DISCUSSION BY: Dr M. R. Shakeebi, MD, Rheumatologist

Transcription

1 Case presentations Related to some Rheumatic Diseases Lab & Clinic i Programs, Tuesday, April 24, 2012 COORDINATOR: Dr M. Mahdi Mohammadi, LMD,PhD, Immunologist COORDINATOR: Dr M. Mahdi Mohammadi, LMD,PhD, Immunologist DISCUSSION BY: Dr M. R. Shakeebi, MD, Rheumatologist

2 A 20 years old man with low back pain from 1 year ago. His LBP improves with activity and aggravate with rest. He has morning stiffness more than 1 hour. He has night pain and sleep disturbances. No radiation to legs. Physical examination is normal except limitation in lumbar extension. Lab results: CBC Normal ESR 80 mm/1 st h LFT Normal CRP 60 mg/dl Creatinine Normal HLA B27 positive Urinalysis Normal PPD 6 mm

3 Clinical i l diagnosis; i Inflammatory LBP Lab result; confirmed Interpretation; seronegative spondyloarthropathy (Ankylosing Spondylitis) Misinterpretation; ; infections What about positive HLA B27? Other evaluation; pelvic x ray shows bilateral sacroiliitis

4 A 25 year old woman with low back pain from 2 years ago. LBP improve with rest and aggravate with activity. She has no morning stiffness. She has no night pain. No radiation to legs. Physical examination is normal. Lab results: CBC Normal ESR 10 mm/h LFT Normal CRP 6 mg/dl Creatinine Normal HLA B27 Negative Urinalysis Normal Wright & Coombs wright Negative

5 Clinical diagnosis; mechanical LBP Lab result; confirmed Interpretation; non inflammatory LBP Misinterpretation; Ankylosing spondylitis

6 A 60 year old woman referred to rheumatology clinic i for evaluation of a 3 week back pain. He has no history of trauma or night pain or fever or any drugs or previous cancer or fever or weight loss or radicular pain. Physical examination was normal except back deformity and local tenderness on back percussion. Lab results: CBC Normal ESR 10 mm/h LFT Normal CRP 10 mg/dl Creatinine Normal HLA B27 Negative Urinalysis Normal PPD 6 mm Wright & Coombs wright Negative

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8 Clinical diagnosis; mechanical LBP Lab result; confirmed Interpretation; non inflammatory LBP Misinterpretation; lumbar spondylosis More evaluation? Lumbar X ray, Bone densitometry, whole body bone scan

9 A 35 year old woman with 2 months of hand and foot pain. She has a 2 hour morning stiffness. She has no significant history and no compliant from any systems. She has swollen joint in MCP, PIP, wrists and Knees. CBC Normal ESR 80 mm/h LFT Normal CRP 60 mg/dl Creatinine Normal RF 1/320 Urinalysis Normal Anti CCP 500mg/dL ANA 1/40 homogenous Pattern

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11 Clinical diagnosis; Rheumatoid Arthritis Lab result; confirmed Interpretation; inflammatory polyarthritis Misinterpretation; SLE What about positive ii ANA? More evaluation? Hand X ray? Anti dsdna

12 A 15 year old girl il with ih 1 month hand pain and fever. She has no morning stiffness. She has no significant history and no complaint from any systems. She has swollen joint in MCP, PIP, wrists and faint malar rash. CBC WBC 3500 ( PMN 75% Lym 20% ) Hb=14, Plt= LFT Normal ESR 20 mm/h Creatinine Normal CRP 10 mg/dl Urinalysis Pro +++ RF 1/40 Anti CCP 10 mg/dl ANA 1/640, Rim Pattern

13 HAND INVOLVEMENT IN SLE MALAR RASH

14 Clinical diagnosis; Systemic Lupus erythematous (SLE) Lab result; confirmed Conclusion; inflammatory polyarthritis and skin rash and proteinuria Misinterpretation; RA, Reactive arthritis What about positive ii RF? More evaluation? Anti dsdna, 24/h urine protein Chest X ray Hand X ray?

15 A 20 yeas old man with 1 week hand and foot pain. He has no morning stiffness. He has no significant history and negative review of systems. He is febrile and has swollen joint in MCP, PIP, wrists and Knees. He has pharyngitis, conjunctivitis and cervical lymphadenitis and generalize papular skin rash. Spleen is palpable. CBC (WBC 20,000 Atypical LYM 20% Hgb 15 Plt 250,000) CRP 6 mg/dl ESR 10 mm/h LFT 2 3 time elevation in liver enzymes Creatinin Normal RF negative Urinalysis Normal Anti CCP negative

16 SKIN RASH ATYPICAL LYMPHOCYTES

17 Clinical diagnosis; Viral polyarthritis (Infectious Mononucleosis) Lab result; confirmed Interpretation; inflammatory polyarthritis and pharyngitis and conjunctivitis and lymphadenitis Misinterpretation; leukemia What about leukocytosis? More evaluation? WBC morphology, Tests for heterophile antibodies are positive in 40% of patients with IM during the first week of illness and in 80 90% during the third week. Therefore, repeated testing may be necessary, especially if the initial test is performed early.

