Module 9 - ID + Rheum Flashcards
A 7-year-old female presents with mild bilateral knee swelling and mildly limited range of motion for six weeks. She has not been taking any medication since she has been active without difficulty. She is diagnosed with oligoarticular juvenile idiopathic arthritis (JIA). Which is a first-line medication for the treatment of her arthritis?
- Naproxen
- Methotrexate
- Etanercept
- Prednisone
- Naproxen
A 3-year-old girl is being evaluated for persistent left knee swelling for three months without other complaints. She was recently diagnosed with pauciarticular onset juvenile idiopathic arthritis (JIA). Which of the following possible features is the most common extra-articular manifestation and requires further evaluation in this child?
- Anterior uveitis
- Generalized lymphadenopathy
- Hepatosplenomegaly
- Macrophage activation syndrome
- Anterior uveitis
- In addition to joint symptoms, children with JIA may present with extraarticular manifestations.
- Anterior uveitis is the most common extraarticular manifestation in JIA; however, it is rare in systemic-onset JIA. Most of the children with JIA and uveitis are asymptomatic without ocular complaints. When they become symptomatic, there are significant damages or complications. An ophthalmologic evaluation is recommended for all children with JIA. Children with JIA, who were not evaluated and treated for uveitis, may develop ocular complications including cataract, band keratopathy, glaucoma, cystoid macular edema, and vision loss.
A 7-year-old girl presents with a limp, loss of appetite, lethargy, and fever for the past 13 weeks. She denies any trauma. She has missed school for the past 2 weeks. She saw her general practitioner, who only prescribed antibiotics. The physical examination reveals an ill-appearing child with a temperature of 101 F (38.3 C), swollen right knee, and ankle, and there is marked joint stiffness. Her calf muscles are tender to deep palpation. Abdominal examination reveals hepatosplenomegaly and there is a linear salmon-colored rash on the trunk. Laboratory testing reveals the elevation of ESR, CRP, and the presence of antinuclear antibodies. X-rays of her joints are unremarkable except for soft tissue swelling. Which of the following is the best treatment?
A. Infliximab
B. Methotrexate
C. Anakinra and corticosteroids
D. Sulfasalazine
C. Anakinra and corticosteroids
- SYSTEMIC Juvenile idiopathic arthritis is not common and in most cases, the joint symptoms start after the constitutional symptoms.
- The child will usually look ill and have a salmon-colored rash. The joints will be swollen and tender.
- Other features of the disorder include hepatosplenomegaly, muscle tenderness, and even signs of pericarditis.
- Systemic juvenile idiopathic arthritis can be treated with oral corticosteroids but in acutely ill patients anakinra is recommended. Those who have no systemic features can be treated with methotrexate or leflunomide. Hospital admission is usually required and an echo should be obtained to ensure that the patient does not have a pleural or pericardial effusion.
A 10-year-old female is brought in by her parents with a history of recurring fever, rash, joint pain, and lethargy for the past two weeks. The fever is episodic, reaching a T max of 38.9 C (102 F), occurring at intervals once or twice a day. Physical examination reveals a salmon-pink, flat, evanescent rash, generalized lymphadenopathy, and mild swelling in the elbows and knees. In addition, the range of motion in her ankles, knees, wrists, and elbows is limited. She has a temperature of 39.1 C (102.4 F). Her lab work includes a white blood cell count of 12,000/uL, an erythrocyte sedimentation rate of 80 mm/h, C- reactive protein of 26 mg/dL, and ferritin of 1590 g/mL. Parvovirus serology, as well as blood cultures, are negative. Which of the following additional findings would support the systemic form of suspected diagnosis?
A. Enlargement of liver or spleen
B. Presence of rheumatoid factor
C. Acute anterior uveitis in a first-degree relative
D. Psoriasis in either the patient or a first-degree relative
A. Enlargement of liver or spleen
A 16-year-old female presents with a history of slowly progressive abnormal movement of her limbs. She had a sore throat one month prior to this event. The patient was conscious and well-oriented to time, place, and person with normal vital signs. She demonstrated the choreoathetotic movement of her upper and lower limbs. The rest of her systemic examination was normal. An echocardiogram study revealed mild mitral valve regurgitation with tethering of the posterior leaflet. What is the most likely etiology of the condition in the patient?
- Infective endocarditis
- Rheumatic fever
- Wilson disease
- Polycythemia
- Rheumatic fever
- The patient has typical features of Sydenham’s chorea secondary to rheumatic fever disease.
- Mitral valve involvement with tethering of the posterior mitral leaflets is pathognomonic for rheumatic heart disease.
- The characteristic movement disorder along with the involvement of the mitral valve concludes the diagnosis of rheumatic heart disease.
- Since the systemic examination did not reveal either Kayser–Fleischer ring in the eyes or hepatomegaly, Wilson’s disease is a rare possibility in the patient. Similarly, the absence of fever or systemic signs of endocarditis and no vegetations in the valves make infective endocarditis unlikely.
A 16-year-old boy presents with fever, shortness of breath, and joint pain following a group A streptococcal pharyngitis 3 weeks prior. Examination demonstrates an abrupt involuntary movement of the right upper limb and a holosystolic murmur at the left sternal border, radiating to the axilla. Given the likely diagnosis, what other findings can be expected during this patient’s exam?
A. Annular dilatation of the mitral valve
B. Mitral valve thickening
C. Aseptic monoarthritis of the knee joint
D. Erythema marginatum on the face
A. Annular dilatation of the mitral valve
(rheumatic fever)
Which of the following immunotherapies can be used to treat acute systemic lupus erythematosus?
- Indomethacin
- Cyclophosphamide
- Topical hydrocortisone
- Intravenous immunoglobulins
- Cyclophosphamide
- Urgent intravenous cyclophosphamide plus a high dosage of prednisolone may be necessary to treat acute lupus.
- Cutaneous manifestations such as vasculitis can treat with topical corticosteroids.
- Intravenous immunoglobulins can be successfully used in patients with acute lupus. This therapy can have an immunosuppressive effect and treat the infections that can affect many patients with SLE.
- Cyclophosphamide is an immunosuppressive drug
A 25-year-old female presents with complaints of a facial rash that started a few months ago and has gotten worse. She states that the rash is often itchy and worsens when she goes out in the sun. In the last few days, she has noticed generalized aches all over her body. She denies any trauma, allergies, or recent travel. She did try several over-the-counter products, but nothing helped. The appearance of her rash is shown in the image. Which of the following is the first-line drug in managing her rash?
A. Chloroquine
B. Methotrexate
C. Mycophenolate mofetil
D. Hydroxychloroquine
D. Hydroxychloroquine
- Butterfly or malar facial rash
A 22-year-old woman presents with asthenia, low-grade fever, butterfly rash, and generalized arthritis. Examination reveals bilateral pitting edema and a pericardial rub. Vitals include a temperature of 99.9 F (37.7 C) and blood pressure of 170/100 mmHg. Urinalysis shows hematuria and proteinuria. Laboratory investigations show urea of 148 mg/dL and creatinine of 2.4 mg/dL, low C3 and C4, a positive antinuclear antibody test, and a high titer of anti-dsDNA and anti-Ro antibodies. A urine pregnancy test is positive, and an ultrasound confirms a viable first-trimester pregnancy. The fetus is most at risk for which of the following complications of this patient’s condition?
A. Intracranial calcifications
B. Heart block
C. Lymphopenia
D. Microcephaly
B. Heart block
