Arthritis PDF

Arthritis I Jason Ryan, MD, MPH Arthritis Joint inflammation and swelling Many types Osteoarthritis Rheumatoid arthritis Others Diagnosis may involve arthrocentesis Aspiration of synovial fluid Used for diagnosis in some cases Also therapeutic for large effusions...

Arthritis I Jason Ryan, MD, MPH Arthritis Joint inflammation and swelling Many types Osteoarthritis Rheumatoid arthritis Others Diagnosis may involve arthrocentesis Aspiration of synovial fluid Used for diagnosis in some cases Also therapeutic for large effusions SCGH ED CME/Slideshare Arthritis Classification Non-inflammatory Degenerative arthritis Usually due to osteoarthritis Joint pain without warmth or swelling Low WBC in synovial fluid May cause brief < 30 min morning stiffness Inflammatory Warm, swollen joints White Blood Count Elevated WBC in synovial fluid Disease (cells/mm3) Prolonged (>30 min) morning stiffness Normal < 200 Osteoarthritis 200-2000 Inflammatory > 2000 Arthritis Classification Number of joints One: monoarthritis Two to four: oligoarthritis More than five: polyarthritis Osteoarthritis Degeneration of synovial joints Hyaline cartilage breakdown Surrounds joint space Provides smooth surface for gliding of bones Hypertrophy of bone “Bone sclerosis” of subchondral bone “Bone spurs” or osteophytes may form Joint space narrows Minimal inflammation of synovial fluid Non-inflammatory OpenStax College/Wikipedia Osteoarthritis Clinical features Insidious onset of joint pain Bone pain fibers irritated by movement Deep, dull ache Worsened by activity Improved by rest Stiffness In morning or after inactivity Lasts < 30 minutes Restricted motion Boney enlargement limits movement Shutterstock Osteoarthritis Clinical features Can affect any joint Weight-bearing joints most common Hips Knees Cervical spine Lumbar spine Monoarticular or polyarticular disease May present as monoarticular symptoms Wikipedia/Public Domain Osteoarthritis Risk Factors Advanced age 80% patients over 55 years old Obesity Modifiable risk factor Especially the knees Hip Trauma Major trauma to joint Repeated microtrauma over time Shutterstock Osteoarthritis Diagnosis Clinical diagnosis Supportive evidence from X-rays Joint space narrowing Subchondral sclerosis Osteophytes (bone spurs) Subchondral cyst Low WBC in synovial fluid “Non-inflammatory arthritis” All blood tests normal Joint Space Narrowing James Heilman, MD/Wikipedia Subchondral Sclerosis Thickening of the subchondral bone ↑ collagen with abnormal mineralization James Heilman, MD/Wikipedia Osteophytes Bone Spurs Thickening of the subchondral bone at joint margins Often insertion points of tendons or ligaments James Heilman, MD/Wikipedia Subchondral Cysts Fluid filled sack Bone cracks → synovial fluid accumulation Anas Bahnassi/Slideshare Osteoarthritis Knee Involvement Often involves both knees More weight-bearing medial knee Asymmetric narrowing may occur on medial side Public Domain Osteoarthritis Hip Involvement Causes groin, buttock or thigh pain Reduced range of motion on exam Crepitus may be present Often unilateral Contrast with knees - often bilateral BruceBlaus/Wikipedia Osteoarthritis Hand Involvement Distal interphalangeal (DIP) joints Contrast with rheumatoid arthritis – DIP joints spared Proximal interphalangeal (PIP) joints Not MCP 1st Carpometacarpal (CMC) joint CMC Wikipedia/Public Domain Nodal Osteoarthritis Occurs in patients with interphalangeal OA of hands Heberden’s (DIP) and Bouchard’s (PIP) nodes Caused by boney overgrowth and osteophytes Over years, joints become less painful Inflammatory signs subside Swellings (nodes) remain Common at index and middle fingers Drahreg01/Wikipedia Osteoarthritis Treatment Weight loss Exercise and physical therapy Maintain range of motion and strength Topical or oral NSAIDs Rheumatoid Arthritis Autoimmune inflammation of synovium Thin layer of tissue (few cells thick) Lines joints and tendon sheaths Secretes hyaluronic acid to lubricate joint space Systemic disease with extraarticular complications More common in women Usual age of onset 20 to 40 years Disease course may wax and wane with flares Open Stax College/Wikipedia Rheumatoid Arthritis Clinical features Symmetric joint inflammation Gradual onset Pain, stiffness, swelling Classically “morning stiffness” Joint stiffness >1 hour after rising Improves with use May have systemic symptoms