Rheumatology

Question 1

Normals ESR

Answer 1

Men < 50: 15 mm/hr.
Men > 50: 20 mm/hr
Women < 50: 20 mm/hr
Women > 50: 30 mm/hr

Question 2

Normal CRP

Answer 2

0.8 mg/L

Question 3

Rheumatoid factor (RF)

Answer 3

• RF positivity is associated with more aggressive disease and more extra-articular manifestations
• sensitivity is equal to anti-CCP for diagnosis of RA

Question 4

Anti-CCP

Answer 4

• strong predictor of erosive disease

Question 5

Anti-DNA topoisomerase I (Scl-70) antibodies

Answer 5

diffuse cutaneous
systemic sclerosis

Question 6

DMARDs in pregnancy

Answer 6

cytotoxic and teratogenic
- prescribe corticoseteroids

Question 7

MS prevalence in Aus

Answer 7

1:1000

Question 8

CREST syndrome

Answer 8

(Calcinosis cutis,
Raynaud phenomenon, Esophageal dysmotility, Sclerodactyly, and Telangiectasia)

Question 9

diagnosis of CREST syndrome

Answer 9

anti-centromere antibodies

CREST syndrome is a limited form of systemic sclerosis (scleroderma), characterized by a specific set of symptoms. The acronym “CREST” stands for:

1. Calcinosis: Calcium deposits under the skin, which can feel like small, hard nodules and may cause pain or skin ulcers.
2. Raynaud’s phenomenon: Episodes of vasospasm in the fingers and toes, typically triggered by cold or stress, leading to color changes (white, blue, and red) and sometimes pain or numbness.
3. Esophageal dysmotility: Difficulty swallowing due to problems with the movement of the esophagus, often leading to acid reflux and heartburn.
4. Sclerodactyly: Thickening and tightening of the skin on the fingers, causing them to become stiff and shiny.
5. Telangiectasia: Small, dilated blood vessels near the surface of the skin, often appearing as red spots, particularly on the face and hands.

The diagnosis of CREST syndrome is primarily based on clinical findings and a combination of patient symptoms and signs. Here are the steps usually involved:

1. Clinical Evaluation: A thorough history and physical examination are crucial. The presence of any combination of the five CREST features (Calcinosis, Raynaud’s phenomenon, Esophageal dysmotility, Sclerodactyly, Telangiectasia) can lead a clinician to suspect CREST syndrome.
2. Laboratory Tests:
   
   • Antinuclear Antibody (ANA) Test: This is usually positive in patients with CREST syndrome, indicating an autoimmune process.
   • Anti-centromere Antibody: A specific type of ANA that is highly associated with CREST syndrome. The presence of anti-centromere antibodies supports the diagnosis.
   • Other Antibodies: Although less common, tests for other antibodies like anti-Scl-70 can sometimes be performed, especially if the clinical picture is not typical.
3. Imaging and Other Studies:
   
   • X-rays: Can show calcinosis or other abnormalities.
   • Esophageal Manometry: This test can assess the function of the esophagus, especially useful in diagnosing esophageal dysmotility.
   • Capillaroscopy: A test where a small microscope is used to look at the tiny blood vessels in the nail beds. Changes in these vessels can be indicative of systemic sclerosis, including CREST syndrome.
4. Differential Diagnosis: It is essential to differentiate CREST syndrome from other conditions that may present with similar symptoms, such as other forms of systemic sclerosis, primary Raynaud’s phenomenon, or autoimmune diseases like lupus or rheumatoid arthritis.

Once a diagnosis is made, the management focuses on symptom relief and preventing complications. Treatment often includes medications for managing symptoms like Raynaud’s phenomenon and acid reflux, as well as monitoring for potential complications associated with systemic sclerosis.

Question 10

elderly px + elevated ESR + CRP pain and stiffness in hips and shoulders in the morning

Answer 10

Polymyalgia rheumatica

Question 11

Polymyalgia rheumatica underlying pathology

Answer 11

giant cell arteritis

Question 12

headaches over 50 + Fever + Anemia + High ESR

Answer 12

Giant cell arteritis

Question 13

face rash + URTI + migrating athralgia

Answer 13

Parvovirus-associated arthritis

Question 14

Parvovirus-associated arthritis investigation

Answer 14

diagnostic: detection of parvovirus B19 specific IgM antibodies

Question 15

Giant cell arteritis investigation

Answer 15

1- Elevated ESR.
2- Normochromic or slightly hypochromic anemia.
3- Liver function abnormalities-increased alkaline phosphatase levels
diagnostic: Temporal artery biopsy

Question 16

Giant cell arteritis management

Answer 16

• glucocorticoid prednisolone

Question 17

rheumatoid nodulosis

Answer 17

Local glucocorticoid injections

RA medication with methotrexate and
other DMARDs can increase the frequency and number of rheumatoid nodules—a
condition known as accelerated nodulosis.

