- Email: [email protected]
Rheumatology quiz
Indian Journal of Rheumatology 2008 June Volume 3, Number 2; p. 80
PG Forum
Rheumatology quiz V Arya1, V Dhir2 1. All the following are true of juvenile idiopathic arthritis except (a) elevation of ESR at baseline is associated with worse outcome (b) patients with oligoarticular disease have higher remission rates (c) rheumatoid factor in polyarticular disease does not influence outcome (d) the platelet count is a predictor of disability in systemic disease 2. All the following predict a worse outcome in SLE except (a) serositis at presentation (b) anti-Ro positivity (c) thrombocytopenia (d) CNS disease 3. Which of the following is false regarding leucopenia in SLE (a) directly related to antiphospholipid antibody levels (b) usually a part of pancytopenia than in isolation (c) lymphopenia is related to drug therapy (d) neutropenia correlated to history of CNS involvement 4. Consumption of which of the following beverages has been shown to reduce the risk of gout? (a) coffee (b) grape juice (c) carbonated soft drinks (d) red wine 5. Which of the following is not true of methotrexate pneumonitis (a) higher risk in smokers (b) fixed bibasilar crackles are found (c) eosinophilia (d) combined treatment with leflunomide increases the risk
1
6. All the following are true of juvenile dermatomyositis except (a) weakness and skin manifestations are almost equally common at presentation (b) 80% of patients have elevated muscle enzymes at presentation (c) ANA is more often positive than anti-ENA (d) sequential muscle enzyme monitoring reliably reflects disease activity 7. Which of the following statements about cyclo-oxygenase 3 (COX-3) is false (a) resistant to inhibition by non-selective NSAIDs (b) more sensitive to inhibition by paracetamol than COX-2 (c) most expressed in the heart and brain (d) a product of the COX-1 gene 8. Which of the following is not true of bone marrow edema as seen on MRI (a) due to increased water content in trabecular bone (b) frequently seen in bone tumors (c) not seen in osteoarthritis (d) associated with trauma 9. Which of the following is true of juvenile localized scleroderma? (a) more common in males (b) Peau d’orange seen in eosinophilic fasciitis subtype (c) plaque morphea more common than linear scleroderma (d) anti-centromere antibodies seen in approximately 50% 10. ANCA-associated vasculitis is not associated with exposure to (a) minocycline (b) silica (c) propylthiouracil (d) penicillin For answers refer to page 82
Department of Medicine, JIPMER, Puduchery and 2Department of Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India. Correspondence: Dr. V Arya, email: [email protected]
82
Indian Journal of Rheumatology 2008 June; Vol. 3, No. 2
the normal of 250–800 mg/d) suggesting that she was an underexcretor. Thus the patient had seropositive RA with chronic tophaceous gout. Although both RA and gout are relatively common, their co-existence is extremely rare.1 It has been reported that there is a strong negative correlation between RA and gout.2 The first well authenticated case reported recently was in 1966.3 Our patient had clinical and serological features that satisfied ACR criteria for RA. Her clinical features together with very high anti-CCP antibody are virtually diagnostic of RA. She also had a high serum uric acid, characteristic radiological findings along with monosodium urate crystals (MSU) aspirated from joints suggesting gouty arthritis. These manifestations provide ample proof for the coexistence of RA and gouty arthritis. Only a few cases have been reported of the unequivocal association of gout with RA, despite an estimate by Wallace et al. of more than 10,000 cases.4 Although the exact cause for this negative association is obscure there have been several hypotheses including inhibition of surface activity of MSU by rheumatoid factor binding, crystal coating by rheumatoid factor, inhibition of crystal deposition by possible connective tissue alterations in RA, impaired phagocytic function of neutrophils in rheumatoid joint fluid, and the anti-inflammatory or immunosuppressive effect of hyperuricaemia.5 On the other hand, analgesic nephropathy may reduce renal urate excretion and precipitate hyperuricaemia, which has been estimated to occur in 10% of patients with RA.6 However, our patient, had normal renal function. Many features of gout especially chronic tophaceous gout during the evolution of the disease may mimic RA or vice versa. Morning stiffness and fusiform swelling of proximal interphalangeal and metacarpophalangeal joints, though suggestive of RA, are misleading since these findings can also occur in polyarticular tophaceous gout. Kozin and McCarty demonstrated positive rheumatoid factor although in low titres in 30% of patients with chronic tophaceous gout.7 Anti-CCP antibodies present in 60–70% of patients with RA at diagnosis, are 90–98% specific for RA. Due to the
Thachil et al.
extremely high specificity, a high anti-CCP titre along with rheumatoid factor positivity in the appropriate clinical setting can be taken as evidence of RA and predictive of erosive disease.8
ACKNOWLEDGEMENTS Source of funding: None. Disclosure statement: Authors have declared no conflict of interest.
