Tasty Morsels of EM 052 – Rheumatic Fever and the Jones Criteria

As always, this is from the ever expanding google doc on bits and bobs I read and learn from and transfer here for all our learning pleasure.

This is something you’re very unlikely to diagnose in Ireland. The real reason for including this is it seems to be a favourite exam question and I put it here in the hope that I’ll remember it. I did look after a couple of kids with ARF when I was in NZ in 2007 but that’s it.

As an acute illness you’re hoping to see

  • kid aged 5-15
  • Migratory Arthritis
    • usually the earliest manifestation
    • usually large joints
    • one joint just settling while another one flares up. Usually over a 2 week period or so
  • Carditis (a poker overuse syndrome?)
    • usually called a pancarditis cause it can affect everything from valves to myocardium
  • Sydenham chorea (nothing to do with the Sydenham bypass apparently…)
    • sometimes called St Vitus’s dance. See this video.
  • Rash
    • Erythema marginatum
    • serpinginous (what a word!) bright pink macules
    • apparently hot water (bath or shower) could make the rash worse
  • Subcutaneous nodules
    • small round and painless over the joints

These are summarised in the Jones criteria:

  • Major
    • Arthritis
    • Carditis
    • Chorea
    • Rash
    • Nodules
  • Minor
    • Fever >38
    • Arthralgia
    • ESR/CRP rise
    • Prolonged PR interval (without other carditis)

Two major criteria nails it or one major and two minor.

More FOAMed Resources:

Featured Image:

  • Painting by Pieter Brueghel the Younger on Wikipedia CC License. Of note it comes from a wonderful article called ‘dancing mania’.

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Tasty Morsels of EM 051 – Spondyloarthropathy

As always, this is from the ever expanding google doc on bits and bobs I read and learn from and transfer here for all our learning pleasure. This one from a recent training day with a rheumatologist. Some is literature based some his good old fashioned doctoring and experience.

  • can be axial (think ank spond) or peripheral (think psoriatic)
  • most important ones
    • ankylosing spondylitis
    • reactive arthritis (formerly Reiter’s)
    • arthritis of inflammatory bowel disease (enteropathic arthritis)
    • psoriatic
  • enthesitis (tendons or ligs into bone) and dactylitis are distinctive features
  • lots of systemic features/associations
    • uveitis
    • skin rash
  • For ank spond MRI will show the SI joint changes so much earlier than plain films and you’re likely wasting your time with plain films (my own opinion on that one)
  • NICE Guidelines suggest diagnosis of ank spond based on radiological and clinical evidence. Beware of unilateral sacroilitis as it’s often infective (esp IDU)
  • Psoriatic
    • nail disease v common
    • back pain, dactylitis and enthesitis all common
    • psoriatic skin changes prior to the arthritis in 60%

 

References:

  • Excellent rheumatology lecture somewhere in the midlands of Ireland Spring 2015
  • Rosen’s 8th Edition Chap 115

 

Featured image:

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Tasty Morsels of EM 050 – Rheumatoid arthritis

As always, this is from the ever expanding google doc on bits and bobs I read and learn from and transfer here for all our learning pleasure. Some of this morsel is straight advice from a local rheumatologist rather than strict EBM.

  • commonest presentation
    • middle aged female with multiple small joints
    • remember that if symptoms less than 6 weeks then it’s usually one of many viruses
  • there are formal diagnostic criteria
    • heavily weighted on number of joints involved and some of the tests
    • >6 weeks duration is on the criteria
  • 10% of healthy population has pos rheumatoid factor.
  • Swollen joint much more diagnostically useful than simple painful joint
  • anti CCP the big new test. Very specific test but not sensitive
  • Rheumatoid in general carries increased CV risk never mind the NSAID use

Treatment pearls

  • flare of known RA
    • steroids depomedrone 80mg IM or 40mg oral for a week
    • NSAIDs – remember naproxen is the only one with low CV risk
  • mouth ulcers on methotrexate?
    • change to nightly dose
    • double up on folic acid dose
  • abnormal LFT on methotrexate?
    • ALT is usually first to rise, if continuing to rise at 2 weeks consider stopping
  • abnormal FBC on methotrexate?
    • neuts <1.5 then stop drug.
    • it was suggested that MTX be held in all infections needing antibiotics even when WCC is normal
  • Long term steroids are rarely appropriate any more – if you find someone floating around on long term steroids from 15 yrs ago the they’ve probably been lost to follow up and it’s worth referring them again.

