Royal College: Emergency Medicine > Immunology & Inflammatory & Dermatology > Flashcards

Immunology & Inflammatory & Dermatology Flashcards

This deck covers Chapters 106-110 in Rosens, comprising all of rheumatology, dermatology, and immunology. (62 cards)

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1
Q

List 2 causes for each:

  • Acute Monoarticular
  • Chronic Monoarticular
  • Polyarticular
  • Periarticular
A

Acute Monoarticular

  • Septic
  • Gout
  • Crystalline (Gout, Pseudogout)
  • Rheumatic fever
  • Lyme
  • Reactive arthritis
  • Viral arthritis

Chronic Monoarticular

  • Still’s disease
  • Osteoarthritis
  • Post-traumatic
  • Seronegative spondyl

Polyarticular

  • RA
  • PMR
  • SLE
  • Lyme

Periarticular

  • Tendonitis
  • Bursitis
  • Periosteal hematoma
  • Tenosynovitis
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2
Q

What is Nikolsky’s Sign? List 4 conditions that are Nikolsky +.

A

Nikolsky’s Sign

  • Easy separation of the outer portion of the epidermis from the basal layer when pressure is applied

Conditions

  1. SJS
  2. TENS
  3. SSS
  4. Pemphigus Vulgaris
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3
Q

Compare and Contrast:

SSSS vs. TEN

A

SSSS

  • Mucosal sparing
  • Tender
  • Not shocky
  • Not multisystem
  • Involves desmosomes from exotoxin
  • Epidermolytic toxin A or B

TEN/SJS

  • Typically drug-induced
  • Unwell
  • MM involved
  • Full-thickness skin
  • SJS< 10% TBSA, otherwise TENS
  • Medications: NSAIDs, sulfa, allopurinol.
  • Dx: Mycoplasm, HIV, malignancy
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4
Q

Describe the most common bug that causes septic arthritis for each age group and one bug that commonly tested and sorta pathognomonic for this condition

  • Neonates
  • Rest of pediatrics
  • Adults
  • Oldies
  • Sicklers
  • IVDU
A

Neonates

  • Staph, GBS, E. coli

Children

  • Staph, H. flu

Adolescents

  • Neisseria, Staph

Older adults

  • Staph, Strep, E. coli

Sickler

  • Staph (MCC), Salmonella

IVDU

  • Pseudomonas, Staph, Strep, E. coli
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5
Q

A patient was prescribed amoxicillin and developed this rash within 48 hours. What is it? How do you treat it?

A

Acute Generalized Exanthematous Pustulosis (AGEP)

  • Remove offending agent
  • Topical steroids
  • Rule out DRESS/SJS
  • Causes: Antibiotics, Anti-Malarials, Diltiazem
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6
Q

How is the diagnosis of eczema made?

A

Itchy skin + 3 or more of:

  • History of skin crease involvement
  • Generalized dry skin
  • History of asthma or hay fever
  • Rash onset <2 yo
  • Flexural surfaces involved

Diagnostic criteria

  • Sensitivity 85%
  • Specificity 96%

Treatment

  • Avoid irritants, perfumes, scented creams
  • Lubricating ointments
  • Vaseline
  • Antihistamines
  • Topical corticosteroid
  • Hydrocortisone 1-2.5% cream/ointment
  • Betaderm 0.05-0.1% ointment severe cases
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7
Q

List 6 causes of a bullous rash.

A
  1. Bullous Impetigo
  2. Pemphigus Vulgaris
  3. Bullous Pemphigoid
  4. Staph Scalded Skin
  5. Burns
  6. Dermatitis Herpetiformis
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8
Q

List THREE risk factors for having anaphylaxis.

List THREE risk factors for increased severity & mortality from anaphylaxis.

