young females

onset in 20s-40s

increased in AA, hispanic, native americans

genetic

environmental sun exposure

infections

hormonal (estrogen)

procainamide

hydralazine

INH

quinidine

+ anti-histone bodies

drug induced lupus usually resolves w/ drug d/c

1. triad of joint pain (90%), fever, & malar "butterfly" rash (cheeks & bridge of nose - sparing nasolabial folds)  Serositis: pericarditis, pleuritis
2. discoid lupus: annular, erythematous patches on face & scalp heals w/ scarring
3. systemic: CNS, cardio, glomerulonephritis, retinitis, oral ulcers, alopecia

1. + anti-nuclear ab (ANA) - best initial test, not specific + RF
2. + anti-double stranded DNA & Anti-smith Ab 100% spp for SLE (not sensitive)
3. antiphospholipid ab syndrome (APLS): increased risk of arterial & venos thrombosis

• + anticardiolipid Ab assoc w/ false + VDRL/RPR 
• lupus anticoagulant
• B-2 glycoprotein I ab. women w/ APLS may have frequent miscarriages, livedo reticularis

4. CBC: +- hemolytic anemia, leukopenia, lymphopenia, thrombocytopenia

sun protection

hydroxychloroquine (for skin lesions)

NSAIDs or acetaminophen for arthritis

+- pulse dose steroids

cytotoxic drugs (methotrexate, cyclophosphamide)

1. Limited cutaneous systemic sclerosis "crest syndrome" 

• Calcinosis cutis
• Raynaud's phenomenon
• Esophageal motility d/o
• Sclerodactyl (claw hand)
• Telangectasia
• MC type
• affects the face, neck as well as distal to elbows & knees
• Raynauds phenomenon : worse w/ cold, smoking, or emotional stress.  CCB tx of choice 

2. Diffuse cutaneous systemic sclerosis: skin thickening - trunk & proximal extremities

ANA: esp antiSS-A (Ro) & antiSS-B (la)

+RF

Shirmer test (decreased tear production)

1. artificial tears, pilocarpine (cholinergic) for xerostoma
2. Pilocarpine: cholinergic drug that increases lacrimation & salivation (SLUDD-C) SE: diaphoresis, flushing, sweating, bradycardia, diarhea, N/V, incontinence, blurred vision. Cyclosporine may help w ocular symptoms
3. Cevimeline (Evoxac): stimulates muscarinic cholinergic receptors

diffuse pain (esp in the morning)

extreme fatigue

stiffness

painful, tender, joints

sleep disturbances

sx often worsened w/ physical/psych stress

1. diffuse pain in 11 out of 18 trigger points > 3 mo + widespread pain
2. Biopsy: "moth-eaten" appearance type 1 muscle fibers, injury to muscle.  

TCA's, cymbalta, SSRI's, neurontin, exercise

Pregabalin only drug FDA approved 

swimming preferred exercise (relaxing effect of water on muscles)

1. bilateral prox jt pain/STIFFNESS morning stiffness > 30 mins of the pelvic and shoulder girdle
2. difficulty w/ combing hair, putting on coat, getting out of chair
3. no severe muscle weakness 

clinical dz

increased ESR, anemia (normochromic normocytic)

+- plts (acute phase reactant)

1. progressive symmetrical proximal m. weakness (usually painless)
2. dysphagia
3. skin rash
4. polyarthralgias
5. muscle atrophy (difficulty rising from chair/climbing stairs, combing hair, problems w/ overhead movement)

1. increased muscle enzymes: increased aldolase, creatine kinase ); increased ESR, + muscle bx, abnormal EKG
2. + anti-Jo 1 Ab: myositis specific antibody. assoc w/ interstitial lung fibrosis, "mechanic hands" (hyperkeratotic "cracked hands" with dirty appearance
3. + anti-SRP Ab; (signal recognition particle ab).  almost exclusively seen w/ PM. Assoc w/ more prominent muscle weakness/atrophy & cardiac manifestations
4. + anti-Mi-2 Ab: specific for dermatomyositis
5. muscle bx: endomysial invovlement w/ PM; perifascicular/perivascular involvement w/ DM

1. heliotrope (blue-purple) upper eyelid discoloration
2. gottron's papules: raised violaceous scaly eruptions on the knuckles. malar rash w/ erythema (including nasolabial folds) photosensitive poikiloderma "shawl or V sign," diffuse alopecia

muscle enzymes: increased aldolase, creatine kinase

increased ESR

increased incidence of malifnancy 

corticosteroids 1st line tx

+- methotrexate, azathioprine, IV immune globulin

mostly adult men (& postmenopausal women)

middle aged

1. first MTP joint MC (podagra) 50% initially, 90% eventually
2. 80% monoarticular typically lower extremities (ankle, knees, foot)

• acute attacks - NSAIDs first line, colchicine, steroids

• chronic - urate lower agents (allopurinol, febuxostate, probenacid) colchicine can also be used .

female predominance, elderly

less common than gout

1. acute attacks: steroids 1st line (intraarticular), NSAIDs, colchicine
2. Chronic managmement: NSAIDS, +- colchicine 

Note that chronic management NOT initiated during acute attack (may precipitate an attack) 

- any acute increase or decrease in uric acid levels may precipitate an attack moreso than the actual uric acid levels

1. renal: HTN (d/t increased renin), renal failure.  usually no glomerulonephritis. No capillaries involved
2. constitutional: fevers, myalgias, arthritis. lungs usually spared
3. CNS: neuropathy, amaurosis fugax, peripheral neuropathy, mononeuritis complex
4. Dermatologic: livedo reticularis, purpura, ulcers, gangrene, nodules, Raynauds phenomenon

1. increased ESR; angiography
2. MC seen in men ~ 45 yo
3. classic PAN is ANCA negative 
4. BX: necrotizing inflammatory lesions. no granulomas
5. Renal or mesenteric angiography: microaneurysms c/ abrupt cut-off of small arteries

steroids (+- cyclophosphomaide if refractory)

+- plasmapharesis in pts w/ HBV

OA

ABSENT in RA

osteopenia

symmetric joint narrowing 

Positive RF

anti CCP ab

ESR, CRP

rare d/o triad

 RA+splenomegaly+decreased WBC/repeated infections

arthritis >= 3 joints

morning stiffness

disease duration > 6 weeks

PROMPT initiation of DMARDs (methotrexate, hydroxychloroquine, leflunamide, minocycline azathioprine) to reduce permanent damage to the joint, cartilage, bone

NSAID for pain control, low dose steroids

1. asymmetric inflammatory arthritis
2. conjunctivitis/uveitis
3. urethritis, cervicitis

chlamydia

+- seen with gonorrhea

GI (salmonella, shigella, campylobacter, yersinia)

conjunctivitis

urethritis

arthritis (esp. lower extremities)

sausage toes/fingers 

keratoderma blennorrhagica (hyperkeratotic lesions on palms/soles)

circinate balantitis 

+ HLA-B27  (80%)

CBC: increased WBC (10,000-20,000)

increased ESR

normochromic anemia

increased IgG

synovial fluid: WBC 1,000-8,000 cells/mm3

synvoial fluid bacterial culture negative (aseptic)

NSAIDS mainstay of therapy

abx to treat infx that triggered disease

if no repsonse to methotrexate --> sulfasalazine, steroids. 

anti-TNF agents (etanercept, infliximab)