Rheumatology Module 5

A 26-year-old man presents with an 19 month history of low back pain and stiffness, a swollen left knee and heel pain. Examination demonstrates reduced lumbar flexion and chest expansion. He is HLAB27 positive and has a C-reactive protein (CRP) of 26 mg/L [ In addition to physiotherapy and NSAIDs

what is the most appropriate initial pharmacological therapy?

Which of the following intervention is least likely to be beneficial in patients with Ankylosing spondylitis?

.Which of the following is least likely to be seen following the treatment with TNF inhibitors in patients with ankylosing spondylitis?

With regards to the treatment for Ankylosing spondylitis ,the following are possible predictors of good response to TNF antagonist except?

The following x ray finding is consistent with which of the following diagnosis?

Which of the following treatment has been proven to slow the radiographic changes in psoriatic arthritis?

Which of the following treatment is not effective in enteropathic arthritis?

.A 40 year old female, a mother of 3 children, presented with the following x ray after complaining of pain on her hip.

What is the most likely diagnosis?

.Which of the following has a protective effect against the development of hip osteoarthritis in older women?

Which of the following is the strongest modifiable risk factor for osteoarthritis of the knee?

A 30 year old lady with SLE admitted with a BP of 190/90 mmHg and acute kidney injury. Her last lupus flare was 1 year ago, and she is currently asymptomatic. Four years ago, she developed deep venous thrombosis and pulmonary embolism after an automobile accident. She has had three first-trimester miscarriages. She is currently on hydroxychloroquine. On physical examination, temperature is normal, blood pressure is 200/96 mm Hg, pulse rate is 100/min, and respiration rate is 20/min. Cardiopulmonary examination is normal. Abdominal examination is unremarkable. There is no rash, lymphadenopathy, or oral ulcers. Laboratory studies: Hemoglobin 123 g/L Leukocyte count 5.3 – 109/L Platelet count 122 – 109/L Reticulocyte count 1.9% of erythrocytes Serum creatinine244.2 mmol/L Serum complement (C3 and C4) Normal Antinuclear antibodies 1:1280 (speckled pattern) Anti-double-stranded DNA antibodies Negative IgM-specific anticardiolipin antibodies >100 U/mL IgG-specific anticardiolipin antibodies >100 U/mL Lupus anticoagulant Positive Urinalysis 2+ protein; 1+ blood; 2-3 leukocytes, 3-5 erythrocytes/hpf Urine protein-creatinine ratio 1.2 mg/mg A direct antiglobulin test (Coombs test) is negative. Peripheral blood smear reveals rare schistocytes. Renal ultrasonography reveals normal-sized kidneys with no obstruction or renal vein thrombosis. Renal biopsy shows capillary congestion and intracapillary fibrin thrombi consistent with thrombotic microangiopathy. Immunofluorescence testing reveals deposition of fibrin but not IgG, IgM, or C3.

What is the most likely diagnosis?

A 70 year old man presents with 5 days history of severe pain and swelling over his left knee. Background includes osteoarthritis, hypertension, diabetes and chronic kidney disease.He is currently on gliclazide,cilazapril and aspirin. 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. Leukocyte count 15.6 × 109/L) (90% polymorphonuclear cells, 10% lymphocytes) Glucose (random) 11.7 mmol/L Serum creatinine 167.9 µmol/L Serum uric acid 0.63 mmol/L Urinalysis Normal 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?

.A 20 year old woman presents with 2 weeks history of pain over her lower legs with a skin lesion which she describes as red knots. Have tried Naproxen in the past but this did not relieve her pain. She had continued to develop new skin lesions. Six months ago, she developed vulvar ulcers that were negative for herpes simplex virus and these lesions healed within 3 weeks. Two years ago, she developed uveitis that was treated with prednisolone drops. She also has a 7-year history of Raynaud phenomenon and a long-standing history of recurrent oral ulcers. She has had no recent infections and currently has no vulvar ulcers. On physical examination, vital signs and cardiopulmonary and abdominal examinations are normal. There is no conjunctival injection. There are two ulcers on her tongue. Cutaneous examination reveals several subcutaneous reddish-colored nodules that are tender to palpation located on the lower extremities bilaterally. There is no synovitis, and range of motion of all joints is full. Laboratory studies: Complete blood count Normal ESR 95 mm/h Metabolic panel Normal Rheumatoid factor Negative Antinuclear antibodies Negative ANCA Negative Urinalysis Normal A chest radiograph is normal.

What is the most likely diagnosis?

A 49-year-old man with chronic asthma and a history of fleeting lung infiltrates presents with worsening symptoms of asthma, low grade fever, purpuric lesions on both legs and a left foot drop. Total white cell count is 18.0 x 109/L [4.5-11.0] of which 3.60 x 109/L [0.05-0.25] are eosinophils. Serum IgE is 1250 U/L [0-250]. In addition to methylprednisone,

which of the following is the most appropriate treatment?