A

Risk Factors for Having

  1. Men <16, women >30
  2. Higher SES
  3. History of atopy

Risk Factors for Severity

  1. Extremes of age
  2. Comorbid disease (heart /pulmonary)
  3. On beta-blockers
  4. Drug use
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9
Q

Differentiate:

  • Macule
  • Papule
  • Patch
  • Vesicle
  • Bullae
  • Petechiae
A
  • Macule < 1cm flat
  • Papule <1 cm raised
  • Patch >1 cm flat
  • Vesicle: <1 cm fluid filled
  • Bullae : >1 cm fluid filled
  • Petechiae: tiny, non-blanchable
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10
Q

What is the typical story of this disease? What is the causative organism?

A

Roseola

  • High fevers for 2-3 days then rash starting on the trunk
  • HSV 6/7
  • Supportive care
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11
Q

Compare and Contrast:

DRESS, SJS/TENS, AGEP, and Erythroderma with respect to onset, duration, mortality, the appearance of the rash

A
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12
Q

Briefly describe the clinical features of RA. Why are they difficult to intubate?

A

Symmetrical swelling + inflammation of joints

  • Hands (MP + PIP) >>> wrists > elbows
  • DIP is spared

Hands

  • Ulnar deviation
  • Swan-neck deformity
  • Boutonniere deformity

Extra-articular

  • SC nodules
  • Vasculitis of skin
  • Pulmonary fibrosis
  • Mononeuritic multiplex

Airway Issue = Atlanto-axial instability

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13
Q

List 4 mechanisms for epinephrine in a patient with anaphylaxis.

A
  1. α1 - vasoconstriction, increased SVR, decreased edema
  2. β1 - inotropy + chronotropy
  3. β2 - bronchodilation
  4. β2 - stabilization of mast cells & basophils
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14
Q

Describe the following tests when assessing the shoulder for rotator cuff tendinopathy or impingement syndrome:

  1. Jobe’s test/Empty can test
  2. Neer test
  3. Hawkins test
  4. Push-off test
  5. Drop arm test
  6. Shrug sign
A
  • Jobe’s/Empty can: supraspinatus
  • Neer’s: subacromial impingement
  • Hawkin’s: subacromial impingement
  • Push off: subscapularis
  • Drop arm: supraspinatus
  • Shrug: rotator cuff
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15
Q

What family of local anesthetics can result in allergic reactions?

A

Two families of local anesthetics:

  1. Esters (procaine, tetracaine, benzocaine)
    * More likely to have an allergic reaction
  2. Amides (lidocaine, bupivacaine, mepivacaine)
    * Rare to have an allergic reaction
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16
Q

What’s the pathophysiology of vasculitis?

List 2 examples of each:

  • Large-cell vasculitis
  • Medium-cell vasculitis
  • Small-cell vasculitis
A

Pathophysiology of Vasculitis

  • Immune complexes deposited in vessel walls
  • Complement activation –> accumulation of PMNs
  • Eventual vessel wall damage & necrosis

Large-Vessel Vasculitis

  • Takayasu
  • Giant Cell

Medium-Vessel Vasculitis

  • PAN
  • Buerger’s
  • Kawasaki

Small-Vessel vasculitis

  • HSP
  • Wegener’s
  • Churg-Strauss
  • Goodpasture’s
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17
Q

Describe Yergasons and Speeds test.

A

Yergasons

  • Resisted supination
  • Pain = Biceps tendonitis

Speeds

  • Straight arm in front, supinated
  • Push arm down against resistance
  • Pain = Biceps tendonitis
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18
Q

What is the treatment of scabies/head lice and bed bugs?

A

Scabies

  • Agent: Sarcoptes Scabiei
  • Treatment: Permethrin 5% at night x1, wash off in AM,
  • Repeat in 1 week

Head Lice

  • Agent: Pediculus humanus capitis
  • Treatment: Permethrin 1% at night x1, wash off in AM,
  • Repeat in 1 week

Bed Bug

  • Agent: Cimex lectularius
  • Treatment: Heat, Insecticide, Itching relief
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19
Q

Negatively-birefringent crystals are associated with what? List 3 treatment options.

A

Gout

  • NSAIDs
  • Prednisone 30 mg x7-10d
  • Colchicine 1.2 mg once, then 0.6 mg in 1 hour, then daily
  • PPI for GI protection
  • May consider allopurinol - not in acute flare

Four Joints Most Commonly Affected

  1. 1st MTP (podagra)
  2. Tarsal joints
  3. Ankle
  4. Knee (gonagra)
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20
Q

Outline 6 steps in the management of anaphylaxis.

