Rheumatology Flashcards
How do you differentiate articular vs non-articular complaints?
Gel phenomenon is seen in inflamm or non inflamm conditions?
NON-inflammatory
WBC of 2000-50000 with predominance of PMNs in synovial fluid analysis is commonly seen in what type of dse condition?
Inflammatory
Most potent risk factor for OA
Age
Joints usually spared in OA
Ankle
Wrist
Elbow
AWE-OA
most effective exercise regimens for OA
aerobic and/or resistance training
however No evidence that patients with hand OA
benefit from therapeutic exercise
Activities that increase pain in the joint should be avoided, and the exercise regimen needs to be individualized to optimize effectiveness.
Range-of-motion exercises, which do not strengthen muscles, and isometric exercises that strengthen muscles, but not through range of motion, are unlikely to be effective by themselves.
Low-impact exercises, including water aerobics and water resistance training, are often better tolerated by patients than exercises involving impact loading, such as running or treadmill exercises
Characteristic xray finding in gout
cystic changes, well-defined erosions, with sclerotic margins (often with overhanging bony edges), and soft tissue masses
Characteristic utz finding in gout
double contour sign overlying the articular cartilage
Indications for starting hypouricemic tx in gout
After 2 acute attacks
Serum uric acid > 9.0 mg/dL (> 535umol/L)
Presence of uric acid stones (radiolucent)
Chronic gouty arthritis or presence of tophi
Hallmark of rheumatoid arthritis
Flexor tendon tenosynovitis
in RA, what do you call the Hyperextension of the PIP joint with flexion of the DIP joint
Swan-neck deformity
in RA, what do you call the Flexion of the PIP joint with hyperextension of the DIP joint
Boutonnière deformity
in RA, what do you call the Subluxation of the 1st MCP with hyperextension of the first IP joint
Z-line deformity
in RA, what do you call the Subluxation of the distal ulna due to inflammation of the ulnar styloid and tenosynovitis of the extensor carpi ulnaris
Piano-key movement
most common cardiac manifestation of rheumatoid arthritis?
pericarditis
most common pulmonary manifestation of rheumatoid arthritis?
pleuritis
DMARD of choice in the treatment of rheumatoid arthritis
Methotrexate
antibody is associated with neonatal
lupus with congenital heart block
Anti SSA (Ro)
antibody associated with drug induced lupus
anti histone
best screening test for SLE
ANA
Antibody that is disease specific and correlates with dse activity
dsDNA
Antibody that when positive in CSF correlates with active CNS lupus
antineuronal antibody including antiglutamate receptor 2
Antibody that when positive in serum correlates with depression or psychosis due to CNS lupus
anti ribosomal P
Among the different drugs being used to treat SLE, which drug is specifically indicated in the treatment of lupus dermatitis?
Methotrexate
Which features are more common in limited compared to diffuse cutaenous SSc
Critical ischemia in digits
Calcinosis cutis
Characteristic autoantibodies in
Limited cutaenous SSc?
diffuse cutaneous Ssc?
Limited cutaenous SSc- anticentromere
diffuse cutaneous Ssc - Anti topoisomerase I (Scl 70) and anti RNA pol III
yung may numbers sa diffuse
What is the mainstay of therapy of
scleroderma renal crisis?
ACE inhibitors
Avoid steroids. Use only in high risk SSC px only when absolutely required and at low doses <10mg/d
What is the most common route of
infection in infectious arthritis?
Hematogenous
What inflammatory myopathy is not responsive to corticosteroids
Inclusion body myositis
The only conventional NSAID for that appears to be safe from a cardiovascular perspective
Naproxen
Most frequent early clinical manifestation of gout
acute gout
uric acid excretion > ____ mg/day entails overproduction of uric acid
800
most frequently affected joint in CPPD
knee
________ deposition dse is associated with Milwaukee shoulder
Calcium Apatite
cell type that is a predominant source of proinflammatory cytokines (TNF-a, IL-1, IL-6) in the joint and thus considered as the major driver of rheumatoid arthritis
macrophage
major genetic risk factor for RA is the ___alleles
(HLA-DRB1)
What is the most common cause of
death among patients with RA?
cardiovascular dse
What constitutes CREST syndrome?
Calcinosis
Raynaud’s
Esophageal Dysmotility
Sclerodactyly
Telangiectasia
Laboratory and Clinical criteria for diagnosing APAS
See table
Dose of prednisone that can induce psychosis
pred > 40 mg
Most common causes of drug induced lupus
procainamide
disopyramide
propafenone
in psoriatic arthritis, which comes first? psoriasis or arthritis?
psoriasis
Which dse entity is arthritis mutilans associated?
Psoriasis
What are the causative agents associated with Reactive arthritis
Enteric causes: Shigella, Salmonella, Yersinia, Campylobacter
Urogenital: Chlamydia
Most serious complication of Ankylosing Spondylitis?
fracture
most commonly involved –> lower cervical spine
In AS, the earliest change in the sacroiliac joint demonstrable on x-ray is
blurring of the cortical margins of the subchondral bone
Which clinical feature of acute rheumatic fever can appear after months after an initial infection?
Chorea and indolent carditis
can last up to 6 mos
Treatment for severe chorea in acute rheumatic fever
Carbamazepine, Sodium Valproate
How long should you give prophylaxis for Acute rheumatic fever
Without carditis
With carditis,no valvular dse
With residual valvular dse
Without carditis - 5 yrs after last attack or until 21 yrs old which ever is longer
With carditis,no valvular dse- 10 yrs after last attack or until 21 yrs old which ever is longer
With residual valvular dse- 10 yrs after last attack or until 40 yrs old which ever is longer
in OA, what has the highest % inheritability based on joint involvement?
Hip and Hand (50%)
Earliest pathologic finding in OA
Fibrillation of cartilage surface
Most common earliest manifestation of gout
Pai and swelling of 1st MTP
Target uric acid level for px with gout
5-6 mg/dL or < 300-360 umol/L
Most commonly involved joints in RA
wrist , PIP, MCP
Most common chronic dermatitis of SLE
Discoid
Circular lesions with slightly raised, scaly, hyperpigmented erythematous rims and depigmented, atrophic centers
Most common hematologic finding in SLE
normocytic normochromic anemia
Autoantibody seen in MCTD
U1RNP
Diagnostic test of choice for confirming PAH in SLE
Cardiac catheterization
Leading cause of death in px with systemic sclerosis
ILD
monitor with PFTs every 6 months
NOT recommended for monitoring: HRCT
Mainstay of tx for inclusion body myositis
PT and OT
Antisynthetase syndrome is associated with this antibody
Anti-Jo1
Antisynthetase syndrome- presence of myositis, non erosive arthritis, Raynauds, mechanic hands, fever
Most sensitive laboratory marker of muscle destruction
CK
Characteristic laboratory finding in EGPA
Eosinophilia > 1000cells/uL
straight-leg-raising maneuver is a sensitive test for nerve root disease, and stretches which nerve roots?
L5-S1
Empiric tx for septic arthritis
3rd gen IV + Vanco
Most common valvular abnormality in RA
MR
earliest plain radiographic finding of
rheumatoid arthritis
Periarticular osteopenia
most common clinical presentation of
acute rheumatic fever (ARF)
polyrthritis (60-75%)
next is carditis (50-60%)
Sausage digits are associated with what condition?
reactive arthritis and psoriatic arthritis
antinuclear antibody (ANA) patterns is most
specific and suggestive of lupus
peripheral
most commonly affected joint in patients
who develop hemarthrosis
knee
Most commonly affected tendon in rotor cuff tendinitis
supraspinatus
Most commonly involved part of the spine in psoriatic arthritis
cervical
Same with RA
All vasculitis patients receiving daily glucocorticoids and immunosuppressive should receive prophylaxis against which organism?
P. jiroveci
treatment regimen for Psoriatic Arthritis that can paradoxically trigger exacerbation of psoriasis
Anti TNF a
Also the drugs that are most useful for psoriatic arthritis
When would you expect clinical response after treatment initiation with cyclophosphamide?
3-16 weeks
Cyclophosphamide + GC are given early to px with renal biopsy of ISN III and IV –> reduce progression to ESRD and death
What constitutes the triad of reactive arthritis
arthritis, urethritis and conjunctivitis
Most common extraarticular manifestation of AS
Acute anterior uveitis
Chronic nasal carriage of ___ has been reported to be assoc with a higher relapse rate of GPA however there is no rol of this organism in the pathogenesis of this dse
S. aureus
Tissue that offers the highest diagnostic yield for GPA
Pulmonary tissue
Tx for GPA
Cyclophosphamide + Glucocorticoids
same with MPA
GPA is AKA Wegeners
Asians expressing this HLA phenotype has inc risk for allopurinol toxicity
HLA B*5801
Examples of non hypourecemic agents with mild uricosuric effects
Losartan, Amlodipine, Fenofibrate, SGLT2i
Most frequent extracutaneous complication of SSc
Raynaud’s phenomenon
What rare complication that presents as encephalopathy is associated with rituximab therapy
PML
Most serious manifestation of SLE
Nephritis
Most common manifestation of diffuse CNS lupus
cognitive dysfunction
most common type of arthritis
OA
pathologic sine qua non of OA
hyaline articular cartilage loss
What does FABER test stand for
Flexion, ABduction, External Rotation
Pathologies at the hip, lumbar and sacroiliac region
Entry criteria for 2015 ACR/EULAR classification of gout
The entry criterion for the new classification criteria requires the occurrence of at least one episode of peripheral joint or bursal swelling, pain, or tenderness.
When do we initiate urate lowering drugs?
