Rheumatology

Answer 1

Thromboangiitis obliterans is a smoking-related vasculopathy affecting small to medium vessels with inflammation and thrombosis of vessels in upper and lower limbs, leading to reduced pulses and gangrenous ulcers. This diagnosis is unlikely in a patient who no longer smokes, and has involvement of internal organs in addition to the legs.

IgA vasculitis (Henoch-Schönlein purpura) can affect lungs, skin, joints, and kidneys but it is an immune complex–mediated vasculitis with deposition of IgA containing immune complexes identified on biopsy, which is not present in this patient.

Question 2

Rheums

Answer 2

Pegloticase is strongly recommended for patients with severe recurrent and/or tophaceous gout that is intolerant or resistant to standard therapies.

Question 3

rheum

Answer 3

This patient has the triad of conjunctivitis, urethritis, and arthritis seen in a subset of patients with chlamydial reactive arthritis.

Nucleic acid amplification urine testing is the appropriate diagnostic test for suspected chlamydial reactive arthritis.

Question 4

rheum

Answer 4

A diagnosis of ankylosing spondylitis can be made in a patient younger than age 45 years with symptoms of inflammatory back pain for 3 months or more and bilateral sacroiliitis on imaging.

Common requirements include the presence of inflammatory back pain for 3 or more months in a person younger than age 45 years, limited lumbar spine motion, elevated inflammatory markers, and evidence of bilateral sacroiliitis on imaging.

Question 5

rheum

Answer 5

Patients with diffuse cutaneous systemic sclerosis are at risk for acute and chronic gastrointestinal bleeding secondary to gastric antral vascular ectasia.

GAVE is the proliferation of blood vessels typically in the antrum of the stomach; on endoscopy, it has the appearance of watermelon stripes (watermelon stomach). Approximately 60% of patients with GAVE have an underlying autoimmune disease; the remainder have portal hypertension secondary to hepatic cirrhosis

Question 6

rheum

Answer 6

For patients with severe and refractory gouty attacks or with contraindications to other treatments, off-label use of interleukin-1 inhibitors (anakinra or canakinumab) can be considered.

This patient has not responded favorably to glucocorticoid therapy, which characterizes some severe acute episodes. In a case such as this, an interleukin-1 inhibitor such as anakinra should be provided as a reliable (although expensive) off-label treatment.

Question 7

rheum

Answer 7

Physical therapy is an effective intervention for the management of pain and reduced functioning due to OA, with numerous guidelines supporting exercise as an appropriate intervention for all patients with OA.

Physical therapy can be prescribed at any point in the course of osteoarthritis instead of medication, as a supplement to medication that does not adequately reduce pain, or prior to surgery to increase strength and potentially influence surgical outcomes.

Question 7

rheum

Answer 7

Physical therapy is an effective intervention for the management of pain and reduced functioning due to OA, with numerous guidelines supporting exercise as an appropriate intervention for all patients with OA.

Physical therapy can be prescribed at any point in the course of osteoarthritis instead of medication, as a supplement to medication that does not adequately reduce pain, or prior to surgery to increase strength and potentially influence surgical outcomes.

Question 8

rheum

Answer 8

MRI is more sensitive than radiography for detecting early spine and sacroiliac joint inflammation and may be indicated in the evaluation of suspected spondyloarthritis if radiographs are normal.

A single anteroposterior pelvis plain radiograph to view the sacroiliac joints is an appropriate first diagnostic step in this setting, which may reveal joint space widening (early) or narrowing (late), erosions, sclerosis, and ankylosis, and can establish the diagnosis of ankylosing spondylitis. However, plain radiographs may be normal early in the course of disease, as seen in this patient. MRI of the sacroiliac joints can then be utilized, which is more sensitive for detecting early spine and sacroiliac joint inflammation

Answer 9

Antisynthetase syndrome is characterized by interstitial lung disease, myositis, Raynaud phenomenon, nonerosive inflammatory arthritis, constitutional findings such as low-grade fever, and mechanic’s hands; anti-aminoacyl-tRNA synthetases antibodies, such as anti–Jo-1, are highly suggestive of the diagnosis.

