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Rheumatology

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Title: Rheumatology


1
  • Rheumatology
  • Summer Board Review
  • Session 1
  • Mashkur Husain

2
Question 1
  • A 47-year-old man is evaluated in the emergency
    department for a 5-day history of acute swelling
    and pain of the right knee. He has a 15-year
    history of gout, with multiple attacks annually
    he also has diabetes mellitus and chronic kidney
    disease. Medications are enalapril, glipizide,
    and allopurinol.
  • On physical examination, temperature is 38.2 C
    (100.8 F), blood pressure is 146/88 mm Hg, pulse
    rate is 96/min, and respiration rate is 15/min.
    BMI is 27. Several nodules are noted on the
    metacarpophalangeal and proximal interphalangeal
    joints and within the olecranon bursa. The right
    knee is swollen, erythematous, warm, tender, and
    fluctuant.

3
Question 1
  • Laboratory studies
  • Hemoglobin 10.1 g/dL (101 g/L)
  • Leukocyte count 13,000/µL (13 109/L, 85
    neutrophils)
  • Serum creatinine 2.8 mg/dL (247.5 µmol/L)
  • Serum uric acid 9.2 mg/dL (0.54 mmol/L)
  • Radiographs of the knee reveal soft-tissue
    swelling.
  • Aspiration drainage of the right knee is
    performed. Synovial fluid leukocyte count is
    110,000/µL (110 109/L, 88 neutrophils).
    Polarized light microscopy of the fluid
    demonstrates extracellular and intracellular
    negatively birefringent crystals. Gram stain is
    negative for bacteria. Culture results are
    pending.

4
Answer Choice
  • Which of the following is the most appropriate
    initial treatment?
  • A Intra-articular methylprednisolone
  • B prednisone
  • C Surgical debridement and drainage
  • D Vancomycin plus piperacillin-tazobactam

5
Answer Choice
  • Which of the following is the most appropriate
    initial treatment?
  • A Intra-articular methylprednisolone
  • B prednisone
  • C Surgical debridement and drainage
  • D Vancomycin plus piperacillin-tazobactam

6
Explanation
  • This patient requires empiric therapy with
    vancomycin plus piperacillin-tazobactam, pending
    the results of synovial fluid cultures. Based on
    his history of gout as well as the presence of
    tophi and intracellular and extracellular
    negatively birefringent (urate) crystals, the
    patient is currently having a gout attack.
    However, an excessively high synovial fluid
    leukocyte count of the joint (gt50,000/µL 50
    109/L) requires that the acute joint process be
    presumed infectious until proved otherwise. In
    this setting, a negative Gram stain is of
    insufficient sensitivity to rule out infection.
    Patients with chronic joint damage such as that
    seen in gout and other arthritides are at greater
    risk for joint infection. This patient also has
    diabetes mellitus and is presumed to be
    immunocompromised and susceptible not only to
    gram-positive, but also to gram-negative and
    anaerobic, organisms. Therefore, empiric
    combination therapy with vancomycin and
    piperacillin-tazobactam is an appropriate
    approach.
  • Although intra-articular methylprednisolone is an
    appropriate approach to treat an acute gout
    attack while minimizing systemic corticosteroid
    effects, corticosteroids should never be injected
    into potentially infected joints.

7
Explanation
  • Prednisone is also an effective treatment for
    acute gout, particularly if polyarticular
    however, use in this patient with diabetes and a
    potential joint infection would not be
    justifiable unless and until infection were ruled
    out.
  • In this patient, infection is empirically assumed
    but not proved, and the joint has been adequately
    drained percutaneously for the time being.
    Surgical debridement and drainage can be
    considered for a definitively infected joint,
    particularly if the percutaneous approach is
    inadequate to fully drain the entire joint, but
    is premature at this time.

8
Key Points
  • Manage infectious arthritis in a patient with
    concurrent gout.
  • Bacterial infectious arthritis and gout can occur
    concomitantly in the same joint and should be
    suspected when there is a very high (gt50,000/µL
    50 109/L) synovial fluid leukocyte count.

9
Septic Arthritis
  • Diagnosis
  • Septic arthritis should be considered in any
    patient who presents with
  • sudden onset of monoarthritis
  • acute worsening of chronic joint disease
  • previously painless joint prosthesis that is now
    painful
  • radiographic loosening or migration of a cemented
    prosthetic device
  • The risk for infection is increased in persons
    with previously damaged joints (e.g., patients
    with rheumatoid arthritis), in older adults, and
    in immunosuppressed patients. In patients with
    underlying rheumatologic disorders, a sudden
    joint flare that is not accompanied by other
    features of the preexisting disorder and is
    unresponsive to usual therapy suggests a
    diagnosis of infectious arthritis.

10
Septic Arthritis
  • The hallmark of a septic joint is pain on passive
    range of motion in the absence of trauma, and an
    infected joint typically appears swollen and warm
    with overlying erythema.
  • Gonococcal arthritis is the most common form of
    bacterial arthritis in young sexually active
    persons in the United States. This condition
    manifests as either a purulent arthritis or a
    syndrome of disseminated gonococcemia. The
    arthritis usually involves one or two joints
    sequentially, most commonly the knees, wrists,
    ankles, or elbows. Disseminated gonococcemia is
    characterized by a prodrome of tenosynovitis,
    polyarthralgia, and cutaneous lesions that
    progress from papules or macules to pustules and
    usually are sterile on culture. Fever and rigors
    are common

11
Septic Arthritis
  • Most patients with purulent gonococcal arthritis
    do not have systemic features or cutaneous
    involvement therefore, gonococcal arthritis
    should be considered in all sexually active
    patients. Blood cultures for Neisseria
    gonorrhoeae are positive in 50 of infected
    patients. Obtaining culture specimens from the
    pharynx, genitals, and rectum in addition to
    synovial fluid cultures increases the diagnostic
    yield.
  • Other less common causes of septic arthritis
  • Gram-negative infections are more common in
    older, immunosuppressed, and postoperative
    patients and those with IV catheters.
  • Tuberculous arthritis typically is indolent, does
    not cause systemic features, and is not
    associated with positive TST synovial fluid is
    usually inflammatory with a predominance of
    polymorphonuclear cells and a negative Gram
    stain.
  • Fungal arthritis typically manifests as subacute
    monoarthritis in patients with a systemic fungal
    infection.

