Rheumatology

Question 1

How can gabapentin and carbamazepine act with a cervical disc
prolapse?

Answer 1

Both of these drugs are useful in neuropathic pain. Gabapentin has fewer
side-effects and is becoming a first-line drug for nerve injury pain.

Question 2

Do patients with cervical spondylosis, experiencing neck pain and
stiffness, benefit from putting on a neck collar? If so, for how long should
the collar be worn?

Answer 2

A collar might be needed in the first 1–2 days. Fortunately, most patients
are sensible enough not to wear them for any longer! They do not help in
the long term.

Question 3

What is indicated by a straightening of the lumbar spine with a
loss of normal lordosis, and is there any relation to ankylosing
spondylitis?

Answer 3

This does occur in ankylosing spondylitis. The lumbar spine can become
straighter with the loss of the normal curvature (lordosis).

Question 4

Can cervical spondylosis cause hypertonia in one upper limb?

Answer 4

Cervical spondylosis can lead to upper motor neurone signs. A spastic
parapesis is the most common finding. There is often, in addition,
evidence of a lateral disc protrusion with cervical root symptoms and
signs.

Question 5

Should a female patient, with mild congestive cardiac failure,
microalbuminuria and cervical spondylosis receive IV vitamin D/
analogues? Would this not increase the risk of calcium stones owing to
the mild renal impairment? Would oral vitamin D be preferable?

Answer 5

Yes. Oral vitamin D is always preferable, except sometimes in chronic
kidney disease. There seems, however, no reason for this particular
patient to be given vitamin D at all.

Question 6

What is the recommended treatment for spinal canal stenosis? Do
carbamazepine or vasodilators have a role to play in its treatment?

Answer 6

Spinal canal stenosis is diagnosed by the clinical history with
confirmation of spinal cord compression on magnetic resonance
imaging (MRI). The best treatment in these confirmed cases is surgery.
Many patients with back pain are misdiagnosed because of slight but
insignificant narrowing of the cord on MRI. Carbamazepine can be
helpful in chronic back pain of undetermined cause. Vasodilators are
of no help.

Question 7

What technique is used for injecting steroids locally in the case of carpal
tunnel syndrome?

Answer 7

This procedure should only be carried out by an experienced person who
has been trained in the procedure. Nerve atrophy or necrosis can occur if
steroids enter the median nerve directly.
The injection site is on the radial side of palmaris longus tendon; a
mixture of lidocaine and steroid is used. The patient should be asked if
he or she feels any distal sensation, which suggests that the needle is in
the median nerve. Some operators use ultrasound to help to get the
steroid into the tendon sheath.

Question 8

In a patient who has sustained an anterior cruciate ligament (ACL) knee
injury and whose pain and swelling have subsided on conservative
treatment, what are the chances of complications (e.g. osteoarthritis,
fibrosis) from the torn ligament. Will the patient be able to lead a
normal life?

Answer 8

With good physiotherapy, patients can lead a normal life but in young
athletes ACL repair is a better option. Osteoarthritis can occur in later life.

Question 9

Is either gapapentin or carbamazepine effective in the treatment of
meralgia paraesthetica?

Answer 9

Both drugs have been used with varying success. This self-limiting
condition usually improves without medication.

Question 10

What is the clinical differentiation between Dupuytren’s contracture and
ulnar nerve palsy? Is it the absence of sensory deficit in the former? Are
there any other differentiating factors?

Answer 10

Dupuytren’s causes flexion contracture of the fingers with thickening of
the palmar fascia. Ulnar nerve palsy causes fixed flexion of the fingers,
mainly the ring and little finger. Sensation can be lost.

Question 11

1. Is a local corticosteroid injection in the palm effective in the case of
   Dupuytren’s contracture?
2. Can Dupuytren’s contracture occur in early or well-controlled
   diabetes, or is it more likely to occur in uncontrolled diabetes?