A
  1. Monitors, Oxygen, Vitals
  2. Epinephrine 0.3-0.5 mg IM
  3. Benadryl 50mg IV
  4. Salbutamol +/-
  5. Steroids (Solumedrol 125mg IV)
  6. H2 blockers +/-
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21
Q

Describe the pathophysiology, clinical features, and treatment of Polyarteritis Nodosa (PAN).

A

Pathophysiology

  • Necrotizing vasculitis of medium-sized vessels
  • Immune deposits minimal/absent; ANCA negative
  • Peak age: 5th or 6th decade; M>F

Symptoms

  • Early
  • Constitutional Weight loss (fever, malaise, arthralgias, myalgias)
  • Cutaneous (1/3 patients) livedo reticularis
  • PALPABLE PURPURA (sometimes with ulcerations)
  • Late: peripheral neuropathy, bowel ischemia, HTN, renal impairment, mononeuritis multiplex

Treatment

  • No organ involvement: corticosteroids
  • Organ involvement: add immunosuppressive agent
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22
Q

List 5 causes of viral arthritis.

A
  1. Rubella
  2. Parvovirus
  3. West Nile
  4. Chikungunya
  5. Dengue
  6. HIV
  7. Hep B
  8. Hep C
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23
Q

List 6 complications of chickenpox.

A
  1. Bacterial superinfection
  2. Cerebellar ataxia
  3. Reye syndrome
  4. Encephalitis
  5. Pneumonia
  6. Hepatitis
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24
Q

Compare and Contrast:

Strep Toxic Shock & Staph Toxic Shock in relation to the organism, toxin, source, appearance, mortality, and treatment.

