MUSCULOSKELETAL PA RT I
QUESTION #1 A 63yo fe ma le pre se nts with b o ny swe lling in he r dista l inte rpha la ng e a l jo ints witho ut e rythe ma . He r pro xima l inte rpha la ng e a l jo ints, ha nds, a nd wrists a re no rma l. Wha t is the unde rlying c a use o f he r c o nditio n? a . Ba c te ria l infe c tio n b . Crysta l de po sitio n c . We a r a nd te a r d. Vira l infe c tio n e . Auto a ntib o die s
QUESTION #1 A 63yo fe ma le pre se nts with b o ny swe lling in he r dista l inte rpha la ng e a l jo ints witho ut e rythe ma . He r pro xima l inte rpha la ng e a l jo ints, ha nds, a nd wrists a re no rma l. Wha t is the unde rlying c a use o f he r c o nditio n? a . Ba c te ria l infe c tio n- se ptic arthritis b . Crysta l de po sitio n- go ut and pse udo go ut c . We a r a nd te a r- o ste o arthritis d. Vira l infe c tio n- transie nt arthralgia/ arthritis e . Auto a ntib o die s- rhe umato id arthritis
WHY CAN WE RULE OUT GOUT/ PSEUDOGOUT? • T he jo ints a re usua lly swo lle n, pa inful, a nd re d in the se c o nditio ns HOW DO WE DIFFERENTIATE BETWEEN RHEUMATOID ARTHRITIS AND OSTEOARTHRITIS? • T he re is usua lly no re dne ss o r te nde rne ss o f jo ints in o ste o a rthritis • Rhe uma to id a rthritis c a n pre se nt with swe lling o f jo ints, b ut re dne ss is no t a lwa ys se e n
OSTEOARTHRITIS Othe r fa c ts • Who : E ly (usua lly >60yo ), lde r o b e se , tho se with tra uma to • Mo st c o mmo n type o f a jo int, wo me n a rthritis • Wha t: No n-infla mma to ry • E nla rg e me nt o f DI Ps= b o ne dise a se invo lving He rb e de n’ s no de s de ge ne r ation of ar tic ular • E nla rg e me nt o f PI Ps= c ar tilage Bo uc ha rd’ s no de s • Whe re : Hip, kne e , c e rvic a l • Pa in in jo ints a fte r use a nd lumb a r ve rte b ra e , DIP and PIP • Ca rtila g e lo ss usua lly • Why: Ne xt slide b e g ins o n the me dia l side • Ho w (to dia g no se ): I ma g ing
THE “WHY” OF OSTEOARTHRITIS • T he me c ha nic a l tra uma F inding s le a ds to de g ra da tio n o f • F ra ying o f c a rtila g e (“jo int a rtic ula r c a rtila g e * mic e ”) • Co mpo ne nts o f c a rtila g e : • E nation (e ro sio n o f bur pro te o g lyc a ns a nd type I I o ve rlying c a rtila g e à c o lla g e n po lishe d a ppe a ra nc e o f b o ne ) • Oste ophyte fo rma tio n (re a c tive b o ne fo rma tio n) • Sub c ho ndra l c ysts • NO ANKYL OSIS (fusio n)
OSTEOARTHRITIS 1) E b urna tio n 2) Sub c ho ndra l c yst 3) No rma l a rtic ula r c a rtila g e Bo uc ha rd no de (PI P) He b e rde n no de (DI P)
RHEUMATOID ARTHRITIS Othe r fa c ts • Who : Wome n 20-50yo • Asso c ia tio n with HL A- DR4 • Wha t: Chro nic , autoimmune syste mic dise a se (T ype I I I ) • E xtr a-ar tic ular manife stations • Whe re : symme tric MCP and • Ple ura l/ pe ric a rdia l e ffusio ns PIP jo ints, wrists, e lb o ws, • Pulmo na ry fib ro sis a nkle s, kne e s • Ane mia o f c hro nic dise a se • Why: Ne xt slide • Rhe umatoid nodule s • Ho w (to dia g no se ): b a se d • E xte nso r surfa c e o f the fo re a rm, lung s o n c linic a l pre se nta tio n a nd • Ce ntra l ne c ro sis surro unde d b y la b finding s histio c yte s • Ca n inc lude r he umatoid fac tor , • F e ve r , ma la ise , we ig ht lo ss a nti-CCP , a ntinuc le a r a ntib o dy • Ba ke r’ s c yst • Swe lling o f b ursa b e hind kne e
THE “WHY” OF RHEUMATOID ARTHRITIS • I nitia l inc iting a g e nt (virus? ) Jo int F inding s à B c e ll a c tiva tio n à a uto a ntib o die s à immune • Ulna r de via tio n o f fing e rs c o mple x de po sitio n à • Usua lly po lya rtic ula r c hro nic syno vitis a nd pa nnus fo rma tio n à • Mor ning stiffne ss (usua lly a nkylo sis >30 minute s tha t impro ve s with use ) • Swa n ne c k de fo rmity • PI P hype re xte nds while DI P fle xe s no rma lly
RHEUMATOID ARTHRITIS X-Ra y: Jo int-spa c e na rro wing , o ste o pe nia , ulna r de via tio n o f fing e rs Swa n-ne c k de fo rmity (fle xio n o f DI P , hype re xte nsio n o f PI P)
COMPARISON Oste oar thr itis Rhe umatoid ar thr itis E lde rly, wo me n>me n Wo me n o f c hildb e a ring Inc ide nc e a g e We ig ht-b e a ring jo ints; Symme tric invo lve me nt; F r e que nt site s DI P a nd PI P PI P a nd MCP Me c ha nic a l injury Auto immune (type I I I ) E tiology uc tion Artic ula r c a rtila g e Syno via l fluid 1° site of de str Oste o phyte s; jo int mic e ; RF ; syste mic sympto ms; Notable fe atur e s e b urna tio n HL A-DR4 NSAI Ds, T yle no l, he a t, NSAI Ds, c o rtic o ste ro ids, T r e atme nt visc o supple me nta tio n dise a se -mo difying (hya luro nic a c id a g e nts (e .g . inje c tio ns), intra -a rtic ula r me tho tre xa te ), g luc o c o rtic o ids, jo int b io lo g ic a l a g e nts (e .g . re pla c e me nt T NF -a lpha inhib ito rs)
QUESTION #2 A 45yo wo ma n pre se nts with swe lling , stiffne ss, a nd pa in invo lving multiple jo ints, e spe c ia lly in he r ha nds. Sympto ms b e g a n 6-7 mo nths prio r a nd ha ve le d to sig nific a nt re stric tio n o f he r da ily a c tivitie s. She e xpe rie nc e s pro lo ng e d mo rning stiffne ss a nd g e ne ra lize d fa tig ue . T yle no l a nd ib upro fe n ha ve pro vide d o nly minima l re lie f. Whic h o f the fo llo wing drug s wo uld pro vide mo st ra pid a nd c o mple te re lie f o f he r sympto ms? • F irst, is this o ste o arthritis o r rhe umato id arthritis?
