Table Of ContentRHEUMATOLOGY
SECRETS
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RHEUMATOLOGY
SECRETS
THIRD EDITION
STERLING G. WEST, MD, MACP, FACR
Professor of Medicine
Department of Medicine
Division of Rheumatology
University of Colorado School of Medicine
Aurora, Colorado
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
RHEUMATOLOGY SECRETS ISBN: 978-0-323-03700-6
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Library of Congress Cataloging-in-Publication Data
Rheumatology secrets / [edited by] Sterling G. West. -- Third edition.
p. ; cm. -- (Secrets series)
Includes bibliographical references and index.
ISBN 978-0-323-03700-6 (hardcover : alk. paper)
I. West, Sterling G., 1950- , editor. II. Series: Secrets series.
[DNLM: 1. Rheumatic Diseases--Examination Questions. WE 18.2]
RC927
616.7’230076--dc23
2014032361
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Printed in the United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1
To my wife, Brenda, my best friend
To my children, Dace and Matthew, the joys of my life
To my amazing grandchildren, Aidan, Eva, and Owen
PREFACE
In the past year, we have been extensively authorized, approved, inspected, renovated, elevated, visited, consulted,
circularized, informed; and have completed so many forms, orders, questionnaires, and reports that no medical progress has
been made.
Rudolf Virchow
Berlin, 1865
With all the regulatory changes, many physicians might agree with Virchow’s lament. In Rheumatology, this
has clearly not been the case. It has been a decade since the last edition of Rheumatology Secrets, and I am amazed
with the advances that have occurred in both the science and treatment of the rheumatic diseases. Each chapter
in the present edition has been extensively reviewed and updated to include those advancements through January
2014.
I have frequently been asked why the long delay between editions? For many years I had the privilege of serv-
ing on the American Board of Internal Medicine Certifying Examination Committee in Rheumatology. As many
use the Secrets to study for board certification and recertification I wanted to avoid what I considered a possible
conflict of interest. With my term on the committee ended it is a pleasure to be able to edit this book again.
As in the previous editions, Rheumatology Secrets, Third Edition, is presented in the Socratic question and
answer format that is the hallmark of The Secrets Series. The chapters are organized into 15 sections, each with a
common theme emphasized by an introductory quotation. Common and uncommon rheumatic disease problems that
we encounter in clinical practice, discuss during teaching rounds, and find on board examinations are covered. Each
chapter reviews basic immunology and pathophysiology, important disease manifestations, and practical management
issues. The book also contains a wealth of mnemonics, lists, tables, figures, and illustrations to emphasize important
points. Chapter 2 lists some of the top Rheumatology Secrets and I encourage readers to send me their top secrets.
I hope that the reader will find Rheumatology Secrets, Third Edition, both enjoyable and useful in daily practice.
Sterling G. West, MD
vi
CONTRIBUTORS
Venu Akuthota, MD, FAAPMR Carolyn Anne Coyle, MD, FACR
Professor and Vice Chair, Staff Rheumatologist
Director, Spine Center St. Peter’s Hospital
Department of Physical Medicine and Rehabilitation Helena, Montana
University of Colorado School of Medicine
Randy Q. Cron, MD, PhD, FACR
Aurora, Colorado
Professor of Pediatrics & Medicine
Ramon A. Arroyo, MD, FACP, FACR Arthritis Foundation, Alabama Chapter, Endowed
Assistant Professor of Medicine Chair;
Department of Medicine Director, Division of Pediatric Rheumatology
Uniformed Services University of the Health Sciences Children’s Hospital of Alabama/University of Alabama
Bethesda, Maryland; at Birmingham
Rheumatology Staff Birmingham, Alabama
San Antonio Military Medical Center
Kevin D. Deane, MD, PhD, FACR
San Antonio, Texas
Associate Professor of Medicine
Daniel F. Battafarano, DO, MACP, FACR Division of Rheumatology
Adjunct Professor of Medicine University of Colorado School of Medicine
University of Texas Health Science Center Aurora, Colorado
San Antonio, Texas;
M. Kristen Demoruelle, MD, FACR
Associate Professor of Medicine
Assistant Professor of Medicine
Uniformed Services University of Health Science
Department of Medicine
Bethesda, Maryland
Division of Rheumatology
Vance J. Bray, MD, FACP, FACR University of Colorado School of Medicine
Assistant Clinical Professor, Rheumatology Aurora, Colorado;
University of Colorado Denver School of Medicine National Jewish Health
Denver Arthritis Clinic Denver, Colorado
Denver, Colorado
Gregory J. Dennis, MD, FACP, FACR
Christina M. Bright, MD, FACR Global Product Development
Rheumatologist PPD, Inc.
