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RheumatologyQ002A 33 year old femalewith systemic lupus erythematosis has arthralgia involving herupperlimbs.Shealsohasabutterflyfacialrashandarashonthetrunk.UrinedipstickshowsnoProteinuriaorhaematuria.Herrenalfunctionisnormal.Whichoneofthefollowingmedicationsismostappropriate?

A.MethotrexateB.PrednisoloneC.AzathioprineD.HydroxychloroquineE.Cyclosporin

Answer:D)Hydroxychloroquine.NSAIDsandhydroxychloroquineareusedforskininvolvementandarthritis.NSAIDs are used for mild disease. Hydroxychloroquine is useful for disease notcontrolled by NSAIDS. Steroids are used in moderate to severe disease.Immunosuppressive treatments such as azathioprine and cyclophosphamide areusedtypicallywhenthereisrenalorcerebaldisease.



RheumatologyQ003A 75 year old woman with longstanding Rheumatoid arthritis has great difficultywalkingandcommentsthatbothherlegsarestiffandjumpy.Whatisthemostlikelycauseofthepresentation?

A.AnkylosingspondylitisB.SyringomyeliaC.OsteoporosisD.AtlantoaxialinstabilityE.Disccompression

Answer:d)Atlantoaxialinstability.CervicalcordcompressionduetoatlantoaxialinstabilityisthemostlikelycauseofUMNnerveweakness.



RheumatologyQ004A50yearoldwomanhassevererheumatoidarthritis.She isadmittedwithworseningbreathlessness.She is currently on ibuprofen, methotrexate, celecoxib, and paracetamol. Onexamination,shehasfeaturesofrheumatoidchangesinherhandsandlookspale.Thereisnopalpablelymphadenopathyandnoabdominalmasses.InvestigationsshowedthatherHblevelis7.8g/dlwithaMCVof90,WCC2.1x10^9/landplatelets55x10^9/l.Reticulocytecountis0.3%(0.5%to1.5%).Whatisthelikelycauseoftheanaemia?

A.NSAIDuseandGIbleedB.TreatmentwithcelecoxibC.TreatmentwithmethotrexateD.AnaemiaofchronicdiseaseE.Felty'ssyndrome

Answer:c)Treatmentwithmethotrexate.The patient has an aplastic anaemia which can be caused by methotrexate orazathioprine,DMARDs(penicillamineorgold).Abnormallylowreticulocytecountcanbeattributedtochemotherapy,aplasticanemia,perniciousanemia,bonemarrowmalignanciesandlowerythropoietinlevels.

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RheumatologyQ007A60yearoldwomanontreatmentforlongstandingrheumatoidarthritispresentswithbreathlessness.Shecomplainsofadrycough.Theoxygensaturationwasfoundbe85%onair.Thechestxrayshowsadiffusebilateralinterstitialinfiltrate.Bloodculturesandsputumculturesarenegative.Whichdrugislikelytohavecausedthisadverseeffect?

A.CyclosporinB.CyclophosphamideC.GoldD.MethotrexateE.Sulphasalazine

Answer:d)methotrexate.Pneumonitisisaseriousandunpredictablesideeffectoftreatmentwithmethotrexate(MTX)thatmaybecomelifethreatening.Chestradiographyrevealsadiffuseinterstitialormixedinterstitialandalveolarinfiltrate,withapredilectionforthelowerlungfields.Pulmonaryfunctiontestsshowarestrictivepatternwithdiminisheddiffusioncapacity.Lung biopsy reveals cellular interstitial infiltrates, granulomas or a diffuse alveolardamagepatternaccompaniedbyperivascularinflammation.

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RheumatologyQ009A60yearoldmanpresentswithapainfulswollenleftkneeaswellaspainandstiffnessofbothhishands.Onexaminationhisskin ispigmented.Thereistendernessandswellingofthe2ndand3rdmetacarpophalangealjointsofbothhands,hehashepatomegalyof8cmbelowthecostalmargin.Hiskneeisswollenandaspirationofthejointyieldsturbid,strawcolouredfluid.Whichoneofthefollowingdiagnosisislikely?

A.Wilson'sdiseaseB.HaemochromatosisC.PseudohypoparathyroidismD.PseudopseudohypoparathyroidismE.Ankylosingspondylitis

Answer:b)haemochromatosis.The history of abdominal pain together with skin pigmentation and hepatomegalysuggest the patient has haemochromatosis. Haemochromatosis is associated withchondrocalcinosis, which commonly affects the 2nd and 3rd metacarpophalangealjoints.Theacutearthropathyislikelytobepyrophosphatecrystalarthritis.

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RheumatologyQ011A60yearoldmanpresentswithgoutytophi.Hehasbeencommencedonallopurinolbutdevelopssevere jointpains3days later.Onexamination,hehasatemperatureof39Canderythematousswellingofhiswrists,kneesandankles.Investigationsreveal:urate0.6(0.230.45),creactiveprotein180mg/L.Whichofthefollowingislikelytohavecausedthepresentation?

A.AllopurinolB.ColchicineC.PrednisoloneD.PseudogoutE.Septicarthritis

Answer:a)allopurinol.Allopurinolblocksuricacidproduction and is thedrugmostoftenused in longtermtreatmentforolderpatientsandoverproducersofuricacid.Allopurinol istakenorallyonce a day in doses of 100mg to 600mg, depending on the patient's response totreatment.Between 3% to 5% of patients experience leukopenia, thrombocytopenia, diarrhea,headache,andfever.

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RheumatologyQ012A75yearoldhashad increasingbackand legpains severalyears.X rays revealbonysclerosis of sacroiliac, lower vertebral and upper tibial regions. Hementions greaterdifficultyhearingovertherecentyears.Bloodtestsrevealanelevatedserumalkalinephosphatase.Whatisthelikelydiagnosis?

A.Paget'sdiseaseofboneB.OsteoarthritisC.OsteomalaciaD.MonoclonalgammapothyofuncertainsignificanceE.Multiplemyeloma

Answer:a)Paget'sdiseaseofbone.In Paget's disease, onset of symptoms is usually insidious,with pain, stiffness, bonedeformity,headaches,decreasingauditoryacuity,andincreasingskullsize.Signsmaybebitemporalskullenlargementwith frontal"bossing,"dilatedscalpveins,nerve deafness in one or both ears, angioid streaks in the fundus of the eye, andanterolateralbowingofthethighorlegwithwarmthandperiostealtenderness.Pageticlesionsaremetabolicallyactiveandhighlyvascularandmayleadtohighoutputheartfailure.Deformitiesmaydevelop frombow ingofthe longbonesorosteoarthritisofadjacentjoints.Pathologicfracturesmaybethepresentingfinding.Characteristicxrayfindingsincludeincreased bone density, abnormal architecture, cortical thickening, bow ing, andovergrowth.Biochemistry includes elevated serum alkaline phosphatase (or bonespecific alkalinephosphatase)andincreasedurinaryexcretionofpyridinolinecrosslinks.Serumcalciumandphosphorus levelsusuallyarenormal,butserumcalciummay increaseduringbedrest.

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RheumatologyQ014A45yearoldwomanpresentswithnumbnessandweaknessofherupperand lowerlimbs.Shedevelopedasthmaattheageof30.Onexaminationshelooksunwell.Shehaspalpablepurpuraoverherfaceandoverherelbowsandknees.Onneurologicalexaminationshehasarightsidedwristdropandthere isweaknessofdorsiflexionofher right foot.Sensation isalso impairedover thedorsumofher rightfoot.Investigations:CXRisnormal.Hb10.9g/dLMCV90flWBC23x10^9/lEosinophils12%ANCAnegativeWhatisthelikelydiagnosis?

