Human leukocyte antigen associated with rheumatoid arthritis
HLA-DR 4
Presence of this substance indicates that rheumatoid arthritis manifests with more extra-articular symptoms and poorer prognosis
A) Rheumatoid factor (RF)
Serves as a better marker than rheumatoid factor for diagnosing rheumatoid arthritis
D) Anti-citrullinated protein antibody (ACPA)
ACPA level is included in the revised 2010 criteria for rheumatoid arthritis.
Proliferation of vascular granulomatous tissue in rheumatoid arthritis eventually leading to fibrosis and ankylosis
Pannus formation
Stage of rheumatoid arthritis with possible osteoporosis
D) Stage 1 (early)
Stage of rheumatoid arthritis with osteoporosis, limitation of joint mobility, adjacent muscle atrophy, rheumatoid nodules, and slight cartilage destruction
A) Stage 2 (moderate)
Stage of rheumatoid arthritis with osteoporosis, subchondral destruction, joint deformity, extensive muscle atrophy, rheumatoid nodules, but without ankylosis
C) Stage 3 (severe)
Stage of rheumatoid arthritis with fibrous/bony ankylosis
A) Stage 4 (terminal)
In the 1987 ACR Criteria for rheumatoid arthritis, what signs and symptoms must be present for at least six weeks?
MASH
1. Morning stiffness (at least one hour before improvement)
2. Arthritis of three or more joints simultaneously (14 possible areas: PIP, MCP, wrist, elbow, knee, ankle, and MTP joints)
3. Symmetrical arthritis
4. Hand arthritis (at least one swollen area in wrist, MCP, or PIP joint)
How many in the 1987 ACR Criteria must be fulfilled in order to make a diagnosis of rheumatoid arthritis?
C) 4 out of 7
What score in the 2010 ACR criteria would you give a patient who has arthritis affecting 5 large joints, decreased RF and ACPA, abnormal ESR and CRP, and symptoms lasting for 3 weeks? Can you diagnose this patient with rheumatoid arthritis?
2010 ACR Criteria
Joint involvement = 1
0 = 1 large joint
1 = 2-10 large joints
2 = 1-3 small joints
3 = 4-10 small joints
4 = >10 joints regardless of size
Serology = 1
0 = (-) RF and ACPA
2 = decreased RF and ACPA
3 = increased RF and ACPA
Acute phase reactants = 1
0 = normal ESR and CRP
1 = abnormal ESR and CRP
Duration = 0
0 = <6 weeks="" br=""> 1 = >= 6 weeks
Total score = 3 out of 10 (Patient cannot be diagnosed with rheumatoid arthritis because minimum score required is 6.)
How many test result/s are needed for serology and acute phase reactants in accordance to 2010 ACR Criteria?
B) One
Steinbrocker functional classification: carry usual duties without handicaps
C) Class I
Steinbrocker functional classification: conduct normal activities despite handicap of discomfort or limited mobility of one or more joints
B) Class II
Steinbrocker functional classification: perform only a few or none of the duties of usual occupation or self-care
A) Class III
Steinbrocker functional classification: largely or wholly incapacitated with patient being bedridden or confined to wheelchair, permitting little or no self-care
D) Class IV
Functional classification: independent in self-care, vocational, and avocation activities
D) Class I
Functional classification: independent in self-care and vocational activities, but limited or dependent in avocational activities
A) Class II
Functional classification: independent in self-care activities, but limited or dependent in vocational and avocational activities
D) Class III
Functional classification: limited or dependent in self-care, vocational, and avocational activities
B) Class IV
Joints commonly affected in rheumatoid arthritis, except:
B) Knee
Floating of ulna on the wrist due to the destruction of ulnar collateral ligament
B) Piano key sign
MC UE nerve entrapment associated with rheumatoid arthritis
D) Carpal tunnel syndrome
Rupture of extensor tendons which progresses from the ulnar to the radial side of the hand, resembling a benediction sign
