류마티스 내과 R2 채정민 류마티스 내과 MGR Case presentation 다발성 관절통을 주소로 내원한 74 세 여성

 C.C.) Polyarthralgia at Lt 2 nd finger, both 3 rd toe Onset : 내원 1 주전  P.I.) F/74. 6 년전 타병원에서 Gout with urate nephropathy 진 단받고 이후 별다른 치료 없이 지내던 자로, 내원 2 달전 acute gout attack 으로 본원 한방병원 입원 치료한 과거력 있음. 당시 급성기 치료에 대하여 류마티스 내과 진료의뢰 되었으며 이후 류마티스 내과 외래 추적 중에 내원 1 주전 부터 Lt. hand 의 2nd finger DIP,PIP 와 양쪽 3rd toe DIP 에 painful swelling, erythema, discharge 발생하여 입원 이 O 기 (F/74)

 Past medical Hx)  HTN(+) : 15 년전 진단.  Gout, urate nephropathy(+) : 6 년 전 진단  Reflux Esophagitis(+) : 한달 전 진단, PPI 복용 중  DM/Hepatitis/Tb(-/-/-)  Allopurinol Hypersensitivity(+) : 외래서 약 복용 후 SKIN RASH 발생하여 중단한 상태  Operation Hx)  Cataract op(2006 년 2 월 ) Colchicine 0.6mg bid Telmisartan 80mg qd Carvedilol 12.5mg qd Atorvastatin 10mg qd Aspirin 100mg qd Rabeprazole 10mg qd

 Family Hx)  Personal Hx)  Smoking(-), Alcohol(-) 남편 : HTN, Angina Pectoris 어머니 : DM

Review of System  General  Fatigue(+), Fever(-), Chills(-), Sweating(-)  Skin  Rash(-), Itching(-), Pigmentation(-)  Head & Neck  Headache(+), Visual decrease (-)  Rhinorrhea (-), Otorrhea (-), Otalgia (-)  Dizziness(-), Stiffness(-)  Sore throat (-), Hoarseness (-)  Respiratory  Cough(-), Sputum(-), Dyspnea(-)

 Cardiac  Palpitation(-), Orthopnea(-), Chest discomfort(-)  Gastrointestinal  A/N/V/D/C (-/-/-/-/-), Abdominal pain (-)  Genitourinary  Urgency (-), Frequency (-), Polyuria (-), Dysuria (-)  Musculoskeletal  Swelling & Erythematous color change(+) & discharge(+)  Lt.hand 의 2 nd finger(PIP&DIP) - Bloody, milkish appearance  Both foot 의 3 rd toe(DIP)  Pain(+), Tenderness(+), Redness(+) Joint pain(+)

Physical Examination  Vital : 140/80mmHg – 68 회 / 분 – 18 회 / 분 – 36.1°C  Height : 156.8cm Weight : 52.8kg BMI : 21.5 kg/m 2  General  Alert mentality  Acute ill looking appearance  Head & Neck  LN enlargement(-/-), Jugular vein engorgement(-/-)  Hepatojugular reflux(-), Carotid bruit(-/-)  Heart & Lung  Chest shape : normal  Clear breathing sound without crackles or rales  Regular Heart beat without murmur

 Abdomen  Soft and flat abdomen  Normoactive bowel sound  Abdominal Td / RTd(-/-)  Palpable abdominal mass(-)  Back&Extremity  Swelling & Erythematous color change(+) & discharge(+)  Lt.hand 의 2 nd finger(PIP&DIP) - Bloody, milkish appearance  Both foot 의 3 rd toe(DIP)  Pretibial pitting edema(+/+)

Initial Lab  CBC/DC  WBC : 5210/ul(seg : 56.2%)PLT : 283 X 10³/ul  Hb : 11.0g/dlHct : 31.9%  Blood Chemistry  TB/DB : 0.81/0.14 Total cholesterol : 106mg/dL  ALP/rGT : 142/53(U/L)Prot/Alb : 6.8/3.1(g/dl)  AST/ALT : 49/30(U/L)Glucose : 90mg/dL  LD/CK : 574/153(U/L)Ca/P/Uric Acid : 8.5/3.5/7.4(mg/dL)  Bun/Cr : 12/1.7(mg/dL)  CRP : <0.5(mg/dL) ESR : 57mm/hr  Urine Analysis  RBC : 0~1/HPF, WBC : 0~1/HPF  occult blood(+-), protein(-), nitrite(-)

