Rheumatology (autoimmune diseases, arthritis)

Rheumatology (autoimmune diseases, arthritis) US Medical PG Question 1: A 47-year-old woman comes to the physician because of body aches for the past 9 months. She also has stiffness of the shoulders and knees that is worse in the morning and tingling in the upper extremities. Examination shows marked tenderness over the posterior neck, bilateral mid trapezius, and medial aspect of the left knee. A complete blood count and erythrocyte sedimentation rate are within the reference ranges. Which of the following is the most likely diagnosis?

• A. Systemic lupus erythematosus
• B. Fibromyalgia (Correct Answer)
• C. Rheumatoid arthritis
• D. Polymyositis
• E. Major depressive disorder

Rheumatology (autoimmune diseases, arthritis) Explanation: ***Fibromyalgia*** - The patient's presentation of widespread **body aches for 9 months**, morning **stiffness**, and **multiple tender points** (posterior neck, bilateral mid trapezius, medial aspect of the knee) in the absence of inflammatory markers (normal ESR, normal CBC) is highly characteristic of **fibromyalgia**. - **Paresthesias** (tingling in the upper extremities) are a common associated feature in fibromyalgia. - Fibromyalgia is a chronic pain syndrome diagnosed clinically based on widespread pain and tender points, with normal laboratory findings. *Systemic lupus erythematosus* - SLE typically presents with **systemic inflammation**, often involving joints, skin, and kidneys, along with abnormalities in inflammatory markers (e.g., elevated ESR, positive ANA, cytopenias). - The widespread tender points and completely normal inflammatory markers make SLE very unlikely. *Rheumatoid arthritis* - RA primarily affects the **synovial joints** symmetrically, leading to joint swelling, warmth, and morning stiffness, typically accompanied by elevated ESR and CRP. - The examination findings show specific **tender points** rather than objective joint swelling, and the normal ESR rules against active RA. *Polymyositis* - Polymyositis is characterized by **proximal muscle weakness** (not diffuse body aches) and is associated with elevated muscle enzymes (CK, aldolase) and inflammatory changes on muscle biopsy. - This patient has pain and tenderness without weakness, and her laboratory tests are normal. *Major depressive disorder* - While **fatigue**, body aches, and sleep disturbances can be symptoms of major depressive disorder, the presence of specific, well-defined **tender points on examination** points towards a primary pain syndrome. - Fibromyalgia often coexists with depression, but the objective physical findings of multiple tender points are more consistent with fibromyalgia as the primary diagnosis.

Rheumatology (autoimmune diseases, arthritis) US Medical PG Question 2: A 71-year-old man presents to the clinic with complaints of right wrist pain for 2 days. On examination, redness and swelling were noted on the dorsal aspect of his right wrist. He had pain with extreme range of motion of the wrist. His history includes 2 hip replacements, 2 previous episodes of gout in both first metatarsophalangeal joints, and hypertension. Two days later, the swelling had increased in the dorsal aspect of his right wrist and hand. Wrist flexion was limited to 80% with severe pain. The pain was present on palpation of the scaphoid bone. Due to the suspicion of fracture, the patient was referred to his general practitioner for radiographs. These findings were consistent with gouty arthritis. What is the most likely cytokine involved in this process?

• A. INFγ
• B. IL-4
• C. IL-10
• D. IL-5
• E. IL-1 (Correct Answer)

Rheumatology (autoimmune diseases, arthritis) Explanation: ***IL-1*** - Interleukin-1 (IL-1) is a crucial **pro-inflammatory cytokine** highly implicated in the pathogenesis of gout. **Monosodium urate (MSU) crystals** activate the **NLRP3 inflammasome**, leading to the production of active IL-1β, which drives the inflammatory response seen in acute gout. - The symptoms of acute gout, including severe pain, redness, and swelling, are largely mediated by IL-1, as evidenced by the effectiveness of **IL-1 inhibitors** in treating acute gout attacks. *INFγ* - **Interferon-gamma (IFN-γ)** is primarily associated with **Th1-mediated immune responses** and cellular immunity, often involved in antiviral and anti-tumor responses. - While it has immunomodulatory effects, it is not the primary cytokine driving the acute inflammatory response in gout. *IL-4* - **Interleukin-4 (IL-4)** is a key cytokine in **Th2-mediated immune responses**, promoting **B cell activation** and **IgE production**, and is primarily involved in allergic reactions and anti-parasitic immunity. - IL-4 generally has **anti-inflammatory effects** regarding acute crystal-induced inflammation and would not be the main driver of the symptoms described. *IL-10* - **Interleukin-10 (IL-10)** is a potent **anti-inflammatory cytokine** that plays a critical role in limiting the immune response and preventing tissue damage. - IL-10 would actively suppress the inflammation seen in gout, rather than contribute to it. *IL-5* - **Interleukin-5 (IL-5)** is primarily involved in the growth and differentiation of **eosinophils** and is important in **allergic reactions** and defense against parasites. - It does not play a significant role in the acute inflammatory cascade triggered by MSU crystals in gout.