12
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14
Question 2
  • A 36-year-old man is evaluated for a 5-month
    history of left knee pain and swelling. He is a
    gardener and frequently scrapes his knees while
    working in the soil. He has mild but chronic
    discomfort when walking and at rest. The patient
    reports no diarrhea or urethral discharge and has
    been sexually inactive for 2 years. He has a
    10-year history of type 2 diabetes mellitus that
    is managed with insulin.
  • On physical examination, temperature is 38.0 C
    (100.4 F), blood pressure is 135/77 mm Hg, pulse
    rate is 78/min, and respiration rate is 12/min.
    BMI is 20. The left knee is warm and swollen with
    a palpable effusion. The knee has decreased
    flexion, and increasing discomfort is noted at
    the limits of range of motion.
  • Laboratory studies reveal a leukocyte count of
    11,000/µL (11 109/L, 35 lymphocytes) and an
    erythrocyte sedimentation rate of 48 mm/h.

15
Question 2
  • Radiographs of the left knee reveal soft-tissue
    swelling and diffuse joint-space narrowing, with
    periarticular osteopenia. Aspiration of the knee
    is performed. Synovial fluid leukocyte count is
    6500/µL (6.5 109/L, 65 lymphocytes).
    Polarized light microscopy reveals no crystals.
    Gram stain is negative.
  • Subsequent bacterial cultures, Lyme disease
    titers, rheumatoid factor, and anticyclic
    citrullinated peptide antibody titers are
    negative. Tuberculin skin test results are
    negative.

16
Answer Choice
  • Which of the following is the most appropriate
    diagnostic test to perform next?
  • A Alizarin red staining of synovial fluid
  • B Antistreptolysin O antibody titers
  • C MRI of the knee
  • D Synovial biopsy

17
Answer Choice
  • Which of the following is the most appropriate
    diagnostic test to perform next?
  • A Alizarin red staining of synovial fluid
  • B Antistreptolysin O antibody titers
  • C MRI of the knee
  • D Synovial biopsy

18
Explanation
  • Synovial biopsy is indicated for this patient
    with probable fungal arthritis. Fungal arthritis
    is rare, typically occurs in patients who are
    immunocompromised, and manifests as subacute
    monoarthritis. This patient has long-standing,
    indolent, chronic monoarticular arthritis a
    history of diabetes mellitus and recurrent skin
    breaks with likely soil exposure. In this
    setting, infection with a fungus, particularly
    Sporothrix schenckii, is the likely cause. S.
    schenckii is associated with plant litter and
    other organic materials. S. schenckii arthritis
    usually manifests as progressive joint pain,
    swelling, and loss of range of motion. The
    diagnosis of fungal arthritis requires a high
    degree of suspicion and is most commonly made by
    synovial biopsy and/or culture of joint fluid.
    Because joint fluid culture may take weeks,
    obtaining a synovial biopsy is appropriate at
    this time.
  • Alizarin red staining of synovial fluid is not
    done routinely but is theoretically helpful for
    identifying basic calcium phosphate (BCP)
    crystals, which are invisible under polarized
    light microscopy. However, the chronic nature of
    the patient's condition, along with his
    relatively young age and an absence of
    calcification seen on radiographs, makes a
    diagnosis of BCP arthritis unlikely.

19
Explanation
  • Obtaining antistreptolysin O antibody titers
    aids in the diagnosis of rheumatic fever
    however, this patient lacks the systemic signs
    (such as cardiac and/or neurologic involvement)
    that warrant consideration of rheumatic fever.
  • MRI of the knee would help delineate the extent
    of the joint damage but would not provide insight
    into the nature of the infectious process.
  • Key Point
  • Fungal arthritis is rare, typically occurs in
    patients who are immunocompromised, and manifests
    as subacute monoarthritis

20
Question 3
  • A 52-year-old man is evaluated for a 5-year
    history of gradually progressive left knee pain.
    He has 20 minutes of morning stiffness, which
    returns after prolonged inactivity. He has
    minimal to no pain at rest. He reports no
    clicking or locking of the knee. Over the past
    several months, the pain has limited his
    ambulation to no more than a few blocks.
  • On physical examination, vital signs are normal.
    BMI is 25. The left knee has a small effusion and
    some fullness at the back of the knee the knee
    is not erythematous or warm. Range of motion of
    the knee elicits crepitus. There is medial joint
    line tenderness to palpation, bony hypertrophy,
    and a moderate varus deformity. There is no
    evidence of joint instability on stress testing.
  • Radiographs of the knee reveal bone-on-bone
    joint-space loss and numerous osteophytes

21
Answer Choice
  • Which of the following is the most appropriate
    next diagnostic step for this patient?
  • A CT of the knee
  • B Joint aspiration
  • C MRI of the knee
  • D No diagnostic testing

22
Answer Choice
  • Which of the following is the most appropriate
    next diagnostic step for this patient?
  • A CT of the knee
  • B Joint aspiration
  • C MRI of the knee
  • D No diagnostic testing

23
Explanation
  • No additional diagnostic testing is indicated for
    this patient who has osteoarthritis, which is a
    clinical diagnosis. According to the American
    College of Rheumatology's clinical criteria, knee
    osteoarthritis can be diagnosed if knee pain is
    accompanied by at least three of the following
    features age greater than 50 years, stiffness
    lasting less than 30 minutes, crepitus, bony
    tenderness, bony enlargement, and no palpable
    warmth. These criteria are 95 sensitive and 69
    specific but have not been validated for clinical
    practice. Additional diagnostic testing is not
    appropriate, because it has no impact on the
    management of advanced disease.
  • CT of the knee is very sensitive for pathologic
    findings in bone and can be used to look for
    evidence of an occult fracture, osteomyelitis, or
    bone erosions. However, none of these are
    suspected in this patient.
  • Small- to moderate-sized effusions can occur in
    patients with osteoarthritis, and the fluid is
    typically noninflammatory. Joint aspiration in
    this patient without evidence of joint
    inflammation and evident osteoarthritis is not
    useful diagnostically but is often done in the
    context of intra-articular corticosteroid
    injection or viscosupplementation.

24
Explanation
  • MRI is useful to evaluate soft-tissue structures
    in the knee such as meniscal tears. Patients with
    meniscal tears may report a clicking or locking
    of the knee secondary to loose cartilage but
    often have pain only on walking, particularly
    going up or down stairs. Patients with
    degenerative arthritis often have MRI findings
    that indicate meniscus tears. These tears are
    part of the degenerative process but do not
    impact management arthroscopic knee surgery for
    patients with osteoarthritis provides no clinical
    benefit. The one exception may be in patients
    with meniscal tears that result in a free flap or
    loose body, producing painful locking of the
    joint. These symptoms are not present in this
    patient.
  • Key Point
  • Osteoarthritis is diagnosed clinically and does
    not require advanced imaging to establish the
    diagnosis.

