Answering the most common rheumatology questions
|
|
- Stanley McKenzie
- 6 years ago
- Views:
Transcription
1 Answering the most common rheumatology questions Sterling West, MD, MACP, MACR Professor of Medicine University of Colorado SOM Disclosures I have no relevant financial relationships to disclose. Learning Objectives Describe the treatment and pitfalls in treating acute gout in a patient with chronic renal disease. Outline an approach to the evaluation and management of a patient with suspected vasculitis. Formulate and implement an approach to evaluate fever in a patient with a rheumatic disease. Discuss the perioperative management of a rheumatic disease patient who requires surgery.
2 Do I have to aspirate all patients with a known history of gout (? crystal- proven) who develop an acute inflammatory monoarticular arthritis? Margaretten ME. JAMA 297: , 2007 Carpenter CR. Acad Emerg Med 18: , 2011 Lim SY. Rheumatology 54: , 2015 You gotta ask yourself one question: Dirty Harry, 1971 Gout vs septic arthritis Cannot clinically separate gout from septic joint based on joint signs/sxs, fever, elevated WBC count, or elevated ESR/CRP. Gout likes to involve distal lower extremity joints (1 st MTP, midfoot, ankle, knee). Gout should not affect the back, shoulder, or hip. Septic arthritis likes large joints (knee, hip, shoulder). Pts with gout have 2-3x increased risk of developing septic arthritis. Gout and septic arthritis can coexist in the same joint. Patients with septic arthritis usually have a risk factor: increased age, other site of infection, HIV, RA, DM, joint surgery, immunosuppression.
3 Recommendations Aspirate an acute monoarticular arthritis in all patients with known crystal- proven gout except for those patients who have only the first MTP involved and no other significant risk factors to suspect a septic MTP joint. When in doubt, aspirate, because: Failure to aspirate, prepare to litigate. What is the best therapy for an acute crystalline arthritis in a patient with significant renal insufficiency? Khanna D. Arth Care Res 64: , 2012 Richette P. Ann Rheum Dis 2016, DOI: Possible treatments for acute crystalline arthritis in patients with normal renal function NSAIDs Indomethacin 50mg TID x 2 days then 25mg TID x 3-5 days Naproxen 500mg BID x 5-7 days Colchicine: 1.2mg followed by 0.6mg one hour later Corticosteroids Intraarticular Oral: 30mg qd x 5 days and D/C or 30mg qd x 2-5 days with taper over 7-10 days Parenteral Triamcinolone acetonide (kenalog) 60mg IM x 1 with option of second shot in 24 hrs if not improved > 20-50%. Can follow with oral prednisone 30mg qd with taper by 5mg qd until off. Methylprednisolone 30mg IV qd until resolved then D/C or taper. ACTH: IU subq
4 Treatment for acute crystalline arthritis in patients with renal insufficiency Corticosteroids: oral, IA, IM What if they also have a systemic infection? Corticosteroids: IA or IM What if they also have diabetes? Corticosteroids: IA Corticosteroids: IM and cover with insulin What if they are on anticoagulation, have diabetes, and are infected? Corticosteroids: IA up to an INR of 4.5 Corticosteroids: IM and cover with insulin Does this patient have some kind of vasculitis (SKV consult)? Sharma AM. Tech Vasc Interventional Rad 17: 226, 2014 Jennette JC. Arthritis Rheum 65: 1-11, 2013 Suresh E. Postgrad Med J 82: 483, 2006 Common vasculitis presentations Consider vasculitis in any patient who is constitutionally ill with multisystem inflammatory disease. Large vessel involvement (GCA, Takayasu s) Neuro: Headaches, visual loss, strokes Limb ischemia: claudication, bruit, asymmetric BP/pulse Medium vessel involvement (PAN) Neuro: mononeuritis multiplex, strokes (GACNS) Skin: livedo reticularis, ulcers, nodules, digital gangrene Renal/GI: HBP, microhematuria, abd pain Small vessel involvement (ANCA vasculitis, cryos, HSP, HUVS) Pulmonary- renal syndromes (ANCA Dz): DAH, RPGN EENT- pulmonary syndromes (ANCA Dz): scleritis, sinusitis, lung nodules, mass lesions (pseudotumor orbiti, subglottic stenosis) Skin: palpable purpura, urticaria lasting > 24hrs
5 Approach to vasculitis Is this a condition that can mimic a primary vasculitis or could there be a secondary cause of vasculitis? R/O infection, cancer, CTD, drugs/meds Suspect vasculitis mimic or a secondary cause in patients with: New heart murmur, unusually high fever, and/or splinter hemorrhages (SBE). Prominent liver dysfunction (hepatitis C with cryos) Drug abuse (HIV, hep B/C, cocaine, amphetamines, etc) Prior hx of cancer (esp lymphoma, myelodysplastic dz) Prior hx of CTD (SLE, Sjogren s, PAPS) Known offending medication (PTU, hydralazine, minocycline, etc) Smoking (Buerger s/thromboangiitis obliterans) Necrosis of LE digits (cholesterol emboli) Vasculitis mimics Large artery Common: fibromuscular dysplasia (FMD), IgG4 dz Uncommon: coarctationof aorta, neurofibromatosis type I, Marfan s, Loeys- Dietz, syphilic aortitis, infection (VZV), sarcoidosis, radiation fibrosis Medium artery Common: cholesterol emboli syndrome, atrial myxoma, FMD Uncommon: segmental arterial