Fever, fatigue, weight loss Rheumatoid Arthritis Clinical features Most often involves wrists and hands Classically affects MCP and PIP joints of hands Often tender to touch DIP joints spared Contrast with osteoarthritis – DIP joints involved Lumbar spine usually spared Also a contrast with osteoarthritis davida__jones/Flikr Rheumatoid Arthritis Clinical features Bones can erode and deviate Ulnar deviation Swelling of MCP joints → deviation Swan neck deformity Hyperextended PIP joint Flexed DIP Phoenix119/Wikipedia Rheumatoid Arthritis Clinical features Axial spine spared except cervical region (usually C1 to C2) “Atlantoaxial joint” Occurs with longstanding disease Neck pain and stiffness Cervical subluxation Possible life-threatening spinal cord compression May require surgical treatment Limited by DMARD therapy Cervical spine X-ray before surgery in RA patients Risk of neurologic injury with intubation West Chiropractic Clinic & Neuropathy @WestChiroClinic Rheumatoid Arthritis Clinical features Baker's cyst (popliteal cyst) Swelling of gastrocnemius-semimembranosus bursa Synovium-lined sac at back of knee continuous with joint space Common in patients with OA or RA of knee Often asymptomatic bulge behind knee If ruptures → symptoms similar to DVT Posterior knee pain, swelling, ecchymosis Usually a clinical diagnosis May need to rule out DVT Wikipedia/Public Domain Rheumatoid Arthritis Extraarticular features Serositis – inflammation of serosal surfaces Pleuritis → pleural effusion Interstitial Lung Disease Pericarditis → pericardial effusion Parenchymal lung disease Interstitial fibrosis Pulmonary nodules Carpal tunnel syndrome Anemia of chronic disease Rheumatoid Arthritis Extraarticular features Palpable nodules common (20 to 35% patients) Pathognomonic for rheumatoid arthritis Common on elbow although can occur anywhere Usually no specific treatment PHAM HUU THAI/Slideshare Rheumatoid Arthritis Extraarticular features Episcleritis and scleritis Red eye Eye pain Discharge Sjogren’s syndrome Common in patient’s with RA Image courtesy of Kribz Rheumatoid Arthritis Osteoporosis Accelerated by RA Also often worsened by steroid treatment 30 percent ↑ risk of major fracture 40 percent ↑ risk hip fracture BruceBlaus/Wikipedia Rheumatoid Arthritis Diagnosis Inflammatory arthritis of 3 or more joints lasting more than 6 weeks Rheumatoid factor (RF) – 70 to 80% of patients Low specificity – elevated in some normal patients and other conditions Antibodies to citrullinated peptides (ACPA) More specific Acute phase reactants Elevated C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) Source: UptoDate Diagnosis and differential diagnosis of rheumatoid arthritis 2021 Rheumatoid Arthritis Treatment Traditional disease-modifying antirheumatic drugs (DMARDs) Protect joints from destruction Provide long term reduction in disease progression and complications Slow onset of effect over weeks Usually given as oral drugs Pain control Bridging therapy until DMARDs take effect NSAIDs – drug of choice for pain control Corticosteroids used if NSAIDs inadequate for pain control Short term steroid treatment used for symptom flairs DMARDs Disease-modifying antirheumatic drugs Methotrexate Best initial DMARD May cause bone marrow suppression Co-administered with folic acid Also causes hepatotoxicity and stomatitis Monitor CBC, LFTs and creatinine Hydroxychloroquine Methotrexate Sulfasalazine Leflunomide Biologics Antibody-based treatments Infusions or injections Used when methotrexate does not control disease Anti-TNF alpha therapy Etanercept and infliximab Non-TNF biologics Abatacept, rituximab, tofacitinib Pre-treatment screening for latent TB Also hepatitis B and C Public Domain Rheumatoid Arthritis Long Term Complications Increased risk of coronary disease Leading cause of mortality Secondary (AA) amyloidosis Shutterstock Felty Syndrome Syndrome of splenomegaly and neutropenia in RA Low WBC on blood testing Increased risk for bacterial infections Abdominal pain from enlarged spleen Classically occurs many years after onset RA Usually in patient with severe RA Joint deformity Extra articular disease Improves with RA therapy Wikipedia/Public Domain Arthritis II Jason Ryan, MD, MPH Septic Arthritis Joint infection May be acquired through several mechanisms Hematogenous spread S. Aureus Contiguous spread (osteomyelitis) (gram positive