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39 yo female evaluated for malar rash, arthralgias, and serositis. CBC and P2 are normal. ANA, anti-dsDNA, and anti-Smith antibodies are positive. HIV is negative. CXR is normal. PPD testing reveals 8mm of induration.

Before initiating prednisone, which of the following is the most appropriate next step in this patient’s management?

A)Rifampin and pyrazinamide for 2 months

B) Pyrazinamide for 4 months

C) INH for 9 months

D) No anti-TB therapy

- Any immunosuppression medication - Any immunosuppression medication increases the risk for TB activation.increases the risk for TB activation.

- Anyone on prednisone >15mg/d with - Anyone on prednisone >15mg/d with induration >5mm should be treatedinduration >5mm should be treated

- INH is recommended 1- INH is recommended 1stst line line treatment of latent TB infection.treatment of latent TB infection.

A 50 yo asymptomatic female is evaluated as a new A 50 yo asymptomatic female is evaluated as a new patient. She was diagnosed with polyarteritis patient. She was diagnosed with polyarteritis nodosa 11 years ago, and was treated with nodosa 11 years ago, and was treated with prednisone and daily oral cyclophosphamide for 2 prednisone and daily oral cyclophosphamide for 2 years. She has remained in remission for 8 years, years. She has remained in remission for 8 years, and currently takes no medication.and currently takes no medication.

In addition to age and gender appropriate screening, In addition to age and gender appropriate screening, which of the following is most appropriate in this which of the following is most appropriate in this patient?patient?

A)A) Pelvic ultrasoundPelvic ultrasound

B)B) CXRCXR

C)C) Upper endoscopyUpper endoscopy

D)D) UAUA

E)E) No additional studiesNo additional studies

• Acrolein, a metabolite of Acrolein, a metabolite of cyclophosphamide, is toxic to urothelium cyclophosphamide, is toxic to urothelium with increased risk for cystitis and with increased risk for cystitis and transitional cell bladder cancer.transitional cell bladder cancer.

• Yearly screening with UA is recommended Yearly screening with UA is recommended for lifetimefor lifetime

• Routine cystoscopy is recommended if any Routine cystoscopy is recommended if any changes noted on cystoscopychanges noted on cystoscopy

• Urine cytology may be helpful, but not Urine cytology may be helpful, but not sensitive.sensitive.

A 70 yo woman is evaluated for a 4-week history of A 70 yo woman is evaluated for a 4-week history of aching bilateral pain and AM stiffness around the aching bilateral pain and AM stiffness around the proximal muscles of the arms, shoulders, hip, and proximal muscles of the arms, shoulders, hip, and thighs. She does not have rash, neck pain, visual thighs. She does not have rash, neck pain, visual symptoms, cough, HA, jaw stiffness, or symptoms, cough, HA, jaw stiffness, or claudication. Although her muscles are sore and claudication. Although her muscles are sore and she feels fatigues, she does not have muscle she feels fatigues, she does not have muscle weakness.weakness.

On exam, strength and ROM is normal. No On exam, strength and ROM is normal. No tenderness to palpation of the hip or shoulders. tenderness to palpation of the hip or shoulders. Otherwise unremarkable exam. ESR is 55 mm/hr.Otherwise unremarkable exam. ESR is 55 mm/hr.

Which if the following is the most Which if the following is the most appropriate management at this appropriate management at this time?time?

A)A) Steroid injection into both glenohumeral Steroid injection into both glenohumeral jointsjoints

B)B) Amitriptyline with exercise programAmitriptyline with exercise program

C)C) PrednisonePrednisone

D)D) IbuprofenIbuprofen

E)E) AcetaminophenAcetaminophen

- Symptoms consistent with PMRSymptoms consistent with PMR- AM pain or stiffness in proximal AM pain or stiffness in proximal

joints/musclesjoints/muscles- ESR > 40 mm/hrESR > 40 mm/hr- No evidence for other disease processNo evidence for other disease process

- Prednisone 10 – 20 mg/d 1Prednisone 10 – 20 mg/d 1stst line therapy line therapy

A 40 yo female is evaluated for a 4-month A 40 yo female is evaluated for a 4-month history of swelling, pain, and stiffness in history of swelling, pain, and stiffness in her wrists, MCP, and PIP joints with similar her wrists, MCP, and PIP joints with similar symptoms in her feet. She has been symptoms in her feet. She has been fatigued but is able to work. Neither fatigued but is able to work. Neither NSAIDS or tylenol have alleviated her NSAIDS or tylenol have alleviated her symptoms.symptoms.