mediolysis, lymphomatoidgranulomatosis, angioblastic T- cell lymphoma, ergotism, thromboembolic dz, PXE, type IV EDS, Buerger s/to Cerebral arteries Common: reversible cerebral vasoconstriction syndrome (RCVS),posterior reversible encephalopathy syndrome (PRES), infections (VZV, others) Uncommon: cerebral amyloid angiopathy, CADASIL syndrome, Susac syndrome, progressive multifocal leukoencephalopathy, Moyamoya, intravascular lymphoma Small artery Common: SBE, cholesterol microemboli syndrome, mycotic aneurysm with emboli, antiphospholipid antibody syndrome, sepsis (Neisseria), SLE, Sjogren s, cryos (HepC), meds (PTU, hydralazine, minocycline, others), drugs (cocaine, amphetamine) Uncommon: Rickettsia, other systemic viral infection (parvo, herpes, EBV, CMV), CVID, calciphylaxis, livedoid vasculopathy (atrophie blanche), Degos disease, TTP, sickle cell Approach to vasculitis: workup Is there a secondary cause of the vasculitis and what is the extent of organ involvement? R/O infection, cancer, CTD, and drugs/medications Tests establishing systemic inflammation CBC: ACD, thrombocytosis, WBC count and differential to look for neutrophilia, eosinophilia, or abnormal cells Low WBC and/or low platelet count never seen in primary vasculitis (R/O SLE, antiphospholipid antibody syndrome, heme malignancy, TTP, medications) ESR and CRP: If both > than 10x ULN with no evidence of infection, acute crystalline arthritis, or cancer, then vasculitis is a likely diagnosis. Tests establishing extent of organ involvement Creatinine and urinalysis Liver- associated enzymes: if elevated consider hep B/C Creatine kinase Stool for occult blood CXR Others depending on Hx and P/E: EMG/NCV, sinus CT, echo, abd CT scan, brain MRI
6 Approach to vasculitis: workup Tests to rule out etiologies not responsive to immunosuppressive meds Blood cultures: R/O SBE PTT: if elevated consider antiphospholipid antibody syndrome LDH (if > 2-3x ULN): consider lymphoma, heme malignancy, myelodysplastic syndrome, TTP Infectious serologies: HepB (PAN), hepc (cryos), HIV, parvo IgM (PAN), CMV/EBV/herpes IgM Cryoglobulins: if positive rule out hepc and lymphoma SPEP: R/O myeloma Urine toxicology screen: cocaine, amphetamines Others depending on presentation: echo (SBE, atrial myxoma), CSF (VZV, herpes) Approach to vasculitis: workup Tests to rule out etiologies responsive to immunosuppressive medications. Tests suggesting immune complex deposition RF and ANA: should not be positive in primary systemic vasculitis. RF positive: R/O SBE, cryos, CTD (RA, Sjogren s) ANA positive: R/O SLE, Sjogren s Complement (C3/C4) levels: if low R/O SLE, cryos, HUVS Tests suggesting ANCA vasculitis canca: if against serine proteinase 3, usually GPA> MPA panca: if against myeloperoxidase, usually MPA> GPA panca not against myeloperoxidase is unlikely to be due to vasculitis Meds (PTU, hydralazine, minocycline) and cocaine can cause atypical ANCA, panca, or less commonly canca. Approach to vasculitis: workup Histologic or radiographic proof must be obtained in most patients with suspected vasculitis. Small vessel vasculitis(lcv, small artery) Idiopathic (50%) Infection (15-20%) Bacterial (strept, Neisseria, Rickettsia), HIV Hep C (cryos) CTD (15-20%) Primary vasculitis HSP (IgA vasculitis): Bx and immunofluorescence HUVS Cryoglobulinemia (essential) ANCA- vasculitis: usually MPA Secondary: SLE, Sjogren s, RA, Behcets, IBD Drugs (10-15%) Antibacterials, NSAIDs, cocaine, sulfasalazine PTU, hydralazine, GM- CSF, anti- TNF, allopurinol Thiazides, phenytoin, pantoprazole Malignancy (5%): heme, solid (lung, GI)
7 Approach to vasculitis: workup ANCA vasculitis Granulomatous polyangiitis (Wegener s) Clinical: ENT, lung, kidney canca against PR3 May be able to diagnose clinically without a biopsy Microscopic polyangiitis (MPA): consider pulmonary- renal syndromes Clinical: kidney, lung > skin Kidney bx: pauci- immune GN +/- crescents panca against MPO R/O drug induced: PTU, hydralazine Eosinophilic granulomatosis with polyangiitis (EGPA) (Churg Strauss) Clinical: asthma, lung, eosinophilia, rhinitis, neuropathy, skin, heart panca> MPO in only 50% Approach to vasculitis: workup If histology difficult to obtain in a patient with large or medium vessel vasculitis then need angiographic documentation. Medium vessel vasculitis (PAN) Histology Nerve bx positive in 45% (+ EMG/NCV) Skin nodule, testes, organ involvement Angiography (aneurysms) Mesenteric angiogram only if Abnormal exam: abd pain, HBP with hematuria Labs: LAEs, creatinine, U/A (blood) Abd CT scan: spleen or renal infarcts Approach to vasculitis: workup Large vessel vasculitis (GCA, Takayasu s) Histology GCA: temporal artery bx abnormal 85% with cranial/visual sxs, less than 50% if no cranial sxs. Takayasu s: hard to get histology Angiography (routine, CTA, MRA) Vessel wall thickening with enhancement Long tapering stenosis PET scan Contrast vessel wall enhancement and hyperemia
