Rheumatological Red Flags Flashcards
What are the usual clinical features suggestive of systemic inflammation?
Fever Fatigue Weight loss Lethargy Insiduous onset
Define vasculitis
Inflammation of blood vessel walls
What are the general clinical features of vasculitis?
Mixture of inflammator and ischaemic/infarction organ dysfunction +/- damage
Lumen of affected vessels becomes narrowed when walls become thickened
What does Takayasu vasculitis affect?
Aorta
Aortic branches
Which organs are commonly affected in multi-organ vasculitis?
Lungs
Kidneys
How are headaches in giant cell vasculitis described?
Different sort of headache from normal
Not relieved by paracetamol
What sort of vasculitis just jaw pain suggest?
Giant cell arteritis
Due to ischaemic masseters
What is polymyalgia rheumatica?
Proximal muscular pain, especially in shoulders
What are the differential diagnoses when someone presents with a headache, systemic inflammatory symptoms, and localised ischaemic symptoms involving masseter muscles and scalp skin and muscles?
Polymyalgia rheumatica/giant cell arteritis Rheumatoid arthritis Polymyositis Hypo-/hyperthyroidism Malignancy Infection
When should you suspect giant cell arteritis?
Caucasian men and women >50 years New headache Jaw claudication Unexplained fever ESR >100 Elevated CRP Polymyalgia rheumatica-type symptoms Anyone with diagnosed polymyalgia rheumatica - Especially if ESR remains elevated despite treatment with low dose steroids Sudden monocular blindness
What are the symptoms of giant cell arteritis?
Superficial headache Scalp tenderness Jaw and tongue claudication Polymyalgia rheumatica with shoulder and hip girdle pain and morning stiffness Fever and fatigue Weight loss Anterior ischaemic optic neuropathy Retinal artery occlusion Rare - Upper limb claudication - Cough - Sore throat
What are the signs of giant cell arteritis?
Usually no obvious signs
Extremely rarely, see visibly enlarged temporal artery
What is seen in a temporal artery biopsy with giant cell arteritis?
Segmental destruction of internal elastic lamina
Granulomatous vessel inflammation with giant cells
Inflammatory exudate extends into intima
Fibrosis in intima
What arteries does giant cell arteritis affect?
Usually superficial temporal artery
Sometimes
- Aorta
- Major aortic branches
What needs to be kept in mind when taking a sample for biopsy in giant cell arteritis?
Inflammation patchy
Need to take big sample
Negative biopsy doesn’t rule out vasculitis
What are the complications of giant cell arteritis when the ophthalmic or long ciliary arteries are involved?
Blindness
What are the complications of giant cell arteritis when the subclavian artery is involved?
Arm claudication
Absent pulses
What are the complications of giant cell arteritis when the renal artery is involved?
Renovascular hypertension - angiotensin II mediated
What are the complications of giant cell arteritis when the aorta is involved?
Aortic valve incompetence, especially if ascending and thoracic
Late - aneurysm rupture
What are the complications of giant cell arteritis when the coronary arteries are involved?
Angina pectoris
Infarction
What are the complications of giant cell arteritis when the internal carotid arteries are involved?
TIA
Stroke
What are the complications of giant cell arteritis when the vertebral arteries are involved?
TIA
Stroke
What are the complications of giant cell arteritis when the iliac artery is involved?
Leg claudication
What are the complications of giant cell arteritis when the mesenteric artery is involved?
Bowel ischaemia
What is the management of giant cell arteritis?
Start prednisolone 40-60 mg daily immediately
Arrange temporal artery biopsy
Decide what to do if biopsy negative
- If respond to prednisolone > treat as giant cell arteritis
Taper corticosteroids according to ESR/CRP
Provide fracture prevention therapy
What is arthrocentesis?
Aspiration of synovial fluid from joint
What is the colour of inflammatory synovial fluid?
Straw-coloured
What is haemarthrosis?
Blood in synovial fluid
What is the differential diagnosis for septic arthritis?
Crystal arthropathy (gout)
What are the differential diagnoses for an acute monoarthritis?