REFERENCES 1.
2.
3. 4.
5. 6.
7. 8.
Khosla P, Gogia A, Agarwal PK, Pahuja A, Jain S, Saxena KK. Concomitant gout and rheumatoid arthritis—a case report. Indian J Med Sci 2004; 58: 349–52. Atdjian, Fernandez-Madrid F. Coexistence of chronic tophaceous gout and rheumatoid arthritis. J Rheumatol 1981; 8: 989–92. Owen DS, Toone EC, Irby R. Coexistent rheumatoid arthritis and chronic tophaceous gout. JAMA 1966; 197: 953–6. Wallace DJ, Linenberg JR, Morhaim D, Berlanstein B, Biren PC, Callis G. Coexistent gout and rheumatoid arthritis. Arthritis Rheum 1979; 22: 81–6. Lussier A, de Medicis R. Inhibition of adjuvant induced arthritis in hyperuricaemic rats. Arthritis Rheum 1975; 18: 414. Talbott JH, Altman RD, Yu JF. Gouty arthritis masquerading as rheumatoid arthritis or vice versa. Semin Arthritis Rheum 1978; 8: 77–114. Spector AK, Christman RA. Arthritis. J Am Podiatr Med Assoc 1989; 79: 552–8. Van Gaalen FA, et al. Autoantibodies to cyclic citrullinated peptides predict progression to rheumatoid arthritis in patients with undifferentiated arthritis: a prospective cohort study. Arthritis Rheum 2004; 50: 709.
ANSWERS TO THE RHEUMATOLOGY QUIZ (page 80) 1c, 2b, 3c*, 4a, 5d, 6d**, 7a***, 8c, 9b†, 10d *Neutropenia is usually due to drug therapy, lymphopenia due to disease activity. **Muscle enzyme levels are not reflective of disease activity.
***COX-3 is maximally susceptible to inhibition by nonselective NSAIDs. †Anti-centromere antibodies seen in approximately 2%.
PG Forum
Rheumatology quiz V Arya1, V Dhir2 1. All the following are true of juvenile idiopathic arthritis except (a) elevation of ESR at baseline is associated with worse outcome (b) patients with oligoarticular disease have higher remission rates (c) rheumatoid factor in polyarticular disease does not influence outcome (d) the platelet count is a predictor of disability in systemic disease 2. All the following predict a worse outcome in SLE except (a) serositis at presentation (b) anti-Ro positivity (c) thrombocytopenia (d) CNS disease 3. Which of the following is false regarding leucopenia in SLE (a) directly related to antiphospholipid antibody levels (b) usually a part of pancytopenia than in isolation (c) lymphopenia is related to drug therapy (d) neutropenia correlated to history of CNS involvement 4. Consumption of which of the following beverages has been shown to reduce the risk of gout? (a) coffee (b) grape juice (c) carbonated soft drinks (d) red wine 5. Which of the following is not true of methotrexate pneumonitis (a) higher risk in smokers (b) fixed bibasilar crackles are found (c) eosinophilia (d) combined treatment with leflunomide increases the risk
1
6. All the following are true of juvenile dermatomyositis except (a) weakness and skin manifestations are almost equally common at presentation (b) 80% of patients have elevated muscle enzymes at presentation (c) ANA is more often positive than anti-ENA (d) sequential muscle enzyme monitoring reliably reflects disease activity 7. Which of the following statements about cyclo-oxygenase 3 (COX-3) is false (a) resistant to inhibition by non-selective NSAIDs (b) more sensitive to inhibition by paracetamol than COX-2 (c) most expressed in the heart and brain (d) a product of the COX-1 gene 8. Which of the following is not true of bone marrow edema as seen on MRI (a) due to increased water content in trabecular bone (b) frequently seen in bone tumors (c) not seen in osteoarthritis (d) associated with trauma 9. Which of the following is true of juvenile localized scleroderma? (a) more common in males (b) Peau d’orange seen in eosinophilic fasciitis subtype (c) plaque morphea more common than linear scleroderma (d) anti-centromere antibodies seen in approximately 50% 10. ANCA-associated vasculitis is not associated with exposure to (a) minocycline (b) silica (c) propylthiouracil (d) penicillin For answers refer to page 82
Department of Medicine, JIPMER, Puduchery and 2Department of Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India. Correspondence: Dr. V Arya, email: [email protected]