QUESTION #2 A 45yo wo ma n pre se nts with swe lling , stiffne ss, a nd pa in invo lving multiple jo ints, e spe c ia lly in he r ha nds. Sympto ms b e g a n 6-7 mo nths prio r a nd ha ve le d to sig nific a nt re stric tio n o f he r da ily a c tivitie s. She e xpe rie nc e s pro lo ng e d mo rning stiffne ss a nd g e ne ra lize d fa tig ue . T yle no l a nd ib upro fe n ha ve pro vide d o nly minima l re lie f. Whic h o f the fo llo wing drug s wo uld pro vide mo st ra pid a nd c o mple te re lie f o f he r sympto ms? a . Co lc hic ine b . Me tho tre xa te c . Pre dniso ne d. Sulfa sa la zine e . Mino c yc line
QUESTION #2 A 45yo wo ma n pre se nts with swe lling , stiffne ss, a nd pa in invo lving multiple jo ints, e spe c ia lly in he r ha nds. Sympto ms b e g a n 6-7 mo nths prio r a nd ha ve le d to sig nific a nt re stric tio n o f he r da ily a c tivitie s. She e xpe rie nc e s pro lo ng e d mo rning stiffne ss a nd g e ne ra lize d fa tig ue . T yle no l a nd ib upro fe n ha ve pro vide d o nly minima l re lie f. Whic h o f the fo llo wing drug s wo uld pro vide most r apid a nd c o mple te re lie f o f he r sympto ms? a . Co lc hic ine - fo r ac ute go ut b . Me tho tre xa te - pre fe rre d in mo de rate o r se ve re RA but take s we e ks c . Pre dniso ne - c o rtic o ste ro id d. Sulfa sa la zine - fo r mild, e arly se ro ne gative RA e . Mino c yc line - fo r mild, e arly se ro ne gative RA
QUICK REVIEW: METHOTREXATE • I nhib its dihydro fo la te re duc ta se • Side e ffe c ts to kno w: e ssion , mye losuppr fa tty live r (AL T / AST e le va tio ns), Me tho tre xa te muc ositis (pa inful mo uth ulc e rs), te ra to g e nic
QUESTION #3 A 35 yo ma n c o me s in c o mpla ining o f se ve re le ft hip pa in tha t is te rrib le whe n he a wa ke ns b ut impro ve s thro ug ho ut the da y. He a lso ha s o c c a sio na l swe lling o f his ha nds a nd fing e rs. On physic a l e xa m, yo u no tic e a g ra y, dry sc a ly ra sh o n his knuc kle s a nd e lb o ws. X-ra ys o f his lumb a r spine a nd hips sho w sa c ro iliitis o n the le ft side . Ha nd X-ra ys sho w se ve re e ro sio ns o f the DI P jo ints o n the rig ht. He is HL A-B27 po sitive . Wha t is the mo st stro ng ly a sso c ia te d c o nditio n? a . Re ite r’ s syndro me b . Budd-c hia ri syndro me c . Sjo g re n syndro me d. Re ye ’ s syndro me e . Go o dpa sture ’ s dise a se
QUESTION #3 A 35 yo ma n c o me s in c o mpla ining o f se ve re le ft hip pa in tha t is te rrib le whe n he a wa ke ns b ut impro ve s thro ug ho ut the da y. He a lso ha s o c c a sio na l swe lling o f his ha nds a nd fing e rs. On physic a l e xa m, yo u no tic e a g ra y, dry sc a ly ra sh o n his knuc kle s a nd e lb o ws. X-ra ys o f his lumb a r spine a nd hips sho w sa c ro iliitis o n the le ft side . Ha nd X-ra ys sho w se ve re e ro sio ns o f the DI P jo ints o n the rig ht. He is HL A-B27 po sitive . Wha t is the mo st stro ng ly a sso c ia te d c o nditio n? a . Re ite r’ s syndro me b . Budd-c hia ri syndro me c . Sjo g re n syndro me d. Re ye ’ s syndro me e . Go o dpa sture ’ s dise a se
Recommend
More recommend
