and infectious diseases. Our review of system questionnaire for episcleritis and scleritis, with the corresponding associated systemic diseases, is shown in Table 3.4.

Constitutional symptoms, such as chills, fever, poor appetite, recent weight loss, and fatigue, may suggest an occult systemic disorder. Skin lesions, including rashes, vesicles, and ulcers, may be manifestations of connective tissue, vasculitic, and infectious diseases; they also may be present in atopy and rosacea. Hair abnormalities, such as hair loss, may be found in systemic lupus erythematosus, and nail Þndings may be associated with reactive arthritis, psoriatic arthritis, and vasculitic diseases. Respiratory manifestations are most commonly present in allergic granulomatous angiitis (ChurgÐStrauss syndrome), granulomatosis with polyangiitis (Wegener), systemic lupus erythematosus, atopy, and tuberculosis. Cardiac symptoms, such as anginal chest pain, may be found in some vasculitic diseases. Genitourinary lesions may suggest reactive arthritis, granulomatosis with polyangiitis (Wegener), and polyarteritis nodosa. Rheumatological abnormalities may be present in any connective tissue or vasculitic disease and in many of the infectious diseases that may cause episcleritis or scleritis. Gastrointestinal symptoms are frequently found in systemic lupus erythematosus, polyarteritis nodosa, reactive arthritis, and inßammatory bowel disease. Neurologic manifestations may be associated with connective tissue, vasculitic, and infectious diseases. Ear and nose abnormalities are commonly associated with relapsing polychondritis, granulomatosis with polyangiitis (Wegener), and CoganÕs syndrome. Mouth lesions, such as oral ulcers, are characteristically present in Beh•etÕs disease.

Table 3.5 General examination of the head and extremities in episcleritis and scleritis

SLE systemic lupus erythematosus, RA rheumatoid arthritis, RP relapsing polychondritis, PAN polyarteritis nodosa, GPA (Weg) granulomatosis with polyangiitis (Wegener), Ch-S allergic granulomatous angiitis (ChurgÐStrauss syndrome), GCA giant-cell arteritis, Ros rosacea, Reactive A reactive arthritis, PA psoriatic arthritis, IBD arthritis associated with inßammatory bowel disease, VZV varicella zoster virus (herpes zoster), Syph syphilis, TB tuberculosis, Behçet Beh•et«s disease, AS ankylosing spondylitis

3.1.6Systemic Examination

Physical signs are the objective marks of the disease and represent indisputable facts. Their signiÞcance is enhanced when they conÞrm a functional or structural change already suggested by the patientÕs history or review of systems. Sometimes, the physical signs may be the only evidence of disease,

especially when the history has been inconsistent or confusing and the review of systems meaningless. Skill in physical diagnosis reßects a way of thinking more than a way of doing.

In a patient with a scleral disease, the examination of the head and extremities, including the

Fig. 3.3 Loss of cartilage in both the nose (saddle nose deformity) and the ears (Òßoppy earsÓ) is an important clue for diagnosis of relapsing polychondritis

nose, mouth, external ear, skin, and joints, may reveal signiÞcant signs either ignored by the patient or considered as of little importance (Table 3.5).

3.1.6.1 Head

The detection of a Òsaddle noseÓ deformity and/ or auricular pinna deformity can be important for the diagnosis of relapsing polychondritis (Fig. 3.3) or leprosy; a saddle nose deformity and/or nasal mucosal ulcers can be manifestations of granulomatosis with polyangiitis (Wegener). Ulcers in the mouth, even if minimal, may guide one to the suspicion of systemic lupus erythematosus, reactive arthritis, arthritis associated with inßammatory bowel disease, or Beh•etÕs disease (Fig. 3.4). A ÒbutterßyÓ rash extending across the bridge of the nose to the malar areas and/or alopecia oblige one to consider systemic lupus erythematosus. Alopecia also can be a sign of syphilis. Erythema, telangiectasias, papules, or pustules on the forehead, cheek, nose, and chin

Fig. 3.4 Classic aphthous ulcers can be important clues in the diagnosis of Beh•etÕs disease

with or without the presence of rhinophyma can establish the diagnosis of acne rosacea. The detection of a temporal artery tenderness obligates one to consider giant-cell arteritis. The Þnding of parotid enlargement can lead to the diagnosis of mumps infection or sarcoidosis. ÒPeg-topÓ teeth, deafness, and/or saddle nose deformity can be signs of congenital syphilis. Lymphadenopathy may be present in rheumatoid arthritis, systemic lupus erythematosus, or any infectious disease. The Þnding of hypopigmented areas may lead to the consideration of relapsing polychondritis or leprosy. A rash can be a manifestation of any vasculitic disease (Fig. 3.5), atopy, or syphilis. Vesicles in periocular areas, the forehead, or the tip of the nose may conÞrm a herpes zoster infection. Skin purpuric lesions or ulcers can be important clues for the diagnosis of any of the vasculitic diseases.

3.1.6.2 Extremities

The Þnding of nail-bed thrombi (Fig. 3.6), small infarcts of the Þngers, or purpuric lesions is suggestive of vasculitic disease. Skin scaling may lead to the consideration of systemic lupus erythematosus, reactive arthritis, psoriatic arthritis,