C) Vaughan-Jackson deformity
Rupture of flexor pollicis longus, resulting to weak pinch
B) Mannerfelt syndrome
Nalebuff classification: boutonniere deformity
D) Type 1
Nalebuff classification: boutonniere deformity and CMC subluxation
B) Type 2
Nalebuff classification: swan neck deformity
D) Type 3
Nalebuff classification: gamekeeper's thumb (CMC adduction and radial deviation due to rupture of ulnar collateral ligament)
B) Type 4
Nalebuff classification: swan neck deformity and MCP disease
D) Type 5
Nalebuff classification: arthritis mutilans (opera glass hand and telescoping sign)
A) Type 6
Cervical segments most commonly affected in rheumatoid arthritis
C) C1-C2
Cervical segments most commonly affected in osteoarthritis
C) C5-C6
Results from collapse of transverse arch
A) Splay foot
MC LE nerve entrapment in rheumatoid arthritis
Tarsal tunnel syndrome
One of the joints to be affected last in rheumatoid arthritis
A) Temporomandibular joint
MC cause of death in rheumatoid arthritis
A) Ischemic heart disease
Manifestations of Felty's syndrome
SLLAANT
1. Splenomegaly
2. Lymphadenopathy
3. Leukopenia
4. Anemia (hypochromic, microcytic)
5. Arthritis
6. Neutropenia
7. Thrombocytopenia
Intrapulmonary nodules associated with rheumatoid arthritis
B) Caplan syndrome
Sjogren's syndrome triad
DAD
1. Dry eyes (sicca, xerophthalmia)
2. Dry mouth (xerostomia)
3. Arthralgia
Other manifestations:
1. Bilateral parotiditis
2. Skin lesions
3. Raynaud's phenomenon
Sjogren syndrome can be associated with the following rheumatic conditions, except:
D) Psoriatic arthritis
True or False: Primary Sjogren's syndrome presents with dry eyes, dry mouth, and (+) RF and ANA.
True
Whereas, secondary Sjogren's syndrome is associated with RA, SLE, PM/DM, or PSS.
Test for dry eyes wherein a strip of paper is placed on lower eyelid and after five minutes, the length of the wetted area is measured
D) Schirmer's test
Test for dry eyes which involves staining of eye to assess epithelial cell damage
A) Rose Bengal Test
Test for dry mouth which involves chewing of a sterile sponge for two minutes, then the weight of the sponge before and after chewing is measured
C) Saxon test
True or False: Juvenile idiopathic arthritis is the most common form of childhood arthritis.
True
Juvenile idiopathic arthritis is also known as juvenile rheumatoid arthritis.
Type of JIA in which five or more joints are involved
C) Polyarticular JIA
Type of JIA in which one to four joints are affected
B) Pauciarticular JIA
Multisystemic manifestation in Still's disease
OPPAH
1. Osteoporosis/osteopenia
2. Pericarditis
3. Pleuritis
4. Anemia
5. Hepatosplenomegaly
JIA which is more common in women and has poorer prognosis, especially if it is unremitting
B) Polyarticular JIA (RF positive)
JIA associated with uveitis
D) Polyarticular JIA (RF negative)
Commonly affected joints in pauciarticular JIA (most to least)
KAWE
1. Knee
2. Ankle
3. Wrist
4. Elbow
Eye impairment associated with pauciarticular JIA which presents with cataract, glaucoma, and eventually blindness
Chronic iridocyclitis
True or False: Late-onset pauciarticular JIA is more common in females.
False
Early-onset pauciarticular JIA is more common in females younger than 5 years old.
True or False: Late-onset pauciarticular JIA is less common in males.
False
Late-onset pauciarticular JIA is more common in males.
ACR Criteria for Systemic Lupus Erythematosus
DOPAMIN RASH
Discoid rash
Oral ulcers
Photosensitivity
Antinuclear antibody
Malar rash
Immunologic disease
Neurologic disease (seizures, psychosis)
Renal disease (proteinuria, lupus nephritis)
Arthritis (Jaccoud's: non-erosive, reversible but deforming arthritis on two or more joints)
Serologic disease (pericarditis, pleuritis)
Hematologic disease (Felty's syndrome)
How many should be fulfilled in the ACR Criteria to be diagnosed with Systemic Lupus Erythematosus?
