STUDY QUESTION GUIDE AND ANSWERS: SPRING 2010

RHEUMATOLOGY
1.

A febrile 56-year-old male alcoholic has pain in his right big toe that woke him up at night. He has
been taking low doses of aspirin to relieve the pain without relief. His mother has severe
osteoarthritis. The right toe is swollen, hot and exquisitely sensitive to touch. Laboratory studies
show a neutrophilic leukocytosis and left shift. A synovial tap is performed. Based on the above
history, which of the following most likely apply to this case? SELECT 2
A.
Septic joint disease
B.
Enhanced purine metabolism
C.
Negatively birefringent crystal
D.
Underexcretion of uric acid
E.
HLA B27 positive spondyloarthropathy
Answers: C, D: the patient has gout: C. Negatively birefringent crystal: yellow and parallel to the slow
ray, D. underexcretion of uric acid: most cases of gout are underexcretion rather than overproduction of
uric acid.
It is not septic joint disease (A) with this kind of history. Most cases are underexcretors (B) rather than
overproducers of purines. There is no relationship with HLA B27 (E) positive spondyloarthropathy.
2.
Which of the following are common findings in both rheumatoid arthritis and osteoarthritis?
SELECT 2
A.
Cartilage fibrillation
B.
Inflammatory arthritis
C.
Osteophytes
D.
Ankylosis of the joint
E.
Female dominance
F.
Subchondral bone cysts
G.
Symmetric joint involvement
H.
Proximal interphalangeal joint involvement
Answers: E, H: E. Female dominance, H. Proximal interphalangeal joint involvement: called Bouchard's
nodes in OA.
Cartilage fibrillation (A), osteophytes (C), and subchondral bone cysts (F) characterize OA. Inflammatory
joint disease (B), ankylosis of the joint (D) and symmetric joint involvement (G) characterize RA.
3.
A 28-year-old man, who works in a summer camp in upstate New York, develops bilateral facial
weakness involving both the upper and lower facial muscles. He also complains of joint pains in
both knees. He has a history a few months ago of an erythematous rash on his right thigh that was
circular, and had a central area of clearing. A CBC shows a mild hemolytic anemia and intraerythrocytic parasites. Which of the following findings apply to this case? SELECT 2
A.
Positive rheumatoid factor
B.
Positive serologic test for a spirochete
C.
Cranial nerve VII palsy
D.
Non-destructive joint disease
E.
Positive serum ANA
F.
Erythema marginatum
G.
Malaria
Answers: B, C: the patient has Lyme's disease with erythema chronicum migrans (not erythema
marginatum (F), which is associated with rheumatic fever), bilateral Bell's palsy, and a hemolytic anemia

due to Babesia microti (not malaria, G): B. Positive serologic test for a spirochete: Borrelia burgdorferi,
C. Cranial nerve VII palsy: bilateral Bell's palsy is very characteristic of Lyme's disease.
Rheumatoid factor (A) and serum ANA (E) are negative. Joint disease, the MC late manifestation of the
disease, is destructive (D).
4.
Which of the following joint disease/x-ray finding relationships are correctly matched? SELECT 2
A.
Reiter's syndrome periostitis at insertion of Achilles' tendon
B.
Rheumatoid arthritis ankylosis of DIP joint
C.
Calcium pyrophosphate deposition arthropathy pencil in cup deformity
D.
Gout erosive arthritis with overhanging margins
E.
Ankylosing spondylitis linear densities in articular cartilage
Answers: A, D: A. Reiter's syndrome periostitis at insertion of Achilles' tendon: very characteristic, D.
Gout erosive arthritis with overhanging margins: characteristic x-ray finding when tophi are involving a
joint
B. Rheumatoid arthritis ankylosis of DIP joint: no, ankylosis may occur in the MCP and/or PIP joints,
not the DIP joint.
C. Calcium pyrophosphate deposition arthropathy pencil in cup deformity: no, this describes psoriatic
arthritis. CPPD has linear calcification in the articular cartilage, usually of the knee.
E. Ankylosing spondylitis linear densities in articular cartilage: no, this describes CPPD. AS is
associated with sacroiliitis and eventually ankylosis of the vertebra ("bamboo" spine).
5.
A febrile, sexually active 23-year-old woman has a hot, swollen right knee and pustular lesions on
the palm of her left hand. She recently returned from a camping trip in Colorado. Which of the
following apply to this case? SELECT 2
A.
Gram positive diplococcus
B.
Septicemia
C.
Complement deficiencies
D.
Spirochetal disease
E.
Tick transmitted
Answers: B, C: the patient has disseminated GC: B. Septicemia: occurs in 40%, C. Complement
deficiencies: C6-C9 deficiencies may be present.
A. Gram positive diplococcus: no, gram negative diplococcus.
D. Spirochetal disease: no, this is not Lyme's disease.
E. Tick transmitted: no, this is not Lyme's disease. It is sexually transmitted.
6.
Synovial fluid aspirated from an inflamed right knee joint of a 45-year-old man shows a triclinic
crystal that is blue when parallel to the slow ray of the compensator. An x-ray of the knee shows a
linear calcification in the articular cartilage. Which of the following apply to this case?
A.
Inflammatory joint disease secondary to a positively birefringent crystal
B.
Association with HLA-B27 spondyloarthropathy
C.
Disorder of purine metabolism
D.
Positive blood culture
E.
Septic arthritis
Answer: A: the patient has chondrocalcinosis (calcium pyrophosphate disease) associated with
hemochromatosis (see bolded areas). A. Inflammatory joint disease secondary to a positively birefringent
crystal
B. Association with HLA-B27 spondyloarthropathy: no, there is no association
C. Disorder of purine metabolism: no, this is not gout.
D. Positive blood culture: no, this is not septic arthritis.
E. Septic arthritis: no, this is not septic arthritis.

