Rheumatology MCQ’s

Dr Himantha Atukorale
Consultant in Rheumatology and Rehabilitation
MBBS (Colombo) MD
MD part one – What are the
avenues??????!!
• After passing part 2 MD

General medicine – Physician

Rheumatology and Rehabilitation
Nephrology
Cardiology
Neurology
Medical Intensivist
Clincal Pharmacology
Pulmonology
Cardiac electrophysiology
Endrocrinology
Neuro electrophysiology
Gastroenterology
Geriatrics (future)
Rehabilitation specialist (Future)
Part 1
• 100 true/false questions
• 30 best of five

• If you pass this

• OSCE 20 stations – one on counselling, ECGS,
picture tests, data interpretation, patient advice,
snakes, equipment naming and
• MANDATORY CPR station – have to pass this or
exam failed
Part 2 – Seven components
• Lot of talking to do
Theory
• 1.Essay
• 2.Data interpretation 10 questions
• 3.Gray (Black) cases 5
• 4.20 pictures to identify in 60 minutes
• Cases
• 1.Six short cases(CVS RS NEURO ABDOMEN 2x
SPECIAL
• 2.Long case one – carries most marks
1. Rheumatoid arthritis
a. Is an erosive inflammatory type of arthritis
b. In a certain proportion of patients cause small
vessel vasculitis related damage
c. Atherosclerosis is not associated with rheumatoid
arthritis
d. Peri-articular osteopenia is seen
e. Seen in mostly females
• 1. TTFTT
RA Male to female ratio – 1 : 2.5
Rheumatoid arthritis (RA) and atherosclerosis are
two inflammatory diseases strictly linked.In fact,
although joint involvement is the prototypical feature
of RA, atherosclerotic cardiovascular diseases are the
major cause of mortality and morbidity in these
patients.
Small vessel vasculitis – neuropathy, skin rashes, eye
involvement etc
2. In diagnosing SLE
a. SLICC criteria can be used
b. ESR is included as a diagnostic criteria
c. Erosive arthritis is a diagnostic criteria
d. Features of migraine are considered under
neuropsychiatric diagnostic criteria
e. Anaemia should be always haemolytic to be
included as diagnostic criteria
• TFFFT
ACR mnemonic of SLE diagnostic criteria
The following are the ACR diagnostic criteria in SLE, presented in the "SOAP BRAIN
MD" mnemonic:
• Serositis - Pleurisy, pericarditis on examination or diagnostic electrocardiogram (ECG)
or imaging
• Oral ulcers - Oral or nasopharyngeal, usually painless; palate is most specific
• Arthritis - Nonerosive, 2 or more peripheral joints with tenderness or swelling
• Photosensitivity - Unusual skin reaction to light exposure
• Blood disorders - Leukopenia (< 4 × 10 3 cells/µL on >1 occasion), lymphopenia (<
1500 cells/µL on >1 occasion), thrombocytopenia (< 100 × 10 3 cells/µL in the
absence of offending medications), hemolytic anemia
• Renal involvement – Based on presence of proteinuria (>0.5 g/day or 3+ positive on
dipstick testing) or cellular casts (including red blood cells [RBCs], hemoglobin,
granular, tubular, or mixed) [96] or based on the opinion of a rheumatologist or
nephrologist [96]
• Antinuclear antibodies (ANAs) - Higher titers generally more specific (>1:160); must
be in the absence of medications associated with drug-induced lupus
• Immunologic phenomena - dsDNA; anti-Smith (Sm) antibodies; antiphospholipid
antibodies (anticardiolipin immunoglobulin G [IgG] or immunoglobulin M [IgM] or