Rheumatology (autoimmune diseases, arthritis) US Medical PG Question 3: A previously healthy 13-year-old girl is brought to the physician for evaluation of a 2-month history of fatigue. She reports recurrent episodes of pain in her right wrist and left knee. During this period, she has had a 4-kg (8.8-lb) weight loss. Her mother has rheumatoid arthritis. Her temperature is 38°C (100.4°F). Examination shows diffuse lymphadenopathy. Oral examination shows several painless oral ulcers. The right wrist and the left knee are swollen and tender. Laboratory studies show a hemoglobin concentration of 9.8 g/dL, a leukocyte count of 2,000/mm3, and a platelet count of 75,000/mm3. Urinalysis shows excessive protein. This patient's condition is associated with which of the following laboratory findings?

• A. Anti-citrullinated peptide antibodies
• B. Anti-dsDNA antibodies (Correct Answer)
• C. Leukocytoclastic vasculitis with IgA and C3 immune complex deposition
• D. Positive HLA-B27 test
• E. Excessive lymphoblasts

Rheumatology (autoimmune diseases, arthritis) Explanation: ***Anti-dsDNA antibodies*** - The patient presents with **fatigue, fever, weight loss, lymphadenopathy, oral ulcers**, **arthralgia/arthritis**, and **proteinuria**, along with **anemia, leukopenia, and thrombocytopenia**. This constellation of symptoms is highly suggestive of **Systemic Lupus Erythematosus (SLE)**. - **Anti-dsDNA antibodies** are highly specific for SLE and are often associated with active disease, particularly **lupus nephritis**, which is indicated by the proteinuria. *Anti-citrullinated peptide antibodies* - These antibodies are highly specific for **rheumatoid arthritis (RA)**, a disease primarily affecting joints in a symmetrical pattern. - While the patient's mother has RA, the patient's systemic symptoms (fever, weight loss, anemia, leukopenia, thrombocytopenia, proteinuria) and oral ulcers are not typical features of RA, especially in a 13-year-old. *Leukocytoclastic vasculitis with IgA and C3 immune complex deposition* - This finding is characteristic of **IgA vasculitis (Henoch-Schönlein Purpura)**, which typically presents with a palpable purpuric rash, arthritis, abdominal pain, and renal involvement (hematuria/proteinuria). - The patient's presentation lacks the characteristic rash and GI symptoms, making this diagnosis less likely. *Positive HLA-B27 test* - A positive **HLA-B27** is associated with **spondyloarthropathies** such as ankylosing spondylitis, psoriatic arthritis, and reactive arthritis. - These conditions primarily affect the spine and sacroiliac joints, often with enthesitis, and do not typically present with the multi-systemic features like cytopenias, oral ulcers, and significant proteinuria observed in this patient. *Excessive lymphoblasts* - The presence of **excessive lymphoblasts** in the bone marrow or blood is indicative of **acute lymphoblastic leukemia (ALL)**. - Although ALL can present with fatigue, fever, weight loss, anemia, and thrombocytopenia, it is less commonly associated with oral ulcers, arthritis, and significant proteinuria. Additionally, while the patient has leukopenia (2,000/mm3), the presence of circulating lymphoblasts would be a key distinguishing feature of ALL that is not mentioned in this case.