A.PolyarteritisnodosaB.ChurgStrausssyndromeC.SLED.AllergicbronchopulmonaryaspergillosisE.Takayasu'sarteritis

Answer:b)ChurgStrausssyndrome.Thecombinationofmononeuritismultiplex,asthma,eosinophilia.TheAmericanCollegeofRheumatology (ACR)hasproposed6criteria fordiagnosisofChurgStrausssyndrome.Thepresenceof4ormorecriteriayieldsasensitivityof85%andaspecificityof99.7%.Thesecriteriaare(1)asthma(wheezing,expiratoryrhonchi)(2)eosinophiliaofmorethan10%inperipheralblood(3)paranasalsinusitis(4)pulmonaryinfiltrates(maybetransient)(5)histologicalproofofvasculitiswithextravasculareosinophils(6)mononeuritismultiplexorpolyneuropathy

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RheumatologyQ015A40yearoldmanhasgeneralisedjointpainsandstiffness,particularlyintheknees.Healsohassore,dryeyesanddifficultytoleratingcontactlenses.Onexaminationtherearenojointswellingsoreffusions.HisESRis80mm/hour,RheumatoidFactorpositivewithatitreof1/1024.Whichofthefollowingislikely?

A.PositiveantibodiestoRoandLaantigensB.PositiveantiSCL70antibodyC.PositiveantimitochondrialantibodiesD.PositiveantiSmantibodiesE.PositiveANCA

Answer:a)positiveantibodiestoRoandLaantigens.Ro isalsoknownasantissAandLa isknownasantissBantibody,botharediagnostictests for Sjogrens. The history of dry eyes (keratoconjunctivitis sicca) and joint painswithstronglypositiveRhFgoeswithSjogrens.



RheumatologyQ016A45yearoldmanhasrecurrentsinusitisandhaemoptysis.Healsohashaematuriaandmildrenalimpairment.TestsaresentforsuspectedWegener'sgranulomatosis.WhichoneofthefollowingtestshasgreatestspecificityforWegener'sgranulomatosis?

A.AntiglomerularbasementantibodyB.PANCApositiveantibodiesproteinase3C.PANCApositiveantibodiesmyeloperoxidaseD.CANCApositiveantibodiesproteinase3E.CANCApositiveantibodiesmyeloperoxidase

Answer:d)cANCApositiveantibodiesproteinase3.On immunofluoresecnce,ifANCAarepresent,thestainingpatternmaybecytoplasmic(cANCA)orperinuclear(pANCA).TypicalantigenspecificityincludescANCAproteinase3which ismore common inWegener's granulomatosis. pANCAmyeloperoxidase ismorecommoninpolyarteritisnodosa.



RheumatologyQ017A ladywithwhiplash injury5yearsagopresentswithpains intheneckandshoulder.Theywerenotrelievedby12cocodamolsaday.Whatshouldbedonenext?

A.AmitryptillineB.NSAIDsC.PhysiotherapyD.MorphineE.Gabapentin

Answer:C)physiotherapy.Whiplash injuriesand radiculopathiescausingbackpainscanbedifficult to treatwithmedications. Physiotherapy has an important role for symptom relief in combinationwithanalgesia.



RheumatologyQ018A 45 year oldman presentswith aweek history of a painful right leg. He has hadprevious episodes of erythema nodosum, recurrent oral and scrotal ulceration.Examinationrevealsadiffuselyswollenleftleg.Whatisthelikelycauseofhisswollenleg?

A.Baker'scystB.GonococcalarthritisC.ReactivearthritisD.DeepveinthrombosisE.Cellulitis

Answer:d)Deepveinthrombosis.Theoveralldiagnosis isBehcet'ssyndrome.There isathrombotictendency,hencethelikelycauseofaDVT.

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RheumatologyQ020A43yearrheumatoidarthritiswasinvestigatedroutinelyandhadthefollowingresults:Haemoglobin11.2g/dLPlatelets385x10^9/LWhiteCellCount8.2x10^9/LMCV110fLWhichdrugisshelikelytohavebeenon?

A.AspirinB.RituximabC.MethotrexateD.VincristineE.Hydroxychloroquine

Answer:C)MethotrexateMethotrexate is associated with bone marrow suppression, and can lead topancytopeniaoramegaloblasticanaemia,especially iffolatetreatment isnotgivenaswell.



RheumatologyQ021A75yearoldwomanhasrecentlybeencommencedonalendronateforosteoporosis.Whatisthemechanismofactionofalendronate?

A.IncreasesosteoblastactivityB.InhibitsosteoclastactivityC.IncreasesvitaminDabsorptionD.CauseshypercalcaemiaE.Increasestheactionofoestrogenonbone

Answer:b)Inhibitsosteoclastactivity.Alendronate isabisphosphonatewhichcan increasebonemineralisationby inhibitingosteoclasticactivity.



RheumatologyQ022An 75 year oldman presentswith bilaterallypainful knees.He has bilateral reducedkneemovements and crepitus. X ray shows sclerosis, osteophytes and loss of jointspace.Whichoneofthefollowingisthemostappropriateinitialtreatment?

A.IbuprofenB.IbuprofenandlansoprazoleC.ParacetamolD.CodeinephosphateE.Celecoxib

Answer:c)paracetamol.Theprinciplegoalofsystemictherapyinosteoarthritisistoprovideeffectivepainreliefwith least associated toxicity. Paracetamol is the recommended initial therapy,especiallyintheelderlyduetopossiblegastrointestinalupset.



RheumatologyQ023A35yearoldwomanrecentlyarrivedintheUKfromGhana.Shecomplainsofneckpainwithpinsandneedlesaffectingtherightarmassociatedwithaweakgrip.Examination reveals tenderness over the cervical spine. X rays of the cervical spineshownarrowingoftheC3/4andC4/5jointspaceandpartialcollapseofC4.Investigationsshow:Hb9.5g/dlWCC11.1platlets520ESR120mminthefirsthourCRP250g/lCalcium2.21micromol/lAlbumin32g/lalkalinephosphatase210units/lphosphate0.8micromol/l.Whatisthemostlikelydiagnosis?

A.PottsdiseaseB.OsteoporosisC.MultiplemyelomaD.AnkylosingspondylitisE.Syringomyelia

Answer:a)Pottsdisease.Potts disease is tuberculous infection of the spine with associated collapse of thevetebralbody.The infection spreads from twoadjacentvertebrae into theadjoiningdiscspace. Ifonlyonevertebra isaffected,thedisc isnormal,but iftwoare involvedtheintervertebraldisc,whichisavascular,collapses.Signsand symptoms include:Localisedbackpain,Paravertebral swelling,Neurologicalsignsincludingparaplegia.Drug treatment (antituberculous drugs) is generally sufficient for Potts disease,withspinal immobilisation if required. Surgery is required if there is spinal deformity orneurologicalsignsofspinalcordcompression.

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RheumatologyQ026A 70 year old patient has a set of investigations due to lethargy. She complains ofpolyuriaandgeneralisedbackpains.Uponinvestigation,shehasthefollowingresults:Hb8g/dlMCV100flPlatelets190x10^9/ltotalprotein90g/l(6076)gm%Albumin35(3749)g/lcalcium2.9(2.252.7)mmol/lphosphate0.75(0.88)pmol/lWhatistheappropriatenextinvestigation?

