Cases For S Teaching1


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Cases For S Teaching1

  1. 1. Cases presentation <ul><ul><li>Prepared by Dr R Musa </li></ul></ul><ul><ul><li>SPR rheumatology </li></ul></ul><ul><ul><li>St Albans City Hospital </li></ul></ul>
  2. 2. Case (1) <ul><li>GP referral (June 2007) </li></ul><ul><li>54 years old Lady </li></ul><ul><li>Progressive Lower back, left hip and left ankle pain </li></ul><ul><li>Diclofenac without improvement </li></ul>
  3. 3. Rheumatology opinion (Sept 2007) <ul><li>Joints pain mainly lower back & both hips </li></ul><ul><li>No hands pain but her toe swell up and painful to walk </li></ul><ul><li>H/O Patch of psoriasis over her scalp </li></ul><ul><li>Blurred vision couple of times although no redness of her eyes </li></ul><ul><li>Diarrhoea bowel open 8 times /day with loss stool, no blood </li></ul><ul><li>Ex-smoker stopped 20/52 earlier (used to smoke 15 – 20 cigarette/day </li></ul><ul><li>Drink 10 – 15 unit/weeks </li></ul>
  4. 4. Past Medical History <ul><li>2000 Very sever eczematous eruption of both ears & scalp? </li></ul><ul><li>GP diagnose her with ?allergic contact dermatitis </li></ul><ul><li>Dermatology opinion </li></ul><ul><ul><li>Psoriasis with secondary eczema </li></ul></ul><ul><ul><li>Betnovate C ointment bd </li></ul></ul><ul><ul><li>Aqueous cream </li></ul></ul><ul><ul><li>Soft paraffin </li></ul></ul><ul><ul><li>Patch test negative (no allergy) </li></ul></ul><ul><li>2004 anaemia treated with ferrous sulphate </li></ul><ul><li>2005 Ca endometrial (hysterectomy) </li></ul><ul><li>2005 vesico-vaginal fistula </li></ul>
  5. 5. On examination <ul><li>No nails changes, psoriatic skin rash over her eye braw, ext ear & scalp. </li></ul><ul><li>No synovitis in both hands & feet </li></ul><ul><li>Eyes look normal (no irregularity of iris) </li></ul><ul><li>Cervical spine: very restricted movement to all direction </li></ul><ul><li>Thoracic spine: chest expansion </li></ul><ul><li>Lumber spine: restricted forward flexion <70 </li></ul><ul><li>Tenderness opposite both SI joints </li></ul><ul><li>Hips, knees and ankles good range of movement and no synovitis or tenderness </li></ul>
  6. 6. Investigation <ul><li>FBC Normal (slightly low MCV & MCHC despite long term iron therapy) </li></ul><ul><li>ESR 28 </li></ul><ul><li>Normal (U&E, LFT and CRP) </li></ul><ul><li>ANA (+) 1:320 </li></ul><ul><li>RF (-) </li></ul><ul><li>DsDNA (-) </li></ul><ul><li>Ferritin level normal </li></ul><ul><li>HLA –B27 (negative) </li></ul>
  7. 7. Impression <ul><ul><li>Sponyloarthritis related to either </li></ul></ul><ul><ul><li>IBD or Psoriatic arthritis </li></ul></ul><ul><ul><li>Inflammatory bowel disease either </li></ul></ul><ul><ul><li>Crohn or Ulcerative colitis </li></ul></ul><ul><li>Plan: </li></ul><ul><ul><li>x-rays whole spine, SI joints & CXR </li></ul></ul><ul><ul><li>Meloxicam 15mg OD </li></ul></ul><ul><ul><li>Gastroenterology referral </li></ul></ul>
  8. 10. Gastroenterology opinion (October 07) <ul><li>Clinically Ulcerative colitis </li></ul><ul><ul><li>Colonoscopy (Oct 2007) </li></ul></ul><ul><ul><li>Histology (Ulcerative colitis) </li></ul></ul><ul><li>Treatment started by Gastroenterologist </li></ul><ul><ul><li>Prednisolone 40mg OD on reducing dose </li></ul></ul><ul><ul><li>Balsalazide & Mesalazine </li></ul></ul><ul><li>December 2007 Gastro OPD </li></ul><ul><ul><li>because of good response to treatment </li></ul></ul><ul><ul><li>steroid was reduced too quickly (5mg every 5 days) and she remain on 5mg/day. </li></ul></ul>
  9. 11. Rheumatology clinic (9/1/08) <ul><li>Flare up of her arthritis and bowel symptoms </li></ul><ul><li>Diarrhoea 4 – 8 times /day </li></ul><ul><li>pain and stiffness in her spine and peripheral joints </li></ul><ul><li>Plan: - </li></ul><ul><ul><li>increase steroid to 20mg /day </li></ul></ul><ul><ul><li>Switch balsalazide to SSZ 1gm bd </li></ul></ul><ul><li>  </li></ul>