Answer 11

1. Triamcinolone is used in early and painful contractions with some
   benefit.
2. It occurs in 40% of diabetics; the incidence increases with age and
   duration of diabetes.

Question 12

Besides cirrhosis of the liver and diabetes mellitus (DM), what other
causes of Dupuytren’s contracture are there? What is the
pathophysiology behind it?

Answer 12

It is also associated with alcohol abuse, DM, chronic obstructive
pulmonary disease (COPD) and epilepsy. The pathophysiology is not
understood.

Question 13

indirect connection between
osteoarthritis and subclinical local infections (such as periodontal
abscesses), changing the pH of bodily fluids. Can you explain this
mechanism?

Answer 13

The pathogenesis of osteoarthritis is unclear and might well be different
in different locations in the body. One explanation has been that it could
be the result of occult infections. There is no good evidence to support
this and most workers in this field think it unlikely.

Question 14

What do you mean by saying that in nodal osteoarthritis each joint is
affected one at a time? Is it that each proximal interphalangeal (PIP) or
distal interphalangeal (DIP) joint is affected alone, or that at any one time
PIP or DIP joints are affected together in one or both hands?

Answer 14

In osteoarthritis there is stuttering onset of inflammation affecting one
joint at a time.

Question 15

What are the criteria for diagnosing osteoarthritis (OA) of the knee joint
radiologically? Are changes to be expected with advancing age? To what
extent would I consider it significant in those below 50 years of age?
Would you give me some X-ray examples if possible?

Answer 15

Plain X-ray and skyline views of the patella are necessary. Joint space
narrowing, osteophytes, subchondral radiolucencies and sclerosis are the
classic signs of OA (Fig. 10.1). Osteophytes are the best predictor of knee
pain. Some of these changes will be seen in a patient of advanced age
and the significance must be correlated with the symptoms and signs.
MRI is commonly used for more precise identification of the damage in
osteoarthritis.

Question 16

1. In a young patient with osteoarthritis, does long-term treatment with
   paracetamol (acetaminophen) 500 mg/day, rather than ibuprofen
   600 mg/day, lower the incidence of renal toxicity?
2. How great is the risk of renal toxicity with both these treatments?

Answer 16

1. Acetaminophen is called paracetamol in many countries. It has no
   renal toxicity in therapeutic dosage. Ibuprofen is a non-steroidal
   anti-inflammatory drug (NSAID).
2. The prevalence of renal toxicity is relatively low but because of
   intensive usage, many persons are at risk.b

Question 17

In India, total knee replacements are being recommended for every case
of severe osteoarthritis, without considering factors such as age, weight
or medical condition. What are the correct indications for surgery?

Answer 17

These are evolving and now many patients with stiff painful knees are
being offered arthroplasty. There are, however, risks to these procedures
and medical therapy should be provided first.

Question 18

doesn’t respond to NSAIDs plus 40–120 mg methylprednisolone depot.
If a remission is then induced, how long should methotrexate therapy
be continued? Will the patient (now in remission) be given maintenance
therapy?

Answer 18

Methotrexate therapy is often continued for many years (at least 10
years) if the patient remains well. Remember to check the liver
biochemistry carefully and make sure that the prescription is for a once
weekly dose.

Question 19

What is the dose and regimen for folinic acid rescue after methotrexate in
rheumatoid arthritis?

Answer 19

Give as calcium folinate 24 hours after the methotrexate, 15 mg orally
every 6 hours for 2–8 doses.

Question 20

1. What are the indicators of remission in rheumatoid arthritis? Is it
   normalization of erythrocyte sedimentation rate (ESR) or clinical
   improvement?
2. Does the rheumatoid factor disappear during a remission of
   rheumatoid arthritis?

Answer 20

1. Both; clinical improvement is the most important but normalization of
   the ESR is also helpful.
2. Reduction in the rheumatoid factor titres occurs with diseasemodifying
   anti-rheumatic drug (DMARD) therapy.

