ACP REVIEW: Rheumatology Volume 1

ACP REVIEW:Rheumatology Volume 1

GREGORY GARDNER, MD, MACP

GILLILAND-HENDERSON PROFESSOR OF MEDICINE

DIVIS ION OF RHEUMATOLOGY

UNIVERSITY OF WASHINGTON

Outline

•Sorting out synovitis

•Common musculoskeletal conditions on the boards

•Arthritis and more arthritis

•Rash and arthritis

•Goutology

BASIC CONCEPTS TO SORT OUT SYNOVITIS

Inflammatory

◦ AM stiffness > 30 min (often several hrs)

◦ Improvement with activity

◦ Swelling common

◦ Rheumatoid arthritis, polymyalgia rheumatica

Mechanical

◦ 10-15 minutes of AM stiffness

◦ Pain worse with use

◦ Osteoarthritis, tendonitis

Fibromyalgia

◦ Non-restorative sleep

◦ Fatigue

◦ Memory difficulty

◦ Pain in up to 19 different areas

◦ Exercise intolerance i.e. feeling “wiped out”

Pearl #1: Three Patterns of Joint Pain

DDx of Monoarthritis: One Joint

InflammatoryInfection• Gonorrhea

• Staphylococcus

• Streptococcus

• Gram negatives

• Rare: fungus/TB (sinus track to skin)

Crystals• Gout

• Pseudogout

Other Inflammatory• Psoriatic arthritis

Mechanical• Osteoarthritis

• Trauma

• Osteonecrosis

GC Dermatitis

DDx of Pauciarthritis: 2-5 Joints

InflammatoryInfection

• Lyme arthritis

• Recurrent large knee effusions

• Bacteria

Other

• Polymyalgia rheumatica

• Spondyloarthropathy

• Psoriatic arthritis

• Reactive arthritis

•Sarcoidosis• Lofgren syndrome: lower

extremity periarthritis, E nodosum, hilar adenopathy

• Chronic arthritis

Crystals• Gout (rarely polyarticular)


DDx of Polyarthritis: 6 or more

InflammatoryInfection

• Viruses

• Parvovirus

• Hepatitis B

• Rubella

• Hepatitis C (+ rheumatoid factor)

• Chikungunya

Other• Rheumatoid arthritis

• Systemic lupus

• Sjogren’s syndrome

• Serum sickness


Chikungunya arthritisCalabrese DO Cleveland Clinic

DDx of a Very Painful Joint

Bugs• NG Bacterial arthritis

• Gonococcal arthritis

Blood• ACL tear

• Intra-articular fracture

• Meniscal tear

• Anticoagulant use

• Hemophilia

BBC Joint

Fat floating on blood = ?

Crystals• Gout

• Pseudogout

“Don’t touch my joint, don’t move my joint”

Common Musculoskeletal Issue that Show up on the Boards

Patient Presentation 1 Hx: A 55-year-old right-handed male complains of right shoulder pain for 1 month. Pain with reaching for his wallet & overhead activities. Has pain when sleeping on right side. Began after painting his house. No paresthesia nor radiation of pain.

Exam: Pain on active abduction between 60 and 120o. Pain on resisted right arm abduction with no obvious weakness on abduction, external or internal rotation. No atrophy of shoulder girdle musculature

The most likely cause of this

patient’s symptoms is:

A. Bicipital tendonitis

B. Acromioclavicular arthritis

C. Rotator cuff disease

D. Glenohumeral arthritis

Differential Diagnosis of Shoulder Problems Based on History and Examination

•Profound stiffness •Polymyalgia rheumatica

•Pain & Limited range of motion• Adhesive capsulitis

• Glenohumeral osteoarthritis

•Mostly weakness• Myositis

• Cervical radiculopathy

•Pain with movement +/-weakness• Rotator cuff pathology

• AC joint arthritis

Dx in 101 pts with shoulder pain over 18 months in an IM clinic

Diagnosis Percent

•Rotator Cuff Disease 62

•Myofascial Pain 22

•Adhesive Capsulitis 10

•AC Joint OA 4

•Bicepital Tendonitis 3

•RA/OA/RSD/PMR 1 each

Anderson, Kaye. West J Med 1983; 138:268

Rotator Cuff DiseaseFunction of rotator cuff

• Stabilize GH joint

• Internal and external rotation, abduction

• Depress humeral head in glenoid to prevent impingement

Muscles

• Supraspinatus, Infraspinatus, Teres Minor, Infraspinatus

Risk factors for developing RTC disease• Age over 50 yrs (30% > 60yrs)

• Diabetes

• Work with frequent use of arms above 90o

Impingement zone

Leong HT, et al. J Rehabil Med. 2019 Oct 4;51(9):627-637.