cocci) Direct inoculation (trauma, surgery) Usually mono-bacterial Most common cause: Staph aureus including MRSA Streptococci Gram negative rods Septic Arthritis Clinical features Acute onset of arthritis symptoms Usually monoarthritis Single swollen, painful joint Knee is most common joint Less commonly wrists, ankles or hips Fever Shutterstock Septic Arthritis Risk factors Pre-existing joint disease Rheumatoid arthritis, osteoarthritis, gout Intravenous drug use Immunosuppression including diabetes Psychonaught/Wikipedia Septic Arthritis Infants Usually involves hip or knee Fever, irritability, poor feeding Swollen, red, warm joint Joint tenderness to palpation Wikipedia/Public Domain Septic Arthritis Diagnosis and treatment Blood cultures and synovial fluid analysis Should be sent before antibiotics Synovial WBC usually 50,000 to 150,000 cells/microL Mostly neutrophils Purulent fluid Gram stain and culture Joint drainage Similar to management of an abscess White Blood Count Disease Serial aspiration for easily accessed joints (knee) (cells/mm3) Arthroscopic drainage or arthrotomy Normal < 200 Antibiotics Osteoarthritis 200-2,000 Inflammatory > 2,000 Septic > 20,000 (PMNs) Septic Arthritis Antibiotics Gram positive cocci – vancomycin Vancomycin Gram-negative bacilli – usually cephalosporins Ceftriaxone Ceftazidime if concern for pseudomonas Acute Monoarthritis Arthrocentesis Crystals WBC < 2000 WBC 2k – 100k WBC > 100,000 Blood, fat Gout Non-inflammatory Inflammatory Septic arthritis Possible occult Pseudogout Osteoarthritis Crystals until proven fracture Septic otherwise RA Other causes Septic Arthritis Prosthetic joint infection Early onset (12 months after surgery) S. aureus, gram-negative bacilli, streptococci Broad antibiotic coverage until culture data available Often vancomycin plus broad-spectrum cephalosporin Surgery often required for debridement or re-implantation Disseminated Gonococcal Infection Hematogenous spread of Neisseria gonorrhoeae Occurs among sexually-active adults N. Gonorrhoeae Two classic patterns Arthritis-dermatitis syndrome Purulent arthritis Patients may have elements of both (spectrum) Jesus Hernandez/Wikidoc Disseminated Gonococcal Infection Arthritis-dermatitis syndrome Fever, chills and malaise Polyarthralgia Small or large joints Migrates over time Tenosynovitis Tendons of wrist, fingers, ankle and toes Dermatitis Often scattered pustules Arun Geetha Viswanathan/Slideshare Disseminated Gonococcal Infection Purulent arthritis Abrupt onset of monoarthritis or oligoarthritis Knees, wrists and ankles most common Shutterstock Disseminated Gonococcal Infection Diagnosis Blood cultures Mucosal testing Urogenital, rectal, and pharyngeal swab Nucleic acid amplification testing (NAAT) Arthrocentesis for synovial fluid testing WBC ~ 50,000 cells/microL (but can be lower) Gram stain and culture (can be negative) NAAT testing - more sensitive than culture Shutterstock Disseminated Gonococcal Infection Treatment Intravenous ceftriaxone Oral doxycycline or azithromycin Treatment for chlamydia co-infection Unless chlamydia infection ruled out by testing Ceftriaxone Lyme Arthritis Occurs in endemic areas for Lyme (Northeast US) Suspect in patients with possible exposure Endemic area Prior tick bite Reported Cases of Lyme Disease Hiking or camping United States, 2018 Arthrocentesis: inflammatory findings Negative gram stain and culture Diagnosis: Lyme serology Treatment: doxycycline, amoxicillin or ceftriaxone CDC.gov Seronegative Spondyloarthritis Spondylo = spine Arthritis = joint inflammation Seronegative = negative rheumatoid factor Family of disorders with common features Ankylosing spondylitis Psoriatic arthritis Inflammatory bowel diseases Reactive arthritis Wikipedia/Public Domain Parvovirus B19 Erythema infectiosum in children “Slapped cheek” rash In adults may cause arthralgia or arthritis Acute, symmetric polyarthritis Small joints especially hands and wrists Diagnosis: clinical +/- anti-parvovirus IgM No specific treatment - self-limited Consider in adults who work with children Daycare, schools Wikipedia/Public Domain Juvenile Idiopathic Arthritis Group of inflammatory disorders Occur in children under age 16 years All involve arthritis of > 1 joint for > 6 weeks Diagnosis: clinical Treatment: NSAIDs, steroids or DMARDs Major subtypes Oligoarticular Polyarticular Systemic Shutterstock