> Hyperuricemia cannot be corrected by nonpharmacological interventions
Consider in those with CKD Stage >3, serum urate levels >9mg/dL, urate nephrolithiasis
More than 2 gout attacks yearly
Those who already has subcutaneous tophi or chronic gouty arthritis
Radiographic evidence of gout arthritis
punctate or linear deposits withing the menisci/ articular cartilage in CPPD are AKA
Chondrocalcinosis
Autoantibodies that are specific and associated with SLE nephritis and correlates with dse activity
anti dsdna
antismith–> does not correlated with dse activity
Autoantibody in SLE associated with Sicca syndrome
Anti Ro
Also assoc in neonatal lupus heart block
Autoantibody that correlates with dse in activity of nephritis but NOT specific to SLE
AntiC1q
Autoantibody more frequent in drug induced lupus than SLE
Anti histone
Most serious cardiac manifestation of SLE
Myocarditis, Libman Sacks endocarditis
however both not included in SLICC
Next step when ssx suggestive of SLE but negative ANA, CBC, plt, UA
Repeat ANA, add dsDNA and anti Ro
if all negative- not SLE
2nd agents that may be used in addition to glucocorticoids in px with SLE with life threatening organ dysfunction
MMF/ Cyclophosphamide
in SLE nephritis, may also add calcineurin inhibitors like tacrolimus
Treatment for SLE assoc with higher incidence of aseptic meningitis
NSAIDs
Treatment for SLE assoc with bladder CA
cyclophosphamide
Treatment for SLE assoc with diffuse yellowing of the skin
Quinacrine
Treatment for SLE assoc with hypercholesterolemia
MMF
Most common venous and aterial consequences of APAS
DVT, Stroke
Hallmark of rheumatic carditis
Valvular damage affecting mitral valves and aortic valves
eg. MR and AR
___% of those with chorea have carditis
50
Subcutaneous nodules are Delayed manifestation of RHD occuring __ weeks after the onset of disease last for 3 weeks associated with carditis
2-3
Lab tests that could signify evidence of strep infection
Positive throat swab/ rapid antigen
Anti ASO, anti DNAse
Treatment for Acute rheumatic fever
Antibiotics: Amoxicillin, 50 mg/kg [maximum, 1 g] daily, for 10 days OR Benzathine Pen G 1.2 million units IM
Salicylates and NSAIDS- Aspirin 50-60mg/kg per day Max 80-100mg/kg/day divided into 4-5 doses; Decrease dose after 2 weeks to 50-60mg/kg/day for 2-4 weeks
Others: Naproxen 10-20mg/kg/day
Note: Salicylates and NSAIDs - no value for carditis and chorea
most common form of chronic inflammatory arthritis
RA
What constitutes Felty’s syndrome?
neutropenia, splenomegaly, and nodular RA
Oral microbiome associated with RA
P. gingivalis
Pathologic hallmark of RA
Synovial inflammation and proliferation, focal bone erosions, thinning of articular cartilage
The presence of serum ____ antibodies has about the same sensitivity as serum RF for the diagnosis of RA.
anti CCP
However, its diagnostic specificity approaches 95%, so a positive test for these antibodies in the setting of an early inflammatory arthritis is useful for distinguishing RA from other forms of arthritis
ACR/Eular criteria for remission in RA
Only biologic for RA that is NOT approved for monotherapy
Infliximab
Wright and Moll 5 patterns of psoriatic arthritis
(1) arthritis of the DIP joints
(2) asymmetric oligoarthritis
(3) symmetric polyarthritis similar to RA
(4) axial involvement (spine and sacroiliac joints)
(5) arthritis mutilans
(3)- most common, occurs in 40%
Radiographic findings associated with peripheral psoriatic arthritis
DIP involvement, classic “pencil-in-cup” deformity; marginal erosions with adjacent bony proliferation (“whiskering”); small-joint ankylosis; osteolysis of phalangeal and metacarpal bone, with telescoping of digits; periostitis, “ray” distribution of lesions.
What constitutes CASPAR criteria for Psoriatic arthritis
Oral JAK inhibitor approved for psoriatic arthritis
Tofacitinib
Monoclonal antibodies approved for psoriatic arthritis
Secukinumab and ixekizumab, monoclonal antibodies to IL-17A;
SEventeen
ustekinumab, a monoclonal antibody to the shared IL-23/IL-12p40 subunit.
Triad of GPA
Upper respiratory tract involvement
Lower respiratory tract involvement
Glomerulonephritis
Most common presentation of MPA
Glomerulonephritis
does NOT have granulomas and pulmonary involvement
Histologic hallmark of GPA
Necrotizing small-vessel vasculitis + Granulomas (intravascular or extravascular)
Most common cause of mortality in GPA
Renal
Most common system involved in GPA
ENT particularly sinusitis
Most common renal manifestation in GPA
Glomerulonephritis
Most common lung manifestation in GPA
Pulmonary infiltrates
Most common eye manifestation in GPA
Scleritis
Important cause of mortality in EGPA
Heart disease (myocardial involvement)
2DECHO should be done in ALL newly diagnosed patients
Saddle nose deformity is seen in what ANCA associated vasculitis
GPA
Venules are NOT involved in PAN. If present, this would suggest this condition
MPA
Most common CBC finding in PAN
Leukocytosis with neutrophilic predominance
Body tissues with the highest yield for biopsy in PAN diagnosis
Nodular skin lesions
Painful testes
Nerve/muscle
May be performed in the absence of biopsy for diagnosis of PAN
Angiographic studies
Mortality in PAN is usually due to:
GI complaints (bowel infarction, perforation)
Cardiovascular causes
Most common artery involved in giant cell arteritis
Temporal artery
Other name for giant cell arteritis is Temporal arteritis
Most common artery involved in takayasu arteritis
subclavian artery
Treatment for Giant cell arteritis
Prednisone (40-60 mg OD x 1 month then taper)
(first-line treatment for general presentation)
Methylprednisolone (1 gram OD x 3 days)
(first-line treatment for ocular presentation)
Treatment for Takayasu arteritis
Prednisone 40-60 mg OD for symptomatic treatment
Most commonly involved vessel in cutaneous vasculitis
Postcapillary venules
Typical presentation in cutaneous vasculitis
Palpable purpura
Most common site of cutaneous vasculitis
Lower extremities
Treatment of cutaneous vasculitis
Prednisone
Most effective therapy for systemic vasculitis but should almost never be used for cutaneous vasculitis
Cyclophosphamide
Syndrome that includes the ff ssx:
Interstitial keratitis
Vestibuloauditory symptoms
Aortitis (AV involvement)
Cogan syndrome
Most involved blood vessel in Kawasaki disease
Coronary arteries – beadlike aneurysms and thromboses
Drugs associated with ANCA-associated vasculitis
Hydralazine
Propylthiouracil
Most common clinical presentation of drug-induced vasculitis
Palpable purpura of the lower extremities
In patients with dermatomyositis, these refer to the raised erythematous rash over the knuckles.
Gottron papules NOT sign
Gottron signs also seen in other areas like elbows , knees, ankles
autoantibody associated with more benign dermatomyositis and a favorable response to treatment
Anti-Mi2
Associated with increased risk of malignancies in dermatomyositis patients
Anti-TIF1 (p155)
Anti-NXP2
autoantibody Associated with amyopathic dermatomyositis (rash only) with severe palmar rash, digital ulcers, rapidly progressive ILD
Anti-MDA5
autoantibody Associated in immune-mediated necrotizing myopathy (NM) in patients taking statins >5 years
Anti-HMGCR
autoantibody Associated in patients with inclusion body myositis (IBM)
Anti-cytosolic 5’nucleotidase 1A (anti-cN-1A)
Inclusion body myositis has predilection for involvement of these muscles
flexor digitorum profundus, vastus medialis, vastus lateralis
Treatment for inflammatory myopathies
High-dose glucocorticoids (0.75 – 1 gram mg/kg/day- First-line treatment to steroid-responsive inflammatory myopathies
Methotrexate – second-line treatment
Exception: IBM –> OT and PT
Which of the following patients with symptomatic gout would require hypouricemic therapy?
a. A 55/M with documented radio-opaque kidney stone
b. A 48/M 2 weeks after resolution of his first acute gouty attack
c. A 38/M with serum uric acid level of 14 mg/dL
d. A 50/M with concomitant osteoarthritis
c. A 38/M with serum uric acid level of 14 mg/dL
Since > 9
Why other options are wrong
a. A 55/M with documented radio-opaque kidney stone–> radiolucent
b. A 48/M 2 weeks after resolution of his first acute gouty attack –> should be at least 2 attacks
d. A 50/M with concomitant osteoarthritis- not indicated
A 63F recently diagnosed with osteoarthritis of the hip asks you if her children are at higher risk to develop the same condition. Considering her profile, which is the most appropriate response?
a. Her pattern of joint involvement makes heritability more likely
b. Her pattern of joint involvement makes heritability less likely
c. Her age at disease onset makes heritability more likely
d. Her age at disease onset makes heritability less likely
a. Her pattern of joint involvement makes heritability more likely
Heritability of OA
o Hip and hand (50%)
o Knee (up to 30%)
o Generalized OA (rarely inherited)
* Growth differentiation factor 5 (GDF5) polymorphism is an associated mutation
Obese individuals are at higher risk for osteoarthritis in which joint/s?
a. Hip
b. Knee
c. Hip and knee
d. Hip, knee and hand
d. Hip, knee and hand
Obesity and OA
* Risk factor for knee, hip, and hand OA
* Obese persons have more severe OA symptoms
* Not just a consequence of inactivity due to OA
* Stronger risk factor among women
* In women, risk is correlated to weight in a linear fashion
* Weight loss reduces risk for symptomatic OA
* Adipokines may also play a role (note risk for hand OA)
Repetitive joint use and exercise
* Exercise is not associated with OA risk in most people
* Joint injury – involved joints are at greater risk with certain types of exercise
* Recreational runners – modestly increased risk for hip OA (but not knee OA)
* Professional runners – high risk for hip and knee OA
* Workers performing repetitive tasks for many years – high risk for involved joints
What happens to the amount of proteoglycan and water in the cartilage of a joint with osteoarthritis?
a. Decrease in proteoglycan, decrease in water content
b. Decrease in proteoglycan, increase in water content
c. No change in proteoglycan, decrease in water content
d. No change in proteoglycan, increase in water content Feedback
b. Decrease in proteoglycan, increase in water content
Pathology
* Cartilage surface fibrillation → non-uniform erosions → extension to bone
* Injury → chondrocyte mitosis and clustering → catabolic > synthetic activity → negative charges of proteoglycans are exposed → cartilage swelling → vulnerability to injury
* Activation of osteoclasts and osteoblasts in subchondral bone
- Osteophyte formation at the joint margin – radiologic hallmark of OA
- Synovial inflammation and proliferation accelerate matrix destruction
- Capsular edema and fibrosis
*Basic calcium phosphate and calcium pyrophosphate dihydrate crystals in end-stage OA → synovitis
A 60F was referred to you for management of diabetes mellitus. On examination, you note foot deformities including loss of the arch of the midfoot and bony prominences. What was the primary predisposing factor that led to this condition?
a. Acute trauma
b. Atherosclerosis
c. Neuropathy
d. Obesity
c. Neuropathy
Neuropathic joint disease (Charcot joint) is a progressive destructive arthritis associated with loss of pain sensation, proprioception, or both.