Rotator Cuff Disease

Symptoms of rotator cuff disease• Painful arc of abduction 60-120o *

• Pain with lying on shoulder

• Pain with overhead activity

• RTC tear: weakness may be present with specific resisted motions• Supraspinatus given its position is most oft torn tendon

• “Drop test positive” for complete RTC tear

Continuum of disease• Tendonitis partial thickness tear full thickness cuff tear

arthropathy

Treatment• Physical therapy has most important long-term impact

• Subacromial injection is adjunctive to PT

• Surgical decompression open vs arthroscopic

Dang A, Davies M. Sports Med Arthrosc Rev. 2018 Sep;26(3):129-133.

Images: Rotator Cuff disease

High riding HH; Cuff Tear Arthropathy

High riding HH in RA

Ultrasound showing supraspinatus tear

Large shoulder effusion cuff tear arthropathy

Patient Presentation 2

72 y/o woman was working in yard, heard pop, arm looks like this. Has “Popeye” muscle

Most common underlying cause of this finding is:

A. Rotator cuff disease

B. Recent use of quinolone antibiotics

C. Underlying inflammatory arthritis

D. Corticosteroid use


Hx: 59-year-old male with 6 months of progressive pain with use of the right shoulder comes to clinic. He has difficulty washing his hair, reaching for his wallet, and these motions are painful.

Exam: there is decreased ROM of the shoulder with pain throughout the limited range. Mild muscle atrophy present about the shoulder. Feeling of creaking with ROM

Next step would be:

A. Shoulder CT scan

B. Shoulder MRI scan

C. Shoulder ultrasound

D. Shoulder x-ray 3 views

OA of Shoulder

Shoulder OsteoarthritisMajor risk factors

• Age > 50 yrs for primary OA

• Activity/trauma

• Inflammatory arthritis i.e. RA, PsA

• Metabolic arthritis ie hemochromatosis

• Advanced RTC tear ie cuff tear arthropathy

Symptoms and signs

• Diffuse shoulder pain

• Painful limited ROM is most plains

• Xrays (external/internal/axillary views) show osteophytes on inferior humeral head and inferior glenoid and joint space narrowing

Treatment• Pain management (acetaminophen, NSAIDs)

• PT/OT

• Total shoulder arthroplasty

Macías-Hernández SI, et al. Disabil Rehabil. 2017 Aug;39(16):1674-1682.

Gardner’s rule 35: anybody over age 50 with a stiff shoulder deserves an X-ray

Patient Presentation 4: Pain in wrist after fall on outstretched hand with snuff box tenderness

Greatest sequela for this injury is:

A. Scaphoid osteonecrosis C. Radial nerve injury

B. Arthritis of CMC joint D. Ulnar artery injury

Scaphoid Fracture

•Symptoms: pain radial aspect of the wrist, swelling, snuff box tenderness

•Radiographs initially may be negative; Prevalence of occult fracture is up to 54%

•Advanced imaging is helpful and suggested do be done soon; if not available can repeat x-rays in 2 weeks

•Rx: With good history and concerning physical examination, treat as though fracture present and splint (thumb spica splint)

•Osteonecrosis: Blood supply is distal to proximal and displaced fracture or nonunion runs the risk of osteonecrosis resulting in a secondary wrist arthritis

Fowler JR, Hughes TB. Clin Sports Med. 2015 Jan;34(1):37-50.


A 55 y/o old woman complains of 1 week of pain in the base of her thumb. She has been trimming her roses prior to the onset of the discomfort. She has noted that there is some swelling along the distal radius and pain with ulnar deviation of the wrist

The most useful diagnostic test would be:A. EMG/NCS

B. X-ray of hand/wrist

C. Musculoskeletal ultrasound

D. Finkelstein test

De Quervain Tenosynovitis

Symptoms:

• Pain at distal radius with gripping and extending thumb, difficulty using tools

Signs:

• Swelling/tenderness at distal radius

• Pain with resisted thumb extension

• Finkelstein maneuver

Pathophysiology:

• EPB/APL strain/microtear

Treatment:

• Ice, NSAIDs, stretches, avoidance

• Injection corticosteroids: 58% resolve with 1 injection, 32% with 2, 10% surgical release

Anderson et al. Arthritis Rheum 1991


Hx: 29 y/o woman recently post partum has tried to go back to exercise but finds her knees ache. Has trouble getting off the couch because of knee pain and going downstairs is also painful. Walking level ground is not a problem.