82
Indian Journal of Rheumatology 2008 June; Vol. 3, No. 2
the normal of 250–800 mg/d) suggesting that she was an underexcretor. Thus the patient had seropositive RA with chronic tophaceous gout. Although both RA and gout are relatively common, their co-existence is extremely rare.1 It has been reported that there is a strong negative correlation between RA and gout.2 The first well authenticated case reported recently was in 1966.3 Our patient had clinical and serological features that satisfied ACR criteria for RA. Her clinical features together with very high anti-CCP antibody are virtually diagnostic of RA. She also had a high serum uric acid, characteristic radiological findings along with monosodium urate crystals (MSU) aspirated from joints suggesting gouty arthritis. These manifestations provide ample proof for the coexistence of RA and gouty arthritis. Only a few cases have been reported of the unequivocal association of gout with RA, despite an estimate by Wallace et al. of more than 10,000 cases.4 Although the exact cause for this negative association is obscure there have been several hypotheses including inhibition of surface activity of MSU by rheumatoid factor binding, crystal coating by rheumatoid factor, inhibition of crystal deposition by possible connective tissue alterations in RA, impaired phagocytic function of neutrophils in rheumatoid joint fluid, and the anti-inflammatory or immunosuppressive effect of hyperuricaemia.5 On the other hand, analgesic nephropathy may reduce renal urate excretion and precipitate hyperuricaemia, which has been estimated to occur in 10% of patients with RA.6 However, our patient, had normal renal function. Many features of gout especially chronic tophaceous gout during the evolution of the disease may mimic RA or vice versa. Morning stiffness and fusiform swelling of proximal interphalangeal and metacarpophalangeal joints, though suggestive of RA, are misleading since these findings can also occur in polyarticular tophaceous gout. Kozin and McCarty demonstrated positive rheumatoid factor although in low titres in 30% of patients with chronic tophaceous gout.7 Anti-CCP antibodies present in 60–70% of patients with RA at diagnosis, are 90–98% specific for RA. Due to the
Thachil et al.
extremely high specificity, a high anti-CCP titre along with rheumatoid factor positivity in the appropriate clinical setting can be taken as evidence of RA and predictive of erosive disease.8
ACKNOWLEDGEMENTS Source of funding: None. Disclosure statement: Authors have declared no conflict of interest.
REFERENCES 1.
2.
3. 4.
5. 6.
7. 8.
Khosla P, Gogia A, Agarwal PK, Pahuja A, Jain S, Saxena KK. Concomitant gout and rheumatoid arthritis—a case report. Indian J Med Sci 2004; 58: 349–52. Atdjian, Fernandez-Madrid F. Coexistence of chronic tophaceous gout and rheumatoid arthritis. J Rheumatol 1981; 8: 989–92. Owen DS, Toone EC, Irby R. Coexistent rheumatoid arthritis and chronic tophaceous gout. JAMA 1966; 197: 953–6. Wallace DJ, Linenberg JR, Morhaim D, Berlanstein B, Biren PC, Callis G. Coexistent gout and rheumatoid arthritis. Arthritis Rheum 1979; 22: 81–6. Lussier A, de Medicis R. Inhibition of adjuvant induced arthritis in hyperuricaemic rats. Arthritis Rheum 1975; 18: 414. Talbott JH, Altman RD, Yu JF. Gouty arthritis masquerading as rheumatoid arthritis or vice versa. Semin Arthritis Rheum 1978; 8: 77–114. Spector AK, Christman RA. Arthritis. J Am Podiatr Med Assoc 1989; 79: 552–8. Van Gaalen FA, et al. Autoantibodies to cyclic citrullinated peptides predict progression to rheumatoid arthritis in patients with undifferentiated arthritis: a prospective cohort study. Arthritis Rheum 2004; 50: 709.
ANSWERS TO THE RHEUMATOLOGY QUIZ (page 80) 1c, 2b, 3c*, 4a, 5d, 6d**, 7a***, 8c, 9b†, 10d *Neutropenia is usually due to drug therapy, lymphopenia due to disease activity. **Muscle enzyme levels are not reflective of disease activity.
***COX-3 is maximally susceptible to inhibition by nonselective NSAIDs. †Anti-centromere antibodies seen in approximately 2%.