EKG

Chest

Initial problem list  1. Painful swelling & discharge at Lt. hand 2 nd finger PIP, DIP & both foot 3 rd DIP  2. Known chronic tophaceous gout  3. Known HTN  4. Chronic renal insufficiency with known urate nephropathy

Initial assessment and plan # 1. Painful swelling & discharge of Lt. hand 2 nd DIP & PIP & both foot 3 rd DIP # 2.Known chronic tophaceous gout A> Acute flare-up of chronic tophaceous gout r/o septic arthritis r/o CPPD P> Joint fluid aspiration (Gram stain,/culture, WBC/DC, crystal microscopy) Blood, wound culture Joint x-ray & bone scan 24hrs urine collection

Initial assessment and plan P> I&D Antibiotics Low dose steroid, colchicine

Hand X-ray

→ I&D (wound culture ) Staphylococcus aureus → ceftriaxone 유지 Blood culture : no growth Acute flare-up of chronic tophaceous gout associated with S.aureus infection

24hr urine collection 24hr urine protein 179 mg /day = 314mg/g 24hr urine creatinine 569 mg/day ( 기대치 20mg/kg/day x 50kg =1000mg/day) 24hr uric acid 197 mg/day = 400mg/g CrCl 23.2 ml/min eGFR 31.3 ml/min/1.73m 2

Clinical considerations Acute management 후 maintenace therapy(uric acid lowering ) 은 어떻게 할것인가 ? 1) 신기능 고려하여 allopurinol  hypersensitivity 2) Probenecid 사용은 신기능을 고려할 때 사용불가 3) Benzbromarone - Uricosuric agent - CrCl 25ml/min 이상 시 사용가능 Benzbromarone !!

Clinical course 5mg Prednisolone 10mg ceftriaxone I&D Colchicine 0.6mg BID 증상호전 Benzbromarone 50mg

Final diagnosis 1. Acute flare up of chronic tophaceous gout and superimposed S.aureus infection 2. Renal insufficiency c urate nephropathy 3. HTN

Clinical consideration Colchicine 0.6mg bid Telmisartan 80mg qd Carvedilol 12.5mg qd Atorvastatin 10mg qd Aspirin 100mg qd Rabeprazole 10mg qd Benzbromarone 50mg qd Colchicine 0.6mg bid Telmisartan 80mg qd Carvedilol 12.5mg qd Atorvastatin 10mg qd Aspirin 100mg qd Rabeprazole 10mg qd Risk-benefit 다시 고려 Amlodipine 변경 ?

류마티스 내과 R2 채정민 류마티스 내과 MGR Case presentation II 다발성 관절통을 주소로 내원한 65 세 여성

 C.C.) Both knee,hand pain & swelling Onset : 내원 3 일전  P.I.) 65 세 여자 환자. 86 년 SLE, 90 년 lupus nephritis WHO class V 진단받고 본원 신장내과 진료 중인 자로 내원 3 일전 절에 다녀온 후 both knee, both hand MCP, PIP 에 tenderness, swelling, local heating sensation 발생하여 류마티 스 내과로 진료의뢰됨 김 O 덕 (F/65)

 Past medical Hx)  DM/HTN/Hepatitis/Tb(+/+/-/+)  HTN(+) : 9 년전 진단  DM(+) : 9 년전 진단  Pulmonary tuberculosis(+) : 2 달전부터 medication 중  SLE(+) : 86 년 진단, lupus nephritis (+) : 90 년 진단  Operation Hx)  None  Personal Hx)  Smoking(-), Alcohol(-) [ Medication list]  Carvedilol 25mg qd  Benidipine 4mg qd  Lasix 60mg bid  Cyclosporine 50mg bid  Prednisolone 5mg qd  Ferrous sulfate 256mg qd  Calcium carbonate 500mg bid  Gliclazide 30mg bid  Novomix 20/16 unit  결핵 4 제 요법 → 3 제요법

