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RHEUMATOLOGY662FIGURE 17.11.The 18 tender points used in the diagnosis of bromyalgia.Classication criteria are those of the American College of Rheumatology. (Reproduced, with permission, from Imboden JB etal. Current Diagnosis & Treatment in Rheumatology, 2nd ed. New York: McGraw-Hill, 2006.)Low cervical: at the anterior aspect of the interspaces between the transverse processes of C5–C7Lateral epicondyle:2 cm distal to thelateral epicondyleSecond rib: just lateral to the second costochondral junctionsSupraspinatus:above the scapular spinenear the medial borderOcciput: at the insertions of one or more of the following muscles: trapezius, sternocleidomastoid, splenius capitis, semispinalis capitisTrapezius: at the midpoint of the upper borderGluteal: at the upperouter quadrant of thebuttocks at the anterioredge of the gluteus maximusGreatertrochanter:posterior to the greatertrochantericprominenceKnee: at the medialfat pad proximalto the joint linePosterior viewAnterior viewRHEUMATOLOGY663■Trigger-point injections and myofascial release are of uncertain benet.Randomized, controlled clinical trials of dry needling, saline injec-tions, anesthetic injections, botulinum toxin, acupuncture, and shamacupuncture as therapies have not shown signicant benet beyondnonspecic, placebo-related effects. Ultrasound treatment of myofas-cial "trigger points" is no more effective in reducing pain than sham ul-trasound.Pharmacologic treatment includes the following:■First-line agents: Low-dose TCAs (e.g., amitriptyline) at bedtime in com-bination with a centrally acting muscle relaxant (e.g., cyclobenzaprine) di-vided 2–4 times daily. Studies show conicting results regarding the ef-cacy of SSRIs in bromyalgia.■Sleep disturbances: If good sleep hygiene and sleep medications are inef-fective, request a formal sleep study to identify sleep apnea and restless legsyndrome, which are particularly common in bromyalgia.■Depression: Encourage formal or informal counseling and treat pharma-cologically.COMPLICATIONSThe adverse impact of bromyalgia on the patient, family, and society is high.More than 25% of patients receive some type of disability or other compensa-tion payment.TABLE 17.16. Differential Diagnosis of FibromyalgiaDISEASE CATEGORY EXAMPLESEndocrine disorders Hypothyroidism,aAddison's disease, Cushing's disease,hyperparathyroidism.Autoimmune Polymyalgia rheumatica,aRA, SLE, polymyositis.disordersMedications Lipid-lowering drugs, antiviral agents, tapering of corticosteroids.Infection HCV,aHIV, parvovirus, Lyme disease, subacute bacterial endocarditis.Malignancy Myeloma; breast, lung, or prostate cancer.Neurologic disorders Carpal tunnel syndrome,aMS,asleep apnea,acervical stenosis.aPsychiatric disordersVitamin D deciencyaCommonly encountered diagnoses.RHEUMATOLOGY664MISCELLANEOUS DISEASESAdult Still's Disease■Sx/Exam: Presents with high-spiking fevers, diaphoresis, chills, sore throat,an evanescent salmon-colored rash coincident with fevers, erosive arthritis,serositis, and lymphadenopathy.■Dx: Laboratory ndings include leukocytosis, anemia, seronegativity,transaminitis, and hyperferritinemia.■Tx: Treat with NSAIDs and corticosteroids.Sarcoidosis■Arthritis associated with sarcoidosis is either acute or chronic. See the Pul-monary Medicine chapter for nonarticular manifestations of sarcoidosis.■Acute sarcoid arthritis = Lfgren's syndrome, which presents with peri-arthritis (most commonly of the ankle/knee), erythema nodosum, and hi-lar adenopathy on CXR. Resolution of acute disease occurs in 2–16 weekswith minimal therapy, NSAIDs, and colchicine.■Chronic sarcoid arthritis usually involves minimally inamed joints withsynovial swelling/granulomata. Treat with NSAIDs, corticosteroids, andimmunosuppressants.Cholesterol Emboli SyndromePrecipitated by invasive arterial procedures in patients with atheroscleroticdisease. Features include fever, livedo reticularis, cyanosis/gangrene of thedigits, vasculitic/ischemic ulcerations, eosinophilia, renal failure, and otherend-organ damage.Musculoskeletal Complications of Diabetes MellitusInclude the fol

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