Treatment consists of intralesional steroid injection to decrease size
NSAIDs may improve the pain but does not reduce the size and number of nodules

Question 18

Malar rash (butterfly rash),

Answer 18

• highly specific for
  the diagnosis of SLE
• flat, scaly, non-pruritic and
  characteristically spares the nasolabial fold

Question 19

SLE management

Answer 19

long term cornerstone: hydroxychloroquine

Question 20

proximal muscle weakness and pain and a heliotrope (lilac color of the periorbital) rash about her eyes.

Answer 20

dermatomyositis
(This rash surrounds both eyes and may extend
onto the malar eminences, the eyelids, the bridge of the nose, and the forehead)

Question 21

Back pain caused by an inflammatory condition

Answer 21

(rheumatoid arthritis, ankylosing
spondylitis, Reiter syndrome)

Question 22

focal and segmental glomerulonephritis + cytoplasm ANCA antibodies+ affecting upper airway

Answer 22

Wegener granulomatosis (WG)

Question 23

vasculitis of small and medium
sized arteries and veins

Answer 23

C-ANCA
Wegener granulomatosis (WG

Question 24

female + widespread pain> 3 months + Fatigue and sleep difficulties + Normal CRP, ESR

Answer 24

fibromyalgia

Question 25

metacarpophalangeal joint + wrists are warm and tender + swollen

Answer 25

RA

Question 26

worsening headaches + episodes transient visual loss and diplopia + on chewing, her jaw muscles ache until she stops chewing. tender nodular right temporal + mild normocytic anemia + sedimentation rate is 95

Answer 26

Temporal arteritis

Question 27

neuropathy + myopathy + noncaseating granulomas

Answer 27

Sarcoidosis

Question 28

dry mouth and a gritty sensation in eyes + buccal mucosa appears dry + salivary glands are enlarged bilaterally + arthritis

Answer 28

Sjögren syndrome Schirmer test and measurement of autoantibodies anti-Ro (SSA), anti -La

Question 29

Sjögren syndrome treatment

Answer 29

Conservative: - artificial tears - artificial saliva - nasal sprays Pharcological: - Hydroxych

Question 30

risk factors for developing pseudogout

Answer 30

Age more than 70 years. -The family history of pseudogout. -Hypothyroidism. -Haemochromatosis. -Hyperparathyroidism. -Hypercalcemia. -Hypomagnesaemia

Question 31

Drug-induced lupus syndrome

Answer 31

– Hydralazine. – Procainamide. – Quinidine. – Phenytoin. – Chlorpromazine. – Isoniazid. – Methyldopa. – ACE inhibitors.

Question 32

SLE

Answer 32

(ANA) is indicated as the best initial screening test. The dsDNA is 90% specific - affects women in high estrogen period - more common in female - weight loss - malar rash and oral ulcers - most common presentation of this arthritis is symmetrical polyarthritis affecting the hands, wrist and knees.

Question 33

Bradycardia in a patient with SLE antibody

Answer 33

Anti-Ro

Question 34

Ankylosing spondylitis

Answer 34

- dull pain, insidious, felt deep in the lower lumbar orgluteal region,low-back morning stiffness - HLA-B27 is of little use - Plain x-ray of the sacroiliac joints is the most useful investigation in establishing the diagnosis. - Spirometry- restrictive pattern - The disease-modifying drugs are useful if there is peripheral joint involvement

Question 35

highest specificity for rheumatoid arthritis

Answer 35

Anti-citrullinated peptide antibody

Question 36

knee pain and swelling + Knee aspiration fluid showed negative birefringent test

Answer 36

Gout

Question 37

osteoarthritis joint involvement

Answer 37

1-The first carpometacarpal joint of the thumb. 2-First metatarsophalangeal joint of the big toe. 3-Distal interphalangeal joint. 4-Proximal interphalangeal joint. 5-Cervical and lumbar spine. 6-Knee joint. 7-Hip joint.

Question 38

X-ray changes of osteoarthritis

Answer 38

narrowing of joint space subchondral sclerosis and osteophytes. These changes are seen years after the onset of osteoarthritis.

Question 39

DEXA

Answer 39

confirm a diagnosis of osteoporosis.