Diabetes mellitus is the most frequent cause of neuropathic joint disease.
Radiographs and physical exam demonstrate loss of the arch due to bony fragmentation and dislocation in the midfoot.
A 65F is in your clinic for a wellness check-up. Which intervention is most effective in the prevention of symptomatic knee osteoarthritis?
a. Calcium + Vitamin D supplementation
b. Glucosamine supplementation
c. Quadriceps exercise
d. Smoking cessation
c. Quadriceps exercise
A 56F consults you for chronic joint pains in her hands as well as difficulty in certain activities such as cooking and doing laundry. You inspect her hands and see nodes on distal interphalangeal joints and the proximal interphalangeal joints. What is the most likely diagnosis?
a. Gouty arthritis
b. Osteoarthritis
c. Psoriatic arthritis
d. Rheumatoid arthritis
b. Osteoarthritis
Hand OA affects the distal interphalangeal joints (Heberden’s nodes) and the proximal interphalangeal joints (Bouchard’s nodes). Another common site of bony enlargement in the hands is the thumb base.
Sources of pain in osteoarthritis
* Cartilage loss is NOT accompanied by pain, unless if with neurovascular invasion in advanced OA
* Innervated structures:
o Synovium, ligaments, joint capsule, muscles, subchondral bone
* Severity of X-ray changes does not correlate well with pain severity
Likely sources of pain
* Synovitis
* Joint effusion
* Bone marrow edema (from loading-related bone injury)
* Periarticular sources including bursae (ie. anserine bursitis, iliotibial band syndrome)
* Peripheral and central sensitization
In a 55M with knee osteoarthritis, which pattern of symptoms is most consistent with his condition?
a. No morning stiffness; pain is associated with fatigue
b. No morning stiffness; swelling is noted above the joint
c. Morning stiffness for 30 minutes, pain subsides with prolonged activity
d. Morning stiffness for 30 minutes, pain worsens with prolonged activity
d. Morning stiffness for 30 minutes, pain worsens with prolonged activity
Clinical features
* Pain is initially episodic, activity-related, triggered by overactive use of involved joint
* Can become continuous pain at progression
* Morning stiffness <30mins
A 57M consults you for 1 month history of left knee pain especially when going up and down the stairs. On physical examination, you note swelling and erythema on the inferomedial aspect of the left knee. What is the most likely diagnosis?
a. Anserine bursitis
b. Iliotibial band syndrome
c. Medial meniscus tear
d. Osteoarthritis
a. Anserine bursitis
Bursitis occurs commonly around knees and hips.
A physical examination should focus on whether tenderness is over the joint line (at the junction of the two bones around which the joint is articulating) or outside of it.
Anserine bursitis, medial and distal to the knee, is an extremely common cause of chronic knee pain that may respond to a glucocorticoid injection.
A 62F consults you for on-and-off right hip pain especially after jogging. Physical examination revealed a loss of internal rotation on passive movement. What is the most likely diagnosis?
a. Ankylosing spondylitis
b. Avascular necrosis
c. Osteoarthritis
d. Trochanteric bursitis
c. Osteoarthritis
For hip pain, OA can be detected by loss of internal rotation on passive movement, and pain isolated to an area lateral to the hip joint usually reflects the presence of trochanteric bursitis.
Ankylosing spondylitis: (+) Schober test, (+) sacroiliitis
A 50F consults you for episodic knee pain especially after walking long distances. She also reports difficulty in getting up from the bed in the morning. There is no joint swelling or crepitus. An x-ray done recently shows a radiographically unremarkable knee. What is the appropriate next step?
a. Request for a knee ultrasound
b. Request for a knee MRI
c. Prescribe an oral analgesic
d. Refer to Psychiatry
c. Prescribe an oral analgesic
in OA, radiographic findings correlate poorly with the presence and severity of pain. Further, in both knees and hips, radiographs may be normal in early disease as they are insensitive to cartilage loss and other early findings.
A 65M with knee osteoarthritis follows-up with you in the clinic. You note warmth over the joint and a moderate amount of effusion, which upon aspiration was clear, straw-colored and stringy. What should be the expected result for synovial fluid white count?
a. <100 /uL
b. <1,000 /uL
c. >1,000 /uL
d. >10,000 /uL
b. <1,000 /uL
Workup for osteoarthritis
* No routine blood test indicated, unless inflammatory arthritis is suspected
* Synovial fluid WBC <1000/uL
Indications for radiographs
* Symptoms or PE findings are atypical for OA
* Pain persists after initial treatment
* Imaging correlates poorly with presence/severity of symptoms
* May be normal in early knee and hip OA
MRI
* Not part of diagnostic workup for OA
* Meniscal tears, cartilage and bone lesions are common in knee OA
* These findings are also common in older persons who are asymptomatic
* MRI findings almost never warrant a change in therapy
** additional note
Prominent nocturnal pain in the absence of end-stage OA merits a distinct workup
A 63M with osteoarthritis reports hip pain whenever he plays tennis. What is the most appropriate advice for this patient?
a. Work through the pain as it will subside eventually
b. Take a dose of analgesic prior to his tennis games
c. Do weighted squats to strengthen his leg muscles
d. Shift to another sport that does not trigger pain
d. Shift to another sport that does not trigger pain
Treatment
* Reassurance and non-pharmacologic tx for mild and intermittent symptoms
* Add pharmacotherapy for ongoing, disabling pain o Adjunct for symptomatic relief only
o Does not alter disease process
* The simplest treatment for many patients is to avoid activities that precipitate pain.
What is the proper way of using a cane for a patient with hip osteoarthritis?
a. Use the hand contralateral to the affected hip, and the elbow bent by around 15 degrees
b. Use the hand contralateral to the affected hip, and the elbow bent by around 90 degrees
c. Use the hand ipsilateral to the affected hip, and the elbow bent by around 15 degrees
d. Use the hand ipsilateral to the affected hip, and the elbow bent by around 90 degrees
a. Use the hand contralateral to the affected hip, and the elbow bent by around 15 degrees
Ways to decrease focal load on joint
* Avoid painful activities
* Improve strength and conditioning of bridging muscles * Redistribute load using a brace or splint
* Unload the joint during weight bearing by using a crane in the opposite hand
* Weight loss – each pound lost has a 3 to 6-fold multiplier effect in unloading knees and hips
Which is the most appropriate exercise regimen for an obese patient with symptomatic hip osteoarthritis?
a. Side planks
b. Treadmill exercises
c. Water aerobics
d. Yoga
c. Water aerobics
Low-impact exercises (water aerobics, water resistance training) are better tolerated Impact loading exercised (running, treadmill) are less tolerable Tai chi may be effective for knee OA
A 58F with hand osteoarthritis complains of pain over the first carpometacarpal joint on her left hand. In addition to analgesics, which is the most appropriate intervention to improve her symptoms?
a. Handgrip exercises
b. Splinting
c. Weight loss
d. Prednisone for 5 days
b. Splinting
In hand joints affected by OA, splinting, by limiting motion, often minimizes pain for patients with involvement especially in the base of the thumb. There is no strong evidence that patients with hand OA benefit from therapeutic exercise.
A 48M complains of chronic left knee pain. Physical examination reveals varus knee deformity, however the patient is not keen on undergoing surgery. What is an appropriate option for the patient?
a. Lateral unloader knee brace
b. Lateral unloader neoprene sleeve
c. Medial unloader knee brace
d. Medial unloader neoprene sleeve
c. Medial unloader knee brace
Correction of malalignment can lessen pain in OA
* Varus-valgus malalignment - surgical correction or fitted knee brace (must not slip)
* Patellar malalignment - patellar brace or tape Other non-pharmacologic approaches to lessen pain (adjuncts)
* Neoprene sleeves – questionable effect on malalignment
* Acupuncture
Your patient with hand osteoarthritis experiences worsening of pain over the past week that is not adequately relieved by oral NSAID. You note swelling and tenderness in the area of the 1st carpometacarpal joint. What is the most appropriate intervention?
a. Topical capsaicin
b. Topical NSAID
c. Intraarticular hyaluronic acid
d. Intraarticular steroid
d. Intraarticular steroid
Topical NSAIDs are slightly less efficacious than oral agents, but have far fewer GI and systemic side effects. Glucocorticoid injections are useful to get patients over acute flares of pain, but their effects usually last less than 3 months.
Hyaluronic acid injections can be given but there is controversy as to whether they have efficacy versus placebo
A 68M with hip osteoarthritis reports moderate episodic pain despite taking paracetamol. Pertinent medical history include an eGFR of 45 mL/min and several episodes of falls. What is the most appropriate pharmacologic agent for the patient?
a. Topical NSAID
b. Chondroitin sulfate
c. Prednisone
d. Oxycodone
a. Topical NSAID
Topical NSAIDs are slightly less efficacious than oral agents, but have far fewer GI and systemic side effects.
- Guidelines recommend against the use of glucosamine or chondroitin for OA. Large trials have failed to show that these compounds relieve pain in persons with disease.
- Opiates - Common side effects include dizziness, sedation, nausea or vomiting, dry mouth, constipation, urinary retention, and pruritus.
Your patient with knee osteoarthritis remains to have difficulty performing ADLs despite optimal non-surgical therapy. What procedure should be recommended for this patient?
a. Arthroscopic debridement & lavage
b. Partial meniscectomy
c. Meniscal transplantation
d. Total knee replacement
d. Total knee replacement
Arthroscopic debri¬dement and lavage – no better than sham surgery for relief of pain or disability
Partial meniscectomy in persons with OA and a symptomatic meniscal tear does not relieve knee pain or improve function or even lead to resolution of catching or locking of the knee
Chondrocyte transplantation has not been found to be efficacious in OA, perhaps because OA includes pathology of joint mechanics, which is not corrected by chondrocyte transplants.
A 68M consults you for chronic knee pain. He shows you a recent knee MRI which reveals cartilage degeneration and a meniscal tear. What should be recommended to the patient?
a. Optimal non-surgical therapy
b. Optimal non-surgical therapy plus arthroscopic debridement
c. Optimal non-surgical therapy plus partial meniscectomy
d. Optimal non-surgical therapy plus total knee replacement
a. Optimal non-surgical therapy
Although MRI may reveal the extent of pathology in an osteoarthritic joint, it is not indicated as part of the diagnostic workup. Findings such as meniscal tears and cartilage and bone lesions occur not only in most patients with OA in the knee, but also in most older persons without joint pain.
MRI findings almost never warrant a change in therapy.