25
Question 4
  • A 76-year-old woman is evaluated for a 3-month
    history of left knee pain of moderate intensity
    that worsens with ambulation. She reports minimal
    pain at rest and no nocturnal pain. There are no
    clicking or locking symptoms. She has tried
    naproxen and ibuprofen but developed dyspepsia
    acetaminophen provides mild to moderate relief.
    The patient has hypertension, hypercholesterolemia
    , and chronic stable angina. Medications are
    lisinopril, metoprolol, simvastatin, low-dose
    aspirin, and nitroglycerin as needed.
  • On physical examination, vital signs are normal.
    BMI is 32. Range of motion of the left knee
    elicits crepitus. There is a small effusion
    without redness or warmth and tenderness to
    palpation along the medial joint line. Testing
    for meniscal or ligamentous injury is negative.

26
Question 4
  • Laboratory studies, including complete blood
    count and erythrocyte sedimentation rate, are
    normal.
  • Radiographs of the knee reveal medial
    tibiofemoral compartment joint-space narrowing
    and sclerosis small medial osteophytes are
    present.

27
Answer Choice
  • Which of the following is the next best step in
    management?
  • A Add celecoxib
  • B Add glucosamine sulfate
  • C MRI of the knee
  • D Weight loss and exercise

28
Answer Choice
  • Which of the following is the next best step in
    management?
  • A Add celecoxib
  • B Add glucosamine sulfate
  • C MRI of the knee
  • D Weight loss and exercise

29
Explanation
  • Weight loss and exercise are indicated for this
    patient with knee osteoarthritis. Her knee pain,
    which is worse with weight bearing, is suggestive
    of tibiofemoral knee osteoarthritis, a diagnosis
    supported by the presence of medial joint line
    tenderness and radiographic findings of medial
    tibiofemoral compartment joint-space narrowing.
    The strongest risk factors for osteoarthritis are
    advancing age, obesity, female gender, joint
    injury (caused by occupation, repetitive use, or
    actual trauma), and genetic factors. Obesity, in
    particular, is the most important modifiable risk
    factor for knee osteoarthritis. Several trials
    have demonstrated that weight loss and/or
    exercise programs can offer relief of pain and
    improved function comparable to the benefits of
    NSAID use. In long-term studies, sustained weight
    loss of approximately 6.8 kg (15 lb) has resulted
    in symptomatic relief.
  • Celecoxib carries an increased myocardial risk
    and is therefore not appropriate for this patient
    who has coronary artery disease. Although
    celecoxib has a lower risk of gastrointestinal
    ulcers than other NSAIDs, it can still cause
    dyspepsia, which occurred in this patient after
    taking naproxen and ibuprofen.

30
Explanation
  • There have been several contradictory studies
    regarding glucosamine sulfate in the management
    of osteoarthritis. After several favorable
    smaller studies, a trial sponsored by the
    National Institutes of Health showed no
    effectiveness in reducing pain. A recently
    conducted meta-analysis also found negative
    results for the use of glucosamine sulfate.
  • MRI of the knee would be indicated to evaluate
    for meniscal or other ligamentous injuries, none
    of which is suggested by this patient's history
    (the knee locking or giving way) or examination
    findings (negative examination for tendinous or
    ligamentous injury).
  • Key Point
  • Obesity is the most important modifiable risk
    factor for knee osteoarthritis, and weight loss
    and exercise are recommended to reduce pain and
    improve function

31
Osteoarthritis
  • Diagnosis
  • Age is the most important risk factor for
    developing primary OA in women and men.
    Additional risk factors include genetics,
    obesity, and trauma-induced mechanical joint
    instability. OA most often affects the lower
    cervical and lumbar spine hips knees DIP, PIP,
    and first carpometacarpal joints.
  • Characteristic findings include
  • morning joint stiffness lasting lt30 minutes
  • gelling (brief stiffness after inactivity)
  • crepitus
  • tenderness along the joint line
  • reduced joint motion
  • bony enlargement (including Heberden and Bouchard
    nodes)
  • involvement of the first carpometacarpal joint
    results in squaring at the base of the thumb

32
Osteoarthritis
  • Two important variants are erosive OA of the hand
    and DISH.
  • Erosive inflammatory OA is characterized by pain
    and palpable swelling of the soft tissue in the
    PIP and DIP joints. This condition also may be
    associated with disease flares during which these
    joints become more swollen and painful.
  • DISH is an often asymptomatic form of OA that
    causes significant radiographic changes similar
    to those associated with degenerative spondylosis
    or ankylosing spondylitis. X-rays of the spine in
    patients with DISH reveal flowing ossification
    that develops along the anterolateral aspect of
    the vertebral bodies, particularly the anterior
    longitudinal ligament. However, neither
    disk-space narrowing nor syndesmophytes are
    visible in this setting, as they are in lumbar
    spondylosis or ankylosing spondylitis,
    respectively.

33
Osteoarthritis
  • Secondary OA results from previous joint injury
    or metabolic diseases such as hemochromatosis.
    Consider metabolic causes when OA develops in
    atypical joints (e.g., MCP joints, shoulder,
    wrist).
  • Be alert for an acutely painful calf mimicking a
    DVT, which represents a ruptured Baker cyst
    (herniation of fluid-filled synovium of the
    posterior knee) or ruptured gastrocnemius muscle.
  • No pathognomonic laboratory tests are available
    for OA. An x-ray is not helpful in the diagnosis
    of symptomatic hand OA (clinical examination is
    more specific) but is the gold standard for hip
    and knee OA. X-rays show joint-space narrowing,
    subchondral sclerosis, and osteophytes. Synovial
    fluid is usually noninflammatory, with a
    leukocyte count lt2000/microliter. Ultrasonography
    is useful in the diagnosis of Baker cyst.

34
Bony enlargement of the DIP joints and squaring
of the first carpometacarpal joint characteristic
of osteoarthritis.
35
Don't Be Tricked
  • Typical OA radiographic changes do not exclude
    other diagnoses. Be alert for
  • septic arthritis superimposed on OA
  • trochanteric and anserine bursitis causing hip
    and knee pain
  • de Quervain tenosynovitis mimicking
    carpometacarpal OA
  • hemochromatosis, particularly if involving the
    second and third metacarpophalangeal joints
  • gout or CPPD deposition disease

36
Therapy
  • Medical therapy includes
  • acetaminophen as first-line therapy for hip and
    knee OA
  • NSAIDs in patients who do not respond to
    acetaminophen or as initial therapy for severe
    pain
  • tramadol if NSAIDs are contraindicated or
    ineffective
  • intra-articular corticosteroids for acute
    exacerbations of knee OA
  • intra-articular hyaluronan injection, which has
    comparable efficacy to NSAID therapy for knee OA
  • glucosamine sulfate, although data for its use
    are conflicting
  • Patients with hip and knee OA benefit from weight
    loss patients with knee OA benefit from
    quadriceps-strengthening exercises. Joint
    arthroplasty of the hip or knee is indicated for
    pain that does not respond to nonsurgical
    treatment, especially when lifestyle or
    activities of daily living are affected.