A) 4 out of 11
MC cardiac event in systemic lupus erythematosus
A) Pericarditis
MC cause of death in systemic lupus erythematosus
B) Cardiovascular disease
Type of scleroderma with rapid onset of skin thickening after Raynaud's phenomenon
C) Diffused cutaneous scleroderma
Type of scleroderma with poorer prognosis and variable course
C) Diffuse cutaneous scleroderma
Type of scleroderma associated with anti-centromere antibody
B) Limited cutaneous scleroderma
The following organs are affected in diffused cutaneous scleroderma, except:
D) None of these
The following organs are affected in diffused cutaneous scleroderma:
1. Heart (pericarditis)
2. Gastrointestinal tract (dysphagia, xerostomia)
3. Kidneys (hypertension)
4. Lungs (restrictive lung disease)
Type of scleroderma with better prognosis and predictable course
B) Limited cutaneous scleroderma
Manifestations of limited cutaneous scleroderma
CREST
1. Calcinosis
2. Raynaud's phenomenon
3. Esophageal dysmotility
4. Sclerodactyly
5. Telangiectasia
Form of localized scleroderma with discolored patches of skin due to uneven collagen deposition
A) Morphea
Type of linear scleroderma found in frontoparietal region, often with loss of hair on the involved side and loss of facial symmetry
En coup de sabre
All of the following are manifestations of edematous stage of scleroderma, except:
D) Raynaud's disease
The edematous stage of scleroderma manifests with pitting or non-pitting edema and Raynaud's phenomenon. Raynaud's disease (primary Raynaud's) occur without an underlying condition.
The sclerotic stage of scleroderma manifests with all of the following signs, except: skin thickening, sclerodactyly, tobacco pouch sign, salt and pepper skin, and flexion contracture
C) Adduction contracture
It should be flexion, not adduction contracture.
True or False: Sclerotic stage of scleroderma which manifests with thinning of skin, making it prone to tearing and ulceration.
False
It should be atrophic, not sclerotic stage.
Life threatening complication of systemic JIA with persistent fever, lymphadenopathy, splenomegaly, and profound depression in one or more blood cell lines (often initially platelets) with raised liver function enzymes and clotting abnormalities
D) Macrophage Activation Syndrome
Persistent pauciarticular JIA affects not more than four joints throughout the disease course. Meanwhile, extended pauciarticular JIA affectS more than four joints after the first six months of disease.
A) Both statements are true.
Pauciarticular JIA is also known as oligoarticular JIA.
Marker which is a risk factor for iridocyclitis seen in pauciarticular/oligoarticular JIA
B) Antinuclear antibody (ANA)
Diagnostic criteria for psoriatic arthritis
1. Simultaneous presence of arthritis and typical psoriatic rash
2. If the rash is absent, arthritis plus two of the following:
a. Family history of psoriasis in a first-degree relative
b. Dactylitis
c. Nail pitting
Most common infection preceding the development of reactive arthritis
B) Chlamydia
Chlamydia trachomatis is sexually transmitted.
Usually monoarticular in children, but may involve multiple joints; presents with fever, joint pain, and decreased mobility
C) Septic arthritis
True or False: Most cases of septic arthritis are caused by gram-positive aerobes.
True
Gram-positive aerobes:
1. Staphylococcus aureus (60%)
2. Beta-hemolytic streptococci (15%)
3. Streptococcus pneumoniae (5%)
True or False: Majority of septic arthritis in neonates and infants younger than six months are caused by gram-positive aerobes.
False
Septic arthritis in neonates and in infants younger than six months are caused by gram-negative aerobes.
Spirochete responsible for Lyme Disease
Borrelia burgdorferi
Borrelia burgdorferi, the spirochete responsible for Lyme Disease, is transmitted to humans via deer tick called
Ixodes dammini
Most common tickborne disease in North American and Europe
Lyme Disease
Characteristic finding in Lyme Disease which looks like a reverse target skin lesion, as it is a large, red lesion with a central clearing area
Erythema migrans
Following a tick bite, how many days would it take before erythema migrans develop in Lyme Disease?
