It is common for rheumatology clinics to encounter female patients with rheumatoid arthritis who are of child-bearing age. In such cases, the priority is to determine the need for treatment while also considering the risks of disease flares and potential harm to the fetus. During pregnancy, most RA patients experience an improvement in their condition, but caution must be exercised with certain medications. Methotrexate, for instance, is highly teratogenic and should be discontinued one to three months before pregnancy. On the other hand, DMARDs like hydroxychloroquine and sulphasalazine are generally considered safe to continue during pregnancy, although the latter should be avoided by male patients attempting to conceive due to the risk of oligospermia. Glucocorticoids can also be used during pregnancy, but only in low doses after 14 weeks, as there is an increased risk of cleft palate and gestational hypertension before this time. In cases where flares occur after discontinuing methotrexate, low doses of prednisolone may be an option.

Rheumatoid arthritis (RA) management has been transformed by the introduction of disease-modifying therapies in recent years. Patients with joint inflammation should begin a combination of disease-modifying drugs (DMARD) as soon as possible. Other important treatment options include analgesia, physiotherapy, and surgery.

In 2018, NICE updated their guidelines for RA management, recommending DMARD monotherapy with or without a short course of bridging prednisolone as the initial step. Previously, dual DMARD therapy was advocated. To monitor response to treatment, NICE suggests using a combination of CRP and disease activity (using a composite score such as DAS28).

Flares of RA are often managed with corticosteroids, either orally or intramuscularly. Methotrexate is the most commonly used DMARD, but monitoring of FBC & LFTs is essential due to the risk of myelosuppression and liver cirrhosis. Other important side-effects include pneumonitis. Other DMARDs include sulfasalazine, leflunomide, and hydroxychloroquine.

TNF-inhibitors are indicated for patients who have had an inadequate response to at least two DMARDs, including methotrexate. Etanercept is a recombinant human protein that acts as a decoy receptor for TNF-α and is administered subcutaneously. Infliximab is a monoclonal antibody that binds to TNF-α and prevents it from binding with TNF receptors, and is administered intravenously. Adalimumab is also a monoclonal antibody, administered subcutaneously. Risks associated with TNF-inhibitors include reactivation of tuberculosis and demyelination.

Rituximab is an anti-CD20 monoclonal antibody that results in B-cell depletion. Two 1g intravenous infusions are given two weeks apart, but infusion reactions are common. Abatacept is a fusion protein that modulates a key signal required for activation of T lymphocytes, leading to decreased T-cell proliferation and cytokine production. It is given as an infusion but is not currently recommended by NICE.

Charcot neuroarthropathy is a condition that presents as a warm, swollen, erythematous foot and ankle, and is often seen in patients with long-standing diabetes and peripheral neuropathy. It can progress through four stages, with radiographs being an important part of diagnosis and treatment involving immobilization and avoidance of weight-bearing. Bisphosphonates and surgery may also be used in severe cases. Antibiotics are not indicated unless there is evidence of cellulitis. The cause of peripheral neuropathy is most likely diabetes.

This patient has positive antibodies associated with rheumatological conditions, but it is important to focus on her specific symptoms and complaints. Based on her gender, age, and medical history, it is likely that she has a systemic autoimmune condition, with Systemic lupus erythematosus being the most probable diagnosis due to her examination results. The patient’s fleeting joint swelling is a common symptom of SLE, along with non-specific symptoms and the characteristic butterfly rash. While palindromic rheumatoid arthritis could explain the fleeting arthralgia, it does not account for the other observed signs. Polymyalgia rheumatica is unlikely due to the patient’s age and would not present with the same findings.

Systemic lupus erythematosus (SLE) can be investigated through various tests, including antibody tests. ANA testing is highly sensitive and useful for ruling out SLE, but it has low specificity. About 99% of SLE patients are ANA positive. Rheumatoid factor testing is positive in 20% of SLE patients. Anti-dsDNA testing is highly specific (>99%) but less sensitive (70%). Anti-Smith testing is also highly specific (>99%) but has a lower sensitivity (30%). Other antibody tests that can be used include anti-U1 RNP, SS-A (anti-Ro), and SS-B (anti-La).

Monitoring of SLE can be done through various markers, including inflammatory markers such as ESR. During active disease, CRP levels may be normal, and a raised CRP may indicate an underlying infection. Complement levels (C3, C4) are low during active disease due to the formation of complexes that lead to the consumption of complement. Anti-dsDNA titres can also be used for disease monitoring, but it is important to note that they are not present in all SLE patients. Overall, these investigations can help diagnose and monitor SLE, allowing for appropriate management and treatment.

The management of cardiac arrest survivors involves various aspects that need to be considered. As per the ACC/AHA/HRS 2008 guidelines, survivors of ventricular fibrillation cardiac arrest should undergo investigations to identify the cause of the arrest and exclude any reversible causes before implanting a cardioverter defibrillator (ICD). Electrolyte abnormalities are common reversible causes, but there are other causes as well.

