RHEUMATOLOGY 1. a. b. c. d. e. 2. In patients with rheumatoid arthritis, the RF can b found in the following Ig subclasses.

IgM RF only IgM RF and Ig A RF only IgM RF and Ig G RF only IgM RF, Ig G RF and Ig A RF only IgM RF, Ig G RF, Ig A RF and Ig E RF only A patentee with rheumatoid arthritis on second-line therapy is investigated with a renal biopsy after the discovery of an abnormality on routine urine testing. Which of the following would not be compatible with this diagnosis and treatment? Amyloidosis Interstitial nephritis Diffuse proliferative GN, WHO grade 4 Mesangial GN Membranous GN You are asked to see a 24 y/o Polynesian lady who has a symmetrical small joint polyarthritis. Which of the following features would allow you to distinguish between a diagnosis of RA and SLE? Presence of small nodules over the extensor tendons at the MCP joints Bibasal fine creps and DLCO 50% of normal Presence of rheumatoid factor Presence of anti-Sm Presence of anti-SS-A/anti-Ro A 36 y/o mother of two children presents with a seropositive arthritis of 6 months duration. As a consequence of the arthritis she is having some difficulty looking after her children, but is still interested in having a third. investigations by the GP show: ESR 54, CRP 44, RF 1512, ANA 1/320, ENA neg, dsDNA neg. Early erosions are present in the MTP joints. You would advise; Optimise NSAIDs, physio, education and see in 6/12 Inject the worst joints (shoulders and wrists) and review in 3/12 Start salazopyrin Start MTX start MTX plus prednisone 5mg daily You are asked to see a 64 y/o man on a surgical round. He is 3/7 post TUR(P). He has developed a swollen painful left knee. T 37.8C. He has a past history of podagra. Your best action would be Start indomethacin Start colchicine Start colchicine plus flucloxacillin Aspirate the knee for synovial fluid analysis Aspirate the knee for analysis and inject steroid. The most sensitive finding to differentiate SLE from RA is RF Keratoconjunctivitis sicca Bilateral knee effusions Nodules over MCP joints Joint erosion in ulnar styloid

a. b. c. d. e. 3. a. b. c. d. e. 4.

a. b. c. d. e.

5.
a. b. c. d. e. 6. a. b. c. d. e.

7.
a. b. c. d. 8. a. b. c. d. 9. a. b. c. d. 10. a. b. c. d. 11. a. b. c. d. 12. a. b. c. d. e. 13.

A 50 y/o man with intermittent knee pain and arthritis predominantly involving 2nd and 3rd MCP joints. Most likely test to confirm diagnosis is RF se ANA se uric acid transferrin saturation Young female with SLE, mild anmia, malar rash, forearm rash. What would you use to treat? panadol NSAIDs prednisone hydroxychloroquine 50 y/o male with 3/12 Hx swollen ankles, wrists and knees. Examination confirms tender swollen wrist and ankles. Xray ankle with elevated periosteum. The Dx is gout RA OA HPOA/lung cancer A 44 y/o patient on dialysis for 10 years has sore shoulders & arms, bilateral carpal tunnel syndrome, cysts on Xray of humerus. Dx is gout pseudogout amyloid arthropathy hyperparathyroidism Female patient with rheumatoid arthritis and occipital headaches. Next Ix should be CT head flexion xray of spine CT spine skull xray 84 y/o female with severe hip pain. Gets night pain but can walk a good distance. Best Rx? panadol NSAIDs THR rest steroid injection What is the most likely finding in a patient with cerebral vasculitis/ ESR abnormal carotid angiography MRI abnormality

a.
b. c.

14.

35 y/o male with palpable purpura, fingertip ischaemia and peripheral neuropathy. Ischaemic colitis at laparotomy. Lab results show monoclonal IgM, polyclonal IgG and abnormal LFTs. The best test for diagnosis is? anti- ds-DNA HCV serology ANCA

a. b. c.