Question 21

What is the relationship between rheumatoid arthritis and weight loss?
Can treatment aid the weight loss at the same time as controlling the
disease?

Answer 21

‘Active’ rheumatoid arthritis makes people feel unwell so that they don’t
eat, and hence lose weight. Control of the disease will allow them to
regain appetite. Be careful not to let the patient get overweight.

Question 22

Can oral folic acid (1 mg/day) be used for high-dose methotrexate
therapy with subsequent leucovorin rescue in the treatment of
rheumatoid arthritis?

Answer 22

Methotrexate 7.5 mg weekly is used in rheumatoid arthritis. Folic acid
5 mg weekly can be given to reduce the side-effects. Calcium folinate
(Leucovorin) is given after high-dose methotrexate to counteract the
folate antagonist action of the drug.

Question 23

How often should a patient, on 8 mg/day methylprednisolone for the
treatment of rheumatoid arthritis and on osteoporosis prophylaxis in
the form of 1000 mg calcium and 400 IU vitamin D daily, have a dual
energy X-ray absorptiometry (DXA) scan to detect the development of
osteoporosis?

Answer 23

Yearly.

Question 24

In what percentage of patients with psoriatic arthritis does the arthritis
precede the onset of skin or scalp lesions?

Answer 24

Six per cent of patients have arthritis preceding the skin lesions

Question 25

Is reactive arthritis a synonym for Reiter’s syndrome?

Bug?

Answer 25

1. Reiter’s describes a form of reactive arthritis where there is arthritis
   with urethritis, conjunctivitis, keratoderma blenorrhagica and circinate balanitis

Chlamydia trachomatis

Question 26

1. Is the response of an acutely inflamed joint to colchicine
   pathognomonic of gouty arthritis?
2. We are told that, other than clinical tests, joint fluid microscopy is
   the specific diagnostic test for gout. What does joint fluid microscopy
   reveal? Is it the same as a polarized light study revealing needleshaped
   urate deposits?

Answer 26

1. Yes
2. In this context, joint fluid microscopy refers to polarized light. In gout,
   crystals are needle shaped and negatively birefringent

Question 27

In the prevention of gout, should allopurinol be used for life in a patient
who is hypertensive, alcoholic and overweight?

Answer 27

In such a patient the hypertension should be treated. Drug therapy may
well be needed but both reduction in weight and reduction in alcohol
consumption are helpful in reducing blood pressure. Reduction in
alcohol consumption (especially beer) will also reduce the number of
attacks of gout.
The above measures are not always successful in preventing further
attacks of gout, and in such a patient allopurinol will be required for life.
However, a new drug, febuxostat, has become available.

Question 28

Does a serum uric acid level of 5.7 mmol/L need treatment? Can it be
significant with cholesterol levels of 213 mg/dL (5.5 mmol/L)? What is
the treatment?

Answer 28

Do not treat uric acid levels unless they are very high. You treat the
symptoms produced by a raised uric acid; that is, gout. Cholesterol
levels should be taken in isolation and not related to the uric acid level.
The level of 213 mg/dL of cholesterol will require treatment in
patients who have evidence of cardiovascular disease, usually with a
statin.

Question 29

In the diet of patients suffering from gout, should tea, coffee or other
compounds containing methylxanthine products be restricted?

Answer 29

Yes, a diet that reduces total calories as well as cholesterol intake
(avoiding offal, fish, shellfish, spinach and beer – all rich sources of
purines) is advised. This can reduce the serum urate by 15%.

Question 30

1. When do joints that appear slightly swollen, but not warm, need to be
   tapped?
2. In what circumstances might an immunologically suppressed patient
   not mount a fever or not have heat around a septic joint?

Answer 30

Aspiration of a joint should always be undertaken if septic arthritis
is a possibility (even if unlikely!). Aspiration is also useful in crystal
arthritis. Constitutional symptoms are common but might not be
present in severely debilitated patients and in patients on steroids or
immunosuppressive agents

Question 31

What is the cause of Pott’s disease?

