RHEUMATOLOGY
Questions&Answers
Q-1
A 33 year old woman comes in with a 6 month history of painless bilateral
swelling of the face and a mild grade fever. The swelling has been progressively
increasing in size. She also complains of having worsening symptoms of dry
mouth. On a routine chest X-ray, she is found to have bilateral perihilar
lymphadenopathy. What is the SINGLE most likely diagnosis?
A. Chronic sialadenitis
B. Carcinoma of salivary gland
C. Lofgren syndrome
D. Adenoid cystic carcinoma
E. Mikulicz’s syndrome
ANSWER:
Mikulicz’s syndrome
EXPLANATION:
Mikulicz’s syndrome is the benign persistent swelling of lacrimal and parotid (or
submandibular) glands due to lymphocytic infiltration. When no specific cause is found
it is called Mikulicz’s disease; and if secondary to disease like sarcoidosis or
tuberculosis, it is termed as Mikulicz’s syndrome. In this case, where it is likely
secondary to sarcoidosis given the patient’s chest X-ray findings it is termed Mikulicz’s
syndrome.
Mikulicz disease and syndrome has the same clinical picture and it comprises of a triad
of:
Symmetrical enlargement of all salivary glands
Narrowing of the palpebral fissures due to enlargement of the lacrimal glands
Dryness of the mouth
Q-2
A 30 year old man attends the GP surgery with pain at the base of his right first
toe that started 5 days ago. On examination, there is swelling and redness of the
surrounding the joint. He denies any fever. This is his first episode of pain at
that area and there is no history of injury at that area. He has not taken any
medication for pain relief. What is the SINGLE most appropriate first line
management?
, A. Naproxen
B. Colchicine
C. Allopurinol
D. Corticosteroids
E. Aspirin
ANSWER:
Naproxen
EXPLANATION:
This is a classic example of gout which most commonly affects the metatarsal-
phalangeal joint of the big toe. Most attacks are sudden can be managed with NSAIDs
such as naproxen. They are to be continued until 1 to 2 days after the attack has been
resolved.
Both NSAIDs and colchicine re considered first line management in acute gout attacks
which makes this question very difficult to answer. NSAIDs is generally more often
prescribed in primary practice for gout and is more tolerable since colchicine is known
for its side effects which include diarrhoea and nausea. So in the exam, if you were
given the choice between the two and the patient is a young adult with no history of
gastritis or asthma, pick NSAIDs.
Always keep in mind that NSAIDs may exacerbate asthma and may worsen gastritis.
They should also not be used in patients with renal insufficiency. Proton pump
inhibitors are often prescribed together with NSAIDs for gastric protection especially in
the elderly where use of NSAIDs should be with caution.
Allopurinol is used to prevent recurrence of gout and it is not used to treat acute gout.
Corticosteroids do have a role in gout that does not respond to NSAIDs or colchicine.
They can be given as a 5 day course of oral tablets, injected into the joint or injected
intramuscularly.
Although it is an NSAID, aspirin is not part of the management for gout as it may
increase levels of serum uric acid.
Gout
Gout is a disease that affects middle-aged men and presents most commonly with
acutemonoarthritis.
The metatarsophalangeal joint of the first toe is commonly affected (podagra), butother
joints like the knee, ankle, PIPs, or DIPs may be initially involved. The first
episodecommonly occurs at night with severe joint pain waking the patient from sleep.
Thejoint rapidly becomes warm, red, and tender (it looks exactly like cellulitis).
Withouttreatment the joint pain goes away spontaneously in 2 weeks.
Certain events that precipitate gout sometimes precede the attack. Question writersvery
commonly give a scenario where a person has consumed excessive amounts ofalcohol
or started taking diuretics such as thiazide diuretics or furosemide.
, Diagnosis
• Diagnosis is made by the analysis of synovial fluid
• Serum uric acid during the acute attack may be normal or low.
o Remember this it is common that questions ask for the diagnostic method for
acute gout – serum uric acid should never be the answer for those questions.
o Serum uric acid level is of no value in the diagnosis of acute urate arthropathy.
o Uric acid should only be performed 4 to 6 weeks after the acute gout.
Treatment:
Acute management
- NSAIDs
- intra-articular steroid injection
- Colchicine
Chronic hypouricemic therapy:
- Allopurinol should not be started until 2 weeks after an acute attack has settledas it
may precipitate a further attack if started too early
- NSAID or colchicine cover should be used when starting allopurinol
Q-3
A 38 year old man recently had an appendicectomy and has now developed
severe pain in his right big toe. He is noted to consume an average of 30 units of
alcohol in a week. On examination, the joint of the right big toe is red and
swollen. What is the SINGLE most likely diagnosis?
A. Rhabdomyosarcoma
B. Osteoarthritis
C. Gout
D. Pseudogout
E. Arthritis
ANSWER:
Gout
EXPLANATION:
Drinking too much alcohol can cause uric acid to build up and cause gout.
Q-4
A 63 year old man presents with muscle weakness. He finds it difficult to walk for
long periods of time or climb stairs. Activities such as rising from a seated
position is difficult. He also finds difficulty in swallowing foods. His blood
results show:
Alkaline phosphatase (ALP) 149 U/L
Aspartate transaminase (AST) 37 U/L
Alanine transferase (ALT) 44 U/L
Creatine kinase 440 U/L
Erythrocyte sedimentation rate (ESR) 16 mm/h
What is the SINGLE most likely diagnosis?