15. An elderly female has shoulder pain. On x-ray there is calcific tendonitis. The most likely crystal to be found is: a. b. c. d. e. 16. a. b. c. d. e. 17. a. b. c. d. e. Sodium urate Calcium hydroxyapatite Calcium pyrophosphate Calcium oxalate Cholesterol Sensitive structures in the knee joint are: cartilage capsule periosteum meniscus synovium Concerning RA - the pannus is principally erosive due to: fibrinoid necrosis procoagulant activity and capillary thrombosis collagenase and other enzymes osteoclasts in pannus localized vasculitis.

18. The most sensitive clinical feature differentiating CREST and systemic sclerosis with more extensive involvement in a young female presenting with severe Raynauds disease is: a. b. c. d. e. facial telangiectasia dysphagia tightness of skin of the chest autoamputation of digits nailfold capillary changes of systemic sclerosis pattern.

19. A young female presents with symmetrical arthritis of the small joints associated with pustular rash. Which is the least likely cause: a. b. c. d. 20. a. b. c. d. SLE RA viral infection psoriatic arthritis The most sensitive finding to differentiate SLE from RA is: RhF keratoconjunctivitis sicca bilateral knee effusions nodules over MP joints

e. 21. a. b. c. d. e. 22. a. b. c. d. e. 23. a. b. c. d. e. 24. a. b. c. d. e. 25. a. b. c. d. e. 26. a. b. c. d. e. 27. a. b. c.

joint erosion in ulnar styloid Which of the following statements regarding amyloidosis is/are The serum amyloid A protein in homologous to C reactive protein The amyloid P component is an acute phase protein Dialysis associated amyloid deposits contain immunoglobulin light chains Tissue deposits show red birefringence with congo red Amyloid deposits secondary to rheumatoid arthritis contain proteins or the AA type Arthritis is a well recognised clinical sequel to infection with which of the following organisms? Rubella vaccine virus Hepatitis A virus Campylobacter jejuni Borrelia burgdorferi Neisseria gonorrheae. Major component(s) of normal cartilage include: type 1 collagen water chondroitin sulphate fibroblasts hyaluronate. Uric acid excretion is increased by low dose aspirin decreased by systemic acidosis Increased by ailopwinoi decreased by hypovolaemia largely unaffected by Indomethacin. Recognised features of polymyalgia rheumatica include: elevated se creatine kinase fever abnormal EMG findings abnormal liver function tests symptom suppression by non-steroidal anti-inflammatory drugs. Recognised complications of chronic juvenile polyarthritis include: chronic iridocyclitis epiphyseal overgrowth hypognathism precocious puberty amyloidosis. Features common to patients with Reiters disease and psoriatic arthritis includes: nail telangiectases mucosal lesions Involving the glans penis sacro-ileitis

d. e. 28. a. b. c.

non-marginal syndesmophytes cardiac conduction defects Which of the following is/are consistent with acute gouty arthritis? Negatively birefringent crystals in synovial fluid Normal serum urate Pyrexia Synovial fluid white cell count greater than 50 X 109/L Polymorphonuclear leukocytosis in peripheral blood Regarding osteoid: is made by fibroblasts contains collagen type I contains proteoglycans contains lymphoid follicles contains macrophages is mainly type I collagen contains osteocalcin mineralization in inhibited in osteoporosis HLA-B27

d.
e. 29. a. b. c. d. e. f. g. h 30.

a. is found in 40-60% of patients with ankylosing spondylitis b. is more common in females than males with ank spond c. is found in 4-8% of th enormal population d. is found in 50% of patients with iritis e. is a risk factor for psoriatic arthritis 31. a. b. c. d. e. 32. a. b. c. d. e. 33. a. b. c. d. e. 34. Helpful in the diagnosis of PAN: testicular biopsy in asymptomatic pts muscle biopsy arteriogram complement level ANCA Takayasu's arteritis: is more common in males presents with upper limb claudication corticosteroids prevent ischaemic symptoms rarely presents after 40 yo can be diagnosed by patch testing Allopurinol hypersensitivity: usually occurs in first 12/52 of therapy is increased by thiazide rarely associated with eosinophilia inc. risk of renal impairment commonly (>12%) causes hepatitis Rheumatoid arthritis:

a. b. c. d. e. 35. a. b. c. d. e. 36. a. b. c. d. e. 37. a. b. c. d. e. 38. a. b. c. d. e.

