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Hypertension Rheumatologic practice HYPERTENSION CLUB JANUARY 21 ST, 2007.

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Presentation on theme: "Hypertension Rheumatologic practice HYPERTENSION CLUB JANUARY 21 ST, 2007."— Presentation transcript:

1 Hypertension Rheumatologic practice HYPERTENSION CLUB JANUARY 21 ST, 2007

2 Hatem Hamdi Eleishi, MD Consultant Rheumatologist, Dr. S. Fakeeh Hospital, Jeddah Assistant Professor of Rheumatology, Cairo University, Egypt HYPERTENSION IN RHEUMATOLOGIC PRACTICE

3 Rheumatologic Disorders That May Cause Hypertension Systemic Disorders That May Cause Rheumatologic Manifestations And Also Hypertension Rheumatologic Treatments That May Cause Hypertension Anti-hypertensive Treatments That May Cause Rheumatologic Problems Anti-hypertensive Treatments That May Benefit/Help Solve Rheumatologic Problems Patient Non-compliance With Cardiologist’s Advice That May Benefit/Help Solve Rheumatologic Problems 1 2 3 4 5 6

4 Rheumatologic Disorders that may cause Hypertension 1 of 6

5 Facial rash A 26-year old female with: HypertensionFatigue, polyarthritis Lab: ESR 100 mm/hr Hb 7gm/dL Creatinine 2.3mg/dL WBC 2.700/cc Fever, weight loss

6 Lab (cont.): Hypocomplementemia Albumin: 2.1 g/dL Systemic Lupus Erythematosus Urinalysis: Proteinuria, hematuria, pyuria, granular casts Positive ANA Positive anti-DNA

7 Polyarteritis Nodosa A 37-year-old man with: Foot drop SC nodule over the calf HBV positive Testicular pain HypertensionArthralgias, myalgias Fever, weight loss Lab: ESR 100 mm/hr Hb 7gm/dL Creatinine 2.3mg/dL

8 Takayasu’s Arteritis A 38-year old woman presents with: Fatigue Increasing pain in both arms Blood pressure measurements: Right arm 105/65mmHg Left arm 140/80mmHg Labs: Hb 10.4g/dL, ESR 68mm/h

9 Takayasu’s Arteritis Early: Non specific symptoms Variable rate of progression Later: manifestation of large vessel occlusive disease Arms, legs Coronaries Renal arteries TOO LATE

10 A 38-year old woman presents with fatigue and increasing pain in both arms. On examination there is mild bilateral polyarthritis affecting the arms and knees. Blood pressure measurements: Right arm 105/65mmHg Left arm 140/80mmHg Labs: Hb 104g/l, MCV 82fl, WBC 12.400/cc, Plt 481000/cc, ESR 68mm/h Answer case 17: Takayasu’s arteritis: A young woman with systemic inflammatory disease. The investigation of choice is arch-aortogram. The picture does not apply for coarctation as, in the proximal form, the BP should be higher in the right arm anyway.

11 Wegener’s granulomatosis A 27-year old female with: Chronic sinusitis Purpuric lesions were noted over the elbows Chest X-ray: a well-circumscribed round lesion in the right upper zone approximately 8 cm in diameter. HypertensionFatigue, polyarthritis Fever, weight loss Negative ANA

12 A 27-year old girl is seen in casualty with diplopia. She has been unwell for the preceding month with malaise and intermittent fevers with some weight loss. Over the preceding three years several episodes of polyarthralgia associated with vasculitic lesions appearing over the elbows had been treated by oral prednisolone. Five years prior to presentation, she had been seen by the ENT surgeons with chronic sinusitis, and later required nasal reconstructive surgery following a nasal collapse. On examination she was pyrexial with a temperature of 900C. Vasculitic lesions were noted over the elbows. Central nervous system examination revealed normal visual acuity in both eyes with no obvious ocular muscle weakness. The diplopia, however. was elicited on right lateral gaze. Chest X-ray on admission revealed a well-­circumscribed round lesion in the right upper zone approximately 8 cm in diameter. Questions: What is the probable diagnosis? What three investigations may he of help in the management of this condition? Wegener’s granulomatosis. Diagnosis is often delayed by an atypical presentation with symptoms wrongly attributed to other connective tissue diseases. Unlike the latter diseases, however, the ANA is usually negative or present in low positive titre and unlike acute systemic lupus erythematosus the neutrophil count rises during attacks accompanied by a thrombocytosis, high ESR and high C-reactive protein levels. C-ANCA antibodies are very helpful in the diagnosis. Histological specimens are often unhelpful in view of the tissue necrosis. In this case a CT scan of the sinuses and orbits revealed masses in both sinuses and the right orbit.

