which autoantibody (auto-ab) is commonly used for dx of lupus?

ANA

results are reported in titers: 1:80 is positive but >1:320 is strongly positive for autoimmune dz

which auto-ab is best for dx of RA?

Anti-CCP → may develop years before joint sx

what would the ESR estimate be for a 64 year old woman?

64/2 = 32 + 10 = 42

what are the 3 Cs for dx of septic arthritis?

cell count/diff

crystals

C&S plus NAATs (for chlamydia)

which dx has the classic triad of dermatitis, migratory polyarthritis, and tenosynovitis?

disseminated gonococcal infection

which joint is MC affected by disseminated gonococcal infection?

knee >>> hand + wrist >>> hip

rarely spine

what is the tx for uncomplicated gonococcal infection?

IM rocephin

tx partners!!!

what is the tx for disseminated gonococcal infection?

IV rocephin + doxy OR azithro (if NAAT positive)

tx partners!!

what is the first line tx for non-gonococcal arthritis?

vanco (bc MC staph aureus)

assoc. w IVDA

If a patient presents with bell's palsy and is found to have Lyme dz, how should you treat?

IV rocephin → neuro/cardio sx = always treat w IV

bell's = MC neuro sx

how many times should you give IV rocephin for Lyme?

NO MORE THAN 2X

what is the confirmatory test for Lyme?

western blot

after ELISA

pt presents with target-like rash that began 3 days ago after a hike. how should you treat?

lyme → doxy x3 weeks

erythro if preg

what is the primary regulator of extracellular calcium?

PTH → secreted in response to hypocalcemia

what is the action of PTH in the kidneys?

increased tubular resorption of calcium and stimulates kidneys to make activated form of Vit D

what is the active form of vitamin D?

1,25-(OH) vit D3

25 (OH) vit D2 = stored

where is calcium released from during a rapid response to hypocalcemia?

lacunar spaces

if the stimulus continues → osteoclasts resorb bone

what is the first line tx for osteoporosis?

Bisphosphonates → alendronate, risedronate, ibandronate, zoledronic acid

"-dronate"

which drug can cause irritation or burning of the esophagus?

bisphosphonates

also causes:

- abd/MSK pain

- osteonecrosis of jaw

- sub-trochanteric fx with >5 yr use

what is the most serious consequence of osteoporosis?

hip fx → often lead to death bc of comorbidities

vertebrae fx is MC

what are some risk factors for osteoporosis?

smoking and alcohol (esp in men)

there are others but she emphasized these

which SERM is approved for treatment of postmenopausal osteoporosis?

raloxifene → risk of DVT!

which type of osteoporosis is postmenopausal? Senile?

primary:

type 1 = postmenopausal (MC)

type 2 = senescence

which drugs are used to up-regulate osteoblasts and "build bone" in pts with osteoporosis?

anaBolics → teriparatide, abaloparatide, PTH, romosozumab

what is the black box warning for anabolics?

osteosarcoma

romosozumab specific = CV dz

what test is used to measure bone mineral density of the femoral neck to determine 10 year probability of fractures?

FRAX

what does a T score of -1 indicate? -2.5?

-1 = osteopenia

-2.5 = osteoporosis

is it okay to perform an arthrocentesis on an uncontrolled diabetic?

NO

dont do it in:

- overlying cellulitis, wound, bacteremia

- neuropathic joint

- coagulopathies

- prosthetics (...??)

- inaccessible joints (duh...?)

- lack of response previously

what dx is defined by compression of the neurovascular structures in the area just above the 1st rib and behind the clavicle?

thoracic outlet syndrome (TOS)

what is the MC facet of TOS?

brachial plexus (95%)

MCC by anomalous cervical rib

what comorbidities are often seen with DISH?

T2DM!!!!!

metaolic syndrome

also more common in men

what is the MC inflammatory dz of the axial skeleton?

ankylosing spondylitis

enthesopathy common

what is the hallmark of AS? Who is it seen in?

hallmark = upward migration of sacroilitis → get MRI

M>W; late teen/early 20s

what are the s/sx of AS?

iPAIN:

i = insidious onset

P = pain in PM/early AM

A = age <45

I = improves w exercise

N = no improvement w rest

what is the first line tx for AS?

NSAIDs → Indocin

2nd line = TNF inhibitors

3rd = IL 12/23, IL-17

4th = JAK inhibitors

what is the first line tx for severe AS?

TNF inhibitors → adalimumab, certolizumab, etanercept, infliximab, golimumab

what happens if you use PO steroids for tx of psoriatic arthritis (PA)?

life-threatening rebound flare

what should you do if a male pt has new onset PA or reactive arthritis?

test for HIV

which dx has the triad of: conjunctivitis, urethritis, oligoarthritis?

reactive arthritis (Reiter's)

can't see can't pee can't climb a tree

what is a common history finding for reactive arthritis?

hx traveler's diarrhea

reactive arthritis = autoimmune condition that develops in response to infection (GI or GU)

which dx is often seen in women who care for sick children, mothers, and daycare workers?

parvovirus B-19 → MC viral arthritis → "fifths" or "slapped cheeks"

IgM titers are _____ in acute parvovirus

HIGH

dx resolves in 2-4 weeks

in which dx may you see a transient generalized rash, small polyarticular joint swelling, and symmetrical pain?

parvo

what arthritis is often seen in IBD and GI pathology?

enteropathic arthritis → bowel related arthritis

which dx shows up as yellow negatively birefringent, long, needle-like crystals?

gout → uric acid crystals

blue when perpendicular

why is gout more common in men?

estrogen is uricosuric

(so is high dose ASA)

which dx shows up as bite-like erosions on XR?

gout

which dx shows up as blue positively birefringent rod or rhomboid shaped crystals?

pseudogout (CPPD)

which dx is secondary CPPD associated with?