Bend Memorial Clinic Rockville, Maryland
Bend, Oregon
Esi Morgan DeWitt, MD, MSCE, FACR
Amy C. Cannella, MD, MS, FACP, FACR, RhUS Associate Professor of Medicine
Assistant Professor of Internal Medicine Pediatric Rheumatology
Rheumatology Fellowship Program Director University of Cincinnati College of Medicine
University of Nebraska Medical Center Division of Rheumatology
Omaha, Nebraska James M. Anderson Center for Health Systems
Excellence
Puja Chitkara, MD, FACR
Cincinnati Children’s Hospital Medical Center
Consultant Rheumatologist
Cincinnati, Ohio
Center for Arthritis and Rheumatologic Excellence
(CARE) Donald G. Eckhoff, MD, MS, FACS
San Diego, California Professor Orthopaedics
Department of Orthopaedics
Marc D. Cohen, MD, FACP, FACR
University of Colorado School of Medicine
Clinical Emeritus Professor of Medicine
Denver, Colorado
Mayo Clinic
Jacksonville, Florida; Alan R. Erickson, MD, FACR
Clinical Professor of Medicine Assistant Professor of Medicine
University of Colorado School of Medicine Section of Rheumatology and Immunology
Aurora, Colorado; University of Nebraska Medical Center
Clinical Emeritus Professor of Medicine Omaha, Nebraska
Mayo Clinic
Jacksonville, Florida
vii
vviiiiii CONTRIBUTORS
David R. Finger, MD, FACP, FACR Jason R. Kolfenbach, MD, FACR
Rheumatology Department Assistant Professor of Medicine
Honolulu Kaiser Permanente Department of Medicine
Honolulu, Hawaii Division of Rheumatology
University of Colorado Denver
Aryeh Fischer, MD, FACR
Aurora, Colorado
Associate Professor of Medicine
National Jewish Health James S. Louie, MD, FACP, MACR
University of Colorado School of Medicine Professor of Medicine
Aurora, Colorado UCLA School of Medicine
Los Angeles, California
William R. Gilliland, MD, MHPE, FACP, FACR
Professor of Medicine, Mark Malyak, MD, FACR
Associate Dean for Medical Education Associate Clinical Professor of Medicine
Uniformed Services University of the Health Sciences Department of Medicine
Bethesda, Maryland Division of Rheumatology
University of Colorado Health Sciences Center;
Karen E. Hansen, MD, MS, FACR
Denver Arthritis Center
Associate Professor of Medicine
Denver, Colorado
Division of Rheumatology
University of Wisconsin School of Medicine & Public Michael T. McDermott, MD, FACP
Health Professor of Medicine and Clinical Pharmacy
Madison, Wisconsin Division of Endocrinology
Metabolism and Diabetes
Robert A. Hawkins, MD, FACP, FACR
University of Colorado Denver School of Medicine;
Associate Professor of Medicine
University of Colorado Hospital and Denver Veterans
Department of Medicine
Administration Medical Center
Wright State University Boonshoft School of
Denver, Colorado
Medicine
Dayton, Ohio; Richard T. Meehan, MD, FACP, FACR
Kettering Medical Center Professor of Medicine
Kettering, Ohio National Jewish Health
Denver, Colorado
Kathryn Hobbs, MD, FACR
Clinical Professor of Medicine Frederick T. Murphy, DO, FACP, FACR
University of Colorado School of Medicine Adjunct Clinical Assistant Professor of Medicine
Denver Arthritis Clinic Division of Rheumatology
Denver, Colorado Department of Medicine
University of Pennsylvania School of Medicine
J. Roger Hollister, MD, FACR
Philadelphia, Pennsylvania;
Professor of Pediatrics
