Arthritis, Osteoporosis, Poly, Fibromyalgia

Which of the juvenile idopathic subsets of arthritis is most likely to start in the hips?
Systemic onset JIA

Which of the juvenile idiopathic subsets is most likely to have uveitis as a complication?
Pauciarticular onset JIA

Which of the juvenile idiopathic subsets has peaks at 2-5 years old and again at 10-14?
Polyarticular onset JIA

Which of the juvenile idiopathic subsets is associated with marked leukocytosis and anemia?
Systemic onset JIA

What are some lab findings for systemic JIA?
Marked leukocytosis
Marked thrombocytosis
Marked anemia
Elevated ESR and CRP

Which of the juvenile idiopathic subsets presents commonly as a child with a painless limp?
Pauciarticular onset JIA

What are the three main symptoms of systemic onset JIA?
Intermittent spiking fever

What is the term for “sausage digits”?

What are the three main symptoms of reactive arthritis?
(can’t see, can’t pee, can’t climb a tree)

What is the MC etiology of reactive arthritis?
Chlamydia trachomatis

What are the MC locations of arthritis in the reactive type?
Lower extremities

What test can be done with reactive arthritis to see if there may be a genetic predisposition?

True or false: the majority of patients with reactive arthritis will have spontaneous resolution within one year?

Is OA or RA more likely to be symmetrical?
Rheumatoid arthritis

What are the three main symptoms of RA?

Which type of arthritis can have morning stiffness that typically resolves within 30 minutes?

What are the two main hand deformities in OA?
Where are they located?
Heberden nodes (DIP)
Bouchard nodes (PIP)

What are the three main hand deformities in RA?
Where are they located?
Swan neck deformity: hyperextension at the PIP and flexion at the DIP
Boutonniere deformity: flexion at PIP and extension of PIP
Ulnar drift

What are the five MC locations of OA?
Weight bearing joints:

Which type of arthritis can have “boggy” feeling joints?
Rheumatoid arthritis

Where is the MC location for subcutaneous rheumatoid nodules?
Extensor elbows

Crepitus and tenderness along the joint line are found most commonly in which type of arthritis?

The 1st line treatment (medication) for OA is what?
Acetaminophen (APAP, acetyl-para-aminophenol)

What are two common findings on x-ray in a patient with OA?
Narrowed joint space
Osteophytes (bone spurs)

What is a common x-ray finding in patients with RA?

What are the three main subsets of juvenile idiopathic arthritis?
Systemic JIA
Pauciarticular JIA
Polyarticular JIA

What is the etiology of JIA?
Idiopathic and autoimmune

What is the epidemiology of Systemic JIA?
It is the LC subset of JIA
Does not occur after age 16

What does the rash look like for systemic JIA?
Macular, salmon-pink MC on axilla and around waist
Most prominent with fever
Koebner phenomenon

What are the MC locations for systemic JIA?
Wrists, knees and ankles

What is one unique presentation of systemic JIA?
symmetrical swelling of the DIP

What are some systemic findings of systemic JIA?

How can you definitively diagnose systemic JIA?
Must have intermittent daily fever for 2 or more weeks and arthritis

What is the prognosis of patients with systemic JIA?
What are some complications for systemic JIA?
Resolves in 40-50% of patients
May cause destructive damage and loss of growth

What is the treatment for systemic JIA?
NSAIDs (first line)
Oral glucocorticoids

What is the epidemiology of pauciarticular JIA?
MC subset of JIA
Peak incidence 2-3 years old

What is the presentation of pauciarticular JIA?
Involves <5 joints MC locations: knees ankles, wrists and elbows Rarely begin in hips, rarely destructive

How is pauciarticular JIA diagnosed?
Based upon presence of arthritis in <5 joints during the first 6 months of disease

Lab findings for pauciarticular JIA
ANA: low or moderate titers presentESR may be mildly elevated or normal

What is the prognosis for pauciarticular JIA?
What are some complications of pauciarticular JIA?
typically resolves within 6 months
Uveitis and leg discrepancy

