Rheumatology Module 4

A 25-year-old woman presents to the clinic with a three-month history of joint aching and stiffness. She describes these symptoms as being most prominent in her hands and wrists. Additionally, she reports experiencing significant fatigue and episodes of Raynaud’s phenomenon, characterized by colour changes in her fingers in response to cold temperatures or stress. Her medical history is notable only for acne, for which she has been taking minocycline. She denies any history of smoking, alcohol, or drug use and has no significant family history of autoimmune diseases.

On examination, she has mild synovitis in her hands and wrists without any evident deformities. There are no skin rashes, and her cardiovascular, respiratory, and abdominal examinations are unremarkable.

Laboratory investigations reveal the following:

• Hemoglobin (Hb): 103 g/L (indicating mild anemia)
• Lymphocyte count: 0.9 x 10^9/L (lymphopenia)
• Erythrocyte Sedimentation Rate (ESR): 52 mm/h (elevated)
• Rheumatoid Factor (RF): 125 IU/L (elevated)
• Antinuclear Antibody (ANA): 1:320 with a speckled pattern
• U1 Ribonucleoprotein (U1 RNP) antibodies: Positive
• Extractable Nuclear Antigen (ENA) panel: Positive
• Anti-double stranded DNA (dsDNA): 9 IU/L (slightly elevated)

Based on the clinical presentation and laboratory findings, what is the most likely diagnosis?

A 54-year-old female presents to the rheumatology clinic with a three-month history of symmetrical polyarthralgia affecting her hands, wrists, and knees. She reports that the joint pain is worse in the mornings and improves with activity throughout the day. Additionally, she mentions experiencing occasional fatigue and a photosensitive rash on her face. She has no significant past medical history and takes no regular medications.

On examination, there is noticeable swelling and tenderness in the metacarpophalangeal and proximal interphalangeal joints of both hands. There are no signs of joint deformity. A malar rash is observed on her face, sparing the nasolabial folds.

Laboratory investigations reveal the following:
– Antinuclear Antibody (ANA): Positive, with a speckled pattern at a titre of 1/160 and a cytoplasmic pattern at a titre of 1/640.
– Antibodies to Extractable Nuclear Antigens (ENAs): Positive for anti-SS-A (Ro).
– Antibodies to Ribosomal P Protein: Positive.
– Anti-double stranded DNA Antibody (anti-dsDNA): 4 IU/mL (within normal range).
– Anti-cyclic Citrullinated Peptide (anti-CCP): Negative.
– Rheumatoid Factor (RF): 45 IU/mL (elevated).

Based on the clinical presentation and laboratory findings, what is the most likely diagnosis?

A 54-year-old woman with a long-standing history of rheumatoid arthritis (RA), currently managed with oral methotrexate and intravenous infliximab, presents with a 6-week history of progressive polyarthralgia, a photosensitive rash, and lower-extremity purpura. She also reports daily low-grade fever and intermittent pleuritic chest pain. Her RA has been mostly stable, with occasional flares treated with prednisone.

On examination, she is febrile with a temperature of 38.0°C. She exhibits a malar rash on her face. Cardiopulmonary examination is notable for normal breath sounds without any rubs, but she experiences pain on deep breathing. Visual inspection of the lower extremities reveals several small 1-cm maculopapular eruptions bilaterally. Musculoskeletal examination shows synovitis in the metacarpophalangeal and proximal interphalangeal joints and wrists, with a nodule on the left elbow and decreased range of motion in the right wrist.

Laboratory studies yield the following results:

• Rheumatoid Factor: Positive
• Antinuclear Antibodies (ANA): Titer of 1:640
• Anti-double-stranded DNA Antibodies: Positive
• Chest Radiograph: Small bilateral pleural effusions

Which of the following antibody 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 known feature of dermatomyositis?

The following are characteristic EMG findings in myositis except?

An elderly man, aged 72, presents to the clinic with a history of gradually progressing muscle weakness that he first noticed about 18 months ago. He reports no associated pain, cramping, or muscle tenderness. The weakness initially began in his fingers, making tasks like buttoning a shirt or gripping objects increasingly difficult. Over time, he also noticed difficulty in rising from a seated position and climbing stairs.

On physical examination, the muscle weakness is noted to be more pronounced in the distal muscles, particularly in the forearms and fingers. Additionally, there is an asymmetric distribution of weakness, with one side being more affected than the other. Notably, there is no significant muscle atrophy at this stage. His reflexes are normal, and there are no sensory deficits.

His Creatine Kinase (CK) is within normal limits.

Based on the clinical presentation and laboratory findings, what is the most likely diagnosis?

What is the most common drug that causes myositis?

