16. Conf 3: Vasculitis, Raynaud's

Question 1

Describe this finding.

Answer 1

• Bilateral symmetric lower extremity erythematous rash.
• Some of the smaller lesions on the legs look petechial.
• Also larger erythematous papules and plaques.

Corresponds with this image of feet

Question 2

Lesions of cutaneous vasculitis: do they blanch witt pressure? why?

Answer 2

They don’t blanch since the blood has extravasated from the vessels due to damaged blood vessel walls.

Question 3

The lesions of cutaneous vasculitis usually occur in what pattern? what body parts?

Answer 3

symmetric distribution of lower extremeties or dependent areas.

Question 4

cutaneous vasculitis: are the lesions usually symptomatic or asymptomatic? if sympt, what are the sx?

Answer 4

Usually asymptomatic

But if there are sx, there may be itching, burning or pain

Question 5

Cutaneous vasculitis: what sized vessels are involved?

Answer 5

small to medium sized vessels

Question 6

Cutaneous vasculitis: what test must be performed in order to distinguish this from other disorders with a similar appearance?

Answer 6

Must do a BIOPSY.

Question 7

What features on histology will help confirm a diagnosis of cutaneous vasculitis?

Answer 7

• Inflammatory infiltrates surrounding or invading blood vessels
• disruption/destruction of vessel walls by inflammatory infiltrate
• fibrinoid necrosis (fibrin deposition within the vessel wall or in the lumen)

Question 8

what feature of histology can help distinguish between different types of vasculitis?

Answer 8

the type of inflammatory infiltrate can help.

neutrophilic, lymphocytic, eosinophilic or granulomatous inflammation all suggest different diagnoses

Question 9

why is it particularly important to consider a differential dx when thinking about a cutaneous vasculitis?

Answer 9

• cutaneous vasculitis is secondary to another underlying condition in 70% of cases
• also, cutaneous vasculitis is a dx of exclusion

Question 10

what are some of the other dx to consider with cutaneous vasculitis? (ie whats on the differential)?

Answer 10

• viral infections (Hep B/C, HIV)
• acute bacterial infections (meningococcus, gonococcus)
• bacterial endocarditis, fungal
• drug induced hypersensitivity vasculitis
• systemic vasculitis: ANCA-associated, polyarteritis nodosa

Question 11

to confirm a cutaneous vasculitis, what tests might you perform and what might they tell you?

Answer 11

(there are a lot; these are just a few)

• cANCA to r/o Wegener’s
• pANCA to r/o microscopic polyarteritis
• CBC for signs of infection (decr WBC, Hgb, platelets -> connective tissue disease. high WBC indicates infection or malignancy)
• ANA, C3, C4 to evaluate lupus

RF for RA, endocarditis, Hep C, cryoglobulinemia

Question 12

Cutaneous vasculitis: initial treatment?

Answer 12

Prednisone

Question 13

what are the long-term side effects of steroid usage?

Answer 13

• exogenous steroid shuts down your adrenal production, have to wean people off very slowly
• long term effects are osteoporosis, diabetes, weight gain
• also leads to skin thinning

Question 14

Triggers for Raynaud’s?

Answer 14

exposure to cold temps. even a small change like walking into AC or into the freezer section.

also stimulation of the sympathetic NS (being startled or upset).

Question 15

what does Raynaud’s present with?

Answer 15

color change in the fingers - may become white, red, or blue. may be painful and numb.

Patient may otherwise feel well.

Question 16

What is the difference between primary and secondary Raynaud’s? What is the age of onset for each?

Answer 16

Primary: occurs alone and not associted with another condition. Typically seen in females ages 15-30.

Secondary: secondary to another condition (often connective tissue disorders). Typically occurs after age 40.

Question 17

What is nailfold capillary microscopy? How can it help us determine primary v secondary Raynaud’s?

Answer 17

examination of the nailfold capillaries under a microscope.

With primary Raynaud’s, the capillaries will look NORMAL. in secondary, the caps will look enlarged and distorted and will eventually drop out or hemorrhage.

Question 18

In patients with Raymauds with dilated capilary loops, they are at higher risk of developing what kind of disease?

Answer 18

Odds ratio is 20 that they will eventualy develop a connective tissue disease

Question 19

Your patient has abnormal-looking nailfold capillaries. What rheumatological conditions should you consider?

Answer 19

scleroderma, lupus, mixed connective tissue disease, dermatomyositis, polymyositis, Sjogren’s, RA, vasculitis

Question 20

what blood tests could you order to further evaluate a patient with Raynaud’s?

Answer 20

CBC, CMP, Urinalysis, RF, ANA, ENA panel (may include some of these), C3, C4, Scl 70, Anti-centromere, Anti-RNA Polymerase III, anti-Ro and anti-La, U1RNP antibody

Question 21

What can a patient with Raynaud’s do in order to prevent attacks?

Answer 21

dress in layers to keep your core warm

avoid rapid changes in temp

hand and foot warmers

avoid smoking

avoid some OTC cold meds, diet pills

stress management

may need to take meds to dilate vessels (sildenaphil).