Exam: is unremarkable except for some patellofemoral crepitus with active ROM

Next step is:

A. Prednisone 10 mg/day

B. X-ray of knees including sunrise view

C. MRI scan of knees

D. Physical therapy

Patellofemoral Pain AKA Chondromalacia Patella

Demographics: women > men; can occur in OA as well

Symptoms:

• Pain with getting up from sitting position

• Pain going downstairs

Causes:

• Tight IT band

• Weakened quadriceps (VMO)

• Excessive foot pronation

Treatment

• NSAIDs, CS injection

• PT very helpful and usually key

Lateralization of patellae with likely VMO weakness

Patient Presentation 7: RA patient with calf swelling

Most likely cause of swelling is:A. Gastoc muscle rupture C. Venous thrombosisB. Baker cyst D. Calf hematoma

Baker’s Cyst

•Location: Bursa b/w gastrocnemius &

semimembranosus tendons

•Causes: Fluid from within knee pushed into

bursa behind the knee with walking

•Dx: Exam, Ultrasound, MRI

•Treatment: Address knee fluid!

Intra-articular injection, US guided aspiration

and injection, occasionally surgery

•Complication: posterior knee pain, venous

obstruction, rupture with calf pain and

fluid/blood tracking down leg

(pseudothrombophlebitis)

Herman AM, Marzo JM. Popliteal cysts: a current review. Orthopedics. 2014 Aug;37(8):e678-84.


HX: A 53 y/o woman complains of pain

and numbness b/w her right 3rd and

4th toes. Present especially with

wearing shoes. Feels best in bare feet.

Exam: shows no tenderness of MTP

joints, no callous formation but a click

is felt when palpating the 3rd and 4th

MTP interspace while transverse

loading the MTPs of the right foot

The next step is to:

A. MRI scan of foot

B. Wear wide toed shoes

C. Refer to podiatry

D. AP/oblique X-ray of

foot

Morton’s Neuroma

Location: Most common in 3rd/4th MTP interspace (aka interdigital neuroma)

Pathology: Perineural fibrosis of branches of plantar nerve

Symptoms & Signs:

• Burning pain and numbness into toes while wearing shoes especially narrow toed shoes

• Tenderness/nodule at interspace

• Mulder’s sign (click with transverse loading)

Dx: exam, US, MRI if needed

Rx: metatarsal bar/pad, wide toe box shoes, steroid injection from dorsal surface NOT plantar as may cause fat pad atrophy, surgery if needed

UpToDate

Researchgate

Valisena et al. Foot Ankle Surg 2018;4:271-281

Plantar Fasciitis

Cause: Strain of plantar fascia as it inserts into medial calcaneus: poor shoes, overweight, underlying spondyloarthropathy

Symptoms & Signs: Heel pain with first step in the morning or after sitting. Pain localized to medial inferior calcaneus

Treatment

• Step 1 - Wt loss, shoes/heel cup, PF/Achilles stretches, NSAIDs

• Step 2 - Add posterior night splint

• Step 3 - Walking boot/referral to podiatry

Trojian T, Tucker AK. Am Fam Physician 2019;99:744-750

Tarsal Tunnel Syndrome

Pathology: Posterior tibial nerve entrapment at medial malleolus often due to excessive foot pronation

Symptoms & Signs: pain, burning, numbness at heel or into first 3 toes depending on which of 3 branches affected; weak toe flexion; Tinels sign under medical malleolus

Diagnosis: can be confirmed using EMG

Treatment: includes fixing foot pronation, surgical release if needed

Kiel J, Kaiser K. StatPearls August 12, 2020


A 65-year-old male noted pain in the left Achilles tendon 2 weeks after taking ciprofloxacin for sinusitis. A week after the pain began, he felt a sudden jolt of pain and has had a difficult time walking. He has a history of PMR and has been on prednisone at 5 mg day and tapering slowly.

