A 54-year-old man presents to the Emergency Department with a 2 day history of an swollen, painful left knee. Aspirated joint fluid shows calcium pyrophosphate crystals.
Which of the following blood tests is most useful in revealing an underlying cause?
Correct Answer A: This is a typical presentation of pseudogout. An elevated transferrin saturation may indicate haemochromatosis, a recognized cause of pseudogout.
A high ferritin level is also seen in haemochromatosis but can be raised in a variety of infective and inflammatory processes, including pseudogout, as part of an acute phase response.
Pseudogout:
Pseudogout is a form of microcrystal synovitis caused by the deposition of calcium pyrophosphate dihydrate in the synovium.
Risk factors:
Features:
Management:
A 41-year-old female presents with lethargy and pain all over her body. This has been present for the past six months and is often worse when she is stressed or cold. Clinical examination is unremarkable other than a large number of tender points throughout her body. A series of blood tests including an autoimmune screen, inflammatory markers and thyroid function are normal.
Given the likely diagnosis, which one of the following is not helpful in management?
Correct Answer B: A recent JAMA paper supported the use of anti-depressants in fibromyalgia Treatment of fibromyalgia syndrome with antidepressants: a meta-analysis; 2009 Jan 14;301(2):198- 209.
Fibromyalgia:
Fibromyalgia is a syndrome characterized by widespread pain throughout the body with tender points at specific anatomical sites. The cause of fibromyalgia is unknown.
Epidemiology:
Diagnosis is clinical and sometimes refers to the American College of Rheumatology classification criteria which lists 9 pairs of tender points on the body. If a patient is tender in at least 11 of these 18 points it makes a diagnosis of fibromyalgia more likely.
The management of fibromyalgia is often difficult and needs to be tailored to the individual patient. A psychosocial and multidisciplinary approach is helpful. Unfortunately there is currently a paucity of evidence and guidelines to guide practice. The following is partly based on consensus guidelines from the European League against Rheumatism (EULAR) published in 2007:
A 47-year-old female is referred to the rheumatology clinic due to cold fingers.
Which connective tissue disease is most strongly associated with Raynaud's phenomenon?
Correct Answer C: Raynaud's phenomenon is associated with all the above conditions but is most strongly linked to systemic sclerosis. Around 2% of women and 6% of men with Raynaud's phenomenon develop systemic sclerosis.
Raynaud's:
Raynaud's phenomena may be primary (Raynaud's disease) or secondary (Raynaud's phenomenon) Raynaud's disease typically presents in young women (e.g. 30 years old) with symmetrical attacks.
Factors suggesting underlying connective tissue disease:
Secondary causes:
Which one of the following is the most common ocular manifestation of rheumatoid arthritis?
Correct Answer C: Keratoconjunctivitis sicca is characterized by dry, burning and gritty eyes caused by decreased tear production.
Rheumatoid arthritis: ocular manifestations:
Ocular manifestations of rheumatoid arthritis are common, with 25% of patients having eye problems.
Ocular manifestations:
Iatrogenic:
Which one of the following drugs is least likely to cause gout?
Correct Answer A: Lithium was actually used to treat gout in the 19th century.
Gout: drug causes:
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 > 0.45 mmol/l).
Drug causes:
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