A.CompleteliverfunctiontestsB.UrinaryalbuminC.PlasmaelectrophoresisD.24hoururineproteinE.Uricacid

Answer:C)plasmaelectrophoresis.Thepatienthasmultiplemyelomaas indicatedbyhypercalcaemia,polyuriaandbonepains.



RheumatologyQ027A72yearoldladyhasseverepainintheleftkneeandrighthand.AnXrayofthehandshows osteophytes and an X ray of the kneewas normal.On examination, she haslimitedlefthipflexion.Whatshouldbethenextinvestigationfortheknee?

A.MRIofthekneeB.BonescanC.ArthroscopyofthekneeD.CTscanofthekneeE.Ultrasoundoftheknee

Answer:A)MRIoftheknee.The patients presentation suggests osteoarthritis, but an MRI would be helpful toexclude other pathology aswell as confirm osteoarthritis in the context of a normalkneeXray.TheMRI isusefulforassessingthestateofthecruciate ligamentsandthejointcartilageaswellasavascularnecrosis.Arthroscopy ishelpfulbut invasive in thisinstance.



RheumatologyQ028A28yearoldpatientwithsystemic lupuserythematosusattendstheobstetricclinicat25 weeks into her pregnancy. The foetal heart rate is 45 beats perminute. Foetalechocardiographyshowscompleteheartblock.Whichoneofthefollowingmaternalautoantibodiesislikelytobepresent?

A.AntiRo(SSA)B.AntidsDNAC.AntiLa(SSB)D.AntiJo1E.Anticentromere

Answer:a)AntiRo(SSA).AntiRoantibody isassociatedwithcongenitalcompleteheartblock.Whencongenitalcompleteheartblockoccurs, SSA antibodies are almost alw ayspresent inmaternalandfetalserum(maternalantiRo(SSA)antibodycrossestheplacenta).



RheumatologyQ029A34yearold ladywithsystemicsclerosiscomplainedof lethargy.Herbloodpressurewas185/90mmHg.Fundoscopyshowedcottonwoolspots.InvestigationsshowedthatherU+Eswere:sodium135mmol/lpotassium4.5mmol/lurea12mmol/lcreatinine225mol/lWhatisthetreatmentofchoiceforthispatient?

A.OralCaptoprilB.IVProstacyclinC.IVLabetalolD.IVSodiumnitroprussideE.OralAtenolol

Answer:A)oralcaptopril.Amajorcomplicationofsclerodermaisrenalcrisis.Thisischaracterisedbyabruptonsetofseverehypertension,usuallyretinopathy,togetherwithrapiddeteriorationofrenalfunctionandheartfailure.Hypertension shouldbe treatedwithanACE inhibitor.This isbecause theunderlyingpathology causing hypertension is angiotensin IIinduced vasoconstriction, and trialshave shownACE inhibitors to have the best antihypertensive efficacy and improvedsurvival.Theaimistoreducepressuregradually,asanabruptfallcanleadtocerebralischemia/infarctions (as in any accelerated hypertension), and may cause decreased renalperfusionaswellasacutetubularnecrosis.CalciumchannelblockersmaybeaddedtoACEinhibitors.Parenteralantihypertensiveagents(suchasintravenousnitroprussideorlabetalol)shouldbeavoidedastheycauseabruptbloodpressuredrops.

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RheumatologyQ034A50yearoldpatientwithactive rheumatoidarthritishas failed treatmentwithgold,methotrexate,hydroxychloroquineandsulphasalasine.Shehasongoingjointpainsanderosivedamage.Whatisthemostappropriatetreatment?

A.HighdoseprednisoloneB.COX2inhibitorsC.InfliximabD.CiclosporinE.Azathioprine

Answer:c)infliximab.The AntiTNF drugs are infliximab and adalimumab. The criteria for treatment withthese drugs are that patients who have been treated with at least tw o DMARDs(diseasemodifyingdrugs)continuetohaveactiverheumatoidarthritis.Examples of the DMARDs are: gold injections, sulphasalazine, hydroxychloroquine,leflunomide, cyclosporin, azathioprine andmethotrexate [One of the tw omust bemethotrexate].



RheumatologyQ035A 45 year old woman presents with a year's history of Raynauds phenomenon,dyspepsiaandjointpains.Onexamination,shehassclerodactylyandsynovitisofsmalljointsofherhands.HerESR is60mm/hr(



RheumatologyQ036A 60 year oldman is on treatment for chronic heart failure with diuretics. He haspreivoushistoryofathma.Hepresentswithsuddenonsetofpainandswellingof themetatarsophalangeal joint of his right big toe. Aspiration of the joint demonstratescrystalsofmonosodiumurate.Whatistherecommendedtreatment?

A.AspirinB.ColchicineC.NonsteroidalantiinflammatorydrugsD.Cyclooxygenase2inhibitorE.Allopurinol

Answer:b)Colchicine.Inthisparticularpatient,colchicineisthebestoption.Inacutegout,eithercolchicineorNSAIDscanbeused.However,asthmacontraindicatesNSAIDs.

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RheumatologyQ038A 42 year old lady has tightening of the skin around her hands andmouth. She hasseveraltelangiectasiaonherhands,andcomplainsofseverecoldhandsinwinter.Shewasnoticedtobepale.Investigationsshow:Hb4.5g/dlMCV105flWCC6x10^9/lplatelets230x10^9/lIron22(1429)mol/lFerritin155(15200)mol/ltotalironbindingcapacity50(4572)umol/lFolate11(320)g/lVitaminB1285(120700pmol/l)Whatisthelikelycauseofanaemia?

A.PerniciousanaemiaB.SecondaryfolatedeficiencyC.CeliacdiseaseD.MethotrexateE.Bacterialovergrowth

Answer:E)bacterialovergrowth.Sclerodermacancausefolatedeficiencyduetomalabsorption.However, inthiscase,thefolatelevelsarenormalandthereisB12deficiency.B12deficiencycanoccurinconditionswherethereisbacteriaovergrowthinthesmallintestine (blind loop syndromes) suchas jejunaldiverticulosis,Crohnsdisease, fistulasand scleroderma. The anaerobic organisms metabolise vitamin B12 and impairabsorption.Whensystemicsclerosis(SSc)involvesthesmallintestine,normalperistalticmovementsarelostandmotilityisimpairedleadingtostasisanddilatation.

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RheumatologyQ040A 80 year old man developed acute monoarthritis of his right ankle following anadmissionwithcongestivecardiacfailure.HementionedthathehadankleoedemaandhadrecentlybeenprescribedfrusemidebytheGP.Whatisthelikelydiagnosis?

A.RheumatoidarthritisB.GoutC.PseudogoutD.OsteoarthritisE.Septicarthritis

Answer:b)Gout.Goutcanbeprecipitatedbydiuretics,e.g.frusemide.



RheumatologyQ041A 45 year old has a past history of systemic sclerosis. She now has headaches andblurredvision.Onexamination,shehasabloodpressureof220/100mmHgandthereisevidenceofbilateralpapilloedema.Whichofthefollowingmedicationsshouldbeprescribed?

A.OralhydrochlorothiazideB.OralLisinoprilC.SublingualNimodipineD.IVSodiumNitroprussideE.IVLabetolol

Answer:b)OralLisinopril.Amajor complication of scleroderma is renal crisiswhich is characterised by abruptonsetofseverehypertension.ThehypertensionalmostalwaysisseverewithadiastolicBPover100mmHg in90%ofpatients.There isassociatedhypertensiveretinopathy inabout85%ofpatients.ACE inhibitors are first line,with an aim to reduce thebloodpressuregradually.