A
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25
**Differentiate** periorbital and orbital cellulitis.
**Periorbital** * Anterior to the orbital septum * Non-toxic * Nothing from the list below * Amox-Clav * Sinusitis, FB, Dental **Orbital** * Pain with EOM * Possible double vision * Globe may be involved * Proptosis possible * Admit (IV ABx) / Ophthal
26
Who would you consider **PEP** if exposed to **VZV**?
**If healthy:** * Immunize **If pregnant/immune-compromised:** * Check titers: if negative, give Varicella Ig * Can't give the vaccine to pregnant/immune comp **Susceptibility** * No previous infection * No vaccine * No lab evidence of immunity **High-risk groups** * Pregnant women * Cystic fibrosis * HIV/AIDS * Chemo * Steroid tx * Newborns of mothers who have active VZV * BMT/SCT patients
27
What is **antiphospholipid antibody syndrome** (APS)?
**Diagnosis of APS** * Clinical event (e.g. thrombosis or pregnancy loss) + * Anti-phospholipid Ab, an inhibitor of phospholipid-dependent clotting (lupus anticoagulant) or BOTH
28
List 5 causes of **desquamating rash**.
1. SSS 2. TSS 3. TENS/SJS 4. Kawasaki 5. Exfoliative Erythroderma 6. Radiation burns
29
What are the FOUR types of **immune reactions**? Give ONE example of each type.
**Type 1 Hypersensitivity Reaction** * IgE-mediated mast cell degranulation * Anaphylaxis **Type 2 Hypersensitivity Reaction** * Cytotoxic reaction * Antibodies against cell surface antigens * ABO incompatibility **Type 3 Hypersensitivity Reaction** * Immune complex * Deposition causes complement activation * Serum sickness **Type 4 Hypersensitivity Reaction** * Delayed T cell-mediated response * Poison Ivy
30
A 3-year-old boy with 4 days of fever has the following rash around his perioral region, hands, feet, and buttocks. Diagnosis and treatment?
_**Hand, Foot, & Mouth Disease**_ **Diagnosis** * Coxsackie Virus * Enterovirus **Treatment** * Supportive
31
Compare the H1/H2 effects on the body re: **anaphylaxis**.
**H1 effects** * Pruritis * Rhinorrhea * Bronchospasm * Tachycardia (Cetirizine, diphenhydramine) **H1 and H2 effects** * Flushing * Hypotension * Headache
32
This man presents with facial swelling. He's on an ACEi. What is the diagnosis and treatment?
**ACEi-induced Angioedema** * 1% of people on ACE will get this * Can randomly get it, even when on forever * Bradykinin mediated * Urticaria and itch is absent **Treatment** * Stop the ACEi * Can give C1 esterase treatment * Consider plasma * TXA also promising for treatment
33
If a patient is allergic to contrast dye, what type of allergic reaction is it? Outline your management steps to prevent an allergic reaction if CT is critical.
**Anaphylactoid mechanism** * Direct degranulation of mast cells + basophils **Protocol** * Institution specific * Prednisone 50 mg * 13 hours before * 7 hours before * 1 hour before * Benadryl 1 hour before
34
A 45-year-old male presents with fever, weight loss, and general malaise. He has a history of asthma. A CXR shows patchy infiltrates. On the CBC differential, you note there is hypereosinophilia. Diagnosis and treatment?
**Granulomatous small-vessel vasculitis of multiple organs** * Previously called Churg-Strauss syndrome * Asthma + allergic rhinitis (often with nasal polyps) * High eosinophils * Mean age = 44 years; M\>F * Multiple organs can be involved: lungs, skin, CV, GI, neuro **Treatment** * Prednisone 60 mg/day
35
A 24-year-old female presents with painful red nodules on her legs (shown below). She has the same lesions on the extensor surfaces of her forearms. The patient also complains of knee and ankle joint pain. Given a DDx of 6.
1. Viral URTI 2. Streptococcal infection 3. Sarcoidosis 4. TB 5. Drugs (PCN, sulfa, aspartame, phenytoin, OCPs) 6. IBD 7. Histoplasmosis 8. Yersinia 9. Salmonella 10. Chlamydia 11. Coccidioidomycosis 12. Psittacosis 13. Autoimmune diseases (SLE)
36
Patient on Septra a few weeks ago. Diagnosis and treatment?
**Exanthematous (Morbilliform) drug eruption** * Type IV hypersensitivity reaction * Typically 1-4 weeks after a drug started * Morbilliform (starts on the trunk) **Treatment** * Rule out DRESS (no fever, no face swelling, get B/W) * Remove the offending agent * Cetirizine up to 20 mg BID * Betaderm 0.1% twice daily * Protopic 0.1% twice daily on face
37
