Rheumatology

Question 1

Which of the following is not useful in treatment of ankylosing spondylitis?

1. Etanercept
2. Adalimumab
3. Secukinumab
4. Abatacept
5. Ixekizumab

Answer 1

4. Abatacept

Principles of ank spond treatment:
1st line: physical therapy + NSAIDs
2nd line after failed x2 NSAIDs trialled for 2-4 weeks each: TNF alpha inhibitor (i.e. etanercept, adalimumab) OR IL-17 inhibitor (Ixekizumab, secukinumab(
3rd line: switch to IL-17 inhibitor OR trial a different TNF-alpha blocker (if inital response then failure)

Abatacept - T cell costimulator, evidence in RA and PsA but not Ank spond

Question 2

What is the first line pharmacologic treatment for Raynaud’s?
What is the second line treatment?
Other than cold, what else can exacerbate Raynaud’s?

Answer 2

1. Dihydropyrine ca channel blockers - amlodipine, nifedipine
2. PDE5 inhibitors (i.e. sildenafil), topical nitrates (i.e. nitroglycerin ointment), some evidence for ARBs and fluoxetine
3. Smoking, vasoconstricting drugs (i.e. tryptans)

Question 3

Which of the following indicates the patient is more likely to have primary rather than secondary Raynaud’s?

1. Signs of tissue ischemia
2. Male gender
3. Age >40
4. Symmetry
5. Positive nailfold capillaroscopy

Answer 3

4. Symmetry is more common in primary Raynauds

Nailfold capillarascopy = scleroderma

Question 4

Name 5 features of mixed connective tissue disease

Answer 4

1. Pulmonary hypertension ( most common cause of death, associated with anti-cardiolipin IgG)
2. Arthritis
3. Antibodies - anti-U1-RNP (diagnostic), anti-SNRP
4. Swollen hands
5. Raynaud’s
6. Esophageal dysmotility
7. Myositis
8. Acrosclerosis (stiff thick skin on distal fingers(

Question 5

Which rheumatologic disorders are associated with anterior uvieitis?
Which is not?

Answer 5

Spondyloarthropathies - ank spond, psoriatic arthritis, reactive arthritis

JIA
Sjogren’s
Kawasaki’s
Sweet syndrome

AIN

Scleritis OR AU: SLE, Sarcoidosis, relapsing polychnditis, IBD

Anterior uveitis NOT associated with RA (scleritis/episcleritis is)

Question 6

The following antibodies are associated with an increased risk of what in Scleroderma?

• Anti-Scl-70 (topoisomerase I)
• Anti-centremere
• Anti-RNA polymerase III

Answer 6

Anti-Scl-70 (topoisomerase I) - pulmonary fibrosis, more common with diffuse scleroderma

Anti-RNA-polymerase III - diffuse scleroderma, increased skin disease and renal crisis.

Anti-centromore - pulmonary HTN + esophageal disease, more common with limited scleroderma. Protective against fibrosis.

Question 7

Rheumatologic disorder strongly associated with anti-U1 RNP (U1 ribonucleoprotein) antibodies? ANA pattern

Answer 7

Mixed connective tissue disorder

Speckled ANA

Question 8

Rheumatologic disorder strongly associated with anti-histone antibodies

ANA pattern?

Answer 8

Drug induced lupus

Homogenous ANA

Question 9

Seronegative polyarthritis with fever, rash and high ferritin

Answer 9

Still’s disease

Question 10

Rheumatologic disorder strongly associated with Anti-SS-B (anti-La) antibodies

Answer 10

Sjogren’s. Poor specificity. Anti-Ro = CHB in SLE.

Question 11

Rheumatologic disorder strongly associated with anti-ribosomal P protein antibodies

Answer 11

SLE. Highly specific but poor sensitivity. Associated cutaneous manifestation

Question 12

Role of IL-1B in OA?

Answer 12

Inhibits chondrocytes (along with TNF)
Inhibits aggrecanase and collagen II
Stimulates release of MMPs

End product = cartilage destruction

Question 13

Features of DISH (dish diffuse idiopathic skeletal hyperostosis)

Answer 13

Older male age >50
Diabetes in 20%
Negative HLA-B27
Thoracic spine pain with loss off thoracic lateral flexion)

Question 14

Which autoimmune disorders can cause RTA? Which type?

Answer 14

Distal (Type 1)

Sjögren’s syndrome
Autoimmune hepatitis/primary biliary cirrhosis
Systemic lupus erythematosus (also can generate hyperkalemic RTA)
Rheumatoid arthritis

Question 15

HLA type associated with Behcets

Answer 15

HLA-B51

Question 16

HLA type associated with hypersensitivity to allopurinol

Answer 16

HLA-B58*01

Question 17

Dermatomyositis associated with mild/amyopathic muscle involvement and rapidly progressive ILD

Answer 17

anti-MDA5 antibodies

Question 18

What is bimekizumab and what is it used for?

Answer 18

Anti-IL17

Plaque psoriasis

Question 19

What is avacopan and what is it used for?

Answer 19

Anti-C5 receptor

ANCA vasculitis

Question 20

Which of the following does not have a role in Scleroderma ILD?
A. Cyclophosphamide
B. MTX
C. Azathioprine
D. Tociluzimab
E. MMF

Answer 20

B - MTX

MMF 1st line, cyclo 2nd line

Question 21

What is the “triad” of Felty syndrome

Answer 21

RA, Neutropenia, Splenomegaly.

Question 22

5 factors associated with poor prognosis in RA

Answer 22

Smoking
Elevated CRP/ESR
High anti-CCP/RF titres
Erosions at baseline
HLA-DRB1*04 homozygosity
Older age

Question 23

What is the major cause for premature death in RA?

Answer 23

CVD

Question 24

What percentage of patients with GCA will have vision loss?

Answer 24

15-20%

Question 25

Which autoimmune diseases are associated with hyposplenism?

Answer 25

``` Antiphospholipid syndrome Goodpastures GPA (PR3) Hashimotos thyroiditis PAN RA SLE IBD Celiac ``` Also sarcoid/amyloid

Question 26

Most common neurologic manifestation of RA

Answer 26

Carpal tunnel

Question 27

Cardiac manifestations of RA

Answer 27

``` Pericarditis (restrictive and granulomatous) Myocarditis Coronary artery disease Heart failure Atrial fibrillation Asymptomatic myocardial disease ```

Question 28

HLA type associatd with RA

Answer 28

HLA DRB1

Question 29

What is the cause of GI hypomotility (oesophagus, stomach, and small/ large intestine) in scleroderma?

Answer 29

Autonomic nerve dysfunction of the GIT Results in esophageal dysmotility, strictures, gastroparesis and psuedo-obstructive

Question 30

Infection commonly associated with PAN

Answer 30

Hepatitis B

Question 31

Key features of anti-synthetase syndrome

Answer 31

``` inflammatory myopathy interstitial lung disease "mechanic's hands" inflammatory arthritis, Raynaud phenomenon anti-Jo 1 ```

Question 32

HLA associated with Behcets

Answer 32

HLA B51