Rheumatology Module 2

A patient with scleroderma has normal lung volumes but low DLCO of 40 percent. There is minimal fibrosis on HRCT. You suspect the patient may have pulmonary hypertension.

What is the next best investigation?

Right heart catheter

Correct Incorrect Correct answer

Echocardiogram

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HRCT

Correct Incorrect Correct answer

V/Q scan

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Lung function test

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Which of the following medication is helpful for scleroderma associated interstitial lung disease, especially when the FVC is less than 70% and the extent of fibrosis on HRCT is above 20 percent?

Oral cyclophosphamide

Correct Incorrect Correct answer

Prednisone

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Rituximab

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Ara-C

Correct Incorrect Correct answer

Imatinib

Correct Incorrect Correct answer

A patient with scleroderma undergoes a screening ECHO and is found to have a systolic pulmonary artery pressure of more than 50mmHg.

What should be the next step in management?

Proceed to right heart catheter study even if no symptom.

Correct Incorrect Correct answer

Perform 6 minute walk test.

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Proceed to right heart catheter study only if symptomatic.

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Do a follow up ECHO.

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Do nothing.

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The following treatments are most useful in pulmonary hypertension associated with Systemic sclerosis except?

Tadalafil

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Calcium channel blockers

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Bosentan

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Epoprostenol

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Sildenafil

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The following are associated with scleroderma renal crisis except?

Glomerulonephritis

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Malignant hypertension

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Microangiopathinc anemia

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Mild protenuria

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RNA polymerase positivity

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What is the medication of choice for the treatment of scleroderma renal crisis?

ACE-inhibitors

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Beta blockers

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Calcium channel blockers

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Diuretics

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Alpha blockers

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Which of the following medication is least useful in the treatment of Raynaud’s?

Aspirin

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Calcium channel blockers

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Topical nitroglycerine

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Fluoxetine

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Phosphodiesterase inhibitor

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Which of the following clinical feature is no longer used to define rheumatoid arthritis?

Presence of rheumatoid nodule.

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Number of joint involvements

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ACPA positivity

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Presence of abnormal CRP

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Duration of symptoms

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All of the following joint may be affected by rheumatoid arthritis (RA) except?

DIP joints

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Elbow joint

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PIP joint

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Cervical spine

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MCP joints

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What is the typical number of WCC (In cells/mm 3) and PMNs seen in the synovial fluid taken from a patient with rheumatoid arthritis?

WCC 2000-10,000 , PMNs >50%

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WCC <200, PMNs <25%

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WCC 200-2000, PMN <25%

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WCC >50,000 , PMNs >75%

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WCC <100 , PMNs <10%

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A 55 year old lady with a known history of rheumatoid arthritis is found to have splenomegaly on abdominal examination. Which of the following feature would most likely suggest the diagnosis of Felty’s syndrome?

Absolute neutrophil count below 2.0 x 109/L

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Platelet count below 150 x 109/L

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Myeloid hyperplasia on bone marrow examination

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Elevation of Anti-glucose-6-phosphate isomerase antibody titers

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Elevation of Anti-double-stranded DNA (anti-dsDNA) antibody titers

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A 45 year old lady with a background of Hepatitis C infection presents to the clinic with a 3 months history of joint pain on both her hands. The pain specifically involves her distal interphalangeal joints. Earlier in the month, the GP had requested a blood test for rheumatoid factor and the result came back positive with very high titres.

What would be the most likely explanation for the rheumatoid factor positivity?

The high titres are related to her Hepatitis C

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The most likely diagnosis is rheumatoid arthritis.

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The rheumatoid factor positivity effectively excludes the diagnosis of systemic lupus erythematosus

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This was likely a lab error.

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This is a normal finding for a person of her age.

Correct Incorrect Correct answer

Rheumatoid factor positivity can be seen in all of the following conditions except?

Ankylosing spondylitis

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Chronic infection

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Cryoglobulinemia

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Sjogrens

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Rheumatoid arthritis

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Which of the following marker is most specific for rheumatoid arthritis?

Anti-cyclic citrullinated protein antibodies

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Rheumatoid factor

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CRP

Correct Incorrect Correct answer

ESR

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TNF-alpha

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The following are poor prognostic markers in RA except?

HLA-DRB1*04 heterozygosity

Correct Incorrect Correct answer

RF and ACPA titre

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Smoking

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High CRP

Correct Incorrect Correct answer

Radiographic erosions at baseline

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Which of the following radiologic features is not typical of RA?