lupus anticoagulant);
• Neurologic disorder - Seizures or psychosis in the absence of other causes
• Malar rash - Fixed erythema over the cheeks and nasal bridge, flat or raised
• Discoid rash - Erythematous raised-rimmed lesions with keratotic scaling and
follicular plugging, often scarring
3. ANCA associated vasculitis
a. Granulomatosis with polyangiitis (Wegner’s)has
necrotising granulomatous inflammation of upper and
lower respiratory tract
b. In ANCA associated vasculitis motor neuropathy is a
predominant feature
c. In Microscopic polyangiitis renal involvement is very
common (Necrotising glomerulonephritis)
d. c- ANCA, p- ANCA, MPO – ANCA and PR3- ANCA are
used in diagnosing ANCA Associated Vasculitis
e. Pseudotumours could cause compressive symptoms
• TTTTT
4. Esoinophilic granulomatosis with polyangiitis
(Churg Strauss Syndrome )
a. Asthma is a feature
b. Eosinophilia of more than 8 percent is
characteristic
c. Pathologically shows eosinophil rich and
necrotising granulomatous inflammation
d. p-ANCA is seen in nearly 99 percent of patients
e. c- ANCA is not present
• TFTFF
 Lodz Ghetto, Poland – 1942,
September 5
• Jewish children were rounded up to be sent to
Chelmno (death camp)for execution inside gas
chambers
• A written account explains how children hid in
furniture and bedding, others in basement, in heaps
of garbage and laundry, or in woodpiles.
• Parents did whatever they could, concealing children
“in barrels in the attics, in ditches in the field, covered
with leaves and branches.” One child sought refuge in
a tree but was shot dead when discovered.
• Child captives fought and scratched at the walls in a
last-ditch effort to resist removal
 Just three blocks away from Lodz
Ghetto. .
• A high-ranking 25 year old
military doctor was at his medical
office
• He was later accused of
conducting unethical experiments
inside the Ghetto on healthy
Jewish civilians
• Just three years before
evacuation, in 1939 he described
a disease that gave him fame
overnight
Dr.Friedrich Wegener (1907 –
1990)
• The American College of Chest Physicians awarded
Wegener a “master clinician” prize in 1989, a year
before he died.
• In 2000, Dr. Eric Matteson, a rheumatologist at the
Mayo Clinic, and Dr. Alexander Woywodt, a kidney
specialist now living in England, set out to write a
column celebrating Wegener for The Lancet and
the British medical journal.
• They uncovered a Nazi past that Wegener had kept
secret after World War II.
• American college of chest physicians cancelled the
prize and, separately, a campaign was begun to
rename Wegener's granulomatosis to ANCA-
associated granulomatous vasculitis.
• 2011 Chapel Hill Consensus Conference (CHCC)
recommended name change from the term
‘Wegner's granulomatosis’ to ‘Granulomatosis with
polyangitis’ (GPA)
• They took into consideration evidence that Dr
Friedrich Wegener was a member of the Nazi party
before and during World War II.
• c-ANCA against PR3- ANCA
• p-ANCA against MPO-ANCA
• Granulomatous pseudotumours can cause
compressive symp – retro orbital pseudotumours
P- ANCA
• Seen in
• Ulcerative colitis
• Primary sclerosing cholangitis
• RA
• Microscopic polyangiitis
• Focal necrotising and crescentic GN

