rheumatology הכנה לשלב א' · • life expectancy in patients with ra is shortened by...

Dr Valerie Aloush Rheumatology Department & Internal Medicine 6 Tel Aviv Medical Center

Rheumatology

' הכנה לשלב א

Presentation

• Highly inflammatory polyarthritis often leading to joint destruction, deformity and loss of function

• Additive, symmetric swelling of peripheral joints

• Extra-articular features and systemic symptoms commonly occur and may antedate the onset of joint symptoms.

• Potential considerable morbidity and mortality

• Recent addition of new and innovative therapies

PATHOPHYSIOLOGY

• No known cause

• Infectious etiology has been speculated

• Numerous autoimmune responses

• Significant genetic component, shared epitope HLA-DR4/DR1 cluster present in up to 90% of RA patients

• Synovial cell hyperplasia , endothelial cell activation are early events in the pathologic process that progresses to uncontrolled inflammation and consequent cartilage and bone destruction

EPIDEMIOLOGY

• Prevalence rate approximately 1%. • Affects all populations • First-degree relatives of individuals with RA are

at an increased risk (2- to 3-fold) of the disease • Disease concordance in monozygotic twins is

approximately 15-20 % • 2-3 times more common in females than in

males. • Frequency of RA increases with age and peaks in

persons aged 35-50 years

Mortality/Morbidity

• Life expectancy in patients with RA is shortened by 5-10 y

• Factors that increase the mortality risk include: • infections • cardiovascular disease • renal disease • GI bleeding • lymphoproliferative disorders

• May be directly due to the disease and its complications (eg, vasculitis, amyloidosis) or to therapy-induced adverse effects.

Risk factors for shortened survival in RA

• Systemic extra-articular involvment

• Low functional capacity

• Low socio-economic status

• Low education

• Chronic prednisone use

?מטופל RAמהי סיבת המוות העיקרית בחולה

.Aעמילואידוזיס

.Bקרדיווסקולרית

.Cזיהומים

שנים קודמות' שחזור שלב א

Mortality/Morbidity

• Risk of cardiovascular death in patients with RA continues to be 60% higher than in the general population

• In studies including 91,916 patients with RA, the overall pooled standardized mortality ratio (SMR) was 1.6

• Reducing cardiovascular mortality should remain a major issue in RA management

Clinical PRESENTATION

• Polyarticular, involving five or more joints • Additive polyarthritis, in contrast to the

migratory arthritis of SLE • PIP, MCP joints of the hands, wrists,

shoulders, elbows, knees, ankles, MTP joints. • DIP joints generally spared • Spine except the atlanto-axial articulation in

late disease is never affected. • Morning stiffness especially characteristic of

rheumatoid arthritis

Clinical PRESENTATION

• Constitutional symptoms • Malaise • Fever • Fatigue • Weight loss • Myalgias • difficulty performing ADL

• Most patients with RA have an insidious onset • Approximately 10% have an abrupt onset with acute

development of synovitis and extra-articular manifestations

• Spontaneous remission is uncommon, especially after the first 3-6 months.

Extra-articular manifestations

All of the following are characteristic

extraarticular manifestations of rheumatoid

arthritis EXCEPT:

A. Anemia

B. Cutaneous vasculitis

C. Pericarditis

D. Secondary Sjögren's syndrome

E. Thrombocytopenia

Harrison self-assessment

Rheumatoidאיזה מהבאים אינו סיבוך של

Arthritis?

.ARheumatoid Nodules

.BEpiscleritis

.CInterstitial Lung Disease

.DGlomerulonephritis

.EPericarditis


Systemic involvement Cutaneous

Cardiac: IHD morbidity and mortality Pericarditis Myocarditis Coronary vasculitis Valvular disease Conduction defects

Systemic involvement

Pulmonary Pleural effusion Interstitial fibrosis, nodules BOOP. Methotrexate (MTX) therapy

can induce interstitial fibrosis that may be difficult to distinguish from that which naturally occurs in patients with RA.

