Rheumatology Module 5

A 26-year-old man presents with a 19-month history of low back pain and stiffness, a swollen left knee, and heel pain. Physical examination reveals reduced lumbar flexion and chest expansion.

Laboratory tests show that he is HLA-B27 positive and has an elevated C-reactive protein (CRP) level of 26 mg/L.

In addition to physiotherapy and nonsteroidal anti-inflammatory drugs (NSAIDs), what is the most appropriate initial pharmacological therapy?

In patients with Ankylosing Spondylitis (AS), which of the following interventions is least likely to be beneficial?

In patients with Ankylosing Spondylitis (AS) treated with TNF inhibitors, which of the following is least likely to be observed?

In the context of Ankylosing Spondylitis (AS) treatment, which of the following is NOT a predictor of a good response to TNF (tumor necrosis factor) antagonists?

A hand x-ray shows a ‘pencil in cup’ deformity. What could be the underlying diagnosis?

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

Which of the following treatment is unlikely to be effective in enteropathic arthritis?

A 40-year-old female, a mother of three children, presents with hip pain. She has a history of childbirth and no significant past medical or surgical history.

An X-ray of the pelvis is performed and shows bilateral and symmetrical wedged shape sclerosis of the iliac side of the sacroiliac joints. There is no erosion or joint space narrowing. 

What is the underlying diagnosis?

A 30-year-old woman with a history of Systemic Lupus Erythematosus (SLE) is admitted with acute kidney injury and hypertension (blood pressure of 190/90 mmHg). She had a lupus flare 1 year ago and is currently asymptomatic. Her medical history includes deep venous thrombosis and pulmonary embolism following an automobile accident four years ago and three first-trimester miscarriages. Her current medication includes hydroxychloroquine.

Physical examination reveals a blood pressure of 200/96 mm Hg, a pulse rate of 100/min, and a respiration rate of 20/min. Cardiopulmonary and abdominal examinations are normal, with no rash, lymphadenopathy, or oral ulcers noted.

Laboratory Findings:

• Hemoglobin: 123 g/L
• Leukocyte count: 5.3 x 10^9/L
• Platelet count: 122 x 10^9/L
• Reticulocyte count: 1.9% of erythrocytes
• Serum creatinine: 244.2 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
• Direct antiglobulin test (Coombs test): Negative
• Peripheral blood smear: Rare schistocytes
• Renal ultrasonography: Normal-sized kidneys with no obstruction or renal vein thrombosis
• Renal biopsy: 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 with a history of osteoarthritis, hypertension, diabetes, and chronic kidney disease presents with a 5-day history of severe pain and swelling in his left knee. His current medications include gliclazide, cilazapril, and aspirin. On examination, he is unable to bear weight on his left leg due to pain. The left knee is swollen, warm, and painful, especially with movement. There are no visible tophi.

Laboratory Findings:

• Leukocyte count: 15.6 x 10^9/L (90% polymorphonuclear cells, 10% lymphocytes)
• Random glucose: 11.7 mmol/L
• Serum creatinine: 167.9 µmol/L
• Serum uric acid: 0.63 mmol/L
• Urinalysis: Normal

Arthrocentesis Findings:

• Synovial fluid leukocyte count: 24,000/µL (90% polymorphonuclear cells, 10% lymphocytes)
• Polarized light microscopy: Intra- and extracellular monosodium urate crystals
• Gram stain: Negative

Which of the following is the most appropriate treatment for this patient?

A 20-year-old woman presents with a 2-week history of pain over her lower legs and the development of red, knot-like skin lesions. She has a history of vulvar ulcers negative for herpes simplex virus, uveitis treated with prednisolone drops, Raynaud’s phenomenon, and recurrent oral ulcers. Naproxen has been ineffective in relieving her pain or preventing new skin lesions.

