Case presentation Rheumatology
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Transcript of Case presentation Rheumatology
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Case presentationRheumatology
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39 yr old female pt, unemployed from Bloemfontein
Routine follow up at rheumatologyBackground history of hypertensionDiagnosis of
? Mixed connective tissue disease/ Overlap syndrome/ seronegative rheumatoid arthritis
Previous serology: ANF, AntiRNP, Scl 70, Anti Jo, elevated CK’s
History
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Severe generalised joint painsNo associated swelling reported Morning stiffness Constitutional symptomsDryness of the eyesNo other systemic complaintsSober habits
History(cont..)
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Medication list:MTX 20 mg /weekNivaquine 200mg daily Prednisone 10mg dailyFolate 5mg daily Ridaq 12.5mg dailyPharmapress 20 mg daily poLosec 20 mg daily poVoltarenDolorol forte
History(cont..)
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General examination: In discomfort due to painNo pallor/jaundice/adenopathyNo vasculitic or skin changes
Systemic exam:CVS: haemodynamically stableResp: clearGIT: no tenderness or organomegalyM/S: bilateral symmetrical tenderness and
warmth of joints in upper and lower extremities. No effusions.
Clinical examination
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AssessmentFlare of arthritis
ManagementDepo Medrol 160 mg imi statBloods for :
Inflammatory markers AST/ALT/Alb
Methotrexate increased to 25 mg/week
Evaluation
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Evaluation(cont..)
06/11/2009 16/04/2010
Total Bili 9
AST 86 669
ALT 73 760
Albumin 40 36
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Drug induced hepatitisViral hepatitisAutoimmune hepatitis(AIH)
Differential diagnosis
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Patient admitted for evaluationReports good response to steroidsMethotrexate stoppedFollow up blood results
Differential diagnosis(cont..)
16/04/2010 26/04/2010Total Bili 9 9AST 669 295ALT 760 500Albumin 36 40
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Virological studiesHepatitis A, B and C studies were negativeHIV negative
SerologyANA , ANCA negativeAnti smooth muscle Ab’s unfortunately not done
SPEP Normal
Abdominal ultrasoundNormal
Investigations
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Diagnostic challenge ?
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Causes related to:Underlying autoimmune diseaseConcurrent infections
Chronic viral hepatitisOpportunistic infections
Drug related toxicityMethotrexateAzathioprine
Other causesAlcoholic liver diseaseMetabolic disordersMalignancy
Hepatitis in autoimmune disease
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Cell-mediated immunologic attack against genetically predisposed hepatocytes
Progressive necroinflammatory and fibrotic process.
Association with other autoimmune diseasesRheumatologic conditions
Rheumatoid arthritis and Felty syndromeSjögren syndromeSystemic sclerosisMixed connective-tissue disease
Autoimmune hepatitis
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Presentation is heterogeneous, and clinical manifestations varyAsymptomaticDebilitating symptomsFulminant hepatic failure
Women are affected more often than men (70-80% of patients are women)
Response to steroid and/or immunosuppressive therapy
Autoimmune hepatitis
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Autoimmune hepatitis
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Risk factors associated with drug induced liver injuryAge: elderly at high riskSex: more common in femalesAlcohol useUnderlying liver diseaseCo- morbid diseasePregnancy Other drugsGenetic factors
Drug induced hepatotoxicity
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Methotrexate can induce: hepatocyte necrosis
Increased ALTHepatic fibrosis and cirrhosis
Common setting in pt treated for psoriasis
Methotrexate hepatotoxicity
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Premethotrexate Evaluation Complete blood count with differential countPlatelet countSerum creatinineUrea UrinalysisLiver function testsSerum bilirubinSerum albuminHepatitis A, B, and C serologiesHIV risk assessment/testing, if appropriateChest radiograph
Information from Roenigk HH, Auerbach R, Maibach H, Weinstein G, Lebwohl M. Methotrexate in psoriasis: consensus conference. J Am Acad Dermatol 1998; 38:478-85.
Methotrexate toxicity(cont..)
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Indications for liver biopsy in pt with RAPersistently elevated liver enzymes Abnormal results in five of nine determinations
of AST levels within a 12-month period( done 4-8 weekly)
Decrease in serum albumin values below the normal range
Not cost-effective in the first 10 years in pt’s with normal enzymes
Presence of moderate fibrosis/cirrhosis warrants discontinuation
Methotrexate toxicity(cont..)
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AIHFemale genderUnderlying
autoimmune disorder
Previous +ANA?Response of
transaminases to steroids
Hepatocellular injury pattern in pt on MTX
?Other possible precipitating factor
?Did pt increase her treatment due to pain
Our patientMTH hepatotoxicity
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Decline in LFT’s to near normalMTX stopped indefinatelyPrednisone increased to 20 mgFor reevaluation in 2/52, ?liver biopsy
Our patient