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Migrant health and rheumatology Dr Jessica Manson Consultant Rheumatologist
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Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

Apr 09, 2018

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Page 1: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

Migrant health and rheumatology

Dr Jessica Manson

Consultant Rheumatologist

Page 2: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

Plan of talk

Chronic widespread pain in migrant populations

Chikungunya infection

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Page 3: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

Chronic widespread pain/fibromyalgia

What has secondary care got to offer?

How is this different for migrants?

Barriers to care

How can we reduce these?

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Page 4: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

Case 1: Mr K

48 year old man

Born in Iran, victim of torture

In prison in the 1990s

Hung from his arms and legs

Beaten around the head

Chronic widespread pain and tinnitus since then

Variable levels, gradually worse

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Page 5: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

List of problems

1. Neck pain

2. Shoulder pain

3. Bilateral knee pain

4. Progressive pain in small joints of hands

5. Numbness in right hand

6. Chronic tinnitus

7. Poor sleep

8. Flash backs

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Page 6: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

Social history

Sculptor

Lives alone

Supportive friends

Previous contact with Freedom from Torture (Medical

Foundation for the Victims of Torture)

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Page 7: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

On examination

No synovitis

Muscle spasm traps and paraspinal muscles

Shoulder movements normal

Signs of carpal tunnel in right hand

Loss of quads muscle bulk

Scars from torture

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Page 8: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

What can I do to help?

Time: in one sitting

Imaging: what should be done and where?

Treat the treatable

Investigate as necessary: getting the balance right

Try not to do things that haven’t worked before: good

collaboration between GP/consultant

Balance the individual issues and the overall picture

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Page 9: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

What I did

1. The easy bits

1. Excluded an inflammatory arthritis

2. Trial of a wrist splint

3. Encourage exercise

2. Investigations

1. Nerve conduction studies (pending)

2. MRI knee (early OA)

3. Treatments

1. Topical lidocaine patch

2. Trial of amitriptyline (failed), gabapentin

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Page 10: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

Now what?

Referral to pain management programme

PTSD – pain

Which to treat first?

Refugee/torture victim support groups

Additional pressures

Benefits/work

Evidence base?

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Page 11: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

Pain case 2: Mr AK

55 year old man

Bangladeshi, in UK since early 20s

Speaks little English

Language line versus face-to-face interpretation

Referred with bilateral shoulder pain

Chronic widespread pain for 10+years

Also

Type 2 diabetes (insulin requiring)

Cirrhosis/ Hepatitis C

Hypertension 11

Page 12: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

Previous pain treatments

Amitriptyline

Gabapentin

Tramadol

Acupuncture

Physiotherapy

One-to-one pain management psychology

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Page 13: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

Social history

Lives with his wife and 6 children

Smokes 10 cigarettes per day

Walks with a stick

Hasn’t worked for 10 years

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Page 14: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

On examination

Evidence of bilateral supraspinatous imgingement

Widespread muscle tenderness

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Page 15: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

What I did

1. Exclude PMR

2. X-ray shoulder to exclude fracture

3. Inject

1. Un-guided initially

2. Then guided

4. Outcome

1. Brief improvement

2. Was it worth it??

Short sharp shock won’t work

Needs community based treatment

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Page 16: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

The use of imaging: showing the patient the

cause of symptoms

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Page 17: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

Language barrier

Psychology through an interpreter

Variable quality

“Judging”

interpreter’s response to distress

Can’t access COPE

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Page 18: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

Chronic widespread pain in migrants: summary

Complex interaction with PTSD

Treat the treatable

Appropriate imaging (therapeutic?)

Language barriers to care

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Page 19: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

Chikungunya case: CN

67 year old woman

Spends 4 months of each year on pacific coast of Mexico

Onset of febrile illness in March

Fatigue, back pain, fever with sweats

Subsequent severe pain in swelling in small joints of

hands and feet

Seen by GP and referred to HTD walk-in 1 month later

Bloods normal except CRP 5.4

Note also hypothyroid

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Page 20: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

Diagnosis

Chikungunya confirmed on serology

High titre IgG, IgM negative (too late)

Dengue IgG and IgM negative

Autoimmune screen negative

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Page 21: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

Treatment

Naproxen

Short course of prednisolone

Follow-up: risk of chronicity

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Page 22: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

Chikungunya: Plan of the talk

The virus and its vectors

Clinical features

Epidemiology

Management

The current epidemic

UCLH’s response

Page 23: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

What is Chikungunya?

Mosquito borne RNA alphavirus

Daytime biters

First outbreak Tanzania 1952

Chikungunya means “to become

contorted/bent up” (Kimakonde)

Not linked to chickens!

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Aedes aegypti

Aedes albopictus

Page 24: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

Why is Chikungunya important?

There is an epidemic now

Huge impact on public health/infrastructure

Chronic morbidity related to ongoing joint pain

Ignorance amongst

Doctors (non-ID!)

The public

“chicken what?”