The most useful next step to look for Achilles’ tendon rupture is:

A. Thompson’s Test

B. Ultrasound examination of the tendon

C. MRI examination of the tendon

D. Gardner’s maneuver

Achilles Tendonitis

DDx:

• Insertional pain think spondyloarthropathy, mid tendon pain think trauma/overuse

• Quinolone Abx tendonopathy most often affects Achilles, rupture in 30% of cases

• Gout and hyperlipidemias can also affect tendon (picture is tendon xanthoma)

Dx: exam, US, MRI; complete tear of tendon may be Dxed by preforming Thompson’s test; squeeze calf and foot should plantar flex if tendon is intact

Rx: Rest, NSAIDs, immobilization, PT, surgery

Maffulli N, et a. Foot Ankle Surg 2020

Quinolone Tendonopathy

Van der Linden PD, et al. Arch Internal Medicine 2003;163:1801-1807

Population based care control study of Achilles Tendon Rupture

Ofloxiacin > Norfloxacin > ciprofloxacin

Variable Odds RatioConfidence

Interval

Quinolone current exposure 4.3 1.5-3.7

Quinolone recent exposure 2.4 0.9-2.1

Current exposure age 60-79 6.4 3.0-13.1

Current exposure age 80 or older 20.4 4.6-90.1

Current exposure plus current use of prednisone age 60 or older

17.5 5.0-60.9

Arthritis and More Arthritis

Rheumatoid Arthritis

Inflammatory polyarthritis

Women > men

AM stiffness > 30 minutes

Laboratory tests◦ ESR/CRP◦ Rheumatoid factor◦ CCP

Radiographic changes◦ Marginal erosions◦ Subluxation◦ Deviation◦ Osteopenia

Joint distribution…..

Earliest RA

Advancing RA

Note MCP prominence

Advanced RA

Note ulnar deviation

and MCP subluxation

As well as cock up

deformities of toes

1896 1901

The Natural History of RA as Modeled by Pierre Auguste Renoir

The arthritis progresses

1903 1911

Autoantibodies in Rheumatoid Arthritis:Rheumatoid Factor and Cyclic Citrullinated Peptide

Pathophysiology• RF is an antibody directed against the patients own IgG

• CCP is directed against citrullinate peptides that form as a result of inflammation

Sensitivity/specificity

• RF sensitivity 75% and specificity of 50%; RF seen in other diseases

• Hepatitis B&C, TB, fungal infections, Sjogren’s syndrome, mixed connective tissue disease, Waldenstrom’s macroglobulinemia, etc

• CCP sensitivity 75% but specificity of 96%

Other

• RF higher level = worse prognosis

• CCP may be present for up to 14 year before arthritis appears; higher the level = worse the prognosis

Radiographs in Rheumatoid Arthritis

Joint Erosions in RA: From Bad to Worse

“What we need in RA is a drug for which one does not need a statistician to see

the beneficial effects”

Irving Kushner, M.D.

J Rheumatol 1989;16:1-4

Changes in Treatment Approaches to RA

1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010

Early intervention

Combination therapy

Single-drug

therapy

Treatment pyramid

Biologics

Methotrexate

Very early intervention

Treatment Principles of RA 2021

•Early recognition, early therapy, treat to target

•Aggressive Rx for patients with concerning features• Erosions at presentation

• Extra-articular features ie nodules

• Large number of joints involved

•Methotrexate is anchor medication

•Routine measure of disease activity with modification of therapy to achieve low disease activity or remission

Therapies For RA 2021

Conventional DMARDs

• Methotrexate

• Hydroxychloroquine

• Leflunomide

• Sulfasalazine

Anti-TNF agents

• Etanercept

• Adalimumab

• Infliximab

• Certozilumab

• Golimumab

Anti-B cell agents

• Rituximab

Anti-T cell agents• Abatacept

Anti-IL6 receptor antagonists• Tocilizumab

• Sarilimumab

JAK inhibitors• Tofacitinib

• Barcitinib

• Upacitinib

IL-1 receptor antagonists• Anakinra


Hx: 34-year-old-woman with 6-year history of RA comes to urgent care due to painful oral ulcers, nausea, and vomiting. Began with nausea and vomiting x 7 days and has had a hard time keeping hydrated. 2 day ago, had onset of painful oral ulcers. Several family members with GI illness. Continued taking medications for RA that consists of methotrexate 20 mg sc weekly.