1. OA (MC)

2. hyperparathyroidism

3. hemochromatosis

4. hyperthyroidism

what is the tx for osteomyelitis?

IV vanco x6 weeks

what is the best study for dx of osteomyelitis?

MRI

what is the order of tx for ACUTE gouty flares?

1. NSAIDs (Indocin)

2. colchicine

3. steroids

don't use NSAIDs in ppl with PUD

don't use steroids in DM

what is the order of treatment for chronic gout (>2 flares/yr, tophi, kidney stones)?

1. ULT (urate-lowering therapy) AKA Xanthine oxidase inhibitors (XOIs)→ allopurinol or febuoxstat

2. add uricosurics → probenecid, lesinurad

3. uricase agent

what is given for gout when ULTs are taking effect?

bridge of colchicine or NSAIDs x6 months to avoid flares

what is the target uric acid for chronic gout? what about tophaceous gout?

chronic = <6 mg/dl

tophaceous = <5 mg/dl

which drug is FDA indicated for chronic tophaceous and/or refractory gout?

Pegloticase (Krystexxa)(Savient)

what drug is recommended for chronic gout after failure with XOIs?

Lesinurad (Zurampic) → add to XOIs to get UA <6

what is the target for RA? OA?

RA = synovium

OA = cartilage

what is the gold standard for tx of RA?

methotrexate (MTX)

what is the #1 COD in RA pts?

ASCVD d/t proinflammatory state

what is the order of treatment for RA?

1. NSAIDs or MTX

2. MTX + TNF

3. MTX +Jak

what are the risks with TNF biologics?

increased risk for infection (esp TB), possible lymphoma/melanoma risk, drug induced lupus

boutonniere deformity and swan neck deformity are associated with ____

RA

what side effects are commonly seen with MTX?

nausea

LFT elevation

mouth sores

rash

diarrhea or loose stools

blood count abnormalities

lung probs

give folic acid!

which dx is associated with +ANA and uveitis in children <16?

juvenile idiopathic arthritis (JIA)

is hallux valgus or varus more common in RA?

valgus bc the lateral compartment is destroyed first

opposite for OA

what is the wink sign associated with?

RA d/t C1-C2 cord compression

look with open mouth XR view

TMJ = panorex

which type of synoviocyte phagocytoses cell debris and waste inside the joint cavity?

Type A

which type of synoviocyte provides nutrition to the joint?

Type B

what are the risk factors for OA?

- increasing age

- female

- obesity → MC in knee

- trauma/repetitive use

which joints are involved in OA?

- 1st CMC

- DIP (Heberden's nodes)

- PIP (Bouchard's nodes)

- knee

- hips

- lumbar spine

weight bearing joints

which joints are NOT involved in OA?

shoulder

elbow

wrist

foot

ankle

MCP

what is seen on XR in OA?

bony sclerosis, eburnation, osteophytes, loss of cartilage

do standing view bc weight bearing joints affected

which is MC in OA: Varus or valgus?

varus bc destruction starts medially

what is the 1st line tx for OA?

- TOPICAL NSAIDs → then oral

- 2nd line= other analgesics (tylenol)

NO SYSTEMIC STEROIDS EVER

what is the 1st line tx for fibromyalgia?

1st = cyclobenzaprine (Flexeril) (muscle relaxant)

NO PAIN MEDS/NSAIDs

what are the first 5 types of collagen?

1 = skin, tendon, bone*

2 = hyaline

3 = blood vessels, parenchymal cells

4 = basement membrane*

5 = smooth muscle

which type of extracellular macromolecule acts as a "multi-purpose glue" and binds extracellular components together?

proteoglycans

which type of extracellular macromolecules are adhesions molecules?

glycoproteins

which cartilage lines the joints?

hyaline

which type of cartilage is found in the C-spine and rib cage?

elastin

what is the enthesis?

connective tissue between tendon or ligament and bone

what are the first line treatments for CRPS in order?

1. analgesics/NSAIDs

2. antidepressants

3. anticonvulsants

who is CRPS common in?

W > M

younger age (<40)

upper extremity MC

follows minor trauma/surgery

which type of CRPS is d/t partial nerve injury?

type 2

type 1 is CNS afferent sympathetic rxn of joints/soft tissue

what is the best test to evaluate for CRPS?

bone scan → use Tc 99 mm

but radiography is initial study

which type of arthritis found in a young population MC affects the knee and is often monoarticular?

septic

knee>>>hand/wrist>>>hip