7.

The patient is a 40-year-old man who has had problems with his back since 22 years of age. He
states that the problem started with pain in his lower back when he got up in the morning and over
time the pain involved other parts of his spine. He know complains of blurry vision and exertional
dyspnea. Physical exam demonstrates severe kyphosis. A ciliary flush is present in both eyes and a
poor pupillary response to light. The intraocular pressure is normal. He also has a high pitched
diastolic blowing murmur off the second heart sound in the right second intercostal space and an S 3
heart sound that increase in intensity with expiration. Which of the following apply to this case?
SELECT 2
A.
Relationship with HLA B27
B.
Optic neuritis
C.
Rheumatoid arthritis variant
D.
Aortic regurgitation
E.
Obstructive lung disease
Answers: A, D: the patient has ankylosing spondylitis (AS) A. Relationship with HLA B27, D. Aortic
regurgitation: due to aortitis, which produces the murmur of aortic regurgitation: note the S 3 heart sound
from volume overload of the left ventricle.
B. Optic neuritis: no, uveitis (ocular problems in the patient) rather than optic neuritis, which is
characteristic of multiple sclerosis.
C. Rheumatoid arthritis variant: no, it is a seronegative (RF negative) spondyloarthropathy.
E. Obstructive lung disease: no, kyphosis produces a restrictive type of lung disease
8.
A 32-year-old man with a long history of ulcerative colitis develops joint pains in his knees and
lower back. Which of the following apply to this case? SELECT 2
A.
Inflammatory joint disease
B.
Positive rheumatoid factor
C.
HLA-B27 haplotype
D.
Hyperuricemia
E.
Septicemia
Answers: A, C: the patient has ankylosing spondylitis associated with ulcerative colitis (UC) A.
Inflammatory joint disease, C. HLA-B27 haplotype: the UC was the environmental trigger that prompted
AS.
B. Positive rheumatoid factor: no, AS is not a variant of rheumatoid arthritis.
D. Hyperuricemia: no, this is not gout
E. Septicemia: no, this is not septic arthritis
9.
A 5-year-old girl has an acute onset of fever, generalized rash, generalized, painful, lymphadenopathy, and polyarthritis. The cardiac exam is normal. A CBC shows an absolute neutrophilic
leukocytosis, mild normocytic anemia, and a normal platelet count. Which of the following apply to
this case? SELECT 2
A.
Positive serum ANA with rim pattern
B.
Inflammatory joint disease
C.
Positive blood culture
D.
Positive antistreptolysin O titer
E.
Negative rheumatoid factor
Answers: B, E: the patient has juvenile rheumatoid arthritis, specifically Still's disease B. Inflammatory
joint disease, E. Negative rheumatoid factor: yes, this is the rule.
A. Positive serum ANA with rim pattern: no, this is not SLE.
C. Positive blood culture: no, this is not infective endocarditis or septic arthritis.
D. Positive antistreptolysin O titer: no, this is not rheumatic fever owing to the negative cardiac exam and
generalized lymphadenopathy.

10.

