Rheumatology

• 51 (HLA B51) yr old Nolan (Anti enolase) on a Bus (behcets)

• Kidney involvement in Systemic Lupus Erythematosus (SLE).

• Complement system involvement in SLE:
• Can cause complement-mediated vasculitis.
• Results in multiple organ affection.

• Lupus nephritis:
• Proteinuria.
• Urinary protein: Urinary creatinine ratio >0.5.
• RBC casts present due to glomerular damage.

• Histopathological subtypes (ISN classification):
• 6 classes of lupus nephritis.
• Class 4: Diffuse lupus nephritis (most common and most severe).

• High mortality risk.

• Progression to end-stage renal disease (ESRD).

• Requires
• hemodialysis (3 times/week) or
• kidney transplantation.
• Kidney transplantation recommended.
• Prognosis improving with advancements

Severity of Lupus Nephritis:

• Best Determined by kidney biopsy

• Best antibody to detect severity
• Anti-C1q antibody titres
• indicate progression and severity compared to previous years

Histological Findings

• Loopus → Wire Loop

• Wire loop lesion:
• Thickening of glomerular capillary loops
• due to subendothelial immune deposits.
• Often seen in Grade II, III, IV.
• Its presence is maximum in Grade IV.
• Deposit: Subendothelial.

Grades of Lupus Nephritis (ISN/RPS Classification)

Immunofluorescence

• Also known as "Full house effect".

• Shows global deposition of:
• All immunoglobulins (IgM, IgG, IgA).
• All complement components (C1q, C3, C4).

Electron Microscopy

• Characterized by Thumb print lesion.

• Mnemonic: SLE → Antibodies ellaam kude oru House Party nadathi → Full Wire () okke vach → but a murder occurred → Solved by Thumb print

Scleroderma/Systemic Sclerosis

• Sclerosis: Thickening/binding down of skin

Types

• Limited Cutaneous Systemic Scleroderma:
• Skin below elbow and knee
• Anti-centromere antibody
• Mnemonic: Limited to centre (Anticentromere)

• Diffuse Cutaneous Systemic Scleroderma:
• Proximal body
• Anti-Scl-70 (topoisomerase I)
• anti-RNA polymerase III
• Diffuse sclerosing (Scl 70) reach to top (Topisomerase)

• Anti-fibrillarin / Anti-U3 RNP:
• Prognostic for scleroderma
• → risk of RPGN/ILD/PAH

Note: Localised scleroderma

---

• Morphea

• Autoimmune connective tissue disorders

• NOT a part of systemic sclerosis
• Involves skin
• Contain collagen
• No visceral organ involvement

---

Clinical Scenario

• Fibrosis around blood vessels in fingertips:
• Hampers autoregulation of blood supply.

• Raynaud phenomenon.
• Early feature
• A lady in a cold environment:
• Color change in fingertips:
• White (exaggerated vasoconstriction).
• Blue (cyanosis due to less blood supply, increased deoxygenated Hb).
• Red (exaggerated vasodilation).

• Skin Presentation:
• Loss of elasticity
• Leather-like skin (fibrosis under skin).
• Salt and pepper appearance of skin.
• inability to pinch skin
• thickened/bound-down

• Other features:
• Microstomia (fibrosis in mouth, difficulty opening mouth).
• Oesophageal dysmotility (fibrosis in esophagus, causes dysphagia).

• Differentiation from achalasia cardia:
• Achalasia cardia: Loss of inhibitory control, increased LES tone.
• Scleroderma: Fibrosis in LES, relatively lesser tone, causes reflux oesophagitis.

• Lung involvement:
• Interstitial lung disease (fibrosis in lungs).
• Specific for Diffuse

• Pulmonary artery hypertension (PAH):
• Specific for CREST
• Fibrosis in pulmonary artery.
• Loud P2.
• DLCO ↓↓ lesser due to vessel wall fibrosis.