A 36F seeks consult for rashes, which were noted to be round lesions on the face with slightly raised and hyperpigmented edges and depigmented centers. Biopsy of the central portion of one of the lesions reveals loss of dermal appendages. She also mentions she has been having on and off pain and swelling in her knees and hands since two months prior. What should be included in the diagnostic workup of this patient?
a. ANA, anti-dsDNA
b. ANA, CBC with platelet, urinalysis
c. ASO, 12L ECG, 2d echo
d. RF, anti-CCP, ESR, CRP
b. ANA, CBC with platelet, urinalysis
Discoid lupus erythematosus (DLE) is the most common chronic dermatitis in lupus; lesions are roughly circular with slightly raised, scaly hyperpigmented erythematous rims and depigmented, atrophic centers in which all dermal appendages are permanently destroyed
A 32F diagnosed with antiphospholipid syndrome was referred to you after also testing positive for ANA ELISA and anti-RNP. She reports having occasional joint pains but is otherwise asymptomatic. CBC and urinalysis are normal. What is the most appropriate management for the patient?
a. Advise to monitor for symptoms
b. Repeat ANA ELISA after 3 months
c. Request for ANA IF
d. Start mycophenolate mofetil maintenance
Advise to monitor for symptoms
The presence in an individual of multiple autoantibodies without clinical symptoms should not be considered diagnostic for SLE, although such persons are at increased risk.
A patient with SLE complains of increasing difficulty in climbing stairs and getting up from a chair. She reportedly does not have any myalgia or muscle tenderness, and is otherwise asymptomatic. Her medications include mycophenolate mofetil 1000mg BID and prednisone 20mg BID. CK-MM is normal. What is the appropriate next step in management?
a. Request for EMG/NCV
b. Refer for a muscle biopsy
c. Decrease prednisone dose
d. Decrease mycophenolate mofetil dose
c. Decrease prednisone dose
In SLE, myositis with clinical muscle weakness, elevated creatine kinase levels, positive magnetic resonance imaging (MRI) scan, and muscle necrosis and inflammation on biopsy can occur, although most patients have myalgias without frank myositis.
Glucocorticoid therapies (commonly) and antimalarial therapies (rarely) can cause muscle weakness; these adverse effects must be distinguished from active inflammatory disease.
Among patients with SLE, disease flare may be heralded by a rise in the levels of which of the following?
a. ANA
b. Anti-dsDNA
c. Anti-Sm
d. C3
b. Anti-dsDNA
Titers of anti-dsDNA vary over time. In some patients, increases in quantities of anti-dsDNA herald a flare, particularly of nephritis or vasculitis, especially when associated with declining levels of C3 or C4 complement.
Antibodies to Sm are also specific for SLE and assist in diagnosis; anti-Sm antibodies do not usually correlate with disease activity or clinical manifesta¬tions.
A 42F develops malaise, joint pains and a photosensitive rash one month after she started taking hydrochlorothiazide. A drug-induced etiology for her condition is supported by a positive result in which test/s?
a. Anti-histone only
b. ANA and Anti-histone
c. Anti-La only
d. ANA, and Anti-La
b. ANA and Anti-histone
Drug-induced lupus: This is a syndrome of positive ANA associated with symptoms such as fever, malaise, arthritis or intense arthralgias/myalgias, serositis, and/ or rash. It is predominant in whites, has less female predilection than SLE, rarely involves kidneys or brain, is rarely associated with anti-dsDNA, is commonly associated with antibodies to histones, and usually resolves over several weeks after discontinuation of the offending medication.
Which test should be included in the long-term follow-up of all patients with SLE?
a. C3
b. ESR, CRP
c. Lipid profile
d. Bone densitometry
c. Lipid profile
Control of hypertension and appropriate prevention strategies for atherosclerosis, including monitoring and treatment of dyslipidemias, management of hyperglycemia, and management of obesity, are recommended.
Statin therapies reduce all-cause deaths in SLE patients and should be considered in patients with elevated LDL or total cholesterol levels.
What targeted therapy in SLE has drug drug interactions with IVIG, live vaccine and tofacitinib
Belimumab
human monoclonal antibody that inhibits B-cell activating factor, also known as B-lymphocyte stimulator
Px to be given anti TNF a should be tested first for
Latent TB via PPD
Hepatitis B
Anti TNF also inc risk for fungal infections
Target INR for APAS
2-3 if unprovoked or if with arterial thrombosis on VKA and low dose aspirin
3-4 if with arterial thrombosis and only on VKA
Treatment for pregnant px with APAS
Aspirin + LMWH
3 cardinal processes that account for clinical manifestations of Systemic sclerosis
Diffuse microangiopathy
Inflammation and autoimmunity
Visceral and vascular fibrosis in multiple organs
Pathologic hallmark of systemic sclerosis
Widespread capillar loss
Obliterative microangiopathy
Fibrosis in the skin
Most common histologic pattern in Systemic sclerosis associated ILD
Non specific interstitial pneumonia
Most specific finding of ankylosing spondylitis
loss of spinal mobility with limitation of anterior and lateral flexion and extension of the lumbar spine and of chest expansion
measured by Schober test (decreased if less than 5)
Treatment for AS
First line: NSAIDs
May also use
>anti-TNF-a –> induce rapid and sustained reduction in dse activity
> Secukinumab –> IL-17a antibody
> Sulfasalazine–> modest benefit for PERIPHERAL arthritis
No role: MTX, oral glucocorticoids, gold compound
MTX is for RA not AS
How do you differentiate reactive arthritis from disseminated gonococcal dse?
ReA: lower extremity symptoms predominate
Gonococcal : LE = UE
How do you differentiate reactive arthritis from PsA
ReA: lower extremity symptoms predominate
PsA: gradual, primarily uppe extremities
A patient with systemic sclerosis presents with palpable subcutaneous lumps on her palms and elbows, with some areas having visible whitish deposits. What is the pathophysiology behind the development of these lesions?
a. Chronic inflammation
b. Hyperparathyroidism
c. Hyperuricemia
d. Paraneoplastic deposition
a. Chronic inflammation
Calcinosis cutis:
Dystrophic calcifications in the skin, subcutaneous, and soft tissues (calcinosis cutis) in the presence of normal serum calcium and phos-phate levels occur in up to 40% of patients, most commonly in those with long-standing anti-centromere antibody-positive lcSSc. These deposits occur when calcium precipitates in tissue damaged by inflammation, hypoxia, or local trauma.
Common locations include the finger pads, palms, extensor surfaces of the forearms, and the olecranon and prepatellar bursae
A 32F consults you after presenting with cyanosis of her hands after carrying a bag of ice. It reportedly lasted 15 minutes and was followed by hyperemia of the involved area. Review of systems was unremarkable and examination of her hands reveal no ulcers or deformities. What is the most appropriate next step in management?
a. Reassure the patient
b. Perform nail microscopy
c. Request for ANA
d. Start metoprolol
b. Perform nail microscopy
Primary Raynaud’s disease is a benign condition that must be differentiated from early or limited SSc. Nailfold microscopy is particularly helpful in this situation, because in contrast to SSc, nail¬fold capillaries are normal.
Aside from the scalp, where else in the body are the “salt-and-pepper” appearance of the skin most prominent in systemic sclerosis?
a. Face
b. Neck
c. Chest
d. Abdomen
c. Chest
Because pigment loss spares the perifollicular areas, the skin may have a “salt-and-pepper” appearance, most prominently on the scalp, upper back, and chest.
A 42F consults for joint pains involving her hands. You note that aside from flexion contractures, her skin appears taut and with a loss of transverse creases. She says she has also been having mild heartburn and occasional indigestion over the past 2 months. Which tests should be included in the evaluation of this patient?
a. Anti-centromere, Anti-topoisomerase I
b. Pulmonary function test, 2D echocardiogram
c. Chest radiograph, esophageal manometry
b. Pulmonary function test, 2D echocardiogram
The diagnosis of SSc is made primarily on clinical grounds and is generally straightforward in patients with established disease.
Patients with PAH are often asymptomatic in early stages. In light of the poor prognosis of untreated PAH and better therapeutic response in patients with early diagnosis, all SSc patients should be screened for PAH at initial evaluation, followed by annual evaluation. Doppler echocardiography provides a noninvasive screening method for estimating the pulmonary arterial pressure.
Pulmonary involvement can remain asymptomatic until it is advanced. Pulmonary function testing (PFT) is relatively sensitive for detecting early pulmonary involvement.
Chest radiography is relatively insensitive for the detection of early ILD
A 45M with systemic sclerosis follows up with you in the clinic. You note increased progression of skin involvement since his previous consult three months ago, as well as palpable tendon friction rubs that were not present previously. What should be monitored closely for this patient?
a. Blood pressure
b. ESR
c. NT-proBNP
d. DLCO
a. Blood pressure
Risk factors for scleroderma renal crisis include African-American race, male sex, and diffuse or progressive skin involvement.
Palpable tendon friction rubs, pericardial effusion, new unexplained anemia, and thrombocytopenia may be harbingers of impending scleroderma renal crisis. High-risk patients with early SSc should monitor their blood pressure daily.
A 45F presents at the ER for progressive muscle weakness. On examination, the patient has symmetric weakness of both upper and lower extremities, more pronounced on the proximal muscle groups. You also note erythematous discoloration of the eyelids, as well as periorbital and grade II bipedal edema. Creatinine and urinalysis were normal. Which test should be included in the evaluation of this patient?
a. 2D echocardiography
b. Chest CT scan
c. Liver ultrasound
d. TSH
a. 2D echocardiography
- Common associated conditions: myocarditis, ILD, malignancy, vasculitis, other CTDs
A 60M presents with proximal muscle weakness, shawl sign and positive anti-TIF1 antibodies. Which of the following tests is most useful in the evaluation of this patient?
a. ANA
b. Colonoscopy
c. EMG/NCV
d. Skeletal MR
b. Colonoscopy
There is a higher risk for malignancy in adult onset cases, ~15% within the first 2–3 years. Anti-TIF1 (or p155) antibodies and anti-NXP2 antibodies are associated with an increased risk of cancer. EMG findings are non-specific and can be seen in other myopathies
In which subset of patients will gout be an unlikely to occur?
a. Middle aged male
b. Middle aged women
c. Post menopausal women
d. Middle aged women with renal disease
b. Middle aged women
Gout is a metabolic disease that most often affects middle-aged to elderly men and postmenopausal women. Women represent only 5–20% of all patients with gout. Most women with gouty arthritis are postmenopausal and elderly, have osteoarthritis and arterial hypertension that causes mild renal insufficiency, and usually are receiving diuretics.
