Rheum PPT 2018

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RHEUMATOLOGY OVERVIEW

Carmelita J. Colbert, MD
Assistant Professor of Medicine
Division of Rheumatology
Loyola University Medical Center
What is Rheumatology?

• Medical science devoted to the rheumatic


diseases and musculoskeletal disorders
• Study of :
– autoimmune diseases
– connective tissue disease

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Inflammatory vs Non-inflammatory
• Erythema • Mechanical pain (worse
with activity)
• Warmth
• Improves with rest
• Pain
• Stiffness after brief
• Swelling periods of rest (not
prolonged)
• Prolonged stiffness
• Absence of systemic signs
• Systemic symptoms

• Laboratory abnormalities
Differential Diagnosis for Different Joint Patterns

• Monoarticular
– Trauma, hemarthrosis, spondyloarthropathy
– Septic arthritis, crystal-induced
• Oligoarticular
– Spondyloarthropathy, crystal-induced, infection
related
• Polyarticular
– RA, SLE, crystal-induced, infectious

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Rheum Diseases You Will Encounter

• Osteoarthritis
• Rheumatoid Arthritis
• Seronegative spondyloarthropathy
• Crystal-induced arthritis
• Systemic lupus erythematosus
• Vasculitis
• Other important rheumatologic diseases
– Scleroderma, Inflammatory Myopathy

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OSTEOARTHRITIS
• Most common form of arthritis

• > 50 years of age

• Risk factors: age, obesity, occupation, history of trauma

• Most common sites: hands, feet, knees, hips, AC joints,


and facet joints of the cervical and lumbosacral spine

• PAIN (mechanical type), stiffness (< 30 minutes)

• Non-inflammatory, no systemic involvement

• DIP/PIP involvement; spares the wrists (Heberden’s/


Bouchard’s)
OSTEOARTHRITIS
Bouchard’s and Heberden’s nodes
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Treatment
• Minimize risk factors
• Physical therapy
• Analgesic medications
– NSAIDs
– Tylenol, Tramadol
– Periodic steroid injection in selected cases
• Joint replacement in advanced cases
RHEUMATOID ARTHRITIS
– Chronic (>6 wks), inflammatory

– Female > Male

– AM stiffness lasting at least 1 hr

– Typically involves wrist, MCP, or PIP joints

– Polyarticular and symmetric

– Swan neck/Boutonniere/ulnar deviation

– Extra-articular manifestations
• Rheumatoid nodules, interstitial lung disease, vasculitis
Diagnostic Criteria: Rheumatoid Arthritis
• Target population
– At least 1 joint with definite synovitis
– Synovitis not better explained by another disease

• Score of >/= 6/10 needed


• Joints
– 1 large (0), 2-10 large (1), 1-3 small (2), 4-10 small (3)
– >10 joints including at least 1 small (5)
• Serology (at least 1 test result needed)
– Negative RF and CCP (0), Low positive RF or CCP (2)
– high positive RF or CCP (3)
• Acute phase reactants (at least 1 test needed)
– Normal CRP and ESR (0), abnormal CRP or ESR (1)
• Duration of symptoms
– < 6 wks (0)
– > 6 wks (1)
RHEUMATOID ARTHRITIS
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RHEUMATOID ARTHRITIS
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Treatment
• Short term: prednisone
• Mild disease:
– NSAIDs, hydroxychloroquine, sulfasalazine
• Moderate to severe:
– Oral weekly methotrexate, leflunomide (alternative to
methotrexate)
– anti-TNF agents
• Adalimumab, Etanercept, Infliximab (IV), et al
– CTLA4 agonist (inhibit T cell co-stimulatory process
• Abatacept
– anti-CD20 (B cells)
• Rituximab
– anti-IL1
• Anakinra
– anti-IL6
• Tocilizumab
Seronegative Spondyloarthropathy

• Seronegative
• Oligoarticular, asymmetric
• Chronic, inflammatory
• Sacroiliac involvement
• Enthesopathy
• Spinal involvement (inflammatory)
• HLA B27
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Seronegative Spondyloarthropathies

• Ankylosing spondylitis
• IBD associated arthropathy
• Psoriatic arthritis
• Reactive arthritis
• Undifferentiated spondyloarthropathy

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Treatment
• Similar to treatment for rheumatoid
arthritis
• 3 differences
– Hydroxychloroquine can worsen psoriasis
– Axial involvement
• Biologic therapy recommended
– TNF alpha inhibitors are mainstay for
biologics (the other biologics not shown to be
as effective)
• Chronic inflammatory disorder

• Main symptom is inflammatory back pain

• Affects the axial spine, entheses,


peripheral joints and eyes

• Prevalence 0.5%

• Etiology unknown

• Genetic predisposition associated with


HLA B27

• Symptoms begin in 20’s

• Commonly seen in caucasian men


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Psoriatic Arthritis

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Dactylitis (Sausage Toes)
Onycholysis (Psoriasis)
ACUTE GOUT
GOUT
• Recurrent, episodic inflammatory arthritis

