Step 2 Crush Rheum

cell count and diff, glucose, gram stain and culture, crystals

non inflamm: <2000 WBC and <25% neutros/polys on aspirate
Older adults DIP (Heberden's nodes), PIP (Bouchard's nodes), hips, knees, weight bearing joints
Osteophytes on XR found late
No morning stiffness, pain increases with use
Tx with weight red and NSAIDS

Inflammatory so >2000 WBC and >50% neutros/polys on aspirate
women 20-45 MCP, PIP, wrist, feet, ankles
morning stiffness >1hr
ulnar deviation, swan neck deck def vs boutonniere
Pannus on XR that's articular cart that looks like granulation tissue
Systemic sxs fever, malaise, pericarditis, uveitis, WL, rheumatoid nodules on extensor surfaces
RF (IgM and IgG Ab)+
ACPA or anti CCP + more specific
increased ESR and CRP
Tx with NSAIDS, oral or intraarticular steroids, DMARDs within 3 mo if est dz and ongoing inf: MTX, AZA, HCQ, anti-TNFs Etanercept/Infliximab

RF often neg, watch for uveitis as presenting sx

inflammatory so >2000 WBC and >50% neutros/polys on aspirate
older men
Big toe (podagra) and subQ tophi UA crystals in fingers, wrists, knees, pinna
Needle shaped Monosodium Urate crystals with negative birefringence
Infection can coexist with attacks
Tx: avoid alcohol, cholchicine and NSAIDS but not ASA b/c it causes decreased excretion of UA by kidney, high fluid intake, alkalinization of urine, steroids
Long term: probenecid (for underexcretors <600mg/24h UA in urine)/allopurinol for XO inhib long term

inflammatory so >2000WBC and >50% neutros/polys on aspirate
presents just like gout but rhomboid positively birefringent CPPD crystals in knees, wrists, MCPs
etiology is idiopathic or 3Hs: Hemochromatosis, HypoT, HyperPTH, can be precipitated by surgery, trauma, illness
chondrocalcinosis on XR
Tx is same as gout

most commonly SA except in sexually active young adults: N gonorrheae
do blood and joint cultures and swabs

asymmetric and patchy
dactylitis sausage fingers
pencil in cup deformity on XR
treat with NSAIDS, MTX, etanercept (TNF inhibitor), infliximab (anti TNF), steroids

IM DAMN SHARP
Immunoglobulins (anti dsDNA, anti Sm, antiphospholipid)
Malar Rash
Discoid rash
ANA pos
Mucositis
Neurologic disorders
Serositis (pleuritis, pericarditis)
Hematologic disorders
Arthritis
Renal dz
Photosens

Also, dont forget about drug induced lupus from drugs that are N-acetylated in liver: Hydralazine, procainamide, esp in slow acetylators
remember false positives on RPR/VDRL due to antiphospholipid antibodies
screen with ANA titers and anti Sm to confirm
Tx with NSAIDS, hydroxychloroquine, steroids, AZA

considered seroneg because no Rh factor.
Strong assoc with HLA B27.
20-40 male with back pain and morning stiffness
sacroiliac joints affected, bamboo spine on XR, uveitis, aortic regurg
Tx with exercise, NSAIDS, MTX, etanercept, infliximab

classic triad: conjunctivitis and anterior uveitis, urethritis, arthritis
(Can't see, can't pee, can't climb a tree)
also seroneg and HLA B27 ass
almost always lower extremity joints
Tx with Ceftriaxone/doxy, NSAIDS, topical steroids, RA drugs for more severe arthritis

recurrent hemarthroses can cause arthritis, treat with tylenol, avoid aspirin

3 stages
1. erythema chronicum migrans, flulike sxs
2. Bell's palsy, cardiac blocks
3. chronic monoarthritis, migratory polyarthritis
Tx: doxy, ceftriaxone, amoxicillin in pregs

JHNES PEACE
Major: Joints (polyarthritis, hot/swollen joints)
Heart: carditis, valve damage
Nodules: subq extensor surf
Erythema marginatum
Sydenham's chorea

Previous rh fever
ECG with PR prolongation
Arthralgias
CRP and ESR elevated
Elevated temp

need hx of recent group A strep infection and 2 major + 1 minor OR 2 minor

can dev arthralgias and avascular necrosis of femoral/humeral head

slipped capital femoral epiphysis, congenital hip dysplasias, Legg-Calve-Perthes dz can cause arthritis in adulthood

DM. after seemingly mild trauma, pts still need xrays

multisystem vasculitis
1 plus 2 others
1. recurrent oral apthous ulcers at least 3x in a year
2. recurrent genital ulcers
3. eye lesions (uveitis, scleritis, retinal vasculitis, optic neuritis)
4. skin lesions: pustules, erythema nodosum
5. pos pathergy test

Can also have symmetric arthritis of knees and ankles and neuro deficits, DVTs

Tx: colchicine, steroids, dapsone, AZA, MTX, CsA, antiTNF

polymyositis (symm prox muscle weakness due to CD8 T cells) plus malar/heliotrope rash, Gottron's papules, increased risk of malignancy
labs: elevated CK and aldolase, and positive ANA, and anti Jo 1
Dx with muscle biopsy
Tx steroids

Asian kids
fever for 5 days mandatory
conjunctivitis
strawberry tongue
lymphadenitis
truncal rash
coronary aneurysms
Tx: IVIG, ASA acutely

assoc w HBV and cryoglobulinemia
pANCA Pos
Renal and visceral vasculitis of the medium sized vessels
multiple aneurysms
fever, WL
abdominal pain
melena
myalgia
peripheral neuropathies
biopsy for diag

CREST
Calcinosis
Raynauds
Esophageal dysmotility
Sclerodactyly
Telangiectasia

ANA screening test
Anti Centromere Ab pos
Anti Scl70 Ab (Anti DNA topoisomerase I Ab)

diffuse scleroderma has widespread skin and visceral sclerosis
look for mask-like leathery facies

Tx with steroids

triad: xerophthalmia, xerostomia, arthritis
Assoc with RA
also parotid enlargement, inc risk of B cell lymphoma, dental caries
SS-A (Ro) and SS-B (La) autoAb to ribonucleoproteins positive
Tx: eyedrops and good oral hygiene

granulomatous thickening of aortic arch and great vessels
inc ESR
FAN MY SKIN On Wednesday
Fever
Arthritis
Night sweats
MY algia
SKIN nodules
Weak pulses in upper ext

complications: stroke sxs if carotids involved, CHF
CT or MR to see
Tx with steroids and/or cyclophos

triad: focal nec vasculitis, nec granulomas in lung and upper airway, nec GN
sxs: hemoptysis, hematuria, perf of nasal septum, chronic sinusitis, otitis media, mastoiditis, cough, dyspnea, ARF
c-ANCA is strong marker
Tx: cyclophos, steroids

only point tenderness, everything else is normal
maybe anxiety, stress, insom, neg workup
tx with antidep, NSAIDS, rest

weakness of proximal muscles due to CD8 cells most often involves shoulders. can't get up out of chair without hands.
Diag: abnormal EMG and muscle biopsy, elevated ESR and CPK
Tx with steroid

elderly women: pain and stiffness in pelvic girdles, shoulders without loss of strength
assoc with temporal arteritis
fever, malaise, WL
Really high ESR normal CPK and normal EMG
Tx: prednisone

older men
usually pelvis and skull
increasing hat size, hearing loss, due to auditory foramen narrowing, bone pain, OA
Ca, phos, PTH all normal
Really high Alk Phos
inc risk of osteosarcoma
Tx: NSAIDS, etironidate or calcitonin for sev