Rheumatology Module 4

A 25-year-old woman presents with a three-month history of aching and stiffness of her joints. She also reports fatigue and Raynaud’s phenomenon. Her only medication is minocycline for acne. The following blood results are obtained: haemoglobin 103 g/L [115-155] lymphocytes 0.9 x 109/L [1.3-4.0] ESR 52 mm/h [1-15] rheumatoid factor 125 IU/L [<28] antinuclear antibody 1:320, speckled pattern U1 ribonucleoprotein (U1 RNP) positive extractable nuclear antigen positive anti double stranded DNA 9 IU/L [<7]

Which of the following is the most likely diagnosis?

A 54-year-old female presents with a three month history of symmetrical polyarthralgia. The following laboratory results are obtained: Antinuclear antibody (ANA) positive, titre: 1/160, pattern: speckled titre 1/640, pattern: cytoplasmic Antibodies to extractable nuclear antigens (ENAs) positive anti-SS-A (Ro) Antibodies to ribosomal p protein positive
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Anti-double stranded DNA antibody (anti-dsDNA) 4 IU/mL [0-5] Anti-cyclic citrullinated peptide (anti-CCP) negative Rheumatoid factor (RF) 45 IU/mL [0-20]

Which of the following is the most likely diagnosis?

A 54-year-old woman presents with progressive polyarthralgia, photosensitive rash, and lower-extremity purpura of 6 weeks duration. She also has daily low-grade fever and intermittent pleuritic chest pain. She has an 11-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 38.0 C, 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. 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 is most likely to be present

Treatment with anti-TNF is contraindicated in the following conditions except?

Which one of the following is NOT a feature of dermatomyositis?

The following are characteristic findings of EMG in myositis except?

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

What is the most likely diagnosis?

What is the most common drug that causes myositis?

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

A previously well 45-year-old man presents with pain, swelling and redness in the left first metatarsophalangeal joint, and a diffusely swollen and painful left fourth toe. He has also had several episodes of low back pain, settling after several weeks, and a recent episode of diarrhoea. Investigations show: full blood examination normal ESR 28 mm/h [<20] serum uric acid 0.49 mmol/L [0.20-0.47] rheumatoid factor negative

The most likely diagnosis is:

A 70-year-old woman presents with intermittent back pain, and has noticed increasing kyphosis over several years. Her medical history includes hysterectomy at 26 years of age, sigmoid colectomy for colon cancer in 1986 and right knee replacement for osteoarthritis in 1990. She has severe kyphosis with reduced spine movement and no bone tenderness or other musculoskeletal abnormality. Mean lumbar spine bone density is 0.2 standard deviations (SD’s) below the age-related mean, and 2.04 SD’s below the young adult mean. Femoral neck bone density is 2.0 SD’s below the age-related mean and 4.2 SD’s below the young adult mean

Which one of the following is the most likely cause of the kyphosis?

.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

The most likely diagnosis is:

In ankylosing spondylitis, syndesmophyte formation is most likely to be first seen in which one of the following areas of the spine?

.A 24-year-old man presents with a six month history of lower back and buttock pain with prolonged stiffness in the morning. Physical examination reveals a Schober test of 3 cm on flexion [>5cm].

Which of the following tests is most likely to support a diagnosis of ankylosing spondylitis?

A 14-year-old boy complains of heel pain of six months duration. The following X-ray is obtained.

Which of the following is the most likely cause of his heel pain?

A 62-year-old man on weekly oral methotrexate for psoriatic arthritis inadvertently receives a course of oral trimethoprim-sulfamethoxazole therapy for urinary infection. He becomes ill with mucositis, fever and bruising and is found to have moderately severe pancytopenia. Folinic acid (in the form of calcium folinate) is administered intravenously as an antidote for presumed methotrexate toxicity.

The principal mode of action of folinic acid is:

A 60-year-old Polynesian man presents with a 12-month history of pain and swelling in the left third proximal interphalangeal joint. X-rays of the hand is shown below

What is the most likely diagnosis?

A 52-year-old female presents with a 12-month history of painful swollen fingers. X-rays of her hands are shown above.

For which of the following conditions are these findings most characteristic?

A 38-year-old woman presents with pain over the radial side of her right wrist radiating down into the thumb. There is no swelling but she is locally tender just distal to the radial styloid. The pain is reproduced by ulnar deviation of the wrist with the thumb folded across the palm.

The most likely diagnosis is:

Which one of the following is the strongest risk factor for osteoarthritis of the hip and knee?

A 45-year-old diabetic man presents with arthritis in his hands. X-rays of the left hand are shown below.

The most likely diagnosis is:

The principal abnormality on the bone scintigram shown below is most likely to be caused by which one of the following conditions?

The condition shown in the X-rays above is most likely to be seen with which one of the following?

An 83-year-old man has osteoarthritis of the knee. Pain limits his ability to walk more than 300 m. Paracetamol gives minimal relief. Examination of the knee reveals a varus deformity and a warm effusion. He is commenced 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?

A 49-year-old female presents with a five week history of symmetrical polyarthralgia. The following laboratory results are obtained: Antinuclear antibody (ANA) positive, titre: 1/80, pattern: speckled Antibodies to extractable nuclear antigens (ENAs) negative Anti-double stranded DNA antibody (anti-dsDNA) 7 IU/mL [0-5] Anti-cyclic citrullinated peptide (anti-CCP) positive Anti-filaggrin antibody positive Rheumatoid factor (RF) < 20 [0-20]

Which of the following is the most likely diagnosis?

.A 70-year-old woman has been on haemodialysis for 11 years. She complains of painful shoulders and knees and wrists and cannot raise her arms beyond 90. She has noted a gradual deterioration in her arthralgias over a period of 12 months. A radiograph of her wrist is shown below.

Which of the following is most likely to explain her symptoms?

.A 76-year-old woman presents with a swollen, painful left knee. The knee has become increasingly painful over two weeks and she is now unable to walk on it. She does not remember injuring the knee and is otherwise well. On examination she is afebrile and has a large left knee effusion with reduced range of movement. An X-ray of the knee is shown above.

What is the most likely diagnosis?

Where is pain most likely to be felt in a patient with osteoarthritis of the hip?

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

A 60 year old man with background of diabetes and recurrent shoulder bursitis presents with 3 months history of lower back pain. On examination,he is afebrile with stable vital signs.There is decreased range of spinal motion and loss of thoracic lateral flexion. There is also tenderness over palpation of thoracic spine. Blood test are unremarkable.HLA-B27 is negative.

What is the most likely diagnosis?