Rheumatology note

1. Rheumatology

2. Overview

3. Osteoarthritis
 Degenerative joint disease (DJD),
 chronic, slowly progressive, erosive damage to joint
surfaces;
 minimal or absent inflammation.

4. Risk Factors
 Increasing age
 trauma to the joint.
 Playing contact sports with trauma.
 Obesity increases DJD

5. Presentation
 weight-bearing joints (knee, hip, ankle).
 The hand is affected, but is not as great a cause of
disability.
 Distal inter-phalangeal (DIP) joints
 Crepitation of the involved joints are common.

6.  Stiffness is of short duration (under 15 minutes).
 DIP enlargement: Heberden nodes
 PIP enlargement: Bouchard nodes

7. Diagnostic Tests
 Laboratory tests are normal:
 Erythrocyte sedimentation rate (ESR)
 Complete blood count (CBC)
 Antinuclear antibody (ANA)
 Rheumatoid factor

8.  The most accurate test is radiography of the affected joint
 Joint space narrowing
 Osteophytes
 Dense subchondral bone
 Bone cysts

9. Treatment
 Weight loss and moderate exercise (hydrotherapy [swimming], tai
chi, yoga)
 Acetaminophen: best initial analgesic
 NSAIDs: used if symptoms are not controlled with acetaminophen
 Capsaicin cream
 Intra-articular steroids if other medical therapy does not control pain
 Hyaluronan injection in joint
 Joint replacement if function is compromised

10. Gout
 Gouty arthritis is a defect in urate metabolism with 90% of
cases in men.
 This can be from overproduction or under-excretion.

11. Overproduction:
Idiopathic
Increased turnover of cells (cancer, hemolysis,
psoriasis, chemotherapy)
Enzyme deficiency (Lesch-Nyhan syndrome,
glycogen storage disease)

12. Under-excretion:
 Renal insufficiency
 Ketoacidosis or lactic acidosis
 Thiazides and aspirin

13. Presentation
 sudden, excruciating pain, redness, and tenderness of the
big toe at night after binge drinking with beer.
 Fever is common, and it can be hard to distinguish the initial
gouty attack from infection without arthrocentesis.
 metatarsal phalangeal (MTP) joint of the great toe is the
most frequently affected site

14. Chronic Gout
 Tophi: tissue deposits of urate crystals with foreign body
reaction.
 Uric acid kidney stones occur in 5% to 10% of patients.

15. Diagnostic Tests
 The most accurate test is aspiration of the joint showing
needle-shaped crystals with negative birefringence on
polarized light microscopy.
 The white cell count on joint fluid is elevated between 2000
and 50,000/μl and are predominantly neutrophils.

16.  Uric acid levels: elevated at some point in 95% of
patients.
 A single level during an acute gouty attack is normal in 25%.
 Acute attacks are associated with an elevated ESR and
leukocytosis.
 X-rays: normal in early disease. Erosions of cortical bone
happen later.

17. Treatment
 Acute Attack
 NSAIDs are superior to colchicine as the best initial
therapy of acute,
painful gouty arthritis.

18.  Corticosteroids by injection in a single joint or orally for
multiple joints are extremely effective.
 No response to NSAIDs
 Contraindication to NSAIDs such as renal insufficiency
 Colchicine is used in those who cannot use either NSAIDs or
steroids.

19. Chronic Management
Diet:
 Decrease consumption of alcohol, particularly beer.
 Lose weight.
 Decrease high-purine foods such as meat and seafood.
 Stop thiazides, aspirin, and niacin.
 Use losartan first for hypertension.

20.  Colchicine is also effective at preventing attacks brought
on by sudden fluctuations in uric acid levels due to
probenecid or allopurinol.
 Allopurinol decreases production of uric acid.
 Febuxostat is used if allopurinol is contraindicated.
 Febuxostat is a xanthine oxidase inhibit

21.  Allopurinol is safe with renal injury.
 Pegloticase dissolves uric acid. Uric
 Lesinurad blocks reabsorption of uric acid in the proximal
tubule.

22. Averse Effects of Chronic Treatment
 Hypersensitivity (rash, hemolysis, allergic interstitial nephritis)
occurs with uricosuric agents and allopurinol.
 Colchicine can suppress white cell production.
 Toxic epidermal necrolysis or Stevens-Johnson syndrome may
occur from allopurinol.