Which of the following are more commonly associated with osteoarthritis than ankylosing
spondylitis? SELECT 2
A.
Blurry vision
B.
Inflammatory joint disease
C.
Bouchard's nodes
D.
Restrictive lung disease
E.
Relationship to obesity
F.
Vertebral column disease
Answers: C, E: C. Bouchard's nodes: osteophytes on the PIP joint, E. Relationship to obesity: OA
involves weight bearing joints.
A. Blurry vision: no, uveitis is a feature of AS.
B. Inflammatory joint disease: no, OA is not inflammatory while AS is inflammatory.
D. Restrictive lung disease: no, this is a feature of AS.
F. Vertebral column disease: both have vertebral column disease, OA with osteophytes and AS with
ankylosis
11. Which of the following are commonly associated with hyperuricemia? SELECT 4
A.
Disseminated cancer
B.
Alcoholic
C.
High doses of aspirin
D.
Lead poisoning
E.
Thiazides
F.
Underactivity of 5-phosphoribosyl-1-pyrophosphate
G.
Sulfinpyrazone
H.
Allopurinol
Answers: A, B, D, E: A. Disseminated cancer: increased production of purines, B. Alcoholic: decreased
excretion of uric acid due to competition with lactate and -OHB anions for excretion in the proximal
tubule, D. Lead poisoning: interferes with excretion of uric acid, E. Thiazides: increased reabsorption
from volume depletion.
C. High doses of aspirin: no, it is uricosuric. Low doses of aspirin inhibit uric acid secretion and may
cause hyperuricemia.
E. Allopurinol: no, it blocks xanthine oxidase in purine metabolism and lowers uric acid.
12. A febrile 23-year-old man develops dysuria associated with a penile discharge, bilateral conjunctivitis, sausage-shaped inflammation of fingers in his left hand, and pain at the insertion of the right
Achilles tendon. His last sexual contact was 10 days ago. Which of the following tests are likely to
be abnormal in this patient? SELECT 2
A.
Rheumatoid factor
B.
Urine sediment exam
C.
Serum uric acid
D.
Standard urine culture
E.
HLA-B27 haplotype
F.
Positive gram stain for bacteria in a conjunctival swab
G.
Positive gram stain for bacteria in a urethral swab
Answers: B, E: the patient has Reiter's syndrome with Chlamydial urethritis, sterile conjunctivitis,
Achille's tendon periostitis, and arthritis (HLA B27 positive type) B. Urine sediment exam: a sterile
pyuria is present from Chlamydial urethritis, E. HLA-B27 haplotype:
A. Rheumatoid factor: no, this is not rheumatoid arthritis.
C. Serum uric acid: no, this is not gout.
D. Standard urine culture: no, it would be negative, since Chlamydia grows on different culture media.
F. Positive gram stain for bacteria in a conjunctival swab: no, it would not reveal organisms, since it is a
sterile conjunctivitis.

G. Positive gram stain for bacteria in a urethral swab: no, Chlamydia do not stain with Gram stains
13. Which of the following findings characterize rheumatoid arthritis rather than ankylosing
spondylitis? SELECT 4
A.
HLA-Dr4 haplotype
B.
Carpal tunnel syndrome
C.
Bamboo spine
D.
Subcutaneous nodules
E.
Autoantibody against IgG
F.
Inflammatory joint disease
G.
Kyphosis
H.
Cervical spine involvement
I.
Ankylosis of joints
Answers: A, B, D, E: A. HLA-Dr4 haplotype: yes, AS is associated with HLA-B27, B. Carpal tunnel
syndrome: yes, often related to amyloid deposition in the transverse ligament, D. Subcutaneous nodules:
yes, usually along the extensor surface of the elbows, E. Autoantibody against IgG: yes, an IgM antibody
against the Fc portion of IgG, called rheumatoid factor. It is not only an autoantibody but is an
immunocomplex that is responsible for the arthritis.
C. Bamboo spine: no, this characterizes AS.
F. Inflammatory joint disease: no, both are inflammatory.
G. Kyphosis: no, this is a feature of AS.
H. Cervical spine involvement: no, they both involve this area. RA leads to atlantoaxial joint instability,
while AS produces ankylosis of the vertebra.
I. Ankylosis of joints: no, both produce ankylosis of joints
14. A 58-year-old man with a 10 year history of gout is noted to have nodular masses in the
periarticular tissue of the proximal and distal interphalangeal joints of his right hand. An x-ray of
the fingers demonstrates an erosive arthritis with overhanging margins. Which of the following
apply to this case? SELECT 2
A.
Chronic gout
B.
Pathognomonic lesion of chronic gout
C.
Nodular masses are histologically similar to a rheumatoid nodule
D.
Nodular masses contain weakly positive birefringent crystals
E.
Nodular masses represent osteophytes
Answers: A, B: the patient has chronic gout with tophus deposition producing an erosive arthritis A.
Chronic gout: presence of tophi indicates chronic gout, B. Pathognomonic lesion of chronic gout: yes,
tophi are only seen in gout.
C. Nodular masses are histologically similar to a rheumatoid nodule: no, fibrinoid necrosis is present in
rheumatoid nodules, while multinucleated giant cells and negatively birefringent crystals are present in
tophi.
D. Nodular masses contain weakly positive birefringent crystals: no, they contain negatively birefringent
crystals of monosodium urate. Calcium pyrophosphate is positively birefringent.
E. Nodular masses represent osteophytes: no, they are tophi. Osteophytes are present in OA.
15. Restrictive lung disease, pleural effusion with low glucose, splenomegaly, absolute neutropenia,
and xerostomia would most likely be associated with which of the following laboratory test
abnormalities? SELECT 3
A.
Positive rheumatoid factor
B.
Anti-SS-B (La) antibodies
C.
Positive serum ANA with rim pattern
D.
Anti-ds DNA antibodies
E.
Lymphocytic destruction of minor salivary glands

