hypertension and rheumatologic practice - hatemeleishi.com课件

Hypertension Rheumatologicpractice HYPERTENSIONCLUBJANUARY21ST 2007 HatemHamdiEleishi MDConsultantRheumatologist Dr S FakeehHospital JeddahAssistantProfessorofRheumatology CairoUniversity Egypt HYPERTENSIONINRHEUMATOLOGICPRACTICE RheumatologicDisordersThatMayCauseHypertension SystemicDisordersThatMayCauseRheumatologicManifestationsAndAlsoHypertension RheumatologicTreatmentsThatMayCauseHypertension Anti hypertensiveTreatmentsThatMayCauseRheumatologicProblems Anti hypertensiveTreatmentsThatMayBenefit HelpSolveRheumatologicProblems PatientNon complianceWithCardiologist sAdviceThatMayBenefit HelpSolveRheumatologicProblems 1 2 3 4 5 6 RheumatologicDisordersthatmaycauseHypertension 1of6 Facialrash A26 yearoldfemalewith Hypertension Fatigue polyarthritis Lab ESR100mm hrHb7gm dLCreatinine2 3mg dL WBC2 700 cc Fever weightloss Lab cont HypocomplementemiaAlbumin 2 1g dL SystemicLupusErythematosus Urinalysis Proteinuria hematuria pyuria granularcastsPositiveANAPositiveanti DNA PolyarteritisNodosa A37 year oldmanwith FootdropSCnoduleoverthecalf HBVpositive Testicularpain Hypertension Arthralgias myalgias Fever weightloss Lab ESR100mm hrHb7gm dLCreatinine2 3mg dL Takayasu sArteritis A38 yearoldwomanpresentswith FatigueIncreasingpaininbotharms Bloodpressuremeasurements Rightarm105 65mmHgLeftarm140 80mmHg Labs Hb10 4g dL ESR68mm h Takayasu sArteritis Early Nonspecificsymptoms Variablerateofprogression Later manifestationoflargevesselocclusivedisease Arms legs Coronaries Renalarteries TOOLATE A38 yearoldwomanpresentswithfatigueandincreasingpaininbotharms Onexaminationthereismildbilateralpolyarthritisaffectingthearmsandknees Bloodpressuremeasurements Rightarm105 65mmHgLeftarm140 80mmHgLabs Hb104g l MCV82fl WBC12 400 cc Plt481000 cc ESR68mm hAnswercase17 Takayasu sarteritis Ayoungwomanwithsystemicinflammatorydisease Theinvestigationofchoiceisarch aortogram Thepicturedoesnotapplyforcoarctationas intheproximalform theBPshouldbehigherintherightarmanyway Wegener sgranulomatosis A27 yearoldfemalewith Chronicsinusitis Purpuriclesionswerenotedovertheelbows ChestX ray awell circumscribedroundlesionintherightupperzoneapproximately8cmindiameter Hypertension Fatigue polyarthritis Fever weightloss NegativeANA A27 yearoldgirlisseenincasualtywithdiplopia Shehasbeenunwellfortheprecedingmonthwithmalaiseandintermittentfeverswithsomeweightloss Overtheprecedingthreeyearsseveralepisodesofpolyarthralgiaassociatedwithvasculiticlesionsappearingovertheelbowshadbeentreatedbyoralprednisolone Fiveyearspriortopresentation shehadbeenseenbytheENTsurgeonswithchronicsinusitis andlaterrequirednasalreconstructivesurgeryfollowinganasalcollapse Onexaminationshewaspyrexialwithatemperatureof900C Vasculiticlesionswerenotedovertheelbows Centralnervoussystemexaminationrevealednormalvisualacuityinbotheyeswithnoobviousocularmuscleweakness Thediplopia however waselicitedonrightlateralgaze ChestX rayonadmissionrevealedawell circumscribedroundlesionintherightupperzoneapproximately8cmindiameter Questions Whatistheprobablediagnosis Whatthreeinvestigationsmayheofhelpinthemanagementofthiscondition Wegener sgranulomatosis Diagnosisisoftendelayedbyanatypicalpresentationwithsymptomswronglyattributedtootherconnectivetissuediseases Unlikethelatterdiseases however theANAisusuallynegativeorpresentinlowpositivetitreandunlikeacutesystemiclupuserythematosustheneutrophilcountrisesduringattacksaccompaniedbyathrombocytosis highESRandhighC reactiveproteinlevels C ANCAantibodiesareveryhelpfulinthediagnosis Histologicalspecimensareoftenunhelpfulinviewofthetissuenecrosis InthiscaseaCTscanofthesinusesandorbitsrevealedmassesinbothsinusesandtherightorbit DiffuseSystemicSclerosis A57 yearoldfemalewith ColdbluehandsSkintightness Hypertension Fatigue polyarthralgias PositiveANA Creatinine3 0mg dL A53 year oldmanisreferredforinvestigationoflow gradepyrexiaandnightsweats Hehaslost5kginweightoversixmonths Morerecentlyhehasbecomebreathless andhasexperiencedsomereliefbyasalbutamolinhaler Hehasatwo yearhistoryofanginawhichiscontrolledonoralnitratesandaspirin Onexaminationthereissometendernessofthewristsandknees butnoactivesynovitis Mildpittingedemaisseenaroundbothankles BP175 100mmHg pulse80 mm regular Finecracklesareauscultatedatthebasesandthereisageneralisedwheeze Abnormallabs Hb138g l WBC10 500 ccwithneutrophils81 eosinophils6 andlymphocytes12 plat482000 cc ESR53mm h crea261mmol