Describe your approach to interpreting a **radiograph of a joint**.
**SECONDS** * **S**oft tissue swelling * **E**rosions * **C**alcifications * **O**steoporosis * **N**arrowed joint space * **D**eformity * **S**eparation (fractures)
38
List 3 different types of **yeast skin** infections and treatment.
**Tinea corporis** * Small lesion on the body * Topical terbinafine **Tinea capitis** * On head * Kerion if severe (systemic antifungals) * Keflex **Tinea versicolor** * Extensively covers body * Topical terbinafine * Fluconazole 300 mg PO weekly x2
39
What causes **reactive arthritis**?
* Chlamydia * Enteritis (Salmonella, Shigella, Yersinia, Campylobacter) * Note: ‘lover’s heel’ = reactive arthritis of the heel
40
Describe the clinical sequelae and complications of **Takayasu’s Arteritis**.
**Pathophysiology** * Most commonly affects the aorta and its major branches * Lymphocytic infiltration + vessel fibrosis * Eventual obstruction of arteries & ischemic complications **Typical patient** * Adolescent girls * Women in 20s + 30s **Symptoms** * HTN (aortic/renal involvement) * Ischemic symptoms: * Diminished or unequal pulses * Claudication * Retinopathy * Lightheaded (think carotid/vertebral dissection) * Visual loss **Complications** * HTN * CHF * Angina * Aortic regurgitation
41
List one finding on **x-ray** for each of the following conditions: 1. Acute arthritis (eg. gout) 2. Late septic arthritis 8-10 days 3. Late pseudogout 4. Degenerative arthritis (eg. OA) 5. Tuberculous arthritis 6. Late rheumatoid arthritis
1. Joint effusion 2. Subchondral bone destruction 3. Linear calcification in cartilage 4. Joint space narrowing, sclerosis, bone spurs 5. Marked demineralization 6. Marginal erosions, joint space narrowing
42
What is **De Quervain’s Tenosynovitis**?
Stenosing tenosynovitis of the APL + EPB * NOT an inflammatory condition **Exam** * Tender over radial styloid * Pain is made worse with grasping maneuvers * Finkelstein test * Pathognomonic for De Quervain’s * Patient holds the affected thumb in the palm by the fingers * Patient asked to ulnar-deviate the wrist * Positive test = PAIN near radial styloid
43
List **antibiotics** active against: * MRSA (6) * Pseudomonas (5) * VRE (2) * ESBL (1)
**MRSA** 1. Doxycycline 2. Vancomycin 3. Clindamycin 4. TMP/SMX 5. Linezolid 6. Daptomycin **Pseudomonas** 1. Ciprofloxacin 2. Pip-Tazo 3. Meropenem 4. Ceftazidime 5. Aminoglycoside **VRE** 1. Daptomycin 2. Linezolid **ESBL** 1. Meropenem 2. Nitrofurantoin
44
What is this? How do you treat it?
**Erysipelas (Strep)** * Sharply demarcated border * Raised skin * Indurated (hard) * Painful * Deeply erythematous **Treatment** * PCN or Ceftriaxone
45
List 4 infectious rashes that involve the **palms and soles**.
1. Syphilis 2. Disseminated gonorrhea 3. Coxsackie 4. RMSF 5. Measles 6. Infective endocarditis
46
What are the diagnostic criteria for **GCA**? How is it treated?
3+ of: 1. Age \>50 2. ESR \>50 mm/hr 3. Pain on palpation of the artery 4. New-onset headache 5. Temporal artery biopsy positive **Treatment** * Prednisone 60 mg daily
47
# Compare and Contrast: Buerger's vs Serum Sickness vs Hypersensitivity vasculitis
**Buergers**: * Small and medium vessels of extremities * Smoking heavy implicated, cold exposure * Digital ischemia * Must quit smoking **Serum Sickness:** * 1-2 weeks after the offending agent * PCN, Sulfa, Drugs, Vaccines (Rabies, Flu) * Fever, arthralgia, erythema multiforme, myocarditis **Hypersensitivity Vasculitis** * Small vessels * Causes: PCN, NSAIDs * Usually just the skin * Livedo, palpable purpura in dependent areas
48
This woman presents to your ED with facial swelling. She reports this happened to family members and it's happened before. She is NOT on an ACEi. What is it? What is the pathophysiology?
**Hereditary Angioedema** * C1 esterase inhibitor deficiency * Excess bradykinins * These patients DO NOT have hives/itch * Prominent GI symptoms **Treatment** * C1 esterase inhibitor concentrate * Icatibant (synthetic bradykinin receptor antagonist) * FFP * TXA?
49
List typical radiographic findings of a patient with **CPPD** (pseudogout).
**Chondrocalcinosis** * Calcium deposited in linear densities within the articular cartilage **Treatment** * NSAIDs * Colchicine
50