Altoona Arthritis & Osteoporosis Center
Department of Pediatrics
Altoona Center for Clinical Research
University of Colorado Health Sciences Center
Duncansville, Pennsylvania
Denver, Colorado
James R. O’Dell, MD, FACP, FACR
Edmund H. Hornstein, DO, FACR
Bruce Professor of Internal Medicine, Rheumatology
Assistant Professor of Medicine,
University of Nebraska Medical Center
Chief, Rheumatology Division
Omaha, Nebraska
Berkshire Medical Center;
University of Massachusetts Medical School Brian D. Petersen, MD
Pittsfield, Massachusetts Associate Professor of Radiology and Orthopaedics,
Chief of Musculoskeletal Radiology
Robert W. Janson, MD, FACP, FACR
University of Colorado Denver
Associate Professor of Medicine
Aurora, Colorado
University of Colorado School of Medicine;
Chief, Rheumatology Section Dianna Quan, MD, FAAN, FANA
Denver Veterans Affairs Medical Center Professor of Neurology,
Denver, Colorado Director, Electromyography Laboratory
University of Colorado Denver
Mark Jarek, MD, FACP, FACR
Aurora, Colorado
Jarek Medical
Republic, Missouri Julia J. Rhiannon, MD, MSW, FACR
Rheumatologist
John K. Jenkins, MD, FACR
Virginia Mason Medical Center
Professor of Medicine (Ret)
Seattle, Washington
Arthritis and Osteoporosis Center
Billings, Montana
CONTRIBUTORS ix
James D. Singleton, MD, FACR Kim Nguyen Tyler, MD, FACR
Assistant Clinical Professor of Medicine Assistant Clinical Professor of Medicine
University of Colorado School of Medicine Division of Rheumatology
Aurora, Colorado; University of Colorado School of Medicine
South Denver Medicine Associates Aurora, Colorado;
Highlands Ranch, Colorado Denver Arthritis Clinic
Denver, Colorado
Marcus H. Snow, MD, FACR
Clinical Assistant Professor Korey R. Ullrich, MD, FACR
University of Nebraska Medical Center Affiliate Assistant Clinical Professor
Omaha, Nebraska Charles E Schmidt College of Medicine at FAU
Rheumatology Associates of South Florida
Robert T. Spencer, MD, FACR
Boca Raton, Florida
Associate Clinical Professor of Medicine
Department of Medicine Scott Vogelgesang, MD, FACP, FACR
Division of Rheumatology Clinical Professor of Medicine
University of Colorado School of Medicine Division of Immunology/Rheumatology
Aurora, Colorado; University of Iowa Hospital and Clinics
Colorado Arthritis Center Iowa City, Iowa
Englewood, Colorado
Sterling G. West, MD, MACP, FACR
Jennifer Stichman, MD, FACR Professor of Medicine
Instructor of Medicine Department of Medicine
Divisions of Rheumatology and General Internal Division of Rheumatology
Medicine University of Colorado School of Medicine
University of Colorado School of Medicine Aurora, Colorado
Aurora, Colorado;
JoAnn Zell, MD, FACR
Denver Health Medical Center
Associate Professor of Medicine
Denver, Colorado
National Jewish Health
Colin Strickland, MD Denver, Colorado;
Assistant Professor of Radiology Assistant Professor
Division of Musculoskeletal Radiology University of Colorado School of Medicine
University of Colorado School of Medicine Aurora, Colorado
Aurora, Colorado
Christopher C. Striebich, MD, PhD, FACP, FACR
Associate Professor of Medicine
Department of Medicine
Division of Rheumatology
University of Colorado School of Medicine
Aurora, Colorado
