Rheumatology-Main风湿病-81-90

RheumatologyMain81-90Q1A30-year-oldmancomesiotheofficeduetoshortnessofbreath;nonproductivecough;andfatigueforthepast3-4weeks.Healsohasbeenurinatingmorethanusual.Thepatienthasnoothermedicalissuesandcurrentlytakesnomedications.Hehassmokedapackofcigarettesdailyfor3years.Vitalsignsarenormal.Cardiopulmonaryexaminationshowsscatteredcracklesbutisotherwiseunremarkable.Theabdomenissoftandnontender.Laboratoryresultsareasfollows:Chestx-rayrevealsbilateralhilarfullnessandinterstitialInfiltrates.ResultsofHIVtestingandpurifiedproteinderivativeskintestingarenegative.Whichofthefollowingisthebesttherapyforthispatient?A.AntifungalsB.AntituberculosisagentsC.BisphosphonatesD.ChemotherapyE.GlucocorticoidsF.ParathyroidectomyA1Correctanswer:Thispatient'spresentationwith3-4weeksofdyspnea,fatigue,andnonproductivecoughwithbilateralhilarfullnessandinterstitialinfiltratesonchestx-rayisconsistentwithsarcoidosis.Diagnosisismadebyacombinationofcompatibleclinicalpresentationandimagingfindings,exclusionofotherdiagnoses,andnoncaseatinggranulomasonbiopsy.Althoughneithersensitivenorspecific,hypercalcemia(presentinthispatientandcausingfrequenturination)occursinupto20%ofpatientsandcanbeanadditionalcluefordiagnosis.Themechanismresponsibleforhypercalcemiaisgranulomatousactivityof1-alphahydroxylasecausingincreasedproductionof1,25-dihydroxyvitaminDandincreasedintestinalcalciumabsorption.Hypercalciuria(occurringinupto50%ofpatients)Ispresentmoreoftenthanhypercalcemiaandcanresultinnephrolithiasis.Patientswithsarcoidosiswhoareasymptomaticareoftenfollowedwithouttreatmentduetoahighrateofspontaneousremission.However,patientswithsymptomaticdisease(eg,cough,dyspnea,fatigue,hypercalcemia)aretreatedwithsystemicglucocorticoids,itisimportanttoruleoutinfectiousgranulomatousdiseaseswithsimilarpresentations,suchastuberculosis(TB)andhistoplasmosis,priortoinitiationofglucocorticoids.(ChoiceA)Antifungaltherapy(eg,itraconazole)wouldbeindicatedfortreatmentofinfectionwithendemicfungisuchashistoplasmosis.Sarcoidosisandhistoplasmosismaypresentwithsimilarsymptomsandchestx-rayfindings,butInfectioninanimmunocompetenthostisextremelyrareandleukocytosiswouldbeexpected.(ChoiceB)TBcanpresentsimilarlytosarcoidosis,butthenegativepurifiedproteinderivativeskintestmakesTBunlikelyinthispatientwithnoevidenceofimmunosuppression.(ChoiceC)Bisphosphonatesareindicatedinthemanagementofsevere,symptomatichypercalcemia,usuallyduetomalignancy.Thispatient'shypercalcemiaislikelyduetosarcoidosisandshouldrespondtotreatmentwithglucocorticoids.(ChoiceD)ChemotherapyisindicatedinthetreatmentofHodgkinlymphoma,which,likesarcoidosis,oftenpresentswithmediastinaladenopathyandfatigue.Hypercalcemiacanoccurbutisrare,andinterstitialinfiltratesarenottypicallyseenonchestx-ray.(ChoiceF)Parathyroidectomyisindicatedinadvancedmanifestationsofprimaryhyperparathyroidism.Thispatient'shypercalcemiaismorelikelyduetosarcoidosisthanprimaryhyperparathyroidism.Educationalobjective:Sarcoidosisisdiagnosedinthesettingofacompatiblehistory,chestx-rayfindingsofhilaradenopathywithorwithoutreticulonodularinfiltrates,andnoncaseatinggranulomasonbiopsy.Hypercalcemiacanbepresentduetogranulomatousproductionof1.25-dihydroxyvitaminD.Symptomaticdiseaseistreatedwithsystemicglucocorticoids.Q2A35-year-oldmancomestotheofficewitha5-dayhistoryofbackpain;whichbeganattheendofalongdayofcarryingheavyboxeswhilemovingtoanewapartment.Sincethemhehashadsharppaininthelumbarspineradiatingtotheposterioraspectoftheleftcalfandfoot.Thepatienthasnoassociatedbladderorbowelincontinence.Medicalhistoryisnotableonlyforrecurrentpoisonivydermatitis.Hesmokesmarijuanafrequentlyonweekendsbutdoesnotusetobacco,alcohol,orotherillicitdrugs.Onexamination,vitalsignsarenormal.Painandtemperatureperceptionarepreservedintheaffectedextremityaswellasintheperinealarea.Analreflexisnormal.Liftingtheleftlegto70degreeswiththekneeheldstraightcausesburningpainradiatingfromthelowbacktotheleftfoot.WhichofthefollowingIsthebestnextstepinmanagementofthispatient?A.MRIofthelumbarspineB.NerveconductionstudiesC.SupervisedexerciseprogramD.SurgicaldecompressionE.Trialofnonsteroidalanti-infiammatorydrugsF.X-rayofthelumbarspineA2Correctanswer:EThispatienthasacutelumbosacralradiculopathy(sciatica),mostlikelyduetonerverootcompressionbyaherniateddisc.Olderpatientsorthosewithpriortraumaticinjurycanalsohavenerverootcompressionduetolumbarspondylosis.Lesscommoncausesincludeinfectiousorinflammatorydisorders,masslesions,vascuiardisorders,anddevelopmentalanomalies.Patientswithuncomplicatedlumbarstraincanhaveradiationofpaintothebuttocksorposteriorthigh,butradiationtothecalfandfootismoreconsistentwithsciatica.Tractiononthenerverootduringthestraightlegraisetestcausesworseningorreproductionofpain.Mostpatientswithacutesciaticawillexperiencespontaneousresolution;therefore,Initialmanagementisprimarilyfocusedonacutereliefofsymptoms.Nonsteroidalanti-inflammatorydrugsandacetaminophenarethepreferredfirst-linedrugs.Short-termuseofopioidsormusclerelaxantscanbeconsideredinpatientswithpersistentpainbutisassociatedwithsignificantse