Indian Journal of Rheumatology 2006 September

PG Forum
Volume 1, Number 2; p. 82

Rheumatology quiz
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V Dhir
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1. All are true about the ‘Smith’ antigen in SLE, except: (c) Oral ulcers in inflammatory bowel disease
(a) Associated with membranous GN (d) Circinate balanitis
(b) Smith refers to the name of a patient 6. Which statement about acute phase reactants is true?
(c) First non-histone, non-DNA autoantigen identified (a) Half life of CRP is 10 days
in SLE (b) Normal CRP value is less than 1 mg/l
(d) Associated with ‘homogenous’ ANA pattern on (c) CRP levels are normal in acute serositis of SLE
indirect immunofluorescence (d) Levels of CRP more than 6 mg/dl in SLE should
2. Infectious sacroiliitis is reported with all of the follow- raise suspicion of infection
ing, except: 7. Which statement about palindromic rheumatism is true?
(a) Salmonella (a) RF positivity is rare
(b) Brucella (b) Rarely progresses to RA
(c) Staphylococcus (c) Erosions in 50%
(d) Coxiella burnetti (d) No sex difference
3. The following is true about enteropathic arthritis: 8. All of the following tests are known for their high speci-
(a) HLA B27 is associated with peripheral polyarthritis ficity except:
(b) HLA DRB1*0103 is associated with peripheral (a) Anti-dsDNA for SLE
polyarthritis (b) Anti-CCP for RA
(c) Septic arthritis of hip can occur in Crohn’s disease (c) Anti-smooth muscle cell for autoimmune hepatitis
(d) Uveitis, clubbing and erythema nodosum are com- (d) Anti-Sm for SLE
mon in ulcerative colitis than in Crohn’s disease 9. Which of the following types of vasculitis is not seen in
4. Which of the following ‘radiographic associations of adults?
rheumatic diseases’ is wrong? (a) Giant cell arteritis
(a) ‘Hook-type’ osteophytes—hemochromatosis (b) Kawasaki disease
(b) ‘Seagull wing’ erosions—inflammatory osteo- (c) Susac’s syndrome
arthritis of distal interphalangeal joints (d) Henoch Schonlein purpura
(c) Crescent sign—avascular necrosis 10. Drug-induced SLE may be caused by the following,
(d) Severe periarticular osteopenia—psoriatic arthritis except:
5. Which of the following mucosal lesions is usually (a) Infliximab
painful? (b) Minocycline
(a) Methotrexate oral ulcers (c) Hydrallazine
(b) SLE oral ulcers (d) Quinacrine

For answer refer to page 84

Department of Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow.

Correspondence: Dr. Varun Dhir, email: varundhir@gmail.com
 84 Indian Journal of Rheumatology 2006 September; Vol. 1, No. 2
of cyclophosphamide. With these measures, her pain sub-
sided gradually, bowel movements improved and eventually
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she recovered completely. The follow-up CNCT scan was
normal. So far, she has received eight cyclophosphamide
pulses and is in complete remission.
Gastrointestinal manifestations in SLE were first
described by Sir William Osler in 1895.1 Abdominal pain,
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nausea, vomiting, and diarrhoea occur in more than 50% of
SLE patients, sometimes during the course of the disease.
Mesenteric vasculitis, with or without infarction is rare, but
is one of the most serious gastrointestinal complication of
SLE.2 It develops in 1–5% of patients with SLE3, 4 and is
far more frequently seen at necropsy than recognized clini-
cally.5 Most patients present with cramping or constant
abdominal pain and fever. Melaena is observed in only
1–6% of patients with mesenteric ischemia. Diffuse direct
or rebound tenderness is present but rigidity or guarding
may or may not be present. As there are several causes of
abdominal pain in a patient with SLE, quick and systemic
assessment is mandatory to establish cause, effective treat-
ment and prevent morbidity.
ANSWERS TO RHEUMATOLOGY QUIZ
(page 82)
1d*, 2d, 3c**, 4d***, 5a, 6d†, 7d, 8c, 9b, 10d
* †
Speckled pattern.
**
HLA DRB1*0103 and B27 are both associated with type
1 (oligoarthritis) and not polyarthritis.
The challenge of differential diagnosis
The challenge of differential diagnosis is to select the most
probable cause of a patient’s condition, yet the size of the
problem, the nature of medical information, and the notorious
inability of human beings to manipulate probabilities in their
heads all conspire against the diagnostician to make it virtually
impossible to employ Bayes’ theorem in routine diagnosis.
Unable to estimate the desired probabilities explicitly,
physicians recast the problem into a form that uses one of
their most effective mental skills—that of comparing patterns.
Sharma et al.
REFERENCES
1. Osler W. On the visceral complications of erythema exuda-
tivum multiforme. Am J Med Sci 1895; 110: 629–46.
2. Hallegua DS, Wallace DJ. Gastrointestinal and Hepatic
Manifestations. In: Wallace DJ, Hahn BH, editors. Dubois
Lupus Erythematosus. 6th ed., Philadelphia: Lippincort
Williams & Wilkins, 2002; 843–61.
3. Vitali C, Bencivelli W, Isenberg DA, et al. Disease activity in
systemic lupus erythematosus: report of consensus study
group of the European workshop for rheumatology research.
A descriptive analysis of 704 European lupus patients. Clin
Exp Rheumatol 1992; 10: 527–39.
4. Hahn BH. Systemic Lupus Erythematosus. Harrison’s
Principles of Internal Medicine. Kasper DL, Braunwald E,
Fauci AS, Hauser SL, Longo DL, Jameson JL, editors.
McGraw Hill, 2005; 1960–7.
5. Nadorra RL, Nakazato Y, Landing BH. Pathological features
of gastrointestinal tract lesions in childhood-onset systemic
lupus erythematosus: study of 26 patients, with review of lit-
erature. Pediatr Pathol 1987; 7: 245–59.
***
Periarticular osteopenia tends to be mild in PsA.
Although CRP does not rise in SLE, acute serositis of SLE
is an exception; half-life of CRP is 18 h; normal level is
less than 1 mg/dl.
A study of 50 clinicopathological conferences published in
the Journal suggests that the following six steps are taken to
arrive at a diagnosis: aggregation of groups of findings into
patterns, selection of a “pivot” or key finding, generation of a
cause list, pruning of the cause list, selection of a diagnosis,
and validation of the diagnosis.
Eddy DM, Clanton CH. The art of diagnosis: solving the clinico-
pathological exercise. N Engl J Med 1982; 306: 1263–8.