8 Is this patient s FUO caused by a rheumatic disease? This patient is known to have a rheumatic disease. Is the fever due to their rheumatic disease? Bleeker- Rovers CP. Medicine 86: 26, 2007 Toth E. Clin Rheumatol 31:1649, 2012 Fever and Rheumatic Diseases Rheumatic disease is found as the cause in 20% of patients with an FUO. Most common rheumatic diseases presenting with an FUO: Adult- onset Still s disease (AOSD) Large vessel vasculitis (GCA, Takayasu s) Rheumatic diseases that can cause sustained daily fever Monoarthritis and fever: acute gout (9%), acute pseudogout (up to 50% can have low grade fever), infectious arthritis (50-90% have fever), osteomyelitis Polyarthritis and fever: RA (< 5% with acute onset), viral arthritis (parvo B19, others), SAPHO, Whipple s disease, rheumatic fever Systemic inflammatory disease and fever (occurs at disease onset or with flares):sle (80-90%), systemic vasculitis [ GCA (33%), Takayasu s (20% early), PAN (60%), EGPA (Churg- Strauss) (60%), GPA (Wegener s) (25%)], inflammatory myositis (antisynthetase antibody syndrome, e.g anti- Jo- 1) Fever and Rheumatic Diseases Rheumatic diseases causing recurrent periodic fevers AOSD Behcet s disease Relapsing polychondritis Sarcoidosis Crystal- induced diseases Autoinflammatory syndromes: familial periodic fever syndromes
9 Clinical pearls on fever and rheumatic diseases Always rule out infection, heme malignancies, and medications first as the cause of the fever. LDH > 2-3x ULN: consider heme malignancy or heme Dz Procalcitonin elevated (>1ng/ml): consider infection (75% spec and sensitivity) (Shaikh M. Rheumatology 54:231, 2015) AOSD Major criteria: recurrent fevers (>39 C) > 7 days, nonpruritic evanescent rash on trunk, polyarthritis/arthralgias, leukocytosis (> 10,000/uL with 80% neutrophils). Plot out fever curve: quotidian or double- quotidian Minor crtieria: hepatosplenomegaly, sore throat, lymphadenopathy, abnormal LAEs Supportive: Ferritin > 1000 ng/ml (70%) Note that procalcitonin can be > 1ng/ml Clinical pearls on fever and rheumatic diseases SLE Fever is common at disease onset and with flares. Ask patient if fever is usually a part of their flare. Fever more likely due to SLE if part of their usual flare, serositis, WBC low, C3/C4 low, elevated anti- dsdna Fever more likely due to infection if atypical for their flares, WBC higher than normal, serologically inactive or unchanged, CRP> 6x ULN, elevated procalcitonin. Macrophage activation syndrome (MAS) Life- threatening (mortality 20%) hemphagocytic syndrome seen in AOSD and SLE patients. Can be triggered by EBV, CMV, or parvovirus infection. High fever and hepatosplenomegaly. No rash or arthritis. Labs: cytopenias ( 2 of 3 cell lines), elevated LAEs, triglyceride level (> 180 mg/dl), PT/PTT, low fibrinogen, low ESR Supportive: ferritin > 10,000, elevated soluble IL- 2 receptor (CD25) Dx: bone marrow or liver bx showing hemophagocytosis by macrophages Your patient with a rheumatic disease is going to surgery. What additional preoperative evaluation or precautions need to be taken? Bissar L. Rheumatology J 7: 42, 2013 Goodman SM. Rheum Dis Clin North Am 38: 747, 2012
10 Perioperative management of patient with rheumatic disease Hx, PE, labs, EKG, CXR per established guidelines. Rheumatic disease pts have their risk of atherosclerosis accelerated by 10 years. Cardiac risk stratification Assessment of specific clinical problems Rheumatoid arthritis: cervical spine xray, assess lung function if rales or sxs (CXR, PFTs) Ankylosing spondylitis: cervical spine xray if clinically involved SLE: pts with lupus anticoagulant and/or high titer anticardiolipin/antib2gpi antibodies need compression stockings and prophylactic anticoagulation perioperatively and continued for seven days after surgery even if no prior hx of clot. Perioperative management of patient with rheumatic disease Adjust medications NSAIDs: stop five half lives before surgery Prednisone: stress dose protocol (solucortef 100mg IV on call to operating room, 100mg during surgery, 100mg 8hrs postop). Decrease by half (IV or oral equivalent) each day until on usual dose. Methotrexate: controversial. Stop week of and week after major surgery. Mycophenolate mofetil: stop 3 days prior to surgery and start 3 days after surgery Other DMARDs (hydroxychloroquine, sulfasalazine, azathioprine): stop 1 day preop and start 3 days postop Biologics: stop two half lives prior to surgery and resume once wound healing is satisfactory. Anti- rheumatic disease drugs can mask infections: prednisone, tocilizumab, and anti- TNF agents are biggest offenders. Summary Failure to aspirate, prepare to litigate. Corticosteroids are best for gout flare if have renal insufficiency. Strategies for how to evaluate a patient with suspected vasculitis. Need biopsy or angiographic confirmation of vasculitis. FUO: AOSD, GCA, Takayasu s most common Rule out infection, heme malignancy, drugs, and MAS as cause for fever before ascribing it to the underlying rheumatic disease. When a rheumatic disease is the cause of a fever there should be other clinical and laboratory evidence that the rheumatic disease is active. Perioperative management considerations for rheumatic disease patients. CAD risk stratification. Clot more common.
