QUESTION: 17

A 60-year-old woman arrives at your office for a routine physical examination. During the course of her examination she asks you about osteoporosis. She is concerned about her risk for osteoporosis, as her mother suffered from multiple vertebral compression fractures at the age of 60. Your patient reports that she still smokes cigarettes ("although I know they are bad for me") and has one alcoholic beverage a week. She reports having had menopause 5 years ago and experiencing a deep venous thrombosis approximately 20 years ago. She is proud of the fact that she regularly exercises at the local fitness center. She has been taking 1500 mg of calcium with 800 IU of vitamin D every day. You suspect that she is at risk for osteoporosis. After performing the appropriate imaging study, you determine that your patient has osteoporosis. Of the following choices, which is risk factor most likely contributing to her osteoporosis?

active lifestyle
late menopause
cigarette smoking
frequency of alcohol intake
her intake of calcium and vitamin D

Answer(s): C

Explanation:

DEXAis the newest, least expensive, and quickest method of assessing BMD. The precision of DEXAis approximately 12%. Standard radiography is inadequate for accurate bone mass assessment. Single photon absorptiometry is used to scan bone, which is in a superficial location with little adjacent soft tissue (e.g., radius). It may not be an accurate reflector of the density in the spine or hip, which are the sites of greatest potential risk for fracture. The quantitative CT scan and dual photon absorptiometry take more time, expose the patient to more radiation, and, in the case of quantitative CT scanning, significantly increase costs, when compared to DEXA. The major risk factors for osteoporosis are family history, slender body build, fair skin, early menopause, sedentary lifestyle, cigarette smoking, medications (corticosteroids or Lthyroxine), more than two drinks a day of alcohol or caffeine, and low calcium intake. The current recommendation for oral calcium in men and premenopausal women is 1000 mg/day. Postmenopausal women and patients with osteoporosis should have 1500 mg calcium a day and 400800 IU of vitamin D, which promotes intestinal calcium absorption. This patient's intake of calcium and vitamin D is not a risk factor for osteoporosis.

Alendronate is a bisphosphonate, which is approved for the prevention and treatment of postmenopausal osteoporosis. Among the many results of the WHI, it was found that combined estrogen plus progestin therapy was associated with an increased risk of nonfatal MI or death from coronary heart disease (CHD). Consequently, while it is recognized that postmenopausal women who are taking estrogen to alleviate postmenopausal symptoms may also experience skeletal benefits, the prevention of osteoporosis should not be a reason in itself to start estrogen therapy. Calcitonin inhibits osteoclastic bone resorption, but is not sufficiently potent to prevent bone loss in early postmenopausal women (within 5 years of menopause). It is best reserved for use in patients with osteoporosis unresponsive to other therapies. Raloxifene is a selective estrogen receptor modulator (SERM), which is effective for prevention of bone loss in early postmenopausal women and treatment of established osteoporosis, but it also increases the risk of venous thromboembolic disease which makes it an inappropriate choice for this patient

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QUESTION: 18

A 60-year-old woman arrives at your office for a routine physical examination. During the course of her examination she asks you about osteoporosis. She is concerned about her risk for osteoporosis, as her mother suffered from multiple vertebral compression fractures at the age of 60. Your patient reports that she still smokes cigarettes ("although I know they are bad for me") and has one alcoholic beverage a week. She reports having had menopause 5 years ago and experiencing a deep venous thrombosis approximately 20 years ago. She is proud of the fact that she regularly exercises at the local fitness center. She has been taking 1500 mg of calcium with 800 IU of vitamin D every day. You suspect that she is at risk for osteoporosis. After a thorough discussion with your patient, you determine that pharmacologic intervention would be beneficial given the severity of her osteoporosis. Which of the following is most appropriate for your patient?

estrogen replacement therapy
combined HRT with estrogen and progestin
alendronate
calcitonin intranasal spray
raloxifene

Answer(s): C

Explanation:

DEXAis the newest, least expensive, and quickest method of assessing BMD. The precision of DEXAis approximately 12%. Standard radiography is inadequate for accurate bone mass assessment. Single photon absorptiometry is used to scan bone, which is in a superficial location with little adjacent soft tissue (e.g., radius). It may not be an accurate reflector of the density in the spine or hip, which are the sites of greatest potential risk for fracture. The quantitative CT scan and dual photon absorptiometry take more time, expose the patient to more radiation, and, in the case of quantitative CT scanning, significantly increase costs, when compared to DEXA. The major risk factors for osteoporosis are family history, slender body build, fair skin, early menopause, sedentary lifestyle, cigarette smoking, medications (corticosteroids or Lthyroxine), more than two drinks a day of alcohol or caffeine, and low calcium intake. The current recommendation for oral calcium in men and premenopausal women is 1000 mg/day. Postmenopausal women and patients with osteoporosis should have 1500 mg calcium a day and 400800 IU of vitamin D, which promotes intestinal calcium absorption. This patient's intake of calcium and vitamin D is not a risk factor for osteoporosis.