POSITIVE ANTI-JO-1 AB
MECHANICS HAND

anti-aminoacyl-tRNA synthetases antibodies, including the subset anti–Jo-1 antibodies, are more specific for the diagnosis.

Question 10

RHEUM

Answer 10

In patients with Sjögren syndrome, constitutional findings and inflammatory arthritis are common, Dry eyes and dry mouth are the most common presenting symptoms, along with positive anti-Ro/SSA and anti-La/SSB antibodies.

Question 11

Rheum

Answer 11

Smoking is a risk factor for the development of rheumatoid arthritis, especially in genetically susceptible individuals; all patients should be counseled to quit smoking.

Question 12

Rheuma

Answer 12

Lupus pneumonitis is a rare but severe presentation of systemic lupus erythematosus characterized by shortness of breath, hypoxia, and diffuse pulmonary infiltrates.

He has clear evidence of active SLE with polyarthritis, a high erythrocyte sedimentation rate, hypocomplementemia, and diffuse pulmonary infiltrates on radiologic studies, as well as lymphocytic predominance on bronchoalveolar lavage. These findings are very suggestive of lupus pneumonitis. It usually requires rapid and aggressive therapy with glucocorticoids and/or immunosuppressive agents.

Question 13

rheum

Answer 13

In patients with systemic sclerosis, gastrointestinal dysmotility can result in small intestinal bacterial overgrowth with resultant chronic diarrhea and malabsorption.

Because of the decrease in motility of the small bowel, bacterial overgrowth occurs and leads to the symptoms described in this patient history, including diarrhea, bloating, and pain, and can lead to malabsorption. Patients with SSc can also develop chronic pancreatic insufficiency and develop symptoms similar to SIBO, which must be considered in the differential diagnosis

Question 14

rheum

Answer 14

Felty syndrome consists of the triad of long-standing aggressive rheumatoid arthritis, neutropenia, and splenomegaly and is associated with the risk for serious infections, lower extremity ulcers, lymphoma, and vasculitis.

Felty syndrome is associated with the risk for serious infections, lower extremity ulcers, lymphoma, and vasculitis. Treatment of Felty syndrome consists of more aggressive therapy for the underlying RA.

Question 15

rheum

Answer 15

Chronic monoarticular arthritis with a large effusion and stiffness but minimal pain is characteristic of Lyme arthritis; diagnosis is made by serologic testing (enzyme-linked immunosorbent assay followed, if positive, by Western blot).

Question 16

rheum

Answer 16

IgG4-related disease is characterized by IgG4-producing plasma cell infiltration and tumefaction of the affected tissue with resultant organ enlargement, fibrosis, and dysfunction.

his patient presents with a classic picture of retroperitoneal fibrosis with back pain and kidney failure from the periaortic mass that is large enough to encase the ureters resulting in obstructive uropathy and kidney injury.

Question 17

rheuma

Answer 17

Elevated antinuclear antibodies in a centromere pattern have a 90% specificity for systemic sclerosis, and in particular for limited cutaneous systemic sclerosis.

Elevated antinuclear antibodies in a centromere pattern occur in 20% to 40% of patients with SSc and have a 90% specificity for the disease, and in particular for LcSSc. The presence of anticentromere antibodies also increases the risk for developing pulmonary arterial hypertension (PAH). This patient will need to be monitored for progression, including PAH screening.

Question 18

rheum

Answer 18

Polyarteritis nodosa is a vasculitis affecting medium-sized arteries and is characterized by constitutional and neurologic symptoms, skin rashes, and kidney involvement that is renovascular rather than glomerular in origin.

This entity may occur in the setting of chronic hepatitis B virus infection, HIV infection, and hairy cell leukemia.