Answer 31

TB of the spine

Question 32

One thing that often baffles me is that patients with systemic lupus
erythematosus often suffer recurrent thrombosis due to lupus
anticoagulants (antiphospholipid syndrome). How can an anticoagulant
cause thrombosis?

Answer 32

This paradoxical association between a prothrombotic state and the
anticoagulant effect of antibodies is not fully understood.

Question 33

Are elevated homocysteine levels an independent risk factor for
progression of systemic lupus erythematosus (SLE)/scleroderma? Kindly
suggest some references if possible.

Answer 33

Yes; homocysteine levels are an independent risk factor for the
progression of cardiovascular disease in SLE/scleroderma.

Question 34

1. What are the indicators of remission in systemic lupus erythematosus
   (SLE)? Is it the normalization of erythrocyte sedimentation rate (ESR)
   and the disappearance of antinuclear antibodies (ANA) and other
   antibodies, or is it clinical improvement?
2. During remission of SLE, do ANA and other antibodies disappear?

Answer 34

High serum levels of ANA and anti-dsDNA with low complement do
reflect disease activity. Clinical improvement is still the best indicator but
a fall in antibody levels is helpful. They do not disappear. The ESR is
raised in proportion to the disease activity.

Question 35

When should the use of cyclophosphamide in systemic lupus
erythematosus (SLE) be commenced? What is the correct and safe dosage
of cyclophosphamide?

Answer 35

Many patients with SLE do well with little treatment. Cyclophosphamide
is mainly used for lupus nephritis and vasculitis. For lupus nephritis,
0.75g/m2 has been used IV over 60 minutes.

Question 36

1. Given the benefits of dexamethasone, which lacks any
   mineralocorticoid activity, why is this not prescribed in your book for
   diseases that require long-term steroid therapy, such as systemic lupus
   erythematosus or giant cell arteritis?
2. Does dexamethasone have more serious adverse effects than
   prednisolone? Why is it not generally preferred?

Answer 36

Dexamethasone is a highly potent glucocorticoid. Its main use is topically
on the skin and by inhaler in asthma. Its high potency means that steroid
side-effects occur very easily and dose can not be adjusted quickly;
prednisolone is therefore usually preferred for chronic conditions.

Question 37

Would an elevated C-reactive protein (CRP) level, in association with a
high erythrocyte sedimentation rate (ESR) and in the absence of infection
and serositis, exclude the diagnosis of systemic lupus erythematosus?

Answer 37

No. The ESR is raised; the CRP is usually normal but this is not reliable
enough to be diagnostic.

Question 38

How do steroids precipitate a crisis in patients with systemic sclerosis?

Answer 38

There is evidence to suggest that steroids precipitate a renal crisis in
scleroderma. The mechanism is unclear but might be related to
hypertension.

Question 39

Are neck and face muscles commonly affected in poly- and
dermatomyositis? Does this differ from the muscles that are affected with
myasthenia gravis?

Answer 39

Symmetric proximal muscle weakness is the most common presentation
of polymyositis. Myasthenia gravis initially affects the eyes and
other muscles controlled by cranial nerves. There can, however, be
overlap.

Question 40

1. In dermatomyositis, what is the shawl sign?

2. How frequently is dermatomyositis associated with Gottron’s papules?

Answer 40

1. Involvement of the skin of the back of the neck, upper torso and
   shoulders in a shawl-like distribution.
2. 70–80% and is pathognomonic.

Question 41

How can cranial arteritis be diagnosed in the absence of any physical
symptom or feature of the disease other than headache?

Answer 41

Headache in an elderly person with a high erythrocyte sedimentation
rate (ESR) is often all that is required. Without a rise in ESR the diagnosis
is unlikely. Biopsy of the temporal artery is usually performed to confirm
diagnosis; but remember, the inflammation is segmental and therefore
might be negative.

