IM - Connective Tissue and Joint Diseases

tonystep1's version from 2017-07-26 01:22

Connective Tissue Diseases Clinical Features

Question Answer
Systemic Lupus Erythematosusfatigue, malaise, fever, weight loss, butterfly rash, photosensitivity,discoid lesions, oral or nasopharyngeal ulcers, alopecia, Raynauds phenomenon, joint pain, arthritis, myalgia with or without myositis, pericarditis, endocarditis, myocariditis, hematologic disease, renal disease, seizures, psychosis
Drug Induced Lupusfatigue, malaise, fever, weight loss, butterfly rash (seldom), photosensitivity (seldom),discoid lesions (seldom), oral or nasopharyngeal ulcers, alopecia, Raynauds phenomenon, joint pain, arthritis, myalgia with or without myositis, pericarditis, endocarditis, myocariditis, hematologic disease
SclerodermaRaynaud's phenomenon, cutaneous fibrosis, dysphagia/reflux, delayed gastric emptying, constipation/diarrhea, abdominal distention, and pseudo-obstruction
Sjorgen's syndromeDry eyes, Dry mouth, arthralgias, arthritis, fatigue, chronic arthritis, interstitial nephritis, vasculitis, Interstitial fibrosis and!or pulmonary HTN, pericardia! effusions, myocardial involvement
CREST syndromeCalcinosis of the digits, Raynaud's phenomenon, Esophageal motility dysfunction, Sclerodactyl of the fingers, Telangiectases (over the digits and under the nails)

Connective Tissue Diseases Diagnostic markers

Question Answer
Systemic Lupus ErythematosusPositive ANA, Anti-ds DNA, Anti-Sm Ab, Anti-ss DNA, Anti Ro
Drug Induced LupusAntihistone Abs
Sjorgren's SyndromePositive ANA, Ro (SS-A) , La (SS-B)
Antiphospholipid Antibody Syndromelupus anticoagulant, anticardiolipin antibody or both Pronlonged PTT or PT is not corrected by adding normal plasma.
SclerodermaPositive ANA , Anticentromere antibody, Anti-topoisomerase I

Connective Tissue Treatment and Management

Question Answer
Acute SLE Exacerbationsystemic corticosteroids
SLE constitutional, cutaneous, and articular manifestationsAntimalarials such as hydroxychloroquine
SLE active glumerulonephritiscyclophosphamide
SclerodermaNo effective treatment
Scleroderma musculoskeletal painsNSAIDs
Scleroderma esophageal refluxPPIs or H2 blockers
Sjorgen SyndromePilocarpine (enhances secretions), artificial tears for dry eyes, good oral hygiene, NSAIDs, steriods for arthalgiasss, arthritis
Raynaud's phenomenonAvoid cold and smoking, keep hands warm; if severe, use calcium channel blockers
Drug Induced Lupusdiscontinue hydralazine, procainamide, isoniazid, chlorpromazine, methyldopa, and quinidine

Joint Diseases Clinical Features

Question Answer
Rheumatoid arthritisSymmetrical inflammatory poly-arthritis - every joint except DIP joints, pain on motion of joints/tenderness in joints (PIP,MCP), Ulnar deviation of the MCP joints, Boutonniere deformities of PIP, Swan-neck contractures, and morning stiffness improves as the day progresses. In addition patients have C1-C2 (subluxation and instability)
Asymptomatic hyperuricemiaincreased serum uric acid level in absence of clinical findings of gout, may present without symptoms for 10 to 20 year or longer.
Acute gouty arthritisInitial attack usually involves one joint of the lower extremity with sudden onset of exquisite pain, often the big toe (podagra). Erythema, swelling, tenderness and warmth over joint. Resolution of pain results in desquamation of overlying skin.
Intercritical goutAn asymptomatic period after monoarticular pain attack of lower extremity. Polyarticular attacks can occur with increased severity over time.
Chronic tophaceous goutTophi cause deformity and destruction of hard and soft tissues. In joints, they lead to destruction of cartilage and bone, triggering secondary degeneration and development of arthritis. They may be extra-articular.
Pseudogout (Calcium Pyrophosphate Deposition Disease)The most common joints affected are knees and wrists.It is classically monoarticular, but can be polyarticular as welL
OsteoarthritisInsidious onset of weight bearing joint pain (knees, hips, lumbar/cervical spine) hands.