Skin rashes, including purpura and necrotic ulcers, occur in more than half of patients.

Diagnosis of PAN is best established by demonstrating necrotizing arteritis in biopsy specimens or finding characteristic medium-sized artery aneurysms and stenoses on imaging studies of the mesenteric or renal arteries.

Question 19

rheum

Answer 19

Topical NSAIDs are beneficial for patients at high risk for toxicity from oral NSAIDs.

Oral naproxen and other oral NSAIDs are relatively contraindicated given the patient’s hypertension, chronic kidney disease, and coronary artery disease.

Question 20

rheum

Answer 20

This patient has signs and symptoms of giant cell arteritis (GCA), including headache, jaw claudication, visual changes, and an elevated erythrocyte sedimentation rate, as well as symptoms of polymyalgia rheumatica (PMR).

High-dose prednisone must be initiated immediately in patients with signs and symptoms that are highly suggestive of giant cell arteritis to prevent irreversible visual loss.

Temporal artery biopsy is the gold standard for diagnosing GCA; at least 1 cm is required in order to reduce the false-negative rate because of skip lesions. However, glucocorticoid therapy should not be delayed in order to establish the diagnosis of GCA.

Question 21

rheum

Answer 21

Inclusion body myositis (IBM) is an inflammatory myopathy that can involve both the proximal and distal muscles with typically symmetric muscle distribution; its insidious onset and distal muscle involvement help to distinguish IBM from the other inflammatory myopathies.

inclusion body myositis (IBM), an inflammatory myopathy that can involve both the proximal and distal muscles;

Polymyositis occurs more frequently in women than in men and has its age of onset before 50 more often than IBM. It generally presents with proximal, rather than distal

Question 22

rheum

Answer 22

Initial management of Sjögren syndrome typically involves treatment of sicca symptoms by restoring moisture of the eyes and mouth.

criteria for Sjögren syndrome, with objective documentation of sicca in the presence of anti-Ro/SSA antibodies, antinuclear antibodies, and rheumatoid factor.

Question 23

Rheum

Answer 23

Rheumatoid arthritis is one of the most common diseases associated with scleritis, which can be vision-threatening and lead to thinning of the sclera and perforation.

Typical features include eye pain, pain with gentle palpation of the globe, and photophobia.

Conjunctivitis also causes a red eye but PAINLESS

Epislceritis is PAINLESS

Question 24

rheum

Answer 24

The arthritis-dermatitis syndrome of disseminated gonococcal infection due to Neisseria gonorrhoeae is characterized by a triad of tenosynovitis, dermatitis, and polyarthralgia without frank arthritis; fever, chills, and malaise are common.

Inflammation of multiple tendons of the wrists, fingers, ankles, and toes distinguishes this syndrome from other forms of infectious arthritis. This presentation of DGI is associated with positive blood cultures and characteristic skin lesions.

Question 25

rheum

Answer 25

Patients with systemic lupus erythematosus and positive antiphospholipid antibodies are at a high risk for developing valvular dysfunction/thickening, in some cases manifesting as Libman Sacks endocarditis.

Patients who have SLE with positive antiphospholipid antibodies are at a high risk for developing valvular dysfunction/thickening, and in some cases manifesting as Libman-Sacks endocarditis.

Question 26

rheum

Answer 26

Giant cell arteritis can affect the great vessels of the chest causing upper extremity claudication and/or aortitis; aortitis may lead to aortic root dilation, aortic regurgitation, and heart failure.

Question 27

rheum

Answer 27

Evidence of acute calcium pyrophosphate crystal arthritis (pseudogout) in a young person should always prompt an investigation for secondary causes such as hyperparathyroidism, hypothyroidism, hypophosphatasia, hypomagnesemia, and hemochromatosis.

Question 28

rheum

Answer 28

Rituximab is appropriate treatment for patients who experience a relapse of granulomatosis with polyangiitis.