ROS  Fatigue(+), Fever(-), Chills(-), Sweating(-)  Melena(-), A/V/N/D/C(-/-/-/-/-), Abd.pain(-)  Cough(-), Sputum(-), Dyspnea(-)  Urgency (-), Frequency (-), Polyuria (-), Dysuria (-)  Arthralgia (+) : both knee, both hand 의 MCP, PIP, Wrist pain (+) swelling (+)  Vital : 110/70mmHg – 84 회 / 분 – 20 회 / 분 – 36.2°C  Height : 147cm Weight : 45kg BMI : 20.8 kg/m 2  Back & Extremity  Swelling (+) Tenderness(+) Redness(+) Heating sense (+) : Both knee, both hand MCP, PIP & wrist  Pretibial pitting edema(-/-) PE

Chest

Initial problem lists  1. Pain & swelling at both knee & both hand MCP, PIP, wrist  2. Known Lupus nephritis with Renal insufficiency  3. Known SLE  3. Known HTN  4. Known DM  5. Known pulmonary Tb

Initial assessment and plan  1. Pain & swelling of both knee A) Acute gouty arthritis r/o rheumatoid arthritis r/o septic arthritis r/o CPPD r/o lupus arthritis P) [Diagnostic plan] Joint x-ray & bone scan MUS & joint fluid aspiration Serologic marker

Initial assessment and plan (con’t) [Therapeutic plan] Diuretics stop & hydration Colchicine, low dose steroid use  2. Known Lupus nephritis with Renal insufficiency  3. Known SLE  3. Known HTN  4. Known DM  5. Known pulmonary Tb

Knee X-ray

Hand X-ray

Foot X-ray

Rt knee sonography

Both 1 st MTP sonography

Joint fluid analysis  Gross finding: yellowish, clear  Cell count  RBC : 108 /mm 3  WBC: /mm 3  Neutrophil: 81 %  Lymphocyte: 13 %  Monocyte: 6 %  Crystal: Negative  Culture: Negative

Joint fluid analysis Gross Examination NormalNoninflamm atory (Group I) Inflammator y (Group II) Septic (Group III) Crystal (Group IV) Hemorrhagic (Group V) Viscosity Color WBC (mm 3 ) PMN (%) Crystals present Culture High Colorless to straw <200 <25 No Negative High Straw to yellow 200-2,000 <25 No Negative Low Yellow Cloudy 2,000-75,000 >50 often No Negative Variable Yellow-white Cloudy Often >100,000 >75 No Often positive Variable Yellow Cloudy 2,000-75,000 >50 often Yes Negative Variable Red Xanthochromic 50-10,000 <50 No Negative

Clinical course Colchicine 0.6mg bid, Prednisolone 15mg Hydration Allopurinol 100mg bid

Clinical course Colchicine 0.6mg bid, Prednisolone 15mg Allopurinol 100mg bid Hydration S: 2 T: 2 L: 1 S: 1 T: 1 L: 1 S: 0 T: 0 L: 0

Final diagnosis 1. Acute gouty arthritis due to Diuretics use and dehydration Pyrazinamide use Renal insufficiency 2. SLE & lupus nephritis 3. HTN 4. DM 5. Pulmonary tuberculosis

Clinical consideration Carvedilol 25mg qd Benidipine 4mg qd Lasix 60mg bid Cyclosporine 50mg bid Prednisolone 5mg qd Gliclazide 30mg bid Novomix 20/16 unit 결핵 4 제 요법 (HERZ) → 3 제요법 Ferrous sulfate 256mg qd Calcium carbonate 500mg bid Valsartan 80mg qd Amlodipine 4mg qd 이뇨제는 중단 Cyclosporine 중단 또는 변경 Prednisolone 5mg qd Metformin 고려 Novomix 20/16 unit 결핵 3 제요법 (HER) 유지 Ferrous sulfate 256mg qd Calcium carbonate 500mg bid renal insufficiency 로 사용 못함