Podcast
Questions and Answers
Which of the following genetic mutations is most commonly associated with spondyloarthropathies (SpA)?
Which of the following genetic mutations is most commonly associated with spondyloarthropathies (SpA)?
Ankylosing spondylitis is most commonly associated with inflammation in which area of the body?
Ankylosing spondylitis is most commonly associated with inflammation in which area of the body?
Which of the following conditions is classified as a peripheral spondyloarthropathy?
Which of the following conditions is classified as a peripheral spondyloarthropathy?
What is the classic clinical presentation of reactive arthritis?
What is the classic clinical presentation of reactive arthritis?
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Which pathogen is most commonly associated with reactive arthritis?
Which pathogen is most commonly associated with reactive arthritis?
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Psoriatic arthritis most often affects which joints?
Psoriatic arthritis most often affects which joints?
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What nail changes are often associated with psoriatic arthritis?
What nail changes are often associated with psoriatic arthritis?
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What is the most common symptom of axial spondyloarthropathies (SpA)?
What is the most common symptom of axial spondyloarthropathies (SpA)?
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Which of the following is a common feature of spondyloarthropathies (SpA) affecting the lower extremities?
Which of the following is a common feature of spondyloarthropathies (SpA) affecting the lower extremities?
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Dactylitis, a key finding in SpA, is commonly described as:
Dactylitis, a key finding in SpA, is commonly described as:
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Which of the following is the initial treatment of choice for spondyloarthropathies (SpA)?
Which of the following is the initial treatment of choice for spondyloarthropathies (SpA)?
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In the case of NSAID treatment failure in axial SpA, which type of medication is commonly used next?
In the case of NSAID treatment failure in axial SpA, which type of medication is commonly used next?
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Which ocular manifestation is most commonly associated with spondyloarthropathies (SpA)?
Which ocular manifestation is most commonly associated with spondyloarthropathies (SpA)?
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Conjunctivitis is most commonly seen in which type of spondyloarthropathy?
Conjunctivitis is most commonly seen in which type of spondyloarthropathy?
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Which of the following is the primary treatment for limiting pain and maintaining joint function in spondyloarthropathies (SpA)?
Which of the following is the primary treatment for limiting pain and maintaining joint function in spondyloarthropathies (SpA)?
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If NSAID treatment fails in patients with axial spondyloarthritis, what is the next step in treatment?
If NSAID treatment fails in patients with axial spondyloarthritis, what is the next step in treatment?
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What is the most common ocular manifestation of spondyloarthropathies (SpA)?
What is the most common ocular manifestation of spondyloarthropathies (SpA)?
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Which of the following types of uveitis is typically associated with reactive and psoriatic arthritis?
Which of the following types of uveitis is typically associated with reactive and psoriatic arthritis?
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According to clinical pearls, which condition should be a top differential when encountering severe dry eye or uveitis that is not unilateral and acute?
According to clinical pearls, which condition should be a top differential when encountering severe dry eye or uveitis that is not unilateral and acute?
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For patients on hydroxychloroquine therapy, which of the following steps should be taken regularly?
For patients on hydroxychloroquine therapy, which of the following steps should be taken regularly?
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Study Notes
Anterior Uveitis
- A 39-year-old female presents with right eye pain, a history of two previous episodes, and morning hand pain.
- The most likely diagnosis is anterior uveitis.
- Treatment should include:
- Prescribe Pred Forte 1% 1 gtt q1hr OD only.
- Instill 1 drop of atropine in-office OD only.
- Refer patient to a rheumatologist.
- Return to clinic the next day for follow-up.
DMARDs
- A possible side effect of DMARDs is Kidney Toxicity.
Juvenile Rheumatoid Arthritis
- A 27-year-old female with a 20-year history of left knee pain due to "arthritis" is most likely to have Pauciarticular Juvenile Rheumatoid Arthritis.
Plaquenil
- Plaquenil is a medication used to treat conditions like rheumatoid arthritis and lupus.
- A test to perform on a 52-year-old Caucasian female who has been taking Plaquenil for 6 years is a 30-2 Sita-Fast Humphrey Visual Field test.