Rituximab is the most appropriate treatment for this patient who has experienced a relapse of granulomatosis with polyangiitis (GPA), manifesting with pulmonary inflammation and nodules despite maintenance treatment with azathioprine.

Question 29

rheum

Answer 29

Use of pregabalin is often limited by side effects, including weight gain, peripheral edema, lethargy, and dizziness; discontinuation may be needed to manage the side effects.

Question 30

rheum

Answer 30

A relapse of polymyalgia rheumatica should be treated with an increase in prednisone to the last pre-relapse dose at which the patient was doing well, followed by a gradual reduction within 4 to 8 weeks back to the relapse dose.

Methotrexate can be added as a glucocorticoid-sparing agent for patients who cannot be successfully weaned off prednisone or who are experiencing significant glucocorticoid toxicity;

Question 31

rheum

Answer 31

Cyclophosphamide with high-dose glucocorticoids is appropriate treatment for primary angiitis of the central nervous system.

Patients typically present with gradual progressive neurologic symptoms such as headaches, cognitive impairment, and other neurologic deficits such as strokes. Laboratory studies, including erythrocyte sedimentation rate, are typically normal, but 90% of patients have abnormal cerebrospinal fluid with lymphocytic pleocytosis and elevated total protein. MRI, MR angiogram, or CT angiogram often demonstrates nonspecific findings; cerebral angiogram sometimes reveals beading, or alternating stenosis and dilation of vessels consistent with vasculitis.

Question 32

rheum

Answer 32

Parvovirus B19 infection should be suspected in patients with an acute onset of small-joint symmetric polyarthritis following a febrile illness with rash, who have exposure to children.

Question 33

rheum

Answer 33

Anti–cyclic citrullinated antibody testing is beneficial in diagnosing rheumatoid arthritis.

This patient has a symmetric inflammatory polyarthritis involving the small joints of the hands and feet, which is highly suggestive of rheumatoid arthritis (RA). Laboratory studies, including rheumatoid factor, anti-CCP antibodies, and inflammatory markers, can assist in confirming the diagnosis, with anti-CCP antibodies the most helpful.

Question 34

rheum

Answer 34

Spondyloarthritis disorders share an overlapping set of features, including inflammation of the axial skeleton, tendons, and entheses; tendon and enthesis calcification; and an association with HLA-B27 antigen. HLA-B27 testing can define a probability for spondyloarthritis but cannot independently confirm or exclude any specific diagnosis.

Question 35

rheum

Answer 35

Adult-onset Still disease is characterized by spiking fever, an evanescent salmon-colored rash on the trunk and extremities that occurs in conjunction with fever, arthritis, lymphadenopathy, and leukocytosis; an extremely high serum ferritin level is characteristic.

Question 36

rheum

Answer 36

Long-term treatment options for bowel and joint symptoms associated with inflammatory bowel disease include sulfasalazine, azathioprine, 6-mercaptopurine, methotrexate, and the tumor necrosis factor α inhibitors adalimumab, certolizumab pegol, golimumab, and infliximab.

Question 37

rheuma

Answer 37

Synovial fluid analysis can confirm inflammation but may be inadequate for diagnosis of a chronic inflammatory monoarthritis; synovial biopsy may be required.

The differential diagnosis in this patient with chronic inflammatory monoarthritis includes mycobacterial, fungal, or Borrelia burgdorferi infection and other systemic rheumatologic diseases such as sarcoidosis. Frequently in these patients, synovial fluid analysis alone may be inadequate for diagnosis; serologies or other laboratory tests or synovial biopsy is required to establish the diagnosis.

Question 38

rheum

Answer 38

Diagnosis of erosive hand osteoarthritis is based essentially on radiographic findings of articular surface erosions at the central portion of the joint; erosions are often symmetric and occur mainly in the distal interphalangeal joints.