What is the treatment for pauciarticular JIA?
Intraarticualr glucocorticoids
Regular eye exam

What is the presentation of polyarticular JIA in children <10 yo?
arthritis in >4 joints
Indolent (painless) onset
MC locations: knees, wrists and ankles
May present with dactylitis

What is the presentation of polyarticular JIA in older children and adolescents?
Relatively rapid onset
MC locations: fingers, wrists, elbows, C-spine, hips, knees and ankles (rarely starts in hips)
Uveitis is less common than in pauciarticular JIA

How is polyarticular JIA diagnosed?
Based upon presence of arthritis in >4 joints during first 6mos of disease

What are the lab finding for polyarticular JIA?
ANA: low titer common in younger children
ESR: mild elevation
Anemia: mild
RF: 10-20% in those older than 10 yo

What is the prognosis for polyarticular onset JIA?
What are some complications of polyarticular JIA?
Young children: low chance of remission
Worse if joint damage evident within first 6 mos or RF+
May cause destructive damage and loss of growth

What is the treatment for polyarticular JIA?
Oral glucocorticoids
Regular eye exams

What is the epidemiology of reactive arthritis?
Very uncommon
Young adults (age 20-40 yo)

How is reactive arthritis diagnosed?
characteristic muskuloskeletal findings
Evidence of preceding infection
Lack of evidence for another cause

What are the lab findings for reactive arthritis?
Leukocytes: may be present
ESR: may be elevated or normal
Genital swab: may reveal Chlamydia
Stool culture: may reveal salmonella, shigella, yersinia or campylobactor

What is the treatment for reactive arthritis?
Antibiotics: if Chlamydia present
NSAIDs (1st line)
Intraarticular glucocorticoid injections (2nd line)

What is RA?
What is the etiology?
RA is a chronic, systemic inflammatory disease that affects synovial joints
Etiology: unknown, autoimmune
Epidemiology: F>M
typical onset: 25-50 yo

What is the MC location of RA?
peripheral joints: MCP, PIP, IP, wrists, MTP, elbows, shoulders, ankles, knees
Usually symmetrical

What are the diagnostic criteria for RA?
Inflammatory arthritis in 3 or more joitns
ESR or CRP elevated
Diseases with similar features excluded
Duration of symptoms for >6 weeks

RA poses increased risk for what?
CV disease
Renal disease

What is the treatment for RA?
Oral or steroid injection

Epidemiology of OA
MC joint disease int he world
50% of US
Peak prevalence: 8th decade

MC symptoms of OA
Pain: exacerbated by activity, night pain may be present
Stiffness: typically resolves within 30 minutes

Common knee deformities in OA

Diagnosing OA
Perform hx and PE
Obtain radiologic imaging if necessary
Diagnostic criteria for hand, knee and hip

Treatment of OA
PT/OT, heat
Weight loss
Acetaminophen (APAP)
Intra-articular glucocorticoid injections
Surgical: when other therapies have failed

Definition of Polyarteritis nodosa
PAN is systemic necrotizing vasculitis typically affecting medium-sized muscular arteries

Epidemiology of PAN
2-33 million affected
Peak incidence in 6th decade
1.5;1 male predominance

Etiology of PAN
Mostly idiopathic
Predisposing diseases (secondary PAN):
Hepatitis B viral infection
Hepatitis C virus infection
Hairy cell leukemia

Clinical presentation of PAN
Systemic symptoms:
Wt loss
Mulisystem involvement:
Skin lesions
Renal insufficiency
Neurologic dysfunction
Abdominal pain

What body systems are involved in PAN?
Skin, Renal, Neurologic, Gastrointestinal, Heart and muscles

What is the presentation of Skin PAN?
Tender erythematous nodules
Palpable purpura
MC in LE

Complications of PAN involving the skin
Limb edema, infarction, gangrene, ulceration

What is the MC organ involved in PAN? How does it present?
Can lead to renal insufficiency and hypertension
UA may show minimal proteinuria and/or hematuria

