This week on PA Study Sesh, we’ll learn about Rheumatology.

A note about ANA, RF, ESR, CRP

ANA: Antinuclear antibodies

Shows antibodies against self

Can be positive in healthy people

Also induced by certain drugs & cancers

NONSPECIFIC

CRP: C-reactive protein

Produced in the early stages of inflammatory process.

NONSPECIFIC

ESR: erythrocyte sedimentation rate “sed rate”

Rate at which rbcs settle

NONSPECIFIC

RF: Rheumatoid Factor

Autoantibody to a fragment of IgG

NONSPECIFIC

In Summary: These are all NONSPECIFIC and only clue you in to the presence of inflammation and auto-immune disease. They do not help you definitively distinguish one disease from another and therefore (in my opinion) are not worth memorizing their absence/presence in each disease for PANCE/PANRE purposes.

Fibromyagia

• Chronic, widespread muscle pain

• Middle aged women

• Associated fatigue, fibro fog

• Diffuse pain in 11/18 trigger points >3 months

• Clinical diagnosis

• Tx: exercise (swimming), OTC pain medication, TCA

Reactive Arthritis (Reiter Syndrome)

• Autoimmune response to an infection elsewhere

• Young males most common

• Arthritis, conjunctivitis/uveitis, urethritis

• Keratoderma blenorrhagicum (hyperkeratotic lesions on palms/soles)

• s/p chlamydia #1, may also follow gonorrhea or GI infections

• Labs: Often HLA B-27 + (young males like ankylosing spondylitis)

• Can’t pee, can’t see, can’t climb a (bamboo) tree, can’t sleep with me

• Tx: NSAIDS

• Abx if infection not treated

Gout

• Uric acid

• Most patients are under excretors, which explains why associated with food consumption

• Purine-rich foods, TZD, ACE/ARBs, ASA, Pyrazinamide, Ethambutol (TAPE)

• Men most common

• 1st MTP joint = podagra

• Red, swollen, tender joint

• Arthrocentesis=gold standard

• Negatively birefringent, needle shaped urate crystals

• Tophi: colletion of solid uric acid (ears, eyelids, fingers)

• X-ray

• Rate bite erosions (recurrent)

• Tx:

• Acute: NSAIDS (indomethacin), but avoid ASA

• 2nd line= colchicine

• Chronic:

• Colchicine (can be used in both!)

• Probenecid (uricosuric drug)= increase excretion

• Allopurinol (Xanthine Oxidase Inhibitor)- decreases uric acid production, so not used in acute disease.

Pseudogout

• Calcium pyrophosphate

• Large joints. Knee #1

• Red, swollen, tender joint

• Arthrocentesis:

• Postitively birefringent prism shaped (rhomboid)

• Tx: NSAIDS, steroid injection

• Colchicine also used acute & chronic.

• Prophylaxis if more than 3 attacks per year

Juvenile RA

• AKA juvenile idiopathic arthritis

• Prior to age 16, typically resolves by puberty

• 3 types

• Oligoarticular (50%)

• Less than 5 joints involved in the first 6 months (typically large joints)

• Swollen, tender, warm, without erythema

• May have concomitant anterior uveitis

• Refer to ophthomology

• • ANA

• Symptomatic treatment (NSAIDS)

• Polyarticular (30%)

• Most similar to adult RA

• If in a teenager, consider early RA presentation

• 5 joints involved during 1st 6 months (usually symmetric)

• Eye involvement less common, but possible

• • ANA +/- RF

• TX: NSAIDS

• Systemic (20%) Still’s Disease

• Intermittent,