Exam: BP 90/60, HR 110, temp 37.9 c. Looks ill. Has multiple oral ulcers on buccal mucosa and tongue. No joint swelling or deformities noted

Labs WBC 1.9k, HCT 35% platelet 229k, creatinine 1.7. BUN 65

Next step after hydration is:

A. Start dialysis

B. Give IV folinic acid

C. Administer activated charcoal

D. Start filgrastim

Important Medication Side Effects

Medication Mild SE Serious SE

Hydroxychloroquine Rash, diarrhea Retinopathy, myopathy

SulfasalazineRash, increased

LFTs, azospermiaAgranulocytosis

Methotrexate

Stomatitis,

increased LFTs,

alopecia

Cirrhosis, BM suppression,

pneumonitis, reversible

lymphoma

TNF inhibitors Injection site Rxn

TB reactivation, fungal

infections, MS- like

disease, Hep B activation,

psoriasis


A 55 y/o male with 15 years of RA comes to clinic for DOE. Noted DOE with stairs about 6 months ago. Now having DOE with walking more than 1/4 mile. No PND, orthopnea, LE edema, wheezing. Does have a persistent non-productive cough though.

Most useful next test would be

A. High resolution CT scan of chest

B. Echocardiogram

C. Right heart catherization

D. Ventilation/perfusion scan of lungs

Rheumatoid Arthritis:Extra-Articular Disease

Scleritis/Scleromalacia

Nodules

Rheumatoid ILD

Rheumatoid ILD

Epidemiology • 5-10% of RA patients

• Male > female

• Age 50-60

• 4.9 yrs of disease

• High titer RF/CCP

HRCT patterns• Usual interstitial pneumonitis

• Non-specific interstitial pneumonitis

• Organizing pneumonia

• Lymphocytic interstitial pneumonitis

Treatment• Steroids

• Mycophenolate/Azathioprine

• Rituximab

• Antifibrotics

Outcome• Second only to cardiac as cause

of mortality in RA

• ILD associated pulmonary HTN may also contribute to mortality

• UIP pattern has highest mortality

Important complication of RA

Felty’s syndrome• Leukopenia, splenomegaly, RA, Infections, leg

ulcers

C1-C2 subluxation• Neck pain, myelopathy, C spine flexion/extension

views, MRI

Septic arthritis• Large joints, fewer systemic symptoms, Staph >

Strep > gram negatives

Tendon ruptures• Especially ring/little finger extensor tendons

Rheumatoid Vasculitis (PAN like)• Male, foot drop, wrist drop, skin ulcers, GI


A 55 y/o male with arthritis has

this x-ray. The term used to

describe this finding is :

A. Opera glass deformity

B. Pencil point deformity

C. Pencil in a cup deformity

D. Shark tooth deformity

Psoriatic Arthritis

•Men = women

•7-20% of psoriasis pts develop PsA

•Types of disease• Pauciarthritis

• Polyarthritis

• DIP invovement

• Arthritis mutilans

• Spondylitis

•Enthesopathy

•Joint distribution…

Diagnosis By Pattern RecognitionDactylitis aka “Sausage Digit”

Psoriatic Arthritis:Radiographic features

PsA Treatment Issues

•NSAIDs/Low dose prednisone

•Methotrexate

•Cyclosporine

•TNF inhibitors

•Aprimelast (PD4 inhibitor)

•Sekukinumab (IL-17 inhibitor)

•Ustekinumab (IL-12/23 inhibitor)

•Tofacitinib (JAK inhibitor)


A 25 years old male

with recent GI illness

after a trip to Mexico

comes to clinic with

eye pain and

redness, joint pain,

and a rash on his

hands and feet.

Rash as noted.

Name of this rash is:

A. Palmar plantar pustulosis

B. Punctate psoriasis

C. Keretodermablennorrhagicum

D. Glomus of the fromus

Reactive Arthritis AKA Reiter’s Syndrome

•Pauci to polyarthritis

•Men > women

•AM stiffness > 30 minutes

•Mucocutaneous involvement

•Enthesitis prominent

•Follows infectious illness

usually GU or GI

•Joint distribution…..

