Rheumatological Red Flags Flashcards by Srishti D

What are the usual clinical features suggestive of systemic inflammation?

Fever
Fatigue
Weight loss
Lethargy
Insiduous onset

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Define vasculitis

Inflammation of blood vessel walls

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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

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What does Takayasu vasculitis affect?

Aorta

Aortic branches

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Which organs are commonly affected in multi-organ vasculitis?

Lungs

Kidneys

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How are headaches in giant cell vasculitis described?

Different sort of headache from normal

Not relieved by paracetamol

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What sort of vasculitis just jaw pain suggest?

Giant cell arteritis

Due to ischaemic masseters

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What is polymyalgia rheumatica?

Proximal muscular pain, especially in shoulders

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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

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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

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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

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What are the signs of giant cell arteritis?

Usually no obvious signs

Extremely rarely, see visibly enlarged temporal artery

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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

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What arteries does giant cell arteritis affect?

Usually superficial temporal artery
Sometimes
- Aorta
- Major aortic branches

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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

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What are the complications of giant cell arteritis when the ophthalmic or long ciliary arteries are involved?

Blindness

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What are the complications of giant cell arteritis when the subclavian artery is involved?

Arm claudication

Absent pulses

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What are the complications of giant cell arteritis when the renal artery is involved?

Renovascular hypertension - angiotensin II mediated

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What are the complications of giant cell arteritis when the aorta is involved?

Aortic valve incompetence, especially if ascending and thoracic
Late - aneurysm rupture

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What are the complications of giant cell arteritis when the coronary arteries are involved?

Angina pectoris

Infarction

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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