• Scleroderma crisis:
• Progressive ↓↓ kidney size.
• GFR lesser.
• RAAS activated, causing hypertension.
• Hypertensive crisis develops.
• Management: ACE inhibitors (oral).

Patient Presentation

 

• Mask-like facies:
• Loss of wrinkling,
• shiny skin,
• restricted mouth opening
• visible incisors
• furrowing along oral commissures
• telangiectasias

• Sclerodactyly:
• Bound-down hand skin, deformities (contractures) in interphalangeal joints

Limited Scleroderma (CREST Mnemonic)

• C: Calcinosis → Calcium deposit in subcutaneous space

• R: Raynaud’s phenomenon:
• DOC: Ca channel blockers like amlodipine
• start with lowest dose to prevent postural hypertension

• E: Esophageal dysmotility (dysphagia).

• S: Sclerodactyly.
• Presence of pitting scars in volar aspect of fingers due to fibrosis.

• T: Telangiectasia.

• Additional:
• Anti-centromere antibody present.

Leading cause of mortality:

• PAH > ILD
• ILD
• Lung transplantation possible
• Severe PAH (up to 60mm)
• requires heart-lung transplantation (difficult)

• Military (Miliary) people
• get TB
• Laugh (Loeffler’s)
• Heal by eating chicken (healed varicella)
• make History (Histoplasmosis)

• Presentation:
• Usually a female patient
• dry cough, shortness of breath
• associated with connective tissue disorder.

• M/c type
• Idiopathic pulmonary fibrosis

• IOC - HRCT.
• UIP/IPF pattern
• Honeycombing pattern +
• Basal Lower lobe dominance +
• Traction bronchiectasis
• Ni thanna (Nintendanib) Feni done (Pirfenidone) ayi → lung fibrosis ayi (IPF)



• TGF α → KGF α → Menetriers disease
• TGB β → KGF β → drink Feni
• Ninte Dani → PD Girl Friend (PDGF)

Crazy pavement appearance:

• Interlobular septal thickening is seen with ground glass opacity.

• no air filled cavities are seen.

• Seen in Pulmonary alveolar proteinosis >>> COVID 19

• Mnemonic: Crazy Pappu (PAP) in pavement

Cystic Bronchiectasis

• Some of these dilated bronchi contain mucus.

• Bronchi appears as cysts.

• Bunch of grape appearance.

Granulomatosis with Polyangiitis (GPA)
(formerly Wegener's Granulomatosis)

• Necrotizing vasculitis with granulomas.

• Strawberry gingiva.

• ENT Triad 
• Ears: Otitis media.
• Nose: Nasal septal perforation / Saddle nose
• Throat: Strawberry gums

• Upper respiratory tract (URT) involvement:
• Recurrent sinusitis.
• Epistaxis.

• Lower respiratory tract (LRT) involvement:
• Hemoptysis.
• Cavitations (due to lung blood supply damage).

• Kidney:
• Hematuria.
• A/w
• RPGN Type 3 (with Microscopic polyangitis)
• PAUCI IMMUNE
• Flea bitten kidney

• Note:
• In TB, cavity in upper lobe of lungs.
• In this condition, multiple small cavities due to necrotizing vasculitis.

• Workup:
• Shows both C-ANCA > P-ANCA.
• against cytoplasmic antigen → anti-proteinase 3

• Treatment:
• Cyclophosphamide + Mesna

• Differentiation from Goodpasture syndrome:
• Goodpasture:
• Hemoptysis + hematuria (basement membrane damage in lung and kidney).
• Wegener’s:
• Lung cavitation + URT involvement + hematuria

Other Causes of Flea Bitten Kidney

• Wegener's granulomatosis

• HUS/TTP/HSP

• SLE/SABE

• Malignant HTN

• PAN

• PSGN, RPGN

 

• Mnemonic:
• Hus () Sleepan (SLE) poyapo Vegetable (wegner) Panil (PAN) vachu → flea vann (flea btten) irunn → kandapo BP (HTN) kuudi

Case scenario

• A 4-year-old child presents with fever and rash for 6 days, along with red eyes and tongue and swelling of hands.