Infectious Agent Associated with ReA in HLA-B27 + Individuals

•Chlamydia trachomatis

•Shigella flexneri

•Salmonella species

•Yersinia species

•Clostridium difficle

•Campylobacter fetus jejuni

•Chlamydia pneumoniae

•Intravesical injection of BCG to treat bladder CA

Salmonella 1.4 millioncases/year 2% complicated

by chronic arthritisCDC website

Reactive Arthritis: Clinical Features

JointsArthritis, dactylitis, sacroiliitis

EyesUveitis, conjunctivitis

Mucocutaneous Asymptomatic oral ulcers, nail changes, circinate balanitis, keratoderma blennorrhagicum

EnthesitisHeels, ribs

UrogenitalUrethritis, prostatitis

Tenosynovitis

Reactive arthritis

Synovitis

Keretoderma blennorrhagicum

Keratoderma and balanitis

Reactive arthritis

Reactive Arthritis - Outcome

•75% have waxing and waning course. Attacks last 6 weeks to 6 months

•25% have persistent disease

•Has been linked to HIV infection

•Morbidity includes:• Aortitis

• Cardiac conduction abnormalities

• Erosive arthritis (often the feet)

• Vision damaging uveitis

•Treatment similar to PsANail changes


Hx: A 22 y/o male complains of 3 weeks of low back pain

especially at night and early AM. Feels better during the day

especially when he is active.

Exam: VVS Afebrile. General exam is normal. Positive

Patrick maneuver on both sides. Schoeber test is normal.

Hyperextension of the lumbar spine causes pain

Labs: HCT 34%, ESR 45 mm/hr

Xrays: AP pelvis shows erosion at the SI joints


The next step should be:

A. Start NSAID therapy

B. Check HLA B27 test

C. CT scan of SI joints

D. Order MRI scan of SI joints

DDx of Inflammatory Low Back Pain

Spondylitis• Ankylosing spondylitis

• Psoriatic spondylitis

• Reactive arthritis

• Inflammatory bowel disease

Infection• Bacterial

• TB

Tumor

P prostate

B breast

K kidney

T thyroid

L liver

M multiple myeloma

Ankylosing Spondylitis

•Demographics• Men > women

• Ages teens to 40s

•Inflammatory LBP• Night and early AM pain

•Peripheral arthritis• Hips and shoulders

•Enthesopathy• Heels, chest

•Gender Differences• Women more C-spine Dz

• Time to Dx 7-10 years(Male 3-5 years)

•Eye disease• Uveitis

Psoriatic Spondylitis:Sacroiliitis

Pelvic outlet view“Ferguson”

CT of SI Joints:

Romanus Lesion

Squaring

Syndesmophytes

Facet Joint Dz

Lumbar Spine Involvement in Spondylitis

AS: Important Complications/Outcome

•Vertebral disc space Fx follows mild trauma at C5-C7

•Bilateral upper lobe pulmonary fibrosis

•Restrictive pulmonary Dz due to rib cage immobility

•Vision threatening uveitis

•Cauda equina syndrome• Saddle anesthesia

• LE weakness

• Bowel/bladder incontinence

•Amyloidosis

•Aortic valve incompetence

•Mortality increase after 20 yrs of disease


Hx: 48 y/o male, Mike Testaronie, former WWF wrestler,

complains of bilateral hand pain. Minimal morning

stiffness but has pain with activity especially driving his

muscle boat on Lake Washington. The MCPs in

particular are painful. Has been on methotrexate for Dx

of RA without benefit

Exam: Tenderness & swelling of 2nd, 3rd, and 4th MCP

joints both hands. X-ray of right hand as shown


The next step would be:

A. Start NSAIDs and reassure

B. Check CCP antibody

C. Start low dose prednisone

D. Check ferritin level

Osteoarthritis

•Senior age group

•Mechanical pain/deformity

•Primary v secondary OA

Spine

Hands

Hips

Knees

1st MTP

Heberden’sNodes (DIP)

Bouchard’sNodes (PIP)

Hands in Osteoarthritis

Hand in Osteoarthritis

X-Ray Changes in OA

Summary of Suggested Rx in OA of the Hand, Knee, and Hip2019 American College of Rheumatology/Arthritis Foundation Guidelines

Non-pharmacologic therapy• Hand: CMC brace

• Hip and knee:

