Rheumatic Disorders Notes

Rheumatology 101
• Fibromyalgia, MFP, CFS, Arthritis: Inflammatory (RA, spondyloarthropathies); Mechanical (OA)
• Lupus, sjorgens, scleroderma, PMR, infectious, etc., Lyme
Fibromyalgia Syndrome (italics = symptoms experienced among most pts)
• Diagnostic criteria by the American College of Rheumatology-see guidelines
• Cardinal features: chronic widespread pain, multiple tender points (that have no cause)
• Characteristic features: pain, fatigue, sleep disturbance (disrupted/poor), stiffness, parathesis, HA, IBS,
Raynaud’s like s/s, depression & anxiety (prior to or due to this disorder), cognitive difficulties
• Pts must have pain for at least 3 months involving upper and lower body, R and L sides, as well as axial
skeleton, and pain in at least 11 of 18 tender points of digital exam
o Trigger pts: front lower neck, base of skull, neck & shoulder, edge of upper breast, upper inner
shoulder, below side bone at elbow, upper outer buttock, hip bone, just above knee on inside
• Use of tender points for dgxs under question due to impracticality in primary care
• Dgx testing is indicated only to the extent that it is necessary to r/o other causes of symptoms  work
them up for all the other diff dgx and then you can dgx with this; exclusionary dgx
• Diff Dgx: SLE, Bursitis or tendinitis, Polymyositis, Myofascial pain
• Temporal arteritis, Depression, Anxiety, Polymyalgia rheumatica, Rheumatoid arthritis
• Lyme disease, MS, Hypothyroidism, Chronic fatigue syndrome
• Tx: QOL & maximize fxing (to what’s acceptable for them), Pain and s/s management are priorities
o Lyrica and Cymbalta have proven most effective (titrate up and titrate off): can have pain crisis
or mental health swing if taken off abruptly
o Gentle exercise (walking, yoga, tai chi), non-repetitive, acupuncture, support grps, counseling,
education on self-management of a chronic condition, CBT (teaches them how to manage their
day and have better QOL), psych support
o SSRIs or SNRIs are also effective, TCAs or sleep agent may be prescribed at bedtime
o Evaluate for OSA or RLS: common comorbidities (no sleep agents unless melatonin )
Myofascial pain syndrome (MFP)
• Deep aching & burning pain due to inflammation of a muscle (arms, legs)
• Check for knots in SQ tissue (in trigger points), erythema, warmth, lesions, spasm & edema, muscle
fatigue, stiffness & spasm that affects sleep
• D/t: Chronic infxs, Metabolic & endocrine pathology such as: hypothyroid, hyperglycemia, &
hyperuricemia, Physical biomechanical dysfunction, poor posture, repetitive strain injury
o Neuro pathology: entrapment neuropathies (sciatica), peripheral neuropathy (may have shuffle
gait bc cant feel ground when walking), & radiculopathy (shooting pain)
o Nx deficiencies, Labs: myoglobin, B12, folate
o Rheumatology pathology: RA, SLE, OA, polymyalgia rheumatica
• Tx: Steroid injections, massage, heat, PT, muscle relaxants (short term), monitor anxiety & depression
Chronic Fatigue Syndrome (CFS): also dgx with fibromyalgia (co dgx): need rheumatology on board
• Chronic fatigue syndrome: chronic muscle fatigue and joint pain can greatly impact one’s life, many
physiologic, physical, psychological causes; need a lot of symptom management bc no cure
• S/S: weakness, tiredness, indifference, lack of energy
• Dgx: Cortisol, thyroid level, bs level; ggx of exemption  very detailed hx and a full physical exam
• Criteria for CFS: Severe fatigue >6 months r/o causes
o 4 of 8: Post exertional malaise >24h , HA new type, Muscle pain, Multi joint pain w/o swelling,
ST, Tender lymph nodes
Mechanical vs. Inflammatory Arthritis (OA= osteoarthritis)
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 • Noninflammatory (OA, athletes): focal, brief morning stiffness that improves throughout day, no
constitutional s/s, peak period of discomfort after prolonged use, locking or instability d/t joint
breakdown (loose body, internal derangement, or weakness), b/l good symmetry is occasional,
tenderness and inflammation unusual, no multisystem disease or lab abnormalities; lg joints involved
• Inflammatory (RA, SLE): significant prolonged (>1hr) morning stiffness (pain all day), constitutional
s/s, peak period of discomfort after prolonged inactivity, locking or instability uncommon, b/l symmetry
is common, tenderness over entire expose joint area (from touch), inflammation common, multisystem
disease and lab common; whole body involved
Inflammatory Arthritis
• Rheumatoid arthritis, Spondyloarthropathies (ankylosing spondylitis, psoriatric arthritis, reactive
arthritis: formerly Reiter’s syndrome )
• SLE, Sjogren’s, Scleroderma, Polymyalgia rheumatica, Vasculitis, Infectious (bacterial, viral, other)
Rheumatoid Arthritis
• Chronic, symmetric, inflammatory polyarthritis that affects 1% ppl ; 3x women >men; ages 40-50
• Genetic, class II molecules (HLA-DRB1), Autoimmune, Environmental
• S/S: Soft tissue swelling, joint narrowing, osteoporosis, AM stiffness >30min
• Most commonly affected joints = hyperextension of proximal interphalangeal joints [PIPs], DIP flexion
and flexion of metacarpophalangeal joints [MCPs]; think fingers, wrists (hands/joint big spot)
• Polyarthralgia  do an H and P  do they have synovitis? If not do they have tender points?