• Age: Typically occurs in children less than 5 years of age.

Diagnostic Criteria (CRASH BURN criteria):

• Fever >39°C for more than 5 days + at least 4 of the following:

• At least four of five criteria: CRASH
• Conjunctivitis (B/L Non Purulent)
• Rash → Polymorphous
• Adenopathy (non tender)
• Strawberry tongue
• Red, fissured lips
• Note: Strawberry tongue also in scarlet fever.
• Hands and feet Erythema that later leads to desquamation → edema

Pathogenesis:

• Associated with anti-endothelial cell antibodies.

Blood Test Findings:

• Thrombocytosis (increased platelet count).

• Leukocytosis, elevated ESR or CRP.

Complications:

• M/c → Myocarditis

• Most dangerous
• Coronary artery aneurysm
• Giant >8mm (>1cm) in diameter
• Risk → resemble infection
• Male sex
• Fever ≥14 days
• Elevated ESR and CRP
• WBC count >12,000/mm³
• Hematocrit (PCV) <35%
• Serum sodium <135 mEq/L

• Can lead to aneurysm or myocardial infarction (heart attack) in child

• Rare but potentially fatal

Treatment

• Aimed at preventing coronary artery aneurysm
• IVIG
• if given within first 10 days, reduces the risk of coronary artery aneurysm
• Corticosteroids
• if persistent fever despite IVIg
• ASPIRIN
• High dose aspirin reduces risk of thrombosis, given until subside fever
• Low dose aspirin is given until ECHO is performed at 6 weeks to exclude aneurysm
• Reye’s syndrome
• Acute Liver Failure
• Microvesicular steatosis

 

• Systemic vasculitis

• Anti alpha enolase Ab

• Pathergy → Pathetic diagnosis → misunderstood young patient with recurrent oral and genital ulcers

• Misunderstood a young as 51 () yr old nolan (Enolase) in bus ()

Triad of Features

• Relapsing uveitis (mainly posterior)

• Recurrent genital ulcers

• Recurrent oral ulcers

Features (Oro-Oculo-Genital Syndrome)

• Most common diagnostic feature:
• Recurrent oral ulceration.
• Painful, like aphthae, recurrent
• Recurrence at least thrice in any 12 months.

• PLUS TWO OF:
• Genital ulcers:
• Female: Vulva ulcer
• Male: Scrotal ulcer
• not penile ulcer as in STDs like H. ducreyi, syphilis
• Eye lesions:
• Anterior uveitis.
• Posterior uveitis.
• Hypopyon
• Retinal vasculitis
• Skin lesions:
• Erythema nodosum
• Pseudofolliculitis or papulopustular lesions, OR
• Acneform nodules in post-adolescent patients not on corticosteroids.
• Positive pathergy test

Other Systemic Involvement:

• Non-erosive, asymmetric oligoarthritis

• Multi-system: Pulmonary, cardiac, GI, neurological

Pathergy Test/ Pathergy phenomenon:

• Positive because it can cause systemic vasculitis

• Not a diagnostic criteria

• Type 4 Hypersensitivity reaction

• Procedure:
• Sterile needle puncture on forearm with hypodermic cutting edge.

• Normal response:
• bleeding, clotting, mark disappears in 2-3 days.

• Behcet’s response:
• After 48 hours, formation of sterile pustule

Complications:

• Pulmonary artery aneurysm possible.
• Rupture: Lethal complication.
• Note: Pulmonary artery not involved in polyarteritis nodosa.

Management:

• Corticosteroids

• Ocular involvement:
• Azathioprine.

