Progressive loss of articular cartilage with reactive changes in the bone, results in pain and joint destruction (most common arthropathy in adults)
Decreased ROM, joint crepitus, pain worsening througout the day
DIP joint (Heberden's nodes + PIP joint (Bouchard's nodes), and wrist/hip/knee/spine
Asymmetric narrowing or joint spaces, subchondral sclerosis, cysts, marginal osteophytes
Weight reduction, physical actibity, acetaminophen, NSAIDs, intra-articular steroids. Total joint replacement in advanced cases.
A chronic autoimmune disease with synovitis affecting multiple joints and other systemic extra-articular manifestations. Joint destruction ultimately occurs.
F>>M, 40-60yo at onset (juvenile in pts <16yo)
Morning stiffness, symmetric, subcutaneous nodules, RF level >95th percentile, arthritis of hand joints, soft-tissue swelling (DIP joints spared)
Osteoporosis, changes in skin/lungs/kidneys/eyes/liver/bloodstream/heart
Elevated ESR + CRP, RF and anti-CCP positive in up to 80%
PT + NSAIDS + DMARDS (MTX, corticosteroids, biologics) and reconstructive surgery for severe cases.
A systemic disease of altered purine metabolism and subsequent sodium urate crystal precipitation into synovial fluid
M>>W (until menopause, then 1:1)
Clinical Features of Initial Attack
Metatarsal phalangeal joint of the great toe (podagra)
Symptoms around involved joint
Pain, swelling, redness, exquisite tenderness
Substance that may form adjacent to the joint, diagnostic!
Tophi (chalky deposits of uric acid)
Joint fluid shows rod-shaped, negatively birefringent urate crystals seen. Serum uric acid level often > 8 mg/dL
Elevation, dietary modifications (avoid purines and EtOH)
NSAIDs (indomethacin), corticosteroid injections, colchicine in between attacks
Polymyalgia Rheumatica (PMR)
Syndrome with pain and stiffness in the neck/shoulder/pelvic girdles and is accompanied by constitutional symptoms (fever, fatigue, weight loss, depression)
Temporal arteritis (30% of cases)
Stiffness, worse after rest and in the morning. MSK symptoms are bilateral, proximal, symmetrical
Giant Cell Arteritis (scalp tenderness, jaw claudication, headache, temporal artery tenderness-->can lead to vision loss)
ESR elevated (>50mm/hr)
Low-dose corticosteroids (higher doses if GCA), might need to be on for 2 years
An autoimmune disease that destroys the salivary and lacrimal glands (exocrine glands)
May be a secondary complication to pre-existing disorders like...
RA, SKE, polymyositis, scleroderma
Mucus membranes most affected. Parotid glands might be enlarged.
Characteristic features of primary Sjogren's
Dry mouth (xerostomia) + dry eyes (seropthalmia or keratoconjunctivitis)
RF in 70% of cases, ANA in 60%, anti-Ro Abs in 60%, anti-La in 40%. Schirmer's tear test wetting of <5mm of filter paper in lower eyelid in 5min = + for decreased secretions
How to confirm lymphocytic infiltrate and gland fibrosis
Mainly symptomatic management, goal of keeping mycosal surfaces moist. Can give artificial tears and saliva, increased oral fluid intake, and lubricants for eyes/vagina. Pilocarpine may increase saliva flow
Childhood-onset idiopathic arthritis
Characterized by chronic synovitis and extra-articular manifestations (fever, rash, weight loss)
F>>M, at age 1-3yo (males older 8-12yo)
Forms of arthritis
Pauciarticular (50%) polyarticular (35%), systemic (15%)
Systemic (JRA) clinical features
Spiking fevers, myalgias, salmon-pink maculopapular rashin evening. Hepatosplenomegaly, lymphadenopathy, leukocytosis, pericarditis, myocarditis
Pauciarticular clinical features
4 or less medium to large joints. Also at risk for asymptommatic uveitis (can lead to blindness if +ANA)
Polyarticular clinical features
Resembles adult RA, symmetri, 5+ joints. Systemic sx: low-grade fever, fatigue, rheumatoid nodules, anemia.
PT + NSAIDs
An inflammatory arthritis with skin involvement usually preceding joint disease
Symmetric, hands and feet. Affects few joints. Pitting of nails and onycholysis. "Sausage-finger" appearance
ESR elevated, hyperuricemia if severe skin involvement, "pencil in a cup" deformity on x-ray
NSAIDs, MTX, reconstructive surgery as last resort
Intra-articular deposition of calcium pyrophosphate dehydrate (CPPD) in peripheral joints
Acute presentations mimic...