. Diagnosis is mostly based on the radiographic findings of articular surface erosions at the central portion of the joint. Erosions are often symmetric and occur mainly in the distal interphalangeal (DIP) and, to a lesser extent, proximal interphalangeal (PIP) joints. Radiographs reveal a “gull-wing” deformity, resulting from marginal sclerosis and osteophytes on the distal side of the joints, whereas the proximal side is centrally eroded or collapsed and thinned

Question 39

rheuma

Answer 39

Elevation of the erythrocyte sedimentation rate, rising anti–double-stranded DNA antibody titer, and low complement levels reliably diagnose a systemic lupus erythematosus flare.

Anti-Smith antibodies are highly specific for the diagnosis of SLE but also do not correlate with disease activity

Question 40

rheum

Answer 40

In patients with immune-mediated necrotizing myopathy, myositis may persist despite statin discontinuation and is often associated with the production of anti-HMG Co-A reductase antibodies.

Question 41

rheum

Answer 41

A lip biopsy should be considered in a patient with sicca and suspected Sjögren syndrome when initial serologic evaluation is uninformative.

The most heavily weighted criteria include focal lymphocytic sialadenitis in labial salivary gland biopsy and the presence of anti-Ro/SSA antibodies. The presence of both will establish the diagnosis.

Question 42

RHEUM

Answer 42

Joint aspiration and synovial fluid analysis for Gram stain, cultures, and crystals are indicated to help diagnose the underlying cause of acute monoarthritis.

Synovial fluid leukocyte counts less than 200/µL (0.2 × 109/L) are considered normal, between 200/µL and 2000/µL (0.2-2.0 × 109/L) are associated with noninflammatory conditions, and greater than 2000/µL (2.0 × 109/L) are associated with inflammatory states. The higher the count is, the more inflammatory the fluid and the greater the suspicion for crystal-related or infectious disease.

Question 43

Rheum

Answer 43

Patients at moderate or high 10-year risk for a major osteoporotic fracture taking at least 2.5 mg of prednisone daily for 3 months or more should begin prophylactic bisphosphonate therapy.

Question 44

rhem

Answer 44

Patients with systemic sclerosis, especially those with limited disease, are at risk for pulmonary arterial hypertension.

Severe disease can lead to right-sided heart failure. This patient with limited cutaneous systemic sclerosis and progressive dyspnea has a normal chest radiograph and a normal pulmonary examination, but an increased pulmonic sound and a widened split of S2 on cardiac examination compatible with pulmonary hypertension

Question 45

rheum

Answer 45

Pes anserine bursitis is an inflammatory condition affecting the bursa at the insertion of the conjoined medial knee tendons into the anteromedial proximal tibia and should be considered when there is localized pain inferomedial to the knee joint.

The diagnosis of pes anserine bursitis is clinical, based on a history of increased medial knee pain worsened with climbing or descending stairs or rising from a seated position.

Question 46

rheum

Answer 46

A meniscal tear could cause medial knee pain, but the pain is usually around the joint line; patients may also have unusual sensations in the knee such as clicking, locking, c

A medial collateral ligament (MCL) tear may cause medial knee pain, which can also extend to where the MCL inserts on the anteromedial proximal tibia; however, an MCL injury is very painful and may cause difficulty ambulating. MCL injury is suspected when there is pain and/or laxity on valgus stress of the knee.

Question 47

rheum

Answer 47

Relapsing polychondritis is characterized by inflammation and damage of cartilaginous tissues; tissues most commonly affected include the cartilaginous portions of the external and middle ear, nose, tracheobronchial tree, and joints.

Polyarteritis nodosa, a medium-vessel vasculitis, affects the mesenteric and renal arteries. Patients usually present with abdominal symptoms, neurologic involvement, and skin findings. Polyarteritis nodosa does not involve the eye or cartilage of the ear, nose, or airways, making this an unlikely diagnosis.

Question 48

rheum

Answer 48

Methotrexate and leflunomide are contraindicated in pregnant patients because these medications are highly teratogenic and must not be used before/during pregnancy; hydroxychloroquine can be safely used during pregnancy.