Juvenile Idiopathic Arthritis Oligoarticular subtype Less than 5 joints affected Peak incidence 2 to 3 years Females > males Often knees or ankles Toddler with limp and swollen joint Usually negative RF Serious complication: uveitis (20 to 25% children) Juvenile Idiopathic Arthritis Polyarticular subtype Similar to oligoarticular but > 5 joints affected Two peaks of incidence: 2 to 5 years and 10 to 14 years Females > males Uveitis may occur but less common Juvenile Idiopathic Arthritis Systemic subtype Previously called Still’s disease Arthritis of > 1 joint Occurs at any age < 16 High “quotidian fever” One high spike per day Normal temp rest of day Rash “Evanescent:” comes and goes Usually pink and macular Hepatosplenomegaly Lymphadenopathy Yuyuricci/Slideshare Juvenile Idiopathic Arthritis Systemic subtype Increased WBC Elevated platelets Elevated ESR ANA and RF usually negative Adult Still’s Similar to systemic JIA but occurs in adults Polyarthritis Quotidian fever Rash ANA and RF usually negative Diagnosis of exclusion Transient Synovitis Benign, self-limited condition Acute inflammation of synovium Commonly affects hip joint in children Usually preceeded by viral infection Upper respiratory, diarrheal Child usually well-appearing Low-grade fever may occur Low WBC, ESR and CRP Treatment: NSAIDs Shutterstock Gout Jason Ryan, MD, MPH Gout Monosodium urate deposition in joints Most uric acid circulates as urate Urate = uric acid after loss of proton (H+) Triggers inflammatory response Recurrent attacks of acute arthritis Severe joint pain Redness, swelling, warmth Acute Gouty Arthritis Hyperuricemia + genes + cool temperatures Usually monoarthritis Most common: base of great toe (podagra) 1st metatarsophalangeal joint Also often occurs in knee More common in obese males Associated with hypertension James Heilman, MD/Wikipedia Gout Clinical course Gout flares Acute arthritis Usually monoarticular Often associated with a trigger Intercritical period Tophaceous gout Shutterstock Chronic Tophaceous Gout Tophi: urate collections in connective tissue Ears, tendons, bursa Slowly-enlarging hard masses Usually not painful or tender May cause erosion of surrounding bone Herbert L. Fred, MD/Hendrik A. van Dijk Seen with longstanding hyperuricemia Don’t confuse with RA nodules History of symmetric polyarthritis in RA History of recurrent bouts of monoarthritis in gout Apoorv Jain/Slideshare Urate Nephropathy Consequence of longstanding hyperuricemia Uric acid crystals in urine Uric acid kidney stones Chronic renal failure Public Domain Gout Triggers Increased serum uric acid levels Overproduction Decreased excretion by kidneys Rare genetic enzyme defects Uric acid produced from metabolism of purine nucleotides Excess purines → increased uric acid Gout Triggers Purine sources Red meat, seafood Trauma/surgery (tissue breakdown) Pixabay/Public Domain Gout Triggers Myeloproliferative disorders Chronic myeloid leukemia Essential thrombocytosis Polycythemia vera Associated with high cell turnover Hyperuricemia → gout Databese Center for Life Science (DBCLS) Gout Triggers Urate excreted mostly via kidneys and urine Any reduction in GFR → ↓ uric acid excretion Renal failure Volume depletion Diuretics Commonly cause gout attacks Diuretics also ↓ uric acid secretion in urine Thiazides, loop diuretics Gout Triggers Alcohol: classic trigger for gout Metabolism leads to lactic acid production Lactic acid increases renal reabsorption of urate Wikipedia/Public Domain Gout Diagnosis Arthrocentesis Sampling of synovial fluid WBC 20k to 50k Crystals seen by polarized light microscopy X-rays May show evidence of joint destruction Particularly in advanced, chronic disease OpenStax College/Wikipedia Gout Crystals Needle-shaped, “negatively birefringent” crystals Two reflections of polarized Change in index of refraction is negative Yellow when parallel to axis of the polarization Blue when perpendicular to polarization axis Bobjgalindo/Wikipedia Hyperuricemia All patients with gout have some degree of hyperuricemia Most hyperuricemic patients never develop gout Normal or low serum urate may be present during gout flares Cytokines may lower urate levels Urate deposits in joints Testing for serum urate not helpful for diagnosis of gout Most accurate testing for urate is two weeks or more after a flare Gout Treatment Acute attacks Oral glucocorticoids