26/06/22 1 Clinical Problem Solving FEVERS and Rheumatic Diseases
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Clinical Problem
Solving FEVERS and Rheumatic
Diseases
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Introduction Introduction
Pyrexia alone as a clinical presentation of rheumatic diseases - PUO differential diagnosis
The investigation and differential diagnosis of fever presenting with musculoskeletal symptoms or signs
MSc relevance - Clinical practice and problem solving
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AgendaAgenda
Fever - Aetiopathogenesis Fever - Periodicity and rheumatic
disease: Childhood fevers Fever - PUO and the rheumatic
diseases Fever - and vasculitis - A simplified
Guide to Investigation
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AgendaAgenda
Fever - AetiopathogenesisFever - PUO and the rheumatic diseases
Fever - Periodicity and rheumatic disease: Childhood fevers
Fever - and vasculitis - A simplified Guide to Investigation
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FEVERFEVER Hypothalamic control Cooling - accelerated
activity of skeletal muscle / Reduction of peripheral blood flow
Heat - Reduced muscle activity / Peripheral vasodilation and sweating
Endogenous Pyrogens PMN / Macrophages but not lymphocytes :TNF / INF alpha / IL1 / IL6 found in many rheumatic diseases
Exogenous pyrogens Bacterial cell wall, LPS, drugs
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LIPOPOLYSACCHARIDELIPOPOLYSACCHARIDE
Endotoxin on surface of bacterial cell wall Lipid A as active component “Shock toxin”: Hypotension, peripheral shutdown Leucopaenia Activation of kinins and complement cascade Activation of macrophages and monocytes Inhibition of macrophage migration Inhibition of PMNs Vascular leakage and inflammation
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AgendaAgenda
Fever - aetiopathogenesis
Fever - PUO and the rheumatic diseases
Fever - Periodicity and rheumatic disease: Childhood fevers
Fever - and vasculitis - A simplified Guide to Investigation
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FeverFever as a symptom as a symptom
Pyrexia Joint and back pain Myalgia Weight loss Normochromic normocytic anaemia Skin rash Lympadenopathy
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PUOPUO
Prolonged obscure fever > 3 weeks usually represents an atypical presentation of a well-known condition
Pattern and periodicity rarely aid diagnosis Aggressive diagnostic efforts are usually
justified - treatment
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PUOPUO without localising signs without localising signs
INFECTION
NEOPLASIA
IMMUNOGENIC INFLAMMATION
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PUO - Don’t Forget...PUO - Don’t Forget...
Factitious Drug induced (anti-TB,cyclophosphamide) Recurrent PEs Chronic granulomatous hepatitis Sarcoidosis Occult bowel inflammation
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PUO without localising PUO without localising
signs- signs- InfectionPUO without localising PUO without localising
signs- signs- InfectionViral longterm infection: EBV CMV Chronic
Pyogens and Granulomatous triggers:
TB
Fungi (Candidiasis, histoplasma, actinomyces, coccidioidomycosis)
Tropical diseases and parasites (Malaria, Toxoplasmosis etc etc)
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PUO with rheumatological PUO with rheumatological signs - signs - InfectionInfection
JOINTS - Septic arthritis: Septic bursitis. Aspirate and Culture for;
Bacteria Fungi Parasites
BONES - Osteomyelitis acute or chronic. Culture and biopsy with stains for;
Bacteria including TB Fungi Parasites especially in
HIV
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PUO PUO - “Arthritogenic” Bacteria - “Arthritogenic” Bacteria with few localising signswith few localising signs
TB SalmonellaBrucella
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Bacterial EndocarditisBacterial Endocarditis
Systemic vasculitis Mimic of immunogenic disease Complement consumption and elevated
ESR CRP Urinary RBC Disclosed by positive blood cultures except
with difficult germs (Q fever, aspergillus)
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BACTERIAL ENDOCARDITIS BACTERIAL ENDOCARDITIS and Rheumatic Diseaseand Rheumatic Disease
Infectious endocarditis has a higher incidence in SLE (?infected Libmann-Sachs)
? Antibiotic prophylaxis of SLE patients pre-surgery
Endocarditis in patients with RA and AS with aortic involvement
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FeverFever, Infection and Rheumatic , Infection and Rheumatic disease - ? A sterile jointdisease - ? A sterile joint
Viral septic arthritis (hepatitis B, AIDs)and reactive arthritis (parvovirus, measles etc)
Reiter’s Syndrome (sexually transmitted and GI infection)
Lyme disease
Venereal diseases (Syphilis, GC)
Mycoplasma
Fungal and protozoal (joint and bone )
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Back Pain and Back Pain and feverfever
Fever as an alert sign with back pain
X RAY:FBC:CULTURE:SCAN:BIOPSY
SPINAL - Infected disc and vertebral lesions: TB 40%: Gram neg 20%: Staph 20%:Strep 20%.