Question 49

Rheum

Answer 49

Patients with fibromyalgia typically benefit from validation of their symptoms by a physician because many patients have previously had their complaints disregarded by caregivers or family. In addition to psychological support and exercise, pharmacotherapy is a mainstay of fibromyalgia management. Three drugs are FDA approved for fibromyalgia: pregabalin, duloxetine, and milnacipran.

Question 50

Rheum

Answer 50

Mycophenolate mofetil is an appropriate treatment option for patients who have interstitial lung disease associated with systemic sclerosis.

Cyclophosphamide has been used to improve and/or stabilize lung involvement in SSc, but its utility is limited because it can only be taken for a limited time and the positive results are lost in the year after stopping cyclophosphamide. Recently, mycophenolate mofetil has been shown to be as effective as cyclophosphamide and is a medication that can be used for many years.

Question 51

rheum

Answer 51

Topical NSAIDs are recommended to treat osteoarthritis in patients aged 75 years or older because they provide similar pain relief as oral medications with greater gastrointestinal safety and tolerability, but with an increased incidence of skin irritation and rash.

Question 52

rheum

Answer 52

Acute calcium pyrophosphate crystal arthritis (pseudogout) is characterized by the sudden onset of pain, warmth, tenderness, and swelling of the affected joint, usually a knee or wrist; attacks are typically longer than those of gout.

. Attacks can last for weeks to months (in general, longer than gout attacks)

Question 53

rheum

Answer 53

Pleuritis is the most common rheumatoid arthritis pulmonary manifestation but is frequently asymptomatic; exudative pleural effusions may occur.

In rheumatoid effusions, pleural leukocyte count is typically less than 5000/µL (5.0 × 109/L), pleural fluid glucose is less than 60 mg/dL (3.33 mmol/L), and pH is less than 7.3. This exudative pleural effusion is compatible with rheumatoid pleurisy, malignancy, and tuberculosis pleurisy.

Question 54

rheum

Answer 54

The typical presentation of scleroderma renal crisis is acute kidney injury and severe hypertension, mild proteinuria, urinalysis with few cells or casts, microangiopathic hemolytic anemia, and thrombocytopenia.

Question 55

rhejum

Answer 55

Behçet syndrome is characterized by recurrent painful oral and genital mucosal ulcerations, inflammatory eye disease, and pathergy.

Question 56

rheum

Answer 56

Glucocorticoid myopathy should be suspected in a patient with recent initiation of high-dose glucocorticoids, cushingoid features, initial clinical improvement, and reduction in serum creatine kinase levels who has an increase in weakness with reduction in the glucocorticoid dose; treatment is appropriate dose reduction or discontinuation if possible.

Question 57

rheum

Answer 57

Takayasu arteritis is a rare chronic granulomatous vasculitis seen in young Asian women that mainly affects the aorta and its major branches as well as the coronary and pulmonary arteries, resulting in claudication, cardiac ischemia, aortic or mitral regurgitation, aortic dissection, and renal artery stenosis.

Giant cell arteritis (GCA) is a large-vessel granulomatous vasculitis that can also affect the great vessels of the chest, leading to a similar presentation, but is unlikely given this patient’s young age; GCA affects individuals over age 50 years.

Question 58

rheum

Answer 58

Folic acid supplementation should be initiated in patients beginning therapy with methotrexate to reduce the risk of side effects and discontinuation of methotrexate.

Question 59

rheum

Answer 59

This patient has a triad of bihilar adenopathy, arthritis, and erythema nodosum, consistent with Löfgren syndrome, a common rheumatologic manifestation of sarcoidosis. Diagnostic specificity for sarcoidosis is 95% when all three parts of the triad are present, thus making further testing unnecessary.

Question 60

rheum

Answer 60

The classic triad for IgA vasculitis (Henoch-Schönlein purpura) is purpura, abdominal pain, and arthralgia; diagnosis is established with biopsy of the affected organ.