Usually prednisone or prednisolone Avoided with infection, post-op (wound healing), brittle diabetes NSAIDs Usually high-dose potent NSAIDs Naproxen or indomethacin Avoided with high bleeding risk (anticoagulant use), CKD, peptic ulcer disease Gout Treatment Acute attacks Colchicine Anti-inflammatory: inhibits white blood cell activity Alternative to glucocorticoids or NSAIDs Glucocorticoid intraarticular injection Used when flare involves only one or two joints Shutterstock Aspirin Not used for treatment of acute gout flares Doses up to 1 to 2 grams/day inhibit urate excretion Low-dose daily aspirin can be used in patients with gout Benefits > Risks for prevention of vascular disease Flikr/Public Domain Gout Treatment Prevention of acute attacks Lifestyle modification Weight loss and exercise: ↓ serum urate and risk of flares Moderation of animal/seafood protein intake and alcohol Pharmacologic therapy indications Frequent or disabling attacks Tophi or structural joint damage Renal insufficiency (CrCl 5 joints Seronegative Spondyloarthritis Common Features Asymmetric oligoarthritis Acute attacks of joint pain and swelling Often lower extremities Contrast with rheumatoid arthritis Symmetric Polyarthritis Often hands Wikipedia/Public Domain Seronegative Spondyloarthritis Common Features Axial spine inflammation Commonly sacroiliac (SI) joints Dactylitis Dactylitis Inflammation of entire digit Creates “sausage digits” Enthesitis Inflammation of ligament/tendon attachment to bone Wikipedia/Public Domain HLA B27 Human Leukocyte Antigens Antigens that make up MHC class I and II molecules Genes on chromosome 6 determine “HLA type” MHC Class I Genes: HLA-A, HLA-B, HLA-C HLA B27: Common in spondyloarthritis disorders 90% of ankylosing spondylitis cases 50% of psoriatic arthritis cases Most people with B27 never develop AS Minimal utility as a diagnostic test Sometimes helpful in equivocal cases Ankylosing Spondylitis Classic form of seronegative spondyloarthritis Ankylosis = new bone formation in spine → stiffness More common in males Usually 20-30 years old Shutterstock Ankylosing Spondylitis “Inflammatory” back pain (~75% of patients) Younger age (5 joints Small joints of the hands Independent of GI disease Can see spondylitis and sacroiliitis Rarely enthesitis and dactylitis BruceBlaus Reactive Arthritis Arthritis following infection Form of autoimmune spondyloarthritis Occurs days to weeks after an infection One or multiple joints affected Sometimes occurs with dactylitis and enthesitis Symptoms usually resolve in 6-12 months Reactive Arthritis Triggering infections GI bacteria: Salmonella Shigella Yersinia Campylobacter Clostridium difficile Urogenital: Chlamydia trachomatis Reactive Arthritis Clinical features Asymmetric oligoarthritis Usually 1 to 4 weeks after infection Most commonly affects lower extremities often knees Enthesitis (heel pain) Dactylitis Inflammatory low back pain Reactive Arthritis Clinical features Conjunctivitis Urethritis (dysuria) Oral ulcers Reiter syndrome Older term Arthritis, urethritis, conjunctivitis following infection Joyhill09/Wikipedia Reactive Arthritis Diagnosis and treatment Clinical diagnosis Must exclude other diagnoses Most patents have negative RF or anti-CCP antibodies Treat underlying infection Arthritis symptoms: NSAIDs Intraarticular or systemic glucocorticoids Rarely requires DMARDs (sulfasalazine, MTX) Muscle Disorders Jason Ryan, MD, MPH Polymyalgia Rheumatica Inflammatory disorder Unknown cause Really a joint disease – muscle tissue normal Muscle pain and stiffness with normal strength Strong association with temporal arteritis PMR occurs in 50% of patients with TA Wikipedia/Public Domain Polymyalgia Rheumatica Clinical Features Occurs in older patients (age > 50) Bilateral proximal muscle stiffness Neck or torso Shoulders/proximal arms Hips/proximal thighs Often difficulty dressing Worse in morning Wikipedia/Public Domain Polymyalgia Rheumatica Clinical Features Muscle pain (myalgias) especially in shoulder Does not cause muscle damage Strength testing normal Normal creatinine kinase level Sometimes malaise, fever, fatigue Shutterstock Polymyalgia Rheumatica Diagnosis and treatment Clinical diagnosis based on characteristic clinical features Elevated acute phase reactants: ↑ CRP, ↑ESR Muscle biopsy not indicated Responds well to low-dose glucocorticoids Often prednisone 