Rheumatology++ for You++

Strategy

vs

Rheumatology++ for You++

"If you know your enemy and know yourself, you need not fear the result of a hundred battles." -Sun Tzu

Christopher Goodman

Scouting Report

The enemy is inscrutable

2014 list

I am not a rheumatologist by training and should not be construed as such. The opinions expressed here are my own and should not be interpreted as the final authority on rheumatology, medicine, or pretty much anything for that matter. There is no guarantee that any of the included material is factually accurate or even appropriate for this time period. Crying and confusion may occur. If it persists, please contact your doctor.

2017: 9% Rheum/ortho

Long list of categories: crystal-induced arthropathy, spondyloarthropathy, rheumatoid arthritis, etc

"<2%"

Conclusion:

It's better than it looks

But first...

Remember non-pharmacologic preferred

-PT/OT favored over NSAIDs

-Some cases need rest

-Some cases need altered mobility plan: ITBS, PFMS, medial tibial stress

1. Focus on major conditions like RA, OA, SLE, SS, AS

2. Don't waste time on extensive orthopedics review, <2% of total

3. Syndrome recognition primarily

Board questions:

MTXtraordinary

Game Plan

High Yield: Therapeutics

-first line in RA, systemic sclerosis, psoriatic arthritis

-avoid EtOH

-take folate to decrease GI side effects, ulcers

1.)

2.)

3.)

1. Ortho and Images - 1 or 2 questions

2. Therapeutics - (~25%)

3. Major condition mgmt (~25%)

4. Lightning round - syndromes!

5. Breaking down a few MKSAP questions

Rule #1:

Pregnancy issues

Read the answers first!!!

-Diagnose SS

Ddx of swollen digits narrow

-MTX is your friend

1.) Only a few meds to remember: subtleties of biologics outside scope

2.) Methotrexate!

3.) Pregnancy

4.) Monitoring of meds

5.) Miscellaneous

Rule #2:

-Diagnose Osteoarthritis

inflammatory vs non-inflammatory

-Conservative Tx

Know your syndromes

-Knowing when to continue or stop:

-MTX, cyclophosphamide, mycophenalate, TNFi

-plaquenil, prednisone, azathioprine, tacrolimus

-Knowing SLE:

check APL, anti-Ro, Anti-La

If APL: LMWH if symptomatic, otherwise low dose ASA/LMWH

If anti-Ro/La: screen for heart block

4.)

6.)

5.)

-CPPD versus OA

-remember "linear calcifications" and hand findings

Drug Management and Adverse Effects

PCP ppx, bone density, vit d/ca/bisphosphonate, AVN, stress - hydrocortisone

retinal exam

-Major Condition Mgmt

-vaccines necessary

-do not give live (MMR, varicella, intranasal flu)

Miscellaneous

hepatitis, anemia, hypersensitivity, TPMT levels, care with allopurinol

1. Prednisone ->

2. Plaquinel ->

4. Imuran ->

3. MTX ->

4. Biologics:

5. Vaccinate!! (except live vaccines)

6. Allopurinol ->

GI, ulcers, liver toxicity - take folate

SLE nephritis, Wegener's, GCA

TB screen, HIV, HBV, VZV, hypersensitivity, lupus, cancer

Osteoarthritis

-Prednisone stat!

-Always treat infections: septic (IV abx), gon/chlam (azithro/cef), HBV/HCV (entecavir), Lyme (doxy)

-If worried about infection - need tissue/culture prior to treatment

-Diagnose Reactive Arthritis:

urethritis/UTI, arthritis +/-conjunctivitis

-Most importantly associated with gonorrhea/chlamydia

TNFi...

testing for HLA b5801

200 trials and $200 billion dollars in sales

-Stay conservative

-Be aware of reasons to avoid NSAIDs

-Contrast with CPPD, "Inflammatory"

Minor Conditions

Major Conditions:

2 minutes of Ortho

High Yield: Images

RA, Sjogren's, Spondylo's, Systemic sclerosis

-Prednisone always a possibility:

sarcoidosis, vasculitis, catastrophic APLS, myopathies (DM, PM, IBM)

-Behcet's, FMF ...

-Paget's or fragility fx...

Colchicine

ACEi

bisphosphonate

Bonus

Methotrexate

NSAIDs

-SS is variable depending on organ

--Scleroderma renal crisis...