RheumatologyQ042A 50 year oldman presents an acutemonoarthritis of left knee. Gout is confirmedfollowingjointaspirationandexaminationoffluidunderpolarisedlightmicroscopy.Hehadalsounderwentendoscopy3weeksearlierbecauseofindigestionthisconfirmedaduodenalulcer.Whichoneofthefollowingisthebesttreatmentforthepatient?

A.AllopurinolB.IntraarticularcorticosteroidinjectionC.IndomethacinandLansoprazoleD.CelecoxibandLansoprazoleE.IndomethacinandMisoprostol

Answer:b)Intraarticularcorticosteroidinjection.Allnonsteroidals includingCox II selective inhibitors are relatively contraindicated inthepresenceofactiveulceration. Ina large joint suchas theknee, the safestoptionwouldbeinjectcorticosteroidintothejoint.



RheumatologyQ043A62yearoldmanhasa5weekhistoryofpainandswellingaffecting leftknee,bothanklesandhisrightwrist.Hehaslost6kginweight.Hisinvestigationsshow:WCC14.1X10^9/lHb10.3X10^9/lMCV72flplt510X10^9/lESR63mminthefirsthourCRP21g/lCK120iuRhF1/80ANAnegativeENAnegativeXRofhandsandfeetnormal.Whatisthemostlikelydiagnosis?

A.ParaneoplasticsyndromeB.OsteoarthritisC.PolymyositisD.SclerodermaE.Behcet'ssyndrome

Answer:a)Paraneoplasticsyndrome.The CK is not significantly raised. Weight loss and anaemia suggest underlyingmalignancy.Paraneoplasticsyndromecanpresentwithanassymetricalarthralgiawhichmorecommonlyaffectsthelowerlimbs.Falsepositiverheumatoidfactorcanoccurbutshouldbeoflowtitre.

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RheumatologyQ047A75yearoldmanpresentswithbilateralhippains.Investigationsreveal:Correctedcalcium2.5(2.22.6)mmol/lESR22mm/1sthrAlkalinephosphatase800iu/L(50100)gammaGT22iu/LWhatisthelikelydiagnosis?

A.OsteoporosisB.OsteomalaciaC.Paget'sdiseaseofthepelvisD.PolymyalgiarheumaticaE.Multiplemyeloma

Answer:c)Paget'sdiseaseofthepelvis.This elderly patient presenting with bone pains has significantly elevated alkalinephosphatasebutnormalcalciumconcentrationssuggestingadiagnosisofPaget's.

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RheumatologyQ049A70yearoldwomanhaspolydipsiaandpolyuria for3months.Shealsocomplainsofloinpains.Shehasnotbeenonanymedication.Investigationsreveal:serumurea6(2.57.5)mol/lserumcreatinine80(60110)mol/lserumalbumin38g/L(3749)serumtotalcalcium3.1(2.22.6)Whatisthelikelycauseofthehypercalcaemia?

A.MultiplemyelomaB.SarcoidosisC.Paget'sdiseaseD.PrimaryhyperparathyroidismE.VitaminDtoxicity

Answer:d)Primaryhyperparathyroidism.PrimaryhyperparathyroidismiscausedbyanoverproductionofPTH.Excess PTH results in an increase in bone breakdown by means of osteoclasticresorption with subsequent fibrous replacement and reactive osteoblastic activity.Historically,inclassicprimaryhyperparathyroidism,nephrolithiasiswasnotedin50%ofpatients,and itwas themostcommonclinicalpresentationof thedisease.Additionalmanifestations of primary hyperparathyroidism include pancreatitis, peptic ulcerdisease,andcardiovascularabnormalities.



RheumatologyQ050A42yearoldladypresentswithbackache.Herbloodresultsareasfollows:Hb11g/dLCa1.9mmol/LPhosphate0.8mmol/LAlkalinephosphatase220U/LAlbumin38g/LUrea7mmol/LSodium142mmol/LPotassium3.9mmol/LWhatisthediagnosis?

A.OsteoporosisB.Paget'sdiseaseC.OsteomalaciaD.XlinkedhypophosphataemicricketsE.Hypoparathyoroidism

Answer:c)osteomalacia.The patient has osteomalacia with secondary hyperparathyroidism causing lowphosphate levels.Osteomalacia isdue tovitaminDdeficiencywhich couldbedue tomalabsorptionordietarydefiency,orrenal/liverdisease.



RheumatologyQ051A 32 year old woman has a deep vein thrombosis. Her previous history includedinvestigationsformiscarriages.Investigations revealed:Haemoglobin 11.9 g/dl,White cell count 4 x10^9/L,Plateletcount30x10^9/L.Whichofthesearelikelytobeabnormal?

A.HomocysteinelevelB.ANCAC.ProteinCD.AntiphospholipidantibodyE.Coomb'stest

Answer:d)Antiphospholipidantibody.Antiphospholipidsyndrome leads tovenousandarterial thrombosis, livedo reticularis,splinter hemorrhages, leg ulcer, multiinfarct dementia, chorea, Thrmobocytopenia(40%ofpatients),hemolyticanemiaandlatetermmiscarriages.



RheumatologyQ052A 35 year oldman presentswith acute stiffness swelling of his knees and ankles, apainful rash on his legs. The ESR was 100 mm/hour. Chest Xray showed hilarlymphadenopathybilaterally.Whatisthelikelyprogressionofthearthralgia?

A.ChronicarthritisB.SepticarthritisC.ImprovementonlywithsteroidsD.SpontaneousimprovementE.Permanentjointdestruction

Answer:d)spontaneousimprovement.Thedescriptiontypicalofacutesarcoidosiserythemanodosum,oligoarthropathyandhilar lymphadenopathy. This usually has a good prognosis, with resolution over 68weeks.



RheumatologyQ053A75yearoldladypresentswithbackpains.LateralspineXraysandpelvicxraysshowosteopenia. A serum corrected calcium is 1.8mmol/l and phosphate is 0.6mmol/l.Alkalinephosphataseis360U/l.Whichdiagnosisismostlikely?

A.MyelomaB.OsteoporosisC.OsteomalaciaD.Paget'sdiseaseE.Ankylosingspondylitis

Answer:c)osteomalacia.Osteomalacia ismore likely thanosteoporosisdue to the lowcalcium, lowphosphateandraisedalkalinephosphatse.TheconditioniscausedbylowvitaminDlevels.Alkalinephosphataseisraisedwhenthereisincreasedosteoblasticactivity,conditionsitmayberaisedin:

Paget'sdiseaseosteomalaciaandricketsrenalosteodystrophybonemetastases



RheumatologyQ054A 22 year old lady has a sw inging fever, half a stone weight loss over 2months,generalised myalgia, polyarthralgia affecting wrists, knees, ankles, elbowsmetacarpophalangealjointsandasorethroat.Investigationsshow :Hb9.5g/l,MCV85fl,ESR92mm infirsthour,CRP45g/l,serumferritin1600mg/dl,RFnegative,ANAnegative,ENAnegative,ASOtitre



RheumatologyQ055A65yearoldwomanhasaswollen,erythematouskneejoint.Aspirationofthejointwasperformed.Microscopyshowedpositivelybirefringentcrystals.Whatarethecrystalscomposedof?

A.CalciumcarbonateB.MagnesiumsulphateC.UrateD.CalciumpyrophosphateE.Aminolaevulinicacid

Answer:D)calciumpyrophosphate.Pseudogout is caused by the deposition of calcium pyrophosphate deposition ratherthan the deposition of uric acid derivatives that cause gout. Also, in pseudogout,synovialfluidsamplesobtainedwithaspirationhavepositivebirefringence.Thisfindingisindirectcontrasttothenegativebirefringenceingout.



