Transcript Core Content Rheumatology

Core Content
Rheumatology
Lauren Cooper
1/26/05
“I’d bet my next paycheck that
this is some rheumatologic
funniness.”
Lauren Cooper
1/26/05
Chapters
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1.
2.
3.
4.
5.
6.
7.
Neck pain
Thoracic and lumbar pain syndromes
Shoulder pain
Emergencies in systemic rheumatic diseases
Hand infections
Acute disorders of the joints and bursae
Soft tissue problems of the foot
A pain in the neck
Anatomic considerations
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cervical disks less likely than lumbar disks
to prolapse
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more mobile
less axial load
nucleus pulposus is more anterior and
reinforced posteriorly along entire width by
posterior longitudinal ligament
Anatomic considerations
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eight paired cervical roots
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exit intervertebral foramina between superior
and inferior pedicles
unlike other vertebrae, in many cases the
ventral and dorsal roots are separate at the
neural foramina
therefore, osteophytes or herniated disks may
cause isolated motor or sensory complaints
Dermatomes
Disk space
Pain
Sensory
Motor
Reflex
C1-C2
Neck, scalp
Scalp
C4-C5
Neck, shoulder,
upper arm
Shoulder,
thumb
Deltoid, biceps
Biceps
C5-C6
Neck, shoulder,
scapula,
forearm, thumb
Thumb and 2nd
finger, lateral
forearm
Deltoid, biceps,
pronator, wrist
ext.
Biceps and
brachioradialis
C6-C7
Neck, posterior
arm, chest,
middle finger
Middle finger,
forearm
Triceps,
pronator teres
triceps
C7-C8
Neck, posterior
arm, medial
hand, 4th & 5th
fingers
4th and 5th
fingers
Triceps, flexor
carpi ulnaris,
hand
triceps
Disk herniations
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nucleus pulposus protrudes through
posterior annulus fibrosis, causing:
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radiculopathy- segmental motor or sensory
signs associated with a nerve root, or
myelopathy- signs of spinal cord disease
most frequently C5-C6 (right sided) or C6C7 (left sided)
Indications for admission
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intractable radicular pain
progressive upper extremity weakness
progressive lower extremity myelopathic
signs: hyperreflexia, motor weakness,
bowel/bladder dysfunction
Spondylosis
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cervical spondylosis- disk degeneration causes
articular degeneration with subsequent
spur/osteophytic bar formation
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pain, loss of flexibility
osteophytes can produce Horner’s syndrome,
vertebral-basilar symptoms, and chest pain mimicking
angina
progresses to cervical stenosis, with radiculopathies,
myopathies
Thoracic and lumbar pain- aka the
dreaded “back pain”
Thoracic spine
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thoracic disk herniations rare- only 1% of
all disk herniations
fractures usually at the T10-L2 levelsoccur from direct trauma, forced
hyperflexion (lap belts), and osteoporosis
if myelopathy, a malignancy must be
suspected
Thoracic spine- other causes of
pain
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acute facet syndrome: localized paravertebral pain from
osteoarthritis
rheumatoid spondylitis: suggested by chest expansion of
less than 1inch at the nipple line, more common in men
herpes zoster
diabetic thoracic radiculopathy may present as
abdominal pain (you can add this to abd pain DDx)
Lumbar spine
back pain in Barca 23
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“60-90% of the
population will experience
back pain in their
lifetime”
50% of people will have
recurrent pain
high work disability
Natural History: 90-95%
of patients, even with
sciatica, will be better in
2 months, regardless of
type of treatment
Spinal stenosis
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causes back and lower extremity pain
key history is neurogenic claudication;
therefore, may be indistinguishable from
vascular insufficiency without CT/MRI
Sacroiliitis
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pain may be referred to inguinal region,
anterolateral or posterior thigh, or lower
abdomen
usually worse at night, with prolonged
sitting or standing
weakness/stiffness in the a.m.
may be associated with new-onset
rheumatoid spondylitis
Radiculopathy
95% of disk herniations occur at L4-L5 or L5-S1
L5 compromise
S1 compromise
Anterior tibial pain, like “shin
splints”
Calf pain, like thrombophlebitis
Parasthesia of great toe
Parasthesia of little toe
Reproduced by palpation of
peroneal nerve at fibular head
Reproduced by palpation of tibial
nerve in tarsal tunnel
Red flags
Fracture
Tumor
Cauda
equina
Spinal
infection
Major trauma
Age >50 or <20
Saddle
anesthesia
Recent bacterial
infection, esp.