o Synovitis: if s/s > 6 wks then probably systemic rheumatic disease (check: CBC, ESR, RE and/or
ANA, Cr, urinalysis, joint aspiration to see if virus)
 < 6 wks may be viral arthritis (from strep/ear infx), early systemic rheumatic disease 
careful f/u (check CBC, LFTs, consider hep B or C, parvovirus serology)
o Tender points present: think fibromyalgia or multiple sites of bursitis or tendinitis
 If not: viral arthralgia, osteoarthritis, soft tissue abnormalities, hypothyroid, neuropathic
pain, metabolic bone disease, depression  check LFTs, Hep B and C, radiographs,
TSH, Ca, albumin, Alk phos
• Joint s/s: Increased pain and stiffness in the morning and after inactivity
o Morning stiffness and pain that lasts more than 30 minutes – 1 hour
o Pain and stiffness symmetrically, Hands involved (wrist, PIP, & MCP), Rheumatoid nodules
(hardened areas at joint level), Arthritis of 3 of > joints that are inflamed
o Red, swollen- is soft not bony as in osteoarthritis & warm joints; deformed, misshapen joints
o 2ndary: carpal tunnel, shoulder bursitis, Baker’s cyst behind knee, hallus valgus (bunion), TMJ,
atlantoaxial (C1-C2) subluxation (misaligned but still in contact)
• Systemic s/s: Intense fatigue/ decreased energy, Muscle aches, decreased appetite, Wt loss, Fever,
sweats, Depression, Problems sleeping, Anemia, Bleeding stomach ulcers, Inflammation of the heart’s
sac (pericarditis), Inflammation of the heart muscle (myocarditis), Lung prob, dry eyes, dry mouth, +
CRP
• Check if skin over joint is thin, shiny, & ruddy; any nodules? Heberden nodes
• DX: Get a good hx, xrays of affected joints, sed rate, Rheumatoid Factor, +ANA complement profile (to
see bleeding), 85% of patients have IgM anti-IgG Ab, Anti-CCP (Ab to cyclic citrullinated peptide)
• Diffs = scleroderma, psoriatic arthritis fibromyalgia, PMR, vasculitis, SLE, OA, viral syndrome
• TX goals: to reduce pain and inflammation and to preserve joint function, IMPROVE QOL
o Early: PT, OT, alternating heat & cold applications, exercise (yoga/walk), rest, assistive devices,
splints, meditation, chiropractic adjustments, and wt loss  all helps to keep joints working
o Analgesics (no opioids): NSAIDs, Steroids ~10mg/day, DMARDs (if analgesics and steroids
fail): expensive, Older therapies (Methotrexate: chemo to decrease immune)

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 • Meds for RA: GOAL: TARGET INFLAMMATION
o SE: HA, fever, weight loss, cough, SOB, allergic response
o Monitor-LFTs, CBC, CMP (4-8wks), PE: 3- 6x/yr per year, massage therapy, complementary
RA: Ulnar Deviation and MCP Swelling (An across-the-room dgx)
• Prominent ulnar deviation in the right hand, MCP and PIP swelling in both hands, Synovitis of left wrist
Systemic Lupus Erythematosus (SLE): Women 15-35yrs  systemic presentation: exacerbations & remissions
• S/S may be constitutional or result from inflammation in various organ systems: skin and mucous
membranes, joints, kidney, brain, serous membranes, lung, heart and occasionally GI
• Organ systems may be involved singly or in any combination. Involvement of vital organs (especially
kidneys and CNS), accounts for significant morbidity and mortality; can be life threatening
• Morbidity and mortality result from tissue damage due to the disease process or its therapy.