15 to 25 mg/day Usually complete resolution of symptoms Differential diagnosis: rheumatoid arthritis Onset usually before age 50 Often small joints of hands and feet Only partial response to low-dose glucocorticoids Positive RF and anti-CCP Shutterstock Fibromyalgia Chronic pain disorder Widespread musculoskeletal pain Unknown cause Common in women 20 to 55 years old Depression/anxiety in 30 to 50% of patients Diagnosed clinically Muscle biopsy: normal Laboratory testing: normal Shutterstock Fibromyalgia Clinical features and diagnosis Chronic, widespread pain Point tenderness on exam Often in specific anatomic locations Labs normal: CK, ESR, TSH 2010 ACR diagnostic criteria Widespread pain Symptoms present for at least three months No other disorder that explains symptoms Sav vas/Wikipedia Fibromyalgia Treatment Patient education Reassurance that fibromyalgia is a real illness Emphasis that fibromyalgia is not life-threatening Treat co-morbidities: depression, anxiety, sleep Exercise Amitriptyline (TCA) Others drugs Shutterstock Inflammatory Myopathies Autoimmune muscle disorders Classic subtypes: polymyositis and dermatomyositis Diagnosis: muscle biopsy Treatment: immunosuppression Usually corticosteroids (prednisone) initially Long term treatment with steroid sparing drugs Inflammatory Myopathies Clinical Features Myalgias Slow onset symmetric muscle weakness Hallmark: proximal muscle weakness Muscles closest to midline Difficulty rising from a chair Difficulty climbing stairs Difficulty combing hair Fine hand movements intact Distal weakness occurs later in disease Inflammatory Myopathies Clinical Features Abnormal strength testing on exam Contrast with PMR Dysphagia may occur Shutterstock Inflammatory Myopathies Lab testing Elevated creatinine kinase (CK) ESR can be elevated (sometimes normal) Anti-nuclear antibodies (ANA) Not specific for myopathies Positive in 80-90% of patients Anti-Jo1 antibodies Antibody to RNA synthetase enzymes Most common myositis antibody Other antibodies (anti-Mi2, anti-SRP) Polymyositis Slow onset proximal muscle weakness No skin involvement Elevated CK and autoantibodies Polymyositis ESR normal or mildly elevated Muscle MRI: inflammation or edema Diagnosis: muscle biopsy Endomysial inflammation with CD8+ T-lymphocytes Endomysium = tissue surrounding each muscle fiber Jensflorian/Wikipedia Dermatomyositis Similar clinical features to polymyositis Skin changes present Diagnosis: muscle biopsy Perimysial inflammation with CD4+ T-lymphocytes Dermatomyositis Perimysium = connective tissue surrounding fascicles Inflammation surrounding bundles of fibers “Perifascicular atrophy” Nephron/Wikipedia Dermatomyositis Classic skin findings Heliotrope rash Purple discoloration of upper eyelid Gottron papules Symmetric red, scaly papules on hand/finger joints Both pathognomonic for dermatomyositis Elizabeth Dugan et al. Dermatomyositis Other skin findings Malar rash (similar to SLE) “Shawl and V signs” Shawl Sign Red-brown discoloration of skin Occurs in sun-exposed area Upper back (like a shawl) Neck/upper chest sparing skin below chin (V sign) Mechanic’s hands Cracks/fissures on palms with increased pigmentation Amir Karkhi/Pintrest Low Back Pain Jason Ryan, MD, MPH Low Back Pain Common presentation in primary care Large differential diagnosis Over 85% of patients have “non-specific” low back pain No identifiable specific underlying condition Extended workup will not identify a specific cause Only ~10% have a specific cause Less than 1% have a dangerous cause Dangerous Causes Specific Causes Metastatic cancer Vertebral compression fracture Spinal abscess Spinal stenosis Vertebral osteomyelitis Radiculopathy Low Back Pain Subtypes Acute: < 4 weeks Most common type Usually resolves May progress to subacute or chronic Subacute: 4 to 12 weeks Chronic: > 12 weeks Mechanical (common) Disease of spine, disks or surrounding tissues Non-mechanical Cancer, infection, rheumatic disease Shutterstock Low Back Pain Workup History Constitutional symptoms (weight loss, fever, sweats) History of malignancy Neurologic symptoms (weakness, numbness, bowel/bladder symptoms) History of injection drug use Physical examination Neurologic exam Straight leg raise test Palpation for vertebral tenderness Vertebral Tenderness Vertebral Compression Fracture Tenderness with palpation of vertebrae Contrast with paraspinal