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Systemic diseases may present with rheumatological complaints
Rheumatic manifestations of systemic diseases: ! Musculoskeletal manifestations and autoimmune phenomena may
A practical approach develop during the course of a systemic disease
! Some systemic diseases are associated with rheumatological conditions
Faith L Chia and vice versa
Consultant, Department of Rheumatology, Allergy and Immunology
Tan Tock Seng Hospital
Joint pain
Vasculitis
Proximal weakness
Generalised pain
Pregnancy

Does this patient have an inflammatory arthritis? Does this patient have an inflammatory arthritis?

A 78 year old lady presents complaining of painful wrists and hands for the A 66 year old lady had paraesthesia in her
last 4 months. The pain is persistent and is associated with warmth and hand that progressed to joint discomfort
swelling. NSAIDs and tramadol provide only partial relief. She also has LOA and stiffness over the last 3 years. She
and has lost 5-6 kg. can’t straighten her fingers fully. There is
no improvement with activity, and using
her hands makes the symptoms worse.

She also has hypertension,
hyperlipidaemia and DM type 2 for 15
years on medical treatment. No family
history of note. FBC, CRP and ESR are
normal. RF positive.

Hypertrophic Diabetic
Pulmonary
Osteoarthropathy
cheiroarthropathy

Joint pain: Systemic causes
Joint pain (or not)

• Be wary of symptoms that are not in keeping with inflammatory joint pain

• Positive RF = Rheumatoid arthritis

• Patients who complain of “joint pain” may actually have periarticular or soft
tissue problems

Articular pain
Non-articular pain
Swelling
Erythema Localisation
If inflammatory: No erythema or swelling
Stiffness >1h Worse with movement
Improvement with activity
Accompanied by systemic
symptoms

Rheumatic manifestations of diabetes mellitus Does this patient have a systemic vasculitis? A 42 year old man was admitted with abrupt onset of fever. Palpable purpura and splinter haemorrhages seen. endocarditis ‣ Vasospasm lymphoma/NHL ‣ TTP ‣ Syphilis ‣ Ergot ‣ Leukaemias ‣ Cholesteral Examination reveals very mild ‣ Tuberculous ‣ Cocaine (mimics ‣ Paraneoplastic emboli proximal weakness. it ‣ Viral infections dysplasia is noted she’s bradycardic ‣ Hep B/C. When phenomenon) ‣ fibromuscular taking her blood pressure. He was toxic with T40oC and had synovitis of the PIPJs. She had asteatotic (Lucio’s causes eczema over her legs. She has ‣ Mycobacteria WG) vasculitis ‣ Cardiac myxoma multiple trigger fingers but no ‣ Leprosy ‣ Congenital synovitis. Treated as for a CAP but with no improvement. • Systemic diseases can mimic vasculitis or cause a true secondary vasculitis She was a chronic smoker but was unaware of any other medical problems. HIV ‣ Marfan’s ‣ Mycotic syndrome aneurysms ‣ Scurvy Hypothyroidism . She also has significant fatigue but has put on weight and not lost weight ‣ Infective ‣ Allergic reactions ‣ Intravascular ‣ DIVC recently. UFEME microscopic haematuria and protein 1+ Infective endocarditis Does this patient have a systemic vasculitis? Vasculitis! A 78 year old lady was admitted with digital ischaemia over the last 2 weeks.TW 32K CRP >200. CK done at her GP was 380. The symptoms get worse after the end of the day. chills and rigors associated with myalgia for 6 days. He then developed this rash and joint pain over his hands and feet. • High swinging fevers should alert to other causes • Many infectious agents and drugs can cause positive ANCA testing (usually p-ANCA but negative anti-MPO or anti-PR3) Cryoglobulinaemia secondary to HBV infection Vasculitis and mimics: systemic causes Does this patient have an inflammatory myopathy? A 42 year old housewife is referred for muscle pain and weakness for 6 Infective causes Drugs Malignancy Others months associated with early morning stiffness lasting 10 minutes.

tenosynovitis • Endocrinopathies (Hypothyroidism. chorea gravidarum • Malignancy Fibromyalgia is not just • Sleep disorders/Depression “rheumatism” Approach to a patient Summary • A thorough and meticulous history and examination is essential • Many systemic diseases have rheumatic manifestations • Baseline labs: FBC. EN • Myopathies • Haematologic: anaemia. back pain. consider Urinalysis Thyroid function Calcium/albumin doing glucose. proteinuria • Metabolic bone diseases (osteomalacia). renal osteodystrophy • Neurologic: nerve entrapment. oedema. Addison’s disease. increased risk of DVT • Vitamin D deficiency • Renal: microscopic haematuria. Hep C) • Musculoskeletal: ligamentous laxity. hyperparathyroidism) • Cutaneous: hyperpigmentation. pruritic urticarial papules and plaques of pregnancy.Inflammatory myopathies Proximal weakness: Systemic causes Cushing’s syndrome • Determining the distribution of weakness is key to generating appropriate Hyperthyroidism differentials Hypothyroidism Hyperparathyroidism • There are many causes for raised CK Hypokalaemia Steroids • High spiking fevers or asymmetrical myositis should alert you to the Hyperkalaemia Statins possibility of infective causes Alcohol ART Becker’s muscular dystrophy Limb-girdle syndrome Myotonic dystrophies type 1 Glycogen storage diseases Lipid storage disorders Mitochondrial disorders Generalised pain Rheumatic manifestations of Pregnancy • Infections: Acute (viruses) and Chronic (Lyme. LFT. U/E/Cr. pruritus. thrombocytopaenia. alopecia (TE). CRP or ESR • Autoimmune diseases are actually quite rare • Differentiation is essential as treatment can be diametrically opposite Joint pain Vasculitis Muscle weakness Generalised pain • Keep an open mind during evaluation Aspirate joint Cultures Muscle enzymes If tendinitis. Hep B/C serologies EMG Vitamin D thyroid function 2DE Biopsy Thyroid function • Fishing expeditions with serologies are rarely helpful .

Langford CA. Rheumatic manifestations of endocrine diseases. 30:1143 • Cacoub P. Current Opinion in Rheumatol 2008. 35: 125 • Sammaritano LR. Clin Rheumatol 2011. 36: 729 . 22: 64 • Molloy E. Terrier B. Rheum Dis Clin N Am 2009. Rheum Dis Clin N Am 2010.References • Markenson JA. Rheumatologic manifestations of pregnancy. Anoop P. Hepatitis B-related autoimmune manifestations. Rheumatologic manifestations of benign and malignant haematological disorders. Current Opinion in Rheumatol 2010. Vasculitis Mimics. 20:29 • Ravindran V.