On exam, vitals are normal and she is On exam, vitals are normal and she is afebrile. She appears health in NAD. She afebrile. She appears health in NAD. She walks slowly. She does not have a rash or walks slowly. She does not have a rash or adenapathy. She has swelling and adenapathy. She has swelling and tenderness to palpation in affected joints. tenderness to palpation in affected joints. The remainder of exam is unremarkable.The remainder of exam is unremarkable.

Measurement of which of the Measurement of which of the following may help predict this following may help predict this patient’s clinical course?patient’s clinical course?

A)A) Anti-cyclic citrullinated peptide Anti-cyclic citrullinated peptide antibodiesantibodies

B)B) ESRESR

C)C) CRPCRP

D)D)HemoglobinHemoglobin

Anti-CCP can help prognosticate which Anti-CCP can help prognosticate which patients will have self-limiting patients will have self-limiting disease, and who is likely to disease, and who is likely to progress.progress.

Positive predictors for aggressive Positive predictors for aggressive disease:disease:

- RF, CCP positive, female, erosions, - RF, CCP positive, female, erosions, functional limitationsfunctional limitations

- Both RF+ and CCP+ very - Both RF+ and CCP+ very suggestive of aggressive diseasesuggestive of aggressive disease

A 75 yo female is evaluated for fever, A 75 yo female is evaluated for fever, fatigue, malaise, a severe headache fatigue, malaise, a severe headache in both temples, and discomfort in in both temples, and discomfort in her jaw when chewing food. Last her jaw when chewing food. Last week, she also had an isolated week, she also had an isolated episode of transient diplopia.episode of transient diplopia.

On exam, temp is 100.1. Except for On exam, temp is 100.1. Except for scalp tenderness, PE is normal. ESR scalp tenderness, PE is normal. ESR is 30. Temporal artery biopsy will is 30. Temporal artery biopsy will be performed in 4 days.be performed in 4 days.

Which of the following is the most Which of the following is the most appropriate management until appropriate management until biopsy is performed?biopsy is performed?

A)A) HeparinHeparin

B)B) PrednisonePrednisone

C)C) VicodinVicodin

D)D)MTX plus prednisoneMTX plus prednisone

E)E) No therapy until biopsy resultsNo therapy until biopsy results

Giant Cell Arteritis – aka temporal Giant Cell Arteritis – aka temporal arteritisarteritis

Treat anytime you are suspicious – Treat anytime you are suspicious – biopsy results will not be affected biopsy results will not be affected with < 2 weeks of steroidswith < 2 weeks of steroids

A 70 yo male with active GCA begins A 70 yo male with active GCA begins treatment with prednisone. His only treatment with prednisone. His only manifestation is headache, and he manifestation is headache, and he has no evidence of GI or renal has no evidence of GI or renal disease. ESR is 80. DEXA is normal.disease. ESR is 80. DEXA is normal.

In addition to calcium and vit D, what is In addition to calcium and vit D, what is the most appropriate next step?the most appropriate next step?

A)A) CalcitoninCalcitoninB)B) A bisphosphonateA bisphosphonateC)C) TeripartideTeripartideD)D)No additional therapyNo additional therapy

Per ACR: Any patient on prednisone Per ACR: Any patient on prednisone >5mg/day for >3 months should have >5mg/day for >3 months should have calcium, vit d, and bisphosphonatecalcium, vit d, and bisphosphonate

Also encourage exercise, tob cessasion, Also encourage exercise, tob cessasion, decrease ETOH usedecrease ETOH use

Teriparatide – synthetic PTH – only for Teriparatide – synthetic PTH – only for severe osteoporosis. Contraindicated severe osteoporosis. Contraindicated if hx bone malignancy, XRT, Paget’s if hx bone malignancy, XRT, Paget’s disease, hypercalcemia.disease, hypercalcemia.

A 30 yo male is evaluated for 3 month A 30 yo male is evaluated for 3 month history of epistaxis and 1 month history of epistaxis and 1 month history of night sweats and cough. history of night sweats and cough. He has lost 10 lbs. No travel He has lost 10 lbs. No travel outside of Montana, and no drug outside of Montana, and no drug use.use.

