Rheumatology

PA Study Sesh

This week on PA Study Sesh, we’ll learn about Rheumatology.
A note about ANA, RF, ESR, CRP
ANA: Antinuclear antibodies
Shows antibodies against self
Can be positive in healthy people
Also induced by certain drugs & cancers
NONSPECIFIC
CRP: C-reactive protein
Produced in the early stages of inflammatory process.
NONSPECIFIC
ESR: erythrocyte sedimentation rate “sed rate”
Rate at which rbcs settle
NONSPECIFIC
RF: Rheumatoid Factor
Autoantibody to a fragment of IgG
NONSPECIFIC
In Summary: These are all NONSPECIFIC and only clue you in to the presence of inflammation and auto-immune disease. They do not help you definitively distinguish one disease from another and therefore (in my opinion) are not worth memorizing their absence/presence in each disease for PANCE/PANRE purposes.
Fibromyagia
* Chronic, widespread muscle pain
* Middle aged women
* Associated fatigue, fibro fog
* Diffuse pain in 11/18 trigger points >3 months
* Clinical diagnosis
* Tx: exercise (swimming), OTC pain medication, TCA
Reactive Arthritis (Reiter Syndrome)
* Autoimmune response to an infection elsewhere
* Young males most common
* Arthritis, conjunctivitis/uveitis, urethritis
* Keratoderma blenorrhagicum (hyperkeratotic lesions on palms/soles)
* s/p chlamydia #1, may also follow gonorrhea or GI infections
* Labs: Often HLA B-27 + (young males like ankylosing spondylitis)
* Can’t pee, can’t see, can’t climb a (bamboo) tree, can’t sleep with me
* Tx: NSAIDS
* Abx if infection not treated
Gout
* Uric acid
* Most patients are under excretors, which explains why associated with food consumption
* Purine-rich foods, TZD, ACE/ARBs, ASA, Pyrazinamide, Ethambutol (TAPE)
* Men most common
* 1st MTP joint = podagra
* Red, swollen, tender joint
* Arthrocentesis=gold standard
* Negatively birefringent, needle shaped urate crystals
* Tophi: colletion of solid uric acid (ears, eyelids, fingers)
* X-ray
* Rate bite erosions (recurrent)
* Tx:
* Acute: NSAIDS (indomethacin), but avoid ASA
* 2nd line= colchicine
* Chronic:
* Colchicine (can be used in both!)
* Probenecid (uricosuric drug)= increase excretion
* Allopurinol (Xanthine Oxidase Inhibitor)- decreases uric acid production, so not used in acute disease.
Pseudogout
* Calcium pyrophosphate
* Large joints. Knee #1
* Red, swollen, tender joint
* Arthrocentesis:
* Postitively birefringent prism shaped (rhomboid)
* Tx: NSAIDS, steroid injection
* Colchicine also used acute & chronic.
* Prophylaxis if more than 3 attacks per year
Juvenile RA
* AKA juvenile idiopathic arthritis
* Prior to age 16, typically resolves by puberty
* 3 types
* Oligoarticular (50%)
* Less than 5 joints involved in the first 6 months (typically large joints)
* Swollen, tender, warm, without erythema
* May have concomitant anterior uveitis
* Refer to ophthomology
* + ANA
* Symptomatic treatment (NSAIDS)
* Polyarticular (30%)
* Most similar to adult RA
* If in a teenager, consider early RA presentation
* >5 joints involved during 1st 6 months (usually symmetric)
* Eye involvement less common, but possible
* + ANA +/- RF
* TX: NSAIDS
*
* Systemic (20%) Still’s Disease
* Intermittent,