13 Diffuse Systemic Sclerosis A 57-year old female with: Cold blue hands Skin tightness HypertensionFatigue, polyarthralgias Positive ANA Creatinine 3.0mg/dL

14 A 53-year-old man is referred for investigation of low-grade pyrexia and night sweats. He has lost 5 kg in weight over six months. More recently he has become breathless, and has experienced some relief by a salbutamol inhaler. He has a two-year history of angina which is controlled on oral nitrates and aspirin. On examination there is some tenderness of the wrists and knees, but no active synovitis. Mild pitting edema is seen around both ankles, BP 175/100 mmHg. pulse 80/mm, regular. Fine crackles are auscultated at the bases and there is a generalised wheeze. Abnormal labs: Hb 138 g/l, WBC 10.500/cc with neutrophils 81%, eosinophils 6% and lymphocytes 12%, plat 482000/cc, ESR 53mm/h, crea 261 mmol/l, Albumin 3g g/l. Answer case 5: The patient has a multisystem disease with predominant renal involvement. The features are most consistent with a vasculitis, the presence of asthma-like symptoms and eosinophilia indicates Chrug- Strauss vasculitis.

15 Systemic lupus erythematosus Takayasu’s arteritis Wegener’s Granulomatosis Polyarteritis Nodosa Systemic sclerosis

16 Takayasu SLE Wegener’s Systemic sclerosis Microscopic polyangitis Churg Strauss Polyarteritis nodosa

17 Renal artery Anterior Branch 3 lobar branches Interlobar Interlobular ArcuateAfferent GM Takayasu Microscopic polyangitis Polyarteritis nodosa SLE Wegener’s Systemic sclerosis Churg Strauss

18 Systemic Disorders that may cause Rheumatologic Manifestations and also Hypertension 2 of 6

19 Endocrinal Cushing’s disease Thyrotoxicosis Acromegaly Thyrotoxic Myopathy Hypertension Proximal, later, generalized muscle weakness Proxmial myopathy Osteoporosis

20 Thyrotoxic myopathy: can be mild, characterized by fatigability, weakness and minimal atrophy, or it can be extreme, character­ized by severe weakness and proximal wasting. Muscle enzymes are, however, typically not elevated. Also myasthenia gravis and thyrotoxic periodic paralysis that is similar to the periodic paralysis of primary hypoka­lemia may occur. Acromegaly: Musculoskeletal symptoms and signs: Symptoms: Gradual proximal, later generalized, weakness and decreased exercise tolerance and fatigue are the usual complaints, followed by myalgias, cramps, and muscle twitching. Signs: The muscles may feel flabby, with weakness out of proportion to muscle mass. Investigations: The serum creatine kinase and aldolase levels, al­ though usually normal, may be increased as a reflection of patchy necrosis.

21 Miscellaneous Systemic Disorders that may cause Rheumatologic Manifestations and also Hypertension (cont.)

22 A 67-year man with: ESR: 10mm/hr Systolic hypertension Pain in left lower arm with deformity No constitutional symptoms

23 Paget’s Disease Elevated ALP Elevated urinary hydroxyproline Normal s. calcium

24 Paget’s Disease A focal disorder of bone remodeling that typically begins with excessive bone resorption followed by excessive bone formation Normal bone Pagetic bone

25 What causes hypertension in Paget’s disease? Normal bone Pagetic bone High cardiac output failure

26 A 56-year man with: ESR: 85mm/hr Long-standing Hypertension Back pain Constitutional symptoms Has a 3-month history of:

