Which of the following is associated with a good prognosis in rheumatoid arthritis?
Correct Answer A:
Rheumatoid arthritis: prognostic features: A number of features have been shown to predict a poor prognosis in patients with rheumatoid arthritis.
Poor prognostic features:
In terms of gender there seems to be a split in what the established sources state is associated with a poor prognosis. However both the American College of Rheumatology and the recent NICE guidelines (which looked at a huge number of prognosis studies) seem to conclude that female gender is associated with a poor prognosis.
A 64-year-old man with chronic kidney disease stage 3 secondary to type 2 diabetes mellitus presents with pain and swelling at the right first metatarsophalangeal joint. On examination the joint is hot, erythematous and tender to touch, although he can still flex the big toe.
What is the most appropriate initial management?
Correct Answer A: Colchicine is useful in patients with renal impairment who develop gout as NSAIDs are relatively contraindicated.
The BNF advises to reduce the dose by up to 50% if creatinine clearance is less than 50 ml/min and to avoid if creatinine clearance is less than 10 ml/min. Co-codamol 30/500 may be used as an adjunct but would not provide relief as monotherapy. Prednisolone is an option but would adversely affect his diabetic control.
Gout: management: Gout is a form of microcrystal synovitis caused by the deposition of monosodium urate monohydrate in the synovium. It is caused by chronic hyperuricaemia (uric acid > 450 μmol/l).
Acute management:
Allopurinol prophylaxis:
Indications for allopurinol*:
Lifestyle modifications:
*Patients with Lesch-Nyhan syndrome often take allopurinol for life
A 25-year-old woman presents with a three day history of dysuria and a painful left knee. During the review of symptoms she mentions a bout of diarrhoea and crampy abdominal pain three weeks ago. She is normally fit and well and takes no regular medication. Her father died of colorectal cancer in his sixth decade. On examination the left knee is red, swollen and hot to touch.
What is the most likely diagnosis?
Correct Answer A: Urethritis + arthritis + conjunctivitis = reactive arthritis.
Two of the classic three features of reactive arthritis (urethritis, arthritis and conjunctivitis) are present in this patient. The family history of colorectal cancer is of no particular significance. Symptoms of reactive arthritis typically appear 1-4 weeks following the initial infection, in this case a diarrhoeal illness.
Reactive arthritis: Reactive arthritis is one of the HLA-B27 associated seronegative spondyloarthropathies. It encompasses Reiter's syndrome, a term which described a classic triad of urethritis, conjunctivitis and arthritis following a dysenteric illness during the Second World War. Later studies identified patients who developed symptoms following a sexually transmitted infection (post-STI, now sometimes referred to as sexually acquired reactive arthritis, SARA).
Reactive arthritis is defined as an arthritis that develops following an infection where the organism cannot be recovered from the joint.
Epidemiology:
The table below shows the organisms that are most commonly associated with reactive arthritis:
Management:
An autoantibody screen reveals that a patient is positive for anti-Jo 1 antibodies.
What is the most likely underlying diagnosis?
Correct Answer D: Anti-Jo 1 antibodies are more commonly seen in polymyositis than dermatomyositis.
Extractable nuclear antigens
Overview:
Examples:
Which one of the following is least recognized as a risk factor for developing osteoporosis?
Correct Answer D: Hyperthyroidism is associated with an increased risk of osteoporosis. Patients with hypothyroidism who take excessive amounts of levothyroxine may also be at risk of osteoporosis.
Osteoporosis causes: Risk factors:
Diseases which predispose to Osteoporosis:
*Research is ongoing as to whether warfarin is a risk factor
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