Rheumatology (autoimmune diseases, arthritis) US Medical PG Question 4: A 39-year-old woman comes to the physician because of progressive pain and swelling of her wrists and hands for the past 2 months. Her hands are stiff in the morning; the stiffness decreases as she starts her chores. She also reports early-morning neck pain at rest for the past 3 weeks. She has no history of serious illness and takes no medications. Her sister has systemic lupus erythematosus. Vital signs are within normal limits. Examination shows bilateral swelling and tenderness of the wrists, second, third, and fourth metacarpophalangeal joints; range of motion is limited by pain. There is no vertebral tenderness. Cardiopulmonary examination shows no abnormalities. Neurologic examination shows no focal findings. Laboratory studies show: Hemoglobin 12.8 g/dL Leukocyte count 9,800/mm3 Erythrocyte sedimentation rate 44 mm/h Serum Glucose 77 mg/dL Creatinine 1.1 mg/dL Total bilirubin 0.7 mg/dL Alkaline phosphatase 33 U/L AST 14 U/L ALT 13 U/L Rheumatoid factor positive Which of the following is the most appropriate next step in management?

• A. Adalimumab
• B. CT scan of the chest
• C. Measurement of anti-CCP antibodies (Correct Answer)
• D. X-ray of the cervical spine
• E. Measurement of anti-Smith antibodies

Rheumatology (autoimmune diseases, arthritis) Explanation: ***Measurement of anti-CCP antibodies*** - This patient presents with **classic rheumatoid arthritis (RA)**: symmetric polyarthritis affecting wrists and MCP joints, morning stiffness improving with activity, elevated ESR, and positive rheumatoid factor. - **Anti-CCP (anti-cyclic citrullinated peptide) antibodies** are highly specific for RA (~95% specificity) and should be measured to **confirm the diagnosis**. - Anti-CCP positivity helps with **prognostication** (associated with more aggressive disease and erosive changes) and guides early initiation of disease-modifying antirheumatic drugs (DMARDs) like methotrexate. - Early diagnosis and treatment of RA is crucial to prevent irreversible joint damage and disability. *Measurement of anti-Smith antibodies* - **Anti-Smith antibodies** are highly specific for **systemic lupus erythematosus (SLE)**, not RA. - This patient has **no clinical features of SLE** (no malar rash, photosensitivity, oral ulcers, serositis, renal involvement, or cytopenias). - Family history of SLE alone does not warrant testing when the clinical presentation clearly points to RA. - The neck pain is consistent with early RA involvement of cervical spine, not SLE. *Adalimumab* - **Adalimumab** is a TNF-alpha inhibitor used for RA, but it is **not first-line therapy**. - The diagnosis must first be confirmed, and conventional DMARDs (especially **methotrexate**) should be tried first. - Biologics like adalimumab are reserved for patients who fail conventional DMARDs or have severe disease at presentation. *CT scan of the chest* - There are **no respiratory symptoms** or abnormal cardiopulmonary findings on examination. - While RA can cause interstitial lung disease or pleural effusions, screening imaging is not indicated without clinical signs or symptoms. - The priority is confirming the diagnosis of RA. *X-ray of the cervical spine* - While the patient has neck pain, the **neurological examination is normal** and there is no vertebral tenderness. - Cervical spine involvement in RA (atlantoaxial subluxation) typically occurs in longstanding disease, not at presentation. - Imaging would be indicated if there were neurological deficits, severe pain, or mechanical symptoms suggesting instability.

Rheumatology (autoimmune diseases, arthritis) US Medical PG Question 5: A 45-year-old woman presents to the clinic with a variety of complaints on different areas of her body, including telangiectasias on both the upper and lower extremities, bluish discoloration of the fingertips when exposed to cold, and burning midsternal chest pain. She is a tobacco smoker and works as a school teacher. After evaluation, an anti-centromere antibody test is ordered, and returns with an elevated titer. Which of the following symptoms are least likely to be seen in this patient's condition?

