Rheumatology Module 1

Leflunomide is an effective but potent immunosuppressive drug for patients with moderate to severe rheumatoid or psoriatic arthritis. However it carries several adverse effects such as diarrhoea, mouth ulcers and skin rash.

Which of the following factor is unlikely to increase the risk of an adverse reaction with Leflunomide?

Use of triphasic oral contraceptives

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pregnancy

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Concurrent use with methotrexate

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Increased alcohol consumption

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low body weight

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What is the best method of distinguishing between primary and secondary Raynaud’s?

Nailfold capilloroscopy

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ANA positivity

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ENA positivity

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Raised ESR

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Presence of pitting ulcers on finger pulps

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Which of the following serum markers have the strongest association with disease activity in both giant cell arteritis (GCA) and polymyalgia rheumatica (PMR)?

BAFF and IL-6

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CXCL-9 and IL-6

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BAFF and IL-10

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CCL11 and IL-10

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Secukinumab is a novel anti– interleukin-17A monoclonal antibody that is useful in which condition?

Ankylosing spondylitis

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Rheumatoid arthritis

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Osteoarthritis

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Reactive arthritis

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Limited scleroderma

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Febuxostat is a potent, non-purine, selective inhibitor of xanthine oxidase that inhibits the production of uric acid by preventing the normal oxidation of purines to uric acid. Although it has a similar mechanism of action to allopurinol, Febuxostat is regarded as being more potent than allopurinol. Why?

inhibition of both reduced and oxidised forms of xanthine oxidase.

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inhibition of the oxidised forms of xanthine oxidase.

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longer half life than allopurinol.

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mostly metabolized in the liver.

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inhibition of reduced forms of xanthine oxidase.

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A 24-year-old man presents with a history of three episodes of low back pain over five months, each lasting for ten days. The pain is relieved after exercise and is worse at rest. Investigations show: full blood examination within normal limits erythrocyte sedimentation rate (ESR) 19 mm/h [2-20] HLA-B27 positive X-ray of lumbosacral spine and sacro-iliac joints normal

What is the most likely diagnosis?

ankylosing spondylitis

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rheumatoid arthritis

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reactive arthritis

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psoriatic arthritis

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diffuse idiopathic skeletal hyperostosis (DISH)

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Which of the following clinical findings would NOT be in keeping with the diagnosis of dermatomyositis?

Raynaud's phenomenon.

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Heliotrope rash

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Shawl sign

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Periungal changes

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Gottron's papule

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Which of the following factor is involved in the breakdown of cartilage in osteoarthritis?

Aggrecanase

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IL-10

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TRAP (Tartrate resistant acid phosphatase)

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Osteoprotegrin

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RANK ligand

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Which of the following biological agent may be useful in patients with refractory giant cell arteritis (GCA) ?

Tocilizumab

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Infliximab

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Keliximab

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Lenercept

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Anakinra

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An elderly man presents with insidious onset of painless muscle weakness. On examination the weakness involves the distal muscles and is asymmetric in distribution. His serum CK is normal.

What is the most likely diagnosis?

Inclusion body myositis

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Polymyositis

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Dermatomyositis

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Systemic lupus erythematosus

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Systemic sclerosis

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An 83-year-old man has osteoarthritis of the knee. The pain limits his mobility to less than 300 m walking on flat ground. Paracetamol gives minimal relief. Examination of the knee reveals a varus deformity and a warm effusion. His GP commenced him on naproxen 500 mg twice daily. Four weeks later his knee has not improved and his serum creatinine has risen from 140 mmol/L to 350 mmol/L [60-120].

In addition to cessation of naproxen, which of the following would be the most appropriate next step in the management of his osteoarthritis of the knee?

Intra-articular corticosteroids

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Sulindac

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Rofecoxib

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Intra-articular hyaluronic acid

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Total joint replacement

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Which one of the following clinical features best differentiates inclusion body myositis from polymyositis?

Weakness of distal finger flexors

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Quadriceps wasting

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Deltoid wasting

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Truncal weakness

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Bilateral ptosis

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A 70 year old man presents with 5 days history of severe pain and swelling over his left knee. He is currently on gliclazide for diabetes, cilazapril for hypertension and also aspirin. His other background includes chronic kidney disease with a baseline creatinine of 170 mmol/L.

On physical examination, vital signs are normal. He is unable to bear weight on the left leg because of pain. The left knee is swollen and warm, and range of motion of this joint is limited and elicits pain. There are no tophi.

His bloods show:

leukocyte count of 15.6 x 10 9/L (90% polymorphonuclear cells, 10% lymphocytes)
random glucose of 11.7 mmol/L
serum creatinine 167.9 µmol/L
serum uric acid 0.63 mmol/L.
normal Urinalysis.