Questions&Answers
Q-1
A 33 year old woman comes in with a 6 month history of painless bilateral
swelling of the face and a mild grade fever. The swelling has been progressively
increasing in size. She also complains of having worsening symptoms of dry
mouth. On a routine chest X-ray, she is found to have bilateral perihilar
lymphadenopathy. What is the SINGLE most likely diagnosis?
A. Chronic sialadenitis
B. Carcinoma of salivary gland
C. Lofgren syndrome
D. Adenoid cystic carcinoma
E. Mikulicz’s syndrome
ANSWER:
Mikulicz’s syndrome
EXPLANATION:
Mikulicz’s syndrome is the benign persistent swelling of lacrimal and parotid (or
submandibular) glands due to lymphocytic infiltration. When no specific cause is found
it is called Mikulicz’s disease; and if secondary to disease like sarcoidosis or
tuberculosis, it is termed as Mikulicz’s syndrome. In this case, where it is likely
secondary to sarcoidosis given the patient’s chest X-ray findings it is termed Mikulicz’s
syndrome.
Mikulicz disease and syndrome has the same clinical picture and it comprises of a triad
of:
Symmetrical enlargement of all salivary glands
Narrowing of the palpebral fissures due to enlargement of the lacrimal glands
Dryness of the mouth
Q-2
A 30 year old man attends the GP surgery with pain at the base of his right first
toe that started 5 days ago. On examination, there is swelling and redness of the
surrounding the joint. He denies any fever. This is his first episode of pain at
that area and there is no history of injury at that area. He has not taken any
medication for pain relief. What is the SINGLE most appropriate first line
management?
, A. Naproxen
B. Colchicine
C. Allopurinol
D. Corticosteroids
E. Aspirin
ANSWER:
Naproxen
EXPLANATION:
This is a classic example of gout which most commonly affects the metatarsal-
phalangeal joint of the big toe. Most attacks are sudden can be managed with NSAIDs
such as naproxen. They are to be continued until 1 to 2 days after the attack has been
resolved.
Both NSAIDs and colchicine re considered first line management in acute gout attacks
which makes this question very difficult to answer. NSAIDs is generally more often
prescribed in primary practice for gout and is more tolerable since colchicine is known
for its side effects which include diarrhoea and nausea. So in the exam, if you were
given the choice between the two and the patient is a young adult with no history of
gastritis or asthma, pick NSAIDs.
Always keep in mind that NSAIDs may exacerbate asthma and may worsen gastritis.
They should also not be used in patients with renal insufficiency. Proton pump
inhibitors are often prescribed together with NSAIDs for gastric protection especially in
the elderly where use of NSAIDs should be with caution.
Allopurinol is used to prevent recurrence of gout and it is not used to treat acute gout.
Corticosteroids do have a role in gout that does not respond to NSAIDs or colchicine.
They can be given as a 5 day course of oral tablets, injected into the joint or injected
intramuscularly.
Although it is an NSAID, aspirin is not part of the management for gout as it may
increase levels of serum uric acid.
Gout
Gout is a disease that affects middle-aged men and presents most commonly with
acutemonoarthritis.
The metatarsophalangeal joint of the first toe is commonly affected (podagra), butother
joints like the knee, ankle, PIPs, or DIPs may be initially involved. The first
episodecommonly occurs at night with severe joint pain waking the patient from sleep.
Thejoint rapidly becomes warm, red, and tender (it looks exactly like cellulitis).
Withouttreatment the joint pain goes away spontaneously in 2 weeks.
Certain events that precipitate gout sometimes precede the attack. Question writersvery
commonly give a scenario where a person has consumed excessive amounts ofalcohol
or started taking diuretics such as thiazide diuretics or furosemide.
, Diagnosis
• Diagnosis is made by the analysis of synovial fluid
• Serum uric acid during the acute attack may be normal or low.
o Remember this it is common that questions ask for the diagnostic method for
acute gout – serum uric acid should never be the answer for those questions.
o Serum uric acid level is of no value in the diagnosis of acute urate arthropathy.
o Uric acid should only be performed 4 to 6 weeks after the acute gout.
Treatment:
Acute management
- NSAIDs
- intra-articular steroid injection
- Colchicine
Chronic hypouricemic therapy:
- Allopurinol should not be started until 2 weeks after an acute attack has settledas it
may precipitate a further attack if started too early
- NSAID or colchicine cover should be used when starting allopurinol
Q-3
A 38 year old man recently had an appendicectomy and has now developed
severe pain in his right big toe. He is noted to consume an average of 30 units of
alcohol in a week. On examination, the joint of the right big toe is red and
swollen. What is the SINGLE most likely diagnosis?
A. Rhabdomyosarcoma
B. Osteoarthritis
C. Gout
D. Pseudogout
E. Arthritis
ANSWER:
Gout
EXPLANATION:
Drinking too much alcohol can cause uric acid to build up and cause gout.
Q-4
A 63 year old man presents with muscle weakness. He finds it difficult to walk for
long periods of time or climb stairs. Activities such as rising from a seated
position is difficult. He also finds difficulty in swallowing foods. His blood
results show:
Alkaline phosphatase (ALP) 149 U/L
Aspartate transaminase (AST) 37 U/L
Alanine transferase (ALT) 44 U/L
Creatine kinase 440 U/L
Erythrocyte sedimentation rate (ESR) 16 mm/h
What is the SINGLE most likely diagnosis?
