Vasculitides in MRCP

Vasculitides in MRCP

Let me makes this topic a very simple one, you just to know two conditions in this topic- Wegener Granulomatosis and Chrug- Strauss Disease.

Anyway, before we zoom in into these two conditions, I think candidates need to know this topic as a whole, vasculitis just means inflammation of blood vessels with reactive damage to the wall which can lead to downstream ischemia and necrosis.

Classification of vasculitis is depending on the size of vessel involved. You might want to know more about Chapel Hill Classification- either big vessel, medium or small vessel.

However, I do not think you need to know all these conditions- for MRCP candidates- big vessels vasculitis, you need to know Giant cell arteritis, medium size vasculitis- you need to know polyarteritis nodosa and small vessel disease- of course you MUST know Wegener Granulomatosis (WG) and Churg-Strauss Disease ( CS)

I will talk about Giant cell arteritis and polyarteritis nodosa next time and for today, we will put emphasis on WG and CS.

( Wegener Granulomatosis patients usually go to see an ENT surgeon first!!)

Since both involve small vessels, multiple organs can be involved, however, just remember the following similarities and differences between these two conditions.

Both of WG and CS can cause pauci immune glomerulonephritis and the classical finding is cresentric GN on biopsy

Both can be ANCA positive but WG is mainly c-ANCA and CS is mainly p-ANCA
WG patients usually have upper respiratory airway problem and can be misdiagnosed as nasopharygeal carcinoma or tuberculosis.

For CS, patients might present with asthma and usually has eosinophilia.
Yes, you are right, that’s all you need to know!!

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Cryoglobulinemia in MRCP

Cryoglobulinemia in MRCP

Frankly speaking, I thought cryoglobulinemia is not an important topic when I was sitting for my MRCP until recently I learned from my friend that actually it is a very popular topic in Part 1 and 2.

There are a few important salient points to remember for your MRCP.

( Rash on lower extremities typical of cutaneous small-vessel vasculitis due to cryoglobulinemia secondary to hepatitis C infection.- Photo from eMedicine)

1) Cryoglobulin just means proteins that become insoluble in low temperature. Therefore, it is understandable that this leads to thrombosis and hyperviscosity leading to Raynaud Phenomenon.

2) There are 3 types of cryoglobulinemia according to Brouet classification- Type I, II, III. Just remember Type I is simple and Type II and III are mixed cryoglubulinemia.

3) Just main causes of Type I include lymphoproliferative disorders (eg, multiple myeloma, Waldenström macroglobulinemia). Type II and III causes are chronic inflammatory diseases such as chronic liver disease, infections (chronic HCV infection), and coexistent connective-tissue diseases (SLE, Sjögren syndrome). Mixed cryoglobulinemia is rarely associated with lymphoproliferative disorders.

4) Remember the common presentation of cryoglobulinemia is Meltzer triad, ie, purpura ( skin manifestation), arthralgia, and weakness ( neuropathy).

5) However, renal involvement is common too- the commonest type is membranoproliferative GN.

Sound easy right? I always remind my friends, if during your MRCP, they give you a case of patient with renal involvement ( proteinuria), skin rash and joint pain- always remember 2 possible diagnosis- SLE and of course cryoglobulinemia!!

Spondyloarthropathies in MRCP (2)

Spondyloarthropathies in MRCP (2)

I talked about Spondyloarthropathies ( Ankylosing spondylitis) in my previous post. In MRCP Part 1 and 2, there are a few more conditions you should know because these conditions are very popular.

1) Reiter’s syndrome

Remember the triad of conjunctivitis, urethritis and arthritis. This was described by Hans Reiter in 1916.

Reactive arthritis is triggered following enteric or urogenital infections. Reactive arthritis is associated with human leukocyte antigen (HLA)–B27, although HLA-B27 is not always present in an affected individual.

Bacteria associated with reactive arthritis are generally enteric or venereal and include the following:, Salmonella typhimurium, Salmonella enteritidis, Streptococcus viridans, Mycoplasma pneumonia, Cyclospora, Chlamydia trachomatis, Yersinia enterocolitica, and Yersinia pseudotuberculosis.

Remember that always suspect this in young patients who come in with large mono- or oligoarthritis especially knee pain.

Other features of this syndrome include Keratoderma blenorrhagica

( a popular image in MRCP, brown, aseptic abscesses on soles and palms)), iritis, mouth ulcers, enthesopathy ( plantar fascitis, Acgilles tendinitis) and aortic regurgitation ( rare)

You may do imaging such as , however, Plain radiography - May show no abnormalities early in the disease

Asymmetric, oligoarticular, and more common in the lower extremities pattern of joint involvement
Juxta-articular osteoporosis in acute episodes of arthritis - Erosions have indistinct margins and are surrounded by periosteal new bone.
Spinal pattern - Unilateral or bilateral sacroiliitis, asymmetric paravertebral comma-shaped ossification involving the lower thoracic and upper lumbar vertebrae

Treatment: bed rest and NSAID

2) Psoriatic arthropathy

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3) Enteropathic spondylitis

Always suspect this if patient has bowel symptoms ( diarrhoe and weight loss) and large mono- or oligo-arthropathy. However, remember as well that peripheral arthritis ( small joints) may be involved but it is rare!