Questions (Rheum) Flashcards
1
Q
Describe what is meant by drug-induced lupus erythematosus [4] - include which antibodies are commonly found [2]
Which drugs most commonly cause this? [2]
A
Most common causes
* procainamide (antiarrhythmic)
* hydralazine (antihypertensive agent)
Features:
* arthralgia
* myalgia
* skin (e.g. malar rash) and pulmonary involvement (e.g. pleurisy) are common
* ANA positive in 100%, dsDNA negative
* anti-histone antibodies are found in 80-90%
* anti-Ro, anti-Smith positive in around 5%
2
Q
A patient is being treated for RA with MTX. They want to start a family.
- How long a washout should you leave before trying for a baby? [1]
- Which medication can be used instead? [1]
A
leave 6 months
use sulfasalazine instead
3
Q
A patient has PAN.
Which Hepatitis is this associated with? [1]
A
Hep B
4
Q
A patient has gout.
They ask for analgesia.
They have a Hx of peptic ulcers.
Which medication should you give? [1]
A
Corticosteroids
5
Q
[] is a common pathogen associated with septic arthritis in intravenous drug users due to its ability to thrive in environments where needles and syringes may not be sterile.
A
Pseudomonas aeruginosa is a common pathogen associated with septic arthritis in intravenous drug users due to its ability to thrive in environments where needles and syringes may not be sterile.
6
Q
Name [1] and describe a severe form of PsA [3]
A
Arthritis mutilans is a severe and destructive form of psoriatic arthritis
* It is characterised by progressive joint damage, leading to bone and cartilage loss, deformity, and disability.
* This condition is relatively rare but can profoundly impact an individual’s quality of life.
* Arthritis mutilans typically affect the small joints of the hands and feet, causing a telescoping or ‘pencil-in-cup’ deformity. Early diagnosis and aggressive treatment are crucial to help manage symptoms, preserve joint function, and improve long-term outcomes.
7
Q
What would the histological findings be of a RA nodule? [1]
A
The histological composition of subcutaneous nodules is areas of fibrinoid necrosis surrounded by palisading epithelioid cells.
8
Q
A 62-year-old female has been scheduled for a left total knee replacement in one month. She has a medical history significant for rheumatoid arthritis (RA), for which she takes methotrexate and hydroxychloroquine.
Which investigation would be most important before the patient’s operation?
Cervical spine X-rays
Eye exam
Rheumatoid factor levels
Electrocardiogram (ECG)
Anti-citrullinated protein antibody levels
A
The patient above has an established history of RA. Although RA typically affects the peripheral joints of the hands and wrists, involvement of the cervical spine at the C1/C2 level can lead to subluxation and instability. In a patient who is scheduled for elective surgery and therefore is likely to be intubated (which typically involves neck manipulation), cervical spine X-rays should be ordered before the surgery to ensure the patient does not have underlying cervical spine instability.
9
Q
A 67-year-old female visits her General Practitioner (GP) with worsening finger and wrist pain and swelling over two months, causing difficulty opening jars. Morning stiffness eases as the day progresses. The GP observes symmetrical metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joint swelling, tenderness, stress pain on passive movement and swan neck and boutonnière deformities. Suspecting rheumatoid arthritis, the GP refers her to a rheumatologist, prescribes anti-inflammatory medication, and recommends rest for her fingers and wrists.
Which of the following is the most common ocular extra-articular manifestation of rheumatoid arthritis?
Episcleritis
Scleritis
Scleromalacia
Keratoconjunctivitis sicca
Optic neuritis
A
10
Q
What are the pulmonary manifestations of RA?
A
Pulmonary conditions that patients with rheumatoid arthritis are at increased risk of developing include interstitial lung disease and pulmonary fibrosis (lower lobes), bronchiectasis, pleural effusions, lung nodule
11
Q
Felty’s Syndrome:
- Treatment of choice is initially with []
A
Treatment of choice is initially with the disease-modifying anti-rheumatic drug methotrexate.
12
Q
A
13
Q
In younger adults, particularly females, disseminated gonococcal infection may cause [hand condition]
A
In younger adults, particularly females, disseminated gonococcal infection may cause acute migratory tenosynovitis
e.g.
On examination, the affected finger is markedly swollen and erythematous, with tenderness to touch – especially along the flexor aspect of the finger. The patient is holding the finger in slight flexion; attempts at straightening the finger passively cause the patient extreme pain.
14
Q
Which disease / infection can cause false positive results for antiphospholipid antibodies? [1]
A
Syphilis
15
Q
A patient is diagnosed with AS.
