Rheuma Case: 37-year-old Woman with Dyspnea and Abdominal Pain

00:00 Alright. Today, we're going to cover a big topic, Vasculitis. Let's go through a case.

00:08 A 37-year-old woman with a history of asthma presents with dyspnea, abdominal pain. She was diagnosed with asthma at age 19 and has had exacerbations with increasing frequency over the past several years despite the use of a maximum dose of a fluticasone inhaler. Over the past few weeks, she has also had increasing episodes of abdominal pain after eating large meals and yesterday morning she noted that her left foot seems to be dragging a bit. She also reports fevers, a 15-pound weight loss but she denies any coughing or sore throat or diarrhea.

00:41 On review of systems, we also find that she is supporting a rash on both of her elbows. No eye pain, no redness, no joint pain. She's a non-smoker, she drinks socially, occasionally uses crack cocaine. Family history is non-contributory. So that's a lot of information. Let's try and at least highlight 4 particular variables that we always do. Number 1, the time course. This is a complicated time course. On 1 hand, we've got something that's been going on since she was 19 for 20 years, that's increasing asthma exacerbations that have been gradually increasing over time.

01:15 But then we've got some new symptoms starting a few weeks ago and then we've got things that just started yesterday morning so I'd call this an acute on sub-acute on chronic kind of picture. Next up, the pattern of disease. We've got a lot of systems involved here. We've got the lungs, some abdominal pain suggested gastrointestinal issue. The left foot drop, maybe that's a neurologic issue. And then a rash on the elbows. So clearly a lot of different systems are involved. Evidence of joint inflammation. At this point, it's not entirely clear, we'll need a physical exam but she's not highlighting any joint pain or effusions at the moment. And next up, systemic involvement. Well, the fevers and the weight loss certainly make us think about a systemic involvement issue and of course she has 4 or 5 systems already involved just based on our HPI.

02:04 Now let's go into our physical exam. We do see that she has a temperature of 38.2°C so she is in fact febrile. Heart rate is tachy at 102. Blood pressure looks okay and she is satting well on room air. Normal sclera, no lymphadenopathy. The examiner does note some nasal polyps.

02:22 She's tachycardic. No murmurs, rubs, or gallops. And we do find some focal crackles up in the right upper lung field. There is some dullness to percussion also at the left base. Something is going on in multiple lung fields. Her abdomen reveals a soft, nondistended belly though she is mildly tender over the epigastrium. And then in the neuromuscular exam, we find 3/5 strength at the left ankle with dorsiflexion though 2+ reflexes throughout except 1+ at the left ankle.

02:51 Her skin and nail exam reveals some subcutaneous nodules with erythema and palpable purpura on the bilateral arms at the extensor surfaces, a little bit more on the left than on the right.

03:03 That is a lot of data. So, which of the following is the most likely diagnosis? Is it eosinophilic granulomatosis with polyangiitis? Is it granulomatosis with polyangiitis? Is it microscopic polyangiitis? Is it anti-glomerular basement membrane disease? Or is it polyarteritis nodosa? Poy, that is a lot of big words. Let's take a quick look at the classification of the vasculitides so that we aren't completely loss in all of those syllables.