27 Back exam: free Anuria, rising creatinine Mid-abdominal bruit CT abdomen confirms the diagnosis Retroperitoneal Fibrosis (RPF)

28 Consider the diagnosis of RPF in: A middle-aged or elderly patient With the triad of: Clue Abdominal and/or back pain Elevated ESR Weight loss

29 A 65-year-old man presented with a 3-month history of back pain that was constant and dull and did not radiate. It was accompanied by low- grade fever and a 5kg-weight loss. Examination: Temp 100.20, Abdomen: midabdominal bruit. Back: free. Extremities: 1+ edema in legs. Laboratory findings: WBC 12,000/cc, Hct 38%, platelets 300,000/cc, ESR 110mm/h, crea 3.8mg/dL, urine: normal. RF and ANA: negative. Abdominal ultrasound: 4-cm aortic aneurysm and bilateral hydronephrosis. CT scan: retroperitoneal mass encircling and obstructing the ureters. Diagnosis: Retroperitoneal fibrosis (Ormond disease) confirmed by biopsy Notes: Retroperitoneal fibrosis is a rare cause of back pain, flank pain or abdominal pain. Less frequent manifestations include leg swelling, claudication, hematuria, oliguria and Raynaud’s phenomenon. Consider the diagnosis of retroperitoneal fibrosis in a middle-aged or elderly patient with the triad of abdominal and/or back pain, elevated ESR and weight loss.

30 Endocrinal Cushing’s syndrome Thyrotoxicosis Acromegaly Miscellaneous Paget’s Disease RPF

31 Rheumatologic Treatments That May Cause Hypertension 3 of 6

32 Corticosteroids Cyclosporine

33 Anti-hypertensive Treatments That May Cause Rheumatologic Problems 4 of 6

34 Thiazide diuretics Hydralazine

35 Anti-hypertensive Treatments That May Benefit Existing Rheumatologic Problems 5 of 6

36 Captropril We like that sulfhydryl (-SH) group

37 Hypertensive Patient Non-compliance With Doctor Advice That May Benefit Some Rheumatologic Problems 6 of 6

38 Smoking is good for……….. Oral ulcers in Behcet’s disease

39 Nicotine and biochanin A, but not cigarette smoke, induce anti-inflammatory effects on keratinocytes and endothelial cells in patients with Behcet's disease. Department of Dermatology, Charite Universitaetsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany. During periods of smoking, patients with Behcet's disease have less oral aphthae than in abstinence. To elucidate this observation, human keratinocytes and dermal microvascular endothelial cells (HMEC-1) were incubated with serum of 20 patients with Behcet's disease and 20 healthy controls for 4 hours. Maximum non-toxic concentrations were determined and the cells were further treated with 6 microM nicotine, 3.3% cigarette smoke extract (CES), 100 microM biochanin A, and 6.25/12.5 microM pyrrolidine dithiocarbamate alone and in combinations for 24 hours. Serum IL- 8 levels of patients were significantly lower than those of controls. However, after 4 hours incubation with patients' sera, IL-8 release by both cell types was markedly increased when compared with the corresponding serum levels. The levels of IL-6 and vascular endothelial growth factor (VEGF) release were after 4 hours similar with the corresponding levels in serum. IL-1 was not detected. Nicotine significantly decreased IL-8 and -6 release by HMEC-1 maintained in both patients' and controls' sera, but only IL-6 release by keratinocytes maintained in patients' sera. VEGF release by both cells was markedly increased after nicotine treatment in either serum. CES significantly decreased IL-8 release and increased production of VEGF in keratinocytes maintained in patients' serum. The phytoestrogen biochanin A alone and in combination with nicotine further decreased the secretion of IL-8, -6, and VEGF in all experimental settings. Our data support a specific anti-inflammatory effect of nicotine on keratinocytes and endothelial cells maintained in the serum of patients with Behcet's disease. Moreover, biochanin A is likely to exhibit similar and even more profound results than nicotine.

40 In conclusion

41 Thank you

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