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By Q. Lester. Lewis University.

Such genetic studies have not as yet had an impact on clinical medicine buy suhagra 100mg on line, but once we have a greater understanding of how genes interact with the environmental agents that trigger diseases discount suhagra 100mg otc, it will be possible to treat them more effec- tively and even prevent them suhagra 100mg with visa. The various forms of spondyloarthropa- thy usually begin in the late teens and early twen- ties buy 100 mg suhagra overnight delivery, but they can also begin in childhood or later in life. They show a strong association with HLA-B27, but the strength of this association varies markedly, not only between the various spondyloarthropathies but also among racial and ethnic groups. The mode of presentation of spondyloarthropathies is very varied and, with the exception of AS, may not necessarily involve sacroiliitis or spondylitis. It may also not be always possible to differentiate clearly between the various forms of spondyloarthropathies, especially in their early stages, because they generally share many clinical features, both skeletal and extra- skeletal. However, this is not a serious clinical problem because it does not usually impact the treat- ment decisions. Spondyloarthropathies other than AS include: • the arthritis associated with chronic inflammatory bowel diseases (i. Patients with psoriasis, ulcerative colitis, Crohn’s disease, or reactive arthritis (Reiter’s syndrome) are more likely to develop AS than the rest of the population. Doctors have found that the clinical features typical of spondyloarthropathies may occur in dif- ferent combinations, so the existing criteria for disease classification may not be appropriate for some patients. The European Spondyloarthropathy Study Group (ESSG) have therefore developed classification criteria (Table 5) to include this cur- rently recognised wider spectrum of spondylo- arthropathies. Reactive arthritis (Reiter’s syndrome) Reactive arthritis is an aseptic inflammatory arthritis that follows an episode of urethritis, cervicitis, or diarrhea, and may also show inflammation at sites other than joints, such as eyes, skin, and mouth. The joint inflammation is triggered by bacterial infection at a distant site, usually in the gastrointestinal or genitourinary tract. Not everyone who develops these bacterial infections will develop reactive arthritis. Some people are genetically susceptible and the inheri- tance of the HLA-B27 gene increases the risk of 126 thefacts AS-17(125-142) 5/29/02 5:55 PM Page 127 Spondyloarthropathies Table 5 The European Spondyloarthropathy Study Group (ESSG) criteria for classifying disease as a spondyloarthropathy Spondyloarthropathy is defined as the presence of inflammatory spinal pain or synovitis and one or more of the following: • family history: presence, in first- or second-degree relatives, of: ankylosing spondylitis, psoriasis, acute iritis, reactive arthritis, or inflammatory bowel disease. The disease tends to be more severe and more likely to become chronic in people with a triggering infection that is symptomatic and proven by bacterial culture, espe- cially if they are born with the HLA-B27 gene, than if the triggering infection produces no symp- toms and is suggested only by a positive antibody test. Depending on the bacterial trigger, reactive arthritis can be more common in men than in women. Table 6 lists some of the important bac- terial triggers. Genitourinary tract infection with Chlamydia is the more commonly recognized initia- tor in the US, but enteric infections with Shigella, Salmonella, Yersinia, or Campylobacter are more com- mon triggers in developing countries. Sometimes there is no recognized antecedent infection, or the triggering infection may be asymptomatic. The term reactive arthritis is often used when the identity of the triggering organism is known, and it encom- passes the more restrictive and less commonly used term Reiter’s syndrome. Table 6 Bacteria triggering reactive arthritis Chlamydia trachomatis Shigella flexneri Salmonella (many species) Yersinia enterocolitica and Y. The prevalence of reactive arthritis in a population varies with that of HLA-B27 and the triggering bac- terial infections. Chlamydia-induced reactive arthri- tis is most commonly seen in young promiscuous men. However, it is under-diagnosed in women because their chlamydial infection is often subclini- cal or asymptomatic, and also because doctors rarely do pelvic examinations to look for the presence of cervicitis (inflammation of the cervix, the part of the uterus that protrudes into the vagina). The post-enteritic form of the disease affects children and adults, both male and female, including elderly people. The incidence of Chlamydia-induced reactive arthritis has declined since 1985 in Europe and the US, but the post-enteritic form of the disease may be increasing. After some epidemics of bacterial gastroenteritis or food poisoning (e. Salmonella enteritis) the incidence of reactive arthritis, or at least some form of musculoskeletal inflammation and pain, can be as high as 20% among B27-positive individuals in the general population, but the initial episode of reactive arthritis in such epidemics is rela- tively weakly associated with HLA-B27 (not more than 33% of these patients may possess this gene). To give one specific example, in the Finnish general population aged 18–60 years the annual incidence of Chlamydia-induced reactive arthritis (confirmed by bacterial culture) is 4. The triggering genitourinary infection is asympto- matic in 36%.