Mnemonic:

• Bus on a path → Pathergy test

• Oro occulo genital → On bus

Differentiation of Connective Tissue Disorders (Broadly)

• Anti-fibrillarin / Anti-U3 RNP:
• Prognostic for scleroderma
• → risk of RPGN/ILD/PAH

Note: Localised scleroderma

• Morphea

• Autoimmune connective tissue disorders

• NOT a part of systemic sclerosis
• Involves skin
• Contain collagen
• No visceral organ involvement

Rheumatoid Arthritis (RA)

• 51 (HLA B51) yr old Nolan (Anti enolase) on a Bus (behcets)

Synovial Disease

• Type: Most common inflammatory arthritis.

General Features

• Rheumatoid factor: IgM Against Fc part of IgG (MRF → M against G)

• Prevalence: Female > Male.

• Characteristic: 
• Erosive arthritis (destroys joints),
• unlike SLE → non-erosive.

• Nature: Chronic autoimmune multisystem disease.

• Symptoms:
• Involvement can be bilateral.
• Initial presentation:
• Only wrist joint may show redness/inflammation.
• PIP inflammation may not be noticed.
• Morning stiffness.
• Symmetrical peripheral joint involvement.

• Prominent periarticular osteopenia.

Joints Involved

• Atlanto axial dislocation → Specific

• Upper Limb: 
• MCP > Wrist > PIP

• Lower Limb: 
• Knee and Hip.

Diagnosis

• Elevated CRP and ESR

• Rheumatoid Factor/RA factor
• Most sensitive marker.
• IgM class antibody,
• 5% false positive,
• can be positive in sore throat

• Anti-CCP (Cyclic Citrullinated Peptide): 
• Most specific marker.
• positive → erosive arthritis

Monitoring:

• Follow up for next 6 weeks.

X-ray Findings

1. Narrowed Joint Space.

2. Osteopenia

3. Juxta-articular Osteoporosis: 
• Generalized bone thinning near joints.

4. Marginal Erosions.

5. Absence of Sclerosis/Osteophytes
• differentiates from OA

Deformities in RA

• Involves small joints of hand:
• MCP > wrist joint > PIP
• Note: Rheumatic fever involves large joints (ankle, knee).

1. Boutonniere's Deformity: 

• Flexion at PIP joint.

• Hyper extension at DIP joint.

2. Swan-neck Deformity: 

• Flexion at DIP joint.

• Hyper extension at PIP joint.

• SFD (Street food of delhi) → Swan neck → Flexion at distal

 

3. Z thumb Deformity: 

• Fingers deviated to ulnar side;

• metacarpals deviated to radial side.

• Z-thumb deformity/Hitch Hiker thumb deformity.

• Different from Z-line deformity (ulnar deviation).

NOTE:

• Mallet finger:



• Flexion at DIP, no deformation at PIP.
• Seen in wicket-keepers (injury to extensor tendon, not part of RA).

 

4. Windswept Deformity: 

• Both knees face the same side.

 

• Windswept deformity
• (valgus on one side, varus on the other).
• Children/Overall:
• Rickets (m/c).
• Adults:
• Rheumatoid Arthritis (m/c)
• Mnemonic: Kaatadichapo kunjnugal rocket (ricket children) pole poi, Adult Room adachitt (RA)

5. Hallux Valgus: 

• Lateral deviation of the great toe.

6. Hammer Toes: 

• Deformity of the
1. second,
2. third, or
3. fourth toe,
4. where the toe is bent at the middle joint.

7. Bilateral Genu Valgum (knock-knees).

Management (erosive arthritis):

• Aggressive treatment.

• NSAIDs

• Triple therapy:
• Start with Methotrexate (MTX).
• If good response
• continue.
• If no response,
• add Hydroxychloroquine and Sulfasalazine.

Extra-Articular Manifestations

• Rheumatoid Nodules:
• Most common extra-articular manifestation.
• Extensor distribution (olecranon process, occiput, spine tips, dorsum of hand).

• Eye Manifestations:
• Keratoconjunctivitis sicca.

• Spinal Risk:
• Avoid yoga/spinal movements/sports (neck rotation, headstand).
• Risk of atlantoaxial subluxation
• Cause spinal cord compression and quadriplegia.