UTI
Bladder/bowel
dysfunction
IV drug abuse
Severe or
progressive
neuro deficit in
LE’s
Immunosupression
Minor trauma in Hx of cancer
older/osteoporot
ic pt
Pain that
worsens when
supine (or at
night)
Treatment of back syndromes
(if no red flags)
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“Nonprescription analgesics will provide
sufficient pain relief for most patients with acute
low back symptoms…Muscle relaxants seem no
more effective than NSAIDs…Opioids appear no
more effective than safer analgesics.”
When lifting, keep objects close to the body.
Aerobic conditioning exercise such as walking,
biking, or swimming may be beneficial.
Shoulder pain
“the most versatile and yet the most vulnerable
joint in the body”
Rotator cuff anatomy
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supraspinatus- initiates
arm elevation and
abducts the shoulder
infraspinatus- external
rotation
teres minor- external
rotation
subscapularis- internal
rotation
Impingement syndrome
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caused by compression within
coracoacromial arch
3 stages
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stage 1- local inflammation and edema,
reversible
stage 2- inflammation, thickening, and fibrosis
of rotator cuff tendons, irreversible
stage 3- degeneration and rupture of rotator
cuff tendon, irreversible
Tests for impingement
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Neer’s test: passive full shoulder
abduction causes pain
Hawkins’ test: with 90 degrees arm
abduction and 90 degrees elbow flexion,
bringing arm in front of body causes pain
Subacromial bursitis
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correlates with stage 1 impingement
if left untreated, will progress to stages 2 and 3
range of motion may be preserved but painful
between 60 and 100 degrees of abduction,
especially against resistance
Xrays negative
treat with relative rest (avoid aggravating
motion but continue gentle ROM), NSAIDs, ice,
f/u 7-14 days
Rotator cuff tendinitis
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correlates with stages 1 and 2 impingement
hx: long duration of pain; night pain interferes
with sleep
exam: atrophy, tenderness at proximal humerus,
crepitus, weakness
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To test the supraspinatus, use the empty beer can
position against resistance.
Xrays may be normal or may show osteophytes
treat as in bursitis
Rotator cuff tears
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correlates with stage 3 impingement
may be acute or chronic
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bony avulsion injuries of the humerus may accompany acute
trauma
may be partial or full thickness
exam: as in tendonitis, plus +drop-arm test
Xrays show sclerosis of humeral head, DJD of AC joint,
and osteophytes
treat acutely with sling, then gentle ROM
f/u with ortho within 7 days, may require surgical repair
Calcific tendonitis
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deposition of calcium hydroxyapatite crystals
within a rotator cuff tendon
onset of pain coincides with resorption of the
calcium
exam: proximal humerus tenderness, pain with
ROM, crepitus
Xrays show calcium deposits
self-limiting, 1-2 weeks
treat acutely with sling, then ROM + NSAIDs,
ice…needling? F/u with ortho within 1 week.
