THE WASHINGTON MANUAL™ Rheumatology Subspecialty Consult Second Edition Editors Leslie E Kahl, MD Professor of Medicine Department of Internal Medicine Division of Rheumatology Washington University School of Medicine St Louis, Missouri Series Editors Thomas M De Fer, MD Professor of Internal Medicine Washington University School of Medicine St Louis, Missouri Katherine E Henderson, MD Assistant Professor of Clinical Medicine Department of Medicine Division of Medical Education Washington University School of Medicine Barnes-Jewish Hospital St Louis, Missouri Senior Acquisitions Editor: Sonya Seigafuse Senior Product Manager: Kerry Barrett Vendor Manager: Bridgett Dougherty Senior Marketing Manager: Kimberly Schonberger Manufacturing Manager: Ben Rivera Design Coordinator: Stephen Druding Editorial Coordinator: Katie Sharp Production Service: Aptara, Inc © 2012 by Department of Medicine, Washington University School of Medicine Printed in China All rights reserved This book is protected by copyright No part of this book may be reproduced in any form by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews Materials appearing in this book prepared by individuals as part of their official duties as U.S government employees are not covered by the above-mentioned copyright Library of Congress Cataloging-in-Publication Data The Washington manual rheumatology subspecialty consult — 2nd ed /editor, Leslie E Kahl p ; cm Rheumatology subspecialty consult Includes bibliographical references and index ISBN 978-1-4511-1412-6 (alk paper) — ISBN 1-4511-1412-5 (alk paper) I Kahl, Leslie E II Title: Rheumatology subspecialty consult [DNLM: Rheumatic Diseases—diagnosis—Handbooks Rheumatic Diseases—therapy— Handbooks WE 39] 616.723—dc23 2012004717 The Washington Manual™ is an intent-to-use mark belonging to Washington University in St Louis to which international legal protection applies The mark is used in this publication by LWW under license from Washington University Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication Application of the information in a particular situation remains the professional responsibility of the practitioner The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with current recommendations and practice at the time of publication However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions This is particularly important when the recommended agent is a new or infrequently employed drug Some drugs and medical devices presented in the publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 223-2320 International customers should call (301) 223-2300 Visit Lippincott Williams & Wilkins on the Internet: at LWW.com Lippincott Williams & Wilkins customer service representatives are available from 8:30 am to pm, EST 10 5 Contributing Authors Zarmeena Ali, MD Fellow Department of Internal Medicine Division of Rheumatology Washington University School of Medicine St Louis, Missouri Amy Archer, MD Resident Department of Internal Medicine Division of Rheumatology Washington University School of Medicine St Louis, Missouri John P Atkinson, MD Samuel Grant Professor of Medicine Department of Internal Medicine Division of Rheumatology Washington University School of Medicine St Louis, Missouri Rebecca Brinker, MD Fellow Department of Internal Medicine Division of Rheumatology Washington University School of Medicine St Louis, Missouri Lesley Davila, MD Fellow Department of Internal Medicine Division of Rheumatology Washington University School of Medicine St Louis, Missouri Maria C Gonzalez-Mayda, MD Fellow Department of Internal Medicine Division of Rheumatology Washington University School of Medicine St Louis, Missouri Richa Gupta, MD Fellow Department of Internal Medicine Division of Rheumatology Washington University School of Medicine St Louis, Missouri Amy Joseph, MD Associate Professor of Medicine Department of Internal Medicine Division of Rheumatology Washington University School of Medicine St Louis VA Medical Center St Louis, Missouri Reeti Joshi, MD Fellow Department of Internal Medicine Division of Rheumatology Washington University School of Medicine St Louis, Missouri Leslie E Kahl, MD Professor of Medicine Department of Internal Medicine Division of Rheumatology Washington University School of Medicine St Louis, Missouri Alfred H. J Kim, MD, PhD Instructor in Medicine Department of Internal Medicine Division of Rheumatology Washington University School of Medicine St Louis, Missouri Ashwini Komarla, MD Resident Department of Internal Medicine Division of Rheumatology Washington University School of Medicine St Louis, Missouri Kristine A Kuhn, MD, PhD Fellow