• Peak of pain: 24 hours; subside in 3-10 days

• 75 % of initial attacks in 1st MTP joint (podagra)

• Usually monoarticular, may be polyarticular

• Hyperuricemia may or may not be present (normal or


low in up to 30% patients with acute attack)

• Predisposing factors and associated conditions: surgery,


medications (DIURETICS, low dose aspirin,
cyclosporine A), alcohol ingestion, hypertension, renal
insufficiency, hyperlipidemia
Gout (diagnosis)
Chronic Tophaceous Gout
Chronic Tophaceous Gout

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Chronic Tophaceous Gout

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Chronic Tophaceous Gout

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Treatment
• Gout
– Acute
• NSAIDs (ibuprofen, indocin, naproxen), Colchicine, Steroids
(prednisone), steroid injection if appropriate, anakinra
– Long term (2 or more attacks/year, tophi, erosions)
• allopurinol, febuxostat, probenecid
– Prophylaxis
• Colchicine, low dose prednisone, or NSAIDs (up to 6 months)
• Pseudogout
– Acute
• same as above
– Long term
• N/A, methotrexate in refractory cases
Systemic Lupus Erythematosus
Young women, multisystemic disease

• Malar Rash • Blood disorder


• Discoid Rash • Renal disorder
• ANA*
• Serositis • Immunologic abnormalities
• Oral ulcers – (anti-Smith antibody, anti-
double stranded DNA, anti-
• Arthritis phospholipid antibodies)
• Photosensitivity • Neurologic symptoms

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SYSTEMIC LUPUS ERYTHEMATOUS
(MALAR RASH)
Discoid Lupus
Treatment
• Short term: prednisone
• Mild or cutaneous disease
– Hydroxychloroquine
• Moderate to severe disease
– Azathioprine, Mycophenolate mofetil
• Severe disease
– Mycophenolate mofetil
– Rituximab
– Cyclophosphamide
Scleroderma
• Localized vs Systemic
• Systemic : Diffuse or Limited
– Limited = CREST (Calcinosis, Raynaud’s, Esophageal
dysmotility, Sclerodactyly, Telangiectasias)
– Limited
• Skin involvement distal to MCPs
• Lung complication: Primary pulmonary hypertension
• More esophageal involvement, less colon involvement, telangiectasias
• Anti-Centromere antibodies
– Diffuse
• Lung complication: Interstitial lung disease/fibrosis
• Diffuse Scl GI complications ie) colon involvement more common
• Scl 70 Antibodies
– Scleroderma renal crisis can occur in both
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SCLERODERMA
SCLERODERMA

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RAYNAUD’S PHENOMENON
SCLERODERMA-GAVE

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SCLERODERMA-LUNG

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Treatment
• No single medication for all manifestations of
scleroderma
• Treat each manifestation
– GERD: Proton pump inhibitors
– Raynaud’s: calcium channel blockers (nifedipine),
losartan, sildenafil
– Pulmonary hypertension: sildenafil, calcium channel
blocker
– Interstitial lung disease: mycophenolate mofetil,
azathioprine
– Scleroderma renal crisis: ACE inhibitor
Vasculitis
• Inflammation & necrosis of blood vessel
• Perforation & hemorrhage, thrombosis, ischemia

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Vasculitis

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GIANT CELL ARTERITIS
Giant Cell Arteritis
• Patients >50 y/o
• Cranial symptoms—superficial HA, scalp
tenderness, jaw claudication, blindness
• Polymyalgia rheumatica—pain and stiffness of
proximal joints
• Fever, systemic symptoms
• Decreased temporal artery pulse
• Elevated ESR and CRP
• Diagnosis: Biopsy of temporal artery

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Idiopathic Inflammatory Myopathy

• Polymyositis
• Dermatomyositis

• PM and DM
– Proximal muscle weakness
– Muscle pain not a typical symptom if chronic
– Elevated muscle enzymes: CK, Aldolase, LDH
– Myositis Panel
• Diagnosis: biopsy
• Lung involvement: interstitial lung disease
• Increased risk for malignancy: breast cancer, ovarian cancer,
adenocarcinoma
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DERMATOMYOSITIS
DERMATOMYOSITIS

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DERMATOMYOSITIS

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DERMATOMYOSITIS

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DERMATOMYOSITIS

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DERMATOMYOSITIS

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DERMATOMYOSITIS

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Treatment
• Steroids, high dose prednisone followed by taper

• Steroid sparing agents


– Methotrexate, azathioprine
• Interstitial lung disease
– Mycophenolate, azathioprine
• Cutaneous manifestations
– Hydroxychloroquine

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