Indian Journal of Rheumatology 2008 June

PG Forum
Volume 3, Number 2; p. 80

Rheumatology quiz
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V Arya1, V Dhir2
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1. All the following are true of juvenile idiopathic arthritis 6. All the following are true of juvenile dermatomyositis
except except
(a) elevation of ESR at baseline is associated with (a) weakness and skin manifestations are almost
worse outcome equally common at presentation
(b) patients with oligoarticular disease have higher (b) 80% of patients have elevated muscle enzymes at
remission rates presentation
(c) rheumatoid factor in polyarticular disease does not (c) ANA is more often positive than anti-ENA
influence outcome (d) sequential muscle enzyme monitoring reliably
(d) the platelet count is a predictor of disability in reflects disease activity
systemic disease 7. Which of the following statements about cyclo-oxygenase
2. All the following predict a worse outcome in SLE 3 (COX-3) is false
except (a) resistant to inhibition by non-selective NSAIDs
(a) serositis at presentation (b) more sensitive to inhibition by paracetamol than
(b) anti-Ro positivity COX-2
(c) thrombocytopenia (c) most expressed in the heart and brain
(d) CNS disease (d) a product of the COX-1 gene
3. Which of the following is false regarding leucopenia in 8. Which of the following is not true of bone marrow edema
SLE as seen on MRI
(a) directly related to antiphospholipid antibody levels (a) due to increased water content in trabecular bone
(b) usually a part of pancytopenia than in isolation (b) frequently seen in bone tumors
(c) lymphopenia is related to drug therapy (c) not seen in osteoarthritis
(d) neutropenia correlated to history of CNS (d) associated with trauma
involvement 9. Which of the following is true of juvenile localized
4. Consumption of which of the following beverages has scleroderma?
been shown to reduce the risk of gout? (a) more common in males
(a) coffee (b) Peau d’orange seen in eosinophilic fasciitis subtype
(b) grape juice (c) plaque morphea more common than linear sclero-
(c) carbonated soft drinks derma
(d) red wine (d) anti-centromere antibodies seen in approximately
5. Which of the following is not true of methotrexate 50%
pneumonitis 10. ANCA-associated vasculitis is not associated with
(a) higher risk in smokers exposure to
(b) fixed bibasilar crackles are found (a) minocycline
(c) eosinophilia (b) silica
(d) combined treatment with leflunomide increases (c) propylthiouracil
the risk (d) penicillin
For answers refer to page 82

1
Department of Medicine, JIPMER, Puduchery and 2Department of Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences,
Lucknow, India.
Correspondence: Dr. V Arya, email: linuxphoenix@gmail.com
 82 Indian Journal of Rheumatology 2008 June; Vol. 3, No. 2
the normal of 250–800 mg/d) suggesting that she was an
underexcretor.
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Thus the patient had seropositive RA with chronic
tophaceous gout. Although both RA and gout are relatively
common, their co-existence is extremely rare.1 It has been
reported that there is a strong negative correlation between
RA and gout.2 The first well authenticated case reported
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recently was in 1966.3
Our patient had clinical and serological features that
satisfied ACR criteria for RA. Her clinical features together
with very high anti-CCP antibody are virtually diagnostic
of RA. She also had a high serum uric acid, characteristic
radiological findings along with monosodium urate crystals
(MSU) aspirated from joints suggesting gouty arthritis. These
manifestations provide ample proof for the coexistence of
RA and gouty arthritis.
Only a few cases have been reported of the unequivocal
association of gout with RA, despite an estimate by Wallace
et al. of more than 10,000 cases.4 Although the exact cause for
this negative association is obscure there have been several
hypotheses including inhibition of surface activity of MSU
by rheumatoid factor binding, crystal coating by rheumatoid
factor, inhibition of crystal deposition by possible connective
tissue alterations in RA, impaired phagocytic function of neu-
trophils in rheumatoid joint fluid, and the anti-inflammatory
or immunosuppressive effect of hyperuricaemia.5 On the
other hand, analgesic nephropathy may reduce renal urate
excretion and precipitate hyperuricaemia, which has been
estimated to occur in 10% of patients with RA.6 However,
our patient, had normal renal function.
Many features of gout especially chronic tophaceous gout
during the evolution of the disease may mimic RA or vice
versa. Morning stiffness and fusiform swelling of proximal
interphalangeal and metacarpophalangeal joints, though sug-
gestive of RA, are misleading since these findings can also
occur in polyarticular tophaceous gout. Kozin and McCarty
demonstrated positive rheumatoid factor although in low
titres in 30% of patients with chronic tophaceous gout.7
Anti-CCP antibodies present in 60–70% of patients with
RA at diagnosis, are 90–98% specific for RA. Due to the
ANSWERS TO THE RHEUMATOLOGY QUIZ
(page 80)
1c, 2b, 3c*, 4a, 5d, 6d**, 7a***, 8c, 9b†, 10d
*Neutropenia is usually due to drug therapy, lymphopenia
due to disease activity.
**Muscle enzyme levels are not reflective of disease activity.
Thachil et al.
extremely high specificity, a high anti-CCP titre along with
rheumatoid factor positivity in the appropriate clinical setting
can be taken as evidence of RA and predictive of erosive
disease.8
ACKNOWLEDGEMENTS
Source of funding: None.
Disclosure statement: Authors have declared no conflict of
interest.
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***COX-3 is maximally susceptible to inhibition by non-
selective NSAIDs.
†Anti-centromere antibodies seen in approximately 2%.