11 Thank You University of Colorado School of Medicine Anschutz Medical Center Aurora, Colorado
PAEDIATRIC VASCULITIS
PAEDIATRIC VASCULITIS Lawrence Owino Okong o, Mmed (UoN); Mphil. (UCT). Lecturer, Department of Paediatrics and Child Health, University of Nairobi. Paediatrician/ Rheumatologist. OUTLINE Introduction
More informationMohammad Reza Shakibi M.D Kerman university of medical sciences (KMU) Shafa Hospital, Rheumatology ward
VASCULITIS SYNDROMES Mohammad Reza Shakibi M.D Kerman university of medical sciences (KMU) Shafa Hospital, Rheumatology ward ILLUSTRATED CASE 1 A 56 years old lady refered me for prolonged fever, arthritis
More informationVasculitis and Vasculitides. OMONDI OYOO Physician/Rheumatologist; Senior Lecturer, Department of Medicine University of Nairobi
Vasculitis and Vasculitides OMONDI OYOO Physician/Rheumatologist; Senior Lecturer, Department of Medicine University of Nairobi Definition Presence of leucocytes in the vessel wall with reactive damage
More informationSHO Teaching. Dr. Amir Bhanji Consultant Nephrologist, Q.A hospital, Portsmouth
SHO Teaching Vasculitis Renal medicine Dr. Amir Bhanji Consultant Nephrologist, Q.A hospital, Portsmouth OUTLINE What is vasculitis Causes Classification Brief look into ANCA Associated Vasculitis (AAV)
More informationDisclosures. Rheumatological Approaches to Differential Diagnosis, Physical Examination, and Interpretation of Studies. None
Rheumatological Approaches to Differential Diagnosis, Physical Examination, and Interpretation of Studies Sarah Goglin MD Assistant Professor of Medicine Division of Rheumatology Disclosures None 1 [footer
More informationDr Rodney Itaki Lecturer Anatomical Pathology Discipline. University of Papua New Guinea School of Medicine & Health Sciences Division of Pathology
Vasculitis Dr Rodney Itaki Lecturer Anatomical Pathology Discipline University of Papua New Guinea School of Medicine & Health Sciences Division of Pathology Disease Spectrum Hypersensitivity vasculitis/microscopic
More informationAnnual Rheumatology & Therapeutics Review for Organizations & Societies
Annual Rheumatology & Therapeutics Review for Organizations & Societies Update on Granulomatosis with Polyangiitis (Wegener s) Learning Objectives Identify the clinical features of granulomatosis with
More informationVasculitis. Edward Dwyer, M.D. Division of Rheumatology. Vasculitis
Edward Dwyer, M.D. Division of Rheumatology VASCULITIS is a primary inflammatory disease process of the vasculature Determinants of the Clinical Manifestations of : Target organ involved Size of vessel
More informationA. Smržová. III. Interní klinika FN Olomouc nefrologická, revmatologická a endokrinologická
A. Smržová III. Interní klinika FN Olomouc nefrologická, revmatologická a endokrinologická Systemic vasculitis destructive inflamatory of the walls of blood vessels. Pathologist Inflammatory destruction
More informationVASCULITIS. Case Presentation. Case Presentation
VASCULITIS Case Presentation The patient is a 24 year old woman who presented to the emergency room with left-sided weakness. She was confused and complained of a severe headache. She was noted to have
More informationDiagnostic Tests in Rheumatic Disease: What s Old, What s New & What s Useful? COPYRIGHT
Diagnostic Tests in Rheumatic Disease: What s Old, What s New & What s Useful? Robert H. Shmerling, M.D. Beth Israel Deaconess Medical Center Boston, MA Diagnostic Tests in Rheumatic Disease: What's Old,
More informationCase Presentation VASCULITIS. Case Presentation. Case Presentation. Vasculitis
Case Presentation VASCULITIS The patient is a 24 year old woman who presented to the emergency room with left-sided weakness. She was confused and complained of a severe headache. She was noted to have
More informationIndex. Note: Page numbers of article titles are in boldface type.
Note: Page numbers of article titles are in boldface type. A ANCA vasculitis. See Antineutrophil cytoplasmic antibody associated (ANCA) vasculitis Angiography 54 Antineutrophil cytoplasmic antibody correlation
More informationSmall Vessel Vasculitis
Banff- Rocky Mountain Barry Kassen, MD, FRCPC,FACP Head, Division of Internal Medicine UBC/VGH/SPH Acting Head, Division of Community Internal Medicine November, 2009 Objectives 1. To understand small
More informationRheumatology Primer: What Labs and When
Rheumatology Primer: What Labs and When Irina Konon, MD Department of Internal Medicine Division of Rheumatology Medical College of Wisconsin Disclosures None 1 Objective Discuss principles of laboratory
More informationVasculitis. Seth Mark Berney, MD Professor of Medicine Chief, Division of Rheumatology University of Arkansas for Medical Sciences
Vasculitis Seth Mark Berney, MD Professor of Medicine Chief, Division of Rheumatology University of Arkansas for Medical Sciences History A 50 year old white male with a history of intravenous drug use
More informationCommon Rheumatology Issues in Hospital Medicine
Common Rheumatology Issues in Hospital Medicine Lianne Gensler, MD Associate Professor of Clinical Medicine UCSF Division of Rheumatology Disclosure UCB Board Member/Advisory Panels 2 1 [footer text here]
More informationVASCULITIC SYNDROMES. Howard L. Feinberg, D.O., F.A.C.O.I., F.A.C.R. OPSC 2018
VASCULITIC SYNDROMES Howard L. Feinberg, D.O., F.A.C.O.I., F.A.C.R. OPSC 2018 2012 REVISED CHAPEL HILL CONSENSUS CONFERENCE Large vessel Takayasu arteritis Giant cell arteritis Medium Vessel Polyarteritis
More informationRituximab treatment for ANCA-associated vasculitis in childhood
Rituximab treatment for ANCA-associated vasculitis in childhood DISCLOSURE I have no relevant financial relationships to disclose Katharine Moore MD Nov 14, 2012 University of Colorado School of Medicine
More informationEssential Rheumatology. Dr Ellen Bruce Consultant Rheumatologist CMFT
Essential Rheumatology Dr Ellen Bruce Consultant Rheumatologist CMFT Saving the best for last! Apparently people recall best the first and last thing they re told. Far too difficult to include everything.
More informationVasculitis and the Dermatologist: General approach, pitfalls, and pearls
Vasculitis and the Dermatologist: General approach, pitfalls, and pearls Robert G. Micheletti, MD Assistant Professor of Dermatology and Medicine Director, Cutaneous Vasculitis Clinic, Penn Vasculitis
More informationA CRP B FBC C LFT D blood culture E uric acid
1 A 39 year old lady with rheumatoid arthritis is admitted to hospital with a hot, swollen and painful right knee. Which is the most important blood test? A CRP B FBC C LFT D blood culture E uric acid
More informationRHEUMATOLOGY OVERVIEW. Carmelita J. Colbert, MD Assistant Professor of Medicine Division of Rheumatology Loyola University Medical Center
RHEUMATOLOGY OVERVIEW Carmelita J. Colbert, MD Assistant Professor of Medicine Division of Rheumatology Loyola University Medical Center What is Rheumatology? Medical science devoted to the rheumatic diseases
More informationVasculitis local: systemic
Vasculitis Inflammation of the vessel wall. Signs and symptoms: 1- local: according to the involved tissue 2- systemic:(fever, myalgia, arthralgias, and malaise) Pathogenesis 1- immune-mediated inflammation
More informationManagement of Acute Vasculitis. CMT teaching 3 rd June 2015 Caroline Wroe
Management of Acute Vasculitis CMT teaching 3 rd June 2015 Caroline Wroe Vasculitis pub quiz Match the date with the event Dr Peter McBride, Scottish Otolaryngologist describes a disease of rapid destruction
More informationVasculitis local: systemic
Vasculitis Inflammation of the vessel wall. Signs and symptoms: 1- local: according to the involved tissue 2- systemic:(fever, myalgia, arthralgias, and malaise) Pathogenesis 1- immune-mediated 2- infectious
More information2/23/18. Disclosures. Rheumatic Diseases of Childhood. Making Room for Rheumatology. I have nothing to disclose. James J.