37
Don't Be Tricked
  • Patients with signs of inflammation should not
    undergo intra-articular corticosteroid therapy
    until synovial fluid analysis excludes infection.
  • Do not select arthroscopic lavage, debridement,
    or closed lavage for knee OA.

38
Medial compartment joint space-narrowing and
subchondral sclerosis consistent with
osteoarthritis are shown.
39
Question 5
  • A 52-year-old man is evaluated for an 8-week
    history of pain and 2 hours of morning stiffness
    of the hands that improves with activity. The
    patient has no pertinent personal or family
    medical history. He takes no medications.
  • On physical examination, vital signs are normal.
    Synovitis is noted at the metacarpophalangeal
    joints of the second through fifth digits
    bilaterally with swelling, tenderness, and pain
    on range of motion. The remainder of the
    examination is normal.
  • Laboratory studies, including complete blood
    count, chemistries, liver chemistry tests,
    thyroid-stimulating hormone, C-reactive protein,
    and urinalysis, are normal erythrocyte
    sedimentation rate is 13 mm/h, and rheumatoid
    factor is negative. Parvovirus serology results
    are negative.
  • Radiographs of the hands are normal

40
Answer Choice
  • Which of the following antibody assays is most
    helpful in establishing this patient's diagnosis?
  • A Anticyclic citrullinated peptide antibodies
  • B Antimitochondrial antibodies
  • C Antineutrophil cytoplasmic antibodies
  • D Antinuclear antibodies

41
Answer Choice
  • Which of the following antibody assays is most
    helpful in establishing this patient's diagnosis?
  • A Anticyclic citrullinated peptide antibodies
  • B Antimitochondrial antibodies
  • C Antineutrophil cytoplasmic antibodies
  • D Antinuclear antibodies

42
Explanation
  • An anticyclic citrullinated peptide (CCP)
    antibody assay is warranted for this patient in
    whom rheumatoid arthritis is suspected. Anti-CCP
    antibodies are present in approximately 40 to
    60 of patients with early rheumatoid arthritis,
    including some patients with a negative
    rheumatoid factor. These antibodies are 95
    specific for rheumatoid arthritis. The presence
    of higher titers of either rheumatoid factor or
    anti-CCP antibodies or the presence of both
    increases the likelihood of disease. Although
    this patient's rheumatoid factor is negative and
    his acute phase reactants are normal, rheumatoid
    arthritis remains a significant concern because
    he has synovitis of eight small joints and
    morning stiffness lasting more than 1 hour,
    common symptoms of rheumatoid arthritis. An
    anti-CCP antibody assay is therefore appropriate
    to determine whether this patient's symptoms are
    caused by rheumatoid arthritis.
  • Antimitochondrial antibodies are present in
    patients with autoimmune hepatitis. Patients with
    this disease can develop arthralgia and arthritis
    similar to this patient however, he does not
    have liver chemistry test abnormalities that are
    characteristic of autoimmune hepatitis.

43
Explanation
  • Antineutrophil cytoplasmic antibodies are
    typically associated with vasculitis such as
    granulomatosis with polyangiitis (also known as
    Wegener granulomatosis), microscopic
    polyangiitis, Churg-Strauss syndrome,
    antiglomerular basement membrane antibody
    disease, and drug-induced vasculitis. Arthritis
    and arthralgia can be associated with these
    syndromes however, the presence of these
    vascular inflammatory disorders would be unusual
    in the absence of other system involvement.
  • Antinuclear antibodies (ANA) can be clinically
    useful when there is clinical suspicion for
    autoimmune conditions associated with these
    antibodies such as systemic lupus erythematosus
    (SLE). SLE may present with arthritis but, in
    this case, SLE is less likely than rheumatoid
    arthritis. SLE typically occurs in women of
    childbearing age, with additional clinical and/or
    laboratory abnormalities rather than isolated
    arthritis. ANA are present in some patients with
    rheumatoid arthritis but are not specific for
    this disorder.
  • Key Point
  • Anticyclic citrullinated peptide antibodies are
    a highly specific marker for rheumatoid
    arthritis.

44
Question 6
  • A 36-year-old woman is evaluated for a 5-week
    history of pain and swelling of the fingers
    accompanied by morning stiffness lasting more
    than 1 hour. Her only medication is ibuprofen,
    which provides minimal relief.
  • On physical examination, vital signs are normal.
    Musculoskeletal examination reveals tenderness
    and swelling of the right second, third, and
    fourth metacarpophalangeal joints and the left
    third, fourth, and fifth metacarpophalangeal
    joints. There is no bony enlargement, ulnar
    deviation, or other abnormalities.
  • Radiographs of the hands and wrists are normal.

45
Labs
Erythrocyte sedimentation rate 40 mm/h
Rheumatoid factor 43 units/mL (43 kU/L)
Antinuclear antibodies Negative
Anticyclic citrullinated peptide antibodies Positive
IgM antibodies against parvovirus B19 Negative
Hepatitis B surface antigen Negative
Hepatitis B surface antibodies Positive
Hepatitis C virus antibodies Negative
46
Answer Choice
  • Which of the following is the most appropriate
    next step in management?
  • A Etanercept
  • B Hydroxychloroquine
  • C Methotrexate
  • D Reevaluate in 6 weeks

47
Answer Choice
  • Which of the following is the most appropriate
    next step in management?
  • A Etanercept
  • B Hydroxychloroquine
  • C Methotrexate
  • D Reevaluate in 6 weeks

48
Explanation
  • Methotrexate is indicated for this patient with
    early rheumatoid arthritis. Experts recommend
    that patients begin disease-modifying
    antirheumatic drug (DMARD) therapy within 3
    months of onset. The sooner DMARDs are
    instituted, the more likely that damage will be
    limited. Methotrexate is the gold standard DMARD
    therapy for rheumatoid arthritis and is central
    to most treatments for the disease. This agent
    can be effective as initial monotherapy for
    patients with rheumatoid arthritis of any
    duration or degree of activity. This patient has
    synovitis of six metacarpophalangeal joints with
    a symmetric distribution not involving the distal
    interphalangeal joints, which is consistent with
    rheumatoid arthritis. She has swelling, prolonged
    morning stiffness, an elevated erythrocyte
    sedimentation rate (ESR), and positive rheumatoid
    factor, which further support the diagnosis of
    rheumatoid arthritis, and initial treatment with
    methotrexate is warranted at this time.
  • Etanercept is a tumor necrosis factor a inhibitor
    used for initial therapy in some patients with
    high disease activity and poor prognostic
    features. This agent may be necessary for this
    patient if her disease does not respond to
    methotrexate.
  • Hydroxychloroquine as monotherapy may be
    effective only in mild cases early in the disease
    course for patients without poor prognostic
    features. This patient has evidence of moderate
    disease activity, given the extent of her
    synovitis and elevated ESR therefore,
    hydroxychloroquine as a single agent is unlikely
    to control this degree of inflammation and is
    more beneficial as an adjunctive agent.

