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Station 5 :

Your Role: You are the skin SHO on call

Subject Mr Amit- 42 years old gentleman

Mr Amit complains of skin rash over his lower limbs with reduced urine output asscoiated with nausea and vomitting.

You are required to address his problems!

Discussion:

OK, this is another popular topic in MRCP PACES!Before we start, you must know the diagnosis first before talking about the possible causes. As I told you before in my ebook, think about all the differential diagnosis before even start opening your mouth in this station. Time is crucial in Station 5.

Yes, you are right, these lesions are palpable purpura mainly located at the lower limbs.( Classic example of vasculitic lesion of the skin).If you are still having problems describing skin lesion, click HERE to learn the basics.

So, now the issue is what are the causes of vasculitis? As you might know, vasculitis can be classified according to the size of the vessel ( which is the popular Chapel Hill classification). It is mainly divided into big,medium and small sized vessel vasculitis.

Since you can see this lesion on the skin, this lesion is mainly small vessel vasculitis which can be due to 4 major causes- ANCA associated ( such as Wegener's granulomatosis), immune complex associated ( such as in SLE, Henoch-Schonlein purpura, croglobulimia etc), paraneoplastic and inflammatory bowel disease.

So, now it is easy, since you know the differential, it will make your clerking very easy, do you get this??

Actually, this gentleman has ANCA-associated vasculitis and now he is presenting with acute renal failure!

Popular questions examiners might ask you during your MRCP PACES,

1) What is the commonest cause of vasculitis among young females?

2) What will be the diagnosis if this gentleman also has upper respiratory airway involvement?

Extra points:

Breaking trial in Clinical Medicine/Nephrology

Background History:

    Cyclophosphamide remains the main treatment option for ANCA-associated vasculitis. Rituximab is gaining popularity to treat autoimune disease due to its anti CD-20 activity. RITUXIVAS is a randomised trial looking at the efficacy of cyclophosphamide comparing rituximab in induction of ANCA-associated vasculitis.The results of this trial were recently published in NEJM.

Click HERE to look at the report.

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