GI: Intestinal involvement often secondary to associated processes such as medication effects, inflammation, and other diseases

Systemic involvement Renal: usually unaffected by RA directly

Secondary involvement is common, including that due to medications NSAIDs, gold, cyclosporin, inflammation and associated diseases

Vascular: Vasculitic lesions can occur in any organ but are most commonly found in the skin

Hematologic: anemia of chronic disease. Neurologic: Nerve entrapment is common CTS

Vasculitic lesions, mononeuritis multiplex, and cervical myelopathy

Ocular: Keratoconjonctivitis sicca

Episcleritis

In patients with established rheumatoid arthritis, all of

the following pulmonary radiographic findings may be

explained by their rheumatologic condition EXCEPT:

A. Bilateral interstitial infiltrates

B. Bronchiectasis

C. Lobar infiltrate

D. Solitary pulmonary nodule

E. Unilateral pleural effusion

Harrison self-assessment

, ירוד DLCO, היפוקסמיה, שיעול, קוצר נשימה, RAחולה עם

?מה נראה בריאות

.A פלאורליתפליט

.Bפלאורלים נודולים

.C אינטרסטיטיאליםשינויים.

.Dקביטציות .


Workup- lab

Markers of inflammation, ESR and CRP

Complete blood cell count Anemia of chronic disease is common and correlates with

disease activity; improves with successful therapy.

Anemia may also be related to DMARD therapy.

Thrombocytosis is common and also associated with disease activity.

Thrombocytopenia may be a rare adverse event of therapy and may occur in patients with Felty syndrome.

Leukocytosis may occur but is usually mild.

Leukopenia may be a consequence of therapy or a component of Felty syndrome, which may then respond to DMARD therapy.

ומופנית למרפאה, שנים 10-קשה מזה כ RA-סובלת מ 56בת

MCV, %'ג 9.8המוגלובין : בבדיקות הדם. ההמטולוגית לבירור אנמיה

80 ,RDW תקין ;

total iron binding; (50-150: תקין) ug/dL 40רמת הברזל בסרום

capacity 200 ug/dL ( 300-360תקין) , תקינה הפריטיןרמת .

?מה נכון לגבי האנמיה בחולה זו

.A היפרפרוליפרטיבימח העצם תדגים מח עצם בדיקת.

.Bל-hepcidin של האנמיה בחולה זו בפתוגנזהתפקיד חשוב.

.C זה אופיינית הארכת משך החיים של הכדוריות האדומותבמצב.

.D מח העצם צפויה להדגים חסר ברזלבדיקת.

.E תורם באופן משמעותי לאנמיה בחולה אריתרופוייטיןחסר


Systemic effects of IL-6 in RA

IL-6

Acute-phase

response1

Alterations in iron

homeostasis2

Liver

Acute-phase proteins (eg, CRP)

Hepcidin production

Osteoporosis1 Alterations in

lipid metabolism3

Thrombocytosis1

1. Choy E. Rheum Dis Clin North Am. 2004;30:405415;

2. McGrath H et al. Rheumatology. 2004; 43:13231325;

3. Al-Khalili L et al. Mol Endocrinol. 2006; 20:33643375.

Workup- lab

• Immunologic

Rheumatoid factor

present in approximately 60-80% of patients with RA over the course of their disease but is present in fewer than 40% of patients with early RA.

Antinuclear antibodies

present in approximately 30% of patients with RA, but test results for antibodies to most nuclear antigen subsets are negative.

Anti CCP

לגבי הנוגדן נכוןאיזה מההיגדים הבאים

Anti cyclic citrullinated peptide (CCP) ?

