!

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, chills and rigors
associated with myalgia for 6 days.
Treated as for a CAP but with no
improvement. He then developed this
rash and joint pain over his hands
and feet.

He was toxic with T40oC and had

synovitis of the PIPJs. Palpable
purpura and splinter haemorrhages
seen.TW 32K CRP >200. 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. • Systemic diseases can mimic vasculitis or cause a true secondary vasculitis
She was a chronic smoker but was unaware of any other medical problems.
• 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. CK done
at her GP was 380. The symptoms get worse after the end of the day. She
also has significant fatigue but has put on weight and not lost weight
‣ Infective ‣ Allergic reactions ‣ Intravascular ‣ DIVC recently.
endocarditis ‣ Vasospasm lymphoma/NHL ‣ TTP
‣ Syphilis ‣ Ergot ‣ Leukaemias ‣ Cholesteral
Examination reveals very mild
‣ Tuberculous ‣ Cocaine (mimics ‣ Paraneoplastic emboli proximal weakness. She has
‣ Mycobacteria WG) vasculitis ‣ Cardiac myxoma
multiple trigger fingers but no
‣ Leprosy ‣ Congenital
synovitis. She had asteatotic
(Lucio’s causes eczema over her legs. When
phenomenon) ‣ fibromuscular
taking her blood pressure, it
‣ Viral infections dysplasia is noted she’s bradycardic
‣ Hep B/C, HIV ‣ Marfan’s
‣ Mycotic syndrome
aneurysms ‣ Scurvy Hypothyroidism
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, Hep C) • Musculoskeletal: ligamentous laxity, oedema, back pain, tenosynovitis

• Endocrinopathies (Hypothyroidism, Addison’s

disease, hyperparathyroidism)
• Cutaneous: hyperpigmentation, alopecia (TE), pruritus, pruritic urticarial
papules and plaques of pregnancy, EN
• Myopathies
• Haematologic: anaemia, thrombocytopaenia, increased risk of DVT
• Vitamin D deficiency
• Renal: microscopic haematuria, proteinuria
• Metabolic bone diseases (osteomalacia), renal
osteodystrophy
• Neurologic: nerve entrapment, 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, U/E/Cr, LFT, 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; consider Urinalysis Thyroid function Calcium/albumin
doing glucose, Hep B/C serologies EMG Vitamin D
thyroid function 2DE Biopsy Thyroid function

• Fishing expeditions with serologies are rarely helpful

References

• Markenson JA. Rheumatic manifestations of endocrine diseases. Current

Opinion in Rheumatol 2010; 22: 64

• Molloy E, Langford CA. Vasculitis Mimics. Current Opinion in Rheumatol

2008; 20:29

• Ravindran V, Anoop P. Rheumatologic manifestations of benign and malignant

haematological disorders. Clin Rheumatol 2011; 30:1143

• Cacoub P, Terrier B. Hepatitis B-related autoimmune manifestations. Rheum

Dis Clin N Am 2009; 35: 125

• Sammaritano LR. Rheumatologic manifestations of pregnancy. Rheum Dis

Clin N Am 2010; 36: 729