Rheumatology Review Natalie A. Nevins, DO, MSHPE

7/28/2014

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Natalie A. Nevins, D.O., MSHPE Director of Medical Education

Downey Regional Medical Center Family Medicine Residency Program

Common Rheumatologic

Presentations in Primary Care

ACOFP Board Review

Is a chronic, systemic, inflammatory disorder of unknown etiology that primarily involves joints

◦ The most common inflammatory arthritis

◦ Arthritis is symmetrical may lead to destruction of joints due to erosion of cartilage and bone which leads to deformity

◦ Extraarticular manifestations may

be present (nodules, neuropathy, scleritis, pericarditis, splenomegaly)

◦ F>M 2:1, mean age 50-55

Rheumatoid Arthritis (RA)

Morning stiffness > 1 hour Arthritis of three or more joint groups with

soft tissue swelling Swelling involving 1 or more joint groups:

wrist, proximal IPJ, MCP, MTP Active symmetric joint swelling Hand X-ray changes typical of RA that must

include erosions or unequivocal bony decalcification

Subcutaneous nodules + Rheumatoid factor

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The characteristic joint deformities appear in more established chronic RA. These findings include ulnar deviation swan neck or Boutonniere deformities of the fingers, or the “bow string” sign (prominence of the tendons in the extensor compartment of the hand)

Occasional patients present with extensor tendon rupture, most commonly affecting the thumb, little or ring fingers of either hand.

RA - Hands

DMARDS are divided into two categories: nonbiological and biological ◦ The nonbiological: methotrexate, sulfasalazine,

lefunomide (Pyrimidine synthesis inhibitor), all primary options. Hyroxychloroquine, secondary option

◦ The biological DMARDS: target specific cytokines or their receptors, such as tumor necrosis factor. Other types of biological DMARDS include B cell depleting agents and Tcell costimulatory blockers. The use of biologic DMARDS has been referred to as “targeted therapy”

◦ 1st line for mild-moderate disease at initial presentation

Possible options: ◦ Mild-moderate disease is usually started on a single

DMARD. MTX most common first line drug. Other options leflunomide (LEF), sulfasalazine (SSZ), and hydroxychloroquine (HCQ)

The addition of ONE of the following agents to MTX: ◦ tumor necrosis factor (TNF) inhibitor: adalimumab,

etanercept, or infliximab, abatacept (T cell costimulation blocker), rituximab (depletes B cells),

or anakinra (interleukin-1 receptor antagonist)

Treatment

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Most common form of chronic arthritis in children

Onset 6 weeks

3 subtypes (per ACR criteria): ◦ Systemic: 10-20% fever, evanescent rash

◦ Polyarticular: 30-40%, > 4 joint involvement (large and small)

◦ Pauciarticular: 40-50%, M 10:1

Increased risk in African American, Hispanic, Asian and Native American

Hereditary Compliment deficiency: C1q, C1r, C1s, C4 and C2

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Fever

Vasculitis

Panniculitis

Myositis

Avascular Necorisis

Endocarditis

Ascites

Venous thrombosis

Pulmonary Fibrosis

Renal failure

Peripheral neuropathy

Stroke syndromes

Pancreatitis/ elevated LFT’s

Infertility

Seizures

1. Malar rash (Butterfly) 2. Discoid rash 3. Photosensitivity rash 4. Oral ulcers 5. Nonerosive Arthritis Involving 2 or more peripheral joints 6. Pleuritis or Pericarditis a) Pleuritis 7. Renal Disorder a) Persistent proteinuria > 0.5 grams per day OR b) Cellular

casts--may be red cell, hemoglobin, granular, tubular, or mixed 8. Neurologic Disorder a) Seizures OR b) Psychosis 9. Hematologic Disorder a) Hemolytic anemia--with reticulocytosis OR b)

Leukopenia--< 4,000/mm3 on ≥ 2 occasions OR c) Lyphopenia--< 1,500/

mm3 on ≥ 2 occasions OR d) Thrombocytopenia--

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Inflammatory reaction to URATE crystals in joints, bones and subcutaneous structures

Crystals in joint fluid is pathognomonic

Hyperacute arthritis ◦ Primary: Most common, under-excretion or

overproduction of uric acid

◦ Secondary: related to myloproliferative DZ, treatments inducing hyperuricemia, renal failure/tubluar disorders, glycogen storage dz

Age 30-60, M>F 20:1

Risks: ETOH, Fam hx, MEDS (diuretics induce 20% of secondary gout), obesity/HTN (50%), diet

S/S: 7mg/dl men, >6mg/dl women)

Risk of kidney stones

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Avoid foods high in purines, such as liver and other organ meats, dried peas and beans, veal, turkey, and some types of fish, including anchovies, shrimp, mackerel, and scallops.

Stop drinking large amounts of alcohol. Alcohol interferes with excretion of uric acid, and alcoholic beverages contain purines

Lose Weight

Acute: NSAIDs (first line) for 10-14 days Treatment of gout should be initiated with an NSAIDs to

control acute inflammation. At the maximum recommended doses, NSAIDs effectively treat arthritis caused by crystals.

◦ Unlike the newer, equally effective NSAIDs, indomethacin frequently causes dyspepsia and can cause central nervous system side effects such as headache and mental status changes

Antigout Agents Colchicine (second line), may be helpful with patients who

cannot tolerate or have contraindications to NSAIDs and corticosteroids.