.A רגישות(sensitivity ) של בדיקה חיובית בחולי דלקת מפרקים

100% -מגיעה ל( RA) שיגרונתית

.B ממצא חיובי שלanti-CCP מבשר מהלך שפיר יותר של דלקת

( RA) שיגרונתיתמפרקים

.C מחולי 15%חיובי בכדיHepatitis C-associated

cryoglobulinemia

.D במפרקים בדלקת ארוזיותמציאותו בדם תואמת התפתחות

( RA) שיגרונתיתמפרקים

.Eעם שיגרונתיתמחולי דלקת מפרקים 60% -חיובי בRF שלילי


Anti CCP

• Same sensitivity as RF

• Specificity > 95%

• Predict worse outcome

• May predict the eventual development into RA when found in undifferentiated arthritis

• marker of erosive disease in RA

• may be detected in healthy individuals years before onset of clinical RA

RF

• 75-80% positive in RA

• Also present in :

▫ Other CTD

▫ Primary Sjogren

▫ SLE

▫ Mixed essential cryoglobulinemia

▫ Chronic infections, SBE

▫ HBV, HCV

▫ Positive in 1-5% of healthy population, increase with age

Workup- lab

▫ Synovial fluid analysis

Inflammatory synovial fluid is present with WBC counts generally from 5,000-50,000/µL.

Usually, neutrophil predominance (60-80)

Because of a transport defect, the glucose levels of pleural, pericardial, and synovial fluids in patients with RA are often low compared to serum glucose levels.

No crystals on microscopy

, תחושה כללית רעה, 39.5חום , מטופלת בתרופות רבות RAחולת

אלף תאים בלי 50בניקור נוזל עכור . עם מפרק ברך נפוח וחם

. משטח ישיר שלילי, גבישים

?מה הטיפול

.Aהזרקת סטרואידים למפרק

.Bלהעלות מינון הסטרואידים PO

.C בצפאזוליןטיפול

.DNSAIDS


• “Finally, if a patient exhibits one or a few actively inflamed joints, the clinician may consider intraarticular injection of an intermediate-acting glucocorticoid. This approach may allow for rapid control of inflammation in the setting of a limited number of affected joints. Caution must be exercised to appropriately exclude joint infection, as it often mimics an RA flare.” (Harrison)

Workup- Imaging

Radiography: erosions MRI: used primarily in patients

with abnormalities of the cervical spine, now in all joints

Ultrasonography: effusions in joints that are not easily accessible (eg, hip

joints, shoulder joints in obese patients) cysts (Baker cysts visualization of tendon sheaths Erosions Synovitis in all joints

Bone scanning may help to distinguish inflammatory from noninflammatory changes in patients with minimal swelling.

Densitometry: helping diagnose changes in bone mineral density indicative of osteoporosis.

Treatment Optimal care of requires an integrated approach of pharmacologic

and nonpharmacologic therapies.

Nonpharmacologic Education Physiotherapy and physical therapy

• to help improve and sustain range of motion • to increase muscle strength • to reduce pain.

Occupational therapy • to help patients to use joints and tendons efficiently without stressing these

structures • to help decrease tension on the joints with specially designed splints, • to cope with daily life through adaptations to the patients' environment and

the use of different aids. Orthopedic measures include reconstructive and replacement-type

surgical measures.

Pharmacologic

Glucocorticoids

Potent anti-inflammatory drugs and are commonly

used in patients with RA to bridge the time until DMARDs are effective.

Doses of 10 mg-20 mg of prednisone per day are typically used, but some patients may require higher doses.

Timely dose reductions and cessation are important because of the adverse effects associated with long-term steroid use.

Recently considered as DMARD during 6 first months

DMARDS

ג לשבוע בגלל "מ 15במינון של מטוטרקסטחולה הנוטל

יכול לפתח את כל הסיבוכים , ראומטואידית ארתריטיס

:הבאים פרט ל

.Aסטומטיטיס

.Bפנאומוניטיס

.C בתפקודי כבדהפרעה

.D בתפקודי כליותהפרעה

.Eנויטרופניה


Biologics

Anti-TNF

Anti TNF efficacy

• Improve pain, inflammation, quality of life, sustained remision at long term, radiologic score.

• Earlier initiation of anti-TNF therapy increases the chances of sustained remission

• Biologic-naive patients treated with TNF inhibitors have higher persistency response, and remission rates compared with first- and second switch patients

? anti-TNFמה חשוב לבדוק לפני מתן

•PPD

צילום חזה•

• Increased risk for infection, especially opportunistic fungal infection and reactivation of latent tuberculosis

• All patients are screened for latent tuberculosis according to national guidelines prior to starting anti-TNF therapy (PPD)

• Skin reactions of more than 5 mm are presumed to have had previous exposure to TB and are evaluated for active disease and treated accordingly.