23. Calcium Pyrophosphate Deposition
Disease, or “Pseudogout”
 calcium-containing salts depositing in the articular cartilage.
 The most common risk factors are
 hemochromatosis and hyperparathyroidism.

24. Presentation
 large joints such as the knee and wrist
 It differs from DJD in that the DIP and PIP are not affected.

25. diagnostic Tests
 Uric acid levels are normal.
 X-ray shows calcification
 The most accurate test is arthrocentesis, which
 reveals positively birefringent rhomboid-shaped crystals.
 Synovial fluid will show an elevated level of white blood cells
between 2000 and 50,000/μl,

26. Treatment:
 The best initial therapy is NSAIDs.
 If there is severe disease not responsive to NSAIDs, give
intraarticular steroids such as triamcinolone.
 Colchicine helps prevent subsequent attacks as prophylaxis
between attacks.

27. Low Back Pain
 Low back pain is so common over a lifetime (80% of
population
 Serious patients will require radiologic testing and possible
surgical treatment.
 DJD on x-ray or MRI of the spine is nearly universal in those
above 50 years
 of age and has no meaning when it is found.

28. compression of the Spinal Cord
 Malignancy or infection
 Neurological emergency that needs urgent identification and
treatment.
 history of cancer with the sudden onset of focal neurological
deficits such as a sensory level.

29. On Examination
 Point tenderness at the spine with percussion of the
vertebra is highly suggestive of cord compression.

 Hyperreflexia is found below the level of compression.

30. Epidural abscess
 is most often from Staphylococcus aureus.
 Epidural abscess presents in the same way as cord
compression from cancer, but there is a high
 fever and markedly elevated ESR.

32. Disk Herniation (Sciatica)
 Herniations at the L4/5 and L5/S1 level account for 95%
 The straight leg raise (SLR) test is pain going into the buttock
and below the knee when the leg is raised above 60 degrees.
 Although only 50% of those with a positive SLR actually
have a herniated disk,
 A negative SLR excludes herniation with 95% sensitivity.

34. Diagnostic Tests
 Imaging is required for cord compression, epidural
abscess, ankylosing spondylitis, and cauda equina syndrome.
 The best initial test for cancer with compression, infection,
and fractures is a
 plain x-ray.

35.  The most accurate test is an MRI.
 CT scan is used as the most accurate test if there is a
contraindication to MRI such as a pacemaker.
 If CT scan is used, intrathecal contrast must be given to
increase accuracy (CT myelogram).

36.  Imaging in disk herniation is somewhat controversial
 If severe or progressive neurological deficits (paralysis,
weakness) are described, then an MRI should be done.

39. Treatment:
 Cord compression:
 systemic glucocorticoids,
 chemotherapy for lymphoma,
 radiation for many solid tumors.
 Surgical decompression if steroids and radiation are not
effective.

40.  Epidural abscess: Steroids are used to control acute
neurological deficits.
 Use anti-staphylococcal antibiotics
 Gentamicin is added for synergy with staphylococcus as
is done for endocarditis.
 Surgical drainage is needed for larger collections of
infected material.

41. cuda equina syndrome:
 surgical decompression

42. Disk herniation (sciatica):
 NSAIDs with continuation of ordinary activities (conservative
management) is superior to bed rest.
 Yoga is just as effective as a more regimented or supposedly specific
formal back exercise program.
 Steroid injection into the epidural space achieves rapid and dramatic
benefit for those with sciatica who do not improve with conservative
management.
 Surgery is rarely needed; it is the answer only if focal neurological
deficits
 develop or progress.

43.  man with a history of prostate cancer comes to the
emergency department with severe back pain and leg
weakness. He has tenderness of the spine, hyperreflexia,
and decreased sensation below his umbilicus.
 What is the most appropriate next step in the management of
this patient?
 Dexamethasone.
 MRI.
 X-ray.
 Radiation.
 Flutamide.
 Ketoconazole.

44. Lumbar Spinal Stenosis
 Narrowing of the spinal canal leading to pressure on the cord
is idiopathic.
 Pain occurs when the back is in extension and the cord
presses backwards
 against the ligamentum flavum.

45. Presentation
 age 60 with back pain while walking,
 radiating into the buttocks and thighs bilaterally.
 The pain is described as worse when walking downhill, and
better when sitting, but the pedal pulses and
ankle/brachial index are normal.