B) 1-30 days
MC involved joint in Lyme Disease
Knee
Others: hip, shoulder, elbow, wrist, and ankle
Multisystem autoimmune disease with widespread immune complex deposition that results in episodic inflammation, vasculitis, and serositis
C) Systemic Lupus Erythematosus
Synovial fluid analysis findings:
1. Color: pale yellow
2. Clarity: transparent
3. Viscosity: high
4. Mucin clot: good
5. Cells/mm3: <25%
6. WBC pecentage that are polymorphonuclear leukocytes: <10%
B) Normal
Synovial fluid analysis findings:
1. Color: yellow or straw
2. Clarity: transparent
3. Viscosity: high
4. Mucin clot: good
5. Cells/mm3: <2,000
6. WBC pecentage that are polymorphonuclear leukocytes: <25%
D) Group I (non-inflammatory)
Synovial fluid analysis findings:
1. Color: yellow or straw
2. Clarity: transparent to opaque, slightly cloudy
3. Viscosity: variably decreased
4. Mucin clot: fair to poor
5. Cells/mm3: 3,000-50,000
6. WBC pecentage that are polymorphonuclear leukocytes: >70%
B) Group II (moderately inflammatory)
Synovial fluid analysis findings:
1. Color: yellow-gray, purulent
2. Clarity: opaque, cloudy
3. Viscosity: low
4. Mucin clot: poor
5. Cells/mm3: 50,000-100,000
6. WBC pecentage that are polymorphonuclear leukocytes: >75% (usually close to 100%)
A) Group III (highly inflammatory, septic)
Synovial fluid analysis findings:
1. Color: red
2. Clarity: opaque
3. Viscosity: high
4. Mucin clot: good
5. Cells/mm3: up to normal count in blood
6. WBC pecentage that are polymorphonuclear leukocytes: may be the same as normal blood
A) Group IV (hemorrhagic)
All of the following are classified as inflammatory connective tissue disease, except:
D) Osteoarthritis
It should be rheumatoid arthritis, not osteoarthritis. Osteoarthritis is non-inflammatory.
True or False: Gout and pseudogout are both classified under inflammatory crystal-induced disease.
True
Inflammatory arthritis classified under seronegative spondyloarthropathies
APIR
1. Ankylosing spondylitis
2. Psoriatic arthritis
3. Inflammatory bowel disease
4. Reiter's syndrome
All of the following infectious agents can cause inflammatory arthritis, except:
A) Protozoas
Infectious agents which can cause inflammatory arthritis include bacteria, viruses, spirochetes, and fungi.
True or false: Non-inflammatory arthritis which are classified under degenerative, posttraumatic, or overuse include osteoarthritis and post-traumatic avascular necrosis.
False
It should be post-traumatic aseptic, not avascular necrosis.
Non-inflammatory arthritis classified under hereditary or metabolic
1. Lipid storage disease
2. Hemochromatosis
3. Ochronosis
4. Hypogammaglobulinemia
5. Hemoglobinopathies
Rheumatic condition which manifests with juxta-articular osteoporosis, fusiform soft-tissue swelling, marginal erosions, and bony cysts
A) Rheumatoid arthritis
Seronegative spondyloarthropathies which manifest with soft tissue swelling, sausage fingers, new bone formation, fluffy periosteal bone, syndesmophytes, enthesopathic ossification and/or erosion, bony ankylosis, and in severe cases arthritis mutilans
1. Ankylosing spondylitis
2. Reiter's syndrome
3. Psoriatic arthritis
Arthritis which manifests with periarticular soft tissue swelling, joint space enlargement, periosteal elevation, and in late stages bony destruction
A) Septic arthritis
Crystal-induced inflammatory disease which manifests with chondrocalcinosis and subchondral cysts
Pseudogout
Arthritis which manifests with epiphyseal enlargement, flattening and abnormal diaphyseal growth, periostitis, and apophyseal narrowing
D) Juvenile idiopathic arthritis
Crystal-induced inflammatory disease which manifests with soft-tissue speckled calcification and tophi deposits
Gout
Rheumatic conditions with symmetric joint involvement
1. Rheumatoid arthritis
2. Pseudogout
3. Systemic lupus erythematosus
4. Progressive systemic sclerosis
Rheumatic conditions with asymmetric joint involvement
1. Spondyloarthropathies (ankylosing spondylitis, Reiter's syndome, and psoriatic arthritis)
2. Septic arthritis
3. Gout
Most frequently involves the MCP, MTP, PIP, and wrist joints
D) Rheumatoid arthritis
Areas most frequently involved in spondyloarthropathies
1. Sacroiliac joint
2. Heel
3. Vertebral column
Rheumatic condition which manifests with acroosteolysis, soft tissue calcification, sausage digits, and joint space loss in late stages
D) Progressive systemic sclerosis
All of the following rheumatic conditions have eye involvement, except:
D) Psoriatic arthritis
All of the following rheumatic conditions have gastrointestinal tract involvement, except:
B) Rheumatoid arthritis
Rheumatic conditions associated with skin involvement
Rheumatic conditions also affecting the respiratory system
1. Rheumatoid arthritis
2. Sarcoidosis
3. Polymyositis
Rheumatic conditions also affect the heart and circulation
1. Amyloidosis
2. Polymyositis
3. Juvenile idiopathic arthritis
4. Reiter's syndrome
5. Ankylosing spondylitis
Inflammatory arthritis which is more common in whites and Native Americans (Pima Indians)
D) Rheumatoid arthritis
Inflammatory arthritis which has a lower prevalence among African Americans, Asian, and Japanese
A) Juvenile idiopathic arthritis
Inflammatory arthritis which is three times higher in blacks and Chinese and has increased prevalence in Haida, North American Indian
D) Systemic lupus erythematosus
Inflammatory arthritis which is higher in Central European
C) Ankylosing spondylitis
Inflammatory arthritis which is three times higher in black females
C) Polymyositis
Inflammatory arthritis which has increase prevalence in Southern US and is higher among African Americans
D) Progressive systemic sclerosis
Inflammatory arthritis common among African Americans and Asian-Pacific Islanders
D) Gout
Inflammatory arthritis more common in men
1. Gout
2. Ankylosing spondylitis
MC inflammatory arthropathy
Rheumatoid arthritis
True or False: Women taking estrogen-based oral contraceptives are at higher risk for having systemic lupus erythematosus than those taking progesterone-based oral contraceptives.