Alendronate is a bisphosphonate, which is approved for the prevention and treatment of postmenopausal osteoporosis. Among the many results of the WHI, it was found that combined estrogen plus progestin therapy was associated with an increased risk of nonfatal MI or death from coronary heart disease (CHD). Consequently, while it is recognized that postmenopausal women who are taking estrogen to alleviate postmenopausal symptoms may also experience skeletal benefits, the prevention of osteoporosis should not be a reason in itself to start estrogen therapy. Calcitonin inhibits osteoclastic bone resorption, but is not sufficiently potent to prevent bone loss in early postmenopausal women (within 5 years of menopause). It is best reserved for use in patients with osteoporosis unresponsive to other therapies. Raloxifene is a selective estrogen receptor modulator (SERM), which is effective for prevention of bone loss in early postmenopausal women and treatment of established osteoporosis, but it also increases the risk of venous thromboembolic disease which makes it an inappropriate choice for this patient

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QUESTION: 19

A28-year-old male, well known to your clinic, presents for management of swelling, pain, and tenderness that has developed in his left ankle and right knee. It has persisted for 1 month. Your patient reports that he developed severe diarrhea after a picnic 1 month prior to the onset of his arthritis. During the interval between the diarrhea and onset of arthritis, he developed a "pink eye" that lasted for 4 days. He denies any symptoms of back pain or stiffness. You remember that he was treated with ceftriaxone and doxycycline for gonorrhea 2 years ago, which he acquired from sexual activity with multiple partners. Since that time, he has been in a monogamous relationship with his wife and has not had any genitourinary symptoms. He promises that he has been faithful to his wife and has not engaged in unprotected sexual activity outside his marriage. His physical examination is notable for a swollen left ankle, swollen right knee, and the absence of penile discharge or any skin lesions. Which of the following is the most likely diagnosis?

pseudogout
gout
reactive arthritis
resistant gonococcal arthritis
ankylosing spondylitis

Answer(s): C

Explanation:

Reactive arthritis consists of a triad of nonspecific urethritis, conjunctivitis, and asymmetric arthritis, usually involving the large joints of the lower extremities. Genitourinary causes of reactive arthritis include Chlamydia or Ureaplasma. GI infections due to Salmonella, Shigella, Yersinia, Klebsiella, and Campylobacter can also cause reactive arthritis. Gout attacks are typically monoarticular and begin abruptly with the affected joint being exquisitely painful, warm, red, and swollen. These attacks often spontaneously resolve in 310 days. While the symptoms from pseudogout may mimic those of gout, they tend to be less painful and take longer to reach peak intensity. Gonococcal arthritis is seen more often in females, is associated with migratory arthralgia, tends to favor the upper limbs and knees and may be associated with cutaneous lesions (pustules). The absence of attacks and joint distribution makes gout and pseudogout less likely. The history of conjunctivitis and association with diarrhea makes the diagnosis of reactive arthritis more likely than resistant gonococcal arthritis. His clinical symptoms do not suggest ankylosing spondylitis, although if he was HLA-B27 positive he would be at increased risk of developing spondylitis. This patient has the classic symptoms and exposure risk (GI infection) to suggest reactive arthritis. For the articular symptoms, reduction of inflammation and restoration of function can be achieved with nonsteroidal antiinflammatories alone. A sufficient number of patients with reactive arthritis will not be HLA-B27 positive, thus rendering this test useless as a screening test. However, it may be useful when the clinical picture is incomplete (such as absence of antecedent infection or lack of extraarticular features). Once an antecedent infection has triggered reactive arthritis, it is unlikely that antibiotics will affect the course of the illness (except in the case of chlamydiaassociated urogenital disease where a trial of prolonged antibiotic therapy may be reasonable).

Systemic corticosteroids are usually ineffective in reactive arthritis, but may be tried for resistant disease or conditions such as AIDS in which cytotoxic therapy is contraindicated. Given the absence of skin lesions, penile discharge, or urogenital symptoms, one would be hard-pressed to challenge the patient's statement that he has not engaged in unprotected sex at the risk of jeopardizing the physicianpatient relationship. Reactive arthritis may be the first manifestation of HIV infection. Therefore, HIV antibody status should be determined when the appropriate risk factors and/or clinical features are present. As mentioned previously, systemic steroids are usually ineffective for reactive arthritis and, with the possibility of joint infection, would necessitate ruling out infection by arthrocentesis of the affected joints. Joint infection cannot be ruled out based on his presentation, and joint sepsis must be excluded prior to corticosteroid injection. The clinical presentation is classic for reactive arthritis, and the absence of systemic symptoms makes the likelihood of disseminated bacterial infection low. Indomethacin, at a dose of 150200 mg/day, is the prototypic NSAID medication for treatment of reactive arthritis. Doses higher than this are associated with significant GI complications and do not improve efficacy in a patient resistant to the standard dose. In the event that the patient does not respond to 200 mg of indomethacin or alternative NSAIDs, disease- modifying antirheumatic drugs (DMARD) such as methotrexate, azathioprine, or sulfasalazine may be used, provided that HIV test results are negative, as these immunosuppressants have been reported to precipitate the onset of AIDS in HIV-positive patients.

