| MCQs in Rheumatology:
Contributors: These questions were written by Dr Fran Rees, Dr Sachin Khetan, Dr Pravin Patil, and Dr Michelle Hui; and were reviewed by Dr Ira Pande and Prof Michael Doherty. Dr A Abhishek facilitated the review process and also edited the questions.
Contributors: These MCQs were written by Dr Dipti Patel, and Dr Pravin Patil, and were reviewed by Dr Ed Roddy. The MCQs were edited by Dr A Abhishek who also facilitated the review process.
Tocilizumab is a humanised monoclonal antibody that inhibits which one of the following cytokines?
What best describes the mechanism of action of febuxostat?
1. blocks tubular reabsorption of uric acid
2. non-purine selective inhibitor of xanthine oxidase
3. purine analogue that selectively inhibits xanthine oxidase
4. stimulates tubular urate secretion
5. uricase analogue
Tocilizumab should be used with caution in patients with following health problems except-
Mrs B., a 30 year old lady has a 3 week history of pain in both Achilles tendons. She returned from a business trip to Bangladesh about 2 weeks ago. While in Bangladesh she developed a diarrheal illness lasting four days. For this, she was prescribed Ciprofloxacin 500mg BD and Metronidazole 400mg TDS for 5 days, along with lactobacillus and Ranitidine 150mg BD. On the third day of illness, she developed bilateral heel pain, and oral ulcers. She was given Vitamin B complex capsules for these. On examination, she has painful swollen tendo achilles bilaterally.
Which of the following is the most likely cause of Achilles tendonitis ?
A 65 year old lady was admitted to the MAU with a 2 day history of bi- temporal headache, jaw claudication & scalp tenderness. She takes aspirin 75 mg/day, is a non-smoker, and drinks 3-5 units of alcohol/week. There is no significant past-medical or family history, and physical examination was normal except for an absent left sided temoral artery pulse. These are the results of tests -
Hb 12.1 gm/dl
ESR 101 mm/hr
CRP 220 mg/l
A diagnosis of temporal arteritis was made and she was commenced on prednisolone 60mg /day. She was subsequently reviewed by a consultant who started omeprazole, calcium and vitamin D, and weekly alendronic acid. A temporal artery biopsy was arranged, and she was reviewed in the rheumatology outpatients after 1 week. The symptoms subsided within 3 days. Temporal artery biopsy showed classical changes of temporal arteritis, and repeat blood tests were as follows
Hb 9.0 gm/dl
WBC 1.0 x103/ml
Neutrophils 0.5 x103/ml
Platelets 30 x105/ml
ESR 60 mm/hr
CRP 33 mg/l
Which of the following is the most likely cause for pancytopenia in this patient?
Calcium and vitamin D
A 50 year old man presents with back pain, and numbness around the left knee, medial shin, and calf. On examination you find absence of the left knee jerk.
Which nerve root (s) have these symptoms originated from?
A clinical geneticist is asked to see a 30 year old man with a history of recurrent bilateral shoulder dislocation, chronic back pain with scoliosis, and a very poor vision in his left eye.
Mutations of which one of the following genes could explain his clinical problems?
Q1. 5. IL-6
Tocilizum is a humanised monoclonal antibody that inhibits cytokine interleukin-6 (IL-6). Reducing the activity of IL-6 may reduce inflammation in the joints, prevent long-term damage, improve quality of life and function, and relieve certain systemic effects of rheumatoid arthritis.
Q2 2. non-purine selective inhibitor of xanthine oxidase
Febuxostat is a non-purine selective inhibitor of xanthine oxidase. Xanthine oxidase is an enzyme that breaks down hypoxanthine (a purine) base to xanthine and then to uric acid. The inhibition of the enzyme therefore reduces the levels of serum uric acid. Febuxostat is indicated for the chronic management of hyperuricemia in patients with gout who have failed or been intolerant of allopurinol, but not for the treatment of asymptomatic hyperuricemia. Allopurinol is a purine analogue. Benzbromarone blocks tubular reabsorption of uric acid by blocking urate transporter 1 (URAT1).
Q3. 1. Asthma
Side effects of tociluzimab include - increase in transaminases, hypertension, leucopenia, neutropenia, hypercholesterolaemia and risk of perforation in patients with intestinal ulceration or diverticulitis. There is no concern about use in those with asthma.
Achillis tendonitis is a known rare side effect of floro-quinolones.
Q5. 4. Omeprazole
Omeprazole can rarely cause neutropenia or pancytopenia. This is from a real life scenario. This is important because as a lot of our patients are on DMARD which can cause similar side effects. We need to bear in mind that PPis can also rarely cause pancytopenia.
The knee reflex is mediated by the L3/4 nerve root. L3 nerve root dermatome supplies the anterior aspect of the knee, while the L4 nerve root supplies the medial aspect of calf and shin.
Q7. 4. Fibrillin
Fibrillin gene mutations lead to Marfan’s syndrome. Mutations in COL1A1, COL2A1, and COL5A1 genes lead to osteogenesis imperfect, Stickler’s syndrome, and Ehlers-Danlos syndrome respectively. Glucocerebrosidase deficiency leads to Gaucher’s disease. Although impaired vision due to myopia, and vitreous degeneration can occur in Stickler’s syndrome, patients usually have axial and apppendicular OA.