False
Women taking progesterone-based oral contraceptives are at higher risk for having systemic lupus erythematosus than those taking estrogen-based oral contraceptives.
Hallmark of this inflammatory arthritis is induration of the skin
A) Progressive systemic sclerosis
Primary idiopathic polymyositis
B) Group 1
Primary idiopathic dermatomyositis
C) Group 2
Dermatomyositis-polymyositis associated with neoplasia
A) Group 3
Juvenile dermatomyositis-polymyositis associated with vasculitis
B) Group 4
Dermatomyositis-polymyositis associated with collagen vascular disease
A) Group 5
Inclusion body myositis
C) Group 6
Familial rheumatic disorder which is associated with deficiency of hypoxanthine-guanine phosphotransferase, resulting in overproduction of uric acid
Gout
Onset before age 16 with arthritis affecting one joint or more for more than six weeks with no other known etiology
Juvenile idiopathic arthritis
Arthritis in one or more joints with or preceded by fever of at least two-week duration with at least three days of daily documented temperatures greater than 39°C, evanescent rash, generalized lymphadenopathy, hepatosplenomegaly, and serositis
Systemic juvenile idiopathic arthritis
Subgroup of polyarticular juvenile idiopathic arthritis which is usually more aggressive, symmetrically affecting small joints of the hands, wrists, and some larger joints similar to the adult form of the disease
A) RF positive
JIA associated with dactylitis, nail pitting, and onycholysis
C) Psoriatic JIA
Juvenile idiopathic arthritis with sacroiliac joint tenderness and/or inflammatory lumbosacral pain, positive HLA-B27 antigen, and acute asymptomatic uveitis
D) Enthesopathic JIA
The following muscles are commonly affected in polymyositis and dermatomyositis, except:
D) Forearm supinators
True or False: Childhood dermatomyositis can be treated with corticosteroids only which can be stopped over time.
True
True or False: Adult polymyositis or dermatomyositis can be treated with corticosteroids supplemented with immunosuppressive medications, both of which can be discontinued.
False
Corticosteroids and immunosuppressants cannot be discontinued.
Myositis which is not responsive to corticosteroids and immunosuppressive agents
A) Group 6
Myositis which involves distal muscle weakness and may be associated with polyneuropathy
A) Inclusion body myositis
Myositis associated with occult carcinoma in adult males aged 40 years and older
A) Dermatomyositis
Characteristic finding in dermatomyositis described as cracking and fissuring on fingertips
C) Mechanic's hand
Characteristic finding in dermatomyositis described as purple rash on the upper eyelid
B) Heliotrope rash
Characteristic finding in dermatomyositis described as scaly dermatitis over joints or bony prominences of the hand
C) Gottron papules
Vasculitis affecting large arteries
1. Giant cell arteritis
2. Takayasu arteritis
Vasculitis affecting small to medium arteries
Polyarteritis nodosa
Vasculitis affecting small arteries
1. Wegener's granulomatosis
2. Behcet's disease
Expression of giant cell arteritis which manifests with pain and stiffness of proximal muscles
Polymyalgia rheumatica
ACR Criteria for polymyalgia rheumatica
1. Hip pain or limitation of motion = 1 point
2. Absence of other joint pain = 1 point
3. Morning stiffness >45 minutes = 2 points
4. Ultrasound findings
a. One abnormal finding (e.g. subdeltoid bursitis, glenohumeral synovitis, biceps tenosynovitis) in the shoulder AND one abnormal finding (e.g. hip synovitis, trochanteric bursitis) in the hip = 1 point
b. Two abnormal findings in the shoulder (e.g. subdeltoid bursitis, glenohumeral synovitis, biceps tenosynovitis) = 1 point
5. Normal RF and ACPA (but abnormal ESR and CRP)
A score of at least 5 out of 7 is needed to diagnose polymyalgia rheumatica.