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Page 25: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

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Stealthy, Debilitating Disease Is

Poised to Sweep the United States

The 'Vacation Virus'

Chikungunya, a new mosquito-borne

illness, is coursing through the

Caribbean. I caught it and it's terrible.

Page 26: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

Clinical features

Short incubation

Abrupt onset

Common features

Fever

Arthralgia

Rash

Rarely

D+V

Eye and ear involvment

Neurological involvement

Myocarditis

Mortality 1:1000

Chronic joint pathology 4-71% 26

Page 27: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

Who is at risk of chronicity?

Chikungunya in France

Returning travellers

Mean age 50

53% women

Predominant joints

Hands, ankles, feet

Risk of chronicity (>3 months)

Women

Age >50

More swollen joints

Comorbidities

Significant impact on QoL (SF36)

Couturier E et al, Rheumatology 2012

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Page 28: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

Diagnosis

Serology (Porton Down)

IgM peaks at 3-5 weeks, persists for 2 months

IgG +ve from 2 weeks onwards

PCR useful if in first week of illness

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Page 29: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

Current outbreak

Begun in late 2013 in Saint Martin

Already affected 1.2 million people throughout Americas

Jamaica declared a state of emergency in November

2014

Returning travellers in the UK

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Page 30: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

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Cases of Chikungunya diagnosed in the UK (PHE)

Page 31: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

The experience from Reunion Island

Epidemic 2005-6

38% population affected (about 300,000 people)

Huge impact on people of working age

Overwhelmed the health service

Well studied group

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Page 32: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

Management

1. Prevention

1. Vector control

2. Vaccination

2. Treatment of infection

1. Anti-viral drugs (favipiravin, ribavarin)

2. Passive immunization with polyclonal IgG from

convalescing patients

3. Treating the arthritis

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Page 33: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

Treatment: evidence from (limited) human

studies

NSAIDs and corticosteroids

Several small studies generally agree about efficacy

Sulphasalazine

Small observational studies suggest some benefit

Chloroquine not more effective than meloxicam

Small randomized trial in India

Symptoms and response to tx not proportional to

inflammatory burden

Chopra et al. A+R 2014

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Page 34: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

Chikungunya at UCLH

Maria Krutikov

Jon Lambourne

Mike Brown

In response to the current Caribbean epidemic

Increase in patients being seen at HTD

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Page 35: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

The ID/Rheumatology clinic

Clinical assessment

Screen for other infectious causes

Screen for other rheumatological causes

Musculoskeletal ultrasound

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Page 36: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

Proposed treatment

1. Naproxen 500mg BD

2. Depomedrone 120mg IM

3. Prednisolone 20mg, reducing by 5mg per week

4. Sulphasalazine

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Page 37: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

Results: cohort

Totals Aug 2014 – Jan 2015: 54 patients

Aug 2013 – Jan 2014: 5 patients

seen in chikungunya clinic: 21 patients

Male 35% Female 65%

Mean age 50.5 years

93% travelled to Caribbean

Jamaica 31%, Granada 19%, DR 6%

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Page 38: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

Results: initial illness

Median time from symptom onset to first review: 25 days

Features of initial illness

Diffuse arthralgia 95%

Fever 67%

Rash 62%

Others: fatigue, headache, GI upset (15-20%)

At presentation, mean CRP 7, mean ESR 16.8

15% had elevated ALT (range 55-115)

2 (with dengue co-infection) had thrombocytopenia

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Page 39: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

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Page 40: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

Results: Chikungunya clinic cohort

For those with persistent arthralgia

Median time between symptom onset & chik clinic rv

12.1 weeks (5.4 weeks – 39.4 weeks)

Joints affected: Knees (71%), Feet (62%), Ankles (57%),

Hands (57%), Wrists (48%), Elbows (14%)

Carpal tunnel syndrome: 9 patients (43%)

15% had positive Rheumatoid Factor (no +ve CCPs)

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Page 41: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

Ultrasound findings from the UCLH Chik clinic

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Page 42: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

Effusion and non effusion IPJ

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Page 43: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

Results: Treatment

NSAIDs 59%

Systemic corticosteroids 15% of whole cohort

33% of chik clinic cohort

Chloroquine + Sulfasalazine 1 patient

Wrist splints for carpal tunnel syndrome

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Page 44: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

Results: Follow up

83% of total cohort followed up (100% of ID/rheum

cohort)

Median time from 1st review to follow-up 6.3 weeks

Progress at time of follow-up

7% improved

83% improving

7% unchanged

0 worse

Most common on-going symptom = mild-arthralgia 44

Page 45: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

Chikungunya: what next

Spreading the word

EULAR

Patient.co.uk

Extended cohort

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Page 46: Dr Jessica Manson Consultant Rheumatologist - The HTD Rheumatology 22 07 15~JM.pdf · Speaks little English ... Exclude PMR 2. X-ray shoulder to exclude fracture 3. Inject 1. ...

Thank-you

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