46.  Unsteady gait and leg weakness when walking also occur.
 About a quarter have diminished lower extremity reflexes.
 Pain is much less with activities that have the patient leaning
forward such as cycling.

47. Diagnostic Test/Treatment
 The only test is MRI.
 Weight loss and pain meds (NSAIDs, opiates, aspirin) are first.
 Steroid injections into the lumbar epidural space improve 25%
to 50% of cases.
 Physical therapy and exercise such as bicycling or swimming really
help and can put off surgery.
 Surgical correction to dilate the spinal canal is needed in 75% of
patients.

48. Fibromyalgia
 young woman with chronic musculoskeletal pain and
tenderness with trigger points of focal tenderness at
 the trapezius, medial fat pad of the knee, and lateral
epicondyle.
 The cause of fibromyalgia is unknown.

49.  Pain occurs at many sites (neck, shoulders, back, and hips) and
is
 associated with:
 Stiffness, numbness, and fatigue
 Headaches
 Sleep disorder

50. diagnostic Tests/Treatment
 There is no test to confirm fibromyalgia.
 Sleep studies show no REM cycle.
 It is based on a complex of symptoms with trigger points at
predictable points.
 All lab tests are normal such as ESR, C-reactive protein,
rheumatoid factor (RF), and CPK levels.

51.  The best initial therapy is dual reuptake inhibitors such
as duloxetine or venlafaxine.
 Other treatments are amitriptyline, milnacipran, and
pregabalin.
 Trigger point injections with local anesthetic are also
sometimes used.
 Strength training with exercise helps.

52. Carpal Tunnel Syndrome
 carpal tunnel syndrome is a peripheral neuropathy from the
compression of the median nerve as it passes under the flexor
retinaculum.
 Pressure on the nerve interferes with both sensory and motor
function of the nerve.

53.  Associated with overuse of the hand and wrist as well as:
 Pregnancy
 Diabetes
 Rheumatoid arthritis
 Acromegaly
 Amyloidosis
 Hypothyroidism

54. Presentation
 pain in the hand
 muscle atrophy of the thenar eminence.
 .
 Tinel sign: reproduction of the pain and tingling with tapping
or percussion of the median nerve

55.  Phalen sign: reproduction of symptoms with flexion of the
wrists to 90 degrees

56. diagnostic Tests/Treatment
 Carpal tunnel is usually obvious from the symptoms.
 The most accurate diagnostic tests are electromyography and
nerve conduction testing.
 Do not do wrist MRI!

57.  The best initial therapy is with wrist splints to immobilize
the hand in a
 position to relieve pressure.
 Steroid injection is used if splints and NSAIDs do not control
symptoms.
 Surgery

58. Dupuytren Contracture
 hyperplasia of the palmar fascia leading to nodule formation
and contracture of the fourth and fifth fingers.
 There is a genetic predisposition and an association with
alcoholism and cirrhosis.
 Patients lose the ability to extend their fingers, which is
more often a cosmetic embarrassment than a functional
impairment.

59.  Triamcinolone, lidocaine, or collagenase injection may help.
 Surgical release is performed when function is impaired.

60. Sports Medicine

61. Rotator Cuff Injury
 inability to flex or abduct the shoulder.
 It presents with pain in the shoulder that is worse at night
when lying on the affected shoulder.
 There can be severe tenderness at the insertion of the
supraspinatus.

62. Diagnosis
 MRI is the most accurate test.
 Treat with NSAIDs, rest, and physical therapy.
 If these are ineffective, steroid injection relieves pain.
 Surgery is used with complete tears

63. Patellofemoral Syndrome
 anterior knee pain secondary to trauma, imbalance of
quadriceps strength, or meniscal tear.

 The pain is in front of the knee or underneath the patella.

 The pain is particularly bad when walking up or down stairs.

64.  It improves after walking.
 Examination reveals crepitus, joint locking, and instability. X-
rays are normal.

65. Plantar Fasciitis
 very severe pain in the bottom of the foot near the calcaneus where the fascia
inserts.
 It is of unclear etiology.
 The pain is worst in the morning and improves with walking a few steps.
 There is point tenderness at the bottom of the foot

66.  tarsal tunnel syndrome because the pain of that disorder
worsens with use, and plantar fasciitis clearly improves with
use.
 Treatment consists of stretching exercises, arch supports,
and NSAIDs.
 Steroid injection is performed if these don’t solve the
problem.