Vasculitis which commonly affects large, elastic arteries such as aorta
Takayasu arteritis
Manifestations of Takayasu arteritis
1. Erythema nodosum
2. Pulselessness
3. Arm claudication
4. Chest pain
5. Difference in blood pressures between two arms
Takayasu arteritis classification which only affects the branches of aortic arch
B) I
All of the following segments of aorta are affected in Takayasu arteritis class IIa, except:
D) Thoracic descending aorta
What segments of aorta are affected in Takayasu arteritis classified as IIb?
1. Ascending aorta
2. Aortic arch
3. Branches of aortic arch
4. Thoracic descending aorta
Takayasu arteritis classification which involves the thoracic descending aorta, abdominal aorta, and renal arteries
A) III
What segments of aorta affected in Takayasu arteritis classified as IV?
A) Abdominal aorta and renal arteries
Takayasu arteritis classification which involves the ascending aorta, aortic arch and its branches, thoracic descending aorta, abdominal aorta, and renal arteries
A) V
MC cause of death in patients with polyarteritis nodosa
Glomerulonephritis
Vasculitis with characteristic saddle nose deformity
B) Wegener's granulomatosis
Triad of Behcet's Disease
1. Oral aphthous ulcers
2. Genital ulcers
3. Uveitis
Autoimmune disease in which the antibodies attack the lungs and kidneys, leading to organ failure
B) Good pasture syndrome
Other names of ankylosing spondylitis
1. Rheumatoid spondylitis
2. von Bechterew's disease
3. Marie-Strumpell disease
How long does the morning lumbar stiffness in ankylosing spondylitis typically last prior to improving?
A) 3 hours
How long should symptoms persist to be diagnosed as ankylosing spondylitis?
B) 3 months
Progression of vertebral joint involvement in ankylosing spondylitis (first to last)
1. Sacroiliac joint
2. Lumbar vertebra
3. Thoracic vertebra
4. Cervical vertebra
Other manifestations of ankylosing spondylitis
1. C1-C2 subluxation
2. Cauda equina syndrome
3. Pulmonary fibrosis
4. Uveitis
Reiter's syndrome is also known as
Reactive arthritis
Infections which could lead to Reiter's syndrome
1. Chlamydia
2. Campylobacter
3. Shigella
4. Salmonella
5. Yersinia
Triad of Reiter's syndrome
1. Conjunctivitis
2. Arthritis (oligoarticular or polyarticular commonly involving sacroiliac, knee, and ankle joints)
3. Non-gonococcal urethritis
Small, painless ulcers in glans penis seen in Reiter's syndrome
C) Balanitis circinata
Hypertrophic lesions on palms and soles of individuals with Reiter's syndrome
B) Keratoderma blennorrhagica
How many percent of individuals with psoriasis develop psoriatic arthritis?
D) 5-7%
Epidemiology of psoriatic arthritis
A) Female = Male; 30-50 years old
MC affected joint in psoriatic arthritis
A) DIP joint
Pinpoint bleeding that occurs when the surface of a psoriatic plaque has been removed and capillaries just beneath the skin's surface rupture
C) Auspitz's sign
Appearance of new skin lesions on previously unaffected skin secondary to trauma
B) Koebner phenomenon
Manifestations of psoriatic arthritis
1. DIP joint involvement
2. Auspitz's sign
3. Koebner phenomenon
4. Onycolysis
5. Telescoping sign (arthritis mutilans)
6. Asymmetric joint involvement
7. Pencil in cup deformity
Remission of enteric arthropathy occurs when the underlying inflammatory bowel disease subsides.
