Rhumatology

Question 1

Investigations for SLE

Answer 1

• CBC normal or leukopenia
• ESR normal or elevated
• CRP normal or elevated
• PCT normal or elevated
• Xray > arthiritis
• Complement levels - C3 and C4 high or low
• Ds-DNA high
• ANA high

Question 2

DDx for SLE

Answer 2

DIFFERENTIAL DIAGNOSIS
•Connective-Tissue Disease
•Systemic Lupus Erythematosus 
•Rheumatoid Arthritis
•Scleroderma
•Sjogren Syndrome
•Fibromyalgia

Question 3

Define SLE

Answer 3

Chronic autoimmune disease characterized by the production of autoantibodies, which deposit within tissues and fix complement leading to systemic inflammation.

Question 4

Describe the arthritis in SLE patients

Answer 4

Small joints of the hands, wrist, and knees
Symmetric
Migratory, chronic, nonerosive
Soft-tissue swelling
Subcutaneous nodules
Jaccoud’s arthritis

Question 5

Types of arthritis in SLE patient

Answer 5

ARTHRITIS

•Nonerosive arthropathy (Jaccoud arthritis)
seen in 10% to 35% of patients. MCP subluxation, ulnar deviation, and swan neck deformities are due to lax joint capsules, tendons, and ligaments.

•Erosive, symmetric polyarthritis (Rhupus)
patients resemble rheumatoid arthritis with fixed deformities associated with radiographic erosions and a positive rheumatoid factor (65%)

Question 6

First step in management SLE flare?

Answer 6

Considerations:
•Rule out infection
•Rule out drug side effect
•Rule out another disease (hypothyroidism, cardiac/renal)

Question 7

TREATMENT APPROACH FOR AN SLE PATIENT WITH INCREASING SYMPTOMS.

Answer 7

•Mild disease
(fatigue, arthritis, rash, serositis)
1.NSAIDs: may cause worsening renal function, photosensitivity, aseptic meningitis (especially ibuprofen).
2.Hydroxychloroquine: needs eye examination yearly.
3.Low-dose prednisone (<20 mg/day)
4.Chemotherapy: Methotrexate

•Moderate disease
(unresponsive and especially high anti-dsDNA antibodies)
1.Immunosuppressive: Mycophenolate mofetil (cellcept) or azathioprine (Imuran)
2.Human monoclonal antibody: Belimumab.
3.Prednisone (20 to 40 mg/day)

•Severe disease (nephritis, CNS, pneumonitis, vasculitis):
1.High-dose prednisone (>60 mg/day) including pulse methylprednisolone
IVMP 1g/day for 3 to 5 days
2.Chemotherapy / Cytotoxic medications: induction therapy with cyclophosphamide or mycophenolate mofetil followed by maintenance therapy with azathioprine, MMF, or calcineurin inhibitors (cyclosporin, tacrolimus).
3.Biologics / Monoclonal Antibody : Rituximab

Question 8

Can RA patient present with muscle tenderness?

Answer 8

Think of other differentials:

1. Fibromyalgia
2. Regional pain syndrom

Question 9

The ACR/EULAR classification system is a score-based algorithm for RA. Name the four components.

Answer 9

1. Joint involvement
2. Serology test results
3. Acute-phase reactant test results
4. Patient self-reporting of the duration of signs and symptoms

•A classification of definitive RA requires a score of 6/10 or higher.

Question 10

How do you manage RA patient:

Answer 10

Nonpharmacologic:

1. Exercise
2. Diet
3. Massage
4. Stress reduction
5. Physical therapy
6. Surgery.

Pharmacologic:

1. NSAIDs
2. Corticosteroids
3. DMARDs
4. Immunosuppressants