Arthrocentesis of the left knee is performed. Synovial fluid leukocyte count is 24,000/µL (90% polymorphonuclear cells, 10% lymphocytes). Polarized light microscopy reveals intra- and extracellular monosodium urate crystals. Gram stain is negative.

Which of the following is the most appropriate treatment for this patient?

Intra-articular methylprednisone

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Allopurinol

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Colchicine

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Prednisone

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Ibuprofen

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Which of the following risk factor causes gout by enhancing crystal formation?

osteoarthritis

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obesity

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hyperlipidemia

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chronic kidney disease

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thiazide diuretic

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Microscopic Polyangiitis is associated with which of the following antibodies?

Anti-MPO antibodies

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anti-PR3 ab

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anti-Ro ab

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anti-La ab

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anti-smooth muscle ab

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A 40-year-old woman presents with a six-week history of increasing shortness of breath while playing tennis and a two-week history of increasing muscle weakness. She reports mild symmetrical polyarthralgia of the hands, wrists and knees for six months and Raynauds phenomenon during the recent winter.

Examination reveals proximal muscle weakness and a hyperkeratotic rash with fissuring on the palmar and lateral surfaces of the fingers on both hands.

Investigations reveal a serum creatine kinase (CK) level of 890 U/L [16139] and widespread interstitial pulmonary infiltrate on high resolution computed tomography (CT) scan of the chest.

ANA test titre 1:2560, speckled pattern
Anti-ENA Jo-1 positive
Anti-DNA antibodies negative

What is the most likely diagnosis?

polymyositis (anti-synthetase syndrome).

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dermatomyositis

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progressive systemic sclerosis

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SLE

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Sjogrens

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Which of the following is a mandatory feature in establishing the diagnosis of PMR based on the 2012 provisional ACR/EULAR classification of PMR?

New onset bilateral shoulder pain

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New hip pain with reduced range of motion

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Absence of peripheral synovitis

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Morning stiffness >45 mins

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Positive RA serology

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Dermatomyositis is sometimes associated with an underlying malignancy.

What is the usual time frame for this to develop from initial diagnosis?

within 2 years

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within 10 years

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within 20 years

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within 30 years

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within 5 years

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What is the highest risk factor for developing scleroderma?

Presence of HLA-DQ7 DR2

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Silica dust exposure

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CMV infection

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Microchimerism

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Raised serum ACE level

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The following are features consistent with limited scleroderma except?

Renal disease

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Lung disease

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GIT involvement

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Pulmonary hypertension

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Long history of Raynauds.

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Limited scleroderma is associated with which of the following antibody?

Anti-centromere Ab

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Anti-topoisomerase Ab

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Anti Jo-1 Ab

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Anti-SM Ab

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Anti-LKM1 ab

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Diffuse scleroderma is associated with which of the following antibody?

Anti-topoisomerase(Scl-70)

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Anti-centromere

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Anti-smooth muscle

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Anti- Ro

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Anti- La

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What is the hallmark feature of diffuse sleroderma?

Tendon friction rubs

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Telangectasia

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Calcinosis

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Raynaud's

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Arthritis

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What is the most common immunological marker for renal crisis in diffuse scleroderma?

Anti-RNA polymerase III

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Anti centromere

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Anti-topoisomerase

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Anti-RNP

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Anti-To

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All of the following are associated with increased risk of developing interstitial lung disease except?

Presence of Centromere ab

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Presence of Topoisomorase ab (Scl-70)

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Black Afro-Americans

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Early decline in lung function

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Male sex

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What is the most common histology of interstitial lung disease in systemic sclerosis?

Non-specific interstitial pneumonia

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Usual Interstitial Pneumonia

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Langerhans cell histiocytosis

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Cryptogenic Organizing Pneumonia

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Lymphocytic Intersitial Pneumonia

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What is the most common gastrointestinal effect in scleroderma?

Oesophageal reflux.

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Oesophageal dysmotility

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Oesophageal stricture

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Telangiectasia in stomach

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Gastroparesis

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According to the ACR/EULAR classification criteria for IgG4-RD, which of the following is NOT considered an exclusion criterion?

Positive antineutrophil cytoplasmic antibody specifically against proteinase 3 or myeloperoxidase

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Diffuse pancreas enlargement (loss of lobulations)

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Peripheral eosinophilia

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Cellular infiltrates suggesting malignancy that have not been sufficiently evaluated

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Rapid radiologic progression

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In the classification of IgG4-related disease, which of the following histopathological findings is assigned the highest weight in the inclusion criteria?

Dense lymphocytic infiltrate and storiform fibrosis with or without obliterative phlebitis

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Uninformative biopsy

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Dense lymphocytic infiltrate

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Dense lymphocytic infiltrate and obliterative phlebitis

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Immunostaining with an IgG4+:IgG+ ratio of 41–70% and ≥10 IgG4+ cells/hpf

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Rheumatology Module 1

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