm/hr

6. Rapid response to prednisone

Corticosteroids (prednisone) until ESR levels and symptoms go back to normal, then slowly taper patient off of the corticosteroid

Studies have shown that GCA patients should also take low-dose aspirin to reduce the risk of blindness and stroke

Cataracts

Osteoporosis

Hypertension

Infection

Glucose homeostasis disruption

PMR/GCA

What is the response to an inflammatory flare-up during the tapering process?

PMR/GCA

What is the response to an inflammatory flare-up accompanied with vision loss

A Systemic Vascular disease that affects arteries and veins, both medium and small.

It is characterized by necrotizing granulomas in the respiratory tract and glomerulonephritis

Upper respiratory tract

Lungs

Kidneys

Range of nodules that cause no symptoms to

fulminant alveolar hemorrhage

(fulminant meaning sudden and severe)

Segmental Necrotizing glomerulonephritis

Possibly proliferative glomerulonephritis

Myalgias

Arthralgias

Arthritis

Palpable purpura (purple discoloration caused by bleeding under the skin)

Ulcers

Vesicles

Papules

Subcutaneous nodules

Orbital pseudotumour

Episcleritis

Peripheral Ulcerative keratitis

Subglottic stenosis

Tracheal stenosis

-both can prove fatal if the disease is untreated

Biopsy of suspicious lesions

Positive anti-neutrophil cytoplasmic antibodies

Cyclophosphamide (an alkylating agent, often a cancer treatment)

Methotrexate (antimetabolite, cancer and RA drug)

Glucocorticoids

What disease is characterized by recurrent attacks of:

Oral aphthous ulcers

Genital ulcers

Uveitis

Skin lesions

Presence of aphthous ulcers plus 2 of these three:

Recurrent genital lesions

Ocular lesions

Skin lesions

Depends on patient:

Immunosuppressants (DMARDs)

Antibiotics

Corticosteroids

Arthritis of the axial skeleton

Oligoarthritis of peripheral joints

Enthesitis

Negative RF (seronegative)

Presence of HLA-B27

1. Palpation of the SI joint elicits pain

2. The Schober test-skin stretches less than 15 cm

3. Chest expansion

4. HLA-B27 positive

5. Radiographic evidence of sacroiliitis

NSAIDs

DMARDs if pt does not respond to NSAIDs

 Arthritis of axial skeleton

Asymmetrical oligoarticular peripheral joint involvement

Frequent involvement of the DIP joint

 Enthesitis

 Negative for RF factor

 Presence of Psoriasis

Dactylitis

Nail Changes

Tricked you!

its neither, the ratio is 1:1

An autoimmune disease that probably involves an infectious trigger

Associated with various HLA (B27, B7, B13, B17 etc.)

Ridging

Pitting

Onycholysis (detachment of nail from nail bed)

Hyper keratosis (thickening of skin)

Joint space narrowing

Joint erosion

Especially on DIP and PIP

Asymmetric joint involvement

Wrists and MCP generally spared (unlike RA)

NSAIDs

DMARDs

Corticosteroids

These bacteria are known for triggering what systemic condition?

Shigella

Salmonella

Campylobacter

Yersinia

Chlamydia

Clostridium