  10. 12. Case (2) <ul><li>GP referral </li></ul><ul><li>29 years old lady with painful hips for many years </li></ul>
  11. 13. Rheumatology opinion (Sept 07) <ul><li>C/O: intermittent neck stiffness and low back pain </li></ul><ul><li>Back pain worse on lying down or site for long time </li></ul><ul><li>No pain in any of her peripheral joints </li></ul><ul><li>She had abdominal pain (colicky) with continues diarrhoea (watery but some times blood in stool around 4-6 times/day) </li></ul><ul><li>H/O peri-anal abscess. </li></ul><ul><li>Weight loss (around 1 Kg in 2/12) despite good appetite </li></ul><ul><li>Known with aggressive psoriasis (Rt hands, elbow & feet) </li></ul><ul><li>Grand-mother had psoriasis </li></ul><ul><li>Known with iritis in Rt eye diagnosed by ophtolomology </li></ul><ul><li>Smoke 20 cigarette/day </li></ul><ul><li>Drink little </li></ul>
  12. 14. On examination <ul><li>Look thin & under Wt (45Kg) </li></ul><ul><li>Psoriatic skin rash over her Rt hand, extensor surface of both elbow </li></ul><ul><li>Eyes not red ( Rt iris irregular ) </li></ul><ul><li>No nails changes </li></ul><ul><li>No synovitis in both hands </li></ul><ul><li>Good movement of all her peripheral joints without pain restriction </li></ul><ul><li>Good movement of her neck without pain or restriction </li></ul><ul><li>Lumber spine restricted forward flexion to 80, lateral flexion good </li></ul><ul><li>No tenderness opposite SI joints </li></ul>
  13. 15. Investigation <ul><li>FBC, U&E, LFT all normal </li></ul><ul><li>ESR 25 </li></ul><ul><li>ANA (-) </li></ul><ul><li>RF (-) </li></ul><ul><li>HLA- B27 (+) </li></ul>
  14. 16. impression <ul><li>Spondyloarthritis related to either </li></ul><ul><ul><li>Psoriasis or IBD </li></ul></ul><ul><li>IBD either (Crohn or Ulcerative colitis) </li></ul><ul><li>Plan: </li></ul><ul><ul><li>X-ray whole spine, SI joints, CXR </li></ul></ul><ul><ul><li>MRI scan of lumber spine & SI joints </li></ul></ul><ul><ul><li>Gastroenterology referral </li></ul></ul><ul><ul><li>Meloxicam 15mg OD </li></ul></ul>
  15. 17. Follow up (Feb 08) <ul><li>Patients not seen by Gastro (she missed two gastroenterology appointment). </li></ul><ul><li>On attending rheumatology follow up (she still have continuous diarrhoea). Reason for missing appointment b/c (very busy on Monday) she is single mother and working </li></ul><ul><li>Her back much better on Meloxicam </li></ul><ul><li>X-ray (show fusion of SI joints & evidence of sacroiliitis) </li></ul><ul><li>MRI show no oedema around SI joints or spine (inactive Sacroiliitis) </li></ul>
  16. 23. Psoriatic arthritis <ul><ul><ul><li>The prevalence of psoriasis among patients with arthritis in the general population is 2–3% but among patients with arthritis it is 7%, while the incidence of PsA has been varied from 3.4 to 8 per 100 000. </li></ul></ul></ul><ul><ul><ul><li>The estimated prevalence of inflammatory arthritis among patients with psoriasis has varied widely from 6% to 42%. </li></ul></ul></ul><ul><ul><ul><li>Prevalence of axial disease varies from 25% to 70% of patients with psoriatic arthritis </li></ul></ul></ul><ul><li>Wright identified five clinical patterns among patients with PsA: </li></ul><ul><ul><li>distal predominant pattern, </li></ul></ul><ul><ul><li>Oligoarticular asymmetrical, </li></ul></ul><ul><ul><li>Polyarticular RA-like, </li></ul></ul><ul><ul><li>spondylosis, and </li></ul></ul><ul><ul><li>arthritis mutilans. </li></ul></ul>
  17. 24. Psoriatic arthritis <ul><ul><li>Moll and Wright’s seminal paper identified the majority of PsA patients as having oligoarthritis </li></ul></ul><ul><ul><li>PsA occurs just as frequently in both sexes </li></ul></ul><ul><ul><li>Nail lesions are very common (occur in about 40–45% of patients with psoriasis uncomplicated by </li></ul></ul><ul><ul><li>arthritis and about 87% of patients with PsA) </li></ul></ul><ul><ul><li>Distal joints involvment, dactylitis with Lower level of tenderness are also typical features of PsA </li></ul></ul><ul><ul><li>Erythema over affected joints </li></ul></ul><ul><ul><li>The presence of spinal involvement, enthesitis </li></ul></ul><ul><ul><li>RF in only 13% </li></ul></ul><ul><ul><li>Arthritis may precede the psoriasis by many years </li></ul></ul><ul><ul><li>Psoriasis and RA may coexist with a prevalence of 3:10 000 </li></ul></ul>