RheumatologyQ056A45yearoldwomanpresentswithclaudicationinherlowerlimbs.Sheisnotedtohaveabsentleftarmpulses.Thepreviousyearshehadasmallhemisphericcerebrovascularinfarct.Whatisthelikelydiagnosis?

A.GiantcellarteritisB.Takayasu'sarteritisC.FamilialhypercholesterolaemiaD.CoarctationoftheaortaE.Antiphospholipidsyndrome

Answer:b)Takayasu'sarteritis.Takayasu'sarteritisisalargevesselvasculitisofunknownorigin.Thevasculiticprocessinvolves structures such as the aorta, great vessels, the sclera and the cardiacconductiontissues.Womenareaffectedmore thanmen,usually in the secondand thirddecadesof life.Presentation is often with symptoms such as fever, weight loss, night sweats andarthralgias. Symptoms related to ischaemia may include ischaemic stroke, visualdisturbancesandclaudication.



RheumatologyQ057A70yearoldmandevelopsweaknessof theshouldersandaround thehipsovera6monthperiod.Hehasalsonoticedweak finger flexors.Hecomplainedofdifficultyswallow ing liquids. There is no other significant past medical history. He smokes 15cigarettesadayanddrinksabottleofw ineattheweekend.Acreatininekinase levelcomesbackat120U/l.A muscle biopsy sample shows myopathic changes. There are also inflammatoryinfiltratesandintracytoplasmicvacuolespresent.Whatisthelikelydiagnosis?

A.PolymyositisB.FibromyalgiaC.PolymyalgiarheumaticaD.DermatomyositisE.Inclusionbodymyositis

Answer:e)inclusionbodymyositis.The diagnosis is inclusion body myositis (IBM). This is an inflammatory conditionaffectingpatientsover theageof50.Proximalmuscles in theupperand lower limbs,andfingerflexorsarepredominantly involved.Theonsetofmuscleweakness inIBM isgenerallygradual(overmonthsoryears).Dysphagia iscommon,occurring in4066%ofpatients.IBMoccursmorefrequently inmenthanwomen.CKmaybenormal.Amusclebiopsyusuallyshowsintracytoplasmicinclusionsandalsoinflammatoryinfiltrates.

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RheumatologyQ059A45yearoldwomancomplainsof12monthsofmidand lowerbackpainassociatedwithstiffnessinhershoulders,wrists,smalljointsofthehands,hipskneesandfeet.Thejointstiffnessismorepronouncedinthemorningandlasts23hoursandisassociatedwithseverefatigue.She also experiences occasional pins and needles affecting all of the right hand andfrequentfrontalandtemporalheadache.Clinicalexaminationdemonstratesnosynovitisbuttendernessaroundthebaseofthecervical spine, across the shoulders, over the costochondral cartilages, greatertrochanterandtheknee.Investigationsareasfollows:CRP



RheumatologyQ060A35yearoldmanpresentswithhotswollenelbowjoint.Hehasatemperatureof37CandCRPof350mg/l.Adiagnosisofsepticarthritisissuspected.Whichofthefollowingorganismsismostcommonlyisolatedfromjoints?

A.StaphyloccocusaureusB.NeisseriagonorrhoeaeC.haemolyticstreptococcusD.PseudomonasaeruginosaE.Moraxellacatarrhalis

Answer:a)staphyloccocusaureus.Staphaureus isthecommonestorganism(over50%).Neisseriagonorrheacanoccurinpatients with sexually transmitted disease. haemolytic streptococci can causeimpetigo,sorethroatandrheumatic fever.Moraxella isagramnegativecoccuswhichcancausepneumoniainCOPDpatients.



RheumatologyQ061A66yearold ladyhada falland fractured femur.ADEXA scan shows reducedbonemineraldensityconsistentwithosteoporosis.Whattreatmentshouldbegiventoreducethelikelihoodoffuturefractures?

A.AlendronateB.AlendronateandcalciumC.Alendronate,calciumandvitaminDD.CalciumE.VitaminD

Answer:C)alendronate,calciumandvitaminDAny patient above the age of 65 with osteoporosis is recommended to be onbisphosphonates. Inaddition,thispatienthassustainedafracture,andshouldalsobeoncalciumandvitaminD(calcichewD3)aswell.



RheumatologyQ062A82yearoldwomanpresentswithconfusion.OfnoteinherpasthistorywasRaynaudsphenomenon.Herinvestigationsshow:haemoglobin9.7g/dlwhitecellcount3.6x10^9/lplateletcount100x10^9/lserumtotalprotein120g/lserumimmunoglobulins:IgA0.75g/l(0.83),IgG16g/l(613),IgM35g/l(0.42.5)Whichofthefollowingcomplicationsisshelikelydevelop?

A.UrinarytractinfectionB.HyperviscositysyndromeC.PathologicalbonefractureD.AcuterenalfailureE.Erythemanodosum

Answer:b)Hyperviscositysyndrome.ThelikelydiagnosisisWaldenstromsMacroglobulinaemia(WM).Waldenstroms macroglobulinaemia is a type of nonHodgkins lymphoma. It is acondition which typically presents in the seventh and eighth decade of life. It ischaracterized by the presence of a high level of amacroglobulin immunoglobulinM[IgM]andelevatedserumviscosityinthepresenceofa lymphoplasmacyticinfiltrateinthebonemarrow.Thetreatmentischemotherapy(ChlorambucilorFludarabine).



RheumatologyQ063A72 yearoldwoman complainedofpainat thebaseofher right thumb.Therewastenderness and swelling of the right first carpometacarpal joint. Finkelsteins test isnegative.Whatisthemostlikelydiagnosis?

A.AvascularnecrosisofthescaphoidB.DeQuervain'stenosynovitisC.OsteoarthritisD.PsoriaticarthritisE.Rheumatoidarthritis

Answer:C)osteoarthritis.The tenderness at the carpometacarpal joint ismost likely due to osteoarthritis in apatientofthisage.

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RheumatologyQ065InapatientwithSLE,theriskofcardiovascularabnormality is increasedwithpresenceofwhichoneofthefollowing?

A.AnticardiolipinantibodyB.AntiRoantibodyC.AntiLaantibodyD.ANAantibodyE.AntiJoantibody

Answer:B)antiRoantibodyAntiRoisimportantinpregnancysinceitisassociatedwithbabiesbornwithcongenitalheartblock.



RheumatologyQ066A50yearoldsecretarynoticedtinglingandnumbnessover thepalmarsurfaceofherthumb,indexandmiddlefingersafterseveralhoursathercomputer.Pain inthesameareasoftenoccuratnight.Whatisthediagnosis?

A.RheumatoidarthritisB.GoutC.DermatomyositisD.CarpaltunnelsyndromeE.Psoriaticarthritis

Answer:d)Carpaltunnelsyndrome.Thediagnosis is carpal tunnel syndrome,and the symptomsaredue to tenosynovitiswhichisworsenedbyrepetitivestrainimposedbytyping.



RheumatologyQ067A75yearoldmancomplainsofpainandstiffnessinbothhisshoulders.Hehaslost1/2a stone in last6weeksdue to lossofappetite. Investigations show :ESR95mm/hr,normochromicnormocyticanaemiaandapositiverheumatoidfactor.Thelikelydiagnosisis:

A.FibromyalgiaB.PolymyositisC.DermatomyositisD.PolymyalgiaRheumaticaE.Chronicmyeloidleukaemia

Answer:d)PolymyalgiaRheumatica.PolymyalgiaRheumaticaisassociatedwithweightloss,anemia&malaise.It can also be associated with a false positive rheumatoid factor, especially in theelderly.



