Gout: A Rapid Review of Presentation, Diagnosis and Management.

Gout is inflammatory arthritis caused by monosodium urate crystal deposition in articular and non-articular structures. Acute gout flares are often monoarticular/polyarticular involving lower extremity joints characteristically involving 1st metatarsophalangeal joint. However, gout flares can also be polyarticular, involving upper extremity joints, especially in patients with multiple comorbidities and contraindications to urate-lowering therapies (ULT). Risk factors exacerbating gout flares include obesity, high alcohol and purine-rich food consumption, and the use of diuretics. Diagnosis requires synovial fluid analysis with direct visualization of monosodium urate crystals. Acute flares are managed with steroids, non-steroidal anti-inflammatory drugs, or colchicine. Long-term management includes lifestyle modifications including a heavy emphasis on weight loss, avoidance of alcohol, purine-rich foods, and diuretics. ULT is indicated in patients with 2 or more gout flares/year, tophi, or radiographic evidence of gouty arthropathy. Although allopurinol is the first-line ULT agent, it does carry a risk of inducing severe cutaneous adverse reactions, especially in patients with chronic kidney disease and patients harboring the HLA-B*5801 allele. Other ULT agents include febuxostat and probenecid. ULT is usually titrated to achieve goal serum uric acid (SUA) levels below 6 mg/dL. However, in patients with tophi, a lower SUA target of less than 5 mg/dL should be implemented for prompt urate crystal dissolution.

Crowned Dens Syndrome: A Challenging Diagnosis in Older Adults Presenting With Acute Neck Pain.

Crowned dens syndrome (CDS) is a rare syndrome of calcium pyrophosphate dihydrate (CPPD) deposition on the odontoid process of the second cervical vertebra leading to unique clinical presentation and radiographical findings. Symptoms usually overlap with more common etiologies, including meningitis, stroke, and giant cell arteritis. Thus, patients struggle with extensive evaluation before diagnosing this uncommon condition. There are few case reports and case series of CDS in the literature. Patients respond well to treatment, but unfortunately, there is a high rate of relapse. Here we present an interesting case of a 78-year-old female patient who presented with acute onset headache and neck pain.

Delayed Diagnosis of West Nile Meningoencephalitis in a Patient Receiving Rituximab for Rheumatoid Arthritis.

West Nile virus (WNV) neuroinvasive disease is associated with substantial morbidity and mortality. Clinical suspicion is usually confirmed with cerebrospinal (CSF) immunoglobulin M (IgM) detection using enzyme-linked immunoassay (ELISA) techniques. CSF polymerase chain reaction (PCR) is rarely used to confirm the disease and is not widely available. We present a detailed report of false-negative WNV IgM in a patient receiving rituximab therapy for rheumatoid arthritis. She was exposed to the virus during peak immunosuppression and strong clinical suspicion was confirmed with WNV PCR, illustrating the importance of such consideration with the recent incremental use of rituximab therapy. Despite the lack of specific anti-viral treatment for WNV, delayed consideration and diagnosis of WNV in those who are immunosuppressed would expose them to a wide panel of testing, with a subsequent increase in the cost of medical care.

Methotrexate Hepatotoxicity Monitoring Guidelines in Psoriasis and Rheumatoid Arthritis: Is There a Consensus?

Methotrexate therapy has evolved over the years to become a fundamental component in the management of rheumatoid arthritis and psoriasis. Liver toxicity remains an ever-present concern when prescribing methotrexate. As such, methotrexate liver toxicity monitoring guidelines have been developed independently by rheumatologists and dermatologists. The main differentiating factor between the dermatology and rheumatology guidelines is risk stratification. Dermatology guidelines are largely based off of the presence or absence of hepatoxicity risk factors (alcohol usage, obesity, type II diabetes, among other) while the rheumatology guidelines do not emphasize this distinction. Thus, the aim of this review is to identify why these screening guidelines differences exist and discuss if the differences in stratification and screening are valid. We will also briefly examine alternatives to the current gold standard hepatoxicity screening test: the liver biopsy.

Statin Associated Muscle Adverse Effects: From Presentation to Management.

Statins inhibit ß-Hydroxy ß-methylglutaryl-CoA (HMG-CoA) reductase, an enzyme involved in cholesterol synthesis, and are widely used for primary and secondary prevention of cardiovascular events. They are generally well tolerated but may cause muscle symptoms ranging from myalgias, myopathy, myositis to rhabdomyolysis. More recently, studies have reported autoimmune necrotizing myopathy associated with statin use, characterized by progressive symmetric weakness even after discontinuation of statins, often warranting immunosuppressive treatment. We describe the spectrum of statin associated muscle adverse effects for primary care physician including the clinical presentation, etiology, diagnostic workup, and appropriate management.