• Cardiovascular Manifestations:
• Rheumatoid nodules in heart
• between SA and AV node, causing 1st-degree heart block
• Damage to myocardium.
• Accelerated atherosclerosis
• important cause of death
• Note: Aschoff nodules in rheumatic fever.

• Respiratory Manifestations:
• Rheumatoid nodules in lungs.
• Pleuritis/pleural effusion (exudative).
• Light’s criteria for exudative effusion:
1. Pleural fluid protein/serum protein >0.5
2. Pleural fluid LDH/serum LDH >0.6
3. Pleural fluid LDH >2/3rd upper reference limit of normal for serum.

• Hematological:
• Anemia of chronic disease (normocytic normochromic & microcytic hypochromic).

• Peripheral Nervous System:
• Mononeuritis multiplex (multiple peripheral nerves involved).

Morning stiffness d/ds:

• 2 conditions
1. Severe in RA
• difficulty brushing teeth,
• getting late for office
2. Ankylosing spondylitis
• stiffness reduces with activity

Scleromalacia Perforans

• Description:
• Anterior necrotising scleritis without inflammation.

• Presentation:
• No redness/pain,
• progressive atrophy → leading to scleral perforation.

• Most common in:
• Women with rheumatoid arthritis.

• If no h/o RA → Staphyloma

Salivary gland swelling D/Ds

• Sialosis → Salivary gland swelling in alocoholics

NOTE: Posterior Uveitis

Heerfordt vs Lofgren Syndrome

• Lofgren syndrome:
• Erythema nodosum + B/L lymphadenopathy + AU
• Mnemonic: L.O.F.G.R.I.N
• L: Lymphadenopathy
• O: Ouch (joint pain)
• F: Fever
• GR: Granuloma (non-caseating)
• N: Erythema Nodosum

• Heerfordt syndrome:
• Uveoparotid fever + 7th CN palsy
• Ford caril poyapo → kannilum mugathumn cheekilum kaattadichiu

• Mnemonic: Sarcoidosis → Nun showing ass → Some put garland (1,2,3 garland) → some throw egg (egg shell) → some buy her galaxy () → Broker () her deal → she has a panda () and a lamb (lambda)

Chest X-ray:

• Mediastinal mass (B/l hilar lymphadenopathy)

• 1-2-3 pattern/ Garland sign

• Scadding staging

Later phase:

CT chest:

• Fissural nodularity and bronchovascular thickening.

• Galaxy sign or Pawnbroker sign.

• (lesions in lung parenchyma).

Gallium scan: (not done currently)

• Panda sign (parotid, lacrimal, salivary gland involvement),

• Lambda sign (hilar lymphadenopathy).

NOTE: Panda sign on MRI brain

• Wilson's disease.

Facial Palsy causes summary

• Most common cause:
• Idiopathic > Traumatic

• Iatrogenic facial palsy:
• Occurs during mastoidectomy
• Mastoid segment affected

Causes of B/L facial Nerve (diplegia):

Condition	Features
Sarcoidosis	ㅤ
Melkersson Rosenthal Syndrome	Triad: • Recurrent facial nerve palsy • Swelling of lips • Fissured tongue Melkerson → Rose koduthitt french kiss cheyth (lips - tongue)
GBS	• Albumino-cytological dissociation • Earliest sign: Distal areflexia. • Bladder and bowel spared. • Bilateral ascending symmetrical flaccid paralysis. • Brighton Criteria for GBS

Histology (Sarcoidosis Granuloma)

• Mnemonic: Saratha (Sarcoidosis) → Naked (Naked) Nun (Non caseating) Showing (Shaumann) Ass (Asteroid body)

Features	Notes
Non-caseating > Caseating	Surrounded by lymphocytes / giant cells
Naked granulomas.	Absence of lymphatic collar Sparse perigranuloma infiltrate
Epithelioid cells:	Contain slipper-shaped nuclei
Inclusion Body	ㅤ
↳ Asteroid	• Star shaped • intracellularly (inside giant cells). • Also seen in sporotrichosis ↳ but → extracellular. • Mnemonic: Rose gardener roams outside, so star is outside
↳ Schauman	• Round bodies → Basophilic calcium concretions • Hypercalcemia