Physical Examination:

• Vital signs: Normal
• Cardiopulmonary and abdominal examinations: Normal
• No conjunctival injection
• Oral examination: Two ulcers on the tongue
• Cutaneous examination: Several tender, subcutaneous reddish-colored nodules on the lower extremities bilaterally
• No synovitis; full range of motion in all joints

Laboratory Studies:

• Complete blood count: Normal
• ESR (Erythrocyte Sedimentation Rate): 95 mm/h (elevated)
• Metabolic panel: Normal
• Rheumatoid factor: Negative
• Antinuclear antibodies (ANA): Negative
• ANCA (Anti-Neutrophil Cytoplasmic Antibodies): Negative
• Urinalysis: Normal
• Chest radiograph: Normal

What is the most likely diagnosis?

A 49-year-old man with a history of chronic asthma and recurrent lung infiltrates presents with worsening asthma symptoms, low-grade fever, purpuric lesions on both legs, and a left foot drop.

The patient has already been commenced on intravenous methylprednisone.

Laboratory Findings:

• Total white cell count: 18.0 x 10^9/L
• Eosinophils: 3.60 x 10^9/L
• Serum IgE: 1250 U/L

Which of the following is the most appropriate treatment?

A 16-year-old girl presents with a six-month history of pain and color change in her fingers when exposed to cold. Initially, her fingers turn white, then blue, and upon rewarming, they become red and painful. This phenomenon is consistent with Raynaud’s phenomenon.

On examination during a warm day, she appears well-grown and healthy for her age, with normal peripheral pulses. Her fingers are noted to be puffy, but there are no trophic changes in the skin. Nail-fold capillaroscopy reveals enalrged and distorted capillary loops.

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

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?

Which of the following is least likely to occur at long-term follow-up in a patient with Sjögren’s syndrome?

What is the most common cause of death for patients with mixed connective tissue disease?

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 examination, 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 a three-month history of right-sided shoulder pain, exacerbated by movement and at night, with radiation to the mid-upper arm. Examination reveals tenderness during shoulder abduction from 60 to 120 degrees, but no restriction on passive movement. The drop arm test is negative. Conservative management has failed, and the patient is reluctant to take NSAIDs. A corticosteroid injection is being considered.

An injection into which of the following areas will result in the best possible outcome for this patient?

A 60-year-old man presents with bilateral ankle pain that has worsened over a month. He finds relief by sleeping with his legs propped up on pillows. He has a history of hypothyroidism and has been off levothyroxine for two weeks.

Examination reveals slight warmth in both legs, 1+ pitting edema, and tenderness on compression of the tibias.

Laboratory findings include a WBC count of 11,300 and an ESR of 46. Radiographs show mild soft tissue swelling around the left ankle joint and periosteal new bone formation on the tibia.

Which is the best next step in the management of this patient?

A 32 year old patient presents with bilateral stiffness and joint pains in the hands and wrists, accompanied by splenomegaly.

Laboratory findings include neutropenia (neutrophil count of 1.3), positive rheumatoid factor, and positive Anti-SSA (anti-Ro) antibodies.

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

A 32-year-old Chinese female presents with central chest pain due to a myocardial infarction. She has a history of post-prandial abdominal pain, peripheral vascular disease, and recently diagnosed hypertension that is difficult to control. Laboratory findings include a normal full blood count (FBC), elevated creatinine (200), and positive antinuclear antibodies (ANA).

What is the next most useful diagnostic test for this patient?

A 50-year-old male presents with gradually increasing muscle weakness, including significant proximal muscle weakness in the upper and lower limbs and distal muscle weakness in the upper limbs bilaterally. He has been on long-term statin therapy. Examination is otherwise unremarkable, but his creatine kinase (CK) level is elevated (>1000).

What is the most likely diagnosis for this patient?

Which of the following drugs lowers the serum uric acid concentration?

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

Which of the following would be the most suitable immunosuppressive agent to use in a renal transplant patient who is started on allopurinol?

Which of the following dietary factor 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?