In a case where a patient has severe left ventricular systolic dysfunction due to lupus myocarditis, medical management is necessary before considering ICD insertion. The underlying condition needs to be treated, and the patient’s left ventricular function should be monitored with repeat echocardiograms. If the function does not improve, an ICD may be indicated in the future.

It is important to note that amiodarone, a medication commonly used to treat cardiac arrhythmias, has several side effects. Therefore, it should only be continued if there is a justifiable reason to do so.

Understanding Systemic Lupus Erythematosus: A Multisystem Autoimmune Disorder

Systemic lupus erythematosus (SLE) is a complex autoimmune disorder that affects multiple systems in the body. It typically develops in early adulthood and is more common in women and individuals of Afro-Caribbean descent. The condition is characterized by a range of symptoms, including fatigue, fever, mouth ulcers, and lymphadenopathy.

SLE can also affect the skin, causing a malar (butterfly) rash that spares the nasolabial folds, as well as a discoid rash that is scaly, erythematous, and well-demarcated in sun-exposed areas. Other skin symptoms may include photosensitivity, Raynaud’s phenomenon, livedo reticularis, and non-scarring alopecia.

Musculoskeletal symptoms of SLE may include arthralgia and non-erosive arthritis, while cardiovascular symptoms may include pericarditis and myocarditis. Respiratory symptoms may include pleurisy and fibrosing alveolitis, and renal symptoms may include proteinuria and glomerulonephritis, with diffuse proliferative glomerulonephritis being the most common type.

Finally, neuropsychiatric symptoms of SLE may include anxiety and depression, psychosis, and seizures. Overall, SLE is a complex and challenging condition that requires careful management and ongoing support.

The correct answer is Jaccoud’s arthropathy, which is non-erosive and associated with systemic lupus erythematosus. This is because the absence of pain is a key factor, which is likely to be present in options B to E. The presence of psoriasis is a distracting factor, and gout typically affects the first metatarsal head. Sarcoid arthropathy is also very rare.

Understanding Systemic Lupus Erythematosus: A Multisystem Autoimmune Disorder

Systemic lupus erythematosus (SLE) is a complex autoimmune disorder that affects multiple systems in the body. It typically develops in early adulthood and is more common in women and individuals of Afro-Caribbean descent. The condition is characterized by a range of symptoms, including fatigue, fever, mouth ulcers, and lymphadenopathy.

SLE can also affect the skin, causing a malar (butterfly) rash that spares the nasolabial folds, as well as a discoid rash that is scaly, erythematous, and well-demarcated in sun-exposed areas. Other skin symptoms may include photosensitivity, Raynaud’s phenomenon, livedo reticularis, and non-scarring alopecia.

Musculoskeletal symptoms of SLE may include arthralgia and non-erosive arthritis, while cardiovascular symptoms may include pericarditis and myocarditis. Respiratory symptoms may include pleurisy and fibrosing alveolitis, and renal symptoms may include proteinuria and glomerulonephritis, with diffuse proliferative glomerulonephritis being the most common type.

Finally, neuropsychiatric symptoms of SLE may include anxiety and depression, psychosis, and seizures. Overall, SLE is a complex and challenging condition that requires careful management and ongoing support.

Osteomalacia is treated by supplementing with vitamin D, often with an initial loading dose regimen. In this patient’s case, her tiredness may be explained by vitamin D insufficiency, which can be managed with a maintenance dose of vitamin D. A loading dose would only be necessary if her serum level was less than 30 nmol/L. Patients with adequate levels, above 50 nmol/L, can benefit from dietary advice. As the patient’s calcium levels are normal and there is no evidence of a low calcium diet, calcium supplementation is not necessary.

To summarize, the treatment for vitamin D deficiency or insufficiency depends on the serum levels. Adequate levels can be maintained with dietary recommendations, while insufficient levels require a maintenance dose of vitamin D. Deficient levels may require a loading dose of vitamin D.

Understanding Osteomalacia: Causes, Features, Investigation, and Treatment

Osteomalacia is a condition characterized by the softening of bones due to low levels of vitamin D, which leads to a decrease in bone mineral content. While rickets is the term used for this condition in growing children, osteomalacia is the preferred term for adults. The causes of osteomalacia include vitamin D deficiency, malabsorption, lack of sunlight, diet, chronic kidney disease, drug-induced factors, inherited factors, liver disease, and coeliac disease.

The features of osteomalacia include bone pain, bone/muscle tenderness, fractures (especially femoral neck), proximal myopathy, and a waddling gait. To investigate this condition, blood tests are conducted to check for low vitamin D levels, low calcium and phosphate levels (in around 30% of patients), and raised alkaline phosphatase (in 95-100% of patients). X-rays may also show translucent bands known as Looser’s zones or pseudofractures.