18 A 30 year old man with history of 2 years lupus nephritis on standard treatment seeks for a newly onset shin edema. No evidence for disease activity on History and physical examination. BP is normal. Bilateral 2 plus pretibial edema exists. Amlodipine 5mg/bid added to drug regimen in the last visit from 2 months ago. CBC Normal ESR 20 mm/h LFT Normal CRP 5 mg/dl Creatinine Normal TFT Normal Urinalysis Normal Ser.Alb 5.7 mg/dl 24h/urine (Pro. 200 mg Cr. 950 mg Vol CC)

19 Clinical i l diagnosis; i drug induced dpedal dledema Lab result; Normal Interpretation; t ti non renal, non GI, non cardiac, non thyroid pretibial edema. Misinterpretation; recurrence of lupus nephritis More evaluation? CXR, GI Evaluation if not responding to Amlodipine DC

20 A 29 years old women was admitted in hospital for leg pain and swelling. She had 2 abortions in 3rd month of pregnancy in the last year. She has history of migraine and convulsion from many years ago. She has normal physical examination except levidoreticularis on her arms and thigh, and DVT sign in right leg. Work up for any causes or fetal loss, including paternal or chromosomal and infectious ethology were negative. WBC (WBC 5700, Normal diff. Hg 14 g/dl, Plt 85000) LFT Normal ESR 20 mm/h Creatinin Normal CRP 10 mg/dl Urinalysis Normal ANA 1/40 Homogenous PT 12 sec (INR 1.1) PTT > 1 minute

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22 Clinical i l diagnosis; i Antiphospholipid h id syndrome Lab result; low platelet, prolong PTT Interpretation; Misinterpretation; SLE, Secondary APS What about Positive ANA? More evaluation? Anti Cardiolipin (IgG and IgM) VDRL? Anti phospholipid lupus anticoagulant test Clotting factor assessment?

23 A 20 years old Afghanian women referred to Rheumatology clinic for evaluation. The last admition in hospital because thrombotic CVA was 3 months ago. She had history of 6 abortion in the past 4 years. She has no child, and request for pregnancy permition. She has normal physical examination except left spastic hemiplegia. Normal chromosomal study. Negative result for infectious i process. No abnormality in death fetus. Multiple infarct in placenta. Study shows compatibility in Hemoglobin, blood group and Rh.

24 WBC (WBC 5700, Normal diff. Hg 14 g/dl, Plt ) LFT Normal ESR 20 mm/h Creatinin i Normal CRP 10 mg/dl Urinalysis Normal ANA 1/40 Homoge PT 16 (INR 1.2) Anti dsdna Negative PTT 45 Anti β2gp1 40 Anti Cardiolipin IgG 295 +>11 Anti Cardiolipin IgM 241 +>16

25 Clinical diagnosis; Antiphospholipid syndrome Lab result; low platelet, l prolong PTT, positive ACL Ab Interpretation; Misinterpretation; SLE, Secondary APS What about Positive ii ANA? More evaluation?

26 A 77 years old man comes with right knee arthritis from 3 days ago. He has no history of trauma or fever. Physical examination was normal except hand and knee DJD, and right knee arthritis. Joint aspiration performed and synovial fluid and other tests result reported as below: CBC Normal ESR 20 mm/h LFT Normal CRP 16 mg/dl Creatinine Normal RF 1/80 Urinalysis Normal Anti CCP negative

27 Synovial fluid tests shows; WBC (PMN 60% MON 40%) Gram stain Culture Crystal Sugar Protein Negative? Wait for 48 hours! Needle Shape crystal under light microscope 60 mg/dl 3 g/dl

28 Clinical diagnosis; DJD, crystal induced arthritis Lab result; inflammatory synovial fluid in DJD knee Interpretation; no infection, Misinterpretation; infectious arthritis What about Negative crystal? More evaluation? Knee X ray

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30 A, Urate crystals in a tophus from a patient t with gouty arthritis. The crystals are negatively birefringent and needle-shaped B, Intracellular urate crystal as seen on a Wright stain

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