• Classification criteria (SOAP BRAIN MD)
• Serositis: pleuritis, or pericarditis, Oral ulcers, Arthritis, Photosensitivity
• Blood/Hematologic disorder: hemolytic anemia or leukopenia of < 4.0 x 109 or lymphopenia of < 1.5
x 109 or thrombocytopenia < 100 X 109. Renal disorder: proteinuria > 0.5 gm/24 h or 3+ dipstick or
cellular casts, Antinuclear antibody (positive ANA)
• Immune disorders: raised anti-native DNA antibody binding or anti-Sm antibody or + anti-
phospholipid antibody work-up, Neurological disorder: seizures or psychosis, Malar rash (butterfly
rash), Discoid rash (raised areas with peeling/sloughing)
• A person is said to have SLE if 4 or more of the 11 criteria are present, serially or simultaneously,
during any interval of observation
• Dgx: ANA elevated in greater than 90%, CBC w. diff, ESR, RF, C-reactive protein, ANA, anti-ds-DNA
anti-Sm or antiphospholipid Abs 75-95% sensitive (in 75-95% it doesn’t miss the dx), C3 & C4, CH
30; casts in urine very common (5-6)
o Five proteins [need 3/5] = IgG, IgM, IgA, C3, fibrinogen (Lupus band test) if positive helps to dx
SLE from cutaneous lupus
• Compare to these Diffs = vasculitis, mixed connective tissue disease, fibromyalgia, MS, drug induced
lupus AKA discoid lupus, Sjogrens, RA
• Tx: Avoid sun, avoid stress, plan rest periods, low stress exercises (yoga etc), omega 3s, ASA,
Azathioprine, methotrexate, steroids, hydroxychloroquine, NSAIDS, Monitor BP (very high BPs: put
on medications)& fever management (cold compress, Tylenol, Advil): NO CURE
Scleroderma (systemic sclerosis)
• Autoimmune connective tissue disorders with skin thickening, fibrosis, and vascular changes
• Dgx: +ANA, BUN & Cr, anti-Scl-70 (topoisomerase 1); CT & PFTs (vascular changes), skin bx,
bronchoscopy
• Differentials: SLE, mixed connective tissue disease
• Complications (revolve around vasculature changes): pulmonary, renal, GI, CV, & musculoskeletal
• CREST Criteria: C (Calcinosis: calcium deposits), R (Raynaud’s), E (Esophageal Dysmotility), S
(Sclerodactyly: full eyes/cant move eyes), T (Telangiectasis)
• Tx: -Mabs, steroids, NSAIDs PRN (low dose use bc of vascular problems)
Sjogren’s Syndrome (SS): one of the most common autoimmune disorders among women
• Intrusion of immune cells into salivary & lacrimal glands = progressive decline in sight, smell, and taste.
• S/S: Insidious, 35-55 y.o., women 95%, Xerostomia, xerophthalmia, fatigue, mouth, eye, vaginal and
skin dryness, arthralgias, Raynaud’s, leukopenia, renal, pulmonary, neuro, GI issues
• Classification-guideline
• Dgx: antibodies to Ro (55%) or La (45%) antigens or ANA (80%) or RF (60%), antibodies in biopsy of
salivary glands
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 • Tx: No cure, Artificial tears, saliva (equal balance to moisturize), Antimalarials, Plaquenil sulfate,
NSAIDS for MSK complaints, Steroids, Education
Spondyloarthropathies (this is a group of diseases)
• Group of inflammatory arthritis that share many genetic, clinical, and radiographic features.
• HLA-B27-immuogenetic marker, more men
• Major characteristic is sacroiliitis, peripheral inflammation, and eye inflammation
• Diseases included: Ankylosing Spondylitis, Reactive arthritis & Reiter’s Syndrome (urethritis,
conjunctivitis, & arthritis: mostly young males), Psoriatic arthritis, and arthritis associated w. IBD
Ankylosing Spondylitis
• Back pain which worsens with rest and improves with exercise similar to other inflammatory back pain
• PE: loss of normal lumbar lordosis, palpable muscle spasm of paraspinal muscles, iritis, aortic
regurgitation murmur (a 4-5+ murmur)
• Dgx: Xray of sacroiliac, later in disease will see fusion bc of inflammation, increased ESR, normocytic
& normochromic anemia, +RF, + ANA bodies
o Spine mobility decreased in most patients and can be documented: Schober’s flexion test of
lumbosacral spine, Moll’s lateral flexion test of thoracic spine, and chest expansion [BECE]
measurement: poor chest expansion
o R/O Lyme Disease with Elisa assay for Borrelia burgdorferi
o DGX: 1. low back pain and stiffness of more than 3 months duration, improving with exercise,
not relieved by rest. 2. limited range of motion of lumbar spine. 3. limited chest expansion
Reactive Arthritis (cant see, cant pee, and hurts to move): autoimmune  can refer after NSAIDs/steriods
• Have: conjunctivitis, urethritis, arthritis
• Dgx: ESR, WBC and CRP increased