What should you screen them for every 2 years according to NICE? [1]
A
Patients with AS are at increased of osteoporosis, likely due to chronic inflammation, and as a result are more prone to fragility fractures, and should be offered screening for osteoporosis every 2 years, as per NICE guidance
16
Q
A
17
Q
What is most commonly associated with rheumatoid arthritis?
Shrinking lung syndrome
Pulmonary hypertension
Apical fibrosis
Bronchiectasis
Yellow nail syndrome
A
Bronchiectasis
18
Q
Which symptoms seperate GCA from PMR? [4]
A
- headache, fever, malaise, and scalp tenderness
- tender & thickened arteries
19
Q
Which of the following tissues is the most common site of calcium pyrophosphate crystal deposition in patients with pseudogout?
Synovium
Ligaments
Cartilage
Tendons
Bursae
A
Synovium
20
Q
A
21
Q
Acromegaly increases the liklihood of:
- Gout
- Pseudogout
A
A swollen and painful joint in a patient with a past medical history of acromegaly and no prior history of gout is likely to be caused by pseudogout
22
Q
How do you differentiate between septic arthritis and RA from fluid aspiration?
With regards to:
- colour [1]
- WBC [1]
- neutrophil % [1]
- gram stain [1]
A
Septc arthritis:
* Colour: yellow/green
* WBC: >50 000 cells/mm3
* Neutrophils: >75 %
* Gram stain: often positive
RA:
* Colour: turbid, yellow
* WBC: 2 - 50, 000/mm³ cells/mm3
* Neutrophils: >70%
* Gram stain: negative
NB: septic arthritis would have WBC > 50k. RA has WBC between 2k and 50k.
23
Q
Hydroxychloroquine - may result in a which important side effect? [1]
A
Hydroxychloroquine - may result in a severe and permanent retinopathy
24
Q
A person is taking a medication that increases that chance of an atypical fracture.
What is this medication? [1]
A
Bisphosphonates are associated with an increased risk of atypical stress fractures
25
Describe the primary [1] and secondary thromboprophylaxis (initial VTE [1]; recurrent VTEs [2]; arterial thrombosis [1]) used for anti-phospholipid syndrome
Management - based on EULAR guidelines
**primary thromboprophylaxis**
* low-dose aspirin
**secondary thromboprophylaxis**
* **initial venous thromboembolic events**: lifelong warfarin with a target INR of 2-3
* **recurrent venous thromboembolic events**: lifelong warfarin; if occurred whilst taking warfarin then consider adding low-dose aspirin, increase target INR to 3-4
* **arterial thrombosis** should be treated with lifelong warfarin with target INR 2-3
26
What is the difference in pathophysiology of Marfans and Ehler-Danlos? [2]
**Marfans**- Mutation to **fibrillin 1**
**Ehler-Danlos** mutation to Collagen (most common subtype is III)
27
What is the most common presenting pattern of psoriatic arthritis?
Arthritis mutilans
Asymmetrical oligoarthritis
Distal interphalangeal joint arthritis
Proximal interphalangeal joint arthritis
Spondylitis
**Asymmetrical oligoarthritis**
28
Sjogrens patients are most likely to develop which cancer? [1]
**mucosa-associated lymphoid tissue (MALT) lymphoma.**
29
What side effect does colchicine give at high dose? [1]
Causes **diarrhoea** when given at high doses
30
Describe the change seen in this x-ray? [1]
What does it indicate? [1]
**Squaring of the thumb**:
- indicates OA
31
Describe what is meant by Löfgren syndrome
**Acute arthropathy in sarcoidosis patients**:
-
32
Which of GPA / eGPA is more associated with sinusitis? [1]
**GPA - cANCA**
| Saddle nose x
33
Describe the difference between presentation of PMR and dermatomyositis [1]
**PMR = pain**
**DM = weakness**
34
Dermatomyositis is strongly associated with which pathology? [1]
With malignancies - especially **lung cancer**
35
Describe how you manage long term bisphosphinate treatment [1]
**After** a **five year period** for **oral** **bisphosphonates** (**three** years for **IV** **zoledronate**), treatment should be re-assessed for ongoing treatment, with an **updated FRAX score and DEXA scan.**
This guidance separates patients into high and low risk groups. To fall into the high risk group, one of the following must be true:
* Age >75
* Glucocorticoid therapy
* Previous hip/vertebral fractures
* Further fractures on treatment
* High risk on FRAX scoring
* T score <-2.5 after treatment
36
This guidance separates patients into high and low risk groups. To fall into the high risk group, one of the following must be true [6]
* Age >75
* Glucocorticoid therapy
* Previous hip/vertebral fractures
* Further fractures on treatment
* High risk on FRAX scoring
* T score <-2.5 after treatment
37
Alendronate can cause **atypical stress fractures** of which bone? [1]
**atypical stress fractures of the proximal femoral shaft**
- they reduce bone remodelling since they inhibit osteoclasts, which means micro fractures can't be healed as well.