tenderness (lumbosacral strain) Spinal infection Sensitive but not specific sign May indicate abscess or vertebral osteomyelitis Vertebral metastases Compression fractures BruceBlaus Low Back Pain Workup Lab testing Rarely necessary ESR or CRP screening for infection/malignancy/AS Imaging Not indicated for most patients Only used in patients with specific indications Should be done in patients with “red flags” Low Back Pain Saddle Anesthesia Red flags Possible cauda equina syndrome Progressive motor or sensory loss New urinary retention or overflow incontinence New fecal incontinence Saddle anesthesia History of cancer Current or recent cancer High risk for cancer Low Back Pain Red flags Risk of infection Fever Immunosuppression Hemodialysis Recent bacteremia Injection drug use Recent spinal procedure past 12 months Risk of vertebral compression fracture Advanced age Prolonged glucocorticoids Trauma Should have X-ray Shutterstock Low Back Pain Imaging Spinal X-ray Often an initial test +/- ESR-CRP Screen for malignancy or infection Identification of compression fractures MRI Most sensitive/specific test CT Usually for patients who cannot have MRI Low Back Pain Treatment for non-specific cases Most patients improve with time Moderate activity Heat or massage NSAIDs Other treatments in select cases Physical therapy Exercise therapy Acupuncture Muscle relaxants/opioids BruceBlaus Lumbosacral Strain Usually due to trauma or overuse Pain worse with movement, relieved by rest Restricted range of motion on exam Paraspinal muscle tenderness Normal neurologic exam Imaging not indicated Same treatment as non-specific low back pain Radiculopathy Radiculopathy = compression of spinal nerve root Lumbar radiculopathy = radiculopathy lumbar spine Also called sciatica Low back pain radiating one down leg Many causes Herniated disc Spondylolisthesis Spinal stenosis Radiculopathy Syndromes Nerve root L5: most common Herniated disc at L4/L5 vertebrae Back pain down lateral leg Weak foot dorsiflexion, toe extension Difficult walking on heels Common Peroneal Nerve Connexions/Wikipedia Radiculopathy Syndromes S1 nerve root: 2nd most common L5/S1 disc Pain down back of leg Weakness plantar flexion Difficulty standing on toes Ankle reflex lost Tibial nerve Connexions/Wikipedia Radiculopathy Syndromes L2/L3/L4 nerve roots Higher nerve roots → thigh/knee symptoms Pain to anterior thigh and knee Weakness: hip flexion, knee extension Reduced knee (patellar) reflex Femoral nerve Straight Leg Raise Test Bedside maneuver for lumbar radiculopathy Examiner raises extended leg on symptomatic side Stretches sciatic nerve and nerve roots Lasègue's sign: worsening pain Davidjr74/Wikipedia Acute Lumbosacral Radiculopathy Workup and treatment Usually a clinical diagnosis Usually not an indication for imaging High suspicion for cauda equina, malignancy, infection or fracture Patients who do not respond to initial conservative treatment Patients with severe/intractable pain or severe weakness Mild/moderate symptoms and no red flags: NSAIDS or acetaminophen Activity modification: avoid activities that cause pain If symptoms persist → neuroimaging Surgery and other advanced treatments based on specific cause Herniated Disc Most common cause of radiculopathy Degeneration of annulus fibrosus Surrounds soft core of disc Bulging/extrusion of nucleus pulposus Unilateral nerve root compression Presents as acute lumbosacral radiculopathy Diagnosis by MRI if necessary Surgical therapy available in select cases BruceBlaus/Wikipedia Herniated Disc Often occurs posteriorly Two ligaments contain disc in spine Anterior and posterior longitudinal ligaments Posterior longitudinal ligament Sits within spinal canal Covers posterior surface of vertebrae Weaker containment than anterior ligament Wikipedia/Public Domain Spondylolisthesis Terminology Spondylosis: age-related change of vertebra/spine Spondylolysis Fracture of pars interarticularis Determined by imaging Usually due to aging/degeneration Spondylolisthesis Forward slippage of a vertebral body Occurs in patients with spondylolysis May lead to lumbar radiculopathy Can occur in children from fracture and overuse Spinal Stenosis Narrowing of spinal canal Usually age-related Intervertebral discs shrink → narrows foramen Classic imaging findings: Facet joint arthritis → bone spurs/osteophytes Ligamentum flavum hypertrophy Disc