Pre-menopausal gout is rare.
Which statement is correct in terms of epidemiology of Calcium pyrophosphate deposition disease (CPPD)?
a. CPPD commonly occurs in the middle aged population
b. CPPD commonly occurs in patients with pre-existing joint damage
c. Majority of CPPD patients have metabolic abnormalities such as hyperparathyroidism or hemochromatosis
d. CPPD commonly occurs in chronic renal failure
b. CPPD commonly occurs in patients with pre-existing joint damage
The deposition of CPP crystals in articular tissues is most common in the elderly. > 80% of patients are >60 years old and 70% have pre-existing joint damage from other conditions.
A minority of patients with CPPD arthropathy have metabolic abnormalities (such as hyperparathyroidism, hemochromatosis, hypophosphatasia, and hypomagnesemia) or hereditary CPP disease.
The presence of CPPD arthritis in individuals aged <50 years should lead to consideration of these metabolic disorders and inherited forms of disease.
Which is not an expected site of involvement in Calcium Apatite Deposition Disease?
a. knees
b. Shoulders
c. Hips
d. Ankle
d. Ankle
The most common sites of apatite deposition include bursae and tendons in and/or around the knees, shoulders, hips, and fingers.
Which of the following is not known to precipitate acute gouty arthritis?
a. Excessive ethanol ingestion
b. Hypouricemic therapy
c. Menstruation
d. Trauma
c. Menstruation
Several events may precipitate acute gouty arthritis: dietary excess, trauma, surgery, excessive ethanol ingestion, hypouricemic therapy, and serious medical illnesses such as myocardial infarction and stroke
Which microscopy finding correctly matches their corresponding crystal associated arthropathy?
a. Small nonbirefringent globules: Gout
b. Needle-shaped negative birefringent crystals: Calcium pyrophosphate disease
c. Rhomboid-shaped weakly positively crystals: Calcium Apatite Disease
d. Bipyramidal shaped strongly birefringent crystals: Calcium Oxalate deposition Disease
d. Bipyramidal shaped strongly birefringent crystals: Calcium Oxalate deposition Disease
Needle- and rod-shaped negative birefringent crystals are consistent with gout.
* Rod-shaped, and rhomboid crystals that are weakly positively or nonbirefringent crystals are consistent with CPPD.
* Small nonbirefringent globules that stain purplish with Wright’s stain and bright red with alizarin red S are consistent with Calcium appatite deposition disease.
* Calcium oxalate deposition disease crystals have variable shape and variable birefringence to polarized light. The most easily recognized forms are bipyramidal, have strong birefringence and stain with alizarin red S.
Which radiologic finding correctly matches their corresponding crystal associated arthropathy?
a. Double contour sign on ultrasound: CaOx deposition disease
b. Linear radio dense deposits within articular hyaline carriage: CPPD
c. Periarticular calcifications: Gout
d. Soft tissue masses: Osteoarthritis
b. Linear radio dense deposits within articular hyaline carriage: CPPD
CPPD shows radiographs or ultrasound findings of punctate and/or linear radiodense deposits within fibrocartilaginous joint menisci or articular hyaline cartilage (chondrocalcinosis). This can also be seen in Calcium oxalate deposition disease in some patients with chronic renal disease.
Radiographic findings of gout include cystic changes, well-defined erosions with sclerotic margins (often with overhanging bony edges), and soft tissue masses are characteristic radiographic features of advanced chronic tophaceous gout. Ultrasound may aid earlier diagnosis by showing a double contour sign overlying the articular cartilage.
Intra- and/or periarticular calcifications with or without erosive, destructive, or hypertrophic changes may be seen on radiographs of Calcium appatite deposition disease
Caution in the colchicine dosage should be practiced when combined with which drug?
a. Amlodepine
b. Clarithromycin
c. Ciprofloxacin
d. Thiazide diuretics
b. Clarithromycin
Colchicine should be given in lower doses to the patients with P glycoprotein or CYP3A4 inhibitors such as clarithromycin that can increase toxicity of colchicine.
Which statement is true regarding the clinical features of Rheumatoid Arthritis?
a. Incidence increases from 55 years old and above
b. Presenting symptoms commonly involve large joints such as knees and shoulders.
c. Most commonly reported joint involvement are distal interphalyngeal and metatarsophalangeal joints.
d. Extraarticular manifestation are significant and may occur prior to the onset of arthritis.
d. Extraarticular manifestation are significant and may occur prior to the onset of arthritis.
Incidence of RA increases between 25 and 55 years of age, after which it plateaus until the age of 75 and then decreases. Patients often complain of early morning joint stiffness lasting more than 1 h that eases with physical activity.
Presenting symptoms typically involve the small joints of the hands and feet, usually in a symmetric distribution. Once the disease process of RA is established, the wrists, metacarpophalangeal (MCP), and proximal interphalangeal (PIP) joints stand out as the most frequently involved joints. Distal interphalangeal joint are usually an manifestation as compared to the ankle and mid tarsal region but is not one of the most common involved joints.
Extraarticular manifestations may develop during the clinical course of RA in up to 40% of patients, even prior to the onset of arthritis
Which biologic agent is part of the armamentarium for the management of gout?
a. Anakinra
b. Abatacept
c. Infliximab
d. Tocilizumab
a. Anakinra
Based on recent evidence on the essential role of the inflammasome and interleukin 1β (IL-1β) in acute gout, daily anakinra has been used when other treatments have failed or were contraindicated
Which of the following joints will rheumatoid arthritis LEAST likely involve?
a. Elbows
b. knees
c. Cervical spine
d. Lumbar spine
d. Lumbar spine
The wrists, metacarpophalangeal (MCP), and proximal interphalangeal (PIP) joints stand out as the most frequently involved joints in rheumatoid arthritis. Elbows are commonly involved, and can have rheumatoid nodules.
In the feet, metatarsophalangeal (MTP) involvement are frequent and is an early feature of disease while chronic inflammation of the ankle and midtarsal regions usually comes late.
Large joints such as knees and shoulders are also often affected in established disease.
Cervical spine involvement was more prevalent before and can cause compressive myelopathy and neurologic dysfunction.
Thoracolumbar spine are rarely affected.
B.C. is a 55 year old old female who was brought by her daughter to your clinic for a 5 year history of progressive joint stiffness and swelling, It initially starting in the hands and feet and more prominent upon waking up and would resolve with movement. It had gradually involved the knees, elbows and shoulders with the duration of the pain lasting longer and longer. She also had difficulty standing or ambulating due to foot and ankle pain. On review of system, you noted that she has been also been having chronic dry cough x 3 months and progressive shortness of breath. She has no chest pain or orthopnea. You include a chest X-ray in your diagnostic tests and expect to see what finding?
a. Normal findings
b. Pleural thickening
c. Bilateral interstitial infiltrates
d. Pulmonary nodules
c. Bilateral interstitial infiltrates
All are potential pulmonary manifestations in RA. Pleuritis is the most common and presents with pleuritic chest pain and dyspnea.
Pulmonary nodules maybe solitary or multiple.
ILD are found in up to 12% of RA patients and is heralded by symptoms of dry cough and progressive shortness of breath.
Diagnosis is readily made by high resolution chest CT scan, which shows infiltrative opacification in the periphery of both lung.
Pulmonary nodules associated with rheumatoid arthritis may be solitary or multiple. They often occur in conjunction with cutaneous nodules.
Bronchiectasis and respiratory bronchiolitis may also be due to rheumatoid arthritis.
Which of the type malignancies should be monitored in px with Feltys syndrome
a. Colon cancer
b. Lung cancer
c. Lymphoma
d. Melanoma
c. Lymphoma
Felty syndrome, typically occurring in late-stage poorly controlled disease, is characterized by the triad of neutropenia, splenomegaly, and rheumatoid nodules
Large cohort studies have shown a two- to fourfold increased risk of lymphoma in RA patients compared with the general population. The most common histopathologic type of lymphoma is a diffuse large B-cell lymphoma. The risk of developing lymphoma increases if the patient has high levels of disease activity or Felty syndrome
Which statement is correct regarding extraarticular manifestation of rheumatoid arthritis?
a. Subcutaneous nodules are the most common extraarticular manifestation of rheumatoid arthritis
b. Subcutaneous Nodules are fluctuant, warm to touch and tender.
c. Subcutaneous nodules are usually in the muscle tissue near the inflamed joints
d. Subcutaneous nodules can become malignant therefore monitoring is advised
a. Subcutaneous nodules are the most common extraarticular manifestation of rheumatoid arthritis
Subcutaneous nodules have been reported to occur in 30–40% of patients and more commonly in those with the highest levels of disease activity. the nodules are generally firm; nontender; and adherent to periosteum, tendons, or bursae; developing in areas of the skeleton subject to repeated trauma or irritation such as the forearm, sacral prominences, and Achilles tendon. They may also occur in the lungs, pleura, pericardium, and peritoneum. Nodules are typically benign, although they can be associated with infection, ulceration, and gangrene.
Which of the following statement is true regarding the pathophysiology of rheumatoid arthritis?
a. The preclinical stage of rheumatoid arthritis is characterized by a break-down in self-tolerance of immune cells
b. B cell derived inflammation is the central causative driver of chronic inflammation in Rheumatoid arthritis
c. Activated synovial CD4+ T cells mainly differentiates into T cell helper type 2 cells
d. Synovial cells and osteoclasts are predominant source of pro inflammatory cytokines inside the joints
a. The preclinical stage of rheumatoid arthritis is characterized by a break-down in self-tolerance of immune cells
The pathogenic mechanisms of synovial inflammation are likely to result from a complex interplay of genetic, environmental, and immunologic factors that produces dysregulation of the immune system and a breakdown in self-tolerance. Smoking, silicone dust, mineral oil, periodontal pathogens are some of the environmental factors described.
Synovial CD4+ T cells differentiate into TH1 and TH17 cells, each with their distinctive cytokine profile. CD4+ TH cells in turn activate B cells, some of which are destined to differentiate into autoantibody-producing plasma cells. Immune complexes, possibly comprised of rheumatoid factors (RFs) and anti–cyclic citrullinated peptides (CCP) antibodies, may form inside the joint, activating the complement pathway and amplifying inflammation.