-RA and Psoriatic arthritis...

-AS very responsive to ...

-Sjogren's... symptomatic

-SLE (cutaneous or mild-mod)...

-SLE nephritis ...

Most of the time, images are low yield:

7.)

9.)

8.)

"pencil in cup," erosions of RA, skin lesions of SLE

Steroid / Cyclo / Myco

-Diagnose MCTD

1. CPPD vs OA

Knee, hip, shoulder... next

Conservative management

Miscellaneous

-plantar fasciitis

-DeQuervain synovitis

-spinal stenosis - better with sitting

"Milwaukee Shoulder"

aka Basic CPPD

-Diagnose RA

-Manage RA

-Max MTX, What next?

-Pre-op?

Recognize PAH

-complication of SS and MCTD

-evaluate and tx

70f has a 4 week history of bilateral aching around her neck and 1 hour morning stiffness of shoulders and hips. No rash, visual symptoms, cough, headache, or jaw claudication. She is very fatigued, awakens frequently during the night. No difficulty climbing steps or getting off the toilet. She notes tingling of fingers of the right hand in the AM.

Exam: muscle strength is normal and range of motion of the shoulders/hips is full. There is no tenderness on palpation of the shoulder joint, subacromial bursa, or surrounding muscles. She has a positive Phalens of the right hand. The remainder of the exam is unremarkable.

ESR is 55 cm/hr, CBC, CPK, creatinine, TSH are normal. Her RF is weakly positive, CCP is negative.

Which of the following is most appropriate management?

A. Weekly methotrexate + 1mg folic acid daily

B. B/l corticosteroid injection into subacromial space + PT

C. Amitriptyline daily + an aerobic exercise program

D. Prednisone 15mg daily

E. Prednisone 1mg/kg daily

2. DISH vs AS

-Diagnose PAN (HBV)

-Tx Infections

Appropriate for screening SS and MCTD

A 37-year-old man is evaluated for a 4-month history of progressively worsening red, scaly lesions involving the scalp, trunk, and extremities. During the past month, he also has had pain in the hands and feet and has lost 4.5 kg (10.0 lb). Aspirin and acetaminophen have helped to relieve his joint symptoms. He does not drink alcoholic beverages, has no other medical problems, and takes no additional medications. He denies allergies. He has sex with men and women and uses condoms inconsistently.

On physical examination, vital signs are normal. The appearance of lesions found on the arms, hands, upper torso, back, inside the umbilicus, and legs is shown.

Which of the following diagnostic studies should be performed next in this patient?

A. Anti-cyclic citrullinated peptide antibody assay

B. Antinuclear antibody assay

C. Hepatitis C virus antibody assay

D. HLA-B27 testing

E. Serologic testing for HIV antibodies

Fist of Finkelstein

Hip

AVN -EtOH, steroids

XR and MRI

OA

Acetabular tear

Bursitis

ITBS

Miscellaneous

Shoulder

Osteoporosis

Fibromyalgia

CRPS

Plantar fasciitis

Topical NSAIDs

Paget's

Overuse injuries

Muscle rupture

Compartment syndrome

Adhesive capsulitis

Rotator cuff tear

Dislocation

OA

Bursitis

Milwaukee

The Knee

Matching!

Final Tune-up

Thromboangitis obliterans

Lightning Round...

Arthrocentesis - cutoffs of WBCs, crystals

ITBS

Bursitis (anserine, prepatellar)

ACL/PCL/MCL/LCL - mechanism

Menisceal tear - wt bearing? effusion?

Patellofemoral syndrome

Baker's Cyst

Patellar tendon rupture - decel, knee ext

GCA

HSP

Takayasu's

c-ANCA, pulmonorenal syndrome

fever, malaise, myalgia, rash, pancytopenia, proteinuria

fever, uveitis, erythema nodosum, oligoarthritis WITH diarrhea

high ferritin, fever, arthritis, young

Wegener's

fever, uveitis, erythema nodosum, oligoarthritis with peri-arthritis

(triad: hilar LAD, acute oligoarthritis, erythema nodosum)

young female, fever, poor distal pulses

SLE

Adult Onset Still's Disease

Wegener's /

Granulomatosis with polyangiitis

IBD arthritis

Takayasu's

-mgmt decisions usually concern particular forms like SLE nephritis or discoid lupus

-Abs: anti-dsDNA, anti-Smith, anti-histone (drug-induced)

Sarcoidosis

-change to older, bronze skin, no fever?

