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MD2 Ambulatory Care and Emergency Medicine > Rheumatological Red Flags > Flashcards

Rheumatological Red Flags Flashcards

1
Q

What are the usual clinical features suggestive of systemic inflammation?

A 
Fever
Fatigue
Weight loss
Lethargy
Insiduous onset
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2
Q

Define vasculitis

A

Inflammation of blood vessel walls

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3
Q

What are the general clinical features of vasculitis?

A

Mixture of inflammator and ischaemic/infarction organ dysfunction +/- damage
Lumen of affected vessels becomes narrowed when walls become thickened

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4
Q

What does Takayasu vasculitis affect?

A

Aorta

Aortic branches

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5
Q

Which organs are commonly affected in multi-organ vasculitis?

A

Lungs

Kidneys

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6
Q

How are headaches in giant cell vasculitis described?

A

Different sort of headache from normal

Not relieved by paracetamol

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7
Q

What sort of vasculitis just jaw pain suggest?

A

Giant cell arteritis

Due to ischaemic masseters

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8
Q

What is polymyalgia rheumatica?

A

Proximal muscular pain, especially in shoulders

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9
Q

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?

A 
Polymyalgia rheumatica/giant cell arteritis
Rheumatoid arthritis
Polymyositis
Hypo-/hyperthyroidism
Malignancy
Infection
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10
Q

When should you suspect giant cell arteritis?

A 
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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11
Q

What are the symptoms of giant cell arteritis?

A 
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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12
Q

What are the signs of giant cell arteritis?

A

Usually no obvious signs

Extremely rarely, see visibly enlarged temporal artery

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13
Q

What is seen in a temporal artery biopsy with giant cell arteritis?

A

Segmental destruction of internal elastic lamina
Granulomatous vessel inflammation with giant cells
Inflammatory exudate extends into intima
Fibrosis in intima

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14
Q

What arteries does giant cell arteritis affect?

A

Usually superficial temporal artery
Sometimes
- Aorta
- Major aortic branches

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15
Q

What needs to be kept in mind when taking a sample for biopsy in giant cell arteritis?

A

Inflammation patchy
Need to take big sample
Negative biopsy doesn’t rule out vasculitis

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16
Q

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

A

Blindness

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17
Q

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

A

Arm claudication

Absent pulses

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18
Q

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

A

Renovascular hypertension - angiotensin II mediated

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19
Q

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

A

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

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20
Q

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

A

Angina pectoris

Infarction

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21
Q

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

A

TIA

Stroke

22
Q

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

A

TIA

Stroke

23
Q

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

A

Leg claudication

24
Q

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

A

Bowel ischaemia

25
Q

What is the management of giant cell arteritis?

A

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

26
Q

What is arthrocentesis?

A

Aspiration of synovial fluid from joint

27
Q

What is the colour of inflammatory synovial fluid?

A

Straw-coloured

28
Q

What is haemarthrosis?

A

Blood in synovial fluid

29
Q

What is the differential diagnosis for septic arthritis?

A

Crystal arthropathy (gout)

30
Q

What are the differential diagnoses for an acute monoarthritis?

A 
Bacterial septic arthritis (until proven otherwise)
Crystal arthropathy
Subchondral bone lesion
Haemarthrosis
Palindromic rheumatism
31
Q

What are the risk factors for joint sepsis?

A 
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
32
Q

What bacteria typically affect single and large joints?

A 
Staphylococcus aureus
Neisseria gonorrhoea
Escherichia coli
Other Gram negative cocci
Streptococcus species
33
Q

What cause does polyarticular arthralgia with or without tenosynovitis suggest?

A

Immune complex response to systemic infection = reactive arthritis

34
Q

What are the clinical features of septic arthritis?

A 
Fever
Joint pain
Joint swelling
Heat over affected joint
Erythema overlying joint
Loss of function
Pain on attempted joint motion
Rapidly progressive joint destruction
35
Q

What are some pitfalls when it comes to diagnosing septic arthritis?

A

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

36
Q

Why does a sample for suspected gout need to be warm?

A

Gout crystals dissolve as sample cools

37
Q

What are the investigations that are important when investigating gout?

A 
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
38
Q

What are the most common bacteria causing septic arthritis?

A 
S aureus
Beta-haemolytic Streptococci
Gram negative bacilli
S pneumoniae
Polymicrobial
39
Q

What are the principles of management of septic arthritis?

A 
Appropriate antibiotics
Joint drainage critical - arthroscopic washout preferred
Analgesia
Initial rest > joint mobilisation
Consider associated infection
40
Q

What empirical antibiotics are used in the treatment of septic arthritis?

A

Flucloxacillin

41
Q

What are the long-term complications of septic arthritis?

A

Significant joint damage

Persistent infection

42
Q

What is the clinical presentation of small vessel vasculitis?

A 
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
43
Q

Do ANCA-negative small vessel vasculitides tend to be primary conditions, or associated with other conditions?

A

Associated with other conditions

44
Q

Do ANCA-positive small vessel vasculitides tend to be primary conditions, or associated with other conditions?

A

Primary conditions

45
Q

What infections are differential diagnoses for purpuric rashes?

A

Meningococcal infection
Staphylococcal bacteraemia
Subacute bacterial endocarditis

46
Q

What non-infectious mimics of small vessel vasculitides are there?

A

Thrombocytopaenic purpura

Arterial thromboembolism

47
Q

What are the bloods ordered for investigating small vessel vasculitides?

A 
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
48
Q

What are the principles of management in small vessel vasculitis?

A

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

49
Q

What are the toxicities of cyclophosphamide?

A

Bone marrow suppression
Haemorrhagic cystitis
Infertility
Increased risk of malignancies

50
Q

How does rituximab work?

A

Anti-CD20 Ab

Standard treatment for non-Hodgkin’s lymphoma

MD2 Ambulatory Care and Emergency Medicine (29 decks)

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