T effector cells stimulate synovial macrophages and fibroblasts to secrete proinflammatory mediators, among which is tumor necrosis factor α (TNF-α). TNF-α upregulates adhesion molecules on endothelial cells, promoting leukocyte influx into the joint and stimulates production of other inflammatory mediator. TNF-α also has a role in regulating other mediators in bone destruction and bone formation.
Which of the following pathologic findings is consistent with rheumatoid arthritis?
a. Synovial lining hyperplasia
b. Cartilage surface fibrillation and irregularity
c. Increased thickness of subchondral bone plate
d. Osteophyte formation
a. Synovial lining hyperplasia
The pathologic hallmarks of RA are synovial inflammation and proliferation, focal bone erosions, and thinning of articular cartilage.
Chronic inflammation leads to synovial lining hyperplasia and the formation of pannus, a thickened cellular membrane containing fibroblast like synoviocytes and granulation-reactive fibrovascular tissue that invades the underlying cartilage and bone. the rest of the pathologic findings are consistent with osteoarthritis.
Which statement is true with laboratory features of rheumatoid arthritis?
a. Rheumatoid factor has the most value for predicting worse outcome in rheumatoid arthritis
b. Anti-CCP is more sensitive than anti-rheumatoid factor in diagnosing rheumatoid arthritis
c. A negative anti-rheumatoid factor rules out rheumatoid arthritis
d. Testing for both rheumatoid factor and anti-CCP has added value
d. Testing for both rheumatoid factor and anti-CCP has added value
Serum RF and anti-CCP antibodies is important in differentiating RA from other polyarticular diseases. RF (IgM subtype) is found in 75-80% of RA patients; therefore, a negative result does not exclude the presence of this disease. It is also found in other diseases (Sjogren, SLE, type II mixed cryoglobulinemia, subacute bacterial endocarditis and hepatitis B and C) as well as in 1-5% of normal population. anti-CCP is as sensitive as rheumatoid factor, but more specific. Therefore positive anti-CCP in early inflammatory arthritis distinguishes RA from other arthritis.
Both RF and anti-CCP has prognostic significance, with anti-CCP showing the most value for predicting worse outcomes. Lastly, there is some incremental value in testing for the presence of both RF and anti-CCP, as some patients with RA are positive for RF but negative for anti-CCP and vice versa.
What is the classic initial radiographic finding in rheumatoid arthritis?
a. Soft tissue swelling
b. Subchondral erosion
c. Symmetric joint space loss
d. Periarticular osteopenia
d. Periarticular osteopenia
Joint imaging is for diagnosing RA and for tracking progression of joint damage.
Plain X-ray is the most common imaging modality used, but is limited to visualization of bony structures and inferences on the state father articular cartilages based on the amount of joint space narrowing. Classically in RA, the initial radiographic finding is periarticular osteopenia.
Other findings on plain radiographs include soft tissue swelling, symmetric joint space loss, and subchondral erosions, most frequently in the wrists and hands (MCPs and PIPs) and the feet (MTPs).
MRI and ultrasound techniques offer the added value of detecting changes in the soft tissues such as synovitis, tenosynovitis, and effusions, as well as providing greater sensitivity for identifying bony abnormalities
Which statement is true regarding imaging findings of rheumatoid arthritis?
a. MRI and ultrasound has no added value over X-ray in detecting joint abnormalities in rheumatoid arthritis
b. Soft tissue abnormalities on MRI occurs later than osseous changes in rheumatoid arthritis
c. Ultrasound can detect more bone erosions than plain radiography
d. Ultrasound offers the greatest sensitivity for detecting synovitis and joint effusion
d. Ultrasound offers the greatest sensitivity for detecting synovitis and joint effusion
MRI and ultrasound offer added value over x-ray in detecting changes in the soft tissues such as synovitis, tenosynovitis, and effusions, as well as providing greater sensitivity for identifying bony abnormalities. MRI offers the greatest sensitivity for detecting synovitis and joint effusions, as well as early bone and bone marrow changes. These soft tissue abnormalities often occur before osseous changes are noted on x-ray. Presence of bone marrow edema has been recognized to be an early sign of inflammatory joint disease and can predict the subsequent development of erosions on plain radiographs as well as MRI scans.
Ultrasound can detect more erosions than plain radiography. It can also reliably detect synovitis, including increased joint vascularity indicative of inflammation. It is technician dependent; however, it does offer the advantages of portability, lack of radiation, and low expense relative to MRI, factors that make it attractive as a clinical tool.
A.G. followed up in 3 months with worsening pain and stiffness in her joints. She claims that she was compliant to medications, and takes NSAIDs on top without relief. She is now unable to do household chores and needs assistance on daily activities. ESR and CRP is 2.5xULN and Xray shows new erosions in multiple metacarpal joints. CXR showed What would you advise the patient?
a. Continue current DMARD
b. Switch to another DMARD
c. Continue current DMARD and add on glucocorticoids
d. Continue current DMARD and add on anti-TNF therapy
d. Continue current DMARD and add on anti-TNF therapy
Failure to achieve adequate improvement with DMARD monotherapy calls for a change in DMARD therapy, usually a transition to an effective combination regimen. Effective combinations include methotrexate, sulfasalazine, and hydroxychloroquine (oral triple therapy); methotrexate and leflunomide; and methotrexate plus a biological
Which of the following conventional DMARD was shown to be ineffective in preventing radiographic progressive disease?
a. Hydroxychloroquine
b. Leflunomide
c. Methotrexate
d. Sulfasalazine
a. Hydroxychloroquine
Conventional DMARDs include hydroxychloroquine sulfasalazine, methotrexate, and leflunomide and all have ability to slow or prevent structural progression of RA except for hydroxychloroquine has not been shown to delay radiographic progression of disease and thus is not considered to be a true DMARD.
Which of the following is an anti-TNF inhibitor?
a. Anakinra
b. Etanercept
c. Abatacept
d. Tocilizumab
b. Etanercept
Anakinra is a recombinant IL-1 receptor antagonist.
Abtacept inhibits the co-stimulation of T cells by blocking CD28-CD80/86 interactions.
Tocilizumab is a humanized monoclonal antibody directed against IL-6 receptor.
To decrease the risk of reactivation, antiviral is indicated for hepatitis B patients or those with previous exposure if will receive this medication?
a. Rituximab
b. Hydroxychloroquine
c. Methotrexate
d. Sulfasalazine
a. Rituximab
Reactivation of viral hepatitis has been observed in association with some of the DMARDs, such as rituximab.
Antiviral prophylaxis is indicated to prevent hepatitis flares and complications.
What are the most common sites of Pott’s disease?
a. Cervical and lumbar spine
b. Thoracic and lumbar spine
c. Atlanto-axial cervical spine
d. Coccyx and sacrum
b. Thoracic and lumbar spine
Which tests has been shown to be present years before the arthritis manifestations in rheumatoid arthritis?
a. Anti Ro antibody
b. Rheumatoid factor
c. Anti-sm antibody
d. Anti-CCP antibody
d. Anti-CCP antibody
Which of the following diseases tests positive for ANA?
a. Dermatomyositis
b. Takayasu’s arteritis
c. Microscopic polyangiitis
d. Acute Rheumatic fever
a. Dermatomyositis
Which of the following joints are also affected most commonly with osteoarthritis, aside from the knees, hips and fingers?
a. shoulders
b. ankles
c. wrists
d. lumbar spine
d. lumbar spine
unlike RA and PsA
Which drug is best maintained in most patients with SLE regardless of disease activity?
a. Antimalarials
b. Aspirin
c. ACE inhibitors
d. Low dose glucocorticoids
a. Antimalarials
A 29/F SLE patient was referred for massive pericardial effusion, new-onset LV dysfunction and heart failure. On PE, she had oral ulcers, increased hair loss, synovitis and grade 2 bipedal edema. Work-up showed a WBC of 2.0, Hgb of 101, PC of 50,000/uL and urine protein of 300mg. Which of her manifestations would warrant a trial of high dose steroids?
a. hematologic
b. myocarditis
c. pericarditis
d. nephritis
b. myocarditis
The number of which cutaneous manifestation of systemic sclerosis is correlated with the severity of microvascular disease and pulmonary hypertension?
a. Calcific deposits
b. Digital pits
c. Rhytides
d. Telangiectasias
d. Telangiectasias
A patient with systemic sclerosis underwent endoscopy with findings of a watermelon stomach. What would be the best intervention in this case?
a.Endoscopic laser cryotherapy
b.Prokinetic agents
c.Octreotide
d.Rotating antibiotics
a.Endoscopic laser cryotherapy
Which drug has been shown to reduce the progression of systemic sclerosis-associated interstitial lung disease?
a. Azathioprine
b. Cyclophosphamide
c. High dose glucocorticoids
d. Methotrexate
b. Cyclophosphamide
A 42/F was referred for suspected vasculitis after presenting with bloody nasal discharge, progressive ulceration on her nose, eye redness and occasional hemoptysis. On work-up, there was elevated ESR, RBC casts on urinalysis and pulmonary infiltrates on radiograph. Which test has a high likelihood of being positive in this case?
a.Anti-Scl70
b.Anti-myeloperoxidase ANCA
c.Anti-proteinase ANCA
d.Anti-nuclear antibody
c.Anti-proteinase ANCA
A 45/F with proximal muscle weakness and myocarditis presents to the clinic with significantly elevated muscle enzymes. Her muscle biopsy showed endomysial and perivascular inflammation with infiltration of CD8+ T cells, macrophages and plasma cells. What inflammatory myopathy is the patient most likely suffering from?
a.Dermatomyositis
b.Polymyositis
c.Inclusion body myositis
d. Necrotizing myopathy
b.Polymyositis
IBM usually >50 and males
Triad of GPA
Lower respiratory tract involvement
Upper respiratory tract involvement
Kidney involvement
Note GPA was also known as Wegener
Difference between GPA and MPA
MPA does not have upper respiratory tract involvement and does not present with pulmonary nodules
MPA does not have granulomas
2nd most common manifestation of EGPA
Mononeuritis multiplex
IHC stain positive for myxovirus resistance protein A is seen in what inflammatory myopathy?
