(Answer questions 1 – 5 on a piece a paper. The Answer Key is at the bottom of the page.)
1. An 80 year old man presents with an acutely swollen R ankle and with erythema and pain. He has a known history of gout with previous attacks in both the first MTP of the R foot and the L ankle. He has Chronic kidney disease, atrial fibrillation and hyper- cholesterolemia and is on Furosemide, Lisinopril , Metoprolol, coumadin and a statin. He continues to drink alcohol liberally. His laboratory tests reveal WBC 3200/µL, platelets 100,000/µL, Hb 9.8g/dL, creatinine 3.6mg/dL, uric acid 9.0mg/dL and INR 4.0. The most appropriate management step in this patient is:
- Aspiration of the R ankle with administration of intra-articular steroids
- Initiation of allopurinol guided by EGFR
- Initiation of colchicine 0.6 mg 2 tabs now followed by 1 tab an hour later and then I tab twice a day
- Start prednisone 40mg a day and titer down based on response
2. A previously healthy 70 year old lady is admitted with pneumonia and on the 2nd day of hospitalization develops a painful swollen R knee with tenderness and warmth. She is afebrile. The rest of her articular exam is normal except for nodular osteoarthritis of her hands and crepitus in the L knee. The most appropriate first step in her management is:
- Start prednisone 40mg a day and titer down based on response
- Aspiration of the R knee with administration of intra-articular steroids
- Initiation of colchicine 0.6 mg 2 tabs now followed by 1 tab an hour later and then I tab twice a day
- Initiation of allopurinol guided by EGFR
3. You are asked to evaluate a currently asymptomatic 67 year-old man who has a long history of gout. During the past six months, he has had multiple acute gouty flares involving the left wrist, the right knee, and the first metatarsophalangeal joints. A year ago, he underwent heart transplantation because of viral cardiomyopathy. At that time, his regimen of allopurinol, 300 mg daily, and colchicine, as needed for acute flares, was discontinued. He has taken no regular medication for gout since then, except for indomethacin during the recent flares.
Current medications are cyclosporine, 400 mg; azathioprine, 100 mg daily, and prednisone, 10 mg daily. Physical examination reveals a tophus in the left olecranon bursa. No joint tenderness or swelling is present. Leukocyte count is 7500/cu mm with a normal differential. Serum creatinine level is 1.8 mg/dL. Serum uric acid level is 10.6 mg/dL. The best treatment plan for this patient is:
- Begin allopurinol, 100 mg daily, and continue other medications unchanged
- Begin allopurinol, 300 mg daily, and reduce the dose of azathioprine
- Begin allopurinol, 100 mg daily, and reduce the dose of azathioprine
- Begin allopurinol, 100 mg daily, and reduce the dose of cyclosporine
- Begin allopurinol, 300 mg daily, and reduce the dose of cyclosporine
4. A 46-year-old man is evaluated because of a three-month history of progressive generalized weakness without pain and the recent onset of numbness in the hands and toes. For the past three weeks, the patient has required support while walking and assistance in rising from a chair. Medical history includes hypertension and two attacks of gout. He has taken colchicine, 0.6 mg twice daily, for the past four years, and he currently takes hydrochlorothiazide, 50 mg daily. He drinks 2 to 3 cans of beer daily. At the time of physical examination, the patient cannot stand or walk without assistance. Blood pressure is 160/100 mm Hg. There is marked symmetric proximal muscle weakness which is more severe in the legs. Sensation to pinprick and vibration is decreased in the toes. Deep tendon reflexes are absent.
Laboratory studies:
Hemoglobin 12.5 g/dL
Mean corpuscular volume 99 fL
Erythrocyte sedimentation rate 32 mm/hr
Serum aspartate aminotransferase 125 U/L (AST)
Serum creatinine 1.9 mg/dl
Serum creatine kinase 2010 U/L
Serum uric acid 8.0 mg/dL
Which of the following is the most likely diagnosis?
- Colchicine-induced neuromyopathy
- Alcohol-induced neuromyopathy
- Inclusion body myositis
- Polymyositis
- Amyotrophic lateral sclerosis
Which of the following findings on synovial fluid analysis is consistent with an asymptomatic lady with a minimal knee effusion that was aspirated after obtaining the X- ray below?
- Turbid and watery fluid with a cell count of 10,000/µL with needle shaped strongly negatively birefringent crystals
- Turbid watery fluid with a cell count of 5,000/µL with rhomboid weakly positively birefringent crystals
- Turbid watery fluid with a cell count of 8,000/µL with no crystals
- Clear, viscous fluid with a cell count of 400/µL and weakly positively birefringent crystals