Churg-Strauss

Usually need biopsy, definitely tx with steroid +/- cyclophosphamide/rituxan

-Mgmt - CXR, ua, EKG, PFTs, biopsy, ophtho exam

-Tx is prednisone if symptomatic

Smoker, rash ->

jaw claudication or amaurosis fugax ->

Young person with palpable purpura ->

Young female, bad pulses ->

Sinus, pulm, renal ->

Asthma, mononeuritis complex ->

Renal dz, HBV ->

Hand and eye rash ->

HCV, rash ->

Abnormal ear ->

Recurrent miscarriages ->

Mgmt details in key conditions

Just syndrome recognition in minor conditions

PAN

Dermatomyositis

Raynaud's, GERD, swollen digits, telangiectasias

triad: pancytopenia, splenomegaly, leg ulcers (+ILD, joint pain)

arthritis (DIPs, PIPs, knees), morning stiffness x20 min.

arthritis (knees, DIPs, MCPs), morning stiffness x 20 minutes

dry eyes, arthritis, fatigue

recurrent ulcers, skin lesions, eye lesions

CREST (lcSSc)

Sjogren's

Behcet's

CPPD

Cryoglobulinemic vasculitis (type II)

Rheumatoid arthritis

Osteoarthritis

No tx

Increased lymphoma risk

-Tx with colchicine

-anti-centromere, anti-Scl-70

-all at risk for PAH, esp limited

-diffuse more at risk for ILD

-check PFT

-Tx PAH

-Tx renal crisis wtih ACE

Either will use the atypical joint locations to confuse you, or paint a picture similar to OA with an XR

MTX, then TNF

f/u X-rays

Relapsing polychondritis

APLS

swollen digits, rash, arthritis

fatigue, arthritis, Raynaud's WITH antiU1RNP

young, low back pain, morning stiffness

fever, wt loss, skin lesions on legs, HBV

asthma, mononeuritis, eosinophilia

proximal weakness, photosensitive rash, no pain

Headache (of some sort), fatigue, fever, age >50

Psoriatic arthritis

PAN

AS

MCTD

Dermatomyositis

Churg-Strauss / Eosinophilic granulomatosis with polyangiitis

GCA

-MTX, then TNF

-topical options

-other: idiopathic, cocaine-induced

-IBM, polymyositis

-association with ILD and malignancy

-Overlap with most autoimmune d/o's, so commit Ab to memory

-biopsy, steroids

-jaw claudication, amaurosis fugax, vertebrobasilar CVAs

-usually respond to NSAIDs

-check MRI for sacroilitis

-associated with uveitis, cardiac complications

www.pollev.com/chrisg

Short differentials help

Sarcoid/Spondylo's > Behcet's

Sclerosis Family

Management Issues

Sarcoid, IBD

Raynaud's, morphea, limited SSc, diffuse SSc, SSc sine scleroderma

PAN > GCA/Takayasu

Takayasu > HSP/Reactive/JRA

Complex diagnostics

-Pattern recognition key

-Labs later

-"next best test" - treat or test?

Complications

-CAD, malignancy, steroids

-Drug-induced SLE

-RA - cervical XR's

Overlap with other subjects (ID)

-Raynaud's tx: none, perhaps CCB

-advanced -> epoprostenol, sympathectomy

-PAH and ILD (dSS more ILD, lSS more PAH), check PFT and TTE - may need CT and RHC

-CREST (lSS) -> GAVE (GI bleed), calcinosis

-Abs: anti-centromere, anti-Scl-70

-Tx PAH: consider PDEi, CCB, endothelin

-Tx renal crisis with ACE

Wegener's > Goodpasture's > SLE/HSP/CS

Uveitis ->

Erythema nodosum ->

Aneurysms->

Young F, temp:

Pulm-renal ->

Runner ->

Thickened digits ->

Drug Use ->

ITBS, PFMS

SS, psoriasis > Reactive/MCTD

Gout

vasculitis: PAN, cryoglobulin, cocaine-induced

Septic vs gouty arthritis

Overlap with CPPD, RA

Culprit meds