Gout (may be recurrent and abrubt)
Painful inflammation (when crystals shed into joint), most common in knees/wrist/elbow
Rhomboid-shaped CPPD crystals, negatively birefringement. Will see chondrocalcinosis in radiographs (fine, linear calcifications)
NSAIDS, colchicine, and intra-articular steroid injections
An inflammatory disease of striated muscle affecting the proximal limbs/neck/pharynx (skin can also be affected=dermatomyositis)
Unknown, but strong association with occult malignancy
Insidious painless proximal muscle weakness, dysphagia, skin rash (malar or heliotrope), polyarthralgias, muscle atrophy
CPK and aldolase elevated. Muscle bx will show myopathic inflammatory changes
High-dose steroids, MTX, or azathioprine
Scleroderma (Systemic Sclerosis)
Characterized by deposition of collagen in the skin, and also lungs, kidney, heart stomach. Unknown etiology.
Clinical Features in general
95% of patients have skin involvement, starts with swelling of fingers and hands, may spread to trunk and face. R
Clinical Features: Limited
Mostly affects skin of face, neck, distal elbows and knees. Causes pulmonary hypertension later in disease.
Clinical Features: Diffuse
Affects the skin plus the heart, lungs, GI tract, kidneys
CREST Syndrome (associated with limited scleroderma
Calcinosis, Raynaud's, esophageal dysfunction, sclerodactyly, telangiectasias
Skin changes, polyarthralgias, esophageal dysfunction
+ANA in 90% of pts, +anticentromere Ab assoc. w/ limited scleroderma, watch for HTN
No cure. Treat specific manifestations of disease (ie PPIs for GERD, ACEis for renal dz, aboid triggers, and immunosuppressives for pulmonary HTN)
Septic (Infectious) Arthritis
The hematogenous spread of bacteremia infection (osteomyelitis) caused by diagnostic or therapeutic procedure (injection) or infection elsewhere (cellulitis, bursitis)
Single joint, usually knee (can also be hip, shoulder, ankle)
Most common pathogen
Pathogen in sexually-active young adults
Acute swelling, fever, joint warmth and effusion, tenderness to palpation, increased pain w/ minimal ROM
Collect/aspirate synovial fluid, many will also have a positive blood culture.
Aggressive IV Abx followed by oral antibiotics, sometimes arthrotomy and arthrocentesis are required.
Reactive Arthritis (Reiter Syndrome)
A seronegative arthritis that has a tetrad of: urethritis, conjunctivitis, oligoarthritis, and mucosal ulcers (leading cause of nontraumatic monoarthritis)
Can be seen as a sequele to...
STDs or gastroenteritis
Asymmetric arthritis in large joints below the waist (knee, ankle), mucocutaneous lesions (balanitis, stomatitis), urethritis, conjunctivitis
M>>F after STDs (1:1 ratio after enteric infx)
Up to 80% HLA-B27+, synovial fluid negative culture
PT + NSAIDs. Abx can reduce chance of developing disorder, but they don't alleviate sx of the reactive arthritis
SLE (Systemic Lupus Erythematous)
An autoimmune disorder characterized by inflammation, plus +ANA, and involvement of multiple organs
Women of childbearing age, and more in African-American women
(4+ criteria including high ANA): malar rash, discoid rash, photosensitivity, oral ulcers, arthritis, serositis, renal dz, ANA, hematologic/immunologic/neurologic disorders
What must be ruled out?
Drug-induced lupus/lupus-like syndrome (from INH, hydralazine, quinidine). Usually pt. will have positive antihistone Abs
Get CBC BUN, Cr, U/A, ESR, serum complement (C3 or C4), anti-Smith antibodies to mark for progression. ANA is present 99% of the time, but low titers have a low predictive value.
Exercise + sun protection, NSAIDs, Antimalarials (hydroxychloroquine), corticosteroids, MTX
Small/medium artery inflammation involving the skin, kidney, peripheral nerves, muscles, and gut
M>>F, 40-60yo, Hep B pts
Unknown (concurrent in Hep B pts. 30% of the time)
Fever, anorexia, weight loss, abdominal pain, peripheral neuropathy, arthralgias, arthritis, skin lesions. If renal involvement: HTN, edema, oliguria, uremia (if renal involvement.
Vessel bx or angiography to diagnose (might also see ANCA, elevated ESR and CRP)
High-dose corticosteroids, cytotoxic drugs, immunotherapy. Might need to also treat for Hep B. Treat HTN if present
A central pain disorder; cause and pathogenesis are poorly understood
Can occur concurrently with...
RA, SLE, Sjogren's
Nonarticular MSK aches, fatigue, sleep disturbance, multiple tender points on exam, anxiety, depression, headaches, irritable bowel syndrome, dysmenorrhea, paresthesias
Diagnosis of exclusion, must r/o hormonal and vitamin disturbances. Sometimes abnormalities of T-cell subsets
SSRIs, SSNRIs, RCAs. Lyrica is only FDA-approved drug to specifically treat fibromyalgia. Aerobic exercise, stress reduction, and sleep assistance are helpful.