Making Room for Rheumatology James J. Nocton, MD Disclosures I have nothing to disclose Rheumatic Diseases of Childhood Juvenile Idiopathic Arthritis (JIA) Systemic Lupus Erythematosus (SLE) Juvenile Dermatomyositis
More informationScott Vogelgesang, MD Division of Rheumatology/Immunology University of Iowa
Scott Vogelgesang, MD Division of Rheumatology/Immunology University of Iowa Basic Concepts ANA DsDNA Sm RNP SSA SSB RF/CCP ESR/CRP ANCA Cases Summary Rheumatology Tests Lie and Mislead! Rheumatology Rally
More informationVasculitides in Surgical Neuropathology Practice
Vasculitides in Surgical Neuropathology Practice USCAP requires that all faculty in a position to influence or control the content of CME disclose any relevant financial relationship WITH COMMERCIAL INTERESTS
More informationAtlas of the Vasculitic Syndromes
CHAPTER e40 Atlas of the Vasculitic Syndromes Carol A. Langford Anthony S. Fauci Diagnosis of the vasculitic syndromes is usually based upon characteristic histologic or arteriographic findings in a patient
More informationDecember 6, 2010 Asthma and Rheumatic Disorders and Vasculitis
December 6, 2010 Asthma and Rheumatic Disorders and Vasculitis Lanny J. Rosenwasser, M.D. Dee Lyons/Missouri Endowed Chair in Immunology Research Professor of Pediatrics Allergy-Immunology Division Childrens
More informationRheumatologic Lab Tests
Rheumatologic Lab Tests What the Practitioner Needs to Know Mary Nakamura M.D. 2008 Rheumatologic Lab Tests Are rarely diagnostic of any specific disease If you do not have in mind a rheumatologic disease
More informationACP Rheumatology Pearls. Adam Q Carlson MD Assistant Professor UVA Rheumatology
ACP Rheumatology Pearls Adam Q Carlson MD Assistant Professor UVA Rheumatology Disclosures I have no personal or professional disclosures Case #1 27 yo woman with a history of systemic lupus complicated
More informationYear In Review: VasculitisPers. Disclosures. Learning Objectives. none 4/16/2018. Describe new medications for the treatment of vasculitis
Year In Review: VasculitisPers Cailin Sibley, M.D., M.H.S. Director, Vasculitis Clinic April 27 th, 2018 NTEREST DISCLOSURE Disclosures none Learning Objectives Describe new medications for the treatment
More informationDISCUSSION BY: Dr M. R. Shakeebi, MD, Rheumatologist
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,
More informationGIANT CELL ARTERITIS. Page 1 of 6 Reproduction of this material requires written permission of the Vasculitis Foundation. Copyright 2018.
What is giant cell arteritis (GCA)? Giant cell arteritis (GCA) is a form of vasculitis a family of rare disorders characterized by inflammation of the blood vessels, which can restrict blood flow and damage
More informationCHECK LIST FORM-MONTH 27 (Please note Month 27 is from enrolment not randomisation)
CHECK LIST FORM-MONTH 27 (Please note Month 27 is from enrolment not randomisation) Participant Initials: Date of Birth: Were the following forms completed for this visit? Follow Up Form Done t Done BVASWG
More informationHigh Impact Rheumatology
High Impact Rheumatology Systemic Lupus Erythematosus Bernard Rubin, DO MPH Case 1: History A 45-year-old woman presents with severe dyspnea and cough. She was in excellent health until 4 weeks ago when
More informationCHECK LIST FORM-SCREENING
CHECK LIST FORM-SCREENING Participant Initials: Date of Birth: Evaluation Date: Were the following forms completed for this visit? Eligibility Form Done t Done Baseline medical History Form Done t Done
More informationSmall Vessel Vasculitis
Small Vessel Vasculitis Paul A Brogan Professor of Vasculitis and Consultant Paediatric Rheumatologist Department of Rheumatology Institute of Child Health and Great Ormond St Hospital, London UK P.brogan@ucl.ac.uk
More informationCENTRAL NERVOUS SYSTEM VASCULITIS
What is central nervous system (CNS) vasculitis? Central nervous system (CNS) vasculitis is among a family of rare disorders characterized by inflammation of the blood vessels, which restricts blood flow
More informationDiagnostic Procedures for Vasculitis
Diagnostic Procedures for Vasculitis Toshiharu Matsumoto, MD Clinical Professor of Department of Diagnostic Pathology Juntendo University Nerima Hospital, Tokyo, Japan Introduction In 1994, the International
More informationThe Vasculitis Syndromes
The Vasculitis Syndromes Definition Inflammation and damage of blood vessels Single organ skin Several organ systems Primary Secondary Heterogeneity Overlap Primary Vasculitis Syndromes Wegener s granulomatosis
More informationUNFOLDING NATURE S ORIGAMI: MEDICAL TREATMENT OF TAKAYASU ARTERITIS AND GIANT CELL ARTERITIS
UNFOLDING NATURE S ORIGAMI: MEDICAL TREATMENT OF TAKAYASU ARTERITIS AND GIANT CELL ARTERITIS CanVasc meeting Montreal Nov 22 2012 Patrick Liang Service de rhumatologie Centre Hospitalier Universitaire
More informationTell me more about vasculitis. Lisa Willcocks Consultant in Nephrology and Vasculitis, Addenbrooke s Hospital