• A. Gastroesophageal reflux
• B. Spasm of blood vessels in response to cold or stress
• C. Thickening and tightening of the skin on the fingers
• D. Dysphagia
• E. Erythematous periorbital rash (Correct Answer)

Rheumatology (autoimmune diseases, arthritis) Explanation: ***Erythematous periorbital rash*** - An **erythematous periorbital rash** (**heliotrope rash**) is highly characteristic of **dermatomyositis**, not the patient's condition. - This symptom, along with **Gottron's papules** and **proximal muscle weakness**, would point away from scleroderma. *Gastroesophageal reflux* - **Gastroesophageal reflux** is common in **scleroderma**, particularly the limited cutaneous systemic sclerosis (CREST) variant. - Esophageal dysmotility and lower esophageal sphincter incompetence lead to reflux and **heartburn**. *Spasm of blood vessels in response to cold or stress* - This describes **Raynaud's phenomenon**, a hallmark feature of **limited cutaneous systemic sclerosis (CREST syndrome)**. - The patient's description of "bluish discoloration of the fingertips when exposed to cold" directly points to this symptom. *Thickening and tightening of the skin on the fingers* - **Sclerodactyly**, or thickening and tightening of the skin on the fingers, is a primary manifestation of **scleroderma**. - This is a key diagnostic criterion for systemic sclerosis, especially in the limited form. *Dysphagia* - **Dysphagia**, or difficulty swallowing, is very common in **scleroderma** due to **esophageal hypomotility** and fibrosis. - The sensation of food sticking or difficulty propelling food down the esophagus is a frequent complaint.

Rheumatology (autoimmune diseases, arthritis) US Medical PG Question 6: A 51-year-old woman comes to the physician because of fatigue and progressive pain and stiffness in her hands for 3 months. She used to play tennis but stopped 1 month ago because of difficulties holding the racket and her skin becoming “very sensitive to sunlight.” Her last menstrual period was 1 year ago. She has diabetes mellitus controlled with insulin. She does not smoke or drink alcohol. Vital signs are within normal limits. The patient appears tanned. The second and third metacarpophalangeal joints of both hands are tender to palpation and range of motion is limited. Which of the following is the most appropriate next step in diagnosis?

• A. Synovial fluid analysis
• B. Testing for parvovirus B19 antibodies
• C. Testing for rheumatoid factors
• D. Testing for anti-nuclear antibodies
• E. Iron studies (Correct Answer)

Rheumatology (autoimmune diseases, arthritis) Explanation: ***Iron studies*** - The patient's presentation with **"tanned" appearance**, **diabetes mellitus**, and **arthropathy specifically involving the 2nd and 3rd metacarpophalangeal joints** is the **classic triad of hemochromatosis** (hereditary iron overload). - The bronze/tan skin pigmentation results from **iron deposition in the skin**, while diabetes occurs from **iron deposition in the pancreas** ("bronze diabetes"). - **MCP 2 and 3 joint involvement** is pathognomonic for hemochromatosis arthropathy, distinguishing it from other arthritides. - **Iron studies** (serum ferritin and transferrin saturation) are the most appropriate initial diagnostic tests, typically showing **elevated ferritin (>200 ng/mL in women) and transferrin saturation >45%**. - Early diagnosis is crucial as hemochromatosis is treatable with phlebotomy, preventing progression to cirrhosis and cardiac complications. *Testing for anti-nuclear antibodies* - While **photosensitivity** could suggest **systemic lupus erythematosus (SLE)**, the patient lacks other characteristic SLE features (malar rash, oral ulcers, serositis). - The **"tanned" appearance** is not typical of photosensitivity, which usually manifests as a **rash or erythema with sun exposure**, not generalized hyperpigmentation. - The **specific involvement of MCP 2 and 3 joints** is more characteristic of hemochromatosis than SLE, which typically has a more diffuse polyarticular pattern. - ANA testing would be appropriate if other SLE features were present, but the constellation of findings here points to iron overload. *Synovial fluid analysis* - This test is performed to evaluate for **septic arthritis**, **crystal arthropathy (gout, pseudogout)**, or other inflammatory conditions when there is **acute monoarticular** or **oligoarticular** involvement. - The patient's **chronic, symmetrical polyarticular** presentation and systemic features make a systemic metabolic disorder (hemochromatosis) more likely than conditions requiring synovial fluid analysis as the initial diagnostic step. *Testing for parvovirus B19 antibodies* - **Parvovirus B19** can cause acute arthropathy mimicking rheumatoid arthritis, typically following a viral prodrome. - However, the **3-month chronicity**, **diabetes**, and **bronze pigmentation** are not explained by parvovirus infection, making this an unlikely diagnosis. *Testing for rheumatoid factors* - While **rheumatoid arthritis (RA)** can present with symmetrical small joint arthritis, it typically involves **PIP and MCP joints more diffusely**, not specifically MCP 2 and 3. - RA does not explain the **tanned appearance** or the specific association with **diabetes mellitus** seen in this patient. - The MCP 2 and 3 predilection is a distinguishing feature of hemochromatosis arthropathy.