• TX: sulfasalazine, NSAIDS, may do a short course of methotrexate if needed (but cancer causing)
Psoriatic Arthritis (associated with psoarsis): ages: 30-40 y.o
• Spine involved if + HLA-B27, + RF with neg ANA; we usually manage psoriasis but not this: refer
• S/S: arthritis precedes psoriatic rash, “sausage fingers”, DIP, can have eye involvement
• Refer: Rheumatologist, dermatology, and ophthalmologist; Tx: MAB
PMR (Polymyalgia Rheumatica)
• Infx cause precipitates, Abrupt or subacute, Very stiff and hard to walk: morning 60 min to 3 hours
• S/S: 40% have weight loss, Fatigue and anorexia, 30% have visual symptoms
• Diffs: viral syndrome
• Tx: Short term: NSAIDs (1st), prednisone (2nd), ice/heat
PR: difficulty walking
• No muscle atrophy or trigger points, always R/O GCA
• Dgx: Negative RF, ANA, and SLE, increased ESR, alk phos may be increased, Muscle biopsy (dgx
factor), nerve conduction-nml
• TX: short dose of prednisone (10 to 15 mg) supplement with Ca and VD
Giant Cell Arteritis (GCA): Age > 50 yrs  complication of PMR: REFER
• S/S: Low grade fevers, wt loss, marked myalgias, anorexia, new HA (2/3), tenderness in scalp area and
over temporal arteries, optic neuritis (eye pain when looking at something), diplopia, jaw claudication
(lock jaw and or eating and jaw pops open); pathology will grade the vasculitis
• Dgx: ESR > 50, Biopsy = vasculitis & granuloma (WBCs), temporal lobe biopsy (bx)
• Tx: 4 to 60 mg steroids for 10 to 14 days -start even before bx results (controversial if should do bx for
every pt)
• Pts feel they “have aged several decades” and usually have scalp tenderness w. HA (this is only found in
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 2/3 of pts so not always a s/s): it is concerning when its new HA in pts > 60: think PR
Raynaud’s Disease
• Vasospastic disorder causing markedly decrease blood flow to digits = fingers white; starts in fingertips
• S/S: pallor, coldness, tissue breakdown, decreased pulse in digits, reversible digital ischemia; if they get
papercut can lose finger
• Primary cause: females 20-30 y.o. without underlying issues, may be smokers
• Secondary: R/t any autoimmune: SLE, Scleroderma, CREST (calcinosis, Raynaud’s phenomenon,
esophageal dysmotility, sclerodactyly, and telangiectasis)
• Dgx: submerge hand in ice water to see first (white pallor or blanching); second (blue cyanosis from
venule dilation) and red rubor (end of vasospasm when hand taken out of water)
• Raynaud’s occurs with many disorders such as OD, trauma, occupational injury, connective tissue
disease, hematological disorders, neurological disorders
• Tx: CCB to prevent vasospasm  success with these may decline over years
Vasculitis (umbrella term to describe many disorders)
• Diverse group of disorders characterized by inflammation & destruction of blood vessel walls; any
organ can be involved; categorized as large, mediu, small/medium, and small (do not need to know
whats in each category)
• Large: GCA, Takayasu
• Medium: polyarteritis nodosa, kawasaki, Primary angiitis of CNS
• Small/medium: Wegeners, microscopic polyangiitis, Curg-Strauss Syndrome
• Small: HSP, Drug induced, leukpcytoclastic angiitis, Goodpasture’s syndrome, cryoglobinemic
vasculitis, Behcets vaculitis, relapsing polychondritis, lupus vasculitis, rheumatoid vasculitis, Sjogrens
syndrome vasculitis
Polyarteritis nodosa: Kussmaul Disease causes this (very rare)
• More common in men > 50 y.o. and is strongly associated with HBV
• Rare autoimmune disorder causing inflammation of the arteries and can affect any organ causing severe
end organ damage
• S/S: Fatigue, weight loss, fever, joint pain
• Tx: Cytoxan (PO), prednisone  may later need IV Cytoxan and managed by Onc
Lyme Disease: consult ID if + Lyme: occurs mostly in spring and fall
• Infectious disease caused by spirochete Borrelia burgdorferi transmitted by deer tick
• S/S: flu like s/s, joint pain (may be localized or disseminated), fatigue, bulls eye rash, can die bc can
cause encephalitis and cardiomyopathy
• 3 stages: early localized, early disseminated, late disease
• Stage 1: Early Localized: Rash with central clearing, flu like s/s
• Stage 2: Multiple system involvement, cardiac manifestations (tachycardia)
• Stage 3: Late persistent, intermittent arthritis, neuro s/s, neurocognitive impairment, peripheral
neuropathy
• Dgx: Lyme Titer
• TX: Stages 1-2: a few weeks of abx (doxycycline) but can extend to months