Refer to physical therapy to initiate strengthening exercises Key Concept/Objective: To be able to recognize steroid myopathy This patient with polymyositis has evidence of steroid myopathy buy cheap suhagra 100 mg online. There is an increasing sense of proximal weakness without any increase in the CK order suhagra 100 mg fast delivery. The best way to determine whether steroid myopathy is contributing to the weakness is to try a steroid taper and see 15 RHEUMATOLOGY 19 if the weakness improves generic suhagra 100mg with mastercard. If so generic suhagra 100mg fast delivery, a second-line agent such as methotrexate would be useful, although even methotrexate may take several weeks to months to be effective. Biopsy of the muscle may show type 2 fiber atrophy typical of steroid myopathy, but in the setting of polymyositis, the diagnosis may be difficult to interpret. A 34-year-old woman complains of weakness, fatigue, hair loss, and numbness of the fingers. Her symp- toms began 4 months ago, soon after the delivery of her second child. While visiting her mother, she saw her mother’ s physician for the above complaints and was found to have a CK of 600 mg/dl. She was told to see her local physician on returning home for evaluation of possible polymyositis. On examination, blood pressure is 90/60 mm Hg; pulse is 60 beats/min; hair appears thin; lungs and heart are normal; mus- cle strength is 5/5 in both the proximal and distal groups; and Phalen testing is positive at both wrists. Of the following, which is the best test to perform next in the evaluation of this patient? Repeat CK Key Concept/Objective: To know that the differential diagnosis of polymyositis includes hypothy- roidism Hypothyroidism can cause all of the symptoms experienced by this patient as well as an elevated CK. CK levels generally do not reach those seen in inflammatory myositis. Rheu- matologic manifestations of hypothyroidism include arthralgias and even joint swelling, myalgias and muscle cramps, carpal tunnel syndrome (which this patient has), and non- specific paresthesias. A 54-year-old woman with a recent diagnosis of dermatomyositis is referred to you for further evalua- tion. She has read that dermatomyositis can be associated with malignancy. She has recently had a thor- ough physical examination, chest x-ray, stool screening for occult blood, mammogram, and pelvic examination, all of which were deemed unremarkable. Suggest that a CA-125 and transvaginal ultrasound be performed E. Suggest that a colonoscopy be done soon Key Concept/Objective: To understand the relationship between dermatomyositis and malignancy It is generally accepted that patients with dermatomyositis are at increased risk of malig- nancy, the relative risk of which is approximately four to five times that of control groups. Cancers of the ovary, lung, lymphatic system, and hematopoietic system are overrepre- sented in patients with dermatomyositis. In women older than 40 years with dermato- myositis, the risk of ovarian cancer is 20 times that of the general population. The most recent recommendations for detecting them in patients with dermatomyositis include a careful gynecologic examination, meas- urement of CA-125, and transvaginal ultrasound at 3- to 6-month intervals. A 45-year-old man is referred to you for a workup of muscle weakness. He presented 2 months ago with proximal weakness and an elevated CK of 4,000 mg/dl. On examination, the patient has 4/5 strength in the proximal muscles and 5/5 strength distally; otherwise, the examination is normal. Refer the patient to a muscular dystrophy clinic D. Perform the ischemic forearm test Key Concept/Objective: To understand the use of MRI in improving the diagnostic accuracy of biopsy Involvement of muscles in polymyositis is often patchy. In recent years, the use of MRI of the proximal muscles has demonstrated the patchy nature of the disease and aided in the localization of biopsy.

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The development of hyperkalemia at higher levels of renal func- tion suggests the presence of tubulointerstitial disease or disturbances in the renin- angiotensin-aldosterone axis purchase suhagra 100mg without a prescription. As renal insufficiency progresses cheap suhagra 100 mg, patients typically become acidotic order suhagra 100mg on line. Initially 100 mg suhagra with mastercard, the acidosis is of the non–anion gap type, but as renal insufficiency becomes far advanced, an anion gap acidosis supervenes. As GFR declines, the serum phosphate level begins to increase, causing a reciprocal decrease in the serum calcium concentration. In response, parathyroid hormone (PTH) is released, resulting in in- creased phosphate excretion in each of the remaining nephrons; thus, calcium and phosphorus levels return to normal. As renal function continues to decline, calcium and phosphorus levels remain within the normal range but at the expense of an ever- increasing level of PTH. A 53-year-old man with type 2 diabetes presents to your office to establish primary care. Which of the following statements is true regarding assessment of renal function? If the patient has renal insufficiency, use of creatinine clearance, as determined by 24-hour urine collection, to assess GFR can lead to an underestimation of the GFR C. The Cockcroft-Gault formula estimates GFR while taking into account the increase in creatinine production with increasing weight and age D. Averaging the urea and creatinine clearance values will provide a more accurate estimation of GFR than use of the creatinine clear- ance value alone E. The major limitation of the use of the serum creatinine level to assess GFR is that it cannot detect loss of renal function until the GFR has declined by more than 50%. Thus, a normal creatinine level does not rule out the possibility that the GFR has declined by more than 25%. The Cockcroft- Gault formula takes into account the increase in creatinine production that occurs with increasing weight and the decrease in production that occurs with advancing age. The most accurate way of following renal function is to directly measure the GFR by meas- uring the clearance of a compound that is freely filtered by the glomerulus but that is neither secreted nor absorbed. Use of creatinine clearance provides a fairly accurate measure of GFR because at normal levels of renal function, only a small percentage of creatinine appears in the urine through tubular secretion. The bulk of creatinine is fil- tered by the glomerulus. With advancing renal insufficiency, however, the percentage of creatinine that reaches the final urine through tubular secretion increases. As a result, use of creatinine clearance tends to lead to progressively larger overestimations of GFR with advancing renal insufficiency. Urea is filtered by the glomerulus and is reabsorbed by the tubule; thus, use of urea clearance leads to underestimations of GFR. However, the extent to which urea clearance leads to underestimations of GFR is similar to the extent to which creatinine clearance leads to overestimations of GFR. Thus, taking the average of urea and creatinine clearance values will give a very accurate estimation of GFR. You are managing a man with long-standing hypertension, diabetes, and chronic renal insufficiency. He has gradually developed anemia and edema and has recently developed hyperkalemia and acidosis as the time approaches when he will require hemodialysis. Which of the following statements is true regarding the etiology and management of these typical abnormalities associated with chronic renal insufficiency? Alkali therapy can help treat the acidosis but is unlikely to improve the hyperkalemia B. Constipation should be avoided because it can cause the hyper- kalemia to worsen C. The target hematocrit value for erythropoietin therapy is 30% D.

