You need to know these practical tips for diagnosis, evaluation and treatment across common rheumatological conditions.
Jason Kolfenbach is the director of the Rheumatology Fellowship program at the University of Colorado and a co-editor of the textbook, Rheumatology Secrets.
John Stone, the well-known Harvard Medical School Professor is also the editor of A Clinician’s Pearls & Myths in Rheumatology (new edition soon to be published).
Together, they shared a range of clinical pearls and myths. Let me share a selection of these:
Anterior uveitis should be thought of as a symptom, not a diagnosis.
A systematic rheumatology evaluation identified undiagnosed spondyloarthritis in 40-45% of unselected acute anterior uveitis patients. Our ophthalmology colleagues probably do know this, so hopefully they will ask the right questions and refer for further assessment.
In patients with systemic sclerosis (SSc), monitor for proton pump inhibitors (PPI) side effects.
Use of PPIs is ubiquitous. They may cause diarrhoea, and this leads to clinical confusion due to the worry of malabsorption in SSc.
PPIs may also lead to reduced absorption of mycophenolate.
Review the medication list in patients with exacerbation of their subacute cutaneous lupus erythematosus.
Think of these commonly used medications: hydrochlorothiazide, NSAIDs, PPIs, calcium channel blockers, ACE-inhibitors.
While SCLE may be triggered by medications, it’s actually rare for medications to trigger discoid lupus.
MYTH: Symmetrical polyarthritis is the rule at presentation of rheumatoid arthritis (RA)
In fact, two common presentations of RA involve:
- Asymmetric oligoarthritis
- Migratory oligoarthritis
PEARL: Migratory oligoarthritis may be the presenting symptom of ANCA-associated vasculitis.
It favours lower extremities and is usually quickly forgotten as it responds exquisitely to steroids. A return of the arthritis often heralds a flare.
MYTH: RA improves dramatically in pregnancy.
The reality is DAS28 remission occurs in only 25%. Flares occur in 29%, with the discontinuation of effective therapy likely to explain part of this. Post-partum flares occur in 47%.
MYTH: Serum complement levels are the Rosetta Stone for understanding lupus activity in pregnancy.
While hypocomplementemia predicts preterm birth if it is present before pregnancy, and it predicts pregnancy loss if observed in the first trimester, the reality is that complement levels actually increase 10-50% in normal pregnancies.
As such, trends are much more helpful than any single measurement.
PEARL: Raynaud’s is usually the first sign of SSc, but there is one important exception…
The patient who presents with puffy hands, often misdiagnosed as having RA. These patients often have anti-RNA polymerase III antibodies, with an increased risk of scleroderma renal crisis.
PEARL: Granulomatosis with polyangiitis (GPA) patients can have submandibular gland enlargement as well as lacrimal gland enlargement (dacryoadenitis).
The differential diagnosis of dacryoadenitis is short:
- Sjogren’s syndrome
- IgG4-related disease
- Sarcoidosis
- AL amyloidosis
- GPA
In his final slides, John Stone recounted a case of a patient admitted with polyarticular pseudogout he had to look after as an intern. This patient also presented with excruciating cervical spine pain.
On reviewing his handwritten clinical notes (he apparently kept photocopies!) decades later, Professor Stone felt certain the diagnosis was Crowned Dens Syndrome.
Crowned Dens Syndrome involves a dramatic presentation of acute cervical pain. It is due to retropharyngeal calcium deposits and is a mimic for GCA/PMR, meningitis and sepsis. CT or MRI imaging is the key to diagnosis and the condition is exquisitely responsive to prednisone.
The session was educational and enjoyable. Hopefully, we can use some of these pearls in clinic soon.