Kveim’s test:

• Skin test

Skin Presentation

• Non-specific features (e.g., Erythema Nodosum)

• Specific skin lesions:
• Red-brown papules with normal surface (no scaling, crust, ulcer)

Lupus Pernio:

• Red papules with normal surface on nose, cheeks (sometimes telangiectasias)

Angiolupoid Sarcoidosis:

• Erythema, telangiectasias limited to specific area

 

Dermoscopy: 

• Apple jelly nodules

Treatment for Skin lesions

• Antimalarials (specifically HCQS)

Uveitis A/w HLA B27 - associated arthritis = JRAP

• Ankylosing Spondylitis

• Psoriatic arthritis

• Reiter's syndrome/Reactive arthritis.

• JIA

Also Known As:

• Marie-Strümpell Disease.

• Bechterew's Disease.

Schober test:

• 2 marks
• 1st → mark at posterior superior iliac spine +
• 2nd → 10cm above

• Reveals spine involvement (flexion not possible).

• Normal person:
• Spine flexible,
• gap increases to 15cm on bending

• In patient:
• Flexion limited

Antibody:

• Targets cytosolic 5' nucleotidase.

Pathology: 

• Enthesopathy
• inflammation where tendons or ligaments attach to bone
• Cause enthesitis affecting Achilles tendon

Presentation

• Young male with low backache.
• Morning Stiffness: 
• Improves with activity (distinguishes from RA).
• When he stands or puts his foot on the ground, there is pain in the foot or sole.
• Decreased Lumbar Spine Movement.
• Sacroiliitis:
• Juxta-articular erosion.
• Blurring of margins.
• Sclerosis leading to joint fusion.

• Involvement: Axial > Peripheral joints.
• Most commonly affects Sacro-iliac (SI) joint (m/c).
• Also affects spine and hip.
• Starts in sacro-iliac joint.
• Spine fused by syndesmophytes anteriorly and posteriorly.

• History of red eye (anterior uveitis - extra-articular manifestation).

X-ray

• It shows sacroiliitis.

• If the disease is progressive, it shows a large number of osteophytes present.

• Calcification present in paravertebral ligaments.
• Causes bamboo spine.

Bamboo Spine: 

• Fusion and squaring of the spine due to:
• Calcification between vertebrae, restricting movement.
• Inflammation → syndesmophyte formation
• (vertical/bridging syndesmophytes)
• → fusion anteriorly and posteriorly

Dagger Sign: 

• Calcification of only the interspinous ligament.

 

Trolley Track Sign: 

• Calcification of paraspinal ligaments and interspinous ligaments.

Enthesopathy

• Tendons like the Achilles tendon involved → tendinitis
• complaints of heel pain.

Cardiovascular Manifestation

• Valvular aortic regurgitation.

Lung Manifestations

• Stiffness of costochondral joint.

• Extra parenchymal restrictive lung disease.
• No proper exhalation
• So residual volume is increased.

• In contrast, in parenchymal restrictive lung disease, there is fibrosis of the lung.

HLAB27 Test = JRAP

• Positive.

• HLAB27 is also Positive in:
• Juvenile rheumatoid arthritis.
• Ulcerative colitis.
• Reiter syndrome/Reactive arthritis.

MRI:

• Most sensitive.
• Bone marrow edema is seen first.
• STIR-MRI identifies bone marrow edema.

Clinical Tests

• Decreased Chest Movements.

For Testing Lumbar Spine Motility:

• Schober Test/Modified Schober Test:



• Measures distance between two points on the spine
• from standing to full flexion;
• in AS,
• distance does not increase due to fusion.

