Common Rheumatology Issues in Hospital Medicine Lianne Gensler, MD - PDF document

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]

Outline  71 year old with a hot knee  A 67 year old with Dyspnea & Acute Kidney Injury  28 year old woman with cough, dyspnea and fever Demography is important!  Age  Gender - Younger age – consider SLE, - Females – SLE, MCTD, Sjogren’s, APS, reactive arthritis & Scleroderma; premenopausal (no genetic disorders (periodic gout) fever syndromes)  Ethnicity - Older age – consider ANCA - African Americans – SLE, Sarcoid; vasculitis, GCA, crystal arthritis almost never GCA - Turkish – Bechet's disease, FMF - Filipino - gout 4 2 | [footer text here]

The case of the swollen knee Initial Presentation • 71 year old man with HFpEF admitted 3 days prior with CHF exacerbation • After 2 days of diuresis, the patient’s dyspnea improved. • Started complaining of left knee pain and swelling Past Medical History HTN, CAD, HFpEF, CKD (stage 3), gout, Psoriatic Arthritis (PsA) Medications Medications: ACEi, Beta blocker, ASA, IL17Ai (monoclonal antibody biologic for PsA) The case of the swollen knee Vital Signs Musculoskeletal • BP 155/88 , Pulse: 80 , Temp 98.9 o C; O2 • Right Knee swelling and warmth. sat 94% on RA Constitutional Skin • Well-developed and well-nourished • No nodules or purpura; no tophi • In no apparent distress • + mild plaque psoriasis and nail dystrophy Cardiac • RRR, S4, no murmurs • 1+ pitting edema Pulmonary • Bibasilar crackles, normal resp effort 3 | [footer text here]

How to identify the hot knee  Temperature - Joints should be cooler than the rest of ext  Bulge test - Squeeze fluid out of the suprapatellar pouch - Medial compartment emptied by pressing medial aspect of joint - Lift hand away - Lateral side sharply compressed  Ripple seen on the flattened medial surface 7 Aspiration of Swollen Joint Narrows ddx Crystals (+) Crystals (-) Septic Joint Acute RA Trauma Bacterial CPPD / Psoriatic Hemarthrosis, Staph, GC Pseudo- Gout meniscal Arthritis Atypical gout birefringent - derangement Reactive Mycobacteri Osteoarthritis birefringent Arthritis a, The differential diagnosis of a monoarticular + spirochete hot joint Fungal 4 | [footer text here]

Differential Diagnosis of the swollen joint - Rule out infection; look for crystals  Septic Joint  Gout - Immunosuppressed - Psoriasis - Damaged joint - Diuresis & low dose ASA - Psoriasis portal of entry - CKD  Psoriatic Arthritis  Acute CPPD (Pseudogout) - Holding meds? Is this typical - The knee is a good joint joint for this patient? - CKD (via Diagnosis of exclusion hyperparathyroidism) 9 The hot joint: Crystals and Pearls Crystals WBCs/mm 3 Pearls Septic joint No >20,000 Early in process, counts can be lower Gout Yes 10,000 - >50,000 Acute CPPD Sometimes! 10,000 - >50,000 Lab can miss crystals (Pseudogout) Rheumatoid Arthritis No 3,000 – 30,000 Not usually acute Spondyloarthritis No Not usually acute Reactive Arthritis 15- > 50,000 Psoriatic Arthritis 3,000 – 30,000 Non-inflammatory No <2000 Not usually warm (Osteoarthritis) 5 | [footer text here]

Bacterial Septic Joint  Prevalence: in adults presenting with >= 1 acutely swollen joint estimated 10% Sensitivity Specificity Risk factors (95%CI) (95%CI) Age Joint pain 85% (78-90) IVDU Joint swelling 78% (71-85) DM, RA, HIV Joint surgery; prostheses Fever 57% (52-62) Skin infection Night sweats 27% (20-34) Rigors 19%(15-24) Margaretten ME, Kohlwes J, Moore D, Bent S; JAMA. 2007;297(13):1478. Gout  Most common inflammatory arthritis in US - 8.3 million adults - 2x hospitalization rates - Increased economic burden - More cardiovascular disease & metabolic syndrome  NHANES 2007-8: > 70% CKD ≥ stage2 / HTN Zhu Y et al. Arth Rheum 2011; 63:3136-41; Lim SY et al. Ann Rheum Dis 2012; 71:1765-70; Kuo CF Nat Rev Rheumatol 2015; 11:649-62; Choi HK et al. Arth Rheum 2007;57:109-15; Zhu Y et al. Am J Med 2012:125(7) 679-87 6 | [footer text here]

What to do with Gout medications in the admitted patient  Allopurinol/Febuxostat Do not stop allopurinol unless absolutely indicated  - Hypersensitivity reaction  Colchicine - Renal Failure - Unexplained myopathy or neuropathy Medicare claims data: higher allopurinol dose protected against incident  renal failure The Health Improvement Network (THIN): incident allopurinol use in incident  gout was not associated with increased HR for CKD ≥ 3 Singh JA Ann Rheum Dis 2017; 76:113-139 Khanna D et al. 2012 Arth Care Res (Hoboken) 64, 1447-61 Vargas-Santos AB et al. Arthritis Rheumatol. 2016; 68 (suppl 10) Colchicine for Acute Gout  Use within 36 hours of an attack  1.2mg followed by 0.6mg 1 hour later followed by 0.6mg 1- 2x/day  For attacks during ULT with colchicine prophylaxis, can consider an additional dose 7 | [footer text here]