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QUESTION: 20

A28-year-old male, well known to your clinic, presents for management of swelling, pain, and tenderness that has developed in his left ankle and right knee. It has persisted for 1 month. Your patient reports that he developed severe diarrhea after a picnic 1 month prior to the onset of his arthritis. During the interval between the diarrhea and onset of arthritis, he developed a "pink eye" that lasted for 4 days. He denies any symptoms of back pain or stiffness. You remember that he was treated with ceftriaxone and doxycycline for gonorrhea 2 years ago, which he acquired from sexual activity with multiple partners. Since that time, he has been in a monogamous relationship with his wife and has not had any genitourinary symptoms. He promises that he has been faithful to his wife and has not engaged in unprotected sexual activity outside his marriage. His physical examination is notable for a swollen left ankle, swollen right knee, and the absence of penile discharge or any skin lesions. What would be the appropriate management for this patient's arthritis?

Screen him for the suspected disease with HLA-B27 testing.
Treat with daily indomethacin (150200 mg daily).
Start him on empiric antibiotics.
Start treatment with prednisone 10 mg daily.
Assume that the patient is not being honest and perform the appropriate urogenital testing to confirm gonorrhea.

Answer(s): B

Explanation:

Reactive arthritis consists of a triad of nonspecific urethritis, conjunctivitis, and asymmetric arthritis, usually involving the large joints of the lower extremities. Genitourinary causes of reactive arthritis include Chlamydia or Ureaplasma. GI infections due to Salmonella, Shigella, Yersinia, Klebsiella, and Campylobacter can also cause reactive arthritis. Gout attacks are typically monoarticular and begin abruptly with the affected joint being exquisitely painful, warm, red, and swollen. These attacks often spontaneously resolve in 310 days. While the symptoms from pseudogout may mimic those of gout, they tend to be less painful and take longer to reach peak intensity. Gonococcal arthritis is seen more often in females, is associated with migratory arthralgia, tends to favor the upper limbs and knees and may be associated with cutaneous lesions (pustules). The absence of attacks and joint distribution makes gout and pseudogout less likely. The history of conjunctivitis and association with diarrhea makes the diagnosis of reactive arthritis more likely than resistant gonococcal arthritis. His clinical symptoms do not suggest ankylosing spondylitis, although if he was HLA-B27 positive he would be at increased risk of developing spondylitis. This patient has the classic symptoms and exposure risk (GI infection) to suggest reactive arthritis. For the articular symptoms, reduction of inflammation and restoration of function can be achieved with nonsteroidal antiinflammatories alone. A sufficient number of patients with reactive arthritis will not be HLA-B27 positive, thus rendering this test useless as a screening test. However, it may be useful when the clinical picture is incomplete (such as absence of antecedent infection or lack of extraarticular features). Once an antecedent infection has triggered reactive arthritis, it is unlikely that antibiotics will affect the course of the illness (except in the case of chlamydiaassociated urogenital disease where a trial of prolonged antibiotic therapy may be reasonable).

Systemic corticosteroids are usually ineffective in reactive arthritis, but may be tried for resistant disease or conditions such as AIDS in which cytotoxic therapy is contraindicated. Given the absence of skin lesions, penile discharge, or urogenital symptoms, one would be hard-pressed to challenge the patient's statement that he has not engaged in unprotected sex at the risk of jeopardizing the physicianpatient relationship. Reactive arthritis may be the first manifestation of HIV infection. Therefore, HIV antibody status should be determined when the appropriate risk factors and/or clinical features are present. As mentioned previously, systemic steroids are usually ineffective for reactive arthritis and, with the possibility of joint infection, would necessitate ruling out infection by arthrocentesis of the affected joints. Joint infection cannot be ruled out based on his presentation, and joint sepsis must be excluded prior to corticosteroid injection. The clinical presentation is classic for reactive arthritis, and the absence of systemic symptoms makes the likelihood of disseminated bacterial infection low. Indomethacin, at a dose of 150200 mg/day, is the prototypic NSAID medication for treatment of reactive arthritis. Doses higher than this are associated with significant GI complications and do not improve efficacy in a patient resistant to the standard dose. In the event that the patient does not respond to 200 mg of indomethacin or alternative NSAIDs, disease- modifying antirheumatic drugs (DMARD) such as methotrexate, azathioprine, or sulfasalazine may be used, provided that HIV test results are negative, as these immunosuppressants have been reported to precipitate the onset of AIDS in HIV-positive patients.

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