Clinical Pearls & Morning Reports

Posted by Carla Rothaus

Published June 8, 2022


What is the usual first-line treatment for rheumatic overlap syndromes? 

If features of a patient’s illness overlap with features of systemic lupus erythematosus (pericarditis, lymphopenia, and anemia), scleroderma (hypertension), and polymyositis, an overlap syndrome such as mixed connective-tissue disease (undifferentiated autoimmune rheumatic disease) can be considered. Read the Case Records of the Massachusetts General Hospital here.

Clinical Pearls

Q: Name some of the viruses that can cause myositis.

A: Many viruses can cause myocardial inflammation and myositis, including severe acute respiratory syndrome coronavirus 2, influenza virus, coxsackievirus, Epstein–Barr virus, herpes simplex virus, parainfluenza virus, adenovirus, cytomegalovirus, echovirus, varicella–zoster virus, measles virus, HIV, and dengue virus.

Q: Does the absence of a friction rub rule out a diagnosis of pericarditis?

A: The absence of a friction rub does not rule out pericarditis. Friction rubs vary in intensity and can wax and wane over a period of hours; therefore, the sensitivity of auscultation for the detection of a friction rub also varies, depending in large part on how frequently auscultation is performed.

Morning Report Questions

Q: What sequence of ECG findings is seen in patients with pericarditis?

A: In patients with pericarditis, ECG findings evolve over time and typically progress through four stages. Stage 1 occurs in the first few hours to days and involves the presence of diffuse ST-segment elevation and PR-segment depression, with reciprocal ST-segment depression and PR-segment elevation in leads V1 and aVR. Stage 2 occurs in the first few days to the first week and involves resolution of the ST-segment and PR-segment abnormalities. Stage 3 occurs days to weeks after the onset of pericarditis and is characterized by diffuse T-wave inversions. Stage 4 is normalization of the ECG.

Q: What is the usual first-line treatment for rheumatic overlap syndromes?

A: The overall treatment of rheumatic overlap syndromes varies considerably according to patient and practitioner, given the heterogeneity of manifestations and our currently limited understanding of underlying causes. Nonetheless, first-line treatment almost always includes the use of glucocorticoid therapy for immunosuppression. Longer-term management of undifferentiated autoimmune rheumatic disease or mixed connective-tissue disease involves the use of glucocorticoid-sparing regimens to treat the most prominent and serious disease features. With any undifferentiated rheumatic syndrome, careful screening for and recognition of occult or later-evolving features drives therapeutic decision making.

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