Laboratory and Radiographic findings in Joint Diseases

Question Answer
Rheumatoid Arthritis labsHigh titers of RF , Elevated ESR, C-reactive protein, Normocytic normochromic anemia (anemia of chronic disease)
Rheumatoid Arthritis joint radiographsLoss of juxtaarticular bone mass (periarticular osteoporosis) near the finger joints. Bony erosions at the margins of the joint
Late Rheumatoid Athritis joint radiographsNarrowing of the joint space (due to thinning of the articular cartilage) is usually seen late in the disease.
Gout synovial fluid analysisjoint aspiration and synovial fluid analysis (under a polarizing microscope) is the only way to make a definitive diagnosis-needle-shaped and negatively birefringent urate crystals appear in synovial fluid.
Gout joint radiographsRadiographs reveal punched-out erosions with an overhanging rim of cortical bone.
Pseudogout (Calcium Pyrophosphate Deposition Disease) synovial fluid analysisjoint aspirate is required for definitive diagnosis-weakly positively birefringent, rodshaped and rhomboidal crystals in synovial fluid (calcium pyrophosphate crystals)
Pseudogout (Calcium Pyrophosphate Deposition Disease) joint radiographRadiographs-chondrocalcinosis (cartilage calcification)

Treatment and Management of Arthritic/Joint Diseases

Question Answer
Symptomatic management of Rheumatoid Arthritisa. NSAIDs (are the drugs of choice for control of pain. They play an important role in controlling inflammation and should be part of most treatment regimens). b. Corticosteroids (low-dose)-(Use these if NSAIDs do not provide adequate relief.)
First line agents of Rheumatoid ArthritisMethotrexate (Closely monitor liver and renal function.Supplement with folate.) Hydroxychloroquine (It requires eye examinations every 6 months because of risk of visual loss due to retinopathy (although quite rare).)Sulfasalazine
Preventive care of GoutIn all stages, avoid secondary causes of hyperuricemia.(thiazide and loop diuretics) Obesity Reduce alcohol intake Reduce dietary purine intake
First line agent for Acute GoutNSAIDs indomethacin
Alternative agent for Acute GoutColchicine
Refractory Acute Gout attackOral prednisone (7- to 10-day course)
Prophylactic Gout RxUricosuric drugs (probenecid, sulfinpyrazone) Allopurinol (a xanthine oxidase inhibitor, decreases uric acid synthesis)
Severe Refractory Rheumatoid ArthritisSynovectomy (arthroscopic) decreases joint pain and swelling but does not prevent x-ray progression and does not improve joint range of motion. or joint replacement surgery for severe pain unresponsive to conservative measures

Evaluation of Joint Pain

Question Answer
Monoarticular pain with Synovial Fluid Analysis with Positive cultureinfectious arthritis
Monoarticular pain with Synovial Fluid Analysis with Negative cultureEarly RA or SLE, Seronegative spondlyothropathies
Monoarticular pain with Synovial Fluid Analysis with CrystalsGout or Pseudogout
Monoarticular pain with Synovial Fluid Analysis with Bloody effusionTrauma, Coagulopathy , Tumor
Monoarticular pain with Synovial Fluid Analysis with Non-Bloody effusionOsteoarthritis, Avascular necrosis, charcot joint
Polyarticular pain with noninflammatory profileOsteoarthritis
Polyarticular pain with acute inflammatory profileGonococcal, Viral , Lyme, Reiter's Syndrome, Rheumatic fever
Polyarticular pain with chronic inflammatory profileRA, SLE, Scleroderma, Psioriatic arthritis

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