RheumatologyQ068A12yearoldboyhasfevers.Hehashadelbow,shoulderandhipandkneepainsoverthe last fewmonths.On examination, he has a temperature of 37.5 C and palpablehepatosplenomegaly.InvestigationsshowaCRPof30andnegativeANA.Whatisthelikelydiagnosis?

A.Marfan'ssyndromeB.EhlerDanlossyndromeC.Perthe'sdiseaseD.JuvenilechronicarthritisE.Osteoarthritis

Answer:d)juvenilechronicarthritis.Juvenile chronicarthritis (JCA) is a formof seronegative arthritis in the young (adultformknownasStillsdisease)whichisrheumatoidfactorandANAnegative.Diagnosticcriteria include high fever, hepatomegaly, splenomegaly, lymphadenopathy, serositis(pleuritis,pericarditis),leucocytosis.Bonedestructionandmicrognathiaoccurs.



RheumatologyQ069A25yearoldladypresentstoclinicwithapainfullyswollenhotrightknee.Shegivesa2week history ofmigratory polyarthritis and urethritis. Clinical examination reveals apustular skin rash, right Achilles tendinitis and left plantar fasciitis. She is HLAB27negative.Whatisthemostlikelydiagnosis?

A.RelapsingpolychondritisB.ReiterssyndromeC.GonoccocalarthritisD.NonspecificurethritisE.Behcet'ssyndrome

Answer:c)Gonoccocalarthritis.Gonoccocalarthritisclassicallypresentswithahotjointonabackgroundofamigratingpolyarthropathy. It affectsw omenmore frequently thanmen (4:1) and its highestincidence isamong sexuallyactiveadolescentgirls.There isalso increased riskduringmenstruationandpregnancy.Twoformsofarthritisexistonewithskinrashesandmultiplejointinvolvement,andasecond,lesscommon,forminwhichdisseminatedgonococcemialeadstoinfectionofasinglejoint(monoarticular)andjointfluidculturesarepositive.



RheumatologyQ070A50yearoldwomanwithlongstandingrheumatoidarthritis,andasiccasyndrome.Shepresentswithincreasingmalaise.Investigationsshowed:Hb7.5g/dlNeutrophilcount1.2x10^9/lplateletcount90x10^9/lHerESRwas120mm/hrandCRP145mg/dlOnexamination,shewaspaleandhadpalpablesplenomegalyof6cmedge.Themostlikelycauseofherhaematologicabnormalitiesis:

A.AnaemiachronicdiseaseB.UpperGIbleedC.Felty'ssyndromeD.FolatedeficiencyE.Irondeficiency

Answer:c)Felty'ssyndrome.Felty'ssyndromeisthetriadofseropositivearthritis,splenomegalyandneutropenia.The cause of Felty's syndrome is not known, but ismost commonly associatedwithrheumatoidarthritis.



RheumatologyQ07132 year old lady uppermiddle classwhite ladywho used to be an athlete has beenreferred for investigationdue to tiredness.Shementions fatiguewhich ischronicandoccurs even after minor physical w ork. This has been going on for 3 years.Investigations including CK, ESR, EMGs andmuscle biopsy have revealed no obviousmedicalcauseforthis.Whichofthefollowingisthebesttreatment?

A.ErythropoietininjectionsB.CognitivebehaviouraltherapyC.GradedexerciseprogrammeD.CodeineE.Fluoxetine

Answer:C)Gradedexerciseprogramme.ChronicFatiguesyndromeisdefinedbysymptomsandnotsigns.Theclinicalprofileofan individualwithCFS isofahighachieving studentorathletewhousually is female(80%),white, andmiddleclass touppermiddleclass. Treatment is largely supportiveandresponsivetosymptomatology.This includesphysicaltherapyandmodestaerobicoranaerobicexercise(ifpossible)toavoidcardiovasculardeconditioning.Sleepmaybeaddressedwithmedication; often,melatonin or nighttime amitriptyline is helpful. Ifpresentandsevere,painoftenisaddressedinapainclinic.

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RheumatologyQ073A9yearoldboyisbroughttothepaediatricianwithcomplaintsoffeverfor1week.Healsohascrackedlips,whicharepainful.Onexamination,hiseyesareredandhehasa lymphnode inthecervicalregion.Kawasakisyndromeissuspected.Whichofthefollowingisthebesttreatmentchoice?

A.IntravenousimmunoglobulimB.HydrocortisoneC.AbxicimabD.AmoxicillinE.Lowmolecularweightheparin

Answer:a)Intravenousimmunoglobulin.This isacaseofKawasakissyndrome,which isalsoknownasmucocutaneous lymphnode syndrome and occursmainly in children under 10 years of age. It is a form ofvasculitis,which affects coronary arteries and is associatedwith the development ofcoronaryaneurysms.AspirinandIVimmunoglobulinathighdosesisthetreatmentofchoice.Corticosteroidsused tobecontraindicated,but recently trialshave shown that it reduced the riskofheartdamagecausedbycoronaryvesselvasculitis.Infliximabisalsobeingusedintrials.Warfarinisusedifcoronaryaneurysmsdevelopasacomplication.



RheumatologyQ074A55yearoldwomanpresentswitha2monthhistoryofpainaffectingthecervicalspineandbothshoulders, thiswasprecededbypain in the lowerbackandbothhips.Earlymorning stiffness lasts until lunchtime and she feels markedly tired and weak.Examinationrevealsbilateralkneeeffusionsandarightcarpaltunnelsyndrome.InvestigationsdemonstrateanormochromicnomocyticanaemiaofHb9.8g/dl,ESR72mm in the firsthour,CRP12g/l, serum immunoglobulinsandproteinelectrophoresisshow a polyclonal increase in gamma globulins and elevated alpha 1 and alpha 2globulinsbutnoparaproteinband.Whatisthemostlikelydiagnosis?

A.RheumatoidarthritisB.ParaneoplasticsyndromeC.MixedconnectivetissuediseaseD.SclerodermaE.Polymyalgiarheumatica

Answer:e)Polymyalgiarheumatica.Polymyalgia rheumatica (PMR) is a clinical diagnosis based on pain and stiffness ofpelvicgirdleandshoulder.Itismorecommonaftertheageof55.Incontrasttopolymyositisthereisnomuscularweakness.Earlymorningstiffnessofthehipandshouldergirdlesiscommon.Anormochromicnormocyticanaemiaisassociated.



RheumatologyQ075A55yearoldmanpresentswithsuddenonsetofarightsidedfootdropwithnumbnessoverthedorsumofhisrightfoot.Hehasweaknessofdorsiflexionandeversionofhisrightfoot.Thereisanareaofdiminishedsensationoverthedorsumoftherightfoot.Healso has a leftwrist dropwith loss of sensation over the dorsal aspect of the firstinterosseusspace.Forthelasttwomonths,hehaslostweightandhehadgeneralizedmyalgia.Investigationsreveal:Hb11.5g/dLWBC13x10^9/lNeutrophils9.2x10^9/lLymphocytes2.2x10^9/lESR60mm/1sthourUrinalysis:Protein++,Blood++Themostlikelydiagnosisis:

A.TuberculosisB.PolyarteritisnodosaC.SarcoidosisD.RheumatoidarthritisE.Systemiclupuserythematosus

Answer:b)Polyarteritisnodosa.Thepatienthasasystemic illnesswithmononeuritismultiplexand renal involvement.Although all the listed conditions can cause mononeuritis, PAN is one of the fewconnective tissuedisorders thatusuallyoccur inmiddleagedmenunlikeRAandSLE,whicharecommonerinfemales.