Rheumatology (autoimmune diseases, arthritis) US Medical PG Question 7: A 34-year-old man with a 2-year history of rheumatoid arthritis is being evaluated on a follow-up visit. He is currently on methotrexate and celecoxib for pain management and has shown a good response until now. However, on this visit, he mentions that the morning stiffness has been getting progressively worse. On physical examination, both his wrists are erythematous and swollen, nodules on his elbows are also noted. Rheumatoid factor is 30 (normal reference values: < 15 IU/mL), ESR is 50 mm/h, anti-citrullinated protein antibodies is 55 (normal reference values: < 20). What is the next best step in the management of this patient?

• A. Sulfasalazine
• B. Adalimumab monotherapy
• C. Methotrexate and Corticosteroids
• D. Methotrexate and Infliximab (Correct Answer)
• E. Infliximab monotherapy

Rheumatology (autoimmune diseases, arthritis) Explanation: **Methotrexate and Infliximab** - The patient is experiencing a **flare-up of rheumatoid arthritis** despite being on methotrexate, indicated by worsening morning stiffness, active synovitis (erythematous and swollen wrists), elevated ESR, and positive rheumatoid factor and anti-CCP. This suggests a need for more aggressive therapy, and adding a **biologic agent like infliximab (an anti-TNF agent)** to methotrexate is a standard approach for moderate to severe RA that is not adequately controlled by methotrexate monotherapy. - Combination therapy with **methotrexate and a biologic DMARD** (e.g., TNF inhibitors like infliximab) has been shown to be more effective than monotherapy for controlling disease activity and preventing joint damage in refractory RA. *Sulfasalazine* - **Sulfasalazine** is a conventional synthetic DMARD that is generally used as a **first-line agent or in combination therapy** for mild to moderate RA. - Given the patient's ongoing active disease despite methotrexate and the severity of his symptoms, sulfasalazine is unlikely to be sufficient to achieve disease control. *Adalimumab monotherapy* - While adalimumab (another anti-TNF biologic) is an effective treatment for RA, **biologic monotherapy is generally less effective** than combination therapy with methotrexate. - Current guidelines and clinical practice favor combining biologic DMARDs with methotrexate for optimal outcomes in RA management, especially in patients with active disease. *Methotrexate and Corticosteroids* - **Corticosteroids** are effective in rapidly reducing inflammation and can be used for **short-term management of RA flares**. - However, corticosteroids are not recommended for long-term use due to significant side effects and do not address the underlying disease progression as comprehensively as biologic DMARDs in patients refractory to methotrexate. *Infliximab monotherapy* - Similar to adalimumab monotherapy, **infliximab is typically more effective when combined with methotrexate**. - Using infliximab alone would be a less optimal choice for this patient whose disease is clearly not controlled by methotrexate, as it may lead to a suboptimal response and potentially increase the risk of developing anti-drug antibodies.

Rheumatology (autoimmune diseases, arthritis) US Medical PG Question 8: A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?

• A. "Does the diarrhea typically precede the constipation, or vice-versa?"
• B. "Is the diarrhea foul-smelling?"
• C. "Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"
• D. "Are the symptoms worse in the morning or at night?"
• E. "Can you tell me more about the symptoms you have been experiencing?" (Correct Answer)