38
Describe the acute phase response of bisphosphinate initiation [3]
**acute phase response**: **fever, myalgia and arthralgia** may occur following administration
39
What change in Ca levels would occur with bisphosphinate tx? [1]
**hypocalcaemia**: due to reduced calcium efflux from bone. Usually clinically unimportant
40
What are RA x-ray changes? [5]
**loss of joint space**
**juxta-articular osteoporosis**
**soft-tissue swelling**
**periarticular erosions**
**subluxation**
41
How do you differentiate gout from pseudogout on x-ray? [1]
**Chondrocalcinosis** helps to distinguish pseudogout from gout
42
Name two drug classes that cause erythema nodosum [2]
penicillins; sulphonamides
43
Felty's syndrome is a triad of **[]**
Felty's syndrome is a triad of **rheumatoid arthritis, splenomegaly and neutropenia (low white cell count).**
44
45
Pneumonic for remembering causes of erythema nodosum? [+]
**NO** : idiopathic
**D** : drugs → penicillin sulphonamides
**O** : oral contraceptives / pregnancy
**S** : sarcoidosis / TB
**U** : ulcerative colitis / Crohn's disease / Behçet's disease
**M** : micro → strep, mycoplasma, EBV and more
46
The concurrent use of [] and [] containing antibiotics may cause bone marrow suppression and severe or fatal pancytopaenia
The concurrent use of **methotrexate** and **trimethoprim** containing antibiotics may cause bone marrow suppression and severe or fatal pancytopaenia
47
What would indicate that Raynaud's is primary and not a secondary cause? [1]
**Raynaud's disease** typically presents in **young women (e.g. 30 years old)** with **bilateral symptoms.**
48
What is the difference in treatment betwen mild and moderate fungal nail infections in terms of:
- presenting features [1]
- treatment [1]
**Mild**:
- < 2 nails impacted
- Topical amorolfine
**Moderate**:
- > 2 nails impacted
- Oral itraconazole
49
**[]** score is a useful tool to assess hypermobility.
**Beighton** score is a useful tool to assess hypermobility.
50
A patient has gout, which they are given long term treatment for.
He comes in with an acute exercabation of another illness he has.
A FBC reveals pancytopenia.
The interaction of which medications is likely to have caused this? [2]
**Azathioprine** and **allopurinol** have a severe in teraction causing bone marrow suppression
51
What is the difference in underlying pathologies causing:
**Low calcium, raised phosphate, raised ALP, raised PTH**
versus
**Low calcium, low phosphate, raised ALP, raised PTH**
Low calcium, raised phosphate, raised ALP, raised PTH = **kidney failure**
Low calcium, low phosphate, raised ALP, raised PTH = **osteomalacia**
52
What is the immediate plan for a patient who has a fragility fracture and is over 75? [1]
**Start alendronate** in patients >= 75 years following a fragility fracture, without waiting for a DEXA scan
- the most likely diagnosis is **osteoporosis**
53
Which two key parts of a question indicate a patient is suffering from polymalgia rheumatica? [2]
**Shoulder Girdle pain** x **raised ESR**
54
A 57-year-old female has noticed that the skin on her hands has become very tight and that her fingers sometimes turn blue. She has also had difficulty swallowing both solids and liquids. What autoantibody is most associated with these symptoms?
Anti-centromere
Anti-topoisomerase (anti-Scl-70)
Anti-double-stranded DNA (anti-dsDNA)
Anti-cyclic citrullinated peptide (anti-CCP)
Anti-mitochondrial (AMA)
A 57-year-old female has noticed that the skin on her hands has become very tight and that her fingers sometimes turn blue. She has also had difficulty swallowing both solids and liquids. What autoantibody is most associated with these symptoms?