A 35-year-old man has RA. Therapy with Infliximab has

been recommended and he is wondering about potential

side effects.

All of the following are common potential side effects

from this medication EXCEPT:

A. Demyelinating disorders

B. Disseminated tuberculosis

C. Exacerbation of congestive heart failure

D. Hypersensitivity pneumonitis

E. Pancytopenia

בבדיקות . מזה תקופה adalimumab מטופל ב, ASעם , 34בן

. Anti-dsDNA-ו ANAמעבדה התגלה כייל גבוה של נוגדי

. המטופל אינו תסמיני

?מהו השלב הבא שיש לבצע

.Aלהחליף את הטיפול ב-Adalimumab ל-Etanercept.

.Bיש להפסיק את הטיפול בתרופה באופן מיידי.

.C להמשיך בטיפול הנוכחי ומעקב אחר כייל הנוגדנים

.בעוד חודש

.Dלהמשיך בטיפול הנוכחי ומעקב קליני בלבד.


Anti TNF side effects

• Injection site reactions

• Infusion reactions

• Neutropenia

• Infections

• Demyelinating disease

• Heart failure

• Cutaneous reactions

• Malignancy

• Induction of autoimmunity

Induction of autoimmunity

• Neutralizing antibodies: ▫ varies with the specific type of TNF-alpha inhibitor.

Not reported with etanercept. ▫ Increasing levels of neutralizing antibodies lead to reduced

clinical benefit ▫ Coadministration of MTX reduces the incidence of

neutralizing antibodies

• Development of autoantibodies ▫ formation of ANA and anti-dsDNA has been reported in

response to all TNF-alpha inhibitors but may be more common with infliximab

▫ Cases of vasculitis and lupus-like syndromes have been reported in association with TNF-alpha inhibitor use

https://vpn.tasmc.org.il/contents/,DanaInfo=www.uptodate.com+etanercept-drug-information?source=see_link

https://vpn.tasmc.org.il/contents/,DanaInfo=www.uptodate.com+infliximab-drug-information?source=see_link

Abatacept (Orencia)

Rituximab (mabthera)

Anti CD 20

on B cells

↑ Risk bacterial viral infections Infusion reaction Rash Fever

Cytopenia Hepatitis B reactivation

X

Tocilizumab: Humanized anti-IL-6R

monoclonal antibody Tocilizumab binds to both the mIL-6R and the sIL-6R, preventing binding of IL-6 and association with the gp130 chain and thus IL-6-mediated signalling

Cell membrane

Signal transduction inhibited

IL-6

mIL-6R

sIL-6R

gp130 gp130 X

Articular effects of IL-6 in RA

Synoviocytes

Osteoclast activation Bone resorption

Endothelial cells

VEGF

Pannus formation

Joint destruction

Mediation of chronic inflammation

IL-6 Macrophage

T cell

B cell

Neutrophil

Antibody production

1. Adapted from Choy E. Rheum Dis Clin North Am. 2004;30:405415;

2. Gabay C. Arthritis Res Ther. 2006;8(suppl 2):S3.

Systemic effects of IL-6 in RA

IL-6

Acute-phase

response1

Alterations in iron

homeostasis2

Liver

Acute-phase proteins (eg, CRP)

Hepcidin production

Osteoporosis1 Alterations in

lipid metabolism3

Thrombocytosis1

1. Choy E. Rheum Dis Clin North Am. 2004;30:405415;

2. McGrath H et al. Rheumatology. 2004; 43:13231325;

3. Al-Khalili L et al. Mol Endocrinol. 2006; 20:33643375.

Strategy

Strategy

• Early, aggressive therapy to prevent joint damage and disability

• Frequent modification of therapy with utilization of combination therapy where appropriate

• Individualization of therapy in an attempt to maximize response and minimize side effects

• Achieving, whenever possible, remission of clinical disease activity

Arthritis

Patient:

male/female young/old

How many joints?