Department of Internal Medicine Division of Rheumatology Washington University School of Medicine St Louis, Missouri Hyon Ju Park, MD Fellow Department of Internal Medicine Division of Rheumatology Washington University School of Medicine St Louis, Missouri Prabha Ranganathan, MD Associate Professor of Medicine Department of Internal Medicine Division of Rheumatology Washington University School of Medicine St Louis, Missouri Michael L Sams, MD Fellow Department of Internal Medicine Division of Rheumatology Washington University School of Medicine St Louis, Missouri Jeffrey Sparks, MD Resident Department of Internal Medicine Division of Rheumatology Washington University School of Medicine St Louis, Missouri Wayne M Yokoyama, MD Sam and Audrey Loew Levin Professor of Medicine Department of Internal Medicine Division of Rheumatology Washington University School of Medicine St Louis, Missouri 10 definition of diagnostic criteria for differential diagnosis of epidemiology of follow-up in history examination in imaging modalities for laboratory evaluation of and neck pain Rheumatoid arthritis (continued ) pathophysiology of physical examination in prognosis for radiographic evaluation of treatment of non-pharmacologic pharmacologic surgical Rheumatoid factor (RF) laboratory assessment of Rheumatoid nodules Risedronate Rituximab in AS in cryoglobulinemia in MPA in rheumatoid arthritis in SLE in vasculitis in Wegener’s granulomatosis Roos hyperabduction/external rotation test 635 Rotator cuff tears Rotator cuff tendinopathy, shoulder pain from RP See Relapsing polychondritis (RP) S Sacroiliac (SI) joints Sacroiliitis, in AS Salicylates Salsalate Sarcoidosis acute arthritis chronic arthritis classification of clinical presentation of conditions associated with diagnostic procedures for differential diagnosis of epidemiology of etiology of imaging for laboratory testing for outcome/prognosis for pathophysiology of treatment of Sausage digit Schirmer’s test Schober’s test Scleredema Sclerodactyly Scleroderma 636 localized systemic (See also Systemic sclerosis (SSc)) Scleroderma renal crisis (SRC) Scleromyxedema Seizures, in SLE patients Selective estrogen receptor modulators (SERMs), for osteoporosis Septic arthritis See also Infectious arthritis radiographic evaluation of Serologic assays, for syphilis Shawl sign Shoulder arthrocentesis of joint exam of pain etiology and pathogenesis of history examination in imaging for physical examination in treatment of rheumatoid arthritis and Shrinking lung syndrome Sialometry Sinus imaging Sjögren’s syndrome (SS) clinical presentation of complications of conditions associated with definition of diagnostic criteria for diagnostic procedures for differential diagnosis of 637 epidemiology of history examination in laboratory testing for outcome/prognosis for pathophysiology of patient education in physical examination in referral in treatment of Skin biopsy in cutaneous vasculitis in HSP Skin manifestations of ARF of BD of RA of relapsing polychondritis SLE See Systemic lupus erythematosus (SLE) SLE-associated psychosis Slit-lamp examination Smoking cessation in AS in thromboangiitis obliterans SpAs See Spondyloarthritides (SpAs) Spinal cord compression See also Cauda equina syndrome Spinal fusion Spinal stenosis and low back pain Spondyloarthritides (SpAs) classification criteria for clinical presentation of 638 complications of diagnostic criteria for differential diagnosis of epidemiology of etiology of history examination in imaging for laboratory testing for monitoring/follow-up in outcome and prognosis for pathophysiology of patient education in physical examination in referral in treatment of non-pharmacologic therapies pharmacologic therapies surgical management types of Spondyloarthropathy See also Psoriatic arthritis (PsA) Spondylolisthesis Spondylolysis Spondylosis Spurling’s test SS See Sjögren’s syndrome (SS) SSc See Systemic sclerosis (SSc) Statins, in SLE Sternoclavicular joints Stiffness, in osteoarthritis Straight-leg raising test Stress fractures, and foot pain 639 Strokes, GCA and Stroke syndrome, in SLE patients Strontium ranelate Subacromial bursa, arthrocentesis of Subacromial bursitis, shoulder pain from Subacute cutaneous lupus erythematosus (SCLE) Subchondral cysts Subcutaneous nodule, of ARF Subglottic stenosis Sulfasalazine (SSZ) in AS in enteropathic arthritis in PsA in ReA in rheumatoid arthritis in SpA Sulfinpyrazone, in gout Swan neck deformity Sweet’s syndrome Sydenham’s chorea Syndesmophytes Synovial calcifications, on radiograph Synovial fluid analysis in infectious arthritis crystal analysis of general analysis of normal