Biceps tendon
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tendonitis: palpation of tendon and
forearm supination reproduce pain
subluxation: supination against resistance
may cause palpable subluxation
rupture: “popeye” deformity
treat with sling, analgesics, NSAIDs, ice
ortho referral for complete tears
Other causes for shoulder pain
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pain referred from neck
brachial plexus injury
axillary artery thrombus
suprascapular nerve entrapment
thoracic outlet syndrome: compression of
brachial plexus or blood vessels, radiates in
C7-C8 distribution
Pancoast’s tumor
thoraco-abdominal disorders
Systemic rheumatic emergencies
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respiratory
cardiac
adrenal
eye
kidney
Respiratory diseases
Disease
Presentation
Treatment
Relapsing polychondritis
airway obstruction or
tracheobronchial collapse
steroids, tracheostomy
RA
cricoarytenoid dysfunction
tracheostomy
Dermatomyositis and
polymyositis
intercostal weakness
ventilation
SLE
pleural effusions
NSAIDs, prednisone
Scleroderma
pulmonary fibrosis
Vasculitides
sinusitis, hemorrhage
Myositis
interstitial pneumonitis
immunosuppression
Cardiac diseases
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pericarditis- RA and JRA
premature atherosclerosis- SLE
MI- Kawasaki disease and polyarteritis
nodosa (small- and medium-caliber artery
vasculitis)
hypertensive crisis- scleroderma (treat
with ACE-I)
pancarditis- acute rheumatic fever
Jones Criteria for Diagnosis of
Rheumatic Fever
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Diagnostic : 1 Required Criteria and 2 Major Criteria
Diagnostic : 1 Required Criteria and 1 Major Criteria and 2 Minor
Criteria
Required Criteria: evidence of antecedent Strep infection: ASO /
Strep antibodies / Strep group A throat culture / recent scarlet fever
/ anti-deoxyribonuclease B / anti-hyaluronidase
Major Diagnostic Criteria:
carditis, polyarthritis, chorea,
erythema marginatum, subcutaneous nodules
Minor Diagnostic Criteria:
fever, arthralgia, previous
rheumatic fever or rheumatic heart disease, acute phase reactions:
ESR / CRP / Leukocytosis, prolonged PR interval
Adrenal insufficiency
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didn’t we do this last week?
stress-dose steroids!
The eye
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temporal arteritis
Sjogren’s syndrome: lymphocytic infiltration of
lacrimal glands causing dry eyes
RA:
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episcleritis causes pink-red eye, is self-limiting
scleritis causes pain and deep purple eye, can cause
scleral rupture…ophtho emergency, steroids
The kidney
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glomerulonephritis- SLE and Wegener’s
rhabdomyolysis- polymyositis
renall dysfunction secondary to HTNscleroderma
nephrotoxicity- NSAIDs
Hand infections
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With the exception of
superficial cellulitis,
hand infections are
surgical problems.
Cellulitis
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lacks involvement of deeper structures
if extensive involvement, parenteral abx
and admission
immobilization, elevation, cephalexin or
augmentin
Flexor tenosynovitis
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Kanavel’s signs (4): tenderness over
tendon sheath, pain with passive
extension, symmetric finger swelling, and
flexed posture at rest
Unasyn or cefazolin and penicillin
suspect N.gonorhhoeae if recent STD and
MRSA if IVDA
emergent hand consult
Other hand infections
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paronychia- warm soaks, elevation, drain
if suppurative
felon- lateral incision to avoid denervation
to distal fingertip
herpetic whitlow- immobilize, elevate, pain
meds, acyclovir
Inflammation of the hand
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Tenosynovitis may be noninfectious, from overuse
syndromes. However, if infection is suspected, it must
be managed aggressively.
trigger finger: a scarred tendon forms a nodule which
catches in the A1 pulley on finger extension
DeQuervain’s stenosing tenosynovitis: inflammation of
the extensor pollicis brevis and abductor pollicis tendons
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Finkelstein’s test
steroid injection, NSAIDs, thumb spica splint
carpal tunnel syndrome: Tinel’s and Phalen’s signs
have poor sensitivity and specificity
Joints and Bursae
Classification of arthritis by number
of affected joints
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Monoarthritis (1)
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trauma
septic
crystal-induced
acute OA
Lyme
avascular necrosis
tumor
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Oligoarthritis (2-3)
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Lyme
Reiter’s syndrome
ankylosing spondylitis
gonococcal arthritis
rheumatic fever
Polyarthritis (>3)
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RA
SLE
chronic OA
viral
Synovial fluid exam
Normal
Noninflam Inflammatory
matory
Septic
WBC/uL
< 200
<200-2000
200-50,000
>50,000
%PMN’s
<25
<25
>50
>50
Culture
negative
negative
negative
>50%
positive; 2550 in
gonococcal
Crystals
none
none
Multiple or
none
none
Organisms in septic arthritis
Patient
Organism
Neonates and infants
Staph, Gram neg, GBS, Candida
Children <5 years
Staph, H. flu
Older children and healthy adults
Staph, Strep, Gonococcus
foot
Staph, Pseudomonas
IVDA
Staph, Gram neg
Sickle-cell
Salmonella
Other causes of pain
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gout
pseudogout
Lyme disease
rheumatoid arthritis
osteoarthritis
Reiter’s syndrome- reactive arthritis preceeded by
urethritis or infectious diarrhea
ankylosing spondylitis- spine (bamboo spine) and
sacroiliitis
olecranon and prepatellar bursitis- aspirate, as they may
be septic
Last chapter: soft tissue problems
of the foot
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calluses become corns
plantar warts are
caused by HPV
Tinea pedis
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Trichophyton rubrum, Micosporum,
Candida, and saprophytic fungi
responsible
Wash your feet.