What are some manifestations of neurologic PAN?
Asymmetric polyneuropathy
Motor and sensory deficits
One of the MC findings in PAN

Presentation of GI PAN
abdominal pain with mesenteric arteritis
Weight loss or malabsorption may occur
Can result in bowel infarction with perforation

Presentation of coronary artery disease (in PAN)
Myocardial ischemia resulting from narrowing or occlusion of coronary arteries
Heart failure may result form vasculitis of coronary arteries or from uncontrolled hypertension from renal disease
Overt myocardial infarction is uncommon

Presentation of muscle disease in PAN
Myalgia and muscle weakness
Serum creatine kinase may be slightly elevated

How is PAN diagnosed?
Clinical diagnosis: based on characteristic symptoms, physical findings and compatible laboratory test results
Diagnosis should be confirmed by biopsy
Angiography may reveal microaneurysms

How is PAN treated?
Treat HTN to prevent associated complications
Treat underlying cause
Treat complications
Corticosteroids +/- other immunosuppresive agents

What is polymyositis?
Polymyositis is a systemic connective tissue disease characterized by inflammatory and degenerative changes in muscles (can be accompanied by skin rash)

What is the epidemiology of polymyositis?
0.5-0.8/100,00 per year
Predominant age: 5-15 and 40-60
Peak incidence: mid 40s

Etiology of polymyositis
Inflammatory process mediated by T cells and cytokine release, leading to damage to muscle cells
Predominantly skeletal muscle involvement
Mild genetic association

What are some associated conditions of polymyositis?
progressive systemic sclerosis
systemic lupus erythematosus (SLE)
mixed CT disease

What are proximal limb symptoms of polymyositis?
Hip and thigh weakness
Shoulder and muscle weakness
Buttock, thigh or calf aching, tenderness to palpation
Usually spares distal muscles

What are other symptoms of poymyositis?
Weakness of extensor neck muscles
Respiratory impairment
Cardiac involvement

What are the diagnostic tests for polymyositis?
Creatine kinase and/or aldolase elevation
LDH elevated
Abnormal electromyogram (EMG)
Findings on muscle biopsy
(labs and tests are used to rule out differentials)

What cancers may patients with inflammatory myopathies at higher risk for?

Treatment for polymyositis
First line: prednisone
Immunosupressants for symptomatic treatment
Caloric and sodium intake moderation
Second line: azathiopine and methotrexate

Prognosis for polymyositis
Residual weakness (30% of patients)
Persistent active disease (20% of patients)
5-year survival rate (65-75%)

What is polymyalgia rheumatica?
PMR is an inflammatory rheumatic condition
Characterized by aching and morning stiffness in shoulder, hip girdle and neck
Can be associated with giant cell arteritis (GCA)

Epidemiology of polymyalgia rheumatica
>50 with increasing incidence with increased age
Average age of diagnosis: >70
Prevalence: 700/100,000 persons greater than 50 yo

What systems are affected in polymyalgia rheumatica?

Pathogenesis of polymyalgia rheumatica
Environmental and genetic factors may play role
Association between history of GCA and parvovirus B19 DNA

Clinical manifestations of polymyalgia rheumatica
Morning stiffness (at least 30 min)
Synovitis and bursitis
Nighttime pain
Decreased ROM
Muscle tenderness
Disuse atrophy may be seen

Laboratory findings in polymyalgia rheumatica
Elevated ESR
Elevated CRP
Anemia may be present
Increased liver enzymes may be present, specifically alkaline phosphatase
Temporal biopsy (if GCA present)

How is polymyalgia rheumatic diagnosed?
At least 50 yo at onset
Bilateral aching and morning stiffness lasting 30 minutes or more, persisting for at least one month
Stiffness involving two or more areas (neck or torso, shoulders, hips)
Erythrocyte sedimentation rate > or= to 40 mm/h

Treatment of polymyalgia rheumatica
Prednisone (10-20 mg/day)
PT for ROM exercises