A 16-year-old girl presents with a six-month history of pain and colour change in her fingers when exposed to cold. The fingers go white in the cold, then blue and become red and painful when they are warmed up. Examination on a warm day reveals a well, appropriately grown 16year-old girl with normal peripheral pulses and puffy fingers but no trophic changes in the skin. Nail-fold capillaroscopy is performed (shown below). The photograph on the left shows a normal control (A) and the photograph on the right is of the patient’s nail fold capillaroscopy (B).

Besides the avoidance of cold, which of the following is the most appropriate treatment?

A 21-year-old woman presents with a two-year history of colour changes in her hands from white to blue to pink following exposure to cold.

Which of the following results would indicate the highest risk of future development of a Raynaud’s phenomenon-associated secondary disease?

.In a patient with Sjgren’s syndrome, which of the following is least likely to occur at long-term follow up?

.In a patient with mixed connective tissue disease, what is the most common cause of death?

.A 62 year old woman is evaluated for pain over the lateral aspect of the left shoulder. She has a history of rotator cuff tendinitis in that shoulder, which was managed conservatively. She has a past medical history of diabetes, hypothyroidism, and stroke. She recently received a pacemaker for sick sinus syndrome, after which the shoulder symptoms worsened. On exam, she cannot actively or passively abduct the left shoulder beyond 90 degrees. Active and passive ROM do not improve after injection of lidocaine into the subacromial bursa.

What is the next step in investigation?

A 30 year old tennis player presents with 3 months history of right sided shoulder pain on movement and at night with radiation to the mid upper arm. On examination, there is active tenderness on shoulder abduction from 60 degress to 120 degrees with no restriction on passive movement.Drop arm test was negative. Conservative management has failed and patient is not keen to take NSAIDs.A corticosteroid injection is suggested.

An injection into which of the following area will result in the best possible outcome?

.A 64 year old man with chronic gout is evaluated for a swollen right elbow. Denies any history of trauma. His last attack of gout occurred 4 months ago and involved the right knee. Medications are metformin, enalapril, atorvastatin and low-dose aspirin. On examination, temperature is 38.1 C. The right elbow is warm with minimal erythema. There is fullness and tenderness over the right olecranon process. Passive flexion > 90 degrees elicits pain. Rotation of the forearm and extension of the elbow is painless.

Which of the following is the best next step?

A 64 year old man is evaluated for bilateral ankle pain that worsened over a month. He sleeps with his legs propped up on 4 pillows to alleviate the pain. He ran out of his prescription for levothyroxine for hypothyroidism 2 weeks ago. On examination, both legs are slightly warm but not red, and there is 1+ pitting edema. The tibias are tender to compression. WBC count is 11,300 and ESR is 46. A radiograph shows mild soft tissue swelling around the left ankle joint and periosteal new bone formation on the tibia.

Which is the best next step?

.A patient presents with bilateral stiffness and joint pains in hands and wrists.Has splenomegaly. Bloods show Neutrophil of 1.3,Rheumatoid factor positive and AntiSSA positive.

Which of the following complication is this patient most likely to have?

A 32 year old chinese female presents with central chest pain secondary to a myocardial infarction. She reports a long history of post-prandial abdominal pain and peripheral vascular disease. Recently she was diagnosed with hypertension which has been difficult to control with multiple agents. The following investigations were obtained. FBC: normal Creatinine: 200 ANA +ve

What is the next most useful diagnostic test?

.A 60 year old male presents with gradually increasing muscle weakness. His regular medications include long term statin therapy. On examination, he has significant proximal muscle weakness of the upper and lower limbs as well as distal muscle weakness of the upper limbs bilaterally.

Remaining examination is unremarkable. His CK is elevated (>1000). What is the most likely diagnosis?

Which of the following drug lowers the serum uric concentration?

Which of the following would be the strongest indication to start allopurinol in a patient with gout?

A renal transplant patient is started on allopurinol for recurrent attacks of gout .Which of the following would be the most suitable immunosuppressive agent to use?

Which of the following is least likely to contribute to hyperuricemia?

Which of the following is the most common site of acute gout?

The most likely reason for persistent hyperuricemia despite probenecid use is:

A 50 year-old man with rheumatoid arthritis that is treated with methotrexate presents to the emergency department with increased pain, swelling, and erythema in his left knee during the past 3 days. Six weeks ago he underwent a total left-knee replacement, and made a remarkable recovery. His rheumatoid arthritis has involved his metacarpophalangeal joints, wrists, knees, and feet bilaterally, but only the left knee bothers him currently. On examination,he has a temperature of 37.9°C, a heart rate of 87 beats per minute, and a blood pressure of 136/84 mm Hg. Examination of his left knee reveals a moderate effusion with warmth and tenderness; extension and flexion are limited by pain. Examination of the rest of his joints is normal. Laboratory evaluation reveals normal creatinine and electrolyte levels, normal liver-function tests, and a normal hematocrit. The leukocyte count is 11,200 per mm3 (reference range, 4500-11,000), the erythrocyte sedimentation rate is 52 mm/hr (0-17), and the C-reactive protein level is 67 mg/liter.

Which of the following is the most appropriate next step in management?

The idiopathic inflammatory myositis has been recently classified into four different clusters. Out of the four clusters, which of the following is classified as having the highest frequency of having inflammatory body myositis?