c-ANCA
• 80-90% of granulomatosis with polyangiitis
• 20-40% of microscopic polyangiitis
• 20-40% of pauci-immune crescentic glomerulonephritis and
• 35% of eosinophilic granulomatosis with polyangiitis
• c-ANCA (atypical) is present in 80% of cystic fibrosis in inflammatory
bowel disease, primary sclerosing cholangitis and rheumatoid
arthritis (with antibodies to multiple antigenic targets).
5. Temporal arteritis( Giant cell arteritis)

a. Gold standard in diagnosing temporal arteritis is

biopsy
b. Typically occurs in people aged 50 or above
c. Associated with shoulder pain in certain instances
d. ESR is 50mm or higher for diagnostic purposes
e. If vision is affected at the onset ,the dose of
steroids used is higher
• TTTTT
American College of Rheumatology diagnostic criteria
The following are diagnostic criteria for GCA issued by the American
College of Rheumatology in 1990 (the presence of 3 or more yields
a diagnostic sensitivity of 93.5% and specificity of 91.2%)

• Age 50 years or older

• New-onset localized headache or localized head pain
• Temporal artery tenderness to palpation or decreased pulsation
• ESR of 50 mm/h or higher
• Positive arterial biopsy results (vasculitis characterized by
mononuclear infiltration or granulomatous inflammation, usually
with multinucleated giant cells)
• Recommended starting dosages of glucocorticosteroids for
GCA are:
• Uncomplicated GCA (no jaw claudication or visual
disturbance): 40–60 mg prednisolone daily.
• Evolving visual loss or amaurosis fugax (complicated GCA):
500 mg to 1 g of i.v. methylprednisolone for 3 days before
oral glucocorticosteroids.
• Established visual loss: 60 mg prednisolone daily to protect
the contralateral eye.
•
Tapered as
40–60 mg prednisolone continued until symptoms and
laboratory abnormalities resolve (at least 3–4 weeks);
then dose is reduced by 10 mg every 2 weeks to 20 mg;
then by 2.5 mg every 2–4 weeks to 10 mg; and
then by 1 mg every 1–2 months provided there is no relapse.
6. Polymyalgia rheumatica
a. Treatment of polymyalgia rheumatica involves a
tapering course of steroids
b. Usually the symptoms are unilateral initially involving
shoulders/ pelvic girdle or both
c. Age should be more than fifty years and symptoms
should last for more than two weeks
d. Serum alkaline phosphatase elevation and liver
enzyme abnormalities could occur
e. Morning stiffness is expected for more than forty-five
minutes
• TFTTT
For polymyalgia rheumatica

Core inclusion criteria: can be diagnosed with normal

inflammatory markers, if there is a classic clinical picture
and response to steroids. These patients should be
referred for specialist assessment.
Age >50 years, duration >2 weeks
Bilateral shoulder or pelvic girdle aching, or both
Morning stiffness duration of >45 min
Evidence of an acute-phase response
Core exclusion criteria:
Active infection
Active cancer
Active GCA
Mx of PMR
Daily prednisolone 15 mg for 3 weeks
Then 12.5 mg for 3 weeks
Then 10 mg for 4–6 weeks
Then reduction by 1 mg every 4–8 weeks or alternate
day reductions (e.g. 10/7.5 mg alternate days, etc.)
7. Anti CCP antibody test
a. Is more sensitive than rheumatoid factor in
determining rheumatoid arthritis
b. Can appear before X ray changes are evident in
rheumatoid arthritis and is an independent predictor
of joint damage
c. Is not an essential component of EULAR/ACR
diagnostic criteria for rheumatoid arthritis
d. Is always negative in seronegative rheumatoid
arthritis
e. Serial measurement of antibody titers is useful to
predict disease outcome
• TTFFF
Definition of “SEROLOGY”
• Negative: ≤ULN (for the respective lab)

• Low positive: >ULN but ≤3xULN

• High positive: >3xULN

8. Serum dsDNA in Systemic Lupus Erythematosus

a. Serum dsDNA titers correlate with disease activity in

SLE
b. Is highly associated with Lupus nephritis
c. Absence of dsDNA rules out SLE
d. Out of various methods used to detect ds DNA ,
Crithidia luciliae immunofluorescence test is thought to
have the highest specificity for SLE
e. dsDNA can be present in normal healthy individuals
• TTFTT
9. Adult onset Still's disease is associated with which
of the following typical features?

a. Lymphadenopathy
b. Rheumatoid factor
c. ANA
d. High ferritin level
e. . Maculopapular rash
• TFFTT
Adult Still's disease
• typically affects 16-35 year olds

Features
• arthralgia
• elevated serum ferritin
• rash: salmon-pink, maculopapular, pruritic
• pyrexia
• lymphadenopathy
• rheumatoid factor (RF) and anti-nuclear antibody
(ANA) negative
10. The following would not suggest an underlying
connective tissue disorder in a patient with
Raynaud's?
a. Calcinosis
b. Digital ulcers
c. Skin rash
d. Onset at 20 years old
e. Bilateral symptoms
• FFFTT
• Raynaud's phenomena may be primary (Raynaud's
disease) or secondary (Raynaud's phenomenon)

Raynaud's disease typically presents in young

women (e.g. 30 years old) with symmetrical attacks

Factors suggesting underlying connective tissue

disease
• onset after 40 years
• unilateral symptoms
• rashes
• presence of autoantibodies
• digital ulcers and calcinosis
Secondary causes
• connective tissue disorders: SLE, scleroderma,
rheumatoid arthritis
• leukaemia
• type I cryoglobulinaemia, cold agglutinins
• use of vibrating tools
• drugs: oral contraceptive pill, ergot
• cervical rib