**Anti-centromere** - patient has **limited cutaneous systemic sclerosis**
Anti-topoisomerase (anti-Scl-70) - for **diffuse systemic sclerosis**
## Footnote
**anti-centromere -->'mere' and 'limited' are synonyms**
55
**[RA drug]** - may result in a severe and permanent retinopathy
**Hydroxychloroquine** - may result in a severe and permanent retinopathy
## Footnote
Donald trump loves hydroxychloroquine- wouldn't stop going on about it
He is **orange** (skin pigmentation), he is nightmarish (**nightmares**), always looks like he's squinting (**reduced visual acuity- bullseye retinopathy)**, and his brother died from alcoholism (**liver toxicity**)
56
Schober's test < **[]** cm is suggestive of ankylosing spondylitis.
Schober's test **< 5 cm** is suggestive of ankylosing spondylitis.
57
Which of the following antibodies is most specific for diffuse cutaneous systemic sclerosis?
Anti-nuclear factor
Anti-centromere antibodies
Anti-Scl-70 antibodies
Rheumatoid factor
Anti-Jo 1antiobodies
Which of the following antibodies is most specific for diffuse cutaneous systemic sclerosis?
Anti-nuclear factor
Anti-centromere antibodies
**Anti-Scl-70 antibodies**
Rheumatoid factor
Anti-Jo 1antiobodies
58
'**[]**' and '**[]**' deformity are typical x-ray features in psoriatic arthritis
**'Plantar spur' and 'pencil and cup**' deformity are typical x-ray features in psoriatic arthritis
59
Ankylosing spondylitis - x-ray findings: [3]
Ankylosing spondylitis - x-ray findings: **subchondral erosions, sclerosis
and squaring of lumbar vertebrae**
60
A positive Schirmer's test would indicate which antibodies to be present? [2]
Positive **Schirmer**'s **test** are suggestive of **Sjogren's syndrome**. **Positive anti-Ro and anti-La antibodies**
61
Co-trimoxazole contains trimethoprim and therefore should never be prescribed with []
Co-trimoxazole contains trimethoprim and therefore should never be prescribed with **methotrexate**
62
Which SLE drug is safe in pregnancy? [1]
Aziothropine
63
**Inflammatory** **arthritis** involving **DIP** **swelling** and **dactylitis** points to a diagnosis of **[]**
Name another common symptom associated with this condition [1]
Inflammatory arthritis involving DIP swelling and dactylitis points to a diagnosis of **psoriatic arthritis**
Commonly presents with **Onycholysis**
64
A patient is diagnosed with dermatomyositis.
What is the initial investigation and why? [2]
Dermatomyositis is commonly a **paraneoplastic phenomenon** - therefore perform a **CT chest/abdomen/pelvis**
65
Patients with suspected visual loss secondary to temporal arteritis are usually given **[]** initially
Patients with suspected visual loss secondary to temporal arteritis are usually given **IV methylprednisolone** initially
66
Which complication are people with Marfan's most likely to suffer from? [1]
**Pneumothorax**
67
When does NICE recommend NOT giving bisphosphinates to patients with osteoporosis? [1]
What should you give instead? [1]
**bisphosphinates**:
- contraindicated if the eGFR is less than 35
**Denosumab**: used as 2nd linea after bisphosphinates
68
A patient has RA.
Which medication is causing this condition? [1]
**Hydroxychloroquine**:
- 'bull's eye maculopathy'
69
Fibromyalgia typically presents in which patient aged population? [1]
Polymyalgia rheumatica (PMR) typically presents in which patient aged population? [1]
Describe the difference in presentation between them [2]
**Polymyalgia rheumatica (PMR)** typically presents in **older adults** with **bilateral aching and stiffness** in the **shoulder and hip girdle muscles**, often with **morning** **stiffness** lasting more than an hour.
**Fibromyalgia** typically affects **younger** **individuals** and presents with **chronic widespread pain,** **tenderness** at specific **points**, fatigue, and sleep disturbances.
70
**[]** is a pharmacological option for Raynaud's phenomenon
**Nifedipine** is a pharmacological option for Raynaud's phenomenon
- causes vasodilation
71
Describe the basic pathophysiology of osteogenesis imperfecta (more commonly known as brittle bone disease) [1]
* **autosomal dominant**
* **abnormality in type 1 collagen** due to decreased synthesis of pro-alpha 1 or pro-alpha 2 collagen polypeptides
72
TOM TIP: The key feature that often appears in exams that should make you think about osteogenesis imperfecta is the **[]**
This is a unique feature that examiners love to drop in. The exam patient may be a young child with unusual and recurrent fractures that would normally make you consider safeguarding, however “you notice a blue discolouration to the sclera”.
TOM TIP: The key feature that often appears in exams that should make you think about osteogenesis imperfecta is the **blue sclera**.
This is a unique feature that examiners love to drop in.