Mono/oligo/polyarthritis

How long?

Acute/subacute/chronic

Pattern

symetric/additive/migratory?

Which joints?

Large joints/small joints

Other symptoms?

Fever/skin/eye/GI/etc

Case 1

• A 32 year old man

• 4 days

How would you define the

case ?

Acute monoarthritis of knee

Case 1 – Clinical history

• Fever

• Previous infection

• Other joints involved

• Sexual relations

• Rash

• GI symptoms

• Eye inflammation

• Trauma

Which diagnosis must be ruled out ?

• Trauma

• Psoriatic Arthritis

• IBD related arthropathy

• Septic Arthritis

• Ankylosing Spondylitis

• Crystal induced arthropathy

• Palindromic rheumatism

Acute monoarthritis

• Septic arthritis

• Crystal induced arthropathy

• Reactive arthritis

• Early spondyloarthritis or early RA

• Non inflammatory arthritis :

▫ Post trauma

▫ OA

▫ Hemarthrosis

What is the most important

laboratory/imaging investigation?

• CBC

• CRP and ESR

• Synovial fluid examination

• X ray

• Blood culture

Synovial fluid examination

• WBC counts : ▫ Up to 1000 non-inflammatory

▫ >50000 Septic crystal induced arthropathy

▫ 1000- 10000 SLE

▫ 10000-50000 inflammatory arthropathy

Synovial fluid examination

• Culture

• Crystals

Crystal Induced Arthropathy

MSU

CPPD

Negative birefringeant

Positive birefringeant

Case 2 • A 82 year old man

• 4 days

What is the most probable

diagnosis ? • Osteoarthritis


• Crystal Induced Arthropathy

• Psoriatic arthritis

• Anlkylosing Spondylitis

Case 3 • A 35 year old man

• Painful, swollen joint

for 1 year


case ?

Chronic monoarthritis

Chronic monarthritis: selected

causes

• Infection related

▫ Mycobacterial

▫ Fungal

▫ Lyme disease

▫ Pyogenic bacterial

▫ Mycoplasma

▫ Adjacent osteomyelitis

• Not infection-related ▫ Spondylarthropathy ▫ Juvenile chronic

arthritis ▫ Hemophilia ▫ PVNS ▫ Synovial sarcoma ▫ Neuropathic

arthropathy ▫ Osteoarthritis

What is the most probable diagnosis ?

• Spondyloarthropathy

• Rheumatoid Arthritis


• Gout

• Osteoarthritis

Case 4


• A 2 weeks history of pain and swelling of the right knee and left ankle

• Physical examination : synovitis of the right knee and left ankle


case ?

Sub-acute oligoarthritis

Discussion

• Reactive arthritis

• Post infectious arthritis

• Spondyloarthritis

5 Case


• Pain and swelling of the right wrist, left ankle and knee for more than 3 months


case ?

Chronic oligoarthritis

Chronic oligoarthritis

• Spondyloarthritis

▫ Psoriatic arthritis

▫ IBD related arthropathy

▫ Ankylosing spondylitis

▫ Undiff. SpA

• Early onset rheumatoid arthritis

• Gout

• Osteoarthritis

Case 6

• 33 year old woman

• Pain joint for 6 weeks

• First – pain and swelling in the rt wrist for 3 days – then lt wrist and after that rt ankle

• How would you define the arthritis ?

Migratory arthritis

Case 6, con’t • After 3 weeks, the joint pain persists and

involves both wrists,MCPs, PIPs, ankle and MTPs

• How would you define the arthritis now?

Additive arthritis

Symmetric polyarthritis

Physical examination

Synovitis of MCPs, PIPS, right ankle and MTPs


case ?

Sub-acute polyarthritis

What is the most probable diagnosis ?