 

References:

  • Excellent rheumatology lecture somewhere in the midlands of Ireland Spring 2015
  • Rosen’s 8th Chap 116

Featured Image: James Heliman MD, CC License, Wikipedia

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Tasty Morsels of EM 049 – Gout

As always, this is from the ever expanding google doc on bits and bobs I read and learn from and transfer here for all our learning pleasure. This one from a recent training day with a rheumatologist. Some is literature based some his good old fashioned doctoring and experience.

  • 10-40% have a normal urate during flares
  • the red hot shiny joint is rarely rheumatoid, much more suggestive of gout
  • 95% of nodules are gout or rheumatoid. If you want a really easy diagnosis then crystals of gout are present in huge numbers in a gouty tophus and if you can read or find someone to read a microscope then it might get you out of needling a joint
  • wine less gout forming than beer or spirit
  • coffee protective against gout
  • intense exercise and micro trauma at 1st MTP can precipitate gout
  • podagra was the old school term for classic 1st MTP disease. Knee disease rejoices in the term gonagra

Acute treatment pearls:

  • NSAIDs, if contraindications then topical still great for single joint
  • Colchicine (1.8mg a day) at a low dose, can be used chronically. Remember SEs (sepsis, home marrow suppression. Mostly D&V)
  • Steroids (personally i use steroids a lot for gout in the older folk with comorbidities and a few joints involved)

Chronic treatment pearls:

  • Colchincine can be used
  • Allopurinol: usually wait 6 weeks but can start immediately as long as they get some steroid cover which was news to me

References:

  • Excellent rheumatology lecture somewhere in the midlands of Ireland Spring 2015
  • Featured Image: Nick Gorton, CC License, Wikipedia

Other FOAMed sources

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Anatomy for Emergency Medicine 031: CFN Eye Anatomy Part 2

This is the second of a series of podcasts I’m doing on basic eye anatomy for the CEM FOAMed Network. This is a developing resource which aims to provide a fully mapped college curriculum with FOAMed resources. Be sure and check it out and get the podcast. This podcast went out a while ago on the CFN and I’m just providing it for everyone else who hasn’t got it already.

The single most important resource you need is Ophthobook.com

Part 1

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Tasty Morsels of EM 048 – ITP

As always, this is from the ever expanding google doc on bits and bobs I read and learn from and transfer here for all our learning pleasure. This one from a recent training day in one of the Dublin children’s hospitals.

  • relatively common, most often in kids 2-6
  • usually without splenomegaly
  • as usual with something with “idiopathic” in the name it is a diagnosis of exclusion
  • very rarely involves serious bleeding despite platelets commonly <20
  • 90% rate of spontaneous remission. Steroids are commonly given but perhaps not always needed given the low mortality (<1%) and good rate of spontaneous improvement.
  • outbreaks in spring and autumn associated with URTIs implying an autoimmune cause
  • vast majority can be discharged (with follow up of course, usually recheck blood count in a week or so). Note Rosen’s suggests initial admission but my own experience and that of the paeds haematologist speaking to us was that admission achieved little.
  • head bleeds
    • a big deal if they happen
    • give lots of platelets (more than usual) as the platelets you transfuse will disappear in the same way that the patient’s platelets have already disappeared
    • definite indication for steroids and some IVIG

References:

  • Lecture by paeds haematologist, Dublin 2015 (high quality referencing there…)
  • Rosen’s 8th ch 122, p 1611

Image credit:

Wikipedia, CC License

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