Tell me more about vasculitis Lisa Willcocks Consultant in Nephrology and Vasculitis, Addenbrooke s Hospital Talk overview Case study ANCA-associated vasculitis What is ANCA vasculitis? What causes ANCA
More informationENFERMEDADES AUTOINMUNES SISTÉMICAS. Dr. J. María Pego Reigosa
ENFERMEDADES AUTOINMUNES SISTÉMICAS Dr. J. María Pego Reigosa ABSTRACT NUMBER: 888 PHASE 3 TRIAL RESULTS WITH BLISIBIMOD, A SELECTIVE INHIBITOR OF B-CELL ACTIVATING FACTOR, IN SUBJECTS WITH MODERATE-TO-SEVERE
More informationHow to interpret and order rheumatology tests
How to interpret and order rheumatology tests Kam Shojania, MD, FRCPC Clinical Professor and Head, UBC Division of Rheumatology Faculty/Presenter Disclosure Faculty: Kam Shojania Relationships with financial
More informationANCA associated vasculitis in China
ANCA associated vasculitis in China Min Chen Renal Division, Peking University First Hospital, Beijing 100034, P. R. China 1 General introduction of AAV in China Disease spectrum and ANCA type Clinical
More informationScleritis LEN V KOH OD
Scleritis LEN V KOH OD 2014 PUCO 1 Introduction A painful, destructive, and potentially blinding disorder Highly symptomatic High association with systemic disease Immunosuppresssive agents 2014 PUCO 2
More informationDisclosures/Conflicts
42nd Annual Recent Advances in Neurology Thursday, February 12, 2009 Cerebral Vasculitis (Primary CNS Vasculitis) Disclosures/Conflicts None J. Donald Easton Department of Clinical Neurosciences Alpert
More informationCUTANEOUS VASCULITIS. Katharine Warburton ST6 Dermatology
CUTANEOUS VASCULITIS Katharine Warburton ST6 Dermatology AIMS Clinical cases introduction The theory Categorising cutaneous vasculitis Features presenting in the skin Mimics/pitfalls How to initially manage
More informationa mimicker of Wegener s Granulomatosis
a mimicker of Wegener s Granulomatosis Combined Meeting October 2009 a story of 2 ladies Madam JA 56 year-old Madam RH 36 year-old Madam JA 56 year-old Apr 2008 May Jun Jul Aug Sept Oct Nov 2008 Madam
More informationCHECK LIST FORM-SCREENING
CHECK LIST FORM-SCREENING Participant Initials: Date of Birth: Evaluation Date: Were the following forms completed for this visit? Eligibility Form Done t Done Baseline medical History Form Done t Done
More informationTAKAYASU S ARTERITIS. Second-stage symptoms include:
What is Takayasu s arteritis (TAK)? Takayasu s arteritis (TAK) is a form of vasculitis a family of rare disorders characterized by inflammation of the blood vessels, which can restrict blood flow and damage
More informationApproach to Glomerular Diseases: Clinical Presentation Nephrotic Syndrome Nephritis
GLOMERULONEPHRITIDES Vivette D Agati Jai Radhakrishnan Approach to Glomerular Diseases: Clinical Presentation Nephrotic Syndrome Nephritis Heavy Proteinuria Renal failure Low serum Albumin Hypertension
More informationUpdate in Vasculitis. Anatomy of vasculitis. General Principles of Vasculitis. Not necessarily as rare as one might think
Black Hole Vasculitis Update in Vasculitis Advances In Internal Medicine 2015 Jonathan Graf, MD Professor of Clinical Medicine, UCSF Division of Rheumatology, SFGH Rare Poorly understood mystery of universe
More informationRhematologic serum testing is: Before request serologic tests, ANCA associated antigens c-anca: most commonly against the proteinase 3 (PR-3)
thorough P/E. Rhematologic serum testing is: Useful to confirm a clinical impression or sort out a differential diagnosis Not useful as a screening test A positive test may or may not be associated with
More informationFAQ Identifying and enrolling participants
FAQ Identifying and enrolling participants WHO IS ELIGIBLE - CASES? Patients with a new diagnosis of primary systemic vasculitis Patients suitable as cases are over 18 years with a new presentation or
More informationOverview. = inflammation of vessel wall. Symptoms and signs depend on the tissue of which the vessels are affected
Vasculitis (1+2) Overview = inflammation of vessel wall Symptoms and signs depend on the tissue of which the vessels are affected Often with systemic symptoms fever, myalgia, arthralgia, malaise etc. Most
More informationRevised 2017 international consensus on testing of ANCAs in granulomatosis with polyangiitis and microscopic polyangiitis.
Revised 2017 international consensus on testing of ANCAs in granulomatosis with polyangiitis and microscopic polyangiitis. Bossuyt X, Cohen Tervaert JW, Arimura Y, Blockmans D, Flores-Suárez LF, Guillevin
More informationSMALL TO MEDIUM VASCULITIS: RENAL ASPECT RATANA CHAWANASUNTORAPOJ UPDATE IN INTERNAL MEDICINE 2018
SMALL TO MEDIUM VASCULITIS: RENAL ASPECT RATANA CHAWANASUNTORAPOJ UPDATE IN INTERNAL MEDICINE 2018 OUTLINE Renal involvement in vasculitis Curr Rheumatol Rep 2013 Renal involvement in ANCA vasculitis GN***:
More informationIs it Autoimmune or NOT! Presented to AONP! October 2015!