Prognosis for polymyalgia rheumatica
2 years of corticosteroid treatment
Prognosis is very good if treated, but relapse occurs in 25-50% of patients

What is osteoporosis?
A disease characterized by low bone density and weakening of bone tissue associated with an increase in fragility and vulnerability to fracture

Epidemiology of osteoporosis
>60 yo
prevelance: 50% of postmenopausal women

Etiology and pathogenesis of osteoporosis
Increased osteoclast activity
Decreased osteoblast activity

Risk factors for osteoporosis
Excessive alcohol consumption
Estrogen deficiency before 45 yo
Calcium/Vit D deficiency
Impaired vision
Poor health/frailty

Advanced age
Caucasian or Asian ethnicity
Female gender
FH of osteoporosis
FH of atraumatic fx

Clinical presentation of osteoporosis
Often asymptomatic
Sx of fragility fx include pain at fracture site or immobility
Sighs: Height loss >1.5 cm, spinal kyphosis, fragility fx (esp hip or spine)

Where is bone densitometry (DXA) performed?
at the hip or lumbar spine

What is the T-score for osteoporosis?
The number of standard deviations from the bone mineral density in healthy young women
Osteopenia: from -1 to -2.5
Osteoporosis = under -2.5

What is the Z-score for osteoporosis?
Similar to T-score, but corrected for age and gender of the patient

What is the recommended therapy for osteoporosis?
Vitamin D and calcium
Bisphosphonates (first-line, inhibits osteoclast activity)
Hormone therapy

What are some recommended bisphosphonates for osteoporosis?
Alendronate (fosamax)
Ibandronate (boniva)
Risedronate (actonel)
Zoledronic acid (Zometa)

What are the risk factors for Zoledronic acid?
Renal failure

Risks associated with Bisphosphonates
Possible increase risk of esophageal cancer
Femur fractures
Osteonecrosis of the jaw

What hormone therapy is recommended for osteoporosis?
Calcitonin: inhibits bone resorption by binding osteoclast receptors
Anabolic agents: teriparatide

What is fibromyalgia?
Chronic, widespread noninflammatory musculoskeletal pain syndrome with multisystem manifestations. Thought to be a disorder of altered central pain regulation

Epidemiology of fibromyalgia
2nd MC condition seen by rheumatologists
Mostly affects women from 20-60 yo
2-5% of the adult US population

What are some characteristics and triggering factors of fibromyalgia?
Considered more central than peripheral pain
Possible triggers
Viral infections (Lyme disease)
Emotional trauma
Physical trauma

What are three causation theories of fibromyalgia?
1: Hyperexcitability of CNS pain receptors (central sensitization)
2: Abnormal central processing of nociceptive input
3: Dysfunction of hypothalamic-pituitary-adrenal axis, specifically dopaminergic neurotransmission; based on partial response to Serotonin Reuptake Inhibitors (SSRIs)

Clinical symptoms of fibromyalgia
Cardinal manifestation: widespread musculoskeletal pain, involving both sides of the body and above and below the waist
Usually in muscles
Fatigue (esp when waking a mid-afternoon)

What cognitive and mood disturbances are present in fibromyalgia?
Problems with attention, depression/anxiety, headaches

What is the diagnostic criteria for fibromyalgia?
Tenderness in soft-tissue anatomic locations
Widespread pain in all quadrants
Pain and tenderness at 11 or more of 18 tender point sites

What are the nine pairs of tender points in fibromyalgia?
1: Under the lower sternomastoid muscle
2: Near the second costachondral junction
3: 2 cm distal to the lateral epicondyle
4: At the prominence of the greater trochanter
5: at the medial fat pad of the knee
6: Insertion of the suboccipital muscle
7: Mid upper trapezius muscle
8: Origin of the supraspinatus muscle
9: Upper outer quadrant of the buttock

Treatment for fibromyalgia
Good sleep hygiene
Exercise program
Physical therapy
Psychological interventions
Nonbenzodiazepine hypnotics
Muscle relaxants
Dopamine agonists

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