Dry your feet.
Change your socks.
Use topical (2-3 weeks) or oral (1 week)
antifungals.
More foot problems
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plantar fasciitisinflammation of
plantar aponeurosis.
Rest, ice, NSAIDs,
heel and arch
supports.
tarsal tunnel
syndrome- posterior
tibial nerve inferior to
the medial malleolus
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72 year-old woman with a history of polymyalgia
rheumatica (PMR) complains of persistant low grade
fever, poor appetite, weight loss and a piercing
headache at night. A head CT and spinal tap are normal.
Which of the following procedures would most likely
reveal this patients diagnosis?
A. A dialated fundoscopic examination
B. CT scan of her head with intravenous contrast
C. MRI of her head
D. Temporal artery biopsy
E. Muscle biopsy
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A 19-year old presents to the ED with a chief complaint of pain in
his knees and a rash. His vital signs are: BP, 120/70; P, 96; T, 38.4
C (101.2F). Physical exam reveals diffuse lymphadenopathy and a
maculopapular rash over his trunk. For the past nine days he has
been taking penicillin for a streptococcal pharyngitis. He has no risk
factors for HIV infection, has a single sexual partner and always
uses condoms. Which of the following is his most likely diagnosis?
A. Penicillin resistant streptococcal pharyngitis
B. Serum sickness
C. Viral syndrome
D. Rheumatic fever
E. Gonorrhea
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The diagnosis of acute rheumatic fever can be made on
finding which of the following set of signs or symptoms:
A. Prolonged PR interval, fever and positive throat
culture for group A streptococcus
B. Carditis, chorea and fever
C. Subcutaneous nodules, fever and positive ASO titer
D. Elevated ESR, fever and positive throat culture for
group A streptococcus
E. Prolonged PR interval, fever, elevated ESR and
positive ASO titer
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A 10 year-old boy awakes with right knee and
ankle pain. On examination in the ED he has a
low grade fever and minimally swollen joints.
Which of the following test would be of least
importance in diagnosing this patient's illness?
A. An echocardiogram
B. Erythrocyte sedimentation rate (ESR)
C. Knee x-ray
D. Anti-strepolysin O (ASO) titer
E. Throat culture
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An African-American female of child-bearing age
presents with fever, joint pain, and a malar rash which is
exacerbated by exposure to light. The patient is noted to
have proteinuria on urine analysis. What potential
complications are associated with this syndrome?
A. Renal failure
B. Seizures
C. Hemolytic anemia
D. Thrombocytpenia
E. All of the above
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Which of the following matches are incorrect?
A. DeQuervain's Tenosynovitis - Finkelstein test
B. Calcific tendonitis - flexor carpi ulnaris
tendon
C. Tenosynovitis of the extensor pollicis longus pain over Listers' tubercle
D. DeQuervain's Tenosynovitis - flexor pollicus
brevis
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The presenting symptoms of de Quervain’s syndrome
are:
A. Pain with flexion of the iliotibial band
B. Pain in the ulnar aspect of the wrist exacerbated with
movement
C. Pain in the anterior shoulder exacerbated with
repetitive movement
D. Pain in the posterior shoulder exacerbated with
repetitive movement
E. Pain in the radial aspect of the wrist & thumb
exacerbated with movement
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A 40 year-old housekeeper presents with mild
knee pain with swelling overlying the lower pole
of the patella. What is the correct diagnosis?
A. Prepatellar bursitis
B. Anserine bursitis
C. Popliteus tendinitis
D. Plica syndrome
E. Meniscal tear
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One of the most devastating hand
infections encountered in clinical practice
is:
A. Herpetic whitlow
B. Flexor tenosynovitis
C. Eponychia
D. Felon