affects @1% population of Australia Tcells in synovial fluid are T-helper cells Current Rx has a major effect on course of Dx majority have Ab to type II collagen at some stage there is no significant assoc. mortality The following are consistent with acute gouty arthritis: neg birefringent crystals N se urate pyrexia >50 X 10 3 WCC in synovial fluid peripheral blood neutrophilia Enthesopathy occurs with: OA Reiter's syndrome psoriasis SLE syndesmophytes Periostitis is seen in: psoriatic arthritis SLE arthropathy pyrophosphate arthropathy reactive arthritis HPOA Dilated nail fold capillaries are seen in: dermatomyositis drug-induced SLE CREST primary sicca syndrome systemic sclerosis

39. a. b. c. d. e. 40. a. b. c. d.

Pt with mild polyarthritis has high anti-DNA, ENA and SSA. Which of the following are possible: primary sicca syndrome SLE MCD RA systemic sclerosis 70 yo female with a vasculitic rash and mild arthritis. IgM paraprotein band is 3.4 - possibilities include: cryofibrinogenaemia cryoglobulinaemia ANA - 1:640 RhF - 1:1200

41. a. b. c. d. e.

Binding of C1,C2,C3 and initiation of classical complement pathway occurs with: surface Ig urate crystals IgE CRP bound to bacterial polysaccharide Ag bound to IgG4

42. A young female presents with symmetrical arthritis of the small joints associated with pustular rash. Which is the least likely cause: a. b. c. d. SLE RA viral infection psoriatic arthritis

43. 60yo female with long history of SLE on Prednisone 10mg daily presents with low-grade fever, headache, diplopia and L arm weakness. Ex shows R 6th n palsy and R sided weakness. WCC = 11, neut 10.9, plt 400, Hb 11, low C3, low C4. The next best test is: a. b. c. 44. a. b. c. d. 45. a. b. c. d. e. 46. a. b. c. d. e. 47. a. b. c. d. e. lupus anticoagulant LP cerebral angiogram Components of normal synovial membrane include basement membrane proprioceptive fibres lymphoid follicles macrophages Arthritis in haemochromatosis often is the presenting feature characteristically involves the PIP joints usually is chondrocalcinosis radiologically has features like osteoarthritis resolves with venesection Granulomatous inflammation is seen in rheumatoid arthritis rheumatic fever ankylosing spondylitis temporal arteritis Sjgrens Concerning immune complexes activity is independent of the type of Ig invariably cause pathology largest with mild antigen excess are cleared by RBC complement receptors size is affected by complement binding

48. a. b. c. d. e.

The acute phase reaction includes decreased serum transferrin decreased serum albumin decreased serum fibrinogen increased C3 increased IL-1

49. 12 yr old male with pain in hands and wrists for 6 mths. ANA 1:80, positive anti SS-a, rheumatoid factor 65, ESR 48. The most likely diagnosis is (one answer) a. b. c. d. SLE MCTD early seropositive RA juvenile pauciarticular arthritis

50. 19 yr old Uni student with one week of pain in right knee and left ankle. 2weeks ago, he had a sore throat and abdominal pain. He also had some transient back stiffness. Clinical examination revealed an effusion in the right knee and left ankle with a swollen right second toe. The most likely diagnosis is (one answer) a. b. c. d. viral arthritis rheumatic fever gonococcal arthritis reactive arthritis

51. 55yr old with Raynauds and purpuric rash on lower limbs. Protein electrophoresis reveals cryoglobulins with IgM kappa monoclonal band and polyclonal IgG band. Which of the following is/are true? a. b. c. d. e. 52. a. b. c. d. e. 53. a. b. c. d. e. f. 54. a. b. c. d. biopsy of rash will reveal leucocytoclastic vasculitis monoclonal band confirms Waldenstroms macroglobulinaemia serum C3 will be reduced should have Schirmers test IgM will have rheumatoid factor activity Known predisposing factors in osteoarthritis include haemochromatosis hyperthyroidism obesity lateral/ medial meniscectomy acromegaly The arthritis associated with haemochromatosis improves with venesection incidence is 1 in 10000 arthropathy involves 2nd and 3rd MCPs usually is chondrocalcinosis radiologically has features like osteoarthritis is usually the presenting feature Methotrexate dose doesnt need to be adjusted in renal failure is almost completely absorbed orally oral folic acid interferes with effectiveness in patients with RA liver disease is worse in diabetics

55. a. b. c. d. e. 56. a. b. c. d. e. 57. a. b. c. d. e. 58. a. b. c. d.