Question 42

Do pulmonary manifestations in Behçet’s syndrome present with
pulmonary infiltrates in the upper zone of the lung?

Answer 42

The findings are variable but nodular and reticular shadowing in the
upper zone have been noted.

Question 43

1. Is Behçet’s disease accompanied by an elevated erythrocyte
   sedimentation rate (ESR)? If so, how often?
2. Can Behçet’s disease be diagnosed in a young adult with an ischaemic
   stroke and a history of almost weekly mouth ulcers that heal quickly,
   but with no other symptoms of Behçet’s disease?

Answer 43

1. Yes, in over 50% of cases. The C-reactive protein is also raised.
2. No; you need recurrent aphthous ulcers occurring more than three
   times per year, plus two of the following: genital ulcers, eye lesions,
   skin lesions, positive pathergy test.

Question 44

Mouth ulcers are too common to be a cardinal feature in the diagnosis of
Behçet’s disease. Are there any distinguishing features other than mouth
ulcers that would confirm diagnosis?

Answer 44

The international criteria for diagnosis of Behçet’s state that the oral
ulcers must recur more than three times per year. In addition to this, the
ulcers are usually more extensive – genital ulcers, defined skin or eye
lesions with a positive pathergy test (papule or pustular formation after a
skin injury for e.g. by a needle) also occur

Question 45

Please explain how to diagnose familial Mediterranean fever. Is a
diagnosis of exclusion still used or are there now more up-to-date tools
for the diagnosis?

Answer 45

The diagnosis is still made on clinical grounds because identifying
mutations in the FMF gene (MEFV on chromosome 16) is not always
possible. The criteria used are:
● Intermittent episodes of fever.
● Serositis with abdominal pain and tenderness; pleuritis.
● The presence of amyloidosis.
● The therapeutic response to colchicine.
● Being of Mediterranean descent with sometimes a possible family
history.

Question 46

Is a leucocytoclastic reaction in a tissue biopsy specific for
Henoch–Schönlein purpura or is it also associated with other problems?

Answer 46

A leucocytoclastic reaction also occurs in the condition known as
leucocytoclastic vasculitis.

Question 47

What are the anatomical, histological and radiological differences
between:
1. physis
2. metaphysis
3. epiphyseal disc
4. epiphyseal line?

Answer 47

● Physis: used for the growing part of a bone.
● Metaphysis: the site of advancing ossification adjacent to the
epiphyseal cartilage.
● Diaphysis: shaft of bone.
● Epiphysis: extremity of bone with separate ossification centre. The
‘line’ is the junction of the epiphysis and diaphysis. The ‘disc’ is
the band of cartilage between the epiphysis and diaphysis which is
replaced by bone in later life.

Question 48

Why does the serum alkaline phosphatase increase in bone disorders and
in some other disorders?

Answer 48

Osteoblasts are rich in alkaline phosphatase, so that in any bone
condition with increased activity of osteoblasts, e.g. in the growing child or in Paget’s disease, there will be an increase in the serum alkaline
phosphatase.
Alkaline phosphatase is also found in the placenta so that the serum
level is raised in pregnancy.

Question 49

What is the normal amount of calcium excreted in the urine in a 24-hour
period?

Answer 49

6.25 mmol (250 mg) in females to 7.5 mmol (300 mg) in men in 24 hours

Question 50

Does hydrochlorothiazide have a prophylactic effect against

osteoporosis?

Answer 50

Yes.

Question 51

How effective is parathyroid hormone in the management of

osteoporosis? Please explain the mechanism.

Answer 51

Recombinant human parathyroid hormone peptide 1–34 (teriparatide)
and the whole protein 1–84 stimulate bone formation. Teriparatide
has been shown to reduce vertebral and non-vertebral fractures in
postmenopausal women with established osteoporosis.