49
Explanation
  • Reevaluation in 6 weeks is not indicated for this
    patient whose laboratory studies reveal no
    evidence of acute parvovirus or hepatitis B
    infection. Such viral infections can cause an
    acute polyarthritis syndrome that mimics
    rheumatoid arthritis. The diagnosis of rheumatoid
    arthritis previously was predicated on symptoms
    lasting more than 6 weeks to exclude many
    self-limiting viral syndromes. However,
    classification criteria no longer require
    symptoms to occur for 6 weeks to avoid delays in
    treatment. The likelihood of rheumatoid arthritis
    is now calculated on the distribution of joints
    involved, rheumatoid factor, anticitrullinated
    peptide antibodies, acute phase reactants, and
    duration of symptoms.
  • Key Point
  • Methotrexate is the gold standard
    disease-modifying antirheumatic drug therapy for
    rheumatoid arthritis and is central to most
    treatments for the disease

50
Rheumatoid Arthritis
  • Diagnosis
  • RA is a symmetric inflammatory polyarthritis that
    primarily involves the small joints of the hands
    and feet. Characteristic findings include
  • morning stiffness lasting gt1 hour
  • seven classic sites of symmetric joint pain (PIP,
    MCP, wrist, elbow, knee, ankle, and MTP joints)
  • synovitis characterized by soft-tissue swelling
    or effusion
  • subcutaneous nodules over bony prominences or
    extensor surfaces

51
  • Laboratory findings include
  • positive rheumatoid factor (sensitivity 80
    specificity 87)
  • elevated ESR or CRP level
  • normocytic anemia
  • positive anti-CCP antibody assay (sensitivity
    76 specificity 96)
  • An x-ray can reveal periarticular osteopenia,
    erosions, and symmetric joint-space narrowing.
    MRI and ultrasonography are more sensitive for
    detecting early RA.

52
  • Don't Be Tricked
  • Negative rheumatoid factor does not exclude RA
    anti-CCP antibody assay may be positive.
  • A positive rheumatoid factor alone is not
    diagnostic of RA.
  • Not all symmetric arthritis is RA.

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54
  • RA extra-articular manifestations
  • arm paresthesias and hyperreflexia ? C1-C2
    subluxation (increased risk of cord compression
    with tracheal intubation)
  • cough, fever, pulmonary infiltrates ? BOOP
  • foot drop or wrist drop ? mononeuritis multiplex
    (vasculitis)
  • hoarseness ? cricoarytenoid involvement
  • multiple basilar pulmonary nodules ? Caplan
    syndrome
  • dry eyes and/or mouth ? Sjögren syndrome
  • pleural effusion with low plasma glucose (lt30
    mg/dL) ? rheumatoid pleuritis
  • pulmonary fibrosis ? rheumatoid interstitial lung
    disease
  • skin ulcers, peripheral neuropathy ? rheumatoid
    vasculitis
  • splenomegaly and granulocytopenia ? Felty
    syndrome
  • red, painful eye ? scleritis
  • HF ? rheumatoid disease or anti-TNF therapy
  • Other complications include increased risk of CAD
    and osteoporosis.

55
Carpal, metacarpal, and PIP joints show
periarticular osteopenia, joint-space narrowing,
and marginal erosions, all characteristic of
rheumatoid arthritis.
56
Therapy
  • Early treatment with one or more DMARDs is
    essential. Choose NSAIDs and low-dose oral and
    intra-articular corticosteroids for quick
    symptomatic relief, but recognize these agents do
    not alter the course of the disease.
  • Monotherapy with hydroxychloroquine or
    sulfasalazine or combination therapy with these
    agents is indicated to manage early, mild, and
    nonerosive disease.
  • In the absence of contraindications, methotrexate
    with or without the addition of another DMARD
    should be instituted immediately in patients with
    erosive disease.
  • In some patients, combination therapy with
    hydroxychloroquine, sulfasalazine, and
    methotrexate has been shown to be more effective
    than monotherapy with methotrexate or
    sulfasalazine plus hydroxychloroquine.
  • Initiate biologic therapy when adequate disease
    control is not achieved with oral DMARDs. The
    initial biologic therapy should be a TNF-a
    inhibitor
  • add a TNF-a inhibitor to baseline methotrexate
    therapy
  • screen for TB before starting therapy
  • treat for latent TB if TST is positive before
    beginning any biologic therapy

57
Therapy
  • perform periodic TST screening while the patient
    continues to receive biologic therapy
  • Common toxicities of TNF-a inhibitor therapy
    include pancytopenia, positive ANA formation
    associated with lupus-like syndromes, and
    demyelinating disorders. Combination therapy with
    multiple biologic therapies is not recommended.
  • Indications for surgical intervention include
    intractable pain or severe functional disability
    from joint destruction. Patients may also require
    surgical repair of ruptured tendons.
  • All patients taking corticosteroids require
    osteoporosis screening and serum calcium and
    vitamin D level measurement. If osteopenia or
    osteoporosis is diagnosed, prescribe a
    bisphosphonate. Annual influenza vaccination is
    indicated for all patients using
    immunosuppressants, and pneumococcal vaccination
    is indicated before beginning treatment with
    methotrexate, leflunomide, or a biologic agent.

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Therapy
  • The most common cause of death in patients with
    RA is CAD. Begin aggressive coronary risk factor
    reduction in all patients. Also, begin adjuvant
    physical and occupational therapy.
  • Don't Be Tricked
  • Hydroxychloroquine and sulfasalazine can be used
    during pregnancy.
  • Test Yourself
  • A 46-year-old man has a 3-month history of
    swelling of the PIP and MCP joints and 90 minutes
    of morning stiffness. Rheumatoid factor is
    negative.
  • ANSWER The probable diagnosis is RA. Select
    anti-CCP antibody assay.