Aspirin in Primary and Secondary Prevention of Cardiovascular Disease.

Aspirin is one of the most widely used drugs for the treatment of cardiovascular disease. While its use in patients with known cardiovascular disease has been supported with trials which have included mortality benefit, the utility of aspirin therapy in patients without established cardiovascular disease has been less clear. Early trials appeared to demonstrate benefit with the use of aspirin, but trials after 2000 did not consistently substantiate using aspirin for primary prevention of cardiovascular disease. Despite the lack of robust supportive evidence, aspirin was recommended and used extensively for primary prevention in patients at higher risk for cardiovascular events. More recently in 2018, results of three randomized, controlled trials: ARRIVE, ASCEND, ASPREE demonstrated modest to no benefit in preventing cardiovascular events and mortality with aspirin use for primary prevention. These trials also demonstrated an increased risk of bleeding in these patients who were on aspirin for primary prevention.

Meningeal rheumatoid nodules in a 55-year-old man presenting with chronic headaches and oculomotor nerve palsy: an uncommon extra-articular manifestation of rheumatoid arthritis.

Rheumatoid arthritis (RA) is a multisystem inflammatory disease which can involve many organ systems including the central nervous system (CNS). Though not very common, the results can be severely debilitating. The spectrum of the CNS involvement includes meningitis, encephalitis and occasionally rheumatoid nodules. Its presentation is variable, though very rarely it can present as focal neurological deficits. Imaging can be suggestive, but diagnosis usually requires tissue biopsy. Treatment consists of high-dose steroids and immunosuppressants. We describe the case of a 55-year-old male patient with a history of RA presenting with a third nerve palsy and headache who was found to have rheumatoid nodules on biopsy. CNS involvement in RA should be considered in anyone with rheumatoid arthritis who presents with focal neurological deficits, though infections and space-occupying lesions should also be ruled out.

Promoting scholarship in a community-based internal medicine residency.

The University of South Dakota Sanford School of Medicine Internal Medicine residency implemented a program to enhance scholarship among residents. This residency is part of a small Mid-Western community-based school. Background: A Director of Research was hired and developed a structured approach consisting of: 1. Independent study regarding research methods and statistical testing and 2. Mentoring of residents and faculty in scholarly pursuits starting in the first months of residency. Methods: Scholarship for two cohorts of residents for years July 2011-2014 and January 2014-2017 were followed. Products included papers accepted/published and papers accepted/presented at national or international meetings. Results: 7 (14.8%) of 47 residents in the first cohort published 12 papers (0.25 papers/resident) with 18 faculty as co-authors (1.5/paper). 20 (43.4%) of 46 residents in the second cohort (structured program) published 39 papers (0.85 papers/resident) with 80 faculty as co-authors (2.1/paper). The difference in papers was significant by chi-square analysis. Conclusion: A structured program requiring independent study in conjunction with individualized mentoring of scholarship starting early in the first postgraduate year was successful in significantly increasing the scholarly activity of our community-based internal medicine residents and faculty. With this program, the percentage of residents publishing exceeds national statistics recently reported.

Polymyalgia Rheumatica and Giant Cell Arteritis: A Review Article.

Polymyalgia rheumatic (PMR) and giant cell arteritis (GCA) are two rheumatological conditions with significant overlap that typically affect the older white population. PMR is the most common inflammatory rheumatic disease of the elderly and shares many pathogenetic and epidemiological features with GCA. Diagnosis is made primarily on clinical grounds with supporting laboratory evidence. Typical symptoms of PMR are bilateral aching of the shoulders and pelvic girdle associated with stiffness. PMR is associated with GCA and is considered to be on a disease continuum. Approximately half of patients diagnosed with GCA have already been or will be diagnosed with PMR. GCA is the most common vasculitis in adults and affects medium and large arteries and can result in blindness if untreated. Clinically it may present either gradually or abruptly. The most common presentation is headache with an aching pain classically localizing to the temporal region of moderate intensity which responds poorly to analgesics. Patients may also experience jaw or tongue claudication with weakening or pain in the muscles of mastication that is relieved by rest. The temporal artery may exhibit palpable beading, diminished pulses, bruits and tenderness.