Rheum

Question 1

Indications for urate-lowering therapy

Answer 1

1. repeated attacks (≥2 per year)
2. one attack in the setting of chronic kidney disease (CKD) of stage 2 or worse
3. tophaceous deposits found on examination or imaging,
4. history of urolithiasis

Question 2

Jaccoud arthropathy

Answer 2

Hand deformities that look like RA but are reducible and no joint destruction (which would be erosions, periarticular osteopenia) present on X-ray
Can see in SLE, scleroderma, mixed connective tissue disease, Sjögren syndrome, recurrent rheumatic fever

Question 3

lab testing for RA

Answer 3

anti-CCP, rheumatoid factor

Question 4

Amyopathic dermatomyositis

Answer 4

Cutaneous findings of dermatomyositis without any muscle findings

Question 5

Leflunomide

Answer 5

non biologic DMARD - for use in combo w biologic DMARD in pt w uncontrolled RA
watch for leflunomide hepatitis

Question 6

Fibromyalgia Dx criteria

Answer 6

widespread pain, wakes unrefreshed, significant fatigue, and cognitive difficulties
last for 3+ mo

Question 7

anti-Ro/SSA or anti La/SSB

Answer 7

Sjogren

SLE: photosensitive rash and neonatal SLE

Question 8

anti-DS DNA

Answer 8

SLE: more severe disease, renal involvement

correlates with dz activity

Question 9

hemochromatosis arthropathy

Answer 9

osteoarthritis-like

involves the second and third metacarpophalangeal (MCP) or wrist joints

Question 10

anti-Jo

Answer 10

myositis: dermatomyositis and polymyositis
Anti-synthetase syndrome:
acute onset
constitutional Sx
myositis
Raynaud's
Mechanic's (hyperkeratotic) hands
Arthritis (usually nonerosive)
ILD = interstitial lung disease: nonspecific interstitial pneumonitis (most common) to usual interstitial pneumonia or bronchiolitis obliterans organizing pneumonia

Question 11

tofacitinib

Answer 11

biologic DMARD, JAK inhibitor

major AE: dyslipidemia (can come on w/in 1mo), lymphopenia/neutropenia/anemia (usually a later effect)

Question 12

Goal urate in gout

Question 13

Features of ankylosing spondylitis

Answer 13

inflammatory back pain, primarily axial involvement, age of onset younger than 45 years, a positive HLA-B27, and a good response to an NSAID

Question 14

Long term risk of familial mediterranean fever

Answer 14

AA amyloidosis

Colchicine decreases risk

Question 15

Tx interstitial lung disease associated with diffuse cutaneous systemic sclerosis

Answer 15

cyclophosphamide

Question 16

Psoriatic arthritis features

Answer 16

psoriasis, enthesitis, dactylitis, tenosynovitis, arthritis of the distal interphalangeal joints, asymmetric oligoarthritis, and spondylitis

Question 17

Eosinophilic granulomatosis with polyangiities features

Answer 17

eosinophilia, migratory pulmonary infiltrates, purpuric skin rash, and mononeuritis multiplex in the setting of antecedent atopy

Question 18

Tx polymyositis, dermatomyositis

Answer 18

prednisone 1mg/kg/d
If refractory or recurrent disease is noted, additional agents such as mycophenolate mofetil, intravenous immune globulin, rituximab, cyclophosphamide, or tumor necrosis factor (TNF)-α inhibitors can also be considered

Question 19

Diffuse idiopathic skeletal hyperostosis

Answer 19

flowing osteophytes involving the anterolateral aspect of the thoracic spine at four or more contiguous vertebrae with preservation of the intervertebral disk space and the absence of apophyseal joint or sacroiliac inflammatory changes such as erosions.

Question 20

diagnosis of acute gouty attack

Answer 20

INTRACELLULAR crystals

Question 21

inclusion body myositis features

Answer 21

insidious onset
diffuse proximal and distal weakness, can by asymmetric
more common in men >50yo
mildly elevated or normal muscle enzymes
EMG w short-duration, small, low-amplitude polyphasic potentials; fibrillation potentials at rest; and bizarre, high-frequency, repetitive discharges

Question 22

Tx RA

Answer 22

methotrexate -> anti-TNF alpha (etanercept, adalimumab, certolizumab, golimumab, infliximab) -> rituximab

Question 23

Cryoglobulinemia

Answer 23

palpable purpura, glomerulonephritis (elevated serum creatinine, active urine sediment with cellular casts), mononeuritis, and skin infarctions of the fingers and ears
low C4, nml C3
RF positive w monoclonal paraprotein = RF itself
Screen for HCV

Question 24

Milwaukee shoulder syndrome

Answer 24

basic calcium phosphate deposition
pain, stiffness, and swelling that tend to occur gradually over time, often with a preceding trauma or history of overuse on the affected side
predilection for women older than the age of 70 years

Question 25

Diffuse alveolar hemorrhage SLE

Answer 25

1. hypoxemia
2. new pulmonary infilitrates
3. .drop in Hct
   (only 50% have hemoptysis)

Question 26

Lofgren

Answer 26

Acute, self limited form of sarcoidosis w no serologic confirmation needed
1. “arthritis” actually a nondestructive periarthritis of the soft tissue, entheses, and tenosynovium
2. bilateral hilar lymphadenopathy
3. erythema nodosum
Tx: NSAIDs (no steroids needed)

Question 27

When to stop gout flare prophylaxis

Answer 27

= colchicine in the setting of allopurinol
keep going if there is any evidence of active disease (tophi or ongoing flares)
otherwise stop for the longest of:
6 months; 3 months after reaching target serum urate in a patient without baseline tophi; or 6 months after reaching target serum urate in a patient with baseline tophi that have resolved

Question 28

Treatment of ankylosing spondylitis

Answer 28

start w NSAIDs: use 2 for minimum of 4 weeks

if fail -> TNF alpha

Question 29

Polyarteritis nodosum

Answer 29

fever, arthralgia, myalgia, skin findings (livedo reticularis, purpura, and painful subcutaneous nodules), abdominal pain, weight loss, peripheral nerve manifestations (mononeuropathy or mononeuritis multiplex)
Associated with HBV
Dx: biopsy or aneurysms/stenosis on medium sized arteries on imaging