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PDCI II Block II: Vasculitis
Terms in this set (56)
What is vasculitis?
1. Inflammation and necrosis of BV --> Dec flow
2. Vessel wall destruction --> hemorrhage in adjacent tissue
3. Endothelial injury --> thromosis/ischemia
What color on histological specimens is a sign of inflammation?
When considering vasculitis, what are 4 things you should always do?
1. suspect the disease - it's not on every differential
2. define the extent - BV are everywhere, so try to localize
3. rule out mimickers - mainly cancer and infection
4. confirm the Dx - using pathology
In what patients is it justified to suspect vasculitis?
Those with multisystem disease and unexplained constitutional signs/symptoms
What are 2 things you should do when identifying palpable purpura in a patient suspected of having vasculitis?
1. give them pain meds
2. biopsy the NEWEST lesions
What should you ask a patient when selecting which palpable purpura lesions should be biopsied?
where are the NEWEST lesions?
- the old lesions will just be scar tissue
What is the key feature of Raynaud's phenomenon?
the whole hand will not change colors
- usually there will be defined ischemic (white) areas and healthy areas that can be delineated
When using an ophthalmoscope to detect Reynaud's, what would be the cause if the vasculature was seen the be normal?
primary --> Reynaud's + no other cause
When using an ophthalmoscope to detect Raynaud's, what would be the cause if the vasculature was seen the be abnormal?
secondary --> Reynaud's is being caused by something else
--> in this context, thought to be vasculitis
What is livedo reticularis?
a lacy rash, usually seen on the legs
--> this is normal when exposed to cold; but vasculitis patients will have these when not exposed
You are suspicious that an older patient has giant cell arteritis. When auscultating a patients heart, you hear a murmur. When you ask the patient if they've ever been told they have a murmur, they say no. What is the most likely explanation for this patient's symptoms?
subacute endocarditis (a main mimicker)
What are 3 ways that endocarditis "mimics" vasculitis?
1. heart murmur -- ask if it's new
2. splinter hemorrhages in the finger -- ask about trauma
3. unusually high fever
What is a key to determine if a patient's suspected vasculitis is actually due to cancer?
a history of cancer
A patient suspected of vasculitis has necrosis of the 2 toes. What should you ask this patient to rule out mimickers? What should you tell the lab to look for in the biopsy?
1. have you had a recent catheterization?
2. look for cholesterol clefts/emboli
A patient suspected of vasculitis has elevated liver NZ. What is a possible mimicker of this condition?
Giant cell arteritis is an example of a _____ vessel vasculitis.
What age group is GCA most common in? Which gender?
> 50 y.o.; more commonly seen in females
What is polymyalgia rheumatica? What condition is it associated with?
proximal stiffness/pain of joints (e.g. shoulders and hips) --> not so much weakness
- associated with Giant cell arteritis
What is the most concerning symptom of giant cell arteritis?
blindness or amaurosis fugax
--> can be acute or insidious onset
What is an observational sign that a patient may have giant cell arteritis?
Temporal artery tenderness with dec pulse
What are the big 5 clues that make you suspect giant cell arteritis?
1. older patient > 50 years (commonly female)
2. new superficial headache
3. jaw claudication
4. unexplained, high fever
5. polymyalgia rheumatica
What is used to calculate a normal ESR for a male patient?
dividing their age by 2
What is used to calculate a normal ESR for a female patient?
add 10 to their age and then divide by 2
- women are more complicated
Why is it necessary to take a large biopsy from the temporal artery for GCA?
the disease has many "skip" regions b/w normal and abnormal
What is the best way to confirm GCA?
biopsy the temporal artery
- simple superficial procedure, like biopsy of a mole
What is the most important complication of giant cell arteritis?
What is the FIRST thing should you do when GCA is highly suspected in a patient?
give them prednisone!