The exam patient may be a young child with unusual and recurrent fractures that would normally **make you consider safeguarding**, however “**you notice a blue discolouration to the sclera”**.
73
Tx for osteogenesis imperfecta? [2]
The underlying genetic condition cannot be cured. Medical treatments include:
* Bisphosphates to increase bone density
* Vitamin D supplementation to prevent deficiency
74
What blood results would you see in osteogenesis imperfecta? [1]
**Adjusted calcium, PTH, ALP and PO4 results **are usually **NORMAL** in osteogenesis imperfecta
## Footnote
**Osteogenesis Imperfecta...but PERFECT blood results.**
75
Drug induced lupus can be indicated by which antibodies being present? [1]
**anti-histone antibodies**
## Footnote
Drug induced lupus: The answer is in their HISTory (drugs) --> anti-HISTone
76
In which cases of osteoporosis do you manage immediately (i.e. before a DEXA scan) ? [2]
**A postmenopausal woman**, or a **man** age **≥50 has a symptomatic osteoporotic vertebral fracture**
77
How can you differentiate between septic and reactive arthritis with regards to time frame of previous infection? [2]
**Septic arthritis:**
- Usually around 1 week
**Reactive arthritis:**
- Precedes 2-4 weeks prior
78
Pneumonic for remembering which drugs cause / trigger psoriasis [7]
**BALI TAN** 'I got a tan in Bali'
B blockers, Antimalarials/ACEi, Lithium, Indomethacin/Inflimab
Trauma Alcohol NSAID
79
Describe the pathophysiological cause of ocular complications in temporal arteritis [1]
**Anterior ischemic optic neuropathy** accounts for the majority of ocular complications in temporal arteritis
80
If a patient is having renal complications of systemic sclerosis - which drug should you give? [1]
Renal complications of systemic sclerosis - **ACE-inhibitors**
81
How do you treat temporal arteritis when there is suspected visual impairment? [1]
**Urgent IV methylprednisolone** and admit to ophthalmology
82
How do you adapt osteoporosis management plans if a patient is on a long term steroid?
* aged > 65 no need DEXA
* aged < 65 do DEXA first
* if T score less than 1.5 -> give **alendronate**
* If T score more than 1.5 ->**repeat scan 1-3 yearly**
83
What is important to note before prescribing bisphosphinates? [1]
**Hypocalcemia/vitamin D deficiency** should be **corrected** before giving bisphosphonates
84
Low levels of which one of the following types of complement are associated with the development of systemic lupus erythematous?
C4
C5
C6
C7
C8
SLE: complement levels **(C3, C4**) are usually low during active disease - may be used to monitor flares
85
A patient has anterior ischaemic optic neuropathy (AION) secondary to temporal arteritis.
What is the most likely finding on fundoscopy? [1]
**swollen pale disc and blurred margins**
86
Should oral bisphosphonates be taken with / without food? [1]
Oral bisphosphonates should be swallowed with **plenty of water** while sitting or standing on an **empty stomach** at least **30 minutes before breakfast**
87
A patient has gout and RA.
Which two medications would you avoid co-prescribing because of the risk of bone marrow suppression? [2]
**Azathioprine and allopurinol have a severe interaction causing bone marrow suppression**
88
89
Treatment for fibromyalgia? [4]
* **explanation**
* **aerobic exercise:** has the strongest evidence base
* **cognitive behavioural therapy**
* medication: **pregabalin, duloxetine, amitriptyline**
90
AS presents with reduction of which movements in clinical examination? [3]
* **reduced lateral flexion**
* **reduced forward flexion** - Schober's test - a line is drawn 10 cm above and 5 cm below the back dimples (dimples of Venus). The distance between the two lines should increase by more than 5 cm when the patient bends as far forward as possible
* **reduced chest expansion**
91
When do you give oral prednisolone vs IV methylpredinisolone for temporal arteritis? [1]
**Oral pred:**
- no visual changes or other ischaemic organ damage
**IV methylprednisolone**:
- patients with visual changes
92
**[]** antibodies are associated with **drug-induced lupus**
**Antihistone antibodies** are associated with drug-induced lupus
93
94
Which tests should you order when investigating secondary causes of osteoporosis? [6]
* full blood count
* urea and electrolytes
* liver function tests
* bone profile
* CRP
* thyroid function tests
95
State investigation findings of AS [4]
Which would you see first? [1]
1. **Syndesmophytes** (ossification of outer fibres of annulus fibrosus)
2. **A bamboo spine** on plain x-ray is a late sign which is rarely seen in clinical practice.
