Rheumatological EmergenciesEmergency

Known vasculitis, now breathless with haemoptysis, creatinine risen from 1.0 to 3.6 mg/dL, urine dipstick blood +++ and protein ++

• Haemoptysis with a falling haemoglobin
• Sudden visual loss or jaw claudication
• Creatinine doubling within days
• Ferritin above 10 000 µg/L
• New multi-territory thrombosis

• Infection on immunosuppression
• Sepsis with acute kidney injury
• Thrombotic microangiopathy
• Drug-induced vasculitis
• Malignancy
• Cardiac failure with pulmonary oedema

• Admit: Any suspected flare with organ involvement
• ICU: Alveolar haemorrhage, rapidly progressive glomerulonephritis, CAPS, MAS/HLH, or airway involvement

• Haemoptysis + active urine sediment = pulmonary–renal syndrome: ANCA and anti-GBM the same day.
• Visual loss in GCA can be permanent within hours — steroid first, biopsy later.
• On immunosuppression, fever is infection until proven otherwise — treat both until you know.

• Wait for biopsy or serology before steroids in GCA with visual symptoms
• Escalate immunosuppression into an untreated infection
• Start high-dose steroids with cyclophosphamide/rituximab without PJP prophylaxis
• Give rituximab without checking hepatitis B
• Stop the ACE inhibitor in scleroderma renal crisis because creatinine rises

• Waiting for serology before treating visual loss in giant cell arteritis
• Escalating immunosuppression into an untreated infection
• Missing PJP prophylaxis with high-dose steroid
• Attributing a rising creatinine to the drug and missing the glomerulonephritis

Joint rheumatology, nephrology and critical care decision; the immunosuppression plan, the prophylaxis and the monitoring are all written down before the patient leaves ICU.