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REVIEW
DR. K. MALONEY
RHEUMATOLOGY REVIEW
• Rheumatoid arthritis
• Systemic Sclerosis
• Atypical presentations:
• Oligoarthritis symmetrical polyarthritis
• Monoarthritis (must rule out septic arthritis)
SPECTRUM OF PRESENTATION
DIAGNOSIS
• Rheumatoid nodules
• Osteoporosis
• Scleritis
• Decreased mobility, glucocorticoid use,
chronic inflammation
• Interstitial lung disease • Bone mineral density alone does not fully
reflect fracture risk
• Secondary amyloidosis
MEDICAL THERAPY
• DISEASE –MODIFYING ANTIRHEUMATIC
DRUGS (DMARDS)
• NSAIDS
• Omega 3
• Calcium
• Vitamin D
NON-PHARMACOLOGICAL
MANAGEMENT
• Patient education and counselling
• About the disease (relapsing/remitting; deformity and disability)
• Smoking cessation
• Modifying risk factors for osteoporosis and atherosclerosis
• Physical therapy
• Occupational therapy
• Multiple autoantibodies
• Common rashes:
• Malar rash
• Discoid lupus
• Lupus profundus
• Subacute cutaneous lupus
• Alopecia
• Mucosal ulcerations
MUCOCUTANEOUS
MUSCULOSKELETAL
• Arthralgia
• Arthritis
• Inflammatory myositis
• Myalgia
• Complications of disease/therapy:
• Osteonecrosis (avascular necrosis)
• osteoporosis
KIDNEY
• Affects 50 -75% • DO NOT WAIT FOR BIOPSY READING TO
COMMENCE THERAPY
• Start corticosteroids immediately if
• Nonwhite patients more affected suspicion high
• Once biopsy establishes disease add
induction agent (CYC/MMF)
• Proteinuria, hematuria, cellular casts
• Anti-ds DNA and ↓ complement with renal
• Uncontrolled: ↓kidney function, hypertension, activity
edema, kidney failure
• Poor prognosis:
• Biopsy important for diagnosis, guide therapy • Older age, black race
and prognosis • Elevated creatinine, low hematocrit
• Class IV, cellular crescents, interstitial fibrosis
NEUROPSYCHIATRIC
• 15-95% • Wide range of presentations
• Aseptic meningitis
• Stroke
• Important contributor to morbidity
• Seizures
and mortality
• Transverse myelitis
DCT
DRUG INDUCED LUPUS
• Clinical presentation, history of • Typical antibodies
medication use, symptom resolution ≤ 6 • ANA
weeks of drug discontinuation • Anti-single stranded DNA
• Anti-Histone
• Typical manifestations
• Rash • Other findings
• Arthritis • Absent Anti-double-stranded DNA
• Pleuropericarditis • Absent anti-Smith
• Cytopenias • Complement levels normal
• Fever
• Procainamide, hydralazine,
methyldopa, TNF α inhibitors
TREATMENT
Immunosuppressives/ Steroid
NSAIDs & Steroids Antimalarials sparing
(hydroxychloroquine) • Necessary when sustained
• NSAIDS - For arthralgia moderate/high dose steroids
required
• Rash, arthritis
• Glucocorticoids
Topical, systemic, intra- • Azathioprine, methotrexate,
articular • Other benefits mycophenolate moefetil,
cyclophosphamide
Prevents lupus flares
Low dose for rash, arthritis
May reduce organ damage
• Biological
High dose - severe Reduces thrombosis risk
manifestations 1. Belimumab (B cell activating
Reduces bone loss factor)
Increases long term survival 2. Rituximab (anti- CD20)
SYSTEMIC SCLEROSIS-
PATHOPHYSIOLOGY & EPIDEMIOLOGY
• Unknown cause
• Characterized by
• Fibrosis of dermal, visceral organs and blood vessels (digital and pulmonary)
• vasculopathy (raynauds, pulmonary hypertension)
• Anti-PM-Scl – myositis
CUTANEOUS MANIFESTATIONS
• Initial manifestation • Antihistamines
• Swelling and puffiness of hand digits
• Emollients
• Pruritus
• Avoid glucocorticoids!
• Dermal induration
• Immunosuppressives for
• Tellangiectasias moderate/severe dermal
edema/swelling
• calcinosis
VASCULAR
• Vasospasm raynauds • Avoidance of cold exposure
• Calcium channel blockers
• Intimal proliferation • Antiplatelet agents
• Terminal arterioles in microvasculature • Topical nitrates
• luminal obliteration
• Terminal digital pits
• Digital ulcerations • Phosphodiesterase-5- inhibitor: Sildenafil
• Digital gangrene • Endothelin receptor antagonists
• Prostacyclin analogues
• Affects digits, lungs, myocardium, GI • Regional sympathetic blockade / digital
tract, kidneys sympathectomy
KIDNEY
• Sceroderma renal crisis • Ace inhibitor
• dcSSc • Prompt and aggressive titration
• Low threshold for commencing
• Intimal proliferation, luminar • Dleays in Rx renal failure
thrombosis in afferent renal arterioles
• Maintain Rx even if renal failure
• High renin levels present bc renal improvement may
• Glomerular ischemia improve months later
• Pleuritis
• Recurrent aspiration
• Organizing pneumonia
• Swollen hands
• Arthritis
• Usually nonerosive
• RA like erosions may occur along with deformities
• Fatigue
TREATMENT & PROGNOSIS
• Tailored to individual symptoms/manifestations
• NSAIDs
• Antimalarials
• Corticosteroids
• Immunosuppressive medications