Answers: A, B, E: the findings characterize the spectrum of diseases seen in rheumatoid arthritis (RA)
A. Positive rheumatoid factor, B. Anti-SS-B (La) antibodies: yes, xerostomia is noted in Sjogren's
syndrome, E. Lymphocytic destruction of minor salivary glands: yes, these are the histologic findings in
Sjogren's syndrome.
C. Positive serum ANA with rim pattern: no, these are findings associated with SLE.
D. Anti-ds DNA antibodies: no, these are specific for SLE with renal disease
16. A 65-year-old woman with rheumatoid arthritis complains of an inability to swallow dry crackers.
She also states that her eyes feel like they have sand in them. You would most expect this woman
to have which of the following additional abnormal test findings?
A.
Lymphocytic destruction of minor salivary glands
B.
Positive anti-Sm antibody
C.
Abnormal esophageal motility study
D.
Positive anti-centromere antibody
Answer: A, the patient has Sjogren's syndrome xerostomia (dry mouth), and keratoconjunctivitis sicca
(dry eyes) A. lymphocytic destruction of minor salivary glands: yes, biopsy is the confirmatory test for
Sjogren's syndrome
B. Positive anti-Sm antibody: no, this is specific for SLE.
C. Abnormal esophageal motility study: no, this is present in systemic sclerosis and CREST.
D. Positive anti-centromere antibody: no, this is present in systemic sclerosis and CREST
17. Which of the following are non-inflammatory joint disorders? SELECT 2
A.
Osteoarthritis
B.
Rheumatoid arthritis
C.
Neurogenic joint
D.
Ankylosing spondylitis
E.
Lymes disease
Answers: A, C: A. Osteoarthritis, C. Neurogenic joint.
B. Rheumatoid arthritis: no, this is inflammatory and neutrophils are present
D. Ankylosing spondylitis: inflammatory joint disease
E. Lymes disease: inflammatory joint disease
18. Which of the following are more often associated with osteoarthritis than rheumatoid arthritis?
SELECT 2
A.
Pannus
B.
Immunocomplexes
C.
Degeneration of cartilage
D.
Decreased joint mobility
E.
Baker's cysts
F.
Joint mice
G.
Extension of DIP joint
H.
Painful MCP joint (not in text)
I.
Atlantoaxial subluxation
J.
Flexion of DIP joint (not in text)
K.
Splenomegaly with neutropenia
Answers: C, F: C. Degeneration of cartilage: yes, OA is a non-inflammatory reaction, F. Joint mice: yes,
pieces of articular cartilage break off from cartilage fibrillation.
A. Pannus: no, this is granulation tissue that grows over and destroys articular cartilage in RA.
B. Immunocomplexes: no, this refers to RA with ICs formed by IgM antibodies against IgG (rheumatoid
factor).
D. Decreased joint mobility: both have this.
E. Baker's cysts: no, these occur in RA and represent synovial cysts in the popliteal space. When they
rupture in the calf muscles, it simulates thrombophlebitis.

G. Extension of DIP joint: no, this is the boutonniere deformity of RA.

H. Painful MCP joint: no, this is characteristic of RA, particularly the 2nd and 3rd MCPs.
I. Atlantoaxial subluxation: no, this characterizes RA.
J. Flexion of DIP joint: no, this is the swan's neck deformity of RA.
K. Splenomegaly with neutropenia: no, this is Felty's syndrome, which is commonly seen in RA.
19. A veterinarian is bitten in the finger by a cat. A few days later she develops a septic arthritis in her
finger. What is the most likely pathogen?
A.
Staphylococcus aureus
B.
Borrelia burgdorferi
C.
Salmonella paratyphi
D.
Pasteurella multocida
E.
Bartonella henselae
Answer: D. Pasteurella multocida.
A.
Staphylococcus aureus: if cat bites are excluded, it is the MCC of non-gonococcal septic arthritis
B.
Borrelia burgdorferi: Lyme's disease
C.
Salmonella paratyphi: osteomyelitis in sickle cell disease
E.
Bartonella henselae: cause of cat scratch disease and bacillary angiomatosis