Regarding MTX in RA: effects are seen in 2/52 infertility is a problem pulmonary toxicity renal toxicity (with proteinuria) is assoc. with secondary malignancy Concerning synovium in Rheumatoid arthritis ICAM-1 expression is decreased local infiltration of B cells mature to antibody producing plasma cells CD4 lymphocytes are involved increased IL-1 increased TNF- Complement deficiencies C4 def: lupus-like illness C1q def: lupus-like illness C8 def: Neisseria infections C3 def: overwhelming bacterial infection C2 def: RA Concerning amyloidosis light chain type occurs in myeloma Familial Meditteranean fever is AA type AL type is associated with nodular urogenital amyloid amyloid plaques in the brain are associated with serum amyloid A protein

59. A middle aged female has Rheumatoid arthritis. She is initially treated with NSAIDS but methotrexate was added 6 months ago because of increasing synovitis. She presents with increasing lethargy. Investigations show chronic anaemia Hb 95, serum Fe 2.3, transferrin 23 (20- ) , transferrin saturation low, Ferritin 120 (100 - ). She is alreadly on prednisone. The best treatment would be a. b. c. d. e. 60. a. b. c. d. change to a different NSAID tricyclic antidepressant increase methotrexate to 15mg weekly increase prednisone iron therapy A mechanic presents with OA of 2nd and 3rd MCPs with osteophytes. The best test for Dx : ANA RF transferrin saturation HLA-B27

61. A 55yr old male presents with a recurrent painful right knee. He has an effusion which is tapped and shows no crystals. His Xray is shown (chondrocalcinosis). The diagnosis a. b. pseudogout RA

c. d. e.

OA calcium hydroxyapatite reactive arthritis

62. A male presents with peripheral neuropathy, Raynauds, ischaemic finger tips and palpable purpura. He has a laparotomy for ischaemic gut. Cryoglobulins are strongly positive with monoclonal IgM and polyclonal IgG. FBC is given; LDH haptoglobin monocytosis 1.7 ( - 0.8), WCC 17 mainly neutrophils, eosinophils normal, plts and Hb normal/?mild anaemia; calcium normal . (dont think LFTs given and no history re IV drugs etc) The best test for diagnosis a.

c.
d. e. 63. a. b. c. 63. a. b. c. d. e. 64. a. b. c. d. e. 65. a. b. c. d. e. 66. a. b. c. d. e. f.

ANCA anti- dsDNA Hepatitis C serology Bone marrow biopsy Concerning complement receptors CR2 acts as a receptor for EBV neutrophil CR3 def causes severe bacterial infections erythrocytes from patients with SLE have increased CR2 receptors Secretory component is produced by B cells is the receptor for IgA IgA secretory component molecule undergoes receptor mediated endocytosis inhibits the proteolysis of IgA transports microglobulin 2Binding of C1,C2,C3 and initiation of classical complement pathway occurs with: surface Ig urate crystals IgE CRP bound to bacterial polysaccharide Ag bound to IgG4 In rheumatoid arthritis the initial damage to the joint occurs in the periosteum central cartilage ligamentous attachments subchondral bone junction of pannus and cartilage What is the cause of elevated ESR In active rheumatoid arthritis CRP increased fibrinogen immunoglobulin tumour necrosis factor plasma proteins / gammaglobulins microcytosis

67. a. b. c. d. 68. a. b. c. d.

A female has severe rheumatoid arthritis. She has had increasing occipital headaches and neck stiffness. Your next investigation is: CT of neck Lateral flexion Xray of cervical spine ESR Myelogram Synovial fluid in rheumatoid arthritis: IL-1 ICAM expression number of CD4+ lymphocytes neovascularisation

69. 25 yo female with 12/12 Hx symmetrical peripheral polyarthritis. The best feature to differentiate RA from SLE is: a. b. c. d. e. Rheumatoid factor Keratoconjunctivitis sicca Nodules Erosion of ulnar process Bilateral knee effusions