Is it Autoimmune or NOT! Presented to AONP! October 2015! Four main jobs of immune system Detects Contains and eliminates Self regulates Protects Innate Immune System! Epithelial cells, phagocytic cells
More informationGRANULOMATOSIS WITH POLYANGIITIS
What is granulomatosis with polyangiitis (GPA)? Granulomatosis with polyangiitis (GPA) is a form of vasculitis a family of rare disorders characterized by inflammation of the blood vessels, which can restrict
More informationHow to Evaluate Patients with Cryptogenic Stroke
How to Evaluate Patients with Cryptogenic Stroke Jeffrey Saver, MD Professor of Neurology Director, How to Evaluate Patients with Cryptogenic Stroke Disclosure Scientific Consultant, Unpaid Trialist: AGA
More informationFirst Presentation of Joint Pain
First Presentation of Joint Pain Andrew Harrison Rheumatologist Wellington Regional Rheumatology Unit, HVDHB Bowen Centre, Crofton Downs, Wellington Assoc. Prof. in Medicine, University of Otago Wellington
More informationPatient #1. Rheumatoid Arthritis. Rheumatoid Arthritis. 45 y/o female Morning stiffness in her joints >1 hour
Patient #1 Rheumatoid Arthritis Essentials For The Family Medicine Physician 45 y/o female Morning stiffness in her joints >1 hour Hands, Wrists, Knees, Ankles, Feet Polyarticular, symmetrical swelling
More informationPyrexia of unknown origin? Think still
Pyrexia of unknown origin? Think still Lawrence Owino Okong o, Mmed (UoN); Mphil. (UCT). Lecturer, Department of Paediatrics and Child Health, University of Nairobi. Paediatrician/ Rheumatologist. DISCLAIMER
More information*HSP is a common vasculitis of small vessels with cutaneous & systemic complications. Its etiology is unknown& often follows URTIs.
BY Introduction The disease is eponymously named after Eduard heinrich Henoch (1820-1910), a German pediatrician, and his teacher Johann Lukas Schonlein (1793-1864), who described it in the 1860s. Cont
More informationVasculitis Prof. Dr. med. Katharina Glatz Pathologie
Vasculitis 08-21-2018 Prof. Dr. med. Katharina Glatz Pathologie Agenda Anatomy and histology Vasculitis: Chapel Hill Classification Examples Giant cell arteritis Single organ vasculitis Artery or Vein?
More informationManaging Acute Medical Problems, Birmingham Vasculitis. David Jayne. University of Cambridge
Managing Acute Medical Problems, Birmingham 2016 Vasculitis David Jayne University of Cambridge Disclosures Astra Zeneca, Aurinia, BIOGEN, Boehringer, Chemocentryx, Genzyme/Sanofi, GSK, Lilly, Medimmune,
More informationDilemmas in Vasculitis
Dilemmas in Vasculitis Robert Janson, MD, FACR, FACP Division of Rheumatology Denver VA, UCSOM Vasculitis: Classification Large vessel vasculitis: Giant cell arteritis: more to follow Takayasu s arteritis:
More informationCase conference. Welcome Dr. Lawrence Tierney
Case conference Welcome Dr. Lawrence Tierney Case: 18 year-old male CC) hamatomesis, Fever and cough HPI) 1 st admission One month ago, he admitted to our hospital because of hematemesis. He had weight
More informationVASCULITIS ACOI Robert L. DiGiovanni, DO, FACOI
VASCULITIS ACOI 2018 Robert L. DiGiovanni, DO, FACOI robdsimc@tampabay.rr.com Disclosures NONE Vasculitis Clinicopathologic process characterized by inflammation of and damage to blood vessels. Vessel
More informationA number of factors point to the likelihood of a person with RA developing RV:
What is rheumatoid vasculitis (RV)? Rheumatoid vasculitis (RV) is a rare but serious complication of rheumatoid arthritis (RA) an inflammatory disease that causes severe joint pain and damage, and can
More informationFever in Lupus. 21 st April 2014
Fever in Lupus 21 st April 2014 Fever in lupus Cause of fever N= 487 % SLE fever 206 42 Infection in SLE 265 54.5 Active SLE and infection 8 1.6 Tumor fever 4 0.8 Miscellaneous 4 0.8 Crucial Question Infection
More informationAnnual Rheumatology & Therapeutics Review for Organizations & Societies
Annual Rheumatology & Therapeutics Review for Organizations & Societies Vasculitis Pearls Learning Objectives Identify significant but less recognized disease Features in common forms of systemic vasculitis
More information9/13/2015. Nothing to disclose
Jared Bozeman Kathleen Luskin MD Bipin Thapa MD Medical College of Wisconsin Milwaukee, Wisconsin Nothing to disclose 24 Year old previously healthy woman presenting from OSH Fatigue Weakness Neck swelling
More informationUndifferentiated Connective Tissue Disease and Overlap Syndromes. Mark S. Box, MD
Undifferentiated Connective Tissue Disease and Overlap Syndromes Mark S. Box, MD Overlap Syndromes As many as 25% of patients with rheumatic diseases with systemic symptoms cannot be definitely diagnosed
More informationCrescentic Glomerulonephritis (RPGN)
Crescentic Glomerulonephritis (RPGN) Background Rapidly progressive glomerulonephritis (RPGN) is defined as any glomerular disease characterized by extensive crescents (usually >50%) as the principal histologic
More informationAPPROACH TO PATIENTS WITH POLYARTHRALGIA
APPROACH TO PATIENTS WITH POLYARTHRALGIA Scott Vogelgesang, MD Division of Immunology University of Iowa No conflicts of interest DEFINITIONS Arthralgia joint pain with no evidence of inflammation Arthritis
More informationESIM Winter School 2014 Case Presentation
ESIM Winter School 2014 Case Presentation Hacettepe University School of Medicine Ankara/Turkey Ozant Helvaci, M.D. Patient T.K., 59 years old, male, married with one child, unemployed, place of birth/
More informationChallenges in Perioperative Medication Management. Learning Objectives. Case 1. » Appropriate use of beta-blockers. Management of diabetes drugs
Challenges in Perioperative Medication Management Dimitriy Levin, MD Assistant Professor of Medicine University of Colorado Hospital Medicine Group Learning Objectives» Appropriate use of beta-blockers
More informationAN OVERVIEW OF ANCA-ASSOCIATED VASCULITIS
GRANULOMATOSIS WITH POLYANGIITIS (GPA), MICROSCOPIC POLYANGIITIS (MPA), and EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS (EGPA) AN OVERVIEW OF ANCA-ASSOCIATED VASCULITIS What is ANCA-associated Vasculitis?
