Rheumatoogy

Question 1

Affected articulations in AR

Answer 1

MCP, PIP, MTP, wrists, knees, elbows, ankles, hips, shoulders. Temporomandibular, cricoarytenoid and sternoclavicular joints

Question 2

Classification criteria for RA 2010

Answer 2

Joint involvement (0- one large joint, 1- 1 to 10 large joints, 3- 1-3 small joints, 4- more than 10 joints).
Serology (0 negative RF and anti CCP, 2- low positive RF or anti-CCP, 3- high positive RF or anti CCP)
acute phase reactants (0- normal CRP and ESR, 1- abnormal CRP or ESR)
Duration of symptoms (0- less than 6 weeks, 1- 6 weeks or more)
AR > 6

Question 3

Laboratory findings in AR

Answer 3

Anemia of chronic disease
Thrombocytosis when active
ESR and CRP elevated

Question 4

CCP antibodies in RA

Answer 4

Cyclic citrullinated peptides.
70% at diagnosis.
98% specific
present before diagnosis and correlates with erosive disease

Question 5

Rheumatoid factor in AR

Answer 5

directed against constant (Fc) region of IgG
50% positive at presentation.
another 35% positive in first 6 months
More severe articular disease and extraarticular manifestations.
Differential dx: Sjogren, SLE; viral infections (hepatitis C, EBV, erythrovirus, influenza), bacterial (endocarditis, osteomyelitis), chronic inflammatory conditions, liver disease, IBD, aging.

Question 6

Methotrexate in AR

Answer 6

Starting dose 7.5 mg a week, increase by 2.5 to 7.5 mg to a maximum of 25.
oral absorption variable.
Monitor: blood cells, ransaminases, creatinine every 12 weeks.
contraindications: liver disease, hepatitis B or C, alcohol, renal impairment (>30)
Toxicity: oral ulcers, nausea, hepatotoxicity, bone marrow suppression, pneumonitis.

Question 7

Gene for ankylosing spondylitis

Answer 7

HLA B-27 (85%)

Question 8

Clues to early ankylosing spondylitis

Answer 8

young man with inflammatory back symptoms; pain/stiffness in buttocks, low back, chest wall worst with rest; reduced spinal mobility; family history; oligoarticular large joint invovement (hips and shoulders); history of eye pain, redness, blurry vision (anterior uveitis);

Question 9

Signs in ankylosing spondylitis

Answer 9

Loss of lordosis
Schober test (

Question 10

hydroxychloroquine in AR

Answer 10

least toxic and least effective as monotherapy.
Dose: 200-400 mg daily.
Retinal toxicity, cumulative dose of 1000 g (5-7 years), ophtalmoligic check in the first year and yearly after 5 years.

Question 11

sulfazalasine in AR

Answer 11

Combination with methotrexate or hydroxychloroquine, dosis of 1-3 g daily, same monitoring as methotrexate

Question 12

leflunamide in AR

Answer 12

pyrimidine antagonist. Dose: 10-20 mg daily.

Toxicity: diarrhea, hepatotoxicity, caution pregnancy.

Question 13

Minocycline in AR

Answer 13

Early seropositive disease. Dose: 100 mg twice daily. Cutaneous hyperpigmentation with more than 2 years

Question 14

Biologic DMARD in AR

Answer 14

bioengineered protein drugs (antibodies or receptor antibody chimeras). Reduce synovitis and diminish radiographic progression. Onset days to weeks. Greater efficacy with methotrexate.
Increase risk of infections. Testing of latent TB with tuberculin skin test or interferon gemma release assay. Contraindications: active or untreated latent TB, untreated hepatitis B infection. Not recommented with solid malignancy or nonmelanoma skin cancer treated within 5 years.

Question 15

Glucocorticoids in AR

Answer 15

Symptomatic improvement and significantly slow radiographic progression. Prednisone should not be used in dose higher than 10 mg daily and slowly tapered off. Long term increases risk of fractures.

Question 16

Liquido sinovial. Birrefringencia

Answer 16

Se valora por la orientación de la luz polarizada en forma paralela al eje longitudinal de los cristales. La positiva es azul, la negativa amarilla.