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Question 7
  • A 56-year-old woman is evaluated during a
    follow-up visit for a 6-year history of Sjögren
    syndrome treated with low-dose hydroxychloroquine
    and cyclosporine eyedrops. She has had two
    episodes of cutaneous vasculitis, which resolved
    with corticosteroids.
  • On physical examination, temperature is 36.4 C
    (97.6 F), blood pressure is 116/64 mm Hg, pulse
    rate is 72/min, and respiration rate is 18/min.
    Oral mucous membranes are dry. There is a new
    firm, left parotid gland enlargement without
    tenderness or warmth, reported by the patient to
    be progressive over several months, with
    asymmetry of the parotid glands.
  • Laboratory studies at the time of diagnosis
    revealed elevated serum immunoglobulin levels
    positive mixed monoclonal cryoglobulin levels
    and positive rheumatoid factor, antinuclear
    antibodies, and anti-Ro/SSA antibodies.

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Labs
Complete blood count Normal
Alkaline phosphatase Normal
Calcium Normal
Rheumatoid factor Negative
C3 Normal
C4 Decreased
Antinuclear antibodies Positive
Anti-Ro/SSA antibodies Positive
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Answer Choice
  • Which of the following is the most appropriate
    management?
  • A Add pilocarpine
  • B Add prednisone
  • C Bone marrow biopsy
  • D Increase hydroxychloroquine
  • E Parotid gland biopsy

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Answer Choice
  • Which of the following is the most appropriate
    management?
  • A Add pilocarpine
  • B Add prednisone
  • C Bone marrow biopsy
  • D Increase hydroxychloroquine
  • E Parotid gland biopsy

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Explanation
  • Parotid gland biopsy is indicated for this
    patient who has Sjögren syndrome and progressive
    parotid swelling suggesting possible non-Hodgkin
    lymphoma. Patients with Sjögren syndrome have up
    to a 44-fold increased incidence of lymphoma,
    which may be confined to glandular tissue. Risk
    factors for the development of lymphoma include
    disappearance of rheumatoid factor, the presence
    of mixed monoclonal cryoglobulinemia, cutaneous
    vasculitis, and low C4 levels, all of which are
    seen in this patient. Although benign parotid
    gland swelling can occur and be unilateral or
    bilateral in patients with Sjögren syndrome, this
    patient's high-risk profile and new asymmetric
    parotid enlargement should prompt a biopsy to
    evaluate for extranodal lymphoma in the parotid
    gland. Extranodal marginal zone B-cell lymphomas
    of the mucosa-associated lymphoid tissue (MALT)
    are the most common lymphomas in patients with
    Sjögren syndrome, and salivary glands are the
    most common location other extranodal sites
    include the stomach, nasopharynx, skin, liver,
    and lungs. The risk of nodal lymphoma is also
    increased in Sjögren syndrome. Although benign
    lymphadenopathy is a common disease
    manifestation, the presence of new or rapidly
    enlarging lymph nodes may indicate development of
    nodal lymphoma and should prompt biopsy.
  • Pilocarpine is effective for reducing dry mouth
    symptoms but is not used to treat parotid
    enlargement.

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Explanation
  • Prednisone is generally used to treat
    inflammatory symptoms of Sjögren syndrome,
    including arthritis, vasculitis, and cytopenias,
    but does not reduce parotid swelling or treat
    symptoms of keratoconjunctivitis sicca and
    xerostomia (dry eyes and dry mouth).
  • Patients with Sjögren syndrome often have
    elevated immunoglobulin levels with monoclonal
    gammopathy stability of this during the
    patient's disease course, as well as normal
    hemoglobin, calcium, and alkaline phosphatase
    levels, suggests that bone marrow biopsy to
    evaluate for myeloma is not warranted. Extranodal
    lymphoma in Sjögren syndrome involves the bone
    marrow in less than 10 of patients.
  • Hydroxychloroquine is used to treat arthritis
    associated with Sjögren syndrome however, it is
    unclear if this agent has efficacy in reducing
    sicca symptoms or parotid swelling.
  • Key Point
  • Patients with Sjögren syndrome have up to a
    44-fold increased incidence of lymphoma, which
    may be confined to glandular tissue

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Sjögren Syndrome
  • Diagnosis
  • Sjögren syndrome is an autoimmune disease
    characterized by keratoconjunctivitis sicca and
    xerostomia. Salivary gland enlargement occurs in
    nearly half of patients during the course of the
    disease and is most obvious in the parotid
    glands. This condition may occur as a primary
    disease process or may be associated with another
    autoimmune disease, most commonly rheumatoid
    arthritis. A cardinal feature of Sjögren syndrome
    is the presence of antibodies to Ro/SSA and
    La/SSB. A positive ANA, RF, and
    hypergammaglobulinemia are also frequently found.
    Diagnosis is established by biopsy of a labial
    minor salivary gland. Patients with Sjögren
    syndrome are up to 44 times more likely than the
    general population to have a B-cell lymphoma.
    Careful follow-up is therefore required.

66
Bilateral parotid gland enlargement in a patient
with Sjögren syndrome.
67
Therapy
  • Treatment is symptomatic. Choose artificial tear
    replacement and artificial saliva and mouth
    lubricants. Systemic immunosuppressive therapy is
    indicated only in patients with severe systemic
    manifestations.

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Spondyloarthritis
  • Key Considerations
  • Spondyloarthritis comprises several systemic
    inflammatory joint disorders that share distinct
    clinical, radiographic, and genetic features.
    These disorders are
  • psoriatic arthritis
  • reactive arthritis (formerly Reiter syndrome)
  • ankylosing spondylitis
  • IBD-associated arthritis
  • Characteristics include
  • inflammatory spine and sacroiliac disease
  • asymmetric inflammation in four or fewer
    peripheral joints (typically large joints)
  • inflammation at the sites of ligament and tendon
    insertion (enthesitis)
  • the presence of HLA-B27
  • extra-articular conditions, such as uveitis,
    colitis, urethritis, aortitis, and psoriasis

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Question 8
  • A 42-year-old man is evaluated for a 1-month
    history of a painful, swollen right finger and a
    swollen left toe.
  • On physical examination, vital signs are normal.
    The right third distal interphalangeal joint is
    swollen, with localized tenderness to palpation
    and pain with active and passive range of motion.
    The appearance of the nails
  • is shown
  • The left second toe is remarkable for fusiform
    swelling and mild diffuse tenderness, with
    decreased active and passive range of motion.
    There is onycholysis of several toenails,
    including the left second toenail. The remainder
    of the physical examination is normal.