composition of Synovial fluid crystals, birefringence of Synovial plica treatment of 640 Synovitis Systemic lupus erythematosus (SLE) ACR criteria for diagnosis of classification of conditions associated with diagnosis of diagnostic criteria for diagnostic procedures for differential diagnosis of drug-induced epidemiology of etiology of imaging for laboratory evaluation of monitoring/follow-up in outcome/prognosis for pathophysiology of patient education in pregnancy and prevention of radiographic evaluation of referral in risk factors for signs and symptoms cardiovascular gastrointestinal hematologic mucocutaneous musculoskeletal Systemic lupus erythematosus (continued) neuropsychiatric 641 ophthalmologic pulmonary renal treatment of Systemic sclerosis (SSc) classification of clinical presentation of definition of diagnostic criteria for diagnostic procedures for differential diagnosis of diffuse cutaneous disease epidemiology of etiology of history examination in imaging for laboratory testing for limited cutaneous disease outcome/prognosis for pathophysiology of physical examination in scleroderma sine scleroderma and special considerations treatment of Systemic vasculitis, in relapsing polychondritis Systolic murmurs, in SLE T TA See Takayasu’s arteritis (TA) Tacrolimus, in inflammatory myopathies Takayasu’s arteritis (TA) 642 clinical presentation of definition of diagnostic criteria for differential diagnosis of epidemiology of history examination in imaging for laboratory testing for monitoring/follow-up in monophasic stages pathophysiology of physical examination in treatment of medical surgical management Tanezumab, in osteoarthritis TAO See Thromboangiitis obliterans (TAO) Tarsal tunnel syndrome T cell modulating agents Temporal arteritis See Giant cell arteritis (GCA) Temporal artery biopsy, in GCA Temporal artery ultrasound Temporal arthritis (TA) See Giant cell arteritis (GCA) Tendinitis Achilles Bicipital Peroneal Posterior tibial Tendinopathy, knee pain from Tendon calcifications, on radiograph Tennis elbow See Lateral epicondylitis 643 Tenosynovitis/tendinopathy Teriparatide for osteoporosis Thompson test Thoracic outlet syndrome, and neck pain Thromboangiitis obliterans (TAO) clinical presentation of complications of diagnostic criteria for diagnostic procedures for differential diagnosis of epidemiology of history examination in imaging for laboratory testing for outcome/prognosis for pathophysiology of patient education in physical examination in prevention of referral in risk factor for treatment of Thrombocytopenia, in SLE Thrombocytosis Thrombotic thrombocytopenic purpura (TTP) Tinel’s sign Tissue biopsy, in amyloid arthropathy TNF inhibitors, in PsA TNF receptor-associated periodic syndrome (TRAPS) clinical presentation of 644 definition of epidemiology of imaging for laboratory testing for pathophysiology of treatment of Tocilizumab in GCA in rheumatoid arthritis Tophi See also Gout Total hip arthroplasty Toxin-induced myopathies Tramadol Transient ischemic attacks (TIAs), GCA and Transthoracic echocardiography, in amyloid arthropathy Transverse myelitis Triamcinolone Trigger finger hand pain from Trimethoprim/sulfamethoxazole (TMP/SMX), in Wegener’s granulomatosis Trochanteric bursitis hip pain from treatment of T score, and fracture risk assessment Tuberculous arthritis Tubulointerstitial nephritis Tumor necrosis factor (TNF)-α antagonists in rheumatoid arthritis in TA U 645 UCTD See Undifferentiated connective tissue disease (UCTD) Ulnar nerve entrapment and elbow pain and hand pain Ultrasound in CPPD disease in HSP in rheumatoid arthritis Undifferentiated connective tissue disease (UCTD) clinical presentation of definition of diagnostic criteria for differential diagnosis of epidemiology of etiology of history examination in imaging for laboratory testing for monitoring/follow-up in physical examination in prognosis for referral in risk factor for treatment of Undifferentiated spondyloarthritis (USpA) See also Spondyloarthritides (SpAs) Uricase (urate oxidase) Uricosuric agents, in gout Urticarial vasculitis Ustekinumab, in PsA Uveitis, treatment of 646 V Vancomycin, in non-gonococcal arthritis Varenicline, in thromboangiitis obliterans Varus angulation, of knee Vasculitis in Behcet’s disease central nervous system classification of clinical presentation of complications of cryoglobulinemic cutaneous definition of diagnostic criteria for diagnostic procedures for differential diagnosis of etiology of giant cell Henoch–Schönlein pupura history examination in hypersensitivity imaging in laboratory testing in leukocytoclastic lymphocytic microscopic polyangiitis