Management
Core body warming
• calcium channel blockers
• IV prostacyclin infusions
• Topical GTN
• Sildenafil
• Bosentan
11. Which of the following are not risk factors for
developing osteoporosis?
a. Smoking
b. Obesity
c. Homocystinuria
d. Diabetes mellitus
e. Female sex
• FTFFF
Low body mass, rather than obesity is associated
with an increased risk of developing osteoporosis
Osteoporosis: Risk factors
• family history
• female sex
• increasing age
• deficient diet
• sedentary lifestyle
• smoking
• premature menopause
• low body weight
• Asians and Orientals
Diseases which predispose
• endocrine: glucocorticoid excess (e.g. Cushing's,
steroid therapy), hyperthyroidism, hypogonadism
(e.g. Turner's), growth hormone deficiency,
hyperparathyroidism, diabetes mellitus
• multiple myeloma, lymphoma
• GI problems: malabsorption (e.g. coeliacs),
gastrectomy, liver disease
• rheumatoid arthritis
• long term heparin therapy
• chronic renal failure
• osteogenesis imperfecta, homocystinuria
12. In drug-induced lupus the following are common
associations?
a. Glomerulonephritis
b. Hydralazine ,carbamazepine
c. anti histone antibody
d. ANA present in 100 percent
e. Pleurisy
• FTTTT
• Drug-induced lupus
• Glomerulonephritis is unusual in drug-induced
lupus

In drug-induced lupus not all the typical features of

systemic lupus erythematous are seen, with renal
and nervous system involvement being unusual. It
usually resolves on stopping the drug
• Features
• arthralgia
• myalgia
• skin (e.g. malar rash) and pulmonary involvement
(e.g. pleurisy) are common
• ANA positive in 100%, dsDNA negative

Causes
• procainamide
• isoniazid
• minocycline
• hydralazine
• chlorpromazine
• anti-epileptics: carbamazepine, phenytoin
13. Systemic sclerosis

a. Anti scl-70 antibodies are very specific for diffuse

systemic sclerosis
b. Nifedipine, Alendronate and steroids are the only
factors predisposing to gastro oesophageal reflux
c. Best antihypertensive of scleroderma renal crises
is calcium channel blockers
d. Small bowel involvement leads to malabsorption
e. Raynaud’s phenomenon is a common
manifestation
• TFTTT
• Although ANA is positive in 90% of patients with
systemic sclerosis, anti-Scl-70 antibodies are the
most specific test for diffuse cutaneous systemic
sclerosis
Systemic sclerosis

A group of conditions of unknown aetiology

characterised by hardened, sclerotic skin and other
connective tissue

Overview
• increase in type I collagen in tissues
• female:male = 4:1
• Three patterns of disease:

Limited cutaneous systemic sclerosis - 'CREST

syndrome'
• CREST: Calcinosis, Raynaud's phenomenon,
oEsophageal dysmotility, Sclerodactyly,
Telangiectasia
• Raynaud's may be first sign
• scleroderma affects face and distal limbs
predominately
• associated with anti-centromere antibodies
Diffuse cutaneous systemic sclerosis
• scleroderma affects trunk and proximal limbs
predominately
• associated with scl-70 antibodies
• hypertension, lung fibrosis and renal involvement
seen
• poor prognosis

Scleroderma (without internal organ involvement)

• tightening and fibrosis of skin
• may be manifest as plaques (morphoea) or linear
In all types
• ANA positive in 90%
• RF positive in 30%
14. Regarding psoriatic arthropathy?

a. Skin disease always precedes joint disease

b. Approximately one-third of patients with psoriasis
eventually develop arthropathy
c. Common site of occurrence in the spine is the
cervical region
d. Males and females are equally affected
e. Arthritis mutilans is the most common subtype
• FFTTF
Males and females are affected equally by psoriatic
arthritis

Psoriatic arthropathy correlates poorly with

cutaneous psoriasis and often precedes the
development of skin lesions.