• Septic arthritis

• Fibromyalgia


• Psoriatic Arthritis

• SLE

Clinical History

• Characterize the joint pain

▫ Night pain, Morning stiffness

• Systemic symptoms :

▫ Fever

▫ Rash

▫ Hypersensitivity

▫ Raynaud phenomenon

▫ Dry mucosa (eye, mouth)

▫ Previous infection

Polyarthritis: selected causes

Acute/subacute • Noninfectious causes

RA/JRA

SLE and other connective tissue diseases

Spondylarthropathies

Gout and pseudogout

Vasculitis

Osteoarthritis

Sickle-cell disease

Infectious causes Viral arthritis

Parvovirus

MMR

HIV

Hepatitis C and B

Cryglobulinemia

Tropical virus

Lyme arthritis

SBE

Rheumatic fever (migratory

pattern)

Tropical infections

Auto-antibodies relevant to chronic

polyarthritis • RF: Rheumatoid Factor

• ACPA (anti-CCP) : anti cyclic citrullinates proteins

• ANA :anti-nuclear antibodies

▫ Autoantibodies

• ANCA : Anti neutrophilic cytoplasmatic antibodies

Case 6’ cont’d

• Increased ESR and CRP

• Positive RF

• Anti- CCP > 300


Chronic polyarthritis: selected causes

• Rheumatoid arthritis

• Psoriatic arthritis

• Juvenile rheumatoid arthritis

• Osteoarthritis

• SLE and other connective tissue diseases

• Gout

• Pseudogout

• Sarcoidosis

Work up

• Clinical history

• Laboratory tests

Summary • Arthritis : Inflammatory / non inflammatory

• Acute vs sub-acute vs chronic

• Mono, oligo, polyarthritis

• Symmetric, migratory, additive

• The importance of defining the arthritis

לאחר אשפוזו . אורוספסיסאושפז בתמונה של 85בן

?מה ההתנהלות. בברך ארתריטיסהופעת

.Aלהזריק + לקריסטלים + לשלוח לתרבית , לנקר

סטרואידים

.Bיש לנקר את המפרק לשלוח לתרבית ובדיקת גבישים

.Cיש לנקר את המפרק ולתת טיפול בNSAIDS


, לאחר הניתוח .עובר ניתוח אלקטיבי לכריתת הערמונית 85בן

מפתח כאב חד בברך ימין , בעודו מאושפז במחלקה האורולוגית

. מלווה באודם ונפיחות מקומיים

?איזה ממצא נוסף סביר שיימצא בחולה זה

.Aבצילום הברך יודגמו הסתיידויות בסחוס המפרקי

.B בניקור המפרק נראים תחת מיקרוסקופ אור מקוטב

.גבישים בצורת מחט עם החזר שלילי

.C גרם שליליים דיפלוקוקיםמשטח הדם צפוי להראות.


• A 62-year-old white male presents with a chief complaint of right knee pain and swelling. Past medical history is significant for obesity with a body mass index (BMI) of 34 kg/m2, diet-controlled Type 2 diabetes mellitus, and hypertension. His medications include hydrochlorothiazide and acetaminophen as needed for pain. Physical examination is remarkable for a moderately sized effusion of the right knee, with range of motion limited to 90° of flexion and 160° of extension. There is minimal warmth and no redness. He has crepitus with range of motion. With weight bearing, he has outward bowing of the legs bilaterally. A radiogram of the right knee shows osteophytes and joint space narrowing. Which of the following is the most likely finding on joint fluid examination?

A. A Gram stain showing gram-positive cocci in clusters B. A white blood cell count of 1110/μL C. A white blood cell count of 22,000/μL D. Positively birefringent crystals on polarizing light microscopy E. Negatively birefringent crystals on polarizing light microscopy

-פרט ל Goutנכון לגבי הכל

.Aשל הברך היא תופעה שכיחה מונוארטריטיס

.B 11.0= עם התקף חד ורמות חומצת שתן בדםבחולה

.ואלופורינול קולכיציןהטיפול יכלול ל"ד/ג"מ

.C ההתקף השני ניתן לשקול טיפול קבוע אחרי

.באלופורינול

.D עם בחוליםTophi באלופורינולדרוש טיפול אגרסיבי

.לתקופה ממושכת

.EPodagra היא התופעה השכיחה ביותר.