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RheumatologyQ077A55yearoldmanpresentswithlethargy,polyuria,polydipsiaandstiffnessofthehands.Hehasevidenceofanarthopathyaffectingthe2nd&3rdmetacarpophalangealjointsofbothhands.Xrayconfirmsevidenceofdegenerativediseaseatthesesites.Whichofthefollowingthelikelydiagnosis?

A.Behcet'ssyndromeB.HaemochromatosisC.AmyloidosisD.Reiter'ssyndromeE.Osteoarthritis

Answer:b)haemochromatosis.The characteristic feature of haemochromatotic arthropathy is involvement of thesecondandthirdmetacarpals.Thearthropathycanleadtoextensivejointdestruction.These patients may have episodes of acute, inflammatory pseudogout from suchdeposition.



RheumatologyQ078An22yearoldgirlpresentswitha6weekhistoryofpolyarthralgiawithearlymorningstiffness.HersymptomsrespondedwellinitiallytoIbuprofenbutshethentheyworsenagain. She is otherw isewell apart from a history of acnewhichwell controlled onMinocycline.Hermothersevererheumatoidarthritis.Investigations show :ESR40mm/hr,CRP110mg/l, rheumatoid factornegative,ANAstronglypositive(1:1600),antidsDNAantibodiesnegative.Whatisthelikelycauseofhersymptoms?

A.DruginducedlupusB.SystemicLupusErythematosusC.PsoriaticarthropathyD.JuvenilechronicarthritisE.Fibromyalgia

Answer:a)Druginducedlupus.The likely diagnosis is drug induced SLE. Minocycline is one of the causes welldocumentedasacauseofdruginducedSLE.Characteristically,inflammatorymarkerssuchasESR&CRParebothmarkedlyelevated.ANAcanbestronglypositivebutAntidsDNAantibodiesareusuallynegative.Symptomsusuallyresolvefollowingwithdrawalofthedrugafterseveralmonths.



RheumatologyQ079A50yearoldwomanpresentstocasualtywitha2dayhistoryofpainandswellingoftheleftankle.Shedeniesanyhistoryofrecenttrauma.Onexamination,shewasfebrile,temperature38.3C.Theleftanklewasswollenandverytenderwithareducedrangeofmovement.Whichofthefollowinginvestigationswouldbemosthelpful?

A.UratelevelB.ESRC.RheumatoidfactorD.AspirationofsynovialfluidE.KneeXray

Answer:d)aspirationofsynovialfluid.Joint fluidexamination is important inexcluding septicarthritis,and canalsohelp toconfimgoutorpseudogout.



RheumatologyQ080A 35 yearoldwomanwithnewlydiagnosed rheumatoid arthritisenquires about riskfactors.Whichoneofthefollowingisariskfactorforrheumatoidarthritis?

A.PneumococcalinfectionB.HLADR4C.SLED.HIVE.Renalfailure

Answer:b)HLADR4.Riskfactorsforrheumatoidarthritisare:

HLADR4EBVparvovirusB19andrubellainfectionsbloodtransfusionsmoking(inducesRFproduction)stressobesityPregnancyandOCPareprotective.



RheumatologyQ081A26yearoldmanpresentswitha6monthhistoryoflowbackpain.Thepainradiatestohis buttocks. There is associated stiffnesswhich isw orse in themorning and afterperiodsofinactivity.Whichofthefollowingsignsismostlikelytobepresent?

A.FootdropB.PositivefemoralstretchtestC.PositiveTrendelenburgtestD.SacroiliacjointtendernessE.Kernigssign

Answer:D)sacroiliacjointtenderness.Thediagnosis isankylosingspondylitisasthis isayoungpatientwith lowerbackpainsandmorningstiffness.Sacroilitisisacommonmanifestation.

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RheumatologyQ085A40yearoldladypresentswithpolyuriaandthirst.Herserumcalciumof2.85mmol/landaparathyroidhormoneof12(18)pmol/l.Shehasnormalrenalfunction.Whichtestprovidesthebestassessment?

A.CTofherspineB.DualenergyXrayabsorptiometryC.VitaminDlevelsD.IsotopebonescanE.Urinebencejonesprotein

Answer:b)DualenergyXrayabsorptiometry.Thispatient is likely tohaveprimaryhyperparathyroidism (secondarytoaparathyroidadenoma).ThebestassessmentistodeterminetheseverityoflossofbonedensitywithaDEXAscaninordertoconsiderparathyroidsurgeryisnecessary.

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RheumatologyQ087A35yearoldwomanhasgeneralizedjointpainsandmuscleaches.Shealsocomplainsofgrittysensationsintheeyeinthemornings.BloodtestsshowAntiNuclearAntibody++,RheumatoidFactor++.Whatisthediagnosis?

A.PolylmyositisB.ReiterssyndromeC.PrimarySjogrenssyndromeD.PolyarteritisnodosaE.Rheumatoidarthritis

Answer:C)PrimarySjogrenssyndrome.Drymouth, dry eyes, fatigue,muscle aches and joint pains are typical of Sjogrenssyndrome.80%ofpatientsareANApositiveand75%areRheumatoidfactorpositive.AusefuldiagnostictestistheSchirmer'stest,whereapieceoffilterpaperisplacedinthecorneroftheeyetomeasurethedegreeofwettingafterfiveminutes.



RheumatologyQ088A60yearoldwomanpresentswithatwoweekhistoryofmalaiseandlowerlimbjointpains.On examination she had a vasculitic rash over her shins, thighs and buttocks.Investigationsrevealed:Hb10.2g/dLplatelets265X10^9/Lcreatinine380mol/LantinuclearantibodiesNegativeantineutrophilcytoplasmicantibodiesNegativeantiglomerularbasementmembraneantibodiesNegativedipstixurinalysisblood+++protein+Whatisthelikelydiagnosiscausingrenalimpairment?

A.PsoriaticarthritisB.HenochSchonleinpurpuraC.PolymyositisD.MembranousnephropathyE.Myeloma

Answer:b)HenochSchonleinpurpura.The distribution of the rash together with lower limb joint pains are suggestive ofHenochSchonleinpurpura.Thisusuallyoccursinchildrenaged210yearsbutcanoccurin older age groups. The onlyw ayof differentiating this condition from other smallvesselvasculitidesisbybiopsy.ThiswouldshowIgAdepositioninvesselwallsondirectimmunofluorescence.



RheumatologyQ089A28yearoldwomanpresentswitha rightknee jointpainanda4monthhistoryofweight loss.Shethinksshehas lostweightbecauseofdiarrhoea,whichoccursseveraltimesaday.Examinationrevealsaswollen,tenderrightkneejointwithasmalleffusion.Thelikelydiagnosisis:

A.Reiter'ssyndromeB.InflammatoryboweldiseaseC.Behcet'sdiseaseD.CampylobacterinfectionE.Rheumatoidarthritis

Answer:b)Inflammatoryboweldisease.The description of weight loss, diarrhoea and a mono/oligoarthropathy suggests adiagnosis of inflammatory bow el disease. Peripheral arthritis, peripheral arthralgiawithoutjointswellingoreffusion,degenerativejointdiseaseorseropositivearthritiscanoccur in inflammatory bow el disease. In patients with peripheral arthralgia andperipheral arthritis, there is a significantly greater prevalence of mucocutaneousmanifestationsofIBDi.e.oralulceration,erythemanodosum,pyodermagangrenosum,anduveitis.