True
MC affected joint in gouty arthritis
First metatarsophalangeal (podagra)
Four stages of gouty arthritis
1. Asymptomatic hyperuricemia
2. Acute gouty arthritis (presence of non-specific symptoms such as fever, chills, and malaise; inflammation of joint/s)
3. Intercritical gout (asymptomatic but uric acid continues to accumulate in the body)
4. Chronic tophaceous gout (presence of sodium urate crystal deposits in joint/s)
Medication used in acute gout attacks
B) Colchicine
Medication used to decrease uric acid formation and is effective in long-term management of gouty arthritis
A) Allopurinol
The following are characteristics of crystals seen in pseudogout, except:
A) Needle-shaped
The following are characteristics of crystals seen in gout, except:
D) Commonly found in the knee
Calcium deposition on alar and cruciform ligaments of dens seen in pseudogout
Crowned dens syndrome
MC affected joint in pseudogout
Knee
Other names of osteoarthritis
1. Degenerative joint disease
2. Kellgren's disease
Non-inflammatory, but progressive rheumatic condition which is associated with degeneration of the articular cartilage due to the weakening of collagen network
Osteoarthritis
True or Fals: In osteoarthritis, weakening of the collagen network of articular cartilages results from decreased water and increased proteoglycan content.
False
Weakening of collagen network of articular cartilages results from increased water and decreased proteoglycan content.
Epidemiology of osteoarthritis
<50 years old (Males > Females)
>50 years old (Females > Males)
Inflammatory variant of hand osteoarthritis which commonly affects the PIP and DIP joints of women aged 50-55 years
Erosive osteoarthritis
Deformities seen in erosive osteoarthritis of the IP joints in the hand
1. Gull wing deformity
2. Saw tooth deformity
Condition commonly mistaken for ankylosing spondylitis as it involves calcification of ALL and PLL in three or more consecutive IV discs
Diffused idiopathic skeletal hyperostosis (DISH)
DISH is also known as
Forestier's disease
Hallmark of osteoarthritis
B) Asymmetric joint space narrowing
MC clinical finding in osteoarthritis
C) Crepitus
How long does joint stiffness in osteoarthritis last prior to improvement?
B) 30 minutes
MC affected joint in osteoarthritis
B) Knee
Disabling form of hip osteoarthritis which causes limitation in hip internal rotation and referred pain to the buttocks, knee, groin, and greater trochanter
Manum coxae senilis
Criteria for knee osteoarthritis
1. Persistent knee pain
2. Limited morning stiffness ≤30 minutes
3. Reduced function
4. Crepitus
5. Bony enlargement
6. Restricted movement
Criteria for hip osteoarthritis
Pain present in combination with either:
a. hip IR ≥15°. morning stiffness ≤60 minutes, age >50 years, and pain upon hip IR
b. hip IR <15° and hip flexion <115°
Criteria for hand osteoarthritis
1. Presence of Heberden's nodes
2. Age >40 years
3. Family history of nodes
4. Joint space narrowing in any finger joint
Kellgren-Lawrence Radiographic Grading Scale for osteoarthritis: no radiographic findings of OA
C) Grade 0
Kellgren-Lawrence Radiographic Grading Scale for osteoarthritis: doubtful joint space narrowing and possible osteophytic lipping
B) Grade 1
Kellgren-Lawrence Radiographic Grading Scale for osteoarthritis: definite osteophytes with possible/questionable joint space narrowing
D) Grade 2
Kellgren-Lawrence Radiographic Grading Scale for osteoarthritis: definite osteophytes with moderate joint space narrowing and some sclerosis
A) Grade 3
Kellgren-Lawrence Radiographic Grading Scale for osteoarthritis: definite osteophytes with severe joint space narrowing, subchondral sclerosis, and definite deformity of bony contour
D) Grade 4
First line agent for mild osteoarthritis because of its benign safety profile
A) Acetaminophen
Strongest risk factor for prevalence and incidence of osteoarthritis
B) Advanced age
Primary modifiable risk factor of osteoarthritis that has the greatest potential for having an impact on treating the disease
Obesity
Segments of the spine MC involved in osteoarthritis
1. C5-C6
2. L4-L5
3. L5-S1
Among the hand joints, which is rarely involved in rheumatoid arthritis because it has less synovium
B) Distal interphalangeal joint
Deformity seen in rheumatoid arthritis characterized by extension of IP joint, as well as flexion and subluxation of MCP joint of the thumb
C) Z deformity