Question 52

1. What is the recommended treatment for severe osteogenesis
   imperfecta?
2. Where two siblings have already been born with severe osteogenesis
   imperfecta, what is the risk of subsequent children of the same parents
   being born with this condition?

Answer 52

1. Bisphosphonates are used for moderate and severe disease
   (see reference).
2. The risk is 1:2 but may be less with decreased penetrance

Question 53

Why does achondroplasia not affect the mandible (when all other bones
are affected)?

Answer 53

This is not known.

Question 54

If an elderly patient with rheumatoid arthritis who has been taking
myocrisin (injectable gold) for several years presents with pancytopenia,
should the gold treatment be stopped? If so, what treatment should
replace it?

Answer 54

The gold treatment should be stopped. If there is ‘active’ disease then
referral to a rheumatologist for possible consideration of infliximab is
recommended.

Question 55

In a patient with dermatomyositis, what laboratory tests
should be ordered to exclude systemic lupus erythematosus
(SLE)?

Answer 55

The differentiation is usually not a problem. The proximal muscle
weakness is unusual in SLE. The creatine kinase is usually raised in
dermatomyositis. Double-stranded DNA is specific for SLE but is present
in only 50% of cases. Remember the overlap syndrome (see K&C, 7e, p. 548)
in which features of both diseases can be present.

Question 56

What treatment is recommended for tarsal tunnel syndrome?

Answer 56

Arch supports and wider shoes often help, and NSAIDs are useful for
pain and inflammation. Steroid injection into the tendon is also effective;
surgery is the last resort

Question 57

In a patient with documented antiphospholipid syndrome, should lupus
anticoagulant be investigated for? If it is found to be present, will this
necessitate the use of anticoagulants?

Answer 57

The lupus anticoagulant is usually looked for but treatment of the
syndrome does not depend entirely on this. Treatment is given if the
patient has had a thrombotic episode or, occasionally, if there are high
levels of antibody and lupus anticoagulant present

Question 58

What are the findings to be looked for during routine fundus
examination in patients on long-term chloroquine or any other
antimalarial therapy for the treatment of systemic lupus erythematosus
(SLE)?

Answer 58

All patients should have near visual acuity of each eye performed before
treatment and annually on treatment. Patients who have any visual
symptoms should be seen immediately. Fundoscopy will show round,
pigmented lesions near the macula but it is the visual acuity and visual
field examination that will give the first clue.

Question 59

What is the sensitivity of plain X-ray in detecting ankylosing spondylitisrelated
spine lesions in both early and late disease, and is there a specific
diagnostic test for this?

Answer 59

In early disease the sensitivity is low. In one series of 199 patients
diagnosed clinically, 76 had a normal plain X-ray. It is very sensitive for
late disease, >95%. In patients suspected clinically to have AS (ankylosing
spondylitis) an MRI scan should be performed if the plain X-ray is
normal.

Question 60

Can high serum titres of C-reactive protein (CRP) with normal
erythrocyte sedimentation rate (ESR) indicate relapse of rheumatoid
arthritis in established rheumatoid arthritis which is in remission?

Answer 60

Yes, the CRP is more sensitive and usually rises before the ESR in many
chronic inflammatory conditions such as rheumatoid arthritis

Question 61

What is the positive predictive value of hyperuricaemia in the diagnosis
of gout?

Answer 61

Hyperuricaemia is not useful in gout. Gout is a clinical diagnosis
supported by finding needle-shaped crystals in the joint fluid. The serum
uric acid is usually raised but the level falls after an acute attack so a
normal level is not helpful. Gout never occurs with the serum uric acid
level in the lower half of the range.

Question 62

What is Scheuermann’s disease? And is this a specific clinical or
radiological or haematological disease? What is the treatment for this
disease?

Answer 62

Scheuermann’s disease is a juvenile kyphosis with anterior wedging
of 5° or greater in at least three adjacent vertebral borders as seen on
lateral spine X-ray. Treatment is with strengthening and stretching
exercises.