• Weight loss

• Exercise

• Tai chi/yoga

• Cane

• Tibiofemoral brace

• Not recommended: TENS

Pharmacologic therapy• Hand

• Oral NSAID

• Topical NSAID conditionally recommended

• Knee

• Topical NSAID

• Oral NSAID

• Glucocorticoid injection

• Hip

• Oral NSAID

• US guided corticosteroid injection

• Not recommended: glucosamine, chondroitin, bisphosphonates, stem cell injections

Osteoarthritis

PsoriaticArthritis

Gout

DDx of DIP

arthritis

Pearl: Major Causes of DIP Arthritis

Rash and Arthritis


Hx: 30 y/o woman complains of 3 weeks of fever to 1010, sore throat, lumps in her neck, joint pain in hands, wrists, and knees, and an intermittent rash on chest and extremities. Works as an elementary school teacher.

Exam: Temp 100.80, pulse 100, mild MP rash on chest, arms and legs, enlarged cervical lymph nodes bilaterally, swelling of wrists, and knees.

Initial labs: WBC 25,000, HCT 34%, ALT and AST 1.5 times normal and CRP 200 mg/l (0-10 normal)

The most useful next test

would be:

A. Serum ferritin

B. ANA panel

C. Hepatitis B studies

D. Parvovirus IgM/IgG

Rash and Arthritis: the Viruses

• Parvovirus - net-like rash, polyarthralgia/itis, self-limited

• Rubella - rash, polyarthralgias, post-wild type and

immunization

• Hepatitis B - prodrome rash and polyarthralgias/it;

precedes hepatitis and resolves when hepatitis develops

• Hepatitis C - chronic polyarthralgias/itis, palpable

purpura of cryoglobulinemia, 50-70% of Hepatitis C

infected patients are rheumatoid factor positive

• Chikungunya - arthritis, fever, rash intense myalgias

Rash and Arthritis: Other Stuff

•Lyme disease - Erythema migrans, Bell’s palsy, heart block, polyarthritis; late knee oligoarthritis

•Gonococcal - Pauciarthritis to monoarthritis, fever, pustular dermatitis

•Stills Disease – Yamaguchi criteria: Major: Fever > 39, rash, arthralgias/arthritis, leukocytosis. Minor: lymphadenopathy, hepatosplenomegaly, sore throat, LFTs. Hyperferritinemia

•Serum sickness - fever, rash, and arthritis with exposure to drug (Abx, antithymocyte globulin, chimeric antibodies)

•Systemic Lupus - TBD

ACR, Mayo Clinic, UpToDate

Erythema Migrans

Parvo in Child

Parvo on trunk

Dermatitis in GC

Still’s Rash

•Salmon colored

•Evanescent

•Koebner phenomenon

•Non-pruitic

Crystalline Arthritis


Hx: A 60 y/o male has 1 days of severe pain in right knee. 3 days post-op for CABG. Unable to bend knee

Exam: mildly obese male in mild distress. Right knee is held in 350

of flexion and resists attempts to flex and extend the knee. Moderate effusion present. Knee is warm to palpation.

Xray: of knee as noted


The next step is to:

A. Start naproxen 500 mg BID

B. Inject knee with 40 mg of triamcinolone

C. Aspirate knee and send for culture/crystal analysis

D. Order MRI scan of the knee

CPPD images

DIEPPE P , SWAN A. Ann Rheum Dis 1999;58:261-263

CPPD Disease

•Calcium Pyrophosphate Arthritis

• AKA pseudogout

• Rare in young adults

• Predilection for wrist and knee

• Crystals positively birefringent, squares,

rhomboids, rectangles

•Treatment is similar to gout acutely

• NSAID, steroids, colchicine

• Evaluate for underlying metabolic disease, use NSAID or

colchicine for prophylaxis

Causes of

chondrocalcinosis

A acromegaly

H hemochromatosis

O orchronosis

T thyroid disease

T trauma

I idiopathic

P parathyroid disease

Rosenthal AK, Ryan LM. N Engl J Med. 2016 Jun 30;374(26):2575-84


HPI - Patient is a 55 y/o male with a Hx of mild HTN who comes to your clinic with 2 days of severe pain in his left 1st toe and medial ankle. He is unable to walk on it without severe pain and even the sheet on it is uncomfortable. Had a similar yet milder attack 1 year ago.