A 67 year old with Dyspnea & Acute Kidney Injury Initial Presentation Family History 67 yo male admitted with fatigue, dyspnea No history of autoimmune disease. Father with progressive over the last month and AKI CAD/MI at 50 years old. Mother with breast CA Past Medical History ROS Bronchiectasis Atrial Fibrillation Tactile fever, no chills or night sweats Former heavy EtoH + 40lb weight loss and generalized weakness No eye pain or vision change Medications Dyspnea, cough non-productive; no hemoptysis Metoprolol No chest pain Aspirin No sinus symptoms, abdominal complaints, numbness or weakness Social History No joint pain Vietnam Veteran. Retired from real estate. Housed. No rashes Divorced. Former smoker. No illicits. No EtoH A 67 year old with Dyspnea & Acute Kidney Injury Vital Signs Gastrointestinal • T 36.8 BP 103/63 P: 90-110 RR 16 Sp02 • Soft, NT, no hepatosplenomegaly 90% RA Musculoskeletal Constitutional • No synovitis, including no joint tenderness or • thin but otherwise well appearing swelling HEENT Neuro • Poor dentition. No oral ulcers • No scleral injection. no cervical adenopathy • A&O x 3. Motor and sensory exam intact • Motor strength 5/5 upper/lower ext Cardiac • Irregularly irregular. No murmurs Skin • No edema • + non blanching macular rash on lower ext. No Pulmonary nodules • Inspiratory bibasilar crackles 8 | [footer text here]

Labs 9.2 7.6 56 135 106 2.0 455 12.2 4.7 18 3.2 23.5 4.1 Micro: ESR >100 Utox: negative Albumin 3.2 Blood cx: 1 of 2 sets CRP 50 total protein 7.9 + MSSA UA: 11 RBCs, 2 WBC, 100 mg/dl IgG 1723 (H) HIV negative protein, few dysmorphic RBCs IgA 508 (H) Hep B and Hep C UPCR: 1.89 grams IgM 105 (wnl) negative QFT negative (6/2017) C3 101 ANA 1:320 SPEP/IFE: no C4 15 speckled paraprotein ANA sub-serologies (-) +ANCA >1:640, MPO>800 The Phenotype of ANA (SLE) & ANCA diseases (AAV) SLE (Younger F) AAV (Older M) Skin +++ Photosensitive + Palpable purpura Renal +++ Immune complex GN +++ Pauci-immune GN Pulmonary ++ DAH, Serositis +++ DAH, Pulm nodules WBC +++ Leukopenia, lymphopenia ++ Leukocytosis Platelets ++ ITP, APS ++ Thrombocytosis Hemoglobin +++ ACD, AIHA +++ ACD Joints +++ Small joint polyarthritis + variable ESR/CRP +++ ESR>CRP +++ ESR & CRP C3/4 +++ Often low -- 18 9 | [footer text here]

IF: Negative Pulmonary manifestations of ANCA Associated Vasculitis (AAV) ILD Nodules Microscopic DAH Granulomatosis Polyangiitis & Polyangiitis (MPA) (GPA) Tracheal/ Bronchiectasis bronchial stenosis Mohammad et al. J Rheumatol 2017. 10 | [footer text here]

ANCA Vasculitis GPA MPA EGPA Sinusitis +++ -- ++ Most common Pulmonary nodules DAH Asthma pulmonary Renal Pauci-immune GN Pauci-immune GN Pauci-immune GN +/- eosinophils Neuro Mononeuritis multiplex Peripheral Neuropathy Mononeuritis multiplex Ocular PUK, scleritis > uveitis ANCA testing  Indirect immunofluorescence assay - pattern & titer - More sensitive  ELISA using purified specific antigens - More specific  Proteinase 3 (PR3)  Myeloperoxidase (MPO) 11 | [footer text here]

ANCA testing Vasculitis type Formally ANCA + Typical ANCA Myeloperoxidase (MPO) known as Fluorescence & Anti-Proteinase 3 (PR3) Granulomatosis with Wegner’s 90% systemic C-ANCA PR3 > MPO Polyangiitis (GPA) Granulomatosis 40% limited Microscopic -- P-ANCA MPO > PR3 Polyangiitis (MPA) Eosinophilic Churg-Strauss 40% MPO > PR3 Granulomatosis with Syndrome Polyangiitis (EGPA) Other considerations Typical ANCA Myeloperoxidas Anti Fluorescence e (MPO) Proteinase 3 Levamisole C-ANCA -- ++ IBD P-ANCA 28 year old woman with Lupus presenting with cough, dyspnea and fever Initial Presentation -1 week ago - developed cough & dyspnea. -Past 6 weeks, lupus has been in a mild-moderate flare, characterized by fatigue, malar rash & increased joint pains -Reported fevers to 101.5 & rigors. No night sweats Past Medical History PMH: Systemic Lupus Erythematosus: ANA+ dsDNA+ low complements, rash, arthritis Medications Hydroxychloroquine Prednisone 15mg per day Methotrexate 15mg per week/daily folate 12 | [footer text here]