Dermatomyositis
dermatoMYXO
Most common cause of inflammatory myopathy >50y/o
Inclusion Body Myositis
M>F
CK levels can be normal or only slightly elevated
+ antibodies against cN-1A
ENDOmysial inflammatory infiltrates
Most sensitive stain for inclusion: p62
Common muscles involved in IBM as seen in MRI
Muscle MRI may show predilection for flexor digitorum profundus, vastus medialis and lateralis with sparing of rectus femoris
Mainstay of tx for IBM
PT and OT
Since IBM does not typically respond to any known immunotherapy
What tx for inflammatory myopathies may cause stomatitis
Methotrexate
What tx for inflammatory myopathies may cause pancreatitis
Azathioprine
What tx for inflammatory myopathies may cause gum hyperplasia
Cyclosporine
What tx for inflammatory myopathies may cause sinusitus
Mycophenolate mofetil
Miners are at inc risk of OA in these areas
Knee and Spine
Farmers: Hip
Runners are at inc risk of OA in these areas
Recreational: hip only
Elite: Hip and Knee
Polarized microscopy can identify most typical crystals except
Apatite
Which of the following is not part of the ACR/EULAR classificationcriteria for rheumatoid arthritis?
A. Duration of symptoms of greater or less than 8 weeks
B. Rheumatoid factor
C. Anti cyclic citrullinated peptides
D. C-reactive protein
A. Duration of symptoms of greater or less than 8 weeks
should be 6 weeks
A 54 year old woman complains of dyspnea on exertion, associated with “dryness” of her skin and episodes of bluish discoloration in her fingernails that gradually and spontaneously return back to normal, On physical examination, she was dyspneic upon arrival at your clinic, can speak in short sentences, and her oxygen saturations are at 99% while breathing room air. Which of the following tests is a sensitive test to perform to detect early pulmonary involvement in her case?
A. Chest CT scan with Pulmonary Angiography
B. Chest Xray
C. Chest MRI
D. Pulmonary Function Test with DLCO
D. Pulmonary Function Test with DLCO
A 50 year old female with 6 month history of symmetrical polyarthritis of wrists MCP’s PIPs and elbow joints with morning stiffness of more than 2 hours. Initial diagnostic tests include anemia on CBC, ESR 98mm/h, CRP 24. What is the most likely pathology in this case?
a. Crystal induced mediated release of proinfIammatory cytokines causing soft tissue and joint infIammation
b. Deterioration of hyaline cartilage due to damage of chondrocytes as a result of infIammatory cytokine mediated release of matrix metalloproteinases (MMPs)
c. Enthesitis, which is inIammation at the site where ligaments, tendons, and joint capsules attach to the bone, is the prominent pathologic lesion
d. ProinIammatory cytokines act on synovial fibroblasts causing synovial membrane infIammation and damage to the soft tissues and cartilage
d. ProinIammatory cytokines act on synovial fibroblasts causing synovial membrane infIammation and damage to the soft tissues and cartilage
Patient has RA
a. Crystal induced mediated release of proinfIammatory cytokines causing soft tissue and joint infIammation –> crystal induced
b. Deterioration of hyaline cartilage due to damage of chondrocytes as a result of infIammatory cytokine mediated release of matrix metalloproteinases (MMPs) –> OA
c. Enthesitis, which is inIammation at the site where ligaments, tendons, and joint capsules attach to the bone, is the prominent pathologic lesion –> spondyloarthropathies
A 44 year old female consults at the OPD for progressive exertional dyspnea for 3 months, bluish discoloration of the fingers of the hands and feet and burning sensation at the retrosternal area for 4 years. On physical examination she has tight skin on the hands with calcific deposits on the subcutaneous area of both arms; a loud S2 and a palpable ventricular heave, with grade 2 bipedal edema. Her pulmonary artery pressure is 52mmHg, with TR jet velocity of >3m/sec. These findings are associated with what type of condition?
a. Diffuse systemic sclerosis
b. Limited systemic sclerosis
c. Localized scleroderma
d. Sine scleroderma
b. Limited systemic sclerosis
CREST –> Limited SCC
A 32-year old male with 3 years history of plaque psoriasis consulted for 8 weeks history of difficulty in walking and low back pain that seem to improve with activity and worsened with prolonged rest. On PE, there was tenderness and swelling of the right ankle, diffuse pain and swelling of the right 2nd toe, and pitting of the toe nails. Work up showed: CRP 48mg/dL, RF negative. What management will you give this patient?
a. Adalimumab
b. Anakinra
c. Rituximab
d. Tocilizumab
a. Adalimumab
Adalimumab is a TNF-α inhibitor, and TNF-α plays a critical role in the pathogenesis of PsA. TNF-α inhibitors are first-line biologics for moderate to severe PsA, especially when there is axial involvement, enthesitis, or peripheral arthritis. Adalimumab has proven efficacy for both joint and skin symptoms in PsA.
A 41-year old female with scleroderma presents at the ER for progressive shortness of breath for the past 1 week, accompanied by headache, blurring of vision, bipedal edema and decreasing urine output for the last 2 days. BP 180/120, CR 104bpm, RR 27cpm, T36.4. Her creatinine was 3mg/dL Urinalysis showing protein +3, RBC 15-20, WBC 5-8. Which antibody would be protective of this condition?
a. Anti-nuclear antibody
b. Anti-centromere antibody
c. Anti-RNA polymerase III antibody
d. Anti-RNP antibody
b. Anti-centromere antibody
Anti-centromere antibody (ACA) is associated with limited cutaneous systemic sclerosis (lcSSc) and a lower risk of developing Scleroderma renal crisis
A 22-year-old pregnant at 10 weeks age of gestation was referred to you from OB service. She has a 2-year history of malar rash and arthralgia of both hands and wrists. For the last 3 months she has had shortness of breath on exertion with swelling of both feet. Her laboratories showed the following results:
Chest Xray PA: normal chest Xray PA view
Hgb 109 g/L, Platelet 250 x 10 /uL, WBC 6 x 10 /uL Urinalysis: albumin +++, RBC casts ++, pH 6.5, bacteria (-), bilirubin
(-) Serum creatinine 130 umol/L
low C3, ANA 1:80 speckled pattern.
What medications are safe and appropriate for her present condition?
a. Prednisone
b. Prednisone and Hydroxychloroquine
c. Prednisone, Hydroxychloroquine and Azathioprine
d. Prednisone, Hydroxychloroquine and Mycophenolate mofetil
c. Prednisone, Hydroxychloroquine and Azathioprine
These 3 are safe in pregnancy
A 47-year-old male, chronic alcoholic with recurrent arthritis is at the ER for 2 days pain in the big toe. What is correct about the pathophysiology of this condition? a. Bipyramidal and small polymorphic crystals are usually found on the synovial fluid
b. Urinary excretion of >800mg/24h uric acid suggest purine overproduction
c. Serum uric acid levels are elevated at the time of an acute attack
d. Synovial Zuid leukocyte counts are generally not elevated
b. Urinary excretion of >800mg/24h uric acid suggest purine overproduction
A 50-year-old male chronic alcoholic maintained on hypouricemic therapy for gout consults with his lab results. Serum uric acid is 2.4mg/dL and 24h urine uric acid excretion is 904mg. What drug is most likely being given to this patient for his gout?
a. Allopurinol
b. Febuxostat
c. Probenecid
d. Rasburicase
c. Probenecid
A 40 female with 6 month oral ulcer, facial rash, joint pains, and progressive bipedal edema was referred due to significant proteinuria on workup. Renal biopsy was done revealing diffuse endocapillary and extra capillary proliferation with diffuse subendothelial immune deposits and mesangial alterations. What is the ideal management for this patient?
a. Advice immediate dialysis or transplant if feasible
b. Has excellent prognosis and does not warrant any specific therapy
c. High dose steroids and hydroxychloroquine
d. High dose steroids, hydroxychloroquine and mycophonelate mofetil
d. High dose steroids, hydroxychloroquine and mycophonelate mofetil
Class IV
A 29-year-old G2P0 (0-0-1-0) pregnant at 6 weeks gestation, was referred for work up. She has occasional headaches with pain scores 7-9/10 occurring 3-4 times a year. On PE, she has bluish discoloration of the dngers, with mottled skin appearance on the upper extremities and. thighs. Which of the following autoantibodies will most likely be positive?
a. Anti-cardiolipin
b. Anti-dsDNA
c. Anti-histone
d. Anti-Ro
a. Anti-cardiolipin
APAS
headache due to arterial thrombosis
mottled skin = livedo reticularis
A 45-year-old female was admitted due to sudden onset of hemoptysis. She had on and off non-productive cough but no episodes of fever. She was diagnosed to have chronic sinusitis 2 months ago and was advised to see a nephrologist due to elevated creatinine. She has no other known comorbidities. CXR done upon admission showed pulmonary nodules. Lung biopsy showed a necrotizing vasculitis of small arteries and veins with granuloma formation. Sputum gene expert was negative. What is the most likely diagnosis for this patient?
a. Eosinophilic Granulomatosis with Polyangiitis
b. Granulomatosis with Polyangiitis
c. Microscopic Polyangiitis
d. Polyarteritis Nodosa
b. Granulomatosis with Polyangiitis
previously known: Wegeners
Triad: URT + LRT +kidney involvement
A 20-year-old male has been experiencing joint pains initially in the left ankle then to the left knee then to the right wrist and then to the right elbow. He has high grade fever (Tmax 39.8C). On PE he has tender and swollen right elbow. His ESR was at 52mm/h. What is the appropriate management?
a. Benzathine Penicillin 1.2M units IM
b. Clindamycin 300mg/cap TID
c. Methotrexate 15mg/week
d. Prednisone 1mg/kg/day
a. Benzathine Penicillin 1.2M units IM
This patient presents with symptoms and signs consistent with acute rheumatic fever (ARF):
Migratory polyarthritis: Joint pain moves from one joint to another (ankle → knee → wrist → elbow), which is characteristic of ARF.
High-grade fever: Suggests systemic inflammation. Elevated ESR (52 mm/h): Indicates active inflammation.
A 32-year-old female with 3 months of body malaise, arthralgia, night sweats and weight loss was seen at the ER. She had decreased to absent right upper extremity pulses. BP 160/80 (Left arm), 100/60 (Right arm). How will you condrm the diagnosis?
a. Arteriography
b. Biopsy
c. Magnetic resonance imaging
d. Ultrasonography of the vessel involved
a. Arteriography
Takayasu Arteritis
The diagnosis is confirmed by the characteristic pattern on arteriography, which includes irregular vessel walls, stenosis, poststenotic dilation, aneurysm formation, occlusion, and evidence of increased collateral circulation.
Complete imaging of the aorta and its major branches by magnetic resonance or computed tomography arteriography should be obtained to fully delineate the distribution and degree of arterial disease.
