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?

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

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

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

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?

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?

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

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

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

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?

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?

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

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?

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

A 54-year-old caucasian lady presents with progressive polyarthralgia, photosensitive rash, and lower-extremity purpura of 6 weeks duration. She also complains of daily low-grade fever along with intermittent pleuritic chest pain.

She has a 10-year history of rheumatoid arthritis treated with oral methotrexate and intravenous infliximab. Her disease has been mostly stable except for occasional flares treated with prednisone.

On physical examination, vital signs are normal except for a temperature of 38 degrees, Malar rash is present. Cardiopulmonary examination reveals normal breath sounds, and no rubs are heard. She is unable to take a deep breath because of pain. Several small 1-cm maculopapular eruptions are visible on the lower extremities bilaterally.

Musculoskeletal examination reveals synovitis of the metacarpophalangeal and proximal interphalangeal joints and the wrists bilaterally. The left elbow has a nodule. Range of motion of the right wrist is decreased.

Her laboratory studies:

• Rheumatoid factor Positive
• Antinuclear antibodies Titer of 1:640
• Anti-double-stranded DNA antibodies Positive

Chest radiograph reveals small bilateral pleural effusions.

Which of the following antibodies would be most useful in establishing a diagnosis?

Microscopic Polyangiitis is associated with which of the following antibodies?

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?

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

Dermatomyositis is sometimes associated with an underlying malignancy.

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

What is the highest risk factor for developing scleroderma?

The following are features consistent with limited scleroderma except?

Limited scleroderma is associated with which of the following antibody?

Diffuse scleroderma is associated with which of the following antibody?

What is the hallmark feature of diffuse sleroderma?

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

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

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

What is the most common gastrointestinal effect in scleroderma?

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

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