Most commonly used DMARD in management of rheumatoid arthritis
D) Methotrexate
Chronic inflammatory arthritis involving the axial structures, manifested by chronic back pain and progressive stiffness of the spine; but may also involves large peripheral joints
Ankylosing spondylitis
Ankylosing spondylitis may involve arthritis outside the spine and the most commonly affected joints, in order of frequency, are:
1. Shoulders
2. Hips
3. Knees
Most common location of enthesitis in ankylosing spondylitis
Calcaneal attachments of Achilles tendon
Others: calcaneal attachments of plantar fascia, shoulders, costochondral junctions, sternoclavicular and manubriosternal joints, and superior iliac crest
Radiographic grading of sacroilitis: normal
B) Grade 0
Radiographic grading of sacroilitis: suspicious changes
C) Grade 1
Radiographic grading of sacroilitis: minimal abnormality - small localized areas with erosions or sclerosis, without alteration in the joint width
D) Grade 2
Radiographic grading of sacroilitis: unequivocal abnormality - moderate or advanced sacroilitis with erosions, sclerosis, widening, narrowing, or partial ankylosis
C) Grade 3
Radiographic grading of sacroilitis: total ankylosis
B) Grade 4
1984 Modified New York Criteria for ankylosing spondylitis
Clinical variables:
1. Inflammatory back pain >3 months
2. Limitation of motion of the lumbar spine in both sagittal and frontal planes
3. Limitation of chest expansion relative to normal values
Radiologic Variables (plain radiographs):
1. Sacroiliitis grade ≥2 bilaterally
2. Sacroiliitis grade 3-4 unilaterally
Definite Diagnosis: at least one clinical variable plus at least one radiologic variable
Disorder characterized by widespread musculoskeletal pain is usually associated with constitutional symptoms such as fatigue, malaise, sleep disturbances, headaches, mood disturbances, memory loss, and irritable bowel symptoms
Fibromyalgia
Joints MC affected in systemic lupus erythematosus
Smaller peripheral joints such as fingers, wrists, elbows, toes, and ankles
Calcium phyrophosphate deposition disease
Pseudogout
The onset of pseudogout is sudden with symptoms reaching maximum intensity within 8-12 hours. Meanwhile, the course of gout is more insidious, gradually intensifying over several days.
B) Both statements are false.
The onset of gout is sudden with symptoms reaching maximum intensity within 8-12 hours. The course of pseudogout is more insidious gradually intensifying over several days.
Hyperechoic, irregular line of monosodium urate crystals on the surface of articular cartilage seen in ultrasound
B) Double contour sign
Non-pharmacologic management of gouty arthritis includes:
1. Abundant hydration
2. Avoiding high purine foods (meats and seafood)
3. Avoiding high-fructose corn syrup (soft drinks and artificial fruit drinks)
4. Decreasing alcohol intake (especially beer)
5. Weight reduction (if obesity is an issue)
True or False: Psoriatic arthritis affects females more than males.
False
Psoriatic arthritis affects males and females equally.
MC clinical pattern of psoriatic arthritis
A) Polyarthritis
Medication which has been shown to reduce radiographic progression of psoriatic arthritis and its effect is superior to methotrexate
TNF inhibitors (e.g. etanercept, adalimumab, or infliximab)
Classification Criteria for psoriatic arthritis
1. Inflammatory musculoskeletal disease (peripheral arthritis, spondylitis, or enthesitis) AND
2. At least three points from the following:
a. Current psoriasis (2 points), a personal history of psoriasis (1 point), or a family history of psoriasis (1 point)
b. Typical nail lesions (1 point): onycolysis, pitting
c. Dactylitis (1 point): present or past, documented by a rheumatologist
d. Negative rheumatoid factor (1 point)
e. Juxtaarticular bone formation (1 point): on hand or foot radiographs
Common feature of dermatomyositis and polymyositis
Painless muscle weakness
ACR Criteria for fibromyalgia
1. Widespread pain on both sides of the body
2. 11 out of 18 tender points
NOTE: To be diagnosed as fibromyalgia, both criteria must be fulfilled.
Tender point sites in fibromyalgia
There are 18 tender point sites, 9 on each side of the body.
1. Occiput
2. Lower cervical
3. Trapezius
4. Supraspinatus
5. Second rib
6. Lateral epicondyle
7. Buttock
8. Greater trochanter
9. Knee
Antihistone antibodies are present in which of the following conditions?