Because of the involvement of the large vessels, tissue is rarely available as a means of diagnosis and obtained only if vascular surgery is necessary
A 27-year-old female with lupus came in due to right hip pain. She was diagnosed with SLE 8 years ago when she presented with arthritis, oral ulcers and malar rash however was lost to follow up, self-medicating with Prednisone 30mg OD. PE showed limitation in abduction and external rotation of the right hip. What is the most likely cause of the patient’s hip pain?
a. Hip fracture
b. Ischemic necrosis of the bone
c. Osteoarthritis
d. Septic arthritis
b. Ischemic necrosis of the bone
This patient has systemic lupus erythematosus (SLE) and has been self-medicating with high-dose prednisone (30 mg/day) for years without medical supervision. These factors strongly predispose her to avascular necrosis (AVN) (also called ischemic necrosis or osteonecrosis of the bone).
Which of the following treatment measures is most useful during an acute attack of gouty arthritis?
a. Giving colchicine at 0.5 mg per day
b. Giving allopurinol at 100mg per day
c. Application of ice pack on affected joint
d. Application of topical NSAID
c. Application of ice pack on affected joint
Colchicine should be 1 mg then 0.5 mg 1 hr after
A 30F was referred to you for a positive ANA, arthralgias of the hand joints and platelet count of 50,000/uL. On examination, you noted nonpainful nasal ulcers, circular lesions with raised borders and atrophic centers on the ears, and ascites. Based on the SLICC Criteria, how many criteria for SLE has the patient satisfied?
a. 3
b. 4
c. 5
d. 6
b. 4
Which of the following is a complication more of limited (lcSSc) than diffuse cutaneous systemic sclerosis (dcSSc)?
a. Arrhythmia
b. Interstitial lung disease
c. Myositis
d. Pseudo-obstruction
d. Pseudo-obstruction
Pseudo-obstruction: This gastrointestinal complication, caused by dysmotility due to smooth muscle atrophy and fibrosis, is more frequently seen in lcSSc. Gastrointestinal manifestations, particularly involving the esophagus and small intestine, are hallmark features of lcSSc.
Which of the following is NOT considered a predictive factor for radiographic progression in axial spondyloarthritis?
a. High ESR/ CRP
b. Presence of syndesmophytes
c. Pregnancy
d. Smoking
c. Pregnancy
Among patients with calcium apatite deposition disease with CKD on hemodialysis, which treatment modality can lead to resorption of apatite deposits?
a. Phosphate lowering agents
b. Liver transplantation
c. Long-term Colchicine
d. IL-1 antagonist anakinra
a. Phosphate lowering agents
A 43-year old female with 16-week progressive muscle pains and weakness involving the upper and lower extremities was seen for follow up at your clinic. She initially had difficulty rising up from the bed and chair, with difficulty combing her hair more observed on the right upper extremity. Glucocorticoid therapy was initially started with noted marked improvement in MMT 3-4/5 from 2/5 on proximal muscles of all extremities. What second line drug can be given to this patient?
a. Hydroxychloroquine
b. Infliximab
c. Methotrexate
d. Sulfasalazine
c. Methotrexate
Methotrexate: A disease-modifying antirheumatic drug (DMARD) commonly used as a second-line agent in inflammatory myopathies to reduce inflammation and allow tapering of steroids. It is highly effective for both muscle weakness and systemic symptoms.
Other second line: Azathioprine, Mycophenolate, IVIG, Rituximab
A 35-year old female consulted due to low back pain for 4 months. Her back pain was associated with morning stiffness for 1 hour and alternating buttock pain. Pain was more intense at night with slight improvement on activity. She denies any history of recent trauma. Pertinent physical examination finding revealed (+) modified Schober test. Which of the following imaging studies can best help clinch the diagnosis?
a. Bone scan
b. CT Scan
c. MRI
d. X-ray
c. MRI
MRI = more useful for early diagnosis of AS
A 69 year old lady with symmetric hand and knee pains for 3 years came for evaluation. Pains usually occur upon movement, with hand joint stiffness for less than 30 minutes in the morning, relieved by hand exercises. Cartilage changes for this condition would include:
a. Infiltration of CD4 and CD8 T cells and TNFs
b. IL-6 that induce chondrocytes to synthesize prostaglandin E2 and nitric oxide
c. Loss of aggrecan, unfurling of collagen matrix, loss of type 2 collagen
d. Osteoclasts that appear in the pannus-bone interface causing erosions
c. Loss of aggrecan, unfurling of collagen matrix, loss of type 2 collagen
The patient’s clinical presentation of symmetric hand and knee pain, worsened by movement, morning stiffness lasting less than 30 minutes, and relief with exercise, is consistent with osteoarthritis (OA)
A 28-year old female consulted for skin discoloration. For the past 3 weeks patient noted persistent skin mottling that appears in a lace-like pattern over the face, buttocks, thighs and arms. On further history she is G3P1 (0-1-2-1), with 2 pregnancy losses on her first and second pregnancies at 14 weeks gestation, her third pregnancy was pre-maturely delivered via NSD at 34 weeks. She denies other symptoms, with no history of OCP use, and no other medications being taken. Her skin manifestation could be a part of:
a. Arterial thrombosis associated with APAS
b. Hematologic malignancy
c. Sepsis
d. Venous thrombosis associated with APAS
d. Venous thrombosis associated with APAS
Livedo reticularis = venous
A 32-year-old HIV patient came for evaluation of progressive joint pains in the cervical neck, left wrist and fingers of the left hand and the right knee for the last 8 months. However the last 3 weeks there were sudden enlargement of the fingers of the left hand with swelling of the right knee resulting to difficulty in ambulation. On PE there were patchy areas of erythematous scaly papules on the chest and legs which according to the patient are also present in his father and siblings; nail discoloration with nail pits on both hands and feet, and tender left achilles tendon. Expected axial imaging findings for this condition would include:
a. Decreased vertebral height involving the thoracic vertebra
b. Disc herniation
c. Severe cervical spine involvement
d. Symmetric marrow edema of the sacroiliac joints
c. Severe cervical spine involvement
The patient’s symptoms and physical examination findings are suggestive of psoriatic arthritis (PsA). This condition is associated with HIV and features a combination of arthritis, enthesitis (e.g., tender Achilles tendon), and skin and nail changes typical of psoriasis (e.g., erythematous scaly papules, nail pits, and discoloration). Psoriatic arthritis can have both peripheral and axial joint involvement.
Axial Imaging Findings in Psoriatic Arthritis: Severe cervical spine involvement: Psoriatic arthritis commonly affects the axial skeleton, particularly the cervical spine, often leading to spondylitis and severe cervical involvement. Imaging typically shows syndesmophytes, asymmetrical sacroiliitis, and cervical spine changes, such as fusion or erosion.
Which of the following is TRUE in diagnosing Gout?
a. The characteristic clinical features (podagra) are enough to diagnose gout
b. If the diagnosis is in doubt, aspiration of joints may be necessary
c. During flares, needle-shaped MSU is usually present both intracellularly and extracellulary
d. Under polarized light, crystals showed bright positive birefringent
c. During flares, needle-shaped MSU is usually present both intracellularly and extracellulary
Which of the following diagnostic findings correlates significantly with pain and disability in osteoarthritis?
a. Synovial WBC of greater than 10,000 WBC
b. Xray finding of joint space obliteration
c. MRI finding of severe meniscal injury and multiple ligament tears
d. No diagnostic testing correlates with pain and disability
d. No diagnostic testing correlates with pain and disability
A 37 year-old patient with a 5-year history of Psoriasis sought consult due to joint pains on her DIP joints associated with pitting of nails. Radiographic examination revealed an ill-defined ossification near the DIP joints. Based on the CASPAR Criteria, the personal history of current psoriasis is assigned with how many points?
a. 1
b. 2
c. 3
d. 4
b. 2
Renal biopsy of a patient with SLE showed that >90% of
the glomeruli are globally sclerosed. What is the
treatment of choice?
A. Belimumab
B. MMF with tacrolimus
C. No additional treatment
D. High dose cyclophosphamide
C. No additional treatment
The patient has Class VI Advanced Sclerotic Lupus Nephritis.
In general, class III and IV disease, as well as class V accompanied by III or IV disease, should be treated with aggressive immunosuppression if possible because there is a high risk for ESRD if patients are untreated or undertreated. In contrast, treatment for lupus nephritis is not recommended in patients with class I or II disease or with extensive irreversible changes (class VI).
The following infectious diseases can mimic vasculitis, EXCEPT?
a. Syphilis
b. Lyme Disease
c. Coccidiodomycosis
d. Pulmonary Blastomycosis
d. Pulmonary Blastomycosis
A G4P1 (1021) patient with SLE and APS consults because of current pregnancy. She had acute DVT a year prior. The most recent Duplex scan showed complete resolution of thrombosis after 6 months of Warfarin. She is currently on Prednisone 5 mg daily. What is the recommended anti-thrombotic therapy?
A. Aspirin alone
B. Aspirin plus LMWH
C. Aspirin plus Apixaban
D. Antithrombotics are not indicated
B. Aspirin plus LMWH
In pregnant women with a history of obstetric APS, combination treatment with low dose aspirin (LDA) and prophylactic dose of low molecular-weight heparin (LMWH) is recommended, whereas in cases of thrombotic APS, LDA plus therapeutic LMWH dose should be administered
Which of the following statements is TRUE regarding risk factor for osteoarthritis?
A. It is a highly heritable disease
B. Nutrition does not play a role in its development
C. It is more common among males than females
D. Regular exercise during adolescence may lead to osteoarthritis
A. It is a highly heritable disease
One of the following mechanisms may explain why cartilage loses its compressive stiffness in osteoarthritis:
A. Formation of Type 2 collagen
B. Gradual depletion of aggrecan
C. Tight weaving of collagen matrix
D. Inhibition of prostaglandin E and nitric oxide
B. Gradual depletion of aggrecan
OA cartilage is characterized by gradual depletion of aggrecan, an unfurling of the tightly woven collagen matrix, and loss of type 2 collagen. With these changes comes increasing vulnerability of cartilage, which loses its compressive stiffness.
What is the most common flexor tendon affected by rheumatoid arthritis?
A. Flexor digitorum superficialis
B. Flexor digitorum profundus
C. Flexor pollicis longus
D. Flexor carpi ulnaris
C. Flexor pollicis longus
Which of the following echocardiographic findings constitute a definite RHD diagnosis?
A. Pathologic mitral regurgitation
B. Pathologic aortic regurgitation
C. MS mean gradient ≥4 mmHg
D. Morphologic feature of RHD of the aortic valve
C. MS mean gradient ≥4 mmHg