3. **sacroiliitis**: subchondral erosions, sclerosis
4. **squaring of lumbar vertebrae**
96
How do you interpret a T-score > -1? [1]
**Osteopenia** or osteoporosis detected in **one measurement site** means there is **generalised osteopenia or osteoporosis**; it is a systemic process and cannot be localised to only one region.
97
NICE guidance recommends that if patients suffer significant upper gastrointestinal side effects from the use of alendronate, then this should first be changed to **[]** or **[]**
NICE guidance recommends that if patients suffer significant upper gastrointestinal side effects from the use of alendronate, then this should first be changed to **risedronate** or **etidronate**
98
A positive **[]** antibody can assist in making the diagnosis of dermatomyositis [1]
**anti-Jo1 antibody**
99
Renal complications of systemic sclerosis - use [1]
ACE-inhibitors
100
Mnemonic for remembering the manifestations of diffuse sclerosis? [8]
**CREST** **CPR** (more serious than limisten
**C**- CAD and HTN (both systemic and pulmonary)
**P**- Pulmonary Fibrosis
**R**- Renal crisis (AKA Scleroderma renal crisis)- anuria, organ failure
101
102
What does prescribing folate alongside MTX specifically reduce the risk of? [1]
Prescribing folate with methotrexate reduces the risk of **myelosuppression**
- Methotrexate inhibits dihydrofolate reductase, an enzyme required for DNA synthesis, which lowers folate levels and impairs blood cell production. This can result in low counts of white blood cells, red blood cells, and platelets, increasing the risks of infection, anaemia, and bleeding
103
Describe the typical joint aspirate in a person with RA [3]
Joint aspirate in rheumatoid arthritis shows a **high WBC count**, predominantly **PMNs**. Appearance is **typically yellow and cloudy with absence of crystals**
104
What type of neuropathy (eye) does PMR x CGA cause? [1]
How does this present in a fundoscope [1]
**Anterior ischemic optic neuropathy** - fundoscopy typically shows a **swollen pale disc and blurred margins**
105
APS causes what finding in a clotting study? [1]
prolonged APTT.
106
Patients with a documented allergy to a sulfa drug (i.e. co-trimoxazole) should not take **[]**
Patients with a documented allergy to a sulfa drug (i.e. co-trimoxazole) should not take **sulfasalazine**
107
What is a skin manifestation of APS? [1]
**livedo reticularis**
## Footnote
Livedo reticularis can also be caused by many other conditions, it is not exclusively a sign of APS.
108
Patients with Sjogren's syndrome have an increased risk of **[]** malignancies
Patients with Sjogren's syndrome have an increased risk of **lymphoid** malignancies
109
What is the gold standard diagnostic test for AS? [1]
Magnetic resonance imaging of the sacroiliac joints
110
haemochromatosis is a risk factor for
RA
Septic Arthritis
Acute gout
Pseudogout
OA
haemochromatosis is a risk factor for
RA
Septic Arthritis
Acute gout
**Pseudogout**
OA
111
Anti Jo-1 is associated with **[]**
Anti Jo-1 is associated with **polymyositis**
112
Which form of vasculitis is associated w hepatitis B infection? [1]
**Takayasu's arteritis**
113
Which of the following patterns of inheritance best describe Marfan's Syndrome?
Autosomal Dominant
Mitochondrial
X-Linked Dominant
X- Linked Recessive
Autosomal Recessive
Which of the following patterns of inheritance best describe Marfan's Syndrome?
**Autosomal Dominant**
Mitochondrial
X-Linked Dominant
X- Linked Recessive
Autosomal Recessive
114
Describe a clinical test you would perfom for a ? lumbar disk herniation [1]
The **straight leg raise** is a test used for diagnosing herniated discs, with a sensitivity of approximately 90% and specificity of 25%.
- **On performing the straight leg raise, the patient complains of back pain**
115
Aneurysms x constitutional symptoms with a purpuric rash can suggest the diagnosis of **[]**
Aneurysms and constitutional symptoms with a purpuric rash can suggest the diagnosis of **Polyarteritis nodosa**.
116
**Adult-onset Still's disease** is a diagnosis of exclusion and can only be diagnosed if rheumatoid factor and anti-nuclear antibody are negative
What presentation would help to suggest this pathology? [5]
The triad of j**oint pain, spiking fevers, and a pink bumpy rash** is very characteristic of adult-onset Still's disease.