.אסמפטומטית היפראוריצמיה

?מתי נטפל

.A 7אורית מעל חומצה

.B 10חומצה אורית מעל

.C 15חומצה אורית מעל

.Dנטפל רק כשיש אבנים בכליות

.Eנטפל רק אם מקבל טיפול כימי לממאירות


מתלונן על כאבים במפרקים , חולה צעיר מאושפז עם שלשול

?מה לעשות. ובבדיקה מפרקים אדומים ונפוחים

.A אין -הקשורות למחלתו האקוטית בארטרלגיותמדובר

צורך בטיפול ספציפי

.Bמדובר בRA סטרואידיםויש להתחיל

.C ויש לטפל באנטיביוטיקה ספטית בארטיריטיסמדובר

.D ויש לטפל ב ארטריטיס בריאקטיבמדוברNSAIDS


, לעתים כאבי ברכיים בהליכה, עודף משקל, 60בת

–בצילום ברך . בברכיים קרפיטציות,בבדיקה

.וסקלרוזיס אוסטאופיטים

?מה הטיפול המומלץ

.Aממושך אצטאמינופן

.BNSAIDS ממושך

.Cהזרקת סטרואידים למפרק

.Dפיזיותרפיה לחיזוק שרירים תומכים

.Eוגלוקוזאמין כונדרואיטין


• A 74-year-old man is seen by his primary care provider 6 weeks following an acute gout attack. He has a prior history of gout presenting similarly on two prior occasions within the past 6 months. His past medical history is significant for congestive heart failure, hypercholesterolemia, and stage III chronic kidney disease. He is taking pravastatin, aspirin, furosemide, metolazone, lisinopril, and metoprolol XL. His glomerular filtration rate is 38 mL/min, creatinine is 2.2 mg/dL, and uric acid level is 9.3 mg/dL. He is wondering if there is any therapy that might lessen his likelihood of repeated gout attacks. Which of the following medication regimens is most appropriate for the treatment of this patient?

A. Allopurinol 800 mg daily B. Colchicine 0.6 mg bid C. Febuxostat 40 mg daily D. Indomethacin 25 mg twice daily E. Probenecid 250 mg twice daily

Case 2: History

• A 36-year-old female is seen for migratory arthritis of 6 months’ duration. She also reports some fatigue and a photosensitive skin rash. ROS notes:

• Patchy hair loss 4 months ago that regrew

• Aphthous-like mouth ulcers every 4 to 6 weeks

• A diagnosis of “walking pneumonia” made last month based on symptoms of pleuritic chest pain

Case 2: Objective Findings

• Pain with mild synovitis over the MCPs and PIPs

• Rash over her face, legs, and trunk

• Hgb = 12.1; ESR = 33

• UA = 3+ protein

• ANA = 1:640 titer

Case 2: Question

• With this clinical history, what is the most important thing to do now?

A. Start an NSAID for the joint pain

B. Start hydroxychloroquine to treat the rash and prevent recurrent pleurisy

C. Fully evaluate her renal status and initiate appropriate therapy

D. Start prednisone at 80 mg qd

Case 2: Answer

• C. Fully evaluate her renal status

• Don’t Wait

• Aggressively evaluate renal status if the urinalysis is abnormal in SLE patients

Case 3: Clinical Findings

• A 26-year-old woman presents with progressive weight loss, fevers to 103.5°F, arthralgias, and ischemic ulcers on the fingers

• Physical examination reveals an enlarged spleen and a harsh midsystolic murmur

• Hgb 9.3 mg%, ESR 82 mm/s

• Urinalysis shows 15 to 20 RBCs

Case 3: Question

• Which of the following would you do first?

A. Echocardiogram and blood cultures

B. Renal biopsy

C. Anti-ds DNA antibody levels

D. C-reactive protein level

Case 3: Answer • A. An echocardiogram and blood cultures

• Echocardiogram showed vegetations on the valves

• Blood cultures were positive for Staph aureus

Don’t Guess

•ALWAYS look for mimics of vasculitis that have specific treatments

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rheumatology הכנה לשלב א' · • life expectancy in patients with ra is shortened by...

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