◦ With the availability of other agents, however, there is little role for colchicine in the treatment of acute gout, particularly in elderly patients.

Recurrent Gout: 2-3 weeks post acute episode ◦ First line: Urate lowering agent

Allopurinol, Febuxostat

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Naproxen Ibuprofen Diclofenac Potassium Meloxicam Celecoxib Febuxostat Triamcinolone acetonide Prednisone/methylpred/ Indomethacin Probenecid Sulindac Allopurinol Colchicine

Acute inflammatory arthritic disease usually involving large joints

Arthrocentesis Synovial fluid Calcium pyrophosphate dihydrate crystal (CPPD)

deposition disease Associated with chondrocalcinosis 80% > 60 y/o Knee involved 50% of all attacks 50% with fever Elevated sed rate, leukocytosis (may have left

shift) Nsaids

Triad of Arthritis, conjunctivitis and either urethritis or cervicitis. 4th feature may be buccal ulceration or balanitis

Sterile joint inflammation with infection starting at non-articular site

2 forms: ◦ Sexually transmitted: S/S emerge 7-14 days after

sex (Chlamydia usual organism)

◦ Postdysenteric (shigella, salmonella, yersina, campylobacter). More common in Women, children and elderly.

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HLA-B27 in 60-80% 20-40 y/o M>F Ankylosing spondylitis develops in 30-50% in

those + for HLA-B27 Asymmetric arthritis (knees, ankles, MTP) Enthsopathy Urogenital tract: Urethritis/prostatitis etc. Eye: Conjunctivitis/scleritis/keratitis Skin: mucocutaneous ulcers Constitutional: fever, malaise, wt loss

WBC: 10-20,000

Increased neutrophils

Increased sed rate

Normochromic anemia

Hypergammaglobulinemia

Ongoing segmental inflammatory, systemic necrotizing vasculitis within the media of small and medium sized muscular arteries

Multisystem involvement: fever, wt loss, malaise, Skin (livedo reticularis), CNS (HA, sz), Renal, MSK, GI, Lung, Cardiac

Labs: nonspecific, may have RF, endothelial cell AB, high neutrophil, anemia, elevated sed rate &

C-reactive protein. Hepatitis surface antigen + in 10-50% of cases. Negative ANA and RF

BX of involved organs: necrotizing vasculitis Angiogram with aneurysmal changes Treatment (Non-HBV related): Good Prognosis: Prednisone Poor Prognosis Prednisone and DMARD

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1. Weight loss: of 4 kg or more of body weight since illness began, not due to dieting or other factors 2. Livedo reticularis 3. Testicular pain or tenderness Pain or tenderness of the testicles 4. Myalgias, weakness or leg tenderness Diffuse myalgias (excluding shoulder and hip girdle) or weakness of muscles or tenderness of leg muscles 5. Mononeuropathy or polyneuropathy Development of mononeuropathy, multiple mononeuropathys, or polyneuropathy 6. Diastolic BP >90 mm Hg Development of hypertension with diastolic BP higher than 90 mm Hg 7. Elevated BUN or creatinine Elevation of BUN >40 mg/dl or creatinine >1.5 mg/dl 8. Hepatitis B virus Presenece of hepatitis B surface antigen or antibody in serum 9. Arteriographic abnormality Arteriogram showing aneurysms or occlusions of the visceral arteries, not due to arteriosclerosis, fibromuscular dysplasia, or other noninflammatory causes 10. Biopsy of small or medium-sized artery containing PMN Histologic changes showing the presence of granulocytes or granulocytes and mononuclear leukocytes in the artery wall

Widespread pain

Stiffness

Poor sleep

Fatigue

Swelling in soft tissue (especially hands)

Numbness in the extremities

Headaches

Restless Leg Syndrome

Diarrhea Abdominal pain Tender joints Limited range of

motion Jaw pain Memory impairment Menstrual cramping Dizziness Skin and chemical

sensitivities

Restless sleep and fatigue Hx of widespread pain & Pain in 11 of 18 tender point sites on digital

palpation for at least 3 months Occiput: Bilateral, at the suboccipital muscle insertions.

Low cervical: bilateral, at the anterior aspects of the intertransverse spaces at C5-C7. Trapezius: bilateral, at the midpoint of the upper border. Supraspinatus: bilateral, at origins, above the scapula spine near the medial border. Second rib: bilateral, at the second costochondral junctions, just lateral to the junctions on upper surfaces. Lateral epicondyle: bilateral, 2 cm distal to the epicondyles. Gluteal: bilateral, in upper outer quadrants of buttocks in anterior fold of muscle. Greater trochanter: bilateral, posterior to the trochanteric prominence. Knee: bilateral, at the medial fat pad proximal to the joint line.

80-95% are women

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First Line: Graded Aerobic Exercise: Walking, Pool, Strength

training Cognitive - behavior therapy Good sleep hygiene

Second line: Mind-Body Therapies: Biofeedback, Guided Imagery,

hypnosis

FDA Approved Meds: ◦ Tricyclic Antidepresants ◦ Cymbalta (Duloxetine HCl) ◦ Lyrica (Pregabalin ) ◦ Savella (Milnacipran HCl)

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