Systemic conditions

Question 1

Polymyalgia rheumatica - symptoms

Answer 1

> 60s,
Rapid onset pain and stiffness in proximal limb muscles, neck, shoulders and pelvic girdle.
Bilateral. No weakness, low mood, +/- fever, fatigue, weight loss.

Question 2

Polymyalgia rheumatica- tests

Answer 2

ESR > 40 and raised CRP.

Question 3

Polymyalgia rheumatica- treatment

Answer 3

Prednisolone 15mg OD. Reduce dose slowly. Usually needed for > 2 years.
Give bone protection- bisphosphonates, gastric protection, monitor blood glucose.

Question 4

Giant cell arteritis- symptoms

Answer 4

Associated with PMR in 50% of cases.
Seen in the elderly
Unilateral headache, scalp tenderness, tongue/jaw claudication.
Amaurosis- sudden unilateral blindness due to loss of blood supply. Can be irreversible.

Question 5

Giant cell arteritis- cause

Answer 5

Granulomatous inflammation of the medium and large blood vessels. Often the carotid artery branches- temporal, ophthalmic and occipital.

Question 6

Giant cell arteritis- tests

Answer 6

Raised ESR and CRP.
Raised platelets, raised ALP and low Hb.
Temporal artery biopsy within 14 days of starting steroids- can be false negative due to skip lesions.

Question 7

Giant cell arteritis- treatment

Answer 7

Prednisolone 60mg OD, typically for 2 years.

Is visual symptoms- Methylprednisolone IV.

Question 8

Systemic lupus erythematosus - who is affected

Answer 8

9 x more common in women
Afro-Caribbean
Onset 20-40 years old

Question 9

Systemic lupus erythematosus- cause

Answer 9

Autoimmune condition, type 3 hypersensitivity reaction. Immune complex deposition can effect any organ in the body- skin, joints, kidneys, brain.

Question 10

Systemic lupus erythematosus- features

Answer 10

Fatigue, fever, lymphadenopathy
Skin- malar/butterfly rash, discoid scaly red rash, photosensitivity, non scarring alopecia, Reynaud’s, livedo reticularis.
Arthralgia, non erosive arthritis
Pericarditis, myocarditis
Proteinuria, glomerulonephritis, systemic lupus nephritis
Anxiety, depression, psychosis, seizures

Question 11

Systemic lupus erythematosus- investigations

Answer 11

99% are ANA +. High sensitivity but poor specificity.
20% RF +
Low complement levels
Raised ESR but normal CRP
Anti dsDNA- highly specific but not sensitive

Question 12

Systemic lupus erythematosus- management

Answer 12

High factor sun cream
Hydroxychloroquine
NSAIDs
Consider methotrexate and low dose steroids for flare ups.

Question 13

Kawasaki disease

• Cause
• Symptoms
• Management

Answer 13

Vasculitis mainly seen in children.

High grade fever > 5 days
Red cracked lips
Strawberry tongue
Cervical lymphadenopathy
Red palms and soles which later peel

Manage with high dose aspirin, intravenous immunoglobulin, echocardiogram to screen for coronary aortic aneurysm.

Question 14

Paget’s disease of the bone

• Cause
• Symptoms and tests
• Treatment

Answer 14

Uncontrolled bone turnover due to excessive osteoclastic resorption and increased osteoblast activity.

1 in 20 in the UK have it but only 5% show symptoms.
Commonly in older men.
Bone pain and a raised ALP.

Treat with bisphosphonates.

Can lead to deafness due to cranial nerve entrapment, bone sarcoma, fractures.