Around 10% percent of patients with skin lesions

develop an arthropathy with males and females
being equally affected
Types
• rheumatoid-like polyarthritis: (30-40%, most
common type)
• asymmetrical oligoarthritis: typically affects hands
and feet (20-30%)
• sacroilitis
• DIP joint disease (10%)
• arthritis mutilans (severe deformity fingers/hand,
'telescoping fingers')
15. Regarding biological agents used for
inflammatory arthritis

a. Infliximab is an anti TNF agent which is also used in

inflammatory bowel diseases
b. Anti TNF agents such as etanercept are useful in
axial spondyloarthritis
c. Rituximab acts on pre B lymphocytes
d. Tocilizumab is an agent used in Sri Lankan for
systemic Juvenile Idiopathic Arthritis and
Rheumatoid Arthritis
e. Are usually considered after DMARDS fail in
controlling inflammatory arthritis
• All true
• Infliximab - is a chimeric monoclonal antibody
biologic drug that works against tumor necrosis
factor alpha (TNF-α)
• Etanercept - fusion protein produced by
recombinant DNA and it fuses the TNF receptor-
works against
• Rituximab - Rituximab is a chimeric monoclonal
antibody against the protein CD20 on pre B
lymphocytes
• Tocilizumab -humanized monoclonal antibody
against the interleukin-6 receptor (IL-6R)
In Sri Lanka
• We have Infliximab (Not the original biologic but
the biosimilar), Rituximab (again the biosimilar),
Tocilizumab (original biological agent), Etanercaept
(Not the biologic, not the biosimilar but an
intended copy!), Golimumab (the original)
• Expensive therapy
• Around Rs 1.2 million per annum for some drugs
per patient.
16. Name whether the following associations are
true or false…
a. Anti-Ro: Sjogren's syndrome, SLE, congenital heart
block
b. anti-Jo 1: polymyositis
c. Screening for possible neonatal lupus in pregnant
SLE patients is done using Anti Ro around 16-weeks
of POA
d. HLA B27 : sero negative spondyloarthritis
e. VDRL positivity : antiphospholipid syndrome
• All true
• Anti Jo 1 – ILD
• SLE pregnant patients – Anti Ro (Anti SSA) second
trimester, Also C3 C4 complement levels each
trimester, anti ds DNA antibodies
• VDRL is positive in some APLS patients
• APLS = Hughes syndrome
17. Sjogren's syndrome is associated with which of
the following,

a. Renal tubular acidosis

b. Marked decrease in lymphoid malignancy
c. Dyspareunia and Raynaud's phenomenon
d. 100% Rheumatoid factor positivity
e. hypogammaglobinemia
• TFTTF
• hypergammaglobilunaemia
• Increase in lymphoma
• dry eyes -artificial tears
• medications to reduce inflammation
• punctal plugs, or surgery to shut the tear ducts
• dry mouth, chewing gum (preferably sugar free),
sipping water, or a saliva substitute
• medications that can cause dryness may also be
stopped such as antihistamines+ cola,coffee.
Best of five
1. A 47-year-old man with a history of haemoptysis and shortness of breath presents to the
medical casualty at Kandy hospital. He smokes intermittently. And gives a history compatible
with long standing sinusitis. Initial investigations reveal:

Hb 10.4g/dl
Platelets 477 * 109/l
WCC 14.3 * 109/l

ESR 92 mm/h

Serum Na+ - 140

K+ - 4.7
Creatinine 2.23mg (elevated)

Urine dipstick blood +++

Rheumatoid factor not detected

What is the most likely diagnosis?

a.Mixed cryoglobulinaemia
b.Takayasu's arteritis
c.Wegener's granulomatosis
d.Haemolytic uraemic syndrome
e.Henoch-Schonlein purpura
• Wegeners
2. A 34-year-old intravenous drug user is admitted with a purpuric
rash affecting her legs. Blood tests reveal the following:

Hb 11.4g/dl
Platelets 489 * 109/l
WCC 12.3 * 109/l

HCV PCR positive

HBsAg negative

Rheumatoid factor positive

C3/C4 reduced

What is the most likely diagnosis?

a.Polyarteritis nodosa
b,Henoch-Schonlein purpura
c.Wegener's granulomatosis
d.Cryoglobulinaemia
e.Systemic lupus erythematous
• d.Cryoglobulinaemia
Hepatitis C infection is associated with type II (mixed) cryoglobulinaemia,
suggested by the purpuric rash, positive rheumatoid factor and reduced
complement levels