Asymmetric involvement

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Periarticular soft tissue swelling

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Juxta-articular osteoporosis

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Marginal erosions

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Joint space narrowing

Correct Incorrect Correct answer

You are doing an annual review of a 50-year-old woman with rheumatoid arthritis.

Which of the following complications is most likely to occur as a result of her disease?

Ischaemic heart disease

Correct Incorrect Correct answer

Chronic lymphocytic leukaemia

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Hypertension

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Colorectal cancer

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Type 2 diabetes mellitus

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Which of the following marker is most predictive of subsequent death from cardiovascular disease in patients with rheumatoid arthritis?

CRP

Correct Incorrect Correct answer

ESR

Correct Incorrect Correct answer

Rheumatoid factor

Correct Incorrect Correct answer

Anti-CCP

Correct Incorrect Correct answer

ANA

Correct Incorrect Correct answer

A 42-year-old female with rheumatoid arthritis still has severe joint pains despite being on 3 DMARDs (prednisone, methotrexate and sulfasalazine) and leflunomide for 6 months.

What should be the next step in management?

Introduce a biological DMARDs

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Increase prednisone

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Start IV methylprednisone

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Increase methotrexate

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Add diclofenac

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A 52-year-old female with known rheumatoid arthritis has been clinically well controlled on a combination treatment of prednisone and methotrexate for many years. However, the last 2 days, she has had a flare up of her RA.

What is the most appropriate step in management?

Pulse of high dose intravenous steroid.

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Add sulfasazine

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Add leflunomide

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Give IV morphine

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Add hydroxychloroquine

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Which of the following DMARDs is least likely to slow the radiographic progression of RA?

Hydroxychloroquine

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Prednisone

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Methotrexate

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Sulfasalazine

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Abatacept

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A 30-year-old female with RA has been on a particular DMARDs for the last 5 years with good symptom control.

Unfortunately, she has now developed reduced visual acuity.

Which of the following is likely the culprit drug?

Hydroxychloroquine

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Methotrexate

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Leflunomide

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Sulfasalazine

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Infliximab

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You are considering starting DMARDs on a patient with RA who is known to be a heavy drinker.

Which would be the best choice of treatment for this patient?

Sulfasalazine

Correct Incorrect Correct answer

Methotrexate

Correct Incorrect Correct answer

Leflunomide

Correct Incorrect Correct answer

Hydroxychloroquine

Correct Incorrect Correct answer

Infliximab

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Which one of the following cytokines is the most important in the pathophysiology of rheumatoid arthritis?

Tumour necrosis factor

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IFN-beta

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IFN-alpha

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IL-4

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IL-2

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A patient on leflunomide for his RA develops severe liver damage and myelosuppression.

What should be the most appropriate management?

Stop leflunomide and give cholestyramine.

Correct Incorrect Correct answer

Stop leflunomide and monitor LFTs

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Reduce dose of leflunomide

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Change leflunomide to methotrexate.

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Add methotrexate.

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Which of the following drug is not known to be a Tumor Necrosis Factor inhibitor (TNF-inhibitor)?

Abatacept

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Infliximab

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Adalimumab

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Etanercept

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Certolizumab

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Which of the following drug is associated with increased risk of reactivation of latent TB?

Infliximab

Correct Incorrect Correct answer

Abatacept

Correct Incorrect Correct answer

Methotrexate

Correct Incorrect Correct answer

Leflunomide

Correct Incorrect Correct answer

Prednisone

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The following are side effects of TNF inhibitors except?

Irreversible lupus like syndrome

Correct Incorrect Correct answer

Demyelinating diseaae

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Cardiac failure

Correct Incorrect Correct answer

Reactivation of latent TB

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Infusion reaction

Correct Incorrect Correct answer

What is the mechanism of action of Abatacept?

Interferes with T cell activation

Correct Incorrect Correct answer

TNF inhbitor

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Anti CD 20.

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Human mAb directed against IL-6 receptor

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IL-1 receptor antagonist

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Which of the following statements regarding the use of JAK inhibitors in the treatment of Rheumatoid Arthritis (RA) is correct?

JAK inhibitors are primarily recommended as first-line therapy before trying any TNF inhibitors.

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JAK inhibitors are less effective than biologic DMARDs in treating active RA.

Correct Incorrect Correct answer

Tofacitinib is usually taken in a dose of 25 mg twice daily.

Correct Incorrect Correct answer

JAK inhibitors are used only after intolerance or inadequate response to at least one TNF inhibitor.

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Peficitinib is a selective JAK1 inhibitor

Correct Incorrect Correct answer

Rheumatology Module 2

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