bulging and spondylolisthesis Leads to nerve root compression Standing (straight spine) narrows lumbar canal Neurogenic Claudication Pseudoclaudication Classic clinical feature of spinal stenosis Leg pain with walking in spinal stenosis Can mimic vascular claudication Often persists with rest when standing Improves with stooped/flexed posture No pain with sitting Diagnosis: symptoms + imaging findings Most patients treated conservatively Surgical treatments available Shutterstock Vertebral Compression Fractures Vertebral Compression Fracture Fracture of vertebral body due to weight-bearing Classic fragility fracture of osteoporosis Occur mid thoracic (T7-T8) or thoracolumbar (T12-L1) Cause back pain and impaired mobility Tenderness to palpation of spine Diagnosis: X-ray Most patients treated conservatively Treatment for osteoporosis indicated Surgical treatments available (vertebroplasty/kyphoplasty) BruceBlaus Shutterstock Spinal Cord Compression Trauma, malignancy or abscess Gradually worsening back pain Classically worse when lying in bed at night Symmetric lower extremity weakness Acute: diminished/absent deep tendon reflexes Chronic: hyperreflexia with positive Babinski Possible cord compression requires urgent MRI Public Domain Neoplastic Epidural Spinal Cord Compression ESCC Caused by cancer metastasis Most commonly prostate, lung, and breast Major clinical feature: back pain Severe back pain at level of lesion Progressively worsens over time Worse at night Advanced cases may have motor or sensory loss Arms or legs depending on level of lesion Public Domain Neoplastic Epidural Spinal Cord Compression ESCC Most commonly in thoracic spine Diagnosis: imaging Initial treatment with glucocorticoids Used for patients with neurologic deficits Anti-edema effect may improve neurologic function Definitive treatment based on tumor type Chemotherapy Radiation Neurosurgery Public Domain Epidural Abscess Abscess in epidural space via several mechanisms Hematogenous spread Direct extension from infected tissue (e.g. vertebra) Direct inoculation from spinal procedure Risk factors Injection drug use Dental abscesses Infected catheters Endocarditis Spinal interventions especially epidural catheter placement Shutterstock Epidural Abscess Clinical features Fever Back pain Neurologic deficits ↑ ESR or CRP Diagnosis: blood culture and MRI Treatment: antibiotics and surgical decompression Most common pathogen: Staph aureus Empiric therapy usually vancomycin + 3rd/4th cephalosporin Oh, K., Inoue, T., Saito, T. et al. Spinal epidural abscess caused by Pasteurella multocida mimicking aortic dissection: a case report. BMC Infect Dis 19, 448 (2019). Vertebral Osteomyelitis and Discitis Infection of vertebrae or disc Most commonly due to hematogenous spread Less commonly from contiguous spread Example: infected pressure ulcer → sacrum Back pain worse at night Tenderness of spine Fever ↑ ESR or CRP Usually no neuro defects Unless complicated by epidural abscess Jmarchn/Wikipiedia Vertebral Osteomyelitis and Discitis Diagnosis and treatment Suspected based on clinical features Fever, back pain, tenderness on exam Diagnosis: MRI and cultures Blood cultures +/- tissue biopsy Treatment: antibiotics Most common pathogen: Staph aureus Empiric therapy with Vancomycin + 3rd/4th cephalosporin Therapy tailored to culture results when available Cauda Equina/Conus Medullaris Syndromes Spinal cord ends about L2 (conus medullaris) Spinal nerves continue inferiorly (cauda equina) Cauda equina contains 18 nerve roots: Motor and sensory to lower extremity Pelvic floor/sphincter innervation Many potential causes of compression Massive disk rupture, trauma, tumor Neural tube defects in children Clinical features often overlap Both are neurosurgical emergencies Cauda Equina Syndrome Saddle Anesthesia Lesion from L2 to sacrum Often caused by herniated disc with gradual onset Low back pain radiating to one or both legs Lower extremity weakness to flaccid paralysis Lower motor neuron deficits with hyporeflexia Bowel and bladder dysfunction Either retention or incontinence Saddle anesthesia Sexual dysfunction in men may occur Conus Medullaris Syndrome Lesion at L1-L2 level More often due to trauma with sudden onset Anesthesia more localized around anus Less severe motor weakness Sexual dysfunction in men more common Upper motor neuron deficits with hyperreflexia