Rheumatology ConsultA casebook for the General Physician

Royal College of Physicians

Acute Medicine

Tankersley Manor, 22 Nov 2018

Dr Yusuf Patel

Consultant Physician/Rheumatologist

Hull Royal Infirmary

Yusuf.patel@hey.nhs.uk

HullYorkMedical School

Objectives

• Use a case-based approach to cover various Rheumatology presentations to the AMU

• Real cases – summarised with salient features

• Assumptions / knowledge

Case 1

• 30 year old male

• Pain and swelling right knee 2 days

• No trauma

• Drinks 3-4 units per day

• Unemployed, smokes 10/day, ‘methadone programme’

• Temp 380C, tender swollen right knee.

• Recent groin puncture right, No abscess/local cellulitis

• Mitral ‘flow’ murmur

Case 1 …

• Investigations:

–WCC 16.7 CRP 210

–BCP normal urate 300umol/L

–Hep B/C neg HIV neg

–Knee fluid cultures: Staph aureus

–CXR normal

– Echo: vegetations on mitral valve

Case 1 – differential diagnosis

• Monoarthritis

• Trauma

•Gout

• Septic arthritis

• Initial presentation of polyarthritis

Management of Monoarthritis

• Post-traumatic – orthopaedics

• Septic Arthritis

– IV antibiotics, urgent orthopaedic referral for drainage/washout.

– Determine and treat underlying cause (endocarditis, bowel ca, liver disease etc)

• Gout

– Colchicine / NSAID (?steroids)

– Urate lowering therapy deferred for 1-2 weeks

– DO NOT stop ULT (allopurinol/febuxostat)

– Target uric acid <320 umol/L

Case 2

• 32 year old male

• Swollen left knee 2 weeks

• Partial response to Ibuprofen

• Previous swelling right fourth toe

• Examination – also has swelling left ankle

• Monoarthritis? Polyarthritis?

• Oligoarthritis…

• ? Reactive arthritis …. Infection, travel, STI

Case 2

• Intermittent loose / bloody stools

• Psoriasis on scalp for 10 years (recent increase)

• Inflammatory back pain (EMS, alternating buttock pain)

• Investigations:

• CRP 11, HLA B27+ve, foecal calprotectin raised

• MRI scan Sacroiliac joints

• Rx

• NSAID, Sulfasalazine, topical skin therapy …. Biologic

• TNFi, PDE-4i, IL12/23i, IL17i

Dactylitis

Enthesopathy/Enthesitis

‘Psoriatic Disease’

Case 3

• 26 year female

• Painful, stiff fingers/wrists 4-6 weeks

• EMS 2-3 hours, feel swollen in the mornings

• Improves with ibuprofen – wants a ‘cure’

• Fatigue

• Travel to Caribbean 3 months previously

• No infections/risky behaviour

• Few mouth ulcers (intermittent over years)

• Raynaud’s symptoms since teenage years (non-smoker)

• Transient rash after sun exposure

Case 3..

• Possible diagnoses?

• Early diagnosis and Rx of Rheumatoid prevents deformity/damage…..start Methotrexate and refer to Rheumatology!

• Xray hands normal, CRP normal, RF neg

• FBC (slightly low lymphocyte count)

• Creatinine 110, normal urea … BP 140/85

• Urine 2+prot/1+blood

• Normal renal ultrasound

Case 3…• ANA result = dsDNA 35, ANA positive

• C3 complement levels below normal

• Renal biopsy – diffuse proliferative nephritis (type IV LN)

• Considered induction cyclophosphamide….chose to go with induction mycophenolate mofetil and steroid (ovarian function).

• 6 months clinical remission with no active renal/joint/systemic problems and off steroid…maintenance MMF (consider Azathioprine)

• Consider other causes of inflammatory polyarthritis (SLE, Sjogren syndrome, Scleroderma)

Lupus Nephritis

Biologics:1) Infections2) Malignancy3) GI perforation

Case 4

• 80 year old male

• Increased fatigue, 4kg weight loss – 6 weeks

• Difficulty dressing (pain arms), and stairs (thigh pain)

• No joint pains or swelling

• Prostate ca (previous resection – recent review ok)

• Never smoked, systemic enquiry normal.

• Hb 120g/L, BCP normal, CRP 56, PsA 0.3

• GP started naproxen 500mg bd – some improvement

• 1 week later, Blurring of vision and right temporal headache

• AMU … ‘ask about jaw/tongue claudication’

Case 4..

• Possible diagnosis?

• Investigations …– CRP 140 (previous 56)

– Biopsy

– US scan

• Rx?– IV methylpred 1g daily x 3

– Prednisolone 60mg daily

– Bone protection

• Rapid improvement in headache/vision/PMR

• Gradual taper steroid

Case 4

• Steroid sparing therapy?

• Biologic therapy?– Role of IL6 inhibition (NICE Tag)

Association of PMR and malignancy?• Ann Rheum Dis. 2014 Oct;73(10):1769-73.

Vasculitis

• Inflammatory leucocytes in vessel wall

• Reactive damage to mural structures

Loss of integrity – bleeding Occlusion – downstream ischaemia / necrosis

EGPA

GPA

Treatment of Vasculitis

• Depends on:– Type/aetiology

– Extent

– Severity

• Steroids

• Immunosuppressants

• Biologics

Causes of Vasculitis

– Infection

– Malignancy

– Drugs

– Autoimmune Rheumatic diseases

• ANCA associated,

• SLE, Sjogren syndrome,

• Behcet’s disease

• RA

Case 5• 72 year old female

• Referred for CK 22000 ?for steroids

• Admitted for ‘fall’ in her home

• Sitting in chair, smiling, well.

• No proximal muscle weakness

• Systems normal except a bit ‘achy in the muscles’

• No bruises

• Had a ‘bad cold’ / flu like symptoms 3 weeks ago

• Important considerations:– Rhabdomyolysis

– Inflammatory myositis (autoimmune)

– post viral scenario (no weakness) - observe

Case 5..

• CK normalised rapidly with no steroids ….

10 000 next day!

• Normal within a week

• Influenza A titres 1/80 --- 1/320

Elevated CK

• CK-MM (skeletal muscle)• Trauma• Injections• Infections• myopathy

Inflammatory Myopathy

Proximal muscle weakness (painless +- rash)

Raised muscle enzymes (5-10x ULN)

EMG – fibrillation potentials / low amplitude

Biopsy – inflammatory endo/perimyseal infiltrate

Abnormal MRI STIR images (inflammation)

Autoantibodies

Malignancy and Inflammatory myopathy?DermatomyositisTIF1-γ antibody associated

Case 6

• 55 female

• Admitted to AMU for painful knee / back

• Examination – no swelling / inflammatory arthritis

• Bloods normal

• Xray moderate osteoarthritis

• Symptoms x years – frustrated with GP

• Rheumatology referral? Orthopaedic referral?

• Basic pain management / encouragement to mobilise and exercise…physiotherapy

• Injection of knee with steroid – swelling

Thank you For

Your attention!