Rheum_Syndromes and vasculitides

Question 1

What is the most likely diagnosis?

A 58-year-old woman presents with a 2-week history of fatigue, anorexia, fevers, and bilateral pain and stiffness in the shoulder and hip girdles. These symptoms are worse at night. Upon awakening in the morning, she feels as if she has a bad flu. She reports difficulty getting out of bed in the morning due to stiffness. Her wrists and finger joints are also painful and swollen.

Answer 1

Polymyalgia Rheumatica

Question 2

Polymyalgia rheumatica:

3 common features?

Answer 2

1. Pain
2. Morning Stiffness
3. > 55 y/o

Question 3

Polymyalgia rheumatica:

Pain distribution?

Answer 3

Either or both:

1. Bilateral shoulder pain - difficulty lifting arms
2. Bilateral girdle/hip pain - difficulty getting out of bed

Question 4

Polymyalgia rheumatica:

Duration of morning stiffness?

Answer 4

> 45 min

Question 5

Polymyalgia rheumatica:

3 examples of systemic symptoms?

Answer 5

1. Fatigue
2. Anorexia
3. Fever
4. Night sweats
5. Weight loss

Question 6

Polymyalgia rheumatica:

Criteria for diagnosis?

Answer 6

A confident diagnosis of polymyalgia rheumatica can usually be made if you meet all of the following criteria:

1. > 50 years of age
2. Pain in shoulders/ hips or both
3. Morning stiffness > 45 minutes
4. Sx lasted > 2 weeks
5. Increased ESR/ CRP
6. Sx rapidly improve after treatment with corticosteroids

Question 7

Polymyalgia rheumatica:

Investigations?

Answer 7

1. FBC may see normocytic anaemia in PMR & GCA
2. ESR and CRP: raised, ESR >50mm/h
3. U&Es and eGFR
4. LFTs
5. TFTs to rule out hyper/hypo thyroidism
6. Rh factor to rule out RA, consider ANA and anti CCP antibodies

Question 8

Polymyalgia rheumatica:

Associated disease, important to ask for Sx in Hx?

Answer 8

Giant cell temporal arteritis

Sx: new onset, unilateral, throbbing headache, facial pain, scalp tenderness, jaw claudication

Question 9

Polymyalgia rheumatica:

First line Tx?

Answer 9

1. Prednisolone 15mg OD for 3 weeks then titrate dose down. Sx should improve within 1 week (>70%) if not consider alternative diagnosis
2. Give steroid card

Question 10

Polymyalgia rheumatica:

5 side effects of long term prednisolone PO?

Answer 10

1. Hepatic impairment
2. Osteoporosis
3. Weight gain
4. Stomach ulcers
5. Increased BP
6. Cushing’s syndrome
7. Heart burn/ indigestion

Question 11

Giant cell arteritis:

Diagnostic criteria?

Answer 11

3 or more of the following:

1. Age >50
2. New onset headache: unilateral, throbbing headache, facial pain, scalp tenderness, jaw claudication
3. Temporal artery abnormality: tender, thickening, reduced pulsation
4. Increased ESR > 50
5. Abnormal temporal artery biopsy

Question 12

Giant cell arteritis:

Important visual symptoms to ask about?

Answer 12

1. Amaurosis fugax
2. Diplopia
3. Sudden loss of vision