monitoring/follow-up in outcome/prognosis for pathophysiology of patient education in physical examination in 647 polyarteritis nodosa in polychondritis primary large vessel vasculitides medium vessel vasculitides small vessel vasculitides referral in retinal secondary temporal arteritis treatment of urticarial Wegener’s granulomatosis Venereal disease research laboratory (VDRL) test Venous thrombosis, in BD Vertebral compression fractures Viral arthritis Viral infections, and cutaneous vasculitis Visceral angiography Visual hallucinations Vitamin supplementation, in osteoporosis W Wedge osteotomies Wegener’s granulomatosis (WG) classification of clinical presentation of generalized phase initial phase definition of diagnostic criteria for diagnostic procedures for 648 differential diagnosis of epidemiology of imaging for laboratory testing for monitoring/follow-up in outcome/prognosis for pathophysiology of treatment of Western blot, in Lyme disease WG See Wegener’s granulomatosis (WG) Whiplash Wilson’s disease clinical presentation of definition of epidemiology of imaging for laboratory testing for pathophysiology of treatment of Wrist arthrocentesis of joint exam of rheumatoid arthritis and X Xanthine oxidase inhibitors, in gout Z Zoledronic acid 649 [...]... worked tirelessly to produce another outstanding edition of this manual I would also like to thank Dr Melvin Blanchard, Chief of the Division of Medical Education in the Department of Medicine at Washington University School of Medicine, for his advice and guidance I believe this Subspecialty Manual will meet its desired goal of providing practical knowledge that can be directly applied at the bedside... Campbell Professor Interim Chairman of Medicine Co-Director of the Infectious Disease Division Washington University School of Medicine 11 Preface have written this manual as a guide to inpatient and outpatient rheumatology W econsultations The target audience includes medical students, residents, and other medical professionals who care for patients with rheumatologic problems In addition, this manual. .. pleasure to present the new edition of The Washington Manual ® I tSubspecialty Consult Series: Rheumatology Subspecialty Consult This pocketsize book continues to be a primary reference for medical students, interns, residents, and other practitioners who need ready access to practical clinical information to diagnose and treat patients with a wide variety of disorders Medical knowledge continues to increase... authors, which include house officers, fellows, and attendings at Washington University School of Medicine and Barnes-Jewish Hospital Their commitment to patient care and education is unsurpassed, and their efforts and skill in compiling this manual are evident in the quality of the final product In particular, I would like to acknowledge our editor, Dr Leslie Kahl, and the series editors, Drs Tom De Fer... be indicated Up to 40% of patients referred to a rheumatologist for evaluation of positive ANAs who do not fulfill criteria on presentation do fulfill criteria for SLE after months to years of follow-up Approach to Patients with Possible Systemic Vasculitis • The vasculitides are a heterogeneous group of disorders characterized by inflammation of blood vessels • Vasculitis is often suspected in patients... overview of the major rheumatologic diseases The editor would like to thank the contributing authors for their participation in this project A special thanks goes to Dr Tom De Fer for his ongoing support and oversight, and to the authors and editors of the first edition of the manual for leading the way L.E.K 12 Contents Contributing Authors Chairman’s Note Preface PART I INTRODUCTION TO THE RHEUMATOLOGY CONSULT. .. periarticular structures are involved, and the number and pattern of joints involved • Number and pattern of joints involved: The number and pattern of joints involved are important in the diagnosis Acute monoarthritis suggests infection but gout and trauma are possible Asymmetric, oligoarticular ( ...THE WASHINGTON MANUAL Rheumatology Subspecialty Consult Second Edition Editors Leslie E Kahl, MD Professor of Medicine Department of Internal Medicine Division of Rheumatology Washington. .. Assistant Professor of Clinical Medicine Department of Medicine Division of Medical Education Washington University School of Medicine Barnes-Jewish Hospital St Louis, Missouri Senior Acquisitions Editor:... Department of Internal Medicine Division of Rheumatology Washington University School of Medicine St Louis, Missouri Amy Archer, MD Resident Department of Internal Medicine Division of Rheumatology Washington