IgA vasculitis is an IgA immune complex–mediated small-vessel vasculitis that almost always affects the skin but frequently affects the bowel, leading to pain, bleeding, and occasionally intussusception; less commonly, it affects the kidneys and rarely causes pulmonary hemorrhage. Biopsy of the most accessible affected organ, in this case the skin, will establish the diagnosis by demonstrating leukocytoclastic vasculitis with predominance of IgA deposits on immunofluorescence. Furthermore, skin biopsy is easily obtainable and does not expose the patient to radiation or contrast agents or the risks of kidney biopsy. Kidney biopsy is reserved for patients in whom the diagnosis is uncertain or if there is clinical evidence of severe kidney involvement

Question 61

Rheum

Answer 61

Risk factors for allopurinol sensitivity include diuretic use, chronic kidney disease, and the presence of the HLA-B*5801 allele in certain Asian ethnic groups.

This patient with gout is at high risk for allopurinol sensitivity. His risk factors include ethnicity (Thai descent) and chronic kidney disease. Patients of Thai, Han Chinese, and Korean descent have a higher likelihood of having the HLA-B*5801 allele, which confers a high risk for allopurinol sensitivity. Diuretic use is also a risk factor for allopurinol sensitivity.

Question 62

rheum

Answer 62

Enthesitis is highly suggestive of spondyloarthritis; when particularly severe, the inflammation may extend along the associated tendon and local ligaments, resulting in dactylitis (“sausage digits”).

Question 63

rhuem

Answer 63

In tuberculous vertebral osteomyelitis, the lower thoracic spine is the most frequently involved segment; common symptoms are back pain, fever, weight loss, and neurologic abnormalities.

Question 64

rheum

Answer 64

The characteristic features of fibromyalgia are widespread chronic pain, fatigue, and sleep disorders, which are frequently accompanied by impaired cognitive function, mood disorders, and symptoms such as headache, gastrointestinal symptoms, and paresthesia.

Question 65

rheum

Answer 65

Mycophenolate mofetil is the most appropriate initial immunosuppressive therapy in the treatment of isolated class V lupus nephritis, especially without kidney dysfunction.

Question 66

rheum

Answer 66

In recalcitrant psoriatic arthritis, the combination of methotrexate and a tumor necrosis factor α inhibitor has shown efficacy in managing joint symptoms and slowing the progression of radiographic damage, including joint space narrowing and erosions.

Question 67

rheum

Answer 67

Patients with long-standing rheumatoid arthritis are at risk for developing C1-C2 subluxation; symptoms include a sensation of the head falling off, drop attacks, and painless paresthesia of the hands and feet.

The most appropriate diagnostic test to perform next is radiography of the cervical spine with flexion/extension views.

Question 68

rheum

Answer 68

Neuropsychiatric systemic lupus erythematosus prevalence is high in patients with systemic lupus erythematosus, with the most common manifestations being headache, mild cognitive dysfunction, and mood disorder; severe acute presentations, including seizures and psychosis, occur infrequently.

Steroid-induced psychosis is seen in patients taking high doses of glucocorticoids (usually >1 mg/kg/d) and is very unusual at doses less than 20 mg/d. This patient’s dose is only 5 mg/d, making steroid-induced psychosis unlikely.

Question 69

rheum

Answer 69

Persistent coronary artery aneurysm conveys the greatest risk for long-term cardiovascular events in survivors of childhood Kawasaki disease.

Question 70

rheum

Answer 70

Obesity is the strongest modifiable risk factor for osteoarthritis incidence; weight loss can lower the risk for developing the disease.

Question 71

rheum

Answer 71

Features of scleroderma renal crisis include hypertensive emergency, headache, microangiopathic hemolytic anemia, thrombocytopenia, elevated serum creatinine levels, and proteinuria; treatment involves ACE inhibitors, typically captopril.

