1. All of the following have been shown to prevent joint destruction in patients with rheumatoid arthritis at least to some extent EXCEPT [1]:

   A. Glucocorticoids
   B. Methotrexate
   C. Etanercept (Enbrel®)
   D. Leflunomide (Arava®)
   E. Hydroxychloroquine (Plaquenil®)

2. All of the following are properties of systemic vasculitis EXCEPT [2]:

   A. Elevated Erythrocyte Sedimentation Rate (ESR)
   B. Elevated C-reactive protein (CRP) also highly elevated and correlates with disease
   C. Increased levels of IL-6 and IL-1
   D. Thrombocytopenia
   E. Anemia (Associated with Chronic Disease)

3. Which ONE of the following is most helpful in distinguishing spondyloarthropathy from rheumatoid arthritis in patients with early, acute, polyarticular synovitis [3] ?

   A. Fever
   B. Chills
   C. Diarrhea
   D. Genitourinary symptoms
   E. Antibodies to specific bacteria

4. A 72 year old white female presents with 2 weeks of increased swelling on the dorsal surface of both hands, swelling in the ankles, symmetric pain and difficulty flexing her wrists and fingers, and mild difficulty raising her shoulders. She denies fevers, chills, nausea, vomiting, diarrhea, or genitourinary symptoms. She has no headaches, paresthesias, or visual symptoms. She has normal range of motion in her back, and no skin lesions. Her family history is notable for two parents who both died of myocardial infarction and heart failure around age 70. She takes enalapril for hypertension, along with a multivitamin and a baby aspirin (81mg) each day. On exam, her vital signs are all within normal limits. Her hands and ankles are mildly swollen, there is 1+ pitting edema, and decreased range of motion. Her shoulders have slightly reduced range of motion with pain. Her blood work is notable for a white count of 8.3K/µL with normal differential, hemoglobin of 9.3gm/dL, platelets 475K/µL, normal electrolytes and renal function, ESR 53mm/hr, serum albumin 3.2gm/dL, normal liver function tests. Urinalysis is normal. ANA is 1:80 (normal range) and Rheumatoid Factor (RF) is negative. The most likely diagnosis is [4]:

   A. Rheumatoid Arthritis
   B. Remitting Seronegative Symmetric Synovitis With Pitting Edema
   C. Reiter's Syndrome
   D. Ankylosing Spondylitis
   E. Psoriatic Arthritis

5. All of the following are common components of Churg-Strauss Syndrome EXCEPT [5]:

   A. Cytoplasmic Antineutrophil Cytoplasmic Antibody (C-ANCA) pattern
   B. Asthma with Pneumonitis
   C. Eosinophilia
   D. Multiple Mononeuropathy (Mononeuritis multiplex)
   E. Allergies and atopy

6. Which ONE of the following is NOT a common feature of cryoglobulinemia [6] ?

   A. Hyperviscosity
   B. Recurrent purpura > petechiae
   C. Association with chronic Hepatitis B Virus (HBV) Infection
   D. Raynaud's phenomenon
   E. Peripheral neuropathy, particulary mononeuritis multiplex

7. A 9 year old boy presents with a one month history of a pink rash on his abdomen which occurs mainly at night, and then usually goes away during the day. He has had 1 week of fevers up to 102.5°F (39.2°C) at home with chills; these fevers resolve with two 325mg acetaminophen (Tylenol®) tablets. He has early morning stiffness in his joints, and has trouble getting out of bed for the last three mornings. He has mild chest pains on deep inspiration and is fatigued when playing sports. He has missed the last two days of school. Exam is notable for a temperature of 38.1°C orally, pulse 96 beats per minute, blood pressure 100/60mmHg, equal in both arms. There is mild swelling over the dorsum of the feet and hands, with warmth in the wrists and carpal- metacarpal joints. Lungs are clear, and heart sounds are normal. The liver is palpated 2cm below the right costal margin; the patient is anicteric. There is no evidence of rash. Neurologic and ocular exams are normal. Laboratory studies are notable for a white blood count of 18K/µL with 86% neutrophils and 4% band (immature) forms, 0.5% eosinophils. Hematocrit is 35.2% with a mean corpuscular volume of 78fL and a reticulocyte count of 0.8%. Renal function and electrolytes are normal. AST and LDH are 1.5X normal; ALT is borderline high. Erythrocyte sedimentation rate (ESR) is 96mm/hour. ANA and RF are negative. The patient most likely has [7]:

   A. Still's Disease
   B. Oligoarticular Juvenille Rheumatoid Arthritis
   C. Systemic Lupus Erythematosus
   D. Scleroderma-Myositis Overlap Syndrome
   E. Giant Cell Arteritis

8. The patient described above is treated with indomethacin 25mg po three times daily. He develops increasing shortness of breath and pain on inspiration. On examination, his heart rate is 110 per minute at rest with a blood pressure of 95/70 mmHg, respiratory rate of 22 per minute, and a temperature of 39.6°C. A pleural rub is heard, and his wrists and ankles are warm with increased swelling. The white blood cell count is 24K/µL (92% neutrophils, 3% bands, 0.2% eosinnophils) and the ESR is 115mm/hour. The most appropriate management for this patient is [8]:

A. If chest radiograph shows effusion, give prednisone; otherwise, maintain on indomethacin
B. Administer hydroxychloroquine 600mg/day loading dose x 14 days, then 400mg/day
C. Rule out cardiac tamponade with echocardiogram and increase indomethacin to 50mg po tid
D. Check chest radiograph for effusion, stop indomethacin, and initiate methotrexate 5mg/week
E. Rule out cardiac tamponade with echocardiogram, check chest radiograph, stop indomethacin and give prednisone

9. A 39 year old man presents with three days of severe pain in his right shoulder. He was painting his house the previous weekend and awoke with the severe pain on Monday morning. He has had no fevers; there is no swelling or erythema in the shoulder area. The remainder of his joints are normal. He is unable to lift his arm at all. However, you are able to raise is about 90° before the pain becomes extremely severe. There is point tenderness over the anterior region of the shoulder in the head of the biceps region. The most likely diagnosis is [1]:

   A. Rotator cuff injury
   B. Biceps tendinitis
   C. Septic Arthritis
   D. Pseudogout
   E. Osteonecrosis

10. A 28 year old woman with two children and a family history of severe rheumatoid arthritis presents with 1 month of increasing morning stiffness and swelling in her hands, wrists, toes and ankles. She takes only birth control pills (oral contraceptives) and is otherwise well. Examination reveals normal vital signs, swelling in the hands and feet with decreased strength and range of motion. Radiographs of the hands reveal early joint space narrowing and bony erosions in the proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints. The rheumatoid factor is positive in high titers, and the sedimentation rate is 55mm/hour. She has no allergies to medications, does not smoke, use alcohol, or abuse drugs. The most appropriate medication for this patient is [2]:

    A. Hydroxychloroquine (Plaquenil®)
    B. Etanercept (Enbrel®)
    C. Sulfasalazine
    D. Methotrexate (Rheumatrex®)
    E. Glucocorticoids (such as Prednisone)

Answers

1. E
2. D (Thrombocytosis is usually found in vasculitis.)
3. C
4. B
5. A (The ANCA pattern in Churg-Strauss Syndrome is Perinuclear, or P-ANCA.)
6. C (Cryoglobulinemia is associated with chronic Hepatitis C Virus, HCV, infection.)
7. A
8. E
9. B
10. D (Methotrexate is relatively safe and prevents progression in some patients.)