Additionally, it is also associated with **high serum ferritin and leucocytosis.**
117
How do you manage clotting risk in APS patients who have not had a thrombosis before? [1]
Patients with anti-phospholipid syndrome who haven't had a thrombosis previously are **generally on low-dose aspirin**
118
An X-ray shows erosions in the centre of the right distal interphalangeal joints, which are described as having a **pencil in cup appearance.**
What is the most likely diagnosis?
Osteoarthritis
Psoriatic arthritis
Rheumatoid arthritis
Gout
Systemic lupus erythematosus (SLE)
**Psoriatic arthritis**
119
Patients who are allergic to aspirin may also react to **[]**
Patients who are allergic to **aspirin** may also react to **sulfasalazine**
120
A 33-year-old man has been diagnosed with ankylosing spondylitis. Unfortunately, it is not well controlled, and his rheumatologist thinks he should start on a new medication.
How many different non-steroidal anti-inflammatory drugs must this patient have failed to respond to before he can be started on anti-TNF alpha inhibitors, in someone with predominantly axial disease?
1
2
3
4
5
**Anti-TNF alpha inhibitors** should be used in **axial ankylosing spondylitis** that has **failed on 2 different NSAIDS** and meets **criteria for active disease on 2 occasions 12 weeks apart**
121
eGPA and microscopic polyangiitis both can present with positive p-ANCA.
How would you distinguish between them through their symptoms? [2]
**Microscopic polyangiitis**:
- **respiratory** (alveolar haemorrhage; haemoptysis, **renal** (necrotising glomerulonephritits) and **generalised** **symptoms** (fever; weight loss; malaise
**eGPA**:
- Asthma
- Rhinosinusistis
- Muscle or joint pain
122
What treatment would you give for symptomatic ocular manifestations of Sjogren's disease? [1]
**Hypromellose**:
- Management of Sjogren's syndrome is mainly topical and targeted towards symptomatic relief. Hypromellose act as **artifical tears** and are applied as eye drops to soothe eyes
123
Why should you Cover with NSAIDS or Colchicine for the first few months of initiating ULT? [1]
Starting urate lowering therapy can cause an **acute** **flare**, hence it is advisable to cover with anti-inflammatory agents such as NSAIDS or Colchicine until effective dose is achieved.
## Footnote
NB: **Allopurinol** given when flare is over.
**Colchicine** can be given during flare.
124
Iloprost is a medication that can be used for Raynauds.
When is it specifically indicated? [1]
Can be given when a **patient** has **evidence of tissue loss**
125
Myeloperoxidase antibodies (MPO) aka? [1]
**pANCA**
126
Which drugs can cause drug induced lupus? [1]
What antibody does this cause to be positive? [1]
**Positive anti-histone antibody**
**Drugs that are known to cause DIL include:**
* sulfadiazine
* hydralazine
* procainamide
* isoniazid
* methyldopa
* quinidine
* minocycline
* chlorpromazine
127
What antibody associations are associated with discoid lupus? [1]
**Usually negative for ANA**
128
When do you give oral pred vs IV methylpred for CGA? [2]
Methylpred: **ocular or neurological involvement**
Pred: **None of above**
129
How do you distinguish between polymyositis from polymyalgia? [1]
(**both** cause **weakness** of proximal muscles) is that **polymyalgia** is associated with **stiffness** and **polymyositis** is associated with **pain** (in 1/3 of cases)
130
(both cause weakness of proximal muscles) is that polymyalgia is associated with stiffness and polymyositis is associated with pain (in 1/3 of cases)
**What drug is used in initial management**
**ACE inhibitors** is first-line in scleroderma renal crisis as it significantly reduces blood pressure for many patients
- It is usually recommended to **start a short acting ACE inhibitor** such as **Captopril** before moving on to a **longer acting agent** such as **Ramipril** once the patient is stabilised.
131
**[]** are an **ophthalmological** **issue** which may be caused by corticosteroids.
**Cataracts**
132
Which biomarkers are raised in dermato- and polymyositis? [4]
CK
LDH
Aldolase
ALT
AST
*DM & P turn muscles into **CLAAA***
133
What is the first and second line treatment for discoid lupus? [2]
1. topical steroid
2. hydroxychloroquine
134
What hearing defects may occur in Pagets [2] and why? [1]
**Tinnitis and hearing loss**
- Cochlea damage due to ankylosis of ossicles and narrowing of internal auditory meatus
135
Pagets dx with a sudden worsening of pain could indicate...? [1]
Osteosarcoma
136
How long do you treat septic arthritis for? [1]
**Abx** for **4-6 weeks**
137
Tx for PAN? [1]
IV steroids and pulse cyclophosphamide
138
Which drug should MTX not be prescribed alongside? [1]
**Trimethoprim**
139
You suspect a patient has gout. You take a serum sample of their uric acid levels.