Bacterial septic arthritis (until proven otherwise) Crystal arthropathy Subchondral bone lesion Haemarthrosis Palindromic rheumatism
What are the risk factors for joint sepsis?
Very young/advanced age Recent joint aspiration/injection Penetrating injury Portals for bacteraemia Previous joint damage Corticosteroid therapy Diabetes Chronic renal disease Chronic liver disease Immunodeficiency Prosthetic joints
What bacteria typically affect single and large joints?
Staphylococcus aureus Neisseria gonorrhoea Escherichia coli Other Gram negative cocci Streptococcus species
What cause does polyarticular arthralgia with or without tenosynovitis suggest?
Immune complex response to systemic infection = reactive arthritis
What are the clinical features of septic arthritis?
Fever Joint pain Joint swelling Heat over affected joint Erythema overlying joint Loss of function Pain on attempted joint motion Rapidly progressive joint destruction
What are some pitfalls when it comes to diagnosing septic arthritis?
History of trauma > mis-attribution
Fever may be absent
Joint sepsis may co-exist with acute gout
Staph joint sepsis may co-exist with endocarditis/deep abscess
Why does a sample for suspected gout need to be warm?
Gout crystals dissolve as sample cools
What are the investigations that are important when investigating gout?
Always obtain synovial fluid for analysis ASAP - Low synovial WCC doesn't exclude infection Plain radiographs - Baseline - Repeat at 1 week if no diagnosis > demineralisation and rapid articular cartilage loss diagnostic of untreated septic arthritis MRI - Only if in doubt of diagnosis FBE - Neutrophilia not specific Blood cultures - Useful CRP - Non-specific but useful if elevated
What are the most common bacteria causing septic arthritis?
S aureus Beta-haemolytic Streptococci Gram negative bacilli S pneumoniae Polymicrobial
What are the principles of management of septic arthritis?
Appropriate antibiotics Joint drainage critical - arthroscopic washout preferred Analgesia Initial rest > joint mobilisation Consider associated infection
What empirical antibiotics are used in the treatment of septic arthritis?
Flucloxacillin
What are the long-term complications of septic arthritis?
Significant joint damage
Persistent infection
What is the clinical presentation of small vessel vasculitis?
Fevers Night sweats Malaise Myalgia Arthralgia Arthritis Rashes - Palpable purpura - Non-palpable purpura - Urticaria Nail-fold/digital infarcts Mononeuropathy multiplex URT - Sinusitis - Epistaxis Lungs - Haemoptysis - Diffuse alveolar haemorrhage Haematuria Microhaematuria Proteinuria
Do ANCA-negative small vessel vasculitides tend to be primary conditions, or associated with other conditions?
Associated with other conditions
Do ANCA-positive small vessel vasculitides tend to be primary conditions, or associated with other conditions?
Primary conditions
What infections are differential diagnoses for purpuric rashes?
Meningococcal infection
Staphylococcal bacteraemia
Subacute bacterial endocarditis
What non-infectious mimics of small vessel vasculitides are there?
Thrombocytopaenic purpura
Arterial thromboembolism
What are the bloods ordered for investigating small vessel vasculitides?
FBE Blood film Acute phase reactants - ESR - CRP Albumin Renal function tests - Creatinine - Urea Septic workup - Blood cultures - MSU - CXR - Multiplex PCR for meningococcus and pneumococcus MSU microscopy MSU culture Echocardiogram - essential for any febrile patients with heart murmur/prosthetic valves/pacemakers Skin punch biopsy
What are the principles of management in small vessel vasculitis?
Consider infection early
Obtain history of drug exposure
Rapid assessment to avoid organ damage
Tissue usually needed to establish diagnosis
Treatment
- Remove/treat triggering cause
- Reserve high dose corticosteroids and immunosuppression for systemic/extensive disease
What are the toxicities of cyclophosphamide?
Bone marrow suppression
Haemorrhagic cystitis
Infertility
Increased risk of malignancies
How does rituximab work?
Anti-CD20 Ab
Standard treatment for non-Hodgkin’s lymphoma