The febrile phase order 100mg suhagra, typically lasting 3 to 5 days buy suhagra 100 mg low price, is characterized by fever purchase 100mg suhagra overnight delivery, myalgia discount suhagra 100mg with mastercard, and malaise. Headache, dizziness, anorexia, nausea, vomiting, and diarrhea may occur. The cardiopulmonary phase is marked by pulmonary edema and shock. Once pulmonary edema develops, rapid onset of circulatory compromise and hypoxia often leads to death. During the diuretic phase, pulmonary edema clears and fever and shock resolve. A 36-year-old woman who recently returned from Africa after spending 6 months there on a medical mission presents to your clinic with complaints of fever, diarrhea, nausea, vomiting, abdominal pain, and rash. You are concerned about her symptoms and travel history, and you admit her to the hospital for observation. She remains ill and develops worsening symptoms of odynophagia, sore throat, and conjunctivitis. Finally, she develops disseminated intravascular coagulation, mucosal bleeding, altered mental status, and anuria, and she dies 9 days later. Which of the following is the most likely diagnosis for this patient? Sabia virus 94 BOARD REVIEW Key Concept/Objective: To know the symptoms and clinical course of Ebola virus infection and to be able to differentiate this disease from other African diseases Marburg and Ebola viruses are two of the most severe filoviruses to emerge as recent pathogens. Ebola virus was first discovered in Sudan in 1976; since then, over 1,000 deaths have resulted from infection with the virus. Ebola-Reston was the fourth subtype discovered in macaques imported from the Philippines for medical research. There are two clinical phases of Ebola virus infection. Early symptoms include fever, asthenia, diarrhea, nau- sea, vomiting, anorexia, abdominal pain, headaches, arthralgia, back pain, bilateral conjunctivitis, nonpruritic rash, sore throat, and odynophagia. The second phase, char- acterized by hemorrhagic manifestations, neuropsychiatric abnormalities, and olig- uria/anuria, portends a worse outcome. Diagnosis can be made with enzyme-linked immunosorbent assay, polymerase chain reaction, and virus isolation. Treatment is sup- portive; efforts are focused on control of outbreaks through early diagnosis, case isola- tion, and other infection-control practices. Patients with Lassa fever may present with symptoms similar to those of Ebola: fever, malaise, gastrointestinal symptoms, and hemorrhage. Finally, Sabia virus is a hemor- rhagic fever found more commonly in Brazil. A 26-year-old man presents to your clinic after being bitten on the arm by a bat. He has no symptoms and has never been vaccinated for rabies. He is treated with prompt postexposure prophylaxis, consist- ing of thorough washing of the bite wound and irrigation of the site with povidine-iodine solution. He is given human rabies immunoglobulin and rabies vaccine and is monitored closely. Which of the following statements regarding the infectivity of rabies virus is false? A bite on the face is associated with a 60% chance of disease B. A bite on the arm is associated with a 75% chance of disease C. A bite on the leg is associated with a 3% to 10% chance of disease D. A bite on the hand is associated with a 15% to 40% chance of disease Key Concept/Objective: To understand the relationship between site of infection and risk of disease Rabies virus is of the family Rhabdoviridae, genus Lyssavirus. However, in the United States, canine rabies has been sharply limited, and therefore, wildlife rabies has increased in importance; 90% of all reported cases of animal rabies now occur in wildlife, particularly wild car- nivores and bats.

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