RheumatologyQ090Aprofessional tennisplayerpresentswithshoulderpainsespeciallywhilstserving theball. He has limited passive and active shoulder abduction to less than 60. Histemperatureis36.5Candhehasanormalwhitecellcount.Thereistendernessaroundtheanteriorportionoftheshoulderjoint.Whichdiagnosisislikely?

A.GlenohumeraljointosteoarthritisB.BursitisC.TenniselbowD.SupraspinatustendonitisE.Septicarthritis

Answer:d)supraspinatustendonitis.Pain during abduction with limitation of movement is suggestive of supraspinatoustendonitis. Palpation or compression around the greater tubercle of the humerus isparticularlytender.



RheumatologyQ091A45yearwomanhasraynaudsphenomenon.Shealsohasdifficultyinswallowinganddyspnoea.Echocardiographyshowsrightheartstrain.Bloodtestsrevealrenalimpairment.Whichoneofthefollowingantibodiesisspecifictothislady'scondition?

A.AnticentromereantibodyB.TopoisomeraseIC.AntidsDNAantibodyD.AntiSCL70antibodyE.Antimitochondrialantibody

Answer:d)antiSCL70antibody.AntiSCL70antibody(topoisomeraseI)istypicallyfoundinprogressivesystemicsclerosis(notthelimitedcutaneousform,CREST).



RheumatologyQ092A55yearoldmanpresentswitha6weekhistoryoflethargyanddiffusepurpuricrash.He is noted to have a right foot drop and a left ulnar nerve palsy.He complains ofarthralgiabuthasnoclinicalevidenceofinflammatoryjointdisease.Echocardiogramisunremarkable, blood cultures are negative, ESR 80 mm/hr, ANCA negative, ANAnegative,rheumatoidfactorstronglypositive,C31.1g/l(0.751.6),C40.03g/l(0.140.5).Dipstickurinalysisshowsblood++.Whatisthelikelydiagnosis?

A.Takayasu'sarteritisB.ANAnegativeSLEC.CulturenegativeendocarditisD.CryoglobulinaemiaE.Rheumaticfever

Answer:d)Cryoglobulinaemia.A low C4 together with a strongly positive rheumatoid factor suggestscryoglobulinaemia as a cause ofmononeuritismultiplex and rash. Palpable purpura,arthralgia, hepatosplenomegaly, diffuse proliferative glomerulonephritis, Raynaud'sphenomenonandthrombosismayoccur.Type I cryoglobulinaemia may be associated with lymphoproliferative disorders,multiple myeloma, and monoclonal gammopathy of uncertain significance, andmacroglobulinaemia.Plasmapheresismayreducethelevelsofcryoglobulin.Type II cryoglobulinaemia (mixedmonoclonal) is usually composed of amonoclonalcomponent (usually IgG, IgMor IgA)andapolyclonalcomponent (mainly IgG).Causesare connective tissue diseases,Hepatitis B and C infection, infectiousmononucleosisandlymphoma.



RheumatologyQ093A70yearoldwomanwithahistoryofmultiplemyelomahasa serumcalciumof2.9mmol/l.Heisprescribedpamidronateinfusionover4days.Whatisitsmechanismofaction?

A.PromotescalcitoninB.IncreasescalcitriollevelsC.InhibitosteoclastsD.inhibitosteoblastsE.Stimulateparathyroidhormonesecretion

Answer:C)inhibitosteoclasts.Bisphosphonates inhibits osteoclasts and reduces progression tow ards bonedestruction.



RheumatologyQ094A 80 year old lady presentswith a 5 day history of severe left temporal headacheradiating fromhereye to the scalp. Shehad also experienced jawdiscomfortduringeating.Whichofthefollowingdrugsshouldbegivenwhileawaitingresultsofdiagnostictests?

A.CarbamazepineB.PrednisoloneC.AzathioprineD.InfliximabE.Intravenousimmunoglobulin

Answer:b)Prednisolone.The history suggests temporal arteritis. In view of the vision threatening nature ofdisease,thepatientshouldbecommencedonsteroids.Typically60mgofprednisoloneperdayisrecommended.

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RheumatologyQ096A60yearoldladyhassevererheumatoidarthritis.SheiscurrentlyonMethotrexate20mg weekly for the past 5months and also has been receiving regular infusions ofInfliximab. Her joint disease dramatically improved. She now presents with fevers,coughandthereisevidencealargeleftsidedpleuraleffusiononherCXR.Whatisthelikelydiagnosis?

A.MethotrexatepneumonitisB.CMVinfectionC.TuberculosisD.BronchialcarcinomaE.Rheumatoidrelatedpulmonaryfibrosis

Answer:c)tuberculosis.Serious opportunistic infections have been associated with the anti TNF alpha druginfliximab, but the frequency of TB exceeds that associated with other infections.Infliximabmayincreasetheriskoflymphoma.



RheumatologyQ097A75yearoldmanpresentswithanacuteonsetofseverepainandswellingoftheleftelbow.Hementionsthathehadachestinfection3weeksago.Onexamination,hehadatemperatureof38Candtheleftelbowwaserythematous,swollenandtender.Whatisthemostappropriateinvestigation?

A.CreactiveproteinB.FullbloodcountC.JointaspirationD.UricacidlevelE.Xrayofthejoint

Answer:C)jointaspiration.This patient is likely to have reactive arthritis.How ever, gram stain and culture arenecessarytoexcludesepticarthritis.



RheumatologyQ098A75yearoldmanhassignificantbonypainswhichhavebeenoccuringfor3years.Hepresents to the clinic for assessment and the investigations results were obtainedbelow:Correctedcalcium2.4(2.22.6)ESR20mm/1sthrAlkalinephosphatase625iu/L(50100)gammaGT42iu/L(1050)Prostatespecificantigen7.4pg/L(06)Whatisthemostlikelydiagnosis?

A.OsteoporosisB.OsteomalaciaC.MetastaticprostaticcarcinomaD.Paget'sdiseaseE.Multiplemyeloma

Answer:d)Paget'sdisease.Paget'sdiseasecausesahighalkalinephosphataseandnormalcalciumlevels.Paget'sDiseaserepresentsan imbalanceofboneformationandresorption. Ittypicallybeginswithexcessiveboneresorptionfollowedbyexcessiveboneformation.Themaindisturbanceisanexaggerationofosteoclasticboneresorption.Themostcommonsitesofinvolvementincludethespine,pelvis,skull,femurandtibia.Skullinvolvementmayproduceenlargementoftheheadcharacterizedbymoreevidentfrontalbossinganddilatedsuperficialcranialmuscles.Conductiveand/orsensorineuralhearing lossmayresult fromdiseaseofthetemporalboneorossicles.



RheumatologyQ099A75yearoldpatientwithosteoarthritisofthekneehasbeentakingcodeine30mgqdsandalsoparacetamolregularly.Hecontinuestohavekneepains.Whatisthenextbesttreatment?

A.DiclofenacB.MorphineC.IbuprofengelD.HigherdoseofcodeineE.Oralhydrocortisone

Answer:C)ibuprofengel.NSAIDS tend to be better for pain control in osteoarthritis, but have significant sideeffects. LocalNSAIDapplication shouldbe consideredaswellas intraarticular steroidinjections.

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