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

A 45-year-old man, previously in good health, presents to the clinic with acute onset of pain, swelling, and redness in his left first metatarsophalangeal joint and a diffusely swollen and painful left fourth toe. He reports no history of similar episodes in the past. Additionally, he describes intermittent episodes of low back pain over the past few months, which resolved spontaneously after several weeks. He also recalls a recent episode of diarrhea, which resolved without specific treatment.

On physical examination, the left first metatarsophalangeal joint is warm, swollen, and tender to palpation. The left fourth toe is diffusely swollen and erythematous. There is no evidence of skin rashes or eye inflammation.

Laboratory investigations reveal:

• Full Blood Examination: Normal
• Erythrocyte Sedimentation Rate (ESR): 28 mm/h (elevated)
• Serum Uric Acid: 0.49 mmol/L (slightly elevated, but within the reference range)
• Rheumatoid Factor: Negative

Based on the clinical presentation and laboratory findings, what is the most likely diagnosis?

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 visits the clinic with a history of recurrent low back pain. He has experienced three separate episodes over the past five months, each lasting approximately ten days. He reports that the pain tends to improve with exercise and worsens during periods of rest, particularly at night and in the early morning. There is no history of trauma, and he denies any other joint pain, eye problems, skin rashes, or gastrointestinal symptoms.

On physical examination, there is no obvious deformity or swelling in the back, but he experiences discomfort during lumbar flexion. Neurological examination of the lower limbs is normal.

Laboratory investigations reveal:

• Full Blood Examination: Within normal limits
• Erythrocyte Sedimentation Rate (ESR): 19 mm/h (upper limit of normal)
• HLA-B27: Positive
• X-ray of the Lumbosacral Spine and Sacroiliac Joints: Normal

Based on the clinical presentation and laboratory findings, what is the most likely diagnosis?

In ankylosing spondylitis, early syndesmophyte formation is most likely seen in which part of the spine?

A 24-year-old man comes to the clinic complaining of lower back and buttock pain that has persisted for six months. He describes the pain as being particularly severe in the morning, with stiffness that lasts for more than an hour and improves with exercise. He has no significant past medical history and takes no regular medications. There is no history of trauma, and he denies any recent infections, eye problems, or skin rashes.

On physical examination, there is noticeable stiffness in his lower back. The Schober test, which measures the flexibility of the lumbar spine, shows an increase of only 3 cm on flexion (normal is considered to be an increase of more than 5 cm), indicating reduced spinal mobility. There is also tenderness over the sacroiliac joints bilaterally.

The rest of the musculoskeletal examination, including examination of peripheral joints, is unremarkable.

Which test would most likely support a diagnosis of ankylosing spondylitis?

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 visits the clinic with a 12-month history of recurrent pain and swelling in his left third proximal interphalangeal joint. He describes the pain as severe, often starting suddenly, especially at night, and is associated with redness and warmth over the joint.

He also reports that these episodes are sometimes triggered by dietary indiscretions, particularly after consuming red meat and alcohol.

His medical history includes hypertension and chronic kidney disease. He is currently on hydrochlorothiazide for blood pressure management.

On physical examination, the left third proximal interphalangeal joint is swollen, warm, and tender to touch. The overlying skin appears red. There are no similar findings in other joints at the time of examination.

X-rays of the hand revealed soft tissue swelling and punched-out erosions overhanging the edges of cortical bone. The joint space are preserved.

Based on the clinical presentation and X-ray findings, what is the most likely diagnosis?

52-year-old woman comes to the clinic with a 12-month history of progressively worsening pain and swelling in her fingers. She describes the swelling as persistent and notes that her fingers often feel stiff, especially in the mornings. Additionally, she reports experiencing episodes of color changes in her fingers in response to cold temperatures or stress, ranging from white to blue to red, suggestive of Raynaud’s phenomenon.

She also mentions recent difficulties in swallowing and a sensation of tightness and thickening of her skin, particularly on her face and hands.

On physical examination, there is noticeable thickening and hardening of the skin on her fingers and face. The fingers are swollen, and there is limited range of motion in the affected joints. Capillary refill time is prolonged, and there are no visible joint deformities.

X-rays of her hands are performed, revealing distinctive changes:

• Resorption of the tufts of the distal phalanges
• Soft tissue calcifications
• Absence of significant joint space narrowing or erosions

Based on the clinical presentation and X-ray findings, what is the most likely underlying diagnosis?

A 38-year-old woman presents with a 3-week history of progressive pain over the radial side of her right wrist, extending to her thumb. She reports no history of trauma or systemic symptoms.