On exam, temp is 98.4, pulse 70, RR On exam, temp is 98.4, pulse 70, RR 14, BP 120/84. He has a large nasal 14, BP 120/84. He has a large nasal septal perforation. Lungs are clear.septal perforation. Lungs are clear.

UA shows 3+ protein, red cells, red cell UA shows 3+ protein, red cells, red cell casts. CT chest reveals bilateral casts. CT chest reveals bilateral cavitary nodules.cavitary nodules.

Which if the following is the most Which if the following is the most likely diagnosis?likely diagnosis?

A)A) SarcoidosisSarcoidosis

B)B) Anti-GBM disease (Goodpasture’s)Anti-GBM disease (Goodpasture’s)

C)C) TBTB

D)D)Wegener’s granulomatosisWegener’s granulomatosis

A 48 yo male is evaluated during an A 48 yo male is evaluated during an annual physical. He has HTN and gout annual physical. He has HTN and gout for several years. Last gout attack for several years. Last gout attack was mild, > 6 months ago, and was mild, > 6 months ago, and resolved after several doses of resolved after several doses of naproxen. Current meds are enalapril, naproxen. Current meds are enalapril, colchicine 0.6mg/d, and allopurinol colchicine 0.6mg/d, and allopurinol 300mg/d.300mg/d.

Exam reveals several nontender, Exam reveals several nontender, movable olecranon nodules and a movable olecranon nodules and a slightly tender left 1slightly tender left 1stst MTP joint with MTP joint with overlying nodules. Urate is 7.2.overlying nodules. Urate is 7.2.

Which of the following is the most Which of the following is the most appropriate next step in this appropriate next step in this patient’s management?patient’s management?

A)A) Stop colchicineStop colchicine

B)B) Stop colchicine, increase allopurinol Stop colchicine, increase allopurinol to 400 mg/dto 400 mg/d

C)C) Increase allopurinol to 400 mg/dIncrease allopurinol to 400 mg/d

D)D)Obtain a 24-hour urine urate Obtain a 24-hour urine urate excretionexcretion

Pt has elevated urate and tophi, so Pt has elevated urate and tophi, so treatment is indicated even in treatment is indicated even in absence of symptoms.absence of symptoms.

Goal urate is 6.0 (any level above 6.8 Goal urate is 6.0 (any level above 6.8 will continue to deposit urate in will continue to deposit urate in tissues)tissues)

Continue NSAIDs while adjusting Continue NSAIDs while adjusting allopurinol as decreasing urate level allopurinol as decreasing urate level can precipitate an attack. D/C daily can precipitate an attack. D/C daily NSAID when on stable therapy.NSAID when on stable therapy.

A 69 yo male is evaluated for severe left A 69 yo male is evaluated for severe left hip pain for 3 days. He has a hx of hip pain for 3 days. He has a hx of degenerative joint disease involving degenerative joint disease involving the hip that is treated with tylenol. He the hip that is treated with tylenol. He has been unable to walk. No fever or has been unable to walk. No fever or chills. One week ago, he had chills. One week ago, he had extensive dental surgery. Xrays 2 extensive dental surgery. Xrays 2 days ago demonstrate mild join-space days ago demonstrate mild join-space narrowing.narrowing.

On exam, temp is 100.6. Cardiac exam On exam, temp is 100.6. Cardiac exam is normal without murmurs. No rash. is normal without murmurs. No rash. Any ROM of hip causes severe pain.Any ROM of hip causes severe pain.

In addition to blood cultures, In addition to blood cultures, which of the following is most which of the following is most likely to establish a diagnosis?likely to establish a diagnosis?

A)A) Imaging-guided hip joint aspirationImaging-guided hip joint aspiration

B)B) Bone scanBone scan

C)C) Empiric antibioticsEmpiric antibiotics

D)D)MRI of the hipMRI of the hip

Must exclude septic arthritis:Must exclude septic arthritis:

- Gram stain (positive in 50%)- Gram stain (positive in 50%)

- Cell count – average WBC count is - Cell count – average WBC count is 50,000-150,000 cells/mm3 50,000-150,000 cells/mm3 (neutrophil predominance)(neutrophil predominance)

- Culture- Culture

- 50% of nongonococcal will have - 50% of nongonococcal will have positive blood culturespositive blood cultures