--> prevents blindness
- the biopsy can be conducted later and the treatment will not "ruin the evidence" by reversing the morph changes
In addition to prednisone, what other medication should be given to a patient with highly suspected GCA?
- this is assuming no CIs (e.g. bleeding); the patient may already be on it since these are typically older patients
What age and gender is more likely to develop polyarteritis nodosa?
males, between the ages of 40-60
contrast with GCA: more likely to be females > 50 y.o.
What are the 2 most common examples of mononeuritis multiplex? Which vasculitis are they most common associated with?
wrist drop or foot drop
- usually polyarteritis nodosa
What are 4 symptoms/clues that point to polyarteritis nodosa?
1. Middle aged man - 40-60 y.o.
2. peripheral neuropathy (wrist/foot drop) --> mononeuritis multiplex
3. palpable purpura
4. New onset HTN
What other condition should you suspect when a patient is thought to have polyarteritis nodosa?
What is the first-line treatment for polyarteritis nodosa?
- cytoxan is the "big gun"
What should you not give to a patient diagnosed with polyarteritis nodosa due to hepatitis B?
How should you treat patients diagnosed with polyarteritis nodosa due to hepatitis B?
treat their underlying hepatitis; use prednisone, antiviral agents and plasmapheresis
Granulomatosis with polyangitis is an example of a _____ vessel vasculitis.
What 3 areas of the body are affected by granulomatosis with polyangitis?
upper respiratory tract
lower respiratory tract
Remember: granulomatosis polyangitis --> GPA (glomerulus, pulm, adults)
What demographic age is most commonly affected by granulomatosis with polyangitis? Which gender?
around 40 (middle age)
- equal distribution between genders
A middle aged man presents to his primary care physician for the 3rd time in 6 months for an otitis media infection. What is a potential cause?
granulomatosis with polyangitis
- kids get AOM all the time, older adults should not
- otitis media is connected to resp infections
What is a rare but important finding in granulomatosis with polyangitis?
Subglottic Stenosis - stridor + respiratory difficulty
What classic disease is associated with a saddle-nose deformity? Which vasculitis?
vasculitis: granulomatosis with polyangitis
What is a very serious lower respiratory complication associated with granulomatosis with polyangitis?
alveolar hemorrhage (coughing up large amounts of blood) --> medical emergency!! (treat all possible causes and de-escalate later)
What is the most important renal finding in a patient with granulomatosis with polyangitis?
Active urine sediment - blood, pus, protein, and casts (mold of renal tubule)
What are two unique clinical findings in granulamatosis with polyangitis?
Proptosis - eye balls stick out
What does C-ANCA test for?
What does P-ANCA test for?
What is the purpose of the ANCA testing?
A postive C-ANCA vs P-ANCA may provide you with clues about what type of vasculitis is most likely
Which ANCA is positive for granulomatosis with polyangitis?
What drug is always used when cytoxan is used as a treatment? What is it for?
bactrim - prophylactic treatment for pneumocystis carinii
note: this is help b/c bactrim happens to be a treatment for granulomatosis with polyangitis
What is often used to treat milder cases of granulomatosis with polyangitis?
methotrexate or cyclosporin
note: cytoxan and prednisone are used for the usual cases
A patient with suspected granulomatosis with polyangitis has alveolar hemorrhage. What drug is most appropriate for treatment of his pre-existing condition?
point here is that alveolar hemorrhage is a severe case, so use the big drug
What demographic age is most commonly affected by Kawasaki's?
You encounter an infant with a strawberry tongue, pruitic rash, and desquamating skin on both hands. What is the name of the condition? What should be performed on these patients?
should do an echo b/c the condition predisposes to aneurysms and other cardiac abnormalities
What is the clinical name for Buerger's disease?
What is the clinical sign of Buerger's disease?
Ischemia or claudication of feet > hands --> pain and gangrene
What is the only treatment for thromboangitis obliterans?
cessation of smoking
note: also known as Buerger's disease
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