Case-based MCQ

Correct Answer Is A The ‘bumps’ shown in the photo are rheumatoid nodulosis. They are the most common cutaneous manifestation of rheumatoid arthritis (RA). The presence of subcutaneous rheumatoid nodules is associated with an increased risk of cardiovascular disease, as well as cardiovascular, respiratory, and all-cause mortality. The nodules are usually non-tender, and treatment is initiated only for cosmetic or functional reasons. Local glucocorticoid injections have been shown to decrease the size of subcutaneous rheumatoid nodules. Treatment of RA with methotrexate and other DMARDs can increase the frequency and number of rheumatoid nodules—a condition known as accelerated nodulosis. Discontinuing methotrexate may improve nodulosis, but this may enhance the long-term progression of joint destruction in RA. Topical steroids are used for ophthalmic manifestations of inflammatory conditions but have not been shown to be effective for treating rheumatoid nodulosis. Using NSAIDs may improve the pain but does not reduce the size and number of nodules. Surgery is reserved for patients with neurologic dysfunction or significantly decreased functionality.

A 55-year-old mechanic presented with non-painful, red bumps on his hand for several years as shown below. They lasted for a month and resolved spontaneously. He had underlying arthralgias in multiple joints such as bilateral hands, hips, and knees. During one episode, he was prescribed an oral steroid that seemed to relieve his symptoms. The nodules were firm and varied in size. There was no skin erosion, signs of infection, neurologic dysfunction, or decreased range of motion. The patient requested treatment because the nodules were interfering with his work. Which one of the following therapies should have been offered? A. Intralesional steroid injection B. Topical steroids C. Nonsteroidal anti-inflammatory drugs D. Surgery E. Disease-modifying anti-rheumatic drugs (DMARDs)

Correct Answer Is A Systemic sclerosis is generally subdivided into localized and diffuse cutaneous subtypes.These two subsets are principally distinguished by the extent of skin sclerosis and by the forms of organ involvement. Patients with localized scleroderma typically have skin sclerosis restricted to the hands and, to a lesser extent, to the face and neck. They also have prominent vascular manifestations and may suffer from the CREST syndrome (Calcinosis cutis, Raynaud phenomenon, Esophageal dysmotility, Sclerodactyly, and Telangiectasia). The presence of anti-centromere antibodies is usually associated with localized scleroderma in 90% of the cases. Only 5% of patients with diffuse systemic sclerosis have positive anti-centromere antibodies. So anti-centromere antibodies are helpful in making diagnosis of CREST syndrome. Anti-DNA topoisomerase I (Scl-70) antibodies are associated with diffuse cutaneous systemic sclerosis. All other given options are not helpful in making diagnosis of scleroderma.

A 34-year-old woman presented with swallowing difficulties, calcinosis and Raynaud’s phenomenon for the last 3 years. Which of the following antibody is most likely to help in establishing the diagnosis? A. Anti-centromere antibodies B. Anti-scl-70 C. Antinuclear antibody D. Rheumatoid factor E. Double stranded DNA

Correct Answer Is C The male is suffering from Cystic Fibrosis and would benefit from having a sweat chloride test. Cystic fibrosis is an autosomal recessive disorder resulting in a defect in an ion channel protein which affects the normal transport of chloride ions, leading to a decreased sodium and water transfer, thus causing viscid secretions. Clinical features include malaise, failure to thrive, chronic respiratory problems, malabsorption, infertility in males (atrophy of vas deferens) and pancreatic insufficiency.

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A couple who have been trying to conceive for the past 2 years were worked-up for primary infertility. The female had a normal examination. Male partner has an atrophy of vas deferens. Which of the following investigations should be done to determine the cause? A. Ultrasound B. Semen analysis C. Sweat Chloride Test D. CT Scan E. Anti-gliadin antibodies

Correct Answer Is A This patient has a very vague presentation of teenage onset of hereditary angioedema. Angioedema has a various range of symptoms including respiratory, gastrointestinal and oral symptoms.The hallmark of this clinical condition is non-itchy non-pitting swellings which develop over a period of day or two and could include laryngeal oedema, abdominal pain, vomiting and diarrhoea. C1 and C4 levels are helpful in making a diagnosis of hereditary angioedema and are low if the condition is present. C1 q level is helpful to diagnose acquired angioedema and are low if the condition is present. Tryptase levels are raised in food poisoning. Alkaline phosphatase level is increased in a number of conditions including bile duct obstruction, Paget’s disease, multiple myeloma, secondary hyperparathyroidism and healing fractured bones. Serum immunoglobulin levels of (IgG, IgM, IgA) etc are helpful in diagnosing various immune deficiency conditions and response to vaccinations and infections.

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A 19-year-old female comes to your office after she had recurrent swelling affecting her face, arms and legs. The swelling is non-pitting and non-pruritic. She had an admission to an emergency department 3 months ago because she was unable to breath. She had an appendectomy because of severe abdominal pain. Which of the following investigations is most helpful in diagnosis of this condition? A. C1 and C4 levels B. C1q level C. Tryptase level D. Alkaline phosphatase level E. Serum immunoglobulin levels

Correct Answer Is D About 95% of patients with systemic lupus arthritis develop intermittent arthritis. The most common presentation of this arthritis is symmetrical polyarthritis affecting the hands, wrist and knees. Tenosynovitis is relatively uncommon in SLE. Joint deformities are also uncommon in SLE. Monoarthritis if present suggests an alternate diagnosis.Osteoarthritis and septic arthritis are usually monoarthritis type presentations of the joint disease.

Which of the following is the most common presentation of arthritis in systemic lupus arthritis? A. Tenosynovitis B. Joint deformity C. Monoarthritis of joints in the hand D. Symmetrical arthritis of joints in the hands E. Osteoarthritis

Correct Answer Is A The first carpometacarpal joint of the thumb is a common area affected by osteoarthritis and this pattern of joint involvement is not seen in rheumatoid arthritis. In osteoarthritis, following joints are commonly involved: 1-The first carpometacarpal joint of the thumb. 2-First metatarsophalangeal joint of the big toe. 3-Distal interphalangeal joint. 4-Proximal interphalangeal joint. 5-Cervical and lumbar spine. 6-Knee joint. 7-Hip joint. Hand osteoarthritis spares the metacarpophalangeal joints and involves the proximal interphalangeal and distal interphalangeal joints, which helps to distinguish it from rheumatoid arthritis. In rheumatoid arthritis commonly involved joints include metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints. Distal interphalangeal (DIP) joint involvement may occur in rheumatoid arthritis, but it usually is a manifestation of coexistent osteoarthritis. Rheumatoid arthritis does not affect the thoracic and lumbar spine. The cervical spine is involved mainly in osteoarthritis, however, atlantoaxial joint (part of the cervical spine) is involved only in rheumatoid arthritis.

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Which one of the following joints is not involved in rheumatoid arthritis and is more commonly affected in osteoarthritis? A. Carpometacarpal joint of the thumb B. Temporomandibular joint C. Cervical spine D. Atlantoaxial-axial joint E. Shoulder joint