Group Teaching - Rheumatology Clinical Cases Flashcards
Case 1
Describe the abnormalities in the photos.
Hand photos:
* Panel A: distal portion of ring and little fingers appear white
* Panel B: dusky blue/purple
* This is Raynaud’s phenomenon (RP).
* RP is characterised by triphasic colour change: Fingers turn white (vasospasm), then blue (deoxygenation), then red (rebound hyperaemia).
* RP can be primary (occurs in isolation; usually benign) or secondary to an underlying autoimmune disease (eg lupus or systemic sclerosis).
* Sometimes secondary RP can be severe and lead to ischaemic ulcers.
Facial photo: malar or butterfly rash consistent with SLE.
Case 1
What is the diagnosis?
Systemic Lupus Erythematosus (SLE)
Case 1
What tests would you do (11)?
- Urinalysis (to look for proteinuria)
- FBC
- U&E
- LFT (includes albumin)
- ESR
- CRP
- ANA: very sensitive but not very specific. If negative rules out lupus, but can be positive in other diseases and some healthy individuals.
- Other autoantibodies: dsDNA, ENA panel (includes Smith, RNP and others), antiphospholipid antibodies. These are more specific but less sensitive.
- Complements C3 and C4 (decrease in active SLE).
NB diagnosis of lupus requires integration of clinical findings and lab tests – it’s not made on blood tests alone.
Case 2
Describe the abnormalities in the photo.
Small joint polyarthritis with marked soft tissue swelling. MCPJs and PIPJs are most affected. This would be consistent with rheumatoid pattern which would be a reasonable answer. However, there are tophi most clearly visible over ring finger PIPJ and middle DIPJ, so this in fact is severe polyarticular gout. Remember to check the ears for tophi.
Case 2
What does it show?
Needle shaped crystals
Suggests gout
Case 2
What is the diagnosis?
Gout
Case 2
What tests would you do (6)?
- CRP
- ESR
-
RF and CCP (will be negative in gout but positive in rheumatoid) and serum urate (high in gout).
- One could try to aspirate fluid from a joint for synovial fluid analysis (but sometimes this is tricky with small finger joints as the volume of fluid is much smaller compared to eg the knee)
Case 3
Describe the visual abnormalities you see in each radiograph:
* Which joints are affected?
* In what way?
Compare and contrast the abnormalities in each image.
Left (Rheumatoid arthritis):
* L hand:
* Subluxation of 2nd and 3rd MCPJs
* Severe erosion/resorption of ulnar styloid.
* Fusion (ankylosis) of carpal bones.
* R hand:
* Severe erosions at MCPJs, with loss of joint space most obvious at 2nd and 3rd MCPJs.
* Ulnar deviation of fingers.
* Erosion very obvious at distal radius and in some carpal bones.
* Severe erosion/resorption of ulnar styloid.
* Periarticular osteopenia.
Right (Osteoarthritis):
* PIPJs and MCPJs look ok i.e. not rheumatoid patern.
* Loss of joint space, osteophytes and subchondral sclerosis (increase whiteness) at DIPJs.
Case 3
Which disease corresponds to each picture?
- Left: Rheumatoid arthritis
- Right: Osteoarthritis
Case 4
H/O:
* An 80 year old woman is admitted to hospital with confusion
* She is dehydrated and found to have a urinary tract infection
* She is given iv antibiotics and iv fluids
* On day 3 of her admission, her wrist becomes painful, warm and swollen
What are the differential diagnoses?
- Septic Arthritis
- Gout
- Pseudogout (most likely)
- Reactive arthritis
Case 4
H/O:
* An 80 year old woman is admitted to hospital with confusion
* She is dehydrated and found to have a urinary tract infection
* She is given iv antibiotics and iv fluids
* On day 3 of her admission, her wrist becomes painful, warm and swollen
What tests would you do (7)?
- Joint aspiration
- FBC
- U&E
- ESR
- CRP
- Blood cultures
- Urate
Pseudogout commonly affects elderly patients who are acutely unwell with some other illness.
Case 5
A 45 year old woman presents with a 12 week history of joint pain involving her fingers and wrists of both hands.
She has prolonged morning stiffness and has had trouble taking off her wedding ring.
The general practitioner has treated her with ibuprofen but her symptoms are persisting.
What are the differential diagnoses (4)? State the one you think is most likely.
- Rheumatoid arthritis (most likely)
- Psoriatic arthritis
- Systemic lupus erythematosous (SLE)
- Pseudogout
Symmetrical small joint polyarthritis. Prolonged morning stiffness indicates inflammatory.
Case 5
A 45 year old woman presents with a 12 week history of joint pain involving her fingers and wrists of both hands.
She has prolonged morning stiffness and has had trouble taking off her wedding ring.
The general practitioner has treated her with ibuprofen but her symptoms are persisting.
What tests would you do (9)?
- Urinalysis (proteinuria)
- FBC
- ESR
- CRP
- U&E
- LFT
- RF
- CCP
- Consider ANA if other symptoms or signs to suggest lupus
Case 5
A 45 year old woman presents with a 12 week history of joint pain involving her fingers and wrists of both hands.
She has prolonged morning stiffness and has had trouble taking off her wedding ring.
The general practitioner has treated her with ibuprofen but her symptoms are persisting.
For your most likely differential diagnosis, outline the likely management plan.
- IM steroid or short course of oral steroid
- Start as soon as possible DMARD combination that includes methotrexate (eg methotrexate + hydroxychloroquine)
Rheumatoid arthritis
Case 6
A 40-year-old man presents with a swollen left knee of 5 weeks duration.
What is the pattern of joint involvement?
Large joint monoarthritis.
Case 6
A 40-year-old man presents with a swollen left knee of 5 weeks duration.
What other questions would you ask?
- Previous gout
- Any possible infections that might suggest reactive arthritis
Case 6
A 40-year-old man presents with a swollen left knee of 5 weeks duration.
What clinical signs would you look for on examination? Can you see any others in the photo?
Note the psoriatic plaque on the other knee.
Case 6
A 40-year-old man presents with a swollen left knee of 5 weeks duration.
What are the differential diagnoses? State the one you think is most likely.
- Reactive arthritis
- Gout
- Psoriatic arthritis (most likely)
Case 6
A 40-year-old man presents with a swollen left knee of 5 weeks duration.
What tests would you do?
- Aspiration and synovial fluid analysis.
Case 6
A 40-year-old man presents with a swollen left knee of 5 weeks duration.
For your most likely differential diagnosis, outline the likely management plan.
- The knee could be injected with steroid at the moment of aspiration
- If the problem is recurrent, methotrexate is a good option for psoriatic arthritis.
Case 7
Can you identify the clinical signs depicted?
What do the results of the investigations show?
Clinical Signs:
* Red eye: iritis (uveitis)
* Sacroiliitis: X-ray shows near fusion of sacro-iliac joints, and of several vertebral. There are bridging syndesmophytes (ossified ligaments) evident.
Investigations:
* Key points on the bloods are evidence of inflammation (high ESR, CRP) and HLA-B27 positive.
Consistent with advanced Ankylosing Spondylitis
Case 7
Can you identify the clinical signs depicted?
What do the results of the investigations show?
Clinical signs:
* Bony swelling at DIPJs and PIPJs. These are Heberden’s and Bouchard’s nodes.
* MCPJs and wrists are spared.
* There is squaring of the R thumb CMCJ.
X-Ray:
* Normal MCPJs. The most prominent changes are at the DIPJs with loss of joint space, osteophytes and some subchrondral sclerosis.
This is Osteoarthritis (and not consistent with rheumatoid)
RF and CCP will be negative
