Crystalline Hallows
Name the crystals responsible for gout, pseudogout, Apatite-associated disease, and Calcium Oxalate Deposition Disease.
Gout = uric acid crystals
Pseudogout = calcium pyrophosphate crystals
Apatite-associated = hydroxyapatite crystals
Calcium Oxalate Deposition Disease** in the name
Most common autoantibody associated with Scleroderma
ANA
Ms. M (68yo F) presents at your office with fuzzy vision in her left eye. She mentions a headache that started a week ago and pain in her jaw when eating meals. What disease is at the top of your differential? What tests will you run? And what are your immediate treatment actions?
Temporal (Giant Cell) Arteritis
Medical emergency; expected elevated ESR & CRP. Confirm diagnosis with temporal artery biopsy. Start steroids immediately. If vision loss, refer to ED.
-Infectious arthritis
-Crystalline Arthropathies
-Reactive arthritis
-Acute forms of chronic rheum diseases (?)
This group of diseases is unique in that it is the only group of rheumatologic disorders characterized by muscle weakness.
Idiopathic inflammatory myopathies
(Dermatomyositis, polymyositis, inclusion Body myositis)
The most common cause of hyperuricemia in patients (who may or may not develop gout).
Underexcretion of uric acid (often due to renal insufficiency).
Morphea describes a skin lesion that hardens and thickens over time. Morphea is a subtype of what disease?
Localized scleroderma
Mr. J presents to your clinic with non-specific joint pain, fatigue, and Raynaud's syndrome. Upon further history taking he notes that he is having trouble swallowing his food because his mouth is dry and his eyes are irritated due to poor lubrication. His exam reveals parotid gland enlargement. What is his diagnosis?
Sjogren's Syndrome (possibly with SLE or RA concurrent disorder)
This is the most common mechanism of infection in septic arthritis.
Bonus: #1 overall etiologic agent of septic arthritis.
Hematogenous spread of infection to affected joint.
Staph. aureus
This disease is characterized by sudden onset stiffness and pain in the shoulder and hip girdles. It is highly associated with GCA and responds quickly to low-dose prednisone.
Polymyalgia rheumatica (PMR)
Treatment goal(s) for acute gout vs. chronic gout. Bonus: name the three main treatment options for acute gout.
Acute: 1) relieve pain and inflammation Bonus: NSAIDs (1st line), Corticosteroids, Colchicine
Chronic: 1) relieve pain and inflammation, 2) prevention of recurrent (ULTs), 3) prevent complications
The most common study used to diagnose sarcoidosis.
Chest x-ray
*Sarcoidosis is a diagnosis of exclusion. Other studies may include labs, lymph node biopsies, pulm function tests, EKGs, other imaging etc.
Mr. K arrives in your office with joint pain at the feet, wrists, ankles, and hands. He is feverish & also has a diffuse itchy papulo-vesicular rash across his body. Upon physical exam, he reports great pain when performing wrist, ankle and toe flexion/extension. When you look in his chart, you see his last visit was 4 weeks ago for STI screening with positive results but no return for treatment. What is Mr. K's most likely diagnosis?
Gonococcal infectious arthritis
The onset timing of an acute gout attack.
Extremely acute (within a day).
This disease is the most common adult inflammatory myopathy. Unlike the other two inflammatory myopathies, this disease first presents as weakness and atrophy of distal muscles (calves, foot and finger flexors), but may involve the proximal muscles.
Inclusion Body Myositis
Chondrocalcinosis is a hallmark xray finding of this crystal arthropathy.
Pseudogout (CPPD)
Lofgren syndrome is characteristic of this disease. Bonus: name the four signs associated with Lofgren's.
Sarcoidosis
Fever, bihilar LAD, ankle edema, erythema nodosum.
Jo (25yo, they/them) arrives in your office concerned about multifocal, symmetric joint pain. No hx of trauma or injury. No redness, warmth, or swelling upon exam, but tender to palpation in the periarticular space. They say the pain is 6/10 and keeps them up at night and that the constant pain has been causing them to feel depressed. What is Jo's most likely diagnosis and what are your preferred treatment options?
Fibromyalgia
Multimodal approach to tx (diet, exercise, CBT, sleep therapy, mindfulness/stress therapy, alternative therapies)
Pharm agents (antidepressants-SSRIs, pregabalin, muscle relaxants, hyponotics, analgesics, anticonvulsants)
Treatment of infectious arthritis should be given in this form.
IV (least 2 weeks IV followed by 1-4 week of oral antibiotics. Six weeks total tx)
This disease is a small vessel vasculitis and often presents with a saddle nose deformity.
Granulomatosis with Polyangiitis (Wegener's)
Calcific tendonitis, calcific periarthritis, Milwaukee shoulder, and subacromial bursitis are clinical manifestations of this crystal arthropathy.
Apatite-associated arthropathy aka Basic Calcium Hydroxyapatite Disease
Systemic scleroderma is further broken down into these two categories. Bonus: what are the two differentiating factors between these two categories?
Limited Scleroderma and Diffuse Scleroderma
Limited SSc: limited to distal skin thickening, generally not accompanied by internal organ fibrosis. CREST syndrome.
Diffuse SSc: involves distal AND proximal skin thickening; commonly with visceral organ involvement
Mrs. W comes into the clinic tired. She has been to multiple sub-specialists for her heart, lungs, GI system, and kidneys but is she is still without a diagnosis. She notes that she recently developed paresthesia in her fingers and when you look at her hands, Raynaud's syndrome is apparent. You also note digital edema and you are concerned about the development of digital ulcers and sclerodactyly. Her labs show a high ANA. What do you think is going on?
Systemic Diffuse Scleroderma
Aspirate all red, warm, and tender joints and send for these three labs.
Crystal analysis, culture and sensitivity, CBC.
Bonus: if septic arthritis is suspected, send out blood culture as well.
This disease causes autoimmune antibody-mediated hypercoagulability. It may lead to severe pregnancy complications (fetal loss, pre-eclampsia, maternal thrombosis) and is highly associated with SLE. It is diagnosed through clinical event (thrombosis or pregnancy complication) AND a lab abnormality).
Antiphospholipid Syndrome (APS).