What FOUR vaccines commonly cause **anaphylaxis**?
1. MMR\* 2. Yellow fever\* 3. Influenza\* 4. Rabies HDCV (human diploid cell vaccine) \*contain egg
51
# Compare and Contrast: **Scarlet Fever** and **Rheumatic Fever** based on cause, presentation, and treatment.
**Scarlet Fever** * 48 hours post * Sandpaper rash * Pastia's Lines * Forchheimer’s spots * Associated with strep * Treatment: Amoxicillin 40 mg/kg/day div BID (max 1 g/d) **Rheumatic Fever** * 4 weeks post GAS * JONES criteria * 2 major or 1 major and 2 minor * Major (JONES) * **J**oint, Heart, **N**odes, **E**rythema, **S**ydenham * Minor (F-PEARL) * **F**ever, **P**R, **E**SR/CRP, **A**rthralgia, **R**F, **L**eukocytosis * Treatment * GAS - Amox 40 mg/kg/day div BID x10d (max 1 g/d) * Arthritis - Naproxen 5 mg/kg/dose BID x10d * Carditis - Prednisone if severe, otherwise support
52
List the 4 most important **seronegative spondyloarthropathies**. What characteristics do they share?
1. Psoriatic Arthritis 2. Ankylosing Spondylitis 3. IBD-related 4. Reactive Arthritis **Shared Characteristics** * SI involvement * Peripheral inflammatory arthropathy * Absence of RF (rheumatoid factor) * Genetic HLA-B27 component * Pathologic changes around the enthesis * The ligamentous + tendinous insertions into bone
53
Which 3 viruses cause the highest number of **viral exanthems**?
1. Coxsackievirus 2. Echovirus 3. Adenovirus Note: These are all enteroviruses
54
List the diagnostic criteria for **SLE**.
**SOAP BRAIN MD** ≥4 of the following: * **S**erositis * **O**ral ulcers * **A**rthritis * **P**hotosensitivity * **B**lood disorder * **R**enal disorder (proteinuria of \>0.5 g/d or casts) * **A**nti-nuclear Ab * **I**mmune disorder (anti-dsDNA Ab, anti-sm Ab, etc.) * **N**eurologic disorder (unexplained seizures or psychosis) * **M**alar rash * **D**iscoid rash
55
What will the synovial fluid show for a **septic joint**? What about inflammatory? What about degenerative (OA)?
**Septic Joint** * Cloudy * \>50,000 usually, likely if \>25,000 * PMR \>90% * Gram stain + * Culture + **Inflammatory** * \>2000 * PMR \>50% * Gram stain - * Culture - * Crystals **Degenerative** * \<2000 * PMR \<25%
56
What is the typical story of measles? Where does the rash start? What is the name of the finding in the picture below?
Cough, coryza, conjunctivitis then Koplik spots... then skin Cutaneous findings: 3-5th day, start on the face, upper neck DDx: Rubella (German measles)
57
What are the diagnostic criteria for **Polymyalgia Rheumatica**? What condition is commonly associated with this?
1. Age \>50 (most \>60; mean age 70) 2. Bilateral pain in shoulders, hips, neck for 1+ month 3. ESR \> 40 mm/hr ## Footnote **50% are associated with temporal arteritis**
58
List 5 ways in which one can develop **septic arthritis**.
1. Post-operative 2. Traumatic 3. Contiguous spread 4. Hematogenous seeding 5. Direct Inoculation (eg. psych patient)
59
List 5 drugs that can cause **drug-induced lupus**.
**CHIMP** * **C**hlorpromazine * **H**ydralazine * **I**NH * **M**ethyldopa * **P**rocainamide
60
# Define: anaphylaxis
**No clear exposure** Acute onset skin/mucosal involvement and * Respiratory * Hypotension **Likely allergen exposure** 2+ of the following: * Skin or mucosal involvement * Respiratory * Hypotension * GI **Known allergen** Hypotension (eg. don't wait for the hives)
61
A 15-year-old male presents with abdominal pain, vomiting, bloody diarrhea, and tea-colored urine. Two weeks ago he had a cold for 4 days. You note a rash on your exam (see pic). Diagnosis?
**Henoch-Schonlein Purpura** * 50% have a recent URTI, really any virus can trigger this. * Strep is also common. **Symptoms** * Arthritis * Abdominal pain * Purpuric rash * Possible hematuria **Workup** * CBC * Electrolytes * BUN/Cr * Urinalysis + casts * Possible U/S of the abdomen **Treatment** * NSAIDs * Steroids controversial Must watch out for HTN and the development of glomerulonephritis. Associated with intussusception.
62
What preservative in **local anesthetics** can cause allergic reactions? Where is it found?
**Methylparaben** * Preservative found in multidose vials of lidocaine * Implicated in allergic reactions
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