Rheumatological Emergencies

Polymyalgia Rheumatica

• Aching pain in the neck, shoulders, and hips
• Symptoms worse in the morning, improve with activity
• Common in individuals over 50, linked to temporal arteritis (giant cell arteritis)
• Inflammatory markers:
  • Elevated CRP and ESR
  • Fever, fatigue
  • Joint pain and swelling
• Treatment:
  • Prednisone (oral)
  • Methylprednisolone (IM)
  • Methotrexate

Gout

• Monosodium urate crystal accumulation in joints due to hyperuricemia
• Uric acid crystallizes in areas with slow blood flow → recurrent attacks → gouty arthritis

Contributing Factors:

1. High purine intake:
   • Shellfish
   • Anchovies
   • Red/organ meats
2. Increased purine production:
   • High-fructose corn syrup
3. Reduced uric acid clearance:
   • Dehydration, excessive alcohol consumption
4. Other risk factors:
   • Obesity, diabetes
   • Chemotherapy
   • Genetic predisposition
   • Chronic kidney disease
   • Medications (thiazide diuretics, aspirin)

Treatment:

• Acute relief: NSAIDs, steroids, colchicine (prevents WBC migration to affected joints)
• Prevention: Dietary adjustments, hydration, uric acid-lowering medications (allopurinol, probenecid)

Sepsis

A severe medical condition triggered by an infection, leading to an excessive immune response and widespread clotting activation.

Pathophysiology:

• Infection → heightened immune reaction → excessive clotting → microthrombi formation
• Hypercoagulability + systemic clotting activation + thrombin production → depletion of platelets → DIC (disseminated intravascular coagulation)
• Exception: Heparin may be administered in obstetric-related cases (e.g., retained placenta, incomplete abortion)
• Cellular debris → further inflammation, coagulation, and cell destruction → progression to organ failure

Organ System	Signs of Dysfunction in Sepsis
Cardiac	Weakened heart contractions, decreased blood volume return
Respiratory	Damage to lung capillaries, fluid accumulation in lungs, ARDS
Gastrointestinal	Weakened intestinal lining barrier
Hepatic	Lowered immune function, slower toxin removal
Renal	Reduced urine output, potential kidney shutdown
Neurological	Altered brain function (encephalopathy)

SIRS (Systemic Inflammatory Response Syndrome) Criteria:

• Abnormal Temperature: Elevated or decreased body temperature
• Increased Heart Rate: >90 BPM
• Respiratory Changes: Tachypnea (>20 breaths per minute) or low PaCO2 (<32 mmHg)
• White Blood Cell Abnormalities: <4,000 or >12,000 WBC count, or >10% bands

QSOFA (Quick Sequential Organ Failure Assessment):

• Altered Mental Status (AMS)
• Rapid Respiratory Rate
• Hypotension (Low Blood Pressure)