Rheumatology (autoimmune diseases, arthritis) Explanation: ***Can you tell me more about the symptoms you have been experiencing?*** - This **open-ended question** encourages the patient to provide a **comprehensive narrative** of their symptoms, including details about onset, frequency, duration, alleviating/aggravating factors, and associated symptoms, which is crucial for diagnosis. - In a patient presenting with vague, intermittent symptoms like alternating constipation and diarrhea, allowing them to elaborate freely can reveal important clues that might not be captured by more targeted questions. *Does the diarrhea typically precede the constipation, or vice-versa?* - While knowing the sequence of symptoms can be helpful in understanding the **pattern of bowel dysfunction**, it is a very specific question that might overlook other important aspects of the patient's experience. - It prematurely narrows the focus without first obtaining a broad understanding of the patient's overall symptomatic picture. *Is the diarrhea foul-smelling?* - Foul-smelling diarrhea can indicate **malabsorption** or **bacterial overgrowth**, which are important to consider in some gastrointestinal conditions. - However, this is a **specific symptom inquiry** that should follow a more general exploration of the patient's symptoms, as it may not be relevant if other crucial details are missed. *Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life* - Quantifying pain intensity is useful for assessing the **severity of discomfort** and monitoring changes over time. - However, for a patient with intermittent rather than acute, severe pain, understanding the **character, location, and triggers** of the pain is often more diagnostically valuable than just a numerical rating initially. *Are the symptoms worse in the morning or at night?* - Diurnal variation can be relevant in certain conditions, such as inflammatory bowel diseases where nocturnal symptoms might be more concerning, or functional disorders whose symptoms might be stress-related. - This is another **specific question** that should come after gathering a more complete initial picture of the patient's symptoms to ensure no key information is overlooked.

Rheumatology (autoimmune diseases, arthritis) US Medical PG Question 9: A 32-year-old man presents to his physician with a complaint of pain with urination that has developed and persisted over the past 8 days. Upon awakening today, he also noted a clear discharge from his urethra. The patient states he is otherwise healthy. Social history is notable for the patient working at a local farm with livestock. Review of systems is notable for left knee and ankle pain for the past week and worsening of his seasonal allergies with red and itchy eyes. His temperature is 97.7°F (36.5°C), blood pressure is 122/83 mmHg, pulse is 89/min, respirations are 14/min, and oxygen saturation is 98% on room air. Which of the following is likely to be positive in this patient?

• A. p-ANCA
• B. HLA-B27 (Correct Answer)
• C. Anti-dsDNA
• D. Anti-CCP
• E. HLA-DR4

Rheumatology (autoimmune diseases, arthritis) Explanation: ***HLA-B27*** - The patient presents with a classic triad of symptoms: **urethritis** (painful urination, clear discharge), **arthritis** (left knee and ankle pain), and **conjunctivitis** (red and itchy eyes), which is highly suggestive of **reactive arthritis**. - **Reactive arthritis** is strongly associated with the presence of the **HLA-B27** allele, found in 30-50% to up to 80% of patients depending on the population. *p-ANCA* - **p-ANCA (perinuclear anti-neutrophil cytoplasmic antibodies)** are typically associated with certain **vasculitides** like microscopic polyangiitis or eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome). - Symptoms of **vasculitis** such as constitutional symptoms, organ damage, or purpuric rash are not described in this patient's presentation. *Anti-dsDNA* - **Anti-double-stranded DNA (anti-dsDNA) antibodies** are a highly specific marker for **systemic lupus erythematosus (SLE)**. - The patient's symptoms (urethritis, arthritis, conjunctivitis) are not typical for a primary presentation of SLE, which often involves skin rashes, serositis, and renal or hematological manifestations. *Anti-CCP* - **Anti-cyclic citrullinated peptide (anti-CCP) antibodies** are a specific and sensitive marker for **rheumatoid arthritis (RA)**. - While the patient has arthritis, the accompanying conjunctivitis and urethritis are not characteristic features of RA, and RA typically presents with symmetrical polyarthritis. *HLA-DR4* - **HLA-DR4** is a genetic marker strongly associated with **rheumatoid arthritis (RA)**, particularly in certain ethnic groups. - As with anti-CCP antibodies, the overall clinical picture, including urethritis and conjunctivitis, makes RA an unlikely primary diagnosis.

Rheumatology (autoimmune diseases, arthritis) US Medical PG Question 10: A 42-year-old woman presents complaining of pain in her hands. She reports that the pain is in both hands, and that it is usually worse in the morning. She reports that her hands are also stiff in the morning, but that this gradually improves throughout the morning. She notes, however, that her symptoms seem to be getting worse over the last three months. What is the most likely pathogenesis of her disease process?