• Note on Non-Erosive Arthritis (e.g., SLE): 
• Joint inflammation occurs,
• no loss of articular cartilage or destruction of subchondral bone.

For Sacroiliitis:

• Gaenslen's Test.

• FABER Test (Flexion, Abduction, External Rotation) / Figure-of-4 Test.

• Pump Handle Test.

Treatment

• NO ROLE OF DMARDS

• Infliximab.

• NSAIDs → Biologicals

• Monoclonal antibody TNF α agonist. Reactive arthritis.

Gout

Gout as a Disease

• Precipitates crystals in the joint space of the patient.

• local erosive lesion
• 1st metatarsal phalangeal joint in the patient.

• Because of recurrent flare up of acute gout.

Pathogenesis

• Metabolism: 
• Abnormality in purine metabolism.

• Uric Acid (UA): 
• Increased uric acid production (normal values: 3.5 to 6.5 mg/dL).

• Mechanism: 
• Sudden change in UA levels
• Deposition of crystals in cold peripheral joints
• Local inflammatory reaction
• Collateral damage and pain.

Clinical Features

• Most Common Joint: 
• First MTP joint of the big toe.

• Preponderance:
• Middle-aged, male > female.
• Associated with consumption of alcohol, red meat, and chemotherapy.

• Symptoms:
• Acute gouty pain,
• often forming tophi (urate crystal deposits).

Joint Aspiration: 

• IOC (Investigation of Choice) for acute gouty attack.

• Fluid-Turbid.

Characteristics of Crystals:

• Monosodium Urate (MSU).

• Needle-shaped.

• Negatively birefringent on polarizing light microscopy
• crystals appear yellow when parallel to the filter

Pseudo gout

• Positive birefringence crystals in polarised microscopy are seen in
• Rhomboid shaped
• Ca pyrophosphate

• That involves knee joint.

• Chondrocalcinosis → Calcification of meniscus

• Mnemonic: Miss U → Needles (needle-shaped), Negatively birefringent, Yellow (when parallel).

X-ray Findings:

• 1st MTP.
• Podagra.

• On X-ray foot:
• Overhanging/Martel's Sign/Rat bite erosions: 
• Erosions with overhanging edges
• Punched-out Lesions.

• Joint Destruction.

• In the skull, vertebra, and pelvis are usually present in multiple myeloma.

DECT (dual energy)

• Helps identify uric acid deposits.

Tests Done Are

• Serum uric acid: Elevated.
• In both overproducer & in under excreter.

• 24 hours urinary uric acid value is used to differentiate b/w
• Overproducer &
• Under excreter

Management

---

Acute Gout Attack:

Chronic Gout:

Drugs decreasing production of uric acid

Drugs increasing excretion of uric acid (Uricosuric agents)

Drugs increasing metabolism of uric acid

Allopurinol

• DOC:
• Chronic gout
• Tumor Lysis Syndrome
• Lesch-Nyhan Syndrome
• Defective purine metabolism
• Organ transplant

• Side effects:
• Hypersensitivity (severe):
• Stevens-Johnson Syndrome (associated with HLA-B*5801)
• Orotate decarboxylase inhibition:
• Causes orotic aciduria
• DRESS syndrome
• Mnemonic: Allu (Allopurinol) arjun → Johnson (SJS) powder → Dress up () and Oridath irunn (Orotic aciduria) muthram ozhich

DermatoMyositis

Features

• Age Group:
• Bimodal (children, adults)

• Prognosis:
• Good in children

• Skin manifestations + Muscle symptoms (myositis)

• Associated with breast/lung/ovarian cancer

• Muscle Involvement
• Proximal muscles affected
• Difficulty: rising, lifting, removing clothes, stairs

• Mnemonic:
• Got to run (gottrun) for jogging (synthetase 1 / jo1) → with a shawl (shawl sign) and holster (Holster sign) → rash () came → cant run

Heliotrope Rash

• Confluent macular violaceous erythema /Violet/Purplish rash around the upper eyelid of a patient.

Gottron Papules