Question 40

X-ray findings (periarticular swelling with normal joint space)

Answer 40

episode of monoarticular gout

Question 41

pain and swelling of the right big toe + low dose aspirin, atorvastatin, metoprolol, nitrates and frusemide + joint is swollen shiny and red

Answer 41

Acute gout

Question 42

history of rheumatoid arthritis + on methotrexate + dysuria and urgency + initial drug

Answer 42

- cephalexin is the drug of choice Trimethoprim, co-trimoxazole, Co-amoxiclav, Ciprofloxacin increases the risk of methotrexate toxicity

Question 43

long-term urate-lowering therapy for gout

Answer 43

- Frequent or disabling gout flares Frequent or disabling gout flares (Two flares or more annually) -Tophi and structural joint damage ( Urate-lowering therapies such as allopurinol, probenecid, or febuxostat can help reduce tophaceous deposits that may be present) - Gout with renal insufficiency Gout with renal insufficiency – Patients with a creatinine clearance (CrCl) <60 mL/minute/1.73 m (stage 3 or higher chronic kidney disease [CKD]).

Question 44

Acute gout

Answer 44

NSAIDS Colchicine glucocorticoids prednisolone - if above two are contraindicated

Question 45

colchicine contraindications

Answer 45

1- Renal insufficiency. 2-Cytopenias. 3-Abnormal liver functions. 4-Sepsis.

Question 46

Chronic use of methotrexate

Answer 46

1-Hepatotoxicity 2-Folic acid deficiency 3-Myelosuppression with low platelet and white cell count. 4-Interstitial pneumonitis 5-Fatigue 6-Nausea and vomiting 7-Stomatitis or mouth ulcers.

Question 47

patients who are steroid dependent for surgery

Answer 47

1-Give intravenous 100 mg hydrocortisone pre-operatively and 100 mg IV hydrocortisone intra-operatively. 2-During first 24 hours post-op give intravenously 100 mg hydrocortisone 6-8 hourly. This can be reduced by half over the next 48 hours. 3-Then change it to oral when patient tolerates oral diet.

Question 48

medications of choice for lupus nephritis

Answer 48

cyclophosphamide and mycophenolate

Question 49

steroid-sparing immunosuppressive drugs

Answer 49

hydroxychloroqulne Methotrexate

Question 50

precipitating factors for acute attack of gout

Answer 50

- Alcoholic Binge – Drugs ( furosemide, thiazides, Low dose aspirin ) – Starvation – Chronic kidney disease – Myeloproliferative disorders – Lymphoproliferative disorders – Cytotoxic drugs – Sugary soft drinks.

Question 51

Disorders and factors associated with Raynaud phenomenon

Answer 51

Sjögren's syndrome Scleroderma Dermatomyositis Systemic lupus erythematosus Thoracic outlet syndrome Emboli Carpal tunnel syndrome Migraine headache

Question 52

Thrombotic thrombocytopenic purpura

Answer 52

- thrombotic microangiopathy - severely reduced activity of the von Willebrand factor-cleaving protease ADAMTS13 - small-vessel platelet-rich thrombi that cause thrombocytopenia, microangiopathic hemolytic anemia, and sometimes organ damage

Question 53

High serum uric acid level can be managed by dietary measure including:

Answer 53

– Decreasing purine diet. – Limiting ethanol use. – Decreasing fructose containing food. – Avoiding diuretics. – Increasing liquid intake

Question 54

Uveoparotid fever or Heerfordt’s syndrome

Answer 54

rare manifestation of sarcoidosis Uveitis Parotiditis Chronic fever Palsy of facial nerves in some cases Uveoparotid fever, also known as Heerfordt’s syndrome, is a rare manifestation of sarcoidosis, a systemic inflammatory disease characterized by the formation of granulomas in various organs. Heerfordt’s syndrome specifically involves the parotid glands (one of the major salivary glands), uveitis (inflammation of the uvea, the middle layer of the eye), and sometimes facial nerve palsy and fever.

Question 55

getting out of chair or walking difficulty + worsening weakness + 3/5 strength proximally + red confluent macular rash on her and reflexes are normal.

Answer 55

Dermatomyositis

Question 56

non-itchy non-pitting swellings + laryngeal oedema + abdominal pain + vomiting + diarrhoea

Answer 56

hereditary angioedema

Question 57

hereditary angioedema investigation

Answer 57

- low C1 and C4 levels

Question 58

acquired angioedema investogation

Answer 58

- low C1 q level

Question 59

earliest sign of flexor sheath tenosynovitis infection

Answer 59

passive extension pain

Question 60

Sheath infection tenosynovitis common findings

Answer 60

Kanavel signs: - exquisite pain - flexed resting position - fusiform swelling - tenderness