  18. 25. Subclinical uveitis (asymptomatic) <ul><li>The reported prevalence of uveitis (symptomatic) in patients with inflammatory bowel disease varies from 2% to 10%, (uveitis also associated with Subclinical inflammatory bowel disease). </li></ul><ul><li>Adults patients with IBD no evidence of Subclinical uveitis. </li></ul><ul><li>Juvenile patients are relatively insensitive compared with adults with respect to the discomfort of an ocular inflammation. Also children may sometimes show a mitigated course of inflammatory disease because of a difference in the immune response in these autoimmune driven diseases, that is why uveitis often asymptomatic in children. </li></ul><ul><li>Always it is necessary to referred paediatric patients with seronegative arthritis / IBD for ophthalmology review even if asymptomatic </li></ul>
  19. 26. Subclinical colitis <ul><ul><li>Between 5 and 10% of cases of ankylosing spondylitis (AS) are associated with inflammatory bowel disease (IBD), either Crohn's disease or ulcerative colitis. </li></ul></ul><ul><ul><li>Much larger percentage (60%) of AS patients have subclinical gut inflammation manifested either by endoscopic findings or by histology. </li></ul></ul><ul><ul><ul><li>The association with HLA-B27 is less strong in IBD-associated AS than in idiopathic AS, </li></ul></ul></ul>
  20. 27. BSR Guideline on Eligability for anti TNF therapy The same as ASAS Consensus (ASsessments in AS working group) <ul><li>Initiation of therapy: </li></ul><ul><ul><li>Ankylosing Spondylitis patient satisfies modified New York criteria </li></ul></ul><ul><ul><li>Failed conventional therapy (2 or > NSAID each taken sequentially at maximum tolerated dose for 4 weeks </li></ul></ul><ul><ul><li>Active disease for at least 4 weeks </li></ul></ul><ul><ul><ul><li>BASDAI =/> 4 and </li></ul></ul></ul><ul><ul><ul><li>Physician global (specialist) yes/no </li></ul></ul></ul><ul><ul><li>Refractory disease </li></ul></ul><ul><ul><ul><li>Failed at least 2 NSAIDS at max tolerated doses during 3 month period and I/A steroids/SSZ if indicated </li></ul></ul></ul><ul><li>ASAS workshop, Berlin January 2003 </li></ul>
  21. 28. BSR definition of response to treatment (the same as ASAS consensus guidelines) <ul><li>Response </li></ul><ul><ul><ul><li>Time of evaluation at 6-12 weeks </li></ul></ul></ul><ul><ul><ul><li>BASDAI >50% improvement and absolute improvement >2 units and Physician global assessment of response to treatment </li></ul></ul></ul><ul><li>Infusions every 6-8 weeks </li></ul><ul><li>The following assessed in all patients in every follow up: </li></ul><ul><ul><li>Patient pain score </li></ul></ul><ul><ul><li>Patient global assessment </li></ul></ul><ul><ul><li>Spinal mobility score </li></ul></ul><ul><ul><li>CRP </li></ul></ul><ul><ul><li>BASDAI </li></ul></ul>
  22. 29. Marzo-Ortega, H et al. Ann Rheum Dis 2003;62:74-76 (A) Sagittal T2 image of the lumbar spine of a patient with Crohn's disease associated spondylitis, showing end plate oedema of the T10 inferior, T11 superior, L4 inferior, and L5 superior vertebral bodies (black asterisks). (B) The follow up scan after treatment with etanercept, showing complete resolution of the bone oedema at all sites.
  23. 30. Marzo-Ortega, H et al. Ann Rheum Dis 2003;62:74-76 Histological section from the large bowel taken at time of colonoscopy show Severe mucosal inflammatory infiltrate (arrowheads) and a crypt abscess (long arrow) can be seen.
  24. 31. End of the slides <ul><li>Thank you for attending </li></ul>