PARASPINAL - Psoas abscesses usually secondary to vertebral OM
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PUOPUO with arthralgia, myalgia with arthralgia, myalgia
and vasculitis- and vasculitis- NeoplasiaNeoplasia
Lymphoma - endogenous pyrogens from Hodgkins LNs
Leukaemia - Usually due to infections Solid Tumours - Hypernephroma, Pancreatic
carcinoma, GI carcinoma (tissue necrosis and release of LPS)
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PUO - PUO - ImmunogenicImmunogenic Rheumatic fever RA - Adult Stills SLE Systemic Vasculitides JIA GCA - 15% PUO >65 years
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Rheumatic Rheumatic FeverFeverMAJOR polyarthritis chorea carditis erythema marginatum sc nodules
MINOR fever arthralgia ESR CRP PR prolonged
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FeverFever and RA and RA
RA - Activity RA - Infection - Beware the septic joint
replacement RA - Vasculitis RA - Amyloid RA - Drugs
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SLE and SLE and FeverFever - The usual - The usual diagnostic dilemmadiagnostic dilemma
Activity OR Infection Clues to infection Clinical (Urinary frequency, CXR, Diarrhoea and
rigors) Elevated CRP, leucocytosis, dsDNA titre low Lab tests (Cultures, Urinary sediment)
Consider drug-induced, PEs, Malignancy
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AgendaAgenda
Fever - aetiopathogenesis
Fever - PUO and the rheumatic diseases
Fever - Periodicity and rheumatic disease: Childhood fevers
Fever - and vasculitis - A simplified Guide to Investigation
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Childhood Childhood feversfevers and Arthritis and Arthritis
Infection: Viruses and Streptococci Post-Viral reactive arthritis Post - Viral vasculitic syndromes JIA and Stills disease
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Familial Mediterranean Familial Mediterranean FeverFever
Genetic: autosomal recessive Sephardic jews and ethnic Armenians: Short arm of chromosome 16
Childhood or early adolescence Brief high fevers at irregular intervals Peritonitis, arthritis and pleuritis Amyloid AA systemic as nephropathy
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AgendaAgenda
Fever - aetiopathogenesis
Fever - Periodicity and rheumatic disease: Childhood fevers
Fever - PUO and the rheumatic diseases
Fever - and vasculitis -
A simplified Guide to Investigation
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ABC of ABC of PUOPUO - ? Vasculitis - ? Vasculitis
A - Acute phase Proteins (ESR, CRP)
B - Blood tests - Other (U and E, LFT, CPK, ANA, ANCA, C3 and C4)
C - Cultures (Blood, MSU, throat swab, Stool)
D - Dipstix urinalysis and renal function
E - ECG/Echocardiogram
F - Films (CXR)
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ABC of Vasculitis ABC of Vasculitis InvestigationInvestigation
More complex serology
Biopsy - liver, BM, Temporal artery
HIV
Cryoglobulins
Hepatitis serology
CSF
Neuroelectrics
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SummarySummary Pyrexia is common in disease and does not
usually aid diagnosis Do not ignore fever - investigate as it
normally represents pathology Exclude infection especially SBE After investigation consider alternatives such
as drug induced fevers/PEs Basic vasculitis work up