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