What level would indicate gout? [1]
What would you do if the level if below^ [1]
* > 360 indicates gout
* < 360 - repeat in 2 weeks
140
How do you manage acute gout in someone in CKD? [1] Why? [1]
Use **steroids** - colchicine is CI in CKD
141
Describe a way of remembering different types of strengh of steroids [4]
Hydrocortisone; Eumovate; Betamethasone; Declomethasone
*Help every budding dermatologist*
142
What are important AEs of CGA need to consider? [3]
Blindess
Stroke
Thoracic AA
143
How does eGPA specifically impact the kidney? [1]
**Granulomas in kidneys**
144
What do you check BEFORE [1] and DURING [1] aziothropine use?
**Before**: TPMT
**During**: risk of myelosuppresion - check markers etc
145
Describe how you start allopurinol [1]
What advice do you give? [1]
* Cover with colchicine for 6 months
* Describe that can cause an initial flare of gout but will settle and help to eradicate uric acid
146
Which antihypertensives are best suited for gout patients? [2]
Amlodopine
Losartan
147
What do you need to check if you dx osteoporosis in young men? [1]
**Testosterone levels:**
* Low testosterone levels can cause rapid bone turnover
148
Describe how you specifically diagnose APS [1]
**two positive anticardiolipin tests 12 weeks apart**
- can get an acute rise in infection
149
Why need to do MRI of C-spine prior to surgery for RA patients? [1]
Risk of atlanto-axial subluxation
150
Felty's syndrome consists of a triad of..?[3]
Ra
Splenomegaly
Neutropaenia
151
CGA has a 17x increased risk of ... [1]
thoracic aortic aneurysm
152
Suspected systemic sclerosis in a patient.
Initiate what test? [1]
Why? [1]
Renal function - check for renal cisis
153
Describe the rash on the face in dermatomyositis [1]
**reddish-purple rash (heliotrope rash)** on the upper eyelid or across the cheeks and bridge of the nose in a “butterfly” distribution and on the forehead and scalp.
- **NB: Lupus doesn't generally appear in the area below the nose and above the lips,** while dermatomyositis does
154
What sign on US would suggest CGA? [1]
**Halo sign**
155
Anky spond. has a decrease in which three movements? [3]
Forward flexion
Chest expansion
Lateral flexion
156
Tx for lupus nephritis? [2]
**Pred and cyclophosphamide**
157
Name 6 different causes of dactylitis [6]
PsA; ReA
SCA
TB; Sarcoidosis; Syphilis
158
When do you initiate ULT in gout? [4]
- 2/3 attacks in a year
- Chronic tophaceaous gout
- X-ray changes
- Severe disabling attacks
159
Hep B is associated with which vasculitis? [1]
PAN
160
What prophylatic screening should you conduct every 2 years for AS patients? [1]
Osteoporosis
161
Long term OA - most optimal treatment? [1]
**Celecoxib** - reduced impact of peptic ulceration
162
An important differential for abdominal pain is which vasculitis? [1]
**Polyarteritis Nodosa (PAN)**
- due to vasculitis of medium-sized mesenteric arteries
163
APS causes which change in clotting markers? [1]
**APTT**
164
What change might you see in FBC if on MTX tx? [1]
**Macrocytic anaemia** due to folate deficiency
165
APS treatment and INR aim for multiple thrombotic events? [1]
APS treatment and INR aim for recurrent thrombosis (despite previous tx) ? [1]
Multiple thrombotic events: **Warfarin with INR of 2-3**
Recurrent thrombosis: **Warfarin and INR of 3-4**
166
What are the different DAS-28 scores and their associated classifications of disease severity in RA? [4]
**< 2.6** = Disease remission
**2.6 - 3.1** = low severity
**3.2 - 5.1** = medium severity
**> 5.1** = high severity
167
All SLE patients need which test? [1]
**Urine dip** - test for lupus nephritis
168
169
In which of the following conditions can tendinitis/tenosynovitis present without being swollen and tender?
Systemic sclerosis
Gout
Rheumatoid arthritis
Disseminated gonococcal infection
Reactive arthritis
In which of the following conditions can tendinitis/tenosynovitis present without being swollen and tender?
**Systemic sclerosis**
Gout
Rheumatoid arthritis
Disseminated gonococcal infection
Reactive arthritis
170
Which vasculitis is also known as ‘pulseless arterial disease' ? [1]
**Takyasu’s** is also known as ‘pulseless arterial disease