The treatment for osteomalacia involves vitamin D supplementation, with a loading dose often needed initially. Calcium supplementation may also be necessary if dietary calcium is inadequate. By understanding the causes, features, investigation, and treatment of osteomalacia, individuals can take steps to prevent and manage this condition.

Disseminated gonococcal infection is a sexually transmitted bacterial infection caused by Neisseria gonorrhoeae. This patient presents with the dermatitis–polyarthritis–tenosynovitis syndrome, which includes symptoms such as fever, symmetrical polyarthralgia, tenosynovitis, and dermatitis. Diagnosis is made through culture of synovial fluid, skin lesions, and urethral swabs. Treatment involves NSAIDs for symptomatic relief, as well as ceftriaxone and azithromycin. Acute gout, reactive arthritis, tuberculous arthritis, and pseudo-gout were considered in the differential diagnosis but were ruled out based on the patient’s age, social history, and associated signs. This case highlights the importance of considering disseminated gonococcal infection in patients presenting with joint symptoms and a history of sexual activity.

Importance of Checking TPMT Levels Before Starting Azathioprine

Prior to initiating treatment with azathioprine, it is crucial to check the patient’s blood for thiopurine methyltransferase (TPMT) levels. Azathioprine is metabolized into 6-mercaptopurine (6-MP) in the body, which can either be converted into inactive 6-methyl mercaptopurine or methylated into active compounds by TPMT. In Caucasians, 89% of individuals have normal or high levels of TPMT, while 11% have low levels and 0.3% are deficient in TPMT. Administering azathioprine to those who are TPMT deficiency can lead to severe side effects such as myelosuppression.

Patients with normal or high levels of TPMT can safely begin treatment with azathioprine. However, those with low levels of TPMT should be closely monitored and given low doses of azathioprine under expert supervision. Therefore, it is essential to check TPMT levels before starting azathioprine to ensure the safety and efficacy of the treatment.

Biologic Agents for Psoriasis and Psoriatic Arthritis

Psoriasis and psoriatic arthritis are chronic inflammatory conditions that can significantly impact a patient’s quality of life. Biologic agents have revolutionized the treatment of these conditions, offering targeted therapy with fewer side effects than traditional systemic treatments.

Adalimumab, etanercept, and infliximab are anti-TNF agents that have shown efficacy as second-line agents in the management of psoriasis and psoriatic arthritis. These drugs target TNF-α, a cytokine that plays an important role in joint inflammation and destruction.

Ustekinumab is an IL-12/23 antagonist that has recently been approved for the treatment of psoriasis and psoriatic arthritis. This drug targets IL-12 and IL-23, two cytokines that are involved in the inflammatory response.

While erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) may fall in response to anti-TNF therapy, they are more non-specific markers of inflammation. Therefore, they are not reliable indicators of treatment response.

In conclusion, biologic agents offer a promising treatment option for patients with psoriasis and psoriatic arthritis. By targeting specific cytokines involved in the inflammatory response, these drugs can provide effective relief with fewer side effects than traditional systemic treatments.

Due to oesophageal irritation and nausea, bisphosphonates are not a viable option for this patient with bone metastases who is at risk of pathological fracture. Instead, denosumab, a monoclonal antibody that inhibits RANKL on osteoclasts, is recommended by NICE for women who have been intolerant to bisphosphonates and have osteoporosis or advanced breast cancer with bone metastases. Strontium ranelate is only recommended for primary prevention of osteoporotic fractures in at-risk women who cannot tolerate bisphosphonates, and lapatinib and letrozole are used to treat HER2 positive breast cancer and oestrogen receptor positive breast cancer, respectively, but have not been shown to reduce skeletal related events in patients with these cancer types.

Denosumab for Osteoporosis: Uses, Side Effects, and Safety Concerns

Denosumab is a human monoclonal antibody that inhibits the development of osteoclasts, the cells that break down bone tissue. It is given as a subcutaneous injection every six months to treat osteoporosis. For patients with bone metastases from solid tumors, a larger dose of 120mg may be given every four weeks to prevent skeletal-related events. While oral bisphosphonates are still the first-line treatment for osteoporosis, denosumab may be used as a next-line drug if certain criteria are met.

The most common side effects of denosumab are dyspnea and diarrhea, occurring in about 1 in 10 patients. Other less common side effects include hypocalcemia and upper respiratory tract infections. However, doctors should be aware of the potential for atypical femoral fractures in patients taking denosumab and should monitor for unusual thigh, hip, or groin pain.

Overall, denosumab is generally well-tolerated and may have an increasing role in the management of osteoporosis, particularly in light of recent safety concerns regarding other next-line drugs. However, as with any medication, doctors should carefully consider the risks and benefits for each individual patient.