Behcet's Disease
- Systemic diagnosis that is characterized by oral and genital ulcers, and ocular involvement such as uveitis and retinal vasculitis.
Giant Cell Arteritis (GCA)
- A 75-year-old woman presents with a new onset of headaches, fatigue, weight loss, and jaw pain when chewing.
- Her symptoms are consistent with Giant Cell Arteritis (GCA).
- GCA is characterized by the inflammation of the temporal artery.
GCA - Affected Arteries
- The most commonly affected artery is the Temporal artery.
GCA - Symptoms
- A hallmark symptom is Jaw pain when chewing.
GCA - Diagnosis
- The gold standard for diagnosing GCA is a Temporal artery biopsy (TAB).
GCA - Diagnostic Criteria
- Age at onset greater than 50 years is necessary for diagnosis.
GCA - Blood Tests
- C-Reactive Protein (CRP) is elevated in 95% of patients with GCA, but a normal result does not exclude the diagnosis.
GCA - Systemic Symptoms
- Fever and weight loss are commonly associated with GCA.
GCA - Steroid Treatment
- Erythrocyte Sedimentation Rate (ESR) is expected to elevate in response to steroid treatment.
Arteritic Anterior Ischemic Optic Neuropathy (AAION)
- A 70-year-old patient with a history of GCA presents with sudden, painless vision loss in the right eye.
- Fundus examination reveals a pale, swollen optic disc, strongly suggestive of AAION.
AAION - Cause
- Most commonly caused by ischemia of the Posterior Ciliary Artery.
AAION - Symptoms
- Sudden, painless vision loss is characteristic.
AAION - Treatment Goal
- Treatment aims to preserve remaining vision and prevent fellow eye involvement.
AAION - Initial Treatment
- Oral or IV steroids are the appropriate initial treatment.
AAION - Key Diagnostic Test
- A Temporal artery biopsy (TAB) should be performed within 2 weeks of starting treatment.
AAION - Monitoring
- Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) should be closely monitored in patients on steroid therapy.
Systemic Lupus Erythematosus (SLE)
- Young, non-white women of child-bearing age are most commonly affected by SLE.
Drug-Induced Lupus
- SLE can be triggered by certain medications, including Hydralazine, Phenytoin, and Isoniazid.
SLE - Diagnostic Criteria
- Malar (butterfly) rash is a diagnostic criteria for SLE.
SLE - Arthritis
- Arthritis occurs in 50% of patients with SLE.
SLE - Lab Tests
- Antinuclear antibody (ANA) is most likely to be positive in patients with SLE.
SLE - Serositis
- Inflammation of the heart and pleura in SLE patients meets the diagnostic criteria for Serositis.
SLE - Complications
- Potential complications of SLE include:
- Pneumonitis
- Interstitial lung disease
- Raynaud’s phenomenon
- Mesenteric vasculitis.
SLE - Ocular Manifestations
- The most common ocular manifestation of SLE is Discoid rash of the periocular skin.
Lupus Retinopathy
- Associated with immune complex deposition in the retinal vasculature and RNFL.
- Typically associated with Cotton wool spots.
Rheumatoid Arthritis (RA)
- Interphalangeal and metacarpophalangeal joints are most commonly affected by RA.
RA - Features
- Key features of RA include:
- Bilateral and symmetric joint involvement.
- Morning stiffness lasting longer than an hour.
RA - Diagnostic Criteria
- Diagnostic criteria for RA include:
- Morning stiffness lasting longer than an hour.
- Arthritis involving three or more joints.
- Rheumatoid nodules.
- Radiographic evidence of arthritis.
RA - Systemic Complications
- Common systemic complications of RA include:
- Pleural effusions and pulmonary fibrosis.
RA - Ocular Conditions
- Peripheral ulcerative keratitis (PUK) is most strongly associated with RA.
Scleritis
- Necrotizing scleritis is the most severe form of scleritis associated with RA.
Sjogren's Syndrome (SS)
- SS is commonly associated with Rheumatoid arthritis and lupus.
SS - Signs
- Typical signs of SS include:
- Enlarged salivary glands.