Question 72

rheum

Answer 72

Ninety percent of cases of mixed cryoglobulinemia are associated with hepatitis C virus infection; therefore, assessing for hepatitis C virus infection in an individual with cryoglobulinemia is indicated.

Question 73

rheum

Answer 73

Anti–Jo-1 antibodies are found in patients with antisynthetase syndrome, which causes myositis and interstitial lung disease.

Anti-U1-ribonucleoprotein antibodies is associated with systemic lupus erythematosus and mixed connective tissue disease, an overlap disease containing features of myositis, systemic sclerosis and lupus;

Question 74

rheum

Answer 74

Characteristic features of psoriatic arthritis include psoriasis, enthesitis, dactylitis, tenosynovitis, arthritis of the distal interphalangeal joints, asymmetric oligoarthritis, and spondylitis.

Question 75

rheum

Answer 75

Characteristic features of psoriatic arthritis include psoriasis, enthesitis, dactylitis, tenosynovitis, arthritis of the distal interphalangeal joints, asymmetric oligoarthritis, and spondylitis.

Question 76

rhem

Answer 76

An uncommon side effect of leflunomide is peripheral neuropathy, and definitive treatment is discontinuation of the medication.

Question 77

rhem

Answer 77

For patients with inadequately treated tophaceous gout who tolerate allopurinol, the dose can be titrated to a maximum of 800 mg/d in 100-mg increments to alleviate symptoms.

Pegloticase is a costly drug that should be considered only when other options have been exhausted.

Question 78

rheum

Answer 78

Belimumab is FDA approved as an addition to standard therapy in patients who have systemic lupus erythematosus with persistent mild to moderately active disease.

Question 79

rhem

Answer 79

Diffuse idiopathic skeletal hyperostosis is a noninflammatory condition that involves ossification of spinal ligaments and entheses and usually presents as back pain and stiffness; characteristic radiographic changes include confluent ossification of at least four contiguous vertebral levels, usually on the right side of the spine.

Question 80

rheum

Answer 80

Ankylosing spondylitis is characterized by bilateral sacroiliac joint abnormalities on spinal radiographs. Other spinal sections may also be involved, but sacroiliac joint involvement is cardinal for diagnosis. Inflammatory back pain is the most common symptom and is usually comprised of four of five of the following features: onset of back discomfort before the age of 40 years; insidious onset; improvement with exercise; no improvement with rest; and pain at night (with improvement upon arising)

Question 81

rheum

Answer 81

Coadministration of colchicine and CYP3A4 inhibitors (such as clarithromycin and fluconazole) should be avoided because potentially fatal colchicine toxicity with kidney failure, rhabdomyolysis, and bone marrow suppression may occur.

Question 82

REHUM

Answer 82

Subacute cutaneous lupus erythematosus (SCLE) can present as annular with central clearing or papulosquamous with patchy erythematous plaques and papules, and both forms can be seen in the same patient; about 50% of patients with SCLE also have systemic lupus erythematosus.

Question 83

RHEM

Answer 83

All patients with gout beginning urate-lowering therapy should also receive a prophylactic agent such as colchicine, low-dose glucocorticoids, or low-dose NSAIDs to prevent mobilization flares; the choice of prophylactic drug is determined by patient comorbidities.

Adding the uricosuric agent probenecid or increasing the allopurinol would not afford protection against mobilization flares because they are both urate-lowering agents, not prophylactic agents.

Question 84

RHEUM

Answer 84

Osteonecrosis is a complication of systemic lupus erythematosus most commonly affecting the hips and should be suspected when there is otherwise unexplained pain and/or reduced range of motion; MRI is the modality of choice for evaluation of early disease.

Question 85

RHEUM

Answer 85

Duloxetine is FDA approved for chronic musculoskeletal pain and has been shown to have analgesic efficacy for chronic low back pain and knee osteoarthritis pain.

Topical capsaicin may benefit localized OA (for example, knee only) but is impractical in this case given the multiple areas of involvement.