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71
Answer Choice
  • Which of the following is the most likely
    diagnosis?
  • A Lyme arthritis
  • B Osteoarthritis
  • C Psoriatic arthritis
  • D Rheumatoid arthritis

72
Answer Choice
  • Which of the following is the most likely
    diagnosis?
  • A Lyme arthritis
  • B Osteoarthritis
  • C Psoriatic arthritis
  • D Rheumatoid arthritis

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Explanation
  • This patient has psoriatic arthritis, a systemic
    chronic inflammatory arthritis associated with
    numerous clinical manifestations. Typically,
    psoriasis predates the arthritis by years,
    whereas arthritis develops before skin disease in
    15 of patients. Although there is a poor
    correlation between the severity of skin and
    joint disease, there is a good correlation
    between the severity of nail disease and the
    severity of both skin and joint disease.
    Psoriatic findings may also be limited to nail
    pitting and onycholysis. There are five patterns
    of joint involvement in psoriatic arthritis
    involvement of the distal interphalangeal joints
    asymmetric oligoarthritis symmetric
    polyarthritis (similar to that of rheumatoid
    arthritis) arthritis mutilans (extensive
    osteolysis of the digits with striking
    deformity) and spondylitis. Characteristic
    features of psoriatic arthritis include
    enthesitis, dactylitis, and tenosynovitis. This
    patient has findings characteristic of psoriatic
    arthritis, including inflammation of a distal
    interphalangeal joint and dactylitis of a toe. He
    also has nail changes, including pitting and
    onycholysis.
  • Lyme arthritis typically involves medium- or
    large-sized joints rather than distal
    interphalangeal joints and does not typically
    cause tenosynovitis. Furthermore, this disorder
    does not cause nail changes, as seen in this
    patient.
  • Osteoarthritis can involve the distal
    interphalangeal joints but does not cause
    dactylitis or nail changes.

74
Explanation
  • Rheumatoid arthritis can initially present with
    an asymmetric pattern, although it classically
    takes on a symmetric distribution with time. In
    contrast to this case, rheumatoid arthritis
    typically spares the distal interphalangeal
    joints, involving the proximal interphalangeal
    joints and metacarpophalangeal joints
    preferentially. Finally, this condition does not
    cause nail changes
  • Key Point
  • Psoriatic arthritis is associated with various
    patterns of joint involvement, most notably
    distal interphalangeal joint involvement, and is
    characterized by enthesitis, dactylitis,
    tenosynovitis, and cutaneous involvement such as
    nail pitting

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Psoriatic Arthritis
  • Characteristic findings are classic psoriasis
    (thick silvery scale on a well-demarcated red
    patch) and nail pitting in a patient with joint
    pain and stiffness. Skin involvement commonly
    precedes joint inflammation, although 15 of
    patients first develop joint inflammation.
  • Patterns of joint involvement are various.
    Approximately 40 of patients present with
    symmetric oligoarthritis of the large joints of
    the lower extremities, and 25 of these patients
    develop small-joint polyarthritis, similar to RA.
    Spinal involvement occurs in almost 50 of
    patients with psoriatic arthritis. A
    sausage-shaped finger or toe (dactylitis) may be
    found and the DIP joints are often involved,
    which helps distinguishes psoriatic arthritis
    from RA.
  • Patients with psoriatic arthritis tend to be
    seronegative for rheumatoid factor, but at least
    15 are seropositive, as are a similar percentage
    of patients with uncomplicated psoriasis. Serum
    uric acid levels may be elevated in patients with
    psoriatic arthritis because of rapid turnover of
    skin cells. X-rays may show a pencil-in-the-cup
    appearance of one or more involved joints. Other
    radiographic findings include syndesmophytes and
    sacroiliitis of the axial skeleton.

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  • Don't Be Tricked
  • No relationship exists between the extent of skin
    and joint disease in patients with psoriatic
    arthritis.
  • Do not make a diagnosis of gout based solely on
    joint pain and elevated serum uric acid levels.
  • Use NSAIDs for mild joint inflammation and
    minimal skin involvement prescribe methotrexate
    for severe skin and erosive peripheral joint
    disease. A TNF-a inhibitor is indicated for
    methotrexate-resistant peripheral disease and may
    be indicated as first-line treatment for patients
    with axial involvement and for those with
    dactylitis or enthesitis that does not respond to
    NSAIDs and locally injected corticosteroids.
    NSAIDs, antimalarial drugs, and (withdrawal from)
    oral corticosteroids may exacerbate psorias

77
Diffuse swelling of the left third and fourth
toes and right fourth toe characteristic of
dactylitis.
78
Tiny pits scattered over the nail plate resulting
from psoriatic involvement of the nail matrix.
79
Question 9
  • A 24-year-old woman is evaluated for a 3-week
    history of pain and swelling of the right knee
    and left ankle. She also has urinary frequency
    and urgency. The patient has no history of tick
    exposure, skin rash, diarrhea, or abdominal pain.
    She has not been sexually active in the past
    month. She takes no medications.
  • On physical examination, vital signs are normal.
    Musculoskeletal examination reveals swelling,
    tenderness, warmth, pain on active and passive
    range of motion, and a palpable effusion of the
    right knee the left ankle is swollen and tender,
    with pain at the extremes of active range of
    motion and no significant pain with passive range
    of motion.
  • Serologic test results for Borrelia burgdorferi
    are negative. Urinalysis reveals 2 leukocyte
    esterase, 18 leukocytes/hpf, and no protein,
    bacteria, squamous epithelial cells, or
    erythrocytes.
  • Aspiration of the right knee is performed
    synovial fluid analysis reveals an erythrocyte
    count of 150/µL and a leukocyte count of 7500/µL
    (7.5 109/L). Gram stain is negative. Synovial
    fluid culture results are pending.

80
Answer Choice
  • Which of the following is the most appropriate
    next step in management?
  • A Antinuclear antibody testing
  • B Rheumatoid factor testing
  • C Synovial fluid polymerase chain reaction
    testing for Borrelia burgdorferi
  • D Urine nucleic acid amplification testing for
    Chlamydia trachomatis and Neisseria gonorrhoeae

81
Answer Choice
  • Which of the following is the most appropriate
    next step in management?
  • A Antinuclear antibody testing
  • B Rheumatoid factor testing
  • C Synovial fluid polymerase chain reaction
    testing for Borrelia burgdorferi
  • D Urine nucleic acid amplification testing for
    Chlamydia trachomatis and Neisseria gonorrhoeae

82
Explanation
  • This patient requires urine nucleic acid
    amplification testing for Chlamydia trachomatis
    and Neisseria gonorrhoeae. She has acute
    arthritis of the right knee, enthesitis of the
    left ankle, and urethritis, all of which can be
    seen with disseminated gonorrheal infection
    however, in the absence of any recent history of
    sexual activity, these findings are more
    suggestive of reactive arthritis as can be seen
    after C. trachomatis infection. Reactive
    arthritis occurs in both men and women, and
    enthesitis and oligoarthritis are common. The
    classic triad of arthritis, urethritis, and
    conjunctivitis occurs in only one third of
    patients. Symptoms typically develop 2 to 4 weeks
    after an infection.
  • Classic pathogens associated with reactive
    arthritis include C. trachomatis as well as
    several enteric pathogens. C. trachomatis
    infection may be asymptomatic. Urine sample
    evaluation with ligase reaction can establish a
    diagnosis of C. trachomatis infection at that
    time, antibiotic treatment (azithromycin or
    levofloxacin) is warranted to prevent potential
    sequelae of untreated disease. Sexual partners
    should also be counseled and treated.
  • Antinuclear antibody testing can be helpful in
    the diagnosis of systemic lupus erythematosus
    (SLE). Although arthritis and pyuria can be seen
    in SLE, the pyuria typically results from
    glomerulonephritis and is therefore not
    associated with the lower urinary tract symptoms
    of frequency and urgency. The patient does not
    have any other symptoms or signs of SLE.