Immunoglobulins which undergo reversible precipitation at 4 deg C,

dissolve when warmed to 37 deg C. One third of cases are idiopathic

Three types
• type I (25%): monoclonal
• type II (25%): mixed monoclonal and polyclonal: usually with RF
• type III (50%): polyclonal: usually with RF

Type I
• monoclonal - IgG or IgM
• associations: multiple myeloma, Waldenstrِ m macroglobulinaemia

Type II
• mixed monoclonal and polyclonal: usually with RF
• associations: hepatitis C, RA, Sjogren's, lymphoma

Type III
• polyclonal: usually with RF
• associations: RA, Sjogren's
Symptoms (if present in high concentrations)
• Raynaud's only seen in type I
• cutaneous: vascular purpura, distal ulceration,
ulceration
• arthralgia
• renal involvement (diffuse glomerulonephritis)

Tests
• low complement (esp. C4)
• high ESR

Treatment
• immunosuppression
• plasmapheresis
3. A 22 year old lady who was holidaying in
Hikkaduwa (originally from a Scandinavian country)
presents with typical erythema nodosum. She has a
low grade fever and bilateral ankle arthritis but no
other symptoms and has no medical history. She is
on no medication. Which of the following would be
the most appropriate investigation for this patient?

1 )Barium enema
2 )Chest x-ray
3 )ESR
4 )Upper GI endoscopy
5 )Viral titres
• Chest X ray
• Löfgren syndrome = triad of erythema nodosum,
bilateral hilar lymphadenopathy on chest
radiograph, and arthralgia.
• Chest X ray more dramatic than functional
impairment
 .
4 A 30 year-old man from Jaffna is admitted to casualty with a 24 hour
history of a painful and swollen right knee. He denies any previous history
of joint problems. Over the last two days, he has also noticed redness and
soreness in both eyes. He has returned from a business trip to Kuala
Lumpur a fortnight ago.
On examination, his temperature is 38.5°C. His eyes are red. His right knee
is hot, swollen and tender to palpate. No other joint appears to be
affected. He does not seem to be septic.
Investigations: Hb 12.9 g/dl WBC 14.0 x 109/l Platelets 200 x 109/l ESR 75
mm/h Blood cultures=No growth after 48 hours
Urinalysis=No blood, glucose or protein detected, Knee x-ray=Soft tissue
swelling around left knee
What is the most likely diagnosis?
1 )Gout
2 )Gonococcal arthritis
3 )Reiter's syndrome
4 )Rheumatoid arthritis
5 )Viral arthritis
• Reactive arthritis (Reiters )
Triad : inflammatory arthritis of large joints
inflammation of the eyes in the form of conjunctivitis
or uveitis
urethritis in men or cervicitis in women
Arthritis occurring alone following sexual exposure or
enteric infection is also known as reactive arthritis.
mucocutaneous lesions, psoriasis-like skin lesions
such as circinate balanitis, keratoderma
blennorrhagicum.
Enthesitis =Achilles tendon
• 1916 - Reported a German Lieutenant with non-
gonococcal urethritis, arthritis and uveitis while
serving in the 1st world war
• Named Reiter’s syndrome
• Reiter designed typhus inoculation experiments
that killed more than 250 Jewish prisoners at
concentration camp-Buchenwald
• Enforced racial sterilisation and euthanasia of Jews
• Served a prison sentence in an American war camp
• 1977 – Term Reactive arthritis instead of Reiter’s
syndrome was suggested
• 2009 – Name change was established
Hans Conrad Julius Reiter(1881-
1969)
5.A 69 year old retired nurse who was on Methotrexate and Infliximab for
Rheumatoid arthritis presented with night sweats, weight loss and fatigue.
She is also on prednisolone and Alendronate. Examination revealed no
synovitis and DAS28 points out to mild disease activity. No rashes were
detected.
Ix Hb – 12.4 White cells – 7100 Platelets 501,000 Rheumatoid factor –
1/320 ANA negative Anti ds DNA negative ESR 89mm CRP – 58 mg/dl
Chest X Ray – Normal Varicella Zoster – Ig G positive

