A 24-year-old man is investigated for chronic back pain. Which one of the following would most suggest a diagnosis of ankylosing spondylitis?
Correct Answer A: Reduced lateral flexion of the lumbar spine is one of the earliest signs of ankylosing spondylitis. There tends to be a loss of lumbar lordosis and an accentuated thoracic kyphosis in patients with ankylosing spondylitis.
Ankylosing spondylitis: features:
Ankylosing spondylitis is a HLA-B27 associated spondyloarthropathy. It typically presents in males (sex ratio 5:1) aged 20-30 years old.
Features:
Clinical examination:
Other features - the 'A's:
A 45-year-old man who is known to have haemochromatosis presents with a swollen and painful right knee. An x-ray shows no fracture but extensive chondrocalcinosis.
Given the likely diagnosis, which one of the following is most likely to present in the joint fluid?
Correct Answer E: Pseudogout - positively birefringent rhomboid shaped crystals.
Pseudogout:
Pseudogout is a form of microcrystal synovitis caused by the deposition of calcium pyrophosphate dihydrate in the synovium.
Risk factors:
Management:
Which of the following statements is true regarding psoriatic arthropathy?
Correct Answer D: Males and females are affected equally by psoriatic arthritis.
Psoriatic arthropathy:
Psoriatic arthropathy correlates poorly with cutaneous psoriasis and often precedes the development of skin lesions. Around 10% percent of patients with skin lesions develop an arthropathy with males and females being equally affected.
Types*:
*Until recently it was thought asymmetrical oligoarthritis was the most common type, based on data from the original 1973 Moll and Wright paper. Please see the link for a comparison of more recent studies.
Which one of the following is most recognized as a risk factor for developing osteoporosis?
Correct Answer A:
Osteoporosis: causes:
Diseases which predispose:
*Research is ongoing as to whether warfarin is a risk factor.
A 71-year-old man presents with an erythematous, swollen first metatarsophalangeal joint on the left foot. This is causing him considerable pain and he is having difficulty walking. He has never had any previous similar episodes. His past medical history includes atrial fibrillation and type 2 diabetes mellitus and his current medications are warfarin, metformin and simvastatin.
What is the most appropriate treatment of this episode?
Correct Answer B: NSAIDs should be avoided in elderly patients taking warfarin due to the risk of a life-threatening gastrointestinal haemorrhage. Oral steroids are an option but would upset his diabetic control. Whilst anti-coagulation is not a contraindication to joint injection it would make this option less attractive.
Gout: management:
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 > 450 μmol/l).
Acute management:
Allopurinol prophylaxis - see indications below:
Indications for allopurinol*:
Lifestyle modifications:
*Patients with Lesch-Nyhan syndrome often take allopurinol for life.
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