83
Explanation
  • Rheumatoid factor is present in approximately 70
    of patients with rheumatoid arthritis. This
    disorder typically presents with a symmetric,
    small joint polyarthritis and does not explain
    this patient's urinary symptoms and pyuria.
  • This patient's negative Lyme disease serology
    results indicate that she does not have Lyme
    arthritis, and testing the synovial fluid for
    Borrelia burgdorferi infection is not needed. In
    patients with Lyme arthritis, testing by
    polymerase chain reaction (PCR) can detect B.
    burgdorferi DNA in synovial fluid. Unlike B.
    burgdorferi serology, synovial fluid PCR testing
    becomes negative after successful antibiotic
    treatment. However, synovial fluid PCR testing
    has not been validated for wide use.
  • Key Point
  • Detection of pathogens such as Chlamydia
    trachomatis in patients with arthritis,
    urethritis, conjunctivitis, and/or enthesitis
    supports a diagnosis of reactive arthritis.

84
Reactive Arthritis
  • Reactive arthritis is an acute aseptic
    inflammatory arthritis that occurs 1 to 3 weeks
    after an infectious event originating in the GU
    or GI tract. A high prevalence of HIV infection
    is found in patients with symptoms of reactive
    arthritis.
  • Characteristic findings include
  • acute asymmetric oligoarthritis (usually in
    weight-bearing joints)
  • dactylitis
  • mouth ulcers
  • inflammatory eye conditions
  • Patients may also have keratoderma
    blennorrhagicum (a psoriasis-like skin lesion on
    the palms and soles) or circinate balanitis
    (shallow, moist, serpiginous ulcers with raised
    borders on the glans penis).

85
  • Diagnostic studies include throat culture for
    Streptococcus, urogenital culture for Chlamydia,
    and serologic studies for Salmonella, Yersinia,
    Campylobacter, Neisseria, and HIV. Obtain
    urinalysis for protein, blood, and leukocytes.
  • If the causative organism can be isolated
    (ß-hemolytic streptococci, N. gonorrhoeae,
    Chlamydia), begin specific antibiotics. If
    infection is ruled out, treat with an
    intra-articular corticosteroid injection in the
    acutely inflamed joint. If arthritis persists for
    longer than 3 to 5 months, begin DMARDs.
    Sulfasalazine is a common first-line choice.
  • Don't Be Tricked
  • The classic triad of arthritis, conjunctivitis,
    and urethritis (or cervicitis) is found in only
    one third of patients with reactive arthritis.
  • Do not prescribe chronic antibiotic therapy for
    patients with reactive arthritis.

86
A papular and pustular rash of the palms and
soles is associated with reactive arthritis.
87
Ankylosing Spondylitis
  • Ankylosing spondylitis primarily affects the
    spine and sacroiliac joints. It also may involve
    the shoulders and hips, although the small
    peripheral joints are not affected. Ankylosing
    spondylitis occurs most often in patients lt40
    years of age and presents as chronic low back
    pain. Characteristic findings are pain and
    stiffness that worsen at night and are relieved
    with physical activity or heat.
  • Physical examination findings include
  • decreased hyperextension, forward flexion,
    lateral flexion, and axial rotation
  • diminished chest expansion
  • asymmetric peripheral arthritis involving the
    large joints
  • painful heels (enthesitis)
  • X-rays show subchondral bony sclerosis, vertebral
    body squaring, and bony ankylosis (bamboo
    spine). When radiographic findings are equivocal
    or absent, MRI can detect the early changes of
    sacroiliitis. HLA-B27 testing is neither
    sensitive nor specific for ankylosing spondylitis
    and does not distinguish ankylosing spondylitis
    from other spondyloarthropathies.

88
  • Extra-articular manifestations include acute
    anterior uveitis (most common), aortic valvular
    regurgitation and cardiac conduction defects,
    apical pulmonary fibrosis and cavitation, and
    cauda equina syndrome.
  • A patient with ankylosing spondylitis with
    increased pain and mobility of the neck following
    a minor accident may have a fracture and requires
    an urgent CT of the cervical spine.
  • Don't Be Tricked
  • Ankylosing spondylitis occurs in both men and
    women.
  • NSAIDs, not aspirin, are the mainstay of
    management. Use corticosteroid injections for
    recalcitrant enthesitis and persistent synovitis.
    Prescribe sulfasalazine for patients with
    primarily peripheral arthritis and a TNF-a
    inhibitor for primarily axial disease. Calcium
    and vitamin D supplements and exercise to retain
    good posture, spinal mobility, and chest
    expansion are beneficial. Begin a bisphosphonate
    if osteopenia or osteoporosis is present.
  • Don't Be Tricked
  • Do not prescribe traditional DMARDs for patients
    with axial disease because they are ineffective.
    Select a TNF-a inhibitor.

89
Sclerosis and erosions of sacroiliac joints and
bridging of the intervertebral disks by
syndesmophytes are characteristic of ankylosing
spondylitis.
90
IBD-Associated Arthritis
  • Inflammatory arthritis can complicate Crohn
    disease and ulcerative colitis. Up to 20 of
    patients with IBD develop a peripheral arthritis,
    which manifests as either a polyarticular
    arthritis resembling RA or an asymmetric
    oligoarthritis predominantly of the lower
    extremities resembling reactive arthritis. The
    course of arthritis often fluctuates with the
    activity of the underlying bowel involvement.
    Another 20 of patients have spinal involvement
    ranging from asymptomatic sacroiliac disease to a
    clinical presentation identical to that of
    ankylosing spondylitis. Unlike peripheral
    arthritis, the progression of spinal involvement
    is independent of the course of the bowel
    disease.
  • The therapies that benefit intestinal disease
    also have efficacy in the treatment of the
    associated peripheral joint and extra-articular
    manifestations. These therapies include
    corticosteroids, sulfasalazine, azathioprine,
    methotrexate, infliximab, and adalimumab.
  • Don't Be Tricked
  • Etanercept has not shown efficacy in treating IBD.

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