- Decreased tear break-up time (TBUT).
- Dry, fissured tongue.
- Poor dental health.
Primary SS
- It occurs independently without association with other autoimmune conditions.
SS - Symptoms
- Xerostomia and keratoconjunctivitis sicca (dry mouth and dry eye) are the most common symptoms associated with SS.
SS - Diagnostic Criteria - Points
- 4 points are required to make a diagnosis of SS.
SS - Diagnostic Criteria - Highest Point Value
- Anti-Ro/SSA positive carries the highest point value in the diagnostic criteria for SS.
SS - Management
- Over-the-counter and prescription dry eye treatments are key management strategies for SS.
SS - Dry Eye Work-up
- It typically involves an evaluation of Tear production, tear osmolarity, tear film stability, and meibomian gland function.
Spondyloarthropathies (SpA)
- HLA-B27 is the most common genetic mutation associated with SpA.
Ankylosing Spondylitis (AS)
- AS is most commonly associated with inflammation in the spine (sacroiliitis).
Peripheral Spondyloarthropathy
- Reactive arthritis is classified as a peripheral spondyloarthropathy.
Reactive Arthritis
- The classic clinical presentation of reactive arthritis is “Can’t see, can’t pee, can climb a tree” (conjunctivitis, urethritis, arthritis).
Reactive Arthritis - Pathogen
- Chlamydia trachomatis is the most commonly associated pathogen.
Psoriatic Arthritis
- Psoriatic arthritis most often affects Distal joints.
Psoriatic Arthritis - Nail Changes
- Nail changes often seen in psoriatic arthritis include pitting, onycholysis, and discoloration.
Nail Changes in Spondyloarthropathies
- Onycholysis: Separation of the nail plate from the nail bed
- Beau’s lines: Transverse grooves in the nail plate
- Nail pitting: Small depressions in the nail plate
- Leukonychia: White spots or streaks on the nail plate
- Nail ridges: Longitudinal ridges on the nail plate
- Splinter hemorrhages: Small, linear hemorrhages under the nail plate
- Subungual hematoma: Blood under the nail plate
- Clubbing: Thickening and widening of the fingertips
- Hyperpigmentation: Darkening of the nail plate
- Thickening: Increased thickness of the nail plate
Common Symptoms of Axial Spondyloarthropathies
- Most Common Symptom: Chronic, inflammatory lower back pain
-
Other Common Symptoms:
- Migratory joint pain
- Severe morning stiffness in the knees
- Widespread muscle cramps
- Fever and night sweats
Spondyloarthropathies Affecting the Lower Extremities
-
Common Features:
- Asymmetric joint pain affecting less than five joints
- Bilateral involvement of the ankles and knees
Dactylitis
- Common Description: Sausage fingers and toes
Initial Treatment of Choice for Spondyloarthropathies
- NSAID monotherapy
Treatment in Case of NSAID Treatment Failure
- Biologic agents such as TNF-alpha inhibitors or IL-17 inhibitors
Ocular Manifestations of Spondyloarthropathies
- Most Common: Acute anterior uveitis
-
Other Common Manifestations:
- Posterior uveitis
- Conjunctivitis
Primary Treatment for Limiting Pain and Maintaining Joint Function
- NSAID monotherapy
Treatment After NSAID Treatment Failure in Axial Spondyloarthropathy
- Biologics such as TNF-alpha inhibitors or IL-17 inhibitors
Uveitis Associated with Certain Spondyloarthropathies
- Reactive and psoriatic arthritis: Typically associated with bilateral, recurrent anterior uveitis
Differential Diagnosis for Severe Dry Eye or Uveitis
- Sarcoidosis
Hydroxychloroquine Therapy
-
Regular Monitoring:
- Communication with the patient's rheumatologist
- Monthly retinal exams
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Description
This quiz covers essential topics in ophthalmology and rheumatology, including anterior uveitis, DMARDs, and treatments for juvenile rheumatoid arthritis. It also discusses the monitoring of patients on Plaquenil and systemic diseases like Behcet's disease. Test your understanding of these interconnected medical cases.
