What's that Antibody
What antibody has the highest specificity for SLE?
anti-smith (does not correlate with disease activity)
What type of arthritis is on this xray finding of periarticular bony erosions, punched out bone lesions with disruption of the cortex (Described as overhanging edges)?
Monosodium uric acid deposition --- severe, long standing inadequately treated gout
CRP > 50 is associated with what 90% of the time?
BACTERIAL INFECTION
50% of first gout flares in men affect this joint
MTP (known as podagra)
What lab result MUST you have to be diagnosed with SLE or to even consider a diagnosis of SLE
+ ANA
> 95% sensitivity for SLE. Actually required by guidelines through ACR to enter the diagnostic criteria
What antibody often corresponds with disease activity in SLE?
Anti-dsDNA
What is the duration of time that most viral illness induced arthropathy will resolve?
6 weeks
Important to help delineate how far up the DDX rheum should be
You patient presents in DIC and has a history of SLE. You get standard labs and see that their ESR is normal, CRP is elevated to 13, she has cytopenias, transaminitis and is appearing grossly ill. Why is her ESR normal?
60% of ESR is fibrinogen. In states of low fibrinogen, your ESR can be falsely low!!!!
Roughly how long does it take for your standard gout to resolve without treatment
10 days
- Can be days to a few weeks, in chronic disease flares can persist for months
A 29 year old woman is presenting to you with a diffuse rash cross her body, fatigue, muscle aches over the past month. Her PCP refers her to your office after ordering an ANA/ENA/dsDNA panel as well as a CBC with diff a CMP.
You review her results and discover the following:
ANA- 1:160
ENA - + anti-histone
dsDNA - negative
CBC - anemia 10.3
CMP wnl
You recently discover that she started a new medication for acne about 1.5 months ago that can cause her presentation. Name that medication.
Minocycline!
What antibody is associated with GPA?
What is c-ANCA?
correlation with disease activity is unclear. High specificity in classic presentations, 90% sensitive when disease is active
what does this ultrasound show (Red arrow). It is of the tibial side of the knee
gout
What percentage of a health population will have a positive ANA at a 1:40-1:80 titer? How about 1:160?
~20-30%, 5%
when do flares typically begin (morning, midday, evening, nighttime) and after how long do they peak?
nightime, 12-24 hours
According to MKSAP 19, what titer of ANA and lower is considered negative?
1:20
1:40
1:60
1:80
1:120
1:80 or lower
Antibody associated with Sicca syndrome?
What is/are Anti-Ro/SSA, anti-La/SSB?
Sicca symptoms; in SLE, associated with photosensitive rash; offspring of mothers who are positive for anti-Ro/SSA or anti-La/SSB are at increased risk for neonatal lupus erythematosus (rash and congenital heart block)
This subtype type of arthritis primarily affects DIP and PIP joints, leading to more joint erythema and swelling that other forms of primary hand arthritis of this type. it is more common in women, and radiographs have diagnostic findings of "seagull" or "gull wing" appearance in the finger joints
Erosive OA
-- controversial as to whether this is a separate disease entity or is party of a continuum of OA
My hands turn blue in the cold/often stay blue and cold but my pulses are strong and I don't have ulcers on my fingertips. Do I have raynauds?
No -- this is acrocyanosis.
Postmenopausal women have initial gout presentations that affect which two joints that are also typically affected by OA?
knees or fingers - usually OA will have affected them first
For more severe or long standing disease, polyarticular flares can occur with acute bursitis (largely olecranon and prepatellar mostly), periarthritis, and gouty panniculitis/cellulitis which can be seen as refractory bacterial soft-tissue infections
In men with established dz - flares can affect almost any joint, including the spine
Pt has two months of skin changes on chest and arms. No other symptoms. She is on birth control. (slide)
Lab eval = ANA 1:640, speckled, anti-Ro +
What type of lupus is this?
SCLE
What antibody has a high sensitivity for MCTD?
What is anti-u1-RNP?
More common in mend, this noninflammatory condition is characterized by calcification and ossification of spinal ligaments (particularly the anterior longitudinal ligament) and entheses (tendon/ligament attachments to bone). It is more common in Men and usually presents as back pain and stiffness, with most often affecting the thoracic spine.
DISH (diffuse idiopathic skeletal hyperostosis)
Spinal calcifications are also seen in ankylosing spondylitis but calcifications in DISH are more "flowing", wider, and less vertically oriented than those seen with ankylosing spondylitis. DISH lacks SI joint involvement as well!
-- Radiographic changes characteristic of DISH include confluent ossification of at least four contiguous vertebral levels, usually on the R side of the spine.
https://mksap19.acponline.org/app/text/rm/mk19_b_rm_s4/mk19_b_rm_s4_3_3
How do you know which drug to choose to treat an acute gout flare? (Steroids, Colchicine, NSAIDs)
by the patient's comorbidities!
Colchicine - 1.2 mg at first symptoms of flare, followed by 0.6mg 1 hour late (most effective within 24 hours of start of flare). NOT IN CKD. Has GI side effects -- diarrhea
NSAIDs - high dose 5-7 days. NOT IN AC, relatively not with CHF
GCS - intra-articular, IM, or an oral burst x 5 days. CONSIDER T2DM, osteoporosis, infections
SEVERE or Refractory Gout w contraindications - Anakinra or Canakinumab
What is the gold standard for diagnosing a gout flare? Describe the finding.
negatively birefringent, needle like monosodium urate crystals, along w neutrophils in synovial fluid.
“Negatively birefringent” means that under polarized light, the crystals appear yellow when parallel to and blue when perpendicular to the polarizing axis of an optical filter.
SLE is associated with certain "non rheumatologic health risks", even when the disease is under good control/in remission. Name these 2 increased health risks (hint: you would address this as a PCP)
1) CAD - pt are 2 to 10 fold increased prevalence of CAD
>> most common cause of death in older patients with SLE
>> h/o high SLE dz activity (particularly with nephritis) and pred > 10mg/d = independent RF for CAD
2) Cancer - due to immunosuppressive medication.
--HPV/cervical cancer
--hematologic cancer - NHL (2-3x higher than average pop)
-- high doses of cytoxan = solid organ tumors, azathioprine is assoc with inc risk of myeloproliferative syndromes