More informationHow do polyarthritis, polyarthralgias, and diffuse aches and pains differ?
Approach to the patient with polyarthritis How do polyarthritis, polyarthralgias, and diffuse aches and pains differ? Polyarthritis is definite inflammation (swelling, tenderness, warmth) of more than
More informationDone by: Shatha Khtoum
Done by: Shatha Khtoum Overview Vasculitis -Vasculitis is a general term for vessel wall inflammation -Symptoms and signs depend on the tissue of which the vessels are affected. (slide 2) -There are usually
More information1. To review the diagnosis of gout and its differential. 2. To understand the four stages of gout
Objectives 1. To review the diagnosis of gout and its differential GOUT 2. To understand the four stages of gout 3. To develop an approach for the acute treatment of gout Anthony Lim 9/13/12 Cycle 3 4.
More informationvasculitis Patomorfologia vasculitis (arteritis) caused by infections vasculitis (arteritis) caused by infections
Patomorfologia Lecture 12 prof hab. n. med. Andrzej Marszałek VASCULITIS infectious vasculitis non-infectious causes: Aspergillus Rickettsiae vasculitis (arteritis) caused by infections Mucormycosis syphylis
More informationCerebrovascular Disease
Neuropathology lecture series Cerebrovascular Disease Physiology of cerebral blood flow Brain makes up only 2% of body weight Percentage of cardiac output: 15-20% Percentage of O 2 consumption (resting):
More informationEDITORIAL. Issue Seventeen, October Editorial Team. Issue Seventeen. Info link
EDITORIAL, October 2004 Welcome to the Spring 2004 Edition of InfoLink. The feature article in this edition has been written by Dr Rodger Laurent, Head of Department, PaLMS Rheumatology Laboratory. The
More informationVasculitis Pearls for Practice
Vasculitis Pearls for Practice Philip Seo, MD, MHS Director, Johns Hopkins Vasculitis Center Director, Johns Hopkins Rheumatology Fellowship Johns Hopkins University School of Medicine Baltimore, MD Learning
More informationVasculitis. Marwan Adwan. 4 th year MBBS. Consultant Rheumatologist. MBChB, MRCPI, MSc, MRCP (rheum)
Vasculitis 4 th year MBBS Marwan Adwan MBChB, MRCPI, MSc, MRCP (rheum) Consultant Rheumatologist Case 1 A 45 man presents with 3 wk hx of fever, fatigue, malaise, abdo pain and polyarthralgia. He noticed
More informationCPC. Chutika Srisuttiyakorn, M.D. Kobkul Aunhachoke, M.D. Phramongkutklao Hospital Bangkok, Thailand
CPC Chutika Srisuttiyakorn, M.D. Kobkul Aunhachoke, M.D. Phramongkutklao Hospital Bangkok, Thailand A 53 year-old woman with fever, facial swelling and rashes on face, trunk and upper extremities for 3
More informationINTERPRETATION OF LABORATORY TESTS IN RHEUMATIC DISEASE
INTERPRETATION OF LABORATORY TESTS IN RHEUMATIC DISEASE Laboratory tests are an important adjunct in the clinical diagnosis of rheumatic diseases and are sometimes helpful in monitoring the activity of
More informationEULAR/ERA-EDTA recommendations for the management of ANCAassociated
EULAR/ERA-EDTA recommendations for the management of ANCAassociated vasculitis Dr. Meharunnisha Syed III year DNB Resident (General Medicine) Narayana Health-MSH Fifteen recommendations were developed,
More informationThe Johns Hopkins Hospital
The Johns Hopkins Hospital 19901006 2016/03/21-04/20 (rheumatology) (emergecny medicine) (rheumatology consult team) attending Dr. Haque, R2 Dr. Michailidou, fellow Dr. Adler "She is a so interesting case.
More informationKelley's Textbook of Rheumatology. 2 Volume Set. Text with Internet Access Code for Premium Consult Edition
Kelley's Textbook of Rheumatology. 2 Volume Set. Text with Internet Access Code for Premium Consult Edition Firestein, G ISBN-13: 9781437717389 Table of Contents VOLUME I STRUCTURE AND FUNCTION OF BONE,
More informationEtiology: Pathogenesis Clinical manifestation Investigation Treatment Prognosis
Etiology: Pathogenesis Clinical manifestation Investigation Treatment Prognosis JIA is the most common rheumatic disease in childhood and a major cause of chronic disability. Etiology: Unknown, but may
More informationCoverage Criteria: Express Scripts, Inc. monograph dated 12/15/ months or as otherwise noted by indication
BENEFIT DESCRIPTION AND LIMITATIONS OF COVERAGE ITEM: PRODUCT LINES: COVERED UNDER: DESCRIPTION: CPT/HCPCS Code: Company Supplying: Setting: Kineret (anakinra subcutaneous injection) Commercial HMO/PPO/CDHP
More informationCase Report. 15th June Carolina Ourique Luciana Frade Daniela Alves
Case Report 15th June 2016 Carolina Ourique Luciana Frade Daniela Alves CASE REPORT Woman 23 year-old Single Profission: Social-cultural animator for children CASE REPORT PERSONAL MEDICAL HISTORY Smoker
More informationGLOMERULONEPHRITIS CLINICAL APPROACH TO GLOMERULAR DISEASE ACOI 2018
GLOMERULONEPHRITIS CLINICAL APPROACH TO GLOMERULAR DISEASE ACOI 2018 Disclosures Nothing to declare Case 1 44 yo Caucasian woman admitted from PCP with dyspnea and HTN Has not felt well for 3-4 months
More information