• A. Production of antibodies against smooth muscle
• B. Anti-neutrophil cytoplasmic antibody production
• C. Production of antibodies against antibodies (Correct Answer)
• D. Type 1 hypersensitivity reaction
• E. Repetitive microtrauma

Rheumatology (autoimmune diseases, arthritis) Explanation: ***Production of antibodies against antibodies*** - The patient's symptoms of **bilateral hand pain and morning stiffness** improving with activity, worsening over three months, are classic for **Rheumatoid Arthritis (RA)**. - RA is characterized by the production of **rheumatoid factor (RF)**, an antibody (typically IgM) directed against the Fc portion of IgG, which is essentially an antibody against an antibody. *Production of antibodies against smooth muscle* - This describes the presence of **anti-smooth muscle antibodies (ASMA)**, which are characteristic of **Autoimmune Hepatitis type 1**. - Autoimmune hepatitis primarily affects the liver, leading to symptoms like fatigue, jaundice, and elevated liver enzymes, not primarily joint pain. *Anti-neutrophil cytoplasmic antibody production* - This refers to **ANCA (anti-neutrophil cytoplasmic antibodies)**, which are associated with various forms of **vasculitis**, such as Granulomatosis with Polyangiitis (Wegener's), Microscopic Polyangiitis, and Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss). - While vasculitis can cause systemic symptoms, the patient's presentation of symmetric, inflammatory arthritis is not typical for primary ANCA-associated vasculitis. *Type 1 hypersensitivity reaction* - A **type I hypersensitivity reaction** involves IgE-mediated mast cell degranulation, leading to immediate allergic reactions like asthma, anaphylaxis, or hives. - This mechanism is completely unrelated to the pathogenesis of an autoimmune, chronic inflammatory arthritis like Rheumatoid Arthritis. *Repetitive microtrauma* - Repetitive microtrauma is more consistent with **osteoarthritis** or **occupational overuse injuries**. - Osteoarthritis typically presents with pain that worsens with activity and improves with rest, **morning stiffness lasting less than 30 minutes**, and often affects weight-bearing joints or specific joints due to trauma or wear and tear, rather than the inflammatory pattern described.

Rheumatology (autoimmune diseases, arthritis) Flashcard 1 of 8

Question: Many patients with ankylosing spondylitis develop peripheral arthritis and _____ (inflammation at tendon insertion into a bone)

Answer: enthesitis

Rheumatology (autoimmune diseases, arthritis) Flashcard 2 of 8

Question: _____ (anti-Jo-1) autoantibodies are associated with polymyositis and dermatomyositis

Answer: Anti-synthetase

Rheumatology (autoimmune diseases, arthritis) Flashcard 3 of 8

Question: Which SLE antibody is a useful predictor of disease activity and renal involvement? _____

Answer: Anti-dsDNA antibodies

Rheumatology (autoimmune diseases, arthritis) Flashcard 4 of 8

Question: First-line treatment for SLE includes _____ for flare ups

Answer: glucocorticoids

Rheumatology (autoimmune diseases, arthritis) Flashcard 5 of 8

Question: Acute interstitial nephritis is less commonly secondary to _____ diseases (e.g. Sjogren syndrome, SLE, sarcoidosis)

Answer: autoimmune

Rheumatology (autoimmune diseases, arthritis) Flashcard 6 of 8

Question: _____ (anti-Mi-2) autoantibodies are associated with polymyositis and dermatomyositis

Answer: Anti-helicase

Rheumatology (autoimmune diseases, arthritis) Flashcard 7 of 8

Question: Which antibody is sensitive, but not specific for SLE? _____

Answer: Antinuclear antibodies (ANA)

Rheumatology (autoimmune diseases, arthritis) Flashcard 8 of 8

Question: multiple sclerosis

Answer: autoimmune

Extra Information: demyelination of CNSrelapsing and remitting symptoms including: optic neuritis, MLF syndrome, hemiparesis, hemisensory loss, bladder/bowel incontinence, scanning speech, intention tremor, nystagmusoligoclonal IgG in CSFMRI: periventricular plaquescore: β-interferon, immunosuppression, natalizumab symptomatic: antimuscarinic (incontinence), baclofen (spasticity), opiods (pain) whites, females, age 20-30