On examination, there is localized tenderness just distal to the radial styloid. Notably, there is no evident swelling or redness. The pain intensifies when she performs ulnar deviation of her wrist while her thumb is folded into her palm.

Which of the following is the most likely diagnosis?

What is the strongest risk factor for osteoarthritis of the hip and knee?

A 45-year-old man, known to have type 2 diabetes mellitus, presents to the clinic complaining of persistent pain and stiffness in his hands. He mentions that the symptoms have been gradually worsening over the past year. On further questioning, he reports a family history of hemochromatosis, but he has never been tested for the condition himself.

Physical examination reveals a reduced range of motion in the metacarpophalangeal (MCP) joints. There is notable joint swelling and tenderness, particularly in the second and third MCP joints. No significant skin changes or nodules are observed.

An X-ray of the hands is performed, which shows several distinctive features. There is evidence of chondrocalcinosis, indicated by calcification in the cartilage of the MCP joints. Joint space narrowing and subchondral sclerosis are noted, particularly in the second and third MCP joints. There are also hook-like osteophytes extending from the metacarpal heads. No significant osteopenia or erosive changes are seen.

Which test would be most helpful in establishing a diagnosis?

An 83-year-old man has osteoarthritis of the knee, which significantly limits his ability to walk more than 300 meters. He reports minimal pain relief from paracetamol. On examination, the knee exhibits a varus deformity and a pronounced, warm effusion indicative of active intra-articular inflammation.

He was commenced on naproxen 500 mg twice daily, but after four weeks, not only has there been no improvement in his knee symptoms, but his serum creatinine has also risen from 140 mmol/L to 350 mmol/L [60-120], suggesting renal impairment. 

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, primarily affecting her hands and wrists. She reports morning stiffness lasting more than an hour and occasional swelling in her knuckles. She has no significant past medical history and takes no medications.

On physical examination, there is noticeable synovitis in both wrists and the proximal interphalangeal joints. Her skin examination is unremarkable with no rashes, and there is no evidence of systemic involvement such as renal or neurological abnormalities.

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 76-year-old woman presents with a swollen, painful left knee. Over the past two weeks, she has experienced a progressive increase in knee pain, leading to an inability to walk on it. She does not recall any specific injury to the knee. Her medical history is otherwise unremarkable.

On physical examination, she is afebrile, and her left knee exhibits a significant effusion and a reduced range of motion. An X-ray of the knee reveals chondrocalcinosis.

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 a background of well-controlled diabetes and a history of recurrent shoulder bursitis presents with a three-month history of lower back pain. The pain is described as constant, dull, and worsening over time, with no specific inciting event. He denies any recent trauma, fever, or unintentional weight loss. His social history reveals that he is a retired office worker and he denies tobacco, alcohol, or recreational drug use.

On examination, he is afebrile with stable vital signs. There is a markedly decreased range of spinal motion, particularly in thoracic lateral flexion, which he finds painful. Tenderness is elicited upon palpation of the thoracic spine, but there is no overlying erythema or warmth. Neurological examination, including lower limb strength, reflexes, and sensation, is normal.

Blood tests including complete blood count, erythrocyte sedimentation rate, and C-reactive protein are unremarkable. HLA-B27 antigen test is negative.

Plain radiographs of the thoracic and lumbar spine reveal flowing ossification along the anterolateral aspect of at least four contiguous vertebral bodies, but preservation of the disc spaces.

What is the most likely diagnosis?

A 36-year-old woman presents to the dermatology clinic with a one-month history of shortness of breath, dry cough, and a painful rash on her upper arms. She denies experiencing any myalgias or muscle weakness.

On examination, her oxygen saturation is 94% on room air. Auscultation of her lungs reveals fine crackles at the bases.

Dermatological examination shows erythematous plaques and patches on the lateral aspects of her upper arms, known as the “sleeve sign,” and erythematous patches, papules, and pustules on the ventral surfaces of her hands, referred to as “inverse Gottron’s papules.” 

Laboratory tests reveal strong positivity for anti–melanoma differentiation–associated protein 5 (anti-MDA5) antibody and a mildly elevated creatine kinase level.

High-resolution computed tomography (CT) of the chest shows diffuse reticular and nodular opacities, and pulmonary function tests indicate a restrictive ventilatory defect with decreased diffusion capacity. Whole-body positron-emission tomography (PET) scan rules out occult cancer.

Based on the clinical presentation, laboratory findings, and imaging studies, what is the most likely diagnosis?

What is the most common joint involvement seen in psoriatic arthritis?

 Identify the monoclonal antibody with its correctly matched target in the treatment of psoriatic arthritis:

Which of the following treatment is not recommended in the management of peripheral psoriatic arthritis?