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RheumatologyMain71-80Q1A31-year-oldCaucasianmalecomplainsofjointpains.Hedescribesrightkneepain,rightheelpainandlow-backpain.Hewasrecentlytreatedforurethraldischargeatanoutsideclinic.Hehasnohistoryoftraumaorillicitdruguse.Heisafebrile,andhisvitalsignsarestable..Hisrightkneeisswollen,tenderandwarmtotouch;tendernessisalsopresentovertheAchillestendon.Oralexaminationshowsmouthulcers.Synovialfluidanalysisfromtherightkneeshowsawhitebloodcellcountof10,000/mm³withmanypolymorphonuclearleukocytesbutanegativeGramstain.Whichofthefollowingisthemostappropriateinitialpharmacotherapyforthispatient?A.AntihistaminesB.NSAIDsC.AntibioticsD.ColchicineE.AllopurinolF.ChondroitinsulfateA1Correctanswer:BIReactivearthritisisatypeofseronegativespondyloarthropathy.Classicreactivearthritisconsistsofatriadofnongonococcalurethritis,asymmetricoligoarthritisandconjunctivitis.Thearthritisofteninvolvesthekneeandsacroiliacspine,whichexplainsthispatient’sbackpain.Inadditiontotheclassictriad,mucocutaneouslesionsandenthesitis(Achillestendonpain)arecommonfindingsinreactivearthritis.Becausenotallsymptomsarealwayspresent,thereshouldbeahighsuspicionforreactivearthritisinthecaseofanyasymmetricoligoarthritisassociatedwithurethritis,conjunctivitisormouthulcers.Synovialfiuidanalysisisusuallysterile.Nonsteroidalanti-inflammatoryagents(NSAIDs)arethefirstlinetherapyduringtheacutephaseofthiscondition.(ChoiceA)Reactivearthritisisnotahistaminemediatedprocess;therefore,antihistamineswouldnotimprovethepatient’sarthritisororalulcers.(ChoiceC)Itisdifficulttodistinguishgonococcalsepticarthritisfromreactivearthritisbecausesynovialfluidculturescanbenegativein50%ofpatientswithgonococcalsepticarthritis.However,thispatientisafebrileandhasothersymptomssuggestiveofreactivearthritis,suchasmouthulcers,enthesitisandlowbackpain.(ChoiceD)Colchicineisananti-inflammatorydrugusedforthetreatmentofacutegout.Itactsbydecreasingleukocyteactivityprimarilybyinhibitingtubulinpolymerization.(ChoiceE)AlIopurinolisusedinthemanagementofchronichyperuricemia.Itdecreasesuricacidproductionbyinhibitionofxanthineoxidase.(ChoiceF)Lossofarticularcartilagecausesosteoarthritis.Manypatientssufferingfromosteoarthritistakechondroitinsulfate,acomponentofthegroundsubstancethatcomposescartilage,toimprovetheirconditionandsymptoms;however,ithasnotbeendefinitivelyshowntoimprovesymptomsandoutcomes.Educationalobjective:Reactivearthritisisaseronegativespondyloarthropathyresultingfromentericorgenitourinaryinfection.Findingsinreactivearthritismayincludeurethritis,conjunctivitis,mucocutaneouslesions,enthesitisandasymmetricoligoarthritis.Notailextra-articularmanifestationsneedbepresenttosuspectthediagnosis.NSAIDsarethefirstlinetherapy.Q2A35-year-oldwomancomestothephysicianwithpainandstiffnessofherwristsandhandjointsforthelastseveralmonths.Hermorningstiffnesslastsformorethananhour.Shealsocomplainsofjointswelling.Herpastmedicalhistoryissignificantonlyforasimilarepisodeayearago,whichresolvedwithover-the-counteribuprofen.Jointexaminationshowsmildredness,warmth,swelling,andtendernessintheproximalinterphaiangealandmetacarpophalangealjointsandwrists.X-raysshowperiarticularosteopeniaanderosionsoftheproximalinterphaiangealandmetacarpophalangealjoints.Thepatientbegantakingindomethacin,whichprovidesgoodrelief,butsymptomsrecurifsheskipsadose.Whichofthefollowingisthemostappropriatenextstepinmanagementofthispatient?A.AzathioprineB.CelecoxibC.EtanerceptD.GlucocorticoidsE.InfliximabF.MethotrexateG.NoadditionaltreatmentA2Correctanswer:FThispatient'spresentationisconsistentwithmoderate-to-severerheumatoidarthritis(RA).RAisachronic,systemicinflammatorydisorderwithprogressiveerosionoftheboneandcartilageandsignificantjointdestructionanddeformity.Patientstypicallypresentwithjointfindings(eg;pain,stiffness,swelling),morningstiffness,involvementofproximalinterphalangealandmetacarpophalangealjoints,andradiographicevidenceoferosionsand/orperiarticularosteopenia.TreatmentgoalsinRAaretoinduceandmaintainearlyremission,controlsynovitis,andpreventprogressionofjointdamage.AllpatientsdiagnosedwithRAshouldbestartedondisease-modifyingantirheumaticagents(DMARDs)assoonaspossibleasjointdamagebeginsearlyinItscourse(ChoiceG).Nonsteroidalanti-inflammatorydrugsandCOX-2inhibitors(eg,ceiecoxib)areadjunctivetherapiesforsymptomaticreliefbutdonotreducediseaseprogression.Glucocorticoidscanalsorelievesymptomsandshort-termradiographicprogressionbutarealsonoteffectiveinpreventingeventualjointdestruction,infact,theycanresultingeneralizedboneloss(ie,osteoporosis).DMARDsincludenonbiologicagents(eg,methotrexate,hydroxychloroquine,sulfasalazine,leflunomide,azathioprine)andbiologicagents(eg.etanercept,infliximab,adaiimumabrtociiizumab,rituximab).MethotrexateisthepreferredinitialDMARDInpatientswithmoderatelytoseverelyactiveRAduetoitsefficacyandlong-termsafetyprofile.PatientsshouldbetestedforhepatitisBandCandtuberculosisbeforestartingtherapy.Methotrexateshouldnotbeusedinpatientswhoarepregnantorareplanningtobecomepregnantinthenearfutureandthosewithsevererenalinsufficiency,liv