Whats the next best test to perform

a. Mantoux test
b. Bone marrow biopsy
c. CT Thorax, Abdomen and Pelvis
d. Quantiferon test for latent TB
e. Muscle enzymes
• CT
B symptoms :

Fever >38°C.
Drenching sweats, especially at night.
Unintentional weight loss of >10% of normal body
weight over a period of 6 months or less

Extra Pul TB - involving organs other than the lungs.

pleura, lymph nodes, abdomen, genitourinary tract,

skin, joints and bones, or meninges
6. A 65 year old lady had stiffness of her shoulders and pelvic girdle for
four weeks. She was started on prednisolone by a doctor at a dose of
15mg mane. After two weeks as she felt better the dose was brought
down to 10mg day. Two days later she came with bilateral wrist pain.
ESR 10mm
CRP 6mg
Rheumatoid factor 8 IU( normal)
WBC and differential counts normal
Serum Ionized calclium normal

What is the next appropriate test to do?

a. Anti CCP antibodies
b. Mammogram
c. Chest X ray
d. Serum CPK
e. Ultrasound scan of 2nd and 3rd MCP joints and wrists
• Anti CCP ab
• PMR – No wrist pain
• USS might not show changes such as synovitis- an
effusion does not point out to a diagnosis
• If Anti CCP positive – one supportive criteria for
2010 ACR EULAR RA
7. A 55 year toddy tapper from Negombo presented with extensive
psoriasis and multiple joint pain worsening over six months. He had
episodes of swelling of right big toe and left wrist but no symptoms of
spine. There is also a history of mild pain and stiffness of his hands. He is
allergic to several NSAIDS. Examination reveals chronic plaque psoriasis
over the extensor surfaces of knees and elbows. No evidence of trophi
exist. His left wrist and right ankle are warm to touch and swollen.
Uric acid 0.62 (normal 0.4) CRP 32 Urea 5 (4-7) Creatinine normal
Rheumatoid factor 20 IU ( < 15)
Together with lifestyle modification advice what is the immediate
intervention that is needed.

a. Allopurinol
b. Disease modifying anti rheumatoid drugs
c. IM steroids, Allopurinol and colchicine prophylaxis
d. IM steroid and DMARD
e. IM steroid and colchicine
• IM steroid and colchicine
• Allopurinol is not the jump start drug in acute gout
• Given in chronic gout
• Steroids steroid injections NSAIDS colchicine are for
acute gout
• Febuxostat is also used for chronic gout
• Allopurinol and Azathioprine combination -
tests for thiopurine methyltransferase (TPMT)
enzyme activity is done prior to or BONE MARROW
TOXICITY
8. A 58 year old male presented to Karapitiya hospital ENT ward. He had an uneventful
past medical history since recently when he started getting pain felt within the throat,
with hoarse voice.
He also had polyarthralgia without swelling of hand joints. Later on he had eye redness
and pain with the both ear lobes becoming red, swollen and very painful to touch.
The medical officer also noted that his nasal bridge was flat, which a bystander
commented was a recent occurrence.
He has not had any skin rashes, lymphadenopathy or evidence of neuropathy.
Blood tests – Full blood count normal,ESR 67mm,CRP 28 mg,Rheumatoid factor –
Negative,ANA negative,Anti cardiolipin antibodies negative,Chest X ray normal, X ray
– Hands – no joint deformities erosions noted, soft tissue swelling noted in MCP joints
The ENT medical officer wants medical registrar( your!) expert opinion as hands are
involved. He knows you are an excellent diagnostician and he prefers not to reveal his
findings.
What is the diagnosis?
a. Rheumatoid arthritis
b. ANCA associated vasculitis
c. Septic arthritis
d. Relapsing polychondritis
e. Poncet’s disease
• d. Relapsing polychondritis
• Relapsing polychondritis - severe, episodic, and
progressive inflammatory condition involving
cartilaginous structures
• Ears, nose, and laryngotracheobronchial tree
• Other structures eyes, cardiovascular system,
peripheral joints, skin, middle and inner ear, and
central nervous system

• Poncet’s disease - is a form of reactive polyarthritis

related with active TB in which no mycobacterial
involvement can be found in the affected bones or
joints
• there is absence of other detectable causes of
polyarthritis
All the best!