l Albumin3gg l Answercase5 Thepatienthasamultisystemdiseasewithpredominantrenalinvolvement Thefeaturesaremostconsistentwithavasculitis thepresenceofasthma likesymptomsandeosinophiliaindicatesChrug Straussvasculitis Systemiclupuserythematosus Takayasu sarteritis Wegener sGranulomatosis PolyarteritisNodosa Systemicsclerosis Takayasu SLE Wegener s Systemicsclerosis Microscopicpolyangitis ChurgStrauss Polyarteritisnodosa Renalartery GM Microscopicpolyangitis ChurgStrauss SystemicDisordersthatmaycauseRheumatologicManifestationsandalsoHypertension 2of6 Endocrinal Cushing sdisease Thyrotoxicosis Acromegaly ThyrotoxicMyopathy Hypertension Proximal later generalizedmuscleweakness ProxmialmyopathyOsteoporosis Thyrotoxicmyopathy canbemild characterizedbyfatigability weaknessandminimalatrophy oritcanbeextreme character izedbysevereweaknessandproximalwasting Muscleenzymesare however typicallynotelevated Alsomyastheniagravisandthyrotoxicperiodicparalysisthatissimilartotheperiodicparalysisofprimaryhypoka lemiamayoccur Acromegaly Musculoskeletalsymptomsandsigns Symptoms Gradualproximal latergeneralized weaknessanddecreasedexercisetoleranceandfatiguearetheusualcomplaints followedbymyalgias cramps andmuscletwitching Signs Themusclesmayfeelflabby withweaknessoutofproportiontomusclemass Investigations Theserumcreatinekinaseandaldolaselevels al thoughusuallynormal maybeincreasedasareflectionofpatchynecrosis Miscellaneous SystemicDisordersthatmaycauseRheumatologicManifestationsandalsoHypertension cont A67 yearmanwith ESR 10mm hr Systolichypertension Paininleftlowerarmwithdeformity Noconstitutionalsymptoms Paget sDisease ElevatedALP Elevatedurinaryhydroxyproline Normals calcium Paget sDisease Afocaldisorderofboneremodelingthattypicallybeginswithexcessiveboneresorptionfollowedbyexcessiveboneformation Normalbone Pageticbone WhatcauseshypertensioninPaget sdisease Normalbone Pageticbone Highcardiacoutputfailure A56 yearmanwith ESR 85mm hr Long standingHypertension Backpain Constitutionalsymptoms Hasa3 monthhistoryof Backexam free Anuria risingcreatinine Mid abdominalbruit CTabdomenconfirmsthediagnosis RetroperitonealFibrosis RPF ConsiderthediagnosisofRPFin Amiddle agedorelderlypatientWiththetriadof Clue Abdominaland orbackpainElevatedESRWeightloss A65 year oldmanpresentedwitha3 monthhistoryofbackpainthatwasconstantanddullanddidnotradiate Itwasaccompaniedbylow gradefeveranda5kg weightloss Examination Temp100 20 Abdomen midabdominalbruit Back free Extremities 1 edemainlegs Laboratoryfindings WBC12 000 cc Hct38 platelets300 000 cc ESR110mm h crea3 8mg dL urine normal RFandANA negative Abdominalultrasound 4 cmaorticaneurysmandbilateralhydronephrosis CTscan retroperitonealmassencirclingandobstructingtheureters Diagnosis Retroperitonealfibrosis Ormonddisease confirmedbybiopsyNotes Retroperitonealfibrosisisararecauseofbackpain flankpainorabdominalpain Lessfrequentmanifestationsincludelegswelling claudication hematuria oliguriaandRaynaud sphenomenon Considerthediagnosisofretroperitonealfibrosisinamiddle agedorelderlypatientwiththetriadofabdominaland orbackpain elevatedESRandweightloss Endocrinal Cushing ssyndrome Thyrotoxicosis Acromegaly Miscellaneous Paget sDisease RPF RheumatologicTreatmentsThatMayCauseHypertension 3of6 Corticosteroids Cyclosporine Anti hypertensiveTreatmentsThatMayCauseRheumatologicProblems 4of6 Thiazidediuretics Hydralazine Anti hypertensiveTreatmentsThatMayBenefitExistingRheumatologicProblems 5of6 Captropril Welikethatsulfhydryl SH group HypertensivePatientNon complianceWithDoctorAdviceThatMayBenefitSomeRheumatologicProblems 6of6 Smokingisgoodfor OralulcersinBehcet sdisease NicotineandbiochaninA butnotcigarettesmoke induceanti inflammatoryeffectsonkeratinocytesandendothelialcellsinpatientswithBehcet sdisease DepartmentofDermatology ChariteUniversitaetsmedizinBerlin CampusBenjaminFranklin Berlin Germany Duringperiodsofsmoking patientswithBehcet sdiseasehavelessoralaphthaethaninabstinence Toelucidatethisobservation humankeratinocytesanddermalmicrovascularendothelialcells HMEC 1 wereincubatedwithserumof20patientswithBehcet sdiseaseand20healthycontrolsfor4hours Maximumnon toxicconcentrationsweredeterminedandthecellswerefurthertreatedwith6microMnicotine 3 3 cigarettesmokeextract CES 100microMbiochaninA and6 25 12 5microMpyrrolidinedithiocarbamatealoneandincombinationsfor24hours SerumIL 8levelsofpatientsweresignificantlylowerthanthoseofcontrols However af