Meds - HCTZ 25 mg/day

Habits - 6-12 beers/week

Exam - Wt 200 lbs, Ht 5’6,” B/P 140/90, severe redness and tenderness to the medial left ankle and left 1st MTP.

Labs - Normal CBC/chem panel, uric acid 6.9 mg/dlaspiration of 1st MTP reveals (see next slide)

Patient Presentation

Needle shaped MSU crystals

Direction of first order red compensator


The next best step is to:

A. Provide alcohol counselling

B. Start oral prednisone 35 mg a day for 7 days

C. Stop HCTZ and start losartan

D. Begin allopurinol 100 mg po qd

Issues in Urate Gout

•Most common form of inflammatory arthritis in men over 40; > 5 million affected; rare in women pre-menopause

•1st attack after years of hyperuricemia

•1st MTP involved at some time in 90%;almost any joint can be affected

•A serum uric acid above 6.8 mg/dl is abnormal; I don’t care if your lab says 8.5 mg/dl is normal!

•Uric acid level may go down to normal during attack

•Certain groups i.e. Pacific Islanders have genetic predisposition to gout

Acute Urate Gout

IntervalHyperuricemia

Tophaceous Gout

Step 1: Options for Treatment of Acute Gout

•NSAIDS: Maximum dose for 5-7 days; Naproxen 500 mg BID x 5 days

•Oral Prednisone/Prednisolone: 35 mg/day for 5-7 days or 40 mg with 7-10 day taper

•Intramuscular Corticosteroids: Depomedrol 120 mg or triamcinalone 60 mg IM are options

•Intra-articular steroids

•Colchicine: 1.2 mg followed in one hour by 0.6 mg. Start within first 24 hours

•Anakinra IL-1 inhibitor: not FDA approved. 100 mg SC daily time 1-3 days

Step 2: Modify Risk Factors

•Avoid medications that raise uric acid level

• Minimize ETOH especially beer/ale

• Encourage slow wt loss

• Rapid weight loss may precipitate gouty attack

• Obesity affects uric acid production and clearnace

• Discuss a low purine diet and one low on fructose

Medications that raise SUA• Diuretics

• Niacin

• Calcineurin inhibitors

• Laxatives in excess

• Low dose ASA

Medications that lower SUA• Losartan

Step 3: Decisions Regarding Hypouricemic Therapy

•Reasons to consider hypouricemic therapy• > 2 attacks/year, tophi, kidney stones, chronic persistent gout

•Hypouricemic agents• Allopurinol - 100-800 mg/d; rash, hypersensitivity syndrome;

reduce dose of azathioprine to 1/4

• Febuxistat - 40-80 mg/d; liver toxicity, azathioprine issue

• Probenecid - 250-1000 mg BID; use with meals and hydration; decrease elimination of meds ie PCN

•Lowering uric acid INCREASES risk of gouty attack• Use colchicine prophylaxis where possible 0.6-1.2 mg/day

• If unable to use, consider NSAID or prednisone,

2020 ACR Guidelines for the Treatment of Gout:Strong Recommendations

•Use ULT in pts with tophi or > 2 attacks per year

•Xanthine oxidase inhibitor (XOI) allopurinol is first line therapy

starting low dose (100 mg/day)and titrating to SUA < 6 mg/dl

•Start prophylaxis with ULT (Colchicine, NSAID, prednisone)

•Pt who have failed XOI ULT and have tophi or have frequent gout

attacks recommend using pegloticase IV

•Conditional recommendation to screen for HLA B5801 allele in

Koreans, Thais, Han Chinese, and African Americans before

starting allopurinol due to increased risk of allopurinol

hypersensitivity syndrome

Fitzgerald JD, et al Arthritis Care and Research June 2020 P 1-17


Hx: A 44-year-old male with gout and mild CKD reports progressive weakness in his arms and legs as well as paresthesia. He has been on colchicine 0.6 mg BID and allopurinol 500 mg per day with good control of his gout. Also takes thyroid replacement

Exam: show 4+ strength in the arm abductors and 3+ hip flexors. Distal strength is 5/5

Labs: CK is 2,200 GFR is 30 ml/minute

The next best step is to:

A. Stop allopurinol

B. Stop colchicine

C. Increase thyroid replacement

D. Start steroids

Tophi Recognition

Allopurinol plus patience

From Bad to Worse

ACP REVIEW: Rheumatology Volume 1

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