Rheumatology

Question 1

RA prognostic features

Answer 1

Poor prognostic features

rheumatoid factor positive
anti-CCP antibodies
poor functional status at presentation
X-ray: early erosions (e.g. after < 2 years)
extra articular features e.g. nodules
HLA DR4
insidious onset

Question 2

S1 lesion

Answer 2

Sensory loss of posterolateral aspect of leg and lateral aspect of foot, weakness in plantar flexion of foot, reduced ankle reflex, positive sciatic nerve stretch test

Question 3

Osteomalacia

Answer 3

Bone pain, tenderness and proximal myopathy (→ waddling gait)

most commonly secondary to vitamin D deficiency

hypocalcaemia, low vitamin D levels a normal or raised phosphate and a raised alkaline phosphatase.

x-ray
translucent bands (Looser’s zones or pseudofractures)

Question 4

major target for pANCA

Answer 4

myeloperoxidase (MPO)

Question 5

major target for cANCA

Answer 5

Serine proteinase 3 (PR3)

Question 6

Mycophenolate mofetil (MMF)

Answer 6

inosine-5’-monophosphate dehydrogenase inhibitor

immunosuppressant commonly used to prevent rejection of organ transplants.

Question 7

apremilast

Answer 7

phosphodiesterase type-4 (PDE4) inhibitor
suppression of pro-inflammatory mediator synthesis and promotion of anti-inflammatory mediators

Question 8

mixed connective tissue disease (Sharps syndrome)

Answer 8

Anti-ribonuclear protein (anti-RNP)

R Raynoud
N swollen hands with No synovitis
P Pain in muscle and joints

Question 9

Polymyositis tx

Answer 9

high-dose corticosteroids tapered as symptoms improve
azathioprine may be used as a steroid-sparing agent

Question 10

Discoid lupus erythematous

Answer 10

topical steroids → oral hydroxychloroquine

Question 11

Osteogenesis imperfecta - what defect?

Answer 11

Type I collagen
Brittle bone disease (AD inheritance)
Labs usually normal

Question 12

Reactive arthritis which HLA

Answer 12

HLA-B27
urethritis, conjunctivitis and arthritis
‘Can’t see, pee or climb a tree’

Question 13

SLE during pregnancy

Answer 13

neonatal lupus erythematosus

neonatal complications include congenital heart block

anti-Ro (SSA) antibodies

Question 14

Dermatomyositis antibodies

Answer 14

anti-Mi-2 antibodies - SPECIFIC
ANA positive - MOST COMMON

Question 15

Rheumatoid arthritis mx

Answer 15

DMARD monotherapy +/- a short-course of bridging prednisolone.

(methotrexate/sulfasalazine/leflunomide/hydroxychloroquine)

Question 16

Sjogren’s syndrome - ?increase risk of malignancy

Answer 16

lymphoid malignancy (40-60 fold)

Question 17

Red flags for lower back pain

Answer 17

age < 20 years or > 50 years
history of previous malignancy
night pain
history of trauma
systemically unwell e.g. weight loss, fever

Question 18

C6 entrapment neuropathy

Answer 18

weakness of the biceps muscle or reduced biceps reflex (proximal symptoms)

Question 19

Marfans inheritance

Answer 19

Autosomal dominant mutation of fibrillin-1

Question 20

RA drug safe in pregnancy

Answer 20

sulfasalazine or HCQ

Question 21

Methotrexate in pregnancy

Answer 21

needs to be stopped at least 6 months before conception

Question 22

Still’s disease in adults treatment

Answer 22

NSAIDs
should be used first-line to manage fever, joint pain and serositis
they should be trialled for at least a week before steroids are added

steroids
may control symptoms but won’t improve prognosis

if symptoms persist, the use of methotrexate, IL-1 or anti-TNF therapy can be considered

Question 22

Osteopetrosis

Answer 22

marble bone disease
calcium, phosphate and ALP are normal
defect in osteoclast function

treatment:
stem cell transplant and interferon-gamma

Question 23

Apremilast